Friday, March 31, 2006
Erysipelas after breast cancer treatment (26 cases)
A Masmoudi1, I Maaloul2, H Turki1, Elloumi Y1, 2, S Marrekchi1, S Bouassida1, M Ben Jemaa2, A Zahaf1 Dermatology Online Journal 11 (3): 12 1.
Department of Dermatology, Hedi Chaker Hospital, Sfax, Tunisia.2. Department of Infection Diseases, Hedi Chaker Hospital, Sfax, Tunisia.
Erysipelas is a bacterial hypodermal cellulitis usually associated with Streptococcal infection. Erysipelas of the upper limbs in women treated for breast cancer is relatively rare. We undertook a 10-year retrospective study identifying 26 cases of erysipelas of the upper limb following treatment for breast cancer; we describe the clinical, therapeutic, and evolutionary aspects. The age of our patients ranged from 37 to 80 years with a mean age of 53. All patients had a breast surgery and lymphadenectomy. Fifteen patients had chemotherapy and 23 had radiotherapy. The erysipelas appeared with an average of 5.23 years after cancer treatment (3 months to 15 years) and was recurrent in nine cases. Lymphedema occurred in eighteen patients. The first signs were fever and shivering in 25 patients. The clinical aspect was an inflammatory plaque. The physical findings of erysipelas included a raised edge (6 cases), blisters (1 case), purpura (1 case), and cellulitis (1 case). The portal of entry was not found in eleven patients. The upper limb was affected in all cases. Involvement of the axillary folds or the chest was observed in eight cases. Treatment with penicillin was undertaken for all patients; the length of treatment varied from 11 to 26 days. Lympadenectomy and radiotherapy in breast cancer may lead to lymphedema, which can be evident or sometimes discrete. Those patients who developed erysipelas in our series usually fared well with treatment, but many had recurrences attributed to persistent lymphedema. It was also of note that for many patients in this series, the portal of entry was not identified.
Erysipelas is a bacterial infection, usually of streptococcal origin, that affects the dermis and dermal lymphatics. Malignancy and local impairment of venous and lymphatic circulation are reported to be predisposing factors. Using a retrospective analysis, we attempted to characterize the clinical and evolutionary characteristics of erysipelas after treatment of breast cancer.
Materials and methods
Our study was a retrospective analysis of 26 patients observed during the period from January 1991 until December 2000 at the department of dermatology and the department of infectious diseases at Hedi Chaker Hospital of Sfax.
The clinical data were collected from the files of the hospitalized patients.
For each patient we recorded the age, past medical history, clinical findings, laboratory finds, treatment, and outcome.
The age of our patients ranged between 37 and 80 years with an average of 53.4 years. All our patients had undergone mastectomy and lymphadenectomy for breast cancer, fifteen had chemotherapy, and 23 had radiotherapy. History of obesity was found in eight patients, diabetes in six, and of HTA in ten. Lymphedema was noted in sixteen patients.
The duration of erysipelas at the time of presentation was 1-3 days with an average of 2 days. For 23 patients the onset of erysipelas was marked by a fever associated with shivering. For eleven cases erysipelas was recurrent; the number of episodes varied from 1 to 3.
The site of involvement was the homolateral superior limb for all the cases with involvement of
forearm: 20 cases (Fig. 1)
arm: 23 cases
hand: 10 cases
axilla: 8 cases
Erysipelas presented as a warm, indurated and painful erythema sharply demarcated by a raised edge in six cases. It was complicated by purpura in one case, blisters in one case (Fig. 2), and cellulitis in one case.
Lymphedema was found in eighteen patients at the time of the examination.
The portal of entry was not known or found in eleven cases. It was present in fifteen cases (post traumatic wound, 16 cases; post radiotherapy burn, 3 cases; interdigital tinea, 2 cases; infected eczema, 1 case; paronychia, 1 case; whitlow, 1 case).
Laboratory abnormalities included increased white blood cell count (with predominance of segmented neutrophils) in sixteen cases, and leukopenia in two cases; the white count was normal in eight cases. The erythrocyte sedimentation rate evaluated in nineteen patients; it was elevated in 17 (43-130 mm/h). Blood cultures were done in fourteen patients and were positive for β-hemolytic Streptococci in one.
Outcome was favorable in 22 patients. All patients were treated with intravenous penicillin (10-20 million units per day). Once the patients became afebrile and otherwise had a marked improvement, the route of penicillin administration was changed to intramuscular or oral. The duration of treatment varied between 11 and 25 days with an average of 16 days. Adequate response was not obtained for two patients and the antibiotic was changed to pristinamycine (Pyostacine®) and those patients did well. One patient, who presented with hard purpuric erysipelas, did not respond to penicillin, clindamycin (Dalacine®) and rifampin; this patient died on the eighth day of hospitalization.
For the eight patients seen in followup, no recurrence was apparent.
Erysipelas is a well-known complication following mastectomy and radiotherapy for breast cancer, however, few cases are reported in literature [1, 2, 3]. The lymphatic circulation is affected by the radiotherapy and mastectomy favoring the obstruction and the progressive destruction of lymphatic communications, hence the lymphedema. This lymphatic stasis appeared to play an important role in the occurrence of erysipelas in our patients.
This lymphedema occurs several years after mastectomy or the radiotherapy and is sometimes revealed by the occurrence of erysipelas, such as the case of two patients in our study. The risk of lymphedema correlates with the use of postoperative radiotherapy and the number of lymph nodes removed .
Lymphostasis results in edema associated with the retention of high-molecular weight proteins in the interstitial compartment. Tissue involved in lymphostasis appears susceptible to infection, which in turn can worsen the lymphatic dysfunction . Other factors that may play a role in developing infection in areas of lymphedema include venous stasis, diabetes, obesity, treatment with corticosteroids, and immune suppression .
Lymphedema following lymph-node dissection for invasive breast cancers is common and its impact on long-term quality of life in survivors of early-stage breast cancer should not be underestimated [7, 8].
Once lymphedema is established, the affected arm is subject to erysipelas developing from minor infections such as paronychia, folliculitis, and interdigital web-space infection; such infections would not be significant in the normal arm. In our study the portal of entry included post-radiotherapy burn (two patients), post-traumatic lesions, eczema, and interdigital tinea. A portal of entry was not identified at the time of the time of examination in 40 percent of cases.
The diagnosis of erysipelas is essentially clinical, a fever of acute onset with a sharply demarcated, warm, indurated and painful erythema. The raised edge was present in 23 percent of our patients.
Penicillin G is the treatment of choice because group A β-hemolytic Streptococcus is sensitive; intravenous injection is advised for the acute phase of the disease. Following the acute phase, penicillin may be given by intramuscular or oral routes. The outcome is generally favorable.
In addition to antibiotics, scrupulous personal hygiene may be beneficial because group-A Streptococci may colonize unbroken skin . Local fungal infection of the skin or nails which may serve as a portal of entry and should be eradicated.
Prevention of lymphedema is often possible; unnecessary irradiation should be avoided. Postoperative early arm motion, isometric exercises, measured compression sleeves; diuretic therapy, and frequent massage have all been found helpful and should be continued throughout the patient's life.
The major late complication of this erysipelas is more lymphedema, which favors recurrence of infection. Each recurrence may do further local damage to lymphatic channels and thus perpetuate a vicious cycle. For patients who have recurrent erysipelas, antibiotic prophylaxis (especially with benzathine-benzylpenicillin or phenoxymethlpenicillin) is recommended . The eradication of every portal of entry is recommended.
The occurrence of erysipelas following treatment of breast cancer correlates with the associated lymphedema. The treatment is an antibiotic during the acute phase of the disease and eventually an antibioprophylaxis to avoid recurrences. Attention should be given to measures that prevent lymphedema and eradicate potential portals of entry.
1. Brewer VH, Hahn KA, Rohrbach BW, Bell JL, Baddour LM. Risk factor analysis for breast cellulitis complicating breast conservation therapy. Clin Infect Dis. 2000 Sep;31(3):654-9. Epub 2000 Sep 21. PubMed
2. Carsuzaa F, Arnoux D, Gourrion M. Erysipelas in irradiated area. Nouv Dermatol, 1993, 12: 564-5
4. Herd-Smith A, Russo A, Muraca MG, Del Turco MR, Cardona G. Prognostic factors for lymphedema after primary treatment of breast carcinoma. Cancer. 2001 Oct 1;92(7):1783-7. PubMed
5. Vaillant L, Gironet N. [Infectious complications of lymphedema] Rev Med Interne. 2002 Jun;23 Suppl 3:403s-407s. Review. French. PubMed
7. Fredriksson I, Liljegren G, Arnesson LG, Emdin SO, Palm-Sjovall M, Fornander T, Holmqvist M, Holmberg L, Frisell J. Consequences of axillary recurrence after conservative breast surgery. Br J Surg. 2002 Jul;89(7):902-8. PubMed
8. Voogd AC, Ververs JM, Vingerhoets AJ, Roumen RM, Coebergh JW, Crommelin MA. Lymphoedema and reduced shoulder function as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. Br J Surg. 2003 Jan;90(1):76-81. PubMed
9. Herman C, Hamdy M. Recurrent streptococcal cellulitis complicating radial hysterectomy and radiation. Obstetrics Gynecology, 1984, 63: 862-410. Sjoblom AC, Eriksson B, Jorup-Ronstrom C, Karkkonen K, Lindqvist M. Antibiotic prophylaxis in recurrent erysipelas. Infection. 1993 Nov-Dec;21(6):390-3. PubMedDermatology Online Journal
Monday, March 27, 2006
Epidemiology, clinical features and prognosis of infections due to Stenotrophomonas maltophilia
Seccion de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, Spain.
Stenotrophomonas maltophilia is a multiresistant pathogen that is being isolated with increasing frequency from patients with predisposing factors. Few studies have assessed the epidemiology and clinical relevance of this pathogen in various types of patients from general hospitals.
This is a prospective study performed in the cohort of patients with infection due to S. maltophilia in Hospital Univeritario Virgen Macarena (Seville, Spain) between January 1998 and January 2001. The following data were collected: demographics, underlying diseases, APACHE II score at admission, invasive procedures, previous antimicrobial treatment, systemic response, therapy and outcome.
S. maltophilia was isolated from a clinical sample in 87 patients and was considered to be the cause of infection in 45 (52%) of them, who were included in the study. Among the total, 40% were in the ICU and 13% were outpatients. The infection was considered health care-associated in 91%; 82% had received antimicrobial treatment. The most frequent type of infection was pneumonia, followed by other infections of the respiratory tract, urinary tract infections, and skin and soft tissue infections. Criteria for severe sepsis or septic shock were present in 12%. The most common antimicrobials used were the combination trimethoprim-sulfamethoxazole (60%). Crude mortality was 44% and the only associated variable was the APACHE II score. Infection-related mortality was 13%; all deaths occurred in patients with pneumonia.
S. maltophilia caused a wide range of health care-associated infections in debilitated patients, even though half the patients from whom the organism was isolated were considered only colonized. Crude mortality was associated with the severity of the baseline situation. Pneumonia was associated with high mortality.
What is it?
Stenotrophomonas maltophilia is an aerobic gram-negative bacillus. It has previously been known as Xanthomonas maltophilia and Pseudomonas maltophilia.
S. maltophilia has recently emerged as an important hospital-associated pathogen as a result of the increasing number of susceptible hosts (due to immunocompromise) and to the use of antimicrobial agents such as Imipenem. It is not associated with infection in healthy individuals.
How is it spread?
S. maltophilia is present in the environment, in soil, water, animals and vegetation. In the hospital it may be associated with water (faucets, sinks), respirometers, suction catheters and ventilation equipment, and can become endemic in critical care units. It is not part of the normal skin or gastrointestinal flora.
Person-to-person transmission of S. maltophilia occurs via the hands of healthcare workers to patient devices such as catheters, needles and respiratory equipment. S. maltophilia is transferred via hands, but does not actually colonize the hands and may be removed with proper handwashing. Shared equipment, such as respirometers, facilitates the spread of this organism.
Signs and Symptoms of S. maltophilia infection
S. maltophilia has been isolated from a variety of sites, including wounds, the respiratory tract and blood. It often is associated with life-threatening systemic infections in a debilitated host.
Infection with S. maltophilia should be suspected in patients who develop superinfection while receiving Imipenem or multiple antibiotics.
Prevention of Transmission
Prevention is based on good personal hygiene, particularly handwashing to remove transient organisms. Minimize environmental contamination by prompt disposal of contaminated gloves, catheters or other patient care articles. Equipment should not be shared. If sharing of equipment is necessary, it must be adequately disinfected between patients.
If respiratory secretions are growing S. maltophilia, the patient requires a private room. In Intensive Care Units, doors between patients must be kept closed. In the event of multiple cases on a unit, cohorting and the use of antiseptic soap may be necessary.
Friday, March 24, 2006
Tuberculosis - News Updates
It is surprising to hear that the outbreak of tuberculosis (TB) has been steadily increasing here in recent years. To our regret, Korea’s outbreaks of tuberculosis and resulting death rate are said to be the highest among the Organization of Economic Cooperation and Development (OECD) member nations.
An alarming fact is that the number of new patients which stood at 30,000 in 2003, increased to 31,500 in 2004 and jumped to 35,000 last year, marking an 11.6-percent increase over previous year. Tuberculosis has long been considered almost conquered here by virtue of effective drugs. But, the disease is rebounding with an added intensity.
According to a statistics, nearly one-third of the world’s population is infected with tuberculosis, which kills almost 2 million people each year. Tuberculosis causes more deaths than any other infectious disease in the world. Though widely considered to be a curable disease thanks to the effective medicines, tuberculosis still remains the leading cause of death.
Though not confirmed, tuberculosis may not be the only disease that has made a comeback here with an added potency. According to health authorities, the disease is spreading rapidly particularly among young people. Of course, the resurgence of the disease is not limited to our country but is also a global problem.
Troublesome is the fact that the disease that used to be easily controlled with standard drugs are getting difficult to treat because the microbes causing it have developed a resistance to these drugs. What we have to pay particular attention to is the fact that the widespread use of these antibiotics is responsible for this resistance.
It is time for us to enhance our awareness of the danger the random use of antibiotics poses. Medical experts warn that the situation, if allowed to grow unchecked, could return the world to the pre-antibiotic era, setting the stage for a worldwide return of such an infectious disease.
Another major cause of its resurgence is rampant dieting among the people as part of their efforts to stay slim and healthy. An unreasonable diet is feared to cause serious nutritional imbalances, doctors said. Even young people with strong physical strength can easily be infected with tuberculosis when they lose their physical balance.
The doctors also pointed out that many people don’t seem to regard it seriously and think that tuberculosis is a disease of the old days and easily curable. But, reality is that as many as 3,000 people here die from tuberculosis every year. The death rate is four times higher that for AIDS.
Super TB strain rekindles fearsHealth officials say number of cases ebbing, drug-resistant disease emerging
By Rebecca Vesely, STAFF WRITER
Tuberculosis cases in California and nationwide are dropping to record lows, but a super-strain of TB resistant to antibiotics is emerging, health officials warned in advance of World TB Day today.
Meanwhile, some counties throughout California — including Alameda and San Mateo — saw an uptick in TB cases last year.
California has the highest number of TB cases of any state, with a total of 2,900 cases in 2005, down from 2,989 the previous year. Although the state saw a record low total cases last year, 10 of the 20 cities nationwide with the most TB cases are in California, including Oakland, Stockton, Vallejo, San Francisco and San Jose.
"The notion remains that TB is a disease of the past but it is anything but," said Dr. Robert Benjamin, medical director of Alameda County's TB control program.
Worldwide, TB kills 1.7 million people each year. Most cases occur in Africa, and global health officials are warning of a rise in what is being called "extensively drug-resistant" TB, especially in the former Soviet states.
In these cases, patients do not respond to the first-line antibiotics or three out of six of the second-line antibiotics available for treatments, according to a study released Thursday by the Centers for Disease Control and Prevention.
One in 50 TB cases throughout the world are "drug-resistant," meaning they do not respond to top-line antibiotics and so are more difficult to treat. These new cases are so drug-resistant that they can mean a death sentence.
"These are individuals who are virtually untreatable with available drugs," said Dr. Kenneth Castro of the CDC.
Even for patients with multidrug-resistant TB that can be controlled, the cost of treatment is far higher than typical TB and take much longer. A typical course of treatment costs
$3,000 for six months. Multidrug-resistant cases cost about $250,000 for two years of treatment, Benjamin said.
In California, about 80 multidrug-resistant TB patients undergo treatment today, according to the American Lung Association of California.
Two-thirds of all TB cases in California are among foreign-born. In Alameda County,
85 percent of TB cases occur among immigrants, Benjamin said.
"TB is coming to us on the wings of an airplane," he said, cautioning that victims should not be blamed, but instead TB programs worldwide should be enhanced.
There were 152 TB cases in Alameda County last year, up from 144 cases the previous year. That is still below a high of 242 cases in 2001.
TB is a contagious disease transmitted when a person with active TB coughs or speaks. TB symptoms include a cough lasting more than two weeks, coughing up blood, weakness, fatigue, weight loss or lack of appetite.
About one in 10 people in California have inactive TB, which can remain dormant for years before making the person sick or contagious, according to the state Department of Health Services. About 10 percent of people with inactive TB eventually become sick at some point in their lives if they are not treated.
"Finding and treating these infected Californians is essential to preventing future TB outbreaks," said Dr. Mark Horton, the state's public health officer, in a statement.
Next week, Sen. Barbara Boxer, D-California, and other lawmakers plan to introduce a bill that would triple United States aid to help control TB, with the goal of cutting international TB deaths in half by 2015. The bill would authorize $225 million for 2007 to combat TB worldwide.
Contact Rebecca Vesely at email@example.com. The Associated Press contributed to this report.
Inside Bay Area
TB still a scourge for Canada's poor, homeless, natives, refugeesProvided by: Canadian
PressWritten by: SUE BAILEYMar. 24, 2006
OTTAWA (CP) - Tuberculosis is still very much a disease of the poor in Canada and around the world, warn experts who say a global scourge could spread here unless more is done to stop it.
Native people, the homeless and refugees face much greater risk of infection, and rates have soared in developing countries plagued by AIDS. Canada has a choice, observers say: do more to stem a growing flood of cases overseas or grapple with the inevitable import and spread of the illness here.
That reality may shock those who assume the lung-attacking sickness once known as consumption has been all but wiped out.
Most Canadians take for granted one of the lowest infection rates in the world. But outside North America and most other industrialized regions, the developing world is caught in a TB outbreak.
"We're kind of like little islands," Dr. Michael Gardam, medical director of the University Health Network's tuberculosis clinic in Toronto, said Friday - World TB Day.
"We're surrounded by a worldwide epidemic.
"In fact, most of the deaths that are occurring in HIV-positive people in Africa are due to tuberculosis.
"Most people have no idea that this is happening."
In Canada, about 1,600 cases of active TB are diagnosed each year - five for every 100,000 people.
The rate for latent TB is many times higher. Gardam estimates that at least 10 per cent of the Toronto population is likely infected but not aware.
Latent TB only flares into the actual disease in about 10 per cent of otherwise healthy people. But those weakened by HIV or other conditions develop potentially deadly symptoms at a much higher rate.
Those who plan extended stays in developing countries should be tested before and after, Gardam said. Annual tests are also recommended for those having close contact with those at higher risk for infection.
There is no vaccine. Antibiotics offer a 97 per cent recovery rate if used properly but are often unavailable in countries where they're most needed, Gardam said.
Reasons for a tragic lack of basic care range from complete breakdowns of public-health services to global indifference.
An estimated two million people die around the world each year from TB, while another nine million become sick.
Improper use of antibiotics has also created an alarming spike in cases of multidrug resistance, Gardam said.
It's crucial that patients complete a six-month course of treatment without mixing antibiotics, he explained.
In Canada, rates of infection are 10 times higher on native reserves, said Phil Fontaine, national chief of the Assembly of First Nations.
"In some northern communities, up to half of the population is infected," he said. "This is simply unbelievable and unacceptable in any community in Canada in the 21st century."
He urged the Conservatives to make good on $870 million in health funding promised to aboriginal Canadians by the former Liberal government.
"TB is a preventable, treatable, curable disease," Fontaine said. "But it will persist for as long as our people continue to suffer in poor living conditions."
On the Northlands First Nation, a fly-in Dene community in northern Manitoba, more than 120 people have been treated for latent TB in the last year to ensure it doesn't become full-blown.
There are just 144 run-down houses for almost 1,000 people, said Chief Joseph Danttouze. Over-crowding is a factor widely blamed for the spread of tuberculosis.
"We've been asking for more money to build more homes . . . but it hasn't worked out for us yet," said Danttouze.
Unemployment on the remote reserve hovers at about 85 per cent.
"I think Indian Affairs should look at what's happening in our community. Why aren't they helping us to resolve some of these problems? We have our treaty rights."
Body and Health
Sunday, March 19, 2006
Multistate Outbreak of Salmonella Typhimurium Infections Associated with Eating Ground Beef --- United States, 2004
February 24, 2006
Salmonella infections cause an estimated 1.4 million human illnesses and 400 deaths annually in the United States (1). Although the incidence of several other foodborne bacterial infections decreased substantially during 1996--2004, the incidence of Salmonella infections declined modestly (2). In September 2004, the New Mexico Department of Health received reports from the New Mexico Scientific Laboratory Division of eight Salmonella enterica serotype Typhimurium isolates that had indistinguishable pulsed-field gel electrophoresis (PFGE) patterns using XbaI and BlnI restriction enzymes. The patients were from three New Mexico counties and had onsets of illness during August 18--29. A review of PFGE patterns submitted to the National Molecular Subtyping Network for Foodborne Disease Surveillance (PulseNet) database for Salmonella revealed 31 indistinguishable patient isolates of S. Typhimurium from nine states (Colorado, Kansas, Minnesota, New Jersey, New Mexico, New York, Ohio, Tennessee, and Wisconsin) and the District of Columbia, with illness onset occurring during August 11--October 2, 2004. The S. Typhimurium isolates were susceptible to all antimicrobial agents tested. An investigation conducted by state health departments, CDC, and the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) identified ground beef purchased at a national chain of supermarkets as the source of S. Typhimurium infections.
Traceback results indicated product originating from a common supplier; however, evaluators determined that plant practices conformed to FSIS production guidelines, and no product recalls were made. This report describes the investigation and underscores the risk for salmonellosis from contact with contaminated ground beef, despite regulatory directives to reduce Salmonella contamination in beef production. Reduced contamination and consumption of raw or undercooked meat and further education of the food service industry and consumers are critical to reducing foodborne salmonellosis.
A case was defined as infection with S. Typhimurium with a PFGE pattern indistinguishable from the outbreak pattern. Participating health departments (Colorado, Kansas, Minnesota, New Mexico, Ohio, Wisconsin, and District of Columbia) used questionnaires to collect detailed information about patient history of food consumption before illness onset. After careful review of food histories and information on other possible exposures among patients, contaminated ground beef was suspected as the vehicle for this outbreak. Several patients reported having eaten ground beef purchased at the same national chain of supermarkets (chain A). To identify exposures associated with illness and to investigate the source of potentially contaminated ground beef, the participating health departments conducted a case-control study during September 30--October 19, 2004. The case-control study included case-patients from the six states and the District of Columbia and controls identified by sequential telephone digit dialing. The controls were matched by age group (ages 2--10, 11--17, 18--60, and >60 years) to case-patients and had no reported gastrointestinal illness within 7 days before onset of illness of the matched case-patients. Case-patients and controls were asked detailed questions regarding ground beef consumption and brand, location, and date of purchase of ground beef.
Twenty-six of 31 case-patients (Figure) and 46 controls were enrolled in the case-control study. Five patients were not enrolled in the study; three were from states that declined to participate, and two could not be contacted. Fourteen (53.9%) case-patients were female, and the median age was 30.5 years (range: 2--80 years). Twenty-one (47.7%) controls were female, and the median age was 35 years (range: 2--87 years). Symptoms reported by the case-patients included diarrhea (100%), abdominal cramps (92%), fever (92%), vomiting (65%), and bloody diarrhea (46%). Median duration of illness was 7.5 days (range: 2--30 days); 35% of patients were hospitalized. No patients died.
Of the 26 case-patients, 23 with matched controls were included in the analyses (three with no matched controls were excluded). Among 23 matched case-patients, 21 (91%) reported eating ground beef during the 7 days before illness, compared with 37 (80%) of 46 controls (matched odds ratio [mOR] = 2.4; 95% confidence interval [CI] = 0.5--11.8). Ten (44%) matched case-patients reported eating raw or undercooked ground beef or tasting the beef while cooking, compared with eight (17%) controls (mOR = 7.4; CI = 1.2--44.6). Among 21 case-patients who ate ground beef, 15 (71%) purchased the beef within 3 weeks before illness onset from chain A, compared with nine (24%) controls (mOR = 12.7; CI = 1.6--99.2).
The Minnesota Department of Agriculture tested a sample of leftover frozen ground beef provided by a Minnesota case-patient. The sample yielded S. Typhimurium with a PFGE pattern indistinguishable from the outbreak pattern.
For seven case-patients who reported consumption of ground beef purchased at chain A, shopper cards or purchase receipts were used to determine the source of ground beef and its production date. Traceback results indicated that the ground beef was packaged at three processing plants. One supplier common to all three plants was identified, although beef was mixed at the three processing plants with ingredients from other suppliers. Two other case-patients provided approximate dates for when they purchased ground beef at chain A; records indicated that their purchases could have been from one of the three implicated plants with product originating from the common supplier.
FSIS evaluators assessed the three processing plants and their common supplier by reviewing existing FSIS records and internal plant Hazard Analysis and Critical Control Point plans, processes, and records, including microbial analyses conducted by FSIS officers for the relevant production periods. After extensive investigation, evaluators determined that plant practices conformed to current FSIS production guidelines. No products were recalled.
Reported by: A Cronquist, MPH, Colorado Dept of Public Health and Environment. S Wedel, MPH, Minnesota Dept of Health. B Albanese, MD, CM Sewell, DrPH, New Mexico Dept of Health. D Hoang-Johnson, Wisconsin Dept of Health. T Ihry, DVM, US Dept of Agriculture, Food Safety and Inspection Svc. M Lynch, MD, J Lockett, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; N Kazerouni, DrPH, C O'Reilly, PhD, D Ferguson, MD, EIS officers, CDC.
Salmonella species colonize the gastrointestinal tracts of cattle and other animals. Many infected cattle are asymptomatic carriers. Carcasses can become contaminated with Salmonella spp. during slaughter operations. Although FSIS has documented a decrease in Salmonella spp. in ground beef, from a baseline prevalence of 7.5% in 1996 to 1.6% of 30,984 regulatory samples collected in 2004 (3,4), outbreaks of human Salmonella infections associated with ground beef continue to occur.
Investigation of this outbreak of S. Typhimurium infection implicated ground beef, particularly consumption of raw or undercooked ground beef, as the source of infection. Ground beef has been implicated as the vehicle for transmission of Salmonella spp. in previous foodborne outbreaks (5--7). Outbreaks of nontyphoidal Salmonella infections and sporadic illness have been associated with various causes, particularly foods of animal origin (1). Recently, the first multistate outbreak of multidrug-resistant S. Typhimurium phage type DT104 associated with consumption of store-bought ground beef occurred in the northeastern United States (8). Epidemiologic and traceback investigations performed during the outbreak described in this report suggested one common supplier as the source. However, processing plant practices appeared to adhere to current FSIS production guidelines. In light of these findings and the findings from previous salmonellosis outbreak investigations (5--8), regulatory requirements and guidelines along the beef production chain, from farming through consumption, should be reviewed to determine whether current critical control points (i.e., preventive measures to control food safety hazards) and pathogen reduction strategies are adequate for Salmonella control.
Although the overall incidence of salmonellosis declined by only 8% from 1996 to 2004, infection with S. Typhimurium declined by 41% (2). A proportion of the decline in the incidence of S. Typhimurium infection might be a consequence of increased pathogen reduction strategies for E. coli O157:H7 in ground beef. In 2003 and 2004, incidence of human infections caused by E. coli O157:H7 declined, according to cases reported to the CDC Foodborne Diseases Active Surveillance Network (FoodNet) (2). This decline in human illness was consistent with declines in E. coli O157:H7 contamination of ground beef reported by FSIS during the same period (9). These declines might have been attributable to multiple interventions by regulators (e.g., USDA's declaration of E. coli O157:H7 as an adulterant in ground beef and a compulsory reassessment of the Pathogen Reduction/Hazard Analysis Critical Control Point plans) and beef industry (e.g., increased product testing, more efficient cleaning and sanitizing of carcasses, and diversion of contaminated product from raw ground-beef manufacturing ). Such interventions might have concurrently reduced Salmonella contamination of ground beef and salmonellosis in humans. However, regulatory and industry prevention measures and public health education need to be strengthened to meet the national health objective for reducing Salmonella infection.*
The findings in this report also highlight the importance of using PFGE (10) to identify clusters of illness, particularly for S. Typhimurium. Use of PulseNet to disseminate PFGE subtype data, combined with specific case interview information, allowed for an efficient and timely traceback investigation. State and local health departments should continue to conduct timely epidemiologic investigations of Salmonella cases. Routine subtyping of isolates of common Salmonella spp. serotypes such as S. Typhimurium and comparison of isolate PFGE patterns through PulseNet might help focus limited epidemiologic resources by identifying cases that likely are linked (10). Investigation of Salmonella spp. clusters associated with raw or undercooked ground beef consumption can 1) elucidate the mechanisms and possible sources of contamination of ground beef, 2) help determine whether regulatory requirements for the beef industry are adequate, and 3) help identify control points for reducing Salmonella spp. in the meat supply.
Salmonellosis outbreaks associated with ground beef continue, despite Hazard Analysis and Critical Control Point systems, enhanced adherence to good manufacturing practices, and education of food processors, preparers, and servers at all levels in the food industry and in the home. Targeting interventions at various steps, from beef production through consumption, might help prevent salmonellosis. Consumers should continue to be made aware of the risks associated with eating raw or undercooked ground beef, tasting ground beef during food preparation, and cross-contamination from raw meat to ready-to-eat foods, as well as the importance of hand washing after handling raw ground beef.
This report is based, in part, on data contributed by D Neises, MPH, Kansas Dept of Health; E Salehi, MPH, A Arendt, MPH, Ohio Dept of Health; S Soubagleh, District of Columbia Dept of Health; M Landen, MD, A Robbins, MPH, D Sena, New Mexico Dept of Health; K Elfering, K Vought, Minnesota Dept of Agriculture; K Holt, DVM, M Karinen, US Dept of Agriculture, Food Safety and Inspection Svc; and M Mueller, MPH, Public Health Prevention Svc Fellow, CDC.
Voetsch AC, Van Gilder TJ, Angulo FJ, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis 2004;38(Suppl 3):S127--34.
CDC. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food---10 sites, United States, 2004. MMWR 2005;54:352--6.
US Department of Agriculture. Salmonella testing of raw meat & poultry products, 1998--2004: progress report. Washington, DC: US Department of Agriculture; 2006. Available at http://www.fsis.usda.gov/science/Progress_Report_Salmonella_Testing_1998-2004/index.asp.
US Department of Agriculture. Nationwide Federal Plant Raw Ground Beef Microbiological Survey, August 1993--March 1994. Washington, DC: US Department of Agriculture; 1996. Available at http://www.fsis.usda.gov/OPHS/baseline/rwgrbeef.pdf.
CDC. Salmonella Typhimurium---Minnesota, Wisconsin, Michigan. MMWR 1972;21:411--6.
CDC. Outbreak of Salmonella serotype Typhimurium infection associated with eating raw ground beef---Wisconsin, 1994. MMWR 1995;44:905--9.
CDC. Outbreak of multidrug-resistant Salmonella Newport---United States, January--April 2002. MMWR 2002;51:545--8.
Dechet AM, Scallan E, Gensheimer K, et al. Outbreak of multidrug-resistant Salmonella enterica Typhimurium definitive type 104 infection linked to commercial ground beef, northeastern United States, 2003--2004. Clin Infect Dis 2006;42:747--52.
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* Healthy People 2010 objective 10-1d is to reduce the incidence of Salmonella species infections to 6.8 per 100,000 population
Article with graphs
Thursday, March 16, 2006
Another step forward in the battle against bacterial infections
Published: Sunday, 12-Feb-2006
Bacterial infections can strike anyone, and they can sometimes be fatal. Because more and more bacteria are becoming resistant to the pre-eminent remedy; antibiotics; the search for new remedies against bacterial infections is in high gear. Research by scientists from the Flanders Interuniversity Institute for Biotechnology (VIB) connected to Ghent University shows that certain mice, by nature, can withstand particular bacterial infections.
Elucidation of the biological process that underlies this natural ability offers perspectives for the development of new therapeutics.
Most of the time, our body can overcome bacterial infections. Only a limited number of bacteria can make us sick, but sometimes they can be fatal. In the US, about 200,000 people die from bacterial infections each year. Normally, our natural immune system bars bacteria from entering our body, or it renders them harmless. The aggressiveness of the bacteria, our general state of health, and the speed with which our immune system reacts determine whether or not we become sick after contact with a bacterium.
Upon contact with a bacterium, or a bacterial component, the immune system springs into action. One such component of the bacterial cell wall is LPS. The binding of LPS with its specific receptor in our immune system - TLR4 - initiates a long series of reactions that bring on an inflammation, which eliminates the bacteria from our body. Of course, this chain of reactions is strictly controlled, because excessive inflammation can lead to lethal shock.
Tina Mahieu and her colleagues from the research group led by Claude Libert are working with mice that are not susceptible to toxic LPS. The VIB researchers have discovered the mechanism behind this insensitivity.
One of the steps in the process of inflammation following contact with LPS is a profuse production of type 1 interferons. These proteins play an important role in the regulation of immunity. The Ghent researchers administered 10 times the lethal dose of LPS to the mutant mice, without deadly consequences. This finding could not be attributed to an alteration in TLR4, but to a reduced production of type 1 interferons. To verify this, Mahieu and her colleagues administered these interferons preventatively to the mice - which made the animals susceptible to LPS once again. Thus, this research shows that the mice are no longer able to produce large quantities of type 1 interferons - with the consequence that an inflammation fails to arise, demonstrating the importance of type 1 interferons to the inflammation process. On the other hand, the mice produce just enough interferons to activate the immune system against the bacteria, so that the mice are protected against bacterial infections.
The results of this research are very relevant to the quest for new therapeutics for bacterial infections. The mutant mice display a combination of important characteristics: they are resistant to LPS, but they still recognize and destroy pathogens. The limited quantity of type 1 interferons enables the mice to cope with a lethal shock resulting from inflammation, but this small quantity also ensures that immunity is preserved. A next step in combating bacterial infections is to uncover the mechanism behind this reduced production.
Friday, March 10, 2006
Is Irritable Bowel Syndrome a Bacterial Infection?
By: William E. Whitehead, Ph.D., Professor of Medicine and Co-Director, University of North Carolina Center for Functional GI and Motility Disorders
A recent article by Dr. Mark Pimentel and colleagues at Cedars-Sinai Medical Center caused a great deal of excitement because it suggested that irritable bowel syndrome is a bacterial infection that can be treated with antibiotics . These claims were widely reported in newspapers . If they are true, then the understanding and management of IBS will be revolutionized.
However, a careful reading of the study suggests caution. The authors made two important observations: first, that 78% of IBS patients had small bowel bacterial overgrowth and second, that eradication of bacterial overgrowth decreased the symptoms of diarrhea and abdominal pain and "cured" IBS in 48%. Let's take these observations one at a time. The patients who entered this study were not a representative group of IBS patients; they were patients who were referred for breath testing because their doctors suspected they had small bowel bacterial overgrowth. Selecting patients for testing in this way may have led to an overestimation of the proportion of IBS patients who have small bowel bacterial overgrowth. The only way to know what proportion of IBS patients have small bowel bacterial overgrowth is to test a large, representative group of patients.
The criteria for diagnosing small bowel bacterial overgrowth may also have been rather liberal. The investigators appropriately considered a test as positive only if they saw two peaks in breath hydrogen concentration, one representing intestinal bacteria and the second representing bacteria in the colon. However, they are unclear how high the first peak had to be for the test to be considered positive. Their rate of positive tests was much higher than expected; for example, out of 144 tests for suspected small bowel bacterial overgrowth carried out in our laboratory during a one year period, only 28% were positive. It is also difficult to evaluate the authors' claim that eradication of abdominal pain and diarrhea with antibiotics "cures" IBS because only 30% of the IBS patients treated with antibiotics returned for evaluation.
This was a retrospective study, so it was left to the discretion of the primary physician (not the investigators) which antibiotics were used to treat and whether the patient was asked to return for testing. It is important to know whether the other 70% were not sent back because they no longer had symptoms or whether they were not sent back because diagnosis and treatment of small bowel bacterial overgrowth made no difference, so their doctors had moved on to other tests. Quite apart from these concerns about the study design, there is a question whether these patients should be diagnosed as IBS. The Rome criteria  state that a patient should be diagnosed IBS if they have a sufficient number of a list of positive symptoms (which these patients had) and if there is no alternative, disease explanation for these symptoms.
Many gastroenterologists are aware that small bowel bacterial overgrowth can produce symptoms similar to IBS, just as inflammatory bowel disease and lactose malabsorption can; they do not label a patient as IBS if there is evidence for one of these alternative diagnoses. Although it is premature to conclude that the authors have found the cause and the cure for IBS, they have drawn attention to the fact that small bowel bacterial overgrowth is a relatively common condition that can cause symptoms suggestive of IBS. This may have the beneficial effect of causing physicians to consider this diagnosis more frequently, to test for it, and to treat appropriately when it is found.
However, antibiotics should only be prescribed when there is definite evidence of small bowel bacterial overgrowth because antibiotics occasionally cause harmful side-effects, and their indiscriminant use may lead to the development of antibiotic-resistant strains of bacteria. References:  Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000;95:3503-3506.  Beasley D. Study links intestinal bacteria to irritable bowel syndrome. Reuters, Los Angeles, December 13, 2000.  Thompson WG, Longstreth G, Drossman DA, Heaton K, Irvine EJ, Muller-Lissner S. Functional bowel disorders and functional abdominal pain. In: Drossman DA, et al. Rome II: The functional gastrointestinal disorders, 2nd edition. Degnon Associates, McLean, Va, 2000. Pp 351-432.
About IBS .
Probiotic bacteria helps irritable bowel syndrome 3/31/2005 -
A drink containing a probiotic strain isolated from infants relieved symptoms of irritable bowel syndrome to the same extent as pharmaceutical treatments for the condition, report Irish researchers. The team from the Alimentary Pharmabiotic Centre, set up last year at Ireland's University College Cork to investigate bacteria and gut health, found that patients who consumed a malted milk drink containing Bifidobacterium infantis 35624 everyday for eight weeks experienced fewer overall symptoms, abdominal pain and discomfort.
The symptom relief was comparable to that seen with Zelnorm (tegaserod) and Lotronex (alosetron), drugs that have been recently approved for the treatment of irritable bowel syndrome (IBS). IBS is a long-term condition that usually involves cramping, diarrhoea and constipation. It affects between 10 and 15 per cent of the Irish population and a similar proportion of people in other western countries. However the precise cause of IBS is not fully understood and there is no cure yet.
Treatments are aimed at alleviating symptoms but medication, for those with moderate to severe forms of the disease, does not work for all patients. Senior author on the new study, Professor Eamon Quigley, who is head of UCC's medical school, said the results "look very good in comparison to pharmacological products". "We believe we have very significant results. It is at least as effective as lots of available products, and probiotics have a good safety profile too," he told NutraIngredients.com.
In contrast, treatment with another probiotic bacteria, Lactobacillus salivarius UCC4331, also isolated at the Irish centre, appeared to have no more effect on IBS symptoms than a placebo drink. Both strains, patented by UCC, had shown interesting properties in laboratory studies.
“Previous studies of probiotic preparations have been small and used different probiotics, different doses and different definitions of IBS. Ours is one of the first properly powered trials conducted to accepted standards in this area,” Dr Quigley added. For the study, published in the March issue of Gastroenterology (vol 128, issue 3, pp541-51), 77 people with IBS were asked to drink a malted milk drink every morning. The drink either contained L. salivarius, B. infantis or no added bacteria. The subjects recorded their symptoms. “Our hypothesis is that low-grade inflammation is a factor in IBS and that certain probiotic bacteria can reduce this inflammation.
We have some evidence to support this theory because our paper shows a change in cytokine ratios after the probiotic treatment," said Dr Quigley. He added that further clinical trials are ongoing and research into the mechanism will also be carried out by the team. Neither of the strains is currently commercially available but the APC works in partnership with Procter and Gamble and is hoping to bring the bacteria to market in new products.
Monday, March 06, 2006
Whirlpools 'harbouring bacteria'
A team from Texas A&M University tested 43 water samples from private and public whirlpool baths, and found all had some kind of microbial growth.
Bacteria derived from faeces were present in 95% of samples, while 81% had fungi and 34% contained potentially deadly staphylococcus bacteria.
Details are published in an online journal called PM Engineer.
Lead researcher Dr Rita Moyes said: "Whirlpool baths are almost always a prime area for potentially harmful microbes.
"The main reason is the lining of the pipes. They are full of inaccessible air, and water in these pipes tends to get trapped, often for long periods of time.
"When the jets are then switched on, this water with harmful bacteria gets blown into the tub where a person is soaking and then trouble can start."
Dr Moyes said a teaspoon of normal tap water contains about 138 bacteria, with many samples not having any bacteria at all.
A teaspoon of whirlpool tub water, on the other hand, contained an average of 2.17m bacteria.
Dr Moyes said such harmful bacteria could lead to numerous diseases, among them urinary tract infections, septicaemia, pneumonia and several types of skin infections.
She said the aerosol mist created by the whirlpool action could force microbes into the lungs, or open cuts.
Dr Moyes says that as long ago as 1972, studies were done to test the bacteria levels in whirlpool baths and hot tubs, but evidence collected has often not shown sufficient reasons for concern.
"That's probably because a hot tub or whirlpool as a source of infection can't be clearly distinguished from other sources," she said.
She said this was similar to how a doctor might be able to tell you that you have a respiratory infection, but not how you got it.
Dr Moyes added: "The best way to prevent such bacteria from forming is to clean out the pipes.
"The pipes in a whirlpool bathtub need to be scraped and cleaned just like you need to brush your teeth with toothpaste.
"We also need to explore effective ways to prevent the growth of bacteria in whirlpool bathtubs through new cleaning methods and new technology in tub design."
Dr John Lee, of the Health Protection Agency, said people fitting whirlpool baths into their own homes should be aware of the need for regular cleaning.
"If you don't clean them regularly you often see discoloured or black bits coming out of the pipes, which is certainly a warning sign," he said.
He said most commercial and healthcare operators did clean their products on a regular basis.
Thursday, March 02, 2006
The Most Dangerous Bacteria
Athletes with infected scrapes that won't go away. Hundreds of soldiers returning from Iraq with wound infections that don't respond to most antibiotics. Often deadly pneumonias. Ninety-thousand patients who die in hospitals every year. That's the toll in the U.S. from germs that are resistant to existing medicines.
The problem is that many common bacteria and fungi have evolved into being resistant to the drugs that have kept them at bay for a half-century. The problem is not new (see: " Bug Wars"), but it is still getting worse, even as a spattering of new antibiotics and anti-fungal drugs reach the market. Now, doctors are trying to get more attention for the problem, hoping that comprehensive legislation could stimulate drug firms to put more effort into developing new antibiotics.
Today, the Infectious Diseases Society of America, an association of 8,000 infectious-disease specialists, is announcing a hit list of the six most worrisome germs doctors now face in clinical practice. The list, which includes five bacteria and one fungus, is described in the current issue of Clinical Infectious Diseases, a medical journal, and will also be unveiled as part of a press conference today. For all of these germs, the authors see very few new drugs being developed and rising rates of illness.
In some cases, the problem is particularly gruesome. To treat soldiers returning from Iraq with wound infections caused by Acinetobacter baumannii, doctors are resorting to using a drug called colistin. The medicine fell out of use decades ago because it can cause severe damage to the kidneys (see: " The Iraq Infection"). The authors of the IDSA report note that Acinetobacter can also cause pneumonia; mortality rates for the pneumonia can be 20% or more.
Why are there so few new medicines targeted at resistant bacteria? In the past decade, many big pharmaceutical players, including Wyeth (nyse: WYE - news - people ), Roche and Eli Lilly (nyse: LLY - news - people ), backed off antibiotic research. At the same time, new antibiotics were becoming increasingly difficult to develop. For 30 years--until 2000--there were no new classes of antibiotics approved.
In the past six years, there have been two clear examples: Zyvox, from Pfizer (nyse: PFE - news - people ), and Cubicin, from Cubist Pharmaceuticals (nasdaq: CBST - news - people ). Wyeth's Tygacil and Sanofi-Aventis' (nyse: SNY - news - people ) Ketek have been touted as new classes, and though the distinction can be argued, both were definitely better at fighting resistant bugs.
Drug companies are starting to become interested in antibiotics again. Pfizer, which always kept a presence in developing new germ-killing drugs, saw its Zyvox become a fast-growing drug in recent years. Then it bought antibiotics maker Vicuron last summer; an antifungal medicine from the deal was approved on Feb. 21. Abbott Laboratories' (nyse: ABT - news - people ) Omnicef, an antibiotic pill, saw sales increase 61% to $627 million last year, according to consulting firm IMS Health (nyse: RX - news - people ).
Biotechs are benefiting too. Shares in antibiotic maker Cubist Pharmaceuticals have more than doubled this year based on sales of Cubicin, its injectable treatment for Staphylococcus aureus, one of the bugs topping the IDSA's hit list (see: " A Better Antibiotic?").
But the IDSA authors say the antibiotics in development simply aren't enough. A review of new medicines finds few that work in new ways, meaning that some of the new drugs may hit the market already facing some resistant bugs. And the authors say the drug companies are not developing drugs to treat the organisms that are the biggest health threat. Market forces, they worry, may not take care of the problem.