International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass.

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Knee and hip arthroplasty infection rates in persons with haemophilia: a 27 year single center experience during the HIV epidemic.

Total joint replacement (TJR) is an option for the management of chronic haemophilic arthropathy. Because surgery is technically challenging, there is a high rate of deep prosthetic infections, particularly in human immunodeficiency virus (HIV)-infected individuals. We determined the incidence of deep infection rates following total knee and hip arthroplasties in HIV-seropositive and HIV-seronegative persons with haemophilia. Fifty-one primary joint replacements were performed on 32 patients seen at a regional comprehensive haemophilia care center from 1975 to 2002. Thirty prostheses were placed in patients who were HIV-seropositive prior to surgery (n = 14) or seroconverted later (n = 16). Median age at the time of surgery was 33 years (range: 20-61) among 19 HIV-seropositive patients and 35 years (range: 26-74) among 13 HIV-negative patients. Median duration of follow-up was 83 months (range: 2-323). Rate of primary joint infection per artificial joint-year by HIV status was compared by Poisson regression. Main outcome measures were the incidence of primary replacement joint infections by HIV status. Deep infections developed in five (9.8%) of 51 replacement joints. There were two infections during 204.15 joint-years without HIV infection and three infections during 205.28 joint-years with HIV infection. The incidence rate of joint infection (0.98 vs. 1.46 per 100 joint-years) was not increased with HIV (relative risk, RR: 1.49, 95% CI: 0.25-8.93, P = 0.66). We conclude that HIV infection is not a contraindication to knee or hip replacement arthroplasty in the appropriate clinical setting.

Spontaneous bacterial peritonitis and bacteremia due to Leuconostoc species in a patient with end-stage liver disease: a case report.

This report describes a case of spontaneous bacterial peritonitis in a patient with end stage liver disease in whom Leuconostoc spp. was isolated from blood and ascitic fluid. In common with several previously described patients with cultures positive for Leuconostoc from other body sites, this patient had recently received vancomycin. The antibiotic susceptibilities and mechanism of vancomycin resistance of this Gram-positive bacteria are reviewed.

Clostridium difficile infection: a common clinical problem for the general internist.

Considering the current wide use of antimicrobial agents, the general internist is commonly faced with the patient at risk for diarrhea due to C. difficile. The diagnosis should be considered for any patient with diarrhea who has received any type of antibiotic therapy in the preceding 4-6 weeks. Symptoms may range from a minor bout of diarrhea to fulminant and fatal colitis. Diagnosis usually requires demonstration of the toxin in stool; culture of the organism and fiberoptic endoscopy may play an adjunctive role in selected clinical settings. The ultimate goal in the treatment for C. difficile infection is to repopulate the normal colonic flora in the most efficacious manner. Minimally symptomatic patients may respond to discontinuing the offending antimicrobial agent or using nonspecific binding agents. Oral vancomycin continues to be the "gold standard" for specific treatment, while metronidazole therapy is considered the first-line agent for individuals with milder infection. Oral bacitracin shows promise, though large studies are lacking. Patients with multiple relapses of C. difficile diarrhea can be treated with prolonged courses of vancomycin or a combination of vancomycin and rifampin. Intensive care unit patients who are NPO have few therapeutic options besides intravenous administration of metronidazole and oral administration of vancomycin via clamped nasogastric tube. Preventive efforts are directed at cautious use of antibiotics and the use of vinyl gloves when caring for patients with known infection.

Endocarditis due to coagulase-negative staphylococci. Microbiologic, epidemiologic, and clinical considerations.

Coagulase-negative staphylococci are the most frequently isolated pathogens in prosthetic valve endocarditis and cause 5% of infections involving native valves. Distinguishing contamination from bacteremia may be challenging. The presence of heteroresistance in many strains makes rigorous susceptibility testing a requirement for selecting appropriate antibiotic selection. Infection is frequently complicated by valvular insufficiency with congestive heart failure, local tissue invasion or synthetic embolization, making surgical intervention necessary in many cases.

Hepatobiliary infections caused by Haemophilus species.

Haemophilus species are rarely associated with hepatobiliary infections. We report a case of hepatic abscess caused by Haemophilus paraphrophilus and review the English-language literature for reports of infections of the liver and biliary system caused by Haemophilus species. Most patients identified had predisposing conditions. The pathogenesis of hepatobiliary infections due to Haemophilus species may involve ascending spread from the gastrointestinal tract or hematogenous seeding following oropharyngeal colonization.

Erythromycin ototoxicity: a call to heighten recognition.

Bilateral sensorineural hearing loss developed in a 64-year-old woman treated with intravenous erythromycin lactobionate for bacteremic pneumococcal pneumonia. Discontinuance of the antibiotic led to prompt correction of the hearing deficit. Reversible hearing loss is an infrequently described adverse effect attributed to high-dose erythromycin therapy. Possible risk factors, including age, gender, and hepatic and renal function, may contribute to the development of erythromycin ototoxicity.

Histogenesis of tubular adenomas in hereditary colonic adenomatous polyposis.

Tubular adenomas were studied morphometrically and histopathologically in colectomy specimens from seven children and five young adults with hereditary colonic adenomatous polyposis. In each age group and in each patient, the diameter and height of adenomas showed a log normal distribution. Both variables differed significantly among patients in each age group and also between the two age groups. In the young adults, there was a selective growth of certain adenomas. Scatter diagrams of the diameter vs height of adenomas showed that adenomas grew preferentially in the horizontal plane in early development, giving adenomas a discoid shape. Adenomas greater than 8 mm in diameter grew both horizontally and vertically. The horizontal growth was due to division of adenomatous crypts, and adenomas greater than 8 mm in diameter also exhibited elongation of crypts.

Epinephrine-induced renin secretion is not initiated by cardiac adrenoceptors.

Experiments were designed to test the hypothesis that epinephrine may act directly on cardiac or pulmonary adrenoceptors to alter the release of a humoral substance that in turn influences renin secretion. Accordingly, anesthetized dogs were prepared with catheters for infusion of epinephrine at three sites: 1) into the aorta just distal to the left subclavian artery, 2) into the left ventricle, and 3) near the right atrium. Left renal renin secretion rates were determined before, during, and after 30-min infusions of epinephrine at each site in each animal; the order of the infusions was randomized. At epinephrine infusion rates of 15 and 75 ng.kg-1.min-1, epinephrine-induced changes in renin secretion rates were dose dependent but were independent of the site of infusion. These data do not support the hypotheses that either pulmonary or cardiac adrenoceptors are involved in the initiation of epinephrine-induced renin secretion. In additional experiments, an isolated canine heart was perfused with femoral arterial blood from an experimental dog, and the coronary venous effluent was returned to the experimental dog via the femoral vein. Intravenous epinephrine infusion at 50 ng.kg-1.min-1 increased plasma renin activity nearly 1.5-fold. In contrast, plasma renin activity did not increase during infusion of epinephrine at 5 ng.kg-1.min-1 directly into the coronary perfusate of the isolated heart. Coronary perfusate epinephrine concentration was 699 +/- 71 pg/ml (mean +/- SE) during intravenous infusion and was 851 +/- 121 pg/ml during direct infusion of epinephrine into the coronary perfusate. We conclude that cardiac adrenoceptors do not participate in the initiation of epinephrine-induced renin secretion.

Byssinosis: Release of prostaglandins, thromboxane, and 5-hydroxytryptamine in bronchopulmonary lavage fluid after inhalation of cotton dust extracts.

New Zealand White rabbits were exposed intratracheally to aerosolized cotton dust extract (CDE) for 5 minutes of tidal breathing and lavaged 15 minutes 1, 4, and 6 hours after exposure. Bronchoalveolar lavage cells were counted, and the number of macrophages and polymorphonuclear leukocytes (PMNs) was determined. Cell recruitment, which began 1 hour after exposure to CDE and plateaued at 6 hours, consisted of both mononuclear cells and PMNs. Lavage fluid was analyzed for concentrations of prostaglandin F2 alpha (PGF2 alpha), prostaglandin E1 and E2 (PGE), thromboxane B2 (TxB2), and 5-hydroxytryptamine (5-HT). PGF2 alpha, PGE, TxB2, and 5-HT were maximally increased in the lavage 4 hours after exposure to CDE. This is the first study to demonstrate the in vivo release of arachidonic acid metabolites and 5-HT in the lung in response to CDE inhalation. This study also demonstrates that maximum mediator release occurs at 4 hours after exposure to aerosolized CDE. These findings strongly suggest that arachidonic acid metabolites are available to mediate either totally or partially the pathogenic mechanism(s) of bronchoconstriction seen in the acute byssinotic reaction of man.