Antibiotic Era Research Articles

Neurosyphilis Update: Atypical is the New Typical.

Syphilis has reemerged as an important cause of neurological disease, affecting any part of the neuraxis at any stage of infection. What was once a dwindling diagnosis is now redoubling, particularly in the HIV-positive and in men who have sex with menpopulations. In the era of antibiotics and HIV coinfection, neurosyphilis presentations are protean, making diagnosis notoriously challenging. Advanced disease may be irreversible, and so early detection and treatment are ideal. Herein, we review recent advances in understanding neurosyphilis.

Detection of aminoglycoside modifying enzymes and β-lactamases in Acinetobacter baumannii isolated from hospitalized Iraqi patients

Background/aim: Acinetobacter baumannii is one of the most commonly encountered as multiresistance microorganism. This study was designated for investigating of β-lactamases resistance genes and aminoglycosides modifying enzymes (AMEs) in Acinetobacter baumannii isolated from Iraqi patients. Materials and methods: A total of 36 A. baumannii isolates were recovered from hospitalized Iraqi patients during May to September 2012. Antibiotic susceptibility test was performed against aminoglycosides antibiotics and phenotypic detection of slactamases was done using Extended Spectrum Beta Lacatmases (ESβL) strip. Polymerase Chain Reaction (PCR) amplification was achieved for investigating β-lactamases genes (blaSHV, blaTEM, and blaCTX) and aminoglycosides modifying enzymes (aac(6)Ib, ant(4')-IIb, aa(c) 3′ and aph(3′)-VI). Results: Out of 36 A. baumannii isolates, 15 (41.66%) were resistant to aminoglycosides antibiotics according to disk diffusion method. 17 (47.22%) isolates gave positive results in the preliminary screening of β-lactamases, the ESβLs type and AmpC enzyme, while 13 (36.11% ) of the isolates gave a positive result in Metallo-βlactamases production test. PCR analysis demonstrated that blaTEM was detected in 3 (20%) of the resistant isolates , blaSHV was detected in 9 (60%) , blaCTX-M was detected in 11 (73.33%), aac (6)-Ib was detected in 7 (46.66%), ant(4')-IIb was detected in 5(33.33%) , aph(3′)-VI in 2 (13.33%), and aa(c) 3′ was found in 10 (66.66%) of the resistant isolates. Conclusion: Local A. baumannii isolates with AMEs and β-lactamases genes represent a powerful nosocomial pathogen that threat the antibiotic era and life of immunocompromied and hospitalizes patients and this should be taken into account to find a new ways for the restriction of these powerful pathogens.

Rehabilitation of a complete maxillectomy patient: A case report of osteomyelitis of maxilla

Osteomyelitis of the jaws is osteomyelitis (which is inflammation of the bone marrow, sometimes abbreviated to OM) which occurs in the bones of the jaws (i.e. maxilla or the mandible). Historically, osteomyelitis of the jaws was a common complication of odontogenic infection (infections of the teeth). Before the antibiotic era, it was frequently a fatal condition. Today osteomyelitis of facial bones is a rare condition. Maxillary osteomyelitis is rare compared to mandible osteomyelitis because extensive blood supply & strut like bone of the maxilla make it less prone to chronic infection. We report a rare case of Osteomyelitis involving whole of the Maxilla in a 63 year old male patient, diabetic and hypertensive for the past 2 years. He presented to us with anpalatally exposed bone with offensive odour from the nose. Examination revealed a necrotic maxilla involving whole hard palate. A computerized tomography scan confirmed Osteomyelitis of whole Maxilla. Patient underwent complete surgical excision with prosthesis reconstruction. Prosthetic rehabilitation of patients with acquired defects of the maxilla present a challenging task because of inadequate retention and stability of prosthesis and these goals are even more challenging in a complete maxillectomy case. This case report describes the fabrication of prosthesis utilizing soft tissue undercuts for retention using soft liners as one technique and fabrication of a two piece prosthesis utilizing magnets to meet the goals.

Gram-positive phage-host interactions.

Bacteriophage research has seen many peaks and troughs over the past century ascending with phage therapy and application in the early 1900's; a research peak which was largely overshadowed by the dawning of the antibiotic era, and which has now deservedly regained attention as an approach against the problematic rise in antibiotic-resistant pathogenic bacteria. Following this initial scientific highlight, the advent of molecular biology and biotechnology sparked a renewed interest in phages and their encoded enzymes and promoters, which are still employed as research tools today. Much of this research was conducted using phages of Gram-negative bacteria, particularly Escherichia coli, due to the reliability of the host and the ease of protein (over) production, in particular many enzymes, in a compatible host background. Consequently, coliphages such as T4 and lambda served as model phages in the development of molecular tools and the fundamental understanding of phage-host interactions. The advent of new generation sequencing technologies has in recent years provided a vast array of sequence data relating to Gram-positive phages and their hosts, which in turn has permitted the development of analogies between Gram-negative and Gram-positive phages. For example, sequence analysis of Bacillus subtilis and Lactococcus lactis phages SPP1 and Tuc2009, respectively, revealed genomes with a conserved gene and/or functional order relative to lambda, the main model for Siphoviridae phages. While the Gram-negative models have been extremely useful platforms, many questions have remained unanswered owing to the fundamental structural and compositional differences between the cell walls of Gram-negative and positive cells. In response to this knowledge gap, there has been a significant upsurge in research in the area of phages infecting Gram-positive bacteria and in particular, lactococcal phage-host interactions, which have now become one of the leading model systems along with the above-mentioned Bacillus subtilis phage SPP1 and the mycobacteriophage L5. In the ensuing 11 articles, many key advances that now define our understanding of phage-host interactions of Gram-positive bacteria and their infecting phages are described. We collate these advances and define the current knowledge of cell wall structures that present the target molecule of phage attachment (Munsch-Alatossava and Alatossava, 2013; Chapot-Chartier, 2014) and the phage-encoded adhesion complexes that phage employ to attach to their host in lactococci (Spinelli et al., 2014). Additionally, we explore the role of genomics in advancing knowledge on phages infecting previously underrepresented bacterial species that are of practical relevance to the food industry including the Leuconostoc, Oenococcus and Weissella (Kot et al., 2014; Mahony and van Sinderen, 2014), and phage therapy including Listeria and Clostridium spp. (Hagens and Loessner, 2014; Hargreaves and Clokie, 2014; Ly-Chatain, 2014). Furthermore, the research articles reinforce the continuing need for isolation and characterisation of phage isolates to retain a current perspective on the ever-changing phage genomics landscape (Cavanagh et al., 2014) and the possibility of deriving and understanding anti-phage measures that may be harnessed in various biotechnology sectors, in particular the dairy industry (Ali et al., 2014; Chirico et al., 2014).

Syphilis testing, typing, and treatment follow-up: a new era for an old disease.

The past 15 years have seen a dramatic increase in syphilis diagnoses in several regions including China, North America, Western Europe and Australia. Worldwide, the disease remains prevalent, contributing to substantial adult morbidity and neonatal mortality. Testing and treatment strategies are largely informed by data from the early antibiotic era, but increasing use of molecular diagnostics and new screening strategies could improve the management of syphilis substantially. The review explores new testing strategies for syphilis, including the importance of screening test selection and advances in point-of-care diagnostics. It then examines molecular studies of Treponema pallidum, covering typing; macrolide resistance; association between genotype and phenotype and the use of PCR in testing and monitoring strategies. Clinicians should be aware of testing strategies employed by their laboratories to ensure optimal sensitivity and specificity. Locally available T. pallidum PCR assays may improve the diagnosis of early disease and inform antibiotic choice. Robust serologic follow-up is still required, but predictors of potential treatment failure, including PCR-measured bacterial load, have been identified. Re-treatment should be considered for patients in the serofast state. The publication of T. pallidum genomes would allow further and more detailed study of strains and disease pathogenesis.

Evolution of extensively drug-resistant tuberculosis over four decades revealed by whole genome sequencing of Mycobacterium tuberculosis from KwaZulu-Natal, South Africa

The largest global outbreak of extensively drug-resistant (XDR) tuberculosis (TB) was identified in Tugela Ferry, KwaZulu-Natal (KZN), South Africa in 2005. The antecedents and timing of the emergence of drug resistance in this fatal epidemic XDR outbreak are unknown, and it is unclear whether drug resistance in this region continues to be driven by clonal spread or by the development of de novo resistance. A whole genome sequencing and drug susceptibility testing (DST) was performed on 337 clinical isolates of Mycobacterium tuberculosis (M.tb) collected in KZN from 2008 to 2013, in addition to three historical isolates, one of which was isolated during the Tugela Ferry outbreak. Using a variety of whole genome comparative approaches, 11 drug-resistant clones of M.tb circulating from 2008 to 2013 were identified, including a 50-member clone of XDR M.tb that was highly related to the Tugela Ferry XDR outbreak strain. It was calculated that the evolutionary trajectory from first-line drug resistance to XDR in this clone spanned more than four decades and began at the start of the antibiotic era. It was also observed that frequent de novo evolution of MDR and XDR was present, with 56 and 9 independent evolutions, respectively. Thus, ongoing amplification of drug-resistance in KwaZulu-Natal is driven by both clonal spread and de novo acquisition of resistance. In drug-resistant TB, isoniazid resistance was overwhelmingly the initial resistance mutation to be acquired, which would not be detected by current rapid molecular diagnostics that assess only rifampicin resistance.

Complications of Acute Mastoiditis in a Child in this Era of Antibiotics

Complications of Acute Mastoiditis in a Child in this Era of Antibiotics

Bezold′s fistula: An unusual presentation of cholesteatoma

Cholesteatoma presenting with a Bezold's fistula is extremely rare, and such presentation has been reported. It is infrequent these days in this era of antibiotics, due to early institution of treatment. Fistula results in untreated and inadequately managed Bezold's abscess. The treatment of Bezold's abscess is with prompt intravenous antibiotics, followed by drainage of cervical abscess, but management that of Bezold's fistula is primarily surgical in which a mastoidectomy is done to eradicate the disease with exposure of the mastoid tip with laying open the fistulous tract. One such unusual case of a Bezold's fistula with cholesteatoma is reported in a teenager with a long-standing history of ear discharge, but without any other complications. The patient had being managed conservatively with ear drops since childhood. High resolution computed tomography (CT) mastoids revealed extensive cholesteatoma is destroying the mastoid and perforating the tip with erosion of the tegmen tympani with extra cranial extension. Patient underwent modified radical mastoidectomy with reconstruction of the mastoid bowl with bone pate. Patient was successfully treated and was followed to 1-year with CT scan without recurrence.

Extensive Bilateral Lemierre Syndrome due to Methicillin-Resistant Staphylococcus epidermidis in a Patient with Lung Adenocarcinoma.

Lemierre syndrome (LS) is a septic thrombophlebitis of the internal jugular vein (IJV) following an oropharyngeal infection. LS is commonly caused by normal anaerobic flora and treated with appropriate antibiotics and anticoagulation therapy. Although the incidence of disease is very rare, 15% cases of LS are fatal even in the antibiotic era because of disseminated septic thromboemboli. We reported a case of extensive bilateral LS due to methicillin-resistant Staphylococcus epidermidis in a 63-year-old female with lung adenocarcinoma. Initial examination revealed a retropharyngeal abscess; hence, intravenous ceftriaxone and steroid were initiated empirically. However, pulmonary thromboembolism developed and methicillin-resistant S. epidermidis was identified in the bacterial culture. Despite intensive antibiotic and anticoagulation therapies, extensive septic thrombophlebitis involving the bilateral IJV and superior vena cava developed. Adjunctive catheter-directed thrombolysis and superior vena cava stenting were performed and the patient received antibiotic therapy for an additional 4 weeks, resulting in complete recovery.

A clinical study of new cases of parenchymal neurosyphilis: has tabes dorsalis disappeared or been missed?

Tabes dorsalis (TD) was documented as the most common parenchymal neurosyphilis, but its incidence dramatically declined in the antibiotic era. Syphilis has resurged on the China mainland since the 1980s. In recent years, physicians have been reporting parenchymal neurosyphilis, and the overwhelming majority was general paresis, but this was not the case in the authors' hospital. To make clear the real situation of parenchymal neurosyphilis in the authors' hospital, a retrospective review was carried out of the records of patients during 2009-2012. Overrepresented clinical new cases of tabetic and paretic parenchymal neurosyphilis were collected. Clinical characteristics, neuroimaging, laboratory data, and responses to penicillin were analyzed in two groups. The efficiency of two current criteria based on CSF antibodies tests was inspected. In the 43 cases with positive serum rapid plasma reagin (RPR) and TPPA tests, 18 patients met the criteria of this study: 11 presented with symptoms of general paresis, and seven had typical presentations of TD. There were statistical differences in serum RPR titers, CSF RPR, white blood cell count, and TP between the paretic and tabetic groups. The response to penicillin was relatively poor in TD. The efficiency of two current criteria was lower in the diagnosis of TD. TD was not uncommon in our area. Its clinical features remained typical, but underdiagnosis with CSF-based criteria and a decreased response to penicillin were prominent issues.

The Sea as a Source of Antibiotics

Over the past few decades, there has been a decline in antibiotics development, resulting in fewer new antimicrobial agents approvals. Thus, the era of antibiotics began in the 1920s and 30s with the discovery of penicillin by Alexander Fleming. There are now over 13 classes of antibiotics, some into their fifth generation, consisting on synthetic derivatives from older antibiotics and natural compounds. In the first decades, about 15-20 new antibiotics were developed each decade, but in the last ten years only 6 new drugs have come on the market. In addition to the scarce development of antibiotics, the emergence and increase of multiresistant bacteria to the existent antibiotics used in clinical practice are limiting treatment options for patients.

Lemierre’s Syndrome: The Forgotten Disease?

Lemierre’s Syndrome is characterised by a history of recent sore throat, clinical or radiological evidence of internal jugular vein thrombosis and isolation of anaerobic pathogens- typically Fusobacterium necrophorum. Previously considered a forgotten disease due to widespread use of antibiotics for pharyngeal infections, over the past two decades Lemierre’s Syndrome has become an increasingly common presenting complaint. Emergence of antibiotic resistance may explain the recent rise in the number of reported cases. Lemierre’s Syndrome is associated with significant morbidity and mortality if not diagnosed and treated early. In the pre antibiotic era Lemierre’s syndrome was fulminant and fatal in 90% of cases. The classical presentation of Lemierre’s Syndrome is that of an acute oropharyngeal infection in a young otherwise healthy young adult, followed several days later by fever, rigors and associated lung complications. Treatment involves a prolonged course of antibiotics, the role of concomitant anticoagulation still remains controversial. This article describes treatment and management of a patient diagnosed with Lemierre’s syndrome to illustrate its classical presentation, common pitfalls in diagnosis and optimal management. Our aim is to raise awareness amongst clinicians of this potentially fatal but curable disease.

The Remedy: Robert Koch, Arthur Conan Doyle, and the Quest to Cure Tuberculosis by Thomas GoetzExperiment Eleven: Deceit and Betrayal in the Discovery of the Cure for Tuberculosis by Peter Pringle

106 BOOK REVIEWS programs as ‘parsimonious’ (p.33), and perhaps she is right to do so, but what this really shows is how much we assume today that welfare provision is a moral good, even though we no longer have any objectively moral reasons for doing so. It is also sobering to read reports that our next two generations may experience a decrease in their living standards as they battle deficit-driven fiscal meltdown, caused by our determination to fund existing welfare programs at their current levels. Who will supply their aged pensions? The old questions remain unanswered, and the debate continues. PHILIPPA MARTYR UNIVERSITY OF WESTERN AUSTRALIA Thomas Goetz, The Remedy: Robert Koch, Arthur Conan Doyle, and the Quest to Cure Tuberculosis (New York: Gotham, 2014). ISBN 978-1-592-40751-4 (HB). xx + 298pp. Peter Pringle, Experiment Eleven: Deceit and Betrayal in the Discovery of the Cure for Tuberculosis (London: Bloomsbury, 2012). ISBN 978-1-4088-1401-7 (HB). 239pp. The Remedy by Thomas Goetz and Experiment Eleven by Peter Pringle are like bookends to a landmark period in the history of tuberculosis (TB). The Remedy commences with the dawning of the germ theory and Experiment Eleven addresses the blossoming of the antibiotic era. Goetz revolves his story around Robert Koch (1843–1910) and Pringle centres upon Albert Schatz (1920–2005). Both had wartime experiences working in medicine that stimulated them to work on infectious disease, both had exceptional laboratory skills, and both made major contributions to developing a treatment for TB. Neither, however, went without their own battles. Goetz describes Koch’s rivalry with his contemporary, Louis Pasteur (1822– 1895), and Pringle uncovers Schatz’s bitter legal fight with Selman Waksman (1888–1973) over credit for the discovery of streptomycin, the first antibiotic effective against TB. By adding another character into the mix, Sir Arthur Conan Doyle (1859–1930), Goetz sets out to demonstrate how the deductive methods of science became part of mainstream culture. Pringle’s narrative is a more conventional, highly stimulating, account of how Waksman overturned patent Health & History ● 17/1 ● 2015 107 limits on products of nature and patented streptomycin behind Schatz’s back. While Doyle had injected science into people’s minds, pharmaceutical companies, thanks to streptomycin, were given the means to inject it into people’s bodies. In The Remedy, Goetz vividly portrays life in late nineteenthcentury Europe where infectious diseases were a leading cause of death but germ theory was not widely accepted. Enter Robert Koch, a country physician, who championed germ theory with rigorous and conclusive scientific proof. Koch’s achievements include the elucidation of the causative agents of anthrax, cholera, and TB as well as the extraction of tuberculin. His most far-reaching contribution, Goetz argues, was his diligent articulation of scientific method. This burgeoning philosophical orientation would have had little impact outside the laboratory were it not for popularisers of science like Sir ArthurConanDoyle.Throughhisliterarycharacter,SherlockHolmes, Doyle successfully popularised scientific methods of deduction. Also a physician, Doyle was inspired by Koch’s rigorous methodology, and ironically used this same approach to debunk Koch’s tuberculin as a potential cure for TB. Closing with a gripping tour of the global TB problem today, the epilogue to The Remedy does require a small spoiler alert for those who will go on to read Experiment Eleven. Journalists love controversy, and in the story of microbiology professor Selman Waksman and his PhD student Albert Schatz, Pringle finds it. Scientific discovery, drug company deals, lawsuits, public relations battles, and a Nobel prize are all contained in this juicy tale. Schatz’s discovery that streptomycin stopped the growth of Mycobacterium tuberculosis was a boon to the pharmaceutical industry and a milestone for biomedical science. The central controversy is how Waksman swindled Schatz out of his share of the royalties—a big blemish on Waksman’s otherwise illustrious career. A court case between Schatz and Waksman was eventually settled out of court with a crafty payout distributed among numerous individuals who had variously contributed to the development of streptomycin. Diluting Schatz’s contribution was an effective strategy for Waksman who went on to be awarded a Nobel prize. Collective laboratory work, it would seem...

Acute Osteomyelitis in the Proximal Humerus Caused by Pyogenic Glenohumeral Arthritis in an Elderly Patient - A Case Report

Reports of osteomyelitis in the proximal humerus with pyogenic glenohumeral arthritis of adjacent joints mostly involve pediatric patients. Nowadays, osteomyelitis that is secondary to adjacent pyogenic glenohumeral arthritis is extremely rare, even more so in adults than in pediatrics. We report a rare case of the pyogenic glenohumeral arthritis followed by osteomyelitis of the proximal humerus in an elderly patient. Initially, we diagnosed a case of pyogenic glenohumeral arthritis only, which, despite arthroscopic synovectomy, did not resolve and severe pain continued. Subsequent radiological imaging, performed after our suspicion of a secondary involvement, allowed us to diagnose osteomyelitis combined with the pyogenic glenohumeral arthritis, which we had overlooked because of the extreme rarity of the condition in adults since the antibiotic era began.

Diagnostic and therapeutic utility of transrectal ultrasound in urological office prostatic abscess management: A short report from a single urologic center

Prostatic abscess (PA) is an infrequent condition in the modern antibiotic era. The everyday use of transrectal ultrasound (TRUS) during diagnostic work-up and the widespread recurrence to prostatic biopsies may lead to an increase of PA diagnosis. In this short report we analyze the patients characteristics and the management of seven recent cases of PA diagnosed in our institution. The records of 7 patients admitted to our Center for LUTS associated to septic fever or acute urinary retention, was prospectively collected. Suspect of PA was done on digital rectal examination (DRE) and confirmed by TRUS performed after urinary system ultrasound (UUS) evaluation. Patients were admitted to hospital only in case of septic signs. A sovrapubic (SPC) or urethral catheter (UC) was placed depending on symptoms. A TRUS-guided aspiration of PA was performed with patient in lithotomic position, using a 18 gauge two-part needle, side/end fire needle access. Patient was discharged with antibiotic therapy and followed up until complete resolution of the PA and symptoms. Mean age was 62 years (range 24-82). Two patients were diabetics and one was affected by the immunodeficiency acquired syndrome (HIV). In one case, PA was detected after a persistent fever post TRUS guided prostate biopsy. Average prostate volume was 69 ml (range 19-118 ml). DRE was able to diagnose PA only in 2 cases (29%), UUS evaluation in 1 case (14%). All cases were confirmed by TRUS as hypo-anechoic areas with or without internal echoes in all patients. Mean PA dimension was 3.64 cm (range 1.5-8). SPC was placed in 3 cases (43%), UC in 3 patients (43%). Only 1 patient refused catheterization. Side fire needle aspiration was performed in all cases and in combination with end fire access in case of particular location of abscess cavities. Second look was needed in 2 cases (29%). Antibiotics were administered in all cases. The aspirated pus showed a positive culture for Escherichia coli (43%), Klebsiella pneumoniae (29%), Pseudomonas aeruginosa (14%) and Enterococcus faecalis (14%). PA resolution time mean was 9 days (range 3-24). TRUS evaluation in case of persistent LUTS associated with fever or acute urinary retention is determinant in the diagnosis of PA. Office or institutional management with TRUS needle aspiration is a good option in these cases.

Antimicrobial Resistance: Are we heading towards Post Antibiotic Era?

The discovery of penicillin in 1928 by Alexander Fleming , a magic antibiotic used for treatment of most of the bacterial infection marked the beginning of antibiotic era. With booming drug development a new drug was always available to treat increasing drug resistant bacteria. Between 1935 to 2003 fourteen classes of antibiotics were developed. However with the indiscriminate and inappropriate use of antibiotics, microbes developed mechanisms to elude the action of antimicrobial agents. JMS 2014;17(2):48-49

Genomic interplay in bacterial communities: implications for growth promoting practices in animal husbandry.

The discovery of antibiotics heralded the start of a “Golden Age” in the history of medicine. Over the years, the use of antibiotics extended beyond medical practice into animal husbandry, aquaculture and agriculture. Now, however, we face the worldwide threat of diseases caused by pathogenic bacteria that are resistant to all existing major classes of antibiotic, reflecting the possibility of an end to the antibiotic era. The seriousness of the threat is underscored by the severely limited production of new classes of antibiotics. Evolution of bacteria resistant to multiple antibiotics results from the inherent genetic capability that bacteria have to adapt rapidly to changing environmental conditions. Consequently, under antibiotic selection pressures, bacteria have acquired resistance to all classes of antibiotics, sometimes very shortly after their introduction. Arguably, the evolution and rapid dissemination of multiple drug resistant genes en-masse across microbial pathogens is one of the most serious threats to human health. In this context, effective surveillance strategies to track the development of resistance to multiple antibiotics are vital to managing global infection control. These surveillance strategies are necessary for not only human health but also for animal health, aquaculture and plant production. Shortfalls in the present surveillance strategies need to be identified. Raising awareness of the genetic events that promote co-selection of resistance to multiple antimicrobials is an important prerequisite to the design and implementation of molecular surveillance strategies. In this review we will discuss how lateral gene transfer (LGT), driven by the use of low-dose antibiotics in animal husbandry, has likely played a significant role in the evolution of multiple drug resistance (MDR) in Gram-negative bacteria and has complicated molecular surveillance strategies adopted for predicting imminent resistance threats.

Abdominal Wall Actinomycosis - A Rare Surgical Scar Infection of the Antibiotic Era

No abstract availableDOI: http://dx.doi.org/10.3329/jom.v15i1.19887 J Medicine 2014; 15: 104

Collateral damage: microbiota-derived metabolites and immune function in the antibiotic era.

Our long-standing evolutionary association with gut-associated microbial communities has given rise to an intimate relationship, which affects many aspects of human health. Recent studies on the mechanisms that link these microbial communities to immune education, nutrition, and protection against pathogens point tomicrobiota-derived metabolites as key players during these microbe-host interactions. A disruption of gut-associated microbial communities by antibiotic treatment can result in a depletion of microbiota-derived metabolites, thereby enhancing pathogen susceptibility, impairing immune homeostasis, and contributing tothe rise of certain chronic inflammatory diseases. Here, we highlight some of the recently elucidated mechanisms that showcase the impacts of microbiota-derived metabolites on human health.

Pneumonia and Purulent Pericarditis Caused by Streptococcus pneumoniae

Bacterial pericarditis in children has become a rare entity in the modern antibiotic era. The most common pathogen is Staphylococcus aureus, being Streptococcus pneumoniae an exceptional cause. We present 2 children, who were diagnosed of pneumonia complicated with a pleural effusion that developed a purulent pericarditis with signs of cardiac tamponade. One of them had received 4 doses of the 7-valent conjugated pneumococcal vaccine. Systemic antibiotics and pericardial and pleural drainages were used. Pneumococcal antigens were positive in pleural and pericardial fluids in both cases, and S. pneumoniae was isolated from pleural effusion in one of them. Both children fully recovered, and none of them developed constrictive pericarditis, although 1 case presented a transient secondary left ventricular dysfunction. Routine immunization with 10- and 13-valent vaccines including a wider range of serotypes should further decrease the already low incidence.