Disseminated Rhodococcus equi infection in a patient with Hodgkin lymphoma.

INTRODUCTION: Rhodococcus (R) equi is an opportunistic, uncommon human pathogen that causes mainly infection in immunocompromised hosts. The disease is usually presented as subacute pneumonia that is mostly cavitary and sometimes bacteremic. CASE REPORT: We reported the extremly rare case of a 43-year-old woman with Hodgkin lymphoma, who developed R equi pulmonary infection after recieving multiple courses of chemotherapy. Secondary, the patient developed bacteremia, leading to sepsis and dissemination of R equi infection in many extrapulmonary sites. At addmission the patient was febrile, tachypnoic, tachycardic, hypotensive, with fa cial edema, splenomegaly, positive meningeal signs, left hemiparesis and paraparesis. Laboratory data included erythrocyte sedimentation rate (ESR) > 140 mm/h, C-reactive protein (CRP) 143.0 mg/L, red blood cells (RBC) 2.14 x 10(12)/L, whyite blood cells (WBC) 2.8 x 10(9)/L, lactate dehydrogenase (LDH) 706 U/L, serum albumin 26 g/L, sodium 127 mmol/L and potassium 2.7 mmol/L. Blood culture and culture of sputum and empyema were positive for R equi. Imaging studies demonstrated a large right cavitary pneumonia and abscess, empyema, pericarditis, mediastinal and intra-abdominal lymphadenopathy, brain and psoas abscesses, osteomyelitis and spondylodiscitis. The patient recovered completely after a 12-month treatment with combinations of parenteral and oral antibiotics (meropenem, vancomycin, teicoplanin, ciprofloxacin, rifampicin, macrolides etc), including drainage of abscesses and empyema. Eight years after completition of the treatment the patient was without recurrence of R equi infection and lymphoma. CONCLUSION: Since the eradication od R equi is very difficult, it is very important to make the diagnosis and initiate appropriate antibiotic therapy as soon as possible.

[Reliability of Cobas Amplicor PCR test in detection of Mycobacterium tuberculosis in respiratory and nonorespiratory specimens].

BACKGROUND/AIM: Traditional methods for detection of mycobacteria, such as microscopic examination for the presence of acid-fast bacilli and isolation of the organism by culture, have either a low sensitivity and/or specificity, or take weeks before a definite result is available. Molecular methods, especially those based on nucleic acid amplification, are rapid diagnostic methods which combine high sensitivity and high specificity. The aim of this study was to determine the usefulness of the Cobas Amplicor Mycobacterium tuberculosis polymerase chain reaction (CA-PCR) assay in detecting the tuberculosis cause in respiratory and nonrespiratory specimens (compared to culture). METHODS: Specimens were decontaminated by the N-acetyl-L-cystein-NaOH method. A 500 microL aliquot of the processed specimen were used for inoculation of Löwenstein-Jensen (L-J) slants, a drop for acid-fast staining, and 100 microL for PCR. The Cobas Amplicor PCR was performed according to the manufacturer's instructions. RESULTS: A total of 110 respiratory and 355 nonrespiratory specimens were investigated. After resolving discrepancies by reviewing medical history, overall sensitivity, specificity, and positive and negative predictive values for CA-PCR assay compared to culture, were 83%, 100%, 100%, and 96.8%, respectively. In comparison, they were 50%, 99.7%, 87.5%, and 98%, respectively, for the nonrespiratory specimens. The inhibition rate was 2.8% for respiratory, and 7.6% for nonrespiratory specimens. CONCLUSION: CA-PCR is a reliable assay that enables specialists to start treatment promptly on a positive test result. Lower value for specificity in a group of nonrespiratory specimens is a consequence of an extremely small number of mycobacteria in some of them.

Characterisation of the first VIM metallo-beta-lactamase-producing Pseudomonas aeruginosa clinical isolate in Serbia.

From the Central-East European region the first VIM metallo-beta-lactamase (MBL) producing Pseudomonas aeruginosa strains were published from Croatia, Poland and Hungary. The aim of this study was to assess the contribution of MBL-production to carbapenem-resistance among P. aeruginosa clinical isolates in the Military Medical Academy (MMA) in Belgrade, Serbia between August 2004 and September 2007. Only one P. aeruginosa isolate with strain number 722 proved MBL-positive that harboured a novel class 1 integron with a bla(VIM-2)-like cassette in the first position, followed by orfD, a putative gene with unknown function. Our data indicate that MBL-producing strains occur at a prevalence of less than 1% among imipenem-nonsusceptible P. aeruginosa clinical isolates in this Belgrade hospital. The newly identified VIM MBL-producing P. aeruginosa strain 722 could be assigned to serotype O11, and it was panresistant to all antimicrobials tested. The isolate displayed sequence type ST235 by multilocus sequence typing which is the founder sequence type of the previously identified international clonal complex CC11 that already contains bla(VIM)-positive isolates from Italy, Greece, Sweden, Hungary and Poland. In conclusion, this is the first report of VIM MBL-producing P. aeruginosa from Serbia and also of the occurrence of such isolates belonging to the international clonal complex CC11 in this country.

[The frequency of resistance to antibiotics of most frequently isolated bacteria from blood cultures during the period 1997-2002]. / Ucestalost rezistencije na antibiotike medu najcesce izolovanim bakterijama iz hemokultura u periodu 1997-2002. Godina.

The aim of this study was to determine the frequency of resistance to antibiotics of the most frequently isolated bacteria from blood cultures of hospitalized patients during the period 1997-2002. The resistance to antibiotics was determined by disk diffusion method according to National Committee for Clinical Laboratory Standards procedures. The majority of staphylococci isolates were resistant to methicillin, and the proportion of methicillin-resistant Staphylococcus aureus was stable (76.8-81.6%), during the follow-up period. None of the staphylococci isolates were resistant to vancomycin, but there was a very high incidence of high-level resistance of enterococci to aminoglycosides (47.2-72.2%). In 1998, only one strain among enterococci was resistant to vancomycin (Enterococcus faecium, VanA phenotype). Enterococcus spp isolates expressed variable frequency of resistance to ampicillin (15-40.1%) during the follow-up period. Among Enterobacteriaceae there were no isolates resistant to imipenem, but dramatic increase of the resistance to ceftriaxone was found from 35.9% in 1997 to 95.9% in 2002 (p<0.001). Extended spectrum beta-lactamases production was found in all the species of enterobacteria isolates. Resistance to imipenem was observed in Acinetobacter spp isolates in 2002 for the first time. Pseudomonas spp isolates expressed high and very variable resistance to all antibiotics tested during the follow-up period.

[Frequency and colonization rate of intravascular catheters]. / Ucestalost i stepen kolonizacije intravaskularnih katetera.

Clinical signs are not sufficiently reliable for establishing diagnosis of intravascular catheter-related infection. Therefore, microbiological confirmation, based on the culture of the catheter tip after its removal, is necessary in diagnosing the infection. The aim of this study was to determine the frequency and the degree of microbial colonization of intravascular catheters (IVK), and the risk for the onset of sepsis, by using qualitative, semiquantitative (roll plate) and quantitative (vortexing) catheter culture techniques. During the period April 2001-December 2002, 289 intravascular catheters were cultured. A total of 284 microorganisms were isolated from 217 (75%) culture-positive catheters. The frequency of isolation of some organisms was the following: coagulase-negative staphylococci (CNS) 41%, Staphylococcus aureus 19%, Enterococci spp 6%, other gram-positive microorganisms 9%, gram-negative microorganisms 21%, and fungi 4%. In 35 catheters, cultures were polymicrobial; two microorganisms were found in 25 cultures and three were found to be in 10 cultures. There were 122 (46%) intravascular catheters, which were found significantly colonized. A high rate of positivity and a high rate of S. aureus isolates and gram-negative bacteria indicate the need of establishing the exact microbiological diagnosis of these infections, and the rigorous undertaking of adequate control and preventive measures.

[Infective endocarditis of a rare etiology (Serratia marcescens)]. / Infektivni endokarditis retke etiologije (Serratia marcescens).

Infective endocarditis (IE) is a unique diagnostic and therapeutic challenge. It is a severe disease, fatal before penicillin discovery. Atypical presentations frequently led to delayed diagnosis and poor outcome. There was little information about the natural history of the vegetations during medical treatment or the relation of morphologic changes in vegetation to late complications. Application of a new diagnostic criteria and echocardiography, increased the number of definite diagnosis. Trans-thoracic and trans-esophageal echocardiography had an established role in the management of patients with IE. The evolution of vegetation size, its mobility, and consistency, the extent of the disease, and the severity of valvular regurgutation were related to late complications. With therapeutic options including modern antibiotic treatment and early surgical intervention IE turned out to be a curable disease. Reduction in mortality also depended on prevention. Antibiotic prophylaxis of IE was important, but low mortality was also the result of early treatment, especially in the event of early recognition of symptoms and signs of the disease.

[Surveillance of bacterial causes of hospital infections during periods of war and peace]. / Nadzor nad pojedinim bakterijskim uzrocnicima bolnickih infekcija u periodu rata i mira.

Surveillance based on laboratory findings of bacteria isolated from hospitalized patients is an important activity in epidemiologic surveillance of nosocomial infections. It provides the insight into the circulation and management of some causative agents of nosocomial infections in hospitals, which facilitates defining of proper measures for the prevention and suppression of nosocomial infections caused by these agents. The aim of this study was to analyze and compare surveillance data collected in Military Medical Academy (MMA) during June 1999 (the period of war), and June 2000 (the period of peace). Isolation frequency of bacteria that were the most common agents of nosocomial: Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Acinetobacter spp. and Enterococcus spp., was monitored in patients from 5 various surgical wards of MMA. In the war period, the increase of number of isolates of all these bacteria was registered, but the increase of isolated Acinetobacter spp. was the most significant. The total number of isolates was greater in June 1999, in comparison to June 2000. Most isolates were recovered from wound cultures, when the increased number of Enterococcus spp. Methicillin-resistant Staphylococcus aureus isolated from the blood was registered. In the period of peace isolates of Pseudomonas aeruginosa manifested reduced resistance to quinolones, imipenem and 3rd generation cephalosporins. Barrier infection control measures are necessary in preventing nosocomial transmission, particularly in the wartime. Thus, preventive medicine is important for performing efficient surveillance, and suggesting the adequate measures for prevention and repression of nosocomial infections, particularly in the period of war.

[Necrotizing fasciitis caused by group A streptococcus]. / Nekrotizujuci fasciitis uzrokovan streptokokom grupe A.

The first case of the confirmed necrotizing fasciitis caused by Group A Streptococcus in Yugoslavia was presented. Male patient, aged 28, in good health, suddenly developed symptoms and signs of severe infective syndrome and intensive pain in the axillary region. Parenteral antibiotic, substitutional and supportive therapy was conducted along with the radical surgical excision of the necrotizing tissue. The patient did not develop streptococcal toxic shock syndrome thanks to the early established diagnosis and timely applied aggressive treatment. He was released from the hospital as completely cured two months after the admission.