Dual infection with polyomavirus BK and acyclovir-resistant herpes simplex virus successfully treated with cidofovir in a bone marrow transplant recipient.

A hematopoietic stem cell transplant recipient developed a mucosal herpes simplex virus-1 (HSV-1) infection while under acyclovir (ACV) treatment (HSV was later shown to be resistant to ACV). Concomitantly, the patient presented a hemorrhagic cystitis (HC) due to polyomavirus BK, for which intravenous cidofovir (CDV) was prescribed. The patient benefited from the broad-spectrum anti-DNA virus activity of CDV, and not only the HC resolved without signs of nephrotoxicity but also the HSV-1 lesions disappeared. This is the first report describing the effect of CDV on 2 simultaneous and unrelated DNA viral infections in an immunosuppressed transplant recipient. In addition, we describe here that this HSV-1 isolate possesses a unique phenotype and genotype.

Surveillance of antibiotic resistance in non invasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winters 2003 and 2004.

A total of 391 and 424 non-invasive isolates of Streptococcus pneumoniae collected by 15 laboratories during the 2003 and 2004 survey were tested for their susceptibility by a microdilution technique following NCCLS recommendations. Insusceptibility rates (IR) in the two surveys (2003/2004) were as follows: penicillin 15.0/14.7% [8.4/6.4% Resistance (R)], ampicillin 17.4/14.6% (R 9.0/7.1%), amoxicillin +/- clavulanic acid 2.6/1.2 % (R 0/0%), cefaclor 14.3/14.1% (R 11.5/13.4%), cefuroxime 13.6/12.7% (R 10.5/11.8%), cefuroxime-axetil 10.5/11.8% (R 10.0/9.2%) (breakpoints based on 250 mg), cefotaxime 4.9/6.2% (R 1.3/2.4%), ceftazidime NotTested (NT)/6.4 (R NT/2.6%), cefepime NT/6.4 (R NT/2.6%), imipenem 7.7/8.9 % (R 1.8/1.4%), ertapenem 0.8/NT% (R O/NT%), ciprofloxacin 13.8/9.0% (R 4.3/2.4%), levofloxacin 3.3/2.8% (R 1.5/0.2%), moxifloxacin 0.6/0.2% (R 0.3/0%), ofloxacin 13.5/9.0% (R 4.3/2.4%), erythromycin 26.1/24.7% (R 25.3/24.5%), azithromycin 25.4/24.7% (R 24.6/24.5%), telithromycin 0.8/0.2% (R 0.5/0%), clindamycin 21.2/18.4% (R 19.2/17.7%) and tetracycline 32.3/22.1% (R 29.2/19.3%). There were only minor differences in resistance rates according to age, sample site, admission type (i.e. ambulatory, hospitalized or long-term care facility patients), gender and geographic origin. Overall, telithromycin (MIC50, MIC90 in 2003/2004: 0.015 microg/ml, 0.12 microg/ml/ 0.008,0.06 respectively), ertapenem (0.03; 0.25/NT), moxifloxacin (0.06; 0.25/0.06, 0.12), and amoxicillin +/- clavulanic acid (0.03; 0.25/0.015, 0.5) were the most active compounds in both surveys. In 2003, the most common resistance phenotype was isolated insusceptibility to tetracycline (10.5%) followed by combined insusceptibility to erythromycin and tetracycline (9.3%). Erythromycin-tetracycline resistance (10.4%) was the most common in 2004. Isolates showing resistance to an antibiotic were significantly more present in 2003 than in 2004 (50.4% versus 40.8%). In penicillin-insusceptible isolates, MICs of all beta-lactams were increased but cross-resistance between penicillin and other beta-lactams in the penicillin-insusceptible isolates was not complete. In the 2003 survey, most of these isolates remained fully susceptible to ertapenem (94.9%) and amoxicillin +/- clavulanic acid (83.1%). In the 2004 survey, 91.9% of the penicillin insusceptible isolates remained susceptible to amoxicillin +/- clavulanic acid. In both surveys, the most common serotypes in penicillin insusceptible isolates were 14, 23,19 and 9 (20.0%, 20.0%, 16.4% and 10.9% respectively in 2003; 41.6%, 11.7%, 15.0% and 18.3% respectively in 2004).

Evaluation of a disk diffusion method with cefoxitin (30 microg) for detection of methicillin-resistant Staphylococcus aureus.

The emergence of heterogeneous populations of methicillin-resistant Staphylococcus aureus (MRSA) causes major problems in routine screening for MRSA. In heterogeneous MRSA populations, a proportion of bacterial cells show low-level resistance to oxacillin, with minimal inhibitory concentrations (MICs) of oxacillin ranging between 1 and 100 mg/l, while in homogeneous MRSA populations, the MIC of oxacillin for all cells is >100 mg/l. Routine oxacillin disk diffusion tests often fail to detect heterogeneous MRSA populations. In the present study, a recently proposed disk diffusion method that employs a cephamycin antibiotic (cefoxitin 30 microg; BD Sensi-disc, Becton Dickinson, Germany) was evaluated using 155 clinical isolates of S. aureus (73 mecA positive and 82 mecA negative). The results were compared with those of other MRSA screening techniques: a disk diffusion test with oxacillin 1 microg and cefoxitin 30 microg (BD Sensi-disc; Becton Dickinson), an MRSA latex agglutination test (Denka Seiken, Japan), and an oxacillin screen agar test (6 microg/ml; Becton Dickinson). Detection of the mecA gene by polymerase chain reaction was considered the gold standard. The performances of the different methods were determined and compared. The results showed that the cefoxitin disk diffusion test is preferable to the oxacillin disk diffusion method for routine screening to detect MRSA.

Surveillance of antibiotic resistance in clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2000-2001.

A total of 314 isolates of Streptococcus pneumoniae collected by 10 different laboratories were tested for their susceptibility by using a microdilution technique following NCCLS recommendations. The following antibiotics were included: penicillin, ampicillin, amoxicillin, amoxicillin/clavulanate, cefaclor, cefuroxime, cefotaxime, imipenem, ciprofloxacin, gemifloxacin, levofloxacin, erythromycin, clarithromycin, azithromycin, miocamycin, clindamycin and tetracycline. The insusceptibility rate (IR) to penicillin was 21.0% [10.8% intermediate (> or = 0.12-1 microgram/mL) and 10.2% high-level (> or = 2 micrograms/mL)], to cefotaxime 7.3% [3.5% intermediate (> or = 1 microgram/mL) and 3.8% high-level (> or = 2 micrograms/mL)], to imipenem 3.8% [3.8% intermediate (> or = 0.25-0.5 microgram/mL) and 0% high-level (> or = 1 microgram/mL)], to ciprofloxacin 11.2% [8.3% intermediate (2 micrograms/mL) and 3.9% high-level (> or = 4 micrograms/mL)], to erythromycin 30.3% [3.5% intermediate (0.5 microgram/mL) and 26.8% high-level (> or = 1 microgram/mL)] and to tetracycline 38.5% [0.9% intermediate (4 micrograms/mL) and 37.6% high-level (> or = 8 micrograms/mL)]. No decreased susceptibility was found for gemifloxacin (> or = 0.5 microgram/mL). This compound was the most active with MIC50, MIC90 and an IR of 0.015 microgram/mL, 0.03 microgram/mL and 0% respectively, followed by amoxicillin/clavulanate, amoxicillin and imipenem (MIC50, MIC90 and IR: 0.015 microgram/mL, 1 microgram/mL, 1.6%/0.015 microgram/mL, 1 microgram/mL, 1.9%/0.008 microgram/mL, 0.12 microgram/mL, 3.8% respectively). Compared to the 1999 surveillance, penicillin and tetracycline-insusceptibility increased with 4.9% and 15.6% respectively, while cefotaxime, erythromycin and ciprofloxacin insusceptibility decreased with 5.4%, 5.8% and 4.4% respectively. MICs of all beta-lactams rose with those of penicillin for penicillin-insusceptible isolates. Imipenem, cefotaxime, amoxicillin and amoxicillin/clavulanate were generally 4, 2, 1 and 1 doubling dilutions respectively more potent than penicillin on these isolates while ampicillin, cefuroxime and cefactor were generally 1, 2 and 4 dilutions respectively [table: see text] less potent. Most penicillin-insusceptible isolates remained fully susceptible to amoxicillin/clavulanate (92.4%), amoxicillin (90.9%) and imipenem (81.8%). Erythromycin-tetracycline insusceptibility was the most common resistance phenotype (14.3%). Three- and four-fold resistance was found in 12.4% and 1.6% respectively of the isolates. Most penicillin-insusceptible isolates were of capsular types 14 (22.7%), 23 (21.2%), 6 (18.2%), 9 (13.6%) and 19 (12.1%).

Tuberculosis of the skull: a case report.

Tuberculosis of the skull is rare. We describe a case of skull tuberculosis in a Somali fugitive. The patient presented with a history of a painful mass at the vertex of the skull. The diagnosis, suspected on histological grounds was established by culture of the operative biopsy. Surgery was performed and antituberculous treatment was started.

Differentiation and identification of Enterococcus durans, E. hirae and E. villorum.

AIMS: To compare different tests in the identification of Enterococcus durans, E. hirae and E. villorum strains. These bacteria belong to the E. faecium species group and are phylogenetically closely related, as evidenced by 16S rRNA sequence homologies of over 98.8%. METHODS AND RESULTS: Sodium dodecyl sulphate-polyacrylamide gel electrophoresis analysis of whole-cell protein, tRNA interpacer polymerase chain reaction (PCR) and arbitrarily-primed (D11344-primed AP) -PCR analysis correctly identified all three species in a collection of strains from very diverse origins. In contrast, biochemical reactions only allowed the unequivocal differentiation of the three species as a group from the other enterococci. Within this group, D-xylose acidification can be used to differentiate E. villorum, but exceptions occur. Strains highly susceptible to clindamycin can be identified as E. durans, but many strains of this species cannot be differentiated from E. hirae and E. villorum due to acquired resistance. CONCLUSIONS: Despite their close relationship, E. durans, E. hirae and E. villorum can be differentiated by genomic methods and by whole-cell protein analysis. SIGNIFICANCE AND IMPACT OF THE STUDY: Only a minority of strains of these three enterococcal species can be identified reliably by the currently available and commonly applied phenotypic tests.

Primary meningococcal arthritis of the hip in an immunocompetent adolescent.

The clinical spectrum of meningococcal infection ranges from asymptomatic carriage to fulminant sepsis, with meningitis and septicemia being well-recognized clinical presentations. Meningococcal arthritis as a complication of Neisseria meningitidis infection occurs in about 2-10% of cases, whereas primary meningococcal arthritis (PMA) is a relatively rare phenomenon, even in children. We report here a case of meningococcal infection in an immunocompetent adolescent suffering from acute pain of the right hip as the only symptom upon presentation at the hospital. In such a situation, meningococci are not usually considered as a possible causative agent.

Recurrent bacteremia by Chryseobacterium indologenes in an oncology patient with a totally implanted intravascular device.

Chryseobacterium indologenes was isolated from the blood cultures of an oncological patient with a totally implantable device. Because a catheter-related infection was suspected, the Port-A-Cath was removed after a 10-day course of piperacillin-tazobactam. Differences in susceptibility may exist if either the criteria for either Pseudomonas or Enterobacteriaceae are used.

Pasteurella dagmatis septicaemia in an immunocompromised patient without a history of dog or cat bites.

We report a rare case of Pasteurella dagmatis septicaemia in a 66-year-old immunocompromised patient, without a history of cat bites, dog bites or scratches.

In vitro study on the antimicrobial activity of various antibiotics against clinical isolates of Streptococcus pneumoniae from Belgium collected during winter 1998-1999.

A total of 205 isolates of Streptococcus pneumoniae obtained from 10 different centres were included in this study. The susceptibilities to penicillin, ampicillin, amoxicillin, amoxicillin/clavulanic acid, cefaclor, cefuroxime, cefotaxime, imipenem, ciprofloxacin, gemifloxacin, grepafloxacin, levofloxacin, trovafloxacin, erythromycin, clarithromycin, miocamycin, clindamycin and tetracycline were determined by a microdilution technique following NCCLS recommendations. Decreased susceptibility to penicillin was 16.1% [6.8% intermediate (0.12-1 microgram/mL) and 9.3% high-level (> or = 2 micrograms/mL)], cefotaxime insusceptibility (> or = 1 microgram/mL) 12.7%, ciprofloxacine insusceptibility (> or = 2 micrograms/mL) 15.6% with 1.5% of high level resistance (> or = 4 micrograms/mL), erythromycin insusceptibility (> or = 0.5 microgram/mL) 36.1% and tetracycline insusceptibility (> or = 4 micrograms/mL) 22.9%. Decreased susceptibility to cefotaxime was found in 78.8% of the penicillin-insusceptible isolates. No decreased susceptibility was found for gemifloxacin (> or = 0.5 microgram/mL) and trovafloxacin (> or = 1 microgram/mL). Compared to the 1996-1997 surveillance, penicillin, cefotaxime and erythromycin insusceptibility rose by 3.8%, 5.2% and 5.0% respectively, while tetracycline insusceptibility decreased with 8.2%. MICs of all beta-lactams rose with those of penicillin for penicillin-insusceptible isolates. Amoxicillin +/- clavulanate, cefotaxime and imipenem were generally 1, 1 and 5 doubling dilutions respectively more potent than penicillin on these isolates. Penicillin, ampicillin and cefuroxime were equally active while cefaclor was generally 5 dilutions less potent. Most penicillin-insusceptible isolates remained fully susceptible to amoxicillin +/- clavulanate and imipenem. The penicillin-insusceptible isolates were 36.4%, 27.3% and 3.0% co-insusceptible to erythromycin, erythromycin plus tetracycline and tetracycline respectively. A subpopulation of 52 isolates obtained from children aged < or = 3 years was also studied. Compared to the other isolates we found a statistically significant increase in insusceptibility for penicillin, cefaclor, cefuroxime, erythromycin, clarithromycin and tetracycline while a significant decrease was found for ciprofloxacin.

Porphyria cutanea tarda associated with human immunodeficiency virus infection.

Since 1987, about 60 cases of porphyria cutanea tarda (PCT) associated with human immunodeficiency virus (HIV) have been reported. The respective roles of HIV and toxic hepatic factor in PCT remain unclear. We report 10 new cases and analyse the following toxic hepatic factors: hepatitis C and B, alcoholism, drugs. The route of HIV transmission to these 10 men were: IV drugs abuse (3), homo/bisexuality (4), heterosexuality (1), and unknown (2). When PCT was diagnosed, their average age was 38 years (29-54) and the HIV-infection had been established for 4.8 years (0.33-9). Seven men had HIV-related symptoms and a CD4+ lymphocyte count below 200/mm3. Cutaneous signs and urinary porphyrin count were characteristic. Alcohol abuse was present in 8/10 patients. AST, ALT and/or gamma GT were high in 9/10 patients; 5/10 patients had HCV antibodies (4 were HCV-PCR positive). HBs antigenemia was negative among the 5/8 patients with HBV antibodies; 10/10 patients took prescribed hepatotoxic drugs. Our series confirms the presence of toxic hepatic factors in PCT of HIV-positive patients. Hepatitis C, alcoholism and hepatotoxic drug consumption seem to be triggers for the appearance of PCT in HIV-positive patients.

Surveillance of pneumococcal resistance in Belgium during winter 1996-1997.

This study tested 212 pneumococcal isolates from 9 institutions for their susceptibilities to penicillin, ampicillin, amoxycillin, amoxycillin/clavulanate, cefaclor, cefuroxime, cefotaxime, imipenem, tetracycline, erythromycin, and clarithromycin using NCCLS-standardized microdilution. Penicillin-insusceptibility was 12.3% [5.7% intermediate (0.12-1 microgram/ml) and 6.6% high-level (> or = 2 micrograms/ml)], tetracycline-insusceptibility (> or = 4 micrograms/ml) 31.1%, and erythromycin-insusceptibility (> or = 0.5 microgram/ml) 31.1% as well. Erythromycin-insusceptible isolates showed cross-insusceptibility to clarithromycin. Penicillin-susceptible isolates were susceptible to all beta-lactams. MICs of all beta-lactams rose with those of penicillin for penicillin-insusceptible isolates. Ampicillin and penicillin were equally potent against penicillin-insusceptible isolates, imipenem, cefotaxime, and amoxycillin +/- clavulanate were more potent (generally 5, 1, and 1 doubling dilution, respectively), and cefuroxime and cefaclor less potent (generally 1 and 6 doubling dilutions, respectively). Most penicillin-insusceptible isolates were high-level resistant to cefaclor (> or = 32 micrograms/ml). Although MICs of all beta-lactams rose with those of penicillin, resistance to penicillin was not absolute in terms of cross-resistance. Most penicillin-intermediate and high-level penicillin-resistant isolates remained fully susceptible and intermediate, respectively, to amoxycillin +/- clavulanate, cefotaxime, and imipenem, but not to cefuroxime. Penicillin-susceptible isolates were 76.9%, 42.3%, and 34.6% co-insusceptible to tetracycline, erythromycin, and tetracycline plus erythromycin, respectively. Most penicillin-, tetracycline-, and erythromycin-insusceptible isolates were of capsular types 23 >> 6 > 19 > 32, 19 > 6 > 28 > 23, and 19 > 6 > 14 > 23, respectively. Compared to winter 1994-1995, insusceptibility to penicillin, tetracycline, and erythromycin rose by some 4%, 4%, and 13%, respectively.

Epidemiology as a tool for hospital infection control.

Epidemiology today studies the occurrence of health and disease and evaluates the global quality of health care, whereas it previously mainly consisted in the investigation of infectious outbreaks. This paper describes basic principles of descriptive and analytical hospital epidemiology, and focuses on the standardized and professional methodology used to manage nosocomial outbreaks. The basis for applied epidemiology for infection control purposes is surveillance. Computer technology permits data retrieval for detailed investigation by filtering the microbiology reports for specific data with nosocomial and epidemiological importance, so that expertise and organization of the microbiology laboratory have become key success factors for surveillance. In Belgium epidemiologists rarely, if ever, practice in hospitals as a separate discipline, although professional hospital epidemiology as part of infection control would be profitable for all. A debate is still to be held on how epidemiology should be organized in Belgian hospitals. It is generally accepted and provided by law that hospital hygiene physicians and nurses should perform epidemiological investigations and surveillance. However, the lack of professional training in epidemiology and insufficient resources constitute two major drawbacks. Microbiological typing techniques have become indispensable tools for epidemiology and should be accessible to every hospital infection control practitioner.

Surgical prophylaxis in Belgian hospitals: estimate of costs and potential savings.

Between 1991 and 1995 the Belgian National Program for Surveillance of Hospital Infections (NSIH) collected data on perioperative antibiotic prophylaxis in 72 acute care hospitals. From the costs of prophylactic antibiotics for six categories of surgical procedure and from discharge summaries for hospitalization episodes nationwide, annual drug costs were estimated for 73% of Belgian surgical activity. Costs of antibiotics used in these surgical activities were estimated at 386-410 million Belgian francs (Bf) per year (US$12.1-12.9 million). After agreeing recommendations for best practice, the hypothetical costs of 'optimal' antimicrobial prophylaxis were calculated for the same selection of surgical procedures. It was calculated that savings of at least 194 million Bf (US$6.1 million) could be made if recommendations were followed closely. Only the costs borne by the National Health Insurance Institute for reimbursement of the dispensed drugs were considered in this study. Other direct costs, such as those related to drug storage, dispensing and administration, were not included.

[Recurrent pyogenic granuloma or Warner and Wilson-Jones syndrome]. / Granulome pyogénique récurrent ou syndrome de Warner et Wilson-Jones.

BACKGROUND: Recurrent pyogenic granuloma with multiple satellite lesions is a rare and benign condition; its diagnosis may be clinically evoked from a characteristic natural history. CASE REPORTS: Two 12 year-old boys developed multiple small cutaneous lesions following removal of pyogenic granuloma, at the periphery of the scar. A CO2 laser treatment was decided in one case, and therapeutic abstention in the other one. CONCLUSION: Our two cases completely fit with the classical features of such a condition that generally clears spontaneously. This syndrome must be known because of its "pseudo-metastatic" clinical features, which may mislead the physician.

Efficacy of Daflon 500 mg in venous leg ulcer healing: a double-blind, randomized, controlled versus placebo trial in 107 patients.

The objective of this study was to evaluate the efficacy of Daflon 500 mg (Dios)* in venous ulcers. A multicenter, double-blind, randomized, controlled versus placebo (Plac) trial was conducted, with stratification according to the size of ulcer (< or = 10 cm and > 10 cm). The protocol called for a two-month treatment with Dios (one tablet = 450 mg micronized purified Diosmin) or a placebo, two tablets/day, in addition to compression therapy. Evaluations were performed every fifteen days, from D0 to D60. The primary endpoint, in accordance with Alexander House group requirements were: percentage of patients with complete ulcer healing, ie, comparison between Dios and Plac group at D60, and comparison of survival curves in each group between D0 and D60 (log rank test). Secondary endpoints included ulcer surface area assessed by computerized planimetric measurements, qualitative evaluation of ulcers, and symptoms. The patients were 105 men and women ranging in age from eighteen to eighty-five years, with standard compression stocking, who were undergoing standardized local care of ulcer and had no significant arterial disease (ankle/arm systolic pressure index > 0.8). Fifty-three patients received Dios, and 52 received Plac. The 2 groups were well matched for age (m +/- 1 SD = seventy-one +/- eleven years), gender, ulcer size, and associated disorders. Among patients with ulcer size < or = 10 cm (Dios = 44, Plac = 47) a significantly larger number of patients had a complete ulcer healing at two months in the Dios group (n = 14) in comparison with the Plac group (n = 6) (32% vs 13%, P = 0.028) with a significantly shorter time duration of healing (P = 0.037). No difference was shown for the secondary criteria, except for sensation of heavy legs (P = 0.039) and a less atonic aspect of ulcer (P = 0.030) in favor of Dios. Among the 14 patients with ulcer size > 10 cm (Dios = 9, Plac = 5), subjected to a descriptive analysis only, no ulcer healed. This study showed that a two-month course of Daflon 500 mg at a daily dose of two tablets, in addition to conventional treatment, is of benefit in patients with venous ulcer < or = 10 cm by accelerating complete healing.

Benefit of a 2-month treatment with a micronized, purified flavonoidic fraction on venous ulcer healing. A randomized, double-blind, controlled versus placebo trial.

OBJECTIVE: To assess the efficacy of a micronized purified flavonoid fraction (Daflon 500 mg = Dios) in venous leg ulcer healing, in addition to compression therapy and standardized local care. DESIGN: Double-blind, multicentre, randomized, parallel groups, controlled versus placebo trial; stratification according to ulcer size. SUBJECTS: 107 patients, with venous ulcer of the leg for at least 3 months, and accepting bandaging therapy. RESULTS: 105 patients (Dios = 53, placebo = 52) were available for an intention to treat (ITT) analysis. Age (mean +/- SD, 71+/-11 years), gender (M = 33, F = 74) and ulcer size were evenly distributed among both groups. 99 patients completed the protocol (Dios = 51, placebo = 48). Among the 91 patients with ulcer size < or = 100 cm (Dios = 44, placebo = 47), a significantly higher number of patients had complete ulcer healing at 2 months in the Dios group (n = 14) in comparison to the placebo group (n = 6) after ITT analysis (32 vs. 13%, p = 0.028) and after per protocol analysis (32 vs. 14%, p = 0.048), and a shorter time duration of healing (p = 0.037). Among the 14 patients with ulcer size > 10 cm (Dios = 9, placebo = 5), no ulcer healed. CONCLUSION: This study showed that a 2-month course of purified micronized flavonoid fraction (2 tablets/day), in addition to conventional treatment, is of benefit in patients by accelerating complete healing of venous leg ulcers which are < or = 10 cm in diameter.