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Probiotics
Abstract
Probiotics recently are defined as “live microorganisms which when administered in adequate amount confer a health benefit on the host” by the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO). Mechanism of action of probiotics Competitive exclusion of pathogenic bacteria. Probiotics may compete with pathogenic bacteria for epithelial binding sites and thus prevent gut colonization by bacterial species such as Clostridium difficile, Salmonella choleraesuis, Staphylococcus aureus, and others. Induction of defensin production. Cytoprotective and antimicrobial substances are produced by the intestinal epithelium to control the microenvironment of the gut. Defensins are antimicrobial peptides synthesized by Paneth cells located in the crypts to counteract bacterial adherence and invasion. Production of antibacterial substances. Many lactic acid-producing bacteria (LAB) produce antibacterial peptides called bacteriocins, such as lactacin B from Lactobacillus acidophilus, having a narrow activity spectrum acting only against closely related bacteria. Improved intestinal barrier function. Recent data indicate that probiotics may initiate repair of the barrier function after damage. Modulation of host immune functions. Probiotic bacteria may act through the stimulation of Toll-like receptors (TLRs) and it appears that certain effects exerted by some probiotic strains or preparations are mediated through interactions with distinct TLRs. It can be assumed that probiotic bacteria stimulate dendritic cells which in turn produce anti-inflammatory cytokines. An ideal probiotic preparation should harbor the characteristics mentioned in Table 209.1. For an adequate amount of health benefits, a dose of 5 billion colony-forming units (CFU) a day (5 × 10⁹CFU/day), for at least 5 days, has been recommended. Bacteria and yeasts may be used as probiotics either in the form of a single strain or combination of microorganisms or mixed with prebiotics (Table 209.2).
The effects of treatment with probiotics on the immunological and hematobiochemical changes in Trypanosoma brucei infection were investigated. Probiotic strains used are Bifidobacterium BB-12, Lactobacillus acidophilus LA-5, Lactobacillus delbrueckii LBY-27, Lactobacillus paracasei LC-01, and Streptococcus thermophilus STY-31. Thirty rats randomly assigned to five groups were used in the experiment. Groups A to C received 1 × 10⁹ CFU, 5 × 10⁹ CFU, and 10 × 10⁹ CFU of the multi-strain probiotics daily and respectively from day 0 post-supplementation (PS) to termination. Group D and E were the infected and uninfected controls respectively. On day seven PS, groups A to D were challenged intraperitoneally with approximately 1 × 10⁶ trypanosomes. Parasitemia, nitric oxide level, hematobiochemical parameters, and antibody titer to heterologous antigen stimulation were monitored post-infection. By days 7 and 16 PS, probiotics-treated groups had significantly lower (p < 0.05) mean creatinine concentration than the controls; however, on day 7 PS, there were no significant variations in the leukocyte counts (LC), total erythrocyte counts (TEC), and the packed cell volume (PCV) in all experimental groups. Following infection, by day 16 PS, the pre-patent period, parasitemia levels, and antibody titer were similar in all infected groups. Furthermore, the probiotics-treated groups and the infected control had significantly lower PCV, TEC, and LC values when compared to the uninfected control, and probiotics treated groups (A and C) had only marginally lower nitric oxide levels than the infected control. Treatment with the probiotic strains gave a creatinine-lowering effect, was innocuous to the hematopoietic system, but was not sufficiently immunostimulatory in trypanosomosis.
Objective
This study aimed to investigate the influence of Lactobacillus rhamnosus intake on the development of candidiasis and cytokines release. Material and methodsCandida suspensions were inoculated into the oral cavity of experimentally immunosuppressed mice for candidiasis induction. The animals were divided into experimental groups: candidiasis with no probiotic intake (F), candidiasis with probiotic intake during Candida inoculation (FP), and candidiasis with probiotic intake 14 days before inoculation with Candida (FPP); and control groups: (C), (CP), and (CPP) without inducing candidiasis with probiotic intake in the same manner as groups F, FP, and FPP, respectively. After these periods, samples were collected from the oral cavity for yeast counts and, after euthanasia, the tongues of the animals were removed for histological analysis. Sera samples were also collected for analysis of IL-1 beta, TNF-alpha, INF-gamma, IL-12, IL-4, and IL-10. ResultsFP group showed lower Candida counts in the oral cavity, and the presence of Candida was almost not detected in FPP group. In tissues, the counts of fungi were significantly lower in FPP group, followed by FP. Groups that consumed probiotics also had lower histological and inflammatory infiltrates compared to F. Cytokines analysis demonstrated low concentrations of TNF-α, IL-12, IL-4, and IL-10 in all the groups, and no statistical difference between them. The production of IL-6 could be better detected, and the experimental groups that consumed the probiotic showed significant lower levels of this cytokine. Conclusions
The results suggest that L. rhamnosus intake, especially preventively, may avoid or decrease the development of candidiasis in immunosuppressed mice. Clinical relevanceThis work adds scientific evidences that probiotics intake can avoid the development of candidiasis.
Objetivo: Mostrar los beneficios de los microorganismos probióticos sobre la salud y su aceptación por parte del consumidor, así como hacer una recopilación de todos los productos probióticos disponibles en el mercado farmacéutico. Material y métodos: Se realizó un estudio del mercado farmacéutico en relación a las formas farmacéuticas con microorganismos probióticos existentes y su evolución en los últimos años. La clasificación de todos los productos probióticos se llevó a cabo en función de la forma farmacéutica en la que se presentan;cada producto irá acompañado de la dosis de microorganismos probióticos que contiene, expresada como Unidades Formadoras de Colonias (UFC). Resultados: Es cada vez mayor el número de cepas probióticas aisladas y los beneficios mostrados sobre la salud del hombre. Encontramos gran diversidad de productos probióticos disponibles en oficinas de farmacia como consecuencia de una demanda cada vez mayor por parte del consumidor; no obstante, cabe resaltar el hecho de que muchos de ellos carecen en envase de información necesaria, por ejemplo, la dosis contenida. Conclusiones: El interés por parte de la industria farmacéutica en lazar nuevas formas farmacéuticas contenidas en microorganismos probióticos será cada vez mayor e irá ligado a la necesidad de una reglamentación específica para estos productos. Muchos de ellos no contienen la dosis mínima requerida para obtener un efecto beneficioso en la salud lo que supone una publicidad engañosa para el consumidor, por tanto, deberían ser retirados del mercado, publicitando únicamente aquellos que contengan una dosis terapéutica y cuyos efectos estén avalados por diferentes ensayos clínicos.
Objetivos: Determinar las características epidemiológicas, clínicas, datos de laboratorio y tratamiento de la Bartonelosis aguda en niños. Materiales y métodos: Se revisaron las historias clínicas de 32 niños con Bartonelosis aguda, internados en el Hospital Nacional Cayetano Heredia y en el Instituto Especializado de Salud del Niño entre 1993 y 2003. Resultados: La edad promedio fue 9,8 años, 72% fueron varones, los lugares de exposición probable fueron principalmente las zonas endémicas de los valles interandinos de Perú, pero hubieron pacientes procedentes de zonas no endémicas de la selva alta; fueron nativos de éstas zonas el 72%. Los síntomas principales fueron fiebre (97%), hiporexia (91%), síntomas gastrointestinales (66%) y malestar general (53%); los signos principales fueron palidez (97%), hepatomegalia (78%), taquicardia (75%) y linfadenomegalia (72%). El promedio de hematocrito fue 18,8 %, 63% cursaron con anemia severa, leucocitosis 63%, hiperbilirrubinemia a predominio indirecto 45% de casos e hipoalbuminemia el 68%. Las complicaciones fueron frecuentes (78%), siendo las infecciosas 25%, no infecciosas 22%, infecciosas y no infecciosas 31%. De las infecciosas destacan las respiratorias (25%), fiebre tifoidea / salmonelosis (19%), un caso de endocarditis infecciosa y otro de probable púrpura fulminans. De las complicaciones no infecciosas desatacan las complicaciones cardiovasculares (34%) y la neurobartonelosis (34%); hubo un caso de anemia hemolítica autoinmune. El 72% recibió transfusiones sanguíneas; el 97% recibió antibiótico, utilizando cloranfenicol (56%) y ciprofloxacino (34%). La letalidad fue de 6%. Conclusiones: La Bartonelosis aguda en esta serie tuvo gran morbilidad, siendo frecuentes las complicaciones cardiovasculares, neurológicas y respiratorias. (Rev Med Hered 2006;17:122-131).
The HACEK organisms (Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species) are rare causes of infective endocarditis (IE). The objective of this study is to describe the clinical characteristics and outcomes of patients with HACEK endocarditis (HE) in a large multi-national cohort. Patients hospitalized with definite or possible infective endocarditis by the International Collaboration on Endocarditis Prospective Cohort Study in 64 hospitals from 28 countries were included and characteristics of HE patients compared with IE due to other pathogens. Of 5591 patients enrolled, 77 (1.4%) had HE. HE was associated with a younger age (47 vs. 61 years; p<0.001), a higher prevalence of immunologic/vascular manifestations (32% vs. 20%; p<0.008) and stroke (25% vs. 17% p = 0.05) but a lower prevalence of congestive heart failure (15% vs. 30%; p = 0.004), death in-hospital (4% vs. 18%; p = 0.001) or after 1 year follow-up (6% vs. 20%; p = 0.01) than IE due to other pathogens (n = 5514). On multivariable analysis, stroke was associated with mitral valve vegetations (OR 3.60; CI 1.34–9.65; p<0.01) and younger age (OR 0.62; CI 0.49–0.90; p<0.01). The overall outcome of HE was excellent with the in-hospital mortality (4%) significantly better than for non-HE (18%; p<0.001). Prosthetic valve endocarditis was more common in HE (35%) than non-HE (24%). The outcome of prosthetic valve and native valve HE was excellent whether treated medically or with surgery. Current treatment is very successful for the management of both native valve prosthetic valve HE but further studies are needed to determine why HE has a predilection for younger people and to cause stroke. The small number of patients and observational design limit inferences on treatment strategies. Self selection of study sites limits epidemiological inferences.
Between 2000 and 2008, measles control improved markedly worldwide, but with poorer countries focused on polio eradication and some richer countries falling prey to opposition to vaccination, the measles genie seems to have slipped out of the bottle in recent years.
Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.
Granulocytopenia and oral mucosal defects have been reported to be important predisposing factors to recently recognized cases of Capnocytophaga septicemia. The authors call attention to an apparent preponderance of these cases in the pediatric age group and emphasize laboratory features which they have found helpful in the diagnosis of Capnocytophaga infections. Thirteen patients with Capnocytophaga infections were seen during a seven-year period. Seven of these patients had Capnocytophaga bacteremia. Six of seven bacteremic patients were granulocytopenic, six had oral mucosal defects, and three died. Five of the seven bacteremic patients were younger than 20 years of age. This represents a disproportionate distribution of cases in the pediatric age group within the author’s institution, because 43% of blood culture specimens submitted to their microbiology laboratory are obtained from pediatric patients. This observation is supported by a review of the reported cases of Capnocytophaga septicemia in which 7 of 12 patients were younger than 20 years of age. Because Capnocytophaga may superficially resemble the more commonly isolated Fusobacterium nucleatum, distinguishing features for laboratory identification are discussed.
The development of immunizations is considered among the top 10 greatest health accomplishments of the twentieth century, and vaccines continue to contribute to improving the health of the world's population. In the United States, all of the diseases for which there are routinely administered vaccinations have been eradicated or have significantly decreased in incidence compared with the prevaccine era. Globally, the number of available vaccines and the number of immunized children have increased in both industrialized and developing nations. Although significant progress has been made in immunizing the global population, much work remains to be done for reaching the geographically and economically disenfranchised. Development of new vaccines and vaccine delivery systems as well as finding new uses for current vaccines are some of the most promising and exciting areas of healthcare research. This section provides information about the vaccines currently available in the United States for routine immunization of children and adolescents. In addition, as there are frequent changes to the vaccine landscape, resources for finding current vaccine information have also been provided.
Description:
Update of 2001 U.S. Preventive Services Task Force (USPSTF) recommendations about screening sexually active adolescents and adults for chlamydial infection.
Methods:
The USPSTF weighed the benefits (improved fertility, pregnancy outcomes, and infection transmission) and harms (anxiety, relationship problems, and unnecessary treatment of false-positive results) of chlamydial screening identified in their 2001 recommendations and the accompanying systematic review of English-language articles published between July 2000 and July 2005.
Recommendations:
Screen for chlamydial infection in all sexually active nonpregnant young women age 24 years or younger and for older nonpregnant women who are at increased risk. (A recommendation) Screen for chlamydial infection in all pregnant women age 24 years or younger and in older pregnant women who are at increased risk. (B recommendation) Do not routinely screen for chlamydial infection in women age 25 years or older, regardless of whether they are pregnant, if they are not at increased risk. (C recommendation) Current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men. (I statement).
Objective: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis. Design: Investigator-initiated, multicenter, randomized clinical trial. Setting: Private and university-based retina-vitreous practices. Patients: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation. Interventions: Random assignment according to a 2 x 2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (cefiazidime and amikacin). Main Outcome Measures: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically. Results: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P<.001, log rank test for cumulative visual at-airy scores) over the entire range of vision. Conclusions: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is not necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision.
In the tumult following Pearl Harbor, tens of thousands of persons of Japanese ancestry in the United States were placed in camps throughout the country as part of the infamous World War II policy of “internment.” Among the locations used was one on the Gila River in the desert of southern Arizona. Since this area was known to be endemic for coccidioidomycosis, there was little surprise when many cases of the disease appeared among the unwilling residents of the camp.
• Febrile illnesses commonly arise in hospitalized patients after admission, but most previous studies have been of specific subsets of febrile illnesses. To provide practical information about the problem as a whole, we studied febrile illnesses arising after admission (nosocomial febrile illnesses [NFIs]) in 123 inpatients of an internal medicine service who had been afebrile for the preceding week. We compared them with 123 randomly selected patients without NFI. Causes of NFI included infections in 83 cases; noninfectious, inflammatory states in 15; malignancy in 12; ischemia in eight; and procedures in three. Evidence for the cause of the NFI was present at onset in at least 110 of the 123 patients. Despite this, antimicrobial agents were administered to 23 (58%) of 40 patients without infections. Thirty-four patients with NFI died; the NFI contributed to death in 26. In contrast, only eight comparison patients died. "Do not resuscitate" status was present in 32 patients with NFI compared with only 12 comparison patients, and 19 (59%) of the former died. The data from this study provide a comprehensive description of NFI arising in hospitalized internal medicine patients, indicate that the occurrence of a new febrile illness signifies a poor prognosis, and provide a rational basis for management.
(Arch Intern Med 1989;149:319-324)
Infectious mononucleosis is primarily a disease of the adolescent and young adult, and in this age group the clinical manifestations are characteristic and uniform in nature but vary in severity. The disease is caused by the Epstein-Barr virus and is characterized clinically by fever, pharyngitis, lymphadenopathy, and splenomegaly and by laboratory findings of lymphocytosis, atypical lymphocytes in the blood, and the presence of heterophile antibody and various antibodies specific for the Epstein-Barr virus. These findings have been described in a number of reviews (Hoagland 1967; Finch 1969; Chervenick 1974, 1983; Karzon 1976; Schleupner and Overall 1979; Chang 1980, Schlossberg 1983). Similar clinical findings may be seen in patients with a heterophile-negative mononucleosis-like illness, most notably cytomegalovirus infection, toxoplasmosis, or infection with human immunodeficiency virus (Steeper et al. 1988).
Lactobacillus and Bifidobacterium species constitute a significant proportion of probiotic cultures used in developed countries in 'microbial adjunct nutrition'. A number of differential plating methodologies have been developed which seek to selectively detect and enumerate these bacterial groups in bioproducts. Differences in oxygen tolerance, nutritional requirements, antibiotic susceptibility, and colony morphology and colour constitute the bases of differentiation in these methods. The choice of methodology depends on the nature of the bioproduct to be examined (wet or dry) and the presence of other bacteria such as starter cultures. In addition, a number of nucleic acid methods have been developed in recent years which enable the specific detection of these bacterial groups at species, subspecies and strain level in mixed populations. The methods use synthetic 16S and 23S rRNA-targeted hybridisation probes, the specificity of which can be adjusted to fit any taxonomic ranking from genus to genotype, for detection, enumeration and identification in situ or after differential plating. The combined use of differential plating and molecular strain typing methodologies provides food and medical microbiologists with a powerful and targeted approach to the detection, enumeration and identification of these bacterial groups and their members in a wide range of food and biological materials. An overview of these methods is presented in this review.
In recent years much new information has been obtained about the epidemiology, population biology and public health significance of infections of Ascaris lumbricoides in humans. Results from experimental infections of A. suum in pigs have helped to elucidate the observations made in the community on human ascariasis. The main purpose of the review is to see how new information may contribute to further acceptance of ascariasis as a serious contributor to ill-health and so to the design and implementation of sustainable control programmes intended to reduce the morbidity due to infection with A. lumbricoides. Eradication is neither a realistic nor prudent aim given the current shortage of appropriate sanitation in many countries where ascariasis is endemic. A substantial body of evidence shows that for the four common species of soil-transmitted nematode, including A. lumbricoides, regular administration of broad-spectrum anthelminthic drugs to children attending primary schools is a cost-effective means of controlling the infections. Anthelminthic drugs must be of proven quality and efficacy and health professionals should be prepared to detect and manage drug resistance should that emerge. Despite a deeper understanding of the immune response of a variety of hosts to infections with either A. lumbricoides or A. suum there is at present little prospect of an effective vaccine against ascariasis. The relationship between A. lumbricoides and A. suum is addressed, particularly since both species, if they are indeed separate species, occur in people and their pigs in many communities.
The changing demographics of splenic abscess in regard to predisposition, clinical setting, diagnosis, bacteriologic findings, and treatment have been presented based on 19 patients from five institutions and 170 patients reported in the literature since 1978. These data, in turn, have been compared with a previously published retrospective review of the world literature from 1900 to 1977. It has become clear that since 1978, splenic abscess is diagnosed earlier in its presentation due to the widespread use of improved imaging techniques, immunocompromised patients comprise a much larger proportion of patients (24 percent) than previously due to increasing use of steroids and chemotherapeutic agents, and the diagnosis of fungal splenic abscess, almost unheard of before 1978, has increased to 26 percent of patients.
Objective:
To review the characteristics of patient presentation, microbiology, and treatment of primary iliopsoas abscess.Design:
A case series of patients with iliopsoas abscess diagnosed on computed tomographic scans from 1987 to 1994.Setting:
Tertiary care inner-city university hospital.Patients:
Eleven patients with secondary iliopsoas abscess, defined as being secondary to gastrointestinal or genitourinary causes or trauma, and seven patients with primary abscess, defined as the absence of the above causes. Main Outcome Measures: Patient characteristics, presenting symptoms and signs, microbiologic characteristics, treatment, and clinical course of patients with primary iliopsoas abscesses compared with those in patients with secondary abscesses.Results:
In the primary group, six patients (86%) were intravenous drug users and four (57%) were positive for human immunodeficiency virus. Staphylococcus aureus grew from cultures from five of seven patients with primary abscesses, whereas secondary abscesses had enteric flora. The typical patient presentation included fever, with complaints of pain in the flank, hip, or abdomen. Comparison of abscess drainage options showed shorter hospitalizations for surgical drainage than for percutaneous drainage (15.9 vs 28.5 days; P≤.01).Conclusions:
A patient who presents with pain in the flank, hip, or abdomen may have a primary iliopsoas abscess. Computed tomography is the standard method of diagnosis. Antibiotic regimens for patients with primary iliopsoas abscess should include coverage for S aureus, and patients with secondary abscesses should have antibiotic regimens tailored for enteric bacteria. Drainage of abscess is essential for appropriate treatment, and surgical drainage is superior to percutaneous drainage in achieving prompt recovery.(Arch Surg. 1995;130:1309-1313)
Background: In patients with moderate to severe histoplasmosis associated with AIDS, the preferred treatment has been the deoxycholate formulation of amphotericin B. However, serious side effects are associated with use of amphotericin B. Objective: To compare amphotericin B with liposomal amphotericin B for induction therapy of moderate to severe disseminated histoplasmosis in patients with AIDS. I)esign: Randomized, double-blind, multicenter clinical trial. Setting: 21 sites of the U.S. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Patients: 81 patients with AIDS and moderate to severe disseminated histoplasmosis. Measurements: Clinical success, conversion of baseline blood cultures to negative, and acute toxicities that necessitated discontinuation of treatment. Results: Clinical success was achieved in 14 of 22 patients (64%) treated with amphotericin B compared with 45 of 51 patients (88%) receiving liposomal amphotericin B (difference, 24 percentage points [95% Cl, 1 to 52 percentage points]). Culture conversion rates were similar. Three patients treated with amphotericin B and one treated with liposomal amphotericin B died during induction (P = 0.04). Infusion-related side effects were greater with amphotericin B (63%) than with liposomal amphotericin B (25%) (P = 0.002). Nephrotoxicity occurred in 37% of patients treated with amphotericin B and 9% of patients treated with liposomal amphotericin B (P = 0.003). Conclusion: Liposomal amphotericin B seems to be a less toxic alternative to amphotericin B and is associated with improved survival.
A review of the literature on orofacial odontogenic infections indicates that the underlying microflora is typically polymicrobial, predominantly involving strictly anaerobic gram-positive cocci and gram-negative rods, along with facultative and microaerophilic streptococci. Although no single species has been consistently implicated in all of these infections, the pathogenic potential of some of these organisms has been documented by many studies. This potential can be explained by a number of virulence factors demonstrated in anaerobic bacteria, as well as by synergistic interrelationships with other members of the infectious flora. Awareness of the anaerobic component of orofacial odontogenic infections dictates to a large extent the selection of antimicrobial therapy, mainly because of the frequency of beta-lactamase production by anaerobic gram-negative rods.
Objective
To study the changes in the incidence, causes, bacteriologic profile, and management of a splenic abscess.
Design
Retrospective case study.
Setting
Tertiary, university referral center.
Patients
Thirty-nine patients with a splenic abscess.
Interventions
None.
Main Outcome Measures
Demographics, signs and symptoms, causes, risk factors, diagnostic methods, bacteriologic profile, treatment, and outcome.
Results
Patients presented at a mean age of 43 years (range, 2-83 years), after a mean symptomatic period of 16 days, with fever (69%), abdominal pain (56%), nausea and vomiting (38%), and splenomegaly (31%). The majority of abscesses represented metastatic infection (n= 19), and 11 were secondary to immunosuppression. Twelve patients had human immunodeficiency virus disease and 9 used intravenous drugs. In patients who underwent computed tomography, all had abnormal scans (n=33), with a well-defined abscess(es) in 28. Nine abscesses were polymicrobial; monomicrobial isolates included gram-positive organisms (23%), gram-negative organisms (31%), fungi (23%), and mycobacteria (23%). Patients presenting before 1989 (1981-1988) (n=15) and those presenting after 1989 (1989-1996) (n=24) differed in risk factors (intravenous drug abuse, 0% vs 47% [P=.02]; hematologic malignancy, 43% vs 9% [P=.04]) and gram-positive isolates (18% vs 64%; P=.06). Patients underwent splenectomy (n= 18), open drainage (n=4), medical therapy (n= 10), or percutaneous drainage (n=5) with respective survival rates of 94%, 50%, 70%, and 100%.
Conclusions
In 1996, splenic abscesses are increasingly common. Intravenous drug abuse and human immunodeficiency virus disease are significant risk factors, and the diagnosis should be considered in a patient with fever and abdominal pain who uses intravenous drugs. Antimicrobial agents should be broad since 36% of abscesses were polymicrobial, and should include coverage of gram-positive organisms.Arch Surg. 1997;132:1331-1336
Objective:
To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.
Design:
A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
Methods:
The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.
Results:
Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).
Conclusions:
Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Study objective
To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission.
Design
Prospective cohort study.
Setting
Barnes-Jewish Hospital, a university-affiliated urban teaching hospital.
Patients
Two thousand consecutive patients requiring admission to the medical or surgical ICU.
Interventions
Prospective patient surveillance and data collection.
Measurements and results
One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission.
Conclusions
Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.
We reviewed 776 previously reported and 44 new cases of CNS listeriosis outside of pregnancy and the neonatal period, and evaluated the epidemiologic, diagnostic, and therapeutic characteristics of this infection. Among patients with Listeria meningitis/meningoencephalitis, hematologic malignancy and kidney transplantation were the leading predisposing factors, but 36% of patients had no underlying diseases recognized. The infection occurred throughout life, with a higher incidence before the age of 3 and after the age of 45-50 years. Fever, altered sensorium, and headache were the most common symptoms, but 42% of patients had no meningeal signs on admission. Compared with patients with acute meningitis due to other bacterial pathogens, patients with Listeria infection had a significantly lower incidence of meningeal signs, and the CSF profile was significantly less likely to have a high WBC count or a high protein concentration. Gram stain of CSF was negative in two-thirds of cases of CNS listeriosis. One-third of patients had focal neurologic findings, and approximately one-fourth developed seizures over their course. Mortality was 26% overall, and was higher among patients with seizures and those older than 65 years of age. Relapse occurred in 7% of episodes. Ampicillin for a minimum of 15-21 days (with an aminoglycoside for at least the first 7-10 days) remains the treatment of choice. Cerebritis/abscess due to L. monocytogenes, without meningeal involvement, is less common but may be diagnosed by blood cultures and CNS imaging, or by stereotactic biopsy. Longer antibiotic therapy (at least 5-6 weeks) is needed in the presence of localized CNS involvement.
In order to establish the role of atypical bacteria and compare characteristics of different infectious agents in acute pharyngitis, 127 patients with acute pharyngitis (66 males; median age, 5.33 years; range, 6 months to 14 years) and 130 healthy subjects of similar sex and age were studied. Serology with paired samples and PCR on nasopharyngeal aspirates and throat cultures were used to identify bacteria and viruses. Viruses were identified in 43 patients (33.8 %) and five controls (3.8 %; P < 0.0001), potential bacterial pathogens in 34 patients (26.8 %) and 26 controls (20 %; P = 0.256) and mixed viral/bacterial pathogens in 26 patients (20.5 %) and none of the controls (P < 0.0001). The main aetiological agents were adenovirus, respiratory syncytial virus (RSV), Mycoplasma pneumoniae, Streptococcus pyogenes and Chlamydia pneumoniae. M. pneumoniae was the agent found most frequently as a single pathogen. A history of recurrent pharyngitis, having older siblings and a negative outcome were significantly more common among patients with acute M. pneumoniae infection than among those with infections due to other pathogens or healthy controls. This study demonstrates that: (i) adenovirus and RSV have a prominent role in acute pharyngitis; (ii) S. pyogenes is found frequently, but it is not possible to distinguish simple carriers from patients with a true infection; (iii) M. pneumoniae appears to be able to cause acute pharyngitis per se; and (iv) C. pneumoniae seems to be mainly a co-pathogen. To avoid the risk of an incorrect therapeutic approach, simple laboratory investigations that allow rapid identification of M. pneumoniae infections are urgently needed.
Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protecte...
Purpose: To describe nodular lymphangitis by reviewing the clinical and epidemiologic features of this disease with an emphasis on distinguishing specific etiologic agents. Data Sources: English-language articles were identified through a MEDLINE search (1966 to September 1992) using sporotrichosis, lymphangitis, and sporotrichoid as key words; additional references were selected from the bibliographies of identified articles. In addition, three new patients with nodular lymphangitis are described. Study Selection: One hundred fifty articles were reviewed to determine details of the etiologic agents and clinical signs and symptoms of patients with nodular lymphangitis
We did not test the use of these drugs for longer than 6 weeks. A longer treatment interval may have resulted in improved symptom scores. Six weeks was chosen because it was representative of the usual interval of treatment with antimicrobial agents; it is generally believed that bacterial organisms responsible for symptoms should be eradicated within this time. Testing of α-adrenergic receptor blockers for longer periods may be justifiable. In their study in men with CP/CPPS, which was reported after we completed recruitment, Cheah and associates (25) compared terazosin with placebo and found that terazosin provided a statistically significant improvement in outcomes based on the NIH-CPSI total score. Patients were treated with terazosin for 12 weeks, including upward dose titration, and had never been treated with α-adrenergic receptor blockers. However, Cheah and associates' study sample was drawn from diverse Asian nations and the median age was younger than that in our study. Another study of alfuzosin (26) showed that this agent modestly but statistically significantly improved symptoms compared with placebo after 6 months of treatment. These studies suggest that longer treatment with α-adrenergic receptor blockers may be warranted in patients with CP/CPPS.
In a recent study1 of convalescence from acute brucellosis the findings strongly supported the view that delay or failure in symptomatic recovery from that disorder is critically dependent upon the emotional state or attitude of the person. While no objective clinical or laboratory findings differentiated those persons who recovered quickly and completely from those who retained symptoms for a long period of time (chronic brucellosis), there were striking differences between these two groups in terms of psychological adjustment and life situation concurrent with the acute phase of the infection. The evidence pointed to the importance of depression particularly in retarding symptomatic recovery from the illness.
The study of convalescence of patients with brucellosis was done retrospectively in that the persons were investigated medically and psychologically some time after the acute illness had been contracted. We felt reasonably assured that certain features of the study enabled us to differentiate between
Program Description
Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. This miniseminar will highlight key recommendations from the new AAO-HNS guideline on tympanostomy tubes, developed by a multidisciplinary panel using methodology consistent with current Institute of Medicine standards. Emphasis is placed on surgical indications (otitis media with effusion and recurrent acute otitis media), caregiver education, management of tube otorrhea, use of water precautions, and special considerations for children who are at risk for developmental delays. The lively panel discussion will include case presentations and time for questions and answers.
Educational Objectives
1) Recognize evidence-based indications for tympanostomy tubes in children with otitis media with effusion and/or recurrent acute otitis media. 2) Identify children with otitis media with effusion who are at risk for developmental delays and might benefit from insertion of tympanostomy tubes. 3) Educate caregivers of children with tympanostomy tubes on the need for water precautions, management of tube otorrhea, and expectations for follow-up and monitoring while the tubes remain in place.
Twenty-eight patients had infections due to Clostridium septicum; 21 of them had documented septicemia. A malignancy was present in 23 of the 27 patients for whom hospital records were available. In three, an intestinal tumor was found one to two months after C septicum was cultured. In contrast with wartime reports, no wound infections due to this organism were observed in otherwise healthy individuals. Of the 27 patients, 13 of 15 treated with antibiotics survived, but 11 of 12 in the untreated group died. In each case the source of the organism was probably the patient's own intestinal tract.
Background: Sequelae of genital Chlamydia trachomatis infection in women are more strongly linked to repeat infections than to initial ones, and persistent or subsequent infections foster continued transmission. Objective: To identify factors associated with persistent and recurrent chlamydial infection in young women that might influence prevention strategies. Methods: Teenage and young adult women with uncomplicated C trachomatis infection attending reproductive health, sexually transmitted disease, and adolescent medicine clinics in five US cities were recruited to a cohort study. Persistent or recurrent chlamydial infection was detected by ligase chain reaction (LCR) testing of urine 1 month and 4 months after treatment. Results: Among 1,194 women treated for chlamydial infection, 792 (66.4%) returned for the first follow-up visit , 50 (6.3%) of whom had positive LCR results. At that visit, women who resumed sex since treatment were more likely to have chlamydial infection (relative risk [RR], 2.0; 95% CI, 1.03–3.9), as were those who did not complete treatment (RR, 3.4; 95% CI, 1.6–7.3). Among women who tested negative for C trachomatis at the first follow-up visit, 36 (7.1%) of 505 had positive results by LCR at the second follow-up visit. Reinfection at this visit was not clearly associated with having a new sex partner or other sexual behavior risks; new infection was likely due to resumption of sex with untreated partners. Overall, 13.4% of women had persistent infection or became reinfected after a median of 4.3 months, a rate of 33 infections per 1,000 person months. Conclusions: Persistent or recurrent infection is very common in young women with chlamydial infection. Improved strategies are needed to assure treatment of women’s male sex partners. Rescreening, or retesting of women for chlamydial infection a few months after treatment, also is recommended as a routine chlamydia prevention strategy.
Seventy-five cases of Kikuchi's lymphadenitis, a self-limiting pseudomalignant condition, were reviewed to determine the spectrum of histologic findings. There were 55 females and 20 males; ages ranged from 9 to 57 years (mean, 25.5). Most patients presented with cervical lymphadenopathy (68 cases). Associated clinical findings were fever (20/52) and leukopenia (15/33). Serum antinuclear antibodies were negative in 15 patients among 16 tested. Among 32 patients with follow-up information, 31 remained well, including one who developed recurrence after 2 years. One patient died of fatal myocardial disease during the active disease. Histologically, the lymph nodes showed paracortical hyperplasia, often associated with a starry-sky appearance resulting from interspersed histiocytes and immunoblasts. The consistent finding was the presence of variable-sized discrete or confluent nodules in the paracortex composed of the following: (a) karyorrhectic and eosinophilic granular debris; (b) histiocytes, many of which were phagocytic and possessed distinctive peripherally placed crescentic nuclei and voluminous cytoplasm containing eosinophilic or karyorrhectic debris (for which we propose the designation crescentic histiocytes), mixed with nonphagocytic histiocytes having twisted or reniform nuclei which were often centrally placed; (c) plasmacytoid monocytes, which were medium-sized cells with eccentrically placed round nuclei and amphophilic cytoplasm; and (d) variable numbers of immunoblasts, which sometimes showed atypia such as irregular nuclear foldings and coarse chromatin. Neutrophils were absent or very sparse. In some nodules, coag-ulative necrosis was present in the center (45 cases). Foamy histiocytes were found in 23 cases, and they predominated in 11. Small clusters of plasmacytoid monocytes were noted in the paracortex in 40 cases. Perinodal inflammation was a common finding, and perinodal involvement by the karyorrhectic process occurred in 15 cases. In addition, we found a number of previously unreported features. Signet-ring histiocytes with clear or homogeneous lightly amphophilic cytoplasm and nuclei compressed into thin crescents, found in seven cases, could mimic signet-ring cell adenocarcinoma. In three cases, some germinal centers were involved by the karyorrhectic process. Foci of lymphocyte-depleted fibrovascular organization were present in eight cases, probably representing the resolving phase of the karyorrhectic process. Despite the broad morphologic spectrum, the intermingling of the distinctive crescentic histiocytes, karyorrhectic debris, and plasmacytoid monocytes in the form of nodules, together with the paucity of neutrophils, are the consistent findings that should permit a confident histologic diagnosis of Kikuchi's lymphadenitis.
Concern regarding the use of biological agents—bacteria, viruses, or toxins—as tools of warfare or terrorism has led to measures to deter their use or, failing that, to deal with the consequences. Unlike chemical agents, which typically lead to violent disease syndromes within minutes at the site of exposure, diseases resulting from biological agents have incubation periods of days. Therefore, rather than a paramedic, it will likely be a physician who is first faced with evidence of the results of a biological attack. We provide here a primer on 10 classic biological warfare agents to increase the likelihood of their being considered in a differential diagnosis. Although the resultant diseases are rarely seen in many countries today, accepted diagnostic and epidemiologic principles apply; if the cause is identified quickly, appropriate therapy can be initiated and the impact of a terrorist attack greatly reduced.