[First report of carbapenemases in Osijek-Baranja County in imported Enterobacter cloacae isolate in vitro susceptible to carbapenems]. / Prvi opis karbapenemaze u osjecko-baranjskoj zupaniji u unesenom izolatu Enterobactera cloacae in vitro osjetljivom na karbapeneme.

Carbapenems are often the only therapeutic option to treat infections caused by multidrug-resistant Gram-negative bacteria. Emergence of carbapenemases in the isolates of Enterobacteriaceae limits therapeutic options. Carbapenem-resistant Enterobacteriaceae have emerged since 2008 throughout Croatia. In Osijek-Baranja County carbapenem-resistant strains of Enterobacteriaceae were not reported until 2013. The first carbapenem-resistant strain (Enterobacter cloacae) was identified in August 2013 in a patient previously hospitalized at University Hospital Center Zagreb for the treatment of acute lymphoblastic leukemia. Molecular analysis revealed the production of VIM-1 metallo-beta-lactamase (MBL). In spite of the metallo-beta-lactamase production the strain was not resistant to imipenem and meropenem in disk-diffusion and microdilution test. This report shows that routine susceptibility testing carried out in most laboratories does not necessarily detect carbapenemase production in Enterobacteriaceae. Since these enzymes are encoded on mobile genetic elements there is a risk of horizontal spread to other enterobacterial isolates and the development of hospital outbreaks.

[Vitamin B12 deficiency in children--underestimated danger in the light of new knowledge]. / Manjak vitamina B12 u djece --podcijenjena opasnost u svjetlu novih spoznaja.

Vitamin B12 (cobalamin) has two active forms, adenosylcobalamin and methylcobalamin which have a key role in two important metabolic pathways in humans and their deficiency is responsible for clinical problems. Cobalamin is essential during whole life, but its sufficient amount is extra important in fetal and neonatal period, when it is essential for normal child growth and development as well as for normal development of the central nervous system. Because of very complex transport and metabolism, its deficiency can be manifested in numerous congenital and acquired disorders. Vitamin B12 deficiency mostly has non-specific clinical features, it carries a great risk of permanent consequences, but most frequently it is easily curable if diagnosed on time. In Croatia cobalamin deficiency in children has been diagnosed too rarely. Accordingly, the aim of this paper is to point to the recently gained knowledge on cobalamin metabolism, present typical case reports and to provide guidelines for rapid and proper diagnostic and therapeutic approach.

Conservative surgical management of necrotic tissues following meningococcal sepsis: case report of a child treated with hyperbaric oxygen.

This article presents the case of a 5-month-old infant, who survived a fulminant meningococcal sepsis with purpura fulminans, septic shock and severe DIC with gastrointestinal bleeding. Amputation and reconstructive surgery were considered to treat the multiple skin and limb necroses at high risk of superinfection, but the surgical intervention was delayed due to the extremely doubtful outcome. On Day 10 after the onset of the disease, a hemodynamic improvement was achieved. The baby overcame early critical period, but was still in poor general condition. The hyperbaric oxygenation (HBO2) as adjuvant therapy was started in the monoplace chamber using the following protocol: from first through fifth day 45 minutes twice a day on 1.5 atmosphere absolute (ATA); after a two-day break, once a day on 1.8 ATA for 60 minutes. During 52 HBO2 treatments multiple areas of necrotic skin and subcutaneous tissue, together with fingertips and toes, detached spontaneously. All wounds healed without reinfections. An increased oxygen concentration during HBO2 therapy promoted spontaneous wound healing. Bacterial superinfection was not observed in numerous low-perfused lesions. Since repeated anesthesia and surgical interventions were not needed, a final invalidity was minimized. To the best of our knowledge, this is the first report on the successful conservative surgical treatment of this mutilating disease without aggressive reconstructive surgery in an infant with the help of HBO2.