- Email: [email protected]
Nosocomial diskitis due to Propionibacterium acnes
Letters to the Editor
77
as a putative reservoir for vancomycin resistant enterococci in man. J Antimicrob Chemother 1994;34: 10
507-515.
Chadwick PR, Woodford N, Kaczmarski EB et al. Glycopeptide resistant enterococci isolated from uncooked meat. J Antimicrob Chemother 1996;38:
908-909.
11 Van der Auwera, Pensart N, Korten V et al. Influence of oral glycopeptides on the faecal flora of human volunteers: selection of highly glycopeptide-resistant enterococci. r Inf Dis 1996; 173: 1129-36.
12 Henning KJ, Delencastre H, Eagen J et al. Vancomycin-resistant Enterococcus faecium on a pediatric oncology ward: duration of stool shedding and incidence of clinical infection. Pediatr Infect Dis J 1996; 15: 84854. 13 Monetcalvo C, Gedris D, Shay C et al. A quantitative analysis of vancomycin resistant enterococci (VRE) in stool of hospitalised patients (Abstract). 36th Interscience Conference on Antimicrobial Agents and Chemotherapy, 1996; J7: 219.
New Orleans
14. Currie BP, Gnass S, Levi MH. A hospitalbased rectal swab survey to detect vancomycinresistant enterococci: utility and application. Int J Infect Dis 1996; 1: 87-9. 15 Boyce JM, Opal SM, Chaw JW et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable van B Class vancomycin resistance. J Clin Microbial 1994; 32: 1148-1153.
Nosocomial diskitis Propionibacterium
due to acnes
Sir, acnes is a Gram-positive, nonspore forming anaerobic bacillus that is implicated in the pathogenesis of acne vulgaris, and is also the aetiologic organism of many, mainly hospital-acquired, infectionsle3. However, despite its relatively ubiquitous presence in the human skin, orthopaedic infections caused by this bacterium are rare”. Here we report a case of intervertebral diskitis secondary to vertebral surgery.
Propionibacterium
* Correspondence to: Jaime Esteban. Tel: l-5504900, Fax: l-5494764, E-mail: [email protected]
The patient was a 33 year old man who underwent LS-Sl discectomy due to disk protrusion. Four months after surgery he developed back pain radiating to the left lower limb that increased with movement. Two months after the beginning of these symptoms, he again presented to the hospital with continual pain. The patient had no fever or any other symptoms or signs. There was a leucocytosis (11 800 leucocytes/mm3) without increase in the percentage of polymorphonuclear cells. Other cytochemical parameters were normal. A magnetic resonance scan showed inflammatory signs in the LS-Sl space. The patient was reoperated, and a large amount of fibrinous material with several oseous fragments was drained. Part of this material was sent to the pathology and microbiology departments. The pathological findings were consistent with inespecific diskitis with a polymorphonuclear infiltrate and scanty intracellular bacillus. Microbiological investigation showed abundant polymorphonuclear cells with no bacteria. A moderate growth of P. acnes in pure culture was revealed after three days’ incubation. No other organisms (including fungi or mycobacteria) were detected in the sample. The P. acnes isolate was susceptible to penicillin, amoxicillin/clavulanic imipenem, acid, cefoxitin, erithromycin and clindamycin, and resistant to metronidazole (E-test, AB Biodisk, Sweden). Empiric therapy was started with erythromycin (500 mg 8 hourly) and maintained for six weeks. The patient recovered uneventfully after this treatment. P. acnes is a rare cause of infection in humans, however, there are many reports that establish clearly its pathogenic potential, mainly related with surgery or other invasive procedures, together with foreign bodieslm3. However, orthopaedic infections due to these bacteria are rarely reported, and there have been only a few reports of infections of the spine, mainly osteomyelitisG7, but also diskitis’. Many of these cases were related to surgery or invasive procedures5-’ but some have not involved manipulation4,6. Most nosocomial cases have a chronic course following surgery, perhaps because of the low pathogenic potential of this bacteria. Therapy for orthopaedic infections due to P. acnes is
Letters
78
but usually with clindamycin or a p-lactam, erythromycin was used in one case”, and in to clindamycin, ours. However, strains resistant erythromycin and tetracycline (used in the topical therapy of acne) exist”, so it is important to establish the antimicrobial susceptibility of the individual strains causing severe infections. The combined use of surgery and antibiotics probably contributed to the good outcome of
our case, despite the fact that the antibiotic is not usual
J. Esteban R. Calvo M. Pardeiro F. Soriano
for these
of Medical Microbiology, Fundacidn Jime’nez Diaz, Av. Reyes Catdlicos 2, 28040 Madrid, Spain Department
References 1. Brook I, Frazier EH. Infections cause by Propionibacterium species. Rev Infect Dis 1991; 13: 819-822. 2. Esteban
J, Ramos J-M, Jimenez-Castillo P, Soriano F. Surgical wound infections due to Propionibacterium acnes: a study of 10 cases. J Hosp Infect 1995; 30: 229-232. 3. Esteban J, Ramos JM, Soriano F. Clinical spectrum of infections due to Propionibacterium acnes. Clinical Microbiology and Infection. 1998; 4: 48-49.
4. Newman
JH, Mitchell RG. Diphteroid infection of the cervical spine. Acta Orthop Stand 1975;
46: 67-70. 5. Noble
RC, Overman SB. Propionibacterium acnes osteomyelitis: Case report and review of the literature. J Clin Microbial 1987; 25: 251254.
6. Suter
the bone marrow. N Eng J Med 1969; 281: 1404-1405. 10. Brown JM, Poston SM. Resistance of propionibacteria to antibiotics used in the treatment of acne. J Med Microbial 1983; 16: 271-280.
Increased
used
infections.
F, Silanos MA, Tabacchi G, Maggiolo F. A case of Propionibacterium acnes spinal osteomyelitis. Eur J Clin Microbial Infect Dis 1992; 11: 196-197. Abolnik IZ, Eaton JV, Sexton DJ. Propionibacterium acnes vertebral osteomyelitis following lumbar puncture: case report and review. Clin Infect Dis 1995; 21: 694-695. Chia JKS, Nakata MN. Intervertebral diskitis caused by Propionibacterium acnes: a report of four cases. Clin Infect Dis 1996; 23: 643-644. Waitzkin L. Corynebacterium acnes infection of
to the Editor
incidence of Clostridium difficile infection
Sir,
Gopal Rao and colleagues suggest that the increased incidence of Clostridium dif@‘le infection in recent years is largely due to improved ascertainment, and not due to an increase in antibiotic usage.’ This has not been the case in our hospital. We have been monitoring the number of toxin tests patients with positive C. difficile since 1994. During this time our criteria for performing the test, and the methodology used have not changed. Irrespective of clinicians’ requests, all stool specimens from hospital inpatients over the age of 16 years have been tested for the presence of C. dif$cile toxin B using a standard cytotoxic assay. Figure 1 demonstrates the rise in the number of hospital 5 *g 2 g G u;
110 100 90 80 70
3 'T 2 !j 2 ,"
60 50 40 30 20 10
o
0
E
600
400; ,002 2ooc,x 0 1oog $
gL$g”gW
a
ul
$
W
0
Q, s
Figure I Incidence of patients with positive C. dificile toxin tests (bars) compared with the number of patients tested (line) from October 1994 to March 1997. * Present address: Hospital, Queens 2UH, UK
Public Health Laboratory, University Medical Centre, Nottingham NG7
77
as a putative reservoir for vancomycin resistant enterococci in man. J Antimicrob Chemother 1994;34: 10
507-515.
Chadwick PR, Woodford N, Kaczmarski EB et al. Glycopeptide resistant enterococci isolated from uncooked meat. J Antimicrob Chemother 1996;38:
908-909.
11 Van der Auwera, Pensart N, Korten V et al. Influence of oral glycopeptides on the faecal flora of human volunteers: selection of highly glycopeptide-resistant enterococci. r Inf Dis 1996; 173: 1129-36.
12 Henning KJ, Delencastre H, Eagen J et al. Vancomycin-resistant Enterococcus faecium on a pediatric oncology ward: duration of stool shedding and incidence of clinical infection. Pediatr Infect Dis J 1996; 15: 84854. 13 Monetcalvo C, Gedris D, Shay C et al. A quantitative analysis of vancomycin resistant enterococci (VRE) in stool of hospitalised patients (Abstract). 36th Interscience Conference on Antimicrobial Agents and Chemotherapy, 1996; J7: 219.
New Orleans
14. Currie BP, Gnass S, Levi MH. A hospitalbased rectal swab survey to detect vancomycinresistant enterococci: utility and application. Int J Infect Dis 1996; 1: 87-9. 15 Boyce JM, Opal SM, Chaw JW et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable van B Class vancomycin resistance. J Clin Microbial 1994; 32: 1148-1153.
Nosocomial diskitis Propionibacterium
due to acnes
Sir, acnes is a Gram-positive, nonspore forming anaerobic bacillus that is implicated in the pathogenesis of acne vulgaris, and is also the aetiologic organism of many, mainly hospital-acquired, infectionsle3. However, despite its relatively ubiquitous presence in the human skin, orthopaedic infections caused by this bacterium are rare”. Here we report a case of intervertebral diskitis secondary to vertebral surgery.
Propionibacterium
* Correspondence to: Jaime Esteban. Tel: l-5504900, Fax: l-5494764, E-mail: [email protected]
The patient was a 33 year old man who underwent LS-Sl discectomy due to disk protrusion. Four months after surgery he developed back pain radiating to the left lower limb that increased with movement. Two months after the beginning of these symptoms, he again presented to the hospital with continual pain. The patient had no fever or any other symptoms or signs. There was a leucocytosis (11 800 leucocytes/mm3) without increase in the percentage of polymorphonuclear cells. Other cytochemical parameters were normal. A magnetic resonance scan showed inflammatory signs in the LS-Sl space. The patient was reoperated, and a large amount of fibrinous material with several oseous fragments was drained. Part of this material was sent to the pathology and microbiology departments. The pathological findings were consistent with inespecific diskitis with a polymorphonuclear infiltrate and scanty intracellular bacillus. Microbiological investigation showed abundant polymorphonuclear cells with no bacteria. A moderate growth of P. acnes in pure culture was revealed after three days’ incubation. No other organisms (including fungi or mycobacteria) were detected in the sample. The P. acnes isolate was susceptible to penicillin, amoxicillin/clavulanic imipenem, acid, cefoxitin, erithromycin and clindamycin, and resistant to metronidazole (E-test, AB Biodisk, Sweden). Empiric therapy was started with erythromycin (500 mg 8 hourly) and maintained for six weeks. The patient recovered uneventfully after this treatment. P. acnes is a rare cause of infection in humans, however, there are many reports that establish clearly its pathogenic potential, mainly related with surgery or other invasive procedures, together with foreign bodieslm3. However, orthopaedic infections due to these bacteria are rarely reported, and there have been only a few reports of infections of the spine, mainly osteomyelitisG7, but also diskitis’. Many of these cases were related to surgery or invasive procedures5-’ but some have not involved manipulation4,6. Most nosocomial cases have a chronic course following surgery, perhaps because of the low pathogenic potential of this bacteria. Therapy for orthopaedic infections due to P. acnes is
Letters
78
but usually with clindamycin or a p-lactam, erythromycin was used in one case”, and in to clindamycin, ours. However, strains resistant erythromycin and tetracycline (used in the topical therapy of acne) exist”, so it is important to establish the antimicrobial susceptibility of the individual strains causing severe infections. The combined use of surgery and antibiotics probably contributed to the good outcome of
our case, despite the fact that the antibiotic is not usual
J. Esteban R. Calvo M. Pardeiro F. Soriano
for these
of Medical Microbiology, Fundacidn Jime’nez Diaz, Av. Reyes Catdlicos 2, 28040 Madrid, Spain Department
References 1. Brook I, Frazier EH. Infections cause by Propionibacterium species. Rev Infect Dis 1991; 13: 819-822. 2. Esteban
J, Ramos J-M, Jimenez-Castillo P, Soriano F. Surgical wound infections due to Propionibacterium acnes: a study of 10 cases. J Hosp Infect 1995; 30: 229-232. 3. Esteban J, Ramos JM, Soriano F. Clinical spectrum of infections due to Propionibacterium acnes. Clinical Microbiology and Infection. 1998; 4: 48-49.
4. Newman
JH, Mitchell RG. Diphteroid infection of the cervical spine. Acta Orthop Stand 1975;
46: 67-70. 5. Noble
RC, Overman SB. Propionibacterium acnes osteomyelitis: Case report and review of the literature. J Clin Microbial 1987; 25: 251254.
6. Suter
the bone marrow. N Eng J Med 1969; 281: 1404-1405. 10. Brown JM, Poston SM. Resistance of propionibacteria to antibiotics used in the treatment of acne. J Med Microbial 1983; 16: 271-280.
Increased
used
infections.
F, Silanos MA, Tabacchi G, Maggiolo F. A case of Propionibacterium acnes spinal osteomyelitis. Eur J Clin Microbial Infect Dis 1992; 11: 196-197. Abolnik IZ, Eaton JV, Sexton DJ. Propionibacterium acnes vertebral osteomyelitis following lumbar puncture: case report and review. Clin Infect Dis 1995; 21: 694-695. Chia JKS, Nakata MN. Intervertebral diskitis caused by Propionibacterium acnes: a report of four cases. Clin Infect Dis 1996; 23: 643-644. Waitzkin L. Corynebacterium acnes infection of
to the Editor
incidence of Clostridium difficile infection
Sir,
Gopal Rao and colleagues suggest that the increased incidence of Clostridium dif@‘le infection in recent years is largely due to improved ascertainment, and not due to an increase in antibiotic usage.’ This has not been the case in our hospital. We have been monitoring the number of toxin tests patients with positive C. difficile since 1994. During this time our criteria for performing the test, and the methodology used have not changed. Irrespective of clinicians’ requests, all stool specimens from hospital inpatients over the age of 16 years have been tested for the presence of C. dif$cile toxin B using a standard cytotoxic assay. Figure 1 demonstrates the rise in the number of hospital 5 *g 2 g G u;
110 100 90 80 70
3 'T 2 !j 2 ,"
60 50 40 30 20 10
o
0
E
600
400; ,002 2ooc,x 0 1oog $
gL$g”gW
a
ul
$
W
0
Q, s
Figure I Incidence of patients with positive C. dificile toxin tests (bars) compared with the number of patients tested (line) from October 1994 to March 1997. * Present address: Hospital, Queens 2UH, UK
Public Health Laboratory, University Medical Centre, Nottingham NG7