Síndrome de Reacción a drogas con Eosinofilia y Síntomas Sistémicos (DRESS) asociados a Nefritis Túbulo Intersticial Aguda en un adolescente / DRESS síndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) associated with Tubulo Interstitial Nephritis in a adolescent

Resumen El síndrome de DRESS (Reacción a drogas con eosinofilia y síntomas sistémicos) es una patología poco frecuente en Pediatría, descrita por primera vez en 1996, por Bocquet. Puede presentarse en un tiempo variable luego de exposición a algunos medicamentos, se caracteriza por fiebre, compromiso cutáneo y de órganos internos. En este caso, se presenta a un paciente de 13 años, con antecedente de uso de Trimetroprim sulfa desde hace 2 meses, con cuadro de 3 días consistente en fiebre y rash cutáneo, sin compromiso de mucosas, con respuesta no favorable al manejo con esteroide, requiriendo Inmunoglobulina IV. Semanas después del inicio de los síntomas y evolución estable presenta insuficiencia renal aguda que requirió terapia de reemplazo renal. Se descartaron otras patologías subyacentes de índole autoinmune. Hubo recuperación de azoados y normalización de los demás paraclínicos el día 40 de la enfermedad. El paciente continúa asintomático, 4 meses después, con tratamiento con esteroide oral, en descenso lento y gradual. Se debe considerar la evaluación permanente de las pruebas de función renal en los pacientes que presenten Síndrome de DRESS, por su asociación con Nefritis intersticial aguda y complicaciones relacionadas.

Abstract DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a rare pathology in Pediatrics, first described in 1996 by Bocquet. It can appear in a variable period of time after exposure to some medications, it is characterized by fever, skin involvement and internal organs. A 13-year-old patient is presented, with a history of use of Trimethoprim sulfa for two months, with a disease of three days of evolution, consisting of fever and skin rash, without mucosal involvement, with an unfavorable response to steroid management, requiring Intravenous inmunoglobulin. Weeks after the onset of symptoms and stable evolution, he presented acute renal failure that required renal replacement therapy. Other underlying autoimmune pathologies were ruled out. There was recovery of renal function test and normalization of the other paraclinical on day 40 of the disease. Patient remains asymptomatic four months later, with oral steroid treatment, in slow and gradual decline. Permanent evaluation of renal function tests should be considered in patients with DRESS syndrome, due to its association with acute tubulointerstitial nephritis and related complications.

YOKENELLA REGENSBURGEI osteoarticular infection: a case report

okenella regensburgei belongs to the family Enterobacteriaceae and is an opportunistic agent rarely associated with infections in humans. We report a case of osteoarticular knee infection caused by Y. regensburgei in a patient under treatment for rheumatoid arthritis, using corticosteroids, with complication in primary total arthroplasty of the knee. Y. regensburgei was identified using the VITEK2 system. Antimicrobial susceptibility testing was performed using the disk-diffusion method, according to the guidelines from the Clinical and Laboratory Standards Institute. The patient presented favorable clinical evolution after the second debridement, with complete removal of the prosthesis and antibiotic therapy with sulfamethoxazole/trimethoprim. This is the first case of Y. regensburgei infection described d in Brazil.

Loss of tolerance 5 days after discontinuing sulphonamide introduced via desensitization in delayed reaction / Perda da tolerância 5 dias após suspensão de sulfonamida introduzida através de dessensibilização por reação tardia

ABSTRACT The fixed drug eruption is a non-immediate hypersensitivity reaction to drug, characterized by recurrent erythematous or violaceous, rounded, well-defined border plaques, which always appear in the same location every time the culprit drug is administered. The usual practice is to avoid the drug involved and to use a structurally different drug. However, there are situations in which there is no safe and effective therapy. In such situations, desensitization is the only option. We describe the case of a patient who presented fixed eruption due to sulfamethoxazole-trimethoprim, who underwent successful desensitization, but required a repeat procedure twice due to relapse after inadvertent full-dose reintroduction. In non-immediate hypersensitivity reaction to drug, the indication is controversial and there is no technical standardization. Furthermore, the time at which such tolerance is lost after discontinuing the drug involved is unknown. In severe non-immediate reactions of types II and III, desensitization is contraindicated. The patient underwent desensitisation to sulfamethoxazole-trimethoprim three times − the first with recurrence of lesions and the second and third without manifestations, all concluded successfully and with no premedication.

RESUMO A erupção fixa por drogas é uma reação de hipersensibilidade a medicamento não imediata, caracterizada por placas eritematosas ou violáceas, arredondadas, recorrentes, de bordas bem definidas e que aparecem sempre na mesma localização cada vez que o medicamento culpado é administrado. A prática habitual é evitar a droga envolvida e utilizar um medicamento estruturalmente diferente. Contudo, há situações em que não há terapêutica segura e eficaz. Em tais situações, a dessensibilização é a única opção. Descrevemos o caso de um paciente que apresentou erupção fixa por drogas por sulfametoxazol-trimetoprim, tendo sido submetido à dessensibilização com sucesso, mas necessitou repetição do procedimento duas vezes, por recidiva da reação após reintrodução inadvertida em dose plena. Em reação de hipersensibilidade a medicamento não imediata, a indicação é controversa e não há padronização técnica. Além disso, não se conhece o tempo durante o qual essa tolerância é perdida após a suspensão da droga envolvida. Nas reações não imediatas graves e dos tipos II e III, a dessensibilização está contraindicada. O paciente foi submetido a dessensibilização ao sulfametoxazol-trimetoprim por três vezes − a primeira com recorrência de lesões, e a segunda e terceira sem manifestações, sendo todas concluídas com sucesso e sem uso de pré-medicação.

Staphylococcus aureus procedentes de quesos costeños de Valledupar; susceptibilidad a antibióticos y perfil plasmídico / Staphylococcus aureus from Valledupar cheeses; susceptibility to antibiotics and plasmid profile

Resumen En este estudio se investigó la susceptibilidad a antibióticos y el perfil plasmídico de S aureus aislado de queso costeño, blando, semiduro y duro, expendidas en diferentes puntos de venta de la ciudad de Valledupar. Por el método de Difusión del disco en agar, se determinó la resistencia a antibióticos y con la técnica de lisis alcalina y electroforesis en gel de agarosa, el perfil plasmídico. Como resultado, se obtuvo una carga microbiana por encima de 103 UFC/g, que está sobre el valor promedio máximo permitido, según la norma covenin 1538-92, el cual indica que se puede desencadenar brotes por intoxicación con estafilocócos. Se demostró la presencia de S. aureus en los quesos costeños blandos (75%), seguidos por los quesos semiduros (25%) ambos de origen (artesanal), los cuales son de alto consumo en Valledupar. Se establecieron 4 patrones diferentes de resistencia en las cepas de S. aureus aisladas de los quesos, siendo el patrón TER común para dos cepas, el resto de los patrones fueron únicos (PR, CR y EI). Una cepa fue resistente a P, productora de β-lactamasas, su CMI más alta fue 32µg/ml; todas las cepas mostraron sensibilidad a oxacilina, gentamicina, ciprofloxacina, cefoxitin, clindamicina, trimetoprim sulfa, vancomicina, rifampin, e imipenen. Hubo bandas plasmídicas con tamaños de 23kb encontrándose cepas con 1 plásmidos.

Abstract In this study, the antibiotic susceptibility was investigated and the plasmid profile of S aureus isolated from coastal cheese, soft, semi-hard and hard, expended in different outlets of the city of Valledupar. For the method of diffusion of the agar disk, the antibiotic resistance was determined and with the technique of alkaline lysis and electrophoresis in the agarose gel, the plasmid profile. As a result, was obtained one microbial load, above of 103 UFC/g, which is on average the maximum allowed value, according to the standard covenin 1538-92, which indicates that it can trigger outbreaks by Staphylococcal poisoning. The presence of S.aureus in coastal soft cheese was shown (75%), followed by semi-hard cheeses (25%) both home (handmade), which are of high consume in Valledupar. four different resistance patterns were established in the strains of the S.aureus isolated from the cheeses, being TER the common pattern for five strains, the rest of the patterns were unique (PR, CR and EI). One strain was resistant to P, producer of the β-lactamases, the CMI more tall was 32µg/ml; All the strains show sensibility to oxacillin, gentamycin, ciprofloxacin, cephoxitin, clindamycin, trimetoprim sulfa, vancomycin, rifampin, and imipenem. There plasmid bands with sizes between 23kb, being 1 strains with plasmids.

Etiología y perfil de resistencia antimicrobiana en pacientes con infección urinaria / Etiology and antimicrobial resistance profile in patients with urinary infection

Introducción: La infección de vías urinarias (IVU) es una de las enfermedades más prevalentes en la práctica clínica Objetivo: Identificar los principales agentes etiológicos y la frecuencia de resistencia a antibióticos por parte de microorganismos aislados por urocultivos en pa cientes con IVU en un hospital de primer nivel de atención. Materiales y Métodos: Estudio descriptivo de corte transversal, a partir de una muestra aleatoria de pacientes con IVU en La Virginia, Risaralda, entre el 1 de abril de 2014 a 31 de marzo de 2015. Se evaluaron las bacterias aisladas en la totalidad de urocultivos procesados y los resultados de los antibiogramas. Se establecieron frecuencias y proporciones. Para el análisis de datos, se utilizó SPSS Statistics 22. Se hizo análisis multivariado. Resultados: Se realizaron 1563 urocultivos en el periodo de estudio, de los cuales 329 (21,0%) mostraron crecimiento mayor a 100.000 UFC. Las frecuencias más altas de resistencia para E. coli se observaron para cefalotina (75,8%), ampicilina (72,6%) y trimetoprim/sulfametoxazol (55,3%). De 296 pacientes seleccionados aleatoriamente se halló que la cistitis era la IVU más frecuente (70,3%) y al 50,7% no se les prescribió ningún antimicrobiano. El uso de antiulcerosos se asoció con mayor probabilidad de uso inadecuado del antibiótico (OR:4,28; IC95%:1,070-17,153; p=0,04). Conclusiones: Existe una elevada resistencia bacteriana a los antibióticos de primera línea para el tratamiento de las IVUs, lo que sugiere la importancia de identi ficar los microorganismos y sus perfiles de sensibilidad a antimicrobianos para seleccionar con mejor criterio cual emplear.

Introduction: Urinary tract infection (UTI) is one of the most prevalent diseases in clinical practice. Objective: To identify the main etiologic agents and the frequency of antibiotic resistance by microorganisms isolated from urine culture and sensitivity in patients with IVU in a hospital primary care. Materials and Methods. Descriptive cross-sectional study, from a random sample of patients with UTI in La Virginia, Risaralda, from April 1, 2014 to March 31, 2015. Bacteria isolated from all processed urine cultures and the results of susceptibility were evaluated. Frequencies and proportions were established. For data analysis was used SPSS Statistics 22. Results: A total of 1563 urine cultures were performed in the study period, of which 329 (21.0%) showed further growth to 100,000 UFC. Higher frequencies of resis tance were observed for E. coli to cephalothin (75.8%), ampicillin (72.6%) and trimethoprim/sulfamethoxazole (55.3%). In the 296 randomized patients it was found that the most common UTI was cystitis (70.3%) and 50.7% were not prescribed any antimicrobial. The use of anti-ulcer is associated with increased probability of inappropriate use of antibiotics (OR:4.28; 95% CI:1.070-17.153; p=0.04). Conclusions: There is a high bacterial resistance to first-line antibiotics for treatment of UTIs, suggesting the importance of identifying microorganisms and their antimicrobial susceptibility profiles to select which use better approach.

Evaluation of in vitro antimicrobial susceptibility of Bacillus anthracis strains isolated during anthrax outbreaks in Italy from 1984 to 2017

Anthrax, caused by Bacillus anthracis, is a non-contagious infectious disease that affects a wide range of animal species (primarily ruminants) including humans. Due to the often-fatal outcome in humans, quick administration of definitely effective antimicrobials is crucial either as prophylaxis or as a clinical case therapy. In this study, 110 B. anthracis strains, temporally, geographically, and genetically different, isolated during anthrax outbreaks in Italy from 1984 to 2017, were screened using a broth microdilution method to determine their susceptibility to 16 clinically relevant antimicrobial agents. The strains were isolated from various matrices (human, animal, and environmental samples) and were representative of thirty distinct genotypes previously identified by 15-loci multiple-locus variable-number of tandem repeats analysis. The antimicrobials tested were gentamicin, ceftriaxone, streptomycin, penicillin G, clindamycin, chloramphenicol, vancomycin, linezolid, cefotaxime, tetracycline, erythromycin, rifampin, amoxicillin, ciprofloxacin, doxycycline, and trimethoprim. All isolates were susceptible to most of the tested antimicrobials, with the exception of trimethoprim for which all of them showed high minimal inhibitory concentration values. An intermediate level of susceptibility was recorded for ceftriaxone and cefotaxime. Although the Centers for Disease Control and Prevention recommend the use of doxycycline, ciprofloxacin, penicillin G, and amoxicillin for treatment of human cases and for post-exposure prophylaxis to anthrax spores, this study shows a high degree of in vitro susceptibility of B. anthracis to many other antimicrobials, suggesting the possibility of an alternative choice for prophylaxis and therapy.

Characteristic Features of Pneumocystis Pneumonia in Pediatric Acute Lymphoblastic Leukemia / 임상소아혈액종양

BACKGROUND: Pneumocystis is difficult to culture or detect in laboratory environments. Its ecology including the timing and method of transmission as well as environmental sources and communicability remain unclear. METHODS: We retrospectively evaluated the pattern and treatment outcome of Pneumocystis jirovecii pneumonia (PCP) in children with acute lymphoblastic leukemia (ALL) who received chemotherapy. RESULTS: A total of 56 patients with ALL were evaluated. While on chemotherapy, all patients received PCP prophylaxis. PCP were found in a total of 6 patients, including definite PCP in 2, probable PCP in 2, and possible PCP in 2 patients. There were no significant differences in sex, age group, National Cancer Institute risk group, or pneumocystis prophylaxis type between PCP and non-PCP groups. However, there was a significant statistical difference in the times of ALL diagnosis. Regarding recent chemotherapy at the time of PCP diagnosis, there were one induction, one consolidation, and four maintenance cases. All PCP patients were treated with high-dose sulfamethoxazole (100 mg/kg/day) and trimethoprim (20 mg/kg/day) intravenously. Five patients survived, while one patient with endotracheal mechanical ventilation therapy died due to respiratory failure in spite of aggressive treatment. CONCLUSION: Pediatric PCP became extremely rare due to routine prophylaxis in clinical practice of pediatric malignancy. Nevertheless, we analyzed patients with acute lymphoblastic leukemia who had received PCP prophylaxis for 14 years, and analyzed the clustered outbreaks of PCP. It is still important to emphasize the need for prophylaxis and to increase the level of attention and isolation under environmental and personal risk factors.

Évaluation de la stabilité du cotrimoxazole 240 mg / 5 ml suspension commercialisé dans les circuits formel et informel de la ville de Douala

Introduction. Le marché parallèle de la vente des médicaments s'est développé au cours des dernières décennies dans les pays en voie d'émergence et il a été établi que la commercialisation de médicaments hors du circuit officiel est une source potentielle de risques pour la santé publique. Notre étude avait pour objectif d'étudier la stabilité du Cotrimoxazole 240 mg / 5 ml suspension stocké dans les circuits formel et informel. Méthodologie : De septembre 2015 à Mai 2016, une étude expérimentale a été conduite dans la ville de Douala. Un total de 81 échantillons de Cotrimoxazole 240 mg/5 mL suspension ont été prélevés dans neuf sites. Tous les échantillons ont subi un contrôle qualité sur la base des évaluations technico-règlementaire, organoleptique, physico-chimique et microbiologique. De plus, des analyses qualitative et quantitative des composés actifs du cotrimoxazole (sulfaméthoxazole et triméthoprime) ont été réalisées. Résultats. Le Ghana et l'Inde sont apparus comme les plus grands fournisseurs du Cotrimoxazole. Les numéros de lot, la notice, les dates de fabrication et de péremption, la présentation et la forme, la classe thérapeutique, les indications, et la posologie étaient présents sur tous les échantillons (100%). Par ailleurs, 41,99% et 55,55% des échantillons étaient de couleur ponceau et avaient un goût aromatisé à la fraise respectivement (p-value < 0,0001). Le pH moyen des suspensions de Cotrimoxazole dans le secteur informel s'est révélé significativement faible par rapport à celui des suspensions du secteur formel (p-value = 0,0054). Tous les échantillons étaient exempts de microorganismes pathogènes. L'analyse spectrophotométrique UV-Vis a montré que la teneur en substances actives était en moyenne significativement plus élevée dans le secteur formel (80,16% contre 73,16%; p-value = 0,001). Conclusion. Cette étude souligne le besoin urgent de lutter activement contre la vente illicite des médicaments ainsi que la nécessité de renforcer les systèmes de contrôle qualité des médicaments dans la ville de Douala

A case of atypical nocardia asteroides sclerouveitis resistant to fourth-generation fluoroquinolones / Um caso atípico de esclero-uveíte por Nocardia Asteroides resistente a fluorquinolona de quarta-geração

ABSTRACT We describe an unusual case of Nocardia spp scleritis in a health girl resistant to topical fourth-generation fluoroquinolones. Clinically, there was only partial response of the scleritis to initial therapy. Treatment was changed to meropenem intravenously and topical amikacin. Following several weeks of antibiotic treatment, the patient's infection resolved but her vision was reduced to no light perception. Nocardia asteroides must be considered as a possible agent in cases of necrotizing scleritis in patients without a clear source. Antibiotic sensitivity testing has a definitive role in view of the resistance to these new medications.

RESUMO Nós descrevemos um raro caso de esclerite por Nocardia spp em uma criança sadia resistente a utilização tópica de fluorquinolona de quarta-geração. Clinicamente, a paciente apresentou apenas uma resposta parcial do quadro de esclerite a terapêutica inicial. O tratamento foi então modificado para meropenem intravenoso e amicacina tópica. Após várias semanas de tratamento com antibiótico, o quadro infeccioso regrediu porém a visao da pacientes evoluiu para perda da percepção luminosa. Em casos de esclerite necrotizante em pacientes sem fatores de risco aparente é necessário considerer a Nocardia Asteroides como possível agente causador. Os testes de sensibilidade medicamentosa apresentam importância significativa em virtude do aparecimento de resistência aos novos medicamentos.

Plásmido conjugativo portador de integrón clase 1 responsable de la resistencia a los antibióticos en aislados de vibrio cholerae O1 en Venezuela / Conjugative plasmid and a class 1integron responsible for the resistance to antibiotics in vibrio cholerae O1 isolates in Venezuela

Se han descrito aislados de Vibrio cholerae resistentes a una amplia variedad de antibióticos. En Venezuela, durante el brote de cólera ocurrido entre noviembre de 1998 y enero 2000 fueron reportados por primera vez aislados de V. cholerae O1 resistentes a ampicilina, trimetoprim-sulfametoxazole. Usando experimentos de conjugación se determinó la capacidad de transferir los determinantes de resistencia a ampicilina y trimetoprim-sulfametoxazole en 11 aislados. La visualización de plásmidos se realizó utilizando la digestión con nucleasa S1 y electroforesis en campo pulsante. La presencia de integrones de clase 1 fue establecida por PCR y se obtuvo la secuencia de la región variable del integrón. Los determinantes de resistencia fueron transferidos en un plásmido conjugativo de aproximadamente 170 kbp, común a todos los aislados. La resistencia a trimetoprim esta codificada en el gen dfra15, el cual se encuentra en un integrón clase 1 presente en el plásmido. En este estudio, se caracterizó la localización genética de los determinantes que codifican la resistencia a los antibióticos, y al conocer el mecanismo probable de dispersión de los determinantes de resistencia se podrán implementar medidas de control más adecuadas.

Vibrio cholerae has been reported to be resistant to a wide range of antibiotics. V. Cholerae O1 strains resistant to ampicillin, trimethoprim-sulfamethoxazole were isolated for the first time in Venezuela during a cholera outbreak that occurred between November 1998 and January 2000. Using conjugation experiments, the capacity of transfer of the resistance determinants in 11 strains resistant to ampicillin and trimethoprim-sulfamethoxazole was investigated. Plasmid analysis was done by S1 nuclease digestion and pulsed field gel electrophoresis. The presence of class 1 integrons was determined by PCR and the sequence of the gene harbored in the variable region of the integron was obtained. The antibiotic resistance determinants were transferred by a conjugative plasmid of approximately 170 kbp, common to all the isolates. Resistance to trimethoprim is encoded by the dfra15 gene that is harbored by a class 1 integron present in the plasmid. In this study, the genetic location of the determinants that code for resistance to antibiotics was characterized, and knowing the probable mechanism of dispersion of the determinants of resistance, control measures can be implemented most appropriate

In Vitro Efficacy of Six Alternative Antibiotics against Multidrug Resistant Escherichia Coli and Klebsiella Pneumoniae from Urinary Tract Infections

<p><b>INTRODUCTION</b>Increasing resistance in Escherichia coli and Klebsiella pneumoniae to firstline antibiotics makes therapeutic options for urinary tract infections (UTIs) challenging. This study investigated the in vitro efficacies of 6 antibiotics against multidrug resistant (MDR) uropathogens.</p><p><b>MATERIALS AND METHODS</b>Minimum inhibitory concentrations to ceftibuten, cefpodoxime, fosfomycin, mecillinam, temocillin, and trimethoprim were determined against 155 MDR-isolates of E. coli and K. pneumoniae. The presence of extended-spectrum beta-lactamases (ESBL) and plasmid-borne AmpC enzymes was determined by phenotypic testing with genotyping performed by multiplex polymerase chain reaction.</p><p><b>RESULTS</b>Temocillin demonstrated highest susceptibility rates for both E. coli (95%) and K. pneumoniae (95%) when breakpoints for uncomplicated UTIs were applied; however, temocillin susceptibility was substantially lower when "systemic infection" breakpoints were used. Fosfomycin demonstrated the best in vitro efficacy of the orally available agents, with 78% and 69% of E. coli and K. pneumoniae isolates susceptible, respectively. The next most effective antibiotics were ceftibuten (45%) and mecillinam (32%). ESBL and ampC genes were present in 47 (30%) and 59 (38%) isolates.</p><p><b>CONCLUSION</b>This study demonstrated few oral therapeutic options for MDR-uropathogens, with fosfomycin demonstrating the best in vitro activity.</p>

Successful rapid desensitization to trimethoprim-sulfamethoxazole-induced delayed hypersensitivity

Trimethoprim-sulfamethoxazole (TMP-SMX) is an antibiotic used for the treatment or prophylaxis of Pneumocystis pneumonia and other infectious conditions. Sulfonamide derivatives have been reported to cause delayed hypersensitivity reactions, resulting in switch to less effective second-line antibiotics. Although desensitization is traditionally known to be effective in patients with immediate hypersensitivity, it is also applied to the treatment of delayed hypersensitivity in recent years. A 66-year-old female who had a history of repeated TMP-SMX-induced delayed hypersensitivity presenting as whole body rashes needed to take prophylactic dose of TMP-SMX (80/400 mg daily) before initiation of chemotherapy for multiple myeloma. Intravenous rapid desensitization was performed by using a 11-step, 4-bottle protocol from 1:1,000 to 1:1 solution for 3 hours to reach the target dose for prophylaxis. After successful rapid desensitization of TMP-SMX, 1-month prophylaxis was completed without any complications until the patient recovered normal immunity. We herein reported a case of delayed hypersensitivity reaction to TMP-SMX in an about-to-be immunocompromised host with planned chemotherapy who successfully completed 1-month prophylaxis with the drug without any complications through rapid desensitization.

A Case of Pneumonia Caused by Pneumocystis jirovecii Resistant to Trimethoprim-Sulfamethoxazole

A 50-year-old male visited the outpatient clinic and complained of fever, poor oral intake, and weight loss. A chest X-ray demonstrated streaky and fibrotic lesions in both lungs, and chest CT revealed multifocal peribronchial patchy ground-glass opacities with septated cystic lesions in both lungs. Cell counts in the bronchoalveolar lavage fluid revealed lymphocyte-dominant leukocytosis, and further analysis of lymphocyte subsets showed a predominance of cytotoxic T cells and few T helper cells. Video-assisted wedge resection of the left upper lobe was performed, and the histologic examination was indicative of a Pneumocystis jirovecii infection. Trimethoprim-sulfamethoxazole (TMP-SMX) was orally administered for 3 weeks; however, the patient complained of cough, and the pneumonia was aggravated in the follow-up chest X-ray and chest CT. Molecular studies demonstrated mutations at codons 55 and 57 of the dihydropteroate synthase (DHPS) gene, which is associated with the resistance to TMP-SMX. Clindamycin-primaquine was subsequently administered for 3 weeks replacing the TMP-SMX. A follow-up chest X-ray showed that the pneumonia was resolving, and the cough was also alleviated. A positive result of HIV immunoassay and elevated titer of HCV RNA indicated HIV infection as an underlying condition. This case highlights the importance of careful monitoring of patients with P. jirovecii pneumonia (PCP) during the course of treatment, and the molecular study of DHPS mutations. Additionally, altering the anti-PCP drug utilized as treatment must be considered when infection with drug-resistant P. jirovecii is suspected. To the best of our knowledge, this is the first case of TMP-SMX-resistant PCP described in Korea.

Treatment of brucellosis in a young child with trimethoprim/sulfamethoxazole anaphylaxis

Brucellosis is a common zoonotic disease throughout the world. Brucella spp. transmit to humans through contact with fluids of infected animals, especially sheep, cattle, and goats. It is also transmitted by ingestion of fluid-derived products of infected animals, such as unpasteurized milk and cheese. Brucella spp. changes pH level of intracellular environment, so the first treatment approach is to administer antibiotics that have activity in acidic conditions. Anti-brucellosis treatment regimens include doxycycline for children older than eight years old and rifampicin and trimethoprim/sulfamethoxazole [TMP-SMX] combination therapy for children under eight years old, which may be able to act intracellularly under acidic conditions. A TMP-SMX allergy causing anaphylaxis has been reported previously. No alternative anti-brucellosis treatments have been reported in the literature for patients under eight years old with a TMP-SMX allergy. Here, we report a case of a child with brucellosis and a TMP-SMX allergy who was under eight years old at the time of diagnosis and was successfully treated with rifampicin, ciprofloxacin, and gentamicin

Susceptibility of Escherichia coli from Community-Acquired Urinary Tract Infection to Fosfomycin, Nitrofurantoin, and Temocillin in Korea

With increase of multi-drug resistant Escherichia coli in community-acquired urinary tract infections (CA-UTI), other treatment option with a therapeutic efficacy and a low antibiotic selective pressure is necessary. In this study, we evaluated in vitro susceptibility of E. coli isolates from CA-UTI to fosfomycin (FM), nitrofurantoin (NI), temocillin (TMO) as well as trimethoprim-sulfamethoxazole (SMX), ciprofloxacin (CIP) and cefepime (FEP). The minimal inhibitory concentrations were determined by E-test or agar dilution method according to the Clinical and Laboratory Standards Institute guidelines, using 346 E. coli collected in 12 Korean hospitals from March 2010 to February 2011. FM, NI and TMO showed an excellent susceptibility profile; FM 100% (346/346), TMO 96.8% (335/346), and NI 99.4% (344/346). Conversely, resistance rates of CIP and SMX were 22% (76/346) and 29.2% (101/349), respectively. FEP still retained an activity of 98.5%. In Korea, NI and TMO in addition to FM are a good therapeutic option for uncomplicated CA-UTI, especially for lower UTI.

Susceptibility of Escherichia coli from Community-Acquired Urinary Tract Infection to Fosfomycin, Nitrofurantoin, and Temocillin in Korea

With increase of multi-drug resistant Escherichia coli in community-acquired urinary tract infections (CA-UTI), other treatment option with a therapeutic efficacy and a low antibiotic selective pressure is necessary. In this study, we evaluated in vitro susceptibility of E. coli isolates from CA-UTI to fosfomycin (FM), nitrofurantoin (NI), temocillin (TMO) as well as trimethoprim-sulfamethoxazole (SMX), ciprofloxacin (CIP) and cefepime (FEP). The minimal inhibitory concentrations were determined by E-test or agar dilution method according to the Clinical and Laboratory Standards Institute guidelines, using 346 E. coli collected in 12 Korean hospitals from March 2010 to February 2011. FM, NI and TMO showed an excellent susceptibility profile; FM 100% (346/346), TMO 96.8% (335/346), and NI 99.4% (344/346). Conversely, resistance rates of CIP and SMX were 22% (76/346) and 29.2% (101/349), respectively. FEP still retained an activity of 98.5%. In Korea, NI and TMO in addition to FM are a good therapeutic option for uncomplicated CA-UTI, especially for lower UTI.

Isospora belli Infection with Chronic Diarrhea in an Alcoholic Patient

Chronic diarrhea with a 35 kg weight loss (75 kg to 40 kg) occurred during 2 years in an alcoholic patient was diagnosed with Isospora belli infection in the Republic of Korea. The patient, a 70-year old Korean male, had been a heavy drinker for more than 30 years. He was admitted to the Seoul National University Hospital because of long-standing diarrhea and severe weight loss. He had an increased white blood cell (WBC) count with high peripheral blood eosinophilia (36.8-39.9%) and lowered protein and albumin levels but without any evidence of immunosuppression. A parasitic infection was suspected and fecal examination was repeated 3 times with negative results. Peroral endoscopy with mural biopsy was performed in the upper jejunum. The biopsy specimens revealed villous atrophy with loss of villi together with various life cycle stages of I. belli, including trophozoites, schizonts, merozoites, macrogamonts, and microgamonts. The patient was treated successfully with oral doses of trimethoprim 160-320 mg and sulfamethoxazole 800-1,600 mg daily for 4 weeks. A follow-up evaluation at 2.5 years later revealed marked improvement of body weight (68 kg), increased protein and albumin levels, and normal WBC count with low eosinophils (3.1%). This is the first clinical case of isoporiasis with demonstration of various parasitic stages in the Republic of Korea.

Two Cases of Autoimmune Neutropenia of Infancy / 임상소아혈액종양

Autoimmune neutropenia of infancy (AIN) is caused by increased peripheral destruction of neutrophils as a result of antibodies in patients' blood that are directed against their own neutrophils. Due to non-specific symptoms, benign clinical courses, and cumbersome diagnostic tests, AIN are commonly undetected. Antineutrophil antibody test for diagnosis of AIN has recently become available. Compared to its relatively lower absolute neutrophil count (ANC), the clinical course of AIN is mostly benign. Therefore, although treatment is not usually necessary for AIN, it is applicable in order to rule out other significant diseases, such as severe congenital neutropenia (SCN), which can be transformed to myelodysplastic syndrome or acute myelocytic leukemia. For this reason, several treatments can be used for neutropenia: granulocyte-colony stimulating factor (G-CSF) for SCN, trimethoprim and sulfamethoxazole (TMP-SMX) for prophylaxis. Here we report on two cases of AIN confirmed by indirect immunofluorescence test using flow cytometry.

Enhancing chloramphenicol and trimethoprim in vitro activity by Ocimum sanctum Linn. (Lamiaceae) leaf extract against Salmonella enterica serovar Typhi

OBJECTIVE@#To evaluate the antibacterial activity of Ocimum sanctum (O. sanctum) leaf extract, alone, and in combination with chloramphenicol (C) and trimethoprim (Tm) against Salmonella enterica serovar Typhi (S. typhi).@*METHODS@#The antibacterial activity of ethanolic extract of tulsi, O. sanctum, leaf (TLE; 500 μg) for 23 S. typhi isolates was determined following agar diffusion. The C (30 μg) and Tm (5 μg) activity alone and in combination with TLE (250 μg) was determined by disk diffusion. The zone diameter of inhibition (ZDI) for the agents was recorded, and growth inhibitory indices (GIIs) were calculated.@*RESULTS@#The S. typhi isolates (n=23), which were resistant to both C (ZDI 6 mm) and Tm (ZDI 6 mm), had TLE (500 μg) ZDIs 16-24 mm. The ZDIs of C and Tm were increased up to 15-21 mm and 17-23 mm, respectively, when TLE (250 μg) was added to the C and Tm discs. The GIIs ranged 0.789-1.235 and 0.894-1.352, due to combined activity against S. typhi isolates, of C and TLE and Tm and TLE, respectively.@*CONCLUSIONS@#The data suggest that TLE, in combination with C and Tm, had synergistic activity for S. typhi isolates, and hence O. sanctum is potential in combating S. typhi drug resistance, as well promising in the development of non-antibiotic drug for S. typhi infection.

Two Cases of Autoimmune Neutropenia of Infancy / 임상소아혈액종양

Autoimmune neutropenia of infancy (AIN) is caused by increased peripheral destruction of neutrophils as a result of antibodies in patients' blood that are directed against their own neutrophils. Due to non-specific symptoms, benign clinical courses, and cumbersome diagnostic tests, AIN are commonly undetected. Antineutrophil antibody test for diagnosis of AIN has recently become available. Compared to its relatively lower absolute neutrophil count (ANC), the clinical course of AIN is mostly benign. Therefore, although treatment is not usually necessary for AIN, it is applicable in order to rule out other significant diseases, such as severe congenital neutropenia (SCN), which can be transformed to myelodysplastic syndrome or acute myelocytic leukemia. For this reason, several treatments can be used for neutropenia: granulocyte-colony stimulating factor (G-CSF) for SCN, trimethoprim and sulfamethoxazole (TMP-SMX) for prophylaxis. Here we report on two cases of AIN confirmed by indirect immunofluorescence test using flow cytometry.