Marilou Corpuz

Spontaneous fungal peritonitis (Candida glabrata) in a patient with cirrhosis

We report a case of spontaneous fungal peritonitis in a patient with cirrhosis. A 70-year-old woman with cirrhosis secondary to autoimmune hepatitis was admitted with fever and abdominal distention. Paracentesis revealed neutrocytosis, and despite appropriate antibacterial coverage, no clinical improvement was noted and the ascitic fluid white cell count increased on repeat paracentesis. Two consecutive ascitic fluid cultures grew Candida glabrata, and antifungal therapy with amphotericin was initiated, pending sensitivity of the isolate. Because of worsening renal function, amphotericin was discontinued and itraconazole was started, as sensitivity of the isolate was then available. Antifungal therapy resulted in resolution of ascitic fluid neutrocytosis and culture negativity. However, the patients renal function continued to deteriorate, necessitating hemodialysis. Despite multiple courses of antibiotics, she died of fulminant sepsis and multiorgan failure.

Intraabdominal vancomycin-resistant enterococcus infections: the new threat.

Goals To determine the clinical course and outcome in patients with intraabdominal vancomycin-resistant enterococcus infections (VRE-A) and to identify probable risk factors for VRE-A. Background Vancomycin-resistant enterococcus is one of the most notable nosocomial emerging pathogens. The incidence is increasing, especially in the abdominal surgery setting. Study A comparative study of patients with VRE-A and VRE infection in other sites (VRE-O) who were hospitalized for over 1 year. Fisher exact test and Student t test were used; a two-tailed p value of less than 0.05 was considered to be significant. Results Of 89 nine patients with VRE, six had VRE-A, 24 had VRE-O, and 59 had VRE colonization. The VRE-A group was comprised of one patient with an inoperable Klatskin tumor and biliary sepsis, one with acquired immune deficiency syndrome and an infected pancreatic pseudocyst, two with fecal peritonitis, and two with biliary sepsis after surgery for common bile duct stones. All six patients with VRE-A had recent surgery before VRE isolation, as compared with three in the VRE-O group (p = 0.0001). Despite adequate treatment with intravenous chloramphenicol, resulting in eradication of VRE in all six VRE-A cases, the mortality rate remained high at 50%. Conclusions Vancomycin-resistant enterococcus should be recognized as an emerging nosocomial pathogen that causes potentially fatal intraabdominal infections in the postsurgical setting. However, the impact of treatment on ultimate outcome needs further evaluation.

Clostridium ramosum bacteremia and osteomyelitis in a patient with infected pressure sores

Case Report. A 91-year-old nursing home resident, with hypertension and diabetes, was referred for evaluation of fever. Initial assessment revealed a demented, bedridden patient who appeared toxic, with a temperature of 102 F. She had multiple pressure sores, including stage IV ulcers over the left hip (9 7 cm) and sacrum (9.5 8 cm) and a stage III ulcer over the right hip (4 3.5 cm). The ulcer over the hip extended to the bone and had a foul-smelling purulent discharge and necrotic debris at the base. Further examination was unremarkable except for scattered rales and a short aortic ejection systolic murmur. Laboratory results showed leukocytosis (18.9) with a left shift and anemia (hematocrit 22.7). Urinalysis was normal, and a chest roentgenogram did not reveal any infiltrates. Blood cultures were drawn, and the patient began receiving ampicillin-sulbactam and gentamicin. The two sets of blood cultures performed at different time intervals, from different sites, both yielded C. ramosum. Blood cultures were incubated in the BACTEC 9240 system (Becton Dickinson, Sparks, MD) and subcultured on a blood agar plate and CDC’s blood agar plate media with a gas pack pouch anaerobic system (BBL Becton Dickinson Microbiology systems, Cockeysville, MD). The identity of the organism was established with the API 20 A anaerobic strip (bioMerieux, Hazelwood, MO). A computed tomographic scan of the abdomen and pelvis, although negative for abdominal pathology, revealed a large ulcer over the left hip, intramedullary gas in the femoral head, and a small pocket of fluid anterior to the hip consistent with osteomyelitis. Gas was also seen in the soft tissue surrounding the ulcer. Antibiotics were continued and surgical debridement was done. The patient received a packed red blood cell transfusion for anemia, and blood sugars were controlled with multiple daily doses of regular insulin. A transthoracic echocardiogram showed mild aortic stenosis but did not reveal any evidence of vegetations. The patient responded well to treatment and was afebrile by the third day. Subsequent blood cultures were negative for C. ramosum. Two weeks later, the patient remained afebrile, the pressure sores appeared to be healing, and she was discharged to the nursing home on antibiotics.

Mucormycosis as a Pathogen in Polymicrobial Necrotizing Fasciitis

Mucormycosis is rare, and its incidence is difficult to calculate accurately. The causative agents are saprophytic fungi of the class Zygomyces, order Mucorales. Rhinocerebral disease, the most common form, which accounts for more than half of the cases, is associated with diabetes and ketoacidosis. The syndromes of pulmonary and disseminated mucormycosis are usually seen in neutropenic patients. The development of primary cutaneous infection from mucormycosis depends on underlying systemic illness and local host factors. Although mucormycosis is infrequent, more cases of cutaneous infections are being noted, especially in the compromised host. We describe a case of Mucor as a predominant organism in a polymicrobial soft tissue infection in a diabetic patient with necrotizing fasciitis.

Hepatitis C (HCV)|[mdash]|still an epidemic hidden from the public eye|[quest]|

Aim: Compare public awareness of HCV to the more publicized HIV epidemic. Methods: A two-part Survey Questionnaire was administered. Part 1 requested demographic information and asked general questions on attitudes and beliefs. Part 2 asked 10 HCV-related and 10 HIV-related questions based on NY State Health Department public information pamphlets. Chi-square analysis, ANOVA and Student t-tests were used for statistical comparison. Information pamphlets and counseling were provided to all participants after testing. Results: 606 individuals participated, 290 were hospital staff (92 physicians). Mean age was 38.7 6 14 yrs, 238 were male, 550 had 12 1 years of education.

CENTRAL VENOUS CATHETER INFECTIONS : IDENTIFICATION OF HIGH-RISK PATIENTS

&NA; Infection of central venous catheters (CVCs) is an independent risk factor for increased mortality and morbidity. As a method to prevent infection, prescheduled changing of all catheters to a new site is costly and is associated with procedurerelated complications. The aim of the study was to analyze various patient‐related parameters that can place patients at risk of acquiring catheter infection and to identify the subset of patients at highest risk of developing catheter infection, so that prescheduled relocation of catheters to a new site is limited to them. A retrospective review of 300 patients with CVC was conducted to identify the patients who had evidence of catheter infection. The patients who did not develop infection were taken as control. The potential risk factors were compared between the groups. The X2 test and Students t test were used, when appropriate, to test the statistical significance. A serum albumin level of <25 g/L on admission, a fall in serum albumin of >9 g/L, and prolonged (>12 days) use of a catheter were also associated with increased risk of CVC infection. The age, past medical history, immunocompromised states, concurrent antibiotic usage, or infusion of nutritional substances through the CVC were not found to have any influence on the infection rate. Serum albumin on admission combined with serial measurements can be used as an inexpensive but reliable guide to identify the patients most likely to develop catheter infection. It would be cost effective and safer if relocation of catheters at predetermined intervals is limited to such high‐risk patients.