Risk factors and clinical significance of invasive infections caused by levofloxacin-resistant Streptococcus pneumoniae.

PURPOSE: Fluoroquinolones are recommended for the treatment of pneumonia. The recognition of risk factors for invasive levofloxacin-resistant Streptococcus pneumoniae is important for the design of treatment. METHODS: A retrospective review of cases of invasive pneumococcal infections in adults was undertaken. Epidemiologic data, predisposing factors, clinical variables, and outcome were recorded from previously established protocols. Antimicrobial susceptibility was determined by disk diffusion and the Etest method. Serotyping was performed by latex agglutination and Quellung reaction. RESULTS: Twenty patients with infection caused by levofloxacin-resistant pneumococci [minimum inhibitory concentration (MIC) ≥2 µg/ml] were compared with 102 patients harboring levofloxacin-susceptible strains; 80% of levofloxacin-resistant pneumococci were resistant to ≥3 antibiotics but susceptible to penicillin. Most levofloxacin-resistant strains (80%) belonged to serotype 8. In comparison, only 8% of levofloxacin-susceptible pneumococci belonged to serotype 8. In the multivariate analysis, residence in public shelters [odds ratio (OR) 26.13; p 0.002], previous hospitalization (OR 61.77; p < 0.001), human immunodeficiency virus (HIV) infection (OR 28.14; p = 0.009), and heavy smoking (OR 14.41; p = 0.016) were associated with an increased risk of infection by levofloxacin-resistant pneumococci. Mortality caused by levofloxacin-resistant and levofloxacin-susceptible pneumococci was 35 and 14%, respectively. Among HIV-positive individuals infected with levofloxacin-resistant pneumococci 44% died, but only 12.5% of HIV-positive patients with levofloxacin-susceptible strains died. CONCLUSIONS: We observed the emergence of serotype 8 as the main cause of invasive disease caused by levofloxacin-resistant S. pneumoniae. HIV-positive patients seem to be prone to infection caused by multidrug-resistant serotype 8 and have a high mortality rate.

Emerging infectious endocarditis due to Scedosporium prolificans: a model of therapeutic complexity.

Scedosporium prolificans is an emerging agent for severe infections. Although among the dematiaceous fungi Scedosporium is the most frequently isolated in blood cultures, Scedosporium endocarditis is rarely reported. We show herein a patient with acute leukaemia who developed S. prolificans endocarditis. Twelve cases were found in an extensive review of the English literature. In six cases (46%), there was predisposing heart conditions such as a prosthetic valve or an intracavitary device. Only 4 patients (31%) were immunocompromised hosts with haematologic neoplasia, solid-organ transplantation or acquired immunodeficiency syndrome (AIDS). Exposure to Scedosporium was observed in immunocompetent patients who developed infection while in the community. Scedosporium endocarditis occurred on both sides of the heart. Systemic and pulmonary emboli and other metastatic complications were seen in all of these patients. The overall mortality was 77% and, specifically, all of the immunocompromised hosts and 6 out of 7 patients with mitral or aortic valve endocarditis died. Patients with right-sided endocarditis associated with a removable intracardiac device exhibited a better prognosis. Scedosporium endocarditis, although still rare, is an emerging infection with an ominous prognosis. At the present time, valve replacement or the removal of cardiac devices plus combined antifungal treatment may offer the best possibility of cure.

Infectious endocarditis in patients with cirrhosis of the liver: a model of infection in the frail patient.

The purposes of this paper was to discover whether cirrhosis is a predisposing cause of infectious endocarditis (IE) and to determine the microbiology, prognosis and the role of cardiac surgery on mortality. A review of cases of IE at a university-affiliated hospital over a period of 10 years was conducted. Thirty-one (9.8%) patients among 316 cases of IE had hepatic cirrhosis. Valve disorders were present in 62.2% of cirrhotic patients and infection occurred on the aortic (48%) and mitral valves (45%). Endocarditis was hospital-acquired in 14 (45%) and 11 (17.7%) cirrhotic patients and controls, respectively (odds ratio [OR] 3.82; 95% confidence interval [CI]: 1.46-9.99; p = 0.005). Staphylococcus aureus was the most common causative microorganism, but ß-hemolytic streptococci were most frequently isolated in cirrhotic patients (OR 8.75; 95% CI: 1.7-45.2; p = 0.001). Renal failure was more frequent in patients with cirrhosis (OR 8.23; 95% CI: 3.06-22.2; p = 0.001). Cirrhotic patients had a higher mortality (51% vs. 17.7%; OR 4.95; 95% CI: 1.89-12.91; p = 0.001) associated with the severity of liver disease. Valve replacement was performed less frequently in cirrhotic patients (56.2% vs. 92%) and the operative mortality was extremely high in patients at stages B and C. Hepatic cirrhosis is a frequent comorbid condition in patients with endocarditis. Due to the presence of severe hepatic dysfunction, cardiac surgery is not undertaken even when indicated and mortality is high in stages B and C. Endocarditis is a serious hazard for hospitalized cirrhotic patients.

Nephrotic syndrome complicating chronic visceral leishmaniasis: re-emergence in patients with AIDS.

Leishmania infection may be associated with immunecomplex-mediated glomerular injury. Contrary to immune-competent individuals, leishmaniasis in HIV patients is a chronic, relapsing disease. Despite the increasing frequency of the Leishmania/ HIV co-infection, there is a paucity of information on the effects of such co-infection in the kidney. We present a patient with AIDS and refractory, relapsing visceral leishmaniasis who developed nephrotic syndrome associated with renal involvement by Leishmania in the absence of immunecomplex glomerular deposition. For the first time, the relapsing nature of renal injury in this context is documented.

Infections of implantable cardioverter-defibrillators: frequency, predisposing factors and clinical significance.

The prognosis for patients with ventricular arrhythmias has improved dramatically with the aid of implantable cardioverter-defibrillators (ICDs). Although infection is a serious complication that frequently causes dysfunction and loss of ICDs, the frequency, predisposing risk-factors, and clinical and microbiological features are only partially understood. This study describes a retrospective review of 423 procedures in 278 patients with ICD primary implants and replacements performed at a tertiary-care hospital. Generators were placed in either a pectoral (68%) or abdominal (32%) site, and electrodes were placed transvenously in 97% of the patients. Most (95%) interventions were performed in a one-stage procedure. Infection developed with ten (2.4%) implanted devices. Four cases occurred within 30 days of surgery ('early infections') and six occurred > 1 month after surgery ('late infections'). In univariate analysis, factors associated with the development of an early infection were: two-stage surgery, a sub-costal approach, and abdominal generator placement. In patients with late infections, a significant association was found with trauma or decubitus ulcer in the generator area. Infection presented with local signs without systemic complications. Seven of the ten patients required complete removal of the system.

Pleuropulmonary infections caused by Mycobacterium bovis: a re-emerging disease.

Between 1980 and 2003, 13 patients (0.95% of all cases of tuberculosis) at a 600-bed university hospital in Madrid, Spain, were diagnosed with Mycobacterium bovis infection. All 13 cases occurred between 1994 and 1999; the mean age of the patients was 50 years (range 23-83 years), and 77% were males. Four (30%) patients were also positive for human immunodeficiency virus (HIV). The most frequent localisation of the disease was the lung (ten patients; 77%). Seven patients, including four HIV-positive patients who died, had multidrug-resistant M. bovis infection. No other patient died, including two HIV-negative patients with multidrug-resistant disease.

Prosthetic valve endocarditis caused by Brucella melitensis. A report of four cases successfully treated with tetracycline, streptomycin, and sulfamethoxazole and trimethoprim plus valve replacement.

Optimal treatment of prosthetic valve endocarditis due to Brucella melitensis is unknown. The presence of ring abscess makes extensive surgical débridement and valve replacement essential steps of management. Antimicrobial therapy with tetracycline hydrochloride plus streptomycin sulfate or sulfamethoxazole and trimethoprim can achieve the sterilization of infected cardiac tissue. Late bland periprosthetic leaks occur frequently. Reoperation can be safely performed after a period of antimicrobial therapy. Prolonged treatment with doxycycline hyclate seems advisable.

Bone marrow biopsy in the diagnosis of fever of unknown origin in patients with acquired immunodeficiency syndrome.

BACKGROUND: Fever is commonly observed in patients with human immunodeficiency virus (HIV) disease and frequently eludes diagnosis. The role of bone marrow biopsy in the diagnosis of fever of unknown origin in patients infected with HIV remains controversial. PATIENTS AND METHODS: One hundred twenty-three consecutive patients with 137 episodes of fever lasting 10 or more days without diagnosis after 1 week of hospitalization were evaluated by bone marrow biopsy. RESULTS: Overall, a specific diagnosis was achieved in 52 episodes by means of culture and histopathological examination (diagnostic yield, 37.9%). Three types of disease were found: mycobacterial infections (n = 36, 69% of documented episodes), including 18 patients with disseminated tuberculosis and 14 with Mycobacterium avium-intracellulare complex infections; non-Hodgkin lymphomas (n = 12, 23%); and visceral leishmaniasis (n = 4, 8%). Although bone marrow cultures were more sensitive than microscopic examination with special stains for the diagnosis of mycobacterial infections, the pathological examination of bone marrow led to a more rapid diagnosis of disease. In addition, the histopathological examination of bone marrow alone led to the diagnosis of a specific condition in 43 episodes (31.3% of all episodes). CONCLUSIONS: Bone marrow biopsy is a useful procedure for the diagnosis of fever in patients with advanced HIV disease, particularly in areas where tuberculosis and leishmaniasis are prevalent. Involvement of the marrow may be the first indication of the existence of extranodal non-Hodgkin lymphoma. For Mycobacterium avium-intracellulare complex infection, blood cultures were more sensitive than bone marrow biopsy.

Visceral leishmaniasis in immunocompromised hosts.

Visceral leishmaniasis is infrequently reported in immunocompromised hosts; hence, the clinical manifestations and outcome of the disease in these patients are unknown. In a series of 10 patients with visceral leishmaniasis complicating renal transplantation (three), hematologic neoplasms (two), systemic lupus erythematosus (two), or infection with human immunodeficiency virus (three), typical hallmarks of kalaazar such as enlargement of spleen or hyperglobulinemia were absent in three and six patients, respectively. Extensive visceral involvement was noted by biopsies or autopsies in four patients. Diagnosis was made during evaluation for fever of unknown origin. Myriads of amastigotes were seen in bone marrow smears. Measurement of antibodies against Leishmania donovani was positive in each patient tested. Ultimately, three patients died, and chronic infections refractory to treatment developed in two other patients. Visceral leishmaniasis is a potentially fatal infection in immunocompromised hosts. Current antiparasitic therapy frequently fails to eradicate L. donovani from infected tissues.

Zoonotic endocarditis.

The so-called zoonotic endocarditis is transmitted from animals to humans and is frequently found in some cattle-raising countries. Brucella endocarditis is a destructive process of the aortic valve with abscess formation that commonly leads to heart failure. Q fever endocarditis is a more indolent infection, but it is also capable of producing severe valvular damage and hemodynamic compromise. Treatment of zoonotic endocarditis includes the prolonged administration of doxycycline in combination with other antimicrobial agents and a judicious use of valve replacement. Mortality of Brucella endocarditis has been decreased significantly by a medical-surgical approach to treatment. On the basis of serologic and valve tissue culture results, no treatment is consistently able to cure Q fever endocarditis, and thus mortality of this infection remains high.

Mycoplasma hominis bacteraemia not associated with genital infections.

We describe two cases of systemic infection with M. hominis without prior genital infection and review the previous literature on this condition.

Salmonella infections of the abdominal aorta cured with prolonged antibiotic treatment.

Three cases of endovascular infection of atherosclerotic aneurysm of the abdominal aorta due to Salmonella spp. are described. 'Breakthrough' or relapsing bacteraemia were major clues for diagnosis in each case. They were treated with a prolonged course of bactericidal antibiotics before surgery. Resection with an interposed graft was performed in all cases and antibiotic treatment continued. Two of our patients have survived for more than two years and the other for 18 months without evidence of relapse. Thus, it would appear possible at times to treat successfully mycotic aneurysm of the abdominal aorta with antimicrobial agents plus resection of the aneurysm followed by in situ bypass grafting. Extra-anatomical grafts should be kept for infections due to antimicrobial-resistant organisms or when periaortic infection is widespread.

[Lemierre's syndrome (post-anginal sepsis): a forgotten infection]. / Síndrome de Lemierre (sepsis postangina): una infección olvidada.

Septic thrombophlebitis of the jugular vein (Lemierre's syndrome) is a severe complication of oropharyngeal infections. The extension of the infection to the cardiovascular system favors its dissemination to the lung and, eventually, to other points in the organism. We report two cases of Lemierre's syndrome seen in a 10-year period. The diagnostic and therapeutic aspects are particularly emphasized so as to stimulate the knowledge of this uncommon condition.

[Infectious endocarditis in patients with liver cirrhosis]. / Endocarditis infecciosa en pacientes con cirrosis hepática.

To evaluate the clinical and microbiological features of infective endocarditis in patients with cirrhosis we compared 18 episodes of endocarditis in these patients with a control group of patients without liver disease. In 61% of patients with cirrhosis the origin of infection was unknown. Four patients developed endocarditis as a consequence of bladder catheterizations and two after hepatic biopsy. None of the four with previously known valvular heart disease had received antibiotic prophylaxis during these procedures. As compared with the control group, the patients with cirrhosis had more infections by enterococci (38.8% vs 11%; p less than 0.007) and non-viridans streptococci (38.8% vs 7.4%; p less than 0.001) and significantly less infections by viridans streptococci (11% vs 42.5%; p less than 0.01). The mortality rate associated with endocarditis was 38.8% and 22% in patients with and without cirrhosis, respectively (less than 0.1; NS). Infective endocarditis in patients with cirrhosis is often a complication of diagnostic or therapeutic procedures and has distinctive microbiological features.

[Septic thrombophlebitis of the great vessels of the neck. A severe complication of central venous catheters]. / Tromboflebitis séptica de las grandes venas del cuello. Una complicación grave de los catéteres venosos centrales.

Septic thrombophlebitis of the large veins of the neck is an uncommon, but extremely severe, complication in carriers of central venous catheters. Treatment of these cases is difficult and, generally, the clinical condition does not permit surgical approach. Four patients with septic central vein thrombophlebitis are reported. They were treated with conservative measures including catheter removal and high-dose parenteral antibiotics for at least four weeks, with excellent results in all. The relevant literature and the therapeutic alternatives are reviewed.

[Withdrawal of Pneumocystis carinii pneumonia prophylaxis in patients receiving efficacious combined antiretroviral treatment. Study of 85 cases]. / Suspensión de profilaxis frente a neumonía por Pneumocystis carinii en pacientes con tratamiento antirretroviral combinado eficaz. Estudio de 85 casos.

OBJECTIVES: To analyse the incidence of Pneumocystis carinii pneumonia after the withdrawal of prophylaxis, in patients with AIDS who were receiving HAART (highly active antiretroviral treatment). PATIENTS AND METHODS: Prospective opened study of 85 patients with AIDS (CD4 lymphocytes < 200 x 10(6)/l) and whose CD4 counts had increased over 200 x 10(6)/l after HAART, 79 were under primary prophylaxis and six secondary. RESULTS: Mean CD4 lymphocytes count at the time of withdrawal was 343 x 10(6)/l. Mean time of follow-up after withdrawal was 358 days (range: 93-1,487; median: 302). None of the patients have had Pneumocystis carinii or toxoplasmosis after withdrawal of prophylaxis. CONCLUSIONS: Pneumocystis carinii prophylaxis in AIDS patients might be safety withdrawn after effective HAART.

[Endocarditis of a natural valve caused by coagulase-negative staphylococci]. / Endocarditis sobre válvula nativa por estafilococo coagulasa negativo.

Eleven patients with endocarditis of a natural valve due to coagulase-negative staphylococci are reported. Nine had some underlying heart disease. The course was subacute in seven and acute (two weeks or less) in the remaining four. All patients developed complications: heart failure in nine, arterial emboli in eight, atrioventricular conduction disorders in four, development of paravalvular and/or myocardial abscesses in four, and perforation or rupture of valve leaflets in four. Eight patients were cured, seven of them requiring surgical treatment. Three of the isolated coagulase-negative staphylococci strains were methicillin-resistant; two of them caused community-acquired endocarditis. Natural valve endocarditis due to coagulase-negative staphylococci usually has a subacute course with a tendency to develop severe complications. This makes surgical therapy necessary in a sizeable number of patients.

[The clinical spectrum of focal infection due to nontyphoid Salmonella: 32 years' experience]. / Espectro clínico de la infección focal por Salmonella no typhi: experiencia de 32 años.

BACKGROUND: The aim of this study was to analyze the manifestations of the syndromes which constitute focal infection by Salmonella no typhi (SNT). METHODS: Ninety-one episodes of SNT infections studied over a period of 32 years in the Fundación Jiménez Díaz (Madrid, Spain) were retrospectively analyzed. RESULTS: Of the 1,892 patients with SNT infection studied during this period, 91 (5%) presented some focal form (57 males and 34 females) with a mean age of 49 years (SD +/- 21.6 years). Sixty percent of the episodes were acquired within the community. The localization of the focal infections by SNT was as follows: urologic tract (24%), intraabdominal (20%), soft tissues (16%), respiratory tract (15%), osteoarticular (14%), cardiovascular (10%) and central nervous system (1%). On comparison with the remaining patients, those with urinary, osteoarticular and respiratory infections were found to be the most frequently immunosuppressed (47%) vs 18%, p < 0.01) with a greater frequency of unfavorable evolution (57% vs 15%; p < 0.001). Mortality ranged between 7% for the osteoarticular forms to 64% for the pleuropulmonary forms of infection. CONCLUSIONS: Focal infection by Salmonella no typhi may be localized in any organ usually occurring in immunosuppressed patients or those with predisposing local factors. The osteoarticular, pulmonary, and urologic infections have a particularly unfavorable course and their presence may suggest the existence of immunosuppression.

[Endocarditis due to penicillin-sensitive and -resistant pneumococci: the current perspectives on the disease]. / Endocarditis por neumococos sensibles y resistentes a penicilina: perspectivas actuales de la enfermedad.

BACKGROUND: To evaluate the clinic characteristics and therapeutic aspects of endocarditis by Streptococcus pneumoniae sensitive and resistant to penicillin. METHODS: Twelve cases of pneumococcal endocarditis evaluated in 4 Spanish hospitals over the last 10 years were studied, analyzing their clinical characteristics and the existence of resistance to penicillin. The features were compared with a series of 98 cases found in a review of the literature. RESULTS: All the patients were males, most being alcoholics. The course of the disease was acute (2 weeks) in all the cases and evolved with great aggressivity: cardiac failure (9 patients), myocardial abscess (7 patients), multiple arterial embolisms (5 patients), septic arthritis (4 patients). Three patients had simultaneous pneumococcal meningitis but only one had pneumonia. The valve most affected was the aortic (9 cases). Three cases were due to strains of Streptococcus pneumoniae with moderate resistance to penicillin (CMI 0.5-1 micrograms/ml). Global mortality was 42%. All the patients receiving inadequate antibiotic treatment died. Vancomycin and cefotaxime appear to be effective in the treatment of cases produced by strains of pneumococcus with intermediate sensitivity to penicillin. There were no apparent differences in mortality between the cases of endocarditis by pneumococcus sensitive or moderately resistant to penicillin. CONCLUSIONS: Pneumococcal endocarditis continues to condition a high mortality similar to that produced in previously made series. The classic relation with meningitis and pneumonia is infrequent today. The appearance of strains resistant to penicillin may increase the incidence of this infection and further worsen prognosis.