Alternative Source Of Infection Research Articles

877. Synovial Fluid Testing Using the BioFire® Joint Infection (JI) Panel Potentially Decreases Time to Antibiotic Optimization for Acute Joint Infections

Abstract Background Traditional synovial fluid culture for acute joint infection (AJI) is time-consuming, potentially delaying initiation of targeted antimicrobial therapy. The BioFire® Joint Infection (JI) panel, a multiplex PCR for synovial fluid, has been shown to have 90.2% sensitivity and 99.8% specificity for diagnosis of AJI. We sought to determine the potential impact of the JI panel on antimicrobial use for AJI at our institution. Methods Antimicrobial use was retrospectively reviewed in a cohort of adult inpatients who underwent synovial fluid culture and were diagnosed with septic arthritis or periprosthetic joint infection from Sept 2021-Apr 2022. Patients were excluded if there was an alternative source of infection or septic shock. Synovial fluid specimens were tested using the JI panel, and results were compared to those of traditional culture methods. Patients who were initially treated with broad-spectrum antimicrobials for AJI were included in a review of antimicrobial prescribing. Records were reviewed to determine the time at which a transition to targeted therapy was made when using culture. This was compared to the time at which panel results could be available and acted upon, in this study presumed to be 12 hours after culture collection. Results 42 inpatients met study criteria for comparison of culture and JI panel results. The panel identified the organism that was grown in culture in 21 cases while detecting an organism in 5/16 culture-negative cases (table 1). In 5 cases, culture identified an organism not included on the JI panel. 29 patients met criteria for review of antimicrobial prescribing. Of these, therapy in 14/16 with positive cultures could have been changed earlier (table 2), resulting in an average reduction of time to targeted therapy of 57 hours (range 27–107 h, median 50.5 h) per patient. Targeted therapy could have occurred in 5/13 culture-negative cases. Summary of comparison of culture and BJI panel results. *Organisms identified by culture: Coagulase-negative staphylococci (n=4), Pasteurella multocida (n=1) **Organisms detected by JI panel: Streptococcus pyogenes (n=2), Streptococcus agalactiae (n=1), Finegoldia magna (n=1), Enterobacter cloacae (n=1) Proportion of patients eligible for a change in antimicrobial therapy. Conclusion Use of the JI panel could have prompted earlier optimized therapy in approximately two-thirds of patients. In 5 instances where cultures were negative, important AJI pathogens were identified. Another potential benefit includes reduced exposure to unnecessary broad-spectrum antimicrobials. Future study should evaluate the actual impact of the JI panel in practice. Disclosures All Authors: No reported disclosures.

Clonal Spread of pESI-Positive Multidrug-Resistant ST32 Salmonella enterica Serovar Infantis Isolates among Broilers and Humans in Slovenia.

Salmonella enterica subsp. enterica serovar Infantis is the most prevalent serovar found in broilers and broiler meat and is among the top five serovars responsible for human infections in Europe. In 2008, a multidrug-resistant S. Infantis isolate emerged in Israel with a mosaic megaplasmid named pESI, associated with increased virulence, biofilm formation, and multidrug resistance. Since then, S. Infantis clones with pESI-like plasmids have been reported worldwide, replacing pESI-free clones. Here, we typed 161 S. Infantis isolates of poultry (n = 133) and human clinical (n = 28) origin using whole-genome sequencing. The isolates were collected between 2007 and 2021. In addition, we performed PacBio/Illumina sequencing for two representative pESI-like plasmids and compared them with publicly available sequences. All isolates belonged to sequence type 32 (ST32), except for one isolate that represented a novel single-locus variant of ST32. Core genome MLST (cgMLST) analysis revealed 14 clusters of genetically closely related isolates, of which four suggested broiler-to-human transmission of S. Infantis. pESI-like plasmids were present in 148/161 (91.9%) isolates; all were highly similar to the publicly available pESI-like sequences but lacked extended-spectrum beta-lactamase (ESBL) genes. PacBio/Illumina hybrid assembly allowed the reconstruction of two novel complete pESI variants. The present study revealed that the multidrug-resistant, pESI-positive S. Infantis clone became the predominant S. Infantis clone in Slovenian broilers and humans during the last decade. Continued surveillance of resistant S. Infantis clones along the food chain is needed to guide public health efforts. IMPORTANCE Salmonella Infantis clones with pESI-like plasmids harboring several virulence and resistance genes have been reported worldwide. In the present study, we compared the population structure of 161 Salmonella Infantis isolates obtained from humans and broilers in Slovenia from 2007 to 2021. Whole-genome sequencing showed that most human isolates clustered apart from broiler isolates, suggesting an alternative source of infection. Most isolates were multidrug resistant due to the presence of pESI-like plasmids, of which two variants (pS89 and pS19) were fully reconstructed using long-read sequencing. Both exhibited high similarity with the original Israeli pESI plasmid and German p2747 plasmid. The prototype plasmid pS89 harbored the typical pESI-associated resistance genes aadA1, qacEΔ1, sul1, and tet(A), which were absent in the truncated plasmid pS19.

Can genetic assignment tests provide insight on the influence of captive egression on the epizootiology of chronic wasting disease?

Identifying the sources of ongoing and novel disease outbreaks is critical for understanding the diffusion of epizootic diseases. Identifying infection sources is difficult when few physical differences separate individuals with different origins. Genetic assignment procedures show great promise for assessing transmission dynamics in such situations. Here, we use genetic assignment tests to determine the source of chronic wasting disease infections in free‐ranging white‐tailed deer (Odocoileus virginianus) populations. Natural dispersal is thought to facilitate the geographic diffusion of chronic wasting disease, but egression from captive cervid populations represents an alternative source of infection that is difficult to detect due to physical similarities with wild deer. Simulated reference populations were created based on allele frequencies from 1,912 empirical microsatellite genotypes collected in four sampling subregions and five captive facilities. These reference populations were used to assess the likelihood of ancestry and assignment of 1,861 free‐ranging deer (1,834 noninfected and 27 infected) and 51 captive individuals to captive or wild populations. The ancestry (Q) and assignment scores (A) for free‐ranging deer to wild populations were high (average Q wild = 0.913 and average A wild = 0.951, respectively), but varied among subregions (Q wild = 0.800–0.947, A wild = 0.857–0.976). These findings suggest that captive egression and admixture are rare, but risk may not be spatially uniform. Ancestry and assignment scores for two free‐ranging deer with chronic wasting disease sampled in an area where chronic wasting disease was previously unobserved in free‐ranging herds indicated a higher likelihood of assignment and proportion of ancestry attributable to captive populations. While we cannot directly assign these individuals to infected facilities, these findings suggest that rare egression events may influence the epizootiology of chronic wasting disease in free‐ranging populations. Continued disease surveillance and genetic analyses may further elucidate the relative disease risk attributable to captive and wild sources.

Diversity of Salmonella serotypes from humans, food, domestic animals and wildlife in New South Wales, Australia

BackgroundSalmonella is an important human pathogen in Australia and annual case rates continue to increase. In addition to foodborne exposures, cases have been associated with animal and contaminated environment contact. However, routine surveillance in Australia has tended to focus on humans and food, with no reported attempts to collate and compare Salmonella data from a wider range of potential sources of exposure.MethodsSalmonella data from humans, food, animals and environments were collated from a range of surveillance and diagnostic sources in New South Wales (NSW). Data were categorised to reflect one of 29 sample origins. Serotype diversity was described for each category, and the distribution of serotypes commonly isolated from humans was examined for each sample origin. The distribution of serotypes along the livestock-food-human continuum and at the companion animal-wildlife interface was also examined.ResultsIn total, 49,872 Salmonella isolates were included in this analysis, comprising 325 serotypes. The vast majority of these isolates were from humans (n = 38,106). Overall S. Typhimurium was the most frequently isolated serotype and was isolated from all sample categories except natural environment and game meat. S. Enteriditis was not isolated from any livestock animal, however sporadic cases were documented in food, companion animals and a reptile. Many serotypes that were frequently isolated from livestock animals and associated food products were only rarely isolated from humans. In addition, a number of key human serotypes were only sporadically isolated from livestock and food products, suggesting alternative sources of infection. In particular, S. Paratyphi B Java and S. Wangata were more often isolated from wild animals. Finally, there was some overlap between serotypes in companion animals and wildlife, with cats in particular having a large number of serotypes in common with wild birds.ConclusionsThis is the most comprehensive description of Salmonella data from humans, food, livestock, wildlife, companion animals and various environments in Australia reported to date. Results confirm that livestock and food are important sources of salmonellosis in humans but that alternative sources - such as contact with wildlife and environments - warrant further investigation. Surveillance in NSW is largely human-focussed: major knowledge gaps exist regarding the diversity and frequency of serotypes in animals. More systematic surveillance of domestic animals and wildlife is needed to inform targeted control strategies and quantitative source attribution modelling in this state.

A Rare Case of Endotipsitis with Multiorgan Involvement

Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used in the setting of portal hypertension and associated symptoms such as variceal bleeding. Infection of the TIPS, or Endotipsitis, is a condition being increasingly recognized. Endotipsitis has an estimated incidence of 1.5% and carries a very high mortality rate. However, there are no guidelines to manage this condition. Here we describe a case of endotipsitis with multiple causative organisms and complications involving several organs. A 41 yo male with history of autoimmune pancreatitis, biliary strictures, and portal hypertension with gastroesophageal varices underwent banding and a TIPS procedure complicated by thrombosis which required revision. He subsequently developed a polymicrobial bacteremia growing Enterobacter cloacae, Klebsiella pneumonia, and Enterococcus faecalis/faecium. TTE and CT Abdomen/Pelvis were negative. Patient was diagnosed with endotipsitis and discharged on a 6-week course of IV daptomycin and ertapenem. Two weeks later, he presented febrile (102°). He was otherwise asymptomatic. Blood cultures were positive for gram positive cocci. Fluid around TIPS was drained. Both blood cultures and the TIPS fluid cultures were growing Enterococcus faecium and Candida lusitaniae. He was also diagnosed with endocarditis by TTE and fungal chorioretinitis. He was to complete a 6-week course of ampicillin and ceftriaxone, fluconazole, and ciprofloxacin. Exact diagnostic criteria of endotipsitis are still being debated, though persistent bacteremia and fever without clear alternative source of infection following TIPS procedure is highly suggestive. Additionally, TIPS thrombosis, as demonstrated in our patient, is a strong risk factor for endotipsitis. As of mid-2017, approximately 56 cases of endotipsitis have been reported with a 32% mortality rate. A wide range of causative organisms have been documented. However, the most common organisms responsible for early endotipsitis (within 120 days) were gram positive bacteria, including staph and enterococci. Candida infections have been associated with the highest mortality at >60%. While anti-microbial agents are the mainstay of treatment, it is unclear how liver transplantation and chronic suppressive antibiotics fit into the long-term management. Given the increased identification of this condition, clinical practice guidelines for the diagnosis and management for endotipsitis are urgently needed.

Recommended Clinical Trial End Points for Dialysis Catheters.

Central venous catheters are used frequently in patients on hemodialysis as a bridge to a permanent vascular access. They are prone to frequent complications, including catheter-related bloodstream infection, catheter dysfunction, and central vein obstruction. There is a compelling need to develop new drugs or devices to prevent central venous catheter complications. We convened a multidisciplinary panel of experts to propose standardized definitions of catheter end points to guide the design of future clinical trials seeking approval from the Food and Drug Administration. Our workgroup suggests diagnosing catheter-related bloodstream infection in catheter-dependent patients on hemodialysis with a clinical suspicion of infection (fever, rigors, altered mental status, or unexplained hypotension), blood cultures growing the same organism from the catheter hub and a peripheral vein (or the dialysis bloodline), and absence of evidence for an alternative source of infection. Catheter dysfunction is defined as the inability of a central venous catheter to (1) complete a single dialysis session without triggering recurrent pressure alarms or (2) reproducibly deliver a mean dialysis blood flow of >300 ml/min (with arterial and venous pressures being within the hemodialysis unit parameters) on two consecutive dialysis sessions or provide a Kt/V≥1.2 in 4 hours or less. Catheter dysfunction is defined only if it persists, despite attempts to reposition the patient, reverse the arterial and venous lines, or forcefully flush the catheter. Central vein obstruction is suspected in patients with >70% stenosis of a central vein by contrast venography or the equivalent, ipsilateral upper extremity edema, and an existing or prior history of a central venous catheter. There is some uncertainty about the specific criteria for these diagnoses, and the workgroup has also proposed future high-priority studies to resolve these questions.

Seroprevalence of HTLV-1 and HTLV-2 amongst mothers and children in Malawi within the context of a systematic review and meta-analysis of HTLV seroprevalence in Africa.

ObjectivesHuman T‐lymphotropic virus (HTLV)‐1 causes T‐cell leukaemia and myelopathy. Together with HTLV‐2, it is endemic in some African nations. Seroprevalence data from Malawi are scarce, with no reports on associated disease incidence. HTLV seroprevalence and type were tested in 418 healthy mothers from Malawi. In addition, we tested the sera of 534 children to investigate mother‐to‐child transmission. To provide context, we conducted a systematic review and meta‐analysis of HTLV seroprevalence in African women and children.MethodsStored samples from a previous childhood cancer and BBV study were analysed. ELISA was used for HTLV screening followed by immunoblot for confirmation and typing. Standard methods were used for the systematic review.Results HTLV seroprevalence was 2.6% (11/418) in mothers and 2.2% (12/534) in children. Three mothers carried HTLV‐1 alone, seven had HTLV‐2 and one was dually infected. Three children carried HTLV‐1 alone, seven had HTLV‐2 and two were dually infected. Only two corresponding mothers of the 12 HTLV‐positive children were HTLV positive. The systematic review included 66 studies of women and 13 of children conducted in 25 African countries. Seroprevalence of HTLV‐1 varied from 0 to 17% and of HTLV‐2 from 0 to 4%.ConclusionsIn contrast to findings from other studies in Africa, the seroprevalence of HTLV‐2 was higher than that of HTLV‐1 in Malawi and one of the highest for the African region. The lack of mother–child concordance suggests alternative sources of infection among children. Our data and analyses contribute to HTLV prevalence mapping in Africa.

Toxoplasma gondii infection in the context of the risk of schizophrenia development

Toxoplasma gondii (T. gondii) is a protozoan parasitizing all warm-blooded mammals, including humans. The main source of infection is contact with the feces of infected animals, particularly housecats, – the definitive hosts, in which T. gondii completes its life cycle. Alternative sources of infection are contact with and consumption of contaminated meat (particularly pork), transmission from mother to fetus, and infection by oocytes present in the soil or in polluted water. T. gondii is geographically ubiquitous; its level of seroprevalence is estimated to range from about 3% in South Korea to 76% in Costa Rica. Despite great efforts and considerable progress, toxoplasmosis remains a serious health threat worldwide. There is currently no available vaccine, and anti-toxoplasmosis drugs have substantial side effects and are not very effective. Furthermore, studies show that the parasite is able to develop resistance to them. Many recent studies have focused on how T. gondii is linked to psychiatric diseases and neurocognitive processes. Research has shown a correlation between T. gondii infection and schizophrenia.

18F-FDG PET/CT evaluation of children and young adults with suspected spinal fusion hardware infection

Evaluation of the child with spinal fusion hardware and concern for infection is challenging because of hardware artifact with standard imaging (CT and MRI) and difficult physical examination. Studies using (18)F-FDG PET/CT combine the benefit of functional imaging with anatomical localization. To discuss a case series of children and young adults with spinal fusion hardware and clinical concern for hardware infection. These people underwent FDG PET/CT imaging to determine the site of infection. We performed a retrospective review of whole-body FDG PET/CT scans at a tertiary children's hospital from December 2009 to January 2012 in children and young adults with spinal hardware and suspected hardware infection. The PET/CT scan findings were correlated with pertinent clinical information including laboratory values of inflammatory markers, postoperative notes and pathology results to evaluate the diagnostic accuracy of FDG PET/CT. An exempt status for this retrospective review was approved by the Institution Review Board. Twenty-five FDG PET/CT scans were performed in 20 patients. Spinal fusion hardware infection was confirmed surgically and pathologically in six patients. The most common FDG PET/CT finding in patients with hardware infection was increased FDG uptake in the soft tissue and bone immediately adjacent to the posterior spinal fusion rods at multiple contiguous vertebral levels. Noninfectious hardware complications were diagnosed in ten patients and proved surgically in four. Alternative sources of infection were diagnosed by FDG PET/CT in seven patients (five with pneumonia, one with pyonephrosis and one with superficial wound infections). FDG PET/CT is helpful in evaluation of children and young adults with concern for spinal hardware infection. Noninfectious hardware complications and alternative sources of infection, including pneumonia and pyonephrosis, can be diagnosed. FDG PET/CT should be the first-line cross-sectional imaging study in patients with suspected spinal hardware infection. Because pneumonia was diagnosed as often as spinal hardware infection, initial chest radiography should also be performed.

Prevalence of urinary tract infection in acutely unwell children in general practice: a prospective study with systematic urine sampling

Urinary tract infection (UTI) in children may be associated with long-term complications that could be prevented by prompt treatment. To determine the prevalence of UTI in acutely ill children ≤ 5 years presenting in general practice and to explore patterns of presenting symptoms and urine sampling strategies. Prospective observational study with systematic urine sampling, in general practices in Wales, UK. In total, 1003 children were recruited from 13 general practices between March 2008 and July 2010. The prevalence of UTI was determined and multivariable analysis performed to determine the probability of UTI. Out of 597 (60.0%) children who provided urine samples within 2 days, the prevalence of UTI was 5.9% (95% confidence interval [CI] = 4.3% to 8.0%) overall, 7.3% in those < 3 years and 3.2% in 3-5 year olds. Neither a history of fever nor the absence of an alternative source of infection was associated with UTI (P = 0.64; P = 0.69, respectively). The probability of UTI in children aged ≥3 years without increased urinary frequency or dysuria was 2%. The probability of UTI was ≥5% in all other groups. Urine sampling based purely on GP suspicion would have missed 80% of UTIs, while a sampling strategy based on current guidelines would have missed 50%. Approximately 6% of acutely unwell children presenting to UK general practice met the criteria for a laboratory diagnosis of UTI. This higher than previously recognised prior probability of UTI warrants raised awareness of the condition and suggests clinicians should lower their threshold for urine sampling in young children. The absence of fever or presence of an alternative source of infection, as emphasised in current guidelines, may not rule out UTI in young children with adequate certainty.

P15 How important are blood cultures in the management of patients suspected to have Community Acquired Pneumonia?

BackgroundIt is acknowledged in the BTS guidelines that the routine use of blood cultures in community acquired pneumonia (CAP) has been questioned on the grounds of cost, low sensitivity and...

Living with the LLSA: Paracentesis and Patientʼs Competence to Consent

Living with the LLSA: Paracentesis and Patientʼs Competence to Consent

Blood safety: bacterial screening of blood products

Bacterial contamination of blood components can cause death and serious morbidity in transfusion recipients [1–3]. Numerous measures to prevent and detect bacterial contamination have been introduced to reduce this hazard. Detection methods, including screening of blood components, are the subject of this review. Preventive measures include careful donor selection and predonation health screening, with donor deferral and follow-up of postdonation information as required [4,5]; optimization of blood collection and manufacturing processes, including improvements in skin cleansing procedures [6–9], choice of collection method and consumables, diversion of initial volume away from the collection bag [10–16], environmental monitoring, and greater availability of the use of apheresis platelets to minimize exposure to donor skin flora [17,18]; developments in pathogen reduction technologies [19–24]; attention to component storage and handling; and promotion of evidence-based clinical transfusion practice [24,25]. However, in spite of the introduction of advancements such as these, haemovigilance programs internationally continue to report serious adverse events because of bacterial contamination. For example, in spite of an overall reduction in numbers of cases reported annually to the French national haemovigilance programme since 2000, there were nine clinical cases in 2008 with imputability ratings of ‘likely ⁄ possible’ to ‘certain’, including one death because of Escherichia coli contamination of a platelet transfusion [26]. In the same year, the annual report from the Serious Hazards of Transfusion (SHOT) scheme described six confirmed clinical cases of sepsis in the United Kingdom because of bacterial contamination of platelet units, with consequences ranging from minor morbidity to death [27]. The spectrum of bacterial contamination ranges from detection of bacteria on routine component surveillance testing without apparent consequence to fatal sepsis. Recognition of transfusion-related sepsis can be difficult at the bedside, especially where patients may be already febrile and ⁄ or on antibiotics for suspected sepsis from other sources [28,29]. In order for bacterial contamination events to be captured by haemovigilance systems, the cases must first be identified clinically, confirmed with appropriate investigations, and then reported at institutional and programme levels. Haemovigilance programs are at various stages of development in different regions. Where they do exist, in some jurisdictions participation is mandatory and in other cases voluntary and therefore not universal. Different systems require variable levels of clinical certainty and laboratory confirmation, and some cases which are deemed highly likely on clinical grounds are unable to be confirmed because of unavailability or inappropriate handling or storage of blood component or patient samples. Thus, the number of confirmed and reported transfusion-related clinical cases can be considered the ‘tip of the iceberg’ or perhaps ‘the nose of the crocodile’ – with the majority of bacterial contaminations of blood components hidden below the surface, and many associated with no apparent harm, but with the potential for devastating outcomes. The cases included in haemovigilance reports therefore represent only a subset of total bacterial events. Even the definition of what constitutes a case of transfusion-transmitted bacterial contamination is a matter of some discussion. SHOT [27] defines a confirmed transfusion-transmitted infection as a case where: • the recipient had evidence of infection post-transfusion, and there was no evidence of infection prior to transfusion, and no evidence of an alternative source of infection; • and either at least one component received by the infected recipient was donated by a donor who had evidence of the same transmissible infection • or at least one component received by the infected recipient was shown to contain the agent of infection. The Dutch Transfusion Reactions in Patients (TRIP) haemovigilance system has recently expanded its scope of reportable bacterial events [30]. To the previous category of ‘post-transfusion bacteraemia ⁄ sepsis’, defined as ‘clinical symptoms of bacteraemia ⁄ sepsis arising during, directly after or some time subsequent to a blood transfusion, for which there is a relevant, positive blood culture of the patient with or without a causal relation to the Correspondence: Erica Wood, Australian Red Cross Blood Service, PO Box 354, 3205 South Melbourne, Victoria, Australia E-mail: woodericam@hotmail.com ISBT Science Series (2010) 5, 46–51

Fusobacterium necrophorum‐induced sepsis: an unusual case of Lemierre's syndrome

Classical Lemierre's syndrome is characterized by severe sepsis with metastatic abscess formation in young, previously fit people from a primary head or neck focus. The causative organisms are the anaerobic fusobacteria, most commonly Fusobacterium necrophorum. We describe the evaluation, therapeutic interventions and management of a patient with Lemierre's syndrome who presented in septic shock with multiple organ dysfunction. The patient required immediate interventions including endotracheal intubation and mechanical ventilation, fluid resuscitation, inotropic support, bilateral thoracostomy tube drainage of empyemata and antimicrobial therapy. The unexpected isolation of Fusobacterium necrophorum from blood cultures and empyema fluid necessitated a change of antibiotic regime to provide anaerobic cover. The patient required 4 weeks of intensive support including prolonged antimicrobial therapy, and after a further 2 weeks was discharged home from hospital. This case highlights the need to raise the awareness of 'the forgotten disease': Lemierre's syndrome. Its diagnosis may, as in this case, be confounded by a lack of symptoms of pharyngitis at the time of presentation, and end-organ dysfunction associated with severe sepsis, possibly suggesting an alternative source of infection. As appropriate antibiotics reduce mortality dramatically, clinicians need to be alert to Lemierre's syndrome and include it in the differential diagnosis in young but otherwise healthy patients presenting with severe sepsis.

Shunt patency required for effective management of endotipsitis

Transjugular intrahepatic portosystemic shunt (TIPS) infections have been reported in up to 20% of newly placed shunts. All of the reported cases responded to antibiotics alone and did not require shunt revision to clear the infection. We report a case that required repeated shunt revision and ultimately a patent shunt in order to clear the infection. A 59 year-old female with advanced liver disease due to autoimmune hepatitis presented with a 2-wk history of fatigue, somnolence and fever. She had TIPS placement 20 months earlier for refractory ascites. She underwent revision of an occluded shunt 3 months later and was found to have good flow through the shunt 1-yr later. On presentation she was febrile, icteric and had ascites and a leukocytosis of 13,000. Blood cultures grew E. coli that was treated with ceftriaxone. Investigation for an alternative source of infection was negative and included CXR, urinalysis and culture, paracentesis, abdominal CT, and echocardiogram. Doppler ultrasound showed TIPS occlusion. She remained febrile for 10 days despite appropriate antibiotics. A shunt revision with balloon angioplasty was completed with good post-procedure flow. During the procedure the patient experienced high-grade fever and chills, tachycardia and tachypnea. She defervesced over the next 48-hrs. However, she again became febrile and the shunt was again found to be occluded. Antibiotic coverage was broadened, however, her fever continued. A second TIPS revision was performed, again with good post-procedure flow. She defervesced over the next 48-hrs and remained afebrile. Good flow was documented through the shunt 3 days later. Since histopathologic confirmation is not possible, endotipsitis, like endocarditis, is diagnosed on positive blood cultures, exclusion of other sources of infection, and imaging studies showing a thrombus. The infection is typically cleared with long-term antibiotics. This case illustrates symptoms of acute bacteremia during shunt manipulation, another criterion for diagnosis of shunt infection, and the need for shunt patency in order to clear the infection.

Lemierre’s syndrome: An unusual cause of sepsis and abdominal pain

To describe a patient with Lemierre's syndrome who presented with acute abdominal findings and to describe the evaluation and treatment of this syndrome. Case report. A 38-bed, pediatric intensive care unit at a tertiary care children's hospital. One patient presenting with signs of severe sepsis and acute abdominal pain. Intravenous hydration, inotropic support, thoracostomy tube drainage of a pleural effusion, and prolonged antimicrobial therapy. The patient presented with severe sepsis and abdominal pain. After Fusobacterium necrophorum grew in blood cultures, anaerobic antimicrobial therapy was initiated. Doppler duplex ultrasonography and magnetic resonance venography demonstrated thrombus formation in the left internal jugular vein. Computed tomography of the chest demonstrated bibasilar lung nodules consistent with septic emboli. The patient was treated with ampicillin-sulbactam and metronidazole intravenously for 3 wks, followed by a 3-wk course of oral amoxicillin/clavulanate. He had a good recovery, and his thrombus had resolved at the time of discharge. Lemierre's syndrome occurs in young, otherwise healthy patients, and it thus needs to remain high on the differential diagnosis for this group of patients presenting with severe sepsis. The diagnosis can be confounded by a lack of symptoms of pharyngitis at the time of presentation and end-organ dysfunction associated with severe sepsis, suggesting alternative sources of infection.

An investigation of risk factors for cases of bovine spongiform encephalopathy born after the introduction of the 'feed ban'

Bovine spongiform encephalopathy (BSE) occurred in cattle in Great Britain after the inclusion of protein derived from infected tissues in their feed, and the incidence of the disease has been reduced by the introduction of legislation to prevent the inclusion of such protein in ruminant feed. This paper describes a case-control study designed to investigate whether there is any evidence for direct transmission of infection to cattle born after the introduction of this legislation. The offspring of animals that were subsequently affected with BSE were not found significantly more often among the cases. There was a statistically significant risk for animals born up to three days after a subsequently affected animal calved, but it may not indicate a causal association. Even after adjusting for an animal's exposure to infected animals that calved but would have been culled from the herd before developing clinical signs of BSE these routes of transmission could not account for the majority of cases born after the introduction of the legislation. A between herd comparison is suggested as a method of investigating alternative sources of infection.

Treatment of critically ill patients with sepsis of unknown cause: value of percutaneous cholecystostomy.

Because of the difficulty in diagnosing acute cholecystitis in critically ill patients with severe intercurrent illness by clinical and imaging methods or percutaneous aspiration of the gallbladder, a trial of percutaneous cholecystostomy was performed in 24 patients in the intensive-care unit with persistent, unexplained sepsis after a complete clinical, laboratory, and radiologic search showed no alternative source of infection. Persistent high fevers, despite antibiotic therapy, were present in all patients, with elevated WBC count in 18 patients, vague abdominal tenderness in 11, and septic shock requiring vasopressors in 15. Sonographically, all patients had distended, spherical gallbladders, six had gallstones, eight had wall thickening, three had pericholecystic fluid, and four had Murphy's sign. All patients were seen by a senior abdominal surgeon, who agreed to a trial of percutaneous cholecystostomy. Fourteen patients (58%) responded to percutaneous cholecystostomy, as evidenced by a decrease in WBC count, defervescence, and the ability to be weaned off vasopressors. Bile cultures were positive in four patients. Ten patients (42%) did not respond to percutaneous cholecystostomy; five eventually died of unrelated causes. A respiratory source of infection was eventually found in three of these 10 patients, with no proved source of infection in the remainder. No complications related to catheter insertion occurred in this group of patients. Bile leaks occurred in two patients when the percutaneous cholecystostomy catheter was removed, but without serious consequence. Our experience suggests that a lower threshold for performing percutaneous cholecystostomy in this difficult clinical subset of patients is worthwhile.

The epizootiology of Salmonella menston infection of fowls and the effect of feeding poultry food artificially infected with salmonella.

Synopsis The cycle of infection of Salmonella menston in poultry has been shown to be similar to that of S. thompson in that S. menston was shown to be present in adult fowls, the eggs laid by these fowls, chicks hatched from these eggs and the eggs laid by these progeny at maturity. When poultry are fed infected foods the water founts may also become contaminated and the importance of this alternative source of infection is noted. The increased occurrence of S. menston in poultry, poultry products and man is discussed.