Nathan Keller

An outbreak of Phialemonium infective endocarditis linked to intracavernous penile injections for the treatment of impotence.

BACKGROUNDnIn March 2002, a patient in Tel Aviv, Israel, died of endocarditis caused by Phialemonium curvatum. As part of his therapy for erectile dysfunction, the patient had been trained to self-inject a compound of vasoactive drugs provided by an impotence clinic into his penile corpus cavernosous.nnnMETHODSnWe identified the used prefilled syringes as the source of his infection. Similar cases were investigated as a putative outbreak of P. curvatum invasive disease among customers of this impotence clinic. P. curvatum isolates, cultured from samples obtained from the patients and from prefilled syringes, were compared by DNA sequencing of the nuclear ribosomal internal transcribed spacer.nnnRESULTSnWe identified 2 additional customers at the impotence clinic who had P. curvatum endocarditis. In addition, cultures of unused, prefilled syringes and bottles provided by the same clinic to 5 asymptomatic customers tested positive for pathogenic molds (P. curvatum in 4 cases and Paecilomyces lilacinus in 1). All P. curvatum isolates were of a single genetic type that is known only from this outbreak but is closely related to 3 other P. curvatum genotypes associated with pathogenicity in humans.nnnCONCLUSIONSnP. curvatum is an emerging pathogen that can be readily isolated from blood. We identified an outbreak of P. curvatum endocarditis among men who had erectile dysfunction treated by intracavernous penile injections from contaminated prefilled syringes.

False-Positive Plasmodium falciparum Histidine-Rich Protein 2 Immunocapture Assay Results for Acute Schistosomiasis Caused by Schistosoma mekongi

ABSTRACT We report seven cases of false-positive Plasmodium falciparum histidine-rich protein 2 (PfHRP2) malaria assay results in patients with acute schistosomiasis caused by Schistosoma mekongi. PfHRP2 assays were negative in travelers infected with Schistosoma mansoni or Schistosoma haematobium (n = 13). Malaria was ruled out and rheumatoid factor was negative in all patients.

Nocardiosis: A 15-year experience in a tertiary medical center in Israel

OBJECTIVESnThe objective of this study is to characterize the common risk factors, clinical presentation, imaging findings, treatment and outcome of nocardial infection.nnnDESIGN AND SETTINGSnA retrospective cohort study. We reviewed the charts of all patients with nocardiosis in the Chaim Sheba Medical Center, a tertiary medical center in Israel, between the years 1996 and 2011.nnnRESULTSnA total of 39 patients who had positive culture of Nocardia were analyzed. The majority of our patients were immunocompromised (74.5%), mostly due to corticosteroid therapy. None had HIV/AIDS. The clinical presentation was either acute or a chronic smoldering illness. The three major clinical syndromes were pleuropulmonary, neurological and skin/soft tissue infection about 20.5% each. Pathology in the lungs was seen in most of the patients by CT scan; discrete nodules and wedge shaped pleural based consolidations were the most frequent findings. Brain lesions consistent with abscesses were detected in 10 patients by brain imaging. Some cases had relapsing disease in spite of antimicrobial treatment. 25% of examined isolates were resistant to trimethoprim/sulfamethoxazole. The duration of intravenous antimicrobial treatment ranged from one month to over a year in the severe cases. One year mortality rate was 32%.nnnCONCLUSIONnNocardiosis requires a high clinical index of suspicion in order to diagnose and treat promptly. Disease extent and bacterial susceptibility have important implications for prognosis and treatment.

Future Prospects and Therapeutic Potential of Streptogramins

SummaryDramatic changes in the epidemiology and susceptibility patterns of Gram-positive cocci during the last decade have mandated new approaches to the management of many bacterial infections. For example, there has been a sharp increase in the incidence of infections caused by Staphylococcus aureus, particularly those resistant to methicillin (MRSA), and methicillin-resistant coagulase-negative staphylococci, particularly those associated with foreign bodies and indwelling medical devices. Additionally, the worldwide spread of Streptococcus pneumoniae strains resistant to penicillin and macrolides, and the emergence of enterococci (particularly Enterococcus faecium) resistant to vancomycin, teicoplanin and other antibiotics, present further therapeutic problems.New antibacterial agents are urgently required to meet the challenges posed by these epidemiological trends. The semisynthetic streptogramins, a unique class of antibacterials currently under development, offer promise in the treatment of such multiresistant infections. Possible future applications include treatment of infections caused by the following organisms: MRSA, enterococci resistant to vancomycin, macrolides or lincosamides; and β-lactam-resistant streptococci. They may also prove useful as therapy for children with staphylococcal infection and patients with multiresistant infections who are unable to tolerate vancomycin, including patients with skin and soft tissue infections caused by Gram-positive pathogens, patients with osteomyelitis, foreign body associated infections, endocarditis and sepsis due to Gram-positive bacteria. Clinical trials are required to evaluate the efficacy and tolerability of streptogramins in these settings.

False-Positive Urine Cultures Using Bag Collection

To the editor: Urinary tract infections (UTI) are a relatively common cause of febrile illness in the first 2 years of life. The majority of UTIs are occult, and most remain undiagnosed if specific tests are not included. Undiagnosed and untreated UTIs can lead to renal scarring, an established risk factor for subsequent hypertension and for end-stage renal failure. Mistakes in the diagnosis of UTI are common because of the difficulty in distinguishing between genuine bacteriuria and contamination of the sample. The methods commonly used for urine collection in infants are bags, suprapubic aspiration (SPA), bladder catheterization, and midstream collection.2 Several studies3,4 compared the reliability of the different methods of urine collection for bacteriological studies. The SPA was recommended over the other methods because of its reliability. However, pediatricians and neonatologists continue to choose bag collection because it is easy to carry out and is noninvasive. Therefore, we conducted a prospective study to evaluate the diagnostic price of the convenience of bag collection compared with SPA. Fifty infants (31 males and 19 females) fulfilled the inclusion criteria of this study: age between birth and 18 months (mean and median ages were 2.8 and 1.4 months, respectively), suspected diagnosis ofUTI or neonatal fever indicating urine culture as part of the sepsis workup, and no antibiotic treatment during the preceding week. Infants with anatomic defects or systemic diseases preventing urine collection by any one of the two methods were excluded. Urine was collected from all patients first by SPA and then by bag collection. Using the SPA results as a gold standard, the bag collection results were assessed for sensitivity, specificity, and positive and negative predictive values. Pure growth was obtained from seven specimens collected by the SPA method, while the bag collection method yielded pure growth from 14 specimens and mixed growth in 23 specimens. All but one case with mixed growth occurred in specimens that were sterile by the SPA technique. In all, 13 urine specimens taken by bag collection revealed a negative culture, a result similar to that obtained by the SPA technique. The contamination rate of the bag technique was 62% while the true UTI rate was only 14%. The sensitivity, specificity, positive predictive value, and negative predictive values were 100%, 30%, 19%, and 100%, respectively. SPA was performed with no difficulties or complications and obtained urine in all subjects. Significant bacteriuria in urine culture has been the sole requirement for the diagnosis of UTI. Bacteriuria can, however, arise from contamination of the urine specimen, colonization of the urinary tract (asymptomatic bacteriuria), or UTI. The main problem is the difficulty in distinguishing between genuine bacteriuria versus contamination. For infants, urine collection methods are either invasive (bladder catheterization and SPA) or noninvasive (bag collection and midstream collection for circumcised males2). In spite of its being

Effect of benzathine penicillin treatment on antibiotic susceptibility of viridans streptococci in oral flora of patients receiving secondary prophylaxis after rheumatic fever

OBJECTIVEnTo assess the level of antibiotic resistance of viridans streptococci in the oral flora of children with a history of rheumatic fever, receiving long-term monthly intramuscular benzathine penicillin G prophylaxis.nnnPATIENTS AND METHODSnOral swabs from patients receiving monthly penicillin G prophylaxis for rheumatic fever were cultured and tested for viridans streptococci. The E-test was used to test susceptibility to penicillin G, clindamycin, clarithromycin and rifampin. Findings were compared with samples from healthy children who had not been exposed to antibiotic treatment for at least 2 months.nnnRESULTSnTwenty-six patients and 20 control children were included in the study. Duration of intramuscular antibiotic treatment ranged from 5 months to 13.5 years. Sixty isolates of viridans streptococci species were obtained, with a similar distribution in the two groups. Intermediate resistance to penicillin (MIC 0.25-2 mg/L) was documented in 10 of the 32 isolates (31.2%) in the study group, and high resistance in none, compared to seven of 28 isolates (25%) with intermediate or high resistance in the control group (p=NS). All isolates in the study group and all but one in the control group were susceptible to clindamycin, and all isolates from both groups were susceptible to rifampin. One isolate (3.1%) in the study group and two (7.1%) in the control group were resistant to clarithromycin.nnnCONCLUSIONnMonthly Intramuscular penicillin prophylaxis has no effect on the antibiotic susceptibility of viridans streptococci in oral flora in children with a history of rheumatic fever, receiving secondary prophylaxis after rheumatic fever, regardless of the duration of treatment.

Postsurgical Prevertebral Abscess of the Cervical Spine

Objectives Prevertebral abscess formation is an uncommon occurrence following cervical spine fusion surgery. Abscesses may present early or in a delayed fashion and require surgical drainage and long‐term antibiotic treatment. The issues of osteomyelitis and the need for plate removal remain unresolved.

Fecal microbial characterization of hospitalized patients with suspected infectious diarrhea shows significant dysbiosis

Hospitalized patients are at increased risk for acquiring healthcare-associated infections (HAIs) and inadequate nutrition. The human intestinal microbiota plays vital functions in nutrient supply and protection from pathogens, yet characterization of the microbiota of hospitalized patients is lacking. We used 16S rRNA amplicon sequencing to characterize the global pattern of microbial composition of fecal samples from 196 hospitalized patients with suspected infectious diarrhea in comparison to healthy, non-hospitalized subjects (nu2009=u2009881), and to traditional culture results. We show that hospitalized patients have a significant rise in α-diversity (richness within sample) from birth to <4 years of age, which continues up to the second decade of life. Additionally, we noted a profoundly significant increase in taxa from Proteobacteria phylum in comparison to healthy subjects. Finally, although more than 60% of hospitalized samples had a greater than 10% abundance of Proteobacteria, there were only 19/196 (10%) positive cultures for Campylobacter, Salmonella, or Shigella entero-pathogens in traditional culturing methods. As hospitalized patients have increased risk for HAIs and inadequate nutrition, our data support the consideration of nutritional and/or microbial modification in this population.

Bacteremia caused by a highly-resistant Streptococcus pneumoniae serotype 19A circulating in a daycare center

We describe the clinical course of a previously healthy 20-month-old toddler admitted with high fever and leukocytosis. Blood culture grew Streptococcus pneumoniae serotype 19A, belonging to the ST663 clone, highly resistant to penicillin, ceftriaxone, and erythromycin. The same clone with identical antibiogram was isolated from the nasopharynx of another three of the other five healthy children attending the same daycare center as the patient. This case exemplifies the potential problems posed by highly-resistant S. pneumoniae serotype 19A, an emerging pathogen worldwide.

Determination of coproporphyrinogen III oxidase activity in bacteria

Abstract A rapid HPLC method for determining protoporphyrin is employed in the procedure described for measuring coproporphyrinogen III oxidase (CO) activity in bacteria. The activity was found to be linear with protein up to 300 μg/assay and with incubation time up to 2 h. CO activities measured in Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae were found to be 237, 128 and 22 pmol protoporphyrin/mg protein/h, respectively.