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PubMed2001

[Clinical analysis of patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents--including a comparative study of an infectious group with monomicrobial agents and an infectious group with unknown agents].

We clinically analyzed 83 patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents who we have treated during the past 15 years. A comparative study among three groups; an infectious group with polymicrobial agents (83 cases), an infectious group with monomicrobial agents (335 cases), and an infectious group with unknown agents (599 cases) was performed. The results were as follows; (1) The highest percentage of patients were elderly and bedridden. (2) Striking atypical pneumonic symptoms, including dyspnea, consciousness disturbance, gastrointestinal symptoms and hypotension (shock) were present. (3) Laboratory findings of poor nutritional conditions, including decreases in serum protein, albumin, and cholineesterase, and hypoxia remarkably increased. (4) The prognosis was poor because the mortality rate (15.7%) was higher. (5) There were two polymicrobial agents for 75 patients and three agents for 8 patients. The coupling of polymicrobial agents was most frequent in five patients with Haemophilus influenzae + MSSA and five with H. influenzae + respiratory virus. These results suggest that the patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents had clinical features and causative microorganisms resembling those of elderly patients with community-acquired pneumonia. We recommended that treatment with antibiotics for them was adequate if the treatment resemble that of elderly patients.

Adolescent↗

PubMed2002

Nosocomial cardiac infections.

The most important nosocomial cardiac infections include nosocomial infective endocarditis on native and prosthetic valves, and nosocomial infections related to transvenous permanent pacemakers, implantable cardioverter-defibrillators and left ventricular assist devices. Although representing rare complications, they are of great importance because they are associated with high morbidity and mortality. Most of them are encountered in older-age groups, related to nosocomial invasive procedures performed within the preceding four to eight weeks of hospital admission. Nosocomial bacteraemia associated with infected central intravascular devices, genitourinary or gastrointestinal tract surgery and instrumentation, breaks in sterile surgical techniques at the implantation of prosthetic valves and cardiac devices as well as wound and skin infections, represent the most important risk factors. Staphylococcus aureus in native valve endocarditis and S. epidermidis in the presence of foreign bodies are the main implicated pathogens. However, because of the steeply increasing incidence of candidaemia in tertiary hospitals, nosocomial cardiac infections caused by Candida spp. have also been steadily increasing over the last decades. Diagnosis of nosocomial cardiac infections, particularly in the presence of foreign bodies, is often difficult because of the severity of patients' co-morbid illnesses and the co-existence of several risk factors. Diagnosis should be based on positive blood cultures and transoesophageal echocardiographic findings in febrile high-risk patients. Therapy necessitates a combination of antibiotics and surgical removal of foreign bodies. Prophylaxis should mainly target the prevention and/or appropriate treatment of bacteraemias secondary to infected intravascular devices, as well as application of prophylaxis guidelines whenever invasive hospital-based procedures are performed in high-risk individuals.

Candidiasis↗

PubMedDate not supplied

Staphylococcus aureus and other bacteremias in hemodialysis patients: antibiotic therapy and surgical removal of access site.

BACKGROUND: Bacteremia is commonplace in patients undergoing hemodialysis since the vascular access site is a ready source of infection. Mortality is notably high. However, uncertainties exist with respect to therapy including indications for surgical removal of vascular access site and duration of therapy. We therefore conducted a large-scale collaborative study of bacteremia in hemodialysis patients in six US academic medical centers to define the epidemiology of such infections and to address issues of management. PATIENTS AND METHODS: We conducted a prospective observational study over 2 years. Severity of illness at onset of bacteremia was defined by objective criteria. Patients were followed for 90 days to assess late complications including endocarditis and mortality. Univariate and multivariate analyses were used to assess risk factors for mortality. RESULTS: Patients experiencing 127 consecutive episodes of bacteremia were enrolled. The most common cause of bacteremia was Staphylococcus aureus (31%), followed by aerobic gram-negative bacilli (28%) and coagulase-negative staphylococci (13%). Polymicrobial bacteremia occurred in 6% of patients. The most frequent focus of infection was the access site for hemodialysis, although urinary tract, gastrointestinal tract and lung were also implicated. Aerobic gram-negative bacilli and enterococci usually originated from the urinary tract. S. aureus was significantly more likely to cause infection of the access site than other bacteria (p = 0.0001). S. aureus endocarditis was diagnosed in two patients who were receiving antibiotic therapy for S. aureus bacteremia. Removal of the infected access site (shunt, fistula, catheter) was performed for 86% of the patients (95% of the intravenous catheters and 80% of the arteriovenous fistulas/shunts). Overall mortality was 33% at 90 days and was significantly associated with severity of illness at onset of antibiotic therapy and age >60 years. Mortality was not significantly different in patients undergoing surgical removal of infected access site versus those treated with antibiotics alone. CONCLUSION: When S. aureus was isolated from the blood, the access site was the most frequent source. Surgical removal of the access site did not have a notable impact on mortality. Until a randomized trial proves otherwise, it appears that surgical removal of the access site can be individualized. Selected patients who are less severely ill (based on objective criteria) can maintain their hemodialysis access site and be treated with 2 weeks of antibiotic therapy.

Abscess↗

PubMed2002

The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, enterococcus, gram-negative bacilli, Clostridium difficile, and Candida.

Recent years have witnessed a rapidly growing crisis in antimicrobial resistance, especially among microorganisms that cause nosocomial infection. To better understand common risk factors among multiresistant organisms, this review explores risk factors for nosocomial infection with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, Clostridium difficile, extended-spectrum beta-lactamase-producing gram-negative bacilli, and Candida. This review comprises data from 74 published studies; 53 (71%) were retrospective studies and addressed few risk factors or did not quantify risk. The analysis shows impressive commonality of risk factors across these diverse multiresistant organisms: advanced age; underlying diseases and severity of illness; inter-institutional transfer of the patient, especially from a nursing home; prolonged hospitalization; gastrointestinal surgery or transplantation; exposure to invasive devices of all types, especially central venous catheters; and exposure to antimicrobial drugs, especially cephalosporins. More restricted use of antibiotics, especially cephalosporins, and strategies to prevent medical device-related infection and cross-infection in the hospital would yield benefit with all types of resistant organisms. Preemptive isolation of all patients with risk factors for infection by resistant organisms would very likely reduce secondary spread within the hospital. Conversely, programs that focus on only one organism or one antimicrobial drug are unlikely to succeed. Prospective studies of sufficient size that address all potential risk factors, especially individual anti-infective agents, and that use matched controls who are shown by surveillance cultures to be free of colonization by resistant organisms would enhance understanding of the epidemiology of antimicrobial resistance in institutions and guide efforts to develop more effective strategies for prevention.

Anti-Bacterial Agents↗

PubMed1978

Cefamandole in treatment of peritonitis.

Cefamandole was evaluated as the sole antimicrobial agent used to treat bacterial peritonitis in 113 patients. Dosage varied between 1 and 2 g given intravenously every 6 hr. Laparotomy for excision of infected or gangrenous tissues, closure of gastrointestinal perforations, or drainage of an established abscess was required in 99 of the cases. A good clinical response was obtained in 107 patients, or 95% of the total group. Of the six deaths only one could be attributed to infection. No evidence of renal, hepatic, or hematopoietic toxicity was noted. There were no allergic reactions, although 13 patients (12%) developed phlebitis in a vein used for antibiotic administration. Bacteriological studies revealed aerobic peritonitis in 99% of the patients, with anaerobe participation in 60% of these cases. Sensitivity testing by the disk diffusion and tube dilution methods confirmed the appropriateness of cefamandole therapy; 91% of the gram-negative rods and 61% of the anaerobes were susceptible. From results of this study, it would appear that cefamandole is a reliably effective antibiotic for use in treatment of most forms of acute peritonitis. Its role in surgical prophylaxis may be even more promising.

Adult↗

PubMed2002

The importance of disinfection therapy using povidone-iodine solution in atopic dermatitis.

The combination of the local disinfection therapy against Staphylococcus aureus with the conventional therapy for atopic dermatitis has been widely used, and the improvement in skin lesions has been reported to be associated with a remarkable decrease in IgE levels and reagin antibody titers. We have already reported that affected organs were not only the skin but also the gastrointestinal tract in a case with atopic dermatitis. In the present study, the duodenal tissues were examined by biopsy in 32 patients with atopic dermatitis, and mild or chronic duodenitis was observed in all samples. Toxins were examined by PCR from 180 Staphylococcus aureus strains obtained from our patients. The detection rate of toxins was 82.8%. In many patients, antitoxin IgE antibody titers corresponding to their types of toxin and IgE levels were decreased in a parallel manner as time passed. We found 1 patient who complained of paresthesia in all four limbs, and her neurological and radiological examinations showed moderate cervical spondylosis. Neurological examinations revealed some abnormalities in 43 out of 50 patients with atopic dermatitis, such as hyperreflexia of the legs. Cervical MRI was carried out randomly and showed abnormal findings in 21 of 25 patients, in whom 18 duodenal tissues were examined by biopsies.

Adolescent↗

PubMed1996

Is nasal polyposis in cystic fibrosis a direct manifestation of genetic mutation or a complication of chronic infection?

Cystic fibrosis (CF) is the most common autosomal recessive disease among Caucasians. It is characterized by abnormal transepithelial sodium and chloride transport. The clinical expressions of the disorder are highly variable including nasal polyposis. Some authors have found that CF children with nasal polyposis form a distinct subgroup of patients within the clinical heterogeneity of the disease with milder gastrointestinal and pulmonary symptoms. The aim of this prospective study was to verify whether the clinical manifestations in CF children with nasal polyposis are different from control CF patients, and to identify any correlation between a phenotype of nasal polyposis and a genotype. Sixty-six CF children, aged 1-25 years, consecutively underwent ENT examination including nasal endoscopy. Twenty-one had nasal polyposis. The remainder formed the control group. There was no statistical difference in the mode and age of presentation of the disease between the two groups. The clinical manifestations (Schwachman and Kulczycki score, colonization by Staphylococcus aureus and Pseudomonas aeruginosa) were comparable between the two groups. We found no statistical difference in the repartition of genotypes between the polyposis and the control groups. Nasal polyposis does not seem to be genetically dependent, but a larger sample of patients is needed to reach an accurate conclusion.

Adolescent↗

PubMed2006

Occurance of Staphylococcus nepalensis strains in different sources including human clinical material.

Five isolates of coagulase-negative staphylococci were obtained from human urine, the gastrointestinal tract of squirrel monkeys, pig skin and from the environment. All key biochemical characteristics of the tested strains corresponded with the description of Staphylococcus xylosus species. However, partial 16S rRNA gene sequences obtained from analysed strains corresponded with those of Staphylococcus nepalensis reference strains, except for two strains which differed in one residue. Ribotyping with EcoRI and HindIII restriction enzymes, whole cell protein profile analysis performed by SDS-PAGE and SmaI macrorestriction analysis were used for more precise characterization and identification of the analysed strains. Obtained results showed that EcoRI and HindIII ribotyping and whole cell protein fingerprinting are suitable and reliable methods for the differentiation of S. nepalensis strains from the other novobiocin resistant staphylococci, whereas macrorestriction analysis was found to be a good tool for strain typing. The isolation of S. nepalensis is sporadic, and according to our best knowledge this study is the first report of the occurrence of this species in human clinical material as well as in other sources.

Bacterial Typing Techniques↗

PubMed1999

Predominant Staphylococcus aureus isolated from antibiotic-associated diarrhea is clinically relevant and produces enterotoxin A and the bicomponent toxin LukE-lukD.

Staphylococcus aureus was isolated as the predominant or only isolate from cultures of stools of 60 patients over 2 years in a university hospital, leading to the collection of 114 isolates. Diarrhea was observed in 90% of the patients. Ninety-eight percent of the patients had received antibiotics in the month before the diarrhea. Ninety-two percent of the S. aureus isolates were methicillin resistant. S. aureus was encountered with antibiotic-associated diarrhea among 47 quite elderly patients affected or not affected by a gastrointestinal disease. Among the antimicrobial treatments, cessation of the previous therapy when possible or rapid application of oral vancomycin therapy was the most appropriate. Analysis of total DNA by pulsed-field gel electrophoresis revealed 27 different SmaI pulsotypes distributed in 15 clusters. The pulsotypes never differed for related isolates from a single patient, even if they originated from patients with bacteremia. S. aureus was not isolated as the predominant isolate in cultures of stools of 57 patients who received an antimicrobial treatment for more than 5 days without diarrhea. Occurence of production of both enterotoxin A and the bicomponent leucotoxin LukE-LukD by the S. aureus isolates was significantly different from that by random isolates. The results strongly suggest that when predominant in stool samples, S. aureus should be considered a possible etiologic agent for some cases of antibiotic-associated diarrhea.

Adolescent↗

PubMed1994

[Studies on the relationship between gastric acidity and the development of MRSA. Especially for the prevention of MRSA enterocolitis].

Enterocolitis caused by methicillin-resistant Staphylococcus aureus (MRSA) has recently been recognized as one of the severe postoperative complications in surgery on the digestive organs. This disease often occurs in the early days after gastrointestinal operation, especially after gastrectomy. MRSA enterocolitis seems to occur when MRSA has first infected the naso-pharyngeal mucosa preoperatively, and then moved into the stomach, and subsequently proliferated in the higher pH gastric juices. The aim of this experiment was to reveal the relationship between the acidity of gastric juices and bacterial growth in the stomach during the pre and post operative period in an effort to prevent of MRSA enterocolitis. In vitro, MRSA was cultured for various periods at various pH values, and its proliferation was observed. MRSA did not grow in the culture at pH 1 at all, neither did it grow at pH 2 when cultured for more than 8 hours. This data shows the germicidal effect of high acidity in the stomach. Clinically, twenty patients with cancer in the digestive tract had the bacteria in their gastric juices examined in terms of acidity before and after operation. In cases with an increased pH level in the gastric juices after the operation. S. aureus including MRSA, was isolated frequently from the stomach. In vitro, incubation of MRSA with gastric juices collected from those cases showed no development of MRSA when the pH was below 3.98. In order to prevent the onset of MRSA enterocolitis, the remnant stomachs of ten patients with stomach cancer were filled with hydrochloric acid lemonade just after operative reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2001

Optimisation of the prevention and treatment of bacterial endocarditis.

This paper reviews currently established guidelines for the prevention and treatment of bacterial endocarditis. Endocarditis remains a life-threatening disease with substantial morbidity and mortality. Primary prevention of endocarditis, whenever possible, is therefore very important. In an individual with endocarditis, rapid diagnosis and effective treatment are essential to good patient outcome. The guidelines discussed here are largely based on those issued by the American Heart Association. While most cases of endocarditis are not attributable to an invasive procedure, certain procedures are associated with bacteraemia by organisms commonly associated with endocarditis, and antibacterial prophylaxis is recommended before such procedures. Patient cardiac conditions are stratified into high, moderate and negligible risk categories based on potential outcome if endocarditis develops. For oral, dental, respiratory tract, and oesophageal procedures (most often associated with viridans streptococci) the standard antibacterial regimen is oral amoxicillin. For gastrointestinal and genitourinary procedures (most often associated with enterococci), parenteral antibacterials are most often recommended. For high-risk patients, intramuscular or intravenous ampicillin and gentamicin (or vancomycin and gentamicin in penicillin-allergic individuals) is recommended. For moderate risk patients, an option of oral amoxicillin or parenteral ampicillin is offered. Treatment of bacterial endocarditis is guided by identification of the causative micro-organism. Approximately 80% of cases of endocarditis are due to the gram-positive cocci: streptococci and staphylococci. Other gram-positive organisms include enterococci (predominantly Enterococcusfaecalis and E. faecium) and the HACEK group of organisms (Haemophilus parainfluenzae, H. aphrophilus, Actinobacillus [Haemophilus] actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae). In general, for uncomplicated cases of endocarditis due to penicillin-susceptible viridans streptococci or Streptococcus bovis 4 weeks of benzylpenicillin (or ceftriaxone) is the preferred regimen for most patients aged >65 years. A 2-week course of treatment can be used when gentamicin is added, in patients at low risk for adverse events caused by gentamicin therapy. When endocarditis is caused by strains of viridans streptococci or S. bovis relatively resistant to penicillin, or by enterococci, both benzylpenicillin and gentamicin are recommended. For staphylococcal endocarditis on native heart valves, nafcillin or oxacillin with or without gentamicin is the preferred regimen. In prosthetic valve staphylococcal endocarditis, nafcillin (or oxacillin) with rifampicin and gentamicin is recommended. For all of the above situations, vancomycin is recommended for the patient allergic to penicillin (or methicillin). Finally, consideration of out-of-hospital therapy in selected patients is discussed.

Ambulatory Care↗

PubMed2006

Selective digestive tract decontamination--will it prevent infection with multidrug-resistant gram-negative pathogens but still be applicable in institutions where methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci are endemic?

The purposes of selective decontamination of the digestive tract are to treat infections that may be incubating at the time a patient is admitted to an intensive care unit (ICU), by intravenous administration of antibiotics during the first days of a stay in the ICU, and to prevent ICU-acquired infections, by topical application of antibiotics in the oropharynx and the gastrointestinal tract. Despite multiple trials in which a considerable reduction in the incidence of ventilator-associated pneumonia was demonstrated, major objections against the routine use of selective decontamination of the digestive tract have included a lack of demonstrated reductions in mortality rates and in length of stay (in individual trials), a lack of cost-efficacy data, and the threat of selection of multidrug-resistant bacteria. Recently, 2 controlled, randomized studies reported significant reductions in mortality rates among patients in ICUs who underwent selective decontamination of the digestive tract in combination with reduced selection of antibiotic-resistant pathogens. However, those studies were performed in settings where levels of antibiotic resistance are low, and some methodological issues remain unresolved. If these beneficial results are confirmed, the question of how to balance these benefits against the expected enhanced selection of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and, possibly, multidrug-resistant gram-negative bacteria will emerge.

Anti-Bacterial Agents↗

PubMed2006

Antimicrobial resistance in gram-positive bacteria.

Gram-positive bacteria are common causes of bloodstream and other infections in hospitalized patients in the United States, and the percentage of nosocomial bloodstream infections caused by antibiotic-resistant gram-positive bacteria is increasing. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are of particular concern. In the United States, approximately 60% of staphylococcal infections in the intensive care unit are now caused by MRSA, and percentages continue to rise. Outbreaks of hospital-acquired MRSA (HA-MRSA) are typically the result of clonal spread by MRSA being transferred from patient to patient, frequently using healthcare personnel as intermediaries. HA-MRSA strains are generally multidrug resistant. Vancomycin is the standard treatment for serious MRSA infections, but a few cases of vancomycin-resistant S aureus (VRSA) have recently emerged in the United States. Community-acquired MRSA (CA-MRSA) is also increasing. Soft tissue infections are the most frequent presentations of CA-MRSA, but life-threatening invasive infections occur as well, including necrotizing pneumonia. The mechanisms of methicillin resistance are the same for CA-MRSA and HA-MRSA, but susceptibilities to non-beta-lactam antibiotics often differ. CA-MRSA exhibits broader antibiotic susceptibility than does HA-MRSA. The proportion of enterococci resistant to vancomycin continues to rise in the hospital setting, with the overwhelming majority of infections due to Enterococcus faecium. Clonal spread of VRE has been documented, but polyclonal outbreaks associated with antimicrobial use are also common. The relations between antibiotic use and VRE colonization are complex and related to the antienterococcal activity, biliary excretion, and antianaerobic activity of the antibiotic. Recent results show a decline in invasive pneumococcal disease (IPD) since the introduction of 7-valent pneumococcal conjugate vaccine, and suggest that, where available, vaccines may be useful in the battle to slow the spread of resistant gram-positive cocci.

Animals↗

PubMed2025

Multi-strain carriage and intrahost diversity of Staphylococcus aureus among Indigenous adults in the USA.

Staphylococcus aureus (SA) is an opportunistic pathogen and human commensal that is frequently present in the upper respiratory tract, gastrointestinal tract and skin. While SA can cause diseases ranging from minor skin infections to life-threatening bacteraemia, it can also be carried asymptomatically. Indigenous individuals in the Southwest USA experience high rates of invasive SA disease. As carriage is the most significant risk factor for disease, understanding the dynamics of SA carriage, and in particular co-carriage of multiple strains, is important to develop strategies to prevent transmission in vulnerable communities. Here, we investigated SA co-carriage and intrahost evolution by sampling several colonies from multiple anatomical sites and whole-genome sequencing (WGS) on 310 SA isolates collected from 60 Indigenous adults participating in a cross-sectional carriage study. We assessed the richness and diversity of SA isolates via differences in multilocus sequence type, core-genome SNPs and genome content. Using WGS data, we identified 95 distinct SA intra-subject lineages (ISLs) among 60 participants; co-carriage was detected in 42% (25/60). Notably, two participants each carried four distinct SA ISLs. Variation in antibiotic resistance determinants among carried strains was identified among 42% (25/60) of participants. Lastly, we found unequal distribution of clonal complex by body site, suggesting that certain lineages may be adapted to specific anatomical sites. Together, these findings suggest that co-carriage may occur more frequently than previously appreciated and further our understanding of SA intrahost diversity during carriage, which has implications for surveillance activities and epidemiological investigations.

Humans↗

PubMed2005

Embolic stroke complicating Staphylococcus aureus endocarditis circumstantially linked to rectal trauma from foreign body: a first case report.

BACKGROUND: Diagnostic and therapeutic instrumentation of the lower gastrointestinal tract has been reported to result in bacteremia and endocarditis. No such case has been reported in persons with a history of rectal foreign body insertion despite its potential for greater trauma. CASE PRESENTATION: A 58-year-old male was admitted with confusion and inability to speak. His past history was notable for hospitalization to extract a retained plastic soda bottle from the rectosigmoid two years prior. On examination, he was febrile, tachycardic and hypotensive. There was an apical pansystolic murmur on cardiac examination. He had a mixed receptive and expressive aphasia, and a right hemiparesis. On rectal examination he had perianal erythema and diminished sphincter tone. Magnetic resonance imaging of the brain showed infarction of the occipital and frontal lobes. Transesophageal Echocardiography of the heart revealed vegetations on the mitral valve. All of his blood culture bottles grew methicillin sensitive Staphylococcus aureus. He was successfully treated for bacterial endocarditis with intravenous nafcillin and gentamicin. The rectum is frequently colonized by Staphylococcus aureus and trauma to its mucosa can lead to bacteremia and endocarditis with this organism. In the absence of corroborative evidence such as presented here, it is difficult to make a correlation between staphylococcal endocarditis and anorectal foreign body insertion due to patients being less than forthcoming CONCLUSION: There is a potential risk of staphylococcal bacteremia and endocarditis with rectal foreign body insertion. Further studies are needed to explore this finding. Detailed sexual history and patient counseling should be made a part of routine primary care.

Endocarditis, Bacterial↗

PubMed2005

Risk factors and molecular analysis of community methicillin-resistant Staphylococcus aureus carriage.

A total of 1,838 subjects from the community and 393 subjects from health care-related facilities in Taiwan were evaluated for the prevalence of nasal Staphylococcus aureus colonization and to identify risk factors associated with S. aureus and methicillin-resistant S. aureus (MRSA) colonization. Among the community subjects, 3.5% had nasal MRSA colonization. Subjects from health care-related facilities had a lower S. aureus colonization rate (19.1%) than community subjects (25.2%) but had a significantly higher rate of colonization with MRSA (7.63%). Age (P < 0.001) was a significant risk factor for S. aureus colonization, with subjects under age 20 years or between 71 and 80 years showing higher rates of colonization. Recent gastrointestinal disease (P = 0.011) and hospital admission (P = 0.026) were risk factors for nasal MRSA colonization. Comparison of hospital MRSA isolates with the colonization strains by staphylococcal cassette chromosome mec (SCCmec) gene typing and pulsed-field gel electrophoresis (PFGE) typing revealed that most MRSA strains carried in the community were SCCmec type IV and that most clinical hospital isolates were type III, while health care facility-related carriage isolates were mainly SCCmec type III and type IV. Two new variant SCCmec types were identified. Six clusters of PFGE patterns were distinguished: two mainly comprised health care facility-related MRSA strains, three mainly comprised community MRSA strains, and one comprised mixed community and health care facility-related MRSA strains. In conclusion, a high prevalence of MRSA colonization was observed among people with no relationship to the hospital setting. The high level of multiple-drug resistance among community MRSA strains in association with the previously reported excessive use of antibiotics in Taiwan highlights the importance of the problem of antibiotic selective pressure. Our results indicate that both the clonal spread of MRSA and the transmission of hospital isolates contribute to the high MRSA burden in the community.

Adolescent↗

PubMed1999

Successful intradialytic parenteral nutrition after abdominal "Catastrophes" in chronically hemodialysed patients.

OBJECTIVE: To assess the therapeutic contribution of intradialytic parenteral nutrition (IDPN) in four acutely ill, hypercatabolic, hemodialysed patients. All underwent major surgery, complicated by infection and malnutrition. DESIGN: A retrospective clinical study. SETTING: An in-center hemodialysis unit, at a tertiary referral hospital. PATIENTS: Patient 1: a young woman, with a good renal transplant. Developed gastric lymphoma, which required gastrectomy. After cessation of immunosuppression, "lost" her kidney and returned to hemodialysis. Received IDPN for 4 months and recovered well from severe malnourishment. Patient 2: an elderly, malnourished man, on continuous ambulatory peritoneal dialysis (CAPD). Developed biliary peritonitis and bacteremia. In a 3-month period, the patient had four operations. Maintained on IDPN for 4 months. Patient 3: a young and obese man, who suffered from life-threatening staphylococcal aureus peritonitis, resulting in widespread bowel adhesions. Underwent repeated aspirations of purulent ascites, laparoscopy, and explorative laparotomy. IDPN was administered for 4 months and stopped on the patient's request. Patient 4: a young man, who after cadaveric renal transplantation remained hospitalized for 6 months because of acute rejection and peritoneal and retroperitoneal abscesses. Had major surgery performed seven times. Received IDPN for 6 months, and is now well. RESULTS: All four patients benefited from 4 to 6 months of IDPN, as an integral part of intensive supportive and nutritional treatment. Weight loss was halted, as patient appetite returned and oral nutrition became adequate. Estimated daily protein intake reached 1.2 g/kg, while caloric intake rose to nearly 30 kcal/kg/d (Table 3). Mean serum albumin levels increased from 25.5 g/L +/- 0.9 g/L to 38.0 g/L +/- 1.5 g/L. No adverse side effects were seen from IDPN. CONCLUSION: IDPN is a worthwhile part of treatments used in the catabolic, postoperative hemodialysed patient. It is safe and efficient when used over a 6-month period in trying to attenuate existing, or worsening malnutrition in these patients. It should be commenced at an early stage in these patients, after attempts at oral nutritional support have been deemed inadequate.

Adult↗

PubMed2001

Ciguatera poisoning: a global issue with common management problems.

Ciguatera poisoning, a toxinological syndrome comprising an enigmatic mixture of gastrointestinal, neurocutaneous and constitutional symptoms, is a common food-borne illness related to contaminated fish consumption. As many as 50000 cases worldwide are reported annually, and the condition is endemic in tropical and subtropical regions of the Pacific Basin, Indian Ocean and Caribbean. Isolated outbreaks occur sporadically but with increasing frequency in temperate areas such as Europe and North America. Increase in travel between temperate countries and endemic areas and importation of susceptible fish has led to its encroachment into regions of the world where ciguatera has previously been rarely encountered. In the developed world, ciguatera poses a public health threat due to delayed or missed diagnosis. Ciguatera is frequently encountered in Australia. Sporadic cases are often misdiagnosed or not medically attended to, leading to persistent or recurrent debilitating symptoms lasting months to years. Without treatment, distinctive neurologic symptoms persist, occasionally being mistaken for multiple sclerosis. Constitutional symptoms may be misdiagnosed as chronic fatigue syndrome. A common source outbreak is easier to recognize and therefore notify to public health organizations. We present a case series of four adult tourists who developed ciguatera poisoning after consuming contaminated fish in Vanuatu. All responded well to intravenous mannitol. This is in contrast to a fifth patient who developed symptoms suggestive of ciguatoxicity in the same week as the index cases but actually had staphylococcal endocarditis with bacteraemia. In addition to a lack of response to mannitol, clinical and laboratory indices of sepsis were present in this patient. Apart from ciguatera, acute gastroenteritis followed by neurological symptoms may be due to paralytic or neurotoxic shellfish poisoning, scombroid and pufferfish toxicity, botulism, enterovirus 71, toxidromes and bacteraemia. Clinical aspects of ciguatera toxicity, its pathophysiology, diagnostic difficulties and epidemiology are discussed.

Adult↗