Efficacy of mupirocin, neomycin and octenidine for nasal Staphylococcus aureus decolonisation: a retrospective cohort study.

BACKGROUND: Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive Staphylococcus aureus (MSSA) is the most frequent organism, and the majority are endogenous. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI. METHODS: Our hospital prospectively collected data on our MSSA decolonisation programme since 2013, including; all MSSA carriers, treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used. RESULTS: During the study period 15,958 primary hip and knee replacements were performed. 3200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1210 neomycin and 1221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P < 0.0001). There was no difference in PJI rates (P = 0.452). CONCLUSIONS: Mupirocin and neomycin are more effective than octenidine at MSSA decolonisation. There was poor correlation between the MSSA status after treatment (on day of surgery) and PJI rates. Further research is needed to compare alternative MSSA decolonisation treatments.

Black Fungus Complicated with COVID-19 in a Man with Underlying Non-Hodgkin's Lymphoma.

COVID-19 is a disease reported to suppress cellular immunity. This may lead to the development of opportunistic infections, among others black fungus, or mucormycosis. On the other hand, pre-existing defect in immunity may render patients susceptible to both mucormycosis and COVID-19. Mucormycosis is a relatively rare fungal infection with rapid progression unless diagnosed promptly and treated adequately, and urgent surgical and medical intervention is lifesaving. The manifestation of mucormycosis largely depends on the presence of exposure to the pathogen and the existing risk factor of the host. As black fungus is locally invasive, the majority of cases will involve tissue damage with local destruction and contiguous spread to nearby structure. We here with present a case of black fungus complicated with COVID-19 in a man with underlying non-Hodgkin's lymphoma.

Rhinocerebral mucormycosis secondary to severe acute pancreatitis and diabetic ketoacidosis: a case report.

INTRODUCTION: Rhinocerebral mucormycosis is a rare and severe form of opportunistic fungal infection that can develop rapidly and cause significant mortality, particularly among diabetic patients suffering from ketoacidosis. Diagnosing rhinocerebral mucormycosis during the early stages of infection is challenging. CASE PRESENTATION: We describe a case of rhinocerebral mucormycosis secondary to severe acute pancreatitis in a patient suffering from diabetic ketoacidosis. In this case, the condition was not diagnosed during the optimal treatment window. we therefore provide a thorough overview of related clinical findings and histopathological characteristics, and we discuss potential differential diagnoses. CONCLUSIONS: In summary, we described a case of rhinocerebral mucormycosis secondary to severe acute pancreatitis in a patient suffering from diabetic ketoacidosis, with the optimal treatment window for this condition having been missed. This report suggests that a definitive mucormycosis diagnosis can be made based upon tissue biopsy that reveals the presence of characteristic hyphae. Early diagnosis and treatment are essential in order to improve patient prognosis.

Acute Invasive Rhino-Orbital Mucormycosis in a Patient With COVID-19-Associated Acute Respiratory Distress Syndrome.

Acute invasive fungal rhinosinusitis is a rare, although highly morbid, infection primarily affecting immunosuppressed individuals. The same population is at particularly high risk of complications and mortality in the setting of SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome. The authors present a case of acute invasive fungal rhino-orbital mucormycosis in a patient with COVID-19 and discuss the prevalence, diagnosis, and treatment of fungal coinfections in COVID-19. Prompt recognition, initiation of therapy, and consideration of the challenges of rapidly evolving COVID-19 therapy guidelines are important for improving patient survival.

Patología infecciosa del vestíbulo nasal / Infectious diseases of the nasal vestibule

El vestíbulo nasal corresponde a la primera porción de la fosa nasal, éste se encuentra delimitado lateralmente por los cartílagos alares y medialmente por el borde caudal del septum nasal y la columela. Las enfermedades infecciosas del vestíbulo nasal son patologías frecuentes en la práctica clínica; su diagnóstico se realiza en base a sospecha clínica y examen físico, requiriendo habitualmente solo manejo médico ambulatorio. Desde el punto de vista etiológico pueden ser virales, bacterianas y fúngicas. Las principales especies bacterianas involucradas corresponden a Staphylococcus coagulasa negativa, S. epidermidis, S. hominis y S. haemolyticus, difteroides spp y S. aureus. Su manejo es esencialmente médico con casos excepcionales requiriendo manejo quirúrgico. En la actualidad existe escasa información epidemiológica al respecto, lo que dificultad la clasificación de los dichos cuadros clínicos. Se realizó una revisión de la literatura sobre cuadros infecciosos que afectan el vestíbulo nasal para lograr sistematizar y clarificar las distintas patologías y sus tratamientos.

The nasal vestibule corresponds to the first portion of the nasal passage, limited laterally by the lateral crus and medially by the caudal edge of the nasal septum and columella. Infectious diseases of the nasal vestibule are frequent in clinical practice, diagnosis is made based on clinical suspicion and physical examination, usually requiring only ambulatory medical management. In terms of etiology, they can be viral, bacterial and fungal. The main bacterial species involved correspond: Coagulase-negative Staphylococcus, S. epidermidis, S. hominis and S. haemolyticus, difteroides spp and S. aureus. Management is essentially medical and only exceptionally requires surgery. Currently, there is a lack of epidemiological information in this regard, which makes it difficult to classify these clinical conditions. A review of the literature on infectious conditions that affect the nasal vestibule was performed, to systematize and clarify the different pathologies and their management.

A Rare Cause of Headache That Should Be Kept in Mind: Isolated Concha Bullosa Fungus Ball.

Concha bullosa is characterized by pneumotization of the middle turbinate and is a common variation of sinonasal anatomy and is often asymptomatic. The presence of a fungus ball in concha bullosa and the associated clinic symptoms are very rare. Concha bullosa fungus balls are a rare differential diagnosis in a patient presenting to the otorhinolaryngology outpatient clinic with headache.In this article, the authors aimed to present an isolated fungus ball case in concha bullosa as a rare cause of headache differential diagnosis.

Interferon inducible GBPs restrict Burkholderia thailandensis motility induced cell-cell fusion.

Innate immunity responds to pathogens by producing alarm signals and activating pathways that make host cells inhospitable for pathogen replication. The intracellular bacterium Burkholderia thailandensis invades the cytosol, hijacks host actin, and induces cell fusion to spread to adjacent cells, forming multinucleated giant cells (MNGCs) which promote bacterial replication. We show that type I interferon (IFN) restricts macrophage MNGC formation during B. thailandensis infection. Guanylate-binding proteins (GBPs) expressed downstream of type I IFN were required to restrict MNGC formation through inhibition of bacterial Arp2/3-dependent actin motility during infection. GTPase activity and the CAAX prenylation domain were required for GBP2 recruitment to B. thailandensis, which restricted bacterial actin polymerization required for MNGC formation. Consistent with the effects in in vitro macrophages, Gbp2-/-, Gbp5-/-, GbpChr3-KO mice were more susceptible to intranasal infection with B. thailandensis than wildtype mice. Our findings reveal that IFN and GBPs play a critical role in restricting cell-cell fusion and bacteria-induced pathology during infection.

Pediatric nasal tip abscesses.

Nasal tip abscesses in children are uncommon. We report on 7 children/teenagers who presented with an advanced nasal tip abscess that required intravenous antibiotics and surgical drainage, despite adequate pre-admission antibiotic therapy with amoxicillin/clavulanic acid or cephalosporins. Cultures were positive for Staphylococcus aureus, that was clindamycin-resistant but TMP/SMX sensitive.

Effect of nicotine on Staphylococcus aureus biofilm formation and virulence factors.

Staphylococcus aureus is a common pathogen in chronic rhinosinusitis (CRS) patients, the pathogenesis of which involves the ability to form biofilms and produce various virulence factors. Tobacco smoke, another risk factor of CRS, facilitates S. aureus biofilm formation; however, the mechanisms involved are unclear. Here, we studied the effect of nicotine on S. aureus biofilm formation and the expression of virulence-related genes. S. aureus strains isolated from CRS patients and a USA300 strain were treated with nicotine or were untreated (control). Nicotine-treated S. aureus strains showed dose-dependent increases in biofilm formation, lower virulence, enhanced initial attachment, increased extracellular DNA release, and a higher autolysis rate, involving dysregulation of the accessory gene regulator (Agr) quorum-sensing system. Consequently, the expression of autolysis-related genes lytN and atlA, and the percentage of dead cells in biofilms was increased. However, the expression of virulence-related genes, including hla, hlb, pvl, nuc, ssp, spa, sigB, coa, and crtN was downregulated and there was reduced bacterial invasion of A549 human alveolar epithelial cells. The results of this study indicate that nicotine treatment enhances S. aureus biofilm formation by promoting initial attachment and extracellular DNA release but inhibits the virulence of this bacterium.

Successful posaconazole salvage therapy for rhinocerebral mucormycosis in a child with leukemia. Review of the literature.

BACKGROUND: Mucormycosis is a fungal infection caused by species of the Mucorales order. These microorganisms are angioinvasive, with rapid disease progression and potentially lethal in its rhinocerebral form. CASE REPORT: We present the case of a 12-year-old female with trisomy 21, acute lymphoblastic leukemia and diabetes, with fever and neutropenia who developed rhinocerebral mucormicosis. After treatment with amphotericin B lipid complex and extensive surgery, disease progressed and posaconazole was added as salvage treatment with full remission of the infection. Four years after diagnosis the patient continues without relapse of mucormycosis or leukemia. CONCLUSIONS: This case highlights the use of posaconazole as either monotherapy or combined therapy. Although it is still debated, it can be considered an option for salvage treatment in children with non-responding mucormycosis, despite lack of standard dosage in pediatric patients.

Anesthetic management of rhinoorbitocerebral mucormycosis; Focus on challenges.

Mucormycosis is a progressive, opportunistic fungal infection with a high risk of mortality. Also mucormycosis may attack any organ system and may be accompanied by hemodynamic instability and difficult airway management. This study aimed to evaluate the anesthetic management of patients undergoing surgical resection for rhino-orbito-cerebral mucormycosis (ROC). The study evaluated 12 patients that underwent surgical resection for ROC mucormycosis under general anesthesia. Demographic characteristics, hemodynamic parameters, invasive monitoring methods, surgical procedures, hospital records, and mortality rates were reviewed for each patient. The patients had a median age of 58 (range, 5-86) years. Two patients had an American Society of Anesthesiologists (ASA) score of II while the remaining 10 patients had a score of III. Eleven (91.7%) patients had a diagnosis of rhino-orbital mucormycosis and 1 (8.3%) patient was diagnosed with ROC mucormycosis. Most common comorbidity was DM (n=8), followed by hematological malignancy (n=4), solid organ malignancy (n=3), and kidney transplantation (n=2). Invasive arterial monitoring was performed in 7 and central venous cannulation was performed in 5 patients. Six patients were transferred to the intensive care unit (ICU) and the mortality rate was 25% with an average mortality time was 7 days in 3 cases. In cases of ROC mucormycosis, necessary precautions should be taken for the difficult airway caused by fungal debris in the oropharyngeal region and supraglottic edema. Postoperative ICU is important due to comorbidities and fungal infection with high mortality.

[Nasal discharge in dogs - are microbiological and histopathological examinations clinically useful?] / Nasenausfluss beim Hund ­ Wie sinnvoll sind bakteriologische und histopathologische Untersuchungen?

OBJECTIVE: Retrospective evaluation of the diagnostic value of bacterial culture of nasal mucosal swabs and histopathologic assessment of nasal mucosal biopsies in dogs with nasal discharge. MATERIAL AND METHODS: Medical records of dogs with the predominant clinical sign of nasal discharge that were referred to the ENT Unit of the Small Animal Department between January 2015 and December 2016 were reviewed. RESULTS: Data of 85 dogs were evaluated. On the basis of the results of computed tomography (CT), rhinoscopy, bacterial culture of a nasal mucosal swab and histopathologic examination of nasal mucosal biopsies, dogs were assigned to one of six groups of primary nasal diseases: nasal neoplasia (24/85, 28 %), oronasal defect (22/85, 26 %), idiopathic chronic rhinitis (17/85, 20 %), foreign body (8/85, 10 %), sinonasal aspergillosis (7/85, 8 %) and diseases of the planum nasale (7/85, 8 %). In brachycephalic dogs (14/85, 17 %), oronasal defects (8/14, 57 %) were the most frequent cause of nasal discharge. No cases of a primary bacterial infection of the nasal cavity were observed and, therefore, antibiotic treatment had not been successful. Nevertheless, 72 % of the dogs in this study had received prior antibiotic treatment. Secondary bacterial infec tions diagnosed via nasal mucosal swabs were not diagnostic for the underlying primary nasal diseases. Targeted biopsies of tumors obtained under endoscopic visualization may lead to a definitive diagnosis, whereas biopsies of the nasal mucosa and the type of the inflammatory infiltrate were not diagnostic. CONCLUSIONS: Nasal discharge in dogs is frequently an indicator of an underlying severe primary nasal disease possibly leading to mortality of the affected dogs. Further diagnostics under anesthesia should be performed early in the diagnostic evaluation. Rhinoscopy as the central diagnostic is supported by CT and biopsy. Bacterial culture of the nasal discharge does not provide a diagnosis for the primary nasal disease process. CLINICAL RELEVANCE: Without further diagnostics, antibiotic treatment of dogs presenting with nasal discharge is considered as not appropriate and can be harmful in dogs with nasal tumors or sinonasal aspergillosis. When an intranasal malignant neoplasia is suspected, endoscopic-guided biopsies of the nasal mass should be obtained, because blind nasal biopsies are associated with a high rate of false-negative results.

Orbitocerebral Mucormycosis in a Patient With Central Nervous System Lymphoma.

A 61-year-old man with well-controlled diabetes mellitus type 2, cirrhosis from hepatitis C, alcohol abuse, and portal hypertension presented with painful vision loss and left orbital swelling. Imaging showed diffuse orbital, perineural, and pachymeningeal inflammation. He was initially diagnosed with neurosarcoidosis. However, cerebrospinal fluid analysis revealed central nervous system lymphoma, and lacrimal gland biopsy showed fungal organisms consistent with mucormycosis. The authors describe a case of Mucorales infection lacking sinonasal involvement and discuss the differential diagnosis and management of patients presenting with orbital and central nervous system inflammation from this uncommon fungal infection.

Resolution of chronic nasal Staphylococcus aureus infection in a non-smoker who started to use glycerine based e-cigarettes: Antibacterial effects of vaping?

BACKGROUND: Smokers who switch to vaping report a decrease in respiratory infections. A previous case report of a non-smoker who started to vape and experienced a resolution of chronic tonsillitis proposed that this could be due to bactericidal effects of propylene glycol. Here were report a similar case where a resolution of chronic nasal infection was associated with using glycerol-based nicotine vaporiser. CASE PRESENTATION: A never-smoker adopted an e-cigarette that his wife was using and after a few weeks of vaping liquids containing vegetable glycerine with low levels of nicotine (3 mg/ml) experienced a complete resolution of chronic nasal Staphylococcus aureus infections. CONCLUSIONS: The improvements cannot be attributed to smoking cessation or bactericidal effects of propylene glycol. The effect could be a coincidence, but it could also be related to bacteriostatic properties of glycerol, or to antimicrobial properties of nicotine and/or the zinc (II) complex of nicotine. Assessments of effects of e-cigarettes with different humectants and nicotine levels in patients with recurrent bacterial respiratory infections could clarify this issue and possibly generate new treatments.

A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years?

BACKGROUND: Rhino-orbital-cerebral mucormycosis (ROCM) is an uncommon yet potentially lethal fungal infection. Although most cases originate from developing countries, an ageing population and increased prevalence of chronic illness may mean some clinicians practicing in developed countries will encounter ROCM cases in their careers. Yohai et al published a systematic review of 145 case reports from 1970 to 1993 assessing prognostic factors for patients presenting with ROCM. We present an updated review of the literature and assess whether survival outcomes have changed in the two decades since that seminal paper. SEARCH STRATEGY: An extensive Medline literature search was performed for case reports published between 1994 and 2015. RESULTS: In total, 210 published cases were identified from the literature review, of which 175 patients from 140 papers were included in this review. Fifty-five were female, with an overall mean age of 43 years. Overall survival rate was 59.5%, which was not significantly better than the previous series reported (60%) reported by Yohai et al. Survival rates in patients with chronic renal disease had improved, from 19% to 52%, and in patients with leukaemia (from 13% to 50%). Facial necrosis and hemiplegia remained poor prognostic indicators (33% and 39% survival rates, respectively). Early commencement of medical treatment related to better survival outcomes (61% if commenced within first 12 days of presentation, compared to 33% if after 13 days). Timing of surgery had less of an effect on overall survival. However, in 28 cases that did not receive any surgical treatment, survival was only 21%. CONCLUSIONS: Although overall survival rates have not improved, survival in patients with renal disease were better, potentially due to the introduction of liposomal amphotericin B which is less nephrotoxic. Prompt recognition of ROCM, reversal of predisposing co-morbidities and aggressive medical treatment remain the cornerstone of managing this highly aggressive disease.

Nasal Cavity Actinomycosis Mimicking Rhinolith.

Actinomycosis is a subacute-to-chronic bacterial infection caused by filamentous, gram-positive, non-acid-fast, anaerobic-to-microaerophilic bacteria. It is characterized by continuous spread, suppurative and granulomatous inflammation, and formation of multiple abscesses and sinus tracts that may discharge sulfur granules. Although the most common clinical forms of actinomycosis are cervicofacial, involvement of the nose and paranasal sinuses are extremely rare. Furthermore, nasal cavity actinomycosis mimicking rhinolith has not been reported in the literature previously. This article reports a patient of nasal cavity actinomycosis causing symptoms similar to those of a rhinolith, which was successfully treated by surgical debridement and antibiotic therapy.

[Nasal phaeohyphomycosis by Curvularia spicifera in pediatric patient with neutropenia and acute myeloid leukemia]. / Feohifomicosis nasal por Curvularia spicifera en un paciente pediátrico con neutropenia y leucemia mieloide aguda.

There are very few reports of pediatric patients with infections by dematiaceous filamentous fungi. In this publication we report a case of invasive fungal infection of the nasal septum by Curvularia spicifera in a pediatric patient with acute myeloid leukemia. The patient presented with a painful scabby wound in the nasal vestibule. Culture and universal PCR were consistent with Curvularia spicifera. Early management with surgical debridement and bi-associated antifungal therapy achieved complete resolution of the lesions, with no evidence of dissemination and relapses. Clinical management of these fungal infections represents a challenge as the antifungal selection and duration of therapy is not yet well stablished.

Rhino-orbito-cerebral mucormycosis: recovery against the odds.

A 22-year-old woman presented with diabetic ketoacidosis, acute right eye blindness and complete ophthalmoplegia. Despite early suspicion and treatment for rhino-orbito-cerebral mucormycosis, her extensive spread of infection led to right internal carotid artery occlusion and cavernous sinus thrombosis, right-sided cerebral watershed infarctions and large abscesses in her right cerebellum, temporal lobe and pons. She underwent surgical removal of her right eye, paranasal sinuses, maxilla and palate, suboccipital craniectomy and shunting for hydrocephalus. Despite the grave prognosis, she has gradually improved and has remained on antifungal treatment for the 18 months since presentation. We discuss the factors that may have influenced her recovery. The case highlights the aggressive nature of rhino-orbito-cerebral mucormycosis, the need for multiple surgeries and the ethical issues in managing such patients.