Disseminated coinfection with Actinomyces graevenitzii and Mycobacterium tuberculosis: case report and review of the literature.

We report the first case of disseminated infection with both Actinomyces graevenitzii and Mycobacterium tuberculosis and review the medical literature. Concomitant actinomycosis and tuberculosis is very rare. The potential of the facultatively aerobic, newly described A. graevenitzii for disseminated invasive infection needs to be evaluated.

Infections related to the ingestion of seafood. Part II: parasitic infections and food safety.

Parasites are responsible for a substantial number of seafood-associated infections. The factor most commonly associated with infection is consumption of raw or undercooked seafood. People with underlying disorders, particularly liver disease, are more susceptible to infection. In the first part of this review, published last month, we discussed the viral and bacterial agents associated with consumption of seafood. In part II, we discuss the parasites commonly associated with seafood consumption. Parasites readily identifiable from both consumable seafood and infected human beings include nematodes, trematodes, cestodes, and protozoa. The salient features associated with seafood-related parasite infestations are discussed. To provide a safe product for consumers, the seafood industry and the government in the USA have undertaken specific measures, which include good manufacturing practices and hazards analysis and critical control points implemented by the government and regulatory agencies. Consumers should take common precautions including obtaining seafood from reputable sources especially if the seafood is to be consumed uncooked. Adequate cooking of seafood is the safest way of preventing related infections.

Infections related to the ingestion of seafood Part I: Viral and bacterial infections.

Foodborne diseases cause an estimated 76 million illnesses in the USA each year. Seafood is implicated in 10-19% of these illnesses. A causative agent can be traced in about 44% of seafood-related outbreaks, viruses accounting for around half of these illnesses. Although viruses are the most common cause of seafood-related infections, most hospitalisations and deaths are due to bacterial agents. A wide variety of viruses, bacteria, and parasites have been implicated in seafood-related outbreaks, which are reported worldwide. The factor most commonly associated with infection is consumption of raw or undercooked seafood. People with underlying disorders, particularly liver disease, are more susceptible to infection. The first part of this two-part review summarises the general incidence of seafood-related infections and discusses the common viral and bacterial causes of these infections. For each agent, the microbiology, epidemiology, mode of transmission, and treatment are discussed. In the May issue of the journal we will discuss parasites associated with seafood consumption, the safety of seafood, and the measures put in place in the USA to increase its safety.

Association of Atopobium vaginae, a recently described metronidazole resistant anaerobe, with bacterial vaginosis.

BACKGROUND: Bacterial vaginosis (BV) is a polymicrobial syndrome characterized by a change in vaginal flora away from predominantly Lactobacillus species. The cause of BV is unknown, but the condition has been implicated in diverse medical outcomes. The bacterium Atopobium vaginae has been recognized only recently. It is not readily identified by commercial diagnostic kits. Its clinical significance is unknown but it has recently been isolated from a tuboovarian abcess. METHODS: Nucleotide sequencing of PCR amplified 16S rRNA gene segments, that were separated into bands within lanes on polyacrylamide gels by denaturing gradient gel electrophoresis (DGGE), was used to examine bacterial vaginal flora in 46 patients clinically described as having normal (Lactobacillus spp. predominant; Nugent score < or = 3) and abnormal flora (Nugent score > or = 4). These women ranged in age from 14 to 48 and 82% were African American. RESULTS: The DGGE banding patterns of normal and BV-positive patients were recognizably distinct. Those of normal patients contained 1 to 4 bands that were focused in the centre region of the gel lane, while those of BV positive patients contained bands that were not all focused in the center region of the gel lane. More detailed analysis of patterns revealed that bands identified as Atopobium vaginae were present in a majority (12/22) of BV positive patients, while corresponding bands were rare (2/24) in normal patients. (P < 0.001) Two A. vaginae isolates were cultivated from two patients whose DGGE analyses indicated the presence of this organism. Two A. vaginae 16S rRNA gene sequences were identified among the clinical isolates. The same two sequences were obtained from DGGE bands of the corresponding vaginal flora. The sequences differed by one nucleotide over the short (approximately 300 bp) segment used for DGGE analysis and migrated to slightly different points in denaturing gradient gels. Both isolates were strict anaerobes and highly metronidazole resistant. CONCLUSION: The results suggest that A. vaginae may be an important component of the complex bacterial ecology that constitutes abnormal vaginal flora. This organism could play a role in treatment failure if further studies confirm it is consistently metronidozole resistant.

Bacteremia due to Bacteroides fragilis group: distribution of species, beta-lactamase production, and antimicrobial susceptibility patterns.

A retrospective analysis of susceptibility data on 542 blood isolates of the Bacteroides fragilis group tested from 1987 to 1999 by the same NCCLS-recommended broth microdilution method throughout is presented. Metronidazole, beta-lactam-beta-lactamase inhibitor combinations, carbapenems, and trovafloxacin were the most active agents (susceptibility of >or=93%). Among the cephalosporin-cephamycins, the order of activity was cefoxitin > ceftizoxime > cefotetan = cefotaxime = cefmetazole > ceftriaxone. All isolates were resistant to penicillin G, and 22% were resistant to clindamycin. The susceptibility rates to piperacillin-tazobactam, imipenem, and meropenem were affected least among isolates resistant to cefoxitin or clindamycin. Except for piperacillin-tazobactam, imipenem, and meropenem, the B. fragilis species was more susceptible than were the non-B. fragilis species. These data underscore the importance of susceptibility testing of the B. fragilis group and can serve as a guide in the choice of empirical antimicrobial therapy.

In vitro susceptibilities of the Bacteroides fragilis group species: change in isolation rates significantly affects overall susceptibility data.

A comparison of antimicrobial susceptibility data of species of the Bacteroides fragilis group for 1989-1990 and 1998-1999 studies showed statistically significant increases or decreases in in vitro activity. Overall significant increases in resistance were noted for ampicillin-sulbactam and clindamycin, while significant decreases in resistance were noted for ertapenem and cefoxitin. Susceptibilities to piperacillin-tazobactam, imipenem, meropenem, and trovafloxacin remained virtually the same for the two studies. Importantly, a change in the rates of isolation of the various species showed the B. fragilis species comprised 58% of the isolates in 1989 to 1990 and 45% of the isolates in 1998 to 1999. This change in rates of isolation of B. fragilis versus non-B. fragilis species had an overall effect on susceptibility data.

Ertapenem (MK-0826), a new carbapenem: comparative in vitro activity against clinically significant anaerobes.

Ertapenem, a new long acting beta-lactam with broad-spectrum antimicrobial coverage, was tested in vitro to compare its activity against 556 clinical isolates of anaerobes to other established agents using a broth microdilution method as recommended by the NCCLS. Against all anaerobes ertapenem inhibited 99.1% of isolates at 4 microg/mL, had a mode MIC of 0.12 microg/mL, and showed activity comparable to imipenem, meropenem, trovafloxacin, piperacillin-tazobactam, and metronidazole. Five of the B. fragilis group (4 B. fragilis, 1 B. vulgatus) isolates tested showed reduced susceptibility (>or=8 microg/mL; <1%) to ertapenem while all isolates of Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus were susceptible. Only piperacillin-tazobactam had susceptible MIC's for all test isolates followed by metronidazole and the carbapenems exhibiting low resistance rates (<1%).

Comparison of the post-antibiotic effect (PAE) induced by ceftizoxime, ceftriaxone, cefoxitin, ampicillin-sulbactam, and ticarcillin-clavulanate against selected isolates of Bacteroides fragilis and B. thetaiotaomicron.

The exposure of bacteria to various groups of antimicrobials at different concentrations can produce damage to the bacteria that persists even after removal of the antimicrobial agent. The post antibiotic effect (PAE) of beta-lactams on aerobic gram-negative bacilli is relatively short (<1 h), however, little information is available regarding anaerobic gram-negative bacilli. We studied the PAE of ceftizoxime, ampicillin-sulbactam, ticarcillin-clavulanate, cefoxitin, and ceftriaxone against strains of Bacteroides fragilis and B. thetaiotaomicron at antimicrobial concentrations 4x, 8x, and 16x the MIC values using colony count determinations of treated and untreated cultures. Against B. fragilis H931, ceftizoxime-induced PAE values were 2 h, 3 h 24 min, and 11 h 36 min at 4xMIC, 8xMIC, and 16xMIC while for the B. thetaiotaomicron isolates PAEs ranged from 2 h 27 min to 6 h 12 min at the same concentrations. Cefoxitin PAE values were 3 h 6 min and 2 h 18 min for the clinical isolates at 16xMIC and 3 h 24 min and 1 h 12 min against the laboratory strains at 16xMIC respectively, and for ceftriaxone 1 h 12 min and 5 h 12 min, respectively, for the B. thetaiotaomicron D933 and B. fragilis H931 strains at 16xMIC. With ampicillin-sulbactam, the longest PAE values were observed at 16xMIC with all the test isolates of B. fragilis and B. thetaiotaomicron. PAE values induced by ticarcillin-clavulanate overall were the shortest for the two clinical isolates. These studies indicate substantial PAE values for beta-lactams against selected anaerobes which may be an important factor in the dosing regimen of these test agents.

Susceptibility trending of blood isolates of the Bacteroides fragilis group over a 12-year period to clindamycin, ampicillin-sulbactam, cefoxitin, imipenem, and metronidazole.

Numerous reports have described a steady overall increase in resistance among clinical isolates of the Bacteroides fragilis group to several antimicrobial agents, particularly clindamycin. Determination of resistance rates is significantly influenced by the number of isolates of each species within the B. fragilis group tested. Historically, the B. fragilis species has remained the most susceptible to most antimicrobials when compared to non-B. fragilis species. This study compares the effect of a gradually changing ratio of blood isolates of B. fragilis to non-B. fragilis species tested by broth micro-dilution over a 12-year period on selected antimicrobial agents. In 1987, the ratio of blood isolates of B. fragilis to non-B. fragilis was 68% to 32%; in 1991 it was 59% to 41%; and in 1999 it was 51% to 49%. Both metronidazole and imipenem showed the least changes because of their inherent high activity against all species. For clindamycin, decreases in susceptibility ranged from 84% to 64% for B. fragilis compared to 58% to 67% for non-B. fragilis species. Ampicillin-sulbactam showed a decrease in susceptibility in B. fragilis and non-B. fragilis species, but was highest in 1999 when the ratio of non-B. fragilis species was the highest. Overall resistance rates to cefoxitin varied from 8% to 25% during the testing years and was consistently higher among the non-B. fragilis species. These comparisons indicate that the ratio of B. fragilis group species isolated from the blood has changed over the last 12 years and has appreciably affected the resistance rates to some commonly used anti-anaerobic agents. Whether the noted changes in species isolation rates are a result of selective antibiotic pressure or other factors is yet to be determined.