Multidisciplinary approach to the management of a case of classical respiratory diphtheria requiring percutaneous endoscopic gastrostomy feeding.

We present a case of a Caucasian woman aged 67 years referred with a 4-day history of sore throat, dysphagia, fever and nasal blockage. Examination revealed a swollen neck and pharyngeal pseudomembrane. A throat swab was positive on culture for Corynebacterium ulcerans, with toxin expression confirmed on PCR and Elek testing. A diagnosis of classical respiratory diphtheria was made, with subsequent confirmation of the patient's domesticated dog as the source of infection. The dog had recently been attacked by a wild badger and was being treated for an ear infection. The patient made a good recovery with intravenous antimicrobial and supportive therapy; however, she subsequently developed a diphtheritic polyneuropathy in the form of a severe bulbar palsy with frank aspiration necessitating percutaneous endoscopic gastrostomy feeding. A mild sensorimotor peripheral neuropathy was also diagnosed. The patient eventually made an almost complete recovery.

Determination of Urinary Neopterin/Creatinine Ratio to Distinguish Active Tuberculosis from Latent Mycobacterium tuberculosis Infection.

Background. Biomarkers to distinguish latent from active Mycobacterium (M.) tuberculosis infection in clinical practice are lacking. The urinary neopterin/creatinine ratio can quantify the systemic interferon-gamma effect in patients with M. tuberculosis infection. Methods. In a prospective observational study, urinary neopterin levels were measured by enzyme linked immunosorbent assay in patients with active tuberculosis, in people with latent M. tuberculosis infection, and in healthy controls and the urinary neopterin/creatinine ratio was calculated. Results. We included a total of 44 patients with M. tuberculosis infection and nine controls. 12 patients had active tuberculosis (8 of them culture-confirmed). The median age was 15 years (range 4.5 to 49). Median urinary neopterin/creatinine ratio in patients with active tuberculosis was 374.1 micromol/mol (129.0 to 1072.3), in patients with latent M. tuberculosis infection it was 142.1 (28.0 to 384.1), and in controls it was 146.0 (40.3 to 200.0), with significantly higher levels in patients with active tuberculosis (p < 0.01). The receiver operating characteristics curve had an area under the curve of 0.84 (95% CI 0.70 to 0.97) (p < 0.01). Conclusions. Urinary neopterin/creatinine ratios are significantly higher in patients with active tuberculosis compared to patients with latent infection and may be a significant predictor of active tuberculosis in patients with M. tuberculosis infection.

Temocillin use in England: clinical and microbiological efficacies in infections caused by extended-spectrum and/or derepressed AmpC ß-lactamase-producing Enterobacteriaceae.

BACKGROUND: Temocillin, a ß-lactam stable against most ß-lactamases [including extended-spectrum ß-lactamases (ESBLs) and derepressed AmpC cephalosporinases (dAmpC)], has been suggested as an alternative to carbapenems when Pseudomonas can be excluded. Aims To assess temocillin clinical and microbiological cure rates (CCR and MCR) in infection caused by ESBL/dAmpC-producing Enterobacteriaceae and the effects of different dosage regimens. METHODS: Data were collected retrospectively from patients treated for at least 3 days with temocillin for urinary tract infection (n = 42), bloodstream infection (n = 42) or hospital-acquired pneumonia (n = 8) in six centres in the UK. RESULTS: Data on 92 infection episodes were collected. Overall CCR and MCR were 86% and 84% respectively; ESBL/dAmpC status had no effect. Significantly higher CCR and MCR occurred in patients treated with temocillin at optimal dosage [2 g twice daily or renally adjusted equivalent (ORAE)] compared with those treated with a suboptimal dosage (<2 g twice daily ORAE) (CCR 91% and MCR 92% versus CCR 73% and MCR 63%). This difference was more pronounced in the ESBL/dAmpC-positive subset (CCR 97% and MCR 97% versus CCR 67% and MCR 50%). CONCLUSIONS: Clinical and microbiological efficacies of temocillin are unaffected by ESBL/dAmpC production, confirming its potential application as a carbapenem-sparing agent. Both CCR and MCR are optimized by a regimen of 2 g twice daily ORAE in ESBL/dAmpC-positive infection.

Sterile surgical helmet system in elective total hip and knee arthroplasty.

PURPOSE: To evaluate the sterility of the sterile surgical helmet system (SSHS) during elective total hip and knee arthroplasty in theatres with (n=20) and without (n=20) laminar flow. METHODS: Three surgeons performed 14 total knee arthroplasties (TKAs) and 6 total hip arthroplasties (THAs) in a laminar flow theatre and 15 TKAs and 5 THAs in a non-laminar flow theatre. An SSHS was used in all the procedures. Samples were taken from the hood at 30-minute intervals during surgery. Swabs were then broken into cooked meat broths for cultivation of organisms. The broths were then directly inoculated onto blood agar and fastidious anaerobic agar for culture of aerobic and anaerobic bacteria, respectively. After 24 hours, these plates were reinoculated with broths that had been incubated for 24 hours. Microbial growth was quantified as 0 (none), 1 (mild), 2 (moderate) and 3 (heavy). Bacterial contamination in the 2 groups at 30, 60 and 90 minutes was compared. RESULTS: Respectively in the laminar and non-laminar flow theatres, 0 and 9 of the SSHSs showed bacterial growth after direct inoculation, and 14 and 18 of the SSHSs grew 18 and 24 types of organisms in the swab cultures after 24 hours of incubation. Respectively at 30, 60, and 90 minutes, the degree of contamination from direct incubation was significant, but the degree of contamination on swabs after 24 hours of inoculation was not significant. The mean time-dependent contamination after direct inoculation was 0 for the laminar flow group and 0.5, 0.75, and 1.0 for the non-laminar flow group, whereas the corresponding values after 24 hours of incubation were 1.8, 1.8, and 2.6, and 2, 2.75, and 2.95. Coagulase negative Staphylococcus aureus was the most common organism in both groups. CONCLUSION: 80% of SSHSs used were contaminated intra-operatively. Direct contact with the SSHS should be avoided by the operating team during surgery. Routine changing of gloves in case of contact with the SSHS should be practised.

BCG vaccination reduces risk of infection with Mycobacterium tuberculosis as detected by gamma interferon release assay.

AIMS: To investigate whether BCG vaccination, in addition to a reduction of active tuberculosis, leads to a reduction of Mycobacterium tuberculosis infection during an outbreak of tuberculosis. METHODS: Pupils (n=199) of a Junior School exposed to a pupil with active pulmonary tuberculosis were screened using a gamma interferon release assay for detection of M. tuberculosis infection (ex vivo ELISPOT assay). Relative risk of M. tuberculosis infection and pulmonary tuberculosis associated with BCG vaccination were calculated and adjusted for exposure risk. RESULTS: Twenty-nine percent of children with previous BCG vaccination had a reactive gamma interferon release assay compared with 47% of unvaccinated children (unadjusted RR 0.61, 95%CI 0.39, 0.96). The protective effect of BCG vaccination persisted following adjustment for other risk factors for infection like ethnicity and proximity to the source case reflected in membership of class and activity groups (corrected relative risk 0.26, 95%CI 0.09, 0.69 and risk reduction of 74%, 95%CI 31%, 91%). A higher proportion of unvaccinated children (11%) were diagnosed with active pulmonary tuberculosis compared with 5% of vaccinated children (RR 0.51 95%CI 0.15, 1.70). CONCLUSION: BCG vaccination was associated with a reduction of M. tuberculosis infection diagnosed by gamma interferon release assay testing in school children during a point source outbreak.