Excretion of Ascaris lumbricoides following reduced-intensity allogeneic hematopoietic stem cell transplantation and consecutive treatment with mebendazole.

Here, we present the unique case of a 51-year-old German patient with multiple myeloma excreting Ascaris lumbricoides in his stool five weeks after allogeneic hematopoietic stem cell transplantation. Stool analysis remained negative for the presence of eggs, and there was no eosinophilia in the peripheral blood at any time around stem cell transplantation. The patient was commenced on a three-day treatment with mebendazole, which was well tolerated. No serious interactions with the concomitant post-transplant medication or negative effects on the hematopoiesis were observed, and the myeloma still is in complete remission. To our knowledge, this is the first report on excretion of A lumbricoides in the context of allogeneic stem cell transplantation. The case is remarkable with view to the fact that the parasite has supposedly survived all courses of myeloma treatment including autologous and allogeneic conditioning. Parasitosis with A lumbricoides has a worldwide prevalence of about a billion and is extremely rare in northern Europe. Possibly the patient got infected during a trip to Egypt years before multiple myeloma was diagnosed.

[Paths to the professional and responsible use of antibiotics]. / Wege zum fachgerechten und verantwortungsvollen Umgang mit Antibiotika.

Germany's position on prescribing antibiotics is among the lower third in Europe. There are some countries that prescribe remarkably fewer antibiotics. In Germany, the number of out-patient antibiotic prescriptions is too high for patients with low-grade infections and non-bacterial infections. Often, broad-spectrum antibiotics are prescribed instead of narrow-spectrum antibiotics. For in-patients, perioperative prophylaxis is given for too long.In this article, different ways to reduce antibiotic prescriptions are introduced. Recommendations are given to improve the quality of therapy, implementation of diagnostics and scores, as well as information for physicians and patients.In this regard, an unsystematic literature search was done.To optimise the quality of prescribing, antibiotic checklists should be used. The important initial questions are if there is a bacterial infection and if antibiotic therapy is necessary. To apply diagnostics correctly is essential. Antibiotic use can be shortened or in some cases totally omitted if point-of-care tests (POCTs) are applied correctly. Species identification and resistance testing are essential for quality assurance. S3-guidelines are central for modern evidence-based medicine. Another key factor is good communication within the team and with patients. All measurements, like the application of POCTs, back-up prescribing, and prescribing an antibiotic, have to be communicated in a clear and sensitive way.

Molecular detection of Campylobacter jejuni as a cause of culture-negative spondylodiscitis.

Spondylodiscitis caused by Campylobacter species is a rare disease which is most often caused by Campylobacter fetus. We report a case of culture-negative spondylodiscitis and a psoas abscess due to Campylobacter jejuni in a 68-year-old woman, as revealed by 16S rRNA gene and Campylobacter-specific PCRs from biopsied tissue.

Epidemiology of Candida blood stream infections in patients with hematological malignancies or solid tumors.

Invasive Candida infections are associated with high morbidity and mortality. Due to an increased incidence in patients with hematological or oncological malignancies, fluconazole prophylaxis became a common practice in many centers in the late 1990s. Until recently, there was insufficient data on the effect of the use of azoles on the incidence of Candida blood stream infections and species distribution. Here we present a single center retrospective study of the epidemiology of Candida blood stream infections in hospitalized patients at a German university medical center from 2003-2009. Twenty-one Candida species were isolated in culture from blood specimens of 20 patients. The annual rate of candidemia approached 1.1 per thousand hospitalizations, during the first 5 years of the survey, but showed a significant increase after 2007. Candida albicans, although still the dominant species, was recovered as the responsible pathogen from only 28.6% of the cases. A high rate of fatal outcomes was noted at 30 days (56%) and 100 days (67%) after the first positive finding of Candida in blood culture. These results underline the clinical significance of this infectious complication, and the need for continuous monitoring for Candida blood stream infections in order to improve the clinical and therapeutic management of this specific patient population.

[MRSA--development, distribution and prevention]. / MRSA--Entstehung, Verbreitung, Behandlung und Prävention.

Multiresistant Staphylococcus aureus (MRSA) are one of the big problems occurring in the hospitals, especially because of the shortage of potent antibiotics. In addition, MRSA are increasingly found outside the hospitals. Beside the development of MRSA, pathogenesis and epidemiology, the article will give advises how to avoid an MRSA infection and how to deal with patients infected with MRSA.

Resistance to ampicillin, third-generation cephalosporins, ciprofloxacin, co-trimoxazole and azithromycin in clinical isolates of Salmonella enterica subsp. enterica from Germany: real problem or sporadic circumstance?

The objective of this study was to determine the in vitro activity of ampicillin, third-generation cephalosporins, ciprofloxacin, co-trimoxazole and azithromycin against Salmonella enterica isolates. None of the isolates tested showed resistance to third-generation cephalosporins or azithromycin. The rates of resistance to ampicillin, co-trimoxazole and ciprofloxacin were 16.8%, 3.2% and 0.8%, respectively. Moreover, 7.2% of the isolates showed reduced ciprofloxacin susceptibility, but none of them harboured qnr genes. To conclude, our data show that resistance to fluoroquinolones and third-generation cephalosporins in clinical isolates found in Germany still represents a rare circumstance.

First survey of metallo-beta-lactamases in clinical isolates of Pseudomonas aeruginosa in a German university hospital.

A total of 489 clinical isolates of Pseudomonas aeruginosa was investigated for metallo-beta-lactamase (MBL) production. Molecular analysis detected a blaVIM-1 gene in the chromosome of one isolate and a blaVIM-2 gene carried on the plasmid in seven isolates. Moreover, we showed that an initial screening by combined susceptibility testing of imipenem and ceftazidime followed by a confirmatory EDTA combination disk test represents a valid alternative to the molecular investigation of MBL genes, making MBL detection possible in routine diagnostic laboratories.

Antimicrobial susceptibility of clinical Campylobacter isolates collected at a German university hospital during the period 2006-2008.

A total of 113 clinical Campylobacter strains (105 C. jejuni, 7 C. coli, 1 C. lari) were collected between 2006 and 2008 and tested for antimicrobial susceptibility to erythromycin, ciprofloxacin, doxycycline and meropenem. Of all the Campylobacter isolates, 52.2% were resistant to ciprofloxacin and 38.0% to doxycycline. None of them was resistant to erythromycin or meropenem. However, 51.3% of all Campylobacter isolates were intermediate susceptible to erythromycin (minimum inhibitory concentration 1-4 mg/l). These data confirm the value of macrolides as the drugs of choice for the treatment of severe Campylobacter infections.

Resistance to tobramycin and colistin in isolates of Pseudomonas aeruginosa from chronically colonized patients with cystic fibrosis under antimicrobial treatment.

Tobramycin and colistin represent 2 standard antimicrobial agents in the treatment of cystic fibrosis (CF) patients who are chronically colonized with Pseudomonas aeruginosa. In this study, we determined the rate of resistance to tobramycin and colistin in 1844 isolates of P. aeruginosa obtained from 22 CF patients under alternate therapy with inhaled tobramycin and colistin. Resistance to tobramycin was observed in 27.5% of isolates. In contrast, all isolates were susceptible to colistin. Molecular typing of selected isolates suggested that only 1 clone occurred over time in each patient. To conclude, resistance to tobramycin in P. aeruginosa isolates from CF patients under antimicrobial therapy may occur while colistin resistance remains uncommon.

Life-threatening infection caused by daptomycin-resistant Corynebacterium jeikeium in a neutropenic patient.

Daptomycin is a novel lipopeptide antibiotic agent approved for the treatment of gram-positive life-threatening infections. Here we report, for the first time, the isolation of a highly daptomycin-resistant strain of Corynebacterium jeikeium causing a life-threatening infection in a neutropenic patient undergoing cord blood transplantation for secondary acute myeloid leukemia.

Validation of Vitek 2 nonfermenting gram-negative cards and Vitek 2 version 4.02 software for identification and antimicrobial susceptibility testing of nonfermenting gram-negative rods from patients with cystic fibrosis.

Accurate identification and antimicrobial susceptibility testing (AST) of nonfermenters from cystic fibrosis patients are essential for appropriate antimicrobial treatment. This study examined the ability of the newly designed Vitek 2 nonfermenting gram-negative card (NGNC) (new gram-negative identification card; bioMérieux, Marcy-l'Etoile, France) to identify nonfermenting gram-negative rods from cystic fibrosis patients in comparison to reference methods and the accuracy of the new Vitek 2 version 4.02 software for AST compared to the broth microdilution method. Two hundred twenty-four strains for identification and 138 strains for AST were investigated. The Vitek 2 NGNC identified 211 (94.1%) of the nonfermenters correctly. Among morphologically atypical microorganisms, five strains were misidentified and eight strains were determined with low discrimination, requiring additional tests which raised the correct identification rate to 97.8%. Regarding AST, the overall essential agreement of Vitek 2 was 97.6%, and the overall categorical agreement was 92.9%. Minor errors were found in 5.1% of strains, and major and very major errors were found in 1.6% and 0.3% of strains, respectively. In conclusion, the Vitek NGNC appears to be a reliable method for identification of morphologically typical nonfermenters and is an improvement over the API NE system and the Vitek 2 GNC database version 4.01. However, classification in morphologically atypical nonfermenters must be interpreted with care to avoid misidentification. Moreover, the new Vitek 2 version 4.02 software showed good results for AST and is suitable for routine clinical use. More work is needed for the reliable testing of strains whose MICs are close to the breakpoints.

Evaluation of new colorimetric vitek 2 yeast identification card by use of different source media.

The new colorimetric Vitek 2 YST card was evaluated for identification of yeasts (136 strains) with respect to the influence of different source media. The Vitek 2 YST card achieved satisfactory results for all yeast species tested, with the exception of Candida guilliermondii, Candida norvegensis, Candida parapsilosis, Candida rugosa, and Candida tropicalis. After simple additional tests, 93.7% of all the strains tested were correctly identified. A significant influence of the isolation medium on the identification rate could not be observed.

Prevalence and antimicrobial susceptibility of microorganisms isolated from sputa of patients with cystic fibrosis.

BACKGROUND: New emerging pathogens and associated antimicrobial resistance mechanisms have been observed in the respiratory tract of patients suffering from cystic fibrosis (CF) in the last years. Amongst others, the rate of metallo-beta-lactamase (MBL)-producing Pseudomonas aeruginosa strains is growing. However, there are no published data on the prevalence of MBL-producing P. aeruginosa in CF patients to our knowledge. METHODS: In this study, 271 sputum samples of 60 CF patients were collected during a 12-months period. Microbiological cultures and antimicrobial susceptibility tests of the most frequently isolated bacteria were performed. RESULTS: 464 bacterial and 414 fungal strains were isolated and characterized. 63.3% of the patients harbored Staphylococcus aureus, 50% P. aeruginosa, 16.6% Haemophilus influenzae, 15% Stenotrophomonas maltophilia and 13.3% non tuberculous Mycobacteria (NTM). Methicillin resistant S. aureus (MRSA) and MBL-producing P. aeruginosa were detected in 3 (5%) and 5 (8.3%) patients respectively. Among the fungi, Aspergillus fumigatus and Candida albicans showed the highest prevalence. CONCLUSIONS: The detection of MBL-producing P. aeruginosa and MRSA in CF patients confirms that antimicrobial resistance patterns should be always kept under surveillance. Moreover hygiene regulations in CF clinics should prevent a further spread of resistant bacterial strains.

Severe pyomyositis caused by Panton-Valentine leucocidin-positive methicillin-sensitive Staphylococcus aureus complicating a pilonidal cyst.

BACKGROUND: To our best knowledge, Panton-Valentine leucocidin (PVL)-positive methicillin-sensitive Staphylococcus aureus (MSSA) has not been described yet as cause for severe pyomyositis. CASE REPORT: We present a 23-year-old apparently healthy male patient without any typical predisposing findings who developed severe pyomyositis secondary to an operated pilonidal cyst. In the follow-up, the patient showed signs of immunocompromisation. The causative agent for purulent infection of multiple muscles was a MSSA strain harbouring PVL toxin. RESULTS: In the reported case, aggressive antibiotic and surgical treatment with additional application of immunoglobulins has lead to recovery from the disease without relapse. CONCLUSIONS: PVL-positive S. aureus are associated with skin diseases, multiple abscesses and often complicated by severe sepsis and necrotising pneumonia. Under such circumstances, the mortality rate can reach up to 75%. In addition, the PVL toxin can cause immunocompromisation and might be therefore involved in the aetiology of pyomyositis. Aggressive antibiotic and surgical treatment with additional application of immunoglobulins is recommended for treatment.

Group B streptococcus isolates from septic patients and healthy carriers differentially activate platelet signaling cascades.

Infection with group B streptococcus (GBS) is the most common cause of early onset neonatal sepsis in many countries, leading to neonatal morbidity and mortality. There is much evidence for a direct involvement of platelets in the pathogenesis of inflammation and sepsis. Several bacteria are known to directly interact with platelets leading to activation and aggregation, a phenomenon also observed with GBS. Here, we demonstrate that GBS rapidly bound to platelets; however, only strains isolated from septic patients bound fibrinogen on their surface and induced platelet thromboxane synthesis, platelet aggregation, and P-selectin (CD62P) expression. In contrast, GBS strains isolated from healthy newborns or healthy pregnant women induced only shape change, but not platelet thromboxane synthesis, platelet aggregation, or CD62P expression. All GBS strains investigated were able to activate FcgammaRIIA receptor signaling pathways including phospholipase C gamma2 (PLCgamma2), as well as calcium/calmodulin-dependent myosin kinase II (CaMKII) and phosphorylation of myosin light chain (MLC). In contrast, protein kinase C (PKC) was exclusively activated by GBS strains isolated from septic patients, and p38 mitogen activated protein kinase (p38 MAP kinase) was preferentially activated by septic GBS strains. Furthermore, stress signaling kinase SEK1/MKK4 and focal adhesion kinase (FAK) were activated by all tested GBS strains in a FcgammaRIIA-independent way. This study demonstrates that septic, but not colonizing, GBS strains bind fibrinogen on their surface, and that septic GBS strains influence platelet function not only via the FcgammaRIIA receptor, but also via pathways distinct from IgG-mediated signalling. These mechanisms lead to platelet aggregation and secretion, thereby possibly modulating the pathophysiologic course of GBS infections.

Fatal Clostridium tertium septicemia in a nonneutropenic patient.

Clostridium tertium septicemia is a rare condition that predominantly occurs in neutropenic patients with concomitant abdominal disease. We report the fatal case of a nonneutropenic, 51-year-old patient with mechanical ileus and post-operative C. tertium septicemia, resulting in widespread pathology with multi-organ failure. As C. tertium is aerotolerant, often gram-variable and mostly resistant to broad-spectrum cephalosporins, differentiation is difficult and empirical therapeutic strategies may fail.

Mycoplasma pneumoniae infection and Tourette's syndrome.

An association between infection and Tourette's syndrome (TS) has been described repeatedly. A role for streptococcal infection (PANDAS) has been established for several years, but the involvement of other infectious agents such as Borrelia Burgdorferi or Mycoplasma pneumoniae has only been described in single case reports. We examined antibody titers against M. pneumoniae and various types of antibodies by immunoblot in patients and in a sex- and age-matched comparison group. Participants comprised 29 TS patients and 29 controls. Antibody titers against M. pneumoniae were determined by microparticle agglutination (MAG) assay and confirmed by immunoblot. Elevated titers were found in significantly more TS patients than controls (17 vs. 1). Additionally, the number of IgA positive patients was significantly higher in the TS group than in the control group (9 vs. 1). A higher proportion of increased serum titers and especially of IgA antibodies suggests a role for M. pneumoniae in a subgroup of patients with TS and supports the finding of case reports implicating an acute or chronic infection with M. pneumoniae as one etiological agent for tics. An autoimmune reaction, however, has to be taken into account. In predisposed persons, infection with various agents including M. pneumoniae should be considered as at least an aggravating factor in TS.

Adult patients with nosocomial pneumonia: epidemiology, diagnosis, and treatment.

BACKGROUND: Nosocomial pneumonia is among the most common types of infection in hospitalized patients. The increasing prevalence of multi-drug resistant organisms (MDROs) in recent years points to the need for an up-to-date clinical guideline. METHODS: An interdisciplinary S3 guideline was created on the basis of a systematic literature review in the PubMed and Cochrane Library databases, with assessment and grading of the evidence according to the GRADE system. RESULTS: 9097 abstracts and 808 articles were screened in full text, and 22 recommendations were issued. It is recommended that any antimicrobial treatment should be preceded by a microbiological diagnostic evaluation with cultures of blood and respiratory samples. The diagnosis of nosocomial pneumonia should be suspected in any patient with a new or worsened pulmonary infiltrate who meets any two of the following three criteria: leucocyte count above 10,000 or below 4000/µL, temperature above 38.3°C, and/or the presence of purulent respiratory secretions. The initially calculated antimicrobial treatment should be begun without delay; it should be oriented to the locally prevailing resistance pattern, and its intensity should be a function of the risk of infection with MDROs. The initial treatment should be combination therapy if there is a high risk of MDRO infection and/or if the patient is in septic shock. In the new guideline, emphasis is laid on a strict de-escalation concept. In particular, antimicrobial treatment usually should not be continued for longer than eight days. CONCLUSION: The new guideline's recommendations are intended to encourage rational use of antibiotics, so that antimicrobial treatment will be highly effective while the unnecessary selection of multi-drug-resistant organisms will be avoided.

Isolation of Brucella melitensis biotype 3 from epidural empyema in a Bosnian immigrant in Germany.

Brucellosis is a regionally emerging infectious disease in Mediterranean countries with an increasing number of human cases and high morbidity rates. Here, we describe a case of severe B. melitensis biotype 3 infection in an immigrant who had contact with ruminants during a short-term stay in Bosnia before he returned to Germany. The patient developed thoracic spondylodiscitis accompanied by a large epidural empyema and neurological deficits. The isolated strain was characterized and compared to other strains from the Mediterranean region by multiple locus variable number of tandem repeat analysis, showing minor differences between emerging strains from neighbouring geographical areas.