Infective endocarditis in Greece: a changing profile. Epidemiological, microbiological and therapeutic data.

The epidemiology, and clinical and microbiological spectrum, of infective endocarditis (IE) in Greece was analysed in a prospective 4-year study in a tertiary hospital and a heart surgery centre in Athens. In total, 101 cases of IE (71 men, 30 women, aged 54.4 +/- 17.1 years) were studied, with a follow-up period of 3 months. Seventy-seven cases were definite and 24 possible; 59 involved native valves (native valve endocarditis; NVE), 31 prosthetic valves (prosthetic valve endocarditis; PVE), of which nine were early and 22 late, and 11 permanent pacemakers (pacemaker endocarditis; PME). There was a predominant involvement of aortic (48/101) and mitral (40/101) valves. Seven patients had rheumatic valvular disease, two had mitral valve prolapse, and eight had a previous history of IE. Thirteen and six patients had undergone dental and endoscopic procedures, respectively. In 13 patients, intravenous catheters were used within the 3 months before diagnosis of IE. There were three intravenous drug users among the patients. Staphylococcus aureus was the most important pathogen, isolated in 22% of cases, followed by viridans streptococci (19%) and coagulase-negative staphylococci (16%). Enterococcus spp. were responsible for 3%, HACEK group for 2%, and fungi for 6% of cases. Viridans streptococci were the leading cause of NVE (29%), Staphylococcus epidermidis of PVE (16%), and S. aureus of PME (54.5%). Six of 22 S. aureus and ten of 16 S. epidermidis isolates were methicillin-resistant. Surgical intervention, including total pacemaker removal, was performed in 51.5% of patients. Overall mortality was 16%, but was 29% with PVE, and was significantly higher with medical than with combined surgical and medical therapy (24.5% vs. 8%). Compared with previous studies, there were changing trends in the epidemiology, microbiology, treatment and prognosis of IE in Greece.

Infected CNS infusion pumps. Is there a chance for treatment without removal?

BACKGROUND: Intrathecal baclofen administration by means of an implantable pump is nowadays a safe and effective method in the treatment of spasticity. One of the rare but devastating complications of this technique is pump infection, with a variety of Gram (-) and Gram (+) organisms being involved. Treatment of these infections, according to international literature, requires removal of the device and appropriate antibiotic therapy. METHOD: This article reports the authors experience in treating 3 patients with severe, medically intractable spasticity, suffering from infection of the intrathecally-delivering pump. A decision was made not to replace the device, but to treat this complication with pump disinfection and with a new treatment modality that has never been used before, the intra-pocket administration of antibiotics. FINDINGS: In all cases the infection was eradicated and the integrity of the pump maintained. None of the patients required a procedure under general anesthesia. CONCLUSIONS: Removal should no longer be considered the first treatment option in infections of intrathecally delivering pumps, especially those due to non-adherent bacteria, with mild clinical symptomatology. An initial attempt should always be made for conservative treatment. Intra-pocket administration of antibiotics helps in achieving high drugs levels locally, and may prove an important element in our armamentarium against such infections.

Induction of in vitro human macrophage anti-Mycobacterium tuberculosis activity: requirement for IFN-gamma and primed lymphocytes.

Mycobacterium tuberculosis (Mtb) is the world's leading infectious cause of mortality. Despite the overwhelming data supporting the critical role of cellular immunity, little is known of the early microbial and immune cell interactions and whether human macrophages can be activated to express anti-Mtb activity. We report the reconstitution of an in vitro system whereby human macrophages express anti-Mtb activity only in coculture with PBL and with IFN-gamma. Omission of IFN-gamma in the cocultures or Mtb lysate/IFN-gamma-primed lymphocytes was associated with high growth of Mtb, high IL-10 and IL-12 p40, nearly undetectable IL-12 p70 levels, and the highest percentages of CD4 and CD8 T cells. In contrast, IFN-gamma treatment of cocultures containing Mtb lysate/IFN-gamma-primed PBL reduced bacilli count by approximately 2.5 log, decreased the production of IL-10 by 5.7-fold, increased IL-12 p70 by approximately 50-fold, and reduced the percentages of CD4 and CD8 T cells. Activation of anti-Mtb activity was time and dose dependent. At 2000 U/ml of IFN-gamma, bactericidal activity was achieved (10-fold reduction from initial inoculum). Anti-Mtb activity against several strains of M. tuberculosis (H37Ra and H37Rv, and C, a clinical isolate) was observed and was associated with expression of inducible nitric oxide synthase. These data suggest that induction of human macrophage anti-Mtb activity required dual signaling from PBL and IFN-gamma. Thus, the development of an in vitro human system may greatly facilitate studies to delineate immune cells, cytokines, and effector functions/genes critical in controlling Mtb. Defining the mechanisms may also provide novel treatment strategies for tuberculosis.