Volume 21, Issue 4, 2013
Review
Recurrent tuberculosis: relapse or reinfection?
Schiroli Consuelo,
Franzetti Fabio
Recurrent tuberculosis (TB) is an issue that makes worldwide eradication of the disease difficult, especially in countries with a high incidence of TB. Recurrent TB may be due to relapse of the original episode or to an exogenous reinfection caused by a different strain of Mycobacterium tuberculosis. We performed a meta-analysis of selected studies on recurrent TB from 2000 to 2013, adopting molecular genotyping to discriminate between exogenous reinfection and relapses, in order to specifically evaluate the role of HIV infection in the origin of recurrence. Comparison among the studies was limited by the population heterogeneity of the different studies in terms of epidemiology, health status, and diagnostic and therapeutic approach. However, exogenous reinfections are more common in high-burden countries, where HIV infection plays a major role in increasing the risk of a new infection. In contrast, this finding was not confirmed in low-burden countries. Vice versa, globally recognized factors for TB relapse were low compliance to anti-tuberculous treatment, multidrug resistance and persistence of cavitations in the lung parenchyma. The role of other factors like social conditions (immigration, homelessness, working conditions), co-morbidities (silicosis), and characteristics of anti-TB treatment is still controversial.
Original article
Annual report on norovirus in children with acute gastroenteritis in 2009 and their genotypes in Turkey
Çöl Defne,
Biçer Suat,
Çiler Gülay,
Giray Tuba,
Gürol Yeşim,
Yılmaz Gülden,
Küçük Öznur ,
Vitrinel Ayça
In order to determine the incidence, seasonal distribution and clinical characteristics of norovirus in children and analyse the genogroups of norovirus, immunochromatography was used to detect the virus in stool samples. Randomly selected subsets of samples were analysed for genogroups with a multiplex polymerase chain reaction method. Seasonal distribution of norovirus, symptoms, physical and laboratory findings of patients and treatment models were evaluated retrospectively in 2009. In all, norovirus was examined in 520 stool samples. The infection rate was 9.6% (50/520) among patients of acute gastroenteritis in 2009. The virus was mostly detected in the first 24 months of life (50%). Gastroenteritis with norovirus was most frequently found in February, May, July and September. The main symptoms were diarrhoea (100%) and vomiting (95.5%). In some patients affected by norovirus infection higher urine density, ketonuria and high CRP levels were observed. Antiemetic drugs and intravenous fluid-electrolyte therapy were given to 37 (84%) and 26 (59%) of patients, respectively. Hospitalisation was required in 11 patients (25%). All the randomly selected 28 samples (100%) had norovirus genogroup II. In conclusion, norovirus (genogroup II) mostly affected children in the first two years of life and was more frequently observed in February, May, July and September of 2009. Diarrhoea and vomiting were the most frequent symptoms. Antiemetic drugs, intravenous fluid-electrolyte therapy and hospitalisation were usually required in these patients.
Early discharge of infectious disease patients: an opportunity or extra cost for the Italian Healthcare System?
Palmieri Fabrizio,
Alberici Francesco,
Deales Alberto,
Furneri Gianluca,
Menichetti Francesco,
Orchi Nicoletta,
Quesada-Rodriguez Carolina,
Pilli Stefano,
Rapisarda Franco,
Tassielli Domenica,
Tringali Michele,
Esposito Silvano,
Ippolito Giuseppe
In order to assess the economic benefits of an early discharge (ED) programme for patients with complicated skin and soft tissue infections (cSSTIs) in terms of hospital and regional authority costs, an economic analysis was conducted comparing two possible alternatives: standard hospital management vs. an ED strategy followed by a period of outpatient management. Utilization of resources and costs were derived from the literature and expert panel evaluation. Patients were classified into four groups: low-intensity non-walking (LINW), low-intensity walking (LIW), high-intensity non-walking (HINW) and high-intensity walking (HIW). The overall costs (inpatient/outpatient) of hospitalization with ED for cSSTIs range from €2,079 for LIW to €2,193 for HINW, with the most expensive regimen (HINW) being 50% lower than the costs for 12.6 days of hospitalization alone (€4,619). The weighted average Diagnosis Related Group (DRG) reimbursement for cSSTIs (€2,042) does not cover the costs of such hospitalization. In conclusion, when a patient's conditions allow for early discharge there is an economic advantage for the hospital with an outpatient management plan, especially for patients requiring low-intensity care. However, this could be disadvantageous in terms of regional costs if outpatient management has to be paid in addition to payment by the DRG.
Tuberculosis deaths in a tertiary hospital in Goiânia, Brazil: a descriptive study
Tuberculosis deaths in a tertiary hospital in Goiânia, Brazil: a descriptive study
Tavares Camila,
Acioli Lins Tatiana Bacelar,
Junqueira-Kipnis, Ana Paula,
de Araújo-Filho João Alves
Tuberculosis (TB) remains a serious global public health problem, being the main cause of death in patients with AIDS, and the third cause of death by infectious diseases throughout the world. This is somewhat surprising because TB is a disease that, if treated properly, displays high rates of healing. It is therefore important to characterise these patients to identify target populations for specific measures seeking to reduce TB deaths. We performed a retrospective descriptive study to analyse the cases of TB deaths in a State public hospital, a point of reference for treatment of infectious diseases, located in the Central-West region of Brazil, in the period from January 1st, 2008 to December 31st, 2009. There were 283 diagnosed and reported cases of TB between 2008 and 2009, and 39 recorded deaths occurred, resulting in a lethality index of 14%. The mean age of TB patients was 42 years, and the median age 37 years. Pulmonary TB was the most common form of TB (51.3% of the patients). Of the 39 TB patients who died, 56.4% (n = 22) were co-infected with HIV. The main immediate causes of death were acute respiratory failure (n = 12) and sepsis (n = 8). Anaemia and hypoalbuminaemia were prevalent in this group, and 27 patients required mechanical ventilation. This study found that hospitalized patients who died had the following characteristics: bilateral pulmonary disease, low levels of haemoglobin and haematocrit, albumin, and those co-infected with HIV that were admitted to the ICU required MV. Prospective studies aiming to analyse the risk factors for death from TB are needed to better understand this process.
In vitro and in vivo effects of sub-MICs of pexiganan and imipenem on Pseudomonas aeruginosa adhesion and biofilm development
Cirioni Oscar,
Silvestri Carmela,
Ghiselli Roberto,
Kamysz Wojciech,
Minardi Daniele,
Castelli Pamela,
Orlando Fiorenza,
Kamysz Elzbieta,
Provinciali Mauro,
Muzzonigro Giovanni,
Guerrieri Mario,
Giacometti Andrea
An in vitro and in vivo study was performed to quantify adhesion and biofilm formation ability of Pseudomonas aeruginosa slime producer under the effect of sub-minimal inhibitory concentrations (MICs) of pexiganan and imipenem. To evaluate adherence, squares of ureteral stents were placed in six-well tissue-culture plates containing 6 ml of a cell suspension grown in the presence of sub-MICs of study antibiotics. To evaluate biofilm formation sterilized squares were placed in six-well tissue culture plates containing 6 ml of triptic soy broth (TSB) supplemented with 0.25% of glucose and the respective amount of antibiotic. For in vivo study a biofilm infection rat model was performed. The study included an uninfected control group to evaluate the sterility of surgical procedure, a group infected with a slime-producer P. aeruginosa strain not previously treated with antibiotics and two groups infected with the strain previously treated with imipenem or pexiganan. Adherence and biofilm in vitro formation was strongly affected by pre-treatment with pexiganan and imipenem, with the latter being the more effective antibiotic. The in vivo results showed a reduction in bacterial load on the ureteral stent tissue of the pre-treated strain. Differently, urine cultures showed no differences in bacterial growth for the pre-treated strain showing that it retained its ability to cause infection. This study suggests that sub-MIC imipenem and pexiganan could be a good strategy to target the adhesion process during the infection cycle.
Absence of occult HCV infection in patients experiencing an immunodepression condition
Pisaturo Mariantonietta,
Guastafierro Salvatore,
Filippini Pietro,
Tonziello Gilda,
Sica Antonello,
Di Martino Filomena,
Sagnelli Caterina,
Ferrara Maria Giovanna,
Martini Salvatore,
Cozzolino Domenico,
Sagnelli Evangelista,
Coppola Nicola
The aim of our study was to evaluate the presence of occult HCV infection in two settings of patients experiencing immunosuppression: patients with Human Immunodeficiency Virus (HIV) infection and those with onco-haematological disease. Sixty consecutive HIV-positive/anti-HCV-negative/HCV RNA-negative patients (HIV group) and 32 consecutive anti-HCV/HCV RNA negative patients with an onco-haematological disease first undergoing chemotherapy (Onco-haematological group) were enrolled. HCV-RNA was sought by real time RT-PCR in plasma and Peripheral Blood Mononuclear Cell (PBMC) samples obtained at enrolment and during follow-up, in the patients in the HIV group every three months and in those in the onco-haematological group at months 1 and 3 during chemotherapy and then every three months after treatment discontinuation. No plasma or PBMC sample collected at enrolment and during the follow-up in the HIV and onco-haematological groups was HCV RNA positive. The results of this study rule out the existence of occult HCV infection in patients with strong immunosuppression due to different conditions, HIV infection and onco-haematological diseases.
Case report
A particular case of tubercular pneumonia
Bovero Anna,
Panarello Alessandro,
Artom Francesco,
Mela Donatella,
Artom Alberto
A 50-year-old woman was seen for fever and persistent cough, with elevated phlogosis markers and a cavitary lesion at the right upper pulmonary lobe at thoracic CT. Even in the absence of any culture-positive finding, but given the strong suspicion of tubercular disease, the patient was treated with standard antitubercular quadruple therapy for two months (isoniazid, pyrazinamide, rifampin and ethambutol) and later with two-drug therapy (isoniazid and rifampin). One month after the beginning of this second regimen we observed clinical relapse and a rise in phlogosis markers. We supposed partial resistance to therapy and, without any antibiogram, we decided to introduce therapy with oral levofloxacin (stopped for polyneuropathy) and then oral linezolid. At the end of therapy we observed complete clinical and radiological healing.
In our opinion this clinical case shows clearly the diagnostic and therapeutic issues of the tubercular disease: the need to start therapy even in the absence of positive cultures, the presence of resistance to conventional therapy and the possibility of alternative therapeutic regimes with oral antibiotics.
Vacuum-assisted therapy accelerates wound healing in necrotizing soft tissue infections: our experience in two intravenous drug abuse patients
Marinis Athanasios,
Voultsos Mavroudis,
Grivas Paraskevas,
Dikeakos Panagiotis,
Liarmakopoulos Emmanouil,
Paschalidis Nicholas,
Rizos Spyros
Negative pressure wound therapy using vacuum-assisted closure (VAC) devices is currently a well established technique for managing complicated wounds. Such wounds occur after aggressive surgical debridement for necrotizing soft tissue infections (NSTI). In this report we present our experience in two intravenous drug abusers managed with VAC for NSTIs. The patients were 25 and 34 years old, HCV positive and presented with oedema of the upper femoral compartments and concomitant severe sepsis. Ultrasonography and computed tomography revealed severe cellulitis, fluid collection and necrosis of the affected fasciae and muscles. After emergent and subsequent aggressive surgical debridement during the first 48h, the VAC device was applied. Both patients had an uncomplicated postoperative course and a fast recovery from their multiorgan dysfunction. Suture closure of the wounds was achieved at the 25th and 38th postoperative days respectively and patients were discharged without any motor deficit. Negative pressure wound therapy is a modern therapeutic modality for treating complicated infected wounds. Moreover, it accelerates wound healing and primary closure, facilitating patient ambulation and recovery. A dedicated medical and nursing team is an important prerequisite for a successful outcome.
Is Chryseobacterium indologenes a shunt-lover bacterium? A case report and review of the literature
Ozcan Nida,
Dal Tuba,
Tekin Alicem,
Kelekci Selvi,
Can Sukran,
Ezin Ozgur,
Kandemir Idris,
Gul Kadri
Chryseobacterium indologenes is a non-fermentative Gram-negative bacillus formerly belonging to the Flavobacterium genus. It is widely found in water and soil, also on wet surfaces of the hospital environment. It rarely causes infections and is usually associated with altered immune status or indwelling devices. We present a case of ventriculoperitoneal shunt infection caused by C. indologenes in a premature pediatric patient. A six-month-old male infant with congenital hydrocephalus and ventriculoperitoneal shunt was admitted with complaints of irritability, high fever and projectile vomiting. He was diagnosed as suffering from meningitis based on the clinical symptoms and laboratory findings of cerebrospinal fluid. The ventriculoperitoneal shunt was externalized and cerebrospinal fluid samples were sent for bacterial cultures. The isolated bacterium was identified as C. indologenes by conventional methods and the BD PhoenixTM 100 (Becton Dickinson, MD, USA) fully automated microbiology system. Antimicrobial susceptibility testing was performed by the microdilution method and Kirby-Bauer’s disk diffusion method according to the Clinical and Laboratory Standards Institute guidelines. The isolate was found susceptible to ciprofloxacin, levofloxacin, cefoperazone and trimethoprim-sulfamethoxazole, while it was resistant to amikacin, aztreonam, cefepime, ceftazidime, gentamicin, imipenem and ticarcillin-clavulanic acid. The treatment was started with trimethoprim-sulfamethoxazole and cefoperazone-sulbactam The ventriculoperitoneal shunt was then removed. The patient was fully healed after two weeks and discharged. Central nervous system infection is a rare form of C. indologenes infections. The case presented herein may make a useful contribution to the existing literature.
The Infections in the History of Medicine
Hallmarks in history of syphilis therapeutics
Karamanou Marianna,
Kyriakis Kyriakos,
Tsoucalas Gregory,
Androutsos George
At the end of the 15th century syphilis appeared in Europe as a devastating epidemic. For nearly four centuries mercury was regarded as a remedy of first-rate importance along with guaiac and potassium iodide. In the early 20th century, two new substances were added to syphilis therapeutics, namely arsenobenzol and bismuth. The absence of treponemal serum tests and the erroneous attribution of the positive Wassermann reaction exclusively to Treponema pallidum infection resulted in prolonged and non-proven effective treatments. In 1943 John Mahoney introduced penicillin, revolutionizing the treatment of syphilis.
The re-introduction of malaria in the Pontine Marshes and the Cassino district during the end of World War II. Biological warfare or global war tactics?
Sabbatani Sergio,
Fiorino Sirio,
Manfredi Roberto
After the fall of the Fascist regime on September 8, 1943, Italy was split into two parts: (i) the Southern regions where the King Victor Emanuel III and the military general staff escaped was under the control of English-American allied armies, and (ii) the northern regions comprising Lazio, Tuscany, Umbria, and Marche still under the control of the Germans. The German Wehrmacht, after suffering several defeats on Southern lines, established a new strengthened line of defence called the Gustav line, located south of Rome and crossing in the western portion the recently-drained Pontine Marshes. In his book published in 2006, Frank Snowden hypothesised that occupying German armies in 1943 had initiated a programme of re-flooding the Pontine plain as a biological warfare strategy to re-introduce malaria infection in the territories south of Rome, Such a plan was intended (i) to slow down the advance of English-American forces, and (ii) to punish Italians who abandoned their former allies. Other authors, including Annibale Folchi, Erhard Geissler, and Jeanne Guillemin, have disputed this hypothesis based on an analysis of recently-uncovered archive documents. What is not disputed is that the flooding of the Pontine and Roman plains in 1943 contributed to a severe malaria epidemic in 1944, which was associated with exceptionally high morbidity and mortality rates in the afflicted populations. Herein, we critically evaluate the evidence and arguments of whether the Wehrmacht specifically aimed to spread malaria as a novel biological warfare strategy in Italy during the Second World War. In our opinion, evidence for specific orders to deliberately spread malaria by the German army is lacking, although the strategy itself may have been considered by Nazis during the waning years of the war.
