Antibiotic prescriptions and laboratory-confirmed cases of Mycoplasma pneumoniae during the epidemic in Sweden in 2011

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Dipslide culture in colonic surgery: a tool for assessment of surgical performance and a guide to antibiotic use

We evaluated a bacterial culture system for the assessment of surgical performance during colorectal operations, and for assessing the impact of selective postoperative antibiotics in contaminated cases. Surgically related infections were recorded and their risk factors were estimated, using univariate and multivariate methods, in 1079 patients undergoing elective colorectal operations. (Study period 1 was prospective, controlled and randomized, and study period 2 was prospective and open). All the patients were given metronidazole, 1 g i.v., at induction of anaesthesia and 12 h postoperatively. The number of colony-forming units (CFU) on an intraoperative dipslide culture was classified as 0, 1-4 or > or = 5 (n = 591, 183 and 305). Patients with > or = 5 CFU were randomized to receive either no further antibiotics or cefuroxime (1.5 g, i.v. every 8 h for 2 days) during the first study period (30 months). During the second period (84 months), all patients with > or = 5 CFU were to be given cefuroxime. Increasing age (p = 0.014), postoperative transfusion of packed red blood cells (p < 0.001), and high bacterial numbers (p < 0.001) were independently associated with infection. Surgeon-related rates of operative bacterial contamination varied between 12 and 50% (p < 0.001). In patients given only metronidazole, the likelihood of infection rose as the density of bacteria in the wound increased according to a sigmoid dose-response curve (5.1, 9.8 and 47.5% with CFU 0, 1-4 and > or = 5, respectively). In the category with > or = 5 CFU, 265 patients were treated with cefuroxime and 23 (8.7%) subsequently had infections [corrected]. Of 40 patients with > or = 5 CFU who did not receive cefuroxime postoperatively, 19 developed infections (p < 0.001, relative risk 5.47; 95% confidence interval 3.29-9.10). In conclusion, dipslide culture can identify patients at high risk of infection after colonic operations. It can be used to assess surgical performance. The addition of postoperative antibiotic cover for aerobic bacteria, detected by the dipslide, reduced the risk of infection more than 5-fold and almost eliminated the risk of contamination.

A foodborne outbreak of group A streptococcal disease at a birthday party

A severe foodborne outbreak of group A streptococcal disease (T28) affected 122/169 people (72%) who attended a church party or ate leftovers from the party. The median incubation time was 42 h. Muscular pain or weakness and fatigue usually preceded pharyngeal symptoms. Complications included otitis media with perforation, peritonsillitis requiring tonsillectomy, arthritis and pericarditis. A 45-year-old man died 36 h after he developed an influenza-like illness, and at necropsy there were histological signs of early streptococcal septicaemia. The strain produced erythrogenic exotoxins B and C. Streptococci were probably transmitted by sliced eggs on sandwiches. Laboratory experiments showed that there was an increment in viable count of streptococci with 6 logs after incubation in egg yolk for 24 h at room temperature. The unusually warm climate and flaws in food handling routines contributed to this large foodborne epidemic.

Predictors of intraoperative bacterial contamination and postoperative infection in elective colorectal surgery

This prospective study of 238 patients undergoing colorectal operations attempted to identify the risk factors for intraoperative bacterial contamination and postoperative infection. The degree of contamination was assessed by the recovery of Enterobacteriaceae spp. or Staphylococcus aureus in peritoneal irrigation fluid using dip-slides. Uni- and multivariate analyses comprised 17 parameters. Intraoperative contamination was strongly associated with postoperative infection (P less than 0.001). Abdominal drains were correlated with contamination (P = 0.019), but not with infection. Decompressive colostomy was over-represented in patients with contamination (P less than 0.001) but contributed to infection independent of its association with contamination (P less than 0.05), as did advanced age (P less than 0.05).

A tissue culture model for study of growth promotion and antimicrobial susceptibility in Bacteroides fragilis

A new model for testing the susceptibility of anaerobic bacteria under in-vivo oxygen pressure is described. Bacteroides fragilis was incubated with a monolayer of mouse fibroblasts or with Escherichia coli or with both in tissue culture medium exposed to an aerobic atmosphere with 5% CO2. B. fragilis started to multiply when the oxygen pressure of the medium was approximately 13 kPa. The resulting growth curves were similar whichever promoter was used. However, the reduction of the medium took place much earlier in the presence of E. coli. This may explain the excellent effect of metronidazole on B. fragilis in the E. coli combinations and its solely bacteriostatic effect in the plain tissue culture. Imipenem exerted a bactericidal effect in all systems and was the most potent agent tested.

Selective cefuroxime prophylaxis following colorectal surgery based on intra-operative dipslide culture

The concept of a very limited effective period for prophylactic antibiotic action was challenged in a prospective, controlled and randomized study featuring a simplified method for assessing the degree of contamination in the operative field during colorectal surgery. The 226 patients were given 1 g metronidazole IV on induction of anaesthesia and 12 h postoperatively. Following standardized saline irrigation of the abdominal cavity, a uriculture dipslide was dipped in the residual fluid just before abdominal closure. The dipslide was incubated for 18 h, and colony counts of coliforms and Staphylococcus aureus were made. The number of colony-forming units (CFU) was classified as 0, 1-4 or greater than or equal to 5 (n = 123, 33 and 70). The patients with CFU greater than or equal to 5 were randomized to receive cefuroxime (1.5 g IV/8 h for 2 days) or no more antibiotics. In the patients given only metronidazole, the incidence of postoperative infections rose with the colony counts (5.7, 9.1 and 41.2 per cent with CFU 0, 1-4 and greater than or equal to 5). Addition of cefuroxime reduced the 41.2 per cent infection rate to 8.3 per cent (P = 0.003). The method thus identified a high-risk group in which a short postoperative course of cefuroxime significantly lowered the rate of sepsis.

Dip slide culture of intraoperative peritoneal irrigation fluid for prediction of septic complication in elective colorectal surgery

A controlled prospective study of a simplified technique, the dip slide culture method, for assessment of bacterial concentration in peritoneal irrigation fluid at the end of an elective colorectal operation is presented. The prediction of postoperative surgical infection based on intraoperative culture was compared between this method and a standard streak-plate technique in 190 patients. One gram of metronidazole was given intravenously as prophylaxis on induction of anesthesia and 12 h postoperatively. Intraoperative growth of members of the family Enterobacteriaceae or Staphylococcus aureus was strongly correlated to infection (P less than 0.001). By using this finding as a single criterion for the prediction of sepsis, sensitivity and specificity for the dip slide method were 70.8 and 94.3%, respectively, compared with 79.2 and 94.6%, respectively, for the streak-plate method. Of the 24 infections, 20 (83.3%) were correctly predicted when a combination of the two methods was used. An increasing number of Enterobacteriaceae or S. aureus in the dip slide culture resulted in a steady rise in the rate of infections from 5.7% at 0 CFU to 57% at greater than or equal to 80 CFU compared with 4.1% at 0 CFU/ml and 45.4% at greater than or equal to 800 CFU/ml with the streak-plate method. The differences were statistically significant at the greater than or equal to 5 CFU level with regard to wound infection (P less than 0.001) and deep surgical infection (P less than 0.01). It is concluded that the dip slide is a simple, rapid, and reliable method for the routine assessment of bacterial contamination in colorectal operations.

Microflora of the gallbladder related to duration of acute cholecystitis

The microflora of the bile and wall of the gallbladder was prospectively investigated in 104 nonselected consecutive patients treated with early cholecystectomy for acute cholecystitis after an average hospital stay of 1.8 days. The chief purpose was to relate the findings of cultures to duration of the illness. Special attention was paid to anaerobic isolation techniques. The cultures yielded 107 strains, representing 36 species, with overall agreement between four different sampling procedures. Aerobic gram-negative rods predominated, followed by streptococci and anaerobes (48, 31 and 15 per cent, respectively). The incidence of positive culture results (always greater than or equal to 10(6) colon forming units per milliliter) was 81 per cent among the patients who underwent operation within two days from the onset of symptoms and 50 to 65 per cent after longer preoperative intervals. The shorter interval was significantly more often associated with growth solely of anaerobes (p = 0.03). Postoperative sepsis was caused by biliary bacteria and not related to preoperative duration of illness. Appropriate perioperative antibiotic coverage significantly reduced sepsis--3 versus 20 per cent (p = 0.05).

Microflora of the biliary tree and liver--clinical correlates

Microbiologic aspects of hepatobiliary tracts are reviewed. The gallbladder, the common duct and the liver are discussed separately. Special attention is paid to bacteriologic sampling technique. Factors associated with bactibilia are surveyed. The relation between biliary bacteria and stone formation is evaluated. The etiology of acute calculous and acalculous cholecystitis, cholangitis and pyogenic liver abscess is discussed from a microbiological point of view. The importance of new imaging techniques, such as ultrasound, radionuclide scanning and computerized tomography, in the diagnosis and treatment of biliary obstruction or hepatic abscess is recognized. The type of bacteria and their incidence in bile was strongly associated with the underlying condition and various host factors. The flora in acute cholecystitis closely resembled that of the small intestine, while cholangitis and hepatic abscess specimens grew species often found in the colon. In addition, 'microaerophilic streptococci' were especially abundant in hepatic abscess. Nonetheless, coliforms predominated at all loci. Depending on selection criteria of the study population, bacteria of biliary origin played varying roles in the development of postoperative sepsis. Principles of perioperative antibiotic prophylaxis and treatment of manifest infection are outlined.

An outbreak of endometritis in a maternity unit caused by spread of group A streptococci from a showerhead

An outbreak of puerperal infection in a maternity unit caused by group A streptococci is described. During a 2 week period, seven mothers suffered from postpartum endometritis and one baby from conjunctivitis. The search for the route of spread involved sampling patients, personnel and the environment. Culture results suggested that infection was probably spread by a hand shower. On the basis of laboratory experiments a new routine for disinfection of these showers was instituted.

Plesiomonas shigelloides in acute cholecystitis: a case report

Plesiomonas shigelloides was isolated as the sole pathogen from gallbladder bile and wall in a 58-year-old woman with acute cholecystitis. The patient developed an unusual postoperative complication characterized by culture-negative discharge from the wound in combination with extensive abdominal cellulitis and afebrility. Agglutinating antibodies to P. shigelloides were demonstrated in the serum of the patient by the microscopic Widal agglutination test.