Staphylococcus aureus bacteraemia in a UK tertiary referral centre: a 'transoesophageal echocardiogram for all' policy.

OBJECTIVES: Infective endocarditis (IE) is a feared complication in up to 38% of cases of Staphylococcus aureus bacteraemia (SAB). BSAC guidelines recommend echocardiography in all cases of SAB. The aim of this study was to determine the incidence of IE in SAB using transoesophageal echocardiography (TOE) as the first step in diagnostic imaging. This study also sought to identify clinical predictors that could improve stratification of those with and without IE. METHODS: A guideline was implemented that any SAB resulted in the microbiology department (i) recommending that the patient be referred for TOE and (ii) notifying the echocardiography department, resulting in streamlined listing of the patient for TOE. All cases of SAB were then assessed prospectively at University Hospitals Birmingham NHS Foundation Trust between September 2011 and October 2012. Previously identified risk factors for complicated S. aureus bacteraemia were recorded. RESULTS: There were 98 SAB episodes in total. TOE was performed in 58 (59%) with a further 22 episodes imaged by transthoracic echocardiography alone. IE was diagnosed overall in 13 (16%) cases investigated with echocardiography. No risk factor for IE other than presence of a cardiac device was detected in this group (P = 0.013). CONCLUSIONS: The rate of IE found in SAB is high when TOE is performed first line. There are no clear risk factors to improve yield or the type of echocardiography to be performed. Echocardiography should be performed in all cases and TOE should be considered where it is expected to influence management, as long as local resources allow.

Chronic Q fever: An ongoing challenge in diagnosis and management.

Chronic Q fever is a potentially fatal disease. The current difficulty in the diagnosis of this condition is discussed in the present article. A 51-year-old woman with a history of aortic valve replacement presented with complaints of feeling generally unwell, pyrexia and occasional unproductive cough over a period of several weeks. Phase 1 immunoglobulin G titre to Coxiella burnetii was initially detected at a low level (1:320, detected using immunofluorescence) and was not considered to be significant according to the modified Duke criteria. Later in the course of her illness, the patient's antibody titre rose to a high level (1:1280). The issues regarding current laboratory diagnosis and management of Q fever are discussed. Chronic Q fever can be associated with an inadequate serological response. Close follow-up of cases is essential. The recommended serological criteria for the diagnosis of Q fever endocarditis needs to be revisited.

La fièvre Q chronique est une maladie au potentiel fatal. Le présent article traite de la difficulté à la diagnostiquer. Une femme de 51 ans ayant des antécédents de remplacement de la valvule aortique a consulté parce qu'elle ne se sentait généralement pas bien et présentait une pyrexie et une toux non productive occasionnelle depuis plusieurs semaine. Les médecins ont d'abord décelé un faible taux du titre d'immunoglobuline en phase 1 à Coxiella burnetii (1:320, décelé par immunofluorescence), lequel n'était pas considéré comme significatif selon les critères de Duke modifiés. Plus tard au cours de l'évolution de la maladie, les titres d'anticorps de la patiente ont atteint un taux élevé (1:1 280). Les auteurs explorent les enjeux relatifs au diagnostic en laboratoire et au traitement de la fièvre Q. La fièvre Q chronique peut s'associer à une réponse sérologique inadéquate. Il est essentiel d'assurer un suivi étroit des cas. Il faudrait revoir les critères sérologiques recommandés pour diagnostiquer une endocardite à fièvre Q.

Bilateral proptosis in a child with vitamin C deficiency.

Scurvy is one of the oldest diseases known to mankind, caused by vitamin C deficiency. Nowadays it exists primarily in certain vulnerable populations such as patients with neurodevelopmental disabilities. Proptosis due to orbital haemorrhage is a rare complication of scurvy. Here we describe a case of diaplegic cerebral palsy presented with sudden onset of bilateral proptosis and swollen and tender knee joints. Subsequent computed tomography of the orbit revealed hematoma in the superior aspect of both orbits in the extraconal position. X-ray of the knee joints revealed bony changes consistent with scurvy. After 6 weeks of treatment with vitamin C orally, the proptosis and the bony changes returned to normal. Although scurvy is a rare disease in the general pediatric population, it still exists in certain vulnerable populations like neurologically disabled ones, and this uncommon cause for proptosis should be considered in such children.

Fulminant hepatitis and glomerulonephritis--a rare presentation of hepatitis A virus infection.

AIM: We report a case of fulminant hepatitis and glomerulonephritis by Hepatitis A virus infection. METHODS: We observed the patient's clinical course and analyzed his data retrospectively. RESULTS: The three-year-old boy presented with features of acute renal failure and stage 2 hepatic encephalopathy. Renal biopsy showed diffuse mesangioproliferative glomerulonephritis with immunoglobulin M and complement 3 deposition. After receiving supportive treatment for over 6 weeks, the hepatic and renal function became normal. Renal biopsy after 3 months was normal. CONCLUSION: Acute renal failure is a rare complication of Hepatitis A virus infection. Physicians should be aware of the potential renal involvement of Hepatitis A virus infection as the prognosis is not always favourable.

Clinical evaluation of a chlorhexidine intravascular catheter gel dressing on short-term central venous catheters.

BACKGROUND: A major source of microbial colonization of short-term central venous catheters (CVC) is the patients' endogenous skin microorganisms located at the CVC insertion site. The aim of this study was to determine if a transparent film dressing incorporating a 2% (weight/weight) chlorhexidine gluconate (CHG) gel decreases CVC and insertion site microbial colonization compared with a nonantimicrobial dressing in adult patients in critical care. METHODS: On CVC removal, samples for microbiological investigation were taken from both the skin surrounding the CVC insertion site and also from sutures securing the CVC. The sutures and intradermal and tip sections of the CVC were also collected for microbiological investigation. Microorganisms recovered from the samples were subsequently tested for susceptibility to CHG. RESULTS: There was a significant reduction in the number of microorganisms recovered from the CVC insertion site, suture site, sutures, and catheter surface in the CHG dressing group (n = 136) compared with the nonantimicrobial dressing group (n = 137). There was no significant difference in susceptibility to CHG between the microorganisms isolated from the CHG and standard dressing study patients. CONCLUSION: A film dressing incorporating a CHG gel pad significantly reduced the number of microorganisms at the CVC insertion and suture sites with concomitant reduced catheter colonization.

Analysis of Outcome of Intraplueral Streptokinase in Pediatric Empyema Thoracis even in Advanced Stages: A Prospective Study.

BACKGROUND: Empyema thoracis in children causes significant morbidity. Standard treatment of Empyema thoracis includes tube drainage and antibiotics. But the tube drainage often fails. Intrapleural Streptokinase has been used in empyema thoracis with good success rate. OBJECTIVES: We evaluated the efficacy of intra-pleural Streptokinase in management of empyema thoracis even in advanced stages. PATIENTS AND METHODS: A total of 28 patients with empyema thoracis requiring intercostal tube drainage aged zero to twelve years were included in the study who were admitted in Pediatric intensive care unit. 15,000 units/kg of Streptokinase was instilled into the pleural cavity. Response was assessed by clinical outcome, after unclamping and subsequent chest radiography and serial chest ultrasounds. RESULTS: Streptokinase enhanced drainage in all patients with complete resolution of empyema thoracis in 26 patients. Two patients were referred for surgery. Only 7.2% required surgery. Streptokinase was equally effective if started before or after seven days. CONCLUSIONS: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema thoracis even in advanced stages and can avoid surgery.

An Atypical form Rhizomelic Chondrodysplasia Punctata in a Newborn.

Rhizomelic Chondrodysplasia punctata (RCDP) is an autosomal recessive metabolic disorder affecting mainly peroxisomal function. We describe a case of RCDP in a 12 days old newborn based on the clinical and radiological ground without any major systemic structural or functional abnormalities.

Methicillin-resistant Staphylococcus aureus bacteremia: epidemiology, outcome, and laboratory characteristics in a tertiary referral center in the UK.

OBJECTIVE: To analyze the recent epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in a UK tertiary referral center. METHODS: We collected epidemiological and laboratory data on all cases of MRSA bacteremia from September 1, 2005 to December 31, 2007. RESULTS: There were 195 clinically significant episodes. Most were hospital-acquired. Only one episode occurred in patients without a history of hospital admission in the previous 12 months. An intravascular device was the most common focus of infection (37%), with no identifiable source found in 35% of episodes. Twenty-eight percent of patients died within 30 days of bacteremia. Mortality was significantly higher in the absence of an identifiable focus. Failure to include an antibiotic active against MRSA in the empirical treatment was only significantly associated with death in patients showing signs of hemodynamic instability (p < 0.001). No isolates had a minimum inhibitory concentration to vancomycin above 1.5mg/l and no heteroresistance to glycopeptide antibiotics (heteroresistant vancomycin-intermediate Staphylococcus aureus; hVISA) was detected. All isolates were sensitive to daptomycin, tigecycline, and linezolid. CONCLUSIONS: Despite improvement in infection control measures, medical devices remain the most common source of infection. Inappropriate empirical antibiotic usage is associated with a poor outcome in patients with signs of severe sepsis. Susceptibility to glycopeptides and newer antibiotics remains good.