Liver abscesses in adult patients with and without diabetes mellitus: an analysis of the clinical characteristics,features of the causative pathogens,outcomes and predictors of fatality: a report based on a large population,retrospective study in China

In China, there are four types of liver abscesses (LAs) that meet the clinical criteria. Pyogenic liver abscesses (PLAs) and amoebic liver abscesses (ALAs) are two of the most common types of abscesses, followed by fungal liver abscesses (FLAs) and hydatid secondary liver abscesses (HsLAs). Diabetes mellitus (DM) is associated with the development of PLAs. However, there is a lack of population-based studies that have evaluated the underlying relationship between LAs (mainly PLAs and FLAs) and DM. We conducted a retrospective study based on a large population to identify the potential differences and factors that affect the mortality of PLA patients in DM and non-DM groups. Our results revealed that the prevalence of DM is 44.3% (158/357) in PLA patients and 35.3% (18/51) in FLA patients. Compared with the non-DM patients, statistically significant differences were found in DM patients according to symptomatology, clinical manifestations, laboratory findings, microbiological characteristics, antimicrobial resistance, clinical treatments and outcomes in relation to mortality. In addition, the status of antibiotic resistance to E. coli and K. pneumoniae, which were isolated from the patient samples, is severe in the area in which the study was conducted. Regarding the treatment of PLAs, our study indicated that broad-spectrum antimicrobial therapy and drug combinations should be recommended and initiated before the pathogens are cultured and identified. In the clinic, therapies that combine percutaneous drainage with antibiotics and surgery with antibiotics are the two most useful strategies for treating an LA. These two combined treatments resulted in satisfactory cure rates. In the DM and non-DM groups, the cure rates for percutaneous drainage with antibiotics were 90.3% and 92.0%, respectively, and the cure rates for surgery with antibiotics were 93.9% and 95.2%, respectively.     

Renal Abscesses Measuring 5 cm or Less: Outcome of Medical Treatment without Therapeutic Drainage

Purpose

Diagnosis and proper treatment of renal abscesses remains a challenge for physicians. We investigated the characteristics and comorbidity factors of renal abscesses measuring 5 cm or less and critically examined the effectiveness of conservative treatment.

Materials and Methods

Between February 2001 and March 2009 the records of 63 patients initially diagnosed at our hospital with renal or perirenal abscesses were retrospectively reviewed. In 63 patients with renal and perirenal abscesses, 51 abscesses measured 5 cm or less, and 49 abscesses were treated with intravenous antibiotics alone.

Results

Most patients were women (91.8%), and their mean age was 42.3 years. The mean size of renal abscesses was 3.6 cm. The most common predisposing condition was diabetes mellitus (DM) (46.9%). Common clinical features were fever (83.7%) and flank pain (53.1%). On urinalysis, 31 (64.6%) cases had positive bacterial cultures with Escherichia coli (50.0%) being the most common pathogen. All 49 patients were treated with broad-spectrum intravenous antibiotics alone. All patients showed complete clinical regression and resolution of the renal lesions shown by CT between 3 and 14 weeks. The average hospital stay was 15.3 days (range, 5-31 days). Significant predictors of a long hospital stay were age, abscess size, and DM.

Conclusion

Medium-sized as well as small-sized renal abscesses were treated successfully with intravenous antibiotics alone. DM was a significant predictor of prolonged hospital stay. If therapeutic drainage is believed to involve considerable risk, then intravenous antimicrobial therapy may be a good alternative treatment.     

Successful treatment of recurrent cerebral empyema and brain abscesses with Imipenem

Imipenem was successfully used to treat a case of subdural empyema complicated by multiple cerebral abscesses, in which surgery and therapy with other antibiotics had previously failed. Imipenem concentrations in serum, cerebrospinal fluid and the cerebral abscess were much higher than the MICs for the infecting organisms, qualifying this antibiotic as an effective option in therapy of suppurative intracranial infections.     

Multiple Aspergillus cerebellar abscesses in a middle-aged female: case report and literature review

Aspergillus abscesses in the cerebellum are extremely rare, and most cases are solitary. Here, we report the first case of multiple Aspergillus cerebellar abscesses in a 46-year-old female after one mastoidectomy, two craniectomies, and extended use of antibiotics. The possible pathogenesis of this unusual event is discussed. Good outcome was achieved by treatment with a combination of neurosurgical resection and voriconazole (VRC) administration, which we suggest is a potential management plan.     

Combined hepatic and splenic abscesses in a patient with ulcerative colitis

Liver abscesses are very rare complications of ulcerative colitis, and furthermore, there has been only one case of splenic abscess in a patient with ulcerative colitis reported in the English literature. We recently encountered a patient with ulcerative colitis accompanied by both hepatic and splenic abscesses. The patient was treated with abscess drainage as well as sulfasalazine and antibiotics. Follow-up sonography of the abdomen showed complete resolution of the lesions. To our knowledge, this is the first report of combined case of multiple liver abscesses combined with splenic abscess in a patient with ulcerative colitis.     

Identification of Occult Fusobacterium nucleatum Central Nervous System Infection by Use of PCR-Electrospray Ionization Mass Spectrometry

Anaerobic bacteria are often difficult to detect, especially after the initiation of antibiotics. We describe the application of PCR-electrospray ionization mass spectrometry (PCR/ESI-MS) using a sample of cerebrospinal fluid to identify an anaerobic Gram-negative bacillus, Fusobacterium nucleatum, in a patient with “culture-negative” meningitis and cerebral abscesses.     

Streptococcus mutans: a rare cause of retroperitoneal abscess

Retroperitoneal abscesses are uncommonly encountered clinical entities and they represent serious surgical infections associated with significant mortality rates because of their insidious clinical manifestations and diagnostic difficulty. The source of retroperitoneal infections is usually an organ contained within or abutting the retroperitoneum, usually the kidney and the microorganisms most commonly isolated are gram-negative bacilli. Gram-positive cocci, mainly staphylococcal species and rarely streptococcal species, are a less common cause of retroperitoneal abscess and are usually isolated in cases of hematogenous spread. Treatment of retroperitoneal abscesses includes identification and treatment of underlying conditions, intravenous antibiotics and adequate surgical drainage of all well-defined collections. We present a rare case of retroperitoneal abscess caused by monomicrobial Streprococcus mutans infection and discuss the possible pathogenesis, clinical presentation, diagnosis and treatment.     

Infections fongiques invasives du grand prématuré

Fungal infections were frequent in premature baby (<1500 g) and were associated with significant morbidity and mortality. In this paper we review the risk factors for invasive fungal infections and clinical settings. A better understanding of the mechanism of fungal infection in preterm infants is important in treatment and prevention. The early neonatal intensive care unit course favours colonization and proliferation of fungi since many preterm infants have central catheters and are exposed to broad spectrum antibiotics and parenteral nutrition. The majority of fungal infections in preterm neonates are due to Candida, with a small number due to other yeasts such as Malassezia. Candida is an opportunistic pathogen, which adheres to the skin, mucosal, and catheter surface. C. albicans account for 50% of cases of fungal sepsis. C. parapsilosis is the second most prevalent species in very low birth weight children; its frequency increased from 1995 to 2000. Risk factors for fungal colonization are: very low birth weight, exposure to broad spectrum antibiotics, parenteral nutrition and use of corticosteroids. Colonization of the skin, gastro-intestinal tract and respiratory tract and central vascular catheter precede infection. The majority of preterm infants with fungal infections develop thrombocytopenia, but this is a common feature shared with other sepsis. The evaluation of infants with fungal sepsis should include cerebrospinal fluid examination and culture of urine with surveillance for endocarditis, renal, liver and brain abscesses and endophthalmitis. The mortality rate can reach 30%, and is higher in very low birth weight infants.     

Liver Abscesses due to Fusobacterium spp. that Mimick Malignant Metastatic Liver Disease

A 71-year-old man presented with the clinical and radiological features of metastatic liver disease but subsequently was found to have multiple liver abscesses caused by Fusobacterium necrophorum. At liver biopsy, pus was aspirated and Fusobacterium necrophorum was isolated from the pus. Serial blood cultures and urine cultures were sterile and negative for Fusobacterium spp. The patient made a complete recovery in response to treatment with penicillin and amoxicillin. This case illustrates the importance of liver abscesses as an uncommon but completely treatable differential diagnosis for the radiological appearances of multiple hepatic lesions. Electronic Publication     

Correlation between antimicrobial resistance and virulence in <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis>

Klebsiella pneumoniae is responsible for a wide range of infections, including urinary tract infections, pneumonia, bacteremia, and liver abscesses. In addition to susceptible clinical isolates involved in nosocomial infections, multidrug-resistant (MDR) and hypervirulent (hvKP) strains have evolved separately in distinct clonal groups. The rapid geographic spread of these isolates is of particular concern. However, we still know little about the virulence of K. pneumoniae except for hvKP, whose secrets are beginning to be revealed. The treatment of K. pneumoniae infections is threatened by the emergence of antimicrobial resistance. The dissemination of resistance is associated with genetic mobile elements, such as plasmids that may also carry virulence determinants. A proficient pathogen should be virulent, resistant to antibiotics, and epidemic. However, the interplay between resistance and virulence is poorly understood. Here, we review current knowledge on the topic.     

A gerbil model for rhombencephalitis due toListeria monocytogenes

Rhombencephalitis due toListeria monocytogenesis a frequent complication of human listeriosis, inducing a high mortality and severe neurological sequelae despite antibiotic therapy. However, there is no animal model which consistently reproduces clinical rhombencephalitis. Here, we present a model ofListeriarhombencephalitis in gerbils. Animals were inoculated in the middle ears with a low infective dose ofL. monocytogenes, thus creating prolonged otitis media with persistent bacteremia. Gerbils developed a severe rhombencephalitis with circling syndrome, paresia, ataxia, rolling movements. The invasion of the central nervous system was visualized on living animals by resonance magnetic imaging and characterized by bacterial growth in the brain, reaching about 10⁷bacteria in the rhombencephalum by day 12 of infection. The histological lesions were mainly located in the brainstem, and consisted in coalescent, necrotic abscesses with perivascular sheaths, mimicking those observed in human rhombencephalitis. Bacteria were detected by electronmicroscopy inside infectious foci, either free in necrotic material or inside inflammatory cells, mainly polymorphonuclear cells. This gerbil model ofListeriarhombencephalitis will be useful to study the molecular mechanisms allowing bacteria to cross the blood–brain barrier, and to evaluate the intracerebral efficacy of antibiotics.     

THE ROLE OF ACTIVE EFFLUX IN ANTIBIOTIC-RESISTANCE OF CLINICAL ISOLATES OF HELICOBACTER PYLORI

Purpose: In gram-negative bacteria, active efflux pumps that excrete drugs can confer resistance to antibiotics however, in Helicobacter pylori this role is not well established. The purpose of this study is to evaluate the role of active efflux in resistance of H. pylori isolates to antibiotics. Materials and Methods: Twelve multiple antibiotic resistant (MAR) isolates resistant to at least four antibiotics, including β-lactams, metronidazole, tetracycline, erythromycin, and ciprofloxacin; three resistant to only β-lactams, and two hyper-susceptible isolates, were obtained from screening of 96 clinical isolates of H. pylori. Their minimal inhibitory concentrations (MICs) for antibiotics and ethidium-bromide (EtBr) were compared in the presence-and absence of a proton-conductor, carbonyl cyanide-m chlorophenyl-hydrazone (CCCP) using agar-dilution and disc diffusion. Drug accumulation studies for EtBr and antibiotics were assessed in the presence and absence of CCCP using spectrofluorometry. Results: MIC of EtBr for eight MAR-isolates was decreased two- to four-folds in the presence of CCCP, of which five showed reduced MICs for β-lactam, metronidazole, tetracycline, and ciprofloxacin with CCCP. Accumulation of EtBr by the MAR-isolates was rapid and not dependant on the pattern of multiple resistance. Antibiotic accumulation assay confirmed the presence of energy-dependant efflux of β-lactam, metronidazole, tetracycline, and ciprofloxacin, but no erythromycin in five MAR isolates. Energy-dependant efflux of EtBr or antibiotics was not observed for four MAR-isolates, and three isolates were resistant only to β-lactams. Conclusion: Energy-dependant efflux plays a role in the resistance of H. pylori clinical isolates to structurally unrelated antibiotics in a broadly specific multidrug efflux manner. Difference in the efflux potential of MAR isolates may be related to the presence or absence of functional efflux-pumps in diverse H. pylori isolates.     

Serial Magnetic Resonance Imagings of Multiple Brain Abscesses in a Patient with Pneumococcal Meningoencephalitis

We report a 43-yr-old man manifesting bacterial meningoencephalitis and multiple abscesses by Streptococcus pneumoniae. Serial magnetic resonance (MR) imagings and MR spectroscopy showed the evolution of multiple brain abscesses over 4 weeks: the enhanced rings became thicker and the dimension of whole lesions larger despite shrinkage of the ring-enhanced regions. These findings may be evidence of active inflammation working to sequestrate the lesion and protect the surrounding normal brain parenchyma from additional damage, even in the final stage of the brain abscess.     

Photorhabdus asymbiotica, a pathogen emerging on two continents that proves that there is no substitute for a well-trained clinical microbiologist

A 54-year-old ranch hand presented to the emergency room with an alleged spider bite and multiple abscesses. Both wound and blood cultures grew Photorhabdus asymbiotica, an enteric gram-negative rod that was initially misidentified by the hospital's rapid identification system. Clinical laboratories should be aware of the limitations of their rapid identification systems and always use them as an adjunct to analysis of morphological and phenotypic traits.     

Transmission of an Extended-Spectrum-Beta-Lactamase-Producing Escherichia coli (Sequence Type ST131) Strain between a Father and Daughter Resulting in Septic Shock and Emphysematous Pyelonephritis

Probable transmission of an extended-spectrum-beta-lactamase-producing Escherichia coli strain (sequence type ST131) between a father and daughter was documented. The father developed severe, recurrent pyelonephritis with multiple small abscesses; the daughter later developed septic shock, bacteremia, and extensive emphysematous pyelonephritis. This multidrug-resistant E. coli clone appears to be highly pathogenic and transmissible.     

Update of treatment algorithms for Clostridium difficile infection

BackgroundClostridium difficile is the leading cause of antibiotic-associated diarrhoea, both in healthcare facilities and in the community. The recurrence rate of C. difficile infection (CDI) remains high, up to 20%. Since the publication of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidance document on CDI treatment in 2014, new therapeutic approaches have been developed and tested to achieve higher sustained clinical cure in CDI.AimTo review novel treatments and approaches for CDI, except probiotics and vaccines. We focused on new antibiotics, antibiotic inactivators, monoclonal antibodies and gut microbiota modulating therapies.SourcesA literature review was performed for clinical trials published in PubMed, Embase or Cochrane Library between January 2013 and November 2017.ContentWe analysed 28 clinical trials and identified 14 novel agents. Completed phase 2 studies were found for cadazolid, LFF571, ridinilazole and nontoxigenic C. difficile strains. Four phase 3 active comparator studies comparing vancomycin with bezlotoxumab, surotomycin (n = 2) and rifaximin have been published. Seven clinical trials for treatment of multiple recurrent CDI with faecal microbiota transplantation were analysed, describing faecal microbiota transplantation by upper or lower gastrointestinal route (n = 5) or by capsules (n = 2).ImplicationsMetronidazole is mentioned in the ESCMID guideline as first-line therapy, but we propose that oral vancomycin will become the first choice when antibiotic treatment for CDI is necessary. Fidaxomicin is a good alternative, especially in patients at risk of relapse. Vancomycin combined with faecal microbiota transplantation remains the primary therapy for multiple recurrent CDI. We anticipate that new medication that protects the gut microbiota will be further developed and tested to prevent CDI during antibiotic therapy.     

Management of Brain Abscesses with Sequential Intravenous/Oral Antibiotic Therapy

 Eight patients with brain abscesses who refused prolonged hospitalisation were treated with a short course (6–12 days) of intravenous antibiotics followed by prolonged treatment (15–19 weeks) with an oral antibiotic regimen consisting of metronidazole, ciprofloxacin and amoxicillin. All patients responded favourably as shown clinically and in imaging studies. No severe adverse events or sequelae were noted. On admission all patients had a normal or mildly impaired mental status, abscesses less than 3 cm in diameter and no serious predisposing factors. Although combined surgical/medical treatment remains the standard approach in management of these patients, the findings suggest that oral antibiotic therapy only subsequent to a short course of intravenous antibiotics may be an acceptable alternative in selected cases.     

Melioidosis: a review of orthopedic manifestations, clinical features, diagnosis and management

Melioidosis is an infectious disease caused by gram-negative soil-dwelling bacillus Burkholderia pseudomallei. Musculoskeletal melioidosis mimics other infections both clinically and radiologically. An extensive literature review has been performed over musculoskeletal melioidosis through various search engines such as Pubmed, Embase, Medscape, Altavista and Google. Diagnosis requires a high index of clinical suspicion and is dependent on microbiological confirmation. Prompt treatment with long-term combination antibiotics in high dosages and surgical drainage of abscesses improves survival.     

The multiple brain abscesses associated with congenital pulmonary arteriovenous malformations: a case report

In this report, we describe a case of multiple brain abscesses associated with diffuse congenital pulmonary arteriovenous malformations (PAVM). Although the cases of brain abscesses associated with congenital PAVM are very rare, the brain abscess could be an initial clinical manifestation in asymptomatic PAVM as in the case presented in this report. PAVM may contribute to the development of a brain abscess by allowing easy bacterial access to systemic circulation through the right-to-left pulmonary vascular shunt, bypassing the filtering effect of the pulmonary capillaries. Hence, this association should be considered in cases with brain abscesses of undetermined etiologic factors.     

Clinical spectrum of intra-abdominal abscesses in children admitted to the pediatric emergency department

BackgroundTo analyze clinical spectrum of intra-abdominal abscesses in children and find helpful clinical parameters could aid physicians in earlier detection and differential diagnosis.MethodsFrom 2004 to 2011, we retrospectively analyzed 66 pediatric patients, aged 18 years or younger with intra-abdominal abscesses. The data were obtained and studied: demographics, clinical presentations, etiologies, laboratory tests, microbiology, imaging studies, treatment modalities, complications and long-term outcomes.ResultsThere were 66 patients (mean age, 9.27 ± 4.16 years) diagnosed as intra-abdominal abscesses. The two most common presented symptoms were fever and abdominal pain (90.9%; 78.8%, respectively). Most patients presented with leukocytosis (81.8%) and elevated C-reactive protein (CRP) levels (95.5%). In patients with abscesses in solid organs, urine white blood cell counts, nitrate and leukocyte esterase were all significant parameters (all P < 0.05), and urine pH and specific gravity were both lower than those in non-solid organs (P = 0.026; P = 0.043, respectively). Escherichia coli (E. coli) was the most common organism cultured from renal abscess. Streptococcus viridans was the most common organism cultured from liver abscess. Moreover, the two most predominant bacteria in periappendical and intraperitoneal abscesses were E. coli and Bacteroides fragilis.ConclusionsWe suggest that primary physicians should keep this disease in mind when children present with predisposing risk factors, fever, abdominal pain, leukocytosis and elevated CRP level. Besides, we recommend the urinary analysis or ultrasonography (US) is valuable in patients with fever and abdominal pain.