Bactericidal activity of oxacillin and glycopeptides against Staphylococcus aureus in patients with endocarditis: looking for a relationship between tolerance and outcome.

BACKGROUND: There is no clear relationship between in vitro bactericidal activity tests and clinical outcome. We studied bactericidal activity of oxacillin, vancomycin and teicoplanin against Staphylococcus aureus isolates in patients with endocarditis and then we sought to determine if there was a relationship between in vitro bactericidal activity and clinical outcome. METHODS: Minimal bacteriostatic and minimal bactericidal concentrations were determined for Staphylococcus aureus strains isolated from patients with endocarditis following standardized methods. Medical records were reviewed retrospectively to collect data on antimicrobial susceptibility at admission, antimicrobial therapy, need for surgery, embolic events and outcome. RESULTS AND DISCUSSION: Sixty-two Staphylococcus aureus strains were studied in 62 patients with endocarditis. Overall, 91.9% definite, 21% methicillin resistant and 72.6% cured. Surgery was performed in 32.3% and embolic events were documented in 64.5%. Tolerance to oxacillin and teicoplanin was more common than vancomycin tolerance among methicillin susceptible Staphylococcus aureus. Among methicillin resistant Staphylococcus aureus teicoplanin was shown to have a higher rate of tolerance than vancomycin. No statistically significant differences on clinical outcome between oxacillin tolerant and oxacillin non tolerant Staphylococcus aureus infections were observed. Tolerance to oxacillin did not adversely affect clinical outcomes of patients with methicillin susceptible Staphylococcus aureus endocarditis treated with a combination of antimicrobials including oxacillin. The cure rate was significantly lower among patients with methicillin resistant Staphylococcus aureus endocarditis. CONCLUSIONS: In vitro bactericidal test results were not valid predictors of clinical outcome. Physicians need to use additional parameters when treating patients with staphylococcal endocarditis.

Prevalence, incidence and clinical outcome of hepatitis B virus and hepatitis C virus hepatitis in patients undergoing allogeneic hematopoietic stem cell transplantation between 2001 and 2004.

The prevalence, incidence and clinical course of viral hepatitis were prospectively determined in consecutive recipients of T-cell depleted hematopoieic stem cell transplants (49 mismatched, 60 matched, mean age 38 years; range 11-65). The prevalence of hepatitis B virus (HBV) was 15.6% and that of hepatitis C virus was 3.7% (HCV). HBV reactivated in one patient. Another developed ex novo acute hepatitis B which progressed to chronic hepatitis. There were no new cases of hepatitis C or worsening of pre-transplant HCV infections. HBV and HBC did not affect the outcome of T-cell depleted hematopoieic stem cell transplantation. Surveillance is important given the risk of HCV and HBV infection and/or reactivation and the efficacy of the new anti-hepatitis drugs.

Impact of treatment with protease inhibitors on aortic stiffness in adult patients with human immunodeficiency virus infection.

BACKGROUND: The role of antiretroviral therapy in acceleration of atherosclerosis in patients with human immunodeficiency virus (HIV) infection is controversial. We hypothesized that aortic stiffness, an early marker of arteriosclerosis, may be increased in HIV patients treated with protease inhibitors. METHODS AND RESULTS: In 32 HIV-infected patients treated with protease inhibitors and 32 age-, sex-, and blood pressure-matched HIV-uninfected control subjects, we obtained aortic pulse wave velocity and central aortic pressure waveform, from which aortic augmentation was calculated. HIV patients had a higher aortic pulse wave velocity (7.6+/-1.1 versus 6.8+/-1.2 m x s(-1), P=0.015) and aortic augmentation (6.8+/-5 versus 4.6+/-4 mm Hg, P=0.037) than control subjects. Age and HIV infection (both P<0.05) independently predicted aortic pulse wave velocity when a consistent number of cardiovascular risk factors was simultaneously controlled for. The cumulative duration of treatment was a predictor of aortic pulse wave velocity, each 5 years of treatment duration being independently related to a 1.35 m x s(-1) increase in pulse wave velocity. CONCLUSIONS: Aortic stiffness is increased in HIV-positive individuals receiving antiretroviral therapy including a protease inhibitor. Pulse wave velocity increases with longer exposure to protease inhibitors. We hypothesize that arteriosclerosis is a side effect of antiretroviral treatment including a protease inhibitor.

Pulsed field gel electrophoresis and random amplified polymorphic DNA molecular characterization of Ralstonia pickettii isolates from patients with nosocomial central venous catheter related bacteremia.

Over a period of 18 months 3 clusters of central venous catheter-related Ralstonia pickettii bacteremia occurred in 3 different units of the same hospital. In order to investigate the relatedness of the clinical isolates we studied 15 strains using pulsed-field gel electrophoresis (PFGE) and randomly amplified polymorphic DNA (RAPD) techniques. The combined analysis of the results obtained by these two methods led us to conclude that all the patients except one were infected by a single clone comprising two variants circulating in the units. Only one case was due to a different strain, probably originating outside the ward. PFGE and RAPD appear to be discriminatory techniques to study the clonal relationship among the isolates and can represent a good tool to perform the epidemiological investigation of an outbreak.

Acute transverse myelitis and hepatitis C virus.

In the last few years, substantial evidence has been provided on peripheral nervous involvement in infection by hepatitis C virus (HCV), whilst central nervous involvement is rare. Here, we report a case of acute transverse myelitis in a woman developing 4 years after documented HCV seropositivity, associated with intrathecal anti-HCV protein IgG. Isoelectrofocusing of all CSF samples before and after immunoabsorption with recombinant structural HCV proteins revealed disappearance or marked decrease of some oligoclonal IgG bands suggesting binding to HCV proteins. To our knowledge, this is the first report of acute myelitis associated with intrathecal immune response against HCV proteins. This finding suggests that in acute myelitis of unknown aetiology, testing CSF for HCV RNA and related antibodies is warranted.

[Nosocomial post-neurosurgery meningitis due to Corynebacterium jeikeium]. / Meningite nosocomiale post-neurochirurgica da Corynebacterium jeikeium.

Among the post neurosurgery infections the meningitis due to Corynebacterium jeikeium are rare, particularly without central nervous system devices. We report a case of a 78 year-old patient with chronic myeloproliferative syndrome, who developed an acute meningeal syndrome by Corynebacterium jeikeium post hypophyseal macroadenoma resection.

Leishmaniasis in patients with chronic renal failure: a diagnostic and therapeutic challenge for the clinician.

BACKGROUND: The role of leishmaniasis in dialyzed or transplanted patients for chronic renal failure is generally neglected. In this study, the authors present a series of three cases of leishmaniasis (one visceral, one mucous and one muco-visceral) in patients with end-stage renal failure characterized by an atypical presentation and/or resistance to therapy. CASE DESCRIPTION: Two patients had an atypical infection: the first patient demonstrated a mucosal form, while the second had visceral and mucosal involvement. These two presentations are very rare and, to the best of our knowledge, other autoctonous disease cases have never been described in Italy. In the first patient, a cycle of oral itraconazole was scarcely effective and poorly tolerated, while treatment with 15% topical paromomycin sulfate was successful. Patients two and three failed to respond to meglumine antimonate and amphotericin B lipid complex. A second cycle with liposomal amphotericin B was effective in both cases. In addition, a superior safety profile for liposomal amphotericin B in comparison with the lipid complex amphotericin B was observed. CONCLUSIONS: These three cases highlight the problem of leishmaniasis in both renal transplanted and dialyzed patients and suggest that this infection could be far from infrequent in addition to being resistant to therapies. Leishmaniasis should be considered in the differential diagnosis of fevers of unknown origin and mucosal lesions in these patients, even in countries not at risk for mucosal leishmaniasis.

Primary brain abscess with Nocardia farcinica in an immunocompetent patient.

In this paper, we describe a case of an immunocompetent patient with cerebral nocardiosis. The onset was with loss of strength, paresthesia and focal epilepsy of the left arm. MRI showed on T2-weighted sequences a hyperintense central area of pus surrounded by a well-defined hypointense capsule and surrounding edema; on T1-weighted sequences a hypointense necrotic cavity with ring enhancement following administration of intravenous gadolinium. The patient underwent surgical excision of the abscess but culture from the specimen was negative. After 40 days of empirical antimicrobial therapy he developed neurological deterioration with focal epilepsy. A new MRI documented an enlargement of the hypointense lesion in the right frontal-parietal region. A second craniotomy with drainage of the abscess was performed; cultures yielded Nocardia farcinica. Therapy with trimethoprim/sulfamethoxazole, amikacin and meropenem was given for 35 days, and clinical and radiological improvement was observed. Home therapy was done with oral trimethoprim/sulfamethoxazole. Currently, 5 months from the second surgery, the patient can walk with support and no new episodes of epilepsy occurred. Side effects were absent from therapy. The MRI appearance of the brain lesion has improved, with a decrease in size, surrounding edema and ring enhancement.

Outbreak of infusion-related septicemia by Ralstonia pickettii in the Oncology Department.

Hospital acquired blood stream infection by Ralstonia pickettii in 9 cancer patients related to the heparin solution contamination used to flush the central venous catheter.

Nosocomial Aspergillus flavus wound infections following cardiac surgery.

In this report we describe three cases of Aspergillus flavus sternal wound infection following cardiac surgery. All three cases occurred in a 3-month period coinciding with hospital renovation activities. The patients were successfully treated with combined surgical and medical therapy.

Late onset opportunistic infections in a renal allograft recipient: a case report.

In renal allograft recipients, infection disease complications remain an important cause of morbidity and mortality during the post-transplant period. This complication occurs more frequently from 1 to 6 months after transplant. The epidemiology of infection during the postoperative period is less well characterized, because recipients routinely reside at home. We describe a case of late onset Candida albicans and HSV-1 esophagitis, and Pneumocystis carinii pneumonia, that occurs 9 years after renal transplantation in a patient with severe CD4+ T-lymphocytopenia and hypogammaglobulinaemia. We underline the importance of monitoring immunosuppressive therapy in these patients and the usefulness of prophylaxis against P. carinii pneumonia

Diagnostic considerations about visceral leishmaniasis. Two case report.

UNLABELLED: Two cases of visceral leishmaniasis (VL) in immunocompetent patients have been described. Both patients lived in endemicic areas for leishmaniasis in the south of Italy, tested positive for anti-Leishmania antibodies. A definitive diagnosis of VL was delayed by false negative microscopic examinations. Both patients were treated successfully with liposomal amphotericin B. CONCLUSIONS: Immuno Fluorescent Assay (IFA) performed as an available test. It helped to pursue the correct diagnosis and therapy. Microscopy is reported to be highly sensitive and specific in the diagnosis of VL, nevertheless it may yield false negative results when examined in laboratories without good expertness.

Drawbacks of antibiotic susceptibility of Streptococcus pneumoniae.

During 10 years penicillin resistance among clinical isolates of S. pneumoniae was more or less stable. The cumulative proportion of penicillin non susceptible S. pneumoniae (PNSP) was 13.0%; 7.2% when isolates with MIC = 2 mg/l were considered. Among PNSP only 2 strains were isolated from sterile body fluids, one having MIC >3.84 mg/l. Lack of susceptibility to cotrimoxazole was 38.4%. All isolates were susceptible to ceftriaxone, levofloxacin, moxifloxacin, and quinupristin-dalfopristin.

[Nosocomial infections in a general surgical ward]. / Le infezioni nosocomiali in un reparto di chirurgia generale.

According to the National Nosocomial Infection Surveillance system we analysed the post-surgical nosocomial infections in a surgery ward of Perugia University. Between May 2000 and April 2001, 677 patients were enrolled mean age 51.5 years: 355 (52%) male, 462 (68%) ASA score 1, "clean" surgery in 355 cases (52%), cephazolin prophylaxis in 256 (38%); 11 (2%) patients deceased perioperatively. A total of 37 nosocomial infections, in 33 patients, were detected: 18 pneumonia (48.6%), 10 surgical site infections (27%) with 18 isolated: 12 gram-negative (E. coli 3, Acinetobacter baumannii 2, Providencia stuartii 2, Pseudomonas aeruginosa 2, Achromobacter spp. 1, Citrobacter freundii 1, Morganella morgani 1) and 6 gram-positive (Staphylococcus aureus meticillin resistant 3, Enterococcus faecalis 2, Streptococcus salivarius 1); 7 sepsis (19%) due to 7 gram-positive (S. aureus meticillin resistant 4, S. aureus meticillin susceptible 1, Staphylococcus coagulase negative 1, Clostridium spp 1), 2 urinary tract infections (5.4%). Patients without infections and with nosocomial infections spent in hospital 6.3 and 16.6 days respectively. We can image that in one year 53 surgical procedure were lost, with a lost gain of 79.500-291.500 euro/year.

[Nosocomial infections in vascular surgery: 1-year surveillance]. / Infezioni nosocomiali in chirurgia vascolare: un anno di sorveglianza.

Among the hospital related complications the nosocomial infections are a major source of problems, especially in the Intensive Care and in the Surgery Units. It has been clearly demonstrated that infection control programs, in Surgery Units, have a large benefit in the reduction of surgical site infections (SSIs) rates. The surveillance method, sponsored by the Centers for Diseases Control of Atlanta, is the most consolidated system and it is active since '70 years. We used this method in the Vascular Surgery Unit of Perugia Hospital. During a 12-month period, 668 consecutive patients were enrolled and followed, after surgery, for 30 days (without implantable devices) or 1 year (with prosthesis). A total of 14 (2.1%) patients had SSIs: 4 superficial, 4 deep, 6 organ-space. We isolated 13 pathogens: 8 gram-positive, 4 gram-negative, and one Candida albicians. The most prevalent pathogen isolated was Staphylococcus aureus methicillin-susceptible. This first positive experience will be used for further more generalized work involving the principal surgical Unit of the Umbria Region.

[Clinico-microbiological comments on various cases of candidemia]. / Osservazioni clinico-microbiologiche su alcuni casi di candidemia.

During a 3 year period 48 patients with one or more blood cultures positive for Candida spp. were enrolled in the study. One patient presented 3 consecutives episodes of candidemia with infection of the port a cath. Fifty cases of candidemia were diagnosed. Candidemia with infection of the central venous catheter was the most frequent diagnosis (52%); in 20% of cases a tissue localization was also present (disseminated candidiasis). Thirty-four out of 50 episodes occurred in the Surgical Department. Among risk factors the most frequent resulted: prolonged antibiotic treatment (100%), intravascular catheter (86%), parenteral nutrition (74%), abdominal surgery (46%). C. albicans was identified more frequently than others Candida spp., resistance to fluconazole was detected in 20% of strains tested. 34/45 episodes of fungemia were treated with fluconazole, none reported side effects. In 5 cases fluconazole was discontinued for clinical failure. Clinical outcome in patients with Candida infection depends on other factors beside in vitro drug susceptibility tests.

[Clinical criteria to diagnosing of streptococcal pharyngitis in young adult patients]. / Criteri clinici per la diagnosi di angina streptococcica in giovani adulti.

Most sore throat is due to viral upper respiratory tract infections, whereas the frequency of antibiotic use in adult patients is about 73%. We evaluate the clinical guidelines (approved by the CDC) about appropriate antibiotic use for acute pharyngitis in young adults. We observe a low prevalence (3,2%) of group A beta haemolytic streptococcus (GABHS) in a population of university students. Minimizing unnecessary antimicrobial therapy in this setting is highly desirable. Use of clinical criteria (Centor algorithm) does indeed identify patients whose risk for GABHS infection is so low that microbiological testing or antibiotic treatment is unnecessary.

[Epidemiological, clinical and therapeutical aspects of HIV/HCV coinfection in a series of HIV seropositive Umbrian patients]. / Epidemiologia, clinica e terapia della coinfezione HIV-HCV in una casistica di pazienti umbri.

Because hepatitis C virus (HCV) and human immunodeficiency virus (HIV) share common transmission pathways, HIV-HCV co-infection is frequent, involving about 40% of seropositive subjects particularly injection drug users and patients with hemophilia. We performed a retrospective analysis on clinical, epidemiological and therapeutical aspects in a population of HIV-HCV coinfected patients, observed in our Department during the period 2001-2003. Forty per cent of 404 observed patients had a co-infection; 90% of those were drug addicts and most (90.2%) were on HAART treatment. Seventy-three per cent of co-infected patients showed transaminases alterations, and 85% had detectable viremia. Prevalent genotypes were 1 (44.6%) and 3 (36.4%). The association PEG-IFN and ribavirine obtained sustained responses in 55% of 9 treated patients.