Non-nosocomial healthcare-associated infective endocarditis in Taiwan: an underrecognized disease with poor outcome

<p>Abstract</p> <p>Background</p> <p>Non-nosocomial healthcare-associated infective endocarditis (NNHCA-IE) is a new category of IE of increasing importance. This study described the clinical and microbiological characteristics and outcome of NNHCA-IE in Taiwan.</p> <p>Methods</p> <p>A retrospective study was conducted of all patients with IE admitted to the Kaohsiung Veterans General Hospital in Kaohsiung, Taiwan over a five-year period from July 2004 to July 2009. The clinical and microbiological features of NNHCA-IE were compared to those of community-acquired and nosocomial IE. Predictors for in-hospital death were determined.</p> <p>Results</p> <p>Two-hundred episodes of confirmed IE occurred during the study period. These included 148 (74%) community-acquired, 30 (15%) non-nosocomial healthcare-associated, and 22 (11%) nosocomial healthcare-associated IE. <it>Staphylococcus aureus </it>was the most frequent pathogen. Patients with NNHCA-IE compared to community-acquired IE, were older (median age, 67 vs. 44, years, <it>p </it>< 0.001), had more MRSA (43.3% vs. 9.5%, <it>p </it>< 0.001), more comorbidity conditions (median Charlson comorbidity index [interquartile range], 4[2-6] vs. 0[0-1], <it>p </it>< 0.001), a higher in-hospital mortality (50.0% vs. 17.6%, <it>p </it>< 0.001) and were less frequently recognized by clinicians on admission (16.7% vs. 47.7%, <it>p </it>= 0.002). The overall in-hospital mortality rate for all patients with IE was 25%. Shock was the strongest risk factor for in-hospital death (odds ratio 7.8, 95% confidence interval 2.4-25.2, <it>p </it>< 0.001).</p> <p>Conclusions</p> <p>NNHCA-IE is underrecognized and carries a high mortality rate. Early recognition is crucial to provide optimal management and improve outcome.</p

Importance of the Collagen Adhesin Ace in Pathogenesis and Protection against Enterococcus faecalis Experimental Endocarditis

Ace is an adhesin to collagen from Enterococcus faecalis expressed conditionally after growth in serum or in the presence of collagen. Here, we generated an ace deletion mutant and showed that it was significantly attenuated versus wild-type OG1RF in a mixed infection rat endocarditis model (P<0.0001), while no differences were observed in a peritonitis model. Complemented OG1RFΔace (pAT392::ace) enhanced early (4 h) heart valve colonization versus OG1RFΔace (pAT392) (P = 0.0418), suggesting that Ace expression is important for early attachment. By flow cytometry using specific anti-recombinant Ace (rAce) immunoglobulins (Igs), we showed in vivo expression of Ace by OG1RF cells obtained directly from infected vegetations, consistent with our previous finding of anti-Ace antibodies in E. faecalis endocarditis patient sera. Finally, rats actively immunized against rAce were less susceptible to infection by OG1RF than non-immunized (P = 0.0004) or sham-immunized (P = 0.0475) by CFU counts. Similarly, animals given specific anti-rAce Igs were less likely to develop E. faecalis endocarditis (P = 0.0001) and showed fewer CFU in vegetations (P = 0.0146). In conclusion, we have shown for the first time that Ace is involved in pathogenesis of, and is useful for protection against, E. faecalis experimental endocarditis

What is new in the management of skin and soft tissue infections in 2016?

Purpose of review Skin and soft tissue infections (SSTIs) are the most frequent infectious cause of referrals to emergency departments and hospital admissions in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology and management of SSTIs. Recent findings Incidence trends of SSTIs were increasing worldwide with Staphylococcus aureus and streptococci predominating and methicillin-resistant S. aureus (MRSA) posing additional challenges, because of high rates of treatment failure and relapse. Development of new antimicrobials was associated with an appraisal of regulatory definitions and endpoints. Prediction of clinical response can be very tricky, because of variable risk factors for recurrence or treatment failure, depending mostly on the host. Precise indications for new antimicrobials should be established; their integration into clinical practice algorithms may serve reduction of unnecessary admissions, overtreatment and total costs. Summary New antimicrobials with activity against MRSA have been recently launched. Long-acting agents, mainly oritavancin and dalbavancin, provide the opportunity of single-dose treatment and early discharge. Further outpatient treatment options include new per os antibiotics such as oxazolidinones. Validated assessment tools are urgently needed to support decision-making toward rational resource utilization and delivery of optimal treatment. © 2017 Wolters Kluwer Health, Inc

Strontium ranelate improves delayed healing of osteolytic lesions of the jaw in a man with chronic osteomyelitis. Case report

We report the case of a man with osteolytic lesions of the right mandible due to chronic osteomyelitis, with delayed healing after six months of antibiotic therapy. The patient received off-label therapy with strontium ranelate, with significant radiological improvement of his condition after 3 months. © CIC Edizioni Internazionali

Pharmacokinetics of fusidic acid and cefepime in heart tissues: Implications for a role in surgical prophylaxis

The pharmacokinetic profiles of fusidic acid and cefepime in heart tissues were assessed in 30 patients undergoing elective valve replacement and cardiopulmonary bypass. Single doses of 1 g of fusidic acid and 2 g of cefepime were administered intravenously to two groups of 15 and 15 patients respectively upon initiation of anesthesia. Samples of serum, heart valves, myocardium, pericardium, mediastinal fat and sternum were collected within &amp;lt;1 hour, 1-2 h and 2-4 h after the end of drug infusion. Drug concentrations were estimated by a microbiological assay. It was found that concentrations of fusidic acid in all specimens were 20-fold higher than the MIC9os of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis, being at such levels throughout all period of sampling. Cefepime concentrations in heart valves collected 1-2 h after drug infusion were higher than the MIC90s of multidrug-resistant Enterobacteriaceae. It is concluded that both fusidic acid and cefepime penetrated heart tissues adequately; however only fusidic acid could also accumulate in the mediastinum. These data suggest that both antibiotics may be a good alternative for prophylaxis in open heart surgery. © E.S.I.F.T. srl - Firenze

Efficacy and Tolerability of Linezolid in Chronic Osteomyelitis and Prosthetic Joint Infections: A Case-Control Study

Clinical experience of prolonged use of linezolid in patients with bone infections is accumulating. However more efficacy and safety data are required. This is a case-control study of patients who received linezolid for difficult-to-treat, intolerant or resistant-to-other-antibiotics bone infections. Linezolid was administered Lv. or orally in 34 patients. Results concerning efficacy and safety were compared to a group of well-matched controls. The clinical arrest rate was 74% in the linezolid group and 68% in the control group (p=NS). Treatment was discontinued in 14 (44%) patients of the linezolid group and in 2 (6%) patients of the control group due to adverse events. In the linezolid group 11 (33%) patients developed anemia and 3 (9%) developed thrombocytopenia that led to discontinuation of treatment. Linezolid is effective in a substantial proportion of patients, but the incidence of hematologic adverse events makes close follow-up and laboratory monitoring mandatory

Septic arthritis due to Salmonella enteritidis associated with infliximab use

A unique case of septic arthritis caused by Salmonella enteritidis in a patient receiving infliximab for rheumatoid arthritis is presented. Antimicrobial chemotherapy with surgical intervention was necessary for eradication of the infection. Physicians should be aware of rare manifestations of Salmonella infections associated with infliximab use, especially in endemic areas