Christina Jorup-Rönström

Epidemiological, Bacteriological and Complicating Features of Erysipelas

233 patients with erysipelas, admitted to the Department of Infectious Diseases, Danderyd Hospital, during a 2-year period were analysed for epidemiological, bacteriological and complicating features. Erysipelas was defined clinically as a febrile skin infection with a sudden onset of a red indurated expanding plaque with a distinct border. Common predisposing factors were alcohol abuse, diabetes mellitus and venous insufficiency, and complications were more common among such patients. No seasonal variation was found. 5% of patients with blood culture had streptococcemia (7/149). Erysipelas emerging from an infected ulcer was seen in 52% (122/233) and in 46% of these streptococci were isolated (57/122), 67% of which were of type A (38/57). Staphylococcus aureus was isolated from 59% of ulcerative cases (72/122) and in 3 of them staphylococci were found in the blood.

Recurrent erysipelas: predisposing factors and costs of prophylaxis.

SummaryAfter an average follow-up time of three years, recurrent erysipelas was observed in 29% of 143 patients admitted primarily with erysipelas. Nineteen patients (13%) had two or more recurrences during this period. The predisposing factor with the highest recurrence rate was venous insufficiency. Regular prophylaxis with phenoxymethylpenicillin (or erythromycin in penicillin allergics) after the second recurrence may be cost-effective. This antibiotic prophylaxis is only recommended in patients with predisposing factors who have suffered severe attacks.ZusammenfassungWährend einer mitteleren Beobachtungszeit von drei Jahren wurde bei 29% von 143 primär mit einem Erysipel stationär aufgenommenen Patienten ein rezidivierender Verlauf beobachtet. 19 Patienten (13%) hatten während dieser Zeit zwei oder mehr Rezidive. Der mit der höchsten Rezidivrate assoziierte prädisponierende Faktor war die venöse Insuffizienz. Eine regelmäßige Prophylaxe mit Phenoxymethylpenicillin (oder Erythromycin bei Patienten mit Penicillinallergie) nach dem zweiten Rezidiv ist möglicherweise kosteneffektiv. Die Antibiotikaprophylaxe wird jedoch nur für Patienten mit prädisponierenden Faktoren, bei denen schwere Formen von Erysipel aufgetreten sind, empfohlen.

Antibiotic prophylaxis in recurrent erysipelas

Recurrences of erysipelas are especially prevalent in patients suffering from local impairment of circulation and intervention might thus be of benefit. Therefore a prospective, randomized, open study was undertaken to evaluate whether daily antibiotic prophylaxis would reduce the risk of recurrence. Patients with venous insufficiency or lymphatic congestion who had suffered two or more episodes of erysipelas during the previous 3 years and were admitted to the Infectious Disease Department at Roslagstull Hospital, Stockholm, Sweden, between November 1988 and November 1991 were included. Fourty patients, 20 on prophylaxis and 20 controls were followed according to a life table analysis during a median time of 15 months. Phenoxymethylpenicillin was prescribed as daily prophylaxis (while erythromycin was given to patients allergic to penicillin). Recurrences of erysipelas appeared to be reduced by daily antibiotic prophylaxis but the effect was not dramatic (p=0.06). Only in patients with a high recurrence rate continuous antibiotic prophylaxis against erysipelas is indicated. Rezidivierende Erysipele sind besonders häufig bei Patienten mit Durchblutungsstörungen. Aus diesem Grund könnte es sinnvoll sein, Gegenmaßnahmen zu ergreifen. Die Frage einer Reduktion des Rezidivrisikos wurde im Rahmen einer offenen, randomisierten Studie zur täglichen Antibiotikaprophylaxe geprüft. Patienten mit venöser Insuffizienz oder Lymphstauung, bei denen in den letzten drei Jahren mehr als drei Episoden eines Erysipels aufgetreten waren und zwischen November 1988 und November 1991 in die Abteilung für Infektionskrankheiten des Roslagstull Krankenhaus, Stockholm, Schweden, eingewiesen wurden, wurden in die Studie aufgenommen. Bei 20 Patienten, die die Prophylaxe erhielten und 20 Kontrollen wurde über einen mittleren Zeitraum von 15 Monaten eine Verlaufsstudie nach Life Table Analysis vorgenommen. Als tägliche Prophylaxe wurde Phenoxymethylpenicillin oder, bei Penicillinallergie, Erythromycin verordnet. Die tägliche Antibiotikaprophylaxe führte offensichtlich zu einer Reduktion der Erysipel-Rezidive, doch war der Effekt nicht sehr ausgeprägt (p=0,06). Eine kontinuierliche Antibiotika-prophylaxe ist somit nur bei Patienten mit hohem Erysipel-Rezidivrisiko indiziert.SummaryRecurrences of erysipelas are especially prevalent in patients suffering from local impairment of circulation and intervention might thus be of benefit. Therefore a prospective, randomized, open study was undertaken to evaluate whether daily antibiotic prophylaxis would reduce the risk of recurrence. Patients with venous insufficiency or lymphatic congestion who had suffered two or more episodes of erysipelas during the previous 3 years and were admitted to the Infectious Disease Department at Roslagstull Hospital, Stockholm, Sweden, between November 1988 and November 1991 were included. Fourty patients, 20 on prophylaxis and 20 controls were followed according to a life table analysis during a median time of 15 months. Phenoxymethylpenicillin was prescribed as daily prophylaxis (while erythromycin was given to patients allergic to penicillin). Recurrences of erysipelas appeared to be reduced by daily antibiotic prophylaxis but the effect was not dramatic (p=0.06). Only in patients with a high recurrence rate continuous antibiotic prophylaxis against erysipelas is indicated.ZusammenfassungRezidivierende Erysipele sind besonders häufig bei Patienten mit Durchblutungsstörungen. Aus diesem Grund könnte es sinnvoll sein, Gegenmaßnahmen zu ergreifen. Die Frage einer Reduktion des Rezidivrisikos wurde im Rahmen einer offenen, randomisierten Studie zur täglichen Antibiotikaprophylaxe geprüft. Patienten mit venöser Insuffizienz oder Lymphstauung, bei denen in den letzten drei Jahren mehr als drei Episoden eines Erysipels aufgetreten waren und zwischen November 1988 und November 1991 in die Abteilung für Infektionskrankheiten des Roslagstull Krankenhaus, Stockholm, Schweden, eingewiesen wurden, wurden in die Studie aufgenommen. Bei 20 Patienten, die die Prophylaxe erhielten und 20 Kontrollen wurde über einen mittleren Zeitraum von 15 Monaten eine Verlaufsstudie nach Life Table Analysis vorgenommen. Als tägliche Prophylaxe wurde Phenoxymethylpenicillin oder, bei Penicillinallergie, Erythromycin verordnet. Die tägliche Antibiotikaprophylaxe führte offensichtlich zu einer Reduktion der Erysipel-Rezidive, doch war der Effekt nicht sehr ausgeprägt (p=0,06). Eine kontinuierliche Antibiotika-prophylaxe ist somit nur bei Patienten mit hohem Erysipel-Rezidivrisiko indiziert.

Fecal transplant against relapsing Clostridium difficile-associated diarrhea in 32 patients

Abstract Clostridium difficile-associated disease (CDAD) with frequent watery stools, sometimes with painful bowel movements, fever and sickness, is probably the major known cause of antibiotic-associated diarrhea and colitis, most probably depending on a disruption of the normal intestinal balance in the microbiome. In this study, we have inoculated a mixture of fecal microbes – as an enema – originating from a healthy Scandinavian middle-aged donor, regularly re-cultivated under strict anaerobic conditions for more than 10 years, to 32 patients. Twenty-two patients (69%) were durably cured. In those patients receiving the transplant by colonoscopy, four out of five were cured. To the best of our knowledge, this is the first time a fecal culture of microbes has retained the possibility for years to cure a substantial number of patients with CDAD.

The course, costs and complications of oral versus intravenous penicillin therapy of erysipelas.

SummaryOral versus intravenous antibiotic therapy of severe erysipelas was compared in a controlled trial of 60 patients. No clinical benefit of intravenous therapy was found, as evaluated by fever duration, hospital stay and sick leave. Untoward reactions were comparable between the groups. No difference in recurrence rate was found. The difference in administration time and drug cost was considerable. It is therefore suggested that erysipelas without complications should be treated orally.ZusammenfassungIn einer kontrollierten Studie wurde an 60 Patienten ein Vergleich der oralen und intravenösen Therapie des schweren Erysipels vorgenommen. Die intravenöse Therapie zeigte keine klinischen Vorteile in bezug auf Dauer des Fiebers, Krankenhausaufenthalt und Arbeitsunfähigkeit. Die unerwünschten Nebenwirkungen waren bei beiden Gruppen vergleichbar. In den Rückfallquoten fanden sich keine Unterschiede. Die Unterschiede im zeitlichen Aufwand für die Applikation und den Arzneimittelkosten waren beträchtlich. Es wird daher empfohlen, das unkomplizierte Erysipel oral zu behandeln.

Septic osteomyelitis and polyarthritis with ureaplasma in hypogammaglobulinemia

SummaryWe describe a hypogammaglobulinemic woman with a one-year history of destructive septic osteomyelitis and polyarthritis with positive cultures forUreaplasma urealyticum from joint exudate and blood. The clinical course was complicated by subcutaneous abscesses from which bothU. urealyticum andMycoplasma hominis were grown. Multiple routine cultures had been negative, except for sporadic findings ofStaphylococcus epidermidis before specific cultures for mycoplasmas were performed. Therapy with beta-lactam antibiotics, clindamycin, rifampicin, fusidic acid and aminoglycosides had been given without obvious clinical effect. Intravenous doxycycline treatment instituted after microbiological diagnosis had a dramatic effect on the clinical course. The clinical suspicion of mycoplasma and ureaplasma as etiologic agents of orthopaedic infections in hypogammaglobulinemic patients is mandatory in order to perform appropriate cultures.ZusammenfassungWir beschreiben den Fall einer destruktiven Osteomyelitis und Polyarthritis bei einer Frau mit Hypogammaglobulinämie; aus Gelenkexsudat und Blut wurdeUreaplasma urealyticum isoliert; der Krankheitsverlauf zog sich über ein Jahr hin. Als Komplikation traten subkutane Abszesse auf, aus denenU. urealyticum undMycoplasma hominis gezüchtet wurden. Routinekulturen waren wiederholt negativ; bevor spezifische Kulturen für Mykoplasmen angelegt wurden, fand sich sporadischStaphylococcus epidermidis. Therapieversuche mit Betalactam-Antibiotika, Clindamycin, Rifampicin, Fusidinsäure und Aminoglykosiden waren ohne eindeutige klinische Wirkung. Der klinische Verlauf nahm eine dramatische Wende, als nach mikrobiologischer Erregerdiagnostik eine intravenöse Therapie mit Doxycyclin eingeleitet worden war. Bei Knochen- und Gelenkinfektionen, die bei Patienten mit Hypogammaglobulinämie auftreten, muß der Kliniker an eine Mykoplasma- und Ureaplasma-Ätiologie denken, um die entsprechenden kulturellen Untersuchungen zu veranlassen.

Parvovirus B19 infection in HIV-1 infected patients with anemia

SummarySerum samples were analysed for IgM and IgG antibodies to parvovirus by ELISA and for parvovirus B19 DNA by polymerase chain reaction (PCR) in 69 HIV-1 infected Swedish patients with anemia and in 37 HIV-1 infected subjects without anemia. In 5/69 anemic patients, parvovirus B19 DNA was detected despite the lack of IgM antibody activity to the virus. The detection of parvovirus B19 DNA was significantly correlated to the degree of anemia in the anemic patients. In two patients who had a chronic anemia, a persistent parvovirus infection was detected by PCR, but not by serology, for 1 and 1.5 years, respectively. The results suggest that persistent parvovirus infection is a rare cause of anemia, but important to identify, since the infection is potentially treatable with intravenous immunoglobulin.ZusammenfassungSerumproben von 69 HIV-infizierten schwedischen Patienten mit Anämie und von 37 HIV-Infizierten ohne Anämie wurden mittels ELISA auf IgM- und IgG-Antikörper gegen Parvovirus B19 untersucht, auch wurde mittels Polymerasekettenreaktion (PCR) das Vorliegen von Parvovirus B19 DNA geprüft. Bei 5/69 anämischen Patienten war Parvovirus B19 DNA nachzuweisen, obwohl keine IgM-Antikörperreaktion gegen das Virus vorlag. Zwischen dem Nachweis von Parvovirus B19 DNA und dem Schweregrad der Anämie bestand bei den anämischen Patienten eine signifikante Korrelation. Bei zwei Patienten mit seit 1 beziehungsweise 1 1/2 Jahren bestehender chronischer Anämie konnte unter Anwendung der PCR eine persistierende Parvovirus-Infektion festgestellt werden, für die serologisch kein Hinweis vorlag. Die Ergebnisse lassen annehmen, daß die persistierende Parvovirus-Infektion eine seltene Ursache für eine Anämie darstellt, ihr Nachweis jedoch wegen der möglichen Behandlung mit intravenösem Immunglobulin von klinischer Relevanz ist.

Skin concentrations of phenoxymethylpenicillin in patients with erysipelas

SummaryIn 45 patients hospitalized with febrile erysipelas that had been treated with oral penicillin, punch biopsies of infected skin were performed and analysed for phenoxymethylpenicillin (pcV) concentrations. The curves for the concurrent serum and tissue levels followed the same course, indicating a rapid diffusion of pcV from serum into tissue. Penicillin concentrations in infected skin exceeded the minimal inhibitory concentrations (MIC) of the streptococci isolated for the first 4 h after tablet ingestion. Venous insufficiency was highly prevalent and pcV concentrations in affected patients were slightly but not significantly higher. A theoretical basis for the successful treatment of erysipelas with oral penicillin is therefore at hand.ZusammenfassungBei 45 Patienten, die wegen eines fieberhaften Erysipels stationär behandelt wurden und orales Penicillin erhielten, wurde die Konzentration von Phenoxymethylpenicillin (pcV) in Stanzbiopsien der Haut bestimmt. Serum- und Gewebekonzentrationskurven verliefen parallel und lassen auf eine rasche Diffusion von pcV vom Serum in das Gewebe schließen. Die Hautkonzentrationen in infizierten Arealen lagen 4 Stunden nach Einnahme der ersten Tablette über den minimalen Hemmkonzentrationen (MHK) der isolierten Streptokken. Eine venöse Insuffizienz war in vielen Fällen vorhanden, dabei lagen die pcV Konzentrationen geringfügig höher als bei Patienten ohne venöse Insuffizienz; der Unterschied war jedoch nicht statistisch signifikant. Die Behandlung des Erysipels mit einem Oralpenicillin hat folglich eine gesicherte theoretische Basis.

Clostridium difficile recurrences in Stockholm.

Sixty-eight hospital-admitted patients with a first episode of Clostridium difficile infection (CDI) were included and followed up during 1 year. Faeces samples were collected at 1, 2, 6 and 12 months after inclusion and analyzed for the presence of C. difficile toxin B, genes for toxin A, toxin B, binary toxin and TcdC deletion by PCR. All strains were also PCR-ribotyped and the MICs of the isolates were determined against eight antimicrobial agents. In 68 patients initially included, antibiotics, clinical signs and co-morbidities were analyzed and 56 were evaluable for recurrences. The mean number of different antibiotics given during 3 months prior to inclusion was 2.6 (range 0-6). Six patients had not received any antibiotics and three of them had diagnosed inflammatory bowel disease. Thirty-two patients (57%) had either a microbiological or clinical recurrence, 16 of whom had clinical recurrences that were confirmed microbiologically (13, 23%) or unconfirmed by culture (3, 5%). Twenty-nine patients were positive in at least one of the follow-up tests, 16 had the same ribotype in follow-up tests, i.e. relapse, and 13 a different ribotype, i.e., reinfection. Most common ribotypes were 078/126, 020, 023, 026, 014/077, 001 and 005. No strain of ribotype 027 was found. Strains ribotype 078/126 and 023 were positive for binary toxin and were the strains most prone to cause recurrence. All strains were sensitive to vancomycin and metronidazole. Patients with recurrences were significantly older (p = 0.02) and all patients had a high burden of comorbidities, which could explain the high fatality rate, 26 (38%) patients died during the 1-year follow-up.

Etiology of bone and joint infections: a case series of 363 consecutive patients from an orthopaedic infection unit

ABSTRACT Background: Bone and joint infections remain a clinical challenge with potentially serious consequences. Nevertheless there is a lack of studies with strict criteria for diagnosis and etiology. The primary aim of this study was to determine the causative agents in orthopaedic infections using strict diagnostic criteria for infection and etiology. The secondary aim was to assess the timing of post-operative infections in relation to pathogens and to compare causative bacteria in different parts of the body. Methods: A retrospective registry study of 363 consecutive cases of bone and joint infections was performed. Microbiological data on sampling and culture results were registered. Results: Staphylococcus aureus dominated in both operated (45%) and non-operated (44%) patients, followed in frequency by coagulase-negative staphylococci (CoNS) in operated patients (11%) and beta-haemolytic streptococci in non-operated patients (16%) (p < 0.001). There were no polymicrobial infections in non-surgical cases (p < 0.001). For operated patients, Gram-negative bacilli were observed in 6%, almost exclusively isolated from the lower extremity. Propionibacterium spp. was the most common finding after spinal surgery. In 90/363 (25%), the agent responsible for the infection could not be defined according to the strict criteria used. Conclusion: S. aureus dominated as etiological agent in all bone and joint infections, including operated patient given peri-operative prophylaxis. Improved timing of antibiotic prophylaxis seen after the introduction of the Swedish national project PRISS may have changed this. The number of infections with uncertain etiology was high, stressing the importance of more studies on diagnostics, as well as strict diagnostic algorithms.