Ghislaine Grollier

Meningitis Due to Capnocytophaga canimorsus after Receipt of a Dog Bite: Case Report and Review of the Literature

We describe a case of meningitis due to Capnocytophaga canimorsus and review 18 cases with attention to risk factors, clinical features, diagnosis, treatment, and outcome. In most of the reported cases, contact with dogs and predisposing factors were found. Clinical manifestations and the findings of examinations of cerebrospinal fluid specimens were similar to those of classic bacterial meningitis; however, the mortality rate for C. canimorsus meningitis very low when compared with the rate for C. canimorsus septicemia (5% vs. 30%).

Characteristics of brain abscess with isolation of anaerobic bacteria

In view of its localization, brain abscess (BA) usually requires medical and surgical care. A broad spectrum of bacteria is involved. Recent reports stress the increasing frequency of anaerobes, but their impact has not been well evaluated. A retrospective review was conducted of all episodes of documented BA admitted in a tertiary-care hospital over a 10 y period. BA due to anaerobic bacteria (group A) were compared with other cases (group B) to determine the frequency and eventual characteristics of BA with isolated anaerobic bacteria. Between 1991 and 2000, BA were diagnosed in 42 patients (28M, 14F, mean age 54.6 y). No differences in clinical features and laboratory findings were found between patients with BA caused by anaerobic (n=22) and only aerobic (n=20) bacteria. Using appropriate microbiological techniques, 41 anaerobic bacteria strains were isolated in 22 of 42 patients (52.4%) with BA. Anaerobic bacteria were associated with aerobic strains in 5 patients (12%), whereas in 17 patients (40.5%) only anaerobic strains were isolated in cerebral puncture cultures. The most frequently isolated species were Fusobacterium nucleatum (n=14), Prevotella sp. (n=8), Actinomyces sp. (n=6) and Bacteroides sp. (n=4). Compared with group B, group A had more cases of a single abscess (p=0.03) and ear, nose and throat (ENT) as a source of infection (p=0.04), and seemed to have a better outcome (p=0.07). These results emphasize the important role that anaerobic bacteria play in BA. The presence of such pathogens must be evoked when faced with a single abscess, an ENT infection, or both. Therapy should take into account this high frequency.

Nosocomial sinusitis with isolation of anaerobic bacteria in ICU patients

Objective: To determine the frequency and the eventual clinical characteristics of nosocomial sinusitis with anaerobic bacteria isolation in patients in the intensive care unit (ICU).¶Design: Retrospective study.¶Setting: A 12-bed medical ICU in a teaching hospital.¶Patients: 30 adult patients with documented nosocomial maxillary sinusitis.¶Interventions: None.¶Measurements and results: Using appropriate microbiological techniques, 33 anaerobic bacterial strains were isolated in 18/30 patients (60 %) with nosocomial sinusitis. Anaerobic bacteria were associated with aerobic strains in 13 patients (72 %), whereas in 5 patients (28 %) only anaerobic strains were isolated in sinus puncture cultures. The most frequently isolated species were Prevotella sp. (n = 20, 60 %) and Fusobacterium nucleatum (n = 5, 15 %). The production of β -lactamase was demonstrated in 13/27 gram-negative anaerobic bacteria. All patients in whom anaerobic bacteria were isolated from transnasal punctures had had a nasogastric tube. Patients in whom anaerobic bacteria were isolated more frequently had neurological disorders upon admission (p < 0.02). Ten patients (30 %) had nosocomial pneumonia, 8 of whom had at least one identical strain in both lung and sinus cultures, including 2 patients with anaerobic bacteria isolation.¶Conclusions: Using appropriate microbiological techniques, anaerobic bacteria were frequently isolated in nosocomial sinusitis. If necessary, the empirical choice of antimicrobial therapy in patients with nosocomial sinusitis should take into account these results.

Cervical spinal epidural abscess and meningitis due to Prevotella oris and Peptostreptococcus micros after retropharyngeal surgery.

usually due to the contiguous spread of infection or can be related to hematogenous spread from a distant infection [1]. To our knowledge only four cases of epidural abscess due to anaerobic bacteria have previously been reported [2, 3, 4, 5]. In our case, since the isolated anaerobic bacteria could be part of the healthy oral flora they can be logically responsible for a contiguous spread of infection following retropharyngeal surgery [1]. Since anaerobic isolation requires specific methods, the involvement of anaerobic bacteria in epidural abscess associated with oropharyngeal infection can be underestimated. In our case Peptostreptococcus micros was isolated after inoculation of the CSF in a blood anaerobic bottle containing charcoal particles that neutralize antibiotics. Peptostreptococcus micros was not isolated from the epidural abscess at day 5, probably because of its high susceptibility to the antibiotics given to the patient. Conversely, Prevotella oris could be isolated in the epidural abscess because of its resistance to amoxicillin and ceftriaxone. The optimal treatment of epidural abscess due to anaerobic bacteria is poorly defined. Prompt surgical decompressive laminectomy and drainage in the presence of signs of spinal cord compression and antibiotics are suggested [2]. This case illustrates the possibility of benign surgery of a retropharyngeal lesion inducing a severe epidural complication. Since anaerobic bacteria are normally part of the oropharyngeal flora, they can be involved in such disease. Their isolation is difficult, requiring specific methods, and can be delayed. Empiric antibiotic therapy should consider anaerobic bacteria in these situations. References

Polyethylene stent blockage: a porcine model

BACKGROUND Endoscopic insertion of biliary stents is a useful treatment for obstructive jaundice resulting from unresectable tumors of the pancreas and biliary tree. The main drawback is the recurrence of jaundice due to clogging. The aim of this study was to establish an experimental model of polyethylene stent clogging in large white pigs. METHODS A straight polyethylene stent of 5F (group I), 7F (group II) or 10F size (group III) was inserted in the common bile duct. Animals were killed at 2 months, or earlier if physical signs suggesting stent clogging occurred. Chemicophysical analysis of stent deposition combined stereomicroscopy and identification of the contents by means of Fourrier transform infrared spectroscopy. Bacteriologic analyses included identification of aerobic and anaerobic bacteria and measurement of beta-glucuronidase, lecithinase and lipase activities. RESULTS Physical signs suggesting stent obstruction or death occurred in 8 of 8 animals in group I, 11 of 12 in group II, and 2 of 8 in group III (p < 0.001). The proportion of mucoprotein in the stent contents tended to fall with increasing stent diameter (mean 82%, 58% and 47% for 5F, 7F and 10F, respectively), whereas wheat starch and calcium bilirubinate content increased with increasing stent diameter (9% and 4%, 18% and 10%, and 29% and 23% for 5F, 7 F, and 10F, respectively), although none of these differences were statistically significant. A variety of bacteria were cultured from the stent deposits, including anaerobic strains. Clostridium species were associated with the highest enzyme activities. CONCLUSIONS In this model the major component of early stent deposits was mucoprotein, and numerous aerobic and anaerobic bacteria were isolated. Formation of calcium bilirubinate was a late phenomenon and poorly related to bacterial enzymatic activities.

Infective endocarditis after transrectal prostatic biopsy.

We report the first case of infective endocarditis secondary to transrectal prostatic biopsy, occurring 2 weeks later in a patient with no obvious risk factors. Enterococcus faecalis was isolated in blood and urine cultures. This case suggests that infective endocarditis can be associated with transrectal procedures.

Entodoxin tolerance in humans in vivo.

To the Editor: The protective effect of repeated doses of endotoxin has been shown in animal models (1), and we read with interest the article of Dr. Draisma and colleagues (2) demonstrating the development of endotoxin tolerance in human in vivo. Although endotoxin tolerance is evidenced after administration of low doses of lipopolysaccharide in human volunteers, the clinical relevance of this phenomenon is difficult to demonstrate in patients (2, 3). We had the opportunity to follow a patient who had 22 positive blood cultures during 17 days, contrasting with attenuation of his clinical symptoms. A 80-yrold patient was admitted to the intensive care unit for septic shock due to portal pylephlebitis that originated from uncomplicated sigmoid diverticulitis. On admission, he had four organ failures according to Sequential Organ Failure Assessment score and required mechanical ventilation, fluid administration, and high-dose norepinephrine dose. Leukocyte count was 18,900/mm, platelet count was 85,000/mm, and C-reactive protein level was 286 mg/L. Blood cultures grew with several anaerobic bacteria, including Bacteroides species, and the patient received adapted antimicrobial therapy, including amoxicillin and clavulanic acid. Contrasting with persisting positive blood cultures on days 1, 2, 3, 4, 8, 11, 12, and 13 and isolation of six species of anaerobes, his clinical condition improved after the third day of hospitalization. His temperature was 38.5°C, he was weaned from mechanical ventilation on day 9, and the norepinephrine infusion was stopped on day 12. Between day 14 and day 17, while the patient had tympanic temperature of 38°C and no substantial clinical abnormalities, five additional blood cultures isolated Escherichia coli sensitive to amoxicillin and clavulanic acid. Leukocyte counts were only 10,900/mm, platelet counts were 234,000/ mm, and C-reactive protein level was 72 mg/L. The patient was discharged from intensive care unit on day 19 and from the hospital on day 25. Similar to the volunteers, our patient had no increase of leukocyte count or C-reactive protein level despite E coli bacteremia. Antimicrobial therapy may have contributed to the clinical improvement of the patient, and we did not measure the cytokine blood levels variations in this patient. Thus, further similar reports are mandatory to confirm this observation. However, the striking point of this case was the absence of clinical symptoms related to the final E. coli bacteremia that can be paralleled to the observations made in human volunteers and might emphasize the clinical relevance of the endotoxin tolerance phenomenon in patients. The authors have not disclosed any potential conflicts of interest.