Osteomielitis por Klebsiella pneumoniae BLEE. Reporte de un caso y revisión de la literatura. / OSTEOMYELITIS DUE TO KLEBSIELLA PNEUMONIAE ESBL. REPORT OF A CASE AND LITERATURE REVIEW

Las betalactamasas de espectro extendido (BLEE) son enzimas producidas por bacilos gram negativos capaces de hidrolizar las cefalosporinas de amplio espectro y los monobactámicos. La mayoría pertenece a la familia de Enterobacteriae, tales como Klebsiella pneumoniae y Escherichia coli: Sin embargo, se asocian también con otras bacterias como Proteus, Serratia, Salmonella, Pseudomonas aeruginosa y Acinetobacter. Las enterobacterias productoras de carbapenemasas no sólo han sido aisladas en el ambiente hospitalario, sino que también provienen de la comunidad. Se presenta una paciente de sexo femenino con antecedentes de sida y osteomielitis secundaria a artritis séptica producida por una Klebsiella pneumoniae BLEE de la comunidad. Un tratamiento oportuno y eficaz puede evitar la opción quirúrgica, disminuyendo la morbimortalidad asociada con esta afección

Extended-spectrum beta-lactamases (ESBL) are enzymes produced by gram-negative rods capable of hydrolyzing broad-spectrum cephalosporins and monobactams. Most belong to the Enterobacteriae family, such as Klebsiella pneumoniae and Escherichia coli. However, they are also associated with other bacteria such as Proteus, Serratia, Salmonella, Pseudomonas aeruginosa and Acinetobacter. Carbapenemase-producing Enterobacteriaceae have not only been isolated from the hospital environment, but also from the community. We present a female patient with a history of AIDS and secondary osteomyelitis to septic arthritis caused by a community Klebsiella pneumoniae ESBL. It is concluded that a timely and effective treatment can avoids the surgical option, reducing the morbidity and mortality of this condition.

A case of late-onset Klebsiella oxytoca keratitis treated with topical imipenem after deep anterior lamellar keratoplasty / Caso de ceratite de início tardio por Klebsiella oxytoca tratado com imipenem tópico após ceratoplastia lamelar anterior profunda

ABSTRACT The aim of this study was to discuss a case of late-onset Klebsiella oxytoca keratitis after deep anterior lamellar keratoplasty and its treatment. A 21-year-old female patient presented with redness and effluence in the left eye at 5 months after uncomplicated deep anterior lamellar keratoplasty surgery. In the examination, a single suture was loosened in the superior nasal region and there was an infiltration area and epithelial defect in the graft and recipient bed junction in the area of the loose suture. Topical fortified vancomycin and fortified ceftazidime treatment was started empirically hourly, but there was insufficient response. After K. Oxytoca growth in a swab and suture culture taken from the patient, fortified vancomycin was replaced with fortified imipenem. It was observed that the infiltration area rapidly regressed and the epithelial defect was closed after fortified imipenem treatment. Fortified imipenem may be considered as an alternative treatment, especially in cases in which there is no response to treatment and culture growth is detected.(AU)

RESUMO O objetivo deste estudo é discutir um caso de ceratite tardia por Klebsiella oxytoca, após ceratoplastia lamelar anterior profunda, bem como seu tratamento. Uma paciente de 21 anos apresentou vermelhidão e efluxo no olho esquerdo 5 meses após cirurgia de ceratoplastia lamelar anterior profunda sem complicações. Ao exame, havia uma única sutura solta na região nasal superior e uma área de infiltração com defeito epitelial no enxerto e na junção com o leito receptor na área da sutura solta. Iniciou-se empiricamente um tratamento tópico com vancomicina e ceftazidima fortificada de hora em hora, porém com resposta insuficiente. Após o crescimento de K. oxytoca a partir de cultura de swab e sutura retirados da paciente, a vancomicina fortificada foi substituída por imipenem fortificado. Observou-se que a área de infiltração regrediu rapidamente e que o defeito epitelial foi fechado com o tratamento com imipenem fortificado. O imipenem fortificado pode ser considerado um tratamento alternativo, especialmente nos casos sem resposta ao tratamento e detecção de crescimento na cultura.(AU)

Modulação in vitro da atividade antibiótica pelo óleo essencial dos frutos de Piper tuberculatum Jacq / Modulación in vitro de la actividad antibiótica por el aceite esencial de frutos de Piper tuberculatum Jacq / In vitro modulation of the antibiotic activity of essential oil from fruits of Piper tuberculatum Jacq

Introdução: Piper tuberculatum Jacq., popularmente conhecida como pimenta-longaou pimenta-d'Arda, é utilizada empiricamente no tratamento de doenças respiratórias (asma, bronquite e tosse) e digestivas (dores abdominais e diarreias). Na literatura é descrita com importantes atividades anti-inflamatória, antimicrobiana, antileucêmico e anti-helmíntica. Objetivos: avaliar a atividade moduladora do óleo essencial dos frutos de P. tuberculatum (OEPT) em associação com diferentes antibióticos frente à Staphylococcus aureus, Escherichia coli e Pseudomona aeruginosa. Metodos: Os frutos (frescos) de P. tuberculatum foram coletados em Barbalha/CE e submetidos à hidrodestilação em aparelho tipo Clevenger para ser extraído o óleo essencial, após a extração o óleo essencial foi tratado com sulfato de sódio anidro para eliminação da umidade residual. A avaliação da atividade antibacteriana e modulação (em resistência bacteriana) frente às cepas de S. aureus (SA358), E. coli (EC27) e P. aeruginosa (PA03) foram determinadas pelo método de microdiluição para identificar a concentração inibitória mínima (CIM), realizada em triplicata. CIM de ≤ 256 µg/mL foi considerado clinicamente relevante. Resultados: a atividade antibacteriana do OEPT exibiu um CIM de ≥ 1024 µg/mL contra as cepas de bactérias de padrão resistente a múltiplas drogas. Na avaliação da atividade moduladora, o OEPT antagonizou o efeito da amicacina contra E. coli e S. aureus, mas teve efeito sinérgico contra P. aeruginosa. Combinado com a getamicina o óleo exibiu antagonismo frente a E. coli, no entanto não apresentou resultado relevante contra S. aureas e P. aeruginosa. A associação do OEPT com o antibiótico imipenem resultou efeito mais relevante, apresentando sinergismo para todas as bactérias avaliadas, por outro lado, em associação com ciprofloxacino não apresentou efeito significante em relação ao controle. Conclusão: O OEPT apresentou uma melhor atividade quando associado ao imipenem frente todas as bactérias avaliadas, mostrando ser uma possível alternativa no desenvolvimento de novos fármacos com atividade antibacteriana advindos de produtos fitoterápicos(AU)

Introducción: Piper tuberculatum Jacq. popularmente conocida como pimenta-longa o pimenta-d'Arda, se utiliza empíricamente en el tratamiento de enfermedades respiratorias (asma, bronquitis y tos) y digestivas (dolor abdominal y diarrea). En la literatura es describe con importantes actividades antiinflamatorias, antimicrobianas, antileucémicas y antihelmínticas. Objetivo: evaluar la actividad moduladora de los aceites esenciales de frutos de P. tuberculatum (AEPT) en asociación con diferentes antibióticos contra Staphylococcus aureus, Escherichia coli y Pseudomona aeruginosa. Metodología: los frutos (frescos) de P. tuberculatum fueron recolectados en Barbalha/CE y sometidos a hidrodestilación en un equipo Clevenger, para extraer el aceite essencial (AEPT), el cual, una vez extraído, fue tratado con sulfato de sodio anhidro para eliminar la humedad residual. Se evaluó su actividad antibacteriana contra las cepas de S. aureus (SA358), E. coli (EC27) y P. aeruginosas (PA03). Empleando el método de microdilución se determinó la concentración inhibitoria mínima (CIM), con tres réplicas por cada tratamiento. Un valor de CIM ≤ 256 µg/mL se considera clínicamente relevante. Resultados: la actividad antibacteriana del AEPT exhibió una CIM ≥ 1024 µg/mL contra las cepas estándar de bacterias resistentes a múltiples fármacos. En efecto, la actividad AEPT antagoniza el efecto de amikacina contra E. coli y S. aureus, pero tenía un efecto sinérgico contra P. aeruginosa. Combinado con la getamicina el aceite exhibió antagonismo contra E. coli, sin embargo no presentó resultado relevante ante S. aureus y P. aeruginosa. La asociación de AEPT con el antibiótico imipenem resultó el efecto más relevante, mostrando sinergismo frente a todas las bacterias evaluadas. Por el contrario, en asociación con ciprofloxacina no mostró ningún efecto significativo con respecto al control. Conclusión: el AEPT presentó una mejor actividad cuando se asoció a imipenem, frente todas las bacterias evaluadas, demostrando ser una posible alternativa en el desarrollo de nuevos fármacos con actividad antimicrobiana, a partir de productos herbarios(AU)

Introduction: Piper tuberculatum Jacq., commonly known as pimenta-longa or pimenta-d'Arda, is empirically used to treat respiratory conditions (asthma, bronchitis and coughing) and digestive disorders (abdominal pain and diarrhea). Reference may be found in the literature to outstanding antiinflammatory, antimicrobial, antileukemic and antihelmintic activity. Objective: Evaluate the modulatory activity of essential oils from fruits of P. tuberculatum (AEPT) combined with various antibiotics againstStaphylococcus aureus, Escherichia coli and Pseudomona aeruginosa. Methods: Fresh fruits of P. tuberculatum were collected in Barbalha, CE, and subjected to hydrodistillation in a Clevenger set to extract the essential oil (AEPT). The oil extracted was then treated with anhydrous sodium sulfate to eliminate residual humidity. Antibacterial activity was evaluated against strains of S. aureus (SA358), E. coli (EC27) and P. aeruginosas (PA03). Minimum inhibitory concentration (MIC) was determined by the microdilution method, with three replications for each treatment. A MIC ≤ 256 µg/mL was considered to be clinically relevant. Results: Antibacterial activity of AEPT displayed a MIC of ≥1024 µg/mL against standard strains of multi-drug resistant bacteria. In fact, activity of AEPT antagonized the effect of amikacin against E. coli and S. aureus, but had a synergic effect against P. aeruginosa. Combined with gentamicin, the oil exhibited antagonism against E. coli, but no relevant result was obtained against S. aureus and P. aeruginosa. Combination of AEPT with the antibiotic imipenem had the most relevant effect, displaying synergism against all the bacteria evaluated. However, in combination with ciprofloxacin it did not show any significant effect with respect to the control. Conclusion: AEPT displayed better activity against all the bacteria evaluated when combined with imipenem, proving to be a possible alternative for the development of new herbal drugs with antimicrobial activity(AU)

The challenge of managing extensively drug-resistant tuberculosis at a referral hospital in the state of São Paulo, Brazil: a report of three cases / O desafio do tratamento da tuberculose extensivamente resistente em um hospital de referência no estado de São Paulo: um relato de três casos

ABSTRACT Here, we report the cases of three patients diagnosed with extensively drug-resistant tuberculosis and admitted to a referral hospital in the state of São Paulo, Brazil, showing the clinical and radiological evolution, as well as laboratory test results, over a one-year period. Treatment was based on the World Health Organization guidelines, with the inclusion of a new proposal for the use of a combination of antituberculosis drugs (imipenem and linezolid). In the cases studied, we show the challenge of creating an acceptable, effective treatment regimen including drugs that are more toxic, are more expensive, and are administered for longer periods. We also show that treatment costs are significantly higher for such patients, which could have an impact on health care systems, even after hospital discharge. We highlight the fact that in extreme cases, such as those reported here, hospitalization at a referral center seems to be the most effective strategy for providing appropriate treatment and increasing the chance of cure. In conclusion, health professionals and governments must make every effort to prevent cases of multidrug-resistant and extensively drug-resistant tuberculosis.

RESUMO Relatamos aqui os casos de três pacientes portadores de tuberculose extensivamente resistente, internados em um hospital de referência no estado de São Paulo, e mostramos sua evolução clínica, radiológica e laboratorial pelo período de um ano. O tratamento instituído foi baseado nas diretrizes da Organização Mundial da Saúde, com a inclusão de uma nova proposta de uso de uma associação de drogas antituberculose (linezolida e imipenem). Nos casos estudados, demonstrou-se o desafio de construir um esquema terapêutico aceitável e eficiente com drogas mais tóxicas, mais dispendiosas e que foram utilizadas por períodos mais prolongados. Mostramos também o importante acréscimo nos custos do tratamento desses pacientes, com possíveis impactos no sistema de saúde mesmo após a alta hospitalar. Ressaltamos que, em casos extremos como os apresentados neste estudo, a hospitalização em centros de referência mostrou-se o caminho mais efetivo para oferecer tratamento adequado com possibilidade de cura. Em conclusão, todos os esforços dos profissionais da saúde e do poder público devem ser direcionados a evitar casos de tuberculose multirresistente e extensivamente resistente.

Avaliações comparativas da associação entre antibióticos frente à Pseudomonas aeruginosa / Evaluación comparativa del uso asociado de antibióticos frente a Pseudomonas aeruginosa / Evaluation of the association antibiotics against Pseudomonas aeruginosa

Introdução: Pseudomonas aeruginosa caracteriza-se como bastonete gram-negativo reto ou ligeiramente curvo, aeróbio estrito, podendo ser encontrado na água, solo, vegetais, esgoto e animais. É um patógeno nosocomial com envolvimento em infecções hospitalares provocando infecções oportunistas em pacientes, principalmente naqueles imunocomprometidos. Uma das características de P. aeruginosa é seu alto nível de resistência intrínseca a agentes antimicrobianos estruturalmente diferentes. Objetivo: avaliar as atividades microbiológicas e comparar as atividades decorrentes da associação entre antibióticos que atuam no mesmo alvo e também em alvos diferentes frente às cepas bacterianas de Pseudomonas aeruginosa. Métodos: a Concentração Inibitória Mínima (CIM) foi realizada pelo método de microdiluição em caldo. Foi realizada modulação com bactérias associando os antibióticos. Resultados: as associações claritromicina‒imipenem e claritromicina ‒ciprofloxacina apresentaram sinergismo frente à P. aeruginosa, porém a associação claritromicina‒gentamicina demonstrou indiferença. Por outro lado as associações imipenem‒claritromicina, ciprofloxacino‒claritromicina e gentamicina ‒claritromicina apresentaram antagonismo. Conclusão: o resultado deste ensaio sugere que a associação de dois antibióticos testados aumenta o seu potencial antimicrobiano, podendo ser usado em combinação mediante investigações posteriores que comprovem a segurança de tal uso(AU)

Introduction: Pseudomonas aeruginosa is an anaerobic and gramnegative rod, they can be isolated from water, soil, vegetables, waste and animals. This microorganism is a nosocomial opportunistic infectious agent, mainly for immunocompromised patients. One of the main traits of P. aeruginosa is its intrinsic drug resistance to structurally different antibiotics. Objective: to evaluate the microbiological effect and to compare the activities derived from the antibiotic association s acting on the same target and on different targets against P. aeruginosa strains. Methods: the Minimun Inhibitory Concentration (MIC) was determined by broth microdilution method. The modulation of the activity on the bacteria was based on the antibiotic association. Results: the association of clarithromycin-imipenem and of clarothromycin-ciprofloxacin demonstrate synergism against P. aeruginosa. However, the association of clarithromycin?gentamycin did not show differences. On the other hand, the association of imipenem-clarihtromycin, of ciprofloxacine-clarithromycin and of gentamycin-clarithromycin showed antagonistic effect. Conclusions: the results of this study indicated that the association of two antibiotics enhances the antimicrobial potential of these drugs, and that they can be used in combination whenever other research studies confirm the safety of such use(AU)

Introducción: la Pseudomonas aeruginosa se caracteriza por ser gramnegativos con imagen de bastones rectos o ligeramente curvos, aeróbios, se pueden encuentrar en el agua, el suelo, en plantas, animales y aguas residuales. Es un patógeno nosocomial implicado en infecciones hospitalarias, causando infecciones oportunistas en pacientes, especialmente en aquellos inmunocomprometidos. Una de las características de la P. aeruginosa es su alto nivel de resistencia intrínseca a agentes antimicrobianos estructuralmente diferentes. Objetivo: evaluar las actividades microbiológicas y comparar las actividades derivadas de la asociación de antibióticos que actúan sobre la misma diana y también sobre diferentes dianas frente a cepas bacterianas de Pseudomonas aeruginosa. Métodos: el cálculo de la Concentración Mínima Inhibitoria (CMI) se realizó por el método de microdilución en caldo. La modulación de la actividad sobre bacterias se realizó por asociación de antibióticos. Resultados: las asociaciones claritromicina‒imipenem y claritromicina ‒ciprofloxacina mostraron sinergismo frente a P. aeruginosa; sin embargo la asociación claritromicina‒gentamicina no mostro diferencias. Por otro lado las asociaciones imipenem‒claritromicina, ciprofloxacino‒claritromicina y gentamicina ‒claritromicina demostraron antagonismo. Conclusión: los resultados de este estudio indican que la combinación de dos antibióticos aumenta su potencial antimicrobiano, y que pueden ser utilizadas en combinación, una vez que otras investigaciones confirmen la seguridad de dicho uso(AU)

Cistitis enfisematosa: una inusual forma de presentación de la infección del tracto urinario bajo / Emphysematous cystitis: Report of one case

Emphysematous cystitis is found in diabetic patients and in individuals with urinary stasis and immunosuppression. We report a 58-year-old male with hypertension, type 2 Diabetes on insulin treatment and central nervous system vasculitis on immunosuppressive therapy. He was admitted with weight loss and gait instability. A PET-CT showed a circumscribed image of air in the bladder contour without involving the upper urinary tract, suggesting emphysematous cystitis. Re-interrogated, the patient referred pneumaturia, dysuria and febrile sensation one week before admission. Urine culture showed Enterobacter aerogenes. He was treated with a urinary catheter, metabolic control and parenteral antimicrobials. The patient was discharged without symptoms 21 days after admission, with the bladder catheter.

Endocarditis infecciosa por Rhizobium radiobacter: Reporte de un caso / Infective endocarditis by Rhizobium radiobacter: A case report

Rhizobium radiobacter es una bacteria Gram-negativa, fijadora de nitrógeno que se encuentra principalmente en el suelo. Rara vez causa infecciones en humanos. Ha sido asociada a bacteriemia secundaria a colonización de catéteres intravasculares en pacientes inmunocomprometidos. El objetivo de este trabajo es informar un caso de endocarditis infecciosa por R. radiobacter. Se trata de paciente masculino, de 47 años de edad, con diagnóstico de enfermedad renal crónica estadio 5 en tratamiento sustitutivo con hemodiálisis, quien acude a centro asistencial por presentar fiebre de dos semanas de evolución. Es hospitalizado, se toman muestras de sangre periférica para hemocultivo y se inicia antibioticoterapia empírica con cefotaxime más vancomicina. El ecocardiograma transtorácico revelo vegetación fusiforme en válvula tricúspide con regurgitación grado III-IV/IV. Al séptimo día del inicio de la antibioterapia el paciente presenta mejoría clínica y paraclínica. La bacteria identificada por hemocultivo es Rhizobium radiobacter resistente a ceftriaxona y sensible a imipenem, amikacina, ampicilina y ampicilina/sulbactam. Debido a la mejoría clínica se decide continuar tratamiento con vancomicina y se anexa imipenem. A los 14 días de iniciada la antibioterapia el paciente es dado de alta con tratamiento ambulatorio con imipenen hasta cumplir seis semanas de tratamiento. En el ecocardiograma control se evidencio ausencia de la vegetación en la válvula tricúspide. Este caso sugiere que R. radiobacter puede ser una causa de endocarditis en pacientes portadores de catéteres intravasculares.

Rhizobium radiobacter is a Gram-negative, nitrogen-fixing bacterium, which is found mainly on the ground. It rarely causes infections in humans. It has been associated with bacteremia, secondary to colonization of intravascular catheters, in immunocompromised patients. The aim of this paper was to report the case of an infective endocarditis caused by R. radiobacter, in a 47-year-old male, diagnosed with chronic kidney disease stage 5, on replacement therapy with hemodialysis and who attended the medical center with fever of two weeks duration. The patient was hospitalized and samples of peripheral blood were taken for culture. Empirical antibiotic therapy was started with cefotaxime plus vancomycin. The transthoracic echocardiogram revealed fusiform vegetation on the tricuspid valve, with grade III-IV/IV regurgitation. On the seventh day after the start of antibiotic therapy, the patient had a clinical and paraclinical improvement. The bacterium identified by blood culture was Rhizobium radiobacter, ceftriaxone-resistant and sensitive to imipenem, amikacin, ampicillin and ampicillin/ sulbactam. Because of the clinical improvement, it was decided to continue treatment with vancomycin and additionally, with imipenem. At 14 days after the start of antibiotic therapy, the patient was discharged with outpatient treatment with imipenem up to six weeks of treatment. The control echocardiogram showed the absence of vegetation on the tricuspid valve. This case suggests that R. radiobacter can cause endocarditis in patients with intravascular catheters.

Identification of ACT-1 Plasmid-Mediated AmpC beta-Lactamase Producing Citrobacter freundii from a Chinese Patient

No abstract available.

Detección fenotípica de metalobetalactamasas en aislados clínicos de Pseudomonas aeruginosa / Phenotypic detection of metallo-beta-lactamase in clinical isolates of Pseudomonas aeruginosa

Pseudomonas aeruginosa, es considerado uno de los más importantes gérmenes hospitalarios, siendo común su aislamiento en pacientes hospitalizados, adicionalmente, este microorganismo presenta una marcada multiresistencia, lo que incrementa la mortalidad. El tratamiento de estos pacientes suele ser difícil, ya que además de su resistencia natural, Pseudomonas puede adquirir mecanismos de resistencia para prácticamente la totalidad de los antimicrobianos disponibles para su tratamiento, por lo que cada vez es más frecuente y necesario el empleo de antibióticos como los carbapenems, lo que facilita la adquisición de mecanismos de resistencia a estas drogas. El presente estudio intenta determinar la producción de metalobetalactamasas (MBL) en aislados clínicos de Pseudomonas aeruginosa, utilizando para ello dos métodos fenotípicos. Se utilizó el método del doble disco (MDD) y el test de Hodge modificado (MHT). Se analizaron 726 aislados clínicos de P. aeruginosa, el 20,11% (146) de estos fueron resistentes a imipenem (IPM) y meropenem (MEM), por lo que se les realizaron los dos métodos fenotípicos, de los 146 aislados resistentes a carbapenems, 139 fueron positivas para el MDD, mientras que 144 lo fueron para el MHT, estos dos métodos permitieron confirmar la presencia de una carbapenemasa tipo MBL en el 98,63% de los aislados de P. aeruginosa, por otra parte, cinco aislados no fueron positivos para el MDD pero si para el MHT, lo que indicaría la presencia de carbapenemasas no MBL en estos aislado, también se obtienen 2 aislados que a pesar de ser IPM y MEM resistentes fueron negativos por los dos métodos fenotípicos utilizados, esto indicaría la presencia de un mecanismo de resistencia no enzimático que confiere resistencia a carbapenems...

Pseudomonas aeruginosa is considered one of the most important hospital germs; its isolation is common in hospitalized patients. In addition, this microorganism has a marked multi-resistance, which increases mortality. Treatment of these patients is often difficult, since in addition to its natural resistance, Pseudomonas can obtain resistance mechanisms to virtually all antimicrobial drugs available for its treatment; due to this, its appearance is increasingly frequent and necessitates the use of antibiotics such as carbapenems, which facilitates the acquisition of resistance mechanisms to these drugs. This study attempts to determine the production of metallo-beta-lactamase (MBL) in clinical isolates of Pseudomonas aeruginosa, utilizing two phenotypic methods: the double disc method (MDD) and the modified Hodge test (MHT). 726 clinical isolates of P. aeruginosa were analyzed; 20.11% (146) of these were resistant to imipenem (IPM) and meropenem (MEM); 139 were positive for the MDD, while 144 were positive for the MHT. These two methods permitted confirming the presence of an MBL-type carbapenemase in 98.63% of P. aeruginosa isolates; five isolates were negative for the MDD but positive for the MHT, indicating the presence of non-MBL-type carbapenemase in these isolates. Also, 2 isolates were obtained that, despite being resistant to IPM and MEM, were negative according to the two phenotypic methods used; this would indicate the presence of a non-enzymatic resistance mechanism conferring resistance to carbapenems. The use of phenotypic methods for detecting MBL in P. aeruginosa isolates is quite an acceptable option for use in routine laboratories where specialized molecular biology tests are not available.

Acinetobacter baumannii: No more a choosy intruder.

Context: Acinetobacter baumannii, a non-fermenter, is fast coming up the list of pathogens causing nosocomial infections. Earlier considered to be a harmless colonizer, or at the most, a pathogen causing mostly respiratory tract infections, it has slowly but successfully emerged as a ubiquitous pathogen causing both community as well as health care associated infections. It has acquired multidrug resistance, and seems to be no more selective in mainly attacking any one or two body systems. According to recent reports, a shy selective bacterium has turned into a dangerous pathogen, capable of causing infections anywhere in the body, thereby adding extra furrows on the forehead of medical community worldwide. AIMS: To determine the range of infections caused by A. baumannii, and the frequencies thereof, in our tertiary care hospital; and to study their resistance patterns. Materials and Methods: A total of 88 isolates of A. baumannii were found from a variety of clinical samples, from hospitalized patients as well as patients attending the outpatient departments. The isolates were subjected to disc-diffusion method for antibiotic sensitivity testing. Results: Acinetobacter was mostly recovered from samples of pus, followed by endotracheal tube, urine, sputum samples, etc., Imipenem showed highest sensitivity, while other drugs with good sensitivity patterns were aminoglycosides and piperacillin-tazobactum. Conclusions: In this tertiary care institution of ours, A. baumannii isolates have shown a high frequency of drug resistance, with imipenem being the best sensitive drug. This non-fermenter is the cause of a variety of infections, irrespective of whether the individuals are hospitalized or are outdoor patients.

A Case of Acute Phlegmonous Gastritis Causing Gastroparesis and Cured with Medical Treatment Alone / 대한소화기학회지

Acute phlegmonous gastritis is an uncommon disease, often fatal condition characterized by suppurative bacterial infection of the gastric wall. It has a high mortality rate mainly because the diagnosis is usually made late. Until recently, gastrectomy in combination with antibiotics was recommended. We had experienced a case of 66-year-old man presented with epigastric pain, nausea, vomiting, and hematemesis, followed by aspiration pneumonia. At upper gastrointestinal endoscopy, the gastric lumen was narrow, and the mucosa was severely inflamed, which was erythematous, swelled, and showed necrotic areas covered with purulent exudate. Klebsiella oxytoca and Acinetobacter lwoffii were isolated in the gastric tissue culture. Contrast-enhanced computerized tomography scan of abdomen demonstrated diffuse gastric wall thickening and an intramural abscess in the gastric antral wall. Although delayed gastric emptying by gastroparesis prolonged the in-hospital period, the only medical treatment with antibiotics alone successfully cured the patient without gastrectomy.

False-positive widal in melioidosis.

Enteric fever is endemic in this part of the world, and Widal test is one of the time-honored laboratory tests that are being used for years to diagnose the disease. On the other hand, melioidosis is a newly emerging disease from this region, which is most often misdiagnosed or underdiagnosed by clinicians. It is well accepted that false-positive Widal reactions following certain non-typhoid Salmonella infections may occur commonly. Three cases of high titers of Widal test are described, where melioidosis was the actual diagnosis in every occasion and was never suspected until diagnosed microbiologically. All the patients had shown a partial response to ceftriaxone. Blood and pus cultures grew Burkholderia pseudomallei, whereas Salmonella typhi was not isolated from blood in any patient. With appropriate antibiotics, the patients showed clinical and microbiological improvement with lowering of Widal titers. These 3 cases show that high Widal titer in any patient may mislead the diagnosis of melioidosis, and further laboratory workup should always be done to rule out melioidosis, especially in cases with nonresponsiveness to treatment.

Indications of carbapenem resistance evolution through heteroresistance as an intermediate stage in Acinetobacter baumannii after carbapenem administration / Indicações da evolução da resistência ao carbapenem através da heteroresistência como estágio intermediário no Acinetobacter baumannii após administração de carbapenem

We describe an in vivo evolution of an antimicrobial profile from susceptibility to full-resistance to carbapenems, with heteroresistance as an intermediate stage, in an Acinetobacter baumannii strain. Heteroresistance was characterized by the growth of sub-populations within the susceptibility halo in both disk-diffusion and Etest. PCRs for the main A. baumannii carbapenemases were negative. The exact resistance mechanism, diagnostic methods and clinical relevance of heteroresistance in A. baumannii warrant further investigations. This is the first description of such phenomenon in vivo and the second report of heteroresistance to carbapenems in A. baumannii.

Descrevemos a evolução in vivo, de um perfil de sensibilidade aos antimicrobianos, passando de sensibilidade a resistência total aos antibióticos carbapenêmicos, com um estágio intermediário de heteroresistência em isolado de Acinetobacter baumannii. A heteroresistência foi caracterizada pelo crescimento de sub-população na zona de inibição pelo método de disco-difusão e pelo Etest. PCRs para as principais carbapenemases envolvidas com resistência neste microrganismo foram negativas. O exato mecanismo de resistência envolvido, método diagnóstico e relevância clínica justificam investigação adicional. Esta é a primeira descrição deste fenômeno in vivo e o segundo relato de heteroresistência em A. baumannii.

Detecção de metalo-beta-lactamases em amostras de pseudomonas aeruginosa isoladas em Porto Alegre, Rio Grande do Sul / Detection of metallo-beta-lactamase producing pseudomonas aeruginosa isolated in Porto Alegre,Rio Grande do Sul, Brazil

As metalo-beta-lactamases (MBLs) pertencem ao grupo 3 de beta-lactamases de espectro estendido, fazendo parte de uma classefuncional de metaloenzimas classificadas com base na sua capacidade de hidrolisar os carbapenemicos como o Imipenem e em suas caracteristicas de serem inibidas por agentes quelantes como o acido etilenodiamino tetra-acetico (EDTA) e acido 2-mercaptopropionico (2-MPA). Este estudo objetivou a deteccao de MBLs em amostras nosocomiais de P. aeruginosa resistentes a Ceftazidima, provenientes de um hospital de medio porte de Porto Alegre-RS. Foram analisados 113 isolados clinicos atraves de testes fenotipicos, sendo: 80 (70,7%) do trato respiratorio inferior, 24 (21,2%) urina, 3 (2,7%) hemocultura, 3 (2,7%) ponta de cateter, 2 (1,8%) colecao de cavidadese 1 (0,9%) liquor. Com relacao a producao de MBLs, detectou-se 35 amostras (31,0%) como sendo produtoras.

Metallo-beta-lactamases belongs to the group 3 of extended spectrum beta-lactamases, making part of a common functional class of metal enzymes classified based in their ability to hydrolyze Imipenem and in your characteristics of been inhibited by ions of chelating metals, like EDTA and 2-MPA. The aim of this study was detect MBLs in samples of P. aeruginosa resistant to ceftazidime in the patients of PortoAlegre- RS Brazil. The samples was provided of different clinical specimens like: 80 (70,7%) respiratory tract, 24 (21,2%) urine, blood 3 (2,7%), catheter 3 (2,7%), 2 (1,8%) corporeal secretions and 1 (0,9%) liquor. With regard to the MBLs production, we detect 35 (31%) as being producing.

Analysis of the use of imipenem at a University Hospital following the restructuring of an antimicrobial audit system

This study analyzed the use pattern of imipenem following the restructuring of the antimicrobial audit system at a University Hospital. It was an observational study before and after the restructuring of the antimicrobial audit system in a University Hospital from May to August and then from September to December 2006. The criteria of the rational use of imipenem were obtained from a non-systematic revision of the literature. The collection of data on the general characteristics and clinical state of the patient, the infection and the established therapy was carried out in a previously tested instrument. Data was recorded, revised and analyzed in a database built with the software SPSS® for Windows® PC, version 10.0. The statistical analysis had a descriptive character: frequencies, mean, median and standard deviation. No differences were encountered in relation to the appropriate indication, consumption and clinical outcomes of patients. However, there was a reduction of 4 to 1 (75.0 percent) in the number of associations with spectrum superposition and an increase of 4 to 8 (50.0 percent) in the change of therapy. The restructuring of the antimicrobial audit system in the studied hospital did not reflect significantly the increase of the appropriate indication of imipenem. It contributed, however, to the reduction of the inappropriate associations of this antibiotic and to changes of therapy, without, however, compromising the quality of services rendered to patients.

Laryngitis and neutropenia from parvovirus-B19.

Parvovirus-B19 has been reported a rare cause of acute laryngitis. Here, we described an 11-month-old girl who had prolonged acute laryngitis and neutropenia associated with parvovirus-B19 infection. Intravenous immunoglobulin therapy resulted in resolution of her symptoms, except neutropenia. We concluded that parvovirus-B19 can cause prolonged laryngitis and intravenous immunoglobulin treatment should be considered.

Sepsis por Chromobacterium violaceum pigmentado y no pigmentado / Sepsis caused by pigmented and no pigmented Chromobacterium violaceum

La sepsis por Chromobacterium violaceum es un cuadro clínico rara vez reportado y asociado con una elevada letalidad. Comunicamos un caso fatal de sepsis en un niño indígena venezolano con 6 años de edad, quien presentó fiebre y aumento de volumen en la región inguinal derecha y que fuera inicialmente diagnosticado como plastrón apendicular abscedado. La cirugía de apendicetomía reveló un absceso en el músculo psoas derecho, del cual se aisló una cepa pigmentada de C. violaceum, mientras que a partir de hemocultivos se aislaron cepas pigmentada y no pigmentada, simultáneamente, del mismo agente. Se administró tratamiento con imipenem y amikacina pero su condición se deterioró y falleció a los 9 días de su ingreso.

Chromobacterium violaceum sepsis is rare but associated with a high mortality rate. We report a fatal case of C. violaceum sepsis in a 6 years old Venezuelan indian boy. Clinical manifestations were fever and swelling in the right inguinal region. The initial diagnosis was an appendicular plastron. Appendicectomy was performed and during surgery a right psoas abscess was identified that resulted culture positive for pigmented C. violaceum. Blood cultures were positive for a pigmented and non pigmented C. violaceum strain. Imipenem and amikacin were administered despite of which the child died 9 days after hospital admission.