Peripheral gangrene in children

The case histories of 36 patients treated for peripheral gangrene between 1973 and 1987 were reviewed. The commonest causes of gangrene were disseminated intravascular coagulation due to bacterial septicaemia (15 patients) and dehydration due to gastro-intestinal fluid loss (8 patients). In only 2 patients was gangrene of truly iatrogenic origin; in 4 no apparent cause could be found. Secondary or contributing factors were recognisable in the majority. The overall mortality was 30%. Major lower limb amputation was necessary in 5 patients (bilateral in 3). The aetiology of peripheral gangrene was therefore multifactorial in most patients and idiopathic in only a small number. Delay before amputation allows both adequate stabilisation of severely ill patients and clear demarcation of gangrenous tissue.Offprint requests to: D. H. Bass     

Diagnostic audit of C-reactive protein in neonatal infection

A prospective study of 250 consecutive neonatal admissions to a regional perinatal referral centre and of 10 additional consecutive cases with culture-proven neonatal septicaemia was undertaken. Quantitative C-reactive protein (CRP) determination, white cell count and differential were performed on blood samples obtained from all babies on admission, as well as 10–14 h and 22–26 h later. Using clinical signs, chest X-rays, blood cultures, tracheal aspirates obtained within 4 h of delivery and an abnormal immature/total neutrophil ratio (I/T), infected babies were defined as belonging to one of the following groups: (1) Culture-proven septicaemia (n=19); (2) Clinical septicaemia (n=35); (3) Congenital pneumonia (n=28). The sensitivity, specificity, positive and negative predictive value of CRP were calculated for each sampling time and patient group. No baby had a rise in CRP (>6mg/l) before an abnormal I/T ratio was first detected. A delayed rise in CRP concentration in the majority of infected babies occurred approximately 12–24 h after the abnormal I/T ratio was first detected. The overall specificity of a CRP level of ≥10 mg/l remained approximately constant (97%–94%) while sensitivity increased from 22%–61% with increasing time after admission. The same pattern emerged if each patient group was considered separately. The positive predictive value for a CRP level of ≥10mg/l 22–26 h after admission was 83% and the negative predictive value 82%. CRP had no value in the early diagnosis of neonatal infection. Its main role lies rather in the exclusion or confirmation of infection 24 h after the first clinical suspicion.     

Is bleomycin-detectable iron present in the plasma of patients with septic shock?

Objective: To assess plasma iron status in critically ill patients with septic shock. Design: Observational, prospective study. Setting: Adult intensive care units in teaching and tertiary referral hospitals. Patients and participants: Fifteen adult patients with established septic shock. Normal control subjects (n = 10) were also investigated. Data from patients and controls were compared with previously published iron values in critical care patients. Measurements and results: The indices investigated and correlated with clinical scores of illness severity included bleomycin-detectable iron, non-haem iron; transferrin and its percentage iron saturation, and the iron binding (anti-oxidant) activity of transferrin. Bleomycin-detectable iron was not present in the plasma of patients with septic shock whilst the plasma transferrin remained unsaturated with iron. One patient in multi-organ failure displayed bleomycin-detectable iron in plasma (1.16 μmol/l) and had 100 % iron-saturation of transferrin. The plasma non-haem iron levels (7.84 ± 1.82 μmol/l) were the lowest of all critical care patient groups studied by us. The plasma transferrin levels were also low but resulted in a near normal percentage saturation of transferrin with iron (34.6 ± 6.5 %). The scores of clinical severity correlated with changes in plasma iron chemistry. Conclusions: Patients with septic shock rarely have iron saturated transferrin in their plasma leading to the presence of bleomycin-detectable iron. Received: 6 November 1996 Accepted: 9 March 1997     

Meningococcal septicaemia: treatment with protein C concentrate

Meningococcal septicaemia is a devastating disease with the potential to develop severe vascular complications. The incidence in Northern Ireland has risen from 27 cases notified in 1992 to 56 notified in 1997. We describe the first use of protein C concentrate in addition to antithrombin III infusion in the management of a life-threatening case of meningococcal septicaemia in the Regional Intensive Care Unit, Royal Group of Hospitals, Belfast, UK. The rationale and the evidence to support the use of protein C concentrate are discussed. Despite the apparent efficacy and safety of this treatment, subsequent cases of meningococcal septicaemia have not received protein C concentrate due to a lack of availability. Received: 16 March 1999 Final revision received: 17 November 1999 Accepted: 1 February 2000     

Molecular diagnosis of microbial aetiologies using SepsiTest™ in the daily routine of a diagnostic laboratory

A universal PCR and sequencing test, SepsiTest™ (Molzym, Germany) was evaluated for its applicability during daily diagnostic routine in a privately operated laboratory. In total, 96 specimens originating from 66 patients under suspect of infectious endocarditis, infections of joints, encephalitis/meningitis, systemic infections and infections of unknown genesis were PCR analysed and compared to culture results. Samples comprised cultured and non-cultured blood, synovial fluid, synovial tissue, heart valves, pacemakers, spinal tissue, cerebrospinal fluid, and swabs. PCR and culture were concordant in 26 negative and 8 positive cases (51.5%). A group of 25 patients was culture-negative but PCR-positive (37.9%). In at least 14 of these, common and/or rare aetiologies were identified, while for 4 patients the results of 16S PCR could not be unequivocally linked with the underlying disease. Benefits and limitations of the molecular test are discussed with special emphasis on technical and economic issues. In conclusion, SepsiTest™ proved to be a valuable tool for the diagnosis of aetiologies, particularly in cases of culture-negative patients who are under strong suspicion for an infection.     

Listeria septicaemia following insertion of a dynamic hip screw: A case report and literature review

INTRODUCTIONListeria monocytogenes is a food borne bacterial pathogen which is rarely encountered in the United Kingdom. This rare and potentially life threatening infection has a high mortality rate and therefore requires early antimicrobial intervention.PRESENTATION OF CASEA case report of a patient who developed Listeria septicaemia following insertion of a dynamic hip screw is described. This 84 year old immunocompromised lady had a mechanical fall at home, from which she sustained a left neck of femur fracture. She had a background of rheumatoid arthritis, and for the last 10 years had been taking 5 mg prednisolone daily. After early surgical intervention with a dynamic hip screw, she developed Listeria septicaemia, following which she was treated successfully with ampicillin and gentamicin.DISCUSSIONInfection with unusual pathogens is not uncommon amongst immunocompromised patients. Regardless of the cause, this cohort of patients’ requires increased post operative surveillance to ensure that such a complication does not go unnoticed.CONCLUSIONThis case report demonstrates the importance of having a low threshold for investigation in immunocompromised patients whilst also stressing the significance of early diagnosis and intervention.     

深圳市儿科葡萄球菌败血症的病原菌种分布及耐药性分析

的:分析深圳市儿科葡萄球菌败血症病原菌种的构成与抗生素耐药性的关系。方法:采用VITEK全自动微生物分析系统进行葡萄球菌的鉴定、15种抗菌药物敏感试验、β-内酰胺酶及耐苯唑西林葡萄球菌(MRS)检测。结果:68株自血培养分离葡萄球菌的鉴定结果金黄色葡萄球菌35株,表皮葡萄球菌14株、人葡萄球菌5株、模仿葡萄球菌5株、头状葡萄球菌3株、溶血葡萄球菌14株、科氏葡萄球菌2株和松鼠葡萄球菌1株;金黄色葡萄球菌和表皮葡萄球菌对氨苄西林/舒巴坦、头孢唑啉、红霉素、苯唑西林和四环素的耐药率分别为63%、63%、77%、63%、71%和86%、86%、64%、86%、79%,对氨苄西林和青霉素均耐药。所分离的葡萄球菌对环丙沙星、克林霉素、庆大霉素和氧氟沙星的耐药性较低,对万古霉素和呋喃妥因均敏感。结论:儿科葡萄球菌败血症抗菌药物治疗时,应注意葡萄球菌种间耐药特性,合理用药。     

Strongyloides stercoralis septicaemia following steroid therapy for eosinophilia: report of three cases

Three apparently immunocompetent patients died in the intensive care unit at Loni Hospital, Ahmednagar, Maharashtra, India, between 2001 and 2006 due to multiorgan failure and Strongyloides stercoralis septicaemia following a short course of corticosteroid (prednisolone) therapy of 6-17 days for peripheral blood eosinophilia associated with urticaria and angioneurotic oedema, bronchospasm, and generalised aches and pains, respectively. None of the patients had any obvious lymphoproliferative disorder, solid tumour or HIV 1+2 infection as an underlying immunosuppressive condition. These three patients highlight the extreme caution that must be exercised in administering a moderate dose of oral corticosteroid even for a short period of time as well as the high degree of suspicion that needs to be maintained if there is clinical deterioration following corticosteroid therapy.