Waleed Javaid

Klebsiella pneumoniae Liver Abscess: An Emerging Disease☆

ABSTRACT Most of the cases of Klebsiella pneumoniae liver abscess reported early on were from Asia, predominantly Taiwan, with a significant number of patients being middle aged diabetic men, and developing metastatic complications, especially endophthalmitis. The entity is now being increasingly recognized in the United States. In this article, the authors review those reported cases, and also the literature regarding the pathophysiology of this intriguing syndrome.

Role of procalcitonin in guiding antibiotic therapy.

PURPOSE The role of procalcitonin in guiding antibiotic therapy is reviewed. SUMMARY Procalcitonin is a prohormone for calcitonin, which is secreted by the parafollicular cells of the thyroid gland. The biological activity of procalcitonin is significantly different from calcitonin and is believed to be part of the complex inflammatory cascade of the immune system. Procalcitonin has been shown to be elevated in bacterial infections but not in viral infections or other inflammatory conditions. The first published study that suggested that procalcitonin levels increased in the presence of bacterial infection was conducted in France in the early 1990s. Numerous studies have been conducted using procalcitonin-guided therapy to reduce antibiotic use. These studies were performed in one of three clinical settings: outpatient primary care (two multicenter, noninferiority studies of patients with upper- and lower-respiratory-tract infections), emergency room and inpatient (five studies in patients with chronic obstructive pulmonary disease, exacerbation, bronchitis, or community-acquired pneumonia), and the intensive care unit (ICU) (two studies in medical ICU patients and two in postoperative ICU patients with infection or sepsis). Based on the findings of these studies, a cutoff value of 0.25 μg/L in non-ICU patients or of 0.5 μg/L in ICU patients seems appropriate for making a decision about the initiation and discontinuation of antibiotic therapy. In patients with a significantly elevated baseline procalcitonin level, a subsequent drop of >80% appears to be reasonable for discontinuing antibiotics. CONCLUSION Published evidence supports the use of procalcitonin as a biomarker of bacterial infection that can be used to reduce antibiotic exposure.

An 86-year-old man with septic arthritis of the knee

Department of Medicine/Infectious Disease, State University of New York Upstate University, Syracuse, New York, USA Correspondence: Dr Tasaduq Fazili, Department of Medicine/Infectious Disease, State University of New York Upstate Medical University, 725 Irving Avenue, Syracuse, New York 13104, USA. Telephone 315-464-9360, fax 315-464-9361, e-mail fazilit@upstate.edu Case presentation An 86-year-old man with a medical history significant for an aortic valve replacement and pacemaker insertion >20 years previously developed a stress fracture of the left leg, which was placed in an immobilizer cast. One week later, he developed progressive left knee swelling and was admitted to the hospital. A physical examination was significant only for a grade 2 (of 6) systolic murmur over the aortic area, and mild swelling and tenderness of the left knee. The surrounding skin was not erythematous. He exhibited leukocytosis with a white blood cell count of 15.1×109/L. An aspirate of joint fluid from the left knee revealed a white blood cell count of 12.9×109/L with 82% neutrophils. A Gram-stained smear of the joint fluid revealed many white blood cells with no bacteria. Culture of this aspirate for bacteria and fungi was negative. A bone scan showed increasing uptake in the left tibia, suggestive of osteomyelitis. The patient was discharged on four weeks of ceftriaxone (2 g intravenously once per day) for presumed bacterial septic arthritis/osteomyelitis. He presented three weeks later with increasing left knee pain and swelling. A joint washout of the knee and surgical debridement of the proximal tibia was performed. A Gram stain (Figure 1) and modified acid-fast stain (Figure 2) of the joint fluid are shown.

Cardiobacterium Hominis Endocarditis of Bioprosthetic Pulmonic Valve:Case Report and Review of Literature

Cardiobacterium hominis is a gram-negative rod and is an uncommon cause of infective endocarditis. Here we report the first published case description of C. hominis endocarditis of the pulmonic valve homograft in a patient who had previously undergone the Ross procedure.