Escherichia coli sequence type 131 (ST131) subclone H30 as an emergent multidrug-resistant pathogen among US veterans.

BACKGROUND: Escherichia coli sequence type 131 (ST131), typically fluoroquinolone-resistant (FQ-R) and/or extended-spectrum ß-lactamase (ESBL)-producing, has emerged globally. We assessed its prevalence and characteristics among US veterans. METHODS: In 2011, 595 de-identified E. coli clinical isolates were collected systematically within 3 resistance groups (FQ-susceptible [FQ-S], FQ-R, and ESBL-producing) from 24 nationally distributed Veterans Affairs Medical Centers (VAMCs). ST131 and its H30 subclone were detected by polymerase chain reaction and compared with other E. coli for molecular traits, source, and resistance profiles. RESULTS: ST131 accounted for 78% (184/236) of FQ-R and 64.2% (79/123) of ESBL-producing isolates, but only 7.2% (17/236) of FQ-S isolates (P < .001). The H30 subclone accounted for ≥95% of FQ-R and ESBL-producing, but only 12.5% of FQ-S, ST131 isolates (P < .001). By back-calculation, 28% of VAMC E. coli isolates nationally represented ST131. Overall, ST131 varied minimally in prevalence by specimen type, inpatient/outpatient source, or locale; was the most prevalent ST, followed distantly by ST95 and ST12 (13% each); and accounted for ≥40% (ß-lactams), >50% (trimethoprim-sulfamethoxazole , multidrug), or >70% (ciprofloxacin, gentamicin) of total antimicrobial resistance. FQ-R and ESBL-producing ST131 isolates had higher virulence scores than corresponding non-ST131 isolates. ST131 pulsotypes overlapped extensively among VAMCs. CONCLUSIONS: Among US veterans, ST131, primarily its H30 subclone, accounts for most antimicrobial-resistant E. coli and is the dominant E. coli strain overall. Possible contributors include multidrug resistance, extensive virulence gene content, and ongoing transmission. Focused attention to ST131, especially its H30 subclone, could reduce infection-related morbidity, mortality, and costs among veterans.

Bacterial "Virulence" Traits and Host Demographics Predict Escherichia coli Colonization Behaviors Within Households.

BACKGROUND: Although intestinal colonization precedes most extraintestinal Escherichia coli infections, colonization-promoting factors are incompletely understood. We compared within-household E. coli colonization patterns with host and bacterial traits. METHODS: Twenty-two veterans with a clinical E. coli isolate and their 46 human and animal household members underwent longitudinal fecal sampling. Distinct E. coli strains were characterized for phylogenetic background, virulence genes, antibiotic resistance, and colonization behaviors. Host and bacterial traits were assessed statistically as predictors of colonization behaviors. RESULTS: Among the 139 unique-by-household fecal E. coli strains, univariable predictors of colonization behavior included (i) host demographics, (ii) matching the index clinical isolate, and (iii) bacterial characteristics (2 phylogroups, 5 clonal lineages, 18 virulence genes, and molecular extraintestinal pathogenic E. coli status). Multivariable predictors of colonization behavior included veteran host, spouse host, matching the index clinical isolate, phylogroup F, ST73, hlyD (alpha hemolysin), hlyF (variant hemolysin), H7 fliC (flagellar variant), vat (vacuolating toxin), and iha (adhesin-siderophore). CONCLUSIONS: Host demographics, multiple bacterial "virulence" traits, and matching the index clinical isolate predicted E. coli fecal colonization behaviors. Thus, certain bacterial characteristics may promote both colonization and pathogenicity. Future interventions directed toward such traits might prevent E. coli infections both directly and by disrupting antecedent colonization.

17-Beta estradiol enhances osteogenic and adipogenic differentiation of human adipose-derived stromal cells.

Adipose-derived stromal cells (ASCs) possess multiple differentiation potentials and may serve as a cell source, if effectively modulated, for regenerative medicine and tissue engineering. Due to estrogen's function in tissue and organ development through regulating cell proliferation and differentiation, we hypothesized that an estrogen supplement may effectively enhance the multiple differentiation potentials of human ASCs. 17-Beta estradiol (E2) was investigated for modulating in vitro osteogenic and adipogenic differentiation in human ASCs isolated from a healthy female donor. After ASCs' exposure to osteogenic and adipogenic differentiation medium supplemented with different concentrations of E2, osteogenic markers (alkaline phosphatase activity, extracellular matrix, calcium deposition, and osteocalcin expression) and adipogenic parameters (lipid accumulation and differentiated cell population) significantly improved. Estrogen's enhancement is dose dependent and linked to differing alpha and beta estrogen receptors. Our data preliminarily demonstrate that estrogen can modulate the differentiation, and potentially improve the efficiency of ASCs in stem cell-based tissue engineering and regeneration. However, further study is needed to verify the regulatory functions of estrogen on ASC differentiations of donors with different ages and genders.

Fever of unknown origin: analysis of 71 consecutive cases.

BACKGROUND: Fever of unknown origin (FUO) is still an important problem in clinical practice. Evaluation of patient characteristics may clarify the utility of diagnostic tests and etiologies of FUO. METHODS: Fever of unknown origin in 71 patients was investigated at Ankara Numune Education and Research Hospital in Turkey between February 2001 and December 2004. RESULTS: Mean hospital stay and fever duration was 20.5 days and 44 days, respectively. Etiologies of FUO were as follows: infections 32 (45.1%), collagen vascular disease 19 (26.8%), neoplasm 10 (14.1%), and miscellaneous diseases 4 (5.6%). Diagnosis remained obscure in 6 patients (8.5 %). Tuberculosis was found to be 40% of the infectious causes of FUO. Mean hospital stay and fever duration were prolonged in infectious cases. Female predominance was observed in collagen vascular diseases (P = 0.047). Splenomegaly and lymphadenopathy were common in the neoplasm group (P = 0.017, P = 0.017, respectively). Erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase and lactate hydrogenase levels were elevated in patients with collagen vascular diseases. Nine (12.7%) patients died during the follow-up period. CONCLUSIONS: Hospital stay and fever duration were prolonged in the infectious group of FUO patients. Infectious diseases, particularly tuberculosis, were the most important cause of FUO in our series. Tuberculosis should be kept in mind as an important etiology of FUO countries where tuberculosis is endemic.

Modulations of 17-beta estradiol on osteogenic and adipogenic differentiations of human mesenchymal stem cells.

Bone marrow mesenchymal stem cells (MSCs) are a promising cell source for tissue engineering and regenerative medicine applications. However, effective regulation to improve differentiation potentials of MSCs plays a critical role in promoting successful tissue formation. Because estrogen has been demonstrated to modulate tissue and organ development and differentiation, we hypothesized that adding estrogen could effectively improve the multiple differentiation potentials of human bone marrow MSCs in vitro. In the present study, 17-beta estradiol (E2) was investigated for in vitro osteogenic and adipogenic differentiations of MSCs isolated from a healthy male human donor. After MSCs were exposed to osteogenic differentiation medium supplemented with E2 at different concentrations, osteocalcin expression is upregulated and calcium deposition (21.0%) is significantly improved ( p < 0.01; n = 4). Under adipogenic stimulation, E2 increased 35.4% lipid accumulations more than that of the group without the E2 supplement ( p < 0.01; n = 4). Estrogen's effect on osteogenesis occurs via estrogen receptors (ER)-alpha and -beta, whereas the effect on adipogenesis is through ER-alpha. Estrogen's regulation of differentiations of MSCs is dose dependent. The present study indicated that estrogen could potentially improve the role of MSCs in tissue engineering and regeneration by serving as a modulator of differentiation.

Evaluation of risk factors for mortality in intensive care units: a prospective study from a referral hospital in Turkey.

BACKGROUND: The aim of the clinical practice is to decrease the mortality rate in intensive care units. Determination of the risk factors for mortality may provide useful guidance for intensive care patients. This study sought to find mortality-related risk factors in intensive care units. OBJECTIVE: To investigate risk factors for mortality in intensive care units (ICUs). METHODS: The prospective study was performed from May 2002 to November 2002 in the surgical and medical ICUs of the Ankara Numune Education and Research Hospital. Three hundred thirty-four patients who were followed in the ICUs for at least 48 hours were enrolled in this study. Those patients who died within 48 hours of ICU discharge were included in the mortality analysis. RESULTS: The overall mortality rate in the ICUs was 46.7%. Among the 334 patients, 104 (31.1%) had ICU-acquired infections. The mortality rate was significantly higher in the patients with nosocomial infections (66.3%) than in the patients without nosocomial infections (37.8%) ( P < .001). The mean age, sex, acute physiology and chronic health evaluation (APACHE) II score, trauma and intraabdominal pathology, nosocomial infection, stay in the medical/surgical ICU, coma, TISS score, use of steroid or chemotherapy, use of antibiotic, and serum urea >50 mg/dL and creatinine >1.2 mg/dL levels were associated with mortality in the univariate analysis. Eight variables were determined as independent risk factors: presence of nosocomial infection (hazard ratio (HR) 0.40; 95% confidence interval (CI), 0.27-0.61), mean age (HR, 1.01; 95% CI, 1.00-1.02), mean APACHE II score (HR, 1.99; 95% CI, 1.50-2.64), mechanical ventilation (HR, 1.98; 95% CI, 1.33-2.95), stay in the medical/surgical ICU (HR, 0.41; 95% CI, 0.27-0.61), enteral nutrition (HR, 0.43; 95% CI, 0.29-0.65), tracheostomy (HR, 0.26; 95% CI, 0.094-0.75), and use of steroid or chemotherapy (HR, 1.61; 95% CI, 1.13-2.29). Nosocomial pneumonia (HR, 0.59; 95% CI, 0.38-0.92) and sepsis (HR, 0.29; 95% CI, 0.16-0.51) were related with mortality. CONCLUSION: The most important risk factors of mortality were observed as nosocomial infection, older age, high APACHE II score, mechanical ventilation, enteral nutrition, tracheostomy, and use of steroids or chemotherapy.

Evaluation of antibiotic use in a hospital with an antibiotic restriction policy.

The study was designed to evaluate rational antibiotic use in relation to diagnosis and bacteriological findings. All hospitalized patients who received antibiotics were evaluated by a cross-sectional study. Of the 713 patients hospitalized, 281 (39.4%) patients received 377 antibiotics. Among 30 different antibiotics the most frequently requested were first generation cephalosporins (19.9%), ampicillin-sulbactam (19.1%) and aminoglycosides (11.7%). Antibiotic use was appropriate in 64.2% of antibiotic requests. In analysis of appropriate use, a request after an infectious diseases consultation was a frequent reason (OR=14, P<0.001, CI=0.02-0.24). Antibiotics requested in conjunction with susceptibility results were found to be more appropriate than those ordered empirically (OR=4.5, P=0.017, CI=0.06-0.76). Inappropriate antibiotic use was significantly higher among unrestricted antibiotics than restricted ones (P<0.001). Irrational antibiotic use was high for unrestricted antibiotics. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

Arthritis and osteomyelitis due to Aspergillus fumigatus: a 17 years old boy with chronic granulomatous disease.

BACKGROUND: Invasive Aspergillus infections are frequently seen in immunocompromised patients but arthritis is a rare complication of Aspergillus infections in the absence of immune suppressive therapy, trauma or surgical intervention. CASE PRESENTATION: A 17 years old male patient with arthritis and patellar osteomyelitis of the left knee whose further investigations revealed chronic granulomatous disease as the underlying disease is followed. Aspergillus fumigatus was isolated from the synovial fluid and the tissue samples cultures. He was treated with Amphotericin B deoxicolate 0.7 mg/kg/day. Also surgical debridement was performed our patient. Amphotericin B nephrotoxicity developed and the therapy switched to itraconazole 400 mg/day. Itraconazole therapy were discontinued at the 6th month. He can perform all the activities of daily living including. CONCLUSION: We think that, chronic granulomatous disease should be investigated in patients who have aspergillar arthritis and osteomyelitis.

Chlamydia pneumoniae infection related atherosclerotic clinical variables on carotid stenosis.

OBJECTIVE: Research results showed that Chlamydia pneumoniae infection is related to atherosclerosis. C. pneumoniae infection may exacerbate atherogenesis. We investigated the presence of this microorganism for patients who underwent carotid endarterectomy and evaluated clinical values of C. pneumoniae infection on carotid stenosis. METHODS: Twenty patients with carotid stenosis were enrolled in this prospective study between 1997 and 1999. The patients were observed on whether they were positive or negative in four C. pneumoniae measures, namely; IgA titers, IgG titers, presence of electron microscopy, and immunocytochemistry in the endarterectomy specimens. Possible clinical findings for atherosclerosis were also observed of Chlamydial measures such as the percentage of carotid stenosis, cholesterol and triglyceride levels, smoking status, symptomatic or non-transient ischaemic attack or stroke, previous ischaemic event, calcification at surgery, ulceration on angiographies, ulceration at surgery and hypertension were included in this evaluation. RESULTS: Specific C. pneumoniae IgG were detected as positive in 9 (45%) of 20 patient samples. These patients were regarded as having chronic Chlamydia pneumoniae infection. None of the patients were positive for IgA antibody. This result demonstrated no evidence of reinfection. Immunocytochemistry and electron microscopy were positive in 7 (35%) of the 20 patients and correlated with positive serological results. The proportion of previous ischaemic events, calcification at surgery, ulceration on angiography, and ulceration at surgery were found significantly higher ( p < 0.05 ) for patients who are positive for chlamydial measures than those who are negative. CONCLUSION: The results of this study demonstrated an association between C. pneumoniae to atherosclerosis. The proportion of patients who are positive for Chlamydia measures (IgG titers, electron microscopy, and immunocytochemistry) is significantly higher for those who were positive for each of these clinical variables (PIE, CALCI, U1, and U2) than who were negative. We emphasise, the higher incidence in clinical variables of PIE, CALCI, U1, and U2 in Chlamydia measures positive group may support the association of C. pneumoniae with atherosclerotic events.

A Case of Brucellosis Presenting with Severe Thrombocytopenia.

Thrombocytopenia is one of the rare hematologic complication of brucellosis. Herein a case of brucellosis with severe thrombocytopenia was reported. The patient was admitted to hematology service with epistaxis, ecchymoses, fever, thrombocytopenia (0.6 x 103/µL) and anemia. His initial diagnosis was idiopathic thrombocytopenic purpura. Corticosteroid treatment was started and erythrocyte and platelet suspensions were transfused. Despite this treatment clinical symptoms and laboratory disorders were not improved. No significant pathology was detected in the examination of bone marrow aspiration. On the seventh day, Brucella abortus was yielded from his blood cultures. Steroid was stopped and rifampicin plus doxycycline started. His clinical symptoms were disappeared and laboratory findings improved (thrombocyte count: 205 x 103/µL) at the second week of the antibiotic treatment. This case was interesting showing us that thrombocyte count might decrease to very low levels in brucellosis. So that, especially in the endemic areas, brucellosis should be kept in mind for the etiology of fever and thrombocytopenia.

Adipose tissue engineering by human adipose-derived stromal cells.

Tissue engineering has emerged as a promising alternative approach to current clinical treatments for restoration of soft tissue defects. The purpose of this study was to investigate adipose tissue formation in vitro and in vivo by using human adipose-derived stromal cells (ADSCs) utilizing a gelatin sponge (Gelform) as a scaffold. Adipogenic potentials of human ADSCs were demonstrated by Oil-O-red staining and cellular morphology. After seeding human ADSCs in a density of 3 x 10(6) cells/ml on three-dimensional gelatin sponges, tissue-engineered constructs were exposed to adipogenic differentiation medium for in vitro studies and implanted in the backs of severe combined immunodeficient (SCID) mice for in vivo adipose regeneration. Adipogenesis of ADSC-seeded gelatin sponges was confirmed by Oil-O-red staining after 4 weeks of in vitro incubation. The optical density of the elution from Oil-O-red staining of adipogenic constructs is significantly higher than that of the control group (p < 0.05, n = 4). With short-term in vitro differentiation, adipogenic constructs turned into fat tissue 4 weeks after in vivo implantation, confirmed by biochemical and immunohistochemical examination. No adipogenic-morphological change or fat formation was observed in in vitro or in vivo studies when ADSCs were exposed to a control medium without adipogenic stimulation. These results indicate that engineered adipose tissue can be achieved using human ADSCs and biocompatible and degradable gelatin sponges.

Brucellar spondylitis.

We carried out a prospective analysis of 86 patients with brucellosis, and 26 (30%) cases were diagnosed as brucellar spondylitis. Two patients had cervical involvement, two thoracic, and 21 lumbosacral as seen in MRI. Four patients had epidural abscess and two had paravertebral abscess. All patients received combined antibiotic therapy for 4 to 12 months. Those with cervical involvement underwent surgical treatment because of medullar compression. Neither death nor severe sequelae were observed.

Venous sinus thrombosis after Proteus vulgaris meningitis and concomitant Clostridium abscess formation.

A 19-y-old woman presented with Proteus vulgaris meningitis as a complication of chronic otitis media. Despite treatment with ceftazidime and amikacin no clinical improvement was observed. Cranial MRI revealed right-sided mastoiditis/otitis media and venous sinus thrombosis. After mastoidectomy, repeat cranial MRI demonstrated abscess formation in the venous sinuses. The abscess was drained. Clostridium spp. was isolated from the abscess culture.

Neurobrucellosis in an endemic area of brucellosis.

Central nervous system involvement occurs less than 5% of patients with brucellosis. A prospective analysis of 73 patients with brucellosis identified 13 (17.8%) neurobrucellosis cases from February 2001 to May 2002. 10 patients had chronic meningitis and 3 acute meningitis. Two patients had only psychiatric disorders. Cranial nerve involvement was observed in 3 patients (6th, 7th and 8th nerves). Three patients had positive blood cultures and 3 others had positive cerebrospinal fluid (CSF) cultures. 12 patients had positive agglutination titres in CSF. All patients received antibiotic therapy with ceftriaxone, rifampicin and doxycycline initially, and after 1 month they were continued with rifampicin and doxycycline up to 4 months. All patients were completely cured. Hearing loss developed in 1 patient as a sequela.

Spontaneous bacterial peritonitis due to Brucella melitensis.

Peritonitis is an extremely rare complication of brucellosis. A case is reported of blood and ascitic culture-proven spontaneous bacterial peritonitis caused by Brucella melitensis, in a patient who had also cirrhosis.

Biotypes and antimicrobial susceptibilities of Brucella isolates.

41 Brucella strains isolated from blood and cerebrospinal fluid cultures were identified to species level and biotypes detected. All of the isolates were Brucella melitensis: 2 strains of B. melitensis biotype-1 and 39 strains of B. melitensis biotype-3. In vitro activities of these strains were detected by the E test method. According to the 90% minimal inhibitory concentration (MIC90) values, the most active agent was doxycycline (MIC90 0.064 microg/ml), followed by ciprofloxacin (MIC90 0.25 microg/ml), trimethoprim-sulfamethoxazole and ceftriaxone (MIC90 0.38 microg/ml). Rifampin exhibited the highest MIC90 value (0.75 microg/ml).