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Polymicrobial meningitis
common anaerobes. This category would include laboratories that do not have a gas chromatograph. The following common and important anaerobes can be presumptively identified without GLC: the B. fragilis group, B. melaninogenicus, F. nucleatum, Peptococcus asaccharolyticus, Peptostreptococcus anaerobius, Propionibacterium aches, Clostridium perfringens, Clostridium ramosum, and Actinomyces israelii (4). Metabolic product analysis by GLC is helpful for identifying most clostridia and certain species of Fusobacterium, and it is required for the genus and species differentiation of most gram-positive non-spore-forming rods. These laboratories would also send their isolates to reference laboratories for confirmation, if warranted by clinical circumstances. The fourth level of capability would include those laboratories able to perform defmitive identification. These might include large university medical centers, state public health laboratories, and certain federal laboratories. While
there has been some progress during this decade, careful definitive identification is still needed to further define the role of obligate anaerobes in health and disease, to educate clinicians and microbiologists, and to aid the physician in providing 013timal care for the patient. For the individual laboratory, the choice of identification procedures used and the extent of anaerobe identification will depend on a number of circumstances. These include the technical competence of personnel, the resources available, the patient population served, and the needs of physicians. The laboratory must be competent in that which it does and should be willing to refer isolates to more sophisticated laboratories when such referrals are warranted by clinical circumstances.
li. U.S. Dept. of Health, Education and Welfare, Public Health Service,Center for Disease Control, Atlanta, Ga. 2. Hoideman, L. V., E. P. Calo, and W. E.
C. Moore (ed.). 1977.Anaerobe laboratory manual, 4th ed. Vkginia Polytechnic Institute and State University,Blacksburg, Va. 3. Jones, R. N., and P. C. Fucks. 1976. Identification and antimicrobial susceptibilityof 250 Bacteroidesfragili~subspeciestested by broth microdilution methods. Antimicrob. Agents Chemother. 9:719- 721. 4. Koneman, E. W., S. D. Allen, V. R. Dowell, Jr., and H. M. Sommers. 1979.
References I. Dowell, V. R., Jr., and G. L. Lombard. 1977. Presumptive identificationof anaerobic nonsporeforming gram-negativebacil-
Color atlas and textbook of diagnostic microbiology. J. B. Lippincott Co., PhJ/adelphia. 5. Slargel, M. D., G. L Lombard, and V. R. Doweil, Jr. 1978.Alternative approaches to biochemical differentiation of anaerobic bacteria. Am. J. Med. Tectmol. 44:709722. 6. Sutter, V. L., and S. M. Finegold. 1976. Susceptibilityof anaerobic bacteria to 23 antimicrobial agents. Antimicrob. Agents Chemother. 10:736- 752. 7. Sut(er, V. L., V. L. Vargo, and S. M. Finegold. 1975. Wadsworth anaerobic bacteriology manual, 2nd ed. Dept. of Med., UCLA School of Med., Los Angeles.
the costo-vertebral angle, and the lumbar and sacral vertebrae, especially 1 cm superior to the left gluteal cleft; a white blood cell 0NBC) count of 21,500/mm 3 with 12% banded cells and 75°70 neutrophils. The urine had a trace of protein and glucose, 25 WBC/high-power field, but no red blood cells. A diagnosis of pyelonephritis was made, and gentamicin and ampicillin therapy was begun, but the fever and gluteal pain persisted. On the third hospital day, x-rays of the lumbar spine and pelvis demonstrated "multiple collections of gas bubbles in the soft tissues of the left buttock." Foul-smelling pus was aspkated; the abscess was then incised and drained. The anesthesiology record from that procedure noted that at the time of surgery, the patient displayed neck stiffness and questionable meningismus. The aspirate was cultured according to the VPI methods (2) and yielded Bacteroides fragilis, Ftuobacterium gonidiaformans, "Gaffkya anaerobia, "Bacteroides biacutis, Bacteroides asaccharolyticus, Clostridium ramosum, Eubacterium lentum, three strains of Escherichia coil (by antibiogram), Staphylococcus epidermidi~, and diphtheroids.
During the first two postoperative days, the patient remained febrile, and the presence of nuchal rigidity was confirmed. She also complained of severe headache and diplopia. A lumbar puncture at L3-4 produced foul-smelling, grossly purulent material. Repeat puncture at L2-3 again yielded purulent material with a WBC count of 40,000/mm', a protein of 1430 mg/dl, and a glucose of 45 mg/dl. The specimen was sent to the anaerobic bacteriology laboratory for culture because of the foul smell and the presence of numerous bacterial morphotypes seen on Gram's stain of the spinal fluid. The culture grew B. fragilis, B. biacutus, B. asaccharolyticus, C. ramosum, E. lentum, three strains ofE. coli, and diphtheroids. The patient's antibiotic therapy was changed to parenteral chloramphenicol and ampiciUin. She underwent extensive diagnostic testing including a laminectomy to rule out the presence of an epidural abscess, but none of the studies provided conclusive evidence of the origin of her polymicrobial infective process. Antibiotic therapy was discontinued after two weeks; the patient remained afebrile and
Case Report i
Polymicrobiai Meningitis
Submitted by W. A. Causcy, M.D. and M. H. Graves, M.S. Section of Infectious Diseasesand Clinical Microbiology Laboratories The Universityof Chicago ttospita~ and Clinics Chicago, Illinoi~60637 An 18-year-old female was admitted to the hospital with a one-week history of fever, chills, low-back pain, headache, malaise, and a constant throbbing pain in the left gluteal region. Two days prior to admission, she noted bilateral flank pain with increased urinary frequency, but no dysuria, hematuria, pyuria, or urgency. She denied any recent change in bowel • habits or trauma to her backside. The patient had been treated three times during the past six months for urinary tract infections and had been hospitalized previously for psychiatric disorders related to problems of multiple oral drug abuse. She denied intravenous drug abuse and further denied any drug use in the previous two months. On physical examination, abnormal findings included a temperature of 39.5 °C, marked tenderness over the liver,
|
was discharged approximately one month after admission. Although anaerobic bacteria are considered to be an uncommon cause of meningitis, a recent literature survey by Finegold (1) cites 198 cases. Most of the infections were monomicrobial; two or more anaerobes were isolated from 16 patients only. The most common predisposing factor to anaerobic meningitis was brain abscess, followed by extra-or subdural abscess and chronic otitis media
and/or mastoiditis. Although in our patient no continuous abscess tract was demonstrated at surgery, it is presumed that her infection originated as a pedrectat abscess that dissected into the left gluteal region, then along the sacrum, through a lumbosacral spinal interspace into the spinal epidural space. Finally, the abscess ruptured into the subarachnoid space producing a polymicrobial meningitis with the same microflora as the gluteal abscess. Provisions should be made
|1
for adequate anaerobic spinal fluid culture whenever the patient's history or symptoms, or the characteristics of the fluid suggest that anaerobes are present. References 1. Finegoid, S. M. 1977. Anaerobic bacteria h human disease, Academic Press, N.Y. pp. 164- 169. 2. Hoideman, L. V., E. P. Calo, and W. E.
C. Moore. 1971. Anaerobe laboratory manual, 4th ed. V.P.I. Anaerobe Lab., Blacksburg, Va.
Abstracts of Recent Literature
Submitted by Robert Fekety, M.D. Chief, Infectious Diseases Section University Hospital University of Michigan Medical School Ann Arbor Michigan 48109 Editors' note: Dr. Fekety prepares abstracts of current, pertinent literature for his staff and has kindly consented to share them with us. They will appear here periodically as space permits. J. F. Acar et al. Human infections caused by thiamine- or menadione-requiring Staphylococcus aureus. J. Clin. Microbiol. 8:142- 147, 1978. Stable dwarf forms of Staphylococcus aureus were identified as the sole or predominant isolates in clinical specimens from eight cases. The organisms were menadione- or thiamine-dependent, i.e., cultivation in the presence of one of these agents permitted growth of typical S. aureus. In vitro resistance of the organisms to aminoglycosides was overcome by cultivation in the presence of menadione or thiamine. These organisms can be significant causative agents of severe human infections, and special care must be taken not to miss them in clinical specimens. Antibiotic susceptibility of these organisms should be determined in both supplemented and nonsupplemented media. Three of these organisms were obtained from blood cultures, three from osteomyelitis, one from CSF, and one from a subcutaneous abscess. The concentration of thiamine in serum is sufficient for the multiplication of these organisms. Systematic use of enriched media, such as chocolate agar containing IsoVitalex is acceptable when deficient strains might be present. Laboratory personnel should i
6
think of these when sterile cultures are obtained after organisms resembling staphylococci are seen on Gram's stain, or when sterile cultures are obtained from patients with known staphylococcal infections, especially osteomyelitis. G. L. Archer et al. Rifampin therapy of Staphylococcus epidermidis. Use in infections from indwelling artificial devices. JAMA 240:751 - 753, 1978. The authors present two patients, one with prosthetic valve endocarditis and the other with CSF shunt infection. The addition of rifampin increased serum or CSF bactericidal activity 16-fold or greater and was correlated with a favorable clinical response in refractory infections. Rifampin is a very active antibiotic against staphylococci but has not often been used because of the rapid and frequent development of resistance when it is used alone. The antibiotics combined with it in the reported cases were gentamicin, nafciUin or vancomycin. Enhanced killing in vitro with these combinations was demonstrated. This paper highlights a growing tendency towards use of antibiotic combinations in staphylococcal sepsis and the increasing popularity of rifampin in this context.
M. R. Jacobs et al. Emergence of multiply resistant pneumococci. N. Engl. J. Med. 299:735 - 740, 1978. The authors report on the pneumococci detected in South Africa in July, 1977. Carders of types 6A and 19A pneumococci that were resistant to penicillin at concentrations between 0.12 and 4/.tg/ml were found in 29070 of 543 pediatric patients and 2070 of 434 hospital staff members. Type 19A strains were also resistant to otherfl-lactam antibiotics, erythromycin, clindamycin, tetracycline, and chloramphenicol, and these were isolated from 128 carders and from the blood of four patients. They recommended that pneumococci can be screened for resistance with modified Kirby-Bauer techniques and that surveillance for this kind of organism should be conducted more vigorously. These isolates were clinically as well as bacteriologically resistant, but fortunately have not spread extensively around the world since they wert first recognized.
Editors: Donna J. Blazevic, L. R. McCarthy, and Josephine A. Morello
Subscrlption Rates in U.S. and Canada: one year$42.50; two years$80.00; three years$110.00. All other cot tries: one year$57.50; two years$109.50; three years$153.25. Singlecopiesare $2.00 in U.S. and Canada, $2.65 all other countries. Singleissuesare availablein quantity (pricesavailableupon request).All subscriptic are payablein advance. Foreignsubscriptionsare sent guaranteedair mail. Firstclasspostagepaid in U.S. an Canada. Addresscorrespondenceregardingsubscriptionto: ClinicaIMicrobiologyNewsletter, G.K. Hall& Co., 70 LincolnSt., Boston, Massachusetts02111. Pleaseincludezip code in subscriptionaddress. The Clink MicrobiologyNewsletteris publishedtwicemonthly. All fights, includingthat o f translation into other languages, reserved.Photomechanicalreproduction (photo: copy, microcopy)of this newsletteror parts thereofwithout specialpermissionof the publisheris prohibited.
there has been some progress during this decade, careful definitive identification is still needed to further define the role of obligate anaerobes in health and disease, to educate clinicians and microbiologists, and to aid the physician in providing 013timal care for the patient. For the individual laboratory, the choice of identification procedures used and the extent of anaerobe identification will depend on a number of circumstances. These include the technical competence of personnel, the resources available, the patient population served, and the needs of physicians. The laboratory must be competent in that which it does and should be willing to refer isolates to more sophisticated laboratories when such referrals are warranted by clinical circumstances.
li. U.S. Dept. of Health, Education and Welfare, Public Health Service,Center for Disease Control, Atlanta, Ga. 2. Hoideman, L. V., E. P. Calo, and W. E.
C. Moore (ed.). 1977.Anaerobe laboratory manual, 4th ed. Vkginia Polytechnic Institute and State University,Blacksburg, Va. 3. Jones, R. N., and P. C. Fucks. 1976. Identification and antimicrobial susceptibilityof 250 Bacteroidesfragili~subspeciestested by broth microdilution methods. Antimicrob. Agents Chemother. 9:719- 721. 4. Koneman, E. W., S. D. Allen, V. R. Dowell, Jr., and H. M. Sommers. 1979.
References I. Dowell, V. R., Jr., and G. L. Lombard. 1977. Presumptive identificationof anaerobic nonsporeforming gram-negativebacil-
Color atlas and textbook of diagnostic microbiology. J. B. Lippincott Co., PhJ/adelphia. 5. Slargel, M. D., G. L Lombard, and V. R. Doweil, Jr. 1978.Alternative approaches to biochemical differentiation of anaerobic bacteria. Am. J. Med. Tectmol. 44:709722. 6. Sutter, V. L., and S. M. Finegold. 1976. Susceptibilityof anaerobic bacteria to 23 antimicrobial agents. Antimicrob. Agents Chemother. 10:736- 752. 7. Sut(er, V. L., V. L. Vargo, and S. M. Finegold. 1975. Wadsworth anaerobic bacteriology manual, 2nd ed. Dept. of Med., UCLA School of Med., Los Angeles.
the costo-vertebral angle, and the lumbar and sacral vertebrae, especially 1 cm superior to the left gluteal cleft; a white blood cell 0NBC) count of 21,500/mm 3 with 12% banded cells and 75°70 neutrophils. The urine had a trace of protein and glucose, 25 WBC/high-power field, but no red blood cells. A diagnosis of pyelonephritis was made, and gentamicin and ampicillin therapy was begun, but the fever and gluteal pain persisted. On the third hospital day, x-rays of the lumbar spine and pelvis demonstrated "multiple collections of gas bubbles in the soft tissues of the left buttock." Foul-smelling pus was aspkated; the abscess was then incised and drained. The anesthesiology record from that procedure noted that at the time of surgery, the patient displayed neck stiffness and questionable meningismus. The aspirate was cultured according to the VPI methods (2) and yielded Bacteroides fragilis, Ftuobacterium gonidiaformans, "Gaffkya anaerobia, "Bacteroides biacutis, Bacteroides asaccharolyticus, Clostridium ramosum, Eubacterium lentum, three strains of Escherichia coil (by antibiogram), Staphylococcus epidermidi~, and diphtheroids.
During the first two postoperative days, the patient remained febrile, and the presence of nuchal rigidity was confirmed. She also complained of severe headache and diplopia. A lumbar puncture at L3-4 produced foul-smelling, grossly purulent material. Repeat puncture at L2-3 again yielded purulent material with a WBC count of 40,000/mm', a protein of 1430 mg/dl, and a glucose of 45 mg/dl. The specimen was sent to the anaerobic bacteriology laboratory for culture because of the foul smell and the presence of numerous bacterial morphotypes seen on Gram's stain of the spinal fluid. The culture grew B. fragilis, B. biacutus, B. asaccharolyticus, C. ramosum, E. lentum, three strains ofE. coli, and diphtheroids. The patient's antibiotic therapy was changed to parenteral chloramphenicol and ampiciUin. She underwent extensive diagnostic testing including a laminectomy to rule out the presence of an epidural abscess, but none of the studies provided conclusive evidence of the origin of her polymicrobial infective process. Antibiotic therapy was discontinued after two weeks; the patient remained afebrile and
Case Report i
Polymicrobiai Meningitis
Submitted by W. A. Causcy, M.D. and M. H. Graves, M.S. Section of Infectious Diseasesand Clinical Microbiology Laboratories The Universityof Chicago ttospita~ and Clinics Chicago, Illinoi~60637 An 18-year-old female was admitted to the hospital with a one-week history of fever, chills, low-back pain, headache, malaise, and a constant throbbing pain in the left gluteal region. Two days prior to admission, she noted bilateral flank pain with increased urinary frequency, but no dysuria, hematuria, pyuria, or urgency. She denied any recent change in bowel • habits or trauma to her backside. The patient had been treated three times during the past six months for urinary tract infections and had been hospitalized previously for psychiatric disorders related to problems of multiple oral drug abuse. She denied intravenous drug abuse and further denied any drug use in the previous two months. On physical examination, abnormal findings included a temperature of 39.5 °C, marked tenderness over the liver,
|
was discharged approximately one month after admission. Although anaerobic bacteria are considered to be an uncommon cause of meningitis, a recent literature survey by Finegold (1) cites 198 cases. Most of the infections were monomicrobial; two or more anaerobes were isolated from 16 patients only. The most common predisposing factor to anaerobic meningitis was brain abscess, followed by extra-or subdural abscess and chronic otitis media
and/or mastoiditis. Although in our patient no continuous abscess tract was demonstrated at surgery, it is presumed that her infection originated as a pedrectat abscess that dissected into the left gluteal region, then along the sacrum, through a lumbosacral spinal interspace into the spinal epidural space. Finally, the abscess ruptured into the subarachnoid space producing a polymicrobial meningitis with the same microflora as the gluteal abscess. Provisions should be made
|1
for adequate anaerobic spinal fluid culture whenever the patient's history or symptoms, or the characteristics of the fluid suggest that anaerobes are present. References 1. Finegoid, S. M. 1977. Anaerobic bacteria h human disease, Academic Press, N.Y. pp. 164- 169. 2. Hoideman, L. V., E. P. Calo, and W. E.
C. Moore. 1971. Anaerobe laboratory manual, 4th ed. V.P.I. Anaerobe Lab., Blacksburg, Va.
Abstracts of Recent Literature
Submitted by Robert Fekety, M.D. Chief, Infectious Diseases Section University Hospital University of Michigan Medical School Ann Arbor Michigan 48109 Editors' note: Dr. Fekety prepares abstracts of current, pertinent literature for his staff and has kindly consented to share them with us. They will appear here periodically as space permits. J. F. Acar et al. Human infections caused by thiamine- or menadione-requiring Staphylococcus aureus. J. Clin. Microbiol. 8:142- 147, 1978. Stable dwarf forms of Staphylococcus aureus were identified as the sole or predominant isolates in clinical specimens from eight cases. The organisms were menadione- or thiamine-dependent, i.e., cultivation in the presence of one of these agents permitted growth of typical S. aureus. In vitro resistance of the organisms to aminoglycosides was overcome by cultivation in the presence of menadione or thiamine. These organisms can be significant causative agents of severe human infections, and special care must be taken not to miss them in clinical specimens. Antibiotic susceptibility of these organisms should be determined in both supplemented and nonsupplemented media. Three of these organisms were obtained from blood cultures, three from osteomyelitis, one from CSF, and one from a subcutaneous abscess. The concentration of thiamine in serum is sufficient for the multiplication of these organisms. Systematic use of enriched media, such as chocolate agar containing IsoVitalex is acceptable when deficient strains might be present. Laboratory personnel should i
6
think of these when sterile cultures are obtained after organisms resembling staphylococci are seen on Gram's stain, or when sterile cultures are obtained from patients with known staphylococcal infections, especially osteomyelitis. G. L. Archer et al. Rifampin therapy of Staphylococcus epidermidis. Use in infections from indwelling artificial devices. JAMA 240:751 - 753, 1978. The authors present two patients, one with prosthetic valve endocarditis and the other with CSF shunt infection. The addition of rifampin increased serum or CSF bactericidal activity 16-fold or greater and was correlated with a favorable clinical response in refractory infections. Rifampin is a very active antibiotic against staphylococci but has not often been used because of the rapid and frequent development of resistance when it is used alone. The antibiotics combined with it in the reported cases were gentamicin, nafciUin or vancomycin. Enhanced killing in vitro with these combinations was demonstrated. This paper highlights a growing tendency towards use of antibiotic combinations in staphylococcal sepsis and the increasing popularity of rifampin in this context.
M. R. Jacobs et al. Emergence of multiply resistant pneumococci. N. Engl. J. Med. 299:735 - 740, 1978. The authors report on the pneumococci detected in South Africa in July, 1977. Carders of types 6A and 19A pneumococci that were resistant to penicillin at concentrations between 0.12 and 4/.tg/ml were found in 29070 of 543 pediatric patients and 2070 of 434 hospital staff members. Type 19A strains were also resistant to otherfl-lactam antibiotics, erythromycin, clindamycin, tetracycline, and chloramphenicol, and these were isolated from 128 carders and from the blood of four patients. They recommended that pneumococci can be screened for resistance with modified Kirby-Bauer techniques and that surveillance for this kind of organism should be conducted more vigorously. These isolates were clinically as well as bacteriologically resistant, but fortunately have not spread extensively around the world since they wert first recognized.
Editors: Donna J. Blazevic, L. R. McCarthy, and Josephine A. Morello
Subscrlption Rates in U.S. and Canada: one year$42.50; two years$80.00; three years$110.00. All other cot tries: one year$57.50; two years$109.50; three years$153.25. Singlecopiesare $2.00 in U.S. and Canada, $2.65 all other countries. Singleissuesare availablein quantity (pricesavailableupon request).All subscriptic are payablein advance. Foreignsubscriptionsare sent guaranteedair mail. Firstclasspostagepaid in U.S. an Canada. Addresscorrespondenceregardingsubscriptionto: ClinicaIMicrobiologyNewsletter, G.K. Hall& Co., 70 LincolnSt., Boston, Massachusetts02111. Pleaseincludezip code in subscriptionaddress. The Clink MicrobiologyNewsletteris publishedtwicemonthly. All fights, includingthat o f translation into other languages, reserved.Photomechanicalreproduction (photo: copy, microcopy)of this newsletteror parts thereofwithout specialpermissionof the publisheris prohibited.