Claus Ola Solberg

Vertebral Osteomyelitis at a Norwegian University Hospital 1987-97: Clinical Features, Laboratory Findings and Outcome

Altogether 40 patients aged 13-91 y (average 58 y) with vertebral osteomyelitis were treated at the Bergen University Hospital between July 1987 and June 1997. All patients presented with back pain, 33 (83%) had vertebral tenderness, and 26 (65%) patients were febrile. The duration of symptoms before diagnosis was < 3 weeks in 13 patients, and from 3 to 16 weeks in the remaining 27 patients. C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) were elevated in 39 and 38 patients, respectively. Staphylococcus aureus was the most frequent cause of osteomyelitis followed by Streptococcus spp., Escherichia coli and Mycobacterium tuberculosis. Magnetic resonance imaging was superior to other radiological methods and demonstrated changes consistent with osteomyelitis in all 23 patients examined with this method. 35 patients survived. 18/35 surviving patients had pareses and 17 underwent surgery with drainage of abscesses or laminectomy. All 35 patients made a good recovery and only 3 patients experienced permanent pareses. The diagnosis of vertebral osteomyelitis is easily missed, and treatment is often delayed, particularly in the elderly in whom signs of sepsis may not manifest. However, persisting localized pain and tenderness over the spine together with elevated CRP and ESR should prompt the physician to consider vertebral osteomyelitis. Fever and leukocytosis may support the diagnosis, but may not always be present.

A longitudinal study of phagocyte function in HIV-infected patients

ObjectiveTo study the influence of HIV infection on phagocyte function. To date, the results of phagocyte function studies in HIV-infected patients have been contradictory. This is the first longitudinal study of these functions in HIV infection. DesignWe followed 50 individuals with HIV infection for 2–51 months (mean, 28 months) and examined polymorphonuclear leukocyte (PMNL) and monocyte functions at intervals of 0.5–1 years. MethodsPMNL random migration and chemotaxis were assessed using an under-agarose method, and PMNL and monocyte oxidative metabolism by chemiluminescence production during phagocytosis of opsonized zymosan. ResultsPMNL random migration and chemotaxis were impaired at entry into the study by 15 and 19%, respectively. After 3 years the reduction was 35 and 32%, respectively. The mean chemiluminescence production by PMNL was reduced by 6% at entry into the study. After 4 years a decrease of 18% was observed. The decrease in PMNL function was most marked in patients with lymphadenopathy syndrome or AIDS. No significant change in monocyte chemiluminescence production was detected at any time during the study. ConclusionsA distinct and progressive decrease of PMNL function occurs during HIV infection. This may contribute to increased susceptibility to opportunistic infections in HIV-infected patients. For monocytes, chemiluminescence production is not influenced by HIV infection.

Serum Levels of Adhesion Molecules and Cytokines in Patients with Acute Leukaemia

The cytokine network and the adhesion molecule system are intercellular signal pathways. The cytokine effects are modulated in vivo by soluble cytokine antagonists, whereas the cell to cell contact mediated by adhesion molecules and their ligands may be blocked by the soluble forms of the adhesion molecules. The cytokine network is important for proliferation and cytokine secretion by acute leukaemia blasts, and membrane-bound adhesion molecules are important for blast interactions with neighbouring cells of the in vivo microenvironment. Both these signal systems are operative during the period of cytopenia following intensive chemotherapy for acute leukaemia. In the present review, we discuss the influence of disease status, chemotherapy and complicating infections on serum levels of cytokines and soluble adhesion molecules in acute leukaemia patients. We have demonstrated increased serum levels of both cytokines and cytokine antagonists in acute leukaemia patients with complicating bacterial infections during chemotherapy-induced cytopenia. Serum levels of the selectin adhesion molecules were decreased during bacterial infections in leukopenic patients compared to healthy individuals. In contrast, the intercellular adhesion molecule-1 response and the cytokine/cytokine antagonist responses were qualitatively similar to responses seen in previously healthy individuals with serious bacterial infections.

Infective Endocarditis 1973–1984 at the Bergen University Hospital: Clinical Feature, Treatment and Prognosis

During the period 1973-1984, 72 patients with infective endocarditis (IE) were hospitalized in the medical department, Bergen University Hospital. The male/female ratio was 1.25/1, the mean age 55.3 years. 35 infections were caused by streptococci, 18 by staphylococci, 6 by other microorganisms and in 13 cases no causal organism was found. Only 13 patients had rheumatic heart disease. The overall mortality was 35%, and the mean age of the patients who died was 65 years. The case fatality rates for staphylococcal and streptococcal endocarditis were 61 and 24% respectively. In the period 1973-1978 the case fatality rate was 50% compared to 26% during 1979-1984. The proportion of patients with culture-negative endocarditis was reduced from 31 to 11% from the first to the second half of the study and the percentage of patients who received antibiotics before diagnosis decreased from 81 to 58%. Valve replacement was performed in 4 patients with staphylococcal and 15 with streptococcal infections. Seven cases (mean age 73.4 years) were diagnosed at necropsy; 3 with staphylococcal infections. With increased clinical awareness of IE, liberal use of blood cultures, better diagnostic tools and earlier surgical intervention, especially in staphylococcal infections, a further reduction in mortality should be possible.

A primer on anaerobic bacteria and anaerobic infections for the uninitiated

Anaerobic bacteria comprise facultative, aerotolerant, microaerophilic, and obligate anaerobes. The latter are usually subdivided into moderate and strict according to their sensitivity towards oxygen. Most anaerobic bacteria involved in human infections are moderate obligate anaerobes. Anaerobic bacteria commonly inhabit the mucous membranes and skin of man and various animals. They are prevalent in the oral cavity and pharynx, the gastrointestinal tract, especially the terminal ileum and large bowel, the genitourinary tract orifices, and on the skin. The indigenous microflora is the source of virtually all anaerobic bacteria involved in disease. Exceptions are those caused by Clostridium tetani, Clostridium botulinum and Clostridium difficile. Anaerobic infections are common, although a decrease has been reported during the 1990s in the relative frequencies of properly collected specimens yielding anaerobic bacteria particularly from bacteremia [1]. Nevertheless, anaerobic bacteria are still frequent causes of diseases associated with severe morbidity and high mortality. Since special precautions are needed in collecting, transporting, processing and culturing anaerobic bacteria, they are easily overlooked in the clinical setting. More important, however, is that many laboratories are unable to culture many or most of the anaerobic bacteria commonly present in clinical infections. Even when proper specimens are collected, some hospitals do not have adequate laboratory support for the handling of anaerobic organisms. The aim of the present review is to provide a primer on anaerobic bacteria and anaerobic infections for the uninitiated, emphasizing general principles, treatment and clinical bacteriology.

Antimicrobial therapy and case fatality in meningococcal disease.

The effect of different initial antimicrobial treatments on the case fatality rate (CFR) was evaluated in 112 consecutive patients with meningococcal disease. The overall CFR was 9.8%. 85 patients received initial therapy with chloramphenicol in addition to benzylpenicillin or other antimicrobials, and 27 patients benzylpenicillin or other antimicrobials without chloramphenicol. Patients treated with chloramphenicol had a lower CFR than those not given chloramphenicol (5% vs. 26%; p = 0.004). However, severely ill patients were treated more often with penicillins, and adjustment for the severity of disease on admission to hospital demonstrated that this difference in favour of chloramphenicol was slight and nonsignificant (p = 0.58). High doses of benzylpenicillin and no chloramphenicol were also associated with a higher CFR than low doses. However, the difference was not significant (p = 0.22). More extensive studies should be carried out to evaluate the effect of benzylpenicillin doses and chloramphenicol on the outcome of meningococcal disease.

Susceptibility of 327 clinical isolates to netilmicin.

Netilmicin, a semisynthetic derivative of sisomicin, was tested against 327 isolates of Staphylococcus aureus, Pseudomonas aeruginosa and Gram-negative enteric bacilli. Seventy-two per cent of the isolates were inhibited at a concentration of 0.5 μg netilmicin per ml, and 93% of the isolates were susceptible to 4 μg per ml or less. The MICs of netilmicin and gentamicin for 24 Providencia and 38 Pseudomonas isolates were compared. The activity of netilmicin closely paralleled that of gentamicin, 46% of the Providencia isolates and 32% of the Pseudomonas isolates not being inhibited by 4 μg per ml of either drug.

Antibiotic susceptibility of blood culture isolates of Enterobacteriaceae. A Norwegian multicenter study.

From May to November 1997 each of six major hospitals throughout Norway collected 72 to 104 consecutive blood culture isolates of Enterobacteriaceae, altogether 563 isolates. Escherichia coli was the predominating organism (69%), followed by Klebsiella spp. (15%), Enterobacter spp. (6%), and Proteus mirabilis (4%). The susceptibility of the isolates to ampicillin, cefuroxime, ceftazidime, imipenem, tobramycin, and ciprofloxacin was determined by the E‐test. 37% and 7% of the isolates were resistant to ampicillin and cefuroxime, respectively, and 1% were resistant to ceftazidime and tobramycin. Only one isolate of P. mirabilis was imipenem resistant. All isolates were susceptible to ciprofloxacin. The prevalence of ampicillin‐resistant isolates at each hospital varied from 21 to 45%, and of cefuroxime‐resistant isolates from 3 to 9%. The results were compared with those of a similar study performed in 1991–1992. No significant changes in the susceptibility to the various agents could be demonstrated. The high frequency of isolates resistant to ampicillin has clearly limited the usefulness of this agent in the treatment of septicemia and other serious infections caused by Enterobacteriaceae.