Clinical neglect of aspergillosis in pulmonary tuberculosis co-infection: a case report of avoidable mortality in a resource-constrained setting

Background: Pulmonary aspergillosis (PA) is common among patients with tuberculosis (TB). With both infections presenting with similar clinical and radiologic features, diagnosis of PA is often made too late or missed completely due to lack of clinical suspicion and poor diagnostic laboratory capacity for mycotic infections prevalent in our settings. We present a case of preventable mortality caused by delayed diagnosis and treatment of PA in a patient with pulmonary TB (PTB). Case presentation: A 13-year-old female was diagnosed and treated for PTB, having received anti-TB regimen for 8 months in a mission hospital from where she was referred due to worsening cough, chest pain and progressive breathlessness. The patient was re-assessed and investigated, with GeneXpert detecting Mycobacterium tuberculosis, susceptible to rifampicin. Diagnosis of pulmonary tuberculosis complicated by right pneumothorax was made indicating an emergency thoracotomy and chest tube insertion and continuation of the first line anti-TB regimen. At about 2 weeks into admission, patients had features of superimposed acute bacterial sepsis with fever becoming high grade, marked neutrophilia with toxic granulation and elevated sepsis biomarker, and this necessitated empiric antibiotic treatment with parenteral meropenem and vancomycin. However, the patient only had mild clinical improvement following which there was progressively worsening respiratory symptoms and massive haemoptysis. Result of sputum fungal study was available on admission day 20 and revealed a growth of Aspergillus flavus. Treatment with intravenous voriconazole was however commenced rather late when the fungal respiratory disease could no longer be remedied. The patient died on admission day 23. Conclusion: Diagnosis of PA in patients with background TB is often made too late to guarantee timely and effective antifungal treatment with negative consequences on patients' outcomes. Improving clinical and laboratory capacities is essential to reducing mortality from PA in healthcare facilities.

Phenotypic and genotypic characterization of plasmid-mediated AmpC beta-lactamases in enteric Gram-negative bacteria from patients with lower respiratory tract infections in a tertiary hospital, southwest Nigeria

Background: AmpC or class C or group 1 beta lactamases are class C cephalosporinases that hydrolyse a wide variety of beta-lactam antibiotics including alpha methoxy beta-lactams (cefoxitin), narrow and broad spectrum cephalosporins. This study was conducted to characterize plasmid-mediated AmpC producing enteric Gram- negative bacteria from patients with lower respiratory tract infections in Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) Ile Ife, Osun State, Nigeria Methodology: A total of 149 patients with clinical features of lower respiratory tract infections (LRTI) were selected by simple random sampling for the study. All Gram-negative isolates recovered from standard microbiological cultures of respiratory specimens of these patients were tested against cefoxitin, third generation cephalosporins (3GCs), and other antibiotics using the disc diffusion AST method, and also screened for production of AmpC beta-lactamases phenotypically by the CLSI method. Plasmid DNA extraction was carried out on twenty-nine cefoxitin-resistant selected isolates using the Kado and Lin method, while genotypic detection of plasmid-mediated AmpC gene was carried out by the polymerase chain reaction (PCR) assay. Results: The results showed that 204 (43.3%) of 471 isolates recovered from the 149 selected patients were resistant to 3GC in the AST assay, among which 121 (59.3%) were resistant to cefoxitin, and 189 of the 471 isolates (40.1%) were AmpC producers. The AmpC producers concurrently showed multiple resistance pattern to other antibiotics tested in this study. Ninety six percent of the 29 selected isolates for plasmid analysis contained plasmids, 45% of which amplified positive on PCR for CMY, 38% for FOX, and 31% for ACC types of AmpC genes. Conclusion: This study showed a high degree of antibiotic resistance among enteric Gram-negative bacteria recovered from patients with LRTIs, as well as high degree of plasmid-encoded AmpC genes responsible for this high antibiotic resistance among the isolates. Proper antibiotic policy and regulation are required to limit the spread of plasmid mediated AmpC ß-lactamase

Invasive Bacteria Isolates from Children with Severe Infections in a Nigerian Hospital

Background: Little information is available about the aetiology and epidemiology of serious bacterial infections in Nigeria. This study determined bacterial isolates from blood and cerebrospinal fluid (CSF) of children presenting in the emergency room of a teaching hospital in Nigeria. Method: From October 2005 to December 2006; children aged two to 60 months presenting with signs of acute systemic infections were recruited. Blood culture and CSF specimens were collected and processed using standard microbiological protocols. Data were analysed using SPSS version 11 software. Results: Two hundred and two blood and 69 CSF samples were cultured. Fifty-five (27) of the blood cultures yielded Gram-negative bacilli and Gram-positive cocci in almost equal proportions. The most common isolates from the blood cultures were Staphylococcus aureus; 26 (12.9) and atypical coliforms; 13 (6.5). Others are Klebsiella spp; 3 (1.5); Klebsiella pneumonia; 2 (1.0); Escherichia coli; 3 (1.5); Enterobacter agglomerans; 2 (1.1); Proteus mirabilis; 2(1); Pseudomonas spp; 2 (1.0); Haemophilus influenza; 1 (1.0); and Coagulase-negative Staphylococcus; 1 (1.0). Fourteen out of 67 (20.9) of the CSF samples yielded bacterial isolates: Streptococcus pneumonia; 3 (4.5); Haemophilus influenza; 8 (11.9); Hemophilus spp; 1 (1.5); E. Coli; 1 (1.5); and atypical coliform; 1 (1.5). Gram-negative coliform isolates were predominantly resistant to penicillin based antibiotics and co-trimoxazole but sensitive to third-generation cephalosporins and quinolones. A high percentage of S. aureus isolates were multi-drug resistant. Conclusions: Bacterial infections contribute to the significant morbidity among children in our environment. S. aureus was more frequently isolated in sepsis while H. influenzae appears to play a major role in meningitis. Appropriate use of antibiotics is needed to manage affected children effectively. We also recommend improved vaccine coverage of children under the age of five years) of the blood cultures yielded Gram-negative bacilli and Gram-positive cocci in almost equal proportions. The most common isolates from the blood cultures were Staphylococcus aureus; 26 (12.9) and atypical coliforms; 13 (6.5). Others are Klebsiella spp; 3 (1.5); Klebsiella pneumonia; 2 (1.0); Escherichia coli; 3 (1.5); Enterobacter agglomerans; 2 (1.1); Proteus mirabilis; 2(1); Pseudomonas spp; 2 (1.0); Haemophilus influenza; 1 (1.0); and Coagulase-negative Staphylococcus; 1 (1.0). Fourteen out of 67 (20.9) of the CSF samples yielded bacterial isolates: Streptococcus pneumonia; 3 (4.5); Haemophilus influenza; 8 (11.9); Hemophilus spp; 1 (1.5); E. Coli; 1 (1.5); and atypical coliform; 1 (1.5). Gram-negative coliform isolates were predominantly resistant to penicillin based antibiotics and co-trimoxazole but sensitive to third-generation cephalosporins and quinolones. A high percentage of S. aureus isolates were multi-drug resistant.Conclusions: Bacterial infections contribute to the significant morbidity among children in our environment. S. aureus was more frequently isolated in sepsis while H. influenzae appears to play a major role in meningitis. Appropriate use of antibiotics is needed to manage affected children effectively. We also recommend improved vaccine coverage of children under the age of five years

Septic arthritis in children

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