Failure of anti-infective mouth rinses and concomitant antibiotic prophylaxis to decrease oral mucosal colonization in autologous stem cell transplantation.

Autologous stem cell transplantation has augmented treatment successes. However, high-dose chemotherapy is still accompanied by dose-limiting toxicities, for example, severe mucositis. Mucosal lesions serve as portals of entry for infections. In order to reduce the oral microbial burden, we prospectively evaluated the microbiological impact of a complex regimen of mouth rinses consisting of concomitantly applied polyene antifungals, povidone-iodine, chlorhexidine, sage tea, and prophylactic ciprofloxacin and fluconazole. A total of 15 patients were enrolled into this longitudinal evaluation. Colony-forming units (CFU) were quantitated from saliva, buccal and palatinal swabs during high-dose chemotherapy and autologous stem cell transplantation. The number of CFU did not show any significant changes after initiation of the mouth rinses and the prophylactic antibiotics. The median CFU count was 268 x 10(6)/ml saliva before chemotherapy and decreased after initiation of intravenous antibiotics only. Neither prophylactic nor therapeutic antifungals significantly reduced the number of cultures positive for yeasts. Since 90% of our patients had febrile neutropenia at some time point during the observation period, the approach evaluated cannot be recommended as prophylaxis of febrile neutropenia as such.

Human cervicofacial actinomycoses: microbiological data for 1997 cases.

Actinomycoses are sporadically occurring endogenous polymicrobial inflammatory processes, in which fermentative actinomycetes of the genera Actinomyces, Propionibacterium, or Bifidobacterium act as the principal pathogens. Difficulties in diagnosing the disease in a timely and reliable fashion have led clinicians and microbiologists to grossly underestimate its medical importance. Therefore, we evaluated microbiological and selected clinical data derived from 1997 culture-positive cases of human cervicofacial actinomycoses examined in our laboratories during 1972-1999. The causative actinomycetes belonged to at least 9 different species, among which Actinomyces israelii and Actinomyces gerencseriae predominated. The well-known predisposition of male patients to acquire the disease varied with age and appeared to be especially pronounced in patients aged 20-60 years, the highest incidence being found in female patients aged 11-40 years and in male patients aged 21-50 years. The relevant procedures necessary for diagnosing human actinomycoses reliably, as well as details of their complex etiology, are discussed.

A randomized monocentric trial in febrile neutropenic patients: ceftriaxone and gentamicin vs cefepime and gentamicin.

A prospective, randomized, controlled monocentric trial was performed to evaluate the efficacy and safety of once daily ceftriaxone 2 g plus gentamicin 5 mg/kg in comparison to cefepime 2 g t.i.d. plus gentamicin 5 mg/kg q.d. in the treatment of neutropenic fever. In case of fever (oral temperature > or =38.5 degrees C on one occasion or > or =38.0 degrees C twice within 24 h) and a granulocytopenia (neutrophil count below 500 or below 1000/microl when expected to fall below 500 within 72 h), patients with hematological malignancies or solid tumors were assigned to ceftriaxone or cefepime, each with gentamicin. The primary endpoint was defined as defervescence on day 4-6 followed by at least 7 afebrile days. Secondary endpoints were overall response, defined as defervescence on day 28 and toxicity. Two hundred eleven episodes were included. Fever of unknown origin (FUO) accounted for 124 episodes (58.8%), microbiologically defined infection (MDI) for 39 (18.5%), clinically defined infection (CDI) for 25 (11.8%), and both clinically and microbiologically defined infection (CMDI) for 19 episodes (9%). On an intent-to-treat basis 207 episodes were evaluable for the primary endpoint. Ceftriaxone plus gentamicin and cefepime plus gentamicin were successful in 49.5% and 51%, respectively. Overall response was achieved on study day 28 in 92.5% and 91%, respectively. Diarrhea was more frequent with ceftriaxone/gentamicin (6.5% vs 17%), while nausea/vomiting was less (12.1% vs 5%). Once-daily ceftriaxone plus gentamicin was not inferior to cefepime t.i.d. plus gentamicin q.d. in the empirical treatment of neutropenic fever.

Actinobacillus actinomycetemcomitans in the human oral microflora.

In this paper, the frequency of the microaerophilic gram-negative bacterium Actinobacillus actinomycetemcomitans (Ac) which is a component of the normal human oral microflora was investigated. Ac could be cultivated from oral material (molar sulcus and/or mucous membrane of the cheek) from 55 out of 405 healthy adults examined. This overall Ac frequency of 13.6% corresponds well to the few other reports existing in literature. A short discussion about the possible pathogenic potential of Ac is given at the end of the paper.

Campylobacter and Salmonella contaminating fresh chicken meat.

1853 packages of fresh chicken breast meat of German, Dutch and French origin were investigated for their contamination with Campylobacter and/or Salmonella. Swabs were taken and cultured from dripwater, meat surface, meat interior and packet bowl. Campylobacter was isolated from 619 meat samples (= 33%), Salmonella from 377 meat packages (= 20%). In 111 of these contaminated chicken samples, both Salmonella and Campylobacter were present. The contamination rate and the species spectrum observed differed depending on the origin of the packages and the time of control.

Empirical liposomal amphotericin-B therapy in a neutropenic patient: breakthrough of disseminated Blastoschizomyces capitatus infection.

Blastoschizomyces capitatus (Trichosporon capitatum) is an uncommon fungal pathogen. Infections have mostly been seen in immunocompromised patients and use of broad spectrum antibiotics was identified as a risk factor. Treatment has been extremely difficult. A report is presented about a case of fatal B. capitatum infection with clinical septicemia and multiorgan failure during intravenous liposomal amphotericin B therapy.

[Illnesses caused by ubiquitous mycobacteria. Clinical, therapeutic and microbiological aspects]. / Erkrankungen durch ubiquitäre Mykobakterien. Klinische, therapeutische und mikrobiologische Aspekte.

Over the last ten years, opportunistic infections with ubiquitous mycobacteria have increased greatly in importance. In particular immunosuppressed patients are affected. Given that present methods of detection are much improved, there has still been a "real" increase in such diseases. For the interpretation of findings in HIV-positive patients, special criteria apply. In the case of AIDS patients, virtually all the organs may be affected, while in HIV-negative patients, chronic diseases of the lungs, lymphadenopathies and infections of the skin and soft tissues predominate. The differentiation between tuberculosis pathogens and ubiquitous mycobacteria is the all-important task of the diagnostic laboratory. Owing to the high resistance of the pathogens, treatment is often problematic.

On the development of mycobacterial infections II. Changing mycobacterial infection spectrum in the Cologne area 1983-1993.

The overall detection rate of mycobacteria in the Cologne area did not change between 1983 and 1993. But a significant shift of the rate of Mycobacterium tuberculosis to nontuberculous mycobacteria, especially Mycobacterium avium-intracellulare complex, could be observed. Whereas the portion of Mycobacterium tuberculosis fell during these years from about 90% to 50-70% the portion of Mycobacterium avium-intracellulare increased steadily from 0 to 23% of all mycobacteria positive patients. The portion of tuberculosis patients positive for HIV remained constantly at 5-7% until 1992. Whether the 10% in 1993 signalizes a definitive increase remains to be proven. HIV positive patients with the diagnosis mycobacteria show another development. Whereas Mycobacterium tuberculosis is isolated constantly from about 2-3% of all HIV positive patients, the Mycobacterium avium-intracellulare complex increased from 0 to 10%. As methodical factors play a special role in the diagnostic procedure of mycobacteria, we evaluated some of the newer techniques for our routine laboratory: The well-known high sensitivity and specificity of the DNA probes (Gen-probe system) was confirmed, and by the radiometric culture system, in fact, the ubiquitous mycobacteria were detected much better. Otherwise from one third of special materials Mycobacterium tuberculosis and Mycobacterium bovis grew only on the conventional solid media. The susceptibility testing of 925 Mycobacterium tuberculosis strains revealed a rate of 10% (95 strains) with resistance to one antituberculotic drug only and 3% (29 strains) with resistance to two or more drugs. Only 0.9% (8 strains) were resistant to isoniacid and rifampicin (multidrug-resistant strains) indicating that drug resistance of Mycobacterium tuberculosis is still no serious problem in our region.

On the development of mycobacterial infections. I. A review concerning the common situation.

In this review concerning the common situation of mycobacterial infections the following problems are discussed: (1) The worldwide epidemiological situation of tuberculosis reveals an increase in the developing countries but even in some industrialized countries like the United States. The reasons for this development are mainly socioeconomic factors. (2) The association between tuberculosis and HIV infection has caused in general a marked increase in the incidence of tuberculosis in some countries. Because of its ability to destroy the immune system, HIV is a significant risk factor for the progression of tuberculosis infection as a clinical disease. Taking into account that 5 million persons worldwide are infected with tuberculosis as well as with HIV (most of them living in the Sub-Saharan Africa), enormous future problems can be anticipated. (3) The new fear of tuberculosis has resulted mainly from reports about outbreaks with multidrug resistant strains of Mycobacterium tuberculosis in the United States. These strains are at least resistant to the most important antituberculotic drugs isoniacid and rifampicin. The frequency of multidrug-resistant tuberculosis in the USA is reported to be overall 3-7%, however for New York 19% is estimated. The main reason for this development is inadequate chemotherapy mostly due to poor compliance. Therefore in the United States the directly observed therapy has been established. Complete and reliable reports of the resistance situation in other countries are not available because most of these have no resistance surveillance programs. (4) As immunocompromised patients become more numerous, the importance of nontuberculous mycobacteria has significantly increased. Mainly organisms of the Mycobacterium avium-intracellulare complex play a special role as opportunistic pathogens for AIDS patients in later stages of their disease. Therapy for these infections is problematic due to the high resistance of most ubiquitous mycobacteria to antituberculotic drugs. (5) New laboratory techniques have shortened the detection time (radiometric culture systems) and the time needed for the identification of the most important mycobacteria species (DNA probes). A further improvement of the laboratory diagnosis of tuberculosis is expected in the near future by nucleic acid amplification techniques (polymerase chain reaction and others).

[1995 status of tuberculosis]. / Situation der Tuberkulose 1995.

While the number of active cases of tuberculosis in the USA and in some European countries has increased over the last few years, the incidence in Germany is (as yet) a relatively constant 17.5/100,000 (figure for 1993). For foreign citizens, however, the case rate was considerably higher at 64.9/100,000. Among persons infected with HIV, the prevalence of active tuberculosis is also comparatively low in Germany. Especially in the USA an increase in multi-resistant strains has been observed which led to outbreaks particularly among AIDS-patients. Modern diagnostic and therapeutic possibilities are outlined. Particular importance should be attached to vigorous initial treatment, which is associated with a high success rate (approx. 98%), and which prevents the development of multi-resistance.

[Ureaplasma urealyticum--a new problem pathogen in neonatology]. / Ureaplasma urealyticum--ein neuer Problemkeim in der Neonatologie.

Some previous studies showed that Ureaplasma urealyticum is the most common germ that appears in the birthway of pregnant women and which is also frequently found in skin swabs and secretions of newborn and premature babies. The colonization of pregnant women by Ureaplasma urealyticum makes a premature birth more likely. Another factor of risk for a premature infant is a premature rupture of membranes for more than 24 hours which also makes an infection possible. There exists an association between pulmonary infection by Ureaplasma urealyticum and the development of a bronchopulmonary dysplasia especially for premature babies. According to our observations acute exacerbations of severe pneumonia can appear even after month. An attempt of therapy of pulmonary infection should be undertaken with erythromycin, if sensitive serotypes are present. In the case of erythromycin resistance chloramphenicol can be used but only under frequent controls of blood levels. We were able to observe rapid improvements with this effective therapy.

[Tuberculosis cutis luposa gigantea with Mycobacterium bovis detection]. / Tuberculosis cutis luposa gigantea mit Nachweis von Mycobacterium bovis.

In an 80-year-old woman, retired farmworker, we observed lupus vulgaris extending over more than half of her leg. The extreme size of the affected area made us talk of a giant form in this case. Bacteriological investigation revealed Mycobacterium bovis. The minimal amount of tuberculin required to induce a positive intradermal reaction was 10 IU (GT Behring). Another case with similar dimensions (reported by Christiansen in 1967) had been caused by Mycobacterium avium and developed over a period of at least 5 years. The vast cutaneous affection of our patient, in contrast, had developed within only one year, starting from a brownish macula of the size of a palm on her upper leg. This macula - presumably the manifestation of quiescent lupus vulgaris - had not changed for more than 40 years. This late exacerbation of post-primary tuberculosis might have been favored by the patient's reduced immunologic resistance on account of her advanced age. In addition, local cofactors - namely ankylosis of her knee and contact eczematous dermatitis - have to be considered. In accordance with the resistogram, the disease responded to monotherapy with isoniazide.

[Coccidioidomycosis--differential diagnosis of lung infiltrates with peripheral eosinophilia]. / Coccidioidomykose--eine Differentialdiagnose bei Lungeninfiltrat mit peripherer Eosinophilie.

A 20-year-old man developed pulmonary coccidioidomycosis after travelling in Mexico and California. Cardinal clinical symptoms were fever, pulmonary infiltrate with ipsilateral hilar adenopathy on the chest X-ray, and a 14% eosinophilia in the peripheral blood. In addition he experienced erythema nodosum, arthralgias and night sweats. After a five-week febrile course the symptoms disappeared spontaneously without specific treatment. Coccidioidomycosis was diagnosed by serology, and Coccidioides immitis grew in the sputum culture. With ever more travellers to other parts of the globe coccidioidomycosis must be considered in the differential diagnosis of pulmonary infiltrates with peripheral eosinophilia.

[Bacterial contamination of pump-collected breast milk]. / Untersuchungen über die bakterielle Kontamination von abgepumpter Muttermilch.

Breast feeding of premature, new-born babies is often difficult when they become sick and are transferred to a children's hospital. The mother's milk should be collected and provided to the child without a loss of quality or too high a bacterial count which could endanger his health. We collected 113 samples of milk using electric vacuum breast pumps and then determined the bacterial contamination. In most cases there was evidence of bacteria normally found on the skin although more than 10(5)/ml of these bacteria were found in only 11.5% of the samples. As potentially pathogenic germs gram-negative bacilli, beta-hemolytic Streptococci Group B and Staphylococcus aureus were found. The electric pumps were cleaned with two different methods: the usual technique (Series I: 41 samples) and second, sterilization or replacement of the various external pump components between the collection of individual milk samples (Series II: 72 samples). The total of bacteria was considerably reduced by these additional hygienic measures; 62.5% of the samples could now be given to the children unpasteurized whereas the former figure was only 29.3%. On the other hand there was no decrease in the number of milk samples containing either beta-hemolytic Streptococci (Group B) or more than 10(5)/ml bacteria normally found on the skin.

[Bacterial growth in breast milk under various storage conditions]. / Bakterienwachstum bei unterschiedlicher Lagerung von Muttermilch.

To find the best temperature for storing human breast milk in the first test series, bacterial growth was determined and recorded at refrigerator temperatures of 8 to 10 degrees C and at 4 degrees C respectively. During a 3-day observation period, there was a slight decrease in bacterial count (b.c.) at higher temperature whereas the b.c. decrease at the lower temperature was more significant. In another test 72 samples of milk were kept for one month at a temperature of -20 degrees C; the b.c. observed after thawing was substantially smaller than that recorded before freezing. Pasteurized milk samples were found sterile with the method we used (in 0.1 ml). In a third test a measured quantity of specific bacteria was added to the milk samples which were first deep-frozen, thereafter pasteurized and finally stored in a refrigerator for 3 days at 4 degrees C. During this process, a decrease was observed in all the bacteria involved. In our opinion, breast milk is best stored at a constant temperature of 4 degrees C. Pasteurization and freezing are also recommended from a bacteriological point of view.

Bacteriophages of Nocardia asteroides.

101 Nocardia strains from different species and different sources were examined with respect to their lysogeny. 18 phages from 17 Nocardia asteroides strains could be isolated, purified, and propagated. All phages were released spontaneously. Induction experiments with mitomycin C and UV-rays brought no practicale advantages. Using 14 of the 18 phages, 38 of the 101 Nocardia strains tested could be grouped into 18 phage patterns. Nearly all of the typable strains belonged to the species Nocardia asteroides.