Volume 22, Issue 2, 2014
Review
Carbapenemase reports from the Balkans: a systematic review
Meletis Georgios,
Oustas Efstathios,
Bagkeri Maria
The spread of carbapenemase-producing bacteria constitutes a worldwide problem of major importance to public health. The detection of these enzymes is often reported by most European countries and infection control measures are implemented in order to limit their dissemination. Despite the strong evidence indicating the Balkans as a reservoir for carbapenemase-encoding genes, especially for NDM-1, data published in the English literature seem to be scarce for many of the Balkan countries. We systematically reviewed studies on carbapenemase-producing bacteria from each country of the Balkan Peninsula and correlated them with foreign reports on carbapenemase detection due to patient transfer from the Balkans to the rest of Europe.
Anidulafungin versus fluconazole: clinical focus on IDSA and ESCMID guidelines
De Rosa Francesco Giuseppe,
Cattel Francesco,
Corcione Silvia,
D’Avolio Antonio,
Di Perri Giovanni,
Motta Ilaria
Invasive infections by Candida spp. play a major role in the management of the critically ill patient. Rates of positive blood cultures for Candida species have risen fivefold in the past ten years, placing this pathogen between the fourth and the sixth-leading cause of nosocomial bloodstream infections in the United States and Europe. Candida albicans is still the cause of approximately 50% of invasive candidiasis, with heterogeneous epidemiology. The echinocandin class, along with voriconazole and liposomal amphotericin B, was recommended by 2009 IDSA guidelines with AI evidence for the treatment of candidaemia, reserving the use of fluconazole in selected situations. Conversely fluconazole was downgraded to CI recommendation (“marginal use”), with BI evidence for voriconazole and liposomal amphotericin B, maintaining AI (“strong support”) for echinocandins by 2012 ESCMID guidelines for the diagnosis and management of Candida disease in non-neutropenic adult patients. Our brief analysis of randomized trials, whereby recommendations are supported, aims to discuss the possible reasons for the different consideration of fluconazole by the two above mentioned guidelines.
Original article
Effect of oral cephalexin in the treatment of BCG lymphadenitis
Ayazi Parviz,
Mahyar Abolfazl,
Taremiha Alireza,
Ghorani Najmeh,
Esmailzadehha Neda
Lymphadenitis and abscess formation are the most common side effects of vaccination with Bacille Calmette Guerin (BCG). The lower the child’s age at the time of vaccination, the higher the incidence of BCG lymphadenitis tends to be. Although various therapeutic approaches are in use for the treatment of BCG lymphadenitis, there is no consensus on which of them is optimal. This study aimed to determine whether oral cephalexin treatment hastens recovery from BCG lymphadenitis. The study involved 40 children (24 boys and 16 girls) with BCG lymphadenitis who were referred to Qazvin Children’s Hospital, Qazvin University of Medical Sciences between December 2008 and the end of September 2009. The patients were randomly assigned to two groups of 20 patients each (12 boys and 8 girls in each group): group A patients did not receive any treatment and served as controls, and group B patients were treated with 50 mg/kg/day cephalexin syrup, administered in four doses, for 10 days. In all patients, clinical examination was normal, except for lymphadenitis. In all patients, BCG vaccination had been performed at birth, and polymerase chain reaction tests were positive for tuberculous bacilli. The recovery period and requirement of fine needle aspiration did not significantly differ between the two groups (P > 0.05). This study showed that treatment with cephalexin does not hasten recovery from BCG lymphadenitis.
Budget impact analysis of efavirenz daily dose reduction at the Verona University Hospital
Costa Enrico,
Biasi Valeria,
Concia Ercole,
Jommi Claudio,
Lattuada Emanuela,
Manfrè Silvia,
Venturini Francesca,
Lanzafame Massimiliano
Efavirenz is a non-nucleoside-reverse-transcriptase-inhibitor used as part of highly-active-antiretroviral-therapy for the treatment of the human immunodeficiency virus (HIV) type 1 infection. The present paper aims to describing the impact of efavirenz dose reduction on the pharmaceutical budget at the Verona University Hospital. A budget impact analysis comparing two prescribing scenarios was conducted: all patients treated with the efavirenz full dose (600 mg per day) vs. a proportion of patients treated with a reduced dose (200-400 mg per day). All outpatients referring to the Infectious Disease Clinic in the period November 2009-October 2011 were selected. Out of 132 patients treated with efavirenz, 25 were not considered, mainly due to a too short treatment period. Of the remaining 107 patients, 68 received the full dose, while 39 received a reduced dosage. The analysis included the cost of the drug and of diagnostic tests, from the National Health Service perspective. The daily dose reduction of efavirenz saved 54,664 euros (a 30% expenditure reduction). In sum, new strategies for pharmaceutical system sustainability are necessary; despite forthcoming expiring patents of several drugs, spending on antiretroviral drugs is expected to rise. This paper suggests a way of linking clinical benefits and cost reduction.
Trends in infective endocarditis in a medium-sized University Hospital in Italy: analysis of 232 cases
Pallotto Carlo,
Martinelli Laura,
Baldelli Franco,
Bucaneve Gianpaolo,
Cecchini Enisia,
Malincarne Lisa,
Pasticci Maria Bruna
The aim of this study was to evaluate the epidemiological and clinical characteristics of 232 cases of infective endocarditis (IE), admitted to the Clinica delle Malattie Infettive of Perugia Italy from 1973 to 2012. The analysis was retrospective until 2004. After this year, all the consecutive IE cases were included by utilizing the same prospective observational protocol of the Italian Study on Endocarditis (SEI). Out of 232 EI cases, 200 (86.2%) were definite. Over the 40-year period, a statistically significant increase was observed in the patients’ age, the rate of IE admissions and prosthetic device IEs. The rate of healthcare-associated IEs also increased in the last 10 years (p=NS). Diabetes mellitus was the most frequent comorbidity. There were no variations in the rate of S. aureus and streptococcal IEs. Central nervous system complications and surgery were reported in 19.4% and 29.3% of the cases, respectively. The in-hospital mortality was 18.9%. In conclusion, the epidemiological and clinical trends of this study are in agreement with the literature. The difference in S. aureus endocarditis, neurological complications and surgery rates may be due to the fact that this was a single centre and, for its first part, a retrospective study. A shared, multidisciplinary protocol may be useful to improve the outcome of patients with IE and its epidemiology.
Case report
Listeria monocytogenes-associated meningitis and arthritis in an immunocompetent 65-year-old woman: a case report
Anyfantakis Dimitrios,
Volakakis Nikolaos,
Kosmidou Kiriaki,
Polimili Georgia,
Kastanakis Serafim
We report an unusual case of concurrent meningitis and infectious monoarthritis due to Listeria monocytogenes in a 65-year-old woman presenting to our department with a transient gastrointestinal tract illness. During hospitalization the patient’s neurological status deteriorated, presenting signs of meningeal irritation along with signs of inflammation and oedema of the right knee. Blood cultures and cultures of the cerebrospinal fluid and of the sinovial fluid aspirate showed growth of L. monocytogenes gram positive rods. The patient received a three-week course of intravenous meropenem with significant improvement. To the best of our knowledge this is the first case of concurrent listerial meningitis and arthritis in an immunocompetent patient. Despite the rarity of the disease in healthy individuals a high index of suspicion is required for unusual manifestations of listerial infections especially among high risk groups such as the elderly.
An atypical deep neck infection in a two-year-old child
Raffaldi Irene,
Scolfaro Carlo,
Garazzino Silvia,
Peradotto Federica,
Calitri Carmelina,
Tovo Pier-Angelo
Non-tuberculous mycobacteria are one of the major causes of lymphadenitis in children and seldom of deep neck infections. We reported the case of an immunocompetent two-year-old girl with adenitis and retropharyngeal abscess caused by an atypical mycobacterium. She had a positive tuberculin skin test, whereas the QuantiFERON® TB Gold test was negative. The child underwent a complete nodal excision. The search for acid fast bacilli was positive and Mycobacterium scrofulaceum was isolated from the surgically removed material. The retropharyngeal abscess was treated only with antimicrobial therapy, which resulted in an appreciable size reduction of the abscess. After two months antimicrobial treatment was interrupted, and complete resolution was achieved after twelve months. No relapse of disease or possible long-term complications were observed. The surgical wound healed completely, with normal overlying skin and a good aesthetic result. The clinical management of atypical mycobacteria lymphadenitis and retropharyngeal abscess in children is discussed.
Chlamydia trachomatis conjunctivitis in a male teenager: a case report
Sulis Giorgia,
Urbinati Lucia,
Franzoni Alessandra,
Gargiulo Franco,
Carvalho Anna Cristina C.,
Matteelli Alberto
An 18-year-old man was seen at a Sexually Transmitted Infections (STIs) clinic for counselling and treatment of Chlamydia trachomatis genital infection which had been diagnosed during a screening survey of high-school students. For two months he had reported conjunctival hyperaemia, increased tearing, itching, and mucopurulent secretions, predominantly on the left eye. His ophthalmologist had made a diagnosis of follicular conjunctivitis and lower superficial punctate keratitis (left eye > right eye), irresponsive to topical treatment. Chlamydial conjunctivitis was suspected and confirmed by a positive nucleic acid amplification test (NAAT) performed on conjunctival scraping. The patient was treated with azithromycin 1 g single dose orally and tetracycline/betamethasone eye ointment for one month. A complete resolution of symptoms was observed three months after aetiological treatment. This case highlights the need to include C. trachomatis infection in the differential diagnosis of acute or chronic follicular conjunctivitis among sexually active young individuals.
Tuberculosis of the tongue in a patient with rheumatoid arthritis treated with methotrexate and adalimumab
Assante Luca Rosario,
Barra Enrica,
Bocchino Marialuisa,
Zuccarini Giacomo,
Ferrara Gerardo,
Sanduzzi Alessandro
In recent years Tumor Necrosis Factor alpha (TNFα) inhibitors have been highly effective in treating rheumatoid arthritis (RA). However, patients receiving these inhibitors have an increased risk of developing tuberculosis (TB). We describe a rare case of tuberculosis of the tongue in an RA patient treated with methotrexate (MTX) and the TNFα inhibitor adalimumab (ADA) for the previous six years. Pre-treatment tuberculin skin test (TST) was negative. The patient was admitted to our division complaining of a sore throat for months. Clinical examination revealed a swollen non-healing ulcer at the base of the tongue, which was suspected to be a squamous cell carcinoma. Histopathological assessment unexpectedly revealed a chronic granulomatous inflammation compatible with tuberculosis. TST was strongly positive and the T-Spot-TB test was also reactive. MTX and ADA were discontinued and the patient received antituberculous treatment with complete healing of the lesion. After three months our patient had a worsening RA that was treated with MTX and rituximab with no TB-related adverse events. This case highlights the importance of considering tuberculosis in the differential diagnosis of ulcerative lesions of the oral cavity, especially in immunocompromised patients treated with TNFα inhibitors. Rituximab can be a valid alternative therapy in such patients.
Leclercia adecarboxylata bacteraemia in an immunocompromised patient with metabolic syndrome
Sánchez Porto Antonio,
Casas Ciria Javier,
Román Enri Manuela,
García Collado Sergio,
Bachiller Luque Ma.-Rosario,
Eiros Josè-Maria,
Leclercia adecarboxylata is being increasingly diagnosed as a causative agent of infection due to the availability of rapid molecular diagnostic techniques Few cases of bacteraemia in subjects with underlying medical conditions have been reported. We report a case of L. adecarboxylata bacteraemia in an immunocompromised patient with metabolic syndrome.
Seven cases of port-a-cath contamination caused by Pantoea agglomerans in the Oncological Service of Iseo Hospital, Brescia (Italy)
Izzo Ilaria,
Lania Donatella,
Castro Antonino,
Lanzini Fernanda,
Bella Daniele,
Pagani Adriano,
Colombini Paolo,
Pantoea agglomerans, a gram negative bacillus in the Enterobacteriaceae family, has been isolated from feculent material, plants and soil. Soft tissue and bone/joint infections due to P. agglomerans following penetrating trauma by vegetation and bacteraemia in association with intravenous fluid, total parenteral nutrition, blood products and anaesthetic agent contamination have been reported. Between October 2009 and January 2010 seven cases of port-a-cath contamination caused by P. agglomerans were observed in the Oncological Service of our hospital. All patients presented with septic fever after heparinization of the central venous catheter. 5/7 patients were female; mean age was 67 years (range 58-75). 6/7 patients were affected by colorectal adenocarcinoma, 1/7 by mammarian cancer. Mean time from CVC insertion was 23.8 months (range 13-42) at the time of fever. In three cases, port-a-cath was removed following the oncologist's prescription. P. agglomerans was isolated from the catheter tip in one case and from CVC blood culture in 6/7 cases. In all cases peripheral blood cultures were negative. Patients were treated with ciprofloxacin lock therapy and systemic therapy (per os), obtaining negative cultures from port-a-cath. Notwithstanding the absence of isolation of Pantoea strains from environmental cultures, after educational intervention, which underlined some faulty procedures in CVC management, no further cases were observed.
The Infections in the History of Medicine
Malaria in endemic areas of Northern Italy and in the Italian context: remedies and substitutes in the Nineteenth-Century Medical Practice
Vicentini Chiara Beatrice,
Manfredini Stefano,
Mares Donatella,
Lupi Silvia,
Guidi Enrica,
Contini Carlo
Some areas of Northern Italy, especially Ferrara during the nineteenth century, represent privileged observatories regard to malaria, a disease that affected the poor, but did not spare the rich and powerful people. The so-called Delta of the River Po, as well as the Maremma and other lowland areas in Italy, was particularly noted for its marshland environment (mosquito breeding grounds). Spared from Malaria because of the better hygienic conditions of the city that restricted the proliferation of anopheles, Ferrara represented an important study centre due to the presence of renowned physicians and scientists who exchanged knowledge and findings in the medical academies. Among these, Antonio Campana was very attentive to the latest scientific findings, and wrote about antimalarial remedies in his famous Ferrarese Pharmacopoeia. This paper analyses the main remedies listed in the various editions of Campana’s Pharmacopoeia since 1798 and particularly that of 1841, in the reports from the Accademia Medico-Chirurgica di Ferrara and of Argenta’s physicians of the mid-nineteenth century and in the Reports (1871 and 1876) from Alessandro Bennati, director of Arcispedale Sant'Anna and concerned with hospital practice. Other printed documents referring to the town of Argenta are discussed.
