Robinsoniella peoriensis: An emerging pathogen and rare cause of wound infection in children.

BACKGROUND: Robinsoniella peoriensis is an anaerobic gram-positive bacilli first isolated from swine manure in 2003 but has since been associated with human infections. METHODS: We describe a pediatric case of R. peoriensis infection following a below-knee amputation for a limb injury and its treatment. Methods of identifying R. peoriensis and reported in vitro antimicrobial minimum inhibitory concentrations from the literature are reviewed. RESULTS: R. peoriensis is readily identifiable via 16S rRNA gene sequencing and Matrix-Assisted Laser Desorption Ionization-Time of Flight. There is variability in the antibiotic susceptibility profiles reported in the literature, but antibiotics with low in vitro minimum inhibitor concentrations against R. peoriensis include beta-lactam/beta-lactamase inhibitors, carbapenems, vancomycin, and metronidazole. CONCLUSION: This is the first reported case of R. peoriensis infection following a traumatic injury in Canada to our knowledge and highlights the importance of recognizing this organism and other anaerobes in settings where wounds are grossly contaminated with soil.

HISTORIQUE: Le Robinsoniella peoriensis est un bacille anaérobie à Gram positif d'abord isolé en 2003 dans le lisier de porc, mais qui a été associé à des infections humaines depuis. MÉTHODOLOGIE: Les auteurs décrivent un cas pédiatrique d'infection à R. peoriensis après une amputation au-dessous du genou à cause de la lésion d'un membre et de son traitement. Les chercheurs ont examiné les méthodes pour identifier le R. peoriensis et les concentrations minimales inhibitrices antimicrobiennes in vitro tirées des publications. RÉSULTATS: Le R. peoriensis est facile à identifier au moyen du séquençage du gène d'ARNr 16S et du spectromètre de masse à temps de vol pour la désorption-ionisation laser assistée par matrice. La description des profils de susceptibilité des antibiotiques est variable selon les publications, mais les antibiotiques aux concentrations minimales inhibitrices contre le R. peoriensis sont les bêta-lactamines et les inhibiteurs de bêta-lactamase, les carbapénems, la vancomycine et le métronidazole. CONCLUSION: À la connaissance des auteurs, il s'agit du premier cas déclaré d'infection à R. peoriensis après une lésion traumatique au Canada, ce qui fait ressortir l'importance de tenir compte de cet organisme et d'autres anaérobies lorsque les plaies sont grandement contaminées par de la terre.

Incidental post-partum isolation of Brucella melitensis in an asymptomatic woman.

A 25-year-old Somali-born female was admitted to the hospital in active labour. Following post-partum hemorrhage, Brucella melitensis grew from a blood culture and the placenta. Identification and relatedness were determined through reverse transcriptase polymerase chain reaction (RT-PCR), single nucleotide polymorphism (SNP), and whole genome sequencing. The patient and her child were completely asymptomatic at their initial assessment.

Une femme d'origine somalienne de 25 ans a été hospitalisée en travail actif. Après une hémorragie postpartum, le Brucella melitensis s'est développé dans une hémoculture et dans le placenta. La réaction de transcriptase inverse et d'amplification en chaîne de la polymérase (RT-PCR), le polymorphisme du nucléotide simple (SNP) et le séquençage du génome entier ont permis d'identifier la bactérie et d'établir sa parenté génétique. La patiente et son enfant étaient complètement asymptomatiques à l'évaluation initiale.

Disseminated histoplasmosis associated with acquired hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening clinical syndrome caused by uncontrolled activation of lymphocytes and histiocytes resulting in high levels of cytokines. Acquired HLH occurs in autoimmune, inflammatory, infectious, and immunosuppressive disorders. Prompt identification and treatment of an underlying triggering cause improves clinical outcome.

Direct mecA polymerase chain reaction testing of blood culture bottles growing Gram-positive cocci and the clinical potential in optimizing antibiotic therapy for staphylococcal bacteremia.

This study evaluated the performance of direct mecA polymerase chain reaction (PCR) from blood culture bottles growing Gram-positive cocci in clusters and its role in optimization of antibiotic therapy. A total of 266 blood cultures including 121 methicillin-resistant and 122 methicillin-susceptible Staphylococci were tested for mecA. Compared to phenotypic testing, the overall performance of direct mecA PCR was 99% for sensitivity, specificity, positive predictive value, and negative predictive value, respectively. Assessment of antibiotic therapy upon microbiology reporting of direct mecA PCR results from 38 patients prior to (phase I) and 48 patients after implementation of testing and reporting (phase II) showed that the mean time to antibiotic optimization in phase II (0.9 ± 0.9 day) was significantly shorter than that in phase I (2.2 ± 3.2 days) (P < 0.05). Methicillin-susceptible staphylococcal bacteremias had significantly higher frequency of antibiotic adjustment upon direct mecA reporting, compared to methicillin-resistant staphylococcal bacteremias. Our study indicated that direct mecA PCR improved timely antibiotic optimization.

Leprosy-like illness in a patient with Mycobacterium lepromatosis from Ontario, Canada.

Here we present the first case of a patient from Ottawa Canada, presenting with leprosy-like illness associated with Mycobacterium lepromatosis. The patient had no history of travel to leprosy-endemic areas or any obvious risk factors. Clinically, the patient presented with an anesthetic maculopapular rash on the trunk, back, and extremities. A skin biopsy of a lesion revealed a dermal lymphohistiocytic infiltration involving the vessels with an inflammatory process extending to the nerves. A neurological exam also identified a severe sensorimotor polyneuropathy. Concurrently, the patient was diagnosed with non-resectable, non small cell carcinoma of the lung, further complicating his clinical presentation. A Kinyoun stain of nasal blows and a Fite stain of the skin biopsy revealed few to moderate acid fast bacilli respectively. Cultures of the skin biopsy and multiple nasal blows were negative. Molecular studies of a skin biopsy sample including sequence analysis of a 765 bp region of the 16s rRNA gene eventually identified the organism with 100% homology to M. lepromatosis. The patient was treated for leprosy and appeared to improve slightly on therapy but died as a result of his malignancy approximately five months after the initiation of therapy. This represents the first case of a patient with M. lepromatosis like illness outside of Mexico and Singapore.

Cardiac device infection due to Streptococcus pneumoniae.

Cardiac device infections (CDIs) are recognized complications of device implantation. Most CDIs are caused by skin flora but can also result from hematogenous seeding of the device. A case involving Streptococcus pneumoniae CDI, which is rare, potentially vaccine preventable and may not be associated with overt antecedent pneumococcal infection, is reported.

Les infections associées à des dispositifs cardiaques (IDC) sont des complications connues des implants cardiaques. La plupart des IDC sont causées par la flore cutanée, mais elles peuvent aussi résulter d'un ensemencement hématogène. Les auteurs présentent une occurrence rare d'IDC à Streptococcus pneumoniae, qui aurait peut-être pu être évitée par la vaccination et qui ne s'associerait pas à une infection pneumococcique antérieure manifeste.

Detection of plasmid-mediated KPC-producing Klebsiella pneumoniae in Ottawa, Canada: evidence of intrahospital transmission.

Klebsiella pneumoniae isolates from three patients admitted to the Ottawa Hospital, a 1,040-bed teaching hospital, were found to contain the plasmid-borne K. pneumoniae carbapenemase (KPC)-producing bla gene (bla(KPC)). There was evidence of person-to-person transmission for two patients. Screening of 186 clinical isolates revealed no additional bla(KPC)-containing isolates.

Surveillance for hospital outbreaks of invasive group a streptococcal infections in Ontario, Canada, 1992 to 2000.

BACKGROUND: Streptococcus pyogenes can cause severe disease in the individual patient and dramatic hospital outbreaks. OBJECTIVE: To describe the epidemiology of hospital outbreaks of invasive group A streptococcal infection in order to understand the potential benefit of proposed outbreak investigation and management strategies. DESIGN: Prospective, population-based surveillance. SETTING: Short-term care hospitals in Ontario, Canada. PATIENTS: Persons with a positive culture for group A streptococcus from a normally sterile site between 1 January 1992 and 31 December 2000. MEASUREMENTS: Laboratory-based surveillance identified patients with nosocomial invasive group A streptococcal infection. Epidemiologic and microbiological investigations were used to detect transmission. RESULTS: Of 2351 cases of invasive group A streptococcal disease, 291 (12%) were hospital acquired. Twenty-nine (10%) nosocomial cases occurred as part of 20 outbreaks. Seventy percent (14 of 20) of outbreaks involved nonsurgical, nonobstetric patients. Community-acquired cases initiated 25% of outbreaks; most were cases of necrotizing fasciitis in patients admitted to the intensive care unit. Outbreaks were small (median, 2 cases [range, 2 to 10 cases]) and short (median duration, 6 days [range, 0 to 30 days]). The median time between the first 2 cases was 4.5 days. The most common mode of propagation was patient-to-patient transmission. A staff carrier was the primary mode of transmission in 2 (10%) outbreaks, but 1 or more health care workers were colonized with the outbreak strain in 6 of 18 (33%) other outbreaks. LIMITATIONS: Some outbreaks with 1 case of invasive disease may have been missed; advice provided to participating hospitals may have reduced the number and size of outbreaks. CONCLUSIONS: Practices to prevent hospital transmission of group A streptococci should include isolation of patients admitted to the intensive care unit with necrotizing fasciitis, investigation after a single nosocomial case, and emphasis on identifying and treating health care worker carriers on surgical and obstetric services and patient reservoirs on other wards.

An evaluation of the management of asymptomatic catheter-associated bacteriuria and candiduria at The Ottawa Hospital.

BACKGROUND: Asymptomatic catheter-associated urinary tract infections (CAUTIs) are common in hospitalized patients. They are associated with a low incidence of sequelae and morbidity, and in most patients resolve spontaneously on removal of the catheter. As a result, it is not recommended that asymptomatic catheter-associated bacteriuria or candiduria be treated with antimicrobial agents while the catheter remains in place because it may lead to the evolution of resistant flora. OBJECTIVE: To assess the current management of patients with CAUTIs with respect to antimicrobial therapy at The Ottawa Hospital and the University of Ottawa Heart Institute, Ottawa, Ontario. METHODS: A prospective observational study over a period of 26 consecutive days was conducted at The Ottawa Hospital (General and Civic campuses) and the University of Ottawa Heart Institute. Inpatients with an indwelling catheter, a positive urine culture and the absence of UTI signs or symptoms were assessed. Patients were followed for five days to determine whether antimicrobials were prescribed. RESULTS: From March 3 to March 28, 2003, 29 of 119 patients screened met inclusion criteria. Of these 29 patients, 15 (52%) were prescribed antimicrobials and were therefore considered to be inappropriately managed. Differences were observed between the appropriate and inappropriate management groups in terms of duration of stay to positive urine culture and whether yeast or bacteria were isolated from the culture. CONCLUSION: Antimicrobial agents were prescribed in over one-half of CAUTI cases, contrary to recommendations from the literature. Education is required to bring this strongly supported recommendation into clinical practice.

Suboptimal clinical response to ciprofloxacin in patients with enteric fever due to Salmonella spp. with reduced fluoroquinolone susceptibility: a case series.

BACKGROUND: Salmonella spp. with reduced susceptibility to fluoroquinolones have higher than usual MICs to these agents but are still considered "susceptible" by NCCLS criteria. Delayed treatment response to fluoroquinolones has been noted, especially in cases of enteric fever due to such strains. We reviewed the ciprofloxacin susceptibility and clinical outcome of our recent enteric fever cases. METHODS: Salmonella enterica Serotype Typhi (S. Typhi) and Serotype Paratyphi (S. Paratyphi) blood culture isolates (1998-2002) were tested against nalidixic acid by disk diffusion (DD) and agar dilution (AD) and to ciprofloxacin by AD using NCCLS methods and interpretive criteria. Reduced fluoroquinolone susceptibility was defined as a ciprofloxacin MIC of 0.125-1.0 mg/L. The clinical records of patients treated with ciprofloxacin for isolates with reduced fluoroquinolone susceptibility were reviewed. RESULTS: Seven of 21 (33%) S. Typhi and S. Paratyphi isolates had reduced susceptibility to fluoroquinolones (MIC range 0.125-0.5 mg/L). All 7 were nalidixic acid resistant by DD (no zone) and by AD (MIC 128- >512 mg/L). The other 14 isolates were nalidixic acid susceptible and fully susceptible to ciprofloxacin (MIC range 0.015-0.03 mg/L). Five of the 7 cases were treated initially with oral ciprofloxacin. One patient remained febrile on IV ciprofloxacin until cefotaxime was added, with fever recurrence when cefotaxime was discontinued. Two continued on oral or IV ciprofloxacin alone but had prolonged fevers of 9-10 days duration, one was switched to IV beta-lactam therapy after remaining febrile for 3 days on oral/IV ciprofloxacin and one was treated successfully with oral ciprofloxacin. Four of the 5 required hospitalization. CONCLUSIONS: Our cases provide further evidence that reduced fluoroquinolone susceptibility of S. Typhi and S. Paratyphi is clinically significant. Laboratories should test extra-intestinal Salmonella spp. for reduced fluoroquinolone susceptibility.

Severe group a streptococcal soft-tissue infections in Ontario: 1992-1996.

A prospective, population-based, surveillance study of invasive soft-tissue infections due to group A streptococci was conducted in Ontario, Canada, from 1992 through 1996. Demographic and clinical information was obtained by patient interview and chart review. Isolates were characterized by M protein and T agglutination typing. The incidence of necrotizing fasciitis (NF) increased from 0.08 cases per 100,000 population in 1992 to 0.49 cases per 100,000 population in 1995. The case-fatality rate was 13% (68 of 520 patients died). Hypotension and multiorgan dysfunction complicated 64 cases (12%), and NF complicated 119 cases (23%). Underlying diabetes, alcohol abuse, cancer, and cardiac and pulmonary disease increased the risk of disease. Prior use of nonsteroidal anti-inflammatory agents did not influence disease severity. All 197 patients without NF, underlying illness, and hypotension at presentation survived, as did 95 (99%) of 96 normotensive patients who were <65 years old but who had underlying chronic illness. Previously healthy patients without hypotension or NF may be considered for outpatient treatment.

An unusual cause for granulomatous inflammation of the penis.

We report a highly unusual type of inflammatory reaction secondary to the insertion of needle in the penis with formation of a nodule of 2.1 cm in diameter, histologically mimicking lymphogranuloma venereum.