Significado clínico del aislamiento de Staphylococcus aureus en muestras de orina

Introduction

To evaluate the clinical significance of the isolation of Staphylococcus aureus in urine samples.

Methods

A retrospective study was performed on adult patients identified from a microbiology database in a 200-bed general hospital between the years 2000 and 2009. The demographic data, comorbidities, and risk factors, were reviewed, particularly those associated with the concomitant isolation of S. aureus in blood cultures.

Results

The frequency of S. aureus found in urine samples was 0.63%. A total of 43 patients (mean age 68.7 years [SD ± 16], and 58.1% males) were identified in the database. A Charlson comorbidity index > 3 was observed in 20.9%. Concurrent bacteremia was seen in 48.8%. Two groups of patients were distinguished: with concomitant bacteremia (n = 21) or without (n = 22). Intervention in the urinary tract significantly predicted (P = .00004) bacteriuria without bacteremia (81.8%), compared to bacteremia cases (19%). The attributable mortality was 47.6% in patients with bacteremia compared to non-bacteremia (no deaths), even though the appropriate antibiotic treatment was more frequent among patients with bacteremia (92% and 60%, respectively).

Conclusion

The presence of S. aureus in urine was accompanied by bacteremia in half of the cases, but in patients without previous urinary tract intervention such a possibility increased to 81%. Concomitant bacteremia predicts a worse prognosis even with appropriate treatment.     

Infección por Rothia mucilaginosa. ¿Un patógeno respiratorio?

Introduction

To describe the spectrum of infections caused by Rothia mucilaginosa.

Methods

Retrospective study of 20 cases diagnosed with R. mucilaginosa from 2009 to 2012.

Results

Pulmonary infection was the most frequent clinical presentation (n = 14, 70%): bronchiectasis infected (10), followed by pleural empyema (2), pneumonia (1) and acute bronchitis (1). Two episodes were of gastrointestinal origin: cholangitis secondary to biliary drainage and secondary peritonitis. Two episodes included bacteremia in patients with hematological malignancy. One patient had a surgical wound infection with bacteremia, and another had a bacteremic urinary tract infection in a patient with nephrostomy.

Discussion

R. mucilaginosa may be responsible for infections of the lower respiratory tract in predisposed patients.     

Dificultades en el diagnóstico de los pacientes con enfermedad de Wilson en la práctica clínica: experiencia de 15 casos

Background

Wilson disease (WD) is an inherited disorder that causes copper (Cu) accumulation, leading to mainly liver, neurological and/or psychiatric manifestations. In the absence of some of the typical features, diagnosis of WD is difficult and is based on the combination of clinical, biochemical and genetic testing. The aim of this study was to illustrate the complexity of the approach to WD in daily clinical practice.

Methods

We retrospectively analyzed the medical records of patients with WD, including the clinical presentation, histological and biochemical findings, and follow up after treatment. We also carried out genetic testing, and the Leipzig diagnostic score was applied.

Results

We included 15 patients. Four were symptomatic, with liver (n = 1), neurological (n = 1), psychiatric (n = 1) and mixed clinical manifestations (n = 1), and 11 were presymptomatic, with elevated transaminases (n = 8) and family study (n = 3).We observed Kayser-Fleischer ring in 2 patients, both without neurologic symptoms.Ceruloplasmin ≤5 mg/dL was present in 73%, and 24-hour urinary Cu > 100 μg in 40%. Liver Cu was > 250 μg/g.d.t. in 85% of the patients. The final diagnosis of WD was given by genetic testing (ATP7B gene mutations) in 5 patients with minimal disease features, including one symptomatic patient (psychiatric symptoms). We identified 5 previously reported mutations (p.M645R, p.R827W, p.H1069Q, p.P768L and p.G869R) and 3 unpublished mutations (p.L1313R, p.I1311T and p.A1179D); the most frequent mutation was p.M645R.After treatment, biochemical parameters (transaminases, urinary cooper) and symptoms improved, except in patients with neurological and psychiatric manifestations.

Conclusions

Our series illustrates the important role of genetic testing in the diagnosis of WD. The identification of the p.M645R mutation in most of our patients should be kept in mind in the molecular analysis of the ATP7B gene in our region.     

Nuevo clon de Acinetobacter baumannii ST187 responsable de un brote en una unidad de cuidados intensivos

Introduction

An ICU-outbreak caused by a novel Acinetobacter baumannii clone is described.

Methods

An active search of carriers and environmental reservoirs was carried out. Carbapenemases genes were studied using multiplex-PCR and genotypic analysis by rep-PCR, PFGE and MLST.

Results

A total 26 infected patients and 10 carriers were identified. A. baumannii was recovered from infusion pumps, walls, floor and washbasins. Phenotypic/genotypic analysis showed clonal expansion of a unique clone ST-187 producer of type OXA-24 and OXA-51 carbapenemases.

Discussion

This is the first outbreak caused by ST-187 (ECI/GCI) multiresistant A. baumannii.     

Association of RAGE (p.Gly82Ser) and MnSOD (p.Val16Ala) polymorphisms with diabetic retinopathy in T2DM patients from north India

Aims

The present study aimed to examine the association of RAGE (p.Gly82Ser) and MnSOD (p.Val16Ala) polymorphisms with diabetic retinopathy (DR) in north Indian T2DM patients.

Methods

In this case-control association study, 758 T2DM patients were recruited. 446 with retinal neovascularization, microneurysms and hemorrhages were considered as cases (DR) and 312 patients with T2DM and no clinical signs of retinopathy (DNR), were recruited as controls. Genotypes for RAGE (p.Gly82Ser) and MnSOD (p.Val16Ala) polymorphisms were generated by direct sequencing of amplified products.

Results

Genotype distribution of p.Gly82Ser (RAGE) and p.Val16Ala (MnSOD) polymorphisms were significantly different between DR and DNR (p < 0.05) whereas distribution of allele frequency did not differ significantly (p > 0.05). A significantly higher frequency of homozygous Ser82 genotype in DR patients was detected compared with DNR (2.4% vs 0.64%) for p.Gly82Ser (RAGE) polymorphism whereas there was a higher frequency of homozygous Ala16 genotype for p.Val16Ala (MnSOD) polymorphism in DR patients compared with DNR (22.6% vs 19.3%). Binary logistic analyses showed an association of homozygous recessive genotype Ser82 with DR (OR: 2.63%, 95% CI: 0.16–15.88, p < 0.033) for p.Gly82Ser (RAGE) polymorphism. However, we did not find a significant association of p.Val16Ala polymorphism in MnSOD with retinopathy.

Conclusions

The findings indicate a statistically significant association of p.Gly82Ser polymorphism in RAGE with DR in T2DM patients.     

High risk of failing eradication of Helicobacter pylori in patients with diabetes: A meta-analysis

Aims

Eradication of Helicobacter pylori (HP) is an effective approach to improve intestinal symptoms and prevent gastric cancer. However, there has been concern that the presence of diabetes reduces the effectiveness of antibiotics. We performed this meta-analysis to investigate the effect of diabetes on the risk of failing eradication in patients with diabetes.

Methods

An electronic literature search was conducted using Biosis, MEDLINE, Embase, PASCAL, and SciSearch through November 30, 2012. Selected studies had to provide data on the number of individuals who received treatment for HP infection and on the failure of HP eradication in groups with and without diabetes. Two authors independently extracted relevant data.

Results

Data were obtained from 8 eligible studies (693 total participants including 273 participants with diabetes). Overall, the pooled risk ratio (RR) of failing HP eradication for diabetic patients compared with non-diabetic participants was 2.19 [95%CI, 1.65–2.90] (P < 0.001). Excluding the 2 studies that used a non-standard protocol for HP eradication, individuals with diabetes had a higher risk of failure of eradication compared to those without diabetes (RR = 2.31 [95%CI, 1.72–3.11]).

Conclusions

Current meta-analysis confirmed the higher risk of HP eradication failure in individuals with diabetes compared with those without diabetes, suggesting the necessity of prolonging treatment or developing a new regimen for HP eradication in patients with diabetes.     

Efecto de la infección por Clostridium difficile sobre la estancia hospitalaria. Estudio de cohortes

Introduction

Clostridium difficile is responsible for a spectrum of diseases known as “Clostridium difficile infection” (CDI). It is currently the leading cause of nosocomial diarrhea in developed countries. This infection has been associated with both increased hospital stay and mortality, and to a greater likelihood of readmission. In our country these undesirable effects have not yet been characterized. Our objective was to quantify the increase in hospital stay attributable to infection by C. difficile.

Methods

A retrospective cohort study matched by age, sex and admission date, was conducted in a tertiary care university hospital during an outbreak of nosocomial transmission of CDI.

Results

The cohort study included 38 infected, and 76 non-infected patients. Patients who developed CDI showed a higher proportion of malnutrition at admission (OR = 10.3; 3.6 to 29.6), were exposed to a wider range of antibiotics (mean difference = 1.5; 0.7-2.2), had a higher mortality (31.6% vs. 6.6% of controls, P < .001), and a longer hospital stay (median 31.5 days versus 5.5 days for controls, P < .001). After adjustment, infection by C. difficile was associated with an increase in hospital stay of 4 days (P < .001).

Conclusions

C. difficile infection has important consequences on the length of hospital stay, and therefore on health costs.     

Estandarización de la técnica Dot-ELISA para la detección de anticuerpos anti-Trypanosoma cruzi y su comparación con ELISA y Western blot

Introduction

Chagas disease is considered endemic of Latin America. Because of migration of people from this region to non-endemic areas, such as the United States, Canada and Europe, it has become a major health problem. There are parasitology and serology tests for its diagnosis, but only the latter are useful during the chronic phase. Most of these tests require expensive equipment, which make them also inaccessible for laboratories in endemic areas. In the present work we standardize Dot-ELISA as a diagnostic test for Trypanosoma cruzi infection, since it is an easy, inexpensive and an accessible test.

Methods

A total of 360 samples were tested: 96 sera from Chagas patients and 153 from healthy people; 40 blood samples spots collected and eluted from filter paper were also tested, as well as 71 serum samples of patients with non-related infections. Sensitivity, specificity and kappa index of Dot-ELISA test were calculated, in order to determine a correlation value of this technique compared to ELISA and Western blot that are already being used for diagnosis.

Results

Dot-ELISA obtained 97% sensitivity and 89% specificity, since it showed cross-reaction mainly with Leishmania spp., and a kappa index of 0,79.

Conclusions

Dot-ELISA results correlate well with other tests that are already being used for diagnosis of Chagas disease. As it is easy and inexpensive, it may be useful as an additional diagnostic test or for field studies.     

Sensibilidad a azitromicina y otros antibióticos en aislados recientes de Salmonella,Shigella y Yersinia

Introduction

Azithromycin represents an alternative option to treat bacterial diarrhea when the antibiotic therapy is indicated. Little is known regarding the susceptibility to azithromycin in enteropathogens in Spain.

Methods

The MICs of azithromycin were determined by E-test against Salmonella non-typhi (SNT), Shigella and Yersinia isolates collected over the last three years (2010-2012). In addition, the susceptibility to other antibiotics usually used to treat gastrointestinal diseases was determined in these isolates by using a microdilution method.

Results

A total of 139 strains of SNT, Shigella and Yersinia were studied. All of them, except one strain, had a MIC ≤ 16 mg/L of azithromycin. In the adult population, 14.7% and 40.6% of SNT and Shigella isolates, respectively, were resistant to at least 2 of following antibiotics: amoxicillin, trimethoprim-sulfamethoxazole and ciprofloxacin. In the pediatric population, 10% of SNT clinical isolates and 28.6% (2/7) of Shigella isolates were resistant to amoxicillin and trimethoprim-sulfamethoxazole.

Conclusions

In our experience, azithromycin would be a useful antibiotic alternative to treat bacterial diarrhea.     

Candida: epidemiología y factores de riesgo para especies no albicans

Introduction

Nosocomial fungal infections have increased significantly in the last decade. Candida detection in clinical specimens can mean either colonization or an infection which can be local (muguet) or invasive. Knowledge of the species helps in choosing the best treatment. The aims of this study were to determine the frequency and distribution of Candida species detected in clinical samples, to analyze the clinical characteristics of the involved population and to determine the risk factors for Candida non-albicans species.

Methods

Retrospective, observational. Period: 2006-2010. Inclusion criteria: all isolates of Candida in clinical specimens from patients hospitalized —at least 48 hours in a neurological center. We analyzed epidemiological characteristics, co morbidities, risk factors, factors associated with Candida non-albicans detection, antifungal treatment, development of adverse events and mortality.

Results

Candida spp. was isolated from 321 clinical specimens: 139 (43.3%) were C. albicans and 182 (56.7%) Candida non-albicans. The distribution of the sample was: urine 122 (Candida non-albicans 67.2%), airway 81, oropharynx 45 (C. albicans) and candidemia 40 (Candida non-albicans 75%). The most frequent co-morbidity was solid tumor (35.5%). The main risk factors were antibiotic therapy (85.5%), steroid therapy (61.7%) and in ICU at diagnosis (61.6%). The analysis of risk factors and the isolation of Candida non-albicans shows that chemotherapy, previous surgery, treatment with aminopenicillins, carbapenems and glycopeptides were statistically significant (P < .05). There is a trend in neutropenic patients (P = .055) and in ICU at diagnosis (P = .076). Overall survival was 71%.

Conclusions

Candida species distribution varies with the type of sample analyzed. Non-albicans species make up the majority of the isolates. The identification of the species involved per sample helps to optimize treatment. The high frequency of isolation of Candida in patients on steroids and antibiotics and admitted to ICU, is worth pointing out. Patients with previous surgery, treated with the aforementioned antibiotics or chemotherapy, could receive non-azole antifungals in the initial empirical treatment strategy.     

No reflow : quels facteurs prédictifs ?

Introduction

During the past 20 years, significant progress has been made in the recanalization of ACS with ST elevation. It is now accepted that the reopening of the large coronary vessels in the acute phase of infarction by thrombolysis or angioplasty is necessary but not sufficient, because in 20–50% of cases, the coronary recanalization is an illusion of reperfusion. This phenomenon is called “no reflow”.

Objective

The main objective of our study was to identify predictors of poor perfusion or “no reflow” in the acute phase of myocardial infarction.

Methods

Observational prospective study, in the department of cardiology and internal medicine, university hospital of Blida, over a period of 28 months from 1st September 2010 to 31st January 2013. We identified all patients hospitalized for myocardial infarction in acute phase, who underwent primary angioplasty or thrombolysis with angiographic control during a good TIMI flow. The endpoint was regression of ST segment (regression < 50% ST-segment defined no reflow).

Results

Three hundred and seventy-nine patients were included. The mean age was 56.3 ± 2.1, 87.8% of patients were male. In total, 35.9% hypertensive, 27.1% diabetic type 2, 50.1% and 10.8% dyslipidemia, smoking. One hundred and forty-seven (38.8%) developed a no reflow. Mortality was 3.9%, strongly correlated with no reflow (P = 0.001). Predictors of no reflow after multivariate analysis were: age (OR 98, 0.961–0.996 95%, P = 0.02), heart rate (1.01, 95% CI 0.998–1.02, P = 0.035), the type 2 diabetes (odds ratio 1.87, CI 1.2–3.0, P = 0.08), reaching the core (OR 7, 95% CI 1.2–18.4, P = 0.027), direct stenting (OR 0.48, 95% CI 0.31–0.78, P = 0.003). An interesting subgroup of patients was identified namely the subgroup strategy deferred primary angioplasty with stenting best reperfusion (OR 3.7, 95% CI 1.5–8.8, P = 0.04), a lower rate of reocclusion of culprit artery and a lower rate of stenting with 23/51 (45.1%) versus 136/136 (100%) of immediate stenting group with a P < 0.001.

Conclusion

No reflow is a common phenomenon, strongly correlated with mortality predictors are age, heart rate, diabetes, achieving the core and direct stenting. The distal embolization in primary angioplasty is an important phenomenon, a delayed stenting strategy appears to limit this phenomenon.     

Erradicación de un brote nosocomial de infecciones por Acinetobacter baumannii multirresistente tras el ajuste de cargas de trabajo y refuerzo de precauciones específicas

Introduction

During 2009, an outbreak of multidrug-resistant Acinetobacter baumannii (MDR A. baumannii) infections was detected in a 27-bed intensive care unit, resulting in 25 cases being infected.

Methods

A matched case-control study was conducted to identify risk factors for infection. The colonization pressure, or the proportion of other patients colonized by MDR A. baumannii, was estimated. TISS-28 and Omega scores of each patient were calculated to evaluate nursing work requirements. Conditional logistic regression analyses were carried out.

Results

Breakdowns in hand washing and glove use were observed. Infected patients (cases) were more likely than paired controls to have had longer exposure to invasive devices and antimicrobial treatment. The independent risk factors identified by the multivariate analysis were, mechanical ventilation [odds ratio (OR) = 1.03; 95% confidence interval (CI), 1.01-1.05; P = .01], and exposure to an infected or colonized patient [OR = 1.7; 95% CI, 1.1-2.6; P = .02). A combined infection control strategy was implemented, including strict compliance with isolation precautions, grouping of patients, reinforcing cleaning and disinfection of surfaces, and a decrease in work load. Subsequently, a sharp reduction in the incidence MDR A. baumannii infections was shown. Therapeutic activity scores were significantly higher for cases than for controls.

Conclusion

The results suggest patient-to-patient transmission of MDR A. baumannii. Reinforcement of specific procedures and work load adjustment were essential to eradicate this outbreak.     

Algorithm proposal based on the C. Diff Quik Chek Complete ICT device for detecting Clostridium difficile infection

Objective

To assess a new immunochromatography (ICT) test that detects glutamate dehydrogenase (GDH) antigen and Clostridium difficile toxin A/B simultaneously, and to propose an algorithm for the diagnosis of C. difficile infection (CDI) based on this test.

Methods

We analysed 970 stool samples. Discrepant results between GDH and toxin A/B were resolved using toxigenic culture as the reference.

Results

This test enabled us to obtain a conclusive result in <30 min in 93.8% of the samples. Among the discrepant results (GDH (+)/Toxin A/B (−)), 41.7% (25/60) were found to be toxigenic C. difficile by toxigenic culture.

Conclusion

This test has a high sensitivity and specificity for the diagnosis of CDI.     

Should we systematically perform central nervous system imaging in patients with Whipple's endocarditis?

Background

Whipple's endocarditis is an uncommon disease, with approximately 100 cases reported to date. Case series suggest that Whipple's endocarditis usually presents without extracardiac manifestations of Whipple's disease.

Methods

We report 4 consecutive cases of Whipple's endocarditis associated with brain lesions. All patients fulfilled Duke Criteria for definite endocarditis. Whipple's disease was diagnosed through 16S rRNA polymerase chain reaction assays on valves excised from patients with culture-negative endocarditis (n = 3) or through polymerase chain reaction and periodic acid staining-positive foamy macrophages on duodenal biopsy (n = 1).

Results

All patients were male, aged 56 to 72 years. They presented with mitral (n = 1), aortic (n = 1), mitral and aortic (n = 1), and tricuspid (n = 1) endocarditis. Brain magnetic resonance imaging was performed because of mild-to-moderate cognitive disorders (n = 3) or ataxia (n = 1) and revealed multiple (n = 3) or solitary (n = 1) contrast-enhancing lesions. Cerebrospinal fluid studies revealed meningitis in 1 case. Polymerase chain reaction assays on cerebrospinal fluid were negative for all patients. All patients received intravenous ceftriaxone (2-4 weeks) associated with gentamicin (2 weeks), followed by 1 year of oral trimethoprim-sulfamethoxazole, with favorable outcomes.

Conclusion

Whipple's associated central nervous system disease may be common but frequently undiagnosed, in patients with Whipple's endocarditis. Because treatment is different when neurologic disease is present (ie, trimethoprim-sulfamethoxazole vs doxycycline/hydroxychloroquine), clinicians should consider brain imaging in patients diagnosed with Whipple's endocarditis.     

LCT-13910C > T polymorphism-associated lactose malabsorption and risk for colorectal cancer in Italy

Background

The activity of epithelial lactase (LCT) associates with a polymorphism 13910 bp upstream the LCT-encoding gene (LCT-13910C > T). The relationship between LCT-13910C > T polymorphism and risk for colorectal cancer is unclear.

Aims

We examined the relationship between the LCT-13910C > T polymorphism causing lactose intolerance and risk for colorectal cancer/polyps onset in the Italian population.

Patients and methods

793 subjects (306 with colorectal cancer, 176 with polyps and 311 controls) were genotyped for the LCT-13910C > T variant by TaqMan real time-PCR.

Results

Lactose malabsorption linked to the CC genotype did not associate with an increased risk for either colorectal cancer (OR = 1.041; 95% CI = 0.751–1.442; p = 0.868) or polyps (OR = 0.927; 95% CI = 0.630–1.363; p = 0.769). There was no association with colorectal cancer/polyps site. 60% of the subjects overall bore the CC genotype.

Conclusion

In the Italian population the LCT-13910C > T polymorphism is not associated to the risk for colorectal cancer or polyps.     

Dilated cardiomyopathy in patients with mutations in anoctamin 5

Background

Homozygous mutations in ANO5, a gene encoding anoctamin 5, a putative calcium-activated chloride channel, have recently been reported in patients with adult-onset myopathies or isolated high-CK levels. Cardiomyopathy has not previously been reported in these populations despite a proven expression of anoctamin 5 in the cardiac muscle.

Methods

Patients presenting for the management of high-CK levels or overt myopathy with proven ANO5 mutations were prospectively investigated between June 2010 and March 2012 in Pitié Salpêtrière Hospital, according to a standardised protocol. Neurological and cardiological clinical examinations, CK assessment, electrocardiogram (ECG), and echocardiography were performed, as well as cardiac MRI and coronary CT angiography in patients with left ventricular (LV) dysfunction.

Results

Our study included 19 consecutive patients (male = 15, age = 46.2 ± 12.7 years) from 16 families. Five had asymptomatic high-CK levels and 14 had overt myopathy. One patient had a personal history of stable coronary artery disease with normal ventricular function. ECG showed ventricular premature beats in one patient. Echocardiography displayed LV dilatation in two patients, LV dysfunction in one, and both abnormalities in two who fulfilled criteria for dilated cardiomyopathy which was confirmed by cardiac MRI and normal CT angiography.

Conclusions

Dilated cardiomyopathy is a potential complication in patients with myopathies due to mutations in the ANO5 gene whose screening requires specific procedures.     

La práctica de un tratamiento antirretroviral empírico es dependiente del porcentaje de resistencias primarias del virus de la inmunodeficiencia humana

Objective

The objective of this study was the analysis of the prevalence and type of primary resistance to antiretroviral drugs in patients diagnosed with HIV infection, and to determine the most appropriate empirical treatment to obtain a virological and immunological response.

Patients and methods

An observational analysis of patients with a de novo diagnosis of HIV infection during the period 2008-2010. Clinical, immunological and virological characteristics, including genotype analysis of resistance to antiretrovirals, were considered as independent variables. The dependent variable was an undetectable HIV viral load after six months of treatment. Data are provided as median (interquartile range) and absolute number (percentage).

Results

Seventy-three patients with a de novo diagnosis of HIV infection were included [53 males (73%); 36 (30-46) years-old; prior use of intravenous drugs: 5 patients (7%); hepatitis C virus co-infection: 13 individuals (18%)]. Ten patients (14%) showed symptoms attributable to acute HIV infection. A CD4+ T cell count lower than 350 mm³ was detected in a 37% (n = 27) of all patients. The initiation of antiretroviral therapy followed the GESIDA recommendations (no therapy: 20 patients; tenofovir + emtricitabine + efavirenz: 28 patients; abacavir + lamivudine + efavirenz: 1 patient; tenofovir + emtricitabine + protease inhibitors: 5 patients; abacavir + lamivudine + protease inhibitors: 1 patient; 18 patients were lost in the follow-up). After starting antiretroviral therapy, the resistance analyses detected the existence of primary resistance to antiretrovirals in 12.7% (confidence interval 95%: 3-22) of the patients, distributed as follows: isolated resistance to, nucleosides was detected in 2% (M184 V), to nevirapine/efavirenz in 9% (K103 N), and combined resistance to nucleosides and non-nucleosides in 2%; there were no cases of resistance to protease inhibitors. Consequently, antiretroviral therapy was changed in 5 (14%) out of 35 patients, attaining an undetectable HIV viral load at 6 months in all of them. The primary resistance to antiretrovirals was not related with epidemiological, virological (including infection by non B subtype) or immunological variables.

Conclusions

In the present study, a change in the epidemiological pattern of de novo diagnosis of HIV infection in our area has been observed. The existence of resistance mutations in more than 5% of the new cases is noteworthy. This finding must be considered in order to establish the rules of empirical treatment in our area.     

Previous immunosuppressive therapy is a risk factor for immune reconstitution inflammatory syndrome in Whipple's disease

Introduction

Whipple's disease is a rare chronic infection caused by Tropheryma whipplei. Although most patients respond to antibiotics, in some of them the start of the treatment is followed by recurrence of inflammation. Since polymerase chain reaction is negative for Tropheryma whipplei, this reinflammation cannot be a relapse of Whipple's disease itself. Very recently, it has been recognised as a complication of Whipple's disease and defined immune reconstitution inflammatory syndrome (IRIS). Our aim is to study the prevalence and the clinical features of IRIS in Italian patients with Whipple's disease.

Methods

Evidence of IRIS was retrospectively revaluated in the clinical notes of 22 patients with Whipple's disease. Patients with no evidence of IRIS served as controls for the clinical findings.

Results

Recurrence of arthralgia and/or fever allowed a diagnosis of IRIS in 5/22 patients. One patient died. Previous immunosuppressive therapy was found in all patients with IRIS but only in 7/17 controls (Fisher test, p = 0.039). Age at diagnosis and diagnostic delay were higher in patients with IRIS compared to controls. However, statistical significance was not reached.

Conclusions

IRIS is a frequent complication of Whipple's disease and it can be fatal. The risk of IRIS is greatly increased in patients previously treated with immunosuppressive therapy.     

Molecular epidemiology of fluoroquinolone resistance in invasive clinical isolates of Streptococcus pneumoniae in Seville

Introduction

Due to the emergence of drug-resistant pneumococcal isolates, new fluoroquinolones have been recommended for the treatment of pneumococcal infections. The purpose of this study was to establish surveillance, and to conduct molecular characterization, of fluoroquinolone-resistant Streptococcus pneumoniae in Seville.

Method

Norfloxacin-resistant S. pneumoniae isolates were characterized by quinolone resistance-determining region (QRDR) substitutions, reserpine-sensitive efflux, serotype and by pulsed-field gel electrophoresis (PFGE) patterns.

Results

Fourteen isolates (5.1%) showed an MIC > 16 μg/ml to norfloxacin. Eight of 10 adult isolates were susceptible to levofloxacin. The 4 infant isolates with norfloxacin MIC > 16 μg/ml were susceptible to levofloxacin. Seven of these 12 low-level-resistant isolates had mutations in ParC, while mutations both in ParC and GyrA genes were only detected in one of the two high-level-resistant isolates. All the isolates without QRDR substitutions that remained norfloxacin-resistant were positive for reserpine-inhibited efflux. The serotyping and PFGE revealed significant heterogeneity. We obtained 9 different profiles, 3 of which had two isolates each. Two of the isolates with the same pulsotype were from the same patient. The first isolate showed a mutation in the QRDR of ParC, and the second one had an additional GyrA mutation.

Conclusion

In our study a levofloxacin resistance rate of 0.7% was found among invasive isolates. Although resistance level is low, surveillance is necessary, especially to prevent cases of in vivo resistance development as reported.