Friday, November 30, 2007
Nosocomial Gram-positive bacterial infections in children: Results of a 7 year study.
Celebi S, Hacimustafaoglu M, Ozdemir O, Ozakin C.
Department of Pediatrics, Division of Pediatric Infectious Diseases, Uludag University Medical Faculty, Gorukle, Bursa, Turkey.
Background: The aim of the present paper was to determine the rate of culture-proven nosocomial infections and evaluate the episodes of nosocomial Gram-positive (GP) bacterial infections in pediatric patients.
Methods: The data of children with positive culture, who were diagnosed as having nosocomial infection on the Centers for Disease Control and Prevention criteria, were examined and only the patients with nosocomial GP bacterial infections were included in the study.
Results: Between January 1997 and January 2004 a total of 836 episodes of nosocomial GP bacterial infections were observed. The most frequently seen nosocomial GP bacterial infections were primary bloodstream infections (BSI; 43%), ventriculoperitoneal shunt infections (18%), and nosocomial pneumonias (11%). Coagulase-negative staphylococci (CONS; 46%) were the most common nosocomial GP bacteria isolated, followed by Staphylococcus aureus (33%). Methicillin resistance rates for CONS and S. aureus were 85% and 25.2%; respectively. The mortality rate was 4% of all children with nosocomial GP bacterial infections in the present study.
Conclusion: In the present patients primary BSI were the most common nosocomial GP bacterial infections and CONS were the most frequent GP pathogen isolated. Antimicrobial resistance in GP isolates is an increasing problem.
PMID: 18045289 [PubMed - in process]
Thursday, November 22, 2007
Necrotizing fasciitis in children: diagnostic and therapeutic aspects.
J Pediatr Surg. 2007 Nov
Bingöl-Koloğlu M, Yıldız RV, Alper B, Yağmurlu A, Ciftçi E, Gökçora IH, Ince E, Emiroğlu M, Dindar H.
Department of Pediatric Surgery, Ankara University School of Medicine, Ankara 06100, Turkey.
BACKGROUND: Necrotizing fasciitis (NF) is a severe life-threatening soft tissue infection characterized by rapidly spreading necrosis of the fascia and the subcutaneous tissue. Its incidence owing to invasive Streptococcus pyogenes has significantly increased in children recently. Our experience with NF in children to describe diagnostic and therapeutic aspects is hence presented herein.
METHODS: Records of children who were treated for NF in our unit from 1999 to 2006, inclusive, were reviewed retrospectively. Information recorded for each patient included medical history, clinical characteristics, diagnostic procedures, treatment methods, and the outcome.
RESULTS: Thirteen patients with a mean age of 35 months were treated for NF during the study period. All of the 13 children had no previous immunosuppression. The predisposing factors were composed of varicella lesions, intramuscular injections, application of a cream containing menthol to the cervical region, penetrant gluteal trauma, omphalitis, dental abscess, and streptococcal toxic shock syndrome. The most common site of the initial involvement was the abdominal wall, followed by the gluteal region and thigh, head and neck, and upper and lower extremities. The initial skin presentations were induration or cellulitis and erythema and edema with progression to skin discoloration and bullae formation. Fever and tachycardia were the most common clinical features. S. pyogenes was the most common causative microorganism, followed by Staphylococcus epidermidis and Pseudomonas aeruginosa. All patients underwent extensive surgical debridement and received appropriate antibiotics and supportive therapy. Twelve patients survived, and 1 patient with delayed diagnosis of NF died of septic shock.
CONCLUSION: Although these infections are rare in children, their lethal potential and early diagnostic signs must be recognized. All children with NF should undergo early surgical debridement to prevent delay in treatment. The mortality and morbidity associated with NF in children can be decreased with clinical awareness, early diagnosis, and adequate and urgent surgical debridement followed by intensive supportive care and early wound resurfacing.
Tuesday, November 20, 2007
Drug-resistant BlaKPC may be spreading
Typically found in bacteria in the East Coast, the gene was recently detected in St. Louis.
by Jay LewisIDN Managing Editor
CHICAGO – Researchers have discovered the presence of the BlaKPC gene in bacteria in patients in a St. Louis hospital. Prior to this, the gene, which enables bacteria to become resistant to several important antibiotics, was typically found in the East Coast. Researchers say this discovery may indicate that BlaKPC is gaining strength and spreading.
Jonas Marschall, MD, a fellow in infectious disease at Washington University School of Medicine in St. Louis, presented the findings at the 47th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy, held in Chicago in September.
BlaKPC was first discovered in Klebsiella pneumoniae taken from patients in hospitals in New York City less than 10 years ago. Experts have remained concerned about the spread of bacteria with BlaKPC; the gene allows bacteria to be resistant to antibiotics in the carbapenem class, which are typically used to treat the most critically-ill patients. Studies have shown that the mortality rate may be as high as 50% for patients who test positive for bacteria with the BlaKPC gene.
Marschall said the study indicated that BlaKPC may be easily transferable, thus indicating that its spread may continue. “It appears that this gene is located on a plasmid and can therefore be passed on to other bacteria relatively easily,” Marschall told Infectious Disease News . “Also, patients that are either infected or colonized with BlaKPC-positive bacteria may be unrecognized using standard clinical lab methods, which can allow for transmission of the bacteria to other patients.”
Marschall and his colleagues used polymerase chain reaction to isolate and amplify bacterial DNA to detect the BlaKPC gene. The researchers studied 243 samples from 223 patients with bloodstream-based bacterial infections. Four of the samples tested positive for BlaKPC.
Marschall said that although this number is small, the finding is significant because the gene is easily spread. It may be only a matter of time before rates increase.
Marschall said hospitals need to take steps to help prevent further spread of BlaKPC. However, there are many challenges.
Stopping the spread
“In general, contact isolation of a patient infected with BlaKPC-positive bacteria would prevent transmission to other patients,” Marschall said. “Isolation, however, implies detection. Detection of these bacteria is not optimal with conventional testing for antimicrobial susceptibility. Some laboratories do not test routinely for susceptibility to carbapenem antibiotics. Thus, as a first step to reduce resistance, methods for detection should be optimized.”
Marschall added that screening methods at many hospitals are inadequate. “There is no established screening method for BlaKPC-positive bacteria, in contrast to methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus,” he said. “The value of screening and the necessary tools are still being discussed in the scientific community.”
Marschall recommended that detection methods for BlaKPC should be improved. “Optimal detection methods should be further investigated, including the question of whether molecular screening tools need to be used,” he said.
Marschall also recommended that researchers investigate alternative antibiotic methods that can be used when antibiotics in the carbapenem class are ineffective. “Further studies should examine alternative treatment regimens that can be used if carbapenems fall away, including the development of new compounds with activity against gram-negative bacteria,” he said.
For more information:
Marschall J, Tibbetts R, Dunne W, et al. Presence of the KPC carbapenemase gene in Enterobacteriaceae bacteremia, correlation with carbapenem susceptibility, and the impact on clinical outcomes. #196. Presented at: the 47th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy; Sept. 17-20, 2007; Chicago.
Infectious Disease News
Thursday, November 15, 2007
Erysipelas: a common potentially dangerous infection.
Acta Dermatovenerol Alp Panonica Adriat. 2007 Sept
Celestin R, Brown J, Kihiczak G, Schwartz RA.
New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103-2714, USA.
Erysipelas is an acute superficial cutaneous cellulitis that commonly occurs not only in elderly and immunocompromised persons, but also in neonates and small children subsequent to bacterial inoculation through a break in the skin barrier. Group A Beta-hemolytic streptococcus (GABHS, Streptoccocus pyogenes) is the usual etiologic agent. Factors that predispose pediatric patients to the development of erysipelas include very young age, diabetes mellitus, an immunocompromised state, and nephrotic syndrome. Patients typically have a well-demarcated, erythematous, indurated, rapidly spreading patch with a palpable advancing border on the face or extremities. Fever with chills and general malaise may be prominent symptoms. Antibiotics are usually effective. Patients handled in a timely manner tend to recover without problems. However, potential complications include abscess formation, necrotizing fasciitis, septicemia, recurrent infection, and lymphedema.
PMID: 17994173 [PubMed - as supplied by publisher]
* * * * * *
Gvozdenović E, Dulović O.
Klinicki centar Srbije, Beograd. firstname.lastname@example.org
INTRODUCTION: Erysipelas is a form of cellulitis and a bacterial infection affecting the most superficial layers of the skin which is caused by group A--hemolytic Streptococcus. The symptoms of erysipelas usually arise quite suddenly and they are often accompanied by fever, chill and shivering. The affected skin is distinguished from other forms of cellulitis by well-defined, raised edge. The affected skin is red, swollen and may be finely dimpled (like an orange skin).
TREATMENT OF ERYSIPELAS: Uncomplicated erysipelas can be treated on an outpatient basis. Indications for hospitalization include a severe clinical picture and socioeconomics factors. Most patients suffering from erysipelas in Belgrade are treated at the Institute of Infectious and Tropical Diseases, and the aim of this study was to analyze patients treated during 2002 and 2003, in order to determine characteristics of erysipelas at the beginning of the XXI century.
MATERIAL AND METHODS: During the studied period, we treated 60 patients (26.7%) of all registrated erysipelas cases in Belgrade. The male/female ratio was 1:1.6.
DISCUSSION AND CONCLUSION: Prevalence was higher during the summer months. In most cases, the severity and the need for hospitalization were recognized at the beginning; therefore, 74% of patients were hospitalized during the first five days from the onset of nonspecific signs of illness. Laboratory tests showed mild leukocytosis (med 12.05 x 10/9/l), with predominant neutrophils (74.8%) and increased fibrinogen (med 5.4 g/l). Predisposing factors were present in 83.3% of cases; of them, in 35% of cases this was not the first episode of this illness. In 85% of cases erysipelas of the leg was established, and it was the most frequent localization of all.
PMID: 17988064 [PubMed - in process]
Wednesday, November 07, 2007
Bacterial dermohypodermitis: a retrospective single-center study of 244 cases in Guinea
Ann Dermatol Venereol. 2007 Oct
BACKGROUND: Dermo-hypodermal bacterial infections (erysipelas, cellulitis and necrotizing fasciitis) are frequent and may be life-threatening.
PATIENTS AND METHODS: A retrospective study of a period of 4 years and 6 months (1 June 1999 to 31 December 2003) was carried out at the Donka University Hospital centre (Conakry-Guinea) in order to analyze the epidemiological, clinical and therapeutic characteristics of bacterial dermohypodermitis in a hospital environment.
RESULTS: Two hundred and forty-four patients (188 women and 56 men) were hospitalized for bacterial dermohypodermitis. Mean age was 38 years. The site of dermohypodermitis comprised the entire lower limbs in 4 cases (2%), legs and feet in 200 cases (82%), thighs in 12 cases (4%), buttocks in 4 cases (2%) and upper limbs in 24 cases (10%). A previous history of dermohypodermitis, chronic alcoholism, use of non-steroidal anti inflammatory drugs, obesity and lymphoedema was identified. Necrotizing bacterial dermohypodermitis and necrotizing fasciitis were the main complications and were seen in 31 patients. These conditions were generally associated with use of non-steroidal anti inflammatory drugs (90% vs. 25%) (OR=27, CI 95=8-94), delayed initiation of suitable treatment and use of traditional medicine.
CONCLUSION: Our study shows female predominance of bacterial dermohypodermitis. This is explained by cutaneous atrophy in women resulting from use of depigmenting drugs that facilitate skin breaks, thus allowing ingress of bacteria. NSAID intake, while frequent in our series, was far higher in the fasciitis group, suggesting a potentially aggravating role of these drugs.Masson
Saturday, November 03, 2007
Dangerous bacterial infections are on the rise
What you can do to counter the trend and stay safe.
When conducting hospital rounds a few months ago, Neil Fishman, M.D., saw five patients whose infections didn’t respond to any available antibiotic. “I was shocked,” says Fishman, an expert in antibiotic resistance with the Infectious Diseases Society of America in Arlington, Va. “I fear we’re at a tipping point--on the verge of returning to a pre-antibiotic era, when none of our antibiotics may work at all.”
Most bacterial infections can still be treated with at least one antibiotic. But there are emerging problems. For example:
Nearly 1 of every 3 pneumococci--the bacteria responsible for many pneumonias--has become resistant to penicillin, and 1 in 10 is resistant to most other antibiotics.
An antibiotic-resistant strain of staphylococcus that triggers potentially deadly lung and bloodstream infections is spreading through hospitals in this country and, increasingly, into communities.
Few if any antibiotics work against a bacterium called Acinetobacter baumannii, which has infected the wounds of many soldiers returning home from Iraq and Afghanistan, in some cases forcing doctors to amputate infected limbs.
Gonorrhea and tuberculosis are making a comeback, in part because the bugs responsible for them have developed defenses against previously used antibiotics.
Consumers have contributed to the growing crisis by not taking antibiotics properly and, in many cases, insisting that their doctor prescribe antibiotics for viral infections, such as the flu, ear infections, and the common cold, even though antibiotics work only against bacterial infections.
Doctors have made the situation worse by acquiescing to those ill-informed requests and, when antibiotics are required, sometimes prescribing the wrong dose, the wrong schedule, or the wrong medication. For example, recent research suggests that doctors often turn to newer, more powerful antibiotics when older ones would suffice. And some doctors use antibiotics for even more controversial purposes, such as the long-term treatment of Lyme disease or rheumatoid arthritis.
In hospitals, the combination of drug misuse and poor hygiene has brought the problem of antibiotic resistance to a crisis. Almost 5 percent of all hospitalized patients now acquire an infection during their stay; nearly 100,000 of them die each year as a result.
Here are some steps you can take in your home, your doctor’s office, and in the hospital to protect yourself from antibiotic-resistant bacteria.
SAFE AT HOME
The more an antibiotic is used as a drug and, to a lesser extent, in animal feed and possibly even household cleaners and other consumer products, the more opportunity bacteria have to adapt to it. Using the wrong drug dose or the wrong medication to treat infection can also breed resistance by allowing some bugs to survive, develop resistance, and multiply. So the key to combating antibiotic resistance is preventing unnecessary and inappropriate antibiotic use--tasks that start at home.
Don’t self-treat. Don’t use your own or other people’s leftover antibiotics to treat a self-diagnosed infection, since the drug may not be right for your current infection--if you have one. And don’t order antibiotics online without a prescription, since you might get the wrong drug, the wrong dose, or even a counterfeit product.
Use antibiotic creams sparingly. These over-the-counter products, such as neomycin (Mycitracin, Neosporin, and generic), are needed only for cuts that leave visible dirt or grit behind. In most other cases, washing the wound thoroughly with regular soap and water will provide all the protection you need.
Avoid “antibacterial” products. Soaps with the germ-killing ingredient triclosan don’t prevent infections when used at home, research suggests. Other antibacterial products, including deodorants, wipes, and cleaning products, probably don’t either. But their widespread use may make antibacterial soaps less effective for people who really need them, such as hospital and nursing-home staff. Prevent infection at home by washing hands with plain soap and water or an alcohol-based product like Purell.
Dispose of old antibiotics properly. Researchers have now detected antibiotics in the water supply, possibly from agricultural runoff, excretion from bodies, or old antibiotics dumped into toilets or thrown into landfills, where they may leach into rivers or the groundwater. So if you have old antibiotics in your medicine cabinet, take them to your pharmacist, who can give you advice on the best way to get rid of the drugs and may even participate in a medication-disposal program.
Consider purchasing certified-organic meat. Organic chicken, beef, and other meat don’t necessarily harbor fewer bacteria-resistant germs than regular meat, recent Consumer Reports tests have shown. And organic meat typically costs more. But at least animals raised organically haven’t been fed antibiotic-laced feed, and organic meat hasn’t been treated with antibiotics. So purchasing organic meat can help reduce the spread of antibiotics in the environment.
WORK WITH YOUR DOCTOR
Doctors know that antibiotics work only against bacteria, not viruses. But they often prescribe the drugs for likely viral infections “just to be safe” or to satisfy an insistent patient. So don’t expect or accept antibiotics for common respiratory-tract infections.
Even when you do require antibiotics, your doctor might not prescribe them appropriately. Here’s how to prevent those mistakes.
Get tested. Expect your doctor to check a blood count or take a culture of the infected tissue or fluid. That will help confirm the diagnosis of a bacterial infection before your doctor prescribes an antibiotic, and will help in matching the drug to the bug.
Fight it off. If you have only a mild infection, ask if you can delay treatment for a few days to see if your body can fight it off.
Consider short courses. Ask whether a brief course of antibiotics--such as the three-day plan advised for simple urinary tract infections--can clear the infection. (That approach should be tried only when studies have proved that short courses eliminate the infection.)
Ask about targeted drugs. “Narrow-spectrum” antibiotics that target the likely bacteria are usually better choices than broad-spectrum ones, which can trigger multiple resistances simultaneously. Those medications are often cheaper, too.
Take as directed.Many people stop taking antibiotics once they start feeling better. But unless you finish the course, some of the responsible bacteria will probably survive and perhaps adapt to the medication. So take all the antibiotic pills your doctor prescribes.
Be leery of preventive and long-term use. Doctors sometimes prescribe antibiotics to ward off recurrent urinary tract infections or before dental surgery. But such preventive use is appropriate only if self-help measures and short courses of antibiotics don’t work, or if you’re at high risk of a dental infection spreading to your heart because, for example, you have an artificial heart valve or certain congenital defects.
Some doctors prescribe antibiotics for months or even years to treat Lyme disease or rheumatoid arthritis. But recent guidelines for Lyme disease emphasize that two to four weeks of treatment usually provides maximum benefits. And though some evidence suggests that tetracycline antibiotics may help certain people with rheumatoid arthritis, researchers say that’s not because the disease is caused by an infection but because the drugs may interfere with certain cartilage-destroying enzymes. More important, that benefit appears small, especially compared with the success of other arthritis drugs now available.
BUG-FREE IN THE HOSPITAL
Surgical procedures, needles, and catheters can carry bugs into the body. And hospital staff may fail to take the necessary steps to stop the spread of infection. To cut your risk of contracting or inadvertently spreading an infection while in a hospital or nursing home:
Insist on clean hands. Expect everyone who touches you to first wash their hands with soap or an alcohol-based solution. If you don’t see them do that, politely ask them to. And ask doctors and nurses to clean their stethoscopes, too, since studies show that they seldom clean those instruments between patients.
Don’t swallow bacteria.Keep your hands away from your eyes, nose, and mouth, and don’t set food or utensils directly on tables or beds.
Monitor antibiotic use. Hospital patients are too often given antibiotics plus an acid-suppressing heartburn drug. That combination of drugs can allow invading bacteria to colonize in the gut and sometimes triggers hard-to-treat infections. Before some kinds of surgery, on the other hand, antibiotics may be underused. Ask your doctor if your operation poses a significant threat of infection and if you should receive a single dose of an appropriate antibiotic in the hour beforehand.
Ask about your catheter. The risk of catheter-associated urinary-tract infections increases the longer the catheter remains in place. So if you’re still using a catheter 48 hours after surgery, find out whether your nurse or your doctor has forgotten to remove it.
Choose your hospital. Ask your doctor or surgeon if he or she knows the infection rates for hospitals in your area and, if possible, ask to be admitted to the one with the lowest rate. The hospital-infection initiative Stop Hospital Infections of Consumers Union, the publisher of this newsletter, offers information on the roughly 20 states that now require hospitals to make infection rates public, and what you can do to help make other states take the same step.
PROTECT YOURSELF FROM STAPH INFECTIONS AT THE GYM
A strain of the bacterium methicillin-resistant Staphylococcus aureus (MRSA) has spread from hospitals into communities, mostly in gyms and health clubs, where people unknowingly share contaminated towels or athletic equipment. While the strain is less deadly than the version found in hospitals, it's now a leading cause of skin-related visits to the emergency room. To protect yourself, don't share towels, put a clean towel over workout mats, and wipe down equipment with the alcohol spray that most gyms provide. And see your doctor if you have signs of skin infection: boils or a localized, painful rash that doesn't heal.
Friday, November 02, 2007
Household contacts were key factor for children's colonization with resistant Escherichia coli in community setting.
Lietzau S, Raum E, von Baum H, Marre R, Brenner H.
Department of Epidemiology, German Centre for Research on Ageing, Heidelberg, Germany.
Keywords: Antibiotic resistance, Bacterial, E. coli, Children, Household, Transmission
OBJECTIVE: In young children infections with resistant Escherichia coli (E. coli) can lead to life-threatening situations. Epidemiological data on the prevalence and major determinants of carriage of antibiotic resistant E. coli among children in the community setting are sparse.
STUDY DESIGN AND SETTING: In a population-based study from Germany, stool samples were obtained from children aged 6 months to 4 years attending a pediatrician for a regular health screening (N=568) or an acute infection (N=316), as well as from their parents (N=1,594) and siblings (N=624). E. coli was cultured, and minimal inhibitory concentrations to various antibiotics were tested. We determined prevalences of E. coli resistance to commonly prescribed antibiotics and their association with potential risk factors.
RESULTS: Prevalence of E. coli resistance was 16.6%, 8.7%, and 11.6% for ampicillin, cotrimoxazole, and doxycycline, respectively. Strong associations were found with antibiotic resistance among siblings (odds ratios [95% confidence intervals] for ampicillin, doxycycline, and cotrimoxazole resistance: 4.4 [1.8-10.8], 8.0 [3.0-21.2], and 10.8 [3.5-32.7], respectively).
CONCLUSION: Resistance prevalences in this community-based study were much lower than those reported from the clinical sector. Household contacts seem to be the key factor for children;s colonization with resistant E. coli in the community setting.
J Clin Epidemiol. 2007 Nov
Thursday, November 01, 2007
Differential diagnosis between viral and bacterial meningitis in children.
Differential diagnosis between viral and bacterial meningitis in children.
Eur J Emerg Med. 2007 DecDe Cauwer HG, Eykens L, Hellinckx J, Mortelmans LJ.
aDepartment of Neurology bClinical Laboratory Departments of cPaediatrics dEmergency Medicine, Klina Regional Hospital, Brasschaat, Belgium.
OBJECTIVE: The differential diagnosis between viral meningitis and bacterial meningitis is often very difficult. The results of peripheral blood and spinal fluid analysis are not 100% accurate. We tried to find a useful 'bedside' decision-making tool, based on laboratory results readily available at the emergency department. METHODS: Retrospective study design. Analysis of a consecutive series of all children (age 0-15 years) admitted to the paediatric ward because of a viral or bacterial meningitis, in the period from 1997 to September 2005.
RESULTS: Seventy-one children with viral and 21 with bacterial meningitis were included. Bacterial meningitis occurred at much younger ages than viral meningitis. The paediatrician decided to administer antibiotics in 41 of 71 children with viral meningitis and in all children with bacterial meningitis. We developed a 'bacterial meningitis score' based on C-reactive protein in peripheral blood, as well as glucose and protein in cerebrospinal fluid. Using this score, we could distinguish 54 of 71 patients with viral meningitis from the group with bacterial meningitis. When the dispensing of antibiotics was based on this score, only 16 patients with viral meningitis would receive antibiotics.
CONCLUSION: We present a bedside bacterial meningitis score. Using this bacterial meningitis score as a decision-making tool, we would be able to avoid antibiotics in a large number of children with viral meningitis. As this gives a 100% success rate, thus guaranteeing that bacterial meningitis patients would receive the proper therapy, our bacterial meningitis score could be an accurate decision-support tool.