Die Rolle coagulasenegativer Staphylokokken in Mischinfektionen: Assoziationstestungen als in-vitro-Modell

Zusammenfassung Die Zunahme von Infektionen durch hochresistente grampositive Kokken hat in den letzten Jahren vornehmlich auf Intensivstationen zu erheblichen therapeutischen Problemen geführt. Hierbei ist eine Gruppe von Erregern in den Vordergrund getreten, die früher als harmlose Saprophyten galten: coagulasenegative Staphylokokken (CNS). In der vorliegenden Arbeit werden zunächst Daten zur Incidenz in verschiedenen Versorgungsbereichen unserer Klinik und zur Coincidenz mit anderen Erregern auf unserer Intensivstation vorgestellt. Es konnte gezeigt werden, daßS. aureus zwar der zahlenmäßig häufigste grampositive Erreger war, aber CNS sowohl aus Wundabstrichen der Intensivstation als auch aus Blutkulturen deutlich häufiger isoliert werden konnte. Ein gleichzeitiger Nachweis von CNS mitS. aureus und den neun häufigsten Enterobacteriaceae konnte in durchschnittlich 6% erbracht werden. Durch mögliche Interaktionen zwischen unterschiedlichen Erregern kann eine Veränderung der in Einzeltestung beobachteten Resistenzen auftreten. Um dies nachzuweisen, wurden sechs Erregerpaare einzeln und in Assoziation gegen Amoxicillin und Amoxicillin/Clavulansäure getestet. Unter Assoziation wurde das gemeinsame Wachstum zweier Keime unter kontrollierten Bedingungen in Boullionverdünnungsreihen oder einem Laborautomaten zur Resistenztestung (Cobas Bact) verstanden. In allen Fällen zeigte sich, daß die-Lactamasen der CNS in Assoziation die MHK der anderen Erreger deutlich erhöhte, was durch den Zusatz von Clavulansäure verhindert werden konnte. Eine Einzeltestung gibt also bei Mischinfekten mit Beteiligung von-Lactamasebildnern nur einen eingeschränkten Eindruck von der tatsächlichen Resistenzsituation.

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Role of coagulase negative staphylococci in mixed infections: associative testing as in vitro model

Summary Infections due to coagulase negative staphylococci (CNS) are of growing concern mainly in patients hospitalized in intensive care units (ICU). The ability of CNS to adhere and to grow on plastic devices and resistance to many antibiotics, including oxacillin, contributes to their pathogenicity. Using the computer assisted system of the Medical Microbiology Department, the incidences of different pathogens and the coincidence of CNS with other bacteria were evaluated in a surgical department.Staphylococcus aureus revealed to be the predominant pathogen; however, CNS showed an increasing incidence in wound specimens and blood cultures of patients on the ICU. Coincidence of CNS withS. aureus and the nine most frequent species of gram negative bacteria could be shown in 6%. To investigate the influence of-lactamases produced by CNS in mixed infections, association experiments were performed. Association means a controlled growth of two or even more bacteria in a susceptibility testing system, either a broth dilution method or an automated broth disk elution method (Cobas Bact). The association experiments showed a significant increase of amoxicillin MIC's of the pathogen associated with CNS. Addition of clavulanic acid restored activity of amoxicillin. It could be shown that in mixed infections CNS may contribute to the failure of antibiotic regimens by production of-lactamases.

     

Vergleichende Untersuchungen über die organotrope carcinogene Wirkung verschiedener N-Nitrosoverbindungen nach einmaliger bzw. langzeitiger Applikation bei Ratten

Zusammenfassung Die einmalige Gabe von 200 mg N-Nitrosodiethylamin/kg Körpergewicht per Magensonde bewirkt bei weiblichen Ratten (SIV 50) das Auftreten von Nierentumoren, während die Anwendung von 10 ppm N-Nitrosodiethylamin im Trinkwasser Oesophagus-und Lebertumore induziert. Diese Veränderung der organotropen carcinogenen Wirkung wird nicht mit den am Phenylrest methylsubstituierten N-Methyl-N-nitrosobenzylaminen erhalten. Sowohl Langzeit-als auch die einmalige Applikation lösen Tumore im Oesophagus und im Pharynx aus.Für die histologischen Befunde, der mit N-Nitrosodiethylamin behandelten Tiere danken wir Prof. Dr. F.-W. Kolkmann, Pathologisches Institut am Kreiskrankenhaus Nürtingen     

Die Nachsorge des Analkarzinoms

Die Entwicklung neuer Behandlungsm?glichkeiten des Analkarzinoms in den letzten 30 Jahren hat die klinischen Ergebnisse bei dieser Krankheitsentit?t merklich verbessert. Innerhalb dieser Zeit diente die konsequente Nachsorge u. a. der Erfassung der relevanten Parameter der lokoregion?ren Tumorkontrolle, des überlebens und der Beurteilung der therapieassoziierten Morbidit?t. Dies führte zur Optimierung der Therapie im Sinne des Patienten. Im Folgenden soll die aktuelle Bedeutung und der notwendige Umfang der tumorspezifischen Nachsorge nach abgeschlossener Prim?rtherapie des Analkarzinoms dargestellt werden.     

Functional results after laparoscopic rectopexy for rectal prolapse

We investigated the functional results after laparoscopic rectopexy for rectal prolapse in 29 patients at least 12 months postoperatively. Twenty patients were evaluated completely pre- and postoperatively (median 22 months postoperatively, range 12 to 54 months). Six patients were interviewed by telephone, two patients were lost to follow-up, and one patient died of causes unrelated to rectal prolapse. Patients underwent a proctologic examination, anoscopy, rigid sigmoidoscopy, fluoroscopic defecography, and anorectal manometry pre- and postoperatively, and an additional standardized interview postoperatively. Anorectal manometry showed a significant increase in maximum anal resting and squeeze pressures postoperatively (resting pressure 72 ±8 vs. 95 ±13 mm Hg, pre- vs. postoperatively; P = 0.046; squeeze pressure 105 ±17 vs. 142 ±19 mm Hg, pre- vs. postoperatively; P = 0.035), and continence improved postoperatively (Wexner incontinence score 6.0 ±1.0 vs. 3.9 ± 0.8 pre- vs. postoperatively, P = 0.02). Twenty (77%) of 26 patients were satisfied with the operative result, but functional morbidity was observed in four patients, with two patients complaining of severe evacuation problems. Rectal prolapse recurred in one patient 42 months postoperatively (recurrence rate 1 [3.8%] of 26 patients). Functional results were very similar to those obtained after open rectopexy, with symptoms of prolapse and incontinence improved in the great majority of patients. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Postoperative colonic motility in patients following laparoscopic-assisted and open sigmoid colectomy

Clinical reports on laparoscopic-assisted sigmoid colectomy (LASC) suggest that the period of postoperative inhibition of gastrointestinal motility is shortened as compared to open sigmoid colectomy (OSC). We aimed to specifically investigate whether colonic motility increases more rapidly following LASC compared to OSC. LASC was performed in 11 patients and OSC in nine patients for recurrent diverticulitis or carcinoma. During surgery a manometry catheter was inserted into the colon via the anus, and the tip was placed in the splenic flexure. Continuous manometric recordings were performed from the day of surgery until postoperative day 3 with a four-channel microtransducer manometry system combined with a portable data logger. The postoperative colonic motility index was 101± 18, 199 ± 30, and 163 ±27 mm Hg/min on days 1,2, and 3 after LASC, respectively, which was increased compared to indexes of 53 ± 15, 71 ± 18, and 76 ± 23 following OSC (mean ± standard error of the mean; P < 0.05). The amplitude but not the frequency of contractions was higher following LASC compared to OSC. Following LASC, patients requested a similar amount of pain medication but resumed oral food more rapidly on postoperative days 2 and 3 (P < 0.05), and they were discharged from the hospital earlier (P < 0.05). Colonic motility in particular and the patient’s condition in general seem to improve more rapidly following LASC compared to the open procedure. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22, 2003 (oral presentation).     

Sulbactam in combination with mezlocillin, piperacillin or cefotaxime. Clinical and bacteriological results in the treatment of severe bacterial infections

An open multicenter study on inpatients of 12 german hospitals was performed to investigate efficacy and safety of sulbactam in combination with mezlocillin, piperacillin or cefotaxim in severe bacterial infections. In total 155 patients were enrolled. The following infections were diagnosed: 48 lower respiratory tract infections, 66 intraabdominal infections, 34 skin/soft tissue infections including post operative wound infections and 5 complicated urinary tract infections. 55 patients received 3 daily doses of 4 g mezlocillin + 1 g sulbactam, 52 patients received 3 daily doses of 4 g piperacillin + 1 g sulbactam and 48 patients received 3 daily doses of 2 g cefotaxim + 1 g sulbactam. Antibiotics and sulbactam were administered concomitantly via intravenous short infusion. Mean duration of therapy was 8 days. Endpoints for assessment of therapeutic efficacy were cure (complete resolution of pretreatment signs and symptoms of the infection) or improvement (marked reduction or partial disappearance or pretreatment signs and symptoms, no further antibiotic therapy required) as well as eradication of pretreatment pathogens. 141 (92%) of 153 evaluable patients were successfully treated (98 cures and 43 improvements), therapy failed in 12 patients (7.8%). Success rates of the 3 sulbactam combinations were almost identical: 91% for mezlocillin/sulbactam, 92% for piperacillin/sulbactam and 93% for cefotaxim/sulbactam. 106 patients (68.4%) were also bacteriologically evaluable. In these patients 192 bacterial pathogens were isolated prior to study therapy, 55 patients had mixed infections. In 96 patients (90%) pretreatment pathogens were eradicated (180 strains = 94%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Akutes Karpaltunnelsyndrom bei Marfan-Syndrom

Acute carpal tunnel syndrome (ACTS) is rare and is mostly the result of fractures of the distal radius or the carpal bones. This paper gives the first report of an ACTS following contusion of the wrist as the result of an extensive haematoma of the flexor tendon sheath, which did not appear until 50 hours after the injury was sustained but then developed rapidly. The patient suffers from Marfan syndrome. This disease is associated with pathologic changes to the major vessels, and especially the aorta, and of the smaller peripheral vessels. It is assumed that the haematoma arose from an aneurysm of such a small vessel. The treatment of choice in ACTS is emergency incision of the carpal tunnel.     

Massive hemorrhage from an "esophageal tumor": thoracic aortic aneurysm rupturing into the esophagus

We report on an arteriosclerotic aneurysm of the descending aorta penetrating into the esophagus. On endoscopy it mimicked a bleeding esophageal tumour. The typical clinical course of aortoesophageal fistulas (AEF) exhibits Chiari's triad of midthoracic pain, sentinel arterial hemorrhage, usually hematomesis, and final exsanguination after a symptom-free interval. The various causes of AEF are discussed together with the respective diagnostic and therapeutic problems.     

Three-dimensional laparoscopy and thoracoscopy in children and adults: A prospective clinical trial

Background: Laparoscopic procedures for children and adults already provide many advantages in two-dimensional (2D) vision. Only limited experiences exist for laparoscopic three-dimensional (3D) procedures in vivo. The aim of this prospective trial was to identify indications and limitations of the 3D-system in laparoscopic minimally invasive procedures in children and adults. Material and methods: In a prospective quality assurance for laparoscopic 3D evaluation in children and adults, a total of 53 consecutive patients (22 children, 31 adults) were included. Laparoscopic transabdominal, retroperitoneal and thoracoscopic procedures were performed. For laparoscopic 3D imaging a Camera Control Unit (CCU), 3D monitor and 3D-TIPCAM® were used. Patient data, operative procedures and image quality of the 3D system were assessed. Results: Of 53 patients, 22/53 were children and 31/53 adults with a mean age of 7.6 years (range, 10 months to 15 years) and 51.5 years (range, 18 to 79 years), respectively. 8/22 children were two years old or younger. No relevant difficulties occurred with nausea, fatigue, vertigo, eye blurring or double vision, burning eyes, visual fatigue, inconvenience of visual adaptation of 3D to 2D, or medical discomforts for the surgeons in both children and adults. Difficulties were mainly addressed to the small distance of the video endoscope and the organ tissue in small children and affected mainly image definition, resolution and eye focusing. Conclusions: Advantages of 3D over 2D were mainly considered to be of relevant benefit in adults. Subjective advantages were seen in children and adults for stereoscopic depth perception, better visualization of anatomical structures and understanding of the anatomy, as well as for complex maneuvers such as suturing.     

Cell-mediated cytotoxicity in hepatitis A virus infection

We studied cell-mediated cytotoxicity to hepatitis A virus-infected cells in seven patients with acute type A hepatitis and two controls. Skin fibroblast cultures obtained from the skin biopsies of seven patients after acute hepatitis A virus infection and from two persons without history of current or past hepatitis A virus infection were inoculated with hepatitis A virus. Infection of fibroblast cultures always resulted in an inapparent, persistent infection with production and release of infectious hepatitis A virus. Peripheral blood lymphocytes were collected from the same patients at different times after onset of icterus and were stored in liquid nitrogen. Cytolytic activity of peripheral blood lymphocytes was determined by a microcytotoxicity assay using autologous 51Cr-labeled hepatitis A virus-infected and uninfected target cells. Cytotoxic peripheral blood lymphocytes capable of lysing autologous hepatitis A virus-infected skin fibroblasts were detected in all patients with hepatitis A but were not demonstrable in the controls without antibodies against hepatitis A virus. The clinical course of the hepatitis A virus infection was normal in five patients; and in these patients, cytolytic activity of peripheral blood lymphocytes against hepatitis A virus-infected autologous targets peaked 2 to 3 weeks after onset of icterus. A clinically protracted form of the disease with persistent elevation of aminotransferases for at least 5 months after onset was present in two patients. In these cases, the highest cytolytic activity was demonstrated in peripheral blood lymphocytes collected 8 to 12 weeks after onset of icterus.(ABSTRACT TRUNCATED AT 250 WORDS)