Group A streptococcal bacteremia: outcome and prognostic factors / Bacteriemia por estreptococos del grupo A: resultados y factores pronóstico

In the last two decades, an increase in the incidence of invasive group A streptococcus (GAS) infections has been reported. The aim of this study was to determine the clinical and epidemiological characteristics and the natural history of GAS bacteremias at our hospital by performing a retrospective study of all cases of GAS bacteremia diagnosed at our University hospital from 1994 to 2003. We reported 42 cases of GAS bacteremia (27 men, mean age 42.3 ± 31.6 years). None had more than one episode and four cases were nosocomial. The mean annual incidence rate was 1.01 cases per 100,000 population. An increase in the incidence but not in severity of GAS bacteremia was observed in the last 5-year period (p<0.001). The rates were highest in young children and the elderly and those with underlying medical conditions; 73.8% of patients had some underlying chronic illness, and the most relevant conditions included peripheral vascular disease and diabetes mellitus. Mortality was high and the worst outcome corresponded to elderly patients with streptococcal toxic shock syndrome (STSS). Thirty patients (71.4%) had a disruption in the integrity of the skin barrier, 14 (33.3%) were immunocompromised patients and 6 patients (14.3%) were intravenous drug users. A source of the bacteremia was noted in 38 patients (90.5%), with skin and soft tissue infection being the major portals of entry. Twelve patients (28.6%) fulfilled the STSS criteria. All strains were susceptible to penicillin and vancomycin. Resistance to erythromycin was 21.4% and to ciprofloxacin was 17.5%. The global mortality rate was 28.6%. Only STSS was significantly associated with increased mortality in the multivariate analysis

En las dos últimas décadas se ha descrito un aumento de la incidencia de infecciones por estreptococos del grupo A invasivos. El objetivo de este estudio fue determinar las características clínicas y epidemiológicas y la historia natural de las bacteriemias por estreptococos del grupo A en nuestro hospital. Se estudiaron retrospectivamente todos los casos diagnosticados en un solo hospital de nivel terciario entre 1994 y 2003, y describimos 42 (27 varones, edad media 42,3 ± 31,6 años). Ninguno presentó más de un episodio y cuatro fueron infecciones nosocomiales. La tasa media de incidencia anual fue de 1,01 casos por 100.000 habitantes. Se ha observado un aumento en la incidencia de bacteriemia por estreptococos del grupo A, pero no de su gravedad, durante los últimos 5 años (p <0.001). Las tasas de incidencia más altas se observaron en niños y ancianos. El 73,8% de los pacientes afectados presentaron una enfermedad crónica subyacente, siendo las más relevantes la enfermedad vascular periférica y la diabetes mellitus. Treinta pacientes (71,4%) presentaban una herida u otra alteración de la integridad de la barrera cutánea, 14 (33%) estaban inmunodeprimidos y 6 (14,3%) eran drogadictos por vía intravenosa. En 38 casos (90,5%) se registró un foco de entrada de la bacteriemia, siendo los más habituales las infecciones cutáneas y de tejidos blandos. Doce pacientes (28,6%) cumplieron los criterios de síndrome de “shock” tóxico estreptocócico. Todas las cepas fueron sensibles a la penicilina y la vancomicina. La resistencia a la eritromicina fue del 21,4% y al ciprofloxacino del 17,5%. La tasa global de mortalidad fue del 28,6%. En el análisis multivariado, sólo el “shock” tóxico estreptocócico se asoció significativamente a una mayor mortalidad. Durante los últimos cinco años se ha observado un aumento en la incidencia de bacteriemia por estreptococos del grupo A en nuestro hospital. Los niños pequeños, los ancianos y los pacientes con enfermedades subyacentes son más susceptibles a adquirir esta infección. La mortalidad fue alta y los peores resultados se observaron en los pacientes ancianos con síndrome de “shock” tóxico estreptocócico

Group A streptococcal bacteremia: outcome and prognostic factors.

In the last two decades, an increase in the incidence of invasive group A streptococcus (GAS) infections has been reported. The aim of this study was to determine the clinical and epidemiological characteristics and the natural history of GAS bacteremias at our hospital by performing a retrospective study of all cases of GAS bacteremia diagnosed at our University hospital from 1994 to 2003. We reported 42 cases of GAS bacteremia (27 men, mean age 42.3 +/- 31.6 years). None had more than one episode and four cases were nosocomial. The mean annual incidence rate was 1.01 cases per 100,000 population. An increase in the incidence but not in severity of GAS bacteremia was observed in the last 5-year period (p<0.001). The rates were highest in young children and the elderly and those with underlying medical conditions; 73.8% of patients had some underlying chronic illness, and the most relevant conditions included peripheral vascular disease and diabetes mellitus. Mortality was high and the worst outcome corresponded to elderly patients with streptococcal toxic shock syndrome (STSS). Thirty patients (71.4%) had a disruption in the integrity of the skin barrier, 14 (33.3%) were immunocompromised patients and 6 patients (14.3%) were intravenous drug users. A source of the bacteremia was noted in 38 patients (90.5%), with skin and soft tissue infection being the major portals of entry. Twelve patients (28.6%) fulfilled the STSS criteria. All strains were susceptible to penicillin and vancomycin. Resistance to erythromycin was 21.4% and to ciprofloxacin was 17.5%. The global mortality rate was 28.6%. Only STSS was significantly associated with increased mortality in the multivariate analysis.

[Meningitis and brain abscess caused by Streptococcus intermedius in a patient infected with HIV-1]. / Meningitis y absceso cerebral por Streptococcus intermedius en un paciente con infección por VIH-1.

Streptococcus milleri group have been recognized as an important pathogens for abscess formation in various organs. Streptococci other than Streptococcus pneumoniae are a rare cause of bacterial meningitis in adults and can be associated with the presence of an undiagnosed brain abscess. Brain abscess is a focal collection within the brain parenchyma which can arise as a complication of a variety of infections. The most common etiologic organisms in clinical series have been microaerophilic streptococci and anaerobic bacteria. Although intracranial mass lesions that occur as a result of infection have commonly been reported in patients infected with the human immunodeficiency virus, brain abscess due to the common bacterial pathogens are rarely described in HIV infected patients and Toxoplasma gondii is the organism most frequently isolated from stereotactic brain biopsy in these patients. We report a patient with both HIV-1 infection and streptococcal meningitis secondary to brain abscess caused by S. intermedius.

Meningitis y absceso cerebral por Streptococcus intermedius en un paciente con infección por VIH-1 / Meningitis and brain abscess caused by streptpcoccus intermedius in a patient infected with HIV-1

Los estreptococos de grupo milleri se caracterizan por su tendencia a provocar infecciones piógenas invasoras en diferentes localizaciones. Las meningitis estreptocócicas no neumocócicas son poco frecuentes en pacientes adultos y pueden asociarse a la presencia de un absceso cerebral. Los abscesos cerebrales son colecciones localizadas dentro del parénquima cerebral que se originan como complicación de una infección, siendo los estreptococos microaerófilos y las bacterias anaerobiaslos microorganismos más frecuentemente aislados. Aunque no es inusual la presencia de colecciones intracraneales de etiología infecciosa en pacientes con infección por VIH-1, los abscesos cerebrales producidos por las bacterias piógenas habituales son muy infrecuentes y es T. gondiiel agente etiológico más frecuente. Aportamos un caso de meningitis y absceso cerebral por S. intermedius en un paciente con infección por VIH-1

Streptococcus milleri group have been recognized as an important pathogens for abscess formation in various organs. Streptococci other than Streptococcus pneumoniae are a rare cause of bacterial meningitis in adults and can be associated with the presence of an undiagnosed brain abscess. Brain abscess is a focal collection within the brain parenchyma wich can arise as a complication of a variety of infections. The most common etiologic organisms in clinical series have been microaerophilic streptococci and anaerobic bacterias. Although intracraneal mass lesions that occur as a result of infection have commonly been reported in patients infected with the human immunodeficiency virus, brain abscess due to the common bacterial pathogens are rarely described in HIV infected patients and Toxoplasma gondii is the organism most frecuently isolated from stereotactic brain biopsy in these patients. We report a patient with both HIV-1 infection and streptococcal meningitis secondary to brain abscess caused by S. intermedius

Serotipos y sensibilidad antibiótica de Streptococcus pneumoniae en niños del área de Valencia y Castellón: estudio prospectivo multicéntrico / Serotypes and antibiotic susceptibility of Streptococcus pneumoniae in children in the health district of Valencia and Castellón, Spain: a multicenter, prospective trial

Se ha realizado un estudio para conocer los serotipos, la cobertura de la vacuna conjugada heptavalente (VCN 7-v) y la sensibilidad a los antibióticos de Streptococcus pneumoniae aislados en niños (<15 años) del área sanitaria de las provincias de Castellón y Valencia desde junio de 1999 hasta diciembre de 2002. En total se evaluaron 271 cepas, de las cuales el 15,5 por ciento fueron invasoras, el 63,5 por ciento de origen respiratorio y el 22,5 por ciento de exudados conjuntivales y óticos. El 67,2 por ciento de las cepas pertenecían a niños menores de 2 años. La distribución de los serotipos cambia ligeramente con la edad y el origen de la muestra; los más frecuentes fueron 19, 6, 23, 14, 3, 9 y 11, pero en los niños menores de 2 años el orden cambia a 19, 6, 14 y 23, 9, 11 y 3, y en las cepas invasoras es 19, 6, 14, 3 y 23. El 27,2 por ciento de las cepas fueron sensibles a los diez antibióticos probados. Frente a la penicilina, el 50,4 por ciento tuvieron sensibilidad disminuida y el 5,8 por ciento fueron altamente resistentes; el 98,3 por ciento fueron sensibles a la ampicilina y a amoxicilina-ácido clavulánico, y el 80,7 por ciento a la cefuroxima. El 52,5 por ciento fueron resistentes a la eritromicina y el 43,7 por ciento a la clindamicina. Ninguna cepa fue resistente a la rifampicina, la vancomicina, el levofloxacino ni la cefotaxima. Los serotipos más sensibles fueron el 3 y el 11, y los más resistentes el 14 (que siempre fue resistente a un antibiótico), 19, 6 y 23.Según los datos, la cobertura teórica de la VCN 7-v sería del 80,1 por ciento en los niños menores de 2 años y del 73,43 por ciento en los de 0 a 14 años (AU)

[Serotypes and antibiotic susceptibility of Streptococcus pneumoniae in children in the health district of Valencia and Castellón, Spain: a multicenter, prospective trial]. / Serotipos y sensibilidad antibiótica de Streptococcus pneumoniae en niños del área de Valencia y Castellón: estudio prospectivo multicéntrico.

A study was conducted to determine the serotypes, the coverage of the heptavalent conjugate vaccine (VCN 7-v) and the antibiotic susceptibility of Streptococcus pneumoniae in children (<15 years) in the health districts of the provinces of Castellon and Valencia, Spain, from June 1999 to December 2002. A total of 271 strains were evaluated, 15.5% of which were invasive, 63.5% were of respiratory origin and 22.5% were from conjunctival and otitic exudates; 67.2% of the strains were found in children younger than 2 years of age. The distribution of the serotypes showed slight changes according to age and the origin of the sample: the most common serotypes were 19, 6, 23, 14, 3, 9 and 11; however, in children younger than 2 years of age the order changed to 19, 6, 14 and 23, 9, 11 and 3, and in the invasive strains to 19, 6, 14, 3 and 23. A total of 27.2% of the stains were susceptible to the ten antibiotics tested. For penicillin, reduced susceptibility was found in 50.4% and high resistance in 5.8%; 98.3% were susceptible to ampicillin and amoxicillin-clavulanic acid, and 80.7% to cefuroxime; 52.5% were resistant to erythromycin and 43.7% to clindamycin. No strains were resistant to rifampicin, vancomycin, levofloxacin or cefotaxime. The most susceptible serotypes were 3 and 11, and the most resistant was 14 (which consistently showed resistance to an antibiotic), 19, 6 and 23. According to these data, the theoretical coverage of VCN 7-v would be 80.1% in children younger than 2 years and 73.43% in those aged 0-14 years.

Infectious complications in patients undergoing unrelated donor bone marrow transplantation: experience from a single institution.

OBJECTIVE: To analyze the incidence and characteristics of documented infections in patients with hematologic malignancies undergoing unrelated donor bone marrow transplantation (UD-BMT). METHODS: We studied the occurrence of infections in 22 patients with hematologic malignancies or severe aplastic anemia who underwent UD-BMT from April 1990 to December 2000. The median age was 26 years (range 13-46). Acyclovir-ganciclovir, co-trimoxazole, fluconazole-nystatin and ciprofloxacin were administered for anti-infectious prophylaxis. RESULTS: We registered 61 infectious episodes. During the early post-transplant period, there were eight clinically documented infections (CDIs), four cases of fever of unknown origin (FUO), seven cases of bacteremia, two cases of cytomegalovirus (CMV) antigenemia, and one case of CMV disease. In the intermediate period (days 30-100 after BMT), there were nine cases of CMV antigenemia, three bacterial infections, two fungal infections, one case of disseminated toxoplasmosis, and one case of FUO. In the late period (day 100 and later), we documented 13 viral infections, eight bacterial infections, one CDI, and one case of invasive aspergillosis. Infections contributed to death in 10 of 17 patients. Citrobacter bacteremia and sepsis of unknown origin were the main causes of infectious mortality in the early period. Infection was the main cause of death in six of seven patients in the late period. CONCLUSION: A high incidence of life-threatening infections and infection-related mortality was observed. A high rate of CMV infection in the early period, and death caused by multiresistant Gram-negative microorganisms in the late period, were the main findings in this series.

Sensibilidad de Staphylococcus aureus aislados de hemocultivo a 11 antimicrobianos y revisión de la literatura / Susceptibility of Staphylococcus aureus isolated from blood to 11 antimicrobial agents and a review of the literature

Entre noviembre de 1998 y febrero de 2000 se estudió la sensibilidad in vitro, mediante el método E-test®, de 91 aislamientos de Staphylococcus aureus procedentes de hemocultivo frente a 11 agentes antimicrobianos. Cincuenta y dos cepas fueron sensibles a meticilina (SASM) y 39 resistentes (SARM). Todos los SASM fueron sensibles a gentamicina, ciprofloxacino, vancomicina, teicoplanina, rifampicina, ácido fusídico, quinupristina-dalfopristina y linezolid, el 90 por ciento fueron sensibles a eritromicina y el 83 por ciento a mupirocina. Todos los SARM fueron sensibles a vancomicina, teicoplanina, rifampicina y linezolid, el 95 por ciento fueron sensibles a quinupristina-dalfopristina y el 92 por ciento a gentamicina, mupirocina y ácido fusídico. Ningún SARM fue sensible a eritromicina ni a ciprofloxacino. La tasa de aislamientos de SARM sensibles a eritromicina o ciprofloxacino fue baja, mientras que el resto de los antibióticos estudiados continúan siendo efectivos frente a S. aureus. (AU)

[Susceptibility of Staphylococcus aureus isolated from blood to 11 antimicrobial agents and a review of the literature]. / Sensibilidad de Staphylococcus aureus aislados de hemocultivo a 11 antimicrobianos y revisión de la literatura.

From November 1998 to February 2000, a total of 91 strains of Staphylococcus aureus isolated from blood were analyzed for their susceptibility to 11 antimicrobial agents using the E-test method. Fifty-two isolates were methicillin-susceptible (MSSA) and 39 were oxacillin-resistant (MRSA). All the MSSA were susceptible to gentamicin, ciprofloxacin, vancomycin, teicoplanin, rifampicin, fusidic acid, quinupristin-dalfopristin and linezolid; 90% were susceptible to erythromycin and 83% to mupirocin. All the MRSA were susceptible to vancomycin, teicoplanin, rifampicin and linezolid; 95% were susceptible to quinupristin-dalfopristin; and 92% to gentamicin, mupirocin, fusidic acid. None of the MRSA were susceptible to erythromycin or ciprofloxacin. The susceptibility of SARM to erythromycin and ciprofloxacin was low, while the susceptibility to the rest of the antimicrobial agents remained active.

Epidemiological, microbiological, clinical, and prognostic factors of bacteremia caused by high-level vancomycin-resistant Enterococcus species.

A case-control study was performed between 1994 and 1996 in order to study the epidemiological, microbiological, clinical, and prognostic features of high-level vancomycin-resistant enterococcal bacteremia. Seventeen consecutive patients who had clinically significant bacteremia due to vancomycin-resistant enterococci (vanA genotype: 16 Enterococcus faecalis, 1 Enterococcus faecium) were compared with 169 who had vancomycin-susceptible enterococcal bacteremia. The following were selected by multivariate analysis as independent risk factors that influenced the development of high-level vancomycin-resistant enterococcal bacteremia: prior glycopeptide therapy (P=0.049); inclusion in a hemodialysis program (P=0.046); prior therapy with corticosteroids or antineoplastic agents (P=0.029); and prior surgical treatment (P=0.022). The following other factors were selected by univariate analysis: tracheostomy (P=0.002); prolonged hospitalization (P=0.01); and any kind of puncture (P=0.02). The crude associated-mortality rate was 13.4%. Gene amplification of vanA was positive for 17 strains of enterococci. Pulsed-field gel electrophoresis of genomic DNA after SmaI digestion of vanA isolates revealed that one strain predominated (10 isolates), though at least four similar banding patterns were identified (6 isolates). The 16 strains closely related to the outbreak were investigated further. The surgical intensive care unit was the first and most involved service. The hospital outbreak of vanA vancomycin-resistant enterococcal bacteremia occurred between 1994 and 1995 and was caused by Enterococcus faecalis. This is believed to be the first and only such outbreak described in a Spanish hospital thus far.

[Abdominal infection by Pasteurella spp. A report of 3 cases]. / Infección abdominal por Pasteurella spp. Presentación de tres casos.

Pasteurella spp. is a gram-negative coccobacillary micro-organism which is a common cause of soft-tissue infections caused by animal bite or scratch and more uncommonly at another locations. We report here the clinical and evolutive characteristics of three patients with different varieties of intra-abdominal infection caused by the microorganism as well as the potential exposure to pet animals.

Endocarditis por Gemella morbillorum en un adicto a drogas por vía parenteral

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[Subacute endocarditis caused by Actinobacillus actinomycetemcomitans]. / Endocarditis subaguda por Actinobacillus actinomycetemcomitans.

BACKGROUND: We describe the cases of endocarditis caused by Actinobacillus actinomycetemcomitans (EAA) observed at our hospital. PATIENTS AND METHODS: We revised clinical records and microbiological documents from patients admitted at our hospital, with A. actinomycetemcomitans in blood cultures occurred from 1972-1998. We used Dukes's diagnostic criterion of infectious endocarditis. RESULTS: Four patients were diagnosed of EAA for twelve years, there were males and two females. Two cases have had valvular prosthesis and three patients suffered a previous odontological manipulation. All cases were clinical subacute presentation. Two patients have had at a distance endocarditis clinical manifestation (neurological deficit and Osler nodules). All patients were febrile and elevation of acute reactants, two cases had inflammatory anemia and one had cardiac failure. We observed growing signs after 7 days of culture and it was necessary, on solid medium, adequate atmosphere and nutritional composition to procure A. actinomycetemcomitans growing. All isolates were susceptible to studied penicillins or aminopenicillins (except one isolate with intermediate susceptibility), aminoglycosides and quinolones. Treatment with penicillin G, lone or combined with aminoglycosides, controlled infection in three patients. No case needed cardiac surgery. CONCLUSIONS: In our experience, EAA is a strange entity and there isn't a previous cardiac disease always. Usually, the place of entrance is a buccal focus. Subacute-chronic course and, sometimes, uncommon, can delay diagnostic during months. Our isolates have an uniform sensibility to penicillins and others betalactamic, anyway aminoglycosides and quinolones, therefore an antibiotic combination of two antibiotics from these families at least could be the choice treatment. Except evolutive complications in some patient, prognostic has been excellent with only antibiotic treatment, without valvular surgery.