Volume 23, Issue 2, 2015
Review
Methicillin-resistant Staphylococcus aureus infections: role of daptomycin/β-lactams combination
Leone Sebastiano,
Noviello Silvana,
Boccia Giovanni,
De Caro Francesco,
Esposito Silvano
Methicillin-resistant Staphylococcus aureus (MRSA) associated infection has become a worrisome issue worldwide. Glycopeptides are the backbone antibiotics for the treatment of MRSA infections. However, several reports have highlighted the limitations of vancomycin. Daptomycin is successfully used for the treatment of serious MRSA infections, however selection of resistant strains has been reported during daptomycin-monotherapy. This review will briefly discuss the available data on daptomycin/β-lactam combination therapies for the treatment of MRSA infections.
Candidemia, and infections Clostridium difficile and carbapenemase-producing Enterobacteriaceae: new enteropathogenetic opportunistic syndromes?
De Rosa Francesco Giuseppe,
Corcione Silvia,
Raviolo Stefania,
Montrucchio Chiara,
Aldieri Chiara,
Pagani Nicole,
Di Perri Giovanni
In this paper we analyze three “enteropathogenetic” opportunistic infections represented by Candida spp., C. difficile and carbapenemase-producing K. pneumoniae. The common pathogenetic pathway is based on an alteration of the intestinal flora, now mainly referred as the human microbiome, with secondary opportunism for infections caused by Candida, C. difficile and carbapenemase-producing Enterobacteriaceae (“CCC”). We highlight the epidemiology, risk factors, clinical syndromes associated with the pathogens and we propose some new issues related to the epidemiology and diagnosis of candidemia, also using hierarchical cluster analysis, definitions of levels of interventions in patients colonized or infected by carbapenemase-producing bacteria. The “enteropathogenetic” opportunistic syndromes are best prevented with antimicrobial stewardship programs aiming at increasing diagnostic specificity of infectious syndromes to reduce the antimicrobial use and costs. Appropriate guidelines for infection control should also be implemented to reduce the nosocomial spread of “enteropathogenetic” microbes.
Original article
Medical care related laboratory-confirmed bloodstream infections in paediatrics
Virano Silvia,
Scolfaro Carlo,
Garazzino Silvia,
De Intinis Carlo,
Ghisetti Valeria,
Raffaldi Irene,
Calitri Carmelina,
Tovo Pier Angelo
The aim of this survey was to describe the incidence, epidemiology, microbiology, risk factors and outcome of medical care related laboratory-confirmed bloodstream infections (LCBIs) observed during a twelve-month prospective study in a Paediatric Teaching Hospital in Turin, Italy. Inclusion criteria were clinical signs of sepsis and positivity of one or more of the following tests: blood culture, polymerase chain reaction for bacterial and fungal DNA on blood, and culture on intravascular device tips. In all, 140 episodes of sepsis were documented in 131 children: 37 (26.4%) were healthcare outpatient-associated, 91 (65.0%) healthcare-associated and 12 (8.6%) community-acquired. The overall incidence of healthcare-associated LCBIs was 13.6/1,000 hospitalized patients and incidence density 1.4/1,000 inpatient days. The overall mortality was 3.9%. Forty-seven (36.7%) episodes involved newborns and 107 (83.6%) episodes were observed in children with an indwelling central venous catheter. Coagulase-negative staphylococci (26.8%), Staphylococcus aureus (15.2%), Escherichia coli (8.7%) and Candida spp. (7.2%) were responsible for the majority of cases. 9.5% of S. aureus isolates were methicillin-resistant and 6.5% of Gram negatives were extended-spectrum beta-lactamase-producing. Incidence and epidemiology of medical care related LCBIs were similar to the existing literature data. LCBIs caused by antibiotic-resistant microorganisms were fewer and mortality rate was lower. Most of the LCBIs recorded involved newborns and oncological children.
Experience of influenza A H1N1 in a paediatric emergency unit
Biçer Suat,
Sariçoban Hülya Ercan,
Özen Ahmet Oğuzhan,
Saf Coşkun,
Ulutaş Pinar Ergenekon,
Gürol Yeşim,
Yilmaz Gülden,
Vitrinel Ayça,
Özelgün Berna
This study was carried out to evaluate symptoms, clinical findings, treatment options and complications of H1N1 influenza infection in patients who applied to our emergency unit during the influenza season in 2009. The clinical and laboratory findings of children with influenza A (H1N1) during the influenza season in 2009 were evaluated retrospectively. Influenza A was diagnosed by polymerase chain reaction and/or rapid antigen test. Clinical and laboratory findings of the patients with H1N1 (group I) and without H1N1 (group II) were compared. Fever and myalgia were noted to be higher in group I (p <0.05). The mean body temperature in group I was 39.0℃, which was statistically different from group II (p <0.001). Myalgia was observed only in group I (15.4%), but not in group II (p <0.05). There were three patients with diarrhoea, two of whom were in group I, and they had no significant respiratory symptoms. Lymphopenia was seen in 18 patients (81.8%) in group I and in four patients (23.5%) in group II (p <0.05). Oseltamivir treatment was applied to 28 patients, where 24 had severe symptoms, nine had comorbid factors and two did not have any of these. The fever was higher in group I and myalgia was present only in group I. In group I, the lymphocyte count was significantly lower than in group II. The fever was higher in patients of H1N1 (average of 39°C) and myalgia was present only in patients with H1N1. The lymphocyte count was significantly lower in patients with H1N1 than those without H1N1. While none of the patients required intensive care, three patients requiring hospitalization were discharged after referral and completion of their treatment.
Role of ITPA and IL28B variants in the management of chronic hepatitis C treatment
Zampino Rosa,
Alessio Loredana,
Marrone Aldo,
Stanzione Maria,
Boemio Adriana,
Grandone Anna,
Minichini Carmine,
Pisaturo Mariantonietta,
Starace Mario,
Adinolfi Luigi Elio,
Sagnelli Evangelista,
Coppola Nicola
The inosine triphosphatase (ITPA) gene and interleukin 28B (IL28-B) gene variants have been associated to protection of anemia and sustained virological response, respectively, in patients with chronic hepatitis C (CHC) during antiviral therapy. Aim of this study was to evaluate the single and combined role of both polymorphisms in the management of peg-interferon-ribavirin treatment in CHC patients.
We studied 79 Italian patients with histology proven CHC treated with pegylated interferon plus ribavirin for 6-12 months on the base of HCV genotype. Patients were carefully followed-up for anemia development which was classified as mild, moderate or severe in relation to levels of haemoglobin decreasing; ribavirin dosage reduction and/or epoietin administration were carried out, where needed. Sustained virological response (SVR) was considered for HCV-RNA clearance after 6 months of treatment stop.
Decay of haemoglobin at month 1 of treatment significantly correlated with ITPA activity (p=0.0004) and at multivariate analysis ITPA activity was the only parameter associate with anemia (R= - 0.4; p = 0.0004). SVR was obtained in 47% of patients. IL28B CC variant was associated with SVR (p= 0.01), but IL28B polymorphisms had no influence on the ITPA polymorphism.
This study confirms the role of ITPA variants in the prediction of development of severe anemia during antiviral treatment for CHC and demonstrates the absence of influence of IL28B variant on ITPA polymorphisms. These two polymorphisms can be useful in the management of patients that need antiviral therapy for HCV chronic infection.
Diagnosis in patients with a painful arthroplasty
Carrega Giuliana,
Antonini Andrea,
Burastero Giorgio,
Casalino-Finocchio Giorgetta,
Ronca Agostina,
Salomone Carlo,
Riccio Giovanni
The differential diagnosis between asepting loosening or prosthetic joint infection is not always easy. Tc-99m-labelled leucocyte scans, frozen section and histology can help recognise doubtful cases. We report the experience of the Unit for Infectious Diseases and Septic Orthopaedics of the ASL-2 Liguria, Italy, with a Tc-99m-labelled leucocyte scan and intraoperative frozen section to choose the best therapeutic approach: one-stage or two-stage exchange or arthrodesis-arthroplastica. All cases underwent histology and intraoperative cultures to confirm the diagnosis, and the effectiveness of the approach was evaluated at follow up after 18 months. From January 2011 to December 2012, 36 patients were evaluated (21 hip and 15 knee arthroprosthesis). The Tc-99m-labelled leukocyte scan was positive in 31 and negative in 5 patients. Frozen section was negative in 7 patients. Five of them were patients with a negative Tc-99m-labelled leucocyte scan and were treated successfully with one-stage exchange, even if, in one of them, Enterococcus faecalis was isolated at replacement and suppressive antibiotic treatment was needed. The other 31 patients were treated with arthrodesis arthroplasty (3 patients) or a two-stage exchange. In this group the Tc-99m-labelled leucocyte scan was positive in all patients and the frozen section was positive in 29/31 cases with 6% false negative. Histology was positive in 27/31 with 13% of false negative. The sensitivity and specificity value was respectively 90% and 100% in the frozen section, 84% and 100% in histology. Cultures were positive in 23/31 cases. Patients subjected to two-stage exchange were evaluated again during prosthesis replacement but the results of the Tc-99m-labelled leucocyte scan and histology showed unclear results more frequently: the Tc-99m-labelled leucocyte scan was positive in two cases, the frozen section in three and histology in seven in spite of positive culture in three cases and one relapse in a patient with a frozen section and histology positive but negative culture. In the second step sensitivity and specificity were respectively 67% and 96% in the frozen section, 75% and 88% in histology. Finally, our experience suggests the utility of nuclear and histological tests during diagnostic work-up for differential diagnosis of aseptic loosening or prosthetic joint infection. The same tests produce more uncertain data when performed in two-stage exchange during the second step.
Antiretroviral therapy in inmates: between guidelines and reality of Italian correctional facilities
Ranieri Roberto,
Sommella Jvana,
Nigro Francesco,
Poccobelli Michelangelo,
Lari Cesare,
Di Benedetto Domenica,
D Arminio Monforte Antonella
In HIV-positive patients detention often represents a unique opportunity for health care. HIV-positive inmates enjoy the same rights as non-restricted people, as established under national and international legislation, declarations and guidelines. Antiretroviral therapy in restricted men shows some peculiarities such as the voluntary non-taking of drugs to worsen the health status or obtain legal benefits and the high frequency of concomitant psychiatric treatment. On the other hand, patient compliance may be considerably improved by adopting DOT strategy. Aiming to define the choices of first and subsequent lines of therapy with respect to the patient’s epidemiological characteristics and other ongoing treatments in two major correctional facilities in Milan (Opera and San Vittore, harbouring about 2500 inmates), we collected punctual data (March 6, 2014) drawn from the single patient forms of therapy.
Our results show the same prevalence of HIV infection in both facilities (3%), AIDS and viral hepatitis coinfection cases being more frequent in Opera. Both in Opera and San Vittore we found a high adherence to antiretroviral therapy (high CD4 count average and high percentage of HIV-RNA suppressed). The first and subsequent choice of main lines was TDF+FTC+RTV+ATV. The choice of efavirenz (EFV) as the third drug was often excluded due to its neuropsychiatric implications. The most common cause of drug change was toxicity followed by simplification and then by virological failure. Finally we showed a high frequency of concomitant psychiatric therapy (77% in Opera, 67% in San Vittore), noting the hypothetical interactions with antiretroviral drugs.
Effectiveness and tolerability of short course co-trimoxazole, norfloxacin and levofloxacin in bacteriological cure of uncomplicated urinary tract infection in outpatient setting. An open label, parallel group, randomized controlled trial
Vachhani Arpit Vallabhbhai,
Barvaliya Manish,
Naik Viren,
Jha Pramod,
Tripathi Chandrabhanu
To compare the bacteriological cure rate of short-course (3-day) treatment of uncomplicated urinary tract infection (UTI) using co-trimoxazole, norfloxacin and levofloxacin, patients with uncomplicated UTI were randomized to receive either co-trimoxazole (960 mg) twice a day or norfloxacin (400 mg) twice a day or levofloxacin (250 mg) once a day for three days. Urine culture was done at the end of treatment and evaluated for bacteriological cure rate in each group. Among a total of 175 patients, Escherichia coli (74.29%) was the most common organism isolated followed by Klebsiella (11.43%), Streptococcus (6.29%), Staphylococcus saphrophyticus (5.14%), and Pseudomonas (2.86%). At the end of three days’ treatment, bacteriological cure rates were 86.2%, 87.7% and 83.3% for co-trimoxazole, norfloxacin and levofloxacin, respectively (p>0.05). Therefore short-course treatment with co-trimoxazole 960 mg twice a day, norfloxacin 400 mg twice a day and levofloxacin 250 mg once a day are almost equally effective for treatment of uncomplicated UTI.
Case report
Geotrichum capitatum septicaemia in a haematological patient after acute myeloid leukaemia relapse: identification using MALDI-TOF mass spectrometry and review of the literature
Miglietta Fabio,
Vella Antonietta,
Faneschi Maria Letizia,
Lobreglio Giambattista,
Rizzo Adriana,
Palumbo Claudio,
Palumbo Carla,
Di Renzo Nicola,
Pizzolante Maria
Emerging fungal pathogens, such as Geotrichum capitatum, are often associated with poor prognosis and represent a new challenge in modern medicine. Invasive Geotrichum capitatum infection is rare and has been reported exclusively in patients who showed signs of severe immunodeficiency, particularly those affected by haematological malignancies. The optimal therapy against systemic geotricosis has not yet been identified due to limited data about its antifungal susceptibility. The use of several therapeutic strategies and the low number of cases treated does not allow identification of specific therapeutic protocols. Furthermore, in spite of antifungal therapy, mortality rates reach very high levels. We report a case of systemic Geotrichum capitatum infection in a 78-year-old male treated with salvage therapy after acute myeloid leukaemia (AML) relapse. Geotrichum capitatum was isolated from his blood culture and identified by using Vitek 2 and Maldi time-of-flight system (MALDI-TOF). The infection was unsuccessfully treated, despite in vitro susceptibility, with micafungin and liposomal amphotericin B.
Renal embolism as a primary manifestation of Streptococcus dysgalactiae subspecies equisimilis endocarditis in a patient with chronic aortic dissection
Ishimaru Naoto,
Kinami Saori,
Ohnishi Hisashi,
Takagi Asuka,
Kawamoto Megumi,
Doukuni Ryota,
Umezawa Kanoko,
Oozone Sachiko,
Yoshimura Sho,
Sakamoto Susumu
We report a case of renal embolism as an initial manifestation of Streptococcus dysgalactiae subspecies equisimilis (SDSE) endocarditis in a patient with chronic aortic dissection. A 37-year-old man who underwent total aortic arch replacement owing to aortic dissection, presented with a 3-h history of fever, chills, and acute right-sided flank pain. The endocarditis affected the native aortic valve and was complicated by a renal embolism. Blood culture results were positive for SDSE. Intravenous penicillin resulted in satisfactory clinical and echocardiographic recovery.
Salmonella paratyphi B mycotic aneurysm of the abdominal aorta in an HIV-infected patient: a case report
Girometti Nicolò,
Giannella Maddalena,
Brocchi Stefano,
Badia Lorenzo,
Calza Leonardo,
Viale Pierluigi
An HIV-infected 49-year-old man was admitted with polyuria, fever, chills and a dull left lumbar pain. Laboratory tests showed increased C-reactive protein while urine analysis and abdomen ultrasound scan were negative. Blood cultures revealed a Salmonella paratyphi B, identified through MALDI-TOF mass spectrometry. Targeted antibiotic therapy with intravenous piperacillin/tazobactam was started and a multi-phase contrast-enhanced abdomen CT-scan was performed at 24 hours from admission showing a saccular aneurysm of the abdominal aorta with a 1 cm penetrating aortic ulcer on posterior wall. The patient underwent emergency vascular surgery at 34 hours from admission for debridement and homo-graft placement of sub-renal aorta, and surgical samples were sent for microbiological analysis. Unfortunately, the patient died on post-surgical day 7 after haemorrhagic shock due to laceration of his graft. Salmonella paratyphi infection can be responsible for sepsis in severely immunosuppressed patients with poorly controlled HIV, requiring careful work-up for cardiovascular involvement.
A case of brucellosis presenting with acute hepatitis and bicytopenia
Denk Affan,
Ozden Mehmet
Although liver involvement is frequently seen in brucellosis, acute hepatitis is a rare clinical entity. In its progress, haematological findings are non-specific and vary in respect to severity. In this paper, we present a case of brucellosis with acute hepatitis and bicytopenia without anaemia. A 19-year-old man presented with a 2-week history of fever, sweating, low back and leg pain, lassitude, loss appetite, nausea and vomiting. He gave a history of raw milk ingestion and animal contact. Physical examination showed signs of icteric skin and sclera, tenderness in the right hypochondriac region and hepatosplenomegaly. On admission to hospital, laboratory tests showed WBC 3500/mm3 (polymorphs 63% and lymphocytes 33%), haemoglobin 13.8 g/dL, platelet 89000/mm3, erythrocyte sedimentation rate 19 mm/h, and C-reactive protein 21.7 mg/dL (N<0.8 mg/dL). Biochemical tests were as follows: AST 771 U/L, ALT 471 U/L, ALP 355 U/L, GGT 432 U/L, total bilirubin 2.61 mg/dL, direct bilirubin 1.45 mg/dL and albumin 3.7 g/dL. Viral hepatitis markers were found to be negative (HBsAg, anti-HBc total, anti-HBc IgM, anti-HAV IgM, and anti-HCV). Blood culture grew Brucella melitensis. Leukopenia and thrombocytopenia returned to normal levels at the 7th and 14th day of his admission, respectively. Liver function tests improved at the 28th day. Treatment of the brucellosis was performed with antibiotics (tetracycline 500 mg orally four times daily for 6 weeks and streptomycin 1 g IM once daily for 21 days). Finally, a case of brucellosis with acute hepatitis and bicytopenia was treated with a successful outcome. In conclusion, we suggest that due consideration be taken of bicytopenia/pancytopenia and acute hepatitis in brucellosis cases in Turkey, an endemic region.
Necrotizing soft tissue infection of the right anterolateral abdominal wall caused by a ruptured gangrenous appendix in an elderly diabetic patient
Marinis Athanasios,
Voultsos Mavroudis,
Foteinos Argyrios,
Tselioti Paraskevi,
Avraamidou Alexandra,
Paschalidis Nikolaos,
Rizos Spyros
Necrotizing soft tissue infections (NSTIs) of the abdominal wall usually occur when either a common superficial soft tissue infection progresses down to, or an injury (e.g. knife stab) penetrates, the investing muscle fascia, or an intra-abdominal infection spreads directly to the muscle layers of the abdominal wall. These infections are severe and associated with significant morbidity and mortality. We present an 83-year-old female diabetic patient who was admitted to the surgical emergency department complaining of right abdominal pain after a fall to the floor. She had previously received oral antibiotics for a minor superficial skin infection attributed to her subcutaneous use of insulin. On admission she exhibited signs of agitation and dyspnoea with hypotension and tachycardia (systolic arterial pressure 90mmHg, heart rate >110 bpm, oxygen saturation 88%). Furthermore, she had a tender right abdomen but without any demonstrable pathology on her skin or crepitus. Arterial blood gases revealed metabolic acidosis and hypoxaemia. An abdominal computed tomography (CT) scan demonstrated signs of infection of the entire right anterior abdominal wall and the LRINEC score was calculated to be 13. Subsequent operative aggressive necrosectomy of all the involved layers of the right anterolateral abdominal wall sparing the peritoneum was undertaken. Unfortunately, the patient died the next day due to multiple organ failure.
Spinal lesions by infectious spondylodiscitis and hepatocellular carcinoma presenting as spinal metastasis in an HIV-HCV co-infected patient
Tonziello Gilda,
Valentinotti Romina,
Stacul Fulvio,
Giacomazzi Donatella,
Luzzati Roberto
Back pain and spine tenderness over the involved spine segment are common clinical findings of a number of relative benign conditions. However, back pain may be the presenting symptom of vertebral metastases in patients with systemic cancer, including hepatocellular carcinoma, a not uncommon complication in HCV-HIV infected patients. We describe a case of a 51-year-old intravenous drug user with HIV and HCV co-infection who developed dorsal spondylodiscitis due to Pseudomonas aeruginosa, which improved following antibiotic therapy. Three months after the end of therapy, the patient referred recurrence of back pain. The MRI showed different vertebral lesions of the dorsal spine and costal arch which turned out to be hepatocellular carcinoma metastasis at the histological examination. The patient had never been treated with the interferon-ribavirine combination therapy because of a major depressive syndrome. Interferon-free regimens are urgently required for HIV-HCV coinfected patients, especially when interferon-based regimens are contraindicated.
The Infections in the History of Medicine
Epidemics on the sea: migrants journeys in the nineteenth century
Sabbatani Sergio
In the nineteenth century travelling by ship became faster due to the introduction of the steam engine. Population growth, economic crises and food shortages forced millions of Italians to consider migration towards the Americas as a real opportunity. Travel conditions on ships and steamers were particularly difficult. People were crammed into dormitories where ventilation was poor, food was insufficient, hygiene was appalling and promiscuity was rife. Under such conditions, epidemics of cholera, typhus and measles were all too likely to develop, but mycobacterium tuberculosis also proliferated. The health authorities attempted to block the spread of epidemics by means of either health licenses - papers certifying good health of the crew and passengers, which had to be exhibited on arrival - or quarantine, involving the ship and all its contents, if infectious diseases were detected or suspicious deaths occurred during the ship’s voyage. In this article the particularly unfortunate stories of Italian immigrants, who boarded ships and steamers, are reported. In the second half of the nineteenth century, but also in the first decades of the twentieth, millions of Italians whose aim was to reach the Americas paid a very high price. Italy did not provide acceptable living conditions for millions of farmers and town-dwellers, and migration in search of work was in many cases the only solution. Although many during their sea voyages became ill or died of starvation or infectious diseases, migration, supported by hope, continued.
Letters to the editor
Arthrographis kalrae arthritis: a new case report
Paolo Pier,
Rossati Antonella,
Buccheri Camillo,
Bargiacchi Olivia,
Luigi Pietro,
Andreoni Stefano,
To date, only 11 cases of infection by Arthrographis kalrae have been described. According to the literature, we report a second case of arthritis caused by this mycete after a penetrating wound successfully treated with voriconazole before arthroscopic knee washout for six weeks.
