Jacob Gilad

Nosocomial multi-drug resistant Acinetobacter baumannii bloodstream infection: risk factors and outcome with ampicillin-sulbactam treatment

The emergence of multidrug-resistant (MDR) Acinetobacter baumannii poses a therapeutic problem. The aim of this study was to assess the risk factors for nosocomial MDR-A. baumannii bloodstream infection (BSI) and the efficacy of ampicillin-sulbactam (A/S) in its treatment. Of 94 nosocomial A. baumannii BSI during the year 2000, 54% involved MDR strains, 81% of which were genetically related. Various risk factors for MDR-A. baumannii were found, of which intensive-care unit admission and prior aminoglycoside therapy were independently associated with MDR-A. baumannii acquisition on multivariate analysis. Of MDR-A. baumannii BSI cases, 65% received A/S and 35% inadequate antibiotic therapy, whereas of 43 non-MDR cases, 86% were treated according to susceptibility and 14% inappropriately with antibiotics to which these organisms were resistant. Crude mortality was comparable in the adequately treated groups. Respective mortalities among patients treated adequately and inadequately were 41.4 and 91.7% (p<0.001). Among severely ill patients, A/S therapy significantly decreased the risk of death (P=0.02 OR=7.64). MDR-A. baumannii has become highly endemic in our institution. A/S appears to be one of the last effective and safe empirical resorts for treatment of MDR A. baumannii BSI.

Fatal Clostridium sordellii ischio-rectal abscess with septicaemia complicating ultrasound-guided transrectal prostate biopsy

Clostridium sordellii is a Gram-positive spore-forming anaerobic bacillus rarely encountered in human infection. A case of C. sordellii ischio-rectal abscess with rapidly fatal septicaemia is described which complicated ultrasound-guided transrectal biopsy of the prostate, despite ciprofloxacin prophylaxis. Neither C. sordellii ischio-rectal abscess nor ischio-rectal abscess complicating transrectal biopsy have been reported previously. Judging from our experience and the reviewed literature, the addition of prophylactic anti-anaerobe drugs should be strongly considered until an optimal prophylactic regimen will be defined by randomized controlled trials.

Antibiotic-Resistant Pneumococci Carried by Young Children Do Not Appear to Disseminate to Adult Members of a Closed Community

Although antibiotic-resistant pneumococci have been frequently detected among day care center (DCC) attendees, the transmission of these organisms to other members of the community has not been adequately studied. Nasopharyngeal cultures were obtained from 152 children and 244 adult members of a closed community (a kibbutz) in Israel. Serotyping, antibiogram, and pulsed-field gel electrophoresis were performed to determine the relatedness of isolated pneumococci. Twenty (30%) of the 66 isolates from children showed decreased susceptibility to penicillin and 9 isolates (14%) were resistant to > or =3 drugs. Of the 16 isolates from adults, 5 (31%) were intermediately resistant to trimethoprim-sulfamethoxazole. Resistant strains carried by DCC attendees were not isolated either from their parents or from other adult members of the community. Despite the high degree of interpersonal contact occurring in a closed community, resistant pneumococcal strains carried by DCC attendees do not appear to be easily transmitted to the adult population, which suggests the existence of an immunological barrier.

FAILURE OF CIPROFLOXACIN PROPHYLAXIS FOR ULTRASOUND GUIDED TRANSRECTAL PROSTATIC BIOPSY IN THE ERA OF MULTIRESISTANT ENTEROBACTERIACEAE

A 69-year-old man with prostatism requiring urinary catheterization underwent elective transrectal biopsy of the prostate due to a prostatic mass. Preoperatively 2 prophylactic doses of 500 mg. ciprofloxacin were administered orally. The patient had a history of multiple antibiotic courses given for recurrent urinary tract infections. Ten days after the procedure the patient was admitted to the hospital with respiratory distress and hemoptysis. At hospitalization he was hernodynamically stable and afebrile. Physical examination demonstrated a purulent urethral discharge. Laboratory evaluation revealed leukocytosis, thrombocytopenia, acute renal failure and severe hypoxemia with metabolic acidosis. Shortly afterward patient condition suddenly deteriorated and he was transferred to the intensive care unit. Severe sepsis was suspected. Multiple cultures were obtained, and treatment with intravenous fluids and piperacillin-tazobactam was initiated. The next day we noted multiple erythematous cutaneous nodules consistent with the diagnosis of ecthyma gangrenosum (see figure). Emergency explorative laparotomy showed no abscess or fluid collection.

Enterococcus hirae septicemia in a patient with end-stage renal disease undergoing hemodialysis.

Enterococcus hirae, member of theEnterococcus genus known to cause infection in animals, is rarely encountered in clinical practice. There are no published reports describing clinical features ofEnterococcus hirae infection in humans. A case ofEnterococcus hirae septicemia in a 49-year-old patient with end-stage renal disease undergoing hemodialysis is reported here. A review of the available literature regarding the clinical spectrum ofEnterococcus hirae infection in humans and the antimicrobial susceptibility ofEnterococcus hirae is also included.

Isolated Splenic Cat Scratch Disease in an Immunocompetent Adult Woman

We report a case of isolated splenic cat scratch disease in an immunocompetent woman. The clinical presentation of prolonged fever, night sweats, weakness, and intrasplenic lesions was highly suggestive of lymphoma. This is the second reported case of isolated splenic cat scratch disease in an adult and the first in a healthy adult.

Massive pumonary haemorrhage caused by leptospirosis successfully treated with nitric oxide inhalation and haemofiltration

A patient with leptospirosis who developed oliguric renal failure, massive pulmonary haemorrhage and respiratory failure is described. The patients clinical condition and arterial oxygenation failed to improve despite vigorous supportive measures. Nitric oxide inhalation and haemofiltration resulted in a marked clinical improvement and subsequent full recovery. We suggest that the addition of haemofiltration and nitric oxide inhalation therapy should be considered in patients with pulmonary haemorrhage and renal failure caused by leptospirosis, in whom conventional therapy fails.

Gender differences and sex-specific manifestations associated with human immunodeficiency virus infection in women

The rapidly growing rates of human immunodeficiency virus (HIV) infection among women has prompted many challenging issues related to the management and consequences of HIV and its complications in this population. This paper reviews the current evidence with regard to various aspects of HIV infection in women. Special emphasis is placed on gender-differences as well as sex-specific manifestation of this disease, including epidemiology, viral load determination and disease progression, related morbidity, and anti-retroviral therapy. It is concluded that current advances in the understanding of HIV infection among women may lead to further refinement and optimization efforts in the management of HIV-infected women.

Incidence and clinical significance of bacteremia and sepsis among cardiac patients treated with intra-aortic balloon counterpulsation pump

In this prospective study, a significant incidence of fever (47%), true bacteremia (15%), and sepsis (12%), were found in 60 cardiac patients treated with an intra-aortic balloon counterpulsation pump. The benefit of antibiotic prophylaxis in this setting should therefore be evaluated.

Atraumatic rupture of the spleen associated with hemophagocytic syndrome and isolated splenic peliosis

Atraumatic rupture of the spleen is an uncommon condition that may be associated with various etiologies. The hemophagocytic syndrome (HS) and isolated splenic peliosis are two rare conditions, each of which has previously been described in association with splenic rupture. We describe a unique case of atraumatic splenic rupture in which concurrent HS and splenic peliosis were diagnosed following splenectomy. Given that both these rare conditions have probably caused the splenic rupture, a possible association between these entities is discussed.