Mark Casewell

Fungal infection : a common, unrecognised complication of acute liver failure

The true incidence and clinical relevance of fungal infection was ascertained in a prospective study of 50 consecutive patients with acute liver failure. Fungal infection was present in 16 (32%) patients (15 candida, one aspergillus) and in seven was considered the major cause of death. All six untreated died, while five of ten patients treated with anti-fungal therapy survived. The diagnosis was made on positive cultures from at least one significant site or on histological evidence of tissue invasion. All 16 had concomitant bacterial infection and shared features suggestive of a clinical syndrome: deterioration in coma grade after initial improvement; pyrexia unresponsive to antibiotics; established renal failure; and a markedly elevated white cell count. Fungal infection is a common, serious complication of acute liver failure and therapy is indicated for those with positive cultures. A prophylactic trial would be justified in those surviving 5 days, especially, with established renal failure.

Nocardiosis in liver transplantation: variation in presentation, diagnosis and therapy.

Nocardiosis arose in seven of 191 liver transplant patients (3.7%) over a period of 3.5 years. Four patients had only pulmonary lesions while three had disseminated disease. Nocardia asteroides was isolated from three patients following bronchoscopy, percutaneous aspirate of a pulmonary lesion in one patients, and from the skin from the aspirates in three patients. Delay in diagnosis in two cases was due to negative microscopy; in one, the diagnosis was made only after repeated bronchoscopy. Of the seven patients, three (43%) died. In two of these, nocardiosis was considered to have directly contributed to death. Co-existent bacterial and viral infections were present in all patients who died. In vitro susceptibility of the organism to co-trimoxazole was variable and did not necessarily reflect clinical efficacy. In one patient, a good clinical response was achieved with co-trimoxazole despite apparently reduced in vitro susceptibility.

Infectious sequelae after endoscopic sclerotherapy of oesophageal varices: role of antibiotic prophylaxis

In order to determine the incidence of infection following sclerotherapy and the role of antimicrobial prophylaxis, a prospective randomized control study was performed comparing i.v. imipenem/cilastatin, with an infusion of dextrose-saline as a control group. One hundred patients with bleeding esophageal varices were included. All episodes of infection were documented during admission to the unit. Ninety-seven patients were evaluable. Post-sclerotherapy bacteremia developed in six (5.6%) of 107 sclerotherapy sessions in the control group and one (1.1%) of the 88 sclerotherapy sessions in the imipenem/cilastatin group (P < or = 0.1, NS): six of these seven post-sclerotherapy bacteremias occurred after emergency sclerotherapy. Infection within 7 days of the procedure was documented after 43 (22.1%) of the 195 sclerotherapy sessions, 18 (20.5%) in the imipenem/cilastatin group and 25 (23.4%) in the control group (P = NS). These infections were significantly more common after emergency sclerotherapy, 40 (34.8%) of 115 sessions, than after elective sclerotherapy, three (3.8%) of 80 sessions (P < or = 0.0001). A short prophylactic antibiotic regime does not reduce the risk of early bacteremia or the frequency of infection after sclerotherapy. The higher risk of infection after emergency sclerotherapy may be therefore related more to the gastrointestinal hemorrhage and its associated effects than to sclerotherapy.

Epidemiology, bacteriology and control of an outbreak of Nocardia asteroides infection on a liver unit

An outbreak of Nocardia asteroides infection affecting seven patients is described. Over a 5-week period, five patients with liver disease admitted to a ward developed clinical and laboratory evidence of nocardiosis, and two further cases were diagnosed 3 and 5 months later. Three out of the five patients who received specific antimicrobial therapy responded to treatment; in three patients nocardia infection was considered to have contributed to death. In six out of the seven patients, nocardiosis followed immunosuppression. A common-source outbreak was considered to be responsible for infection in the first five patients. In two patients, presentation of infection 5 and 7 months after the first case may have been due to prolonged colonization or subclinical infection with Nocardia. Biotyping of the seven isolates using a fluorogenic biochemical method identified three distinct strains of N. asteroides. The most probable source of Nocardia was contaminated brick and plaster dust arising from building work in an area adjacent to the ward. However, samples of air, dust and water failed to yield N. asteroides. Infection control measures included ward closure followed by thorough cleaning, and formaldehyde fumigation.

Isolation of Vancomycin-Resistant Enterococci from Supermarket Poultry

Vancomycin-resistant enterococci (VRE), especially Enterococcus faecium, are emerging as a significant cause of infection, particularly in immuno-suppressed patients, including individuals receiving liver transplants (1). The origin of these strains is uncertain but it has been suggested that the use of glycopeptide antibiotics, notably avoparcin, as growth promoters in poultry and animal feeds, may select for vancomycin-resistant (Vr) strains (2–5). Cross-contamination of these strains at poultry farms and packaging plants, plus poor hygiene in domestic kitchens, may lead to these Vr strains being ingested by humans. Such contamination could provide the opportunity for transfer of resistant determinants between poultry and more clinically relevant strains.

Pristinamycin for Enterococcus faecium resistant to vancomycin and gentamicin

drivers. The patients were all physically healthy and able to walk fair distances, had a carer in attendance, generally lived within easy reach of good public transport, and were visited at home for assessment. These characteristics would tend to reduce any bias towards car use. The sample consisted of 12 men (mean age 71-7 years, mean mini-mental state examination [MMSE] score1 21-9) and 10 women (mean age 72-8, mean MMSE 19-4). All the drivers

Salmonella bacteraemia in sickle cell disease at King's College Hospital: 1976-1991.

A review of all blood culture isolates for the 16 years from 1976 were collated with prospective laboratory and clinical records of 620 sickle cell patients treated at Kings College Hospital. Over half of all salmonella bacteraemias diagnosed in the clinical laboratory occurred in sickle cell disease (SCD) patients. Of 21 bacteraemias in SCD patients, 11 (52.3%) were due to Salmonella spp. compared with 23 (0.4%) of 4884 bacteraemias in patients without SCD (P = < 0.00001). In SCD, Gram-negative bacilli were responsible for 16 (76.2%) bacteraemias, of which 11 (68.8%) were due to Salmonella spp. but there were no cases of S. typhi or S. paratyphi. An increase in the number of salmonella infections over the past 5 years were noted in the SCD and non-SCD patients, nine and 16 cases respectively, compared with two and seven cases in the previous decade. However, the recent increase of S. enteritidis phage type 4 in the UK was not evident in SCD patients. These findings have important preventative and therapeutic implications for the management of SCD patients.

The in-Vitro Activity of LY333328, a New Glycopeptide, against Clinical Isolates of Vancomycin-Resistant Enterococci

Vancomycin has been the mainstay of treament for infections caused by multiply-resistant enterococci and staphylococci. The emergence of E. faecium with high-level resistance to vancomycin and gentamicin (VGREF) that are also resistant to all other clinically useable antimicrobials (1,6,8) highlights the need for new agents for the treatment of infections, including bacteraemia, caused by VGREF (8). Several experimental glycopeptides related to vancomycin have been produced (7) but there is little in-vitro data for LY333328, a novel glycopeptide (3) which may have useful activity against vancomycin-resistant enterococci. We have therefore investigated LY333328 in vitro, as a new and potentially invaluable agent for the treatment of sepsis caused by VRE.

Mupirocin: A New Antibiotic that Reduces Colonisation of Central Venous Cannulae by Skin Organisms

218 cardiothoracic patients had the skin insertion site for their internal jugular cannulae treated with tincture of iodine alone or with mupirocin in addition. 17% of 110 mupirocin-treated patients had significantly colonised cannulae by culture of any segment compared to 54% of 108 controls (P<0.001) as judged by the criteria of Maki. Overall, 25% of the 186 cannula tips from control patients were significantly colonised compared to 5% of 172 canulae from mupirocin treated patients (P<0.001). Coagulase negative staphylococci were the most commonly isolated organisms.