Clear Source Of Infection Research Articles

Unanswered questions about the Middle East respiratory syndrome coronavirus (MERS-CoV).

BackgroundThe Middle East respiratory syndrome coronavirus (MERS-CoV) represents a current threat to the Arabian Peninsula, and potential pandemic disease. As of June 3, 2014, MERS CoV has reportedly infected 688 people and killed 282. We briefly summarize the state of the outbreak, and highlight unanswered questions and various explanations for the observed epidemiology.FindingsThe continuing but infrequent cases of MERS-CoV reported over the past two years have been puzzling and difficult to explain. The epidemiology of MERS-CoV, with many sporadic cases and a few hospital outbreaks, yet no sustained epidemic, suggests a low reproductive number. Furthermore, a clear source of infection to humans remains unknown. Also puzzling is the fact that MERS-CoV has been present in Saudi Arabia over several mass gatherings, including the 2012 and 2013 Hajj and Umrah pilgrimages, which predispose to epidemics, without an epidemic arising.ConclusionsThe observed epidemiology of MERS-CoV is quite distinct and does not clearly fit either a sporadic or epidemic pattern. Possible explanations of the unusual features of the epidemiology of MERS-CoV include sporadic ongoing infections from a non-human source; human to human transmission with a large proportion of undetected cases; or a combination of both. The virus has been identified in camels; however the mode of transmission of the virus to humans remains unknown, and many cases have no history of animal contact. In order to gain a better understanding of the epidemiology of MERS CoV, further investigation is warranted.

Maternal Near Miss Review: A Way Forward

Maternal Near Miss Review: A Way Forward

Impact and Etiology of Periungual Toe Infections in Neutropenic Patients

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is a genetic disorder of abnormal vasculature that leads to an increased risk of bleeding, with recurrent epistaxis being the most common presentation. To our knowledge, we report the first described case of Staphylococcus epidermidis mitral valve endocarditis in a man with recurrent epistaxis due to HHT. We presume that nasal carriage of S epidermidis was the source of infection. Because it is the most common organism isolated from contaminated blood cultures, the patient’s initial presentation of S epidermidis bacteremia was misdiagnosed as a skin contaminant because he had no clear source of infection (eg, central venous catheter) and he was largely asymptomatic. We present this case to highlight the importance of recognizing the risk of infection in patients with HHT with organisms associated with nasal carriage such as S epidermidis.

Clinical profile of patients treated with cefepime/tazobactam: A new ß-lactam/ß-lactamase inhibitor combination

Abdul Ghafur, Ashwini Tayade, Priyadarshini Kannaian Background and Purpose: Cefepime-tazobactam is a new s-lactam s-lactamase inhibitor combination licensed for clinical use by Drugs Controller General of India. Aim of our study was to analyze the clinical efficacy and safety of cefepime-tazobactam in patients with sepsis. To the best of our knowledge, this is the first published clinical study on this drug. Materials and Methods: A retrospective observational study on the efficacy and safety of cefepime-tazobactam was conducted at tertiary care hospital, South India. Patients who had a clear source of infection, having a single organism as the causative agent and being treated with cefepime-tazobactam alone were analyzed for efficacy and those cases who had a clear source of infection but either had multiple organism grown or cultures being negative or those patients who received a combination of antibiotics were analyzed for the safety analysis. Results: Thirty two patients satisfied our study criteria. All 15 patients in the efficacy group (nine with ventilator associated pneumonia, three tracheitis, two bacteraemia and one with urosepsis) had complete clinical cure, with microbiological cure in cases where a repeat culture was indicated. There were no significant side effects in any of the evaluable 32 patients assessed for safety. Conclusion: Cefepime-tazobactam is a safe and effective agent to treat patients with nonlife threatening sepsis due to Gram negative bacteria.

Septic venous thromboembolism

A 61-year-old man was admitted to an outside medical facility with left leg deep vein thrombosis and bilateral pulmonary emboli. His clinical course was complicated by hypotension, azotemia and declining mental status. Positive blood cultures for gram-positive cocci prompted transfer to our institution. Despite broad-spectrum antibiotics (vancomycin, cefepime, and ciprofloxacin), the patient remained febrile (temperature 39.4°C) with persistent leukocytosis. An echocardiogram revealed no valvular vegetations. Bacteremia persisted with methicillin-sensitive Staphylococcus aureus despite antimicrobial therapy. In the absence of a clear source of infection, an indium-111labeled white blood cell (WBC) scan was performed, revealing radiotracer enhancement of the left popliteal, femoral, and common femoral veins (Panels A and B) corresponding to thrombus location as assessed by ultrasound (Panels C and D). Radiotracer uptake within these Images in Vascular Medicine

Unexplained high fever in an elderly patient treated with clonidine, duloxetine, and atorvastatin

Background: Drug-induced fever is a clinical diagnosis and should always be considered when the fever is constant and high without a clear source of infection. Although drug-induced fever has been reported with other centrally acting antihypertensive drugs such as methyldopa, published reports of this adverse effect with clonidine in humans were not identified in a search of the literature. Case summary: A 66-year-old institutionalized white female with a history of morbid obesity (body mass index, 40 kg/m2), Alzheimer's dementia, hypertension, and depression presented to a hospital in Boston, Massachusetts (Caritas Saint Elizabeth's Medical Center) with generalized weakness and shortness of breath and was found to have a non-ST segment elevation myocardial infarction. Before hospitalization, the patient was taking memantine 10 mg PO BID, donepezil 10 mg PO once daily, duloxetine 60 mg PO once daily, clonidine 0.1 mg PO TID, metoprolol 50 mg PO BID, and amlodipine 10 mg PO once daily. On admission, the patient was initiated on aspirin 325 mg, atorvastatin 80 mg, and clopidogrel 75 mg PO daily. Her dose of clonidine was increased to 0.2 mg PO TID to optimize blood pressure control, and metoprolol and amlodipine were continued at the same doses. The patient developed fever on the third day after the cardiac catheterization. The fever ranged from 99.0°F to 102.7°F. The physical examination, laboratory data analysis, multiple blood cultures, urinalysis, chest radiograph, and a computed tomography of the head, chest, abdomen, and pelvis did not reveal any source of infection. On the sixth day after admission, clonidine was reduced to the baseline dose of 0.1 mg PO TID and on the ninth day it was stopped. The patient was afebrile on the twelfth day and remained so for the duration of her hospitalization. Naranjo scores for her newly initiated concomitant medications were as follows: aspirin, 1; atorvastatin, 3; clonidine, 6; and clopidogrel, 1. The rating of 6 for clonidine suggests that it was probably associated with the fever in this patient. Conclusion: We describe a case of drug-induced fever probably associated with clonidine administration. The higher dose of clonidine alone or in interaction with duloxetine and atorvastatin may have contributed to the development of drug-induced fever.

An Unusual Cause of Abdominal Pain in a Patient with Severe Traumatic Brain Injury (TBI): Intussusception of the Jejunum

A 37-yr-old man who sustained severe traumatic brain injury as a result of a motorcycle accident was found to have multiple lumbar, thoracic spine, and rib fractures without spinal cord injury. He had a J-tube inserted about 2 mos before transferring to our hospital. On admission to our rehabilitation unit, he developed episodic fever, diffuse abdominal pain, intermittent loose stools, diaphoresis, elevated liver enzymes, and leukocytosis. Infectious disease service was consulted, but no clear source of infection could be identified. After finishing one course of antibiotics for presumed urinary tract infection, he redeveloped low-grade fever with intermittent leukocytosis, increased transaminase, dark urine, increased spasticity, and mental status changes. Fluoroscopic study of the J-tube revealed a functional feeding tube (Fig. 1). Stool examination was positive for Clostridium difficile. Thus, Flagyl orally and Cefepime intravenously were started for presumed C. difficile infection and possible pneumonia. The leukocytosis subsided, but chest x-ray failed to confirm pneumonia. The abdominal pain continued without diarrhea. Repeat fluoroscopic study revealed a functioning J-tube. An abdominal computed tomographic scan (Fig. 2) was ordered to rule out hepatobiliary disease. Surprisingly, instead of finding any abnormality in the liver or gallbladder, it revealed an intussusception around the J-tube. The patient was made NPO, and the balloon was deflated. Within a few days, his fever, leukocytosis, and liver enzymes normalized, with improvement of his abdominal symptoms. Repeat computed tomography of the abdomen showed resolution of the intussusception.FIGURE 1: Plain abdominal x-ray (with fluoroscopic contrast) showing a functional J-tube.FIGURE 2: Abdominal computed tomography showing (i) a normal intestine (thin arrow) and (ii) an intussusception (thick arrow) indicating invagination around the J-tube.Intussusception is a rare but potentially fatal disorder in which a portion of the intestine invaginates into itself, leading to an obstruction. This pathology is usually seen in children. Risk factors for intussusception include abdominal surgery,1 prolonged use of intestinal tube, and migration of the J-tube.2,3 Wu et al.4 suggested that abdominal ultrasound and computed tomographic scan are better diagnostic tools than plain x-ray for J-tube–induced intussusception. Intussusception can cause serious setbacks for the rehabilitation process and can be life threatening if left untreated. The clinical diagnosis is particularly challenging because the patient was aphasic, on J-tube feeding, at high risk for infections, and on dantrolene for spasticity. We hope that this case will remind us and our colleagues when confronted with similar situations.

Procalcitonin in Young Febrile Infants for the Detection of Serious Bacterial Infections: Is This the “Holy Grail”?

Over the last several decades, the search for an accurate and rapid diagnostic method of identifying young infants at high risk for serious bacterial infections (SBIs) who present with fever and no clear source of infection has been an ongoing and elusive challenge for clinicians. Published studies of infants who present with fever without an identifiable source have reported rates of SBIs of up to 12% in infants <28 days of age and up to 9% in infants 1 to 3 months of age.1–5 Previous guidelines that used clinical examination alone or in combination with laboratory investigation have been shown to be less than optimal at identifying young infants at high or low risk for SBIs.1,6,7 In an attempt to more accurately differentiate infants at higher risk for bacterial infections, various biomarkers have been studied. These biomarkers have included using a peripheral white blood cell (WBC) count cutoff of 15000/mm3 and absolute neutrophil count8,9 and C-reactive protein (CRP) level.10,11 Although a peripheral WBC cutoff of 15000/mm3 and absolute neutrophil count have been adopted for use in multiple guidelines and algorithms, these parameters have … Address correspondence to Tina Q. Tan, MD, Children's Memorial Hospital, Department of Pediatrics, 2300 Children's Plaza, Box 20, Chicago, IL 60614. E-mail: ttan{at}northwestern.edu or titan{at}childrensmemorial.org

Methicillin-resistant Ascending Facial and Orbital Cellulitis in an Operation Iraqi Freedom Troop Population

To present a descriptive case series of methicillin-resistant ascending facial and orbital cellulitis in an Operation Iraqi Freedom troop population. A physician's transfer records of patients cared for and or transferred from the 31st and 86th Combat Support Hospitals during Operation Iraqi Freedom between September 2004 and March 2005 were reviewed. Cases of facial and orbital cellulitis caused by a nasal mucosal source were included in the case series. Five cases of ascending facial and/or orbital cellulitis caused by an aggressive nasal source are reported. All nasal microabscess cultures demonstrated methicillin-resistant Staphylococcus aureus species. None of the patients complained of nasal pain as the chief complaint, and all patients overlooked the follicular abscess at or inside the nares. Occult nasal infections with methicillin-resistant Staphylococcus aureus can be the source of an aggressive ascending facial and orbital cellulitis. The nasal source can be overlooked because of the distracting presentation of the orbital and systemic findings. With the increasing prevalence of community-acquired methicillin-resistant Staphylococcus aureus infections, a nasal examination and nasal culture can greatly assist in the diagnosis and management of patients presenting with orbital cellulitis without a clear source of infection.

Orthopaedic outcome of total knee replacement in haemophilia A.

A consecutive series of 16 patients with classical Haemophilia underwent 21 total knee replacements between 1989 and 1997 for haemophilic arthropathy. The patients received Factor VIII replacement therapy via continuous infusion, and fibrin glue was used to facilitate haemostasis. Three different types of prostheses were used. A follow-up evaluation was undertaken between 2 and 10 years after the operation (mean 5.6 years) and two patients with infection were excluded. Knee scores averaged 77.5 (pre-operative 24. 1) and functional scores averaged 84.4 (preoperative 23.2). There were no cases with aseptic loosening of the prosthesis. Complications included one early deep infection controlled by conversion of the TKR into an arthrodesis, one case of late septic loosening that had to be re-operated upon, one case of patellar dislocation, two cases of stiff knee (fibro-arthrosis) that required manipulation under anaesthesia, one postoperative hepatitis, one superficial infection treated by incision and drainage and four febrile patients with no clear source of infection, who responded to antibiotics alone. In conclusion, TKR offers haemophilic patients a long-lasting improvement of their quality of life and we therefore advocate its use with the appropriate indications.

The role of Citrobacter in clinical disease of children: review.

Various species of Citrobacter may cause infections in neonates and immunocompromised hosts. Citrobacter koseri (formerly Citrobacter diversus) is best known as the cause of sepsis and meningitis leading to central nervous system (CNS) abscesses in neonates and young infants. Early onset and late-onset infections occur as for other neonatal bacterial infections. The majority of cases are sporadic, with no clear source of infection. A few have been confirmed to be vertically transmitted, and nosocomial outbreaks have occurred in neonatal care units. The pathophysiology is not well understood, but a surface protein has been identified as a possible virulence factor among strains that cause citrobacter brain abscesses in neonates. Despite improvements in diagnostic imaging techniques, surgery, and antibiotic therapy, approximately one-third of infants with abscesses die, and one-half sustain CNS damage. In this article, the taxonomy, epidemiology, pathogenesis, diagnosis, treatment, and outcome of citrobacter disease in children are reviewed.

Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms

Mycotic aneurysms are a fulminant infectious process frequently resulting in rupture and death if not properly treated. A review of the University of California, Los Angeles, medical records identified 10 patients with extrathoracic, extracranial mycotic aneurysms. In addition, a search of the English literature revealed 178 patients with 243 mycotic aneurysms. These patients were reviewed to identify the aneurysm location, etiology, bacteriology, and modality of treatment in order to determine the relationship between these factors and the outcome. The femoral artery was the most common site (38%), followed by the abdominal aorta (31%). Arterial trauma was the primary etiology in 42% of mycotic aneurysms. In 25% no clear source of infection could be identified. Staphylococcus aureus was cultured from 28% of mycotic aneurysms, and Salmonella from 15%. A trend toward the involvement of more gram-negative aerobes and anaerobes is noted. Aortic aneurysms were repaired with in situ Dacron in 61% of patients with a 32% mortality rate and 16% reinfection rate. Simple ligation of femoral artery mycotic aneurysms resulted in a 34% incidence of ischemia necessitating amputation. Methods of treatment of superior mesenteric, carotid, iliac, and peripheral arteries are also analyzed. On the basis of these data, specific surgical procedures are recommended for the treatment of mycotic aneurysms.