Disinfection of Immature Teeth with a Triple Antibiotic Paste

This study assessed the efficacy of a triple antibiotic paste in the disinfection of immature dog teeth with apical periodontitis. The canals were sampled before (S1) and after (S2) irrigation with 1.25% NaOCL and after dressing with a triple antibiotic paste (S3), consisting of metronidazole, ciprofloxacin, and minocycline. At S1, 100% of the samples cultured positive for bacteria with a mean CFU count of 1.7 x 10. At S2, 10% of the samples cultured bacteria-free with a mean CFU count of 1.4 x 10. At S3, 70% of the samples cultured bacteria-free with a mean CFU count of only 26. Reductions in mean CFU counts between S1 and S2 (p < 0.0001) as well as between S2 and S3 (p < 0.0001) were statistically significant. These results indicate the effectiveness of a triple antibiotic paste in the disinfection of immature teeth with apical periodontitis.

Osteomyelitis of the ischium: unusual presentation

A 7-year-old boy presented with urinary symptoms and umbilical discharge. A perivesical abscess was drained from which Staphylococcus aureus was cultured. He responded to antibiotics. Subsequently, he developed a discharging sinus in the gluteal region. A plain radiograph, which had previously been normal, confirmed osteomyelitis of the ischial bone.

Pelvic girdle sepsis in childhood. An illustrative case of the difficulty in diagnosis

The child who presents with fever, limp and hip pain will often undergo multiple diagnostic procedures before a definitive diagnosis is made. We describe a diagnostically challenging case of a 14-year-old boy presenting with an atraumatic painful limp and pyrexia. Eventually the diagnosis of obturator internus muscle abscess with associated ischial osteomyelitis was made. Of the 19 previous cases reported, four children had associated osteomyelitis and were of an older age. Symptomatology varies, clinical examination is non-specific and the diagnosis can be difficult. Haematological indices are more predictive than in cases of classical osteomyelitis or septic arthritis. Subtle features on conventional radiography and isotope bone scanning should not be overlooked while CT and MRI may be complementary in diagnosis.

Mucormicosis cutánea primaria en un paciente con virus de la inmunodeficiencia humana

Primary cutaneous mucormycosis is an unusual mycotic infection associated to immunosupression. We present a 34 year-old woman with HIV infection with a necrotic primary mucormycosis of the skin associated to a venous catheter. She was treated with amphotericin B and surgical debridement.

Effect of Helicobacter pylori eradication in patients with chronic idiopathic thrombocytopenic purpura-a randomized controlled trial

OBJECTIVE

Eradication of Helicobacter pylori was reported to increase the platelet counts in some H. pylori-positive patients with chronic idiopathic thrombocytopenic purpura (cITP). However, the efficacy of the eradication was quite different according to the previous reports. To determine whether H. pylori infection can contribute to cITP, we performed a randomized controlled trial for the first time. In addition, to investigate the possible pathogenic mechanisms and to predict the platelet response after eradication of H. pylori in each cITP patient, several H. pylori virulence factors, the urease activities of the infected H. pylori strains, and the titers of anti-CagA IgG antibodies were analyzed.

METHODS

Patients with cITP underwent gastroscopy and gastric H. pylori infection was confirmed by culture. H. pylori-positive cITP patients were randomly assigned to either the eradication or the non-eradication group. The eradication group received a standard antibiotic therapy for H. pylori. Response to treatment was defined as complete (CR) if the platelet count was above 150x10(3)/microl and partial (PR) if the platelet count increased by more than 50x10(3)/microl above the pretreatment count. The virulence factors were investigated by PCR and PCR-based direct sequencing. Anti-CagA IgG antibody titer of each patient's serum was measured by ELISA.

RESULTS

Of the 36 ITP patients, 25 (69.4%) were positive for H. pylori and eradication was achieved in 84.6% of these patients. The platelet response was significantly different between the eradication group (46.2%) and the non-eradication group (0%). No significant differences were found in clinical factors between the responders and the nonresponders. H. pylori virulence factors and the urease activity were not associated with the response. The titers of anti-CagA antibodies in the responders were significantly higher than those in the nonresponders (p=0.04).

CONCLUSIONS

H. pylori eradication treatment is a favorable therapeutic option for H. pylori-positive patients with cITP. Moreover, an ELISA titer of serum anti-CagA antibody may be a good predictor of platelet recovery, and immunological reaction between platelet and anti-CagA antibodies may have some relation to the pathogenesis of H. pylori-positive patients with cITP.

Histamine-2 receptor expression in gastric mucosa before and after Helicobacter pylori cure

BACKGROUND

Helicobacter pylori infection prevents the occurrence of the tolerance phenomenon of Histamine-2 (H2) receptor antagonists. Gastro-esophageal reflux disease develops in some cases with the restoration of acid secretion after H. pylori eradication therapy.

AIM

To clarify the mechanisms of H2 receptor restoration after the eradication of H. pylori on parietal cells.

METHODS

We enrolled 80 consecutive asymptomatic male patients with H. pylori infection, having chronic gastritis with or without the presence of peptic ulcers. Biopsy specimens from the greater curvatures at the mid-corpus of the stomach were obtained endoscopically from all subjects before and 12 weeks after the eradication of H. pylori. Degrees of gastric atrophy were evaluated by serum pepsinogen levels. The amounts of mRNA expression of H2 receptor were evaluated in each subject's gastric mucosa by real time reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

H2 receptor mRNA expression levels significantly correlated with serum pepsinogens I and II ratios. The expression level of H2 receptor mRNA was lower in subjects with hypergastrinemia. The median expression level of H2 receptor after H. pylori eradication was threefold greater than prior to treatment. In addition, its restoration became more pronounced in subjects with severe gastric atrophy. However, a comparatively low restoration of H2 receptor mRNA was found in subjects with hypergastrinemia.

CONCLUSIONS

H2 receptor mRNA levels decrease with the progression of gastric atrophy induced by H. pylori infection, and are restored after H. pylori eradication. Such expression levels of H2 receptor may explain a part of the tolerance phenomenon to H2 receptor antagonists.

Drug susceptibility of isolates from severe postoperative intraperitoneal infections causing multiple organ failure

PURPOSE

To select the most appropriate antibiotic regimens for life-threatening postoperative infections, we obtained isolates from patients with severe postoperative infections over a 12-year-period, and examined their drug susceptibility.

METHODS

The subjects of this study were 55 patients with multiple organ failure (MOF) caused by postoperative infection.

RESULTS

All strains of Methicillin-resistant Staphylococcus aureus (MRSA) were susceptible to Vancomycin (VCM) and Teicoplanin (TEIC). Only 0.3% of all the Pseudomonas aeruginosa strains were resistant to Imipenem (IPM), but 53.6% of the strains from the severe infections were resistant to IPM. On the other hand, there were few P. aeruginosa strains resistant to Meropenem (MEPM), Ceftazidime (CAZ), Ciprofloxacin (CPFX), and Pazufloxacin (PZFX), even among strains isolated from severe infections. The resistant rate of Bacteroides fragilis to Clindamycin (CLDM) was 35.9%, but there were strains resistant to IPM and Panipenem.

CONCLUSION

These findings suggest that VCM or TEIC are most appropriate for severe abdominal abscess caused by MRSA, whereas MEPM, CAZ, CPFX, and PZFX are more effective against P. aeruginosa infections. The only antibiotic effective against B. fragilis infections in this study was IPM.

Laparoscopic diagnosis and management of primary bacterial peritonitis

Primary bacterial peritonitis is a rare condition occurring, by definition, in patients without an underlying cause as is otherwise observed in patients with perforated viscus, pre-existing ascites, or nephrosis. The diagnosis is usually made at laparotomy. Laparotomy, however, is often associated with significant morbidity and wound complications. We report a case of primary bacterial peritonitis diagnosed at laparoscopy that was managed successfully by laparoscopic peritoneal lavage and appropriate antibiotic therapy with expeditious recovery. This is yet another argument for the application of laparoscopy in the management of generalized peritonitis.

Simplified treatment of postoperative mediastinitis

BACKGROUND

Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication. A variety of treatment plans have been advocated, and there is lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis who have been treated in a simple, consistent manner.

METHODS

We reviewed our experience with 40 consecutive patients with mediastinitis who were treated between January 1995 and May 2003 with a single-stage treatment consisting of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Tubes were placed posterior to the sternum in all patients and were irrigated continuously for at least 7 days with antibiotic or antibacterial solution. Systemic antibiotics were selected based on culture and sensitivity data and were administered for 2 to 6 weeks.

RESULTS

All patients with mediastinitis treated in this manner survived. Of the 40 patients, 38 achieved complete healing of the wound without further operative intervention or major complication. One patient had recurrent infection and required sternal resection and advancement of muscle flaps. One patient had a residual localized focus of chondritis and underwent limited resection of cartilage.

CONCLUSIONS

In this series of patients with postoperative mediastinitis, a simplified approach consisting of wound debridement, reclosure over drains, and anterior mediastinal irrigation has been an effective treatment. The results we have achieved suggest that this technique may be a suitable option for treating this condition.

Recurrent acute rheumatic fever: a forgotten diagnosis?

The incidence of acute rheumatic fever has seen a dramatic decline over the last 15 to 20 years in most developed countries and treatment of this disease has changed little since. The ease of travel and immigration and the cosmopolitan nature of many cities mean that occasionally the disease will come to the attention of clinicians not familiar with its presentation, resulting in delayed diagnosis and treatment. We present a case of recurrent acute rheumatic fever in a patient who was initially thought to be suffering from acute bacterial endocarditis on her previously diseased rheumatic aortic valve. This culminated in her undergoing urgent aortic valve replacement during a phase of the illness that should have been treated with high dose anti-inflammatory medication. Therefore, clinicians should be aware of this condition and include it in their differential diagnosis of the febrile patient with a previous history of rheumatic fever. We briefly discuss the diagnostic dilemma of patients suffering from this condition and in differentiating it from acute endocarditis.

Detection of virulence factors in a corneal isolate of Klebsiella pneumoniae

OBJECTIVE

To report on the microbiological findings of a Klebsiella pneumoniae strain isolated from a patient with keratitis.

DESIGN

Interventional case report.

INTERVENTION AND TESTING

Conjunctival swabs and corneal scrapings from the right eye were inoculated for culture. The isolate was analyzed for the presence of the mucoid phenotype and the ability to form biofilm. We also investigated whether the formation of biofilm by the corneal Klebsiella isolate is affected by N-acetylcysteine.

MAIN OUTCOME MEASURES

Culture results and biofilm production were analyzed.

RESULTS

K. pneumoniae was grown from the conjunctiva and cornea. The isolate showed the mucoid phenotype and strong biofilm production. N-acetylcysteine had an inhibitory effect on both biofilm formation and preformed biofilm.

CONCLUSIONS

K. pneumoniae can cause severe keratitis. The presence of virulence factors, such as the mucoid phenotype and the ability to form biofilm, may be important in determining corneal infection. N-acetylcysteine is a potential candidate for use as an inhibitor of Klebsiella biofilm formation.

Severe neuroborreliosis: The benefit of prolonged high-dose combination of antimicrobial agents with steroids--an illustrative case

Neuroborreliosis frequently occurs in endemic areas, whereas encephalomyelitis is uncommon. Treatment consists classically of 2 to 4 weeks of recommended antimicrobial agents with a generally good outcome. A severe case is reported combining an encephalomyelitis with an axonal polyneuropathy. Clinical improvement was observed only with the use of prolonged high dose of 2 antimicrobial agents combined with steroids.

A Rare Case of Lactobacillus acidophilus Presenting as Mitral Valve Bacterial Endocarditis

Lactobacillus acidophilus is a gram-positive rod that is a commensal of human mucosal tissues. They are usually considered nonpathogenic flora of the mouth, gut, and female genital tract. Lactobacillus is a rare cause of endocarditis with less than 50 cases reported in the world literature to date. We report the case of a 63-year-old woman who developed native mitral valve endocarditis secondary to L. acidophilus, and examine the literature regarding this rare entity.

Recurrent Enterococcus faecalis endophthalmitis after phacoemulsification

We present the first reported case of late recurrence of postoperative Enterococcus faecalis endophthalmitis after cataract surgery in a 45-year-old diabetic man. Culture-positive E faecalis endophthalmitis was diagnosed 2 days after uneventful phacoemulsification. Early vitrectomy with intravitreal and subconjunctival vancomycin and amikacin and topical vancomycin resulted in apparently complete clinical resolution after 4 months and a best corrected visual acuity of 20/25. Recurrent endophthalmitis with hypopyon occurred 7 months postoperatively and resolved with intravitreal vancomycin and topical prednisolone acetate 1%. However, the patient had a similar relapse at 9 months that resulted in deterioration of visual acuity to no light perception despite a repeat vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal antibiotics. The late recurrences could have been the result of persistent sequestration of the organism in the capsular bag.

Moxifloxacin-based strategies for first-line treatment of Helicobacter pylori infection

BACKGROUND

Standard anti-Helicobacter pylori therapy may not achieve a satisfactory eradication rate. Fluoroquinolones, such as moxifloxacin, are safe and promising agents for H. pylori eradication.

AIM

To compare the efficacy of two 1-week moxifloxacin-based H. pylori eradication regimens with two standard treatments.

METHODS

Three hundred and twenty H. pylori-positive subjects were randomized into four groups to receive: moxifloxacin, amoxicillin, esomeprazole (Group MAE); moxifloxacin, tinidazole and esomeprazole (Group MTE); standard triple therapies with clarithromycin, amoxicillin and esomeprazole (Group CAE) or tinidazole (Group CTE) for 7 days. H. pylori status was re-assessed 6 weeks after the end of therapy by 13C urea breath test.

RESULTS

Three hundred and twenty patients completed the efficacy analysis per protocol; H. pylori eradication rate in group MTE was 90% (72 of 80) and 92% (72 of 78), in group MAE was 88% (70 of 80) and 89%, (70 of 79) in Group CAE was 73% (58 of 80) and 78% (58 of 74), and in Group CTE was 75% (60 of 80) and 79% (60 of 76), respectively, in intention-to-treat and in per protocol analyses. Eradication rates of moxifloxacin-based triple therapies were significantly higher than that observed using standard triple schemes. The incidence of side effects was significantly lower in moxifloxacin groups than in control groups.

CONCLUSIONS

Seven-day moxifloxacin-based triple therapies provide optimal eradication rates with a good compliance when compared with the standard triple therapy schemes.

7-day rescue therapy with ranitidine bismuth citrate after Helicobacter pylori treatment failure

BACKGROUND

Quadruple rescue therapy requires a complex scheme with four drugs.

AIM

To evaluate the efficacy of ranitidine bismuth citrate-tetracycline-metronidazole rescue regimen, and to compare two different metronidazole dose schemes.

METHODS

Prospective multicentre study including proton-pump inhibitor + clarithromycin + amoxicillin failures. Rescue regimen included two 7-day treatment: (i) ranitidine bismuth citrate (400 mg b.d.)-tetracycline (500 mg q.d.s.)-metronidazole (500 mg t.d.s.; RTM1); or (ii) the same regimen but with metronidazole 250 mg q.d.s. (RTM2). Eradication was confirmed with (13)C-urea breath test.

RESULTS

A total of 150 patients were included (58 RTM1, 92 RTM2). All patients but two (one in each group) returned after treatment. About 86% in group RTM1 and 95% in RTM2 correctly took all the medications (P = 0.076). Per-protocol eradication rates with RTM1 and RTM2 were 74 (95% CI: 60-84) and 69% (59-78). The intention-to-treat eradication rates were 64 (51-75) and 70% (59-78; P > 0.05). The type of regimen was not associated with eradication in the multivariate analysis. Adverse effects were more frequent with RTM1 (41%) than with RTM2 (30%; P > 0.05).

CONCLUSION

Seven-day triple rescue therapy with ranitidine bismuth citrate-tetracycline-metronidazole is effective for Helicobacter pylori eradication, and represents an encouraging alternative to quadruple therapy, with the advantage of simplicity. The administration of metronidazole every 6 h (together with tetracycline), and at a low dose (250 mg), achieves similar efficacy and is probably associated with a better compliance and a lower incidence of adverse effects.

Helicobacter pylori eradication does not cause reflux oesophagitis in functional dyspeptic patients: a randomized, investigator-blinded, placebo-controlled trial

BACKGROUND

The protective role of Helicobacter pylori in gastro-oesophageal reflux disease has been widely discussed.

AIM

To assess the risk of reflux oesophagitis in patients with functional dyspepsia after treatment for H. pylori infection.

METHODS

A randomized, placebo-controlled, investigator-blinded trial was carried out on 157 functional dyspeptic patients. Patients were randomized to receive lansoprazole, amoxicillin and clarithromycin (antibiotic group) or lansoprazole and identical antibiotic placebos (control group). Upper gastrointestinal endoscopy was performed at baseline, 3 and 12 months after randomization. The primary aim was to detect the presence of reflux oesophagitis. Analyses were performed on an intention-to-treat basis.

RESULTS

A total of 147 patients (94%) and 133 (85%) completed 3 months and 12 months follow-up, respectively. The eradication rate of H. pylori was 90% in the antibiotic group (74 of 82) and 1% (one of 75) in the control group. At 3 months, reflux oesophagitis was diagnosed in 3.7% (three of 82) in the antibiotic group and 4% (three of 75) in the control group (P > 0.2). At 12 months, diagnosis was established in five new cases within the first group and in four within the second (P > 0.2). No difference was found in heartburn symptoms.

CONCLUSIONS

H. pylori eradication does not cause reflux oesophagitis in this western population of functional dyspeptic patients.

Do patients with non-ulcer dyspepsia respond differently to Helicobacter pylori eradication treatments from those with peptic ulcer disease? A systematic review

AIM: It is controversial whether patients with non-ulcer dyspepsia (NUD) respond differently to Helicobacter pylori (H pylori) eradication treatment than those with peptic ulcer disease (PUD). To review the evidence for any difference in H pylori eradication rates between PUD and NUD patients.

METHODS: A literature search for full articles and meeting abstracts to July 2004 was conducted. We included studies evaluating the efficacy of a proton pump inhibitor (P) or ranitidine bismuth citrate (RBC) plus two antibiotics of clarithromycin (C), amoxicillin (A), metronidazole (M), or P-based quadruple therapies for eradicating the infection.

RESULTS: Twenty-two studies met the criteria. No significant difference in eradication rates was found between PUD and NUD patients when treated with 7-d RBCCA, 10-d PCA or P-based quadruple therapies. When the 7-d PCA was used, the pooled H pylori eradication rate was 82.1% (431/525) and 72.6% (448/617) for PUD and NUD patients, respectively, yielding a RR of 1.15 (95%CI 1.01-1.29). However, the statistically significant difference was seen only in meeting abstracts, but not in full publications.

CONCLUSION: There is no convincing evidence to suggest that NUD patients respond to H pylori eradication treatments differently from those with PUD, although a trend exists with the 7-d PCA therapy.