Zoonotic necrotizing myositis caused by Streptococcus equi subsp. zooepidemicus in a farmer.

BACKGROUND: Streptococcus equi subsp. zooepidemicus is a beta-hemolytic group C streptococcus mainly causing infections in domesticated animals. Here we describe the first case of zoonotic necrotizing myositis caused by this bacterium. CASE PRESENTATION: The patient was a 73-year-old, previously healthy farmer with two asymptomatic Shetland ponies in his stable. After close contact with the ponies while feeding them, he rapidly developed erythema of his left thigh and sepsis with multiple organ failure. The clinical course was severe and complicated, requiring repetitive surgical excision of necrotic muscle, treatment with vasopressors, mechanical ventilation and continuous venovenous hemofiltration, along with adjunctive hyperbaric oxygen therapy. The patient was discharged from hospital at day 30, without obvious sequelae. The streptococcal isolate was identified as Streptococcus equi by MALDI-ToF MS, and was later assigned subspecies identification as S. equi subsp. zooepidemicus. Multilocus sequence typing identified the strain as a novel sequence type (ST 364), closely related to types previously identified in horses and cattle. A focused proteomic analysis revealed that the ST 364 expressed putative virulence factors similar to that of Streptococcus pyogenes, including homologues of the M protein, streptodornases, interleukin 8-protease and proteins involved in the biosynthesis of streptolysin S. CONCLUSION: This case illustrates the zoonotic potential of S. equi subsp. zooepidemicus and the importance of early clinical recognition, rapid and radical surgical therapy, appropriate antibiotics and adequate supportive measures when necrotizing soft tissue infection is suspected. The expression of Streptococcus pyogenes-like putative virulence determinants in ST 364 might partially explain the fulminant clinical picture.

ANGIOGENESIS INHIBITOR ENDOSTATIN PROTECTS MICE WITH SEPSIS FROM MULTIPLE ORGAN DYSFUNCTION SYNDROME.

Endostatin is an endogenous inhibitor of vascular endothelium. It can inhibit endothelial cell migration, proliferation, and vascular angiogenesis and is mainly used for anticancer therapy. We have previously found that endostatin is an important node protein in the pathogenesis of sepsis. However, its impacts on sepsis have not yet been reported. We established a septic mouse model using cecal ligation and puncture (CLP) and gave the mice either endostatin or placebo (saline). The effects of endostatin on serum enzyme, Evans blue leakage, lung wet-to-dry weight ratio, and cytokine (tumor necrosis factor α, interleukin 1ß [IL-1ß], and IL-6) production were assessed. Survival rates were observed for up to 3 days. In addition, we examined the effects of endostatin on serum vascular endothelial growth factor A (VEGF-A), VEGF-C, and pathological changes and scores of lung tissues as well as the phosphorylation of JNK, p38, and ERKl/2 proteins in lung tissues of mice with sepsis. We found that endostatin can increase the survival of septic mice in a time- and dose-dependent manner probably by reducing multiorgan dysfunctions shown by serum indicators, morphologic changes, Evans blue leakage, wet-to-dry weight ratio, and inflammation of lung tissues. In addition, endostatin could reduce serum tumor necrosis factor α, IL-1ß, IL-6, and VEGF-C levels in septic mice as well as inhibit phosphorylation of p38 and ERK1/2 in lung tissues of septic mice. This is the first study demonstrating the protective effect of endostatin on sepsis and its possible underlying mechanisms from the aspects of inhibiting inflammatory responses, blocking VEGF receptor, attenuating VEGF-C expression, and reducing vascular permeability. Overall, the study revealed the potential protect role for endostatin in the treatment of sepsis.

Effect of intestinal function-recovering decoction on treatment of multiple organ dysfunction syndrome in rats.

OBJECTIVE: To analyze the effect of intestinal function-recovering decoction on multiple organ dysfunction syndrome in rats, and to investigate a novel solution to multiple organ dysfunction syndrome. METHODS: Multiple organ dysfunction syndrome was induced in 60 Sprague-Dawley rats by intestinal ischemia-reperfusion combined with cecal ligation and puncture. Then these rats were intragastrically administered physiological saline (group I, n=20), ampicillin (group II, n=20) or intestinal function-recovering decoction (group III, n=20). After treatment, serum malondialdehyde and superoxide dismutase levels were compared among three groups. Simultaneously, bacterial culture of various organ tissues was performed and bacterial and endotoxin translocation were observed. RESULTS: Compared with group I, serum malondialdehyde, alanine aminotransferase and aspartate aminotransferase levels were significantly decreased (all P<0.05) and serum superoxide dismutase level was significantly increased (P<0.05) in the group III. However, there were no significant differences in these indices between groups II and III (P>0.05). The rate of bacterial translocation in the groups II and III was significantly lower than in the group I (P<0.05), and no significant difference was observed between groups II and III (P>0.05). CONCLUSIONS: Intestinal function-recovering decoction can significantly reduce endotoxin and bacterial translocation and stabilize enteral oxidative-antioxidative balance.

Protective effect of Aloe vera on polymicrobial sepsis in mice.

Sepsis is an acute life-threatening clinical condition and remains the major cause of death in intensive care units. The primary pathophysiologic event central to the septic response is an overwhelming activation of the inflammatory system and countervailing response from the anti-inflammatory system. However, the cause of this perturbation has yet to be elucidated. In this study, we report that Aloe vera therapeutically reverses the lethality induced by cecal ligation and puncture (CLP), a clinically relevant model of sepsis. The administration of Aloe vera ameliorated the multiple organ dysfunction syndrome, as evidenced by the serum levels of biochemical parameters and histological changes. In order to investigate the pharmacological mechanism of Aloe vera, the levels of the cytokines, tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, and IL-6 were determined by ELISA at various time points. The increases in the levels of TNF-alpha, IL-1beta, and IL-6 were attenuated by Aloe vera.In vivo administration of Aloe vera also markedly enhanced bacterial clearance. Our findings suggest that Aloe vera could be a potential therapeutic agent for the clinical treatment of sepsis.

[Current situation of the study on treatment of bacteria translocation with integrated traditional Chinese and Western medicine].

Bacteria translocation (BT) induced enterogenous infection in multiple organs dysfunction syndrome (MODS) is closely related with the stress pyemia and MODS. For prevention of BT, western medicine stresses to improve the blood and oxygen supply of intestinal tract, mucosa protection, and application of microorganism preparation, while traditional Chinese medicine could also win good effect by using such drugs as rhubarb, red sage root, and compound decoctions.

Drug susceptibility of isolates from severe postoperative intraperitoneal infections causing multiple organ failure.

PURPOSE: To select the most appropriate antibiotic regimens for life-threatening postoperative infections, we obtained isolates from patients with severe postoperative infections over a 12-year-period, and examined their drug susceptibility. METHODS: The subjects of this study were 55 patients with multiple organ failure (MOF) caused by postoperative infection. RESULTS: All strains of Methicillin-resistant Staphylococcus aureus (MRSA) were susceptible to Vancomycin (VCM) and Teicoplanin (TEIC). Only 0.3% of all the Pseudomonas aeruginosa strains were resistant to Imipenem (IPM), but 53.6% of the strains from the severe infections were resistant to IPM. On the other hand, there were few P. aeruginosa strains resistant to Meropenem (MEPM), Ceftazidime (CAZ), Ciprofloxacin (CPFX), and Pazufloxacin (PZFX), even among strains isolated from severe infections. The resistant rate of Bacteroides fragilis to Clindamycin (CLDM) was 35.9%, but there were strains resistant to IPM and Panipenem. CONCLUSION: These findings suggest that VCM or TEIC are most appropriate for severe abdominal abscess caused by MRSA, whereas MEPM, CAZ, CPFX, and PZFX are more effective against P. aeruginosa infections. The only antibiotic effective against B. fragilis infections in this study was IPM.

[Optimization of empirical antibacterial therapy of diffuse purulent peritonitis during the stage of multiple organ failure]. / Optimizatsiia émpiricheskoi antibakterial'noi terapii rasprostranennogo gnoinogo peritonita v stadii poliorgannoi nedostatochnosti.

The experience of optimization of empirical antibacterial therapy of diffuse purulent peritonitis at toxic and terminal stages is presented. The treatment results were compared in main (209) and control (130) patient groups taking into account the clinical and bacteriological efficiency. The technology of combined antibacterial multi-component retroperitoneal lymphotropic therapy was used that included the following drugs: novocain, haemodesum, trisaminum, hydrocortison hemisuccinas, heparin, tripsinum and antibacterial group (kanamicini, levomycetinum, natrii hemisuccinas, dioxydinum, metronidazole) for abdominal and retroperitoneal treatment. 96.7% from the main group and 74.6% from the control group recovered, lethal outcomes and complications decreased in 2.78 and 4 times respectively.

[Coagulation inhibitors in severe sepsis: state of the art]. / Inhibiteurs de la coagulation et états septiques graves.

OBJECTIVE: To present and discuss the rationale and the results of clinical trials using supplementation with physiologic anticoagulants (Tissue Factor Pathway Inhibitor (TFPI), AntiThrombin (AT), and Protein C (PC) in patients with severe sepsis. RATIONALE: An early activation of the coagulation cascade occurs in severe sepsis. TFPI, AT, and PC are major inhibitors of the coagulation cascade, and additionally modulate inflammatory and vascular reactions. They are consumed or inhibited in the sepsis pathologic process. Therapeutic supplementation with these inhibitors could improve the sepsis-induced organ failures and mortality. CLINICAL RESULTS: Randomized controlled studies were recently completed. No effect on the mortality rate could be documented after treatment with recombinant TFPI. AT concentrates neither improve mortality, but a biological interaction with heparin therapy could have biased the study results. Treatment with recombinant activated PC (alpha-drotrecogin) was associated with a significant reduction in the mortality rate of severely ill patients and received recently the approval from FDA and EC authorities in this indication. An increase in the rate of hemorrhagic adverse effects has been observed with these compounds, justifying a strict observance of contraindications and of patients selection. PROSPECTIVE: Additional studies are needed to give confirmation of the positive effects of activated PC supplementation in less severely ill patients, children and specific clinical situations. The effects of new anticoagulant compounds are currently evaluated in preclinical studies.

The microbiology of necrotizing soft tissue infections.

OBJECTIVE: A large number of necrotizing soft tissue infections (NSTI) treated at a single institution over an 8-year period were analyzed with respect to microbial pathogens recovered, treatment administered, and outcome. Based on this analysis, optimal empiric antibiotic coverage is proposed. METHODS: A retrospective chart review of all patients with documented NSTI was conducted. Microbiologic variables were tested for impact on outcome using Fisher's exact test and multivariate analysis by logistic regression. RESULTS: Review of the charts of 198 patients with documented NSTI revealed 182 patients with sufficient microbiologic information for analysis. These 182 patients grew an average of 4.4 microbes from original wound cultures, although a single pathogen was responsible in 28 patients. Eighty-five patients had combined aerobic and anaerobic growth, the most common organisms being, in order, Bacteroides species, aerobic streptococci, staphylococci, enterococci, Escherichia coli, and other gram-negative rods. Clostridial growth was common but did not affect mortality unless associated with pure clostridial myonecrosis. Mortality was affected by the presence of bacteremia, delayed or inadequate surgery, and degree of organ system dysfunction on admission. CONCLUSIONS: NSTI are frequently polymicrobial and initial antibiotic coverage with a broad-spectrum regimen is warranted. The initial regimen should include agents effective against aerobic gram-positive cocci, gram-negative rods, and a variety of anaerobes. The most common organisms not covered by initial therapy were enterococci. All wounds should be cultured at initial debridement, as changes in antibiotic coverage are frequent once isolates are recovered.