Pathological, Immunological, and Hematological Parameters Associated with Experimental Infection of Citrobacter Freundii in Rabbits

Citrobacter freundii is one of the most important nosocomial opportunistic pathogens, which causes sepsis, as well as different gross and histopathological lesions in various internal organs in humans and animals, especially dogs and fish. This study aimed to investigate the hematological parameters, immunological responses, and pathological effects of the infection induced by the virulent strain of C. freundii on rabbits. A total of 42 rabbits (local breed; male and female), with a mean weight of 1.5-2 kg, were housed under controlled environmental conditions (20±2°C, 14:10 h light: dark cycle) and allowed ad libitum access to food and water. After two weeks of adaption, the rabbits were divided randomly into three groups of 14 animals per group. Group one (G1) received 3×10⁸ CFU/ml of the virulent isolate (intraperitoneally [IP]) of C. freundii. Group two (G2) was injected subcutaneously (SC) with 3×10⁸ CFU/ml of the virulent strain of C. freundii, while group three was IP injected with phosphate buffer saline and considered a negative control group. Results showed the variable gross pathological effects which included hemorrhage, edema, and congestion of visceral organs. Furthermore, the microscopic lesions showed pneumonia due to inflammatory cells infiltration, mainly neutrophils, macrophages, plasmacytes, and lymphocytes, severe interstitial and intra-alveolar edema, extensive pulmonary hemorrhage, emphysema, and atelectasis. The recorded data from the liver samples revealed hepatitis which was characterized by perivascular and periportal leukocyte cuffing, marked centrilobular with periportal necrosis, extensive hepatic edema, and periportal edema in addition to extensive fibrosis in interlobular septa and periportal fibrosis with severe interstitial hemorrhage. In the kidneys, there were severe renal edema, mixed inflammatory exudation, mainly neutrophils, macrophages, plasmacytes, lymphocytes, fibroblast infiltration in renal parenchyma and renal cortex, extensive renal hemorrhage, edema, as well as fibrosis and severe renal tubular necrosis. In addition, enteritis appeared in the intestine with mucosal edema, especially in lamina propria; moreover, necrosis of entire villi, epithelial necrosis, mucosal and submucosal hemorrhage, and fibrosis were observed. The present study revealed a significant increase in total leukocytes count and the concentration of TNF-α in the infected groups. To the best of the authors' knowledge, this study is considered the first attempt aimed to detect the pathological effects of C. freundii on visceral organs in rabbits. It is concluded that this bacterium could induce a significant pathological, hematological, and immunological changes in the infected animals.

Monte Carlo simulation evaluation of tigecycline dosing for bacteria with raised minimum inhibitory concentrations in non-critically ill adults

PURPOSE

Tigecycline is one of few antibiotics active against multidrug-resistant bacteria; however, the assessment of dosing strategies to optimize its activity is needed. The purpose was to use Monte Carlo Simulation (MCS) to determine if safe tigecycline dosing options attaining breakpoints for pharmacokinetic/pharmacodynamic (PK-PD) targets in non-critically ill adults could be identified.

METHODS

Publications that evaluated tigecycline dosing regimens and provided mean PK variables of interest (minimum 2 of: elimination rate constant or half-life and volume of distribution or clearance), with SDs, were included. Weighted mean (±SDs) for each PK parameter were determined. Food and Drug Administration minimum inhibitory concentration (MIC) tigecycline breakpoints for susceptible (MIC ≤ 2 μg/mL), intermediate (MIC 4 μg/mL), and resistant (MIC ≥ 8 μg/mL) Enterobacteriaceae were used. MCS probability distributions for PK-PD target attainment of AUC for total tigecycline plasma concentration from 0 to 24 h following an intravenous dose (AUC_{total, 0-24h}) to MIC ratios of ≥ 18, 7, and 4.5 were generated, with success defined as ≥ 80% probability of target attainment at a given MIC.

RESULTS

Ten studies (n = 442) were eligible. Tigecycline 150 mg IV q12h for ward patients with resistant bacteria up to a MIC of 0.48, 1, and 2 μg/mL for an AUC_{total, 0-24h}/MIC target attainment of 18, 7, and 4.5, respectively, may be appropriate.

CONCLUSION

Bacterial infections with tigecycline MICs ≥ 0.48-2 μg/mL, depending on AUC_{total, 0-24h}/MIC target, may require treatment with alternate antibiotics due to target attainment failure.

Hematological and immune genes responses in yellow catfish (Pelteobagrus fulvidraco) with septicemia induced by Edwardsiella ictaluri

Yellow catfish (Pelteobagrus fulvidraco) has been an economically important freshwater species in China because of its good meat quality. In present, the high-density breeding industry has suffered great damage from bacterial infections, in especial, the rapid illness and death of fish caused by bacterial septicemia leads to huge economic losses. Therefore, it is urgent and important to identify pathogenic bacteria and study its pathogenicity. In this study, we isolated a bacterial strain from the yellow catfish with typical septicemia and named it E. 719, then, by morphological observations, regression infection, biochemical identification, 16S rDNA sequence analysis and triple PCR identification, E. 719 was determined to be Edwardsiella ictaluri. Further, we infected yellow catfish with E. ictaluri to study its effects on mortality rate, hematological, histopathological disturbances and expression of immune genes. The mortality results showed that E. ictaluri was highly pathogenic, all infected fish died after 14 days post injection, and the distribution of bacteria in body kidney, spleen, liver, head kidney and brain of fish was continuously detected by measuring the amount of bacteria in the tissues. In addition, the number of red blood cells decreased significantly with the time of infection, while the number of white blood cells and thrombocytes increased. In particular, the number of monocytes and neutrophils increased significantly in the differential leucocyte count (DLC). Histopathologic changes observed by HE staining showed similar results, gill, intestine, spleen and head kidney showed obvious inflammation, bleeding and necrosis. Besides, checking by real time quantitative RT-PCR assays, in both spleen and head kidney tissues which were the major immune organs, mRNA expressions of immune gene IL-1β, TNF-α, and MR significantly increased in the early and middle stages of infection, which suggested that the infection of E. ictaluri caused a strong immune response in yellow catfish. This study provides a preliminary basis for the diagnosis and treatment of pathophysiology septicemia in yellow catfish induced by E. ictaluri.

Epidemiology of Carbapenem-resistant Enterobacteriaceae in Egyptian intensive care units using National Healthcare-associated Infections Surveillance Data, 2011-2017

Objective

To describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) healthcare-associated infections (HAI) in Egyptian hospitals reporting to the national HAI surveillance system.

Methods

Design: Descriptive analysis of CRE HAIs and retrospective observational cohort study using national HAI surveillance data. Setting: Egyptian hospitals participating in the HAI surveillance system. The patient population included patients admitted to the intensive care unit (ICU) in participating hospitals. Enterobacteriaceae HAI cases were Klebsiella, Escherichia coli, and Enterobacter isolates from blood, urine, wound or respiratory specimen collected on or after day 3 of ICU admission. CRE HAI cases were those resistant to at least one carbapenem. For CRE HAI cases reported during 2011-2017, a hospital-level and patient-level analysis were conducted using only the first CRE isolate by pathogen and specimen type for each patient. For facility, microbiology, and clinical characteristics, frequencies and means were calculated among CRE HAI cases and compared with carbapenem-susceptible Enterobacteriaceae HAI cases through univariate and multivariate logistic regression using STATA 13.

Results

There were 1598 Enterobacteriaceae HAI cases, of which 871 (54.1%) were carbapenem resistant. The multivariate regression analysis demonstrated that carbapenem resistance was associated with specimen type, pathogen, location prior to admission, and length of ICU stay. Between 2011 and 2017, there was an increase in the proportion of Enterobacteriaceae HAI cases due to CRE (p-value = 0.003) and the incidence of CRE HAIs (p-value = 0.09).

Conclusions

This analysis demonstrated a high and increasing burden of CRE in Egyptian hospitals, highlighting the importance of enhancing infection prevention and control (IPC) programs and antimicrobial stewardship activities and guiding the implementation of targeted IPC measures to contain CRE in Egyptian ICU's .

Population Pharmacokinetic Modeling and Probability of Target Attainment Analyses in Asian Patients With Community-Acquired Pneumonia Treated With Ceftaroline Fosamil

Efficacy of ceftaroline fosamil, the prodrug of the active metabolite ceftaroline, was demonstrated in a phase 3 study of hospitalized Asian patients with Pneumonia Outcomes Research Team (PORT) risk class III-IV community-acquired pneumonia (NCT01371838). The objectives of the current analysis were to expand an existing ceftaroline and ceftaroline fosamil population pharmacokinetic (PK) model with data from this phase 3 study and a phase 1 study (NCT01458743) assessing ceftaroline PK in healthy Chinese volunteers and to evaluate the probability of PK/pharmacodynamic (PK/PD) target attainment (PTA) in Asian patients with community-acquired pneumonia (CAP) treated with ceftaroline fosamil. The ceftaroline plasma concentration-time course was simulated for 5000 Asian patients with CAP for different renal function subgroups using the final model. PTA was calculated for Streptococcus pneumoniae, Staphylococcus aureus, and non-extended-spectrum β-lactamase-producing Enterobacteriaceae. PTA was also evaluated for ceftaroline MIC90 values of isolates collected from Asia-Pacific surveillance studies (2012-2014) and for EUCAST and FDA/CLSI ceftaroline susceptibility break points. The final model reasonably described the ceftaroline PK. Race was not found to be a significant covariate impacting ceftaroline PK, suggesting similar ceftaroline PK in Asian and Western populations when corrected for body weight. High PTAs (90%-100%) were predicted for Asian patients with CAP treated with ceftaroline fosamil, covering MIC90 values of target CAP pathogens from the region. Similarly, >90% PTAs were predicted at EUCAST and FDA/CLSI clinical break points for these pathogens. These results support the use of the ceftaroline fosamil dosing regimens approved in Europe and the United States in Asian patients with PORT III-IV CAP.

Improved blood culture workflow for faster identification of KPC-producing Enterobacterales

Carba-NP original report for blood cultures described the need of subculture and mechanical lysis before testing, reaching the turnaround time of approximately 4 hours for sample preparation. We tested 100 consecutive blood cultures positive for Gram-negative bacilli on the Gram stain from a large clinical laboratory. Bacterial pellets were prepared by centrifugation and submitted to Carba-NP and Blue-Carba tests and used further to prepare smears for Vitek MS. Results obtained with colonies grown on sheep blood agar using the same methodologies were used as the gold standard. Carbapenemase genes were confirmed by PCR and DNA sequencing. Vitek MS identified correctly 86% of the samples. Of note, 7% of the samples were incorrectly reported by the instrument as containing a single isolate. KPC-2 was the predominant carbapenemase detected. There was 100% concordance for both negative and positive results for Carba-NP. In contrast, for Blue-Carba the concordance for positive results was 92.8%, and 41% of strains negative for carbapenemases presented a yellowish color on control well turning the test non-interpretable. The turnaround time for sample preparation for preparing the pellet was 13 min, and no subculture or mechanical lysis is needed when detecting KPC production in Enterobacterales.

A Phase 1 Study To Assess the Pharmacokinetics of Intravenous Plazomicin in Adult Subjects with Varying Degrees of Renal Function

Plazomicin is an FDA-approved aminoglycoside for the treatment of complicated urinary tract infections. In this open-label study, 24 adults with normal renal function or mild, moderate, or severe renal impairment (n = 6 per group) received a single 7.5-mg/kg of body weight dose of plazomicin as a 30-min intravenous infusion. Total clearance declined with renal impairment, resulting in 1.98-fold and 4.42-fold higher plazomicin exposures, as measured by the area under the concentration-time curve from 0 h to infinity, in subjects with moderate and severe impairment, respectively, than in subjects with normal renal function. (This study has been registered at ClinicalTrials.gov under identifier NCT01462136.).

Systemic Edwardsiella tarda infection in a Western African lungfish (Protopterus annectens) with cytologic observation of heterophil projections

This report describes a case of systemic bacterial infection caused by Edwardsiella tarda in a Western African lungfish (Protopterus annectens) exposed to poor environmental and husbandry conditions. The fish presented with a large, external ulcerative lesion and died 2 weeks after developing anorexia. Histological evaluation revealed multifocal areas of necrosis and heterophilic and histiocytic inflammation throughout multiple tissues. Gram stain identified small numbers of intra- and extracellular monomorphic Gram-negative 1 to 2 μm rod-shaped bacilli. Cytology of lung granuloma, kidney and testes imprints identified heterophilic inflammation with phagocytosis of small monomorphic bacilli and some heterophils exhibiting cytoplasmic projections indicative of heterophil extracellular traps (HETs). Initial phenotypic analysis of isolates from coelomic fluid cultures identified E. tarda. Subsequent molecular analysis of spleen, liver and intestine DNA using an E. tarda-specific endpoint PCR assay targeting the bacterial fimbrial subunit yielded a 115 bp band. Sequencing and BLASTN search revealed the sequence was identical (76/76) to E. tarda strain FL95-01 (GenBank acc. CP011359) and displayed 93% sequence identity (66/71) to Edwardsiella hoshinae strain ATCC 35051 (GenBank acc. CP011359). This is the first report of systemic edwardsiellosis in a lungfish with concurrent cytologically identified structures suggestive of HETs.

Citrobacter freundii fitness during bloodstream infection

Sepsis resulting from microbial colonization of the bloodstream is a serious health concern associated with high mortality rates. The objective of this study was to define the physiologic requirements of Citrobacter freundii in the bloodstream as a model for bacteremia caused by opportunistic Gram-negative pathogens. A genetic screen in a murine host identified 177 genes that contributed significantly to fitness, the majority of which were broadly classified as having metabolic or cellular maintenance functions. Among the pathways examined, the Tat protein secretion system conferred the single largest fitness contribution during competition infections and a putative Tat-secreted protein, SufI, was also identified as a fitness factor. Additional work was focused on identifying relevant metabolic pathways for bacteria in the bloodstream environment. Mutations that eliminated the use of glucose or mannitol as carbon sources in vitro resulted in loss of fitness in the murine model and similar results were obtained upon disruption of the cysteine biosynthetic pathway. Finally, the conservation of identified fitness factors was compared within a cohort of Citrobacter bloodstream isolates and between Citrobacter and Serratia marcescens, the results of which suggest the presence of conserved strategies for bacterial survival and replication in the bloodstream environment.

Particle-Induced X-ray Emission Analysis of Zierum Trace and Major Elements in Cattle with Acute Coliform Mastitis

The aim of the present study was to examine the applicability of the direct determination of trace and major element concentrations in serum samples collected from Holstein dairy cattle with acute coliform mastitis (n = 53) compared with a healthy control group (n = 39). Twenty-eight elements (Na, Mg, Al, Si, S, Cl, K, Ca, Ti, V, Cr, Mn, Fe, Ce, Ni, Cu, Zn, Ga, As, Se, Br, Rb, Sr, Y, Zr, Nb, Mo, and Pb) were detected by particle-induced X-ray emission (PIXE). Significant differences were observed in serum K, Fe, Zn, and Br concentrations, but not in those of the remaining twenty-four elements. Furthermore, serum Fe concentrations (0.751 ± 0.583 μg/ml, n = 18) were significantly lower in dairy cattle with a poor prognosis than in those with a good prognosis (0.945 ± 0.393 μg/ml, n = 35, P < 0.05) and healthy controls (1.458 ± 0.391 μg/ml, n = 39, P < 0.01). We proposed a diagnostic cut-off point for serum Fe concentrations of <0.82 μg/ml based on receiver operating characteristic (ROC) curves in order to identify cattle with a poor prognosis. The results of the present study indicated that assessing the elemental composition of serum, particularly iron, is a promising prognostic tool for determining the outcomes of cattle with severe acute coliform mastitis.

Prevalence of ESBL-Producing Enterobacteriaceae in Pediatric Bloodstream Infections: A Systematic Review and Meta-Analysis

Background

Pediatric bloodstream infections (BSIs) with Extended-Spectrum Beta-Lactamase- producing Enterobacteriaceae (ESBL-PE) are associated with worse clinical outcomes. We aimed to estimate the prevalence of and the mortality associated with ESBL-PE in this patient population.

Methods

A systematic review and meta-analysis using PubMed and EMBASE and included studies reporting the prevalence of ESBL-PE among confirmed BSIs in patients <19 years old.

Results

Twenty three (out of 1,718 non-duplicate reports) studies that provided data on 3,381 pediatric BSIs from 1996 to 2013 were included. The prevalence of ESBL-PE was 9% [95%CI (6, 13)] with an annual increase of 3.2% (P = 0.04). The prevalence was 11% [95%CI (6, 17)] among neonates, compared to 5% [95%CI (0, 14)] among children older than 28 days. The pooled prevalence was 15% in Africa [95%CI (8, 23)], 12% in South America [95%CI (5, 23)], 11% in India [95%CI (7, 17)], 7% in the rest of Asia [95%CI (0, 22)], 4% in Europe [95%CI (1, 7)] and 0% in Oceania [95%CI (0, 3)]. Importantly, the mortality in neonates with BSI due to ESBL-PE was 36% [95%CI (22, 51)], compared to 18% [95%CI (15, 22)] among all other neonates with BSI and this difference was statistically significant (P = 0.01).

Conclusions

In the pediatric population, the prevalence of BSI due to ESBL-PE is significant and is associated with increased mortality in neonates. Further studies are warranted to establish a high-risk group and the evaluation of preventive measures, such as antibiotic stewardship programs and infection control measures, in this population is urgently needed.

Plasmid-mediated quinolone resistance among extended spectrum beta lactase producing Enterobacteriaceae from bloodstream infections

The purpose of this study was to determine prevalence and molecular characterization of plasmid-mediated quinolone resistance (PMQR) genes [qnrA, qnrB, qnrC, qnrD, qnrS, aac(6')-Ib-cr, qepA, and oqxAB] among extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp. isolates from bloodcultures in Hungary. A total of 103 isolates were tested for quinolone susceptibility by microdilution method and PMQR genes were detected by polymerase chain reaction. About 40 ESBL-producing E. coli (39%) and 50 ESBL-producing Klebsiella spp. strains (48%) were resistant to ciprofloxacin; 40 ESBL-producing E. coli (39%) and 47 ESBL-producing Klebsiella spp. strains (45%) were resistant to levofloxacin; and 88 strains including 40 ESBL-producing E. coli (39%) and 48 (47%) ESBL-producing Klebsiella spp. were resistant to moxifloxacin. Among the 103 ESBL-producing isolates, 77 (75%) isolates (30 E. coli and 47 Klebsiella spp.) harbored PMQR genes. The most commonly detected gene was aac(6')-Ib-cr (65%). The occurrence of qnrS gene was 6%. Interestingly, qnrA, qnrB, qnrC, qnrD, and qepA were not found in any isolates. Among 77 PMQR-positive isolates, 27 (35.1%) and 1 (1.3%) carried two and three different PMQR genes, respectively. Only Klebsiella spp. harbored more than one PMQR genes. Observing prevalence of PMQR genes in the last 8 years, the increasing incidence of aac(6')-Ib-cr and oqxAB can be seen. Our results highlight high frequency of PMQR genes among ESBL-producing Klebsiella pneumoniae and E. coli isolates with an increasing dynamics in Hungary.

[LEVELS OF SERUM ANTIBODIES TO ENTEROBACTERIAL LIPOPOLYSACCHARIDES AND THEIR RELATIONSHIP WITH CONCENTRATION OF C-REACTIVE PROTEIN IN DIABETES MELLITUS PATIENTS]

We examined patients with type 1 (DM 1) and type 2 (DM 2) diabetes mellitus. The concentration of C-reactive protein (CRP) in the blood and levels of serum antibodies to different classes of enterobacterial lipopolysaccharides (LPS) were determined by ELISA. Using cluster analysis it was shown that in 40.8% DM-1 patients the increased concentration of CRP is associated with a decrease in the levels of serum anti-LPS-IgA, anti-LPS-IgM and anti-LPS-IgG. In 56.7% of DM-2 patients with increased concentration of CRP levels of serum anti-LPS-IgA and anti-LPS-IgM were not significantly different from the normal values, but the levels of serum anti-LPS-IgG were significantly increased. Activation of inflammation and increase of concentration of the CRP in the blood of DM-2 patients is accompanied by a significant increase in the levels of serum anti-LPS-A and anti-LPS-G, as well as the tendency to reduce the levels of anti-LPS-IgM. The results of this study suggest an association between low intensity inflammation and immune response to enterobacterial LPS in type 1 and 2 diabetes mellitus.

Blood infection with Enterobacter aerogenes--an unusual cause of portal vein gas

Portal vein gas was once thought of as an invariably fatal condition. Now, with the availability of better equipment and expertise, the condition is more frequently diagnosed. A case of fever with rigors is presented and on ultrasound and CT examination was found to have portal venous gas which resolved with adequate antibiotic treatment. Blood culture revealed growth of gram negative bacillus; Enterobacter aerogenes. Patient was investigated further for portal vein gas, and although no other cause for the development of portal vein gas was found, she was treated with antibiotics and showed an immediate response. The aim of this case report is to highlight the benign causes of portal vein gas as well as to discuss the causes which warrant immediate surgery. Portal vein gas may herald a more ominous condition, which if intercepted in its course may result in complete cure.

[Antibacterial antibodies in human immunoglobulins and sera: past and present]

AIM

To measure levels of several types of antibacterial antibodies in preparations of normal human immunoglobulin as well as in samples of donor sera obtained in 1965 and 2009.

MATERIALS AND METHODS

Five batches of human normal immunoglobulin manufactured in 1965 and five batches manufactured in 2009 as well as 77 and 28 blood serum samples respectively were tested by agglutination assay for the presence of antibodies to enterobacteria, Brucella species, tularemia agent, Rickettsia burnetii, Rickettsia prowazekii, and several species of opportunistic bacteria.

RESULTS

Higher antibody titers to Salmonella typhi, Salmonella paratyphi A and B, Salmonella enteritidis, Salmonella typhimurium, Shigella flexneri and Shigella sonnei were revealed in immunoglobulin preparations and donor sera obtained in 1965 compared to that obtained in 2009. There was no difference in antibody titers to Shigella boydii, Salmonella choleraesuis, Escherichia coli O-55, Pseudomonas aeruginosa, Proteus vulgaris, Serratia marcescens and E. coli. Antibodies to Brucella species, tularemia agent, R. burnetii, R. prowazekii were not detected in normal human immunoglobulin.

CONCLUSION

Decrease of antibody levels to several pathogenic enterobacteria in human immunoglobulin preparations as well as in sera of donors for 40 years could be linked with decrease of number of immunized persons, changes in circulation of pathogenic bacteria, decrease of rate of asymptomatic infections. Stability of antibody titers to opportunistic bacteria is a rationale to use them for assessment of humoral immunity function.

Centers for Disease Control and Prevention (CDC). Cronobacter species isolation in two infants - New Mexico, 2008

Cronobacter spp. (formerly Enterobacter sakazakii) are rare causes of infant septicemia and meningitis, resulting in death in approximately 40% of cases. Since 1958, 120 cases of Cronobacter infection in infants have been reported, an average of fewer than three cases per year worldwide. Powdered infant formula (PIF), which is not sterile, has been implicated repeatedly as a vehicle of Cronobacter infection; consequently, the World Health Organization (WHO) has issued guidelines for safer preparation, handling, and storage of PIF. This report describes isolation of Cronobacter spp. in two nonhospitalized, unrelated infants (one male and one female) in New Mexico in 2008; one infant developed severe brain injury and hydrocephalus, and the other infant died. An investigation by the New Mexico Department of Health (NMDOH) determined that PIF consumption was the only known risk factor in the two cases, although the sources of the Cronobacter spp. could not be determined. Cronobacter spp. were not isolated from sealed canisters of formula associated with the two infants, and clinical isolates from the infants differed by pulsed-field gel electrophoresis (PFGE). However, a Cronobacter organism was isolated from an opened canister of formula consumed by the male infant and was indistinguishable from an isolate from his postmortem blood culture. Education of formula preparers regarding potential PIF contamination, universal adoption of WHO PIF preparation guidelines, and continued improvement of PIF manufacturing processes might help prevent Cronobacter infection among infants.

Antibodies against recombinant heat shock proteins of 60 kDa from enterobacteria in the sera and synovial fluid of HLA-B27 positive ankylosing spondylitis patients

OBJECTIVE

To study the association of HLA-B27 with IgG antibodies to different enterobacterial HSP60s in patients with ankylosing spondylitis (AS).

METHODS

IgG antibodies to 60 kDa enterobacterial HSPs were determined by ELISA in paired samples of sera and synovial fluid from 21 HLA-B27+ ankylosing spondylitis (AS) patients; and in sera from 32 HLA-B27+ AS patients, 35 HLA-B27+ healthy relatives of AS patients, and 60 HLA-B27- healthy individuals with no family members with AS.

RESULTS

HLA-B27+ patients and healthy individuals showed significantly higher IgG antibody levels to recombinant enterobacterial HSP60s than HLA-B27- healthy controls. The levels of anti-HSP60Sf and anti-HSP60Ec antibodies correlated with disease activity and anti-HSP60Ec antibodies with male gender. No association between enterobacterial HSP60 antibody levels and disease duration was observed. All groups had lower levels of IgG antibodies to rHSP60 from Streptococcus pyogenes (rHSP60 Spy). In paired samples of sera and synovial fluid from B27+ patients, IgG antibodies to enterobacterial HSP60s were detected, but in significantly higher levels in sera than in synovial fluid. The anti-rHSPSpy IgG response in these samples was lower and similar in the three groups.

CONCLUSIONS

A correlation was found between HLA-B27 and the response to recombinat enterobacterial HSP60s. This response could be associated with disease activitir and gender in some proteins and the presence eof IgG antibodies to these proteins in synovial fluid could be associated with the inflammatory process and initiation of AS.

Aroclor 1248 exposure leads to immunomodulation, decreased disease resistance and endocrine disruption in the brown bullhead, Ameiurus nebulosus

The brown bullhead Ameiurus nebulosus is a species of the family Ictaluridae commonly used as a sentinel of environmental contamination. While these fish have been utilized for this purpose in areas contaminated with polychlorinated biphenyls (PCBs), few controlled, laboratory-based studies have been designed to document the effects of PCB mixtures in this species. Here, brown bullhead were exposed to the PCB mixture, Aroclor 1248, via intraperitoneal injection and the effects on immune function, plasma hormones and disease resistance were evaluated. Exposure to this mixture led to a decrease in bactericidal activity and circulating antibodies to Edwardsiella ictaluri present from a previous exposure to this pathogen. A subsequent E. ictaluri disease challenge led to significantly higher mortality in A1248 treated fish compared to vehicle-control fish. The mitogenic response to the T-cell mitogen, phytohemaglutinin-P, was increased compared to vehicle-control fish. The steroid hormone, cortisol, and the thyroid hormone, T3, were also significantly lower in A1248 exposed fish. In summary, we have validated a number of functional immune assays for application in brown bullhead immunotoxicity studies. Additionally, we have demonstrated that the PCB mixture (A1248) modulates both immune function and endocrine physiology in brown bullhead. Such data may compliment the interpretation of data yielded from applied field studies conducted in PCB contaminated aquatic ecosystems.

[Severe perioperative thrombocytosis in a patient undergoing lung resection]

Severe thrombocytosis (platelet count > 1,000,000 microL(-1)) is a rare, usually reactive, process and few perioperative cases have been reported. We describe the management of a patient who developed severe reactive thrombocytosis in the preoperative period before undergoing segmentectomy to remove a malignant nodule. A platelet count of 2,086,000 microL(-1) was observed during the first few days after surgery; we therefore started antiplatelet therapy to prevent thrombotic complications. We analyze the factors that might have contributed to the development of severe thrombocytosis in this case and discuss the different treatment options that may affect perioperative outcomes in these patients.

Enterobacteriaceae bloodstream infections: presence of integrons, risk factors, and outcome

A prospective observational study was conducted to identify factors associated with bloodstream infections (BSIs) caused by integron-carrying Enterobacteriaceae and to evaluate the clinical significance of integron carriage. Consecutive patients with Enterobacteriaceae BSIs were identified and followed up until discharge or death. Identification of blood isolates and susceptibility testing were performed by the Wider I automated system. int-1-specific PCR, conserved-segment PCR, and DNA sequencing were used to determine the presence, length, and content of integrons. The relatedness among the isolates was examined by pulsed-field gel electrophoresis. Two hundred fifty episodes of Enterobacteriaceae BSI occurred in 233 patients; 109 (43.6%) were nosocomial, 82 (32.8%) were community acquired, and 59 (23.6%) were health care associated. Integrons were detected in 11 (13.4%) community-acquired, 24 (40.7%) health care-associated, and 46 (42.2%) nosocomial isolates. Integron-carrying organisms were more likely to exhibit resistance to three or more classes of antimicrobials (odds ratio [OR], 9.84; 95% confidence interval [95% CI], 5.31 to 18.23; P < 0.001) or to produce extended-spectrum beta-lactamases (OR, 5.75; 95% CI, 2.38 to 13.89; P < 0.001) or a VIM-type metallo-beta-lactamase (P, 0.003). Inter- or intraspecies integron transfer and cross-transmission of integron-carrying clones were observed. Use of cotrimoxazole (OR, 4.77; 95% CI, 1.81 to 12.54; P < 0.001) and a nosocomial or other health care setting (OR, 3.07; 95% CI, 1.30 to 7.22; P, 0.01) were independently associated with BSIs caused by integron-carrying Enterobacteriaceae. Patients with a nonurinary source of bacteremia (OR, 9.46; 95% CI, 2.77 to 32.32; P < 0.001) and a Pitt bacteremia score of > or =4 (OR, 23.36; 95% CI, 7.97 to 68.44; P < 0.001) had a significantly higher 14-day mortality rate, whereas integron carriage did not affect clinical outcomes. These findings may have implications affecting antibiotic policies and infection control measures.

Identification of Gram-negative bacilli directly from positive blood culture vials

The provision of rapid results from positive blood cultures is important for the clinical management of septicaemia. This study tested the accuracy of direct inoculation of biochemical tests from positive blood culture vials for the identification of members of the Enterobacteriaceae and Acinetobacter species. A hundred and eighty-one samples were included in the study, with 25 % subsequently excluded as a result of mixed colonial growth. The study method successfully identified 133 (98 %) isolates from 136 vials to genus level and was technically simple to perform, requiring an additional 3 min for the processing of each positive vial. The results of this study demonstrate that a direct inoculation method provides acceptable genus identification of Gram-negative bacilli in positive blood culture vials, with a potential saving of 24 h compared with traditional methods.

Real-time TaqMan PCR for rapid detection and typing of genes encoding CTX-M extended-spectrum β-lactamases

The prevalence of CTX-M-producing members of the Enterobacteriaceae is increasing worldwide. A novel, multiplex, real-time TaqMan PCR assay to detect and type bla CTX-M genes is described which is an improvement on previously described techniques with respect to reduced assay time, elimination of the need for protracted post-PCR processing and the convenience of a single reaction vessel. Based on β-lactam antibiogram and MIC data, 478 of 1279 Enterobacteriaceae isolates from clinical blood and urine culture specimens were selected and tested for extended-spectrum β-lactamase (ESBL) production using phenotypic methods. The new TaqMan assay detected and typed bla CTX-M genes in 21 of 28 ESBL-producing isolates.

Effects of chronic bacterial prostatitis on prostate specific antigen levels total and free in patients with benign prostatic hyperplasia and prostate cancer

BACKGROUND

Prostatic-specific antigen (PSA), a tumor marker helpful in the diagnosis and follow-up of prostate cancer, may rise due to causes such as prostatitis, chronic benign prostatic hyperplasia (BHP), etc. The aim of this study was to investigate the relationship between prostatitis and the level of total and free prostate-specific antigen in patients with no clinical evidence of prostate cancer.

METHODS

A comprehensive urological examination was performed on 156 patients aged 35-61 years old. All patients have symptoms of prostatitis. Prostate fluid culture was preformed. All patients underwent a course of antibacterial treatment after which the levels of total prostate specific antigen (TPSA) and free prostate specific antigen (FPSA) were evaluated.

RESULTS

An increase in TPSA (> 4 ng/ml) was observed in 14/24 (58.3%) patients with acute prostatitis and in 7/45 (15.5%) and 4/44 (9.1%) in patients with chronic bacterial prostatitis (CBP) and a bacterial prostatitis, respectively. Low blood concentration of TPSA and FPSA were observed after effective antibacterial and anti-inflammatory treatment therapy in most cases.

CONCLUSION

These data suggested that prostatitis must be considered when interpretation of TPSA and FPSA values as tumor marker.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae at Middlemore Hospital

AIMS

To review patients colonised or infected with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLPE) at Middlemore Hospital, Auckland, New Zealand.

METHODS

All patients who had an ESBLPE isolated at the Middlemore Hospital Microbiology Laboratory from January 2001 to June 2004 were included in this review.

RESULTS

ESBLPE were isolated from 132 patients during the review period. There were 12 patients colonised or infected with an ESBLPE in 2001, 34 in 2002, 43 in 2003, and 43 in the first 6 months of 2004. The isolates were Escherichia coli (n=56), Enterobacter spp. (n=55), and Klebsiella pneumoniae (n=21). ESBLPE were isolated from a wide range of specimens including peripheral blood in 18 patients. Thirty-three (25%) patients had an ESBLPE isolated within 48 hours of admission; seven of these patients were neither long-term care facility (LTCF) residents nor had hospital admissions in the previous 6 months. Thirty-one patients (23%) resided in a LTCF before their admission; four patients from the same LTCF had indistinguishable isolates. All isolates tested were susceptible to meropenem and imipenem. All but one isolate tested was susceptible to ertapenem, and all but two were susceptible to amikacin.

CONCLUSIONS

Colonisation and infection due to ESBLPE are increasing at Middlemore Hospital and in the Auckland community. We expect this trend to continue. There is evidence to suggest transmission of ESBLPE both in the Auckland community and LTCFs. Antibiotics useful for treatment of patients with proven ESBLPE infection at Middlemore Hospital include amikacin or a carbapenem. Careful infection control practices and antibiotic prescribing will be necessary to reduce the rate of increase of ESBLPE colonisation and infection at Middlemore Hospital and in the Auckland community.

High prevalence of extended-spectrum beta-lactamase-producing strains among blood isolates of Enterobacter spp. collected in a tertiary hospital during an 8-year period and their antimicrobial susceptibility patterns

Of 72 blood isolates of Enterobacter spp. collected over an 8-year period, 50% (36 of 72) were derepressed or partially derepressed AmpC mutants. The extended-spectrum beta-lactamase (ESBL) production rate was 43% (31 of 72 isolates), and 67.3% (31 of 46) of extended-spectrum cephalosporin-resistant strains produced ESBLs. Thus, a confirmatory test for ESBL production is necessary for extended-spectrum cephalosporin-resistant Enterobacter spp.

Enterobacter cloacae bloodstream infections in pediatric patients traced to a hospital pharmacy

The sources of an outbreak of Enterobacter cloacae bloodstream infections in a pediatric hospital were investigated, as were the risk factors for acquiring the infection: Two retrospective case-control studies were conducted. The study sample included all patients admitted to the general pediatric wards from February 5 through March 30, 2001, who had a positive blood culture for E. cloacae. Pediatric ward and pharmacy infection-control practices were reviewed, personnel and environmental cultures were obtained, and pulsed-field gel electrophoresis (PFGE) molecular typing of the bloodstream isolates was conducted. Four subjects were identified. These infants were more likely than control patients to receive i.v. ranitidine (p < 0.01). Among patients receiving i.v. ranitidine, subjects were more likely than controls to receive i.v. ranitidine prepared by a pharmacist. No environmental or personnel cultures yielded E. cloacae. Patients' E. cloacae isolates had four different PFGE patterns, suggesting environmental rather than point-source contamination. Ranitidine multidose vials were kept connected to an automatic compounding machine for up to 48 hours at room temperature after the first dose was drawn, contrary to manufacturer recommendations. Further, preparation of ranitidine infusions was not conducted in accordance with recommendations for risk level 2 sterile i.v. products. The use of contaminated ranitidine multidose vials was the most likely cause of an outbreak of E. cloacae. However, a combination of other factors such as inadequate hand-washing techniques, presence of E. cloacae in the environment, noncompliance with guidelines for the preparation of sterile infusions and medications, and a susceptible population may have contributed to the infections.

Recommended amikacin doses in newborns often produce excessive serum levels

Emergence of a multiply drug resistant Enterobacter cloacae during a seven-week period in 1980 caused amikacin to become the aminoglycoside of choice in the initial management of suspected sepsis in a neonatal intensive care unit. Recommended doses (7.5-10 mg/kg loading; 15 mg/kg in two divided doses IV) were given to 5 infants < or = 1,000 gm and to 13 larger babies. Trough levels 11.5 hours after a dose were 16.6 +/- 11.9 microg/ml in infants < or = 1,000 gm and 6.5 +/- 4.3 microg/ml in the larger infants (P < 0.02). Peak levels one hour postinfusion exceeded 40 microg/ml in 3 of 5 < or = 1,000-gm babies and 4 of 12 > 1,000-gm infants (P = NS). Overall, 7 of 10 peak and/or trough levels in < or = 1,000-gm infants were in the range considered toxic in adults, versus 7 of 24 in larger babies (P = 0.03). These data show that surprisingly excessive blood levels of amikacin are likely in infants < or = 1,000 gm and may also occur in larger infants using currently recommended dosage schedules. These unexpected findings emphasize the need to monitor drug levels and individualize therapy in very low birthweight infants.

Enterobacter cloacae ventriculitis successfully treated with cefepime and gentamicin: case report and review of the literature

A 55-year-old woman was found unresponsive and subsequently was diagnosed with a subarachnoid hemorrhage secondary to a right posterior communicating artery aneurysm. The development of hydrocephalus and decreased mental status necessitated placement of an intraventricular catheter; 18 days later she was diagnosed with Enterobacter cloacae ventriculitis. After treatment was begun with intravenous cefepime 2 g every 8 hours and intraventricular gentamicin 5 mg every 24 hours, the catheter was replaced. Cerebrospinal fluid (CSF) and plasma cefepime concentrations and a CSF trough gentamicin concentration were obtained. Intraventricular gentamicin was administered for 6 days and cefepime for 21 days; both clinical and microbiologic resolution of the ventriculitis occurred. The literature reports limited clinical experience with cefepime for the treatment of central nervous system infections in humans. This case report provides clinical evidence to support administration of intravenous cefepime in critically ill adult patients with Enterobacter ventriculitis. Because CSF is easily obtained from patients with intraventricular catheters, strong consideration should be given to monitoring CSF cefepime concentrations in concert with the minimum inhibitory concentration of the offending pathogen to help assure the efficacy of this approach to therapy.

Central venous catheter removal versus in situ treatment in neonates with enterobacteriaceae bacteremia

OBJECTIVE

To determine how often neonates with Enterobacteriaceae (ENTB) bacteremia can be treated successfully without removing central venous catheters (CVCs).

METHODS

A retrospective cohort study was conducted of ENTB bacteremia and CVCs in infants in a neonatal intensive care unit during a 7-year period (1994-2000). Cases of ENTB bacteremia were identified from a microbiology database and limited to late-onset cases occurring after 3 days of age.

RESULTS

There were 53 cases of ENTB bacteremia in infants with CVCs. Blood cultures were positive for ENTB within a median of 10 hours (range: 5-43). Timing of CVC removal was at the discretion of attending neonatologists. Fifteen cases had early-removal CVC (ER-CVC) within 2 days, and 38 cases had late-removal CVC (LR-CVC) >2 days after the first positive blood culture for ENTB. There were no significant differences between infants in the ER-CVC and LR-CVC groups for case fatality, recurrence, or duration of ENTB bacteremia. Although 16 (42%) of 38 (95% confidence interval [CI]: 26%-59%) LR-CVC cases required CVC removal to resolve ENTB bacteremia, 17 (45%) of 38 (95% CI: 29%-62%) LR-CVC cases were treated successfully without removal of CVCs. ENTB bacteremia was successfully treated without CVC removal in 85% of 13 LR-CVC cases with 1 day of bacteremia in contrast to 24% of 25 LR-CVC cases with >1 day of bacteremia (relative risk: 3.5; 95% CI: 1.7-7.4). CVC removal was required to resolve ENTB bacteremia in 9 (82%) of 11 LR-CVC cases with severe thrombocytopenia compared with 7 (32%) of 22 LR-CVC cases without severe thrombocytopenia (relative risk: 2.6; 95% CI: 1.3-5.0).

CONCLUSIONS

Retention of CVCs was successful in 45% of cases of ENTB bacteremia in which it was attempted, but success was unlikely when bacteremia lasted >1 day. ENTB bacteremia cases associated with severe thrombocytopenia rarely resolved unless CVCs were removed.

IgG antibodies to enterobacteria 60 kDa heat shock proteins in the sera of HLA-B27 positive ankylosing spondylitis patients

OBJECTIVE

To study the association of HLA-B27 and the IgG response to the 60 kDa HSPs of Klebsiella pneumoniae, Yersinia enterocolitica, Shigella flexneri, Escherichia coli and Salmonella typhi.

METHODS

IgG against the 60 kDa HSPs of enterobacteria was determined by ELISA in the sera from 49 HLA-B27+ ankylosing spondylitis (AS) patients; 41 HLA-B27+ healthy relatives of AS patients and 101 HLA-B27-unrelated healthy individuals.

RESULTS

HLA-B27+ patients and healthy individuals, showed significantly higher IgG antibody levels to the Klebsiella, Yersinia and Salmonella HSPs than HLA-B27- healthy controls. B27+ patients had a significantly higher response to E. coli HSP than the two other groups. IgG response anti-Shigella HSP was similar in the three groups.

CONCLUSIONS

There is a relationship between HLA-B27 and the response to HSPs 60 from Klebsiella, Yersinia, Escherichia and Salmonella, that may be important in the initiation of AS.

Laparoscopic transgastric pancreatic necrosectomy for infected pancreatic necrosis

BACKGROUND

Secondary infection of pancreatic necrosis is an indication for surgical debridement, and has traditionally been treated by laparotomy, and more recently by laparoscopic transmesocolic or transgastrocolic and retroperitoneoscopic approaches. This report describes and evaluates the safety and feasibility of a laparoscopic transgastric approach to extensive necrosectomy for infected pancreatic necrosis.

METHOD

A 66-year-old man developed severe acute pancreatitis with more than 50% necrosis of the body and some necrosis of the tail of the gland. Clinical deterioration with respiratory and renal impairment at 2 weeks prompted a computed tomogram (CT) guided fine-needle aspiration of the necrosis, which proved to be infected with Gram-negative bacilli. A favorable response to supportive therapy and systemic antibiotics enabled a cautious deferment of surgery to week 6 of the illness while the necrosis and its inflammatory wall matured. A laparoscopic transgastric pancreatic necrosectomy with drainage of an associated abscess was performed.

RESULT

Intraoperative blood loss was minimal, and Operative time was 270 min. The debrided pancreas (30 g) was infected with anaerobes. The patient made an uneventful recovery and was discharged on postoperative day 14. At this writing, he remains well after 2 months of follow-up evaluation.

CONCLUSION

Laparoscopic transgastric pancreatic necrosectomy appears to be a safe and effective minimally invasive approach for the debridement and internal drainage of infected pancreatic necrosis in the selected patient. Further experience with this technique is needed to define the selection criteria and its limitations, advantages, and disadvantages.

[Detection of tissue specific antigen-binding lymphocytes in patients with acute enteric infections]

A total of 88 patients with salmonellosis, acute dysentery, alimentary toxicoinfection, acute gastroenterocolitis were examined. The study was aimed at early determination of the involvement of organs and tissues into the inflammatory process and detection of antigen-binding lymphocytes with the use of erythrocytic immunoreagents prepared from tissue antigens of mucous membranes of small and large intestine, duodenum, stomach, gall bladder, as well as liver and pancreas. The study demonstrated that as early as on day 1-3 of the disease the development of the inflammatory process in different organs was accompanied by the appearance of the corresponding tissue specific (organ specific) antigen-binding lymphocytes in all patients. As a rule, patients with different acute enteric diseases significantly differed by the frequency and spectrum of the involvement of such organs and tissues into pathological process.

[Possible use of total blood analysis for diagnosis of intestinal dysbacteriosis accompanied by bacteremia]

Possible application of total blood analysis in the diagnosis of intestinal dysbacteriosis of the 2nd--3d degree, accompanied by bacteriemia, is substantiated. The proposed method includes the calculation of tentative coefficients of peripheral blood characteristics. These coefficients reflect changes in the intestinal microbiocenosis and make it possible to make conclusions on the presence of bacteriemia. This method is recommended for use as the screening test in the laboratory diagnostics of bacteriemia.

Development of oligonucleotide primers for the specific PCR-based detection of the most frequent Enterobacteriaceae species DNA using wec gene templates

Oligonucleotide primers were designed for the PCR-based detection of the wec gene cluster involved in the biosynthetic pathway leading to the production of enterobacterial common antigen (ECA). Escherichia coli DNA was detected using wec A, wec E, and wec F gene primers. The wec A primers were specific for E. coli. The wec E and wec F primers enabled the detection of the most frequent species of the Enterobacteriaceae found in blood and urine specimens as well as in water. The sensitivity of the assay was approximately 1.2 x 102 bacteria/mL of water. Thus, these primers represent an important step in the molecular diagnosis of major Enterobacteriaceae infections. Their role in the routine testing of contamination in drinking water and food may prove to be very useful. The DNA of Enterobacteriaceae species is detected in a first step PCR, followed by specific identification of important pathogens like E. coli O157, Shigella spp., Salmonella spp., and Yersinia spp.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae strains in community-acquired bacteremia in Southern Israel

BACKGROUND

In recent years, extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae have emerged in many hospitals worldwide. The increasing dissemination and long-term carriage of these organisms within the community carry tremendous implications on the empirical therapy of community-acquired infection.

MATERIAL/METHODS

To evaluate the prevalence and clinical features of community-acquired bacteremia involving ESBL-producing Enterobacteriaceae in southern Israel (ESBL-P) we retrospectively studied all Enterobacteriaceae bacteremias during an 8-month period in the Negev region using medical and laboratory records. Antibiotic susceptibility was determined using the disk-diffusion method. ESBL production was determined using an E-test ESBL strip. Cases involving ESBL-P were compared to those involving non-producing strains (ESBL-NP) using the chi-square test.

RESULTS

In all, 187 Enterobacteriaceae bacteremias were detected, of which 119 were community-acquired (63.6%). ESBL-P were found in six cases (5%) which are described herein in greater detail. Patients with ESBL-P bacteremia were older, and were more likely to stay in the intensive-care unit. Urinary catheterization and bed-ridden conditions were significant risk factors for ESBL-P. ESBL-P strains were significantly resistant to nearly all antibiotic agents except for imipienem and piperacillin-tazobactam as opposing to ESBL-NP. Patients with ESBL-P bacteremia were more likely to suffer from complications and had a higher mortality.

CONCLUSIONS

This paper is the first to describe community-acquired Enterobacteriaceae bacteremia involving ESBL-P strains in Israel. Although the exact prevalence of these organisms in Israel is currently unknown, our findings suggest that ESBL-producers have already begun to disseminate in our community.

Resolution of infectious parameters after antimicrobial therapy in patients with ventilator-associated pneumonia

Although recommended durations of antimicrobial therapy for ventilator-associated pneumonia (VAP) range from 7 to 21 d, these are not based on prospective studies and little is known about the resolution of symptoms after start of antibiotics. Resolution of these symptoms was investigated in 27 patients. VAP was diagnosed on clinical, radiographic, and microbiological criteria, including quantitative cultures of bronchoalveolar lavage. All patients received appropriate antibiotic therapy. Highest temperatures, leukocyte counts, Pa(O(2))/FI(O(2)) ratios, and semiquantitative cultures of endotracheal aspirates were recorded from start of therapy until Day 14. Resolution was defined as the first day that these parameters fulfilled the following definition: temperature < or = 38 degrees C, leukocytes < or = 10 x 10(9)/L, Pa(O(2))/FI(O(2)) ratio > or = 25 kPa, and no or +1 of bacterial growth of etiologic pathogens in cultures of endotracheal aspirate. VAP was caused by Enterobacteriaceae (n = 14), P. aeruginosa (n = 7), S. aureus (n = 6), H. influenzae (n = 3), and S. pneumoniae (n = 1). H. influenzae and S. pneumoniae were eradicated from tracheal aspirates, whereas Enterobacteriaceae, S. aureus, and P. aeruginosa persisted, despite in vitro susceptibility to antibiotics administered. Significant improvements were observed for all clinical parameters, most apparently within the first 6 d after start of antibiotics. Newly acquired colonization, especially with P. aeruginosa and Enterobacteriaceae, occurred in the second week of therapy. Six patients developed a recurrent episode of VAP, four of them with P. aeruginosa. Clinical responses to therapy for VAP occur within the first 6 d of therapy, endotracheal colonization with Gram-negative bacteria persists despite susceptibility to therapy, and acquired colonization usually occurs in the second week of therapy and frequently precedes a recurrent episode.

[Septic shock complicating amniocentesis]

Amniocentesis is a routine technique for prenatal diagnosis. The incidence of severe intra-amniotic infection is very low. We report a case of septic shock following an amniocentesis in a 34-year-old women. Patient admitted in intensive care unit and need mechanical ventilation and vasoactives drugs to control hemodynamic pertubation. Bacteriological data showed positive polymicrobial blood cultures to Klebsiella pneumoniae and Enterobacter. The patient gradually improved, however her renal function was still impaired and she was discharged three months after admission.

Concordance of endotoxemia with gram-negative bacteremia. A meta-analysis using receiver operating characteristic curves

OBJECTIVE

To apply meta-analysis to compare the concordance between the results of 2 types of limulus amebocyte lysate (LAL) assay, gelation (GLAL) and chromogenic (CLAL), with the detection of gram-negative bacteremia in patients with suspected bacteremia.

DESIGN

Meta-analysis using receiver operating characteristic-based analytical method.

DATA SOURCES

MEDLINE literature search and manual reviews of article bibliographies together with direct approaches to authors of potentially eligible studies.

STUDY SELECTION

The studies that were selected had all included at least 10 patients, of whom at least 2 patients were diagnosed with gram-negative bacteremia, and all had data available for extraction into a contingency table format.

RESULTS

Fifty-six studies (28 GLAL and 28 CLAL studies) met the inclusion criteria. Studies were stratified by type of test (GLAL vs CLAL). Each analysis was repeated with smaller studies excluded. There was no difference between the 2 types of LAL assays. Among the CLAL studies, there was no difference between studies that did versus those that did not use the sepsis syndrome criteria as a basis for patient inclusion. Among 45 studies for which data on the proportion of non-Enterobacteriaceae were available, there was a trend toward higher concordance as this proportion increased.

CONCLUSIONS

The concordance between the LAL test and the detection of gram-negative bacteremia in patients with suspected bacteremia is no higher with the CLAL assay than with the original GLAL version. However, the concordance is higher among studies with a higher proportion of non-Enterobacteriaceae among the gram-negative bacteremia isolates.

ELISA for bovine interleukin-1 receptor antagonist and its application to mastitic sera and whey

A sandwich ELISA for the bovine IL-1 receptor antagonist (bIL-1ra) was developed using recombinant (r) bIL-1ra produced by Escherichia coli, anti-rbIL-1ra rabbit IgG, its biotinylated one and avidin-peroxidase. This ELISA system enabled detection of rbIL-1ra at a concentration of more than 2 ng/ml. This ELISA was applied to quantitation of bIL-1ra in sera and whey of mastitic and healthy cows. The results indicate that although IL-1ra levels in healthy and mastitic sera and whey were comparable, serum IL-1ra/IL-1beta ratio of euthanized cows was significantly lower than that of the recovered.

Isolation of Pantoea agglomerans in two cases of septic monoarthritis after plant thorn and wood sliver injuries

Arthritis after plant injury is often apparently aseptic. We report two cases due to Pantoea agglomerans. In one case, the bacterium was isolated only from the pediatric blood culture media, BACTEC Peds Plus, monitored in BACTEC 9240, and not from the other media inoculated with the joint fluid. This procedure could help improve the diagnosis of septic arthritis.

IgM, IgG and IgA class enterobacterial antibodies in serum and synovial fluid in patients with ankylosing spondylitis and rheumatoid arthritis

IgM, IgG and IgA class antibodies against three Klebsiella pneumoniae capsular types, Escherichia coli and Proteus mirabilis, as well as total immunoglobulin concentrations, were measured by enzyme immunoassay and radial immunodiffusion technique, respectively, in paired serum and synovial fluid samples from eight patients with ankylosing spondylitis and 10 with rheumatoid arthritis. No clear evidence for intra-articular antibody production against any of the studied microbes was found.

Citrobacter sedlakii meningitis and brain abscess in a premature infant

Citrobacter sedlakii was isolated from blood and cerebrospinal fluid cultures of a 5-day-old premature infant with sepsis, meningitis, and brain abscess. This newly described organism was difficult to identify due to discrepancies between the Vitek and API 20E identification systems. To our knowledge, this is the first report of the isolation of C. sedlakii from cerebrospinal fluid.

Use of physiologic variables to predict milk yield after clinical mastitis in dairy cattle

OBJECTIVE

To determine the association between intramammary infections caused by various bacteria and hepatic damage, as measured by serum sorbitol dehydrogenase (SDH) activity, WBC counts, and PCV and the association of clinical variables with milk production after a case of clinical mastitis.

DESIGN

Prospective, cohort study.

ANIMALS

82 cows with clinical mastitis.

PROCEDURE

Information on milk production, mastitis status, and selected physiologic variables was collected during a 1-year period. Milk samples for bacteriologic evaluation were collected on day 1 of an episode of clinical mastitis. Physical examination was performed and blood samples for laboratory evaluation were collected on days 1, 5, and 9. Primary outcome was mature equivalent 305-day (ME305) milk production. Correlations were assessed using a multiple regression model.

RESULTS

Higher WBC counts were associated with higher ME305 values. For cows with coliform mastitis, increases in SDH values were associated with higher ME305 values. For cows with coliform and streptococci/staphylococci mastitis, PCV was associated with ME305 values. Higher PCV values were associated with lower ME305 values for streptococci/ staphylococci and coliform infections.

CLINICAL IMPLICATIONS

The association between milk production and WBC count indicated that cows mobilizing WBC were better able to neutralize mammary gland infections, which may result in better milk production. The association between milk production and PCV suggested that maintaining hydration in cows with clinical mastitis may be a critical aspect of treating all cows with mastitis.

Effect of transportation on lower respiratory tract contamination and peripheral blood neutrophil function

OBJECTIVE

To evaluate the effect of transportation on lower respiratory tract contamination and peripheral blood neutrophil function in horses and to compare results from transported horses with those obtained in earlier experiments from horses confined with heads elevated.

DESIGN

A prospective study.

PROCEDURE

Six horses were transported by road for 12 h. Clinical and haematological examination, transtracheal aspiration and cell function studies were conducted before and after transportation. Results obtained after transportation were compared to pre-transportation values.

RESULTS

After transportation, peripheral blood leucocyte and neutrophil numbers were increased and rectal temperatures were evaluated. Transtracheal aspirates showed an accumulation of purulent respiratory tract secretions with increased numbers of bacteria, particularly beta-haemolytic Streptococcus spp and members of the Pasteurellaceae family. Three horses also had increased numbers of bacteria from the Enterobacteriaceae family relative to corresponding samples from earlier studies. Phagocytosis by peripheral blood neutrophils was significantly reduced, while the oxidative burst activity of peripheral blood leucocytes was either unchanged or enhanced.

CLINICAL IMPLICATIONS

Bacterial contamination of the lower respiratory tract occurs as a routine consequence of transportation of horses and is likely to be an important determinant in the development of transport-associated respiratory disease. Inflammatory airway secretions and increased numbers of bacteria were rapidly cleared, without clinical evidence of significant pulmonary disease and without additional treatment, in normal horses that were allowed to lower their heads after transportation. Peripheral blood neutrophilia and a reduction in neutrophil phagocytic function were evident for at least 36 h after transportation, suggesting that horses may require a number of days to recover from the stress of transportation. As the potential role of bacteria from the Enterobacteriaceae family in the development of transport-associated respiratory disease has not been elucidated, horses which develop clinical disease following transportation should undergo thorough bacteriological investigation to ensure appropriate treatment.