Necrotising fasciitis with extensive necrosis caused by Lactobacillus: a case report.

BACKGROUND: Necrotising fasciitis (NF) is a life-threatening soft-tissue infection that rapidly destroys the epidermis, subcutaneous tissue, and fascia. Despite their low virulence, Lactobacillus spp. can cause NF, and because of its rare incidence, there is limited information about its molecular and clinicopathological characteristics. We report a rare case of NF in a patient with type 2 diabetes mellitus diagnosed on admission and severe obesity due to infection with two types of Lactobacillus spp. that manifested in extensive necrosis. CASE PRESENTATION: A 48-year-old woman was referred to our hospital with a complaint of difficulty walking due to severe bilateral thigh pain. She presented with mild erythema, swelling, and severe skin pain extending from the pubic region to the groin. The patient was morbidly obese, had renal dysfunction, and had diabetes mellitus diagnosed on admission.; her LRINEC (Laboratory Risk Indicator for Necrotising Fasciitis) score was 9, indicating a high risk of NF. An exploratory surgical incision was made, and NF was diagnosed based on fascial necrosis. Emergent surgical debridement was performed, and cultures of the tissue culture and aspirated fluid/pus revealed two types of Lactobacillus spp.: Lactobacillus salivarius and L. iners. The patient was admitted to the intensive care unit (ICU), where antibiotics were administered and respiratory and circulatory management was performed. Diabetic ketoacidosis was detected, which was treated by controlling the blood glucose level stringently via intravenous insulin infusion. The patient underwent a second debridement on day 11 and a skin suture and skin grafting on day 36. The patient progressed well, was transferred from the ICU to the general ward on day 41, and was discharged unassisted on day 73. CONCLUSIONS: Lactobacillus spp. are rarely pathogenic to healthy individuals and can scarcely trigger NF. However, these bacteria can cause rare infections such as NF in immunocompromised individuals, such as those with diabetes and obesity, and an early diagnosis of NF is imperative; surgical intervention may be required for the prevention of extensive necrosis. The LRINEC score may be useful for the early diagnosis of NF, even for less pathogenic bacteria such as Lactobacillus.

Rapid detection of vanB vancomycin-resistant enterococci by laboratory-developed PCR on enrichment broth.

Diagnostic accuracy of laboratory-developed PCR after overnight enrichment for the detection of vanB vancomycin-resistant enterococci was evaluated on 537 rectal swabs. Defining Ct-values of 27-34 (40 samples, 7 % inconclusive), we found an excellent sensitivity of 98,3 % and specificity of 99,7 % for the remaining 497 samples.

Development of an ultrafast PCR to detect clinically relevant acquired vancomycin-resistance genes from cultured enterococci.

BACKGROUND: VRE are increasingly described worldwide. Screening of hospitalized patients at risk for VRE carriage is mandatory to control their dissemination. Here, we have developed the Bfast [VRE Panel] PCR kit, a rapid and reliable quantitative PCR assay for detection of vanA, vanB, vanD and vanM genes, from solid and liquid cultures adaptable to classical and ultrafast real-time PCR platforms. METHODS: Validation was carried out on 133 well characterized bacterial strains, including 108 enterococci of which 64 were VRE. Analytical performances were determined on the CFX96 Touch (Bio-Rad) and Chronos Dx (BforCure), an ultrafast qPCR machine. Widely used culture plates and broths for enterococci selection/growth were tested. RESULTS: All targeted van alleles (A, B, D and M) were correctly detected without cross-reactivity with other van genes (C, E, G, L and N) and no interference with the different routinely used culture media. A specificity and sensitivity of 100% and 99.7%, respectively, were determined, with limits of detection ranging from 21 to 238 cfu/reaction depending on the targets. The Bfast [VRE Panel] PCR kit worked equally well on the CFX and Chronos Dx platforms, with differences in multiplexing capacities (five and four optical channels, respectively) and in turnaround time (45 and 16 minutes, respectively). CONCLUSIONS: The Bfast [VRE Panel] PCR kit is robust, easy to use, rapid and easily implementable in clinical microbiology laboratories for ultra-rapid confirmation of the four main acquired van genes. Its features, especially on Chronos Dx, seem to be unmatched compared to other tools for screening of VRE.

Bacteremia due to Leuconostoc species: A 13-year single-center case series.

INTRODUCTION: Leuconostoc spp. are facultatively anaerobic Gram-positive cocci involved in cases of hospital-acquired bacteremia, mainly in immunocompromised hosts. The available data is scarce due to its uncommon presentation. METHODS: We describe all the episodes of Leuconostoc spp. bacteremia in a third level hospital in a 13-year period (2008-2021). RESULTS: Four cases of clinically relevant bacteremia were detected. All cases were categorized as catheter-related. The following risk factors were found: previous glycopeptide therapy (75%), use of parenteral nutrition (100%) and cancer (75%). All isolates showed susceptibility to beta-lactams. Catheter removal was performed and wide spectrum antimicrobials were administered, with clinical response in all cases except one. DISCUSSION: Apart from cancer and glycopeptide exposure, disruption of skin barrier and gastrointestinal conditions were identified as risk factors, as it was concordantly underlined in other case series. Susceptibility to beta-lactams is usually maintained. Catheter removal and administration of an active antibacterial therapy seem to be the best approach for Leuconostoc spp. catheter-related bacteremia.

Detection of Cutibacterium (Propionibacterium) acnes in orthopaedic surgery: serious problem or contamination?

PURPOSE: Bone and joint infections are an important and increasing problem. Whether intraoperatively detected bacteria should be considered relevant or not is often difficult to assess. This retrospective cohort study analyzes the relevance of C. acnes cultured from deep intraoperative specimens. METHODS: All deep tissue samples collected intraoperatively between 2015 and 2020 from a quartiary care provider were evaluated for detection of C. acnes and its therapeutical consequences. Infection rates were determined according to a standardized definition and protocol and analyzed in dependence of patient's demographic data (age and gender), operative parameters (type of surgery, body region/location of surgery, and impression of the surgeon), and initiated therapy. RESULTS: In 270 cases of more than 8500 samples, C. acnes was detected. In 30%, the detection was considered an infection. The number of samples taken and tested positive for C. acnes correlated significantly with its classification as a cause of infection. If more than one sample of the patient was positive, the detection was significantly more likely to be treated as infection (p < 0.001). In 76% of cases, a consultation to the infectious diseases (ID) department took place regarding the classification of the pathogen detection and the therapy to be carried out. Almost all of the tested isolates demonstrated the wild-type susceptibility for penicillin and clindamycin. CONCLUSION: Intraoperative detection of skin-colonizing bacteria such as C. acnes is not always synonymous with infection. In particular, if other examination results contradict an infection (pathological sample without evidence of an infectious event, detection of malignant cells, etc.), the situation must be considered in a very differentiated manner. Interdisciplinary boards, for example, are suitable for this purpose. Care should be taken to obtain a sufficiently large number of tissue samples for microbiological examination to be able to better classify the result.

The incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery: a retrospective chart review.

BACKGROUND: Shoulder instability continues to be a common problem that is difficult to treat. Part of this difficulty can be attributed to the numerous postoperative complications that can impact the clinical course. Our study aims to primarily identify the incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery and secondarily identify any risk factors for developing a subclinical infection. MATERIALS AND METHODS: From January 2012 to December 2022, 94 charts of patients who underwent revision surgery by the senior author after a previous arthroscopic or open stabilization surgery for shoulder instability were reviewed. All patients of any age who underwent either bony or soft tissue revision surgery, regardless of the number of previous surgeries or corticosteroid injections, were included. Patients were excluded if they had a previous infection in the shoulder, if there was no record of the procedures performed in the previous surgery, or if cultures were not available for review. For each patient, demographic information (age, sex, race, smoking status, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, and intravenous drug use), surgical information (procedures performed, type of surgery, and date of surgery), and culture results were recorded. RESULTS: Overall, 107 patients were included in our study. Twenty-nine patients (27.1%) had positive cultures (60 cultures in total). Twenty-six patients had positive Cutibacterium acnes (C. acnes) cultures. On average, C. acnes cultures took 10.65 days to turn positive, whereas 24 of 27 patients had cultures that were positive within 14 days of the culture being obtained. There was no difference in infection incidence rates between soft tissue and bony stabilization procedures (P = .86) or arthroscopic and open procedures (P = .59). Males were more than 5 times more likely than females to be culture positive in our cohort (93.1% vs. 73.1%, relative risk [RR] = 1.27, P = .03). Finally, 10 control cultures were taken from the operating room air environment (8 distinct surgeries had 1 control culture taken, whereas 1 surgery had 2), 2 of which were positive for C. acnes (both taken from the same patient operation). This patient had their shoulder cultures positive for C. acnes as well. CONCLUSION: More than a quarter of patients requiring revision surgery after shoulder stabilization procedures have a subclinical shoulder infection, with males being at a higher risk of developing an infection than females. Surgeons should always consider infection as a reason for the lack of clinical improvement and possibly needing revision surgery after shoulder stabilization. The prompt diagnosis and treatment of these infections could be vital in improving results after these surgeries.

Evaluating the Trend of VRE carriages in Health Facilities: A Retrospective Study from 2019-2022.

Background: Healthcare-associated infections (HAIs) and multidrug resistance (MDR) are a growing public health threat and pose a risk to patient safety in healthcare facilities. Vancomycin-resistant Enterococci (VRE) are responsible for nosocomial infections and have intrinsic and acquired resistance to many antibiotics, including glycopeptides. VRE carriage can remain undetected, increasing the risk of contact transmission. Identifying colonized patients is crucial for the implementation of preventive measures. Aims: The aims of this study were to evaluate the trend of VRE carriage based on rectal swab results between 2019 and February 2022 in a large Italian trust and the percentage of patients with VRE colonization at the time of hospitalization. Methods: This was a retrospective observational study based on results of rectal swabs performed for screening on admission between January 2019 and February 2022 in four hospitals part of a single trust in Turin, North-Western Italy. The study collected data on the date of specimen collection, type of specimen, isolated pathogen and the date of hospital admission. Descriptive analysis of data was performed, and duplicate samples were not considered. Results: From January 2019 to February 2022 we collected 5025 rectal swabs performed in hospitals of the trust, of which 3037 were performed in 2019 (60%), 741 in 2020 (15%), 611 in 2021 (12%) and 636 in the first two months of 2022 (13%). VRE positivity was found in 162 (3%) rectal swabs, of which 2 cases in both 2019 (0.1%) and 2020 (0.3%), 95 in 2021 (15.5%) and 63 in the first two months of 2022 (9.9%). Furthermore, 52% (84/162) of positive rectal swabs were performed at admission, whereas the remaining 48% (78/162) of positive rectal swabs were performed after 48h. Conclusions: This study found an increasing trend of VRE carriage in the study population during the SARS-CoV-2 pandemic, highlighting the importance of screening patients for VRE carriage to prevent worsening clinical conditions, environmental contamination, and prolonged hospitalization.

Abiotrophia defectiva triple threat: A rare case of infective spondylodiscitis, endocarditis, and brain abscess.

Abiotrophia defectiva is a pathogen of the oral, gastrointestinal, and urinary tracts that can cause significant systemic disease with uniquely negative blood cultures depending on the growth medium. Prior cases note possible seeding from relatively common procedures such as routine dental work and prostate biopsies, however case literature describes prior infectious complications to include infective endocarditis, brain abscess formation, and spondylodiscitis. While prior cases describe some aspects of these presentations, we highlight a case of a 64-year-old male who presented to the emergency department (ED) f5or acute onset of low back pain with fever symptoms four days after an outpatient transrectal ultrasound-guided needle biopsy of the prostate, with a prior dental extraction described four weeks prior to arrival. Findings on initial ED presentation and subsequent hospitalization revealed infective spondylodiscitis, endocarditis, and brain abscess formation. This is the only cases noted in literature with all three infection locations with dual risk factors of dental and prostate procedures prior to symptom onset. This case highlights the multifocal illness that can complicate Abiotrophia defectiva infections, and the importance of thorough ED evaluation and multiservice approach for consultation and treatment.

Epidemiology of vancomycin-resistant enterococci in the United Arab Emirates: a retrospective analysis of 12 years of national AMR surveillance data.

Introduction: Enterococci are usually low pathogenic, but can cause invasive disease under certain circumstances, including urinary tract infections, bacteremia, endocarditis, and meningitis, and are associated with peritonitis and intra-abdominal abscesses. Increasing resistance of enterococci to glycopeptides and fluoroquinolones, and high-level resistance to aminoglycosides is a concern. National antimicrobial resistance (AMR) surveillance data for enterococci from the Middle East and North Africa (MENA) and the Gulf region is scarce. Methods: A retrospective 12-year analysis of N = 37,909 non-duplicate diagnostic Enterococcus spp. isolates from the United Arab Emirates (UAE) was conducted. Data was generated by routine patient care during 2010-2021, collected by trained personnel and reported by participating surveillance sites to the UAE National AMR Surveillance program. Data analysis was conducted with WHONET. Results: Enterococcus faecalis was the most commonly reported species (81.5%), followed by Enterococcus faecium (8.5%), and other enterococci species (4.8%). Phenotypically vancomycin-resistant enterococci (VRE) were found in 1.8% of Enterococcus spp. isolates. Prevalence of VRE (%VRE) was highest for E. faecium (8.1%), followed by E. faecalis (0.9%). A significant level of resistance to glycopeptides (%VRE) for these two species has been observed in the majority of observed years [E. faecalis (0-2.2%), 2010: 0%, 2021: 0.6%] and E. faecium (0-14.2%, 2010: 0%, 2021: 5.8%). Resistance to fluoroquinolones was between 17 and 29% (E. faecalis) and was higher for E. faecium (between 42 and 83%). VRE were associated with higher patient mortality (RR: 2.97), admission to intensive care units (RR: 2.25), and increased length of stay (six excess inpatient days per VRE case), as compared to vancomycin-susceptible Enterococcus spp. Discussion: Published data on Enterococcus infections, in particular VRE-infections, in the UAE and MENA region is scarce. Our data demonstrates that VRE-enterococci are relatively rare in the UAE, however showing an increasing resistance trend for several clinically important antibiotic classes, causing a concern for the treatment of serious infections caused by enterococci. This study also demonstrates that VRE were associated with higher mortality, increased intensive care unit admission rates, and longer hospitalization, thus poorer clinical outcome and higher associated costs in the UAE. We recommend the expansion of current surveillance techniques (e.g., local VRE screening), stricter infection prevention and control strategies, and better stewardship interventions. Further studies on the molecular epidemiology of enterococci are needed.

Are enterococcal bloodstream infections an independent risk factor for a poorer 5-year survival or just a marker for severity of illness?-The Munich multicentric enterococci cohort.

IMPORTANCE: The present study provides a substantial contribution to literature, showing that patients with enterococcal bloodstream infections (BSI) have a lower survival rate than those with Escherichia coli (E. coli) bloodstream infections after adjusting for 17 limiting prognostic factors and excluding patients with a limited life expectancy [metastatic tumor disease, Charlson Comorbidity Index (CCI) (greater than or equal to) 5]. This difference in the 5-year long-term survival was mainly driven by Enterococcus faecium (ECFM) bloodstream infections, with vancomycin resistance not being a significant contributing factor. Our findings imply that E. faecium bloodstream infections seem to be an independent risk factor for poor long-term outcomes. As such, future research should confirm this relationship and prioritize investigating its causality through prospective studies.

Characterization of an Emerging Enterococcus cecorum Outbreak Causing Severe Systemic Disease with Concurrent Leg Problems in a Broiler Integrator in the Southern United States.

Enterococcus cecorum has been associated mainly with osteomyelitis of the free thoracic vertebra in chickens. However, there are reports of E. cecorum producing septicemic lesions and having tropism for cartilages, resulting in the presentation of femoral head necrosis and synovitis. This paper discusses the presentation of E. cecorum as it relates to an outbreak in one vertical integrator where the main lesions were related to septicemia. Using a convenience sampling method, 100 broiler chicken cases received at the Poultry Research and Diagnostic Laboratory of Mississippi State University from April to December of 2021 were analyzed. The peak in cases was observed from June to August. The average age of broilers was 21 days with a range of 15-31 days. Most of these cases were related to systemic disease and leg problems, with gross lesions including characteristic pericarditis along with perihepatitis, osteomyelitis, and arthritis. In six of the 100 cases, E cecorum was isolated from the free thoracic vertebra, with the remaining being recovered from various other locations including liver, pericardium, hock/joint, femoral head, and bone marrow. Enterococcus cecorum identification was performed by using Vitek matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. These results were then sent to the research-use only SARAMIS database for analysis. Once the spectra of the isolates were imported, the relative and absolute taxonomy were analyzed. Two super spectrums and three clusters by homology were identified. The minimal inhibitory concentrations obtained by antimicrobial sensitivity tests were analyzed using WHONET Microbiology Laboratory Database Software. No isolates were pan-susceptible, 80% of isolates were noted to be resistant to ≥3 classes of antibiotics and, in general, isolates exhibited a high degree of variability when examining antimicrobial resistance patterns.

Reporte de caso- Caracterización de un brote reciente de Enterococcus cecorum causante de una enfermedad sistémica grave simultáneamente con problemas en las patas en un integrador de pollo de engorde en el sur de los Estados Unidos. La bacteria Enterococcus cecorum se ha asociado principalmente con osteomielitis de la vértebra torácica móvil de los pollos. Sin embargo, existen reportes de E. cecorum produciendo lesiones septicémicas y presentando tropismo por los cartílagos, resultando en la presentación de necrosis de la cabeza femoral y sinovitis. Este artículo analiza la presentación de E. cecorum relacionada con un brote en un integrador vertical donde las principales lesiones estaban relacionadas con septicemia. Utilizando un método de muestreo de conveniencia, se analizaron 100 casos de pollos de engorde recibidos en el Laboratorio de Investigación y Diagnóstico Avícolas de la Universidad Estatal de Mississippi de abril a diciembre del 2021. El mayor número de casos se observó de junio a agosto. La edad promedio de los pollos de engorde fue de 21 días con un rango de 15 a 31 días. La mayoría de estos casos estaban relacionados con enfermedad sistémica y problemas en las patas, con lesiones macroscópicas que incluían pericarditis característica junto con perihepatitis, osteomielitis y artritis. En seis de los 100 casos, E cecorum se aisló de la vértebra torácica móvil, y el resto de los casos se recuperó de otros lugares, incluyendo el hígado, el pericardio, articulación del corvejón, la cabeza femoral y la médula ósea. La identificación de E. cecorum se realizó utilizando la plataforma Vitek de espectrometría de masas MALDI-TOF. Posteriormente, estos resultados se enviaron a la base de datos SARAMIS de uso exclusivo para investigación para su análisis. Una vez importados los espectros de los aislados, se analizó la taxonomía relativa y absoluta. Se identificaron dos superespectros y tres grupos mediante homología. Las concentraciones inhibitorias mínimas obtenidas mediante pruebas de sensibilidad antimicrobiana se analizaron utilizando el software de base de datos de laboratorio de microbiología de WHONET. Ningún aislamiento fue pan-susceptible, se observó que el 80% de los aislamientos eran resistentes a tres o más clases de antibióticos y en general, los aislamientos exhibieron un alto grado de variabilidad al examinar los patrones de resistencia a los antimicrobianos.

Contact tracing for vancomycin-resistant Enterococcus faecium (VRE): evaluation of the Dutch policy of quintuple screening cultures.

Detection of vancomycin-resistant Enterococcus faecium (VRE) is hampered by low sensitivity of rectal swab cultures. This study aimed to define the number of screening cultures needed to increase sensitivity to detect VRE transmission, and to determine time from presumed exposure to detectable colonization. In a tertiary care setting, we retrospectively analyzed data from 9 VRE outbreaks. As a proxy or estimation for time to detectable colonization, the time between first positive culture of the presumed index patient and that of their contacts was determined. Only 64% of secondary cases were positive in the first out of five cultures. By using the first three out of five rectal swabs, 89% (95%CI: 78-95%) of all secondary cases would have been identified. The median number of days between the positive culture of the index patient and the first positive culture of secondary cases was 9 days. Eleven percent of secondary cases would have been missed if only three rectal samples would have been obtained. Furthermore, our results show that one or more rectal swabs taken around day 9 after presumed exposure should at least be included in the screening approach. In our setting, obtaining a fourth and a fifth rectal swab showed a relevant additional value compared to only one to three swabs. Our findings are useful for determining the most effective VRE contact tracing approach to prevent transmission.

E. hirae Causing Biliary Tract Infection in a Patient with Cholangiocarcinoma: A Case Report.

INTRODUCTION: E. faecium and E. faecalis are the common species of Enterococcus responsible for the majority of infections. Earlier, species other than the common ones were usually unidentified and reported as Enterococcus species. However, modern equipment, like MALDI-TOF and VITEK2, have been utilitarian, helping us to identify the previously unidentified species. E. hirae is an organism seldom reported to cause human infections. Here, we report a case of a biliary tract infection in a female patient with cholangiocarcinoma caused by E. hirae. CASE: A 56-year-old female presented with fever and abdominal pain. Bile aspirated during the ERCP was received in our laboratory. The gram stain of the bile sample revealed abundant polymorphonuclear leucocytes along with gram-positive diplococci. The organism failed to grow on MacConkey agar. On blood agar, non-hemolytic colonies grew. The organism was identified as E. hirae by MALDI-TOF MS. The antibiotic susceptibility performed using VITEK2 revealed it to be resistant to high-level gentamicin and susceptible to all remaining drugs. She was successfully treated with oral ciprofloxacin for the infection. DISCUSSION: Bile is colonized with bacteria due to obstruction in the biliary tree, leading to cholangitis. This causes bacterial proliferation and translocation of bacteria into the systemic circulation. Our case was resistant to high-level gentamicin, while all previously reported cases were susceptible. The resistant isolates of E. hirae being isolated from cattle and their surroundings amidst the rampant use of antibiotics in livestock can pose a difficult situation for humans. Thus, there should be regulations on antibiotic usage in livestock. Cases like these should be reported and recognized for their potential to cause outbreaks if they remain unreported. CONCLUSION: Thus, E. hirae, when encountered, should not be ignored but considered a pathogen and reported. The presence of drug-resistant organisms in cattle and their surroundings, their zoonotic potential to cause infections in humans, and the uncontrolled usage of antibiotics in livestock are causes for concern. Thus, we need to be more vigilant regarding it in the future.

Short report: impact of selective reporting of antibiotic susceptibility testing on antibiotic use in patients with bloodstream infection with Enterococcus faecalis.

INTRODUCTION: Bloodstream infections with Enterococcus faecalis are associated with relevant morbidity and mortality. Targeted antimicrobial therapy is essential. The choice of an adequate treatment may be challenging when susceptibility testing offers different options. Selective reporting of antibiotic susceptibility test results might lead to a more tailored antibiotic therapy and could therefore be an important antimicrobial stewardship program intervention. The aim of this study was to analyse whether the introduction of selective reporting of antibiotic test results leads to a more targeted antibiotic therapy in patients with bloodstream infection with Enterococcus faecalis. METHODS: This study was performed as a retrospective cohort study at the University Hospital Regensburg, Germany. All patients with blood cultures positive for Enterococcus faecalis between March 2003 and March 2022 were analysed. In February 2014 selective reporting of antibiotic susceptibility test results omitting sensitivity results for agents not recommended was introduced. RESULTS: 263 patients with blood cultures positive for Enterococcus faecalis were included. After introduction of selective reporting of antibiotic tests (AI) significantly more patients received ampicillin than before introduction of selective reporting (BI) (9.6% BI vs. 34.6% AI, p < 0.001). CONCLUSION: Selective reporting of antibiotic susceptibility test results led to a significantly higher use of ampicillin.

Urinary tract infection caused by Lactococcus garvieae in a premature neonate: A case report.

Lactococcus garvieae is a gram-positive cocci that has primarily been described as a pathogen in various fish species, but has increasingly been reported to cause endocarditis and other infections in humans [1]. Neonatal infection caused by Lactococcus garvieae has not been previously reported. Here we describe a premature neonate who developed a urinary tract infection with this organism and was successfully treated with vancomycin therapy.