Randomized comparison of ceftazidime versus clindamycin-tobramycin in the treatment of obstetrical and gynecological infections.

A randomized comparison of ceftazidime versus clindamycin-tobramycin was performed for the treatment of obstetrical and gynecological infections. Entry criteria were an oral temperature of greater than or equal to 38 degrees C and a clinical diagnosis of endometritis, salpingitis, or pelvic cellulitis after hysterectomy. All patients with endometritis had cultures of intrauterine material obtained via a transcervical single-lumen catheter. The patients with pelvic cellulitis had material from the vaginal apex aspirated for culture, and all patients with salpingitis had a culdocentesis for culture of intraperitoneal material. Of 38 patients who received ceftazidime, 34 had endometritis after cesarean section, 3 had endometritis after abortion, and 1 had pelvic cellulitis. Of 39 patients who received clindamycin-tobramycin, 35 had endometritis after cesarean section, 3 had salpingitis, and 1 had pelvic cellulitis. The most common bacterial isolates were Lactobacillus sp., Bacteroides bivius, Escherichia coli, other gram-negative aerobic bacilli, group B streptococci, and other aerobic streptococci. Bacteremia occurred in 9.0% of the patients. Of the patients receiving clindamycin-tobramycin and ceftazidime, 34 (87.2%) and 34 (89.5%), respectively, responded to therapy. All the clinical failures occurred in patients with endometritis after cesarean section. Clinical failures had persistent fever despite 3 or more days of treatment. One of the patients receiving clindamycin-tobramycin developed an urticarial rash after her infection had resolved. No patient in either group developed diarrhea. In these small groups of patients, there were no significant differences in cure rate, side effects, or length of hospital stay.     

Sepsis in a renal transplant recipient due to Citrobacter braakii

Cellulitis is usually caused by organisms such as beta-hemolytic streptococci and Staphylococcus aureus. Citrobacter are gram-negative bacilli that can cause opportunistic infections in immunocompromised hosts. They are rarely implicated in skin or soft tissue infections. The genus Citrobacter has been respeciated according to genetic relatedness. Citrobacter braakii refers to the genomospecies 6 of the Citrobacter freundii complex. There are no detailed studies of infections caused by the newly formed specific genetic species. We report a case of C. braakii infection in a renal transplant patient receiving immunosuppressive therapy. The patient's lower extremity cellulitis did not respond to conventional antibiotic therapy. Blood cultures grew C. braakii. Sensitivity studies and treatment with appropriate antibiotics resulted in prompt recovery. Immunosuppressive therapy in renal transplant recipients predisposes to infection by unusual pathogens, and this should be suspected when lack of a clinical response to conventional antibiotics is observed. We believe this is the first reported case of C. braakii cellulitis and bacteremia in a renal transplant recipient.     

Group A streptococcal pharyngitis in adults 30 to 65 years of age.

BACKGROUND: Although the frequency of group A streptococcal pharyngitis in adults is assumed to be low, there is little information on frequency other than in military populations. METHODS: A prospective, observational study was done to determine the frequency of group A streptococcal pharyngitis in adults seen in the emergency department. Throat swabs were obtained on adults (30 to 65 years of age) with sore throat and pharyngitis on examination. Swabs were also obtained in a group of control subjects. RESULTS: Of the 148 adults with pharyngitis, 65 (44%) had throat specimens positive for group A streptococci. In the 50 control subjects, all throat cultures were negative for group A streptococci. A significant number of patients with group A streptococcal pharyngitis had school-aged children at home. CONCLUSION: The high rate of detection of group A streptococci in adults outside the military has not been previously reported.     

Value of cultures in patients with acute cellulitis.

A retrospective review of blood and wound cultures obtained from adult patients admitted for acute cellulitis revealed positive culture rates of 0.77% of 86% respectively. Organisms from wound cultures were predominantly Staphylococcus aureus and Streptococcus pyogenes. The majority of our patients were otherwise healthy. Our study suggests that blood cultures are not necessary in acute cellulitis in adults without serious underlying diseases.     

Group G streptococcal sacroiliitis

We describe herein an unusual case of recurrent pyogenic sacroiliitis in an intravenous drug abuser. Blood cultures grew group G streptococcus. The patient was treated effectively with 7 wk of penicillin G. Group G streptococci are emerging as important pathogens of serious infections.     

Synergism, killing kinetics, and antimicrobial susceptibility of group A and B streptococci.

The susceptibility of 110 group A and 179 group B streptococci to 25 antimicrobics was tested by broth microdilution and agar disk diffusion tests. Representative strains were used in killing kinetics, penicillin-gentamicin synergy, and minimal bactericidal concentration tests. Group A streptococci were more susceptible than group B streptococci to 17 of the 25 antimicrobics tested. Group A and B streptococci were killed at the same rate if the amount of penicillin used was equivalent to their respective penicillin minimal inhibitory concentrations. Synergism was demonstrated for both group A and B streptococci when penicillin was used at concentrations equal to each respective minimal inhibitory concentration and subinhibitory concentration of gentamicin. This synergy could be demonstrated best using minimal bactericidal concentrations obtained by culturing 3- and 6-h cultures from the microdilution checkerboard tests rather than from 24-h subcultures. A greater synergistic effect was achieved by adding penicillin first and then adding gentamicin rather than in the reverse order, or simultaneously.     

One Health and Streptococcus Canis in the Emergency Department: A Case of Cellulitis and Bacteremia in an Immunocompromised Patient Treated With Etanercept

BackgroundOne Health is a biomedical approach that aims to optimize the health of humans, animals, and the environment through interdisciplinary collaboration. Cellulitis is an infection of the dermis and subcutaneous fat that may be caused by zoonotic streptococci species.Case ReportWe report a case of cellulitis caused by Streptococcus canis in a woman who was taking Etanercept. We frame the presentation within a One Health approach and urge emergency physicians to collaborate with veterinarians in the management of patients with zoonotic diseases who are discharged home.Why Should an Emergency Physician Be Aware of This?Pets are a source for zoonotic diseases, including resistant bacteria, that pose particular risk to immunocompromised patients. Emergency physicians often discharge patients with potential zoonotic infections such as cellulitis home without a long-term, holistic care plan, according to a One Health approach. Physicians should then collaborate with veterinarians in caring for humans and animals.     

Clinical evaluation of the improved streptex method for grouping streptococci

The improved Streptex method for serogrouping streptococci incorporates a new extraction enzyme and a simplified procedure requiring no centrifugation. A total of 114 clinical isolates of beta-hemolytic streptococci were serogrouped from primary plates, isolation plates, and Todd-Hewitt broth cultures using this system. Results were compared to those of the heat extraction Lancefield precipitin method. An additional 33 stock culture isolates of related streptococcal species and 5 strains of Listeria were serogrouped to assess the specificity of the test. Agreement between the two methods was 82.5% with primary plates and 96.5% with both isolation plates and broth cultures. Four isolates from three different serogroups were nongroupable by the Lancefield method, but did agglutinate in specific Streptex antisera; therefore, the enzyme extraction procedure appeared more sensitive than the heat extraction method. Streptex accurately grouped five isolates of gamma-hemolytic group B streptococci, but failed to detect antigen in 33% of the group D streptococcal extracts tested. In addition, cross-reactions were observed with strains of alpha-hemolytic streptococci. Streptex produced fewer ambiguous results and required fewer repeat tests. When used with isolation plates or broth cultures, Streptex is both sensitive and specific for the grouping of beta-hemolytic streptococci of groups A, B, C, F, and G.     

Facial and periorbital cellulitis in children

Facial and periorbital cellulitis require emergent recognition and treatment. Hemophilus influenzae type B is the most common pathogen, with Streptococcus pneumoniae being cultured less frequently. Infections following injury are usually caused by Staphylococcus aureus and group A streptococci. Initial evaluation must exclude more severe orbital involvement. Appropriate bacteriological specimens should be obtained. Management requires parenteral antibiotics and careful monitoring for a clinical response or dissemination to other sites of infection.     

Buccal cellulitis

Buccal cellulitis (BC) is an innocuous appearing infection of the cheek that is found in children and has a high incidence of concomitant bacteremia. Typically, the child is younger than 12 months and has a 2 to 8 hour prodrome of coryza and fever before developing the cellulitis on the cheek. A purplish hue on the cellulitic region is highly suggestive of Hemophilus influenzae bacteremia. The differential diagnosis is reviewed. A complete blood count, blood culture, and cellulitis aspirate culture, should be obtained on all patients with BC. Meningitis may be present despite the lack of meningeal signs. A lumbar puncture should be performed on all children at risk for bacteremic BC. The vast majority of these children are bacteremic and require parenteral antibiotics. A typical case of BC is presented and its management is reviewed.     

Daptomycin tested against 915 bloodstream isolates of viridans group streptococci (eight species) and Streptococcus bovis

OBJECTIVES: To evaluate the activity of daptomycin tested against numerous species of viridans group streptococci and Streptococcus bovis, which are associated with wound infections, sepsis, cellulitis, endocarditis, abscesses and dental caries. The incidence of penicillin-resistant (non-susceptible) and MLS(B)-resistant strains among viridans group streptococci often varies by species. METHODS: The activity of daptomycin was compared with seven other antimicrobial classes using reference broth microdilution and disc diffusion methods tested against 915 bacteraemic isolates of streptococci (815 viridans group strains; 100 S. bovis). RESULTS: Among all species of viridans group streptococci and S. bovis, 99.9% of isolates were susceptible to daptomycin (MIC values, < or = 0.016-2 mg/L). In contrast, penicillin, erythromycin and tetracycline susceptibility varied widely between species. Erythromycin susceptibility was in the range 48.6-88.7%, penicillin susceptibility in the range 65.5-98.1% and tetracycline in the range 35.0-93.9%. The inter-method agreement between daptomycin and linezolid resistance (comparison agent) disc diffusion and broth microdilution test results was high, each showing near complete susceptibility (99.9%). CONCLUSIONS: Daptomycin is an active antimicrobial agent that has a usable potency against eight species of viridans group streptococci, as well as S. bovis, with all MIC values at < or =2 mg/L.     

Group B streptococcal retropharyngeal cellulitis in a young infant: a case report and review of the literature

The diagnosis of retropharyngeal cellulitis and abscess, although most common in children under 6 years of age, is often misdiagnosed in the newborn or early infancy period. The clinical signs of drooling, neck swelling, dysphagia, and torticollis may be absent or not easily identifiable. The following case report details a 2 1/2-month-old infant who presented with fever and irritability, and was subsequently diagnosed with group B streptococcal retropharyngeal cellulitis. Retropharyngeal cellulitis and abscess should be considered in the differential diagnosis of infants and young children who present with fever and irritability, particularly when lumbar puncture results are normal. This case also serves to highlight a rare manifestation of late-onset group B steptococcal disease.     

Group B streptococcal cellulitis

We have described a 2-week-old infant with cellulitis in the left submandibular region due to beta hemolytic Streptococcus, group B, and presented 16 additional cases compiled from the literature.     

A CONTRIBUTION TO THE BACTERIOLOGY OF ACUTE ANTERIOR POLIOMYELITIS

Four different varieties of easily cultivated microorganisms have been cultured from the cerebrospinal fluid and tissues of cases of acute anterior poliomyelitis; namely, a streptococcus, a diplococcus, diphtheroids, and Gram-negative bacilli. It is not contended that they were all inherent in the tissues; a part were doubtless extraneous. The streptococci and diplococd may be considered as the most significant of the bacteria cultivated and are distinguishable from each other by biological tests. The streptococci grew both aerobically and anaerobically; under anaerobic conditions growth was slow, the cocci became small and round, and were more easily decolorized with alcohol in the Gram stain. They were not found in the anaerobic cultures of 106 cerebrospinal fluids; they were found in one of twenty anaerobic blood cultures and frequently in the cerebrum, cerebellum, pons and medulla, cord, tonsils, lungs, liver, kidneys, spleen, pancreas, thymus gland, suprarenal glands, and mesenteric glands of fatal cases. The diplococci are Gram-positive and, transplanted to solid media, yield luxuriant growths and a staphylococcus grouping. They grew aerobically and anaerobically, but more slowly under the latter condition, and the cocci became smaller and more rounded. Diplococci were found in the anaerobic cultures of 48 of 106 cerebrospinal fluids; also in the cerebrum, cerebellum) pons and medulla, cord, tonsils, lungs, liver, kidneys, spleen, pancreas, and mesenteric glands of fatal cases. The filtrates of emulsions of tissues containing streptococci and diplococci passed through fine Kitasato and Pasteur-Chamberland filters were sterile unless large amounts of filtrates were collected. The amount of filtrate collected and cultured is therefore of considerable importance in filtration experiments. The small forms of streptococci and diplococci in old anaerobic cultures are filterable with these filters, while young aerobic cultures containing large forms are not, unless large amounts of culture are filtered. Intracranial, intravenous, and intraperitoneal injection of these easily cultivated streptococci, diplococci, diphtheroids, and Gramnegative bacilli failed to produce paralysis in rabbits or monkeys. With two exceptions all the cultures were transplants from the original anaerobic ascites-broth-kidney cultures of cerebrospinal fluid and various tissues. Arthritis and meningitis were produced by the streptococci, but there were neither clinical iior histological evidences of true poliomyelitis. Occasional bacteriological studies since 1898 have shown that easily cultivated micrococci and bacilli may be present in the cerebrospinal fluid and tissues of the central nervous system of persons suffering with acute anterior poliomyelitis. The majority of bacteriologists have found the cerebrospinal fluid, blood, and nervous organs sterile. Opinions have varied in regard to the significance of the organisms and the micrococci in particular, but the consensus of opinion has been to the effect that they are secondary invaders and unable of themselves to produce poliomyelitis in the lower animals. After allowing for contaminations due to technical errors in securing specimens, the total number of observations indicates that easily cultivated micrococci occur sometimes in the brain and cord of persons suffering from epidemic poliomyelitis. Our studies have shown that they may be found not only in these locations, but also in the spleen, kidneys, suprarenal glands, and other organs. It is not known that they exert an influence in this disease, although they may possibly give rise to the production of antibodies) assuming their entrance not to be wholly agonal,as the cultures of streptococci are frequently of sufficient virulence to produce meningitis in rabbits and monkeys. Our experiments are in accord with those of other investigators who found that these microorganisms do not produce poliomyelitis in the lower animals, and are therefore in sharp contrast with the recent reports which would attribute an etiologic relationship of streptococi and allied organisms to that disease. At present this wide divergence of result cannot be accounted for, but it does not seem that it is possible for it to reside in any condition of the cultures employed by us as they were obtained from undoubted cases of epidemic poliomyelitis and inoculated in early generations. As regards these easily cultivatable microorganisms, we agree at present with those who regard them as secondary and probably terminal invaders rather than the actual etiologic agent of the disease.     

Eschar with cellulitis as a clinical predictor in community-acquired methicillin-resistant Staphylococcus aureus (MRSA) skin abscess

This study was designed to determine the validity of a central eschar with surrounding cellulitis as a clinical predictor for CA-MRSA infection. In this 10-month prospective observational study, patients with a chief complaint or clinical findings of skin infection with abscess had study data sheets placed on their chart. All abscesses were treated with incision and drainage, and wound cultures were obtained. Exclusionary criteria included patient age under 18 years, recently incarcerated within 14 days, and hospitalized or in a nursing home within 10 days. Correlation of wound culture results with recorded physical examination determined the sensitivity, specificity, and positive/negative predictive values. A total of 224 patients with abscesses were enrolled; 18 patients met exclusion criteria. An additional 78 patients were excluded because no wound cultures had been obtained, study data form was incomplete, or there was no evidence of wound cellulitis. Of the 128 remaining patients, 91 wound cultures grew MRSA (71% prevalence). Of these 91 cases, 50 tested positive for central black eschar, yielding a sensitivity of 55% (95% confidence interval [CI] 0.45-0.65). Thirty-seven patients had abscesses that grew non-MRSA bacteria. Three of these were positive for central black eschar, yielding a specificity of 92% (95% CI 0.83-1.01). The positive predictive value was 94% (95% CI 0.88-1.01) and the negative predictive value was 45% (95% CI 0.32-0.59). A central black eschar with cellulitis has good specificity and high positive predictive value in diagnosing CA-MRSA infection.     

Effect of atmosphere of incubation on the isolation of group A streptococci from throat cultures

The optimal atmosphere of incubation for the isolation of group A beta-hemolytic streptococci from throat cultures has been the subject of considerable debate. To resolve this issue, we examined 5992 consecutive throat cultures performed at a private pediatric office in children with acute upper respiratory tract infections. All throat cultures were streaked onto duplicate blood agar plates, one of which was then incubated anaerobically and the other aerobically. beta-Hemolytic streptococci were isolated in cultures from 1885 (31.5%) of the patients; 1479 (24.7%) were identified as group A, and 406 (6.8%) were identified as non-group A. Group A streptococci were recovered significantly more often from the plates incubated anaerobically than from those incubated aerobically (1467 vs. 1054; anaerobic only, 425; aerobic only, 12; P less than 0.01). Non-group A streptococci were also recovered significantly more often from the plates incubated anaerobically than from the plates incubated aerobically (397 vs. 170; anaerobic only, 236; aerobic only, 9;P less than 0.01). Anaerobic incubation maximizes the yield of the throat culture. The additional cost and effort of anaerobic incubation are small, and would appear to be justified by the increased isolation rate of group A beta-hemolytic streptococci. The significance of the increased isolation rate of non-group A beta-hemolytic streptococci with anaerobic incubation needs to be investigated further.     

Immunity to the group B streptococci: interaction of serum and macrophages with types Ia, Ib, and Ic

The opsonization and phagocytosis of group B streptococci of types Ia, Ib, and Ic were studied in vitro by measuring the uptake of radioactivity by coverslip cultures of rabbit alevolar macrophages during incubation with radiolabeled, nonviable bacteria which had been exposed to rabbit serum. The uptake of counts per minute was quantitative, reproducible, and reversibly inhibited by cold, indicating that it was largely a measurement of phagocytic ingestion rather than of attachment of bacteria-immunoglobulin complexes to macrophage membranes. Moreover, suspended macrophages killed approximately 90% of viable streptococci in the presence of specific antiserum. The opsonic activity of immune serum was heat stable, and phagocytosis of streptococci was insignificant after incubation with normal serum and antiserum to some heterologous group B streptococci. By absorption studies, it was possible to identify the effect of antibodies to specific bacterial antigens. Phagocytosis of streptococci containing the corresponding antigens was maximal after opsonization with homologous or heterologous sera containing antibody to IaCHO, IbCHO, or Ibc protein. Phagocytosis of all three serotypes was intermediate when opsonization could be attributed to anti-IabcCHO. The opsonization of a specific group B streptococcus is complex and may involve two or more antigen-antibody systems.     

Deadly case of Pasteurella multocida aortitis and mycotic aneurysm following a cat bite

Animal bites are frequently encountered in the emergency department (ED). Aortitis leading to mycotic abdominal aortic aneurysm is a rare and potentially deadly complication of Pasteurella multocida (P. multocida) following an animal bite. We present the case of a 68-year-old male who presented to the ED after falling at home. He complained of weakness and abdominal pain. He was in septic shock and was treated empirically with broad-spectrum antibiotics and intravenous fluids. He reported previous antibiotic treatment of a cellulitis secondary to a cat bite injury to his right thumb four weeks prior. Abdominal ultrasound and subsequent computed tomography scan revealed a leaking mycotic abdominal aneurysm that was surgically repaired. Blood cultures and aortic wall tissue cultures grew P. multocida. Given how common animal bite presentations are in the ED, this case highlights the need to consider aortitis and mycotic abdominal aortic aneurysm in an unwell patient with an animal bite.     

Pyomyositis in patients with diabetes. Computed tomography as a key to diagnosis

Pyomyositis rarely occurred in nontropical climates in the past but is becoming increasingly recognized in temperate climates. Nevertheless, this diagnostic possibility is often not immediately recognized. Pyomyositis should be considered in diabetic patients with lower-extremity cellulitis who do not respond to presumptively appropriate therapy. A high index of suspicion and documentation with appropriate imaging techniques, aggressive surgical intervention, and adjunctive antibiotic therapy are the keys to prompt resolution without sequelae. The patients in this report were diabetic adults who responded to appropriate therapy after computed tomographic scans, surgical exploration, and cultures established the diagnosis.     

Group G streptococcal bacteraemia in a community teaching hospital

The group G streptococci are beta-haemolytic streptococci which are characterised by the presence of the Lancefield group G antigen, and have been implicated in a variety of infections. Underlying malignancy has been reported in up to 67% of patients with group G streptococcal bacteraemia in some series. The clinical records of 11 patients with positive blood cultures for group G streptococci over the period from January 1993 to December 1997 were evaluated. Group G streptococci were recovered from only 0.025% (19 out of 77,323 total cultures) of blood cultures during this period. The source of bacteraemia was determined to originate from skin in seven patients (64%). Bacteraemia in the other four patients was probably due to endometritis, septic arthritis, osteomyelitis, and a central venous catheter. All of the patients had an underlying chronic disease or other predisposing factor such as a joint prosthesis or venous catheter. Only one patient in this series had an underlying malignancy, a metastatic pelvic sarcoma. One patient died of multiple organ failure after several days in the hospital. All surviving patients were successfully treated with antibiotics, typically a beta-lactam agent. This study suggests that in the community-hospital setting, skin infection is the most common source of group G streptococcal bacteraemia, typically in patients with underlying chronic disease; however, malignancy appears to be an uncommon predisposing factor.