Bacteriology of peritonsillar abscess: the changing trend and predisposing factors / Bacteriologia do abscesso peritonsilar: tendência de mudança e fatores predisponentes

Abstract Introduction: Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors. Objective: To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration. Methods: This retrospective study included 415 hospitalized patients diagnosed with peritonsillar abscess who were admitted to a tertiary medical center from June 1990 to June 2013. We collected data by chart review and analyzed variables such as demographic characteristics, underlying systemic disease, smoking, alcoholism, betel nut chewing, bacteriology, and hospitalization duration. Results: A total of 168 patients had positive results for pathogen isolation. Streptococcus viridans (28.57%) and Klebsiella pneumoniae (23.21%) were the most common microorganisms identified through pus culturing. The isolation rate of anaerobes increased to 49.35% in the recent 6 years (p = 0.048). Common anaerobes were Prevotella and Fusobacterium spp. The identification of K. pneumoniae increased among elderly patients (age > 65 years) with an odds ratio (OR) of 2.76 (p = 0.03), and decreased in the hot season (mean temperature > 26 °C) (OR = 0.49, p = 0.04). No specific microorganism was associated with prolonged hospital stay. Conclusion: The most common pathogen identified through pus culturing was S. viridans, followed by K. pneumoniae. The identification of anaerobes was shown to increase in recent years. The antibiotics initially selected should be effective against both aerobes and anaerobes. Bacterial identification may be associated with host clinical factors and environmental factors.

Resumo Introdução: O Abscesso Peritonsilar é a infecção cervical profunda mais comum. O microrganismo infeccioso pode ser diferente de acordo com os fatores clínicos. Objetivo: Identificar o principal agente causador do abscesso peritonsilar e investigar a relação entre o patógeno causador, os fatores clínicos do hospedeiro e a duração da hospitalização. Método: Este estudo retrospectivo incluiu 415 pacientes hospitalizados diagnosticados com abscesso peritonsilar que foram internados em um centro médico terciário de junho de 1990 a junho de 2013. Coletamos dados através da análise dos arquivos médicos dos pacientes e analisamos variáveis como características demográficas, doença sistêmica subjacente, tabagismo, alcoolismo, hábito de mascar noz de betel, bacteriologia e duração da hospitalização. Resultados: Um total de 168 pacientes apresentaram resultados positivos para isolamento de patógenos. Streptococcus viridans (28,57%) e Klebsiella pneumoniae (23,21%) foram os microrganismos mais comuns identificados pela cultura da secreção. A taxa de isolamento de anaeróbios aumentou para 49,35% nos últimos 6 anos (p = 0,048). Os anaeróbios comuns foram Prevotella e Fusobacterium spp. A identificação de K. pneumoniae aumentou em pacientes idosos (idade > 65 anos) com razão de chances (Odds Ratio - OR) de 2,76 (p = 0,03) e diminuiu na estação do calor (temperatura média > 26 °C) (OR = 0,49, p = 0,04). Nenhum microrganismo específico foi associado à hospitalização prolongada. Conclusão: O patógeno mais comumente identificado através da cultura de secreção foi S. viridans, seguido por K. pneumoniae. A identificação de anaeróbios mostrou ter aumentado nos últimos anos. Os antibióticos selecionados inicialmente devem ser efetivos contra aeróbios e anaeróbios. A identificação bacteriana pode estar associada a fatores clínicos e fatores ambientais do hospedeiro.

Risk factors for infection in burn in children and adolescents: a cohort study / Fatores de risco para infecção em crianças e adolescentes com queimaduras: estudo de coorte

Introduction: Prevention of infection in burned patients poses great challenges such as infection, which constitutes the most common cause of mortality after burn injury. An analysis of burned patients younger than 20 years-old was performed prospectively to identify the incidence of nosocomial infection (NI) and risk factors for N. We included in the study those admitted and treated from January 2012 to December 2012 at a public burn unit in Brazil. Methods: A total of 136 patients admitted at Burn Care Unit during the study period fulfilled inclusion criteria. We collected information related to NI and epidemiological data. Results: Most patients were male (63.2%) and non-white (57.4%). Patients' mean age was 7.64 years. Scalding was the most frequent causal agent (45.6%). The mean body surface area (BSA) was 15.7%. Most of patients (80.9%) had two or more damaged areas. Surgical treatment with grafts was needed in 69 cases (50.7%). Infection was seen in 59 cases (43.4%), and sepsis in 27 (19.8%). Cultures were positive in 22.8%, and Staphylococcus aureus was the most frequent isolated agent (31.2%) found. Antimicrobial drugs were used in 45.6% of patients. The mean length of hospital stay was 22.36 days and mortality rate was 2.5%. According to the statistical analysis there was an association between infection and admission to the Intensive Care Unit (ICU), invasive procedures, grafts, length of hospital stay and BSA. Conclusion: Risk factors for infection in burn patients are length of hospital stay, BSA, invasive procedures, admission at ICU and grafts.

Introdução: A prevenção de infecções em pacientes queimados é grande desafio, pois trata-se da causa mais comum de mortalidade após queimaduras. Um estudo prospectivo em 136 pacientes queimados menores de 20 anos, internados e tratados entre janeiro e dezembro de 2012, foi realizado para identificar a incidência e fatores de risco para infecção hospitalar (IH). Métodos: Pacientes internados na Unidade de Tratamento de Queimados que aceitaram participar e preencheram os critérios de inclusão, participaram do estudo. Foram coletadas informações referentes à IH e dados epidemiológicos durante o período de internação. Resultados: Do total dos pacientes, a maioria era do gênero masculino (63,2%) e não branco (57,4%). A média de idade foi 7,64 anos. Escaldadura foi o agente causal mais frequente (45,6%). A média de superfície corporal queimada (SCQ) foi 15,7%. A maioria dos pacientes (80,9%) apresentou duas ou mais áreas acometidas por queimadura. O tratamento cirúrgico com enxertos foi necessário em 69 casos (50,7%). Ocorreu infecção em 59 pacientes (43,4%) e sepse em 27 (19,8%). As culturas foram positivas em 22,8% e Staphylococcus aureus foi o agente isolado mais frequente (31,2%). Antimicrobianos foram usados em 45,6% dos pacientes. O tempo médio de permanência hospitalar foi 22,36 dias e a taxa de mortalidade 2,5%. Houve associação entre infecção e admissão em Unidade de Terapia Intensiva (UTI), monitorização invasiva, enxertos, tempo de internação hospitalar e SCQ. Conclusão: Os fatores de risco para infecção em queimaduras são: tempo de internação hospitalar, superfície corporal queimada, monitorização invasiva, internação em UTI e enxerto.

Ex vivo evaluation of three instrumentation techniques on E. faecalis biofilm within oval shaped root canals

The objective of the present study was to assess the effectiveness of reciprocating instrumentation in disinfecting oval-shaped root canals infected with Enterococcus faecalis. Forty-five human lower premolars were infected with a culture of E. faecalis (ATCC 29212) for 28 days. Five other teeth that were neither contaminated nor instrumented were used as controls. The 45 specimens were divided into three experimental groups (n = 15) based on the root canal preparation technique used: manual (K-type, Dentsply Maillefer, Ballaigues, Switzerland); rotary (MTwo, VDW GmbH, Munich, Germany); and reciprocating (Reciproc R50, VDW GmbH, Munich, Germany) instruments. During chemomechanical preparation, 21 mL of 2.5% NaOCl was used as the irrigating solution. Microbiological sampling was performed before (S1) and immediately after (S2) the chemomechanical preparation using sterilized paper points. Specimens were then cleaved, and 0.02 g of dentine chips was collected from the root thirds to verify the presence of microorganisms in dentinal tubules. All three preparation techniques reduced the number of microorganisms in the root canal lumen and dentine chips from the root thirds, but no significant differences were observed between the three groups (p > 0.05). Reciprocating instrumentation with Reciproc R50 was effective in reducing the number of microorganisms within the root canal system. Although this technique involves the use of only one file to perform the root canal therapy, it is as effective as conventional rotary instrumentation in reducing theE. faecalis biofilm from the root canal system. However, further clinical investigations are warranted in order to ratify these results.

Pyogenic liver abscess caused by Gemella morbillorum / Absceso hepático piógeno causado por Gemella morbillorum

Even though Gemella morbillorum infection (GMI) is rare in humans, it may, nevertheless, cause endocarditis, meningitis, brain abscess, pleural empyema, nephritis, mediastinitis, and - occasionally - liver abscess. We are describing the case of a 64-year-old Caucasian male admitted with fever and abdominal pain. Laboratory parameters revealed inflammation signs, and instrumental examinations showed the presence of diverticula in the ascending colon. Abdominal ultrasound (US) and computer tomography (CT) showed two focal lesions in the right liver lobe. One had the characteristics of a simple cyst; the second was hypoechoic with a low density area, possibly containing necrotic material. US-guided needle biopsy was found negative for neoplastic cells, showing purulent infiltrate. Pus culture was found positive for GMI. Systemic antibiotic therapy, coupled with repeated US-guided needle aspiration, induced the resolution of the hepatic abscess. Few cases have been reported of hepatic abscess caused by GMI in immunocompetent non-cirrhotic subjects.

A pesar de que la infección por Gemella morbillorum (GMI, por el término en inglés) es poco común en seres humanos, puede causar endocarditis, meningitis, absceso cerebral, empiema pleural, nefritis, mediastinitis y en ocasiones, absceso hepático. Describimos el caso de un hombre caucásico de 64 años que ingresó con fiebre y dolor abdominal. Los parámetros de laboratorio revelaron signos de inflamación y los exámenes mostraron la presencia de divertículos en el colon ascendente. La ecografía abdominal (US) y la tomografía computarizada (CT) mostró dos lesiones focales en el lóbulo hepático derecho. Una presentó las características de un quiste simple; la segunda fue hipoecóica con una zona de baja densidad, que posiblemente contenía material necrótico. Biopsia con aguja guiada por US dio un resultado negativo para células neoplásicas, mostrando infiltrado purulento. Cultivo de pus fue encontrado positivo para GMI. Una terapia con antibióticos sistémicos, junto con aspiración repetida con aguja guiada por US indujo a la resolución del absceso hepático. Pocos casos se han reportado de absceso hepático causado por GMI en sujetos inmunocompetentes no cirróticos.

[ effectiveness of Hero [taper 4% and 6%] instrumentation techniques on the elimination of Enterococcus faecalis from root canal]

Due to the deeper penetration of bacteria like Enterococcus faecalis into dentinal tubules in pulp diseases, different tapering in root canal therapies leads in different dentinal removal from root canal wall. Then, root canals with higher tapering will contain lower microbial contents. Furthermore, together with higher prevalence of root fractures in teeth with more tapering, the aim of this study is comparing the effect of different tapering of Hero Rotary files [6% versus 4%] in reduction of Enterococcus faecalis bacteria from the root canal of human extracted teeth. Seventy human extracted teeth were divided in two equal experimental [Hero 4%as group 1and Hero 6% as group 2] [n=27] and the control group [n=6].Two extra control group [positive n=5 and negative n=5] took for confirmation the canal reinfection, too. All of the samples prepared by K file No 20 and Gates Gilden No 2 and 3 before sterilization. Then the teeth were autoclaved and were infected with Enterococcus faecalis. The experimental groups were instrumented either with Hero 4% or with Hero 6% files up to #30. Bacteriological samples were taken after instrumentation to determine the level of remaining bacteria. In the group 1 two samples and in the group 2 six samples represented complete reduction of bacteria. There was not statistically significant different between the two groups. Aggressive preparation with an instrumentation technique removing substantial amounts of dentin [Hero 6%] did not reduce the intracanal bacteria more effectively than a more conservative instrumentation technique [Hero 4%] [P>0.05]

Analysis of Enterococcus faecalis in samples from Turkish patients with primary endodontic infections and failed endodontic treatment by real-time PCR SYBR green method

OBJECTIVE: The aims of this study were to investigate the presence of Enterococcus faecalis in primary endodontic infections and failed endodontic treatments using real-time PCR and to determine the statistical importance of the presence of E. faecalis in a Turkish population with endodontic infections. MATERIAL AND METHODS: E. faecalis was investigated from 79 microbial samples collected from patients who were treated at the Endodontic Clinic of the Dental School of Atatürk University (Erzurum, Turkey). Microbial samples were taken from 43 patients (Group 1) with failed endodontic treatments and 36 patients (Group 2) with chronic apical periodontitis (primary endodontic infections). DNA was extracted from the samples by using a QIAamp® DNA mini-kit and analyzed with real-time PCR SYBR Green. RESULTS: E. faecalis was detected in 41 out of 79 patients, suggesting that it exists in not less than 61 percent of all endodontic infections when the proportion test (z= -1.645,

Absceso cerebral posquirúrgico causado por Propionibacterium acnes / Post-surgery cerebral abscess due to Propionibacterium acnes

Los abscesos cerebrales por Propionibacterium acnes son poco frecuentes. Es importante para el médico clínico la rápida identificación de este patógeno para la elección de una terapéutica antibiótica adecuada. En este caso se describe un paciente con una exéresis de un glioblastoma multiforme donde a los 9 meses se evidenció la existencia de una recidiva tumoral, se efectuó una extirpación tumoral subtotal y la colocación de implantes de quimioterapia en el lecho tumoral residual. Al cabo de un mes de esta reoperación presentó una lesión ocupante compatible con un absceso cerebral, motivo por el cual se realizó nueva craneotomía y drenaje del mismo. En los cultivos de las biopsias y del material purulento se aisló P. acnes como flora única. Para la identificación se realizaron pruebas bioquímicas y se aplicó el sistema API20A. Se determinó la concentración inhibitoria mínima (CIM) a clindamicina, penicilina, amoxicilina y metronidazol, los valores de CIM (ug/ml) obtenidos fueron: 0.250, 0.040, 0.023 y 256, respectivamente. El paciente recibió cefepime más metronidazol por vía endovenosa durante un período de 30 días y completó tratamiento con clindamicina por vía oral durante 60 días, dada la posible complicación ósea en el sitio de la infección. Luego de 8 meses de la intervención quirúrgica y el drenaje del absceso cerebral no hubo evidencia de signos clínicos de recidiva tumoral e infecciosa. P. acnes es un patógeno infrecuente como causal de abscesos cerebrales, sin embargo no se debe desestimar en muestras neuroquirúrgicas.

Brain abscesses by Propionibacterium acnes are rare. The rapid identification of this pathogen is important in order to choice the appropriate antibiotic therapy. We describe the case of a patient with excision of a multiform glioblastoma who 9 months later presented a tumor recurrence. A subtotal tumor excision was made and implants chemotherapy were placed in the residual tumor. After one month of surgery the patient presented a brain abscess. A craniotomy for drainage was performed. P. acnes was isolated from the biopsy and from purulent material. Identification was made by conventional biochemical tests and by the API system 20 A. The Minimum Inhibitory Concentration (MIC) to clindamycin, penicillin, amoxicillin and metronidazole was determined. The values of MIC (ug/ml) obtained were: 0.250, 0.040, 0.023 and 256, respectively. The patient received cefepime and metronidazole intravenously during 30 days and completed treatment with oral clindamycin for 60 days, considering the possibility of adjacent bone involvement. Eight months after the drainage the patient had no evidence of infection or tumor recurrence. Although P. acnes is a rare cause of post-neurosurgical infection, it should be considered as a possible pathogen in postoperative brain abscesses.

Periradicular repair after two-visit endodontic treatment using two different intracanal medications compared to single-visit endodontic treatment

The number of appointments necessary to treat infected root canals is one of the most controversial issues in endodontics. This study evaluated, in dogs, the response of the periradicular tissues to the endodontic treatment of infected root canals performed in a single visit or in two visits, using different interappointment dressings. Periradicular lesions were induced by inoculating Enterococcus faecalis in the root canals. After confirming that a periradicular lesion developed, the root canals were treated within one or two visits, using either ozonized oil or calcium hydroxide in camphorated paramonochlorophenol (CMCP) as an intracanal medication. After 6 months, the animals were sacrificed and the specimens were processed for histological and histobacteriological analysis. The root canals treated in a single visit showed a success rate of 46 percent. When a calcium hydroxide/CMCP-based interappointment intracanal medication was used, 74 percent of the cases were categorized as success. In cases where ozonized oil was used as the intracanal medication, a success rate of 77 percent was observed. These results of the present study demonstrated that the two-visit treatment offered a higher success rate compared to one-visit therapy. In addition, ozonized oil may potentially be used as an intracanal medication.

O número de sessões necessárias para tratar um canal radicular infectado é um dos assuntos mais controversos da endodontia. O objetivo deste estudo foi analisar, em cães, a resposta dos tecidos perirradiculares ao tratamento endodôntico de canais infectados em uma ou duas consultas, usando diferentes medicamentos entre as sessões. Lesões perirradiculares foram induzidas pela inoculação de Enterococcus faecalis nos canais. Após a confirmação do desenvolvimento de uma lesão perirradicular, os canais foram tratados em uma ou duas sessões, usando óleo ozonizado ou hidróxido de cálcio associado ao paramonoclorofenol canforado (PMCC) como medicação intracanal. Após 6 meses, os animais foram sacrificados e os espécimes processados para análise histológica e histobacteriológica. Os canais tratados em sessão única apresentaram uma taxa de sucesso de 46 por cento dos casos. Quando a medicação usada entre as sessões foi o hidróxido de cálcio associado com o PMCC, 74 por cento dos casos resultaram em sucesso. Nos casos em que o óleo ozonizado foi usado, uma taxa de sucesso de 77 por cento foi observada. Esses achados demonstraram que o tratamento em duas sessões oferece uma taxa de sucesso mais alta quando comparado à terapia em uma sessão. Além disso, o óleo ozonizado mostrou potencial para ser usado como medicação intracanal.

Predictors of poor outcome in neonates with bacterial sepsis admitted to the University Hospital of the West Indies / Predictores de resultados clínicos pobres en recién nacidos con sepsis bacteriana, ingresados en el Hospital Universitario de West Indies

To determine factors that affect outcome in neonates with culture-proven sepsis, the charts of all neonates with culture-proven sepsis admitted to the University Hospital of the West Indies between January 1995 and December 2000 were reviewed retrospectively. Neonates who survived without developing any complications (favourable outcome group) were compared with those who died and/or developed severe complications during the course of treatment (poor outcome group). Chi-square tests were done to determine factors associated with poor outcome; univariate and multivariate logistic regression analyses were also performed. One hundred and thirty-five neonates had culture-proven sepsis, of which 89 (66) were term infants and 46 (34) were preterm. Male to female ratio was 1.6:1. One hundred and twenty-six (93) survived and 9 (7) died. Case fatality rates were higher for premature infants (15) than for term infants (2). Twenty-four (18) of the neonates with culture proven sepsis had a poor outcome. Gram negative organisms accounted for 19 (70) of the cases with poor outcome. Prematurity (p < 0.001), very low birthweight (p < 0.001) and female gender (p < 0.05) were factors associated with poor outcome. Strategies aimed at decreasing morbidity and mortality in neonates with sepsis must include measures that will decrease the incidence of prematurity and low birthweight.

A fin de determinar los factores que afectan la evolución clínica de los recién nacidos con sepsis probada por cultivo, se realizo un estudio retrospectivo de las estadísticas de todos los neonatos con sepsis probada por cultivo, ingresados en el Hospital Universitario de West Indies entre enero de 1995 y diciembre de 2000. Los neonatos que sobrevivieron sin desarrollar complicación alguna (el grupo de resultados clínicos favorables) fueron comparados con los que murieron y/o desarrollaron complicaciones severas durante el curso del tratamiento (el grupo de resultados clínicos pobres). Se realizaron pruebas de chi-cuadrado para determinar los factores asociados con los resultados clínicos pobres. También se llevaron a cabo análisis de regresión logística univariable y multivariable. Ciento treinta y cinco recién nacidos presentaron sepsis probada por cultivo. De ellos, 89 (66%) eran infantes de término y 46 (34%) de pre-término. La proporción varón/hembra fue 1.6:1. Ciento veintiséis (93%) sobrevivieron y 9 (7%) murieron. Las tasas de fatalidades fueron más altas para los infantes prematuros (15%) que para los infantes de término (2%). Veinticuatro (18%) de los neonatos con sepsis probada por cultivo tuvieron resultados clínicos pobres. Organismos gram-negativos fueron la causa de 19 (70%) de los casos con resultado clínico pobre. La prematuridad (p <0.001), el peso extremadamente bajo al nacer (p <0.001) y el sexo femenino (p <0.05) fueron factores asociados con el resultado clínico pobre. Las estrategias dirigidas a disminuir la morbilidad y la mortalidad en los recién nacidos con sepsis tienen que incluir medidas que reduzcan la incidencia de la prematuridad y el bajo peso.

Atividade antimicrobiana da Linezolida frente a cocos Gram-positivos isolados no Hospital Divina Providência, Porto Alegre, RS / Antimicrobial activity of Linezolid against Gram-positive cocci isolated in Hospital Divina Providência, Porto Alegre, RS

A linezolida é a primeira droga de uma nova classe de antimicrobianos, as oxazolidinonas, que apresentam ampla atividade in vitro contra uma grande gama de patógenos gram-positivos, como staphylococcus aureos, enterococcus sp. e streptococcus pneumoniae. Foram estudadas 81 cepas isoladas de diversas amostras clínicas, provenientes de pacientes internados no Hospital Divina Providência de Porto Alegre, Rio Grande do Sul, durante o período de abril a agosto de 2002. Os microorganismos gram-positivos mais frequentemente encontrados foram staphylococcus sp. Coagulase negativa (33,3%), staphylococcus aureos (32,1%) e streptococcus sp. (16,1%). A linezolida, vancomicina e teicoplanina foram as drogas que tiveram 100% de atividade frente aos cocos gram-positivos testados. A excelente atividade in vitro apresentada pela linezolida neste estudo pode representar uma importante opção terapêutica para o tratamento de infecções causadas por cocos gram-positivos.

Estudio clínico de eficacia y tolerancia con sultamicilina fipexiam en procesos infecciosos de tratamiento ambulatorio / Clinic study of efficacy and toleration with sultamicilina fipeham in infectious process of ambulatory treatment

Se realizó un estudio abierto, multicéntrico, no comparativo donde se avaluó la eficacia y tolerancia de la combinación Ampicilina/Sulbatam por vía oral-Sultamicilina-(Fipexiam), en adultos y niños con infecciones del tracto respiratorio superior e inferior y con infeciones de piel y partes blandas, y adultos con Enfermedad Inflamatoria Pélvica (EIP). El estudio reunió los investigadores de 73 Centros. Se trataron un total de 195 pacientes obteniéndose una efectividad global de 93.3 por ciento. De estos pacientes 84 presentaron Otitis media aguda, resultando curas clínicas en el 89.2 por ciento, 67 presentaron procesos orofaríngeos con curación en el 94 por ciento; en los casos con infecciones de piel y partes blandas, así como en las mujeres tratadas con (EIP) la curación clínica fue de 100 por ciento. Se reportaron efectos adversos en 10.9 por ciento, siendo las molestias gastrointestinales más resaltantes con 8.7 por ciento de los casos reportados, siendo menores a lo reportado por la literatura médica

Estudio multicentrico sobre sensibilidad in-vitro a cefalosporinas de tercera generación y cefepine / Multicentric study on densibility in-vitro to cephalosporins of third generation and cefepime preliminary report

Se presenta un estudio multicéntrico efectuado en nueve hospitales de Caracas entre julio de 1995 y marzo de 1996. En este trabajo se comparó la sensibilidad a cefalosporinas de tercera (cefotaxima, ceftazidima, ceftriaxona y cefoperazona) y cuarta generación (cefepime) en diferentes cepas de bacterias mantenidas in-vitro. Para tal efecto se obtuvieron un total de 1 717 microorganismos, de los cuales 1 369 (80 por ciento) eran Gram negativos y 342 (20 por ciento) Gram positivos. En los Gram negativos se encontró resistencia considerable a cefalosporinas de tercera generación en algunos centros de estudio, no así a cefepime. Las bacterias Gram positivas, Staphylococcus aureus y Streptococcus pneumoniae, fueron más sensibles a cefepine que a todas las cefalosporinas de tercera generación. Se concluye que las bacterias tienen a ser resistentes a cefalosporinas de tercera generación. Por tal razón, cefepime representa una alternativa importante en el tratamiento de infecciones causadas por germenes Gram negativos multiresistentes y mixtas por bacterias tanto Gram positivas como Gram negativos.