Sporadic human cutaneous anthrax outbreak in Shaanxi Province, China: report of two cases from 2018

ABSTRACT China's compulsory annual livestock anthrax vaccination policy has remarkably reduced but not completely eradicated human anthrax infections. Herein we describe a sporadic human cutaneous anthrax outbreak involving two cases in 2018 in Shaanxi Province, both involving herdsman who dealt with unvaccinated and potentially sick cattle. Both patients showed Bacillus anthracis-positive blister smear and blood culture. Treatment with penicillin was followed by uneventful recovery for both. The prompt performance of the prophylactic measures successfully interrupted the further transmission of this sporadic human cutaneous anthrax outbreak.

Microbiologic characteristics and antibiotic resistance rates of diabetic foot infections / Perfil microbiológico e de resistência bacteriana no pé diabético infectado

ABSTRACT Purpose: the purpose of this research was to identify the sociodemographic and microbiological characteristics and antibiotic resistance rates of patients with diabetic foot infections, hospitalized in an emergency reference center. Methods: it was an observational and transversal study. The sociodemographic data were collected by direct interview with the patients. During the surgical procedures, specimens of tissue of the infected foot lesions were biopsied to be cultured, and for bacterial resistance analysis. Results: the sample consisted of 105 patients. The majority of patierns were men, over 50 years of age, married and with low educational level. There was bacterial growth in 95 of the 105 tissue cultures. In each positive culture only one germ was isolated. There was a high prevalence of germs of the Enterobacteriaceae family (51,5%). Gram-negative germs were isolated in 60% of cultures and the most individually isolated germs were the Gram-positive cocci, Staphylococcus aureus (20%) and Enterococcus faecalis (17,9%). Regarding antibiotic resistance rates, a high frequency of Staphylococcus aureus resistant to methicillin (63,0%) and to ciprofloxacin (55,5%) was found; additionally, 43,5% of the Gram-negative isolated germs were resistant to ciprofloxacin. Conclusions: the majority of patients were men, over 50 years of age, married and with low educational level. The most prevalent isolated germs from the infected foot lesions were Gram-negative bacteria, resistant to ciprofloxacin, and the individually most isolated germ was the methicillin resistant Staphylococcus aureus.

RESUMO Objetivo: identificar o perfil sociodemográfico, microbiológico e de resistência bacteriana em pacientes com pé diabético infectado. Métodos: tratou-se de estudo observacional, transversal que avaliou os perfis sóciodemográfico e microbiológico de pacientes portadores de pé diabético infectado internados em Pronto Socorro de referência. Os dados sociodemográficos foram coletados por meio de entrevista. Foram colhidos, durante os procedimentos cirúrgicos, fragmentos de tecidos das lesões podais infectadas para realização de cultura/antibiograma. Resultados: a amostra foi composta por 105 pacientes. O perfil sociodemográfico mais prevalente foi o de pacientes do sexo masculino, acima dos 50 anos, casados e com baixa escolaridade. Das 105 amostras de fragmentos de tecidos colhidos para realização de cultura e antibiograma, 95 foram positivas, com crescimento de um único germe em cada um dos exames. Houve predomínio de germes da família Enterobacteriaceae (51,5%). Germes Gram-negativos foram isolados em 60,0% das culturas e os espécimes mais isolados individualmente foram os cocos Gram-positivos, Staphylococcus aureus (20,0%) e Enterococcus faecalis (17,9%). Considerando-se os perfis de resistência bacteriana, verificou-se alta taxa de Staphylococcus aureus resistente à meticilina (63,0%) e à ciprofloxacino (55,5%); verificou-se, também, que 43,5% dos germes Gram-negativos eram resistentes à ciprofloxacino. Conclusões: o perfil sociodemográfico majoritário, foi o de homens, com mais de 50 anos e com baixa escolaridade. Concluímos que os germes mais prevalentes nas lesões podais dos pacientes diabéticos foram os Gram-negativos, resistentes ao ciprofloxacino e que o germe mais isolado individualmente foi o Staphylococcus aureus resistente à meticilina.

Infección por Serratia marcescens: una inusual causa de lesiones cutáneas / Serratia marcescens infection: an unusual cause of skin lesions

Serratia marcescens corresponde a un bacilo gram negativo, miembro de la familia Enterobacteriaceae. Este microorganismo tiene una alta capacidad de supervivencia en condiciones hostiles y ha sido implicado en infecciones del tracto respiratorio, vía urinaria, meningitis, endocarditis y sistema musculoesquelético. No obstante, es considerado una causa rara de infecciones cutáneas. Esta última tiene distintas presentaciones clínicas, la más frecuente es fascitis necrotizante seguida de celulitis. Los nódulos, las pápulas después de inyecciones de rellenos, las erupciones papulares diseminadas, las placas eritematosas, las pústulas y las úlceras son parte del amplio espectro de formas clínicas descritas en la literatura. Presentamos el caso de una paciente de 50 años, con historia de compromiso del estado general, lesiones cutáneas polimorfas y fiebre. Se confirmó una infección cutánea por Serratia marcescens mediante cultivos. Se destaca el polimorfismo y la coexistencia de distintas manifestaciones en una misma paciente, incluyendo celulitis, nódulo, ulceras y necrosis cutánea y la importancia del estudio microbiológico para el adecuado tratamiento antibiótico.

Serratia marcescens corresponds to gram negative bacillus, a member of the Enterobacteriaceae family. This microorganism has a high survival capacity in hostile conditions and has been implicated in respiratory tract, urinary tract, meningitis, endocarditis and musculoskeletal system infections. However, it is considered a infrequent cause of cutaneous infections. Has different clinical presentations, the most frequent is necrotizing fasciitis followed by cellulite. Nodules, papules after filler injections, disseminated papular eruption, erythematous plaques, pustules and ulcers are part of the broad spectrum of clinical forms described in the literature. We present the case of a 50 year old patient with a history of compromised general condition, polymorphic cutaneous lesions and fever. Serratia marcescens cutaneous infection was confirmed by cultures. The polymorphism and the coexistence of different manifestations in the same patient, including cellulitis, nodule, ulcers and skin necrosis, and the importance of the microbiological study for the adequate antibiotic treatment are highlighted.

Ántrax cutáneo, último brote diagnosticado en Chile / Cutaneous anthrax, the last outbreak diagnosed in Chile

Resumen El ántrax, es una zoonosis causada por una bacteria generadora de esporas, llamada Bacillus anthracis. En forma natural tiene una distribución global, con una predilección en zonas agrícolas con pocas normativas de sanidad pública veterinaria. El contagio humano ocurre por el consumo de carnes de animales enfermos, por contacto a través de una puerta de entrada en la piel o por la inhalación de esporas de productos derivados del animal afectado (lana, cuero, huesos). La infección en los seres humanos compromete con mayor frecuencia la piel, seguido por el tracto gastrointestinal y los pulmones. El control de la enfermedad se basa en la prevención, de allí la importancia de la vigilancia en la detección de casos y brotes. Presentamos el último brote de ántrax cutáneo diagnosticado en Chile con descripción de dos primeros casos clínicos del brote.

Anthrax is a zoonosis caused by a spore-forming bacterium, called Bacillus anthracis. Naturally it is of global distribution, with a predilection in agricultural zones with few norms of public veterinary health. Human contagion occurs through the consumption of diseased animal's meat or through a doorway into the skin or through the spores inhalation of products derived from the affected animal (wool, leather, bones). The most frequent infection in humans occurs in the skin, followed by the gastrointestinal tract and lungs. We present the last outbreak of cutaneous anthrax diagnosed in Chile with a description of the first two clinical cases of the outbreak. Control disease is based on prevention, hence the importance of surveillance in detecting cases and outbreaks.

Infecções da pele e de tecidos moles na unidade de terapia intensiva: estudo retrospectivo em um centro terciário / Skin and soft tissue infections in the intensive care unit: a retrospective study in a tertiary care center

RESUMO Objetivo: Descrever o prognóstico, os fatores de risco e a etiologia das infecções da pele e dos tecidos moles na unidade de terapia intensiva. Métodos: Estudo retrospectivo de uma coorte de 1.123 pacientes graves admitidos a uma unidade de terapia intensiva com o diagnóstico de infecção grave de pele ou tecidos moles. Resultados: Foram selecionados 30 pacientes, sendo 20 (66,7%) com fasceíte necrotizante, predominantemente da região perineal; 8 (26,7%) com abscesso cutâneo; e 2 (6,6%) com celulite. A maioria dos pacientes tinha fatores de risco, como imunossupressão e lesões cutâneas. O microrganismo isolado predominante foi Escherichia coli. Pacientes com fasceíte necrotizante na admissão à unidade de terapia intensiva apresentaram mortalidade significativamente maior (55%; p = 0,035), assim como aqueles com maior índice de severidade, choque séptico, parada cardiorrespiratória e leucocitose. Organismos resistentes à antibioticoterapia foram comuns, mesmo na ausência de fatores de risco. Quando presente, o fator de risco mais comum foi o uso prévio de antibiótico. Conclusão: Foram identificados fatores de risco e microrganismos diferentes dos classicamente descritos na literatura, além de elevada mortalidade da fasceíte necrotizante e presença de microrganismos multirresistentes na ausência de fatores de risco. Dada a aparente evolução etiológica das infecções da pele e tecidos moles, a identificação de novos fatores de risco e etiologia pode contribuir para uma terapêutica antimicrobiana mais adequada.

ABSTRACT Objective: To identify factors that may influence outcomes in patients with severe skin and soft tissue infections in the intensive care unit. Methods: A retrospective observational study was conducted in a cohort of 1,123 critically ill patients admitted to an intensive care unit with a primary or secondary diagnosis of severe skin and soft tissues infection between January 2006 and December 2014. Results: Thirty patients were included, 20 (66.7%) of whom were diagnosed with necrotizing fasciitis; in these patients, perineal area involvement was most commonly identified. Abscess was diagnosed in 8 (26.7%) patients, most commonly involving the cervical area. Risk factors such as immunosuppression and previous surgical trauma were commonly observed in this population. The most commonly isolated microorganism was Escherichia coli. Multidrug resistant microorganisms were commonly detected, even in the absence of traditional risk factors; among these patients, previous use of antibiotics was the most common risk factor for drug resistance. The rate of mortality was significantly higher in patients with necrotizing fasciitis (55%, p = 0.035) and associated with disease severity, presence of septic shock, cardiac arrest and leucocytosis. Conclusion: Different risk factors and etiologies of severe skin and soft tissue infections were identified. Necrotizing fasciitis and drug-resistant bacteria were significant predictors of mortality, even in the absence of traditional risk factors. Obtaining a better understanding of trends in the risk factors and microorganisms associated with severe skin infections may help in the determination of prompt treatment and antibiotic choices.

Efficacy, safety, tolerability and population pharmacokinetics of tedizolid, a novel antibiotic, in Latino patients with acute bacterial skin and skin structure infections

Abstract Acute bacterial skin and skin structure infections are caused mainly by Gram-positive bacteria which are often treated with intravenous vancomycin, daptomycin, or linezolid, with potential step down to oral linezolid for outpatients. Tedizolid phosphate 200 mg once daily treatment for six days demonstrated non-inferior efficacy, with a favourable safety profile, compared with linezolid 600 mg twice daily treatment for 10 days in the Phase 3 ESTABLISH-1 and -2 trials. The objective of the current post-hoc analysis of the integrated dataset of ESTABLISH-1 and -2 was to evaluate the efficacy and safety of tedizolid (N = 182) vs linezolid (N = 171) in patients of Latino origin enrolled into these trials. The baseline demographic characteristics of Latino patients were similar between the two treatment groups. Tedizolid demonstrated comparable efficacy to linezolid at 48–72 h in the intent-to-treat population (tedizolid: 80.2% vs linezolid: 81.9%). Sustained clinical success rates were comparable between tedizolid- and linezolid-treated Latino patients at end-of-therapy (tedizolid: 86.8% vs linezolid: 88.9%). Tedizolid phosphate treatment was well tolerated by Latino patients in the safety population with lower abnormal platelet counts at end-of-therapy (tedizolid: 3.4% vs linezolid: 11.3%, p = 0.0120) and lower incidence of gastrointestinal adverse events (tedizolid: 16.5% vs linezolid: 23.5%). Population pharmacokinetic analysis suggested that estimated tedizolid exposure measures in Latino patients vs non-Latino patients were similar. These findings demonstrate that tedizolid phosphate 200 mg, once daily treatment for six days was efficacious and well tolerated by patients of Latino origin, without warranting dose adjustment.

Brazilian Spotted Fever: the importance of dermatological signs for early diagnosis

Brazilian spotted fever is an acute febrile infectious disease caused by Rickettsia rickettsii, transmitted by tick bite. As this disease is rare and has high mortality rates in Brazil, the clinical aspects and epidemiological data may help the diagnosis. We report a case of Brazilian spotted fever in a 19-year-old patient who presented maculopapular exanthema in the palmar region and upper limbs, lymphadenopathy, fever, chills, headache, conjunctival hyperemia, nausea, vomiting, dyspnea, myalgia, developing neurological signs and abdominal pain. He was treated with doxycycline with clinical improvement. We emphasize the importance of the recognition of this disease by dermatologists as cutaneous manifestations are the key findings to establish early diagnosis and prevent complications.

Treatment of Mycobacterium marinum with lymecycline: new therapeutic alternative?

Skin infections by Mycobacterium marinum are quite rare in our environment and, therefore, little studied. The majority of the lesions appear three weeks after traumas in aquariums, beaches and fish tanks. Lymph node drainage and systematization of the disease are rare and most lesions disappear in about three years. This case aims to show the effectiveness of the treatment used (lymecycline 150 mg/orally/day). This medication may be a new therapeutic option for the treatment of Mycobacterium marinum.

Long-term treatment of persistent disseminated Nocardia cyriacigeorgica infection

In this paper a disseminated persistent Nocardia cyriacigeorgica infection in an immunocompetent patient is described. The patient's long-term treatment, as well as its implications for managing similar cases in the future, is emphasized. Presenting with high fever, multiple nodules, and ulcerative cutaneous lesions of body sites, the patient was treated with various antimicrobials. Under combined therapy, empyema and arthritis, leading to disseminated nocardiosis, were seen. The overall treatment course was 28 months. It can be concluded that the choice of the antibiotics and optimal duration of treatment are uncertain; therefore the treatment of nocardiosis requires expertise.

Spectrum and potency of ceftaroline against leading pathogens causing community-acquired respiratory tract and skin and soft tissue infections in Latin America, 2010

Ceftaroline, the active metabolite of the prodrug ceftaroline fosamil, is a cephalosporin with in vitro bactericidal activity against Gram-positive organisms, including methicillinsusceptible and -resistant Staphylococcus aureus, β-haemolytic and viridans group streptococci, and Streptococcus pneumoniae, as well as common Gram-negative organisms. In this study a total of 986 isolates collected in 2010 from patients in 15 medical centers in five Latin American countries from the Assessing Worldwide Antimicrobial Resistance Evaluation Program were identified as community-acquired respiratory tract or skin and soft tissue infection pathogens. Ceftaroline was the most potent agent tested against S. pneumoniae with a MIC90 value (0.12 µg/mL) that was eight-fold lower than ceftriaxone, levofloxacin, and linezolid. Its spectrum of coverage (100.0% susceptible) was similar to tigecycline, linezolid, levofloxacin and vancomycin. Against Haemophilus influenzae and Moraxella catarrhalis, ceftaroline was the most active agent tested. The activity of ceftaroline against S. aureus (including MRSA) was similar to that of vancomycin and tetracycline (MIC90,1 µg/mL) and linezolid (MIC90,2 Jg/mL). The 1-haemolytic streptococci exhibited 100.0% susceptibility to ceftaroline. Ceftaroline activity against Escherichia coli, Klebsiella spp., and Enterobacter spp. was similar to that of ceftriaxone and ceftazidime. These parenteral cephalosporin agents have potent activity against non-extended-spectrum These parenteral cephalosporin agents have potent activity against non-extended-spectrum-lactamase-phenotype strains, but are not active against extended-spectrum β-lactamase-phenotype strains. These results confirm the in vitro activity of ceftaroline against pathogens common in communityacquired respiratory tract and skin and soft tissue infection in Latin America, and suggest that ceftaroline fosamil could be an important therapeutic option for these infections.

Early diagnosis of relapse in borderline leprosy: two case reports / Diagnóstico precoce de recidiva em hanseníase dimorfa: apresentação de dois casos

Two cases of relapse in borderline leprosy were reported. Despite the late-reversal, reaction-like feature, the suspicion of relapse in both was based on persistent and slow-developing skin lesions and an absence of acute neuritis or reaction during one year of follow-up. The authors have considered this possible occurrence in lepromatous borderline-treated patients after their immune cellular restoration and defend that not all Type 1 reactions would be an inflammatory answer to persistent Mycobacterium leprae, but that they could be. Therefore, a relapse diagnosis could be applied and it is more advisable, as one year of Multi-Drug Therapy (MDT) is less dangerous and more efficient for these cases than one year of corticosteroids.

São apresentados dois casos de recidiva de hanseníase borderline. Apesar das características de reação reversa tardia, a suspeita de recidiva foi baseada no desenvolvimento insidioso e persistente de lesões cutâneas sem reação e neurite agudas, durante um ano de seguimento. Os autores consideram a possibilidade de recidiva em pacientes borderline virchowinano tratados, pela restauração da imunidade celular e postulam que embora nem toda reação tipo 1 seja devida a presença de M. leprae persistentes, isso também pode ocorrer. Assim, o diagnóstico de recidiva foi considerado ressaltando-se que um ano de poliquimioterapia oferece menos danos e pode ser mais eficiente nesses casos, que um ano de corticosteróides.

Infección por Staphylococcus aureus meticilino-resistente comunitario en un grupo familiar / Community meticiline resistant Staphylococcus aureus skin infection in a family setting

Staphylococcus aureus es un patógeno que causa infecciones de diversa gravedad en niños y adultos. Su frecuencia es alta (28,4 casos por cada 100.000 personas). En los últimos años reemerge como patógeno de infecciones severas de piel y partes blandas en pacientes de la comunidad, con características feno y genotípicas diferentes; se lo denomina Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMRAC). En nuestro país constituye un patógeno emergente subdiagnosticado. Se presenta una familia que durante 1 año consultó por múltiples episodios de infecciones cutáneas recidivantes, tratadas con esquemas antibióticos empíricos, sin aislamiento microbiológico y fracaso terapéutico. Se observaron nódulos eritematosos, algunos con centro necrótico y ulcerados, en diversas localizaciones. El cultivo de las lesiones de los 3 pacientes confirmó el diagnóstico de SAMRAC. Los hisopados nasales fueron negativos. Realizaron tratamiento con trimetoprima-sulfametoxazol 800/160 mg cada 12 hs y clindamicina 300 mg cada 6hs por 14 días, con curación total de las lesiones

Staphylococcus aureus is a pathogen responsible for infections of variableseverity both in children and adults. Its prevalence is high (about28.4 cases per 100.000 persons). Nowadays this pathogen cause severeskin and soft tissue infections in the community setting. Neverthelessits features are different and has been denominated communityacquired meticiline resistant S. aureus (CA-SAMR). In our countrythis pathogen is under diagnosed.We describe a family with multiple episodes of recidivate skin infectionswhich were treated empirically and without success. The clinical featurewas the presence of eritemathous nodules, some of them ulcerated andnecrotic, in diff erent sites. CA-SAMR was isolated in all patients. Nasalsamples were negative in all family members. They were treated with trimetoprimsulfamethoxazol 800/160 mg each 12 hours and clindamicine300 each 6 hours for 14 days with complete cure of the lesions. (DermatolArgent 2010;16(2):126-128).

Estudio prospectivo, descriptivo y multicéntrico acerca de la infección de piel y partes blandas por Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMRAC) / Multicentric prospective and descriptive study about community-acquired methicillin-resistant Staphylococcus aureus cutaneous and sof tissue infection (CA-MRSA)

El Staphylococus aureus meticilino-resistente adquirido en la comunidad (SAMRAC) es uno de los principales patógenos emergentes de la última década, y en algunos países es la principal causa de infecciones de piel y partes blandas. El objetivo de este estudio es describir las características epidemiológicas, clínicas y microbiológicas de las infecciones de piel y partes blandas producidas por SAMRAC en pacientes ambulatorios. Materiales y métodos. Estudio descriptivo, prospectivo, multicéntrico realizado en seis Servicios de Dermatología de la ciudad de Buenos Aires entre julio de 2008 y junio de 2009. Se incluyeron pacientes con infección de piel y partes blandas por SAMRAC documentada por cultivo. La definición de adquisición en la comunidad se basó en criterios epidemiológicos. Resultados. Se reclutaron 114 pacientes, de los cuáles 49% fueron hombres y 51 % mujeres. La media de la edad fue 27 años. El 74% recibió tratamiento con ß lactámicos previo al diagnóstico. Los forúnculos representaron la forma clínica más frecuente (59%), seguido de los abscesos (20%). El antibiótico más indicado fue trimetoprima-sulfametoxasol (68,4%).Las resistencias más frecuentes fueron eritromicina (21,7%) y clindamicina (16,2%), 6 pacientes requirieron internación, 18 pacientes presentaron recurrencias y no se registró ninguna muerte. Conclusiones. Los datos demográficos y clínicos obtenidos en este estudio son similares a los comunicados previamente. La mayoría de los pacientes recibieron tratamiento antibiótico previo, lo que denota una baja sospecha diagnóstica. El impétigo representó una forma de presentación frecuente en la población pediátrica y la celulitis sólo comprometió a mujeres. La resistencia a clindamicina fue mayor al 15%, por lo que no debería ser considerado un antibiótico de primera línea. Las infecciones de piel y partes blandas por SAMRAC son frecuentes en nuestro medio, por lo que debe considerarse en pacientes con lesiones supurativas o falta de...

Community acquired methicillin-resistant Staphylococcus aureus is oneof the main emergent pathogens of the last decade, being the fi rstcause of skin and soft tissue infections in some countries. The purposeof this study is to describe the epidemiologic, clinical, and microbiologicalcharacteristics of CA-MRSA cutaneous and soft tissue infections inan ambulatory setting.Methods. We conducted a multuicentric, prospective, descriptive studyperformed in 6 dermatology units at Buenos Aires from july 2008 to june2009. Patients with documented CA-MRSA skin and soft tissue infectionswere included. Community acquisition was defi ned based on epidemiologiccriteria.Results. We included 114 patients, of which 49% were male and 51%were female. The median age was 27 years. Seventy four percent of the patientshad received beta-lactamic antibiotic treatment prior to inclusion.The main clinical presentation were furuncules (59%) followed by abscesses( 20%). The most frequently prescribed antibiotic was trimethoprim-sulfametoxazole(68,4%). The most frequently recovered isolates were erithromicin-(21,7%) and clindamycin-resistant (16,2%). Six patients requiredhospital admission, 18 had recurrent diseases, and no death was recorded.Discussion. Demographic and clinical data obtained in this study aresimilar to those previously reported. Most of the patients had received antibiotictreatment before inclusion, which shows the low CA-MRSA clinicalsuspicious. Impetigo was fecuently observed among children, and celulitiswas exclusively observed in females. As clindamycin resistance washigher than 15%, this antibiotic should not be considered a fi rst-line treatmentoption. CA-MRSA infections were frecuently observed in our patients,therefore its diagnosis should be considered on suppurative lesionsand non responding pyodermitis (Dermatol Argent 2010;16(2):110-116).

Manifestaciones muco-cutáneas de la infección por Mycoplasma pneumoniae: Presentación de cuatro casos / Mucocutaneous findings of the Mycoplasma pneumoniae infection: Presentation of four cases

The mucocutaneous manifestations oí Mycoplasma pneumoniae infection appear in approximately 20 percent of all the infections produced by this microorganism. Maculopapular rash, vesicular or urticarial exanthemas, are frequent manifestations that can constitute Erythema multiforme or more rarely, Stevens - Johnson syndrome or epidermal toxic necrolisis. We describe the clinical evolution, diagnosis and treatment of four children with mucous and cu-taneous manifestations associated to infection by Mycoplasma pneumoniae and a review of the medical literature.

El compromiso muco-cutáneo de la infección por Mycoplasma pneumoniae se presenta en aproximadamente 20 por ciento de todas las enfermedades producidas por este microorganismo. Frecuentemente se manifiesta con lesiones máculo-papulares, vesiculosas o urticariales, que pueden constituir el eritema multiforme, más raramente síndrome de Stevens-Johnson o necrosis epidérmica tóxica. Describimos la evolución clínica, diagnóstico y el tratamiento administrado a cuatro niños que presentaron manifestaciones de piel y mucosas en relación a la infección por Mycoplasma pneumoniae. Se efectuó además una revisión de la literatura médica.