Posts filed under ‘REPORTS’

Imported toxin-producing cutaneous diphtheria— Minnesota, Washington, and New Mexico, 2015–2018.

MMWR Morb Mortal Wkly Rep March 29, 2019 V.68 N.12 P.281-284

Griffith J et al.

Summary

What is already known about this topic?

Cutaneous diphtheria has not been notifiable in the United States since 1980, and U.S. disease incidence data are limited.

What is added by this report?

Toxin-producing Corynebacterium diphtheriae was identified in cutaneous wounds from four U.S. residents after return from international travel. Public health response for toxin-producing diphtheria includes treating patients, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage, and providing diphtheria toxoid–containing vaccine to incompletely immunized patients and close contacts.

What are the implications for public health practice?

Cutaneous toxin-producing diphtheria should be considered in travelers with wound infections who have returned from countries with endemic disease to permit prompt public health response and prevent disease transmission.

 

From September 2015 to March 2018, CDC confirmed four cases of cutaneous diphtheria caused by toxin-producing Corynebacterium diphtheriae in patients from Minnesota (two), Washington (one), and New Mexico (one). All patients had recently returned to the United States after travel to countries where diphtheria is endemic. C. diphtheriae infection was not clinically suspected in any of the patients; treating institutions detected the organism through matrix-assisted laser desorption/ionization–time-of-flight mass spectrometry (MALDI-TOF) testing of wound-derived coryneform isolates. MALDI-TOF is a rapid screening platform that uses mass spectrometry to identify bacterial pathogens. State public health laboratories confirmed C. diphtheriae through culture and sent isolates to CDC’s Pertussis and Diphtheria Laboratory for biotyping, polymerase chain reaction (PCR) testing, and toxin production testing. All isolates were identified as toxin-producing C. diphtheriae. The recommended public health response for cutaneous diphtheria is similar to that for respiratory diphtheria and includes treating the index patient with antibiotics, identifying close contacts and observing them for development of diphtheria, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage in the nose and throat, and providing diphtheria toxoid–containing vaccine to incompletely immunized patients and close contacts. This report summarizes the patient clinical information and response efforts conducted by the Minnesota, Washington, and New Mexico state health departments and CDC and emphasizes that health care providers should consider cutaneous diphtheria as a diagnosis in travelers with wound infections who have returned from countries with endemic diphtheria.

FULL TEXT

https://www.cdc.gov/mmwr/volumes/68/wr/mm6812a2.htm?s_cid=mm6812a2_w

PDF

https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6812a2-H.pdf

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April 18, 2019 at 9:57 am

Chile: Primer reporte de colonización por Candida auris uris en un paciente procedente de India

Sociedad Chilena de Infectología

Microbiólogos e infectólogos del Hospital del Salvador, de Santiago, reportaron el 1er aislamiento en Chile de Candida auris en un paciente de nacionalidad india y radicado en Chile hace 30 años. El paciente es diabético tipo II de larga data.

En agosto 2018 evolucionó con signos de isquemia y posteriormente necrosis del 4to dedo izquierdo asociado a celulitis del mismo pie.

Sus familiares decidieron el traslado a Mumbay (India), para su tratamiento.

Fue amputado en un hospital en Mumbay el 20/agosto/2018. Completó 24 días de hospitalización por dificultad en el manejo de su diabetes mellitus, y posteriormente continuó con curaciones ambulatorias en el mismo centro.

Una semana antes de volver a Chile, en octubre 2018, notó signos compatibles con necrosis en la falange distal del 3er dedo ipsilateral.

Consultó a su regreso a Chile en el Servicio de Urgencia de un centro privado. Fue derivado al Hospital del Salvador, donde se estudió y derivó a cirugía vascular para amputación del 3er y 5to dedos  izquierdos con diagnóstico de pie diabético con complicaciones vasculares, sin signos de infección.

El 26/diciembre/2018 ingresó a pabellón, donde se tomaron cultivos de tejido del lecho de amputación y de una úlcera plantar en relación a la base del 5to dedo.

Luego de 48 hs de incubación no hubo crecimiento de colonias en el cultivo corriente, por lo que se realizó un traspaso final desde el caldo tioglicolato a un agar sangre.

El 31/12/2018 se estudió una colonia blanca pequeña, la que es identificada como Kokuria kristinae (98% de concordancia). Se realizó tinción de Gram de dicha colonia, observándose levaduras.

El 2/enero/2019 se procesó nuevamente, dando como resultado C. auris con 99% de concordancia.

En función de los resultados obtenidos, se envió la cepa al Instituto de Salud Pública (ISP), quien el 17/enero/2019 confirmó la identificación.

El paciente no fue tratado con antifúngicos debido a que este hallazgo fue interpretado como una colonización, al no existir síntomas ni signos inflamatorios en el sitio quirúrgico.

En controles posteriores, un mes después de la amputación, se evidenciaron elementos compatibles con infección del sitio quirúrgico (ISQ) realizándose toilette de la zona en la cual se aislaron Klebsiella pneumoniae (en tejido óseo y partes blandas) y Staphylococcus aureus (partes blandas), pero no se ha vuelto a aislar C. auris en muestras de tejido y hueso del paciente.

Producto del patrón de susceptibilidad de los agentes identificados, se hospitalizó para tratamiento ATB IV, siendo sometido finalmente a una amputación trans-metatarsiana el 19/febrero/2019.

En dicho procedimiento se tomaron cultivos óseos y de tejidos blandos adyacentes con resultados negativos.

Durante esta hospitalización, se obtuvieron hisopados nasal, orofaríngeo, axilar e inguinorrectal para estudio de portación de C. auris, con resultados negativos.

Para los procesos de atención clínica, el paciente fue manejado con precauciones de contacto (unidad individual, uso de elementos de protección personal, aseo de unidad supervisado de acuerdo a protocolo interno).

Candida auris es un hongo emergente considerado una seria amenaza para la salud pública. La preocupación mundial por C. auris se debe principalmente a tres razones:

1) la resistencia que presenta a múltiples antifúngicos comúnmente utilizados para tratar las infecciones por Candida;

2) los errores en la identificación con los métodos de laboratorio estándar;

3) ser causa de brotes intrahospitalarios en los cinco continentes.

Por esta razón, es importante identificar rápidamente la presencia de C. auris en un paciente hospitalizado, para que se puedan tomar las precauciones especiales para detener su propagación. Dado el gran potencial de diseminación de esta Candida, es muy importante reforzar las medidas de control para reducir el riesgo de transmisión.

Fuente:

Primer reporte en Chile de colonización por Candida auris en un paciente procedente de India.

Sociedad Chilena de Infectología (Chile)

PDF

http://www.sochinf.cl/portal/templates/sochinf2008/documentos/2019/Primer_reporte_Chile_colonizacion_Candida_auris_India.pdf

April 15, 2019 at 8:35 am

Cost-effectiveness analysis of quadrivalent seasonal influenza vaccines in England.

BMC Med. September 8, 2017 V.15 N.1 P.166.

Thorrington D1, van Leeuwen E2,3, Ramsay M4, Pebody R2, Baguelin M2,5.

Author information

1 Respiratory Diseases Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK. dominic.thorrington@phe.gov.uk

2 Respiratory Diseases Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.

3 Imperial College Faculty of Medicine, London, SW7 2AZ, UK.

4 Immunisation, Hepatitis & Blood Safety Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.

5 Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Abstract

BACKGROUND:

As part of the national seasonal influenza vaccination programme in England and Wales, children receive a quadrivalent vaccine offering protection against two influenza A strains and two influenza B strains. Healthy children receive a quadrivalent live attenuated influenza vaccine (QLAIV), whilst children with contraindications receive the quadrivalent inactivated influenza vaccine (QIIV). Individuals aged younger than 65 years in the clinical risk populations and elderly individuals aged 65+ years receive either a trivalent inactivated influenza vaccine (TIIV) offering protection from two A strains and one B strain or the QIIV at the choice of their general practitioner. The cost-effectiveness of quadrivalent vaccine programmes is an open question. The original analysis that supported the paediatric programme only considered a trivalent live attenuated vaccine (LAIV). The cost-effectiveness of the QIIV to other patients has not been established. We sought to estimate the cost-effectiveness of these programmes, establishing a maximum incremental total cost per dose of quadrivalent vaccines over trivalent vaccines.

METHODS:

We used the same mathematical model as the analysis that recommended the introduction of the paediatric influenza vaccination programme. The incremental cost of the quadrivalent vaccine is the additional cost over that of the existing trivalent vaccine currently in use.

RESULTS:

Introducing quadrivalent vaccines can be cost-effective for all targeted groups. However, the cost-effectiveness of the programme is dependent on the choice of target cohort and the cost of the vaccines: the paediatric programme is cost-effective with an increased cost of £6.36 per dose, though an extension to clinical risk individuals younger than 65 years old and further to all elderly individuals means the maximum incremental cost is £1.84 and £0.20 per dose respectively.

CONCLUSIONS:

Quadrivalent influenza vaccines will bring substantial health benefits, as they are cost-effective in particular target groups.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590113/pdf/12916_2017_Article_932.pdf

April 13, 2019 at 12:58 pm

RECOMENDACIONES PARA LA PREVENCIÓN DE INFECCIONES ASOCIADAS A ARTOPLASTIA ELECTIVA EN ADULTOS

Medicina (Buenos Aires). 2017 V.77 N.2 P.143-157

JUAN CARLOS CHULUYÁN1*, ANDREA VILA2*, ANA LAURA CHATTÁS3*, MARCELO MONTERO3*, CLAUDIA PENSOTTI4*+, CLAUDIA TOSELLO5*, MARISA SÁNCHEZ6*, CECILIA VERA OCAMPO7*, GUILLERMINA KREMER8*, RODOLFO QUIRÓS8*, GUILLERMO A. BENCHETRIT9*,CAROLINA FERNANDA PÉREZ10*, ANA LAURA TERUSI11*, FRANCISCO NACINOVICH12*

1 Grupo de Trabajo Infectología, Hospital General de Agudos Dr. T. Álvarez,

2 Servicio de Infectología, Hospital Italiano de Mendoza,

3 Hospital General de Agudos Dr. Pirovano,

4 Clínica Monte Grande,

5 Hospital de Clínicas José de San Martín, UBA,

6 Hospital Italiano de Buenos Aires,

7 Sanatorio Dupuytren,

8 Hospital Universitario Austral,

9 Instituto de Investigaciones Médicas A. Lanari, UBA,

10 Policlínico del Docente-Centro Médico Huésped,

11 Instituto César Milstein,

12 Instituto Cardiovascular de Buenos Aires, Centros Médicos Dr. Stamboulian, Argentina

Las infecciones del sitio quirúrgico que complican las cirugías ortopédicas con implante prolongan la estadía hospitalaria y aumentan tanto el riesgo de readmisión como el costo de la internación y la mortalidad. Las presentes recomendaciones están dirigidas a:

(i) optimizar el cumplimiento de normas y la incorporación de hábitos en cada una de las fases de la cirugía, detectando factores de riesgo para infecciones del sitio quirúrgico potencialmente corregibles o modificables; y

(ii) adecuar la profilaxis antibiótica preoperatoria y el cuidado intra y postoperatorio.

PDF

http://www.medicinabuenosaires.com/PMID/28463223.pdf

April 13, 2019 at 12:39 pm

TUNGIASIS

NEJM april 2019

Tunga penetrans

Una niña (10) sana, se presentó en la clínica de atención primaria con un historial de 10 días de múltiples pápulas con picazón en las plantas de los pies y en los dedos de los pies. Las lesiones tenían puntos negros en el centro y eran dolorosas.

Dos semanas antes, ella y su familia habían viajado a zonas rurales de Brasil. Durante este tiempo, el niña había jugado descalza sobre terrenos sucios.

Se extrajeron pulgas de arena de múltiples lesiones y se diagnosticó tungiasis.

La tungiasis es una infestación de la piel causada por la pulga de arena Tunga penetrans, un ectoparásito que se encuentra en todas las partes tropicales y subtropicales del mundo.

La niña había recibido previamente todas las vacunas recomendadas incluyendo la antitetánica. El tratamiento incluyó la extirpación del parásito y el cuidado local de heridas.

Después del tratamiento, hubo una remisión completa de las lesiones, sin complicaciones en el seguimiento.

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMicm1810588

April 5, 2019 at 3:53 pm

Microscopic Examination and Broth Culture of Cerebrospinal Fluid in Diagnosis of Meningitis

Journal of Clinical Microbiology June 1998 V.36 N.6 P.1617-1620

Dunbar SA et al

We reviewed the results of microscopic Gram stain examination and routine culture for 2,635 cerebrospinal fluid (CSF) samples processed in an adult hospital microbiology laboratory during 55 months. There were 56 instances of bacterial or fungal meningitis (16 associated with central nervous system [CNS] shunt infection), four infections adjacent to the subarachnoid space, four cases of sepsis without meningitis, and an additional 220 CSF specimens with positive cultures in which the organism isolated was judged to be a contaminant. Because 121 of these contaminants were isolated in broth only, elimination of the broth culture would decrease unnecessary work. However, 25% of the meningitis associated with CNS shunts would have been missed by this practice. The most common cause of meningitis was Cryptococcus neoformans, followed by Streptococcus pneumoniaeand Neisseria meningitidis. In 48 of 56 (88%) of cases, examination of the Gram-stained specimen revealed the causative organism. If patients who had received effective antimicrobial therapy prior to lumbar puncture are excluded, the CSF Gram stain is 92% sensitive. Microscopic examination incorrectly suggested the presence of organisms in only 3 of 2,635 (0.1%) CSF examinations. Thus, microscopic examination of Gram-stained, concentrated CSF is highly sensitive and specific in early diagnosis of bacterial or fungal meningitis.

Bacterial meningitis is a life-threatening infection. Although patients typically present with fever, headache, stiff neck, and altered mental status, these symptoms may be subtle in elderly or immunocompromised persons (1, 6, 7,18). Early implementation of appropriate antimicrobial therapy requires prompt identification of the infecting pathogen. Although culture is considered to be the definitive diagnostic test, microscopic examination of a Gram-stained specimen of cerebrospinal fluid (CSF) may provide immediate information about the causative microorganism. Previous studies have suggested that the sensitivity of this technique ranges from 60 to 90% and the specificity approaches 100% (1, 5,6, 8, 12, 18). Scheld concludes that the overall sensitivity is only 75% (14). It is often unclear whether earlier studies have stratified patients based upon their having received prior antimicrobial therapy. Further, the role of semiquantitative assessment of leukocytes (WBC) by microscopic examination as an indicator of infection (8, 12) is uncertain. The value of using broth culture in various populations is also questionable (9, 10,17). In the present study, we reviewed the results of microscopic examination and routine culture of 2,635 CSF specimens to establish the predictive value of the cytocentrifuged Gram stain and the usefulness of broth culture in a veteran population.

FULL TEXT

https://jcm.asm.org/content/36/6/1617

PDF

https://jcm.asm.org/content/jcm/36/6/1617.full.pdf

April 2, 2019 at 6:15 pm

Predictive Value of Cerebrospinal Fluid (CSF) Lactate Level vs CSF-Blood Glucose Ratio for the Diagnosis of Bacterial Meningitis Following Neurosurgery

Clinical Infectious Diseases July 1999 V.29 N.1 P.69-74

Stephen L. Leib; Remy Boscacci; Othmar Gratzl; Werner Zimmerli

The value of cerebrospinal fluid (CSF) lactate level and CSF/blood glucose ratio for the identification of bacterial meningitis following neurosurgery was assessed in a retrospective study. During a 3-year period, 73 patients fulfilled the inclusion criteria and could be grouped by preset criteria in one of three categories: proven bacterial meningitis (n = 12), presumed bacterial meningitis (n = 14), and nonbacterial meningeal syndrome (n = 47). Of 73 patients analyzed, 45% were treated with antibiotics and 33% with steroids at the time of first lumbar puncture. CSF lactate values (cutoff, 4 mmol/L), in comparison with CSF/blood glucose ratios (cutoff, 0.4), were associated with higher sensitivity (0.88 vs. 0.77), specificity (0.98 vs. 0.87), and positive (0.96 vs. 0.77) and negative (0.94 vs. 0.87) predictive values. In conclusion, determination of the CSF lactate value is a quick, sensitive, and specific test to identify patients with bacterial meningitis after neurosurgery.

FULL TEXT

https://academic.oup.com/cid/article/29/1/69/323396

PDF (CLIC en PDF)

April 2, 2019 at 6:13 pm

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