History Of Recent Antibiotic Use Research Articles

Clinical features and treatment strategies of febrile urinary tract infection caused by extended-spectrum beta-lactamase–producing Enterobacteriaceae in children: a multicenter retrospective observational study in Japan

ObjectivesThe incidence of infections caused by extended-spectrum beta-lactamase (ESBL)–producing bacteria has increased. This study aimed to clarify the risk factors and treatment strategies for febrile urinary tract infection (fUTI) caused by ESBL-producing bacteria in Japanese children. MethodsA retrospective observational study was conducted in 21 hospitals among children aged <16 years diagnosed with an fUTI between 2008 and 2017. Clinical data of children with fUTI caused by ESBL-producing and non-ESBL–producing bacteria were compared. ResultsOf the 2049 cases of fUTI, 147 (7.2%) were caused by ESBL-producing bacteria. Children in the ESBL group were more likely to have a history of recent antibiotic use or prophylactic antibiotic use, and experience recurrent UTIs (P <0.001) compared with those in the non-ESBL group. Of the 124 cases of fUTI due to ESBL-producing bacteria that were reviewed, 20 and 100 had concordant and discordant antibiotic use, respectively, and four had unknown antibiotic susceptibility. The median time from the start of treatment to fever resolution was 24 hours and did not differ significantly by therapy group (P = 0.39). ConclusionESBL-producing bacteria should be considered in children with recurrent UTIs and recent antibiotic use. Most children with fUTI experience clinical improvement regardless of the choice of antibiotic.

Community Acquired Methicillin Resistance Staphylococcus Species and Inappropriate Antibiotics use among Women of Reproductive Age Group in Enugu, Nigeria

Introduction: The burden of community acquired antibiotic resistance is increasing with an alarming rate in the developing countries. Many factors, including inappropriate use of antibiotics, have been suggested as the causes of spread of resistant strains in the community. Aim: To compare antibiotics susceptibility pattern of community acquired gram positive isolates among women of reproductive age with history of recent inappropriate antibiotics use and those with no history of antibiotics use. Materials and Methods: The present study was a crosssectional descriptive study carried out from August 2020 to February 2021 at the State Teaching Hospital in Enugu, Nigeria. The participants for the study were 713 apparently healthy women who presented to the family planning unit for preconception care. All the participants were screened for asymptomatic bacteriuria by culturing their Midstream Urine (MSU). The isolated organisms were identified, and Antimicrobial Susceptibility (AST) test performed using the Vitek 2. Polymerase Chain Reaction (PCR) was done for the presence of mecA gene among methicillin resistant Staphylococcus species. The antibiotic susceptibility pattern of the isolates from participants with positive history of recent antibiotic use was compared with the susceptibility pattern of those with no history of antibiotics using Chi-square test. Results: Out of the 713 participants, 59 (8.3%) had a positive history of recent antibiotics use. Only 1 (1.7%) participant had her antibiotics prescribed by the doctor while 13 (22) and 45 (76.3) obtain their antibiotics at the patent medicine dealer shop and through self-medication respectively. The commonest indication for inappropriate use was febrile illness followed by upper respiratory symptoms. Ciprofloxacin was the most abused antibiotics followed by amoxicillin-clavulanic acid. Twenty (83.3%) and 4 (16.7%) had Asymptomatic Bacteriuria (ASB) among those with recent antibiotic use and those with no history of recent antibiotic use respectively. All the Methicillin Resistant Staphylococcus aureus (MRSA) was isolated from the participants with recent history of inappropriate antibiotic use. Also, of significant among this group were quinolone resistant gram positive organisms. Conclusion: ASB and multidrug resistant gram positive isolates were common among the participants with recent history of inappropriate antibiotic use. There is need to regulate antibiotics use in the community to prevent selection of multidrug resistant organisms.

Characterizations of Bacterial Vaginosis among HIV-Positive and HIV-Negative Women in Rural Eastern Cape Province, South Africa.

Bacterial vaginosis (BV) is extremely common among the African population and is associated with the transmission and acquisition of human immunodeficiency virus (HIV) infection. The objective of this study was to determine the prevalence and characteristics of BV among HIV-infected and -uninfected women in rural Eastern Cape province of South Africa. A descriptive cross-sectional study was conducted between September 2017 and March 2018 on women aged 18 years and above (n = 100), attending Nelson Mandela Academic Hospital and Ngangelizwe Community Health Centre with signs and symptoms suggestive of vaginal infection. High vaginal swabs were collected, and BV was diagnosed using Nugent's score. The prevalence rate of BV was 70% irrespective of HIV status. Of the 61 HIV-infected patients, 49 (80.3%) and 12 (19.7%) were BV positive and BV negative, respectively; whilst of the 39 HIV-uninfected women, 21 (53.8%) and 18 (46.2%) were BV positive and BV negative, respectively (OR = 3.5; CI: 1.4–8.5; p=0.005). Women aged above 35 years were highly likely to develop BV (p=0.049). The presence of Mobiluncus species (>25 per high microscopic field) was significantly associated with BV among HIV-infected patients (p=0.030). A recent history of antibiotic use (≤3 months) was significantly associated with BV among HIV-negative patients (p=0.044). This study shows that BV is more prevalent among HIV-positive women than their HIV-negative counterparts, and its occurrence is higher among those aged above 35 years. The predominance of Mobiluncus species in the vagina microbiota of HIV-infected women might play a significant role in the development of BV. These findings suggest that the treatment of BV could restore normal flora and reduce susceptibility to and transmission of HIV.

Frequency and risk factors of non-alcoholic fatty liver disease in Helicobacter pylori-infected dyspeptic patients: A cross-sectional study.

Background:In dyspeptic patients with Helicobacter pylori contributes to non-alcoholic fatty liver disease. However, little evidence available from Pakistan.Objective:The study aims to determine the frequency and risk factors of non-alcoholic fatty liver disease in dyspeptic patients with Helicobacter pylori.Methods:This cross-sectional study was conducted between 22 November 2016 and 30 June 2018. Adults of age between 18 and 90 years who attended the out-patient department due to abdominal discomfort, pain, fullness, and bloating who underwent upper gastrointestinal tract endoscopy were enrolled after taking informed consent. Patients with celiac disease, inflammatory bowel disease, taking alcohol, pregnant women and lactating mothers, known cases of hepatitis B and C, and history of recent antibiotic use were excluded. Data on age, gender, smoking, alcohol use, dyslipidemia, hypertension, type 2 diabetes mellitus, and ischemic heart disease were collected. Non-alcoholic fatty liver disease was diagnosed through ultrasonography. Helicobacter pylori infection was detected using a carbon urea breath test.Results:A total of 698 patients were screened for eligibility, and 399 (57.2%) had Helicobacter pylori infection and were enrolled in the study after consent. The median age was 50.1 (interquartile range = 14.5) years and 209 (52.4%) were males. Frequency of non-alcoholic fatty liver disease in patients with Helicobacter pylori dyspeptic patients was 153 (38.3%). Factors associated with non-alcoholic fatty liver disease in the presence of Helicobacter pylori were dyslipidemia 7.38 (95% confidence interval = 2.4–22.71), type 2 diabetes mellitus 5.96 (95% confidence interval = 1.86–19.07), hypertension 3.0 (95% confidence interval = 1.21–7.45), and moderate gastritis 2.81 (95% confidence interval = 1.2–6.59).Conclusion:The frequency of non-alcoholic fatty liver disease in Helicobacter Pylori dyspeptic patients was 38.3%. Male gender, dyslipidemia, hypertension, ischemic heart disease, and moderate gastritis were associated with non-alcoholic fatty liver disease.

Prevalence and Clinical Characteristics of Asymptomatic Pyuria in Chronic Kidney Disease.

BackgroundPyuria seems to be common in chronic kidney disease (CKD), irrespective of urinary tract infection (UTI). It has been hypothesized that sterile pyuria occurs in CKD because of chronic renal parenchymal inflammation. However, there are limited data on whether CKD increases the rate of pyuria or how pyuria in CKD should be interpreted. We investigated the prevalence and characteristics of asymptomatic pyuria (ASP) in CKD via urinary white blood cell (WBC) analysis.MethodsUrine examination was performed for all stable hemodialysis (HD) and non-dialysis CKD patients of the outpatient clinic (total N=298). Patients with infection symptoms or recent history of antibiotic use were excluded. Urine culture and WBC analysis were performed when urinalysis revealed pyuria.ResultsThe prevalence of ASP was 30.5% (24.1% in non-dialysis CKD and 51.4% in HD patients). Over 70% of the pyuria cases were sterile. The majority of urinary WBCs were neutrophils, even in sterile pyuria. However, the percentage of neutrophils was significantly lower in sterile pyuria. In multivariate logistic regression analysis, the degree of pyuria, percentage of neutrophils, and presence of urinary nitrites remained independently associated with sterile pyuria.ConclusionsThe prevalence of ASP was higher in CKD patients and increased according to CKD stage. Most ASP in CKD was sterile. Ascertaining the number and distribution of urinary WBCs may be helpful for interpreting ASP in CKD.

Clostridium difficile colitis: CT findings and differential diagnosis.

Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.

Antibiotic use, knowledge and health literacy among the general population in Berlin, Germany and its surrounding rural areas.

ObjectivesKnowledge concerning antibiotic use in the general population is insufficient. The way health literacy is related to antibiotic use aside from knowledge needs further investigation. Our aim was to compare the levels of knowledge of antibiotics and health literacy in individuals who had taken antibiotics in recent years compared with those who not had taken antibiotics.MethodsA population-based cross-sectional survey of 2,000 individuals aged 35 and older from Berlin, Germany and its surrounding rural and suburban areas (response rate 59%) with strata urban/rural, sex, age, and education. Computer-assisted personal interviews were conducted by external, trained interviewers during home visits. Knowledge, health literacy, and antibiotic use were assessed using standardized questionnaires.ResultsIn all, 33.3% (666/2,000) of the participants indicated having had an antimicrobial therapy during the previous 12 months. Adjusting for sex, age, educational level and health literacy, individuals with four correct answers regarding antibiotics were 1.70 times and those with three correct answers 1.94 more likely to have had a history of recent antibiotic use than those who did not have any correct answers. Individuals with sufficient health literacy were 0.57 times less likely to have had a recent history of antibiotic use than individuals with insufficient health literacy.ConclusionPatients who have used antibiotics might have more knowledge as a result of their recent involvement with the topic of antibiotic use; health literacy may be a preventive mechanism to use antibiotics more critically. Besides improving the health knowledge of the general population and of vulnerable groups such as patients with low levels of health literacy, intervention strategies should focus on providers as well.

Ciprofloxacin-induced Thrombotic Thrombocytopenic Purpura: A Rare Case

Introduction: Fluoroquinolones are widely used in the clinical practice due to their broad spectrum of coverage, high oral bioavailability, and high tissue concentrations. Although usually tolerated well, a potential rare complication of fluoroquinolone-induced thrombotic thrombocytopenic purpura (TTP) has been observed. We report the rare case of a patient who developed TTP after being treated for small intestinal bacterial overgrowth (SIBO) with ciprofloxacin. Case: 77 year-old female presented to gastroenterology clinic for evaluation of chronic diarrhea which was associated with flatulence and cramping. Patient denied any history of fever, recent antibiotic use or any travel in the last few months. After her stool studies came back negative for any infectious cause, she was empirically treated with ciprofloxacin and metronidazole for 10 days for possible SIBO to which her symptoms responded well. She presented to the emergency room three days after finishing her antibiotics with symptoms of confusion and dyslexia. Her MRI of the brain and CT angiography of head and neck did not show any evidence of acute stroke. Over the next three days during her hospital stay, she developed progressive thrombocytopenia, acute renal failure, and evidence hemolytic anemia. Stool cultures were negative for Salmonella, Shigella, Campylobacter, or E. coli 0157:H7. Patient was diagnosed with thrombotic thrombocytopenic purpura likely secondary to ciprofloxacin. Plasmapheresis therapy was initiated promptly resulting in mild improvement of her renal failure, thrombocytopenia, and anemia. She was eventually started on rituximab infusions every week for 4 weeks due to inadequate response to plasmapheresis. She responded well and was able to be discharged home. She was found to be doing well at her follow-up clinic visit with normal chemistries and hematological profile. Discussion: Prompt recognition and early start of the treatment can be lifesaving in patients with TTP. Ciprofloxacin, although safe, should be kept in my mind as a possible culprit in patients who present with TTP with recent history of antibiotic use.

Severity and frequency of community-onset Clostridium difficile infection on an Australian tertiary referral hospital campus

Clostridium difficile infection (CDI) is increasingly being found in populations without traditional risk factors. We compared the relative frequency, risk factors, severity, and outcomes of community-onset CDI with hospital-acquired infection. This was a retrospective, observational study of CDI at a tertiary hospital campus in Sydney, Australia. Patients aged 15 years and older with a first episode of CDI from January 1 to December 31, 2011 were included. CDI was defined as the presence of diarrhoea with a positive enzyme immunoassay in conjunction with a positive cell cytotoxicity assay, toxin culture, or organism culture. Main outcome measures were onset of infection (hospital or community), risk factors, markers of severity, and outcomes for the two groups. One hundred and twenty-nine cases of CDI infection were identified, of which 38 (29%) were community-onset. The community-onset infection group were less likely to have a recent history of antibiotic use (66% vs. 98%; p<0.001) or proton pump inhibitor use (38% vs. 69%; p=0.03) than the hospital-acquired infection group. Markers of severity and outcomes were similar in the two groups, with an overall mortality of 9%. Community-onset CDI accounts for a large proportion of C. difficile infections and has a similar potential for severe disease as hospital-acquired infection. Using a history of previous antibiotic use, proton pump inhibitor use, or recent hospitalization to predict cases is unreliable. We recommend that patients with diarrhoea being investigated in emergency departments and community practice are tested for Clostridium difficile infection.

The Prevalence of Clostridium difficile Infection in a Cohort of Sri Lankan Patients with Acute Severe Ulcerative Colitis

Introduction: Global studies report that 5%-19% of patients with acute severe ulcerative colitis (ASUC) are positive for Clostridium difficile. Data from Sri Lanka, as well as from other countries in South Asia are lacking. Guidelines recommend all patients with ASUC be tested for Clostridium difficile in stools. The implications of this on developing countries such as ours are a higher cost to patients. Therefore in this study we sort to find out the prevalence of Clostridium difficile infection in patients with ASUC presenting to a teaching hospital over an eighteen month period. Method: All ulcerative colitis (histologically proven) patients admitted with ASUC from July 2011 to December 2012 were included. ASUC was diagnosed according to True love and Witt's criteria. A Clostridium difficile infection was diagnosed based on the ELISA test to detect Clostridium difficile toxins, done on a single sample of stools within 24 hours of admission. Results and discussion: 32 patients; with ASUC were included. Six (18.75%) tested positive for Clostridium difficile. The mean age was 28 and 48 years in the positive and negative group respectively. Of the positive patients three were previously on Aminosalicylates and three were treatment naive. Apart from one patient with a history of recent antibiotic use, none of the other patients gave a history of antibiotic, PPI use or hospital admission within 3 months. The White blood cell count, ESR or stools full report were unable to predict the presence of Clostridium difficile infection. Apart from one patient with pseudo-membranes on endoscopy, none of the other toxin positive patient's endoscopy or histology was suggestive of Clostridium difficile infection. Conclusion: This study shows a high prevalence of Clostridium difficile infection among Sri Lankan patients presenting with ASUC, which is in keeping with studies reported previously. Although local or regional guidelines are lacking, this study also reconfirms the necessity to test for Clostridium difficile in ASUC. As suggested by previous authors the risk factors associated with the development of Clostridium difficile infections in ASUC seems different to the general population.

A Case of Collagenous Gastroenteritis with Pseudomembranes

A 51-year-old woman was admitted to hospital with a two-month history of watery diarrhea and 9 kg weight loss. Stool frequency was eight to 10 per day but without blood, steatorrhea or abdominal pain. There was no history of recent antibiotic use or infectious contacts. Her history was significant for type I diabetes mellitus treated with insulin. She was a lifelong nonsmoker who consumed no alcohol. The family history was unremarkable. Physical examination was normal. Laboratory data showed an elevated white blood cell count of 13.3×109/L (normal range 4.8×109/L to 10.8×109/L), a C-reactive protein level of 15.4 mg/L (normal range 0 mg/L to 8 mg/L) and an albumin level of 19 g/L (normal range 33 g/L to 45 g/L). Her tissue transglutaminase level was 0 U/mL (normal range 0 U/mL to 10 U/mL) with a normal immunoglobulin A level. Stool testing was negative for bacterial and parasitic pathogens, while Clostridium difficile testing was negative on three separate occasions.

Chemotherapy characteristics are important predictors of primary prophylactic CSF administration in older patients with breast cancer

Chemotherapy is vital for breast cancer management, but early onset toxicities like neutropenia hinder its administration. Primary prophylactic (PP) use of colony- stimulating factors (CSF) helps prevent neutropenia and ensures successful chemotherapy completion. Nevertheless, lack of specific guidelines for CSF administration in older patients has lead to unexplained geographic and racial, and counter-intuitive clinical variations in CSF administration. This study examined the reasons for these variations and for the first time looked at variations in PP-CSF administration and duration of administration in breast cancer patients receiving chemotherapy. This retrospective observational study of newly diagnosed breast cancer patients receiving chemotherapy used SEER-Medicare data from 1994-2003. Regression analyses were used to explore the factors associated with PP-CSF administration and duration of administration. Clinical and therapeutic characteristics previously unexplored by other studies were included. Univariate analyses demonstrated geographic, racial and clinical disparities similar to previous studies. However, clinical correlations resolved to statistical insignificance after inclusion of chemotherapy characteristics. The analysis showed that significant geographic and racial disparities existed. History of recent antibiotic use was associated with shorter PP-CSF administration. Physicians' decision to administer PP-CSF is predominantly driven by neutropenia risk associated with pre-planned chemotherapy regimen. Older, sicker women at a higher risk of neutropenia receive less intense/toxic chemotherapy and thus do not require PP-CSF. Geographic variations are driven by proportion of physicians administering PP-CSF with no evidence for overuse among specific physicians. Association of recent antibiotic use with shorter PP-CSF administration suggests intended substitution of the expensive PP-CSF with prophylactic antibiotics.

Antimicrobial resistance among uropathogens that cause acute uncomplicated cystitis in women in Hong Kong: a prospective multicenter study in 2006 to 2008

A prospective multicenter study was conducted to assess the epidemiology of antimicrobial resistance among uropathogens causing uncomplicated cystitis. Adult women with clinical diagnosis of uncomplicated cystitis were enrolled from 54 participating centers distributed all over Hong Kong during 2006 to 2008. A positive urine culture was found in 59.5% (352/592) patients. The patients had mean age of 44.9 years, and most (89.2%) were otherwise healthy. The most prevalent causative organism was Escherichia coli (77%), followed by other Enterobacteriaceae (14.2%), staphylococci (5.1%), and other Gram-positive bacteria (3.7%). The resistance rates of E. coli to co-trimoxazole and ciprofloxacin were 29.5% and 12.9%, respectively, and 14 isolates (5.2%) were confirmed as extended-spectrum β-lactamase (ESBL) producers. Of the ESBL producers, molecular studies showed CTX-M-14, CTX-M-24, or CTX-M-9. Nitrofurantoin and fosfomycin were active against >90% of the isolates, regardless of resistance phenotypes for other drugs. Pulsed-field gel electrophoresis of representative isolates showed that the antibiotic-resistant strains were genetically diverse. Patients with history of recent antibiotic use were significantly more likely to have infection by E. coli with co-trimoxazole resistance (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.4–5.7; P = 0.003) and ciprofloxacin resistance (OR, 2.5; 95% CI, 1.1–5.8; P = 0.03). Knowledge of the resistance data and risk factors could inform better use of antibiotics for empiric therapy for acute uncomplicated cystitis.

Rectal prolapse secondary to antibiotic-associated colitis in a dog

Many animals with rectal prolapse have an antecedent history of dyschezia and tenesmus associated with colonic inflammatory disease. However, it seems that there are no reports of rectal prolapse concurrent with antibiotic-associated colitis in the veterinary literature. A 3-month-old male cross-bred dog presented with a history of recurrent episodes of rectal prolapse following the administration of oral cephalexin. The rectal prolapse was corrected surgically. Based on the dog's recent history of antibiotic use, the sudden onset of bloody diarrhoea, tenesmus and subsequent rectal prolapse, antibiotic-associated diarrhoea was considered as the primary cause of rectal prolapse in this case. Clostridium perfringens were isolated from a bacteriological stool culture. The dog was treated with amoxicillin for three consecutive weeks. There were no detectable signs of diarrhoea or a recurrence of rectal prolapse during the 2-month follow-up period.

Clinical Efficacy of Dexamethasone for Acute Exudative Pharyngitis

The objective of this study was to investigate whether treatment with single-dose dexamethasone can provide relief of symptoms in acute exudative pharyngitis. A prospective, randomized, double-blinded, placebo-controlled clinical trial was undertaken over a 3-month period in a university-based Emergency Department. The study included all consecutive patients between 18 and 65 years of age presenting with acute exudative pharyngitis, sore throat, odynophagia, or a combination, and with more than two Centor criteria. Each patient was empirically treated with azithromycin and paracetamol for 3 days. The effects of placebo and a fixed single dose (8 mg) of intramuscular injection of dexamethasone were compared. The patients were asked to report the exact time to onset of pain relief and time to complete relief of pain. After completion of the treatment, telephone follow-up regarding the relief of pain was conducted. A total of 103 patients were enrolled. Thirty patients with a history of recent antibiotic use, pregnancy, those who were elderly (> 65 years of age) and patients who failed to give informed consent were excluded. Forty-two patients were assigned to the placebo group and 31 were assigned to the intramuscular dexamethasone group (8-mg single dose). Time to perceived onset of pain relief was 8.06 ± 4.86 h in steroid-treated patients, as opposed to 19.90 ± 9.39 h in the control group ( p = 0.000). The interval required to become pain-free was 28.97 ± 12.00 h in the dexamethasone group, vs. 53.74 ± 16.23 h in the placebo group ( p = 0.000). No significant difference was observed in vital signs between the regimens. No side effects and no new complaints attributable to the dexamethasone and azithromycin were observed. Sore throat and odynophagia in patients with acute exudative pharyngitis may respond better to treatment with an 8-mg single dose of intramuscular dexamethasone accompanied by an antibiotic regimen than to antibiotics alone.

Splenic Abscess due to Clostridium perfringens

To the Editor: Splenic abscess is an uncommon clinical entity with an incidence of 0.14% to 0.7%.1 The common causative organisms are aerobic. Anaerobic organisms such as clostridial species are rarely implicated. We present a case of an elderly woman with splenic abscess that grew Clostridium perfringens. CASE REPORT A 64-year-old woman presented with a 2-week history of left upper quadrant abdominal pain associated with fever, nausea, vomiting, and diarrhea. She denied any history of recent antibiotic use, travel, or sick contacts. Patient had a colonoscopy 4 years before presentation which revealed a polypoid leiomyoma in the sigmoid colon; a follow-up colonoscopy a year later revealed hyperplastic polyps in the transverse colon that were removed. History was otherwise noncontributory. On examination, patient was in mild distress because of abdominal pain. Vital signs showed a temperature of 36.4°C and a pulse rate of 110/min. Abdominal examination was significant for left upper quadrant tenderness and splenomegaly. The rest of the physical examination finding was unremarkable. Laboratory data showed marked leukocytosis (white blood cell count of 21.8 × 103/mm3 with 82% neutrophils and 7% bands) and C-reactive protein of 17.5 mg/dL. The rest of the laboratory results were within normal limits. Chest radiograph revealed an elevated left hemidiaphragm. Computed tomography (CT) of the abdomen with contrast revealed an air-fluid level along the posterior part of the spleen consistent with an abscess (Fig. 1). The patient was empirically started on intravenous piperacillin-tazobactam and had a CT-guided percutaneous catheter drainage of the abscess. Abscess drain cultures were positive for C. perfringens, and the antibiotics were changed to ampicillin-sulbactam. Stool was negative for Clostridium difficile toxin. Blood cultures were negative. An echocardiogram of the heart revealed no valvular vegetations. Malignancy workup was negative. Colonoscopy revealed adenomatous polyps in the transverse colon, and she underwent polypectomy. The patient was discharged on intravenous clindamycin for dosage convenience. Her condition improved, and serial abdominal CT scans done over the next few weeks revealed a decrease in the abscess size. The drain was removed after she completed a 6-week course of antibiotics.FIGURE 1: Computed tomography of the abdomen with contrast showing air-fluid level in the spleen.She presented with similar complaints 4 weeks later. A repeat CT of the abdomen revealed recurrence of the splenic abscess. She then underwent splenectomy; dense adhesions were noted along the splenocolic ligament on exploratory laparotomy. She was discharged uneventfully on postoperative day 8. DISCUSSION Splenic abscess is rare with a subtle clinical presentation and requires a high index of suspicion. The most common clinical features are fever, left upper quadrant pain, and splenomegaly.2 Diagnosis is mainly radiological. Ultrasonography is a good noninvasive technique, but CT has the highest sensitivity and specificity.2 Aerobic organisms are the most common organisms isolated and include staphylococcus and streptococcus species, salmonella, and Escherichia coli1-3; anaerobes account for 10% only. Most of the cases reported in the past due to clostridial species had predisposing factors such as malignancy, colitis, hematologic diseases, diabetes, or trauma.4-7 A review of literature revealed 2 reported cases of splenic abscess due to C. perfringens6,8; one had trauma as a predisposing cause, and the other one speculated diabetic microvascular injury as a possible factor. The source of C. perfringens in our patient remained obscure except for the history of diarrhea suggesting colitis and repeated polypectomies with breach in colonic mucosa acting as a possible portal of entry.

Clostridium difficile Associated Disease. Acid Suppression

Purpose: There has been a recent rise in incidence of Clostridium difficile associated disease (CDAD) in hospitalized patients, especially with identification of new virulent strains. The recent wide spread use of acid suppressing agents may play an important role in altering gut flora and substantially increasing susceptibility to CDAD. The aim of this study was to identify the use of acid suppressing agents, as a risk factor, in patients diagnosed with C. difficile infection. Methods: This was a retrospective, cross sectional review of US veterans hospitalized in NY Harbor Healthcare system, over one year period (5/2005 to 5/2006). All patients with complaints of diarrhea, with positive stool toxin for Clostridium difficile over a period of one year were identified. The data was collected regarding age, gender, acid suppressing agent use and antibiotic use. Information was also gathered, whether the use of acid suppressing agent was chronic as out patient or acute as inpatient, at least 1 week prior to diagnosis of CDAD. Results: A total of 136 subjects were identified with positive stool toxin for C. difficile over a period of one year. Ninety six percent of the subjects were men. The mean age of the subjects was 71 ± 1.2 (± SEM). Seventy eight percent of patients were on acid suppressing agents: 68% were on proton pump inhibitors and 10% were on H2 receptor antagonists. In the group of subjects on acid suppressing agents 31% were on chronic acid suppression as out patient and 64% were on acid suppression during the hospitalization. Recent history of antibiotic use was present in 88% of subjects. 67% of the subjects had simultaneous use of acid suppressing agents and antibiotic use which was significantly (p <.05) higher then subjects who were either only on antibiotic or acid suppressing agent alone. Conclusions: CDAD is on the rise in hospitalized patients, especially in elderly age group. The known risk factors, age, concomitant medical condition, immune suppression, antibiotic use, have remained unchanged. The recent wide spread use of acid suppressing agents may be one of the factors, increasing the risk of acquiring Clostridium Difficile infection. We observed from our cohort analysis that combined acid suppression and antibiotic use is present in significant number of patients diagnosed with C. difficile. These results need to be further tested in a prospective randomized controlled trial.

Executive summary

Executive summary

Antibiotic-resistant Streptococcus pneumoniae in the heptavalent pneumococcal conjugate vaccine era: predictors of carriage in a multicommunity sample.

Despite immunization with heptavalent pneumococcal conjugate vaccine (PCV7), the rising prevalence of antibiotic resistance makes Streptococcus pneumoniae a continuing threat to child health. Data on carriage of resistant organisms by healthy children in communities in which immunization with PCV7 has been implemented will help to define and decrease these risks further. Children who were <7 years old, resided in a study community, and presented for routine well care or a "sick" visit between March 13 and May 11, 2001, at 31 primary care practices in 16 geographically distinct Massachusetts communities were studied. Consenting parents provided demographic information and data on potential risk factors for carriage of S pneumoniae and of penicillin-nonsusceptible S pneumoniae (PNSP). S pneumoniae isolates from nasopharyngeal specimens were tested for resistance to commonly used antibiotics including penicillin, ceftriaxone, erythromycin, and trimethoprim/sulfamethoxazole. Isolates were serotyped and grouped into PCV7-included serotypes, potentially cross-reactive serotypes (ie, an organism of a serogroup included in the vaccine), or non-PCV7 serotypes. Diagnosis on the day of collection, history of recent antibiotic use, and history of PCV7 immunization were obtained by chart review. Separate bivariate and multivariate analyses were performed to identify correlates of colonization with S pneumoniae and colonization with PNSP, accounting for clustering within communities. S pneumoniae was isolated from the nasopharynx of 190 (26%) of the 742 children studied. Of the 166 tested, 33% were nonsusceptible to penicillin, with 14% showing intermediate susceptibility (minimum inhibitory concentration [MIC] 0.12-1.0) and 19% fully resistant (MIC > or =2). Nonsusceptibility to other antibiotics was common, including ceftriaxone (14%), erythromycin (22%), and trimethoprim/sulfa (31%); 20% of S pneumoniae isolates were not susceptible to > or =3 antibiotics. Thirty-six percent of isolates were of serotypes covered by PCV7; 30% were of PCV7 serogroups and potentially cross-reactive, but not 1 of the 7 included serotypes; and 34% were unrelated to PCV7 serogroups. Nonsusceptibility to penicillin was more common in PCV7-included strains (45%) and potentially cross-reactive strains (51%) than in non-PCV7 serotypes (8%). Risk factors for PNSP colonization included child care attendance (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 2.3-6.5), current respiratory tract infection (OR: 4.7; 95% CI: 2.5-8.6), and recent antibiotic use (OR: 1.7; 95% CI: 1.0-2.8). PCV7 immunization was associated with decreased carriage of PCV7-included serotypes but not with an overall decrease in S pneumoniae colonization or with a decline in PNSP colonization. In this multicommunity sample, pneumococcal antibiotic resistance was common and was most frequently found in PCV7-included and PCV7 serogroup strains. The long-term impact of PCV7 immunization will be partially determined by the protection that it affords against invasive infection with potentially cross-reactive serotypes, as well as the virulence and future resistance patterns of unrelated serotypes.

Diversity of tetracycline resistance genes in bacteria from Chilean salmon farms.

Twenty-five distinct tetracycline-resistant gram-negative bacteria recovered from four Chilean fish farms with no history of recent antibiotic use were examined for the presence of tetracycline resistance (tet) genes. Sixty percent of the isolates carried 1 of the 22 known tet genes examined. The distribution was as follows. The tet(A) gene was found in six isolates. The tet(B) gene was found in two isolates, including the first description in the genus Brevundimonas: Two isolates carried the tet(34) and tet(B) genes, including the first description of the tet(34) gene in Pseudomonas and Serratia and the first description of the tet(B) gene in Pseudomonas: The tet(H) gene was found in two isolates, which includes the first description in the genera Moraxella and Acinetobacter: One isolate carried tet(E), and one isolate carried tet(35), the first description of the gene in the genus Stenotrophomonas: Finally, one isolate carried tet(L), found for the first time in the genus Morganella: By DNA sequence analysis, the two tet(H) genes were indistinguishable from the previously sequenced tet(H) gene from Tn5706 found in Pasteurella multocida. The Acinetobacter radioresistens isolate also harbored the Tn5706-associated 1,063-bp IS element IS1597, while the Moraxella isolate carried a 1,026-bp IS-like element whose 293-amino-acid transposase protein exhibited 69% identity and 84% similarity to the transposase protein of IS1597, suggesting the presence of a novel IS element. The distribution of tet genes from the Chilean freshwater ponds was different than those that have previously been described from other geographical locations, with 40% of the isolates carrying unidentified tetracycline resistance genes.