Prevalence of Bordetella pertussis and Bordetella parapertussis in Infants Presenting to the Emergency Department with Bronchiolitis

Background: The clinical presentation of Bordetella pertussis can overlap with that of respiratory syncytial virus (RSV), and coinfection does occur, but management differs. Hypothesis: The prevalence of B. pertussis is < 2% among Emergency Department (ED) patients with bronchiolitis. Our secondary hypothesis was that the prevalence of Bordetella parapertussis is also < 2% among these patients. Methods: Nasal washings were obtained from children up to 18 months of age (inclusive) who presented to a county hospital ED with a clinical diagnosis of bronchiolitis. These washings were frozen to −70°C before testing for B. pertussis and B. parapertussis using species-specific real-time polymerase chain reaction (PCR) assays. The assays were optimized to target conserved regions within a complement gene and the CarB gene, respectively. A Bordetella spp. genus-specific real-time PCR assay was designed to detect the Bhur gene of B. pertussis, B. parapertussis, and B. bronchiseptica. RSV antigen detection was also performed. Results: There were 227 patients enrolled. After exclusions, 204 remained in the analysis. RSV antigen testing was positive in 109/186 (59%) of the patients in whom it was performed. All samples were tested for B. pertussis. B. parapertussis testing could not be completed on 23 samples. No cases (0/204; 95% confidence interval [CI] 0–1.8%) tested positive for B. pertussis or B. parapertussis (0/181; 95% CI 0–2%). Conclusion: The prevalence of B. pertussis in children presenting to the ED with bronchiolitis was < 2%.     

Loss of erythromycin resistance genes from strains of Streptococcus pyogenes that have developed resistance to levofloxacin

In the past 2 to 3 decades, erythromycin resistance in Streptococcus pyogenes has been decreasing, whereas fluoroquinolone resistance (or reduction in its susceptibility) has been reported often. Although a shift of M-type prevalence and decreased pressure from macrolides have been suggested for the decrease in erythromycin resistance, we hypothesized that this might also be a result of increased antimicrobial pressure from fluoroquinolone use. Levofloxacin resistance for 4 erythromycin-resistant parent strains was induced in vitro. Their mutants became highly resistant to the fluoroquinolones but lost their erythromycin resistance trait. Erythromycin resistance was fully restored by transconjugation with respective parent strains with either mefA- or ermTR-mediated mechanisms.     

Necrotizing Fasciitis in the Adult Patient: Implications for Nurse Practitioners

Necrotizing fasciitis is a life-threatening skin and soft tissue infection associated with high morbidity and mortality in adult patients. Nurse practitioners in both outpatient and inpatient settings should be vigilant for the hallmark signs and symptoms, such as pain out of proportion to the wound appearance and gray or “dishwasher”-colored discharge from the wound. Prompt recognition of these signs and symptoms, rapid surgical debridement, and early initiation of broad-spectrum antimicrobial management are necessary for optimizing patient outcomes and reducing hospital length of stay, cost, morbidity, and mortality.     

Macrolide-resistant Streptococcus pyogenes from Chinese pediatric patients in association with Tn916 transposons family over a 16-year period

To investigate changes in the antimicrobial susceptibility of Streptococcus pyogenes isolates over a 16-year period, 456 group A streptococci isolates were collected from Chinese pediatric patients among 1993 to 1994 and 2005 to 2008. Susceptibilities to antibiotics were performed using agar dilution methods. The macrolide resistance genes ermB, ermTR, mefA, and tetracycline-resistant gene tetM and the int and xis genes of Tn916 family were detected by polymerase chain reaction. All 456 strains were analyzed by emm typing. Selected strains representing each emm type were further characterized by pulsed-field gel electrophoresis. The resistance rates of erythromycin and clindamycin both significantly increased during the 2 sample periods (79.7% versus 94% for erythromycin and 75.4% versus 96.9% for clindamycin). Telithromycin resistance rate increased from 20.37% to 87.93%. Among the macrolide resistance strains, the rate of strains with the genes int, xis, tetM, and ermB increased with time (16.05% versus 86.91%, P < 0.05). The emm1 and emm12 isolates had high rates of ermB gene, which increased after 16 years (65.2% versus 86.23% for emm1 and 7.7% versus 91.8% for emm12). This study demonstrates the increase in macrolide resistance in S. pyogenes in Chinese children over a 16-year period. The phenomenon may be related not only with the shift in the emm types but also with the change of macrolide-resistant mechanisms. The change of Tn916 family among the isolates may be related with the increased resistance.     

Antimicrobial susceptibility of Streptococcus pyogenes in Central,Eastern, and Baltic European Countries, 2005 to 2006: the cefditoren surveillance program

The in vitro activity of penicillin, ampicillin, cefditoren, cefotaxime, erythromycin, clarithromycin, and levofloxacin against 763 clinical isolates of Streptococcus pyogenes was determined. Clinically significant isolates collected from November 2005 to December 2006 in the Czech Republic, Slovakia, Hungary, Poland, Romania, Estonia, Latvia, and Lithuania (the latter 3 analyzed as Baltic countries) were studied. No resistance to β-lactams and levofloxacin was found. The rate of erythromycin resistance in S. pyogenes varied among countries, being low (<10%) in Romania and Baltic countries, intermediate (10–20%) in Poland and Czech Republic, and high (>25%) in Hungary and Slovakia. The predominant (75.0%) erythromycin-resistant phenotype among S. pyogenes isolates was MLS_B. The identification of the prevalence of erythromycin resistance mechanism could have impact on the choice of empiric antibiotic therapy for the clinicians in such countries.     

Development of a single-tube polymerase chain reaction assay for the simultaneous detection of Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus spp. directly in clinical samples

This study describes the development and evaluation of a multiplex single-tube polymerase chain reaction assay for the simultaneous detection of Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus spp. used as target species-specific or genus-specific genes. The assay enables the detection of 5 to 50 pg of bacterial DNA. The sensitivity of the assay was evaluated as 100% for P. aeruginosa, S. aureus, and Streptococcus spp., and 94.3% for H. influenzae; the specificity was 100% for all 4 microorganisms (positive predictive value, 100%; negative predictive value, 98.2%). The assay permits rapid and accurate detection of these 4 microorganisms in a wide range of clinical samples such as whole blood, cerebrospinal, ear, pleural and ophthalmic fluids, as well as bronchoalveolar lavage and bronchial secretions.     

Macrolide resistance in Streptococcus pyogenes: prevalence,resistance determinants,and emm types

To investigate the antimicrobial resistance trends and the distribution of emm types of group A streptococci (GAS), we examined 1160 clinical isolates of GAS collected between 2003 and 2006. Susceptibilities to commonly used antimicrobial agents were determined by Etest, and macrolide resistance genes were detected by polymerase chain reaction (PCR). GAS isolates were typed by polymerase chain reaction PCR and sequencing of emm gene. The rates of resistance to erythromycin (ERY), clindamycin, azithromycin, tetracycline, and chloramphenicol were 14.9%, 1.4%, 14.9%, 18.9%, 0.6%, respectively. None of the isolates exhibited resistance to penicillin, ceftriaxone, linezolid, moxifloxacin, rifampicin, or vancomycin.     

Risk Factors for Mortality of Bacteremic Patients in the Emergency Department

Objectives: Patients with bacteremia have a high mortality and generally require urgent treatment. The authors conducted a study to describe bacteremic patients in emergency departments (EDs) and to identify risk factors for mortality. Methods: Bacteremic patients in EDs were identified retrospectively at a university hospital from January 2007 to December 2007. Demographic characteristics, underlying illness, clinical conditions, microbiology, and the source of bacteremia were collected and analyzed for their association with 28-day mortality. Results: During the study period, 621 cases (50.2% male) were included, with a mean (±SD) age of 62.8 (±17.4) years. The most common underlying disease was diabetes mellitus (39.3%). Escherichia coli (39.2%) was the most frequently isolated pathogen. The most common source of bacteremia was urinary tract infection (41.2%), followed by primary bacteremia (13.2%). The overall 28-day mortality rate was 12.6%. Multivariate stepwise logistic regression analysis showed age > 60 years (odds ratio [OR] = 2.52, 95% confidence interval [CI] = 1.29 to 4.92, p = 0.007), malignancy (OR = 2.66, 95% CI = 1.44 to 4.91, p = 0.002), liver cirrhosis (OR = 2.08, 95% CI = 1.02 to 4.26, p = 0.044), alcohol use (OR = 5.73, 95% CI = 2.10 to 15.63, p = 0.001), polymicrobial bacteremia (OR = 3.99, 95% CI = 1.75 to 9.10, p = 0.001), anemia (OR = 2.33, 95% CI = 1.34 to 4.03, p = 0.003), and sepsis (OR = 1.94, 95% CI = 1.16 to 3.37, p = 0.019) were independent risk factors for 28-day mortality. Conclusions: Bacteremic patients in the ED have a high mortality, particularly with these risk factors. It is important for physicians to recognize the factors that potentially contribute to mortality of bacteremic patients in the ED.     

The Prevalence of Methicillin-Resistant Staphylococcus aureus on Inanimate Objects in an Urban Emergency Department

Background: There is a rising prevalence of both hospital-acquired and community-associated strains of methicillin-resistant Staphylococcus aureus (MRSA) infections. Both strains are found in patients presenting to emergency departments (EDs). Objective: The purpose of this study was to identify objects in the ED that might contribute to the spread of MRSA. Methods: This was a cross-sectional prevalence study in which culture swabs were taken from 20 different objects in a large urban ED between May and August 2006. The objects were identified a priori, and included common items found in an ED. Items ranging from computers to telephones, desktop surfaces, security door keypads, and ultrasound probes were included in the study. Each item was cultured twice, on separate days, for a total of 40 samples. The samples were screened for the presence of MRSA, and positive samples underwent additional susceptibility analysis. Results: Only one sample of 40, from the ambulance bay security door keypad, was positive for MRSA. Thus, the prevalence of MRSA was 2.5%. The single strain isolated was resistant to clindamycin, erythromycin, oxacillin, and penicillin. Conclusion: MRSA does not seem to thrive on inanimate objects found in the ED. Routine cleaning measures in an urban ED must include all areas of medical personnel use, including areas outside of the department utilized by non-ED workers.     

Impact of identification of Streptococcus dysgalactiae subspecies equisimilis from throat cultures in an adult population

Streptococcus dysgalactiae subspecies equisimilis (SDSE) are isolated from the throat of patients with pharyngitis, although the clinical significance remains debated. We sought to determine the incidence and association with pharyngitis of SDSE in an adult veteran population. Organisms were phenotypically identified to subspecies and Lancefield group, with selective 16S rRNA gene sequencing. From 833 throat cultures, the overall frequency of SDSE was 3.4% (64% group C and 36% group G) as compared to 8.6% for S. pyogenes (GAS). SDSE was described as a large colony in only 29% of the original culture evaluations by bench technologists, and clinical symptoms were similar for GAS and SDSE. Laboratory algorithms that are limited to identification of only GAS or are based on Lancefield group or visual identification of “large-colony type” β hemolytic Lancefield group C and G streptococci may be missing or misidentifying SDSE along with Anginosus group streptococci.     

A case of osteitis due to Staphylococcus aureus and Arcanobacterium bernardiae coinfection

Arcanobacterium bernardiae human infections remain rare. Only 2 reports are described in the literature. We report on an immunocompetent patient with a long history of chronic osteitis who developed a polymicrobial infection of the knee. The initial isolation of Staphylococcus aureus confounded the diagnosis of A. bernardiae infection, which underlines the need for extended period of incubation and subcultures of enriched liquid culture media. A. bernardiae is a new bacterium implicated in osteoarticular infections.     

High prevalence of multiresistance in levofloxacin-nonsusceptible Streptococcus pneumoniae isolates in Korea

Korea exhibits the highest rates of multidrug resistance among Streptococcus pneumoniae. The increasing use of levofloxacin has raised concern about the dissemination of levofloxacin resistance in dominant multidrug-resistant (MDR) clones of our pneumococcal population. A total of 50 levofloxacin-nonsusceptible S. pneumoniae (MIC, ≥4 μg/mL) collected from a multihospital network from 1996 to 2006 were analyzed for serotype, antibiotic resistance profile, quinolone resistance–determining region mutation, and multilocus sequence type. Most levofloxacin-nonsusceptible S. pneumoniae (94.0%) exhibited an MDR phenotype. This phenotype was closely associated with a limited number of epidemic MDR clones that are well-known key agents of the global spread of antimicrobial resistance in S. pneumoniae. However, the clonal dissemination of levofloxacin-nonsusceptible S. pneumoniae was rare. Levofloxacin-nonsusceptible clones with nonvaccine serotypes increased during the post-vaccine era in this study. This result suggests that Korean clinicians must be aware of the levofloxacin resistance trend and need to be more prudent for the first choice of fluoroquinolone for empiric treatment of respiratory tract infections in clinical setting. Moreover, the emergence of new clones and their variations may be more frequently associated with resistance under this selective pressure, such as the introduction of a 7-valent pneumococcal conjugate vaccine into our community.     

Antimicrobial susceptibility of multidrug-resistant Streptococcus pneumoniae strains with penicillin MICs of 8 to 32 mg/L

The in vitro activity of 22 antibiotics (including novobiocin) and β-lactam/gentamicin combinations was assessed against 11 multidrug-resistant pneumococcal strains. Among orally administered drugs, only telithromycin, levofloxacin, and linezolid were active against all isolates, but their use is not indicated in pediatrics. Novobiocin could be a potential therapeutic alternative.     

Antimicrobial activity against Streptococcus pneumoniae and Haemophilus influenzae collected globally between 2004 and 2008 as part of the Tigecycline Evaluation and Surveillance Trial

We report here on the in vitro activity of tigecycline and comparators against a global collection of Streptococcus pneumoniae and Haemophilus influenzae collected between 2004 and 2008 as part of the Tigecycline Evaluation and Surveillance Trial. A total of 6785 S. pneumoniae and 6642 H. influenzae isolates were collected, most from North America. The percentages of penicillin-intermediate resistance and penicillin resistance among S. pneumoniae in North America were 27.8% and 14.3%, respectively. Penicillin resistance ranged from 9.3% in Europe to 25.1% in the Asia-Pacific Rim. The rate of β-lactamase–producing H. influenzae was 25.8% in North America, and among the other regions, it ranged from 8.7% in South Africa to 26.8% in the Asia-Pacific Rim. Tigecycline MIC₉₀'s were 0.03 to 0.12 mg/L and 0.5 to 2 mg/L, depending on the region considered, against S. pneumoniae and H. influenzae, respectively. Tigecycline had low MIC₉₀'s against S. pneumoniae and H. influenzae, irrespective of resistance to β-lactams.     

Necrotizing fasciitis of the neck due to an odontogenic infection: A case report

Deep fascial space infections of the neck are most frequently odontogenic in origin. We describe a case of odontogenic infection of the mandible which extended to the lateral pharyngeal space and resulted in a severe life-threatening necrotizing fasciitis of the neck. A 69-year-old nondiabetic male complained of dysphagia and a severe toothache of the lower left molar and was transported to the emergency ward. A CT scan revealed swelling of the peritonsillar, lateral pharyngeal and masticator space with narrowing of the airway of the middle pharynx. The patient underwent a tracheotomy with surgical drainage. The strap muscles, including the fascia, of the neck were necrotic. He was treated with a combination of ampicillin and clindamycin-2-P. On the second postoperative day, the patient's platelet count fell to 20,000/mm³. The patient was transfused with platelet concentrate, and given gamma globulin and gabexate mesilate, and his predisseminated intravascular coagulation (DIC) status improved. However, on the eight post operative day, progressive tissue necrosis of the face and neck was observed. Panipenem betamipron was started and continued for 20 days. A second extensive surgical debridement of the neck and face was carried out, and the patient ultimately recovered.Prevotella buccae, Streptococcus intermedius, Lactobacillus fermentum, L. casei, L. catenaforme, L. acidophilus, andBifidobacterium sp. were isolated from either the peritonsillar, submandibular, lateral pharyngeal or carotid space abscesses. We emphasize the importance of proper diagnosis, early surgical intervention and systemic antimicrobial chemotherapy to control this aggressive infectious disease.     

Acinetobacter pittii and Acinetobacter nosocomialis among clinical isolates of the Acinetobacter calcoaceticus-baumannii complex in Sichuan,China

Among 82 clinical isolates of the Acinetobacter calcoaceticus-baumannii complex recovered in 13 hospitals of Sichuan, China, in 2011, 13 were Acinetobacter pittii and 2 were Acinetobacter nosocomialis. Multilocus sequence typing revealed a novel sequence type (ST) of A. nosocomialis and 7 novel STs of A. pittii. Most isolates were hospital-acquired and colonized in the respiratory tract, while 6 cases with pneumonia due to A. pittii were identified. This study provided a snapshot of the local incidence of A. pittii and A. nosocomialis.     

A Survey of the Emergency Department Population and Their Interest in Preventive Health Education

OBJECTIVE: To determine which preventive health information the emergency department (ED) population (patients and visitors) would be most interested in having available to them while they spend time in the waiting area. METHODS: This was a prospective survey of consecutive adults seated in the ED waiting area during a representative week on predetermined shifts. The survey asked them to indicate whether they would be interested in obtaining information about the following preventive health issues: breast cancer, prostate cancer, smoking, obesity, stress reduction, exercise programs, alcohol/drugs, HIV, blood pressure screening, immunizations, referrals to primary care physicians, Pap smears, car safety, smoke detectors, domestic and youth violence, depression, gun safety, and safe sex. RESULTS: Of the 1284 subjects approached, 878 (68%) made up the study group (56% female, mean age = 44 years, 60% white); 406 refused. The information people were most interested in obtaining was the following: 52% of the respondents were interested in referral to stress reduction programs, 51% in information about exercise programs, 42% in blood pressure screening, 40% in information about breast cancer screening, 33% in depression information/screening, 33% in prostate cancer screening, 26% in immunization against pneumococcus, 24% in immunization against tetanus, 26% in smoking cessation programs, and 26% in safe driving information. Women were most interested in breast cancer screening (64%); and men, in prostate cancer screening (55%). CONCLUSIONS: Of the 878 subjects in the study group, 96% were interested in obtaining information about one or more preventive health issues. An opportunity exists to respond to this interest by providing material for public health education in the waiting area of EDs.     

Cutaneous Methicillin-Resistant Staphylococcus aureus in a Suburban Community Hospital Pediatric Emergency Department

Background: Studies on methicillin-resistant Staphylococcus aureus (MRSA) infections have typically focused on pediatric and adult populations at urban tertiary care hospitals. Limited data exist on MRSA rates in skin and soft tissue infections (SSTI) in suburban community hospital pediatric emergency departments (PED). Objectives: To describe the prevalence of MRSA in SSTIs in a contemporary suburban community hospital PED population. Methods: Patients 0-21 years old with SSTI wound cultures who were seen at our PED from 2003-2007 were studied. Data analyzed included type of infection (abscess vs. non-abscess), site of infection, and culture results. Chi-squared and t-tests were used as appropriate;p < 0.05 was considered significant. Results: During the study period, 204 cultures were obtained for SSTIs, 11 of which were contaminants. The subjects had a mean age of 12.9 years (SD 6.8 years); 60% were male. The prevalence of MRSA was 27%; MRSA was present in 30% of abscesses vs. 2.2% of non-abscess SSTI (p < 0.005). By year, the prevalence of MRSA was 10% in 2003, 31% in 2004, 33% in 2005, 31% in 2006, and 29% in 2007. No differences between MRSA and non-MRSA infections were present for gender, age, or site of infection. Conclusions: At our suburban community hospital pediatric ED, MRSA was present in 30% of all SSTI wound cultures; MRSA was unlikely with non-abscess SSTI. Our overall MRSA prevalence data among SSTIs are consistent with previously published reports in pediatric ED populations but may be less than those reported in the adult literature.