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Study Design: This report describes two cases of acute spondylodiscitis, caused by, complicating two different conditions: microdiscectomy for herniated nucleus pulposus and decompressing laminotomy for spinal stenosis., Objective: To describe a rare and life-threatening spinal infection and discuss its successful management., Summary of Background Data: To our knowledge, no published reports in the English language have described this potentially devastating infection as a complication of elective noninstrumented discectomy or decompressive laminotomy., Methods: Two cases of a very early onset of acute spondylodiscitis, caused by, after minimally invasive lumbar spine surgeries are presented. The elapsed time between these two complications was 1 week. The clinical presentation was characteristically stormy in both cases. On postoperative day 2, the patients developed high fever with intense chills and concomitant acute low back pain rapidly increasing in severity. The overall clinical appearance was alarming. The patients were carefully investigated immediately and scrutinized for possible origin of the infection. Treatment consisted of prompt intravenous antibiotics and surgical debridement., Results: The history and clinical manifestations of postoperative spondylodiscitis were corroborated with magnetic resonance imaging findings and bacteriologic and hematologic laboratory examination. Blood cultures revealed as the responsible pathogenic microorganism. The source of the pathogens was contaminated normal saline used for surgical lavage. Both patients were able to completely resume their previous occupations after aggressive surgical debridement/irrigation and 3 months of antibiotic treatment., Conclusions: may become a potential pathogen, causing severe spinal infection after elective surgery. For prompt diagnosis and effective treatment of this life-threatening infection, one should maintain high index of suspicion and should not procrastinate in initiating treatment, which should consist of appropriate intravenous antibiotics and surgical debridement.

Background: We investigated an outbreak of Serratia marcescens in the neonatal intensive care unit (NICU) and the pediatric intensive care unit (ICU) of the University Children's Hospital Leipzig, Germany., Patients and Methods: From September to November 1998 15 patients were infected or colonized by S. marcescens. During the outbreak swabs from eye, blood, throat and nose were taken from every patient hospitalized in the ICUs., Results: In 15 cases (14 from the NICU and one from the pediatric ICU) the cultures yielded S. marcescens. All strains were investigated by pulsed field gel electrophoresis (PFGE) as well as by polymerase chain reaction (PCR) fingerprinting. Both molecular typing methods revealed corresponding fingerprint patterns in all of the 15 isolates. Typing results of the outbreak-related isolates demonstrated that two epidemic strains of distinct genotypes were associated with cross-infections of a group of five and a group of ten patients, respectively. The three invasive and seven of the colonizing isolates were related genotypically., Conclusion: This survey shows that PCR and PFGE are comparable in respect to the discrimination and reproducibility for epidemiological studies of S. marcescens strains in nosocomial outbreaks. Genotypic fingerprinting of bacterial isolates is useful and important to limit nosocomial infections. Fingerprinting sources of nosocomial infections can be traced both by PFGE and PCR. All patients infected recovered completely and the nosocomial outbreak could be stopped rapidly.

Between October 20 and November 11, 1997, Serratia marcescens bacteremia was identified in 8 patients in a pediatric ward at Siriraj Hospital. The organism was isolated from 17 blood and 3 bone marrow specimens. The only common associated factor in these patients was that they all had received an intravenous fluid infusion. In the attempt to investigate the source of S. marcescens implicated in the outbreak, 108 specimens of intravenous fluid, 3 intravenous fluid bottle caps, 4 specimens from intravenous fluid tubing sets, 21 specimens of antiseptics used on the ward, 28 specimens of rectal swabs from patients on the ward, 1 sample of blood culture media prepared by the hospital for routine use, and 62 environmental specimens including hand swabs of the medical personnel, refrigerator, air conditioning, milk samples, room air, water sink, wooden splint and adhesive tape used to immobilize the intravenous access. Of 227 specimens sent for culture, S. marcescens was isolated from only one specimen collected from the in-use intravenous fluid given to a patient with Serratia bacteremia. S. marcescens was not found in any other surveillance culture. The 8 patients were placed under quarantine in the same room with an exclusive nursing team. With the investigation and intervention including monitoring for meticulous hand washing of the ward staff, the outbreak was stopped within 7 days. Although the investigation failed to discover the environmental reservoir of S. marcescens in this outbreak, the data suggested that intravenous fluid was probably the route of transmission and the medical personnel played an important role in spreading the infection.

A case of endogenous Serratia marcescens endophthalmitis in a patient with diabetes, end-stage renal disease, and an indwelling venous catheter is reported. The patient presented with a tan hypopyon and elevated intraocular pressure. Diagnosis was established by positive blood, vitreous, conjunctival, and catheter tip cultures. After a deteriorating course the eye was enucleated. Gross and histopathologic examination revealed the presence of a dark hypopyon with iris necrosis and pigment dispersion and possible spontaneous globe perforation. This is the eleventh reported case of endogenous Serratia endophthalmitis. Previous association of a pink hypopyon and of pigmented vitreous fluid and Serratia endophthalmitis has been reported. This is the first case of dark hypopyon in endogenous Serratia marcescens endophthalmitis reported in the medical literature. Previous entities associated with dark hypopyon have been limited to intraocular melanoma and Listeria monocytogenes endophthalmitis. Dark hypopyon in the appropriate clinical setting may be useful in aiding diagnostic and therapeutic decisions.

Serratia marcescens is a well-recognized hospital-acquired pathogen, which has been associated with a number of specific outbreaks, particularly in critically ill neonates. We used pulsed-field gel electrophoresis (PEGE) typing to analyse an outbreak in a neonatal intensive care unit (NICU). We included samples from nine patients, three handwashes and ten environmental isolates from an outbreak (February to August 1999) in addition to four patient isolates from different wards of our hospital during the same time period. The clinical presentations of the outbreak included bacteraemia (four cases), pneumonia (three cases), umbilical wound infection (one case) and conjunctivitis (one case). Nine outbreak isolates exhibited an identical PFGE fingerprint, while the epidemiologically unrelated strains demonstrated distinct patterns. Epidemiological investigation failed to reveal a common source of the outbreak, although the epidemic S. marcescens strain was isolated from hand-washes and doors of incubators. We concluded that cross-transmission via transient contamination of hands was the major route for this outbreak. Strict handwashing practices, the cohorting and isolation of colonized and infected patients, and the regular dis-infection of incubators are crucial steps for preventing the transmission of S. marcescens in an NICU. This PFGE method is highly discriminatory for the thorough epidemiological investigation of an outbreak of S. marcescens., (Copyright 2001 The Hospital Infection Society.)

Outbreaks of infection in neonatal intensive care units (NICUs) due to Serratia marcescens are well recognized. In some outbreaks no point source has been found, whereas in others cross-infection has been associated with contaminated ventilator equipment, disinfectants, hands and breast pumps. We report an outbreak due to S. marcescens that involved two geographically distinct NICUs. The outbreak occurred over a six week period; 17 babies were colonized, 12 at Glasgow Royal Maternity Hospital (GRMH) and five at the Queen Mothers Hospital (QMH). At GRMH three babies developed septicaemia, of whom two died. The outbreak isolates were of the same serotype and phage type and were indistinguishable on the basis of restriction fragment length polymorphism analysis. During the outbreak, two babies shown consistently to be negative on screening, were transferred between the two units. In addition, two members of medical staff attended both units. In QMH no means of cross infection was identified. However, in GRMH the outbreak strain of S. marcescens was isolated from a laryngoscope blade and a sample of expressed breast milk., (Copyright 2000 The Hospital Infection Society.)

Purpose: To report a Serratia marcescens infection that clinically simulated a conjunctival neoplasm., Method: Case report., Results: A healthy 80-year-old man without contact lenses presented with a pink-yellow conjunctival mass that resembled a solid neoplasm. Stains and cultures of material that exuded from the mass during surgery revealed S. marcescens. Histopathology disclosed an epithelial-lined cyst with macrophages containing S. marcescens., Conclusion: Although S. marcescens usually affects the eye as a keratoconjunctivitis in patients with contact lenses, it can also present as a mass simulating a neoplasm in a patient who does not wear contact lenses.

A total of 106 cases of rib osteomyelitis were reviewed, including 2 cases described in detail. Mycobacterial and bacterial infections accounted for 47 cases each. Fungal rib osteomyelitis occurred in 11 cases and 1 case was caused by Entamoeba histolytica. Most cases occurred in children and young adults. The mean duration of symptoms before diagnosis was 16, 26 and 32 weeks for bacterial, mycobacterial and fungal rib osteomyelitis, respectively. Common clinical signs were fever (73%), soft tissue mass (64%) and chest pain (60%). Route of infection was defined in 85 cases: 62% from contiguous spread and 38% via haematogenous route of infection. Eighty-nine percent had a favourable outcome after antimicrobial therapy with or without surgery. In conclusion, rib osteomyelitis is a rare infection of various aetiologies. The majority of cases occur in children and young adults and its diagnosis is usually delayed for several weeks.

A 68-year-old man with a DeBakey type II chronic aortic dissection developed bacteremia secondary to a urinary tract infection with the Serratia species. This resulted in an infected thrombus in the false channel and a subsequent rupture of the ascending aorta. An emergency resection of the ascending aorta and a Dacron graft interposition were performed. The patient suffered from severe neurological insufficiency and died of pneumonia 6 months postoperatively. The optimal operation time and surgical options of an infected aortic dissection should be determined.

Skin infection secondary to gram-negative organisms is uncommon and is typically limited to persons who are immunocompromised. When these do occur, they are acute, progressive, and severe. Here we report 2 cases of painful red nodules that presented with a waxing and waning course over a long period. One case is that of a 45-year-old healthy white man who developed Serratia marcescens infection in 1 leg. The other case is that of a 78-year-old man with chronic lymphocytic leukemia treated with prednisone who developed infection of the leg secondary to Pseudomonas aeruginosa. In the first case, symptoms were present for 2 years before definitive diagnosis and treatment. In the second case, 4 months elapsed. Ultimately, both patients responded to antibiotic therapy and recovered. These cases illustrate an unusual presentation of chronic red painful nodules of the leg secondary to infection with gram-negative organisms and underscore the importance of culture even when infection seems unlikely.

Background: Pulsed field gel electrophoresis (PFGE) is a commercially available technique that can establish clonal relationships among many common hospital-derived organisms with a high degree of accuracy and can yield results in a sufficiently short time to guide interventions during an outbreak investigation., Methods: The CHEF Genomic Bacterial DNA Plug Kit (Bio-Rad) was applied to an unfolding nursery outbreak of Serratia marcescens infections according to the manufacturer's guidelines. Bacterial genomic DNA was digested with XbaI or SpeI and separated on 1% agarose gels, and the isolates were grouped by restriction endonuclease patterns according to established standards., Results: S. marcescens was isolated from nine patients in an intensive care nursery during an 8-week period. Initial PFGE analysis performed after identification of the first eight patients, when closure of the nursery was imminent, revealed that the epidemic was caused by two groups of four isolates each. In both instances the group was geographically contained, and the nursery remained open. A second PFGE analysis indicated that a ninth S. marcescens isolate, recovered in Week 8, was genetically unrelated to the other two. Surveillance during an additional 6 weeks revealed no new cases, and the epidemic was declared over. No cases of invasive S. marcescens infection were identified during the subsequent 10 months., Conclusion: Real-time PFGE determined that an apparent nursery outbreak of S. marcescens infection was, in fact, caused by three genetically distinct strains. This information allowed the nursery to remain open after other appropriate infection control measures had been imposed.

Three episodes of Serratia marcescens pseudobacteraemia occurred on a neonatal intensive care unit. Following the first two cases, one full term and one pre-term infant, the source was identified as a glucose/lactate analyzer. Blood culture and environmental isolates of the organisms involved were indistinguishable when subjected to pulsed-field gel electrophoresis of Spe 1 digests and PCR ribotyping. Failure to recognize pseudobacteraemia in neonates results in inappropriate therapy for the individual and increased antibiotic pressures on the unit. Attention to the possibility of cross infection when using automated analyzers is required to minimize the risks of true or pseudoinfection to patients.

Over the last 30 years, Serratia marcescens has become an important cause of nosocomial infection. There have been many reports concerning the identification, antibiotic susceptibility, pathogenicity, epidemiological investigations and typing of this organism. Accurate identification is important in defining outbreaks. The API 20E system has been used widely, but is not individually satisfactory. The growth of S. marcescens in the environment has been investigated in relation to water, disinfectants and plastics such as blood bags. Certain extracellular products are unique to S. marcescens. Pigment (prodigiosin) biosynthesis by S. marcescens has been investigated fully since the emergence of the organism as a cause of infection. Many other aspects of the pathogenicity and virulence of S. marcescens have been studied, including adherence and hydrophobicity, lipopolysaccharide (LPS) and extracellular products. Two modes of adhesion to host epithelial surfaces have been suggested. These are mannose-resistant (MR) pili and mannose-sensitive (MS) pili. LPS, which is responsible for the biological activity of endotoxin, has been investigated fully and 24 somatic antigens have been described. The production of different enzymes by S. marcescens as virulence factors has also been reported, including chitinase, lipase, chloroperoxidase and an extracellular protein, HasA. Antibiotics used to treat serratia infection include beta-lactam agents, aminoglycosides and fluoroquinolones and a variety of different resistance mechanisms have been demonstrated. Typing methods used to study the epidemiology of S. marcescens include biotyping, bacteriocin typing, phage typing, plasmid analysis, polymerase chain reaction amplification of enterobacterial repetitive intergenic consensus sequences (ERIC-PCR) and ribotyping. Serological typing has also been used and this method seems to be a suitable first-line typing method for S. marcescens, although some strains remain untypable. RAPD-PCR has also been applied to a small number of isolates and seems to be a promising method, especially for rapid monitoring of an outbreak and tracing the source of initial infection.

Serratia marcescens has emerged in the last few years as an important nosocomial pathogen. Many methods for typing this organism have been described. In this study the random amplified polymorphic DNA-polymerase chain reaction (RAPD-PCR) was shown to be a convenient typing method for S. marcescens. Different combinations of primers previously used for typing other gram-negative bacilli were assessed. The combination of primer HLWL-74 and 1254 gave distinguishable patterns for different serotypes and proved to be the most satisfactory. By applying this combination to 175 isolates of S. marcescens, which could be classified into 38 groups on the basis of serotyping and phage typing, 73 different RAPD patterns with good reproducibility were obtained. This is, to our knowledge, the first application of the method to a large collection of S. marcescens representing a wide range of serotypes.

An unusual presentation of calcaneal osteomyelitis is described, where-by the infection remained undiagnosed for 25 years. The 36-year-old patient recently sought medical treatment for a reported ankle sprain, but the pain was recalcitrant to conservative care. Further investigation yielded a history significant for stepping on a chicken bone as a child, which entered the inferior lateral heel. Magnetic resonance imaging revealed what plain radiographs did not: a well demarcated lytic lesion in the body of the calcaneus. Intraoperative findings were consistent with an abscess of chronic osteomyelitis. The treatment included incision and drainage, antibiotic beads, and a tricortical bone graft.

This case report describes the spontaneous healing of a 20-cm massive tibial cortical defect. The defect was created during debridement of necrotic bone and soft tissue in a low-velocity gunshot wound of the tibia that became infected in a skeletally mature patient. The patient was treated in an external fixator and had a soleus flap to provide soft-tissue coverage. He had refused any surgical reconstructive options. Despite the absence of surgical reconstruction, his tibia healed, and he returned to full activity without any orthotic device 9 months after the original injury.

In order to establish a peripheral blood stem cell graft, repeated apheresis are necessary in the majority of patients. Each apheresis requires withdrawal and reinfusion of blood with high flow rates. To guarantee these flow rates, large-bore catheters are needed for central venous access. Subcutaneously tunneled silicone catheters (Hickman) caused venous thrombosis in 10-40% of the patients. We therefore used polyurethane large-bore catheters only for the time of peripheral blood stem cells (PBSC) collection. Via a Seldinger guidewire following delineation of the right (160 patients) or left (23 patients) internal jugular vein by ultrasound, 183 apheresis catheters have been inserted when the white blood cell count was > 1.0 x 10(9)/L and a measurable population of CD34+ cells was detected by fluorescence-activated cell sorter analysis. The median flow rate was 70 ml/min (range 50-80 ml/min). We observed the following complications: puncture of the carotid artery in 2%, pneumothorax in 0.5%, local infection in 3%, and catheter-related septicemia in only 2% of the patients. At the time of the removal of the catheters, we detected thrombosis of the internal jugular vein in 5% of the patients by ultrasound. The collection of PBSC with short-term, large-bore catheters is effective and is associated with a low incidence of infection and thrombosis.

The aim of the present study was to develop a method for identification of strains of Serratia marcescens that is also suitable for use in the epidemiologic studies. 40 clinical strains of Serratia marcescens were investigated by using the polymerase chain reaction (PCR). We used primers to amplify spacer regions between the 16S and 23S genes in the prokaryotic rDNA genetic loci. When the spacer amplification products were resolved by electrophoresis, the resulting patterns could be used to distinguish all of the strains tested into 3 groups (group A-35, group B-3 and group C-2 isolates). Digestion of PCR fragments of the group A strains with HinfI enzyme enabled separation of organisms into 3 distinct groups (A1-A3).

The case of a 21-year-old man coming from rural Paraíba, northwestern Brazil, with schistosomiasis mansoni associated with Serratia marcescens bacteremia, is reported. His main complaints on admission were fever, diaphoresis and chills for ten days, and diarrhoea that lasted for four days. On physical examination he had jaundice and hepatosplenomegaly. Diagnosis of S. marcescens bacteremia was made by isolation of the bacterium in blood culture, and schistosomiasis was diagnosed by rectal and liver biopsies. This is the first time that the association of S. marcescens bacteremia and schistosomiasis mansoni is recognized. Although our case does not fit into the classic definition of prolonged bacteremia associated with schistosomiasis, it can be considered as a mild form of this association. With the improvement of medical assistance and laboratory facilities, early diagnosis of this association will be made more frequently, cases with short duration will be diagnosed few days after the start of the symptoms, and classic prolonged cases will become rarer.

Serratia marcescens is an infrequent cause of cellulitis with only 5 reported cases. Four of the 5 patients were immunocompromised. Additionally, the cellulitis usually occurred at a site contiguous with a wound. We report a case of S. marcescens cellulitis in a patient with end-stage renal disease on chronic hemodialysis. The initial presentation was a soft tissue infection that progressed to septic shock. Ultimately, the patient responded to antibiotics and surgical debridement of infected tissue. This case serves as a reminder to consider infections due to gram-negative bacilli as a cause of cellulitis in immuno-compromised patients regardless of the presentation.