Disseminated nocardiosis in an immunocompetent host with occupational exposure.

Nocardia is a genus of Gram-positive, partially acid-fast bacteria consisting of over 120 species, of which 50 are recognized as human pathogens. Nocardia spp. are common colonizers in the environment, particularly in soil and water. Nocardia spp. typically cause opportunistic infections in the immunocompetent host, although cases of nocardiosis have been described in those with a normal immune system. Nocardiosis can be localized, most often in the skin or lung, or be disseminated, with involvement of the brain, bone, and visceral organs. Treatment of nocardiosis is complex, as multiple culture-directed antibacterials with appropriate tissue penetration may need to be used for a prolonged duration. To our knowledge, we describe the first successfully treated case of disseminated Nocardia beijingensis infection in an immunocompetent host with doxycycline and trimethoprim-sulfamethoxazole and hypothesize that his occupational exposure to ubiquitous saprophytes may have led to his infection.

Rapid detection of Enterobacterales that produce carbapenemases.

PURPOSE: The rapid detection of carbapenemases among Enterobacterales in clinical laboratories is critical for management of patients, and infection prevention and control efforts. METHODS: A study was designed to evaluate the performances of the RAPIDEC CARBA NP®, ß-CARBA®, NG-Test CARBA 5®, modified carbapenem-inactivation method, and EDTA version (eCIM) assays against a global collection of Enterobacterales (n = 216) with diverse carbapenemases. RESULTS: The RAPIDEC CARBA NP® assay had a sensitivity of 98.6% and specificity of 19.6% and ß-CARBA® a sensitivity of 94% and specificity of 97.8%, but showed low sensitivity with Klebsiella Pneumoniae Carbapenemase (KPC)-containing isolates. The NG-Test CARBA 5® had an overall sensitivity of 96.3% and specificity of 100% and failed to detect isolates with blaIMP-13, blaIMP-14. The eCIM gave false- positive results with Oxacillinase (OXA)-48-like enzymes. CONCLUSION: The NG-Test CARBA 5® assay was technically simple and provided rapid accurate results on the types of carbapenemases. Such information has potential treatment benefits for patients.

Sociodemographic correlates of urine culture test utilization in Calgary, Alberta.

BACKGROUND: Many clinical practice guidelines encourage diagnosis and empiric treatment of lower urinary tract infection without laboratory investigation; however, urine culture testing remains one of the largest volume tests in the clinical microbiology laboratory. In this study, we sought to determine if there were specific patient groups to which increased testing was directed. To do so, we combined laboratory data on testing rates with Census Canada sociodemographic data. METHODS: Urine culture testing data was obtained from the Calgary Laboratory Services information system for 2011. We examined all census dissemination areas within the city of Calgary and, for each area, testing rates were determined for age and gender cohorts. We then compared these testing rates to sociodemographic factors obtained from Census Canada and used Poisson regression and generalized estimating equations to test associations between testing rates and sociodemographic variables. RESULTS: Per capita urine culture testing is increasing in Calgary. For 2011, 100,901 individuals (9.2% of all people) received urine cultures and were included in this analysis. The majority of cultures were received from the community (67.9%). Substantial differences in rate of testing were observed across the city. Most notably, urine culture testing was drastically lower in areas of high (≥ $100000) household income (RR = 0.07, p < 0.0001) and higher employment rate (RR = 0.36, p < 0.0001). Aboriginal - First Nations status (RR = 0.29, p = 0.0008) and Chinese visible minority (RR = 0.67, p = 0.0005) were also associated with decreased testing. Recent immigration and visible minority status of South Asian, Filipino or Black were not significant predictors of urine culture testing. Females were more likely to be tested than males (RR = 2.58, p < 0.0001) and individuals aged 15-39 were the most likely to be tested (RR = 1.69, p < 0.0001). CONCLUSIONS: Considerable differences exist in urine culture testing across Calgary and these are associated with a number of sociodemographic factors. In particular, areas of lower socioeconomic standing had significantly increased rates of testing. These observations highlight specific groups that should be targeted to improve healthcare delivery and, in turn, enhance laboratory utilization.

Detection of Plasmodium Infection by the illumigene Malaria Assay Compared to Reference Microscopy and Real-Time PCR.

Malaria is one of the leading causes of infectious disease in travelers returning from the tropics. The diagnosis of malaria is typically performed by examining Giemsa-stained thick and thin peripheral blood smears, which is time consuming, labor intensive, and requires high levels of proficiency. Alternatively, loop-mediated isothermal amplification (LAMP) is a new molecular method, which is rapid, sensitive, and requires less capital equipment and technological training. We conducted a retrospective study comparing two formats of a commercial LAMP assay (Meridian illumigene malaria [M] and malaria Plus [MP]) versus reference microscopy on archived blood specimens (n = 140) obtained from unique returning travelers suspected of having malaria. Discrepant results were resolved by either repeat testing or a laboratory developed ultrasensitive real-time PCR method. On initial testing, the Meridian illumigene M and MP kits had sensitivities of 97.3% (95% confidence interval [CI], 90.7 to 99.7%) and 100.0% (95.1 to 100.0%) and specificities of 93.8% (84.8 to 98.3%) and 91.5% (81.3 to 97.2%), respectively, versus reference microscopy. We project a significant cost reduction in low prevalence settings where malaria is not endemic with LAMP-based malaria screening given the excellent negative predictive value achieved with LAMP.

Prosthetic joint and implant contamination caused by Ralstonia pickettii: a report of three casesÙ­.

We describe three cases of orthopaedic contamination caused by Ralstonia pickettii grown from prosthetic joint and implant material cultures following sonication in the microbiology laboratory. Given the temporal association between the cases, lack of clinical or intra-operative features of infection, growth of the organism in the water bath, and unlikely etiology of Ralstonia as a prosthetic joint or implant pathogen, the bacteria were judged to be contaminants.

Schistosomiasis Presenting as a Case of Acute Appendicitis with Chronic Mesenteric Thrombosis.

The manifestations of schistosomiasis typically result from the host inflammatory response to parasitic eggs that are deposited in the mucosa of either the gastrointestinal tract or bladder. We present here a case of a 50-year-old gentleman with a rare gastrointestinal presentation of both schistosomal appendicitis and mesenteric thrombosis.

Tackling antimicrobial resistance in lower urinary tract infections: treatment options.

INTRODUCTION: Urinary tract infections (UTIs) are among the most common infectious diseases occurring in either the community or healthcare settings. A wide variety of bacteria are responsible for causing UTIs, however extra-intestinal pathogenic E. coli or ExPEC) remains the most common etiological agent. Since 2000, resistance to antibiotics emerged globally among ExPEC and is causing delays in appropriate therapy with subsequent increased morbidity and mortality. AREAS COVERED: The aim of this review article is to provide an overview on the definitions, etiology, treatment guidelines (including agents for infections due to antimicrobial resistant bacteria) of lower UTIs and to highlight recent aspects on antimicrobial resistance of ExPEC. Expert commentary: For patients with acute uncomplicated lower UTIs, nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin or pivmecillinam should be prescribed for a 1-5 day course depending on the agent used. Single-dose fosfomycin is an excellent option for uncomplicated lower UTIs and has had similar clinical and/or bacteriological efficacy for 3- or 7-day regimens for alternate agents (i.e., ciprofloxacin, norfloxacin, cotrimoxazole or nitrofurantoin).

The characteristics of Klebsiella pneumoniae that produce KPC-2 imported from Greece.

We report a case of lower urinary tract infection due to KPC-2-producing K. pneumoniae (KpCG02) in an elderly patient who had recently been hospitalized in Greece. The patient was treated successfully on an outpatient basis by removing the Foley catheter and with a prophylactic dose of gentamicin. KpCG02, which belonged to ST258, contained repFII plasmids that tested positive for the vagCD addiction system and the uge, wabG, urea, mrkD, and fimH virulence factors. This case reemphasizes the need for vigilance screening for carbapenem-resistant Gram negatives in patients with a history of travel to endemic areas, such as Greece.

Artemisinin combination therapy can result in clinical failure if oral therapy is not directly observed.

Intravenous artesunate therapy is the first-line therapy for severe malaria, and is highly efficacious when used in combination with an oral partner drug such as doxycycline or atovaquone-proguanil. However, treatment failure occurs routinely with artesunate monotherapy due to the very short half-life of this drug. In North America, experience with artesunate is limited. With the pressure to discharge patients early, administration of the essential oral partner drug is often left to the discretion of the patient. Thus, treatment failure may be commonplace if nonadherence is a factor, as was observed in the case described in the present report.

L'artésunate par voie intraveineuse, le traitement de première ligne du paludisme sévère, est très efficace lorsqu'on l'utilise en association avec un médicament complémentaire par voie orale, comme la doxycycline ou l'atovaquone-proguanil. Cependant, à cause de sa très courte demivie, l'artésunate échoue régulièrement en monothérapie. En Amérique du Nord, on a peu d'expérience de l'artésunate. En raison des pressions exercées pour donner rapidement leur congé aux patients, l'administration essentielle du médicament complémentaire par voie orale est souvent laissée au gré du patient. L'échec thérapeutique peut être courant en cas de non-observance, comme on l'a constaté dans le présent rapport de cas.

Parasitic liver disease in travelers.

Liver disease is an important source of morbidity among ill returning travelers. Jaundice is one of the most common and obvious symptoms of liver disease, the differential diagnosis of which is extensive, especially in travelers. Jaundice in travelers can arise from both infectious and noninfectious causes. We herein summarize the most common parasitic etiologies that may lead to jaundice in the returned traveler, visitors of friends and relatives, or new immigrants, and describe the etiology, epidemiology, and pathogenesis of clinical features of each.

Left atrial appendage closure with AMPLATZER cardiac plug for stroke prevention in atrial fibrillation: initial Asia-Pacific experience.

BACKGROUND: Left atrial appendage (LAA) is the main source of left atrial thrombus that causes stroke in patients with non-valvular atrial fibrillation (NVAF). This study reported the initial safety, feasibility, and 1-yr clinical outcomes following AMPLATZER cardiac plug (ACP) implantation in Asia-Pacific region. METHODS: Twenty NVAF patients (16 males, age 68 ± 9 yr) with high risk for developing cardioembolic stroke (CHADS(2) score: 2.3 ± 1.3) and contraindications to warfarin received ACP implants from June 2009 to May 2010. Patients received general anesthesia (n = 9) or controlled propofol sedation (n = 11) and the procedures were guided by fluoroscopy and transesophageal echocardiography (TEE). Clinical follow-up was arranged at 1 month and then every 3 months after implantation, whereas, a TEE was scheduled at 1 month upon completion of dual anti-platelet therapy. RESULTS: The LAA was successfully occluded in 19/20 patients (95%) at two Asian centers. One procedure was abandoned because of catheter-related thrombus formation. Other complications included coronary artery air embolism (n = 1) and TEE-attributed esophageal injury (n = 1). The median procedural and fluoroscopic times were 79 (IQR: 59-100) and 18 (IQR 12-27) minutes, respectively. The mean size of implant was 23.6 ± 3.1 mm. The average hospital stay was 1.8 ± 1.1 days. Follow-up TEE showed all the LAA orifices were sealed without device-related thrombus formation. No stroke or death occurred at a mean follow-up of 12.7 ± 3.1 months. CONCLUSIONS: Our preliminary data suggested LAA closure with ACP is safe, feasible with encouraging 1-yr clinical outcomes. Further large-scaled trials are needed to confirm the efficacy of this device.

Pseudomonas skin infection: clinical features, epidemiology, and management.

Pseudomonas aeruginosa is a Gram-negative bacillus that is most frequently associated with opportunistic infection, but which can also present in the otherwise healthy patient. The range of P. aeruginosa infections varies from localized infections of the skin to life-threatening systemic disease. Many P. aeruginosa infections are marked by characteristic cutaneous manifestations. The aim of this article is to provide a comprehensive synthesis of the current knowledge of cutaneous manifestations of P. aeruginosa infection with specific emphasis on clinical features and management. The ability of P. aeruginosa to rapidly acquire antibacterial resistance is an increasingly well recognized phenomenon, and the correct application of antipseudomonal therapy is therefore of the utmost importance. A detailed discussion of currently available anti-pseudomonal agents is included, and the benefits of antimicrobial combination therapy versus monotherapy are explored. Rapid clinical recognition of P. aeruginosa infection aided by the identification of characteristic cutaneous manifestations can play a critical role in the successful management of potentially life-threatening disease.

Left main stem rupture caused by methicillin resistant Staphylococcus aureus infection of left main stent treated by covered stenting.

Coronary artery infection after angioplasty or stent implantation is a rare and dreaded complication of percutaneous coronary intervention. 80% of the cases are due to Staphylococcus aureus. About half the cases lead to rupture or perforation of the coronary artery while the other half presents as abscesses or aneurysms. Surgical treatment is the conventional therapeutic modality but it carries a high mortality. We report a case of a high risk patient who had methicillin resistant Staphylococcus aureus infection of left main stem stent leading to rupture and pseudoaneurysm formation that is successfully treated with stent graft.

The confluent balloon technique--two cases illustrating a novel method to achieve rapid wire crossing of chronic total occlusion during retrograde approach percutaneous coronary intervention.

We describe two cases of a retrograde approach to treat a chronic total occlusion (CTO) of the right coronary artery in which we were initially unable to achieve wire crossing. A novel technique of pushing both antegrade and retrograde balloons into the CTO lesion so that the balloons overlapped each other during inflation created a new confluent subintimal space allowing easy, reliable and rapid passing of the retrograde wire into the antegrade true lumen. This novel "confluent balloon" method is recommended to other operators who may struggle with wire crossing during a retrograde approach to CTOs.

Antegrade balloon transit of retrograde wire to bail out dissected left main during retrograde chronic total occlusion intervention--a variant of the reverse CART technique.

Left main dissection is usually caused by catheter manipulation during diagnostic angiography and occasionally during angioplasty. It is a dangerous complication due to the potential risk of left main territory ischemia. We report a novel iatrogenic cause of left main dissection from a retrograde wire during ostial left anterior descending artery chronic total occlusion retrograde angioplasty. We also report the use of the antegrade balloon as a transit chamber for the retrograde wire after a successful reverse CART technique in order to prevent further left main dissection. This technique is applicable to other retrograde approaches for chronic total occlusion cases where proximal artery dissection is undesirable.

Utility of the pneumoslide test in identification of Streptococcus pneumoniae in blood cultures and its relation to capsular serotype.

The performance of the Pneumoslide test for rapid identification of Streptococcus pneumoniae was evaluated when used directly on positive blood culture specimens. The sensitivity was 75.3%, and the specificity was 98.6%. Pneumoslide test performance accuracy varied depending on the pneumococcal serotype.

Retrograde chronic total occlusion intervention: tips and tricks.

Retrograde approach via collateral channels in coronary angioplasty for chronic total occlusion (CTO) can improve the success rate. Most interventionists will meet a few cases where the retrograde approach will provide unequaled advantages, but many are held back from taking retrograde approach by lack of proper equipment and expertise. In this article, we give detail description of techniques to shorten the guiding catheter, to traverse the collateral channels, and to cross the CTO. We also illustrate the difficulties in collateral channel crossing with different examples providing a basic guide for case selection purposes. We hope that many others would find rewardingly successful cases of retrograde approach CTO percutaneous coronary intervention, as in our experience.

Three cases of left main stem thrombus complicating PCI: the role of FilterWire protection for the virgin territory.

We report on three cases of left main stem thrombosis complicating percutaneous coronary angioplasty. We focused on the issue of dealing with emboli in the non-culprit vessel, as embolism in the "virgin" vessel is often associated with severe cardiogenic shock. We describe the use of a FilterWire technique to protect the non-culprit vessel and a case in which the FilterWire was occluded by thrombus leading to shock. The third case illustrates the difficulty with FilterWire protection if stenting is required in the left main stem itself.