Evolutionary trends in bacteria isolated from moderate and severe diabetic foot infections in a Portuguese tertiary center

INTRODUCTION

Diabetic Foot infections (DFI) are a major cause of hospitalization in patients with diabetes. The microbiological study of diabetic ulcers is essential to adequate antibiotic therapy and to minimize the selection of resistant microorganisms. The aim of this study was to characterize and to compare the evolution of isolated microorganisms between the biennium 2010-2011 and 2016-2017, in hospitalized patients with DFI.

MATERIAL AND METHODS

Retrospective evaluation of the clinical and analytical data of patients who were admitted due to DFI in 2010-2011 (group 2010/11) and 2016-2017 (group 2016/17). Only the first hospitalization for each patient was included. An adequate descriptive and comparative statistical analysis was performed.

RESULTS

There were 274 admissions due to DFI, 151 in 2010/11 and 123 in 2016/17. There was an increase in admissions due to neuroischemic DFI (51.0% in 2010/11 to 61.8% in 2016/17, p = 0.048). Staphylococcus aureus (SA) was the most common isolate in 2010/11 (26.7%). In 2016/17 most cultures were mixed polymicrobial and isolation of Enterobacteriaceae and Pseudomonas aeruginosa increased from 2010/11 to 2016/17 (15.9% to 30.6%, p = 0.001, and 9.1% to 13.7%, p = 0.048, respectively).

CONCLUSION

There was an increase in the prevalence of neuroischemic DFU. The Enterobacteriaceae family replaced SA as the most prevalent pathogen in DFI, with an increase in the isolation of gram-negative microorganisms and mixed polymicrobial cultures. Chronic neuroischemic infected ulcers usually present distinct bacterial isolates; knowledge about the most common agents is warranted in order to better select empiric antibiotic therapy.

Orolabial Lymphogranuloma Venereum, Michigan, USA

Orolabial lymphogranuloma venereum was diagnosed for a man in Michigan, USA, who had sex with men, some infected with HIV. High index of suspicion for lymphogranuloma venereum led to accurate diagnosis, successful therapy, and description of an L2b variant with a unique genetic mutation.

Pseudomonas piscis sp. nov., isolated from the profound head ulcers of farmed Murray cod (Maccullochella peelii peelii)

A Gram-stain-negative, strictly aerobic, motile, rod-shaped bacterium with monopolar flagella, designated as MC042^T, was isolated from the profound head ulcers of farmed Murray cod sampled from Zhejiang Province, China. Analysis of its 16S rRNA gene sequence and multilocus sequence analysis phylogeny showed that strain MC042^T belonged to the genus Pseudomonas, showing the highest 16S rRNA gene sequence similarity to Pseudomonas juntendi BML3^T (98.9 %), and less than 98.8 % similarity to other Pseudomonas species with validly published names. Whole-genome sequencing and phylogenetic reconstruction based on a core set of 1563 Pseudomonas genes further indicated that strain MC042^T was most closely related to the clade formed by Pseudomonas protegens CHA0^T and Pseudomonas saponiphila DSM 975^T and distantly related to any of the validly published species of the genus Pseudomonas. Furthermore, strain MC042^T could be distinguished from its closely related species of the genus Pseudomonas by its ability to assimilate maltose, d-xylose and melibiose, but not d-mannitol. The principal fatty acids were C_16 : 0, summed feature 3 (iso-C_15 : 0 2-OH and/or C_16 : 1ω7c) and summed feature 8 (C_18 : 1 ω7c and/or C_18 : 1 ω6c). The respiratory quinone was Q-9. Polar lipids of strain MC042^T comprised diphosphatidylglycerol, phosphatidylethanolamine, phosphatidylglycerol, unidentified glycolipids, an unidentified lipid, an unknown glycolipid and aminolipid. Based on its phenotypic, chemotaxonomic and phylogenetic features, strain MC042^T is considered to represent a novel species, for which the name Pseudomonas piscis sp. nov. is proposed. The type strain is MC042^T (=KCTC 72033^T=MCCC 1K03575^T).

Ulcerative, granulomatous glossitis and enteritis caused by Rhodococcus equi in a heifer

Rhodococcus equi infection in horses is common and is characterized by pyogranulomatous pneumonia and ulcerative enterocolitis. R. equi clinical disease in cattle, however, is rare and typically manifests as granulomatous lymphadenitis discovered in the abattoir. A 19-mo-old female Santa Gertrudis had a history of intermittent inappetence and weight loss for a 3-mo period before euthanasia. Gross and histologic examination revealed severe, chronic, ulcerative, and granulomatous inflammation in the tongue, pharynx, and small intestine. Also, the heifer had severe, granulomatous pharyngeal and mesenteric lymphadenitis. Bacterial cultures from the ileum, tongue, and liver yielded numerous-to-moderate numbers of R. equi. PCR analysis of the isolate detected the linear virulence plasmid vapN, which is often identified in bovine isolates (traA- and vapN-positive). The bacteria also lack the circular plasmids vapA and vapB that are associated with virulence in horses and swine, respectively. We report herein an atypical and unusual clinical presentation of R. equi infection in cattle, which has zoonotic potential.

Lipschütz ulcer and group A streptococcal tonsillitis

Lipschütz ulcers (LU) are non-sexually related genital ulcers, rarely reported. We describe a healthy 11-year-old girl, who presented with fever and a painful vulvar ulcer associated with erythematous tonsillitis. Throat swab test for Group A Streptococcus (GAS) was positive. She was treated with amoxicillin. Further investigation was negative, including Herpes Simplex virus DNA from ulcer swab and serology for Epstein-Barr virus, cytomegalovirus and Mycoplasma pneumoniae Antistreptolysin O titre was high. The ulcer healed in 2 weeks, with no recurrence in a 1 year follow-up period. The association of LU with GAS tonsillitis is very rare.

Mycobacterium gordonae in Patient with Facial Ulcers, Nosebleeds, and Positive T-SPOT.TB Test, China

Mycobacterium gordonae is often regarded as a weak pathogen that only occasionally causes overt disease. We report a case of M. gordonae infection in the facial skin, nasal mucosa, and paranasal sinus in an immunocompetent patient and review previous cases. The T-SPOT.TB test might be useful in diagnosing such cases.

Mycoplasma pneumoniae as a cause of vulvar ulcers in a non-sexually active girl: a case report

BACKGROUND

Non-sexually active young females very rarely develop genital ulcers. Such ulcers pose a diagnostic challenge as well as physical and emotional distress for patients and family; therefore, the search for their etiology requires exhaustive investigation. Several viruses such as Epstein-Barr virus have been associated with this entity; however, Mycoplasma pneumoniae has rarely been linked to such ulcers in the literature. We present a case of vulvar ulcers in a non-sexually active young girl during the course of pneumonia caused by Mycoplasma pneumoniae.

CASE PRESENTATION

A 10-year-old non-sexually active girl of cypriot origin presented at a hospital with fever, dry cough, and acute vulvar ulcers. Laboratory investigations as well as imaging studies revealed Mycoplasma pneumoniae as the cause of her pneumonia and acute vulvar ulcers.

CONCLUSIONS

Although a rare cause of vulvar ulcers, Mycoplasma pneumoniae should be considered in the differential diagnosis of acute vulvar ulcers coexisting with respiratory symptoms.

[THE ROLE OF WOUND DRESSING IN BIOFILM DESTRUCTION AND REFORMATION]

Application of supportive wound dressing is an important segment for successful result of modern treatment of chronic ulcers. The right choice of dressing is the key to faster, better, and ultimately more cost-effective treatment outcome. Due to the extremely large number of generic types and variants, the main element for proper dressing selection is to know the mechanisms of action and clinical evidence of the effectiveness because of many local factors that delay ulcer healing. The advent of wound dressing that is efficient at the three clinically identified key local factors that largely impede the healing of ulcers, i.e. exudate, infection and biofilm, has made a significant step forward in the creation of optimal conditions for faster healing of chronic ulcers. The complexity of the effects of new technologies, which integrate hidrofiber technology and Ag + technology, provides effective antimicrobial control while at the same time preventing biofilm reformation.

Sexually Transmitted Infections

Sexually transmitted infections (STIs) remain a significant burden on public health in the United States. Primary prevention counseling with early diagnosis and treatment remain the best methods to decrease the incidence of STIs. Through significant public heath interventions, the incidence of gonorrhea, Chlamydia, and trichomoniasis is decreasing; however, the incidence of primary and secondary syphilis is increasing. Human papilloma virus remains the most common STI, but new vaccinations have the possibility of having a significant impact on this virus's disease potential. This review discusses the most common STIs in the United States, focusing on clinical presentation, diagnosis, and treatment.

Histoplasmosis Presenting as a Laryngeal Ulcer in an Immunocompetent Host

Histoplasmosis is a granulomatous disease of worldwide distribution caused by a dimorphic fungus Histoplasma capsulatum. Majority of primary infections in immunocompetent hosts are asymptomatic or may present with flu-like illness. Histoplasmosis may occur in three forms: (i) Primary acute pulmonary form, (ii) chronic pulmonary and (iii) disseminated form. The manifestations of disseminated form of histoplasmosis are fever, weakness, weight loss, hepatosplenomegaly, and mucocutaneous lesions. The mucosal involvement could be oropharyngeal or laryngeal involvement. We report an unusual case of histoplasmosis presenting as a laryngeal ulcer in an immunocompetent host.

Rapid Treponema pallidum clearance from blood and ulcer samples following single dose benzathine penicillin treatment of early syphilis

Currently, the efficacy of syphilis treatment is measured with anti-lipid antibody tests. These can take months to indicate cure and, as a result, syphilis treatment trials require long periods of follow-up. The causative organism, Treponema pallidum (T. pallidum), is detectable in the infectious lesions of early syphilis using DNA amplification. Bacteraemia can likewise be identified, typically in more active disease. We hypothesise that bacterial clearance from blood and ulcers will predict early the standard serology-measured treatment response and have developed a qPCR assay that could monitor this clearance directly in patients with infectious syphilis. Patients with early syphilis were given an intramuscular dose of benzathine penicillin. To investigate the appropriate sampling timeframe samples of blood and ulcer exudate were collected intensively for T. pallidum DNA (tpp047 gene) and RNA (16S rRNA) quantification. Sampling ended when two consecutive PCRs were negative. Four males were recruited. The mean peak level of T. pallidum DNA was 1626 copies/ml whole blood and the mean clearance half-life was 5.7 hours (std. dev. 0.53). The mean peak of 16S rRNA was 8879 copies/ml whole blood with a clearance half-life of 3.9 hours (std. dev. 0.84). From an ulcer, pre-treatment, 67,400 T. pallidum DNA copies and 7.08x107 16S rRNA copies were detected per absorbance strip and the clearance half-lives were 3.2 and 4.1 hours, respectively. Overall, T. pallidum nucleic acids were not detected in any sample collected more than 56 hours (range 20–56) after treatment. All patients achieved serologic cure. In patients with active early syphilis, measuring T. pallidum levels in blood and ulcer exudate may be a useful measure of treatment success in therapeutic trials. These laboratory findings need confirmation on a larger scale and in patients receiving different therapies.

Syphilis is an infection that is spread both sexually and from mother-to-child. Worldwide, it affects an estimated 11 million people each year. Treatment is available, but relies heavily on penicillin and may not be as effective where the infection involves the brain or nervous system. Clinical trials are needed to assess new treatments, but proving that people are cured with current tests can take months. We developed a new test to measure the success of treatment for the early stage of syphilis. We then used it in four patients and found that the syphilis bacteria were cleared from the blood and ulcer samples collected by 56 hours. All four patients were followed up with normal tests and found to have been cured. Our new test is the first to show the speed of bacterial clearance after treatment and we plan to use it in clinical trials of new treatments. Our data may also mean that patients with syphilis are unable to pass on the infection three days after treatment, but this also needs proving on a larger scale.

Successful endoscopic hemoclipping of massive lower gastrointestinal bleeding from paratyphoid A fever

Paratyphoid fever can be complicated by massive lower gastrointestinal bleeding with ileocolonic ulcerations, which are commonly localized using colonoscopy. The most common manifestations include multiple, variable-sized, round or oval-shaped, punched-out ulcers. Occasionally, massive lower gastrointestinal bleeding can occur from erosion of blood vessels. We present a rare case of severe lower gastrointestinal bleeding due to paratyphoid A fever that was successfully controlled with hemoclippings. A 30-year-old man experienced high fever and hematochezia whose blood culture showed Salmonella paratyphi A. A complete colonoscopy was successfully performed up to the level of the terminal ileum, which showed multiple, shallow, ulcerated lesions over the entire terminal ileum. A bleeding vessel was seen in one of the ulcers, with overlaying blood clots. Endoscopic hemostasis was successfully performed with four pieces of endoclip and without immediate complication. This report highlights the use of colonoscopy and endoscopic therapy with endoclips for lower gastrointestinal bleeding, which should be considered before surgery.

[Microbiology of pressure and vascular ulcer infections]

INTRODUCTION

Pressure ulcer (PU) infection is a significant clinical problem in many elderly patients.

MATERIAL AND METHODS

To determine the microbiology of PU and vascular ulcer (VU) infections by conducting a cross-sectional study of outpatients treated in a chronic wounds unit over an 18 month period.

RESULTS

Sixty six patients with PU infection and 159 patients with an infected VU were identified. The PUs were located below the knee in 36 patients (52%). Patients with pressure ulcers had a higher proportion of institutionalization, cognitive impairment, inability to walk, and sphincter incontinence. There was a greater number of infections caused by Enterobacteriaceae (52%, P=.002) and fewer S. aureus infections (24%, P<.001) in patients with a PU compared to those with those with a VU. Forty-one percent of S. aureus strains isolated in all the patients were resistant to methicillin (MRSA). The proportion of Enterobacteriaceae infections was similar in patients with infection of pelvic girdle PU and in those located below the knee.

CONCLUSIONS

PU patients suffer a higher rate of infection by enterobacteria. The most common pathogen in UV infections is S. aureus. The proportion of MRSA infection in patients with chronic wounds is high. The microbiology of the infection in the pelvic girdle PU is similar to those located below the knee.

Correlation of adherence to the 2012 Infectious Diseases Society of America practice guidelines with patient outcomes in the treatment of diabetic foot infections in an outpatient parenteral antimicrobial programme

AIM

To evaluate adherence to the 2012 Infectious Diseases Society of America practice guidelines for the management of patients with diabetic foot infections and to determine an association between adherence and clinical outcome.

METHODS

A retrospective chart review was performed to evaluate the management and clinical outcomes of patients with diabetic foot infections treated with outpatient parenteral antimicrobial therapy between 1 January 2011 and 30 June 2012 at Wishard Health Services/Eskenazi Health. Adherence to individual Infectious Diseases Society of America diabetic foot infection treatment guideline recommendations was measured, and then assessed in relation to clinical outcome.

RESULTS

A total of 57 patients (61% male, mean age 54 years) with moderate to severe diabetic foot infection met the inclusion criteria. None of the treatment courses of these patients adhered to all the Infectious Diseases Society of America guideline recommendations. The recommendations most frequently adhered to were consultation of appropriate multidisciplinary teams (n=54, 94.7%) and performance of diagnostic imaging (n=52, 89.5%). The recommendations least frequently adhered to were diabetic foot wound classification scoring on admission (n=0, 0%), appropriate culture acquisition (n=12, 21.2%), surgical intervention when indicated (n=32, 46.2%) and appropriate empiric antibiotic selection (n=34, 59.7%). Of 56 patients, 52 (92.9%) experienced clinical cure at the end of outpatient parenteral antimicrobial therapy compared with 34 of 53 patients (64%) at 6 months after the completion of therapy. Adherence to individual guidelines was not associated with clinical outcome. Patients who experienced treatment failure were more likely to have severe diabetic foot infection or peripheral neuropathy.

CONCLUSIONS

Adherence to the Infectious Diseases Society of America diabetic foot infection guideline recommendations was found to be suboptimal in the present study. The effect of adhering to individual Infectious Diseases Society of America diabetic foot infection recommendations on clinical outcome needs to be investigated.

Invasive primary aspergillosis of the larynx presenting as hoarseness and a chronic nonhealing laryngeal ulcer in an immunocompetent host: a rare entity

Primary aspergillosis usually affects the paranasal sinuses, orbit, ear, and lower respiratory tract. Laryngeal aspergillosis usually occurs as a result of secondary invasion from the tracheobronchial tree, more commonly in immunocompromised hosts. Primary laryngeal localization of Aspergillus infection is seldom encountered. We report the case of an immunocompetent 42-year-old man who presented with hoarseness and a laryngeal ulcer of fairly long duration. A malignancy was initially suspected clinically, but a laryngoscopic biopsy led to a diagnosis of invasive primary laryngeal aspergillosis. No other focus of aspergillosis was found on x-ray and computed tomography. After identification of Aspergillus niger on culture, inquiries revealed no exposure to steroids, cytotoxic drugs, or irradiation, and workups for malignancy, human immunodeficiency virus infection, tuberculosis, and diabetes were negative. Although isolated laryngeal involvement is rare, aspergillosis may be considered in the differential diagnosis of a chronic nonhealing laryngeal ulcer that is clinically suggestive of a malignancy, even in an immunocompetent host.

Lymphogranuloma venereum: an old, forgotten re-emerging systemic disease

Lymphogranuloma venereum (LGV) is a sexually transmitted infection endemic in parts of Africa, Asia, South America, and the Caribbean, but once was rarely observed in Western countries, where most cases were considered to be imported. However, recent outbreaks have been reported in Europe, Australia, New Zealand, the United States and Canada, mainly among HIV positive men who have sex with men, signaling LGV re-emergence. The etiological agent of LGV is Chlamydia trachomatis serotypes L1, L2 and L3, and current outbreaks are mostly sustained by L2b type. The clinical course can be classically divided into three stages: an initial papule, which may ulcerate at the site of inoculation, followed by regional lymphoadenopathy (second stage, generally unilateral). In the tertiary stage, lymphatic obstruction, with elephantiasis of genitalia, and rectal involvement can lead to the formation of strictures and fistulae that may require surgical treatment. Recent cases are observed mainly among HIV positive people, often co-infected with HCV and others STIs, engaging in high-risk sexual practices. The main clinical picture is a relative new entity characterized by progressive ulcerative proctitis, the so called anorectal syndrome. Diagnosis is often delayed, requires a high index of clinical suspicion and must rely on the use of nucleic acid amplification tests. The differential diagnosis of proctitis should include LGV infection. Gastroenterologists, coloproctologists, dermatologists and other specialists need to be aware of LGV proctitis to avoid diagnostic delay and progression of disease to the tertiary stage.

Photodynamic topical antimicrobial therapy for infected foot ulcers in patients with diabetes: a randomized, double-blind, placebo-controlled study--the D.A.N.T.E (Diabetic ulcer Antimicrobial New Topical treatment Evaluation) study

This study was designed to assess the antimicrobial effect and tolerability of a single dose of a photo-activated gel containing RLP068 in the treatment for infected foot ulcers in subjects with diabetes. A randomized, double-blind, parallel series, placebo-controlled phase IIa trial was performed with three concentrations of RLP068 (0.10, 0.30, and 0.50 %), measuring total and pathogen microbial load on Day 1 (before and 1 h after topical gel application and photoactivation with 689 nm red light), on Days 3, 8, and 15, as add-on to systemic treatment with amoxicillin and clavulanic acid. Blood samples were also drawn 1, 2, and 48 h after administration for the assessment of systemic drug absorption. The trial was performed on 62 patients aged ≥18 years, with type 1 or type 2 diabetes and infected foot ulcer, with an area of 2-15 cm(2) and a maximum diameter ≤4.6 cm. A dose-dependent reduction in total microbial load was observed (-1.92 ± 1.21, -2.94 ± 1.60, and -3.00 ± 1.82 LogCFU/ml for 0.10, 0.30, and 0.50 % RPL068 vs. -1.00 ± 1.02 LogCFU/ml with placebo) immediately after illumination, with a progressive fading of the effect during follow-up. No safety issues emerged from the analysis of adverse events. Systemic absorption of RLP068 was negligible. Photodynamic antimicrobial treatment with RLP068 of infected diabetic foot ulcers is well tolerated and produces a significant reduction in germ load. Further clinical trials are needed to verify the efficacy of this approach as add-on to systemic antibiotic treatment.

Isolated rectal tuberculosis with multiple ulcers

Isolated rectal tuberculosis is a rare disease. It most commonly presents with haematochezia. Here we present a case of a 17 year old female patient, presenting with fever, diarrhoea and haematochezia, who was subsequently diagnosed as having rectal tuberculosis with multiple ulcers on colonoscopy-guided biopsy.

Chronic Ulcers in Ikeja-Lagos, Nigeria: an eighteen month review of infecting bacterial agents and susceptibility pattern

BACKGROUND

Chronic ulcers are an important cause of morbidity among surgical and medical patients. Infection in ulcers may delay healing and cause septicemia resulting in mortality. Microbial studies are important for the appropriate management of these ulcers.

METHODS

Details of all patients treated for ulcers that were investigated at the department of Medical Microbiology and Parasitology, Lagos State University Teaching Hospital, Ikeja-Lagos, Nigeria between July 1st 2009 and December 31, 2010 were retrieved from the computer database and transferred into the proforma designed for the study. Data collected were demography, date of onset of ulcer, mode of specimen collection, names of isolates and drug sensitivity patterns.

RESULTS

A total of 329 cases were seen and reviewed during the study period. Males constituted 50.2%, females 38.3% and the gender of the remaining 11.6% were not indicated. There were 259 (78.7%) adults and 42 (12.8%) children. The ages of 28 cases were not indicated. Microbial growths were obtained in 217 (66.7%) patients. Gram negative (Gn) organisms were isolated in 181 (83.5%) and Gram positive (Gp) in 35 (16%). The most common isolates were Pseudomonas aeruginosa (19.1%) Staphylococcus aureus (9.7%), Proteus mirabilis (7.6%) and Escherichia coli (7.3%). There were widespread resistances by the isolates to the common antibiotics in the study environment.

CONCLUSIONS

The wide spread resistance may be due to lack of an antibiotic use policy. Certain antibiotics should be reserved for second line treatment in the emergency setting.

[Rationale for improved treatment of ulcerative disease complicated by chronic pyelonephritis]

In summary, to come to objective conclusions as proven treatment that achieved by improvement schemes. Detected somewhat smaller difference in the degree of risk in the treatment of existing and improved schemes ulcer and neasotsiyovanoyi it when the underlying disease complicated by chronic inflammation, in our opinion, due to greater perfection, adapted first for this category of patients, among other options.

[Diagnosis and treatment of chronic wound infections]

The treatment of chronic wounds is slow and difficult and the presence of an infection can further delay the healing. Diagnosis of this infection is clinical. It must be accompanied by targeted sampling carried out in accordance with a specific technique in order to adapt the treatment as best as possible.

Chronic ulcers in Ikeja-Lagos, Nigeria: an eighteen month review of infecting bacterial agents and susceptibility pattern

BACKGROUND

Chronic ulcers are an important cause of morbidity among surgical and medical patients. Infection in ulcers may delay healing and cause septicemia resulting in mortality. Microbial studies are important for the appropriate management of these ulcers.

OBJECTIVE

The study investigates on eighteen month review of infecting bacterial agents and susceptibility pattern in chronic ulcers in Lagos, Nigeria.

METHODS

Details of all patients treated for ulcers that were investigated at the department of Medical Microbiology and Parasitology, Lagos State University Teaching Hospital, Ikeja-Lagos, Nigeria between July 1st 2009 and December 31, 2010 were retrieved from the computer database and transferred into the proforma designed for the study. Data collected were demography, date of onset of ulcer, mode of specimen collection, names of isolates and drug sensitivity patterns.

RESULTS

A total of 329 cases were seen and reviewed during the study period. Males constituted 50.2%, females 38.3% and the gender of the remaining 11.6% were not indicated. There were 259 (78.7%) adults and 42 (12.8%) children. The ages of 28 cases were not indicated. Microbial growths were obtained in 217 (66.7%) patients. Gram negative (Gn) organisms were isolated in 181(83.5%) and Gram positive (Gp) in 35 (16%). The most common isolates were Pseudomonas aeruginosa (19.1%) Staphylococcus aureus (9.7%), Proteus mirabilis (7.6%) and Escherichia coil (7.3%). There were widespread resistances by the isolates to the common antibiotics in the study environment.

CONCLUSION

The wide spread resistance may be due to lack of an antibiotic use policy. Certain antibiotics should be reserved for second line treatment in the emergency setting

Bacterial cultures, rapid strep test, and antibiotic treatment in infected hard-to-heal ulcers in primary care

OBJECTIVE

In-depth studies on antibiotic treatment for patients with hard-to-heal ulcers in primary care are lacking. The present study was undertaken to update the bacteriological spectrum for this patient group and to investigate antibiotic treatment. A further aim was to investigate the potential of a rapid strep test to find group A streptococci (GAS) causing ulcer infection.

DESIGN

A prospective study from August 2009 to August 2010.

SETTING

Blekinge Wound Healing Center.

SUBJECTS

Patients with clinical signs of infected hard-to-heal ulcers of any etiology.

MAIN OUTCOME MEASURES

A bacterial culture and a rapid strep test were taken from every ulcer to capture the bacteriological spectrum. Antibiotic treatment before and during the study period was measured.

RESULTS

Forty-one patients with 49 infected ulcers were recruited. Staphylococcus aureus, found in 68.8% of all cultures, was the most observed species. Group G streptococci (GGS) were found in 12.5%. GAS was found in one case where the rapid strep test was positive. Staphylococcus aureus was found in three patients out of four with clinical signs of erysipelas. Some 59% of the patients were treated with antibiotics before the study period compared with 44% during the study period.

CONCLUSION

Antibiotic treatment was largely reduced because of structured wound management. The current bacteriological spectrum showed high rates of GGS and erysipelas caused by Staphylococcus aureus. The rapid strep test was found useful in identifying GAS but we would not recommend its use in the clinical setting due to the low rate of GAS in this patient group.

Microbial diversity of genital ulcer disease in men enrolled in a randomized trial of male circumcision in Kisumu, Kenya

Background

Medical male circumcision (MMC) reduces the risk of genital ulcer disease (GUD) in men by 50%. In Ugandan and Kenyan trials, a sexually transmissible agent was not identified in 50–60% of GUD specimens by polymerase chain reaction (PCR) assay. We sought to better define the etiology of GUD in men participating in the Kenyan trial and examine how MMC affects GUD etiology.

Methods

We defined GUD of unknown etiology as negative for HSV (type 1 and type 2), T. pallidum, and H. ducreyi by PCR, and negative for HSV-2 and T. pallidum by serology. We identified bacterial microbiota in a subset of 59 GUD specimens using multitag pyrosequencing of the 16S rRNA gene, and compared results by unknown vs. STI-associated etiology. Statistical analysis employed Bray-Curtis similarity measure of bacterial community by etiology, hierarchical clustering and logistic regression.

Results

In 59 GUD specimens from 59 men, 23 (39%) had unknown etiology. Bacterial diversity was greater in GUD of unknown than STI etiology (p = 0.01). Fusobacteria (Fusobacterium spp. and Sneathia spp.) were more commonly detected in men with GUD of unknown etiology [adjusted OR = 5.67; 95% CI: 1.63–19.8] as were Oxobacter spp. and Anaerovorax spp. [adjusted OR = 3.12; 95% CI: 0.83–11.7]. Sequences from these four anaerobic bacterial taxa were more often detected in uncircumcised men than circumcised men (p<0.05).

Conclusions

Anaerobic bacteria are more common in genital ulcers of uncircumcised men. The specific anaerobic bacteria associated with GUD of unknown etiology have cytotoxic properties that can exacerbate epithelial disruptions leading to ulcer-like appearance. MMC may reduce GUD through a reduction in these anaerobic bacteria.

The pattern of bacterial isolates and drug sensitivities of infected ulcers in patients with leprosy in ALERT, Kuyera and Gambo hospitals, Ethiopia

INTRODUCTION

Leprosy remains a public health problem, mainly in Africa, Asia and Latin America. Leprosy has many complications that include leprosy reactions, development of plantar and hand ulcerations, lagophthalomus and corneal anesthesia.

OBJECTIVES

In Ethiopia there is scarce information on the pattern of bacterial isolates and drug sensitivities of infected ulcers in patients with leprosy. This study was undertaken to identify the bacteriology of infected ulcers and to determine their antimicrobial susceptibility pattern.

STUDY DESIGN

A descriptive cross-sectional study was conducted in 245 informed and consented leprosy patients with infected ulcers visiting ALERT, Kuyera and Gambo hospitals during the period August 2006 to May 2007.

MATERIAL AND METHODS

Wound aspirate specimens were collected from ulcers of each patient aseptically and inoculated into standard bacteriological media. Antimicrobial susceptibility testing was performed for all isolates according to the criteria of the National Committee for Clinical Laboratory Standards (NCCLS) by disk diffusion method.

RESULTS

Of the 245 patients investigated, 64.1% were males and 35.9% females (P < 0.05). The average age of the patients was 50 years (age range 13 to 92 years). According to Ridley-Jopling classifications, patients presented with TT (3.7%), BT, (31.4%), BL (44.5%) and LL (15.9%) types of leprosy. Plantar and hand ulcers were observed in 92.2% and 7.8% of patients, respectively. According the patients, the commonest cause of their ulcers was 'spontaneous' (56.7%). There were 44% Gram-positive and 56% Gram negative bacteria (P > 0.05). Proteus spp. accounted for 29.5% of the total isolates followed by Staphylococcus spp. (28.8%), beta-hemolytic streptococci (15.1%) and different types of Gram-negative bacteria (26.2%). Multiple organisms (two or three) were isolated from 19.6% patients. Of the 212 wound samples cultured anaerobically, 5.2% were positive for anaerobic culture. In this study both Gram-positive and Gram negative bacteria showed decreased sensitivity to most antimicrobial agents tested.

CONCLUSION

Proteus spp. was the most common isolate from infected ulcers. Ciprofloxacin, norfloxacin and gentamicin were the most effective drugs against the tested bacteria mainly for Gram-negative bacteria. This refers to the in vitro-sensitivity during the study period. The results of this study may help inform clinicians about the selection of an antibiotic in situations where use of an antibiotic may be indicated.

[Prevalence of Helicobater pylori infection among population of Northwestern federal district of Russian Federation]

AIM

Studies of Helicobater pylori infection rate among population of North-western federal district including St. Petersburg in 2007 - 2009.

MATERIALS AND METHODS

1021 individuals with various digestive tract pathologies as well as healthy individuals and blood donors were examined. 378 children and adolescents up to 19 years of age, and 643 adults 20 - 80 years of age were among the examined individuals. IgG to H. pylori complex antigen and IgG to its CagA toxin were determined in blood sera.

RESULTS

Infection rate among children and adolescents was 40.48%, CagA positive strain infection rate--34.92%. Among adults these parameters were 63.61% and 49.61%, respectively. During the 3 year study a tendency of CagA positive strain rate increase was noted among children and adolescents. Prevalence of H. pylori infection in subjectively healthy individuals, intestine oncology disease and gastric cancer patients was 55.1%, 67.16% and 83.33%, respectively.

CONCLUSION

High rate of infection and CagA positive strain prevalence among children and adolescents can be considered as a possible factor of gastritis and ulcer rate increase in these age groups.

[Ulcerated lesion of the cecum as a form of presentation of gastrointestinal tuberculosis]

In recent years there has been an increase in the number of cases of intestinal tuberculosis mainly due to the HIV epidemic. Its clinical manifestations and endoscopic findings are nonspecific, making diagnosis difficult, requiring high degree of suspicion. The authors present the case of a man, 55 years old, immunocompetent, who goes to the doctor due to constitutional symptoms after two months of evolution. Given the family history of colon cancer, colonoscopy is sought, showing an ulcerated lesion at the blind. Histology showed non-caseating granulomas and for AFB was negative. The following study carried out with TC chest, sputum and bronchoscopy, has lead to the diagnosis of pulmonary tuberculosis with achievement of the digestive tract. The purpose of this case history is to emphasize the importance of differential diagnosis with other pathologies with similar clinical symptoms and endoscopic changes, and the role of bronchoscopy in diagnosis of pulmonary tuberculosis in patients with negative smear.

A rare case of infectious colitis with ulcers in the cecum caused by Mycobacterium gordonae

A 69-year-old female complained of persistent abdominal pain, and annular ulcers and ulcer scars were detected endoscopically in the cecum. Pathological findings included caseous granulomas with some Langhans giant cells, and Ziehl-Neelsen staining was negative. Mycobacterium gordonae (M. gordonae) was identified by the DNA-DNA hybridization method and culture (Ogawa medium) of biopsy samples from ulcerous cecal lesions. After 6 months of antibiotic therapy, ulcerous cecal lesions were healed, and no acid-fast bacteria were detected by culture of biopsy samples from scar tissue. We believe this is the first report of M. gordonae infection in the alimentary tract.

Evaluation of a rapid culture-based screening test for detection of methicillin resistant Staphylococcus aureus

The performance of a culture based assay, BacLite Rapid MRSA for the rapid detection (5 hours) of methicillin resistant Staphylococcus aureus (MRSA) from specimens (n = 377) obtained from nares, throat, wounds and perineum was investigated. Compared to culture based reference methods (chromogenic MRSA ID (bioMerieux)), selective enrichment broth, PBP2' latex agglutination (Oxoid) and VITEK 2 identification (bioMerieux), an overall sensitivity of 71% with a 82% specificity and a negative predictive value (NPV) of 95% was provided. The Baclite test is rapid and easy to use and has the advantage of a culture-based detection method for MRSA.

[Colonic histoplasmosis as a diagnostic manifestation of AIDS]

We report the case of 48 year old female patient without a history of significance importance.(refuses blood transfusion). She complaint of diarrhea of four months of duration and weight loss of 8 kg. she added episodes of hematochezia and severe anemia requiring transfusion. An intrahemorrhagic colonoscopy was performed detecting three ulcerated lesions. First at 10 cm from the anus, one in transverse colon distal, another similar ulcer in the proximal transverse The biopsies showed ulcer granulation tissue, abundant macrophages with intracytoplasmic structures consistent with histoplasmosis. Tests showed no tuberculosis or intestinal parasitosis. HIV testing (ELISA and Western Blot) were positive. The CD4 (78 cells) and extrapulmonary histoplasmosis were the criteria defined stage AIDS. The extrapulmonary histoplasmosis defines stage IV in immunosuppressed patients with HIV. Lower gastrointestinal bleeding colonic ulcer secondary to Histoplasma is a rare form presentation as a diagnostic manifestation of AIDS.

Length of vancomycin administration for treatment of clostridium difficile-associated diarrhea may depend on presentation of colonic ulcer

BACKGROUND/AIMS

Clostridium difficile-associated diarrhea (CDAD) is a notorious iatrogenic infection with typical endoscopic features consisting of pseudomembranes (PMs). Concomitant colonic ulcers are sometimes endoscopically detected. We hypothesized that length of vancomycin (VCM) administration for treatment depends on presentation of colonic ulcer.

METHODOLOGY

We investigated retrospectively endoscopic findings and total number of days of vancomycin administration for patients who showed evidence of C. difficile toxin A or PMs at our hospitals. We excluded CDAD cases with inflammatory bowel disease.

RESULTS

Sixteen patients were diagnosed as having CDAD. All patients receiving endoscopic examination presented PMs. Two cases had PMs in the transverse and small intestine. The patients with ulcers needed 5-28 days of administration of VCM, while all those without ulcers except one were cured within seven days.

CONCLUSIONS

Our results suggest that ulcer may be a factor of poor prognosis, and we recommend endoscopic examination for all patients with CDAD for identification of poor prognostic groups.

Genital ulcers in women: clinical, microbiologic and histopathologic characteristics

Female genital ulcer is a disease that affects a large number of women, and its etiologic diagnosis can be difficult. The disease may increase the risk of acquiring HIV. Genital ulcer may be present in sexually transmitted diseases (STD)--syphilis, chancroid, genital herpes, donovanosis, lymphogranuloma venereum; and other non-STD disorders (NSTD)--Behçet's syndrome, pemphigus, Crohn's disease, erosive lichen planus and others. This study evaluated the clinical-histopathologic-microbiologic characteristics of female genital ulcers. A cross-sectional descriptive prospective study was conducted during a six-month period to investigate the first 53 women without a definitive diagnosis, seeking medical care for genital ulcers at a genital infections outpatient facility in a university hospital. A detailed and specific history was taken, followed by a dermatologic and gynecologic examination. In addition to collecting material from the lesions for microbiologic study, a biopsy of the ulcer was performed for histopathologic investigation. The average age of the patients was 32.7 years, 56.6% had junior high school education and higher education. The most frequent etiology was herpetic lesion, followed by auto-immune ulcers. At the time of their first consultation, around 60% of the women were using inadequate medication that was inconsistent with the final diagnosis. Histologic diagnosis was conclusive in only 26.4% of the patients (14/53). Cure was obtained in 99% of the cases after proper therapy. The female genital ulcers studied were equally distributed between sexually transmitted and non-sexually transmitted causes. Herpes was the most frequent type of genital ulcer, affecting women indiscriminately, mostly between the ages of 20 and 40 years. The etiologic diagnosis of herpetic ulcers is difficult to make even when various diagnostic methods are applied. It is imperative that NSTD should be included in the differential diagnoses of female genital ulcers. The histopathologic exam is not a diagnostic tool in the majority of cases and should not be considered the gold standard test, being of little value in cases of NSTD and STD ulcers.

Herpes simplex virus infection and genital ulcer disease among patients with sexually transmitted infections in Dar es Salaam, Tanzania

The relative importance of Haemophilus ducreyi and Treponema pallidum in genital ulcer disease in Africa has decreased recently, whereas that of herpes simplex virus (HSV) type 2 has increased. We analysed 301 lesional specimens from Tanzanian patients with genital ulcer disease for the presence of H. ducreyi, T. pallidum and HSV-1/HSV-2 by performing a separate PCR for each pathogen. Infectious agents were detected in 211 (70%) of the cases. A single pathogen was found in 191 samples and two or more pathogens in the remaining 20. HSV-2 represented 83% of all identified pathogens, HSV-1 8%, T. pallidum 4% and H. ducreyi 5%. HSV-1 was identified as a single pathogen in four samples, in combination with others in an additional 14 samples. Thus, HSV-1 can also be the cause of genital ulcer disease in Africa. Regular surveillance of genital ulcer disease aetiology is important in programs for management of genital ulcer disease and HIV in Africa.

Role of virulence plasmid of Aeromonas hydrophila in the pathogenesis of ulcerative disease syndrome in Clarias batrachus

Pathogenic Aeromonas hydrophila (strain VB21), a multiple-drug resistance strain contains a plasmid of about 21 kb. After curing of plasmid, the isolates became sensitive to antimicrobials, to which they were earlier resistant. The cured bacteria exhibited significant alterations in their surface structure, growth profile and virulence properties, and failed to cause ulcerative disease syndrome (UDS) when injected into the Indian catfish Clarias batrachus. Routine biochemical studies revealed that the plasmid curing did not alter the biochemical properties of the bacteria. After transformation of the plasmid into cured A. hydrophila the bacterium regained its virulence properties and induced all the characteristic symptoms of UDS when injected into fish. Thus, the plasmid plays a pivotal role in the phenotype, growth and virulence of A. hydrophila and pathogenesis of aeromonad UDS.

Syphilitic tonsillitis presenting as an ulcerated tonsillar tumor with ipsilateral lymphadenopathy

We describe a 49-year-old man who presented with a cervical mass of a week's evolution, which clinically mimicked a tumoral expansion. Physical examination showed a left cervical mass of 6 x 4 x 2 cm, associated to a left ulcerated tonsillar tumor. The presumptive diagnosis was a tonsillar cancer with lymph node involvement. An amygdalectomy and a frozen section biopsy of the cervical tumor were performed. The biopsy displayed a reactive lymphadenopathy with follicular and interfollicular hyperplasia rich in plasma cells, epithelioid areas, and an outstanding parcel fibrosis of subcapsular, interfollicular, and perifollicular distribution associated to an isolated focus of polymorphonuclear leukocytes and obliterative parietal angiovascular proliferation. The tonsil presented a similar but ulcerated process. These results suggested an infectious reactive process, probably luetic. A Warthin-Starry stain revealed spirochetes in the tonsillar ulcer. Laboratory examinations revealed a positive VDRL test and negative serology for HIV. In conclusion, a primary syphilis of the oropharyngeal tonsil with a syphilic lymphadenopathy was diagnosed. The literature about tonsillar syphilis is reviewed.