Volume 25, Issue 2, 2017
Review
Infections in patients affected by liver cirrhosis: an update
Ascione Tiziana,
Di Flumeri Giusy,
Boccia Giovanni,
De Caro Francesco
Patients with liver cirrhosis present an increased incidence of infections.
The main cause has been founded in alterations of the enteric flora and of the intestinal barrier probably due to portal hypertension, in addition to a reticulo-endothelial system dysfunction. Furthermore, those living with cirrhosis can report a high predisposition to sepsis and septic shock, due to the excessive response of pro-inflammatory cytokines and a complessive hemodynamic derangement.
By the analysis in the experimental model of the cirrhotic rat, it was demonstrated that radio-labelled Escherichia coli given by the oral route resulted in the location of the bacteria in the gut, the ascitic fluid and mesenteric lymph nodes, a phenomenon known as bacterial translocation.
Bacteria encountered with the highest frequency are those colonizing the intestinal tract, such as E. coli, Klebsiella pneumoniae and Enterobacteriaceae, intracellular bacteria and parasites are reported with a lower frequency. Multi-drug resistant bacteria are cultured with the highest frequency in those with frequent hospitalisations and report both high septic shock and mortality rates.
Spontaneous bacterial peritonitis (SBP) is the commonest infection in cirrhotic, estimated to occur in 10-30% of the cases with ascites. A practical approach may include administration of a protected penicillin, III generation cephalosporin or quinolones in uncomplicated cases. Instead, in complicated cases and in nosocomial SBP, administration of cephalosporin or quinolones can be burned by the high resistance rate and drugs active against ESBL-producing bacteria and multi-drug resistant Gram positive bacteria have to be considered as empiric therapy, until cultures are available. When cultures are not readily available and patients fail to improve a repeated diagnostic paracentesis should be performed. Current investigations suggest that norfloxacin 400 mg/day orally has been reported to successfully prevent SBP in patients with low-protein ascites and patients with prior SBP.
Original article
Patterns of multi-drug resistant bacteria at first culture from patients admitted to a third level University hospital in Calabria from 2011 to 2014: implications for empirical therapy and infection control
Reale Mariaconcetta,
Strazzulla Alessio,
Quirino Angela,
Rizzo Claudia,
Marano Vito,
Postorino Maria Concetta,
Mazzitelli Maria,
Greco Giuseppe,
Pisani Vincenzo,
Costa Chiara,
Cesana Bruno Mario,
Liberto Maria Carla,
Torti Carlo,
Focà Alfredo
Surveillance of antimicrobial drug resistance is fundamental to guide empirical treatment. However, the European Antimicrobial Resistance Surveillance Network provides a general picture, which might not be applicable to clinical settings that are excluded from this survey. We evaluated resistance patterns of ESKAPE isolates over a four-year period in a third level University hospital in the province of Catanzaro (Southern Italy).
In this retrospective study, we evaluated the frequency of ESKAPE isolates with different resistance patterns (group 1=low-resistant bacteria; group 2=multi-drug and extremely drug-resistant bacteria; group 3=pan-resistant bacteria), stratified by year (2011, 2012, 2013 and 2014), hospital units (intensive care units, medical and surgical units) and by sample type (urine, blood, wound swabs, respiratory samples, other samples). χ2 test was applied to find differences between isolates with different resistance patterns by hospital unit and by organs and systems. Cochran-Armitage trend test was applied to assess the trend in resistance patterns during the four years analyzed.
Amongst 2385 isolates, Escherichia coli (38%) was the most frequent, followed by Pseudomonas aeruginosa (15%), Klebsiella pneumoniae (14%), Staphylococcus aureus (13%), Acinetobacter baumannii (9%), Enterococcus faecalis (8%) and Enterococcus faecium (3%). From 2011 to 2014, frequency of isolates in group 2 plus 3 decreased from 23% to 14% (χ2=55.093; p<0.0001), particularly for E. coli and K. pneumoniae, but the trend increased for S. aureus (from 5% in 2011 to 10% in 2014), and remained stable for the other species. Frequency of isolates in group 2 plus 3 was higher in intensive care units for K. pneumoniae (χ2=32.292; p<0.0001), A. baumannii (χ2=6.947; p<0.0001) and S. aureus (χ2=22.079; p<0.0001). It was also higher from blood than from different sources for most species.
Our results provided indications for an empirical antimicrobial choice. Importantly, antibiotic resistances have declined in recent years, probably due to optimized infection control and therapeutic algorithms, but still remain a significant problem. In particular, A. baumannii and K. pneumoniae were the most difficult to treat but also the frequency of methicillin-resistant S. aureus appeared to be on the rise. In our hospital, surveillance and efforts to reduce multidrug resistant bacteria should be enforced, particularly focusing on these species, and in specific settings (i.e., intensive care units).
A surveillance system model for central line-associated bloodstream infections (CLABSI) coordinated at the regional level: a pilot feasibility study
Zeneli Anita,
Mezzadri Sergio,
Bertozzi Lucia,
Resi Davide,
Golinucci Monica,
Dodi Simona,
Prati Elena
We describe the methods used to define a surveillance model to incorporate into activities aimed at preventing central line-associated bloodstream infections (CLABSI) in non-critical care units (NCCUs) and designed to be implemented at the regional level. In 2015 we conducted a pilot feasibility study in three NCCUs based in hospitals of the Regional Health System of Emilia Romagna to evaluate the feasibility of the proposed model and to test its accuracy and cost-effectiveness in terms of resources needed to maintain the system. Our results indicate that the system is feasible at the regional level by using the available sources and instruments to collect data in clinical practice context. Observation of device utilization for at least three months in all NCCU wards is needed in order to prioritize the medical area on which to focus costs for surveillance prior to implementing it on a regular basis.
Molecular epidemiology and antibiotic resistance patterns of Enterococcus faecalis isolates from hospitals in Tehran
Saeidi Somayyeh,
Mirnejad Reza,
Zavaryani Sara Masoumi,
Rostamzadeh Shiva
Enterococcus faecalis is one of the most important causative agents of nosocomial infections. Control and prevention of these infections require appropriate epidemiological knowledge. This study investigated the correlation between molecular characteristics and drug resistance of E. faecalis isolates from local hospitals. A total of 125 isolates of Enterococcus faecalis from two hospitals in Tehran were identified by using culture and biochemical method. An antibiotic resistance assay was carried out by a disk diffusion method according to the Clinical and Laboratory Standards Institute guidelines. The genetic diversity of the strains was determined using a repetitive sequence-based polymerase chain reaction (REP-PCR) method. All isolates were typed by REP-PCR, and different PCR amplification products (from 9 to 17 amplified DNA fragments) were detected by gel electrophoresis. There were eight different PCR patterns (A–H), and a significant correlation was detected between the resistance to antibiotics and the obtained PCR patterns. The most relevant cases (28%) belonged to the fourth group (D). All group D isolates were resistant to tetracycline and quinupristin/dalfopristin. A high resistance to certain common antibiotics and clonal propagation were detected among isolates from patients in different wards of the hospitals. This study was the first to investigate E. faecalis isolates from Iranian patients and to describe patterns that showed correlation between infection prevalence and genetic origin/similarity of the isolates.
High frequency of hopQ genotypes among Iranian Helicobacter pylori clinical isolates
Dara Mahintaj,
Khashei Reza,
Dehghani Behzad
Different virulence factors are involved in Helicobacter pylori pathogenesis. H. pylori outer membrane proteins are a family of virulence factors that have diverse members. HopQ (H. pylori outer membrane protein) is the largest of them that contains types I and II alleles. The role of hopQ is not exactly known, but it has been considered in H. pylori adhesion and colonization. The aim of this study was to determine the frequency of hopQ genotypes among H. pylori isolates obtained from patients with gastroduodenal disorders and their association with the clinical outcome. The DNA of 100 H. pylori clinical isolates was investigated by polymerase chain reaction (PCR) method using specific primers for determining the hopQI and hopQII genotypes. hopQI was present in 35%, while hopQII was positive in 55% of the isolates. Amongst the gastritis subjects, the rate of hopQII compared to hopQI was higher, and a statistically significant difference was found between hopQII genotype and the clinical outcome. With respect to the significant difference between the hopQ genotype and clinical outcome in our clinical isolates, it seems that this genotype is a useful marker for evaluating its association with H. pylori-related diseases.
Identification of Aspergillus sections Flavi, Nigri, and Fumigati and their differentiation using specific primers
Ashtiani Nafiseh Mohebbi,
Kachuei Reza,
Yalfani Roozbeh,
Harchegani, Asghar Beigi,
Nosratabadi Mohsen
Aspergillus species are important in medicine, agriculture and various industries. The sections Fumigati, Flavi, and Nigri are the most important members of the Aspergillus genus. This study intended to identify and separate these three Aspergillus sections and to differentiate among them using specific primers. A bioinformatics study was initially performed to analyse the sequences of five genes, namely, beta-tubulin, calmodulin, the pre-rRNA processing protein Tsr1, the DNA-replication licensing factor Mcm7, and RNA polymerase II second largest subunit (RPB2) in the three Aspergillus sections using MEGA6 software and the NCBI database. Primers were designed to select genes for each of the Aspergillus sections being analysed. A total of 134 environmental and clinical Aspergillus species were isolated, purified and initially identified by colony morphology.. Subsequently, DNA was extracted using the phenol-chloroform method, specific primers were synthesized, PCR was performed for DNA from all isolates, and the results were compared to morphological characteristics. Of the 134 isolates tested, 56 were Nigri, 32 were Fumigati, 32 were Flavi, and the rest (14 isolates) belonged to other sections. The beta-tubulin and calmodulin genes were found to be the most suitable for differentiating among these three groups; the beta-tubulin gene was used for molecular identification of Aspergillus section Fumigati, and the calmodulin gene for identifying sections Flavi and Nigri.
Prevalence of intestinal parasitoses detected in Padua teaching hospital, Italy, March 2011 - February 2013
The aim of this study was to evaluate the distribution of parasitic intestinal infections in patients attending Padua teaching hospital during a two-year period. Between 1st March 2011 and 28th February 2013, we examined stool specimens from 7341 patients (6127 Italians, 1214 non-Italians) for ova and parasites using microscopy, rapid enzyme immunoassays, culture techniques and molecular methods. Stools of 1080 patients (14.71%) were positive for parasites; a total of 1349 intestinal parasites were counted. Protozoa were detected in 1028/1080 patients (95.19%), while helminths were present in 80/1080 patients (7.41%). The protozoa most commonly detected were Blastocystis spp., Dientamoeba fragilis and Giardia duodenalis. Enterobius vermicularis was the helminth most frequently encountered. Of the 1080 infected patients, 227 (21.02%) had more than one parasite in their stool. To conclude, in Italy intestinal parasitoses must be unquestionably considered in differential diagnoses of gastrointestinal diseases. For this purpose, sound knowledge of epidemiology is essential.
Where are we after 60 years of paragonimiasis research? A bibliometric assessment
Culquichicón Carlos,
Hernández-Pacherres Arturo,
Labán-Seminario L. Max,
Cardona-Ospina Jaime A. ,
Rodríguez-Morales Alfonso J.
Paragonimiasis is highly prevalent endemic food-borne disease in Southeast Asia and Latin America, and constitutes a major public health concern. A bibliometric analysis was performed about the worldwide scientific production of paragonimiasis. We browsed in the Science Citation Index-Expanded (SCI-E) (1957-2015), Scopus (1976-2015), Medline/PubMed/GoPubMed® (1970-2015), ScIELO (1981-2014) and LILACS (1985-2011). All types of articles were included and categorized by year of publication, number, type of scientific article, city and institution of origin, international cooperation, scientific journal, impact factor, language of publication, authors and H index. In SCI-E, 1,028 manuscripts were recovered, while Japan (21.9%) and the USA (17.7%) were the countries with highest scientific production. In this database, Asian region studies received 5,454 citations (H index=32). In Scopus 2161 items were recovered, corresponding to 45.8% of Asian countries. Japan (18.2%) was the first with the University of Miyazaki (11.7% of the country); South Korea (9.5%) was second with the Seoul National University (11.2% of the country). In SciELO 29 items were found, with no contributions from the Asian region. In LILACS 1487 articles were found (22.9% covering Asia). Among the databases, the Journal of Parasitology (Impact factor=1.227) showed the highest number of manuscripts and “Agatsuma T”, from Japan, was the author with most records. Japan and South Korea lead global scientific production on paragonimiasis. By contrast, in Latin America, production has been extremely low especially in the last five years.
What to start with in first line treatment of chronic hepatitis B patients: an Italian multicentre observational cohort, HBV-RER study group
Cuomo Gianluca,
Borghi Vanni,
Giuberti Tiziana,
Andreone Pietro,
Massari Marco,
Villa Erica,
Pietrangelo Antonello,
Verucchi Gabriella,
Levantesi Fabio,
Ferrari Carlo
Treatment options for chronic hepatitis B (CHB) are pegylated interferon (Peg-IFN) in minimal/mild liver fibrosis and nucleot(s)ide analogues (NUC) in more advanced disease. Since little is known about their use in daily clinical practice, we conducted a multicentre prospective study to investigate treatment regimens applied to naïve CHB patients in real life. HBV-RER is an observational multicentre Italian network that collect clinic and virologic data of patients with CHB. Among the 2527 CHB patients seen during the study period (2009 - 2012), 502 patients started a first line antiviral treatment. Liver biopsy was performed in 30.9% of the patients, with high levels of fibrosis being detected in 19.4% of them. In 216 patients (43%) Peg-IFN was used as first-line therapy while the remaining patients started NUC therapy (entecavir and tenofovir in 75%, lamivudine in 15%, telbivudine and adefovir 10%). By multivariate logistic regression, an age under 40 (OR 0.92, 95%IC 0.90-0.94; p <0.001) and the execution of liver biopsy (OR 3.83; 95%IQR 1.76-8.36; p <0.001) were the only determinants of choice between Peg-IFN vs NUC.
Peg-IFN was expected to be used in first-line treatment for CHB in 70% of the patients based on Italian recommendations, but a much lower proportion of patients were actually treated with Peg-IFN with a limited use of the biopsy. Thus, in daily clinical practice physicians prefer to use NUCs, presumably because of their optimal tolerability and anti-viral efficacy, even if they frequently require life-long treatment as opposed to the short duration of Peg-IFN.
Case report
Drug resistant pulmonary tuberculosis mimicking a flu-like syndrome in an elderly man: an atypical case report
Hadjipetrou Athanasios,
Anyfantakis Dimitrios,
Damianaki Angeliki,
Krietsepi Vasiliki,
Kastanakis Serafim
Despite remarkable reductions in its incidence and mortality, tuberculosis (TB) continues to be a major health burden globally. Pulmonary TB occasionally challenges physicians, either due to TB's ability to mimic many different conditions or because of the increasing number of drug-resistant Mycobacterium tuberculosis isolates. Here we present a case of pulmonary TB with both characteristics and a brief review of the relevant literature.
Miliary tuberculosis: the role of necropsy studies
dos Santos Vitorino Modesto,
dos Santos Lister Arruda Modesto
This case study of generalized miliary tuberculosis in a Brazilian man without AIDS is reported in order to emphasize the role of histopathological study for diagnosis. We comment on a recent Indian study involving 40 cases of surgical and necropsy specimens in which the diagnosis of tuberculosis was made, as well as a previous Brazilian case report. The authors believe that non-specialists should be better informed about the possibility of miliary tuberculosis, which involves clinical diagnostic challenges. Despite limitations, minimally invasive necropsy may be an alternative to elucidate causes of death in low-income countries.
Contact lens-related Fusarium keratitis: a case report
Amadasi Silvia,
Federico Giovanni,
Colombini Paolo,
Bonomini Annalisa,
Farina Claudio,
Pietrantonio Filomena,
Pedroni Palmino
We aim to highlight the key factors for a good outcome of fungal keratitis. We describe a case of contact lens-related Fusarium keratitis in a young girl. After identification of Fusarium spp under direct microscopic examination and in culture, a prolonged treatment with topic natamycin 5% was started and administered for five months with restitutio ad integrum of the eye. Prompt microbiological diagnosis and a specific and prolonged treatment are essential for correct management of Fusarium keratitis.
Retropharyngeal abscess with cervical diskitis and vertebral osteomyelitis caused by Escherichia coli in a patient with liver cirrhosis
Sakaguchi Ayu,
Ishimaru Naoto,
Ohnishi Hisashi,
Kawamoto Megumi,
Takagi Asuka,
Yoshimura Sho,
Kinami Saori,
Sakamoto Susumu
We describe the case of a 67-year-old male with liver cirrhosis who presented with fever and neck pain. Magnetic resonance imaging of the spine detected cervical vertebral osteomyelitis, and enhanced CT of the neck and spine revealed retropharyngeal abscess. The patient was treated with empirical antimicrobial therapy and surgical drainage due to significant airway involvement. Escherichia coli was cultured from the blood and pus in inferior cervical vertebrae which was a rare pathogen. Haematogenous spread may have resulted in cervical vertebral osteomyelitis and retropharyngeal abscess. With high mortality rates, early diagnosis of retropharyngeal abscess is required to avoid debilitating complications such as airway obstruction.
Cerebrospinal fluid shunt-associated meningitis caused by Gordonia sputi: case report and review of the literature
Martín Daniel,
Barrios Ana,
Domingo Diego,
Sánchez Pedro,
Sánchez Marta,
Ruiz-Dassy Ana,
Miqueleiz Ana,
Sanz Jesús
We report the first known case of cerebrospinal fluid (CSF) shunt-associated meningitis caused by Gordonia sputi and review published cases of Gordonia CNS infections.
The Infections in the History of Medicine
The study of ocular tuberculosis during the 19th and early 20th century
Laios Konstantinos,
Moschos Marilita M.,
Androutsos George
During the 19th and early 20th century the achievements in the study of ocular tuberculosis were of great significance. The development of pathological anatomy in those years helped physicians to understand the histological image and the pathophysiology of the disease and allowed the scientists to detect the specific anatomical structures of the eye, where the disease could be present. The physicians of those years tried to describe the clinical image of the disease and to give value information, in order to facilitate the diagnosis. Despite major efforts made in the field of clinical approach to ocular tuberculosis, the treatment of the disease in those years was not very effective. Nevertheless, the physicians of the time used every new pharmacological or not pharmacological treatment to fight the disease.
The treatment of wounds during World War I
Sabbatani Sergio,
Fiorino Sirio
The First World War was a huge tragedy for mankind, but, paradoxically, it represented a source of significant progress in a broad series of human activities, including medicine, since it forced physicians to improve their knowledge in the treatment of a large number of wounded soldiers. The use of heavy artillery and machine guns, as well as chemical warfare, caused very serious and life-threatening lesions and wounds. The most frequent causes of death were not mainly related to gunshot wounds, but rather to fractures, tetanus and septic complications of infectious diseases. In the first part of this article, we describe the surgical procedures and medical therapies carried out by Italian physicians during the First World War, with the aim of treating wounded soldiers in this pre-antibiotic era. Antibacterial solutions, such as those of Dakin-Carrel and sodium hypochlorite and boric acid, the tincture of iodine as well as the surgical and dressing approaches and techniques used to remove pus from wounds, such as ignipuncture and thermocautery or lamellar drainage are reported in detail. In the second part of the paper, the organization of the Italian military hospitals network, the systems and tools useful to transport wounded soldiers both in the front lines and in the rear is amply discussed. In addition, the number of soldiers enrolling, and those dying, wounded or missing during the Great War on the Italian front is estimated.
Letters to the editor
New strategies for the eradication of Aedes aegypti: what challenges do we face in Latin America?
Abstract not available
Erratum
Erratum: An unnoticed origin of fever: Periapical tooth abscess – Three case reports and literature review
Arslan Ferhat,
Karagöz Ergenekon,
Arslan Birsen Yigit,
Mert Ali
Erratum
Following publication of the Original article
An unnoticed origin of fever: Periapical tooth abscess – Three case reports and literature review
(Infez. Med., volume 24, issue 1, pages 67-70, year 2016)
We became aware that some authors were missing from the title page
The correct list of the authors and affiliations is the following
An unnoticed origin of fever: Periapical tooth abscess – Three case reports and literature review
Ferhat Arslan1, Ergenekon Karagöz2, Mesut Yilmaz1, Ayse Batirel3, Birsen Yigit Arslan4, Nedim Ozer5, Nadir Alpay6, Ali Mert1
1Department of Infectious Diseases and Clinical Microbiology, Istanbul Medipol University Hospital, Istanbul, Turkey
2Department of Infectious Diseases and Clinical Microbiology, Van Military Hospital, Van, Turkey
3Department of Infectious Diseases and Clinical Microbiology, Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
4Department of Anesthesiology and Reanimation, Esenyurt State Hospital, Istanbul, Turkey
5Department of Dentistry, Istanbul Medipol University Hospital, Istanbul, Turkey
6Department of Internal Medicine, Istanbul Medipol University Hospital, Istanbul, Turkey
