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Nitric oxide synthesis during acute SIV mac251 infection of macaques.

During HIV1 infection, nitric oxide (NO) could significantly contribute to immune dysregulation by its multiple effects on the modulation of the host immune response. The in vivo regulation of NO production is attributable to several nitric oxide synthases, one of which is a cytokine-inducible enzyme (iNOS). In vitro experiments suggest that iNOS expression in macrophages may be directly modulated by HIV infection. Acute infection of macaques with a pathogenic strain of the simian immunodeficiency virus (SIV) represents a relevant animal model for the in vivo study of the relationships between iNOS expression and lentiviral replication. Indeed, acute infection in this model is characterized by high rates of viral replication associated with early cytokine dysregulations, in the absence of opportunistic infection. In our experiment, two cynomolgus macaques were inoculated intravenously with a pathogenic isolate of SIVmac251, and iNOS gene expression was investigated ex vivo during acute infection in mononuclear cells obtained from bronchoalveolar lavage (BALMCs). An enhancement of this gene expression was observed as early as the second week of infection, at the time of peak of systemic viraemia, and increased until day 31 p.i. This overexpression was concomitant with a marked linear increase in IFN gamma expression in BALMCs. At the time of systemic viral load peak, the production of NO in plasma of these two monkeys was evidenced by the detection of large amounts of nitrate.

Acute Disease↗

Treatment of lower urinary tract infection in pregnancy.

Urinary tract infection (UTI) is a common complication of pregnancy. Approximately 20--40% of women with asymptomatic bacteriuria will develop pyelonephritis during pregnancy. All pregnant women, therefore, should have their urine cultured at their first visit to the clinic. In a clinical study comparing single-dose treatment with 3 g fosfomycin trometamol versus a 3-day course of 400 mg ceftibuten orally, the inclusion criteria were acute symptomatic lower UTI (acute cystitis), significant bacteriuria (> or =10(3) CFU/ml), pyuria and confirmed pregnancy. Excluded were patients with asymptomatic bacteriuria or acute pyelonephritis. Predisposing factors comprised a history of recurrent UTI, diabetes mellitus, analgesic nephropathy, hyperuricaemia or Fanconi's syndrome. Escherichia coli was the most frequently isolated pathogen in both groups. Therapeutic success (clinical cure and bacteriological eradication of uropathogens) was achieved in 95.2% of the patients treated with fosfomycin-trometamol versus 90.0% of those treated with ceftibuten (P, non-significant). The treatment of acute cystitis in pregnant women using a single-dose of fosfomycin trometamol was equally effective as the 3-day course of oral ceftibuten. Both regimens were well tolerated with only minor adverse effects. Long-term chemoprophylaxis should be suggested in patients with recurrent UTI or following acute pyelonephritis during pregnancy.

Adult↗

A comparison between single-dose fosfomycin trometamol (Monuril) and a 5-day course of trimethoprim in the treatment of uncomplicated lower urinary tract infection in women.

This study is a comparison of the microbiological and clinical efficacy of single-dose fosfomycin trometamol therapy and a 5 day course of trimethoprim in the treatment of uncomplicated urinary tract infection in female patients. Urine dip-slide samples were obtained from 547 female patients aged 18-65 by 22 General Practitioners (GPs) participating in the study from 21 centres in the UK. All patients were diagnosed as having a urinary tract infection by their GP on the basis of history and clinical examination. Patients were randomised to receive either single dose fosfomycin trometamol or a 5 day course of trimethoprim in a 2:1 ratio. Patients who had significant bacteriuria (> or = 10(5) c.f.u/ml) at the first visit (300) were included in the microbiological analysis. The two commonest urinary pathogens isolated were Escherichia coli and Staphylococcus saprophyticus. Trimethoprim resistance was more frequent amongst E. coli isolates whereas fosfomycin trometamol resistance was more common amongst S. saprophyticus isolates. Microbiological cure was demonstrated in 83.3% of the trimethoprim treated group and 83% of the fosfomycin trometamol treated group. Persistence of the infecting bacteria was seen in 17% of each treatment arm.

Adult↗

A randomised, multicentre study of ceftriaxone versus standard therapy in the treatment of lower respiratory tract infections.

In this study the efficacy and cost-effectiveness of i.v. ceftriaxone 1 g once daily (CTX) was compared with standard i.v. antibiotic treatment (STD) for lower respiratory tract infections (LRTI). STD was given according to the guidelines of the American Thoracic Society and consisted of either cefuroxime 1500 mg three times daily (q8h), amoxicillin/clavulanic acid 1200 mg q8h or ceftriaxone 2 g once daily; each with or without a macrolide. After a minimum of 5 days i.v. therapy, patients could be switched to oral therapy. One hundred patients were enrolled in the study; 52 patients received CTX and 48 STD. Groups were comparable with respect to demographic and baseline characteristics. Seventy patients had a confirmed diagnosis of pneumonia. Twenty-nine patients had a severe type I exacerbation of chronic bronchitis. In one patient the diagnosis of LRTI could not be confirmed. In approximately 50% of the patients a microbiological diagnosis could be made. The most important isolated pathogens from sputum and blood were (positive blood cultures in brackets): Streptococcus pneumoniae 14 (9) and Haemophilus influenzae 16. Mean duration of i.v. therapy was 7.4 days in both groups. Average duration of hospitalisation was 15.0 days for CTX patients and 15.9 days for STD patients. Overall cure and improvement rate at the end of treatment was 47 (90%) for patients receiving ceftriaxone 1 g compared to 37 (77%) for patients receiving standard therapy. Pathogens were eradicated or presumed to be eradicated in 84% of the CTX patients and in 76% of the STD patients. Mean total costs per treatment were lower for CTX than for STD treatment: NLG 169 versus 458. These results show, that i.v. ceftriaxone 1 g once daily is as effective as standard therapy in the treatment of LRTI and that its use reduces treatment costs, in view of the multiple daily dosing regimens of most standard therapies.

Adolescent↗

The MYSTIC (meropenem yearly susceptibility test information collection) programme.

The primary objective of the MYSTIC study is to monitor the performance of meropenem over a period of at least 3 years during which this carbapenem is prescribed in different hospital units thus allowing profiles to be established within individual hospitals. Monitoring is being carried out by assessing the antibiotic susceptibility of bacterial pathogens isolated from patients with a predominate problem of intraabdominal infections (IAI) and/or lower respiratory tract infections (LRTI), treated in specialist centres (haematology wards, the Intensive Care Unit [ICU], cystic fibrosis units) and non-specialised centres. Samples will be collected over each year and tested against meropenem and a set of comparators. The data obtained from the first year of the study (1997) come from 33 centres spread mainly throughout Europe but also in Israel and Mexico. The results shows that meropenem retains its broad spectrum and potency whilst there is evidence that the activity of comparator antibiotics is being eroded by a variety of resistance mechanisms. Data from subsequent years of the programme will determine whether these trends continue and will allow a series of individual centre profiles to be compiled and presented.

Bacteria↗

Combined percutaneous transhepatic and endoscopic placement of biliary stents.

Combined percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography can be used to stent biliary obstruction when attempts at endoscopic stenting have failed. Between January 1987 and August 1991 we performed 35 combined procedures in 31 patients with malignant obstruction. Post stenting serum bilirubin and serum alkaline phosphatase concentration fell after 33 and 29 procedures, respectively. In six studies there was evidence of infection prior to stenting. In spite of the use of prophylactic antibiotics, septic complications developed after eight procedures (23%). Pseudomonas was the most commonly isolated pathogen (46%). Twenty-three patients were discharged, 30-day mortality was 8 (23%) and median survival was 14 weeks (range 0-75 weeks). Seven patients required eight stent changes because of blockage (median patency time 18 weeks; range 7-75 weeks). Use of this technique allows relief of biliary obstruction. Potential infective and bleeding complications must be anticipated.

Aged↗

Differentiation of Mycobacterium species by restriction enzyme analysis of amplified 16S-23S ribosomal DNA spacer sequences.

SETTING: Mycobacteriology research and service laboratories in Thailand. OBJECTIVE: To evaluate the possibility of differentiating species of mycobacteria by amplifying 16S-23S ribosomal deoxyribonucleic acid (DNA) spacer and restriction enzyme analysis of the products. DESIGN: DNA of 113 strains of mycobacteria belonging to 18 species of the genus Mycobacterium were amplified by primers PL1 (5'-GAAGTCGTAACAAGG) and PL2 (5'-CAAGGCATCCACCAT). The amplified products as well as their HaeIII-, MspI- and BstXI-digested products were visualized after agarose gel electrophoresis. RESULTS: The amplified products of rapid-growing mycobacteria were different from the slow-growing mycobacteria. The restriction profiles of members of M. tuberculosis complex were the same as each other but different from other investigated species. The restriction profiles of some species, such as M. avium, M. intracellulare and M. gordonae, were unique, while those of the other species had more than one pattern. However, the restriction profiles of most investigated species were different from each other. CONCLUSION: This preliminary study suggested that the method might be useful for species differentiation of some commonly isolated pathogenic mycobacteria.

Bacterial Typing Techniques↗

Hypermutation in pathogenic bacteria: frequent phase variation in meningococci is a phenotypic trait of a specialized mutator biotype.

Expression of serogroup B meningococcal capsular polysaccharide undergoes frequent phase variation involving reversible frameshift mutations within a homopolymeric repeat in the siaD gene. A high rate of phase variation is the consequence of a biochemical defect in methyl-directed mismatch repair. The mutator phenotype is associated to the absence of DNA adenine methyltransferase (Dam) activity in all pathogenic isolates and in 50% of commensal strains. Analysis of the meningococcal dam gene region revealed that in all Dam- strains a gene encoding a putative restriction endonuclease (drg) that cleaves only the methylated DNA sequence 5'-GmeATC-3' replaced the dam gene. Insertional inactivation of the dam and/or drg genes indicated that high rates of phase variation and hypermutator phenotype are caused by absence of a functional dam gene.

Amino Acid Sequence↗

[Utility of bronchoalveolar lavage in immunocompromised children: diagnostic yield and complications].

OBJECTIVE: Immunocompromised children are at high risk for developing pneumonia due to opportunistic pathogens. The role of bronchoalveolar lavage (BAL) in the evaluation of such patients is still controversial. MATERIAL AND METHOD: We reviewed the hospital records of immunosuppressed patients with respiratory symptoms who had undergone BAL in the pediatric department of the Hospital Clinico de la Pontificia Universidad Católica of Chile. RESULTS: Sixty-eight BAL were performed on 54 children (mean age: 7.5 years) receiving wide-spectrum antibiotic treatment. The most frequent respiratory signs and symptoms were fever (90%) and cough and respiratory distress (81%); 18% had neutropenia and 43% thrombocytopenia. A specific pathogen was identified in BAL samples for 25 patients (37%). The pathogens isolated were bacteria in 21 cases, viruses in 6, Pneumocystis carinii in 5, fungi in 4, and Mycobacterium tuberculosis in one. Fourteen (19%) of the children who underwent BAL were on mechanical ventilation. Outcome was satisfactory in all cases. Twenty-one complications were recorded, 17 of which were minor (mild hypoxemia or fever) and 4 major, requiring tracheal intubation. No deaths were recorded. CONCLUSIONS: Evaluation by fiberoptic bronchoscopy together with BAL proved to be a safe procedure with an adequate diagnostic yield that made it possible to determine the etiology of the pulmonary infiltrates seen in chest x-rays. Both positive and negative results of BAL were useful for treating the patients.

Adolescent↗

Preseptal and orbital cellulitis: a 10-year review of hospitalized patients.

BACKGROUND: Preseptal and orbital cellulitis range in severity from minor to potentially severe complications. The purpose of this study is to describe the clinical features of patients with preseptal or orbital cellulitis in one medical center in Taiwan, and to assess the effectiveness of treatments and the complications. METHODS: Patients admitted between 1996 and 2005 to Taipei Veterans General Hospital under the diagnosis of preseptal or orbital cellulitis were retrospectively reviewed. The demographics, administrative history, past history, clinical presentations, treatments, and complications were analyzed. RESULTS: In total, 94 patients fulfilling the diagnostic criteria for preseptal or orbital cellulitis were identified (67 had preseptal cellulitis, 27 had orbital cellulitis). While paranasal sinus disease was the most common predisposing cause in orbital cases, skin lesions in children and dacryocystitis in adults were the most common in preseptal cases. Microbiologic investigations showed variable results, but the most common pathogen isolated was Staphylococcus aureus. Cultures from eye swabs and local abscesses gave the highest positive yield. Blood cultures were taken in some patients, but the positive rate was extremely low. Treatments included intravenous antibiotics alone, or intravenous antibiotics combined with surgical drainage. Only one case had permanent ocular motility impairment after removal of the orbital foreign body. CONCLUSION: Despite the past history of potential morbidity and even mortality from orbital cellulitis, early diagnosis and prompt treatment with proper antibiotics and/or surgical intervention can achieve a good prognosis.

Adolescent↗

Feasibility and efficacy of in-home water chlorination in rural North-eastern Brazil.

The purpose of this study was to assess the feasibility, acceptability and effect of an in-home water chlorination programme in a rural village. Previous studies at this site showed high levels of faecal coliforms in household water, high diarrhoea rates in children, and enterotoxigenic Escherichia coli and rotaviruses were the most common pathogens isolated from patients. Household water came from a pond and was stored in clay pots. No homes had sanitary facilities. A blind, cross-over trial of treatment of household water with inexpensive hypochlorite by a community health worker was carried out over 18 weeks among 20 families. Water in the clay pots was sampled serially, and symptom surveillance was done by medical students. The programme was generally acceptable to the villagers and no change in water use patterns were apparent. The mean faecal coliform level in the chlorinated water was significantly less than in the placebo treated samples (70 vs 16000 organisms/dl, P less than 0.001). People living in houses receiving placebo treatment had a mean of 11.2 days of diarrhoea per year, and the highest rate of 36.7 was among children less than 2 years old. Diarrhoea rates were not significantly different among the participants while exposed to water treated with hypochlorite. We conclude that a low-cost programme of this type, which utilizes community resources, is logistically feasible, appears to be culturally acceptable in this setting, and can result in a marked reduction in water contamination. The lack of effect on diarrhoea rates suggests that improvement in water quality may affect morbidity only when other variables relating to faecal-oral agent transmission are ameliorated at the same time.

Adult↗

Retropharyngeal abscess: a clinical review.

Retropharyngeal abscesses are uncommon but potentially lethal infections, especially in the paediatric population under the age of five years. Abscesses in this group are classically secondary to upper respiratory infections especially oropharyngeal infections, while in the adult group they are usually secondary to trauma, foreign bodies, or as a complication of dental infections. Early diagnosis and the wide spread use of antibiotics have made these infections less common today. Between the years 1985-1996, 19 cases of retropharyngeal abscesses were treated in our department. Factors such as age, sex, aetiology, presenting signs, symptoms, methods of diagnosis, treatment and complications were reviewed. Thirty-two per cent of the cases were secondary trauma. A lateral neck film showing widening of the prevertebral space was the most important diagnostic tool, computed tomography (CT) scan was used in 63 per cent of cases to verify the signs of an abscess and to provide more accurate anatomical localization. Thirteen cases required surgical drainage. The single most commonly-isolated pathogen was Streptococcus pyogenes. There were no deaths and only one recurrence requiring repeated surgical drainage. One case was complicated by a spinal canal abscess. We also report two cases of retropharyngeal abscess in children caused by swallowing of unusual foreign bodies.

Adolescent↗

CSF shunt infections: a fifteen-year experience with emphasis on management and outcome.

A retrospective study of patients with cerebrospinal fluid shunt infections was undertaken from 1975 to 1989 in a university hospital. The data were analyzed with emphasis on the choice of treatment and outcome. There were 44 infectious episodes in 38 patients for an overall rate of 2.6%, including 30 ventriculoperitoneal, 11 ventriculoatrial and 3 lumboperitoneal shunts. The most frequently isolated pathogens were staphylococci in 61% of the cases followed by gram-negative bacilli in 25%. Different modalities of treatment were used: support (2), intravenous antibiotics alone (6), intravenous antibiotics and shunt revision (3), intravenous antibiotics and shunt removal with or without prior externalization of the distal end (33: 13 + 20). The cure rate was 94% (31/33) with this last modality of treatment. Only 3 patients received intraventricular antibiotics. All deaths occurred in patients treated with support only (2) or with antibiotics alone (1). Four of the six recurrent episodes occurred in patients treated with antibiotics alone (2) or with a shunt revision (2). We conclude that carefully chosen intravenous antibiotics combined with shunt removal preceded or not by externalization of the distal end as an alternative therapy to repeated ventricular taps or insertion of an external ventricular drainage device is an appropriate therapy.

Adolescent↗

Identification of Candida albicans genes that induce Saccharomyces cerevisiae cell adhesion and morphogenesis.

Morphogenesis and adhesion to host tissues and medical devices contribute to the virulence of Candida albicans, the most common fungal pathogen isolated from humans. However, identification of molecular mechanisms of C. albicans adhesion and morphogenesis has been impaired by the lack of effective molecular and genetic tools available for this organism. Saccharomyces cerevisiae provides an attractive model system for studying C. albicans adhesion and morphogenesis because of its well-characterized genetics and gene expression systems. To gain insight into the genetic mechanisms of C. albicans adhesion and morphogenesis, we used a parallel plate flow chamber to screen and quantitatively characterize attachment to polystyrene of an adhesion-deficient nonfilamentous flo8Delta S. cerevisiae strain expressing a C. albicans genomic library. We identified six C. albicans genes that are capable of promoting cell adhesion and pseudohyphal development in S. cerevisiae. We also analyzed the ability of these adhesion-promoting genes to regulate the expression of FLO11, which encodes an endogenous S. cerevisiae adhesin. One C. albicans gene, EAP1, appears to directly mediate adhesion and morphogenesis while the remaining five (EAP2, SWI1, MSB1, AAF1, and TEC1) upregulate expression of endogenous S. cerevisiae adhesins. These results suggest that S. cerevisiae is a useful system for molecular characterization of factors that regulate C. albicans adhesion and morphogenesis and that parallel plate flow chamber-based adhesion assays can be used in conjunction with genetic screens to identify molecular mechanisms regulating fungal cell adhesion.

Biotechnology↗

Primary cutaneous fungal infections in solid organ transplantation: a case series.

Cutaneous fungal infections in solid-organ transplant patients present in a variety of nonspecific ways, requiring a high index of suspicion to diagnose correctly. In the present series of four transplant recipients, subsequent primary cutaneous fungal infections presented as papules, plaques, ulcers and subcutaneous nodules. Transplantations included one cardiac, two renal and one renal-pancreatic transplant. Fungal infections were limited to the skin; there was no evidence of disseminated disease in any case. The pathogens isolated were Scedosporium apiospermum (Pseudallescheria boydii), Alternaria species, Aspergillus fumigatus, and a coelomycete in the Coniothyrium-Microsphaeropsis complex of dark molds. Individuals were successfully treated with surgical debridement, antifungal agents, and reduction of immunosuppressive therapy. All patients and allografts survived. Accurate diagnosis, aggressive surgery and appropriate antifungal therapy, combined with close outpatient follow-up, optimize the likelihood of a cure in a transplant population.

Adult↗

Fatal invasive cerebral Absidia corymbifera infection following bone marrow transplantation.

A 56-year-old dairy farmer received a fully HLA matched unrelated donor marrow transplant for high risk CML in chronic phase. His early post-transplant course was complicated by a series of massive intracerebral bleeds and by sepsis related to a malignant otitis externa. The microbial pathogen isolated from ear swabs was found to be Absidia corymbifera, but CT scan at the time showed no intracerebral extension. Despite neutrophil engraftment and aggressive antifungal management he succumbed. Autopsy revealed invasion of Absidia into the brain from the ear. We speculate that colonisation by Absidia resulted from occupational exposure.

Absidia↗

Infectious complications after high-dose chemotherapy and autologous stem cell transplantation: comparison between patients with lymphoma or multiple myeloma and patients with solid tumors.

From November 1994 to May 1998, 117 patients (66 with solid tumor, 36 with lymphoma, 14 with multiple myeloma, one with acute leukemia) underwent 178 cycles of high-dose chemotherapy and autologous stem cell transplantation (ASCT) at our institution. We retrospectively analyzed the infectious complications that occurred after ASCT. Median duration of neutropenia (granulocyte count <0.5 x 10(9)/l ) was 8 days, the overall incidence of fever requiring antimicrobial treatment was 63%. 35.4% of patients had fever of unknown orign (FUO), whereas primary bacteremia occurred in 21.3%, pneumonia in 3.4% and severe skin infection in 1.1% of patients. Invasive fungal infections occurred in three, and enterocolitis in one patient. Infection was fatal in three patients (2.6%), in each case due to septic shock. The most frequently isolated pathogens were Gram-positive cocci. Median time to defervescence with antimicrobial therapy was 4 days (6 days in patients with bacteremia or other severe infection, and 3 days in patients with FUO). First-line antimicrobial therapy was successful in 65% of patients with FUO and 30.6% of patients with documented infections. With respect to the incidence, type and clinical course of infection, no significant differences between patients with lymphoma or multiple myeloma and those with solid tumors were detected.

Adolescent↗

Paediatric epiglottitis: the influence of the Haemophilus influenzae b vaccine, a ten-year review in the Sheffield region.

Cases of acute epiglottitis in children have become very uncommon in recent years. This study set out to find whether the introduction of the Haemophilus influenzae b (Hib) vaccine in the UK in October 1992 has influenced the incidence of acute epiglottitis in the Sheffield region, and whether the pathogenesis has altered. A 10-year retrospective case note review was undertaken. A total of 30 children were treated for acute epiglottitis in Sheffield Children's Hospital over that time period. A sharp decline in the number of cases was found after the vaccine was introduced. Most children presenting with the disease after October 1992 had not been vaccinated. In addition, the pathogens isolated in those children who had received the vaccine were all Streptococci. This is the first study in the UK to examine the influence of the Hib vaccine on acute paediatric epiglottitis.

Catchment Area, Health↗