Transcatheter vacuum aspiration of valvular and lead related infective endocarditis

BACKGROUND

Transcatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes.

METHODS

PubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed.

RESULTS

Data from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50-85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each.

CONCLUSIONS

Transcatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

[Acute Aortic Dissection with Rapidly Enlarged Aneurysm after Methicillin-resistant Staphylococcus Aureus Bacteremia]

The patient is a 62-year-old man. He was referred to our hospital from a nearby clinic with a complaint of chest and back pain, and was urgently admitted with a diagnosis of Stanford type A (Debakey typeⅢbR) acute aortic dissection. During the course of his treatment, he developed a urinary tract infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Thereafter, the patient developed bacteremia, and follow-up computed tomography( CT) showed a rapidly enlarging descending aortic aneurysm and a left external iliac artery( EIA) aneurysm. On day 49 after admission, thoracic endovascular aortic repair, left EIA resection, and right EIA-left femoral artery bypass were performed. However, a contrast-enhanced CT scan on day 70 of hospitalization revealed a type Ia endoleak and enlargement of the descending aortic aneurysm, so the patient underwent replacement of the descending aorta on day 84. Postoperatively, the patient needed time for recovery, but was discharged on day 158. Three years after discharge, there has been no recurrence of infection, and the patient has been visiting our outpatient clinic. We report a case of acute aortic dissection with rapidly enlarged aneurysm after MRSA bacteremia. This serious condition was succesfully cured with continued antibiotic treatment, two surgical resections and revascularization.

The impact of infectious diseases consultation on the management and outcomes of Pseudomonas aeruginosa bacteraemia in adults: a retrospective cohort study

BACKGROUND

Pseudomonas aeruginosa bacteraemia (PAB) is associated with high mortality. The benefits of infectious diseases consultation (IDC) has been demonstrated in Staphylococcal aureus bacteraemia and other complex infections. Impact of IDC in PAB is unclear. This study aimed to evaluate the impact of IDC on the management and outcomes in patients with PAB.

METHODS

This is a retrospective cohort single-centre study from 1 November 2006 to 29 May 2019, in all adult patients admitted with first episode of PAB. Data collected included demographics, clinical management and outcomes for PAB and whether IDC occurred. In addition, 29 Pseudomonas aeruginosa (PA) stored isolates were available for Illumina whole genome sequencing to investigate if pathogen factors contributed to the mortality.

RESULTS

A total of 128 cases of PAB were identified, 71% received IDC. Patients who received IDC were less likely to receive inappropriate duration of antibiotic therapy (4.4%; vs 67.6%; p < 0.01), more likely to be de-escalated to oral antibiotic in a timely manner (87.9% vs 40.5%; p < 0.01), undergo removal of infected catheter (27.5% vs 13.5%; p = 0.049) and undergo surgical intervention (20.9% vs 5.4%, p = 0.023) for source control. The overall 30-day all-cause mortality rate was 24.2% and was significantly higher in the no IDC group in both unadjusted (56.8% vs 11.0%, odds ratio [OR] = 10.63, p < 0.001) and adjusted analysis (adjusted OR = 7.84; 95% confidence interval, 2.95-20.86). The genotypic analysis did not reveal any PA genetic features associated with increased mortality between IDC versus no IDC groups.

CONCLUSION

Patients who received IDC for PAB had lower 30-day mortality, better source control and management was more compliant with guidelines. Further prospective studies are necessary to determine if these results can be validated in other settings.

Successful Lung Re-transplant in a Patient with Cepacia Syndrome due to Burkholderia ambifaria

Chronic airway inflammation and infection drive morbidity and mortality among patients with cystic fibrosis (CF). While Haemophilus influenzae and Staphylococcus aureus predominate in children, the prevalence of Pseudomonas aeruginosa increases as patients age. Other bacteria, including species within the Burkholderia cepacia complex (Bcc), are also more prevalent among adults with CF. Species within the Bcc accelerate lung function decline and can trigger development of "cepacia syndrome," both before and after lung transplantation. As a result, some centers advise against lung transplantation for Bcc-infected patients; however, little is known about the relative virulence of uncommon Bcc species. We describe a successful lung re-transplant in a patient with CF, chronic Burkholderia ambifaria airway infection, and cepacia syndrome.

Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal

BACKGROUND

Primary amputation (stump closure) for diabetic foot sepsis is perceived to have a higher re-amputation rate due to stump sepsis. A guillotine amputation with elective stump closure is widely practised due to the lower risk of stump sepsis and re-amputation.

AIMS

To provide an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospital.

METHODS

A prospective cohort study of 100 patients who underwent surgery for diabetic foot sepsis over a 5-year period was undertaken at Madadeni Provincial Hospital, in northern KwaZulu-Natal. Demographic data, co-morbid profile, radiographic features, anatomical level of vascular occlusion and type of surgery performed were recorded. The Wagner classification (Wag) was used to classify disease severity. Outcome measures included length of hospital stay, in-hospital mortality and re-amputation rates.

RESULTS

Of the 100 patients, females (n = 50) accounted for 50% of admissions. The median age was 61 years (range: 29 to 80 years). Most patients presented with advanced disease: Wag 5, n = 71 (71%); Wag 4, n = 20 (20%); Wag 3, n = 7 (7%); Wag 2, n = 2 (2%). The anatomic levels of vascular occlusion comprised: aortoiliac disease n = 2 (2%), femoropopliteal n=21(21%) and tibioperoneal disease n = 77 (77%). The following surgical procedures were undertaken: above knee amputation (AKA), n = 35 (35%); below knee amputation (BKA), n = 46 (46%); transmetatarsal amputation (TMA), n = 8 (8%); toe ectomy, n = 8 (8%) and debridement, n = 3 (3%). The re-amputation rate to above knee amputation was n = 2/46 (4.3%). All AKA stumps healed completely. The overall in-hospital mortality was n = 7 (7%) and median length of hospital stay was 7.8 ± 3.83 days.

CONCLUSION

Most patients present with advanced disease requiring a major amputation. A definitive one stage primary amputation is a safe and effective procedure for diabetic foot sepsis with distinct advantages of a short hospital stay, low reamputation rates and mortality. A guillotine amputation should be reserved for physiologically unstable patients.

Septic arthritis following arthroscopic reconstruction of cruciate ligaments of the knee: retrospective case review

INTRODUCTION

Rupture of cruciate ligaments of the knee is a common injury that is repaired by arthroscopic reconstruction, which can give rise to septic arthritis. The objective of this article is to describe the clinical and microbiological aspects of this entity.

METHODS

Retrospective review of cases of septic arthritis following arthroscopic reconstruction of cruciate ligaments of the knee that occurred at a single institution from 2000-2015. According to time elapsed from surgery, infections were classified as acute (< 14 days), subacute (> 14 days and<30 days), and late (> 30 days). A descriptive and comparative analysis stratified by type of infection and causative microorganism was performed.

RESULTS

3,219 patients underwent arthroscopic reconstruction of cruciate ligaments of the knee and 30 (0.9%) developed septic arthritis. Seventeen (57%) were acute infections and 12 (40%) subacute; there was one late infection. The causative microorganisms were coagulase-negative Staphylococci (n=13; 43%), Staphylococcus aureus (n=12; 40%), other grampositive cocci (n=3; 10%), and gramnegative bacilli (n=2; 7%). All patients underwent arthroscopic debridement; no grafts were removed. All patients received antibiotic therapy for a median of 23.5 days (range: 14 - 78 days); all infections were cured. No significant differences were found in any of the variables analysed among the infection type or the causative microorganism.

CONCLUSIONS

Septic arthritis after arthroscopic reconstruction of cruciate ligaments of the knee is uncommon. It generally presents within 4 weeks of surgery and is caused by Staphylococci. Its treatment consists of arthroscopic debridement (without necessarily removing the graft) and antibiotic therapy.

Bacteremia with an iliopsoas abscess and osteomyelitis of the femoral head caused by Enterococcus avium in a patient with end-stage kidney disease

A 70-year-old man on hemodialysis for end-stage kidney disease due to polycystic kidney disease presented with hip pain on extension and a high C-reactive protein level. Further examinations revealed an iliopsoas abscess and femoral head osteomyelitis caused by Enterococcus avium (E. avium) detected in blood and pus cultures. Complete resolution of the infection with ampicillin-resistant E. avium required six months of vancomycin therapy and two surgical drainage procedures. There have been no previous case reports in which both blood and abscess cultures confirmed E. avium infection. Careful attention should be paid to the detection of non-specific symptoms in patients on hemodialysis, with blood cultures being essential in such cases.

Early dynamics of leptin plasma level in surgical critically ill patients. a prospective comparative study

BACKGROUND

Leptin (LPT), a hormone secreted by adipocytes,plays a role in inflammation and infection. Our study aimed to characterize the early dynamics of LPT in comparison with CRP and IL-6 during systemic inflammatory response syndrome(SIRS) and sepsis in surgical patients.

METHODS

Sixty patients were assigned into 3 equal groups:SIRS (SI) group with major abdominal elective surgery;sepsis (SE) group with community-acquired complicated intra-abdominal infection and controls (C). LPT, CRP and IL-6 were measured initially in all groups and repeated in groups SI and SE within 5 days after surgery (9 samples - 4 day 1, 2 day 2, 1 next 3 days).

RESULTS

LPT increased at 12-24 hours in SI group, but stayed within normal range in SE group. CRP and IL-6 had higher values in SE group versus SI group with an early peak for IL-6 and a late peak for CRP.

CONCLUSIONS

LPT has a different early dynamics during SIRS and sepsis. LPT measurement in association with CRP or IL-6 may be useful in the differential diagnosis and prognosis of surgical critical illness at different time courses.

[Risk factors for infective endocarditis in cardiac valve prosthesis patients]

Infective endocarditis (IM) of the artificial cardiac valve (ACV) constitutes one of severe postoperative complications and presents a total spectrum and number of observations, concerning infectioning of the implanted ACV or of the adjacent tissues, which have had occurred in various time postoperatively. Wide introduction in practical cardiosurgery have caused the raising of the IM of ACV occurrence rate from 16 to 45%. Basing on analysis of data of 276 patients there were studied up the factors and conditions, predisposing to occurrence of IM in ACV. The main causes of a primary affection of natural cardiac valves in the patients were rheumatism and IM, the leading role in occurrence of bacteriemia have played nosocomial factors while performing stomatological, urological, gynecological and general surgical manipulations.

Innate immunity in surgical patients

The innate immune system is the first line of defence against pathogens that acts immediately in order to prevent, control and eliminate infections. This paper reviews some important aspects of innate immune sensing, namely the LPS-TLR signalling pathway and endotoxin tolerance (ET) as a host protective mechanism against uncontrolled immune activation. The fine-tuning of the innate immune response is enabled by miRNAs which constitute an additional level of gene expression regulation between messenger RNA (mRNA) and protein translation. Finally clinical relevance of this complex and dynamic process is pointed out: acute phase reaction, sepsis and the particular case of the splenectomised patient are discussed.

A very late-onset deep infection after prosthetic inguinal hernia repair

Prosthetic repair of inguinal hernias has low recurrence and infection rates in practice. However, surgical site infection is still a potential complication. A limited number of cases have been reported to date describing late-onset deep mesh infection following prosthetic repairs. We herein report a new case of postherniorrhaphy infection with a very late onset.

An unusual complication of transradial coronary angiography

We report the first case of extensive cellulitis and staphylococcal bacteremia with the subsequent development of a remote mycotic pseudoaneurysm in the ipsilateral brachial artery following right transradial coronary angiography in a diabetic patient with previous right axillary node clearance. The potential for serious complication should be borne in mind when deciding on the site of vascular access in such patients.

[Pelvic actynomycosis as the result of a long standing use of an intrauterine device. Case report]

The aim of the study was to introduce a case of a 49-year-old woman who had been using an intrauterine contraceptive device for 20 years. The pelvic actynomycosis in her case led to sepsis and consequently to her death. Colonisation Actinomyces israeli in women using IUD may amount up to even 20%, however infections occur very seldom. Following the recommended time of IUD usage, cytology and early start of antibiotic therapy may protect patients against the Actinomyces infection.

Retrievable Günther Tulip filter complicated by sepsis and retroperitoneal hemorrhage: successful management by filter retrieval

We encountered complications of septic shock and retroperitoneal hemorrhage which occurred after implantation of a retrievable Günther Tulip filter. A 79-year-old woman was diagnosed as right femoral vein thrombosis, and a retrievable Günther Tulip filter was deployed prior to a total knee replacement surgery. However, the patient developed septicemia due to Citrobacter freundii, followed by thrombocytopenia and retroperitoneal hemorrhage. A large hematoma was formed along the lateral side of the filter struts. We considered that the filter should be removed to control retroperitoneal hemorrhage and prevent secondary infection of the hematoma. Removal of the retrievable filter was effective in managing these complications.

A mycotic aneurysm of the ascending aorta and aortic arch induced by salmonella enteritidis

In very rare cases, salmonella infection may be associated with extra-intestinal manifestations. Of these, a mycotic aneurysm represents a life-threatening complication that is characterised by a high mortality rate. Prompt treatment with a combination of antibiotic therapy and surgical intervention is urgently required. We report on the case of a 60-year-old woman who presented with salmonella bacteraemia and the rare complication of an infected aneurysm of the ascending aorta and aortic arch.

Thoracodorsal Artery Perforator (TAP) Flap Reconstruction of a Soft-Tissue Defect of the Knee Following Below-Knee Amputation

Soft-tissue coverage of lower extremity defects with thin, sensate, mobile, and durable soft tissue is challenging. Reconstructive options are further limited in the setting of a below-knee amputation. The authors present the first report of an innervated thoracodorsal artery perforator (TAP) flap for coverage of an anterior knee soft-tissue defect in a patient with bilateral below-knee amputations following disseminated meningococcemia. The soft-tissue defect measured 11 x 17 cm2 centered over the patella, and the TAP flap provided adequate pedicle length, with optimal soft-tissue thickness and pliability with the potential for innervation and minimal donor-site morbidity. Six months postoperatively, the patient is ambulating well with prostheses fitted over her well-healed, stable, knee coverage.

Rehabilitation of a child with meningococcal septicemia and quadrilateral limb loss: a case report

Acquired quadrilateral limb loss is a rare occurrence in children. One cause of this condition is severe meningococcal septicemia. We present the case of a boy who, at 14 months of age, required extensive amputation after an episode of meningococcal septicemia. We review his medical recovery and rehabilitation, including upper- and lower-limb prosthetic prescription and training, and adaptation to his altered body. A multidisciplinary approach led to effective management of his complex clinical and psychologic needs. This case illustrates the need to address a range of medical, prosthetic, and family issues central to successful clinical outcome.

[Osteomyelitis in children]

Acute hematogenous osteomyelitis is a typical childhood illness, occurring predominantly in boys. The main symptom is inflammation but poor general condition also occurs occasionally. Elevation of CRP and sedimentation rate as well as leucocytosis are the most important laboratory findings. Conventional x-ray is mandatory, however scintigram and MRI are now specific in the early stage. Ultrasound can show abscess formation in the soft tissue. Treatment involves the immediate use of specifically targeted, intravenous antibiotics. Surgical intervention stands in second place. Immobilisation is only useful in the initial treatment of pain. Strict diagnostic and therapeutic management prevents complications, which would need reconstructive bone and soft tissue reconstruction, and is the key to a good primary prognosis.

LVAD bloodstream infections: therapeutic rationale for transplantation after LVAD infection

INTRODUCTION

Patients who have ventricular assist devices (VADs) and experience bloodstream infection (BSI) have high mortality. We addressed 2 questions raised by the United Network for Organ Sharing (UNOS) priority policy for this problem: 1) Are organs wasted on this ultra-high-risk group? 2) Can device-related BSI be differentiated from transient BSI?

METHODS

Patients with VADs who underwent heart transplantation from 1987 to 2001, who had BSI during VAD support, and who had positive cultures at VAD explant (device-related BSI, n = 10) were compared with those with negative cultures at explant (non-device-related BSI, n = 11).

RESULTS

Patients with device-related BSI had an 80% (8/10) rate of persistent bacteremia; 30 days and 1 year after transplantation, mortality was 14% and 26%, respectively. Non-device-related BSI (n = 11) persisted in 18% (2/11); peri-operative and 1-year mortalities were 9% and 13%. Duration of VAD support predicted infection (132 vs 48 days, p < 0.001); hypo-albuminemia (2.9 +/- 0.5 mg/dl vs 3.3 +/- 0.8 mg/dl, p < 0.05), and a resistant organism predicted a device-related BSI. These patients had increased intubation requirements and had increased creatinine concentration during the first post-operative week, with no difference in liver function, blood loss, transfusions (packed red blood cells, fresh frozen plasma, or platelets), or hemodynamic stability vs patients with non-device BSI. Despite decreased immunosuppression, we found no difference in acute rejection events with device-related BSI. Re-infection with the pre-operative organism occurred in only 1 patient per group.

CONCLUSIONS

These data suggest that urgent (Status 1A) cardiac transplantation is effective in stable patients with device-related BSI, and these data support the current UNOS policy. However, an extra-device source of BSI should be excluded by considering the isolated organism, the baseline nutritional status, and other risk factors.

Open peritoneal drainage versus primary closure for the treatment of septic peritonitis in dogs and cats: 42 cases (1993-1999)

OBJECTIVE

To determine survival rates in dogs and cats with septic peritonitis treated with open peritoneal drainage (OPD) versus primary closure (PC) after laparotomy.

STUDY DESIGN

Retrospective analysis of medical records from Colorado State University Veterinary Teaching Hospital from 1993 to 1999.

SAMPLE POPULATION

Thirty-six dogs and 6 cats with septic peritonitis documented by cytological examination or microbiological culture of abdominal fluid.

METHODS

Medical records of dogs and cats with septic peritonitis treated by OPD or PC were reviewed. Age, weight, species, white blood cell (WBC) count, band neutrophil count, platelet count, serum glucose concentration, heart rate, body temperature, duration of hospitalization, and clinical outcome were recorded for each animal. Differences in treatments administered between the OPD and PC groups as well as the underlying cause of septic peritonitis were determined.

RESULTS

There was no significant difference in survival between animals in the OPD versus PC groups (P =.26) with an overall survival rate of 71%. White blood cell count, band neutrophil count, platelet count, serum glucose and total bilirubin concentrations, heart rate, age, and weight were not significantly different between groups (P >.05). A significantly greater number of animals in the OPD group received plasma (P =.009), blood (P =.037), and a jejunostomy tube (P =.02) than animals in the PC group. There was a significant difference in the number of days spent in critical care unit with a mean of 6.0 +/- 4.1 days for the OPD group and 3.5 +/- 2.3 days for the PC group (P =.02).

CONCLUSIONS

Open peritoneal drainage for the management of septic peritonitis in dogs and cats is an acceptable alternative to PC.

Hematogenous pyogenic facet joint infection of the subaxial cervical spine. A report of two cases and review of the literature

Two cases of hematogenous, pyogenic, subaxial cervical facet joint infection are reported, and the literature is reviewed. Infection of the cervical facet joint is a rarely diagnosed condition; only one case has been reported in the literature. Lumbar facet joint infections are also rare but more commonly reported. Approximately one fourth of facet joint infections in the lumbar spine are complicated by epidural abscess formation, which can lead to a neurological deficit. Because of the paucity of reports on cervical facet joint infections, the clinical characteristics of this entity are not well known. Both patients presented with an acute onset of unilateral neck pain that radiated into the ipsilateral shoulder. Frank radicular pain was initially absent. Unilateral upper-extremity motor weakness that was attributed to associated epidural abscess or granulation tissue formation was also demonstrated in both patients. Leukocyte count and erythrocyte sedimentation rate were elevated in both cases. Magnetic resonance imaging was necessary to obtain an accurate diagnosis. Staphylococcus aureus was identified as the offending pathogen in both cases. Decompressive surgery and antibiotic therapy were required to cure the condition. One patient recovered completely and the other sustained a permanent motor deficit. Hematogenous cervical facet joint infection is a rare clinical entity that has many characteristics in common with the more-common lumbar homolog. All three reported cases, however, have been complicated by epidural abscess or granulation tissue formation that has led to a neurological deficit. This finding suggests that a facet joint infection in the cervical spine may have a less benign clinical course than that in the lumbar spine.

Case report: recovery from persistent septicemic melioidosis

Septicemic melioidosis is often fatal despite treatment with antibiotics such as ceftazidime to which Burkholderia pseudomallei, the causal pathogen, is sensitive in vitro. We report a near-fatal case of septicemic melioidosis with persistent B. pseudomallei bacteremia despite intravenous ceftazidime in which combination therapy with meropenem and ciprofloxacin, splenectomy and correction of metabolic acidosis allowed for hospital discharge. The choice of antibiotic agents was supported by intracellular minimum inhibitory concentration analysis using B. pseudomallei co-culture in Acanthamoeba trophozoites. The patient's B. pseudomallei isolates were indistinguishable by pulsed-field gel electrophoresis from clinical and environmental isolates previously analyzed during investigation of a Western Australian melioidosis outbreak. A combination of antibiotics known to possess intracellular activity against B. pseudomallei, surgery and supportive critical care may provide a means of improving the probability of survival in persistent septicemic melioidosis.

Myocardial abscess with contained rupture: successful repair

Spontaneous rupture of the heart from myocardial abscess is a rare occurrence. Most cases of spontaneous cardiac rupture are due to myocardial infarction. We present a case of a contained rupture of the heart in a patient with staphylococcal septicemia. Although cultures from the pericardial space were negative the macroscopic and clinical picture was compatible with an abscess.

Diagnostic value of intraoperative swabs of heart valves in infective endocarditis

BACKGROUND AND AIM OF THE STUDY

Intraoperative swabs of heart valves are obtained regularly from patients undergoing heart valve surgery for infective endocarditis (IE) in order to confirm the preoperative diagnosis and to adjust the antibiotic regimen. The study aim was to assess the diagnostic value of intraoperative swabs of heart valves in IE.

METHODS

A total of 83 patients was referred for surgical treatment of active IE between October 1994 and May 1999. Preoperatively, microorganisms were isolated using a minimum of two positive blood cultures; results were compared with those obtained from intraoperative heart valve swab cultures.

RESULTS

Preoperatively, 73 patients (88%) had a positive blood culture, and 10 (12%) had culture-negative endocarditis. The intraoperative swab confirmed the preoperative diagnosis in 31 cases (37%). Bacteria were isolated in three of the ten patients with preoperative culture-negative IE. Despite positive histopathological findings in seven patients, no microorganisms were cultured either pre- or intraoperatively. Among the remaining 42 patients (51%) with active IE, 25 valve cultures were sterile and 17 valve swabs were presumed to be contaminated.

CONCLUSION

In patients with active IE in whom the causative agent could be isolated and identified before surgery, intraoperative valve swabs did not contribute further to patient management. In isolating contaminants, the risk of inappropriate modification of the antibiotic regimen is imminent. The diagnostic validity in culture-negative IE appears negligible.

A first case of Streptococcus bovis bacteremia and peritonitis from endometrial cancer origin

BACKGROUND

The most important clinical infections caused by Streptococcus Bovis are bacteremia and endocarditis. Usually, Streptococcus Bovis bacteremia has been described in association with bowel pathology.

CASE REPORT

A 67-year-old woman with an history of endometrial cancer Ic was admitted with the suspicion of peritonitis at examination. At exploratory laparotomy, a total hysterectomy was performed and the abdomen was drained. Histology revealed an uterine adenocarcinoma staged IIIa with intramyometrial cocci accumulation. Streptococcus Bovis was isolated from the peritoneal fluid cultures and three haemocultures.

CONCLUSION

Because we excluded bowel pathology and endocarditis, this is the first case of Streptococcus Bovis bacteremia from endometrial cancer origin.

Surgical treatment of septic peritonitis without abdominal drainage in 28 dogs

The purpose of this study was to evaluate the surgical outcomes of 28 dogs with generalized septic peritonitis treated without postoperative abdominal drainage. The overall mortality rate was 46%, with most cases of peritonitis being caused by leakage of the gastrointestinal tract (75%). Etiology of peritonitis, abdominal cytopathology, total white blood cell count, packed cell volume, total protein, and results of serum biochemistries were not statistically different between survivors and nonsurvivors. The mortality rate of 46% is similar to other studies in which the abdomen was left open postoperatively for the management of septic peritonitis, although more advanced medical treatment than that used in earlier studies may have positively affected the outcome. The results of this study show that closure of the abdomen after the source of contamination has been successfully corrected, in combination with thorough intraoperative peritoneal lavage and appropriate postoperative medical management, may be an acceptable alternative method for the management of septic peritonitis.

Isolated pulmonic valve endocarditis in healthy hearts: a case report and review of the literature

The case of a 53-year-old man with isolated pulmonic valve endocarditis in a structurally normal heart is presented. The patient had a history of chronic obstructive pulmonary disease and was admitted to hospital with an apparent exacerbation with pneumonia. Blood cultures grew Staphylococcus aureus, and an echocardiogram identified a large vegetation on the pulmonic valve in a structurally normal heart. He was unsuccessfully treated with antibiotics and eventually required pulmonic valve replacement. The literature from 1960 to 1999 identified only 36 reported cases of pulmonic valve endocarditis in structurally normal hearts. The present report underscores the importance of suspecting pulmonic valve endocarditis in patients with multiple pulmonary lesions, and discusses the predisposing factors, clinical features, diagnostic role of echocardiography and the potential benefits of early surgical treatment.

Necrotizing proctitis caused by Streptococcus pyogenes

We report the case of a 65-year-old patient with peritonitis, septicaemia and toxic shock syndrome in whom the primary focus of infection was acute purulent proctitis with necrosis. Streptococcus pyogenes serotype T28R28 was isolated from blood culture and peritoneal pus. The patient recovered after a prolonged period of intensive therapy and four abdominal operations including anterior resection of the rectum. We believe this to be the first clinical description of streptococcal necrotizing proctitis.

[A case report: suppurative pericardial effusion]

We present the case of a 67 year old woman who was resuscitated due to cardiac tamponade. Examination of the pus fluid showed a bacterial infection with streptococcus milleri. Four days before resuscitation the patient experienced weakness, dyspnoea, increased temperature (39 degrees C), swelling of the neck, and pain on swallowing. Using computed tomography, examination revealed an infection extending from the right tonsil to the mediastinum and into the pericardium. After surgery to remove the retropharyngeal abscess, the patient healed well. Therefore, on presentation of a cardiac tamponade, possible hematogenous or lymphogenous causes or per continuitatem infections should always be considered. In this case the germs in the fluid and the typical patient history indicated an oropharyngeal reason.

Infection of left atrial thrombus associated with mitral stenosis: A case report

We describe the first reported case of an infected left atrial thrombus. The case of the 65-year-old male patient in this report was associated with mitral stenosis and involved Escherichia coli, and was treated successfully with surgical resection of the infected thrombus. This case suggests that such infection should be considered as a possible complication of intracardiac thrombus when bacteremia is present.

[Surgical treatment of septicemia after pacemaker implantation: a case report of removal of infected lead under median sternotomy]

A 73-year-old woman was admitted to our hospital because of septicemia associated with infection of an old retained pacemaker lead and a reimplanted pacemaker system. After general condition was recovered, the pacemaker system was removed and then the retained pacemaker lead was removed through median sternotomy. Then a new pacemaker system was implanted using myocardial leads. The postoperative course was uneventful.

Risk factors for predicting surgical salvage of sternal wound-healing complications

A retrospective study was performed to determine whether clinical factors can predict which complicated poststernotomy wounds can be managed successfully by debridement and reclosure, and which wounds require a muscle flap for healing. Between January 1990 and December 1996, 3,435 median sternotomies were performed at Indiana University Medical Center and affiliated hospitals. A total of 91 patients (2.6%) were reoperated for sternal wound-healing complications. Seventy-six patients (83.5%) underwent debridement and rewiring, and 15 patients (16.5%) underwent primary flap coverage. Of the 76 patients who underwent initial rewiring, 45 (59%) healed and 31 (41%) required additional operative procedures. Of the 31 rewiring failures, 26 patients (84%) were healed with muscle flaps and 4 patients (13%) were managed with a second successful rewiring. The following clinical factors were correlated with operative procedure and outcome: history of smoking, chronic obstructive pulmonary disease, steroid use, previous sternotomy, age, diabetes, harvest of the left or right internal mammary artery (IMA), emergency operation, operation time, pump time, cross-clamp time, ischemic time, coronary artery bypass grafting alone versus combined with a valve replacement, positive wound cultures, positive blood cultures, elevated white blood cell count, and fever. When comparing patients with successful rewiring with those who had a failed rewiring, positive wound and blood cultures were significant risk factors (p < 0.05) on univariate analysis. Presence of a positive wound culture was significant on multivariate analysis. When comparing risk factors in patients who were rewired successfully versus all patients who had muscle flap coverage, the presence of a positive blood culture was significant on both univariate and multivariate analyses. We conclude patients most likely to fail rewiring and to require muscle flap closure are those with infected wounds, positive blood cultures, and possibly left IMA bypasses.

Impact of laparoscopy with carbon dioxide versus helium on local and systemic inflammation in an animal model of peritonitis

Increased intraperitoneal pressure and insufflation of carbon dioxide during laparoscopy may cause sepsis by promoting systemic inflammation in patients with intra-abdominal inflammatory diseases. The influence of carbon dioxide and helium during laparoscopy on bacteremia, endotoxemia, the plasma concentration of tumor necrosis factor-alpha (TNF-alpha), TNF-alpha secretion ex vivo by peripheral blood mononuclear cells (PBMCs), and intraperitoneal abscess formation was investigated in an animal model. A standardized fecal inoculum was injected intraperitoneally, and rats underwent laparoscopy with either carbon dioxide (N = 20) or helium (N = 20) or no further manipulation (control group; N = 20). Bacteremia was significantly more common 1 hour after laparoscopy with CO2 than in animals receiving helium or the control group. Furthermore, helium use led to a significant decrease of bacteremia 1 week after intervention. Fecal inoculation caused significant leukocytopenia in all groups within 1 hour after intervention, with complete recovery only in the helium-treated group (p < 0.05). The TNF-alpha plasma concentration was significantly lower in the helium-treated group, and suppression of ex vivo production recovered only in the animals undergoing laparoscopy with helium (p < 0.05). The number of intraperitoneal abscesses was significantly lower after laparoscopy with helium (2+/-1.5) than after CO2 laparoscopy (6.3+/-5.1) or in the control group (5.2+/-4.8). Laparoscopy with CO2 increased systemic inflammation only slightly, while helium use was associated with a significant lower incidence of bacteremia and local and systemic inflammation compared with the control group.

[Diagnosis and therapy of pediatric and juvenile hematogenous osteomyelitis]

Haematogen osteomyelitis is mostly found in children and adolescents. In western Europe acute haematogen osteomyelitis (AHOM) is a rare disease. This is the cause why AHOM is often diagnosed with delay. The treatment usually is an antibiotic medication and/or surgical interventions. Uncharacteristic pain of extremities in children should always consider the diagnosis of acute osteomyelitis. Investigation should include conventional X-rays, ultrasounds or MRI to prevent the spreading of infection. In cases of multifocal infection radionuclide imaging should be undergone. Differential diagnosis should always include malignant tumor. If under treatment of antibiotics the clinical signs of illness do not decrease within 24 h surgery with fenestration of the involved bone, debridement and local application of antibiotics is indicated. In unusual cases or in cases with clinical signs of AHOM but no bacteria specification a malignant tumor has to be excluded.

A study of 47 bacteremic Staphylococcus aureus endocarditis cases: 23 with native valves treated surgically and 24 with prosthetic valves

A retrospective review of medical records from the Staphylococcus Laboratory, Copenhagen, 1982-1991, was carried out at the Department of Clinical Microbiology, Statens Serum Institut, 1994-1995, to investigate the clinical features and outcome of two subgroups of bacteremic Staphylococcus aureus endocarditis cases in non-drug addicts: patients with prosthetic valve endocarditis (PVE) and patients with native valve endocarditis treated surgically. Twenty-four cases of PVE were included. Six cases were early (within 60 days of valve implantation) and 18 were late. The overall in-hospital mortality was 42%. Surgical treatment resulted in a non-significantly lower mortality as compared with medical treatment alone (0% vs 50%, p = 0.19). Medical treatment of aortic and mitral valve endocarditis resulted in similar mortality rates (44% and 50%, respectively). Twenty-three cases of native valve infective endocarditis had the valve replaced surgically. The in-hospital mortality was 22%, which was significantly lower as compared with medical therapy (69%, p < 0.0001). The treatment changed significantly during the study period: 6 of 112 patients (5%) were treated surgically in the first half of the period (1982-1986) compared to 17 of 124 patients (14%) in the second half (1987-1991, p = 0.049). Severe congestive heart failure was the main indication for cardiac surgery in 21 patients. In conclusion, a shift towards a more aggressive surgical approach has taken place in the 10-year period. This development should be strengthened in the future as surgical intervention may improve survival in patients with infective endocarditis caused by S. aureus whether the infected valve is prosthetic or native.

Effect of quinupristin/dalfopristin on the outcome of vancomycin-resistant Enterococcus faecium bacteraemia: comparison with a control cohort

Serious infection with vancomycin-resistant Enterococcus faecium (VREF) strains has no proven effective antimicrobial therapy. We compared the clinical and bacteriological outcomes of 20 patients with VREF bacteraemia treated with quinupristin/dalfopristin (RP 59500), an investigational streptogramin, with a historical cohort of 42 patients with VREF bacteraemia treated with other agents. Quinupristin/dalfopristin demonstrated in-vitro bacteriostatic activity against all 20 initial VREF blood isolates (MIC range 0.03-0.50 mg/L) by macrobroth dilution. The clinical characteristics of both groups were comparable for major outcome-dependent variables. There were five cases of recurrent VREF bacteraemia in the quinupristin/dalfopristin-treated cohort and 21 in the controls (P = 0.11); persistence of VREF at the primary site was found in six and 18 of the evaluable patients with follow-up cultures in these two cohorts (P = 0.06). In-hospital mortality was high in both groups: 65% in the quinupristin/dalfopristin group and 52% in the control group; however, VREF-associated mortality was significantly lower in the quinupristin/dalfopristin group (five and 17 respectively; P = 0.05). Follow-up susceptibility testing of five VREF isolates in the quinupristin/ dalfopristin group did not demonstrate resistance to quinupristin/dalfopristin. Quinupristin/ dalfopristin may be a useful agent for the therapy of serious VREF infection. Further clinical investigations are warranted to confirm or refute its clinical efficacy.

A case of brain abscess as complication of esophageal dilation for caustic stenosis

The authors report a case of a two-year-old child with esophageal stricture -- caused first by caustic ingestion and by the end-to-end anastomosis, performed after the excision of the stenotic esophageal segment-- that required repeated dilations. These manouvres unfortunately led to bacteremia and a serious complication of a brain abscess, in the right fronto-parietal area, that was promptly removed. A few months later the child was subjected to an esophageal substitution with a colonic transposition. At present he is in good condition and the follow-up showed normal function of the neo-esophagus.

[Comparative study of the protective role of the vaccine against Haemophilus influenzae type b and partial splenectomy in an experimental model]

BACKGROUND

Although the vaccine against Haemophilus influenzae type b has demonstrated its efficacy in children, this bacteria continues to be a cause or overwhelming sepsis in splenetomized patients.

METHODS

To compare the degree of protection provided by partial splenectomy and the conjugated diptheria toxoid vaccine against H. influenzae type b, the bacteremia generated 24, 48 and 96 hours after intravenous inoculation with this bacteria at concentrations of 5 x 10(14), 5 x 10(13) and 5 x 10(12) colony-forming units was assessed in rats subjected to total splenectomy, with and without previous vaccination, to partial splenectomy or to sham operation.

RESULTS

With respect to both the proportion of positive blood cultures and the concentration of H. influenzae in the blood stream, the sham-operated control rats and those vaccinated prior to splenectomy presented similar behaviors; the widest differences with respect to the latter two groups were found in the nonvaccinated total splenectomy rats, and the results with the partial splenectomy group fell between these two extremes.

CONCLUSIONS

The protection of H. influenzae type b vaccine against infection is equivalent to that provided by the intact spleen for inoculum concentrations of 5 x 10(13) colony-forming units and less. Thus, the possibility of its systematic use in asplenic patients should be considered. The protection provided by the remnant spleen following 50% splenectomy is intermediate between those observed with eusplenia and with asplenia. These results suggest that when partial splenectomy is to be performed in normal spleen, the attempt should be made to conserve as much of the organ as possible.

Caval thrombectomy for severe staphylococcal osteomyelitis

Two children are presented in whom thrombosis of the inferior vena cava developed in association with an acute staphylococcal osteomyelitis. One case involved the left femur and the other the left ileum. Both children had diffuse bilateral staphylococcal pneumonia from presumed septic embolization. There were close similarities between their illness and management, except that the child who survived underwent a caval thrombectomy in the acute phase of her illness. It is hypothesized that the thrombectomy played an important role in her recovery.

Lemierre's syndrome: a case of postanginal septicemia and bilateral flank abscesses

Lemierre's syndrome is characterized by pharyngeal infections in young healthy adults with secondary septic thrombophlebitis and multiple metastatic infections. In the preantibiotic era, Lemierre's syndrome was common and lethal. With the advent of antibiotics, Lemierre's syndrome has become such a rare entity that the diagnosis is often delayed or missed. With prompt recognition, appropriate antibiotic therapy, and surgical drainage of metastatic abscesses, the majority of patients can be cured. A case of Lemierre's syndrome in a 22-year-old previously healthy man treated on a plastic surgery service is presented. Surgeons who can be consulted for deep space infections should be aware of this disease so that the diagnosis and treatment can be initiated promptly to prevent patients from succumbing to this life-threatening but curable disease.