Oerskovia xanthineolytica implicated in peritonitis associated with peritoneal dialysis: case report and review of Oerskovia infections in humans.

Oerskovia species are nocardialike bacteria that have been implicated as pathogens only rarely. These organisms are branched, gram-positive bacilli that are oxidase negative, catalase positive, and non-acid fast. Unlike Nocardia species, these organisms are motile, do not produce aerial mycelia, and possess a cell wall with large amounts of galactose. Colonies are bright yellow and produce branched vegetative hyphae on nutrient agar. A 70-year-old patient undergoing chronic ambulatory peritoneal dialysis for end-stage renal dysfunction developed recurrent peritonitis. Five peritoneal fluid cultures and one catheter specimen obtained over a period of two weeks yielded a gram-positive bacillus; Oerskovia xanthineolytica was isolated from all six cultures. Prolonged systemic therapy with gentamicin and vancomycin was unsuccessful in curing the peritonitis, but the infection resolved following removal of the peritoneal catheter. This is the first reported case of peritonitis associated with this microorganism. A review of previously described Oerskovia infections, most of which were associated with foreign bodies, showed that removal of infected foci was usually necessary for cure.     

Clearance of Cellulosimicrobium cellulans bacteremia in a child without central venous catheter removal

Cellulosimicrobium cellulans (formerly known as Oerskovia xanthineolytica) rarely causes human infection. Infections have been reported in immunocompromised hosts or in patients with foreign bodies, such as catheters, where treatment has generally involved removal of the foreign body. We report on a case in which the organism was isolated in multiple blood cultures from a 13-year-old male. After initial therapy failed, treatment with vancomycin and rifampin resulted in infection clearance without removal of the central venous catheter.     

Salmonella prosthetic joint septic arthritis

We describe a case of Salmonella enteritidis infection of a prosthetic knee joint that was cured with ceftriaxone therapy for 6 weeks and replacement of the tibial component of the prosthesis. Eleven other cases of salmonella prosthetic joint infection have been reported in the English-language literature. Five infections occurred within 20 days of prosthesis placement, and seven occurred several months to years later; ten of 12 infections involved hip prostheses. Nine of 12 patients who had prosthesis removal were cured of the infection. Two of the three patients with retention of the prosthesis required long-term suppressive antibiotic therapy.     

Catheter-related bacteremia caused by Oerskovia turbata.

A case of Broviac catheter-related bacteremia in a 3-year-old boy infected with Oerskovia turbata is discussed. The blood cultures of the patient remained positive despite antibiotic therapy, and only with catheter removal was his blood sterilized. The microbiology and antimicrobial susceptibilities of this organism are described.     

Management of long-term catheter-related Brevibacterium bacteraemia

Brevibacterium has been reported as a rare cause of implanted-device infection. In two cases of recurrent Brevibacterium casei bacteraemia associated with infection of surgically implanted intravascular devices, relapse occurred 2 and 5 months, respectively, after completion of therapy with vancomycin via the infected catheter. A second intravenous antibiotic therapy course by the antibiotic-lock technique led to bacteriological cure in one patient. Molecular typing results demonstrated that the recurrent bacteraemia was caused by the same strain. Implanted-device removal may be necessary, in addition to appropriate antibiotics, for successful management of such infections.     

Mycobacterium fortuitum infection following total knee arthroplasty: a case report and literature review

Although Mycobacterium fortuitum is ubiquitous in our environment, infection of total knee arthroplasties with this organism is uncommon. This particular mycobacterium belongs to a group of organisms known as rapidly growing mycobacteria that distinguishes itself from the more typical Mycobacterium tuberculosis by their lower virulence and lack of human-to-human transmission. Another distinguishing feature is their resistance to almost all traditional anti-tuberculous medications and many antibiotics. Because such infections are encountered so infrequently, delays in reaching a microbiological diagnosis are not unusual. This inevitably compromises patient care. At present, there is no universally accepted treatment protocol. Management tends to be individualized, but cure may be possible with a prolonged course of appropriate anti-microbial therapy, removal of the implant, biopsy to confirm eradication of the organism, and finally, reimplantation of a new prosthesis. This paper presents the successful treatment of such an infection. Use of the combination of meropenem and moxifloxacin has not been previously reported in this setting. This case suggests that their in vivo activity is clinically effective against M. fortuitum peri-prosthetic infections when combined with surgical therapy.     

Antibiotic treatment of chronic central venous hemodialysis catheter infection without catheter removal

Most catheter or shunt infections in hemodialysis patients require the removal of the access before the infection is eradicated. A hemodialysis patient is reported who had multiple previous vascular accesses which failed and thus who had very limited sites for future access placement. When a recurrent Proteus mirabilis catheter infection occurred, a 6-week course of ampicillin intraluminal and tobramycin systematically, eradicated the infection and thus the central venous catheter was salvaged. Serum bactericidal levels with these two antibiotics were obtained early in the course and supported the continued use of antibiotics alone to treat the infection.     

Late prosthetic hip joint infection with Actinomyces israelii in an intravenous drug user: case report and literature review

Late infections with Actinomyces israelii have been described for prosthetic hip joints but not in association with intravenous drug use. We present a case of a 43-year-old intravenous drug user who developed A. israelii infection in connection with a hip prosthesis 11 years after implantation, and we review four previously reported cases of Actinomyces prosthetic joint infections.     

Chronic septic arthritis and osteomyelitis in a prosthetic knee joint due toClostridium difficile

A case of chronic septic arthritis and osteomyelitis in a prosthetic knee joint due toClostridium difficile is reported. A knee prosthesis was installed in a 16-year-old boy for surgical treatment of an osteosarcoma of the femur. Later, the patient suffered a traumatic closed fracture of his patella, and a sterile fluid was aspirated. One month later, the joint displayed inflammation. Culture of the articular fluid yielded a nontoxigenicClostridium difficile strain. Despite several attempts using conservative medical treatment with penicillins and ornidazole,Clostridium difficile strains with the same antibiotic susceptibility pattern were repeatedly isolated from the joint over an eight-month period. The foreign material was then ablated, and finally, the patient's leg was amputated one year afterClostridium difficile was first isolated. The possible sources of contamination in our case and other reported cases of extraintestinal infection due toClostridium difficile are discussed.     

Vacuum-assisted closure in the treatment of early hip joint infections

The aim of the present study was to evaluate the efficacy of the vacuum-assisted closure (V.A.C.) system in the treatment of early hip joint infections. 28 patients (11 m / 17 f; mean age 71 y. [43-84]) with early hip joint infections have been treated by means of the V.A.C.-therapy. At least one surgical revision [1-7] has been unsuccessfully performed for infection treatment prior to V.A.C. - application. Pathogen organisms could have been isolated in 22/28 wounds. During revision, cup inlay and prosthesis head have been exchanged and 1-3 polyvinylalcohol sponges inserted into the wound cavity/ periprosthetically at an initial continuous pressure of 200 mm Hg. Postoperatively, a systemic antibiosis was given according to antibiogram. 48-72 h after surgery an alteration from haemorrhagic to serous fluid was observed in the V.A.C.-canister. Afterwards, the pressure was decreased to 150 mm Hg and remained at this level till sponge removal. After a mean period of 9 [3-16] days the inflammation parameters have been retrogressive and the sponges were removed. An infection eradication could be achieved in 26/28 cases. In the two remaining cases the infected prosthesis had to be explanted and a gentamicin-vancomycin-loaded spacer has been implanted, respectively. At a total mean follow-up of 36 [12-87] months no reinfection or infection persistence was observed. The V.A.C.-system can be a valuable contribution in the treatment of early joint infections when properly used. Indications should be early infections with well-maintained soft-tissues for retention of the negative atmospheric pressure.     

Clostridium infection in a knee extensor mechanism allograft: case report and review

An unusual case of Clostridium perfringens infection after an allograft reconstruction of an extensor mechanism in a multiply revised total knee arthroplasty is reported. The case occurred in an elderly patient with an underlying bleeding dyscrasia who had previously undergone two revision total knee arthroplasties. The patient was treated by open irrigation, debridement, removal of allograft and prosthesis, intravenous antibiotics, and implantation of an antibiotic impregnated cement spacer utilizing an intramedullary rod.     

Staphylococcus caprae bone and joint infections: a re-emerging infection?

Staphylococcus caprae has been recently classified as a human pathogen, but the incidence of S. caprae in human bone and joint infections (BJIs) is under-reported. In this study, we report 25 cases of S. caprae BJI, and we review the 31 cases published in the literature. Molecular techniques and matrix-assisted laser desorption ionization time-of-flight mass spectrometry improved the identification of clinically relevant S. caprae strains. In this study, 96% of S. caprae BJIs were localized to the lower limbs, and 88% of the cases involved orthopaedic device infections. S. caprae joint prosthesis infections (JPIs), internal osteosynthesis device infections (I-ODIs) and BJIs without orthopaedic device infections were recorded in 60%, 28% and 12% of cases, respectively. Ten (40%) S. caprae BJIs were polymicrobial infections. These infections were associated with past histories of malignancy (p 0.024). Of the 14 bacterial species related to S. caprae BJI, 57% were staphylococci. I-ODIs were significantly associated with polymicrobial infections (p 0.0068), unlike JPIs, which were monomicrobial infections (p 0.0344). Treatment with rifampicin and fluoroquinolone was recorded in 40% of cases. Surgical treatment was performed in 76% of cases, e.g. prosthesis removal (36%), osteosynthesis device removal (24%), and surgical debridement (16%). Thirty per cent of cases were not treated. Relapses were observed mainly in the patients treated by surgical debridement only (p 0.033). In summary, S. caprae BJI is an underestimated hospital-acquired emerging infection. S. caprae BJI is correlated with infections in orthopaedic devices, which must be removed to control the infection.     

Clinical potential of DAS181 for treatment of parainfluenza-3 infections in transplant recipients

Parainfluenza virus (PIV) infections can cause serious respiratory infections and death in immunocompromised patients. No antiviral agents have proven efficacy against PIV, and therapy generally consists of supportive care. DAS181, a novel sialidase fusion protein that temporarily disables airway epithelial PIV receptors by enzymatic removal of sialic acid moieties, has been shown to inhibit infection with PIV strains in vitro and in an animal model. We describe here the clinical course of 2 immunocompromised patients with PIV-3 infection, one with a history of lung transplantation and the other neutropenic after autologous hematopoietic stem cell transplantation for multiple myeloma. Both patients had substantial clinical improvement in respiratory and systemic symptoms after a 5-day DAS181 treatment course, although the clinical improvement in the autologous stem cell transplantation patient also paralleled neutrophil engraftment.     

Miliary tuberculosis with delayed-onset total knee arthroplasty Mycobacteria tuberculosis infection successfully treated with medical therapy alone: A case report and literature review

Tuberculosis (TB) affecting a prosthetic knee is an unusual and diagnostically challenging presentation of this disease. This study reported a case of an 80-year-old man with a left total knee arthroplasty (TKA) performed eight years before his presentation. He presented with left knee swelling and pain for one month. Knee X-rays showed a normal joint space with no loosening of his prosthesis. His chest X-ray showed miliary disease, and microbiological studies of his sputum and synovial fluid aspirate grew Mycobacteria tuberculosis complex. He was successfully medically treated with anti-tuberculous therapy alone for one year. His knee hardware was retained, and he did not require debridement, resection, or revision. It is believed that this is the first reported case of miliary TB with delayed-onset TKA prosthetic joint infection (PJI) in which the prosthesis was successfully retained. Thirty-eight published TB TKA PJI cases in medical literature were also reviewed.     

Characteristics and prognosis in patients with prosthetic vascular graft infection: a prospective observational cohort study

Prosthetic vascular graft infection (PVGI) is a devastating complication, with a mortality rate of up to 75%, which is especially caused by aortic graft infection. The purpose of this study was to evaluate factors associated with in-hospital mortality of patients with definite graft infection, and with long-term outcome. We reviewed medical records of 85 patients treated for PVGIs defined by positive bacterial culture of intraoperative specimens or blood samples, and/or clinical, biological and radiological signs of infection. In-hospital patient mortality was defined as any death occurring during the initial treatment of the graft infection. Cure was defined as the absence of evidence of relapsing infection during long-term follow-up (≥1 year). Eighty-five patients (54 aortic and 31 limb graft infections) treated by surgical debridement and removal of the infected prosthesis (n=41), surgical debridement without removal of prosthesis (n=34) or antimicrobial treatment without surgery (n=10) were studied. The only microbiological difference observed between patients with early (occurring within 4 months after surgery) vs. late PVGI and between those with aortic vs. limb PVGI was the incidence of PVGI caused by Staphylococcus aureus, which was greater in patients with limb PVGI. Overall cure was observed in 93.2% of 59 patients with a follow-up of a minimum of 1 year. Overall in-hospital mortality was 16.5% (n=14). Two variables were independently associated with mortality: age >70 years (OR 9.1, 95% CI 1.83-45.43, p 0.007) and aortic graft infection (OR 5.6, 95% CI 1.1-28.7, p 0.037).     

Reactivation of acyclovir-resistant thymidine kinase-deficient herpes simplex virus harbouring single base insertion within a 7 Gs homopolymer repeat of the thymidine kinase gene

HSV infections are treated efficiently and prevented by acyclovir, although resistant strains have been reported. Resistance to acyclovir involves mainly mutations in the viral gene encoding thymidine kinase; mutations may lead to an altered or, more frequently, deficient TK. These acyclovir-resistant TK deficient strains are not able to reactivate from a latent infection in an experimental model, compared to TK positive strains. A case is reported of a bone marrow transplant child who developed HSV infection at 11 days post-transplantation. Acyclovir-resistant HSV 1 was isolated on day 19 post-transplantation. The patient was cured of his infection. A resistant virus was detected 20 months later that harboured the same TK gene mutation as the first resistant virus. This mutation is an insertion of one guanine in a homopolymer repeat of seven guanines located at codon 146 of TK. It has previously been reported and associated with the expression of a deficient TK activity and the ability to reactivate in mice. These results corroborate the clinical relevance of this mutation, which is associated with acyclovir-resistant recurrent infections in humans.     

Oerskovia species: rare opportunistic pathogens

The second documented instance of opportunistic infection by member of the genus Oerskovia is reported. There is some evidence to suggest that this group of bacteria, which is extensively distributed in the soil, may be more closely associated with man than has hitherto been supposed.     

Infections by the Yeast<Emphasis Type="Italic"> Kodomaea</Emphasis> (<Emphasis Type="Italic">Pichia</Emphasis>)<Emphasis Type="Italic"> ohmeri</Emphasis>: Two Cases and Literature Review

A 14-year-old boy who was neutropenic following chemotherapy for leukemia developed fungemia caused by the yeast Kodomaea ohmeri (Pichia ohmeri). The infection was cured by catheter removal and the use of fluconazole. A 74-year-old man who had undergone surgeries for a subcutaneous tumor developed polymicrobic cellulitis involving Kodomaea ohmeri. Despite surgical debridement and antibiotic therapy, the patient died of complications. Including these 2 cases, there have been 10 Kodomaea ohmeri infections reported thus far, all occurring in patients with pre-existing conditions. There have been seven cases of fungemia and one case each of peritonitis, funguria, and cellulitis. The treatment employed varied depending on the site/source of infection. Seven patients recovered and three died. The microbiological data available suggest that Kodomaea ohmeri can be identified definitively by biochemical tests and is susceptible to amphotericin B and either susceptible to or dose dependently susceptible to itraconazole and fluconazole.     

Moraxella osloensis blood and catheter infections during anticancer chemotherapy: clinical and microbiologic studies of 10 cases

Moraxella osloensis, a gram-negative bacterium that is saprophytic on skin and mucosa, rarely causes infections. Moreover, infections in patients with cancer have not been reported. We describe 10 cases of M. osloensis blood or catheter infections that occurred during anticancer chemotherapy with or without preexisting neutropenia. The organism was identified definitively by sequencing analysis of the 16S ribosomal RNA gene. Fever (up to 39.7 degrees C) with substantial neutrophilia characterized these infections. The infections were monomicrobic for 3 patients and polymicrobic for 7 patients. Nine patients acquired the infection through central venous catheter colonization. The likely sources of the organism were sinusitis (3 cases), bronchitis (1 case), presumed subclinical mucositis from anticancer therapy (4 cases), and cutaneous graft-vs-host disease (2 cases). The infections resolved, without catheter removal, after antibiotic therapy with cell wall-active agents, to which all strains were shown to be susceptible. The M. osloensis strains exhibited significant morphologic variations on gram stain, and sheep blood agar was the preferred culture medium for 9 strains.     

Cryptococcus laurentii fungemia in a premature neonate

Cryptococcus spp. other than Cryptococcus neoformans are generally considered nonpathogenic to humans. There are only 15 case reports of disease in humans caused by Cryptococcus laurentii infection. Underlying diseases and predisposing risk factors seem to play an important role in these cases. Our patient is the first case of an extremely low birth weight infant with C. laurentii fungemia reported in the English literature. In our case, the MIC of amphotericin B for C. laurentii was 0.25 to 1 microg/ml and the patient had a good outcome following the administration of amphotericin B at 10 mg/kg combined with central venous catheter removal. There will undoubtedly be an increasing occurrence of unusual fungal infections accompanying further advances in medicine. A high degree of suspicion and improvements in the techniques for culture and identification will contribute to the earlier diagnosis and treatment of unusual fungal infections.