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To develop a new radiography-based score to assess the potential of bacteria to cause odontogenic infections derived from the occurrence of bacteria at small or large radiographical lesions.The patients analyzed were a sub-population from a large randomized clinical trial comparing moxifloxacin and clindamycin in the treatment of inflammatory infiltrates and odontogenic abscesses. Routine radiographs were used to analyze the area of the periapical radiolucent lesions. Lesions were stratified by their radiographically measured area as large (9 mm(2)) or small (≤9 mm(2)). A risk ratio was calculated for each species from the frequency of their occurrence in large vs in small lesions.Fifty-one patients, 19 with abscesses and 32 with infiltrates, were evaluated. Overall, the radiographical lesion areas ranged from 0.4-46.2 mm(2) (median = 9 mm(2)). An increased risk (risk ratio1) to occur at large abscess lesions was observed for Prevotella (P.) oralis, P. buccae, P. oris, P. intermedia, Fusobacterium nucleatum and Streptococcus (Strep.) anginosus group. An increased risk to occur at large infiltrate lesions was found for Strep. salivarius, Strep. parasanguis, Strep. anginosus group, Capnocytophaga spp., Neisseria (N.) sicca, Neisseria spp., Staphylococcus (Staph.) aureus, P. intermedia, P. buccae, Prevotella spp. and P. melaninogenica.The radiography-based score suggests that certain Prevotella spp., F. nucleatum and Strep. anginosus groups play a crucial role in the pathogenesis of odontogenic abscesses, and that various streptococci, Neisseria spp., Capnocytophaga spp., Staph. aureus and Prevotella spp. are involved in the pathogenesis of odontogenic infiltrates.

T helper (Th)17 cells are important for host defense against bacteria and fungi, but are also involved in the pathogenesis of autoimmune diseases. In primary sclerosing cholangitis (PSC), bile fluid is frequently colonized with pathogens and its strong association with inflammatory bowel disease suggests the contribution of pathogen responses to disease pathogenesis. Interleukin (IL)-17A, the signature cytokine of Th17 cells, was recently described to promote inflammation and fibrosis within the liver. Therefore, we investigated Th17 immune response to pathogens in patients with PSC. Bile fluid was obtained by endoscopic retrograde cholangiography, and bacterial and fungal species grew in the majority of samples. In addition, bacterial RNA was stained in liver sections using 16sRNA fluorescence in situ hybridization and was detected in the portal tracts in 12 of 13 tested PSC patients. Bacteria grown from patients' bile fluid were then used to stimulate peripheral blood mononuclear cells (PBMCs) and to assess their Th17 response. Compared to healthy controls or primary biliary cirrhosis patients, PBMCs from PSC patients manifested significantly higher frequencies of Th17 and Th1/Th17 cells after pathogen stimulation. The highest frequencies of Th17 cells were detected after stimulation with Candida albicans, a pathogen that has been linked to disease progression. Immunohistochemically, IL-17A-expressing lymphocytes were detected within the periductal areas of PSC patients. Th17 induction was also noted after stimulation of Toll-like receptor 5 or 7, but not of other pattern recognition receptors tested, pointing to signaling pathways potentially involved in Th17 induction in PSC. Conclusion: We demonstrate an increased Th17 response to microbial stimulation in patients with PSC. These data should prompt further studies investigating the link between pathogen responses, inflammation, and fibrosis in patients with PSC. (Hepatology 2013;53:1084–1093)

Invasive aspergillosis, especially neuroaspergillosis, predominantly affects immunocompromised patients such as transplant recipients. Early diagnosis and subsequent early initiation of therapy may improve final outcome. In cerebral aspergillosis, samples for culture or histopathology, the diagnostic reference standard, are often impossible to obtain without risk. Because of these limitations, serological, nucleic acid amplification tests such as polymerase chain reaction or enzyme immunoassay from cerebrospinal fluid appear advantageous for early diagnosis and probably also for therapy monitoring. We report on the successful detection and treatment monitoring by serial testing of galactomannan in cerebrospinal fluid in a patient with neuroaspergillosis after heart transplant.

Introduction The aetiology of osteochondritis dissecans is still unclear. The term ‘osteochondritis’ implies an infectious aetiology. The aim of our prospective clinical study to was to discover whether or not an infection is a possible aetiological factor.

Moxifloxacin penetrates well into oromaxillary tissue and covers the causative pathogens that show an increasing resistance to standard antibiotics. Clinical reports suggest that moxifloxacin may be effective for the treatment of odontogenic infections that can lead to serious complications. The objective of this prospective, randomized, double-blind, multicenter study was to compare the efficacies and safeties of moxifloxacin and clindamycin for the medical treatment of patients with gingival inflammatory infiltrates and as an adjuvant therapy for patients with odontogenic abscesses requiring surgical treatment. Patients received either 400 mg moxifloxacin per os once daily or 300 mg clindamycin per os four times daily for 5 days consecutively. The primary efficacy endpoint was the percent reduction in patients' perceived pain on a visual analogue scale at days 2 to 3 from baseline. Primary analysis included 21 moxifloxacin- and 19 clindamycin-treated patients with infiltrates and 15 moxifloxacin- and 16 clindamycin-treated patients with abscesses. The mean pain reductions were 61.0% (standard deviation [SD], 46.9%) with moxifloxacin versus 23.4% (SD, 32.1%) with clindamycin ( P = 0.006) for patients with infiltrates and 55.8% (SD, 24.8%) with moxifloxacin versus 42.7% (SD, 48.5%) with clindamycin ( P = 0.358) for patients with abscesses. A global efficacy assessment at days 2 to 3 and 5 to 7 showed faster clinical responses with moxifloxacin in both abscess and infiltrate patients. Rates of adverse events were lower in moxifloxacin- than in clindamycin-treated patients. In patients with inflammatory infiltrates, moxifloxacin was significantly more effective in reducing pain at days 2 to 3 of therapy than clindamycin. No significant differences between groups were found for patients with odontogenic abscesses.

A Salmonella enterica serovar Hadar strain resistant to tigecycline (MIC, 16 μg/ml) was isolated. Molecular characterization revealed the presence of a plasmid-borne tet (A) variant associated with Tn 1721 mediating a rise of the MIC for tigecycline when transferred to Escherichia coli . Additionally, a truncating mutation in ramR was detected. Transformation with wild-type ramR but not with the mutated ramR lowered the MIC for tigecycline. Characterization of this Salmonella isolate implicates ramR in resistance to tigecycline.

In this paper, we describe the phenotypic and molecular characteristics of two clinically relevant, vancomycin-resistant (VanB), linezolid-resistant Enterococcus faecium isolates. Pyrosequencing™ showed the G to T single nucleotide polymorphism at bp 2576 in the genes coding for 23S rRNA and was used to quantify the proportion of G to T mutations among six different 23S rRNA genes in E. faecium as a marker for the molecular level of resistance to linezolid. In both isolates, the G to T mutation was found in two of six alleles, and no further mutations in the genes coding for 23S rRNA were found. The dynamic process of linezolid resistance could be demonstrated by the complete reversion of resistant alleles back to only wild type alleles in consecutive isolates of one isolate. Pyrosequencing™ being used to detect and quantify resistance to linezolid has been proven as a fast and reliable molecular screening method for monitoring linezolid resistance.

Aim of this study was to determine the incidence and molecular epidemiology of carbapenemase-producing Escherichia coli and Klebsiella pneumoniae in Germany. E. coli and K. pneumoniae isolates from clinical samples which were non-susceptible to carbapenems were collected in laboratories serving 20 hospitals throughout Germany from November 2013 to April 2014. The isolates were tested for the presence of carbapenemases by PCR and phenotypic methods and typed by multilocus sequence typing. Risk factors including a previous hospitalization abroad were analysed. Carbapenemases were detected in 24 isolates from 22 patients out of 464,514 admissions. Carbapenemases included OXA-48 (n=14), KPC-2 (n=8) and NDM-1 (n=2). Except for two K. pneumoniae isolates with ST101, all OXA-48 producing strains belonged to different clones. In contrast, half of KPC-2 producing K. pneumoniae were of ST258 and both NDM-1 producing strains were of ST11. Compared to carbapenem-susceptible controls, patients with carbapenemase-producing strains differed by a significantly higher proportion of males, a higher proportion of isolates from wound samples and a more frequent previous stay abroad in univariate analysis. This multicentre study demonstrated an incidence of carbapenemase-producing E. coli and K. pneumoniae from clinical samples in Germany of 0.047 cases per 1000 admissions. OXA-48 was more frequent than KPC-2 and NDM-1 and showed a multiclonal background.

The case of a thirty-two-year-old female HIV-positive patient from Ghana admitted with a septic illness, diarrhoea, anaemia, and severe weight loss is presented. During an extensive diagnostic work-up Mycobacterium tuberculosis infection and typhoid fever were detected. Specific treatment led to marked improvement in the patient's condition. However, five weeks later high fever and diarrhoea recurred. Histological examination of biopsies from coloscopy and blood cultures revealed Histoplasma capsulatum. The patient recovered completely following antifungal therapy with amphotericin B and itraconazole. The case presented emphasises the need for medical staff dealing with immunocompromised patients from endemic areas to be aware of symptoms, diagnostic features, and therapeutic measures of this rare fungal infection.

Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) after base-specific cleavage of PCR-amplified and in vitro-transcribed bla SHV genes was used for the identification and genotyping of SHV β-lactamases. For evaluation, bla SHV stretches of 21 clinical Enterobacteriaceae isolates were PCR amplified using T7 promoter-tagged forward and reverse primers, respectively. In vitro transcripts were generated with T7 RNA and DNA polymerase in the presence of modified analogues replacing either CTP or UTP. Using RNase A, the in vitro transcripts were base-specifically cleaved at every “T” or “C” position. Resulting cleavage products were analyzed by MALDI-TOF MS, generating a characteristic signal pattern based on the fragment masses. All 21 individual SHV genes were identified unambiguously using reference sequences, and the results were in perfect concordance with those obtained by fluorescent dideoxy sequencing, which represents the current standard method. As multiple point mutations can be detected in a single assay and newly emerged mutations which are not yet described in public databases can be identified too, MALDI-TOF MS appears to be an ideal tool for analysis of sequence polymorphisms in resistance-associated gene loci.

OBJECTIVES The aim of this study was to evaluate phenotypic detection of beta-lactamase-mediated resistance to oxyimino-cephalosporins in Enterobacteriaceae using the Mastascan Elite Expert System challenged with a battery of genotypically characterized organisms. METHODS Isolates (n = 120) were identified to species level and antimicrobial susceptibilities were determined using agar incorporation methods and Mastascan Elite. Phenotypes were examined using an Expert System (ES) and putative genotypes were suggested using interpretative reading. RESULTS Identification was correct in 119 of 120 isolates. The ES was able to identify the correct beta-lactam phenotype (as deduced from molecular methods) in a single choice in 98 of 120 (81.7%) isolates. In an additional 15 (12.5%) cases, the ES identified the correct beta-lactam phenotype within two or more choices. The detected phenotype was incorrect in seven (5.8%) isolates, but three of these were not inherent to the ES. CONCLUSIONS The Mastascan Elite ES is relatively inexpensive and flexible and can identify the mechanism of resistance to oxyimino-cephalosporins in the majority of Enterobacteriaceae without recourse to molecular methods.

A new agar screen plate for extended-spectrum β-lactamase (ESBL) detection was evaluated with 50 clinical isolates of ESBL-producing Enterobacteriaceae species: Enterobacter cloacae ( n = 10), Escherichia coli ( n = 10), Klebsiella oxytoca ( n = 3), Klebsiella pneumoniae ( n = 25), and Proteus mirabilis ( n = 2). Fecal samples were artificially inoculated with 2 concentrations (25 and 250 colony forming units [CFU]/plate) of the test strains and then applied to the new agar screen plates. By this approach, the new agar formula detected growth that was suggestive of ESBL activity in 44 of 50 (88%) and 50 of 50 (100%) of ESBL strains with 25 and 250 CFU/plate, respectively. A limitation of the agar screen plates was a lack of some specificity. Among 15 strains with resistant phenotypes other than ESBL (K1 producers of K. oxytoca , 6 strains; 9 strains with AmpC phenotype), growth was recorded in 7 (25 CFU/plate) and 11 (250 CFU/plate) of 15 strains. In conclusion, the new agar screen plate is a sensitive and convenient method to directly screen for ESBL organisms in rectal swabs or stool samples, with the potential for incorporation into routine clinical laboratory service.

Objectives: In this study, we evaluated the performance of a new ESBL Etest configuration based on clavulanate synergy with cefepime compared with cefotaxime‐clavulanate and ceftazidime‐ clavulanate ESBL Etest strips for the detection of extended-spectrum b-lactamases (ESBL) in an Enterobacteriaceae strain collection, with special focus on Enterobacter spp. Methods: Overall, a total of 54 clinical isolates of ESBL-producing Enterobacteriaceae species were evaluated: Enterobacter aerogenes (n 5 3), Enterobacter cloacae (n 5 10), Escherichia coli (n 5 10), Klebsiella oxytoca (n 5 3), Klebsiella pneumoniae (n 5 25) and Proteus mirabilis (n 5 3). To check Etest behaviour with resistance phenotypes similar to ESBL, our panel was expanded by six clinical isolates of K. oxytoca that were identified as putative producers of their chromosomal K1 b-lactamase. Results: With this panel, ESBL Etest was 98% sensitive with cefepime‐clavulanate, 83% with cefotaxime‐clavulanate, and 74% with ceftazidime‐clavulanate strips. Concentrating on Enterobacter spp., reliable ESBL detection could only be achieved by the new cefepime‐clavulanate strip since it confirmed ESBL production in all strains (100% sensitivity) whereas only 4/13 (31%) of Enterobacter strains were positive using cefotaxime‐clavulanate or ceftazidime‐clavulanate strips. A limitation of using the new cefepime strip was less than optimal specificity with K1 phenotypes of K. oxytoca: among six strains, four isolates were scored false-positive by Etest strips containing cefepime‐clavulanate. Conclusion: The new Etest ESBL strip containing cefepime‐clavulanate is a valuable supplement to current methods for detection of ESBLs. In our study collection, the cefepime‐clavulanate strip was the best configuration for detection of ESBLs, particularly in Enterobacter spp.

Mycobacterium haemophilum has rarely been implicated in human disease. The organisms have been isolated mainly in patients with human immunodeficiency virus (HIV) disease or transplant recipients. We describe the first case of a disseminated M. haemophilum infection as initial manifestation of AIDS in Europe.

The present study compares the ability to detect extended-spectrum β-lactamases (ESBL) among a collection of 34 ESBL producing clinical isolates belonging to Escherichia coli and Klebsiella species with two new rapid susceptibility and identification instruments—VITEK2 (bioMerieux, Marcy l'Etoile, France) vs. BDPhoenix (BD Biosciences, Sparks, MD). ESBL content in these isolates was previously characterized on the basis of PCR amplification and sequencing results which were used as the reference method in our evaluation. BDPhoenix correctly determined the ESBL outcome for all strains tested (100% detection rate), whereas VITEK2 was not able to detect the ESBL status in 5 isolates (85% detection rate). Detailed analysis revealed that the discrepancies were mainly observed with ‘difficult-to-detect' strains. Misidentification was either due to low oximino cephalosporin MIC in these strains or was associated with pronounced ‘cefotaximase' or ‘ceftazidimase' phenotypes. Klebsiella oxytoca chromosomal β-lactamase (K1) is phenotypically quite similar to ESBL enzymes. In order to evaluate whether the K1 and ESBL enzymes could be discriminated, we expanded our analysis by 8 clinical K. oxytoca strains with K1 phenotypes. VITEK2 gave excellent identification of these strains whereas 7 out of 8 were falsely labeled ESBL-positive by the BDPhoenix system.

Using outbreak-related strains of Enterobacter aerogenes, we cloned and sequenced ompK39, the structural gene coding for outer membrane protein OmpK39. Its lack of expression was closely associated with a phenotype exhibiting low-level carbapenem resistance. Detailed alignment of the predicted amino acid sequence revealed that OmpK39 is a member of the OmpC subclass of enterobacterial porins, with the highest degree of homology to Klebsiella pneumoniae OmpK36. Based on a computerized alignment including Escherichia coli PhoE and OmpF, the 3D structures of which are known from X-ray studies, OmpK39 can be assumed to form the typical β-barrel structure which is common to all enterobacterial porins. Since no inhibitory DNA sequences could be detected in ompk39 in the resistant strains, porin deficiency leading to carbapenem resistance seems to involve alterations in key regulatory genes and/or the promotor sequence rather than a direct mutation in the structural gene.

In the microbiology laboratory, there is an augmented need for rapid screening methods for the detection of bacteria in urine samples, since about two-thirds of these samples will not yield any bacteria or will yield insignificant growth when cultured. Thus, a reliable screening method can free up laboratory resources and can speed up the reporting of a negative urine result. In this study, we have evaluated the detection of leukocytes, bacteria, and a new sediment indicator, the “all small particles” (ASP), by an automated instrument, the iQ200 urine analyzer, to detect negative urine samples that can be excluded from culture. A coupled automated strip reader (iChem Velocity), enabling the detection of nitrite and leukocyte esterase, was tested in parallel. In total, 963 urine samples were processed through both conventional urine culture and the iQ200/iChem Velocity workstation. Using the data, a multivariate regression model was established, and the predicted specificity and the possible reduction in urine cultures were calculated for the indicators and their respective combinations (leukocytes plus bacteria plus ASP and leukocyte esterase plus nitrite). Among all options, diagnostic performance was best using the whole microscopic content of the sample (leukocytes plus bacteria plus ASP). By using a cutoff value of ≥10 4 CFU/ml for defining a positive culture, a given sensitivity of 95% resulted in a specificity of 61% and a reduction in urine cultures of 35%. By considering the indicators alone, specificity and the culture savings were both much less satisfactory. The regression model was also used to determine possible cutoff values for running the instrument as part of daily routine. By using a graphical representation of all combinations possible, we derived cutoff values for leukocyte, bacterial, and ASP count, which should enable the iQ200 microscope to screen out approximately one-third of the urine samples, significantly reducing the workload in the microbiology laboratory.

Microsporidia of the genus Encephalitozoon are increasingly being reported as a cause of severe, often disseminated infections, mainly in patients with acquired immunodeficiency syndrome (AIDS). Immunological identification of each of the three recognized species (E. cuniculi, E. hellem, and E. intestinalis) requires the availability of specific immune sera. All sera available thus far have been generated by direct inoculation of rabbits with virulent microsporidian spores. This study demonstrates for the first time that subcutaneous immunization with inactivated spores of E. cuniculi, E. helleri, or E. intestinalis is capable of generating highly active rabbit hyperimmune sera to the homologous antigens, with maximal titers being 1:5,120, 1:1,280, and 1:2,560, respectively, as determined by the indirect immunofluorescence technique (IIF). Broad cross-reactivity of the rabbit antisera with all heterologous Encephalitozoon antigens was determined by IIF and immunogold electron microscopy; however, only the E. hellem immune serum strongly cross-reacted with spores of Enterocytozoon bieneusi. During the 35-month follow-up period the antibody titers to the homologous antigens declined to 1:640, 1:160, and 1:320, respectively. The observed decay curves for antibody titers against E. cuniculi, E. hellem, and E. intestinalis were fitted using mathematical modeling, resulting in a predicted duration for specific immune responses of about 7 years on average. Knowledge of the magnitude and duration of specific immune responses is a prerequisite for further evaluation of the concept of using inactivated microsporidian spores in the quest for vaccines against microsporidian infections.

This paper presents, for the first time, documentation by detailed scanning electron microscopy of the life cycle of microsporidia of the genus Encephalitozoon. Phase 1 is represented by the extracellular phase with mature spores liberated by the rupture of host cells. To infect new cells the spores have to discharge their polar filament. Spores with everted tubes show that these are helically coiled. When the polar tubules have started to penetrate into a host cell they are incomplete in length. The infection of a host cell can also be initiated by a phagocytic process of the extruded polar filament into an invagination channel of the host cell membrane. After the penetration process, the tube length is completed by polar tube protein which passes through the tube in the shape of swellings. A completely discharged polar tube with its tip is also shown. The end of a polar tube is normally hidden in the cytoplasm of the host cell. After completion of the tube length the transfer of the sporoplasm occurs and phase 2 starts. Phase 2 is the proliferative phase, or merogony, with the intracellular development of the parasite that cannot be documented by scanning electron microscopy. The subsequent intracellular phase 3, or sporogony, starts when the meronts transform into sporonts, documented as chain-like structures which subdivide into sporoblasts. The sporoblasts finally transform directly into spores which can be seen in their host cell, forming bubble-like swellings in the cell surface.

Invasive aspergillosis is one of the most severe complications after liver transplantation characterised by early dissemination of disease and high mortality. Recent data show that the prognosis is diminishing even further when Aspergillus terreus, a strain resistant to standard treatment with amphotericin, is isolated. We report a high risk liver transplant recipient with multiple co-morbidities including renal failure and allograft dysfunction in whom pulmonary aspergillosis due to A. terreus was successfully treated by the echinocandin antifungal agent caspofungin.

In view of the increasing number of cases of human microsporidiosis, simple and rapid methods for clear identification of microsporidian parasites to the species level are required. In the present study, the polymerase chain reaction (PCR) was used for species-specific detection of Encephalitozoon cuniculi. Encephalitozoon hellem, Encephalitozoon (Septata) intestinalis, and Enterocytozoon bieneusi in both tissue and stool. Using stool specimens and intestinal biopsies of patients infected with Enterocytozoon bieneusi (n = 9), Encephalitozoon spp. (n = 2), and Encephalitozoon intestinalis (n = 1) as well as stool spiked with spores of Encephalitozoon cuniculi and Encephalitozoon hellem and tissue cultures of Encephalitozoon cuniculi and Encephalitozoon hellem, three procedures were developed to produce PCR-ready DNA directly from the samples. Specific detection of microsporidian pathogens was achieved in the first PCR. The subsequent nested PCR permitted species determination and verified the first PCR products. Without exception, the PCR assay confirmed electron microscopic detection of Enterocytozoon bieneusi and Encephalitozoon intestinalis in stool specimens and their corresponding biopsies and in spiked stool samples and tissue cultures infected with Encephalitozoon cuniculi and Encephalitozoon hellem. Moreover, identification of Encephalitozoon spp. could be specified as Encephalitozoon intestinalis. Whereas standard methods such as light and transmission electron microscopy may lack sensitivity or require more time and special equipment, the PCR procedure described facilitates species-specific identification of microsporidian parasites in stool, biopsies, and, probably, other samples in about five hours.

Suspected deep or systemic mycosis in patients undergoing high-dose therapy and autologous or allogeneic bone marrow transplantation (BMT) requires an immediate systemic antimycotic therapy. Intravenous therapy with the standard drug conventional amphotericin-B is associated with severe adverse effects like nephrotoxicity and chills. Furthermore, BMT patients often receive other potential nephrotoxic drugs such as CsA or virustatics. In this study, we report 74 BMT-patients treated with liposomal amphotericin-B for culture-documented aspergillosis (n = 5) or candidiasis (n = 6), or for serologically (n = 35) or clinically suspected mycosis or as prophylaxis (n = 2). Therapy was initiated with a median dose of 2.8 (0.64-5.09) mg/kg body-weight and continued for 13 (1-55) days. The drug was excellently tolerated and only in one was therapy stopped due to severe chills and fever. Severe organ impairment was not observed under therapy with liposomal amphotericin-B. Creatinine decreased in five patients after an increase under preceding therapy with the conventional formulation. Influence of liposomal amphotericin-B on bilirubin and transaminases was difficult to evaluate due to therapy-related toxicity, veno-occlusive disease (VOD), and graft-versus-host disease (GvHD). 10/11 culture-positive patients died from aspergillosis (5/5) or candidiasis (5/6), but in 9/11 of these subjects the immunity was additionally compromised by GvHD, steroid therapy, and VOD. Liposomal amphotericin-B was effective in preventing relapse of systemic mycosis in 10/12 patients with a history of aspergillosis (n = 11) or candidiasis (n = 1). We conclude, that favourable toxicity of liposomal amphotericin-B should encourage dose escalation studies of liposomal amphotericin-B randomised against the conventional formulation and that the comparison of patients undergoing BMT with patients under standard chemotherapy might be difficult because of additional risk factors of the BMT-patients.

60 patients undergoing bone marrow or stem cell transplantation were treated with liposomal Amphotericin-B for documented or suspected mycosis. 34 patients had a prior course of conventional Amphotericin-B with the following adverse effects: increasing creatinine above 1.4 mg/dl (n = 17), increasing creatinine below 1.5 mg/dl (n = 9), no response (n = 6), and clinical side-effects (n = 4). Liposomal Amphotericin-B failed in 6/7 patients with culture-proven mycosis who died from infection with Aspergillus (n = 2) and Candida (n = 4), respectively. One patient with Candida lambica sepsis was cured. No patient with clinically or serologically suspected or diagnosed infection died from mycosis. Liposomal Amphotericin-B was well tolerated in 57 patients, even after side-effects of the conventional formulation. Adverse effects occurred in three cases, requiring the withdrawal of the drug in one patient. Due to toxic side-effects of the high-dose therapy and transplant-related complications, it was difficult to evaluate the influence of liposomal Amphotericin-B on laboratory parameters. Eight patients showed a decrease of creatinine levels, which had increased above normal values under preceding therapy with conventional Amphotericin-B. Liposomal Amphotericin-B is well tolerated in patients undergoing high-dose therapy and bone marrow transplantation. The efficacy of liposomal Amphotericin-B needs to be investigated in randomized studies in comparison with conventional Amphotericin-B.

Four months after delivery of a healthy full-term infant, a 1-year-old woman presented with a first-ever epileptic seizure. he had a history of several operations on the right maxillary inus for treatment of a not otherwise specified chronic inflammaion. Besides that, the personal and family medical histories were nremarkable. Physical examination revealed visual loss (50%) n the right eye, but no further focal neurological signs. Blood ests showed moderately elevated C-reactive protein (16 mg/l, noral

The objective of this study was to identify the oral pathogens found in odontogenic infections, to determine their susceptibilities to amoxicillin-clavulanic acid (AMC), clindamycin (CLI), doxycycline (DOX), levofloxacin (LVX), moxifloxacin (MXF), and penicillin (PEN), and to search for associations between specific pathogens and types of infection. Swabs from patients enrolled in a randomized, double-blind phase II trial comparing MXF with CLI for the treatment of odontogenic abscesses or inflammatory infiltrates were cultured on media for aerobes and anaerobes. All bacterial isolates were identified at the species level. Overall, 205 isolates were cultured from 71 patients: 77 viridans group streptococci, 56 Prevotella spp., 19 Neisseria spp., 17 Streptococcus anginosus group isolates and hemolytic streptococci, 15 other anaerobes, and 21 other bacteria. Ninety-eight percent of pathogens were susceptible to MXF, 96% to AMC, 85% to LVX, 67% to PEN, 60% to CLI, and 50% to DOX. S. anginosus group and hemolytic streptococci were found significantly more frequently ( P = 0.04) in patients with abscesses (12/95) than in patients with infiltrates (5/110). In four patients with infiltrates who failed to respond to CLI therapy, three isolates of the Streptococcus mitis group and four Neisseria spp. resistant to CLI were found. In this study, S. anginosus group and hemolytic streptococci were clearly associated with odontogenic abscesses. Our analysis suggests that viridans group streptococci and Neisseria spp. play a decisive role in the etiology of odontogenic infiltrates. The high in vitro activity of MXF against odontogenic bacteria corresponds well to its clinical results in the treatment of odontogenic abscesses and infiltrates.

Spontaneous bacterial peritonitis (SBP) represents a common and severe complication of liver cirrhosis with ascites, with microorganisms of enteric origin accounting for the majority of cases [1]. SBP due to Listeria monocytogenes is uncommon and most often occurs as a complication of liver cirrhosis or continuous ambulatory peritoneal dialysis [2]. Reported here is the first case of SBP caused by Listeria monocytogenes occurring in a young adult with ascites due to heart failure resulting from primary pulmonary hypertension. A 36-year-old white male was admitted with severe progressive dyspnoea, increasing weight and ascites. The patient denied having diarrhoea, nausea, vomiting or fever. He had not been abroad for several years and he had not had contact with wild or domestic animals. Six months before admission, primary pulmonary hypertension had been diagnosed after the exclusion of obstructive or restrictive lung diseases, vasculitis or recurrent pulmonary emboli. Serology was negative for hepatitis A, B and C virus and for the human immunodeficiency virus. There was no history of alcohol abuse, illicit drug use or other medications. The patient had stopped smoking 15 years previously, but reported a history of 10 pack-years before quitting. He was treated with diuretics and oral anticoagulants.

Enterobacter cloacae (E. cloacae) is a Gram-negative rod commonly found on intensive care units (ICU) causing severe infections with high mortality. Specific characteristics of E. cloacae pneumonia, however, have not been identified. Evaluation of clinical and microbiological records of patients with positive respiratory samples for E. cloacae was performed by a 1-year retrospective study in a large university hospital. Ninety-seven of 115 eligible patients with E. cloacae-positive respiratory samples developed pneumonia. Patients were predominantly male (68%), older (median age = 62 years), and immunodeficient (54%). Seventy-eight percent required ICU admission, of which 97% required mechanical ventilation. Ventilator-associated pneumonia (VAP) occurred in 58%. Those who developed E. cloacae VAP had undergone twice as many surgical procedures under translaryngeal intubation prior to VAP onset (89 vs. 48%, P

Early and adequate antimicrobial therapy has been shown to improve the clinical outcome in bloodstream infections (BSI). To provide rapid pathogen identification for targeted treatment, we applied matrix-assisted laser desorption-ionization time of flight (MALDI-TOF) mass spectrometry fingerprinting to bacteria directly recovered from blood culture bottles. A total of 304 aerobic and anaerobic blood cultures, reported positive by a Bactec 9240 system, were subjected in parallel to differential centrifugation with subsequent mass spectrometry fingerprinting and reference identification using established microbiological methods. A representative spectrum of bloodstream pathogens was recovered from 277 samples that grew a single bacterial isolate. Species identification by direct mass spectrometry fingerprinting matched reference identification in 95% of these samples and worked equally well for aerobic and anaerobic culture bottles. Application of commonly used score cutoffs to classify the fingerprinting results led to an identification rate of 87%. Mismatching mostly resulted from insufficient bacterial numbers and preferentially occurred with Gram-positive samples. The respective spectra showed low concordance to database references and were effectively rejected by score thresholds. Spiking experiments and examination of the respective study samples even suggested applicability of the method to mixed cultures. With turnaround times around 100 min, the approach allowed for reliable pathogen identification at the day of blood culture positivity, providing treatment-relevant information within the critical phase of septic illness.

We report a case of a 64-year-old veterinarian working in a state camel veterinary laboratory who was diagnosed with and treated for acute brucellosis with complicating epididymo-orchitis. Genomic tandem repeat analysis (MLVA-16) revealed identical Brucella strains in patient cultures and from different dromedary milk samples positive for Brucella melitensis, thereby confirming the diagnosis of a laboratory acquired infection. The case illustrates the high (airborne) infectivity of brucellosis in laboratory settings and the need to implement vigorous bio-safety measures in veterinary laboratories handling camel specimen diagnostic veterinary laboratory.

Based on its in vitro activity and spectrum of activity, the new 8-methoxyquinolone antibiotic moxifloxacin (MXF) seems suited for the antibiotic therapy of odontogenic infections. Penetration into the relevant tissue is another prerequisite for clinical efficacy. For this reason, the levels of MXF in plasma, soft tissue, and mandibular bone were determined in an animal model with Wistar rats.Samples of 49 rats were analyzed. Tissue samples were homogenized and proteins were precipitated. The pharmacokinetic evaluation was conducted based on non-compartmental analysis.The concentration-time courses of tissues show a more plateau-shaped curve compared to plasma. Calculated AUC (area under the curve) ratios tissue:plasma were M. masseter:plasma = 2.64 and mandibles:plasma = 1.13.Administration of antibiotics is considered an important part of therapy during and/or after surgical procedures in the maxillofacial area. Because of the good penetration into bone and muscle tissues demonstrated in Wistar rats, MXF might be an option for clinical application in this indication.

Ein 14-jahriger Junge stellt sich wegen hochakut einsetzender allgemeiner Schwache, Kopfschmerzen, Ubelkeit und Brechreiz in der Notaufnahme einer Hamburger Klinik vor. Weiterhin klagt er uber Brustschmerzen beim Atmen und ein Gefuhl von Luftnot. Noch in der Notaufnahme kommt es zu einer schnellen Zunahme der Atemnot bis zur vollstandigen respiratorischen Insuffizienz. Zusatzlich fallen weite lichtstarre Pupillen auf. Der Patient wird wegen der fortgeschrittenen Atemlahmung sofort intubiert, maschinell beatmet und auf die Intensivstation einer Kinderklinik verlegt. Unter der Verdachtsdiagnose einer zerebralen Blutung wird ein kraniales CT veranlasst. Die erste Anamnese ist unauffallig, kein Trauma erinnerlich und keine Reiseanamnese.

We prospectively investigated six fatal cases of clostridial gas gangrene using autopsy, histology, immunohistochemistry, microbiology, and scanning electron microscopy. The causative pathogen was Clostridium perfringens in four cases, C. sordellii in one case, and a mixed infection with both C. perfringens and C. sordellii in one case. According to the previous medical history and autopsy findings, clostridial infection was related to trauma in three cases. Characterized by extensive tissue necrosis and total absence of an accompanying leukocyte infiltration and tissue inflammatory response, the histopathological picture of clostridial gas gangrene is distinctly different from other bacterial infections. In medicolegal casework, the proof of the source of infection and the portal of entry of the responsible pathogen is not always an easy task, especially in the absence of trauma.

Relapse of a preceding fungal infection is a considerable risk during haemopoietic stem cell transplantation. The optimal secondary prophylaxis has not been found so far since the application of standard drugs is hampered by potential ineffectiveness or intolerable side effects. This investigation describes haemopoietic cell transplantation of patients with a history of invasive or systemic fungal infection (IFI). The strategy was either administration of liposomal amphotericin B as secondary prophylaxis or an early switch to liposomal amphotericin B after administration of azoles. The 43 patients had a history of proven (n = 14), probable (n = 14) and possible (n = 15) IFI. Twenty-eight patients (65%) could be discharged from the BMT ward without signs of mycosis. Transplant-related mortality was 35%. Overall, 12 fungus-related (IFI) deaths (28%) occurred. The percentage of fungus-related deaths was highest in the ‘proven’ group with 43% compared to 20 and 21% in the two other groups. Side effects of liposomal amphotericin B were low. A discontinuation of the drug was not necessary in any patient. Serum creatinine showed a slight increase to 128% (median) of the baseline allowing continuous administration of concomitant nephrotoxic drugs such as cyclosporin A. In conclusion, secondary prophylaxis with or early switch to liposomal amphotericin B facilitates allogeneic stem cell transplantation of patients with a history of IFI with minor side effects. However, fungal infections and transplant-related mortality remain major problems in this often heavily pretreated subgroup of patients.

We evaluated the antimicrobial susceptibility of 87 pathogens isolated from 37 patients with odontogenic abscesses. The most prevalent bacteria were viridans group streptococci and Prevotella species. Considering all bacterial isolates, 100% were susceptible to amoxicillin-clavulanic acid, 98% were susceptible to moxifloxacin and to levofloxacin, 76% were susceptible to doxycycline, 75% were susceptible to clindamycin, and 69% were susceptible to penicillin.

Saliva antibodies to Escherichia coli O157 were investigated as markers of the immune response in children with enteropathic hemolytic uremic syndrome (HUS). Paired serum and saliva samples were collected from 22 children with HUS during acute disease and convalescence and were tested for E. coli O157 lipopolysaccharide (LPS)-specific IgM and IgA antibodies by ELISA. Serum and saliva samples from 44 age-matched controls were used to establish the cut-off values. Elevated levels of IgM and/or IgA antibodies to O157 LPS were detected in saliva of 13/13 HUS patients with Shiga toxin-producing E. coli (STEC) O157 in stool culture and from 4 of 5 HUS patients in whom STEC were not detected. These results closely mirrored the results obtained with paired serum samples. In contrast, saliva and serum samples from four children with STEC isolates belonging to O-groups O26, O145 (n = 2), and O165 lacked detectable O157 LPS-specific antibodies. The specificity of the ELISA was confirmed by western blotting. In STEC O157 culture-confirmed cases, the sensitivity of the ELISA was 92% for saliva IgM and IgA, based on the first available sample, and 100% and 92%, respectively, when subsequent samples were included. The specificity was 98% for IgM and 100% for IgA. Children with E. coli O157 HUS demonstrate a brisk, easily detectable immune response as reflected by the presence of specific antibodies in their saliva. Saliva-based immunoassays offer a reliable, noninvasive method for the diagnosis of E. coli O157 infection in patients with enteropathic HUS.

Microsporidia of the genus Encephalitozoon are emerging protozoal agents that mainly infect immunocompromised patients with AIDS. At present, disseminated infections with members of the genus Encephalitozoon can only be successfully treated with albendazole. As chitin is a basic component of the microsporidian spore. we evaluated, in vitro, the susceptibility of a human-derived strain of Encephalitozoon cuniculi to polyoxin D and nikkomycin Z, which are known competitive inhibitors of chitin synthetase enzymes. Using an in vitro assay, polyoxin D at 1, 10 and 100 microg/ml significantly reduced the number of parasitic foci on days 6, 9, and 15 post-infection. However, nikkomycin Z revealed a marked but lower reduction in the number of parasitic foci than polyoxin D. A significant reduction of parasitic foci was achieved for nikkomycin Z at 10 and 100 microg/ml up to day 9 post-infection. Polyoxin D was approximately tenfold more effective in our in vitro assay than nikkomycin Z.

Using outbreak-related strains of Enterobacter aerogenes, we cloned and sequenced ompK39, the structural gene coding for outer membrane protein OmpK39. Its lack of expression was closely associated with a phenotype exhibiting low-level carbapenem resistance. Detailed alignment of the predicted amino acid sequence revealed that OmpK39 is a member of the OmpC subclass of enterobacterial porins, with the highest degree of homology to Klebsiella pneumoniae OmpK36. Based on a computerized alignment including Escherichia coli PhoE and OmpF, the 3D structures of which are known from X-ray studies, OmpK39 can be assumed to form the typical beta-barrel structure which is common to all enterobacterial porins. Since no inhibitory DNA sequences could be detected in ompk39 in the resistant strains, porin deficiency leading to carbapenem resistance seems to involve alterations in key regulatory genes and/or the promotor sequence rather than a direct mutation in the structural gene.

Ninety-five household contacts (aged 2 months to 73 years) of patients with enteropathic hemolytic-uremic syndrome (HUS) were investigated for the presence of immunoglobulin (Ig) G antibodies to Shiga toxins Stx2 and Stx1 by Western blot assay. Thirty-one percent of the household contacts and 19% of 327 controls had anti-Stx2 IgG (heavy and light chain [H + L]), 5 and 8%, respectively, had anti-Stx1 IgG (H + L), and 3 and 2%, respectively, had both anti-Stx2 and anti-Stx1 IgG (H + L). The incidence of infections with Stx-producing Escherichia coli (STEC) was determined based on the following diagnostic criteria: STEC isolation, detection of stx gene sequences, free fecal Stx in stool filtrates, and serum IgM antibodies against E. coli O157 lipopolysaccharide. Evidence of STEC infection was observed in 25 household contacts, of whom 18 (72%) were asymptomatic and represented a potential source of infection. Six of 13 (46%) household contacts with Stx2-producing E. coli O157:H7 in stool culture developed anti-Stx2 IgG (H + L), compared to 71% of Stx2-associated HUS cases. In individuals showing anti-Stx2 IgG (H + L), the antibody response was directed against the B subunit in 69% of household contacts and 71% of controls, in contrast to 28% of HUS patients. In this investigation controls had a significant increase of the median of IgM antibodies to O157 lipopolysaccharide (LPS) with age, up to the fifth decade. The lack of disease in household contacts with B subunit-specific antibodies, as well as the significantly higher median of anti-O157 LPS IgM antibodies in controls beyond 4.9 years of age, suggests a protective role for anti-Stx and anti-O157 LPS antibodies.

Eine 58-jahrige Lehrerin kommt Mitte Juni 1999 in den Zentralen Aufnahmedienst des Klinikums, nachdem sie eine Asymmetrie des Gesichts bemerkt hat. Seit dem Vortag habe sie sich schon mude und abgeschlagen gefuhlt, wie bei einem grippalen Infekt. Weiterhin klagt sie uber generell schwindende korperliche und berufliche Belastbarkeit. Schmerzen oder Schwindelgefuhl gibt sie nicht an. Auf Befragen ist kein Zeckenstich erinnerlich.

Bei einem 33-jahrigen homosexuellen Patienten ist 7 Jahre zuvor eine HIV-Infektion festgestellt worden. In der Zwischenzeit ist keine kombinierte antiretrovirale Therapie erfolgt. 3 Monate vor stationarer Aufnahme entwickelt der Patient masige Durchfalle. Die Untersuchung zahlreicher Stuhlproben auf enteropathogene Bakterien, atypische Mykobakterien, Rotaviren, Adenoviren und CMVerbringt keinen pathologischen Befund. Mit der Kinyoun-Farbung konnen vereinzelt Kryptosporidien nachgewiesen werden. Unter einer Therapie mit Paromomycin (3-mal 2 g/Tag) bessert sich anfanglich die Durchfallsymptomatik. Wahrend der nachsten Wochen aber nehmen die Durchfalle erheblich zu (>10 Stuhlgange/Tag), was zu einem Gewichtsverlust von 18 kg fuhrt. Zusatzlich klagt der Patient uber eine chronische Sinusitis mit einem glasig-zahen, nichteitrigen Nasenschleim. Zur weiteren Abklarung wird der Patient stationar aufgenommen.