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Amsel Criteria

StatPearls-/- 2019; ():

Bacterial vaginosis has universal acknowledgment as the most prevalent cause of vaginal disorders in women of reproductive age, present in an estimated 10 to 20% of White women and 30 to 50% of Black women.[1] Estimates for the exact percentage of women afflicted at any one time vary from as low as 5% to as high as 70% worldwide.[2] If symptomatic, patients often complain of vaginal discharge having a classic "fishy" odor; however, many women remain asymptomatic until detection during a routine vaginal exam or pap smear.[3] Unfortunately, leaving bacterial vaginosis untreated provides an opportunity for several complications including inflammation of endometrial or cervical tissue, urinary tract infection, chronic pelvic pain, increased risk of HIV and other STDs, and elevated risk of ectopic pregnancy as well as difficult conception.[4] As pertains to pregnancy, consequences may be even more severe and include the potential for prematurity of the newborn, premature rupture of membranes, and low birth weight.[5] Treatment for this issue generally involves antibiotic therapy via intravaginal gel or oral pill. Metronidazole or clindamycin are the most commonly used antimicrobial agents. Unfortunately, the complete cure rate for bacterial vaginosis is between 65 to 85 percent, and many women experience a relapse in the weeks or months following treatment.[6] The Nugent scoring system had previously been considered the gold standard for the diagnosis of bacterial vaginosis. This system, discovered by RP Nugent and published in 1991, added more specific qualifications to the previous gold standard, the Spiegel criteria - otherwise known as Gram staining of vaginal smears. Using the Nugent score, vaginal smears are plated on a microscopic slide in oil immersion, and a minimum of 10 high power fields are examined for three bacteria morphotypes: Lactobacillus, Gardnerella, and curved gram rods. Each of these three categories receives a score based on the number of bacteria counted. Subsequently, these three scores are added together for a total score ranging from 0 - 10. The scoring is as follows[7]: 0-3: negative for BV. 4-6: intermediate. 7+: positive for BV. While accurate, the Nugent scoring system has been disregarded by many physicians as cumbersome due to the skill level required with microscopy as well as the time it takes to physically perform bacteria counts. The Amsel criteria have, by and large, replaced the Nugent system. The Amsel criteria, originally published in the American Journal of Medicine in 1983, provides a more accessible, clinically defined basis for the diagnosis of bacterial vaginosis using only four criteria. Though older and seemingly simpler, the Amsel criteria have been validated as equivalent to Nugent scoring when diagnosing bacterial vaginosis.[8] It is generally preferred for its ease and ability to be performed using only basic observational microscopic techniques.



StatPearls-/- 2019; ():

Clindamycin is FDA-approved for the treatment of septicemia, intra-abdominal infections, lower respiratory infections, gynecological infections, bone and joint infections, and skin and skin structure infections. Clindamycin is also used in the treatment of streptococcal pharyngitis, acne vulgaris, bacterial vaginosis and severe pelvic inflammatory disease. Although not a first-line treatment, Infectious Diseases Society of America (IDSA) has published guidelines for using intravenous (IV) clindamycin for the inpatient treatment of community-acquired pneumonia. Dentists will use clindamycin for prophylactic coverage against endocarditis. Anesthesiologists and surgeons will often administer clindamycin per American Society of Health-System Pharmacists (ASHP) and IDSA guidelines as prophylaxis in the operating room.


Case Study: 8-Year-Old With a Murmur and Hypertension

StatPearls-/- 2019; ():

An 8-year-old female presents to the emergency department (ED) referred by her primary care provider (PCP) for left-sided neck swelling and murmur. Per patient's mother, the patient has had left-sided neck swelling for 1 month. The patient also experienced subjective fevers, chills, headache, and malaise. Over that same period, mom also noticed about 5 pounds of weight loss and intermittent side pain. Because of these concerns, mom took her daughter to the PCP 2 weeks before ED presentation and was diagnosed with lymphadenitis and started on oral amoxicillin-clavulanic acid and told to follow-up the following week. At the following visit, there was a minimal improvement of the neck swelling, so the patient was switched to oral clindamycin. After a week of being on the clindamycin, the patient presented again to the PCP with minimal improvement of her symptoms. At this visit, the PCP also noticed a new cardiac murmur. Because the patient had failed outpatient antibiotic therapy and had this new heart murmur, the PCP referred the patient to the ED.


Enterococcal Infection-Treatment and Antibiotic Resistance

Enterococci: From Commensals to Leading Causes of Drug Resistant Infection-/- 2014; ():

The clinical importance of the genus Enterococcus is directly related to its antibiotic resistance, which contributes to the risk of colonization and infection. The species of the greatest clinical importance are Enterococcus faecalis and Enterococcus faecium. Although the resistance characteristics of these two species differ in important ways, they can generally be categorized as intrinsic resistance, acquired resistance, and tolerance. Relative to the streptococci, enterococci are intrinsically resistant to many commonly used antimicrobial agents. All enterococci exhibit decreased susceptibility to penicillin and ampicillin, as well as high-level resistance to most cephalosporins and all semi-synthetic penicillins, as the result of expression of low-affinity penicillin-binding proteins. For many strains, their level of resistance to ampicillin does not preclude the clinical use of this agent. In fact, ampicillin remains the treatment of choice for enterococcal infections that lack other mechanisms for high-level resistance. Enterococci are also intrinsically resistant to clindamycin, which is mediated by the product of the lsa gene, although the mechanism remains poorly defined. Trimethoprim-sulfamethoxazole appears to be active against enterococci when tested in vitro on folate-deficient media, but fails in animal models, presumably because enterococci can absorb folate from the environment (Zervos & Schaberg, 1985). Enterococci also have a native resistance to clinically achievable concentrations of aminoglycosides, which precludes their use as single agents. Although E. faecalis is naturally resistant to quinupristin-dalfopristin, this combination is highly active against E. faecium strains that lack specific resistance determinants. Enterococci are tolerant to the (normally) bactericidal activity of cell-wall active agents, such as beta-lactam antibiotics and vancomycin. Tolerance implies that the bacteria can be inhibited by clinically achievable concentrations of the antibiotic, but will only be killed by concentrations far in excess of the inhibitory concentration. Enterococcal tolerance can be overcome by combining cell-wall active agents with an aminoglycoside. The mechanism by which beta-lactam-aminoglycoside combinations yield synergistic bactericidal activity remains a mystery, but in vitro data indicate that a higher concentration of aminoglycoside enters cells that are also treated with agents that inhibit cell wall synthesis, which suggests that the cell wall active agents promote uptake of the aminoglycoside (Mohr, Friedrich, Yankelev, & Lamp, 2009). Tolerance is normally detected in vitro by plotting survival in kill curves, and can be observed for a number of antibiotic-bacteria combinations. In vitro tolerance has an important impact on therapy for treating enterococcal infections. The treatment of endocarditis requires bactericidal therapy, due to the inaccessibility of the bacteria within the cardiac vegetations to the mammalian immune system. Recognition of synergism between penicillin-streptomycin led to an improvement in cure rates for enterococcal endocarditis, from approximately 40% to greater than 80% (Jensen, Frimodt-Moller, & Aarestrup, 1999; Rice & Carias, 1998). Despite considerable effort, investigators have yet to find other combinations of antibiotics that are synergistically bactericidal against enterococci. In addition to intrinsic resistance and tolerance, enterococci have been extraordinarily successful at rapidly acquiring resistance to virtually any antimicrobial agent put into clinical use. Introduction of chloramphenicol, erythromycin and tetracyclines was quickly followed by the emergence of resistance, in some cases reaching a prevalence that precluded their empirical use. While the occurrence of ampicillin resistance in E. faecalis has been quite rare, there is now widespread, high-level resistance to ampicillin among clinical E. faecium isolates. High-level aminoglycoside resistance, which negates the synergism between cell-wall active agents and aminoglycosides, has been recognized for several decades. Vancomycin resistance is widely prevalent in E. faecium, although it remains relatively rare in E. faecalis. In response to the growing problem of vancomycin resistance in enterococci, the pharmaceutical industry has developed a number of newer agents that have activity against vancomycin-resistant enterococci (VRE). However, none of these newly licensed agents (quinupristin-dalfopristin, linezolid, daptomycin, tigecycline) has been entirely free of resistance. Thus, the widespread resistance of enterococci has had a substantial impact on our use of both empirical and definitive antibiotics for the treatment of enterococcal infections, a situation that is likely to persist for the foreseeable future.


Treatment of Pregnant Women with Asymptomatic Bacterial Vaginosis with Clindamycin

Treatment of Pregnant Women with Asymptomatic Bacterial Vaginosis with Clindamycin-/-NIPH Systematic Reviews: Executive Summaries 2010; ():

Bacterial vaginosis is present in up to 20% of women during pregnancy, and is associated with complications such as preterm birth. Approximately half of the infected pregnant women are asymptomatic. Asymptomatic pregnant women with bacterial vaginosis and without a medical history of preterm births are usually not treated with antibiotics in Norway. We searched systematically for articles in international databases, included articles that met our inclusion criteria, critically appraised and summarised the results descriptively or in meta-analysis. We included seven randomized controlled clinical trials showing that:Clindamycin is associated with little or no change in the risk of preterm birth before 37 weeks when administered to pregnant women with asymptomatic bacterial vaginosis. This applies when the treatment is given during the second trimester and if treatment is given before 20 weeks gestation. Our quality assessments suggest that the quality of the evidence is moderate. Treatment of asymptomatic bacterial vaginosis with clindamycin is probably associated with little or no difference in the incidence of low birth weight or postpartum uterus infections. Our quality assessment suggest that the quality of the evidence is low for these outcomes, implying that further research is likely to change the effect estimates. The quality of available research is too low to determine whether treatment with clindamycin can reduce the risk of preterm birth before 33 week gestation. This conclusion applies both if the treatment is given during the second trimester and if treatment is given before 20 week gestation (early treatment).



Drugs and Lactation Database (LactMed)-/- 2006; ():

Clindamycin has the potential to cause adverse effects on the breastfed infant's gastrointestinal flora. If oral or intravenous clindamycin is required by a nursing mother, it is not a reason to discontinue breastfeeding, but an alternate drug may be preferred. Monitor the infant for possible effects on the gastrointestinal flora, such as diarrhea, candidiasis (thrush, diaper rash) or rarely, blood in the stool indicating possible antibiotic-associated colitis. Vaginal application is unlikely to cause infant side effects, although about 30% of a vaginal dose is absorbed. Infant side effects are unlikely with topical administration for acne; however, topical application to the breast may increase the risk of diarrhea if it is ingested by the infant. Only water-miscible cream, foam, gel or liquid products should be applied to the breast because ointments may expose the infant to high levels of mineral paraffins via licking.[1]


Polycystic Kidney Disease, Autosomal Dominant

GeneReviews((R))-/- 1993; ():

CLINICAL CHARACTERISTICS: Autosomal dominant polycystic kidney disease (ADPKD) is generally a late-onset multisystem disorder characterized by bilateral renal cysts, liver cysts, and an increased risk of intracranial aneurysms. Other manifestations include: cysts in the pancreas, seminal vesicles, and arachnoid membrane; dilatation of the aortic root and dissection of the thoracic aorta; mitral valve prolapse; and abdominal wall hernias. Renal manifestations include hypertension, renal pain, and renal insufficiency. Approximately 50% of individuals with ADPKD have end-stage renal disease (ESRD) by age 60 years. The prevalence of liver cysts increases with age and occasionally results in clinically significant severe polycystic liver disease (PLD). Overall the prevalence of intracranial aneurysms is fivefold higher than in the general population and further increased in those with a positive family history of aneurysms or subarachnoid hemorrhage. There is substantial variability in the severity of renal disease and other extrarenal manifestations even within the same family. DIAGNOSIS/TESTING: The diagnosis of ADPKD is established in a proband with age-specific renal imaging criteria and an affected first-degree relative with ADPKD or identification of a heterozygous pathogenic variant in PKD1, PKD2, GANAB, or DNAJB11. MANAGEMENT: Treatment of manifestations: Vasopressin V2 receptor antagonists (e.g., tolvaptan) to slow disease progression. Treatment for hypertension may include ACE inhibitors or angiotensin II receptor blockers and diet modification. Conservative treatment of flank pain includes nonopioid agents, tricyclic antidepressants, narcotic analgesics, and splanchnic nerve blockade. More aggressive treatments include cyst decompression with cyst aspiration and sclerosis, laparoscopic or surgical cyst fenestration, renal denervation, and nephrectomy. Cyst hemorrhage and/or gross hematuria is usually self-limiting. Treatment of nephrolithiasis is standard. Treatment of cyst infections is difficult, with a high failure rate. Therapeutic agents of choice may include trimethoprim-sulfamethoxazole, fluoroquinolones, clindamycin, vancomycin, and metronidazole. The diagnosis of malignancy requires a high index of suspicion. Therapeutic interventions aimed at slowing the progression of ESRD in ADPKD include control of hypertension and hyperlipidemia, dietary protein restriction, control of acidosis, and prevention of hyperphosphatemia. Most individuals with PLD have no symptoms and require no treatment, but rare severe cases may require surgical resection or even liver transplantation. The mainstay of therapy for ruptured or symptomatic intracranial aneurysm is surgical clipping of the ruptured aneurysm at its neck; however, for some individuals, endovascular treatment with detachable platinum coils may be indicated. Thoracic aortic replacement is indicated when the aortic root diameter exceeds established size. Prevention of secondary manifestations (lifestyle and therapeutic factors that may modulate disease): Maintain appropriate blood pressure and urine osmolarity; low osmolar intake (e.g., moderate sodium and protein); increase hydration by moderate water intake; maintain sodium bicarbonate >/=22 mEq/L; moderate dietary phosphorus intake; moderate caloric intake to maintain normal BMI; low-impact exercise; lipid control; tolvaptan therapy. Surveillance: Early blood pressure monitoring starting in childhood; MRI screening for intracranial aneurysms in those determined to be at high risk; screening echocardiography in those with a heart murmur and those with a family history of a first-degree relative with a thoracic aortic dissection. Agents/circumstances to avoid: Long-term administration of nephrotoxic agents, high levels of caffeine, use of estrogens and possibly progestogens by individuals with severe PLD, smoking, and obesity. Evaluation of relatives at risk: Testing of adult relatives at risk permits early detection and treatment of complications and associated disorders. Pregnancy management: Pregnant women with ADPKD should be monitored for the development of hypertension, urinary tract infections, oligohydramnios, and preeclampsia; the fetus should be monitored for intrauterine fetal growth restriction, oligohydramnios, and fetal kidney anomalies including cysts, enlarged size, and atypical echogenicity. GENETIC COUNSELING: ADPKD is inherited in an autosomal dominant manner. About 95% of individuals with ADPKD have an affected parent, but at least 10% of families can be traced to a de novo pathogenic variant. Each child of an affected individual has a 50% chance of inheriting the pathogenic variant. Once the pathogenic variant has been identified in an affected family member, prenatal testing for a pregnancy at increased risk and preimplantation genetic diagnosis for ADPKD are possible.


Incidence of constitutive and inducible clindamycin resistance among hospital-associated Staphylococcus aureus.

3 Biotech 2014; 4 (1): 85-89;

Clindamycin is one of the important alternative antibiotics in the therapy of Staphylococcus aureus infections. Clinical failure of clindamycin therapy has been reported due to multiple mechanisms that confer resistance to macrolides, lincosamides and Streptogramin B (MLSB) antibiotics. In vitro routine tests for clindamycin susceptibility may fail to detect inducible clindamycin resistance due to erm genes, resulting in the treatment failure. Although data from the developed countries have shown to be enormity of the problem, data from the developing countries are lacking. The aim of the study was to distinguish different resistance phenotypes in erythromycin-resistant S. aureus by a simple double-disc diffusion test (D test). A total of 153 S. aureus isolates were subjected to routine antibiotic susceptibility testing, including cefoxitin disc (30 mug) and by oxacillin screen agar. Inducible clindamycin resistance was tested by 'D test' as per CLSI guidelines. Odds ratios (OR) and 95 % confidence intervals (95 % CI) were calculated. P values were calculated using SPSS (version 18). Among 153 S. aureus isolates, 42 (27.45 %) were resistant to methicillin, whereas 111 (72.54 %) were methicillin susceptible. Out of the 63 (41.17 %) erythromycin-resistant S. aureus isolates, 14 (9.15 %) showed inducible resistance [P = 0.0002, odds ratio (OR) 18.30; 95 % confidence interval (CI) 8.72-25.77), 20 (13.07 %)] showed constitutive resistance (P = 0.002, OR 14.38, 95 % CI 5.33-21.49), while the remaining 29 (18.95 %) showed inducible phenotype. Inducible and constitutive resistance was found to be higher in MSSA when compared with MRSA. Clinical laboratories should perform D test routinely to guide the clinicians about the inducible clindamycin resistance and to prevent misuse of antibiotics.


Emergency management of pediatric skin and soft tissue infections in the community-associated methicillin-resistant Staphylococcus aureus era.

Acad Emerg Med 2010; 17 (2): 187-93

OBJECTIVES: Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. METHODS: This was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. RESULTS: In total, 366 of 606 (60.3%) list-serv members responded. The mean (+/- standard deviation [SD]) duration of practice was 13.6 (+/-7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA-inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections. CONCLUSIONS: Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated.


Cutaneous community-associated methicillin-resistant staphylococcus aureus among all skin and soft-tissue infections in two geographically distant pediatric emergency departments.

Acad Emerg Med 2007; 14 (1): 35-40

OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.


Clinicopathological conference: multisystem failure in a child.

Acad Emerg Med 2000; 7 (2): 169-73


Clinical pearls: painful tongue swelling.

Acad Emerg Med 2000; 7 (8): 918, 941-3


Antibiotic selection for purulent skin and soft-tissue infections in ambulatory care: a decision-analytic approach.

Acad Pediatr 2009; 9 (3): 179-84

OBJECTIVE: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused a nationwide epidemic of skin and soft-tissue infections in ambulatory pediatrics. Antibiotic treatment recommendations suggest incorporating local epidemiology for the prevalence of CA-MRSA. We sought to identify the antibiotic strategy with the highest probability of activity and to identify threshold values for epidemiologic variables including bacterial prevalence and antibiotic resistance. METHODS: We used decision analysis to evaluate 3 empiric antibiotic strategies: clindamycin, trimethoprim/sulfamethoxazole (T/S), and cephalexin. We calculated the probability of activity against the bacteria causing the infection (CA-MRSA, methicillin-sensitive S. aureus and group A Streptococcus [GAS]) by incorporating estimates of prevalence and antibiotic resistance to determine the optimal strategy. Sensitivity analysis was used to identify thresholds for prevalence and antibiotic resistance where 2 strategies were equal. RESULTS: Clindamycin (0.95) and T/S (0.89) had substantially higher probability of activity than cephalexin (0.28) using baseline estimates for bacterial prevalence and antibiotic resistance. Cephalexin was the optimal antibiotic only when CA-MRSA prevalence was <10%. The probability of activity for clindamycin and T/S was highly sensitive to changes in the values for bacterial prevalence (both CA-MRSA and GAS) and CA-MRSA resistance to clindamycin. CONCLUSIONS: Empiric treatment of skin and soft-tissue infections with either clindamycin or T/S maximizes the probability that the antibiotic will be active when CA-MRSA prevalence is >10%. Deciding between T/S and clindamycin requires consideration of antibiotic resistance and prevalence of GAS. This model can be customized to local communities and illustrates the importance of ongoing epidemiologic surveillance in primary care settings.


Effect of calcium phosphate particle shape and size on their antibacterial and osteogenic activity in the delivery of antibiotics in vitro.

ACS Appl Mater Interfaces 2013; 5 (7): 2422-31

Powders composed of four morphologically different calcium phosphate particles were prepared by precipitation from aqueous solutions: flaky, brick-like, elongated orthogonal, and spherical. The particles were then loaded with either clindamycin phosphate as the antibiotic of choice or fluorescein, a model molecule used to assess the drug release properties. A comparison was carried out of the effect of such antibiotic-releasing materials on: sustained drug release profiles; Staphylococcus aureus growth inhibition; and osteogenic propensities in vitro. Raman spectroscopic analysis indicated the presence of various calcium phosphate phases, including monetite (flaky and elongated orthogonal particles), octacalcium phosphate (brick-shaped particles), and hydroxyapatite (spherical particles). Testing the antibiotic-loaded calcium phosphate powders for bacterial growth inhibition demonstrated satisfying antibacterial properties both in broths and on agar plates. All four calcium-phosphate-fluorescein powders exhibited sustained drug release over 21 days. The calcium phosphate sample with the highest specific surface area and the smallest, spherical particle size was the most effective in both drug loading and release, consequently having the highest antibacterial efficiency. Moreover, the highest cell viability, the largest gene expression upregulation of three different osteogenic markers--osteocalcin, osteopontin, and Runx2--as well as the least disrupted cell cytoskeleton and cell morphologies were also noticed for the calcium phosphate powder composed of the smallest, spherical nanosized particles. Still, all four powders exerted a viable effect on osteoblastic MC3T3-E1 cells in vitro, as evidenced by both morphological assessments on fluorescently stained cells and measurements of their mitochondrial activity. The obtained results suggest that the nanoscale particle size and the corresponding coarseness of the surface of particle conglomerates as the cell attachment points may present a favorable starting point for the development of calcium-phosphate-based osteogenic drug delivery devices.


Two Cases of Acute Febrile Neutrophilic Dermatosis Thought to be Caused by Topical Clindamycin.

Acta Derm Venereol 2019; 99 (2): 228-229


Clonality and anatomic distribution on the skin of antibiotic resistant and sensitive Propionibacterium acnes.

Acta Derm Venereol 2014; 94 (5): 534-8

Increasing antibiotic resistance in the population of Propionibacterium acnes is a major concern. Our aims were to examine the clonal relationships and anatomical distribution of resistant and sensitive P. acnes. A collection of 350 P. acnes isolates was therefore used to determine the minimum inhibitory concentration of tetracycline, erythro-mycin and clindamycin, multilocus sequence type, and the identity of genetic resistance markers. Two hitherto unknown resistance mutations were detected. Resistant P. acnes mainly belonged to clonal clusters in division I-1a frequently isolated from skin and associated with moderate to severe acne. All high-level tetracycline resistant strains were members of a single clone. Multiple isolates from distinct anatomic areas of surface skin and follicles of 2 acne patients revealed substantial clonal diversity between areas and co-existence of resistant and sensitive clones. Fifty-two percent of Danish acne patients and 43% of controls carried at least one resistant P. acnes strain, resistance to clindamycin being most frequent followed by tetracycline and erythromycin. Resistance to tetracycline was detected exclusively among isolates from acne patients. In conclusion, antibiotic resistance is associated with particular evolutionary clades of P. acnes and a substantial part is due to a single geographically widespread clone (ST3). Individuals carry a strikingly complex population of P. acnes with distinct virulence potential and antibiotic resistance.


Drug-induced hypersensitivity syndrome induced by clindamycin.

Acta Derm Venereol 2013; 93 (1): 83-4


Recurrent erysipelas secondary to a late prosthetic femoropopliteal bypass infection.

Acta Derm Venereol 2013; 93 (1): 78-9


Treatment of severe acne with low-dose isotretinoin.

Acta Derm Venereol 2012; 92 (3): 247-8


Clinical and microbiological comparisons of isotretinoin vs. tetracycline in acne vulgaris.

Acta Derm Venereol 2007; 87 (3): 246-54

The aim of this study was to compare the clinical and microbiological effect on Propionibacterium acnes of oral tetracycline plus topical adapalene vs. oral isotretinoin in moderate to severe acne vulgaris. Male and female acne patients with moderate or severe inflammatory disease were enrolled and assigned randomly to 6 months of treatment with oral tetracycline hydrochloride plus topical adapalene, or oral isotretinoin, in a controlled, open study. After cessation of oral treatment the antibiotic-treated group received topical adapalene for the 2-month follow-up period. Clinical and microbiological assessments were performed. Skin samples for microbial identification and quantification were taken at baseline, after 2, 4 and 6 months of treatment, and 2 months after cessation of treatment. Patients treated with isotretinoin showed prolonged significant remission compared with the other group. The density of resistant propionibacteria did not change significantly in any of the groups and there was no correlation between resistant P. acnes and the clinical response in any of the regions investigated. Antibiotic treatment was found to be a good alternative to isotretinoin, regardless of the presence of antibiotic-resistant P. acnes, although isotretinoin had a better effect, with prolonged remission after treatment.


A double-blind treatment study of bacterial vaginosis with normal vaginal lactobacilli after an open treatment with vaginal clindamycin ovules.

Acta Derm Venereol 2005; 85 (1): 42-6

The expected 4-week cure rate after conventional treatment of bacterial vaginosis are only 65-70%. In an attempt to improve the cure rate by adding probiotic lactobacilli we performed a double-blind placebo-controlled study of adjuvant lactobacilli treatment after an open treatment with vaginal clindamycin ovules. Women with bacterial vaginosis as defined by Amsel's criteria were treated with clindamycin ovules. Vaginal smears were collected and analysed according to Nugent's criteria. During the following menstruation period the women used, as an adjuvant treatment, either lactobacilli-prepared tampons or placebo tampons. The lactobacilli tampons were loaded with a mixture of freeze-dried L. fermentum, L. casei var. rhamnosus and L. gasseri. The cure rate was recorded after the second menstruation period. There was no improvement in the cure rate after treatment with lactobacilli-containing tampons compared to placebo tampons; the cure rates as defined by Amsel's criteria were 56% and 62%, respectively, and 55% and 63%, as defined by Nugent's criteria. This is the first study to report cure rates for women with 'intermediate' wet smear ratings according to Nugent's classification and this group had an overall cure rate of 44%. The cure rate of treatment of bacterial vaginosis was not improved by using lactobacilli-prepared tampons for one menstruation.


Two men with toxic shock syndrome presenting with targetoid and spotty skin rashes.

Acta Derm Venereol 2002; 82 (6): 449-52

Two previously healthy men who presented with hypotension, constitutional symptoms, and targetoid and discrete spotty erythematous plaques were diagnosed with toxic shock syndrome based on histopathological findings. Specifically, their biopsies revealed necrotic keratinocytes, neutrophils in the epidermis, and neutrophils surrounding dilated superficial vessels. In one case, the diagnosis of toxic shock syndrome was confirmed with rising titers to toxic shock syndrome toxin-1. Both patients recovered with supportive care and clindamycin administration. We suggest that patients with fever, hypotension, constitutional symptoms and rash should be started on clindamycin and have a skin biopsy as part of their initial evaluation. An understanding that toxic shock syndrome can strike anyone has manifold dermatological manifestations and defined histopathological findings is important for its early diagnosis and effective treatment.


Microbiological characteristics of perianal streptococcal dermatitis: a retrospective study of 105 patients in a 10-year period.

Acta Dermatovenerol Alp Pannonica Adriat 2016; 25 (4): 73-76

Beta-hemolytic streptococci (BHS) are the most common causative agents of perianal streptococcal dermatitis (PSD). This study evaluates the distribution of BHS isolates in perianal bacterial cultures. We retrospectively reviewed microbiological results for perianal BHS that were isolated in our laboratory between 2006 and 2015. We identified a total of 105 BHS isolates from rectal swabs and swabs of clinically intact perianal skin. The majority of BHS were of group A (GABHS) (73/105; 69.5%), followed by group B BHS (GBBHS) (27/105; 25.7%), and non-group A or B BHS (5/105; 4.8%). The distribution of GABHS was age-specific, with the majority of GABHS obtained from young children. All BHS isolates were susceptible to penicillin. GABHS were universally susceptible to clindamycin, whereas 1.4% were resistant to erythromycin. GBBHS were resistant to erythromycin and clindamycin in 14.8% and 7.4% of cases. In addition, we wanted to emphasize the importance of correct diagnosis of PSD. Hence, we provide a review of protocols that can decrease the time to diagnosis and treatment of PSD, reduce patients' discomfort, and prevent unnecessary diagnostic procedures.


Folliculitis decalvans of the scalp: response to triple therapy with isotretinoin, clindamycin, and prednisolone.

Acta Dermatovenerol Alp Pannonica Adriat 2006; 15 (4): 184-6

Folliculitis decalvans of the scalp is a recurrent, purulent follicular inflammation leading to scarring alopecia. We report on a 27-year-old man with folliculitis decalvans successfully treated with a combination of isotretinoin, corticosteroids, and clindamycin.


Typing of Methicillin Resistant Staphylococcus Aureus Using DNA Fingerprints by Pulsed-field Gel Electrophoresis.

Acta Inform Med 2016; 24 (4): 248-252

BACKGROUND: Methicillin resistant Staphylococcus aureus (MRSA) is responsible for a wide spectrum of nosocomial and community associated infections worldwide. The aim of this study was to analyze MRSA strains from the general population in Canton Sarajevo, B&H. METHODS: Our investigation including either phenotypic and genotypic markers such as antimicrobial resistance, pulsed-field gel electrophoresis (PFGE), SCC typing, and Panton-Valentine leukocidin (PVL) detection. RESULTS: Antimicrobial susceptibility: all MRSA isolates were resistant to the beta-lactam antibiotics tested, and all isolates were susceptible trimethoprim sulphamethoxazole, rifampicin, fusidic acid, linezolid and vancomycin. Sixty-eight per cent of the MRSA isolates were resistant to erythromycin, 5% to clindamycin, 5% to gentamicin and 4% to ciprofloxacin. After the PFGE analysis, the isolates were grouped into five similarity groups: A-E. The largest number of isolates belonged to one of two groups: C: 60 (60%) and D: 27 (27%). In both groups C and D, SCCmec type IV was predominant (60% and 88, 8%, respectively). A total of 24% of the isolates had positive expression of PVL genes, while 76% showed a statistically significantly greater negative expression of PVL genes. CONCLUSION: SCCmec type IV, together with the susceptibility profile and PFGE grouping, is considered to be typical of CA-MRSA.


Methicillin-resistant Staphylococcus aureus in North-east Croatia.

Acta Med Acad 2015; 44 (1): 10-7;

OBJECTIVE: The aim of this 5-year study was to determine the frequency and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA)-related infections at Osijek Clinical Hospital. MATERIALS AND METHODS: A total of 1987 staphylococci-infected clinical isolates were collected and analysed at the Microbiology Department of the Public Health Institute of Osijek-Baranja County. RESULTS: Between 2008 and 2012, the average rate of MRSA-related infections in staphylococci-infected patients was 27.4%. The proportion of MRSA-related infections on all Staphylococcus aureus (S. aureus) isolates from clinical specimens showed a decreasing trend, from 32.6% in 2008 to 25.5% in 2012. MRSA-related infections were mostly detected in wound swabs (50.6%) and aspirates (28.8%) of patients hospitalized in the surgical (49.8%) and intensive care units (27.9%). MRSA-related infection showed an increase compared to S. aureus-infections in samples of wounds and aspirates in 2011 and 2012 (57.9%/34.9% and 35.2%/16.3%, respectively). The majority of strains of MRSA-related infections were resistant to several antibiotics, including erythromycin and clindamycin, where susceptibility were less than 10%. All MRSA isolates were susceptible to vancomycin, teicoplanin and linezolid. Therefore, antibiotic therapies for MRSA infections include vancomycin, teicoplanin and linezolid, but microbiological diagnostics need to be performed in order to know when the use of glycopeptides and oxazolidinones is indicated. CONCLUSION: Our results suggest that appropriate prevention measures, combined with the more rational use of antibiotics are crucial to reduce the spread of MRSA-related infection in healthcare settings. Further monitoring is necessary of the incidence and antibiotic susceptibility of MRSA-related infections in our community.


Bile bacteria of patients with cholelithiasis and theirs antibiogram.

Acta Med Iran 2013; 51 (11): 779-83

To prevent post cholecystectomy infection, the most common microorganisms causing it and their antibacterial susceptibility pattern should be determined. Therefore, the aim of the present study was to determine the exact incidence and nature of the microbial flora in the bile of the patients with cholelithiasis and chronic cholecystitis as well as their antibiotic sensitivity pattern. In this study, a total of 132 samples from the patients were tested for bacterial strains using the appropriate methods for testing them. The isolated bacteria were subsequently subjected to antibacterial susceptibility test using Kirby-Bauer method. The data were analyzed using Frequency, Chi-square and t-test. Fifty of 132 (37.87%) studied patients were positive for bacteria. The most common isolated organisms were Escherichia coli (13; 26%), Enterobacteriaceae (9; 18%), and Salmonella typhi (7; 14%). The most effective antibiotics were sequentially Amikacin, Ceftriaxone, and Clindamycin. Isolating bacteria and determining their sensitivity to different antibiotics may be help physicians take prophylactic measures against postoperative infection of cholelithiasis and chronic cholecystitis.


Meningite bacteriana. Uma etiologia pouco frequente.

Acta Med Port 2011; 24 Suppl 3 (): 627-30

BACKGROUND: Meningitis is an uncommon clinical manifestation of invasive infection by Streptococcus pyogenes. CASE REPORT: A four years-old female child, previously healthy, started a history of high fever, associated to right otorrhea, prostration and vomiting. On admission she was haemodynamically stable but prostrated, with stiff neck and right otorrhea. Laboratory evaluation showed leukocytosis with neutrophilia, thrombocytosis and high C-reactive protein. The cerebrospinal fluid (CSF) examination suggested bacterial meningitis and treatment with ceftriaxone was started. After Streptococcus pyogenes grew in the CSF, clindamycin was added. She completed 15 days of antibiotics and was discharged clinically recovered. No neurological or hearing sequelae were observed. CONCLUSIONS: Although the incidence of group A streptococcal meningitis seems to be low, invasive infection by this agent is raising. Despite the excellent evolution of this case, a fatal outcome or neurological sequelae can arise, even in healthy children.


Choque toxico por streptococcus beta-hemoliticus do grupo A.

Acta Med Port 2004; 17 (5): 395-8

In the last years has been observed an increased incidence of invasive group A beta-hemolytic streptococcal infections, including the toxic shock syndrome. The most common portal of entry is the skin and mucous membranes. The toxic shock syndrome can occurred as a rare complication of pharyngitis. The association between varicella and the use of nonsteroidal antiinflammatory drugs with necrotizing fasciitis by Streptococcus pyogenes has been discussed without reach at consensus, but some authors disapproved the use of nonsteroidal antiinflammatory drugs in this viral infection. The authors reported the clinical case of a 12 year old adolescent, that 15 days after the diagnosis of mononucleosis infectious confirmed by serology and treated with ibuprofen, was internment by streptococcal toxic shock syndrome with rhabdomyolysis, hepatitis, cellulitis of the leg, arthritis of the knee and pleural effusion. Therapeutics was made with penicillin G and clindamycin. We present this case for the severity of the clinical situation and for the questions that rise.


Is the use of antibiotic-impregnated external ventricular drainage beneficial in the management of iatrogenic ventriculitis?

Acta Neurochir (Wien) 2012; 154 (1): 161-4; discussion 164

BACKGROUND: Profound evidence substantiates significantly reduced risk of catheter-related infections with prophylactic use of rifampin- and clindamycin-impregnated silicone catheters (Bactiseal((R)), Codman Johnson & Johnson, Raynham, MA, USA) for external ventricular drainage (EVD). However, whether Bactiseal((R))-EVD (B-EVD) influences the treatment of EVD-related ventriculitis remains controversial. METHODS: We performed a retrospective analysis of patients who developed ventriculitis after EVD or ventriculoperitoneal (VP) shunt placement and consequently underwent either placement of B-EVD (group 1) or a standard non-antibiotic-impregnated EVD (group 2). Analyzed parameters included demographic and clinical data, hospitalization time, time until remission of the infection parameters, detection of new bacterial resistance on antibiograms, and clinical outcome in terms of the modified Rankin scale (mRS). RESULTS: Time until remission of cerebrospinal fluid (CSF) pleocytosis was significantly longer in patients undergoing B-EVD (8 +/- 3.8 days; n = 15; group 1) than in patients who underwent standard EVD (5.1 +/- 1.8 days; n = 10; group 2). There was no significant difference between both groups for the time until polymorphonuclear cells dropped below 50% of peak value (5.8 +/- 1.6 vs. 4.1 +/- 2.9 days), CRP dropped below 10 mg/l (4.2 +/- 3.5 vs. 5.6 +/- 3.3 days), the time of plasma neutrophil remission (5.7 +/- 2.6 vs. 5.3 +/- 3.2 days) and hospitalization time (28 +/- 12.5 vs. 35 +/- 19.4 days). The mRS for both groups was 2. Development of new antibiotic resistance did not occur in either group. CONCLUSIONS: This retrospective pilot study indicates that B-EVD might have no major advantage in the management of EVD or VP-shunt-related ventriculitis. Based on published reports and the results of this study, data support only the prophylactic use of B-EVD for prevention of EVD-related infections. Prospective randomized clinical trials are warranted to further evaluate the role of B-EVD in the treatment of ventriculitis.


Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin.

Acta Orthop 2017; 88 (5): 562-567

Background and purpose - Clindamycin has not been compared with other antibiotics for prophylaxis in arthroplasty. Since 2009, the Swedish Knee Arthroplasty Register (SKAR) has been collecting information on the prophylactic antibiotic regime used at every individual operation. In Sweden, when there is allergy to penicillin, clindamycin has been the recommended alternative. We examined whether there were differences in the rate of revision due to infection depending on which antibiotic was used as systemic prophylaxis. Patients and methods - Patients who had a total knee arthroplasty (TKA) performed due to osteoarthritis (OA) during the years 2009-2015 were included in the study. Information on which antibiotic was used was available for 80,018 operations (55,530 patients). Survival statistics were used to calculate the rate of revision due to infection until the end of 2015, comparing the group of patients who received cloxacillin with those who received clindamycin as systemic prophylaxis. Results - Cloxacillin was used in 90% of the cases, clindamycin in 7%, and cephalosporins in 2%. The risk of being revised due to infection was higher when clindamycin was used than when cloxacillin was used (RR =1.5, 95% CI: 1.2-2.0; p = 0.001). There was no significant difference in the revision rate for other causes (p = 0.2). Interpretation - We advise that patients reporting allergic reaction to penicillin should have their allergic history explored. In the absence of a clear history of type-I allergic reaction (e.g. urticaria, anaphylaxis, or bronchospasm), we suggest the use of a third-generation cephalosporin instead of clindamycin as perioperative prophylaxis when undergoing a TKR. No recommendation can be given regarding patients with type-1 allergy.


Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better.

Acta Orthop 2009; 80 (6): 633-8

BACKGROUND AND PURPOSE: There are rising concerns about the frequency of infection after arthroplasty surgery. Prophylactic antibiotics are an important part of the preventive measures. As their effect is related to the timing of administration, it is important to follow how the routines with preoperative prophylactic antibiotics are working. METHODS: In 114 consecutive cases treated at our own university clinic in Lund during 2008, the time of administration of preoperative prophylactic antibiotic in relation to the start of surgery was recorded from a computerized operation report. In 291 other cases of primary total knee arthroplasty (TKA), randomly selected from the Swedish Knee Arthroplasty Register (SKAR), the type and dose of prophylactic antibiotic as well as the time of administration in relation to the inflation of a tourniquet and to the start of surgery was recorded from anesthetic records. RESULTS: 45% (95% CI: 36-54) of the patients operated in Lund and 57% (CI: 50-64) of the TKAs randomly selected from the SKAR received the preoperative antibiotic 15-45 min before the start of surgery. 53% (CI: 46-61) received antibiotics 15-45 min before inflation of a tourniquet. INTERPRETATION: The inadequate timing of prophylactic antibiotics indicates that the standards of strict antiseptic and aseptic routines in arthroplasty surgery are falling. The use of a simple checklist to ensure the surgical safety may be one way of reducing infections in arthroplasty surgery.


Espondilodiscitis por Fusobacterium nucleatum: nueva forma de diagnostico.

Acta Ortop Mex 2014; 28 (4): 248-52

Fusobacterium spp. are Gram negative anaerobe bacteria. Vertebral osteomyelitis caused by these bacteria is very unusual; in fact, we could only find 11 cases in the literature. We report the case of a male, 46 year-old patient who had had lumbar pain for several weeks that irradiated to the right leg, and did not respond to NSAID treatment. The work-up included MRI, biopsy with draining of the collection and a universal PCR followed by 16S rDNA sequencing. The latter was used to make the microbiologic diagnosis, which identified Fusobacterium nucleatum as the causative agent. Final treatment consisted of clindamycin. In conclusion, spondylodiscitis due to Fusobacterium spp. is a rare and difficult to diagnose entity, due both to its clinical characteristics and to the difficulty in making the right microbiologic diagnosis. Vertebral biopsy and molecular microbiologic techniques such as Universal PCR rDNa, are essential to identifying the organism, making the diagnosis and prescribing appropriate antibiotic therapy.


Comparison of the bacterial flora of the nasal vestibule and cavity in haemodialysis patients.

Acta Otorhinolaryngol Ital 2009; 29 (5): 251-4

Staphylococcal infections are the major causes of morbidity in haemodialysis patients. The source of the staphylococci is the anterior nares. Elimination of nasal carriage of staphylococci could result in a remarkable decrease in the infection rate. The aim of this study was to investigate if there was a difference in the bacterial flora between the nasal vestibule and cavity as well as their antibiotic susceptibility in haemodialysis. Swab samples obtained from 35 haemodialysis patients were subjected to conventional microbiological methods. The antimicrobial susceptibility test was performed for Staphylococcus spp. using cephazolin, cephaclor, trimetoprim + sulfamethoxazole, amoxicillin, oxacillin, clindamycin, erythromycin, tetracycline, ampicillin + sulbactam and amoxicillin + clavulanic acid. Staphylococcus spp. was found more often in the vestibule than in the cavity (88.5 vs. 77.1%). The effectiveness of clindamycin, erythromycin and tetracycline was particularly striking for the methicillin-resistant Staphylococcus aureus and methicillin-resistant coagulase-negative Staphylococci isolates. In conclusion, existence of difference in bacterial flora between the nasal cavity and vestibule and their responsiveness to antibacterial agents may require reconsideration of elimination of secondary infections in haemodialysis patients.


Sudden myositis of the posterior cervical muscular compartment. Case report.

Acta Otorrinolaringol Esp 2010; 61 (1): 81-4

An atypical case of deep neck infection is presented with muscular involvement as the main feature. Streptococcus pyogenes was the causal agent and abrupt haemodynamic impairment and severe systemic failure characterized its clinical course, requiring emergency surgical examination and subsequent admission to the critical care unit. After the diagnosis of streptococcal myositis was obtained and the antibiotic treatment adjusted, the patient progressively recovered completely.


Estudio del reflujo laringofaringeo mediante pH-metria en el postoperatorio inmediato de los laringectomizados.

Acta Otorrinolaringol Esp 2007; 58 (7): 284-9

OBJECTIVE: Little is known about incidence of laryngo-pharyngeal reflux (LPR) and gastroesophageal reflux (GER) in the early postoperatory period of laryngectomy. To evaluate the effect and characteristics of the LPR and GER in laryngectomized patients, by means of double pH-metry during 48 hours after surgery. MATERIAL AND METHOD: In 50 patients, 48-hour double-probe pH monitoring was performed in postoperative of laringectomy, after a intraoperatory placement. Descriptive analysis of 4 variables of pH to level of the sensor proximal, and definition of the presence of esofagic reflux and LPR. RESULTS: The incidence of LPR in the postoperatory of laringectomy ranges between 30% and 40%. A esofagic reflux has been observed in 40%. CONCLUSIONS: A high incidence of LPR and GER in the postoperatory immediate of laryngectomized patients was found.


Situacion actual de las resistencias a antibioticos en infecciones amigdalares.

Acta Otorrinolaringol Esp 2006; 57 (4): 171-5

OBJECTIVE: To obtain the main responsible organisms, its sensitivity and resistances to antibiotics in tonsillitis. MATERIAL AND METHODS: We have studied the post-surgical tonsils, carrying out a microbiologic study, its culture and sensitivity. RESULTS: The most frequent isolated organisms were Staphylococcus aureus (29.3%), followed by Streptococcus pyogenes (23.4%), and Haemophilus influenzae (12.1%). The highest resistances were for the S. aureus (penicillin 91%, erythromycin 18% and 5% to the rest of the beta-lactams), followed by H. influenzae (50% clarithromycin, 30% amoxyciIlin and 2% cephalosporins) and S. pyogenes (28% erytromycin, 10% clindamycin and 3% penicillin). CONCLUSIONS: We noticed the minimal resistance found to cephalosporins, and for this reason they appear to be the safest option, except in children under five years old, in which amoxicillin is still the first line treatment, because the causative agent is S. pyogenes, sensitive to that antibiotic.


Profilaxis antibiotica en cirugia oncologica faringolaringea: ceftriaxona versus clindamicina + gentamicina.

Acta Otorrinolaringol Esp 2001; 52 (2): 142-5

There are many papers comparing two antibiotic protocols for the profilaxis of head and neck infections after laryngeal surgery. We present one prospective and randomised study in 60 patients comparing the efficacy of two protocols. The comparison was between ceftriaxone versus the association of clindamicyn and gentamicyn. In our database we included the risk factors for infection, the surgical approach, the duration of surgery and the patient characteristics. We observed an incidence of 28% of infection, with a 23.3% in the clindamicyn + gentamicyn group and a 33.3% in the ceftriaxone group. The differences between the two groups were not statistically significant. In this study we observed a small difference between the amount of alcohol comsuption, the effectiveness of the surgical drainage, the surgical approach and the presence of wound infection. The difference was not statistical significant due to the small group of patients. The profilaxis was adequate for the total laryngectomy and cordectomy group, with a higher incidence of wound infection in patients treated with a supraglottic laryngectomy.



Acta Pol Pharm 2015; 72 (2): 253-60

Alteration of plasma lipid profile and induction of lipid peroxidation may take place due to drug effect, which may be correlated with adverse drug reactions and drug-induced toxicity. Considering this fact, the present in vivo study was carried out to evaluate the effect of clindamycin on plasma lipid profile and peroxidation parameters alone and in combination with ascorbic acid, a promising antioxidant. After administering drug and antioxidant alone and in combination in rabbit, it was found that clindamycin had mild lipid peroxidation induction and profile alteration capacity, which can be arrested on co-administration of ascorbic acid.


Susceptibility to antibiotics and biochemical properties of Desulfovibrio desulfuricans strains.

Acta Pol Pharm 2001; 58 (6): 439-45

Susceptibility to several antibiotics and biochemical properties of intestinal and soil strains of Desulfovibrio desulfuricans bacteria were investigated using the tests: ATB ANA, Sceptor Anaerobic MIC/ID and API ZYM. It was demonstrated that the D. desulfuricans strains were resistant to penicillin, cefoxitin, clindamycin, metronidazole, erythromycin, rifampicin and teicoplanin. The strains initially susceptible to imipenem became resistant to this drug following 72 h incubation with it. Of 25 analyzed antibiotics there was none that after 72 h action on the bacteria was effective in relation to all of the investigated strains. The differences in susceptibility of D. desulfuricans strains to antibiotics were not associated with the strains' biochemical properties.


Prevalence, species distribution and antimicrobial resistance patterns of methicillin-resistant staphylococci in Lithuanian pet animals.

Acta Vet Scand 2015; 57 (): 27;

BACKGROUND: The bacterial genus Staphylococcus consists of many species that causes infections in pet animals. Antimicrobial resistant staphylococci cause infections that are difficult to treat and they are important from the point of one health perspective. The aim of this study was to determine the prevalence of methicillin-resistant Staphylococcus (MRS) species, including methicillin-resistant S. aureus (MRSA) in diseased pet animals (Group A) and kennel dogs (Group B) in Lithuania and to characterize the isolates according to their antimicrobial resistance. RESULTS: Twenty-one MRS isolates were obtained from 395 clinical samples (5.3 %; CI 95 % 3.5-8.0) of Group A animals. Sixteen, four and one isolates were from dogs, cats and a pet rabbit, respectively. The mecA gene was present in 20 isolates, whereas one isolate was positive for the mecC gene. Twenty-one MRS isolates (20.0 %; CI 95 % 13.5-28.6) were obtained from the vagina of female dogs (n = 105) (Group B). All isolates carried the mecA gene. Twelve MRS species were isolated of which S. pseudintermedius was the most common (18/42) followed by S. haemolyticus (8/42) and S. lentus (4/42). MRSA was not found. All MRS strains were susceptible to vancomycin, linezolid, daptomycin and quinupristin/dalfopristin. Resistance to tetracycline (16/21), clindamycin (15/21) and erythromycin (14/21) was the most common types of resistance in Group A animals. Three isolates also demonstrated resistance to rifampin. Resistance toward gentamicin (16/21), ciprofloxacin (15/21), macrolides (15/21) and tetracycline (12/21) was the most common in kennel dogs (Group B). The most common genes encoding resistance to antimicrobials (excluding beta-lactams) in isolates from Group A pets were tetK (21/42), aph(3')-IIIa (11/42) and aac(6')-Ie-aph(2'')-Ia (9/42). CONCLUSIONS: A wide range of MRS species were found in pet animals in Lithuania. MRSA was not found.


Antimicrobial susceptibility of udder pathogens isolated from dairy herds in the west littoral region of Uruguay.

Acta Vet Scand 2002; 43 (1): 31-41

A total of 522 strains belonging to streptococci, enterococci and staphylococci isolated from sub-clinical and clinical cases of bovine mastitis from the west littoral region of Uruguay were analysed for their susceptibility to several antimicrobial agents. The susceptibility patterns were studied by agar disk diffusion methods (ADDM) and broth micro-dilution to determine the minimum inhibitory concentration (MIC). The concentration that inhibits 90% (MIC90) of the analysed strains reported in micrograms per millilitre, for Staphylococcus aureus were > 8, 8, < or = 0.5, < or = 4, < or = 1, < or = 0.5, > 64, < or = 0.25, 0.5, < or = 1 and < or = 1 to penicillin, ampicillin, oxacillin, cephalotin, gentamicin, erythromycin, oxitetracycline, enrofloxacin, trimethoprim/sulfamethoxazole, neomycin, and clindamycin, respectively. Coagulase-negative staphylococci (CNS) had different values for penicillin (4) and ampicillin (2), while the other antimicrobial agents had the same MIC90 values as reported for S. aureus. The MIC90 values for streptococci were 0.12, 0.25, < or = 4, 16, < or = 0.25, 0.5, 0.25 for penicillin, ampicillin, cephalotin, gentamicin, erythromycin, oxytetracycline and trimethoprim-sulfamethoxazole, whereas MIC90 for enterococci were 4, 4, 4, < or = 0.5, 2, > 8 for penicillin, ampicillin, gentamicin, erythromycin, oxytetracycline and trimethoprim-sulfamethoxazole, respectively. Of 336 strains of S. aureus, 160 (47.6%) were resistant to penicillin. For 41 CNS strains, 10 (27%) presented penicillin-resistance. All the streptococcal strains were susceptible to penicillin, while 3 (7%) of the 43 enteroccocal strains were resistant. Non significant statistical differences were found between the results obtained by ADDM and broth micro-dilution for classifying bacterial isolates as susceptible or resistant according to the National Committee of Clinical Laboratory Standards.


Descending necrotizing mediastinitis: 5 years of published data in Japan.

Acute Med Surg 2015; 2 (1): 1-12

Descending necrotizing mediastinitis implies infection originating from the neck, most commonly an oropharyngeal or odontogenic focus, that spreads in the cervical fascial spaces and descends into the mediastinum. Early diagnosis is essential because descending necrotizing mediastinitis can rapidly progress to septic shock and organ failure. A comprehensive review of the current data of descending necrotizing mediastinitis in Japan was carried out using PubMed and ICHUSHI from the last 5 years. The symptoms, origins, comorbid conditions, treatment modalities, complications, and survival rates were analyzed. Tonsillar and pharyngeal origin was more identified compared to odontogenic origin. More than one-third of patients were diabetic and 28% of them were not identified as having any comorbidity. Streptococcus sp. and anaerobes were most isolated, reflecting the microflora of the oral cavity. Of the broad antibiotics, carbapenem was the most used as treatment, and clindamycin was the most co-given. Mediastinal drainage approach varied widely and the optimal approach is controversial. Twenty-one patients were treated with video-assisted thoracic surgical drainage and 15 cases by percutaneous catheter drainage, whereas transcervical approach was applied in 25 patients and thoracotomy was carried out in 21 patients. The overall mortality was 5.6%. Many authors advocated that the most effective management tool is a high degree of clinical suspicion followed by prompt and adequate drainage with intensive care including hemodynamic and nutritional support and repeat computer tomographic monitoring.


Comparison effect of azithromycin gel 2% with clindamycin gel 1% in patients with acne.

Adv Biomed Res 2016; 5 (): 72

BACKGROUND: Acne vulgaris is the most common skin disease. Local and systemic antimicrobial drugs are used for its treatment. But increasing resistance of Propionibacterium acnes to antibiotics has been reported. MATERIALS AND METHODS: In a double-blind clinical trial, 40 patients with mild to moderate acne vulgaris were recruited. one side of the face was treated with Clindamycin Gel 1% and the other side with Azithromycin Topical Gel 2% BID for 8 weeks and then they were assessed. RESULTS: Average age was 21. 8 +/- 7 years. 82.5% of them were female. Average number of papules, pustules and comedones was similarly reduced in both groups and, no significant difference was observed between the two groups (P > 0.05, repeated measurs ANOVA). The mean indexes of ASI and TLC also significantly decreased during treatment in both groups, no significant difference was observed between the two groups. (P > 0.05, repeated measurs ANOVA). Also, impact of both drugs on papules and pustules was 2-3 times greater than the effect on comedones. Average satisfaction score was not significant between the two groups (P = 0.6, repeated measurs ANOVA). finally, frequency distribution of complications was not significant between the two groups (P > 0.05, Fisher Exact test). CONCLUSION: Azithromycin gel has medical impact at least similar to Clindamycin Gel in treatment of mild to moderate acne vulgaris, and it may be consider as suitable drug for resistant acne to conventional topical therapy.


Distribution of erm genes among Staphylococcus aureus isolates with inducible resistance to clindamycin in Isfahan, Iran.

Adv Biomed Res 2016; 5 (): 62

BACKGROUND: The rising frequency of methicillin resistant Staphylococcus aureus (MRSA) has led to an increased use of antibiotics such as macrolide, lincosamide, streptogramin B (MLSB) for the treatment of S. aureus infections. Resistance to MLSB in S. aureus is commonly encoded by erm genes, which can be constitutive MLSB (cMLSB) or inducible MLSB (iMLSB). The purpose of this study was to determine the frequency of cMLSB, iMLSB, and MS phenotypes using D-test and polymerase chain reaction (PCR) methods. MATERIALS AND METHODS: A total of 215 isolates of S. aureus were collected from January 2010 to May 2012 from Al-Zahra Hospital in Isfahan. PCR was performed for detection of mecA gene on all isolates using specific primers. The frequency of MLSB-resistant isolates was determined using D-test, and then a multiplex PCR was performed for detection of ermA, ermB, and ermC genes. RESULTS: Among 215 S. aureus isolates examined, 82 (40.9%) were MRSA, and iMLSB, cMLSB, and MS resistance phenotypes had a frequency of 9 (4.18%), 58 (26.9%), and 11 (5.1%), respectively. Among nine isolates with iMLSB resistance phenotype, four isolates contained ermC gene, two isolates ermB gene, and one isolate ermA gene. Two isolates did not have any erm gene. CONCLUSION: In the current study, cMLSB was the most frequent phenotype and ermC was the most common gene in iMLSB resistant phenotypes.


Thermoanalytical characterization of clindamycin-loaded intravitreal implants prepared by hot melt extrusion.

Adv Biomed Res 2015; 4 (): 147

BACKGROUND: The aim of the present study was to evaluate a non-destructive fabrication method in for the development of sustained-release poly (L, D-lactic acid)-based biodegradable clindamycin phosphate implants for the treatment of ocular toxoplasmosis. MATERIALS AND METHODS: The rod-shaped intravitreal implants with an average length of 5 mm and a diameter of 0.4 mm were evaluated for their physicochemical parameters. Scanning electron microscopy (SEM), differential scanning calorimetry (DSC), Fourier-transform infrared (FTIR), and nuclear magnetic resonance (1H NMR) studies were employed in order to study the characteristics of these formulations. RESULTS: Drug content uniformity test confirmed the uniformity in different implant batches. Furthermore, the DSC, FTIR, and 1H NMR studies proved that the fabrication process did not have any destructive effects either on the drug or on the polymer structures. CONCLUSION: These studies showed that the developed sustained-release implants could be of interest for long-term sustained intraocular delivery of clindamycin, which can provide better patient compliance and also have good potential in terms of industrial feasibility.


Design and development of intraocular polymeric implant systems for long-term controlled-release of clindamycin phosphate for toxoplasmic retinochoroiditis.

Adv Biomed Res 2015; 4 (): 32

BACKGROUND: The release of the anti-toxoplasmosis drug, clindamycin phosphate, from intraocular implants of the biodegradable polymers poly (D, L-lactic acid) (PLA) and poly (D, L-lactide-co-glycolide) (PLGA) has been studied in vitro. MATERIALS AND METHODS: The preparation of the implants was performed by a melt-extrusion method. The developed extrudates were characterized and compared in in-vitro release profiles for elucidating the drug release mechanism. The formulations containing up to 40% w/w of drug were prepared. Release data in phosphate buffer (pH 7.4) were analyzed by high performance liquid chromatography. The release kinetics were fitted to the zero-order, Higuchi's square-root, first order and the Korsmeyer-Peppas empirical equations for the estimation of various parameters of the drug release curves. Degradation of implants was also investigated morphologically with time (Scanning Electron Microscopy). RESULTS: It was observed that, the release profiles for the formulations exhibit a typical biphasic profile for bulk-eroding systems, characterized by a first phase of burst release (in first 24 hrs), followed by a phase of slower release. The duration of the secondary phase was found to be proportional to the molecular weight and monomer ratio of copolymers and also polymer-to-drug ratios. It was confirmed that Higuchi and first-order kinetics were the predominant release mechanisms than zero order kinetic. The Korsmeyer-Peppas exponent (n) ranged between 0.10 and 0.96. This value, confirmed fickian as the dominant mechanism for PLA formulations (n


Comparison of the clinical and microbiological effects of antibiotic therapy in periodontal pockets following laser treatment: An in vivo study.

Adv Clin Exp Med 2018; 27 (9): 1263-1270

BACKGROUND: Laser technology in periodontal therapy could help in reducing total bacterial count. OBJECTIVES: The aim of this study was to evaluate the effects of pocket debridement using an erbium-doped yttrium aluminium garnet laser (Er:YAG laser - ERL), scaling and root planing (SRP) with photodynamic therapy (PDT), or SRP alone. Teeth vitality and soft tissue carbonization were also assessed. MATERIAL AND METHODS: This study included 1,169 single-rooted teeth from 84 patients divided into 3 groups (n = 28). The G1 group had ERL with 40 mJ of energy, a frequency of 40 Hz and a fluence of 63.66 J/cm2. The G2 group had SRP + PDT (635 nm diode laser, 12 J of energy and irradiation time of 30 s) and a Toluidine Blue photosensitizer (PS) (application time of 60 s). The G3 group was administered SRP alone. In the 42 subjects (G1: n = 11, G2: n = 14 and G3: n = 17) with high amounts of Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Treponema denticola (Td) and Tannerella forsythia (Tf), additional 1-week antibiotic treatments with clindamycin or amoxicillin + clavulanic acid - in doses of 600 mg/day or 1000 mg/day, respectively - were prescribed 3 months after the therapy. Microbiological and clinical analyses of the probing depth (PD), recession (RC), plaque index (PI), bleeding on probing (BOP), and attachment loss (AT) were performed at baseline and at the follow-up of 3 months, 3 months and 1 week, and 6 months. RESULTS: Plaque index decreased in G1 after 3 months, 3 months and 1 week, and 6 months (p < 0.05) and was lower in G1 vs G2 after 3 months (p < 0.05). The reduction in BOP in G1 after 3 months and 1 week was higher in comparison with G2 or G3 (p < 0.02). Probing depth decreased in all groups (p < 0.05). We found a reduction in the percentage of sites with some bacteria after 3 months - Prevotella intermedia (Pi) (G1 and G2), Capnocytophaga gingivalis (Cg) and Eubacterium nucleatum (En) (G3), and after 3 months and 1 week with En, Td, Tf (G1, G2 and G3), Pi (G1 and G2), Aa, Peptostreptococcus micros (Pm), and Cg (G3), and with Pi (G1 and G2), Tf (G2), Pg, En (G2 and G3), and Pm (G3) after 6 months (p < 0.05). We observed no signs of carbonization or teeth injury. CONCLUSIONS: Scaling and root planing + PDT and ERL may be an alternative therapy for chronic periodontitis.


Micelle-Coated, Hierarchically Structured Nanofibers with Dual-Release Capability for Accelerated Wound Healing and Infection Control.

Adv Healthc Mater 2018; 7 (11): e1800132

Tailoring nanofibrous matrices-a material with much promise for wound healing applications-to simultaneously mitigate bacterial colonization and stimulate wound closure of infected wounds is highly desirable. To that end, a dual-releasing, multiscale system of biodegradable electrospun nanofibers coated with biocompatible micellar nanocarriers is reported. For wound healing, transforming growth factor-beta1 is incorporated into polycaprolactone/collagen (PCL/Coll) nanofibers via electrospinning and the myofibroblastic differentiation of human dermal fibroblasts is locally stimulated. To prevent infection, biocompatible nanocarriers of polypeptide-based block copolymer micelles are deposited onto the surfaces of PCL/Coll nanofibers using tannic acid as a binding partner. Micelle-modified fibrous scaffolds are favorable for wound healing, not only supporting the attachment and spreading of fibroblasts comparable to those on noncoated nanofibers, but also significantly enhancing fibroblast migration. Micellar coatings can be loaded with gentamicin or clindamycin and exhibit antibacterial activity as measured by Petrifilm and zone of inhibition assays as well as time-dependent reduction of cellular counts of Staphylococcus aureus cultures. Moreover, delivery time of antibiotic dosage is tunable through the application of a novel modular approach. Altogether, this system holds great promise as an infection-mitigating, cell-stimulating, biodegradable skin graft for wound management and tissue engineering.


Increasing Resistance of Coagulase-Negative Staphylococci in Total Hip Arthroplasty Infections: 278 THA-Revisions due to Infection Reported to the Norwegian Arthroplasty Register from 1993 to 2007.

Adv Orthop 2014; 2014 (): 580359

We investigated bacterial findings from intraoperative tissue samples taken during revision due to infection after total hip arthroplasty (THA). The aim was to investigate whether the susceptibility patterns changed during the period from 1993 through 2007. Reported revisions due to infection in the Norwegian Arthroplasty Register (NAR) were identified, and 10 representative hospitals in Norway were visited. All relevant information on patients reported to the NAR for a revision due to infection, including bacteriological findings, was collected from the medical records. A total of 278 revision surgeries with bacterial growth in more than 2 samples were identified and included. Differences between three 5-year time periods were tested by the chi-square test for linear trend. The most frequent isolates were coagulase-negative staphylococci (CoNS) (41%, 113/278) and Staphylococcus aureus (19%, 53/278). The proportion of CoNS resistant to the methicillin-group increased from 57% (16/28) in the first period, 1993-1997, to 84% (52/62) in the last period, 2003-2007 (P = 0.003). There was also significant increase in resistance for CoNS to cotrimoxazole, quinolones, clindamycin, and macrolides. All S. aureus isolates were sensitive to both the methicillin-group and the aminoglycosides. For the other bacteria identified no changes in susceptibility patterns were found.


Nasal Carriage Rate, Antimicrobial Susceptibility Pattern, and Associated Factors of Staphylococcus aureus with Special Emphasis on MRSA among Urban and Rural Elementary School Children in Gondar, Northwest Ethiopia: A Comparative Cross-Sectional Study.

Adv Prev Med 2018; 2018 (): 9364757

Introduction: Staphylococcus aureus is a Gram-positive, catalase-positive, and coagulase-positive bacterial species commonly found on the skin and in the nose of most healthy individuals. The anterior nares of nose are the most frequent carriage sites for S. aureus in both adults and children. Methicillin resistance among S. aureus isolates has steadily increased worldwide. Objective: The main objective of this study was to determine nasal carriage rate, antimicrobial susceptibility pattern, and associated risk factors of Staphylococcus aureus with special emphasis on MRSA among urban and rural elementary school children in Gondar, Northwest Ethiopia. Method: A community based comparative cross-sectional study was conducted on 622 urban and rural elementary school children in Gondar from January 1(st) to March 30(th), 2018. Data was collected using a questionnaire and nasal swab samples were collected by sterile cotton tip swab moistened with sterile normal saline. Collected samples were inoculated on mannitol salt agar and incubated aerobically at 37 degrees C for 24 hrs. S. aureus was confirmed by observing colony characteristics and biochemical tests. MRSA was detected using cefoxitin disc by Modified Kirby-Bauer disk diffusion technique. Finally data was entered, cleared, and checked using Epi-info version 7 and exported to SPSS version 20 for analysis. Odds ratio and logistic regression were used for statistical association. P-value


Pattern and microbiological characteristics of diabetic foot ulcers in a Nigerian tertiary hospital.

Afr Health Sci 2019; 19 (1): 1617-1627

Purpose: To determine the pattern and bacteriological characteristics of diabetic foot ulcers in patients attending a tertiary health care facility. Method: 160 Patients with Diabetes Mellitus foot syndrome were recruited, out of which 52 had diabetic foot ulcers. Relevant clinical, biochemical, and microbiological evaluations were carried out on the subjects. Data analysis was done using SPSS version 20. p value was set at <0.05. Results: 52 (32.5%) out of 160 subjects with Diabetes Mellitus Foot Syndrome (DMFS) had diabetic foot ulcers. Poor glycaemic control (mean HbA1c = 9.2 (2.7) %), and abuse of antibiotics (76.9%) characterized the subjects. Foot ulcers mainly involved the right lower limb and followed spontaneous blister formation (50%). Microbiological culture pattern was polymicrobial (71.2%); predominantly anaerobic organisms (53.3%). Gram positive and negative aerobic isolates yielded high sensitivity to common quinolones (76% - 87.8%). The gram positive and negative anaerobic isolates were highly sensitive to Clindamycin and Metronidazole respectively (80.2% - 97.8%). High sensitivity (>80%) yield for gram negative anaerobes was recorded for Imipinem and Ampicillin/Sulbactam. Conclusion: Diabetic foot ulcers (DFU) contribute about one-third of DMFS. The bacteriological isolates from these ulcers are mainly polymicrobial with high sensitivity to common antibiotics. The need for appropriate use of antibiotics should be advocated among the patients.


Inducible clindamycin resistance and nasal carriage rates of Staphylococcus aureus among healthcare workers and community members.

Afr Health Sci 2015; 15 (3): 861-7

BACKGROUND: Nasal carriage of Staphylococcus aureus is becoming an increasing problem among healthcare workers and community individuals. OBJECTIVES: To determine the prevalence of methicillin-resistant S. aureus (MRSA) nasal colonization and inducible clindamycin resistance (ICR) of S. aureus among healthcare workers at Soba University Hospital and community members in Khartoum State, Sudan. METHODS: Five hundred nasal swabs samples were collected during March 2009 to April 2010. Isolates were identified using conventional laboratory assays and MRSA determined by the disk diffusion method. The D-test was performed for detection of ICR isolates with Clinical Laboratory Standard Institute guidelines. RESULTS: Of the 114 S. aureus isolated, 20.2% represented MRSA. The occurrence of MRSA was significantly higher among healthcare worker than community individuals [32.7% (18/55) vs. 6.9% (5/59)] (p=0.001). Overall the 114 S. aureus isolates tested for ICR by D-test, 29 (25.4%) yielded inducible resistance. Significantly higher (p=0.026) ICR was detected among MRSA (43.5%) than methicillin-susceptible S. aureus (MSSA) (20.9%). CONCLUSION: MRSA nasal carriage among healthcare workers needs infection control practice in hospitals to prevent transmission of MRSA. The occurrence of ICR in S. aureus is of a great concern, D- test should be carried out routinely in our hospitals to avoid therapeutic failure.


Comparison of identification and antimicrobial resistance pattern of Staphylococcus aureus isolated from Amassoma, Bayelsa state, Nigeria.

Afr Health Sci 2015; 15 (4): 1282-8

BACKGROUND: Staphylococcus aureus is often responsible for fatal infections and recent upsurge of resistant strains has resulted in therapeutic failure. The identification of this microorganism is a major challenge to medical microbiologists in developing countries. METHODS: One hundred and eighty five isolates which had been previously isolated from the nares of 185 healthy college students' volunteers in Amassoma, Bayelsa State, South Nigeria were identified by MALDI TOF mass spectrometry, and PCR amplification of the spa gene. The identified isolates were compared with presumptive identities obtained by growth on MSA, tube coagulation and slide agglutination tests. Antimicrobial susceptibility testing of S. aureus isolates was performed by Kirby Bauer technique while MRSA was screened for by growth on chromlDTM MRSA plate and confirmed by PCR-amplification of mecA/mecC genes. RESULTS: From the 185 staphylococci that grew with yellow colonies on MSA, 24 were positive in the slide coagulase test, while 17 were positive in the tube coagulase test; MALDI TOF mass spectrometry and PCR amplification of the spa gene showed excellent concordance with the tube test, as all tube coagulase-positive strains were identified as S. aureus, while tube coagulase-test negative isolates in all cases were designated as other staphylococcal species by MALDI-TOF mass spectrometry and were spa PCR test negative. All S. aureus isolates were susceptible to clindamycin, vancomycin, fusidic acid, rifampicin and linezolid, while observed resistance to penicillin and trimethoprim were high. Only one MRSA strain was detected. CONCLUSION: The study confirms that the tube coagulase test is an accurate diagnostic method for identification of S. aureus, while growths on MSA and slide agglutination tests are inaccurate. We found a low prevalence of MRSA and a high rate of trimethroprim-resistance in the studied population.


Experimental phage therapy against haematogenous multi-drug resistant Staphylococcus aureus pneumonia in mice.

Afr J Lab Med 2016; 5 (1): 435

BACKGROUND: Community-acquired haematogenous Staphylococcus aureus pneumonia is a rare infection, though it can be acquired nosocomially. Currently, antibiotics used against S. aureus pneumonia have shown reduced efficacy. Thus, there is need for an alternative therapy against multidrug-resistant S. aureus (MDRSA) strains in the community. OBJECTIVE: We sought to determine the efficacy of environmentally-obtained S. aureus lytic phage against haematogenous MDRSA pneumonia in mice. METHODS: Phages and MDRSA were isolated from sewage samples collected within Nairobi County, Kenya. Isolated S. aureus bacteria were screened for resistance against ceftazidime, oxacillin, vancomycin, netilmicin, gentamicin, erythromycin, trimethroprim-sulfamethoxazole and cefuroxime. Thirty BALB/c mice aged six to eight weeks were randomly assigned into three groups: the MDRSA-infection group (n = 20), the phage-infection group (n = 5) and the non-infection group (n = 5). Mice were infected with either MDRSA or phage (108 CFU/mL) and treated after 72 hours with a single dose of clindamycin (8 mg/kg/bwt) or 108 PFU/mL of phage or a combination therapy (clindamycin and phage). The efficacy of phage, clindamycin or clindamycin with phage combination was determined using resolution of lung pathology and bacterial load in lung homogenates. RESULTS: The viable MDRSA count was 0.5 +/- 0.2 log10 CFU/gm in the phage-treated group, 4.4 +/- 0.2 log10 CFU/gm in the clindamycin-treated group and 4.0 +/- 0.2 log10 CFU/gm in the combination-treated group. The efficacy of phage therapy was significantly different from other therapeutic modes (p = 0 < 0.0001). Histology showed that the mice treated with phage did not develop pneumonia. CONCLUSION: Phage therapy is effective against haematogenous MDRSA infection. Thus, it can be explored as an alternative treatment method.


Clostridium difficile in a HIV-infected cohort: incidence, risk factors, and clinical outcomes.

AIDS 2013; 27 (17): 2799-807

OBJECTIVE: Clostridium difficile is the most commonly reported infectious diarrhoea in HIV-infected patients in the United States. We set out to determine the incidence, risk factors and clinical presentation of C. difficile infections (CDIs) in a cohort of HIV-infected individuals. DESIGN: We performed a nested, case-control analysis with four non-CDI controls randomly selected for each case. METHODS: We assessed the incidence of CDI in the Johns Hopkins HIV Clinical Cohort between 1 July 2003 and 31 December 2010. Incident cases were defined as first positive C. difficile cytotoxin assay or PCR for toxin B gene. We used conditional logistic regression models to assess risk factors for CDI. We abstracted data on the clinical presentation and outcomes from case chart review. RESULTS: We identified 154 incident CDI cases for an incidence of 8.3 cases per 1000 patient years. No unique clinical features of HIV-associated CDI were identified. In multivariate analysis, risk of CDI was independently increased for CD4 cell count of 50 cells/mul or less [adjusted odds ratio (AOR) 20.7, 95% confidence interval (CI) 2.8-151.4], hospital onset CDI (AOR 26.7, 95% CI 3.1-231.2) and use of clindamycin (AOR 27.6, 95% CI 2.2-339.4), fluoroquinolones (AOR 4.5, 95% CI 1.2-17.5), macrolides (AOR 6.3, 95% CI 1.8-22.1), gastric acid suppressants (AOR 3.1, 95% CI 1.4-6.9) or immunosuppressive agents (AOR 6.8, 95% CI 1.2-39.6). CONCLUSION: The incidence of CDI in HIV-infected patients was twice that previously reported. Our data show that compromised cellular immunity, as defined by CD4 cell count of 50 cells/mul or less, is a risk factor for CDI. Clinicians should be aware of the increased CDI risk, particularly in those with severe CD4 cell count suppression.


Short communication: methicillin-resistant Staphylococcus aureus infections in children and young adults infected with HIV.

AIDS Res Hum Retroviruses 2009; 25 (12): 1219-24

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) infections, in particular with Panton-Valentine leukocidin (PVL)-positive strains, has not been well characterized in children and young adults with HIV infection. It is not known if PVL-positive strains of MRSA cause an increased morbidity in this population compared to PVL-negative strains. The purpose of this study was to retrospectively analyze the epidemiology of PVL-positive and PVL-negative MRSA infections in children and young adults with HIV from 2000 to 2007. Molecular typing was performed by polymerase chain reaction (PCR) for detection of the PVL genes. Staphylococcus Cassette Chromosome (SCC) mec and spa typing were performed on all PVL-positive isolates. The number of HIV patients with MRSA infection increased significantly between 2000 and 2007 ( p=0.0015). Twenty seven (87%) of the 31 MRSA isolates were from skin and soft tissue infections (SSTI). Clindamycin resistance was observed in 19% of the MRSA isolates. PVL-positive isolates bearing the type IV SCC mec element comprised 16 of 31 (52%) MRSA isolates. All the PVL-positive isolates belonged to the USA300 pulsed-field type. There was no difference in the mean CD4 count and HIV viral load between patients with PVL-positive and PVL-negative MRSA infections. PVL-positive MRSA infections were associated with more SSTI ( p=0.043) but not with increased morbidity or a higher risk of complications compared to PVL-negative MRSA infections in children and young adults with HIV.


Methicillin-Resistant Staphylococcus aureus Infections in Human Immunodeficiency Virus-Infected Children and Adolescents.

AIDS Res Treat 2012; 2012 (): 627974

Background. Methicillin-resistant Staphylococcus aureus (MRSA) infection incidence has increased in healthy US children. Our objective was to evaluate MRSA incidence and correlates in HIV-infected youth. Methods. The CDC-sponsored LEGACY study is a US multicenter chart abstraction study of HIV-infected youth. We identified MRSA infections among participants with >/=1 visit during 2006. We used bivariate and multivariable analyses to compare sociodemographic and HIV clinical factors between MRSA cases and noncases. Results. Fourteen MRSA infections (1 invasive, 12 soft tissue, 1 indeterminate) occurred among 1,813 subjects (11.1 infections/1,000 patient-years (PY), 95% CI: 11.06-11.14). Most (86%) isolates were clindamycin susceptible. Compared with noncases, MRSA cases were more likely older (17 versus 14 years), black (100% versus 69%), behaviorally HIV infected (43% versus 17%), and in Maryland (43% versus 7%) and had viral loads (VL) >1000 copies/mL (86% versus 51%) and lower mean CD4% (18% versus 27%) (all P < 0.05). In multivariate analysis, independent risk factors were Maryland care site (adjusted odds ratio (aOR) = 9.0), VL >1000 copies/mL (aOR = 5.9), and black race (aOR undefined). Conclusions. MRSA occurred at a rate of 11.1 infections/1,000 PY in HIV-infected youth but invasive disease was uncommon. Geographic location, black race, and increased VL, but not immunosuppression, were independently associated with MRSA risk.


Meta-analysis: randomized controlled trials of clindamycin/aminoglycoside vs. beta-lactam monotherapy for the treatment of intra-abdominal infections.

Aliment Pharmacol Ther 2007; 25 (5): 537-56

AIM: To compare the effectiveness and safety of clindamycin/aminoglycoside with broad-spectrum beta-lactam monotherapy in patients with intra-abdominal infections by performing a meta-analysis of randomized controlled trials (RCTs). METHODS: The relevant 28 RCTS were retrieved from PubMed searches and reviewed by two reviewers independently. RESULTS: beta-lactam monotherapy was more effective regarding cure of the infection than clindamycin/aminoglycoside (3177 clinically evaluable patients, fixed effects model, OR = 0.67, 95% CI: 0.55-0.81). The same result was found in several subset analyses. There was no difference in all-cause mortality and attributable-to-infection mortality [2382 intention-to-treat (ITT) patients, fixed effects model, OR = 1.25, 95% CI: 0.74-2.11 and 1976 ITT patients, OR = 1.19, 95% CI: 0.59-2.41, respectively]. There was no difference regarding overall adverse events and ototoxicity (1460 ITT patients, OR = 1.05, 95% CI: 0.80-1.37, and 1404 ITT patients, OR = 3.22, 95% CI: 0.72-14.45, respectively). However, treatment with clindamycin/aminoglycoside was more likely to be associated with nephrotoxicity compared to beta-lactam (3065 ITT patients, OR = 3.7, 95% CI: 2.09-6.57). Clindamycin/aminoglycoside was less likely to be associated with antibiotic-associated diarrhoea compared to beta-lactam (3050 ITT patients, OR = 0.68, 95% CI: 0.46-1.00). CONCLUSION: The results of our meta-analysis suggest that beta-lactams are more effective in the treatment of intra-abdominal infections compared with clindamycin/aminoglycoside.

  • Abdomen (Infection)
  • *17305755*

    Acute generalized exanthematous pustulosis (AGEP) triggered by a spider bite.

    Allergol Int 2009; 58 (2): 301-3

    BACKGROUND: Acute generalized exanthematous pustulosis (AGEP) is a rare and severe cutaneous reaction usually triggered by drugs. Other causative factors such as viral infections are rarely involved. In this study, we report a case of AGEP caused by a spider bite. CASE SUMMARY: A 56-year-old woman was referred to the allergy unit after a spider bite at the left popliteal fossa, while gardening, 5 days earlier. The offending spider was captured and identified by an entomologist as belonging to the Loxosceles rufescens species. No acute reaction was observed; however, after 24 hours, due to the occurrence of typical dermonecrotic skin lesions associated with erythema and edema, Cefuroxime and Clindamycin were administered intramuscularly after medical advice was given. Almost 72 hours after the spider bite, an erythematous and partly edematous eruption appeared locally in the gluteus area bilaterally, which progressively expanded to the trunk, arms and femors. Within 24 hours dozens of small, pinhead sized, non-follicular pustules were present, mainly in the folds. The patient complained of a burning sensation of the skin in addition to pruritus; and simultaneously had a fever of 38-39 degrees C as the eruption expanded. DISCUSSION: A spider bite may represent a possible causative factor of AGEP. A spider's venom contains sphingomyelinase that stimulates the release of IL8 and GM-CSF, which are involved in AGEP pathogenesis. Whether or not the con-current use of antibiotics has an effect in AGEP appearance when combined with a spider's venom, cannot be excluded.


    In Vitro Diagnostic Testing for Antibiotic Allergy.

    Allergy Asthma Immunol Res 2017; 9 (4): 288-298;

    Allergy to antibiotics is an important worldwide problem, with an estimated prevalence of up to 10% of the population. Reaction patterns for different antibiotics have changed in accordance with consumption trends. Most of the allergic reactions to antibiotics have been reported for betalactams, followed by quinolones and macrolides and, to a lesser extent, to others, such as metronidazole clindamycin and sulfonamides. The diagnostic procedure includes a detailed clinical history, which is not always possible and can be unreliable. This is usually followed by in vivo, skin, and drug provocation tests. These are not recommended for severe, potentially lifethreaten reactions or for drugs that are known to produce a high rate of false positive results. Given the limitations of in vivo tests, in vitro test can be helpful for diagnosis, despite having suboptimal sensitivity. The most highly employed techniques for diagnosing immediate reactions to antibiotics are immunoassays and basophil activation tests, while lymphocyte transformation tests are more commonly used to diagnose non-immediate reactions. In this review, we describe different in vitro techniques employed to diagnose antibiotic allergy.


    Vaginitis: Diagnosis and Treatment.

    Am Fam Physician 2018; 97 (5): 321-329

    Vaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Bacterial vaginosis is implicated in 40% to 50% of cases when a cause is identified, with vulvovaginal candidiasis accounting for 20% to 25% and trichomoniasis for 15% to 20% of cases. Noninfectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis, are less common and account for 5% to 10% of vaginitis cases. Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing. Bacterial vaginosis is traditionally diagnosed with Amsel criteria, although Gram stain is the diagnostic standard. Newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity have similar sensitivity and specificity to Gram stain. Bacterial vaginosis is treated with oral metronidazole, intravaginal metronidazole, or intravaginal clindamycin. The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available. Culture can be helpful for the diagnosis of complicated vulvovaginal candidiasis by identifying nonalbicans strains of Candida. Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy. The Centers for Disease Control and Prevention recommends nucleic acid amplification testing for the diagnosis of trichomoniasis in symptomatic or high-risk women. Trichomoniasis is treated with oral metronidazole or tinidazole, and patients' sex partners should be treated as well. Treatment of noninfectious vaginitis should be directed at the underlying cause. Atrophic vaginitis is treated with hormonal and nonhormonal therapies. Inflammatory vaginitis may improve with topical clindamycin as well as steroid application.


    Common Questions About Streptococcal Pharyngitis.

    Am Fam Physician 2016; 94 (1): 24-31

    Group A beta-hemolytic streptococcal (GABHS) infection causes 15% to 30% of sore throats in children and 5% to 15% in adults, and is more common in the late winter and early spring. The strongest independent predictors of GABHS pharyngitis are patient age of five to 15 years, absence of cough, tender anterior cervical adenopathy, tonsillar exudates, and fever. To diagnose GABHS pharyngitis, a rapid antigen detection test should be ordered in patients with a modified Centor or FeverPAIN score of 2 or 3. First-line treatment for GABHS pharyngitis includes a 10-day course of penicillin or amoxicillin. Patients allergic to penicillin can be treated with firstgeneration cephalosporins, clindamycin, or macrolide antibiotics. Nonsteroidal anti-inflammatory drugs are more effective than acetaminophen and placebo for treatment of fever and pain associated with GABHS pharyngitis; medicated throat lozenges used every two hours are also effective. Corticosteroids provide only a small reduction in the duration of symptoms and should not be used routinely.


    Impetigo: diagnosis and treatment.

    Am Fam Physician 2014; 90 (4): 229-35

    Impetigo is the most common bacterial skin infection in children two to five years of age. There are two principal types: nonbullous (70% of cases) and bullous (30% of cases). Nonbullous impetigo, or impetigo contagiosa, is caused by Staphylococcus aureus or Streptococcus pyogenes, and is characterized by honey-colored crusts on the face and extremities. Impetigo primarily affects the skin or secondarily infects insect bites, eczema, or herpetic lesions. Bullous impetigo, which is caused exclusively by S. aureus, results in large, flaccid bullae and is more likely to affect intertriginous areas. Both types usually resolve within two to three weeks without scarring, and complications are rare, with the most serious being poststreptococcal glomerulonephritis. Treatment includes topical antibiotics such as mupirocin, retapamulin, and fusidic acid. Oral antibiotic therapy can be used for impetigo with large bullae or when topical therapy is impractical. Amoxicillin/clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, minocycline, trimethoprim/sulfamethoxazole, and macrolides are options, but penicillin is not. Natural therapies such as tea tree oil; olive, garlic, and coconut oils; and Manuka honey have been anecdotally successful, but lack sufficient evidence to recommend or dismiss them as treatment options. Treatments under development include minocycline foam and Ozenoxacin, a topical quinolone. Topical disinfectants are inferior to antibiotics and should not be used. Empiric treatment considerations have changed with the increasing prevalence of antibiotic-resistant bacteria, with methicillin-resistant S. aureus, macrolide-resistant streptococcus, and mupirocin-resistant streptococcus all documented. Fusidic acid, mupirocin, and retapamulin cover methicillin-susceptible S. aureus and streptococcal infections. Clindamycin proves helpful in suspected methicillin-resistant S. aureus infections. Trimethoprim/sulfamethoxazole covers methicillin-resistant S. aureus infection, but is inadequate for streptococcal infection.


    Prevention of perinatal group B streptococcal disease: updated CDC guideline.

    Am Fam Physician 2012; 86 (1): 59-65

    Group B streptococcus is the leading cause of early-onset neonatal sepsis in the United States. Universal screening is recommended for pregnant women at 35 to 37 weeks' gestation. The Centers for Disease Control and Prevention recently updated its guideline for the prevention of early-onset neonatal group B streptococcal disease. The new guideline contains six important changes. First, there is a recommendation to consider using sensitive nucleic acid amplification tests, rather than just routine cultures, for detection of group B streptococcus in rectal and vaginal specimens. Second, the colony count required to consider a urine specimen positive is at least 104 colony-forming units per mL. Third, the new guideline presents separate algorithms for management of preterm labor and preterm premature rupture of membranes, rather than a single algorithm for both conditions. Fourth, there are minor changes in the recommended dose of penicillin G for intrapartum chemoprophylaxis. Fifth, the guideline provides new recommendations about antibiotic regimens for women with penicillin allergy. Cefazolin is recommended for women with minor allergies. For those at serious risk of anaphylaxis, clindamycin is recommended if the organism is susceptible [corrected] and vancomycin is recommended if there is clindamycin resistance or if susceptibility is unknown. [corrected]. Finally, the new algorithm for secondary prevention of early-onset group B streptococcal disease in newborns should be applied to all infants, not only those at high risk of infection. The algorithm clarifies the extent of evaluation and duration of observation required for infants in different risk categories.



    Am Fam Physician 2011; 83 (7): 807-15

    Bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis are the most common infectious causes of vaginitis. Bacterial vaginosis occurs when the normal lactobacilli of the vagina are replaced by mostly anaerobic bacteria. Diagnosis is commonly made using the Amsel criteria, which include vaginal pH greater than 4.5, positive whiff test, milky discharge, and the presence of clue cells on microscopic examination of vaginal fluid. Oral and topical clindamycin and metronidazole are equally effective at eradicating bacterial vaginosis. Symptoms and signs of trichomoniasis are not specific; diagnosis by microscopy is more reliable. Features of trichomoniasis are trichomonads seen microscopically in saline, more leukocytes than epithelial cells, positive whiff test, and vaginal pH greater than 5.4. Any nitroimidazole drug (e.g., metronidazole) given orally as a single dose or over a longer period resolves 90 percent of trichomoniasis cases. Sex partners should be treated simultaneously. Most patients with vulvovaginal candidiasis are diagnosed by the presence of vulvar inflammation plus vaginal discharge or with microscopic examination of vaginal secretions in 10 percent potassium hydroxide solution. Vaginal pH is usually normal (4.0 to 4.5). Vulvovaginal candidiasis should be treated with one of many topical or oral antifungals, which appear to be equally effective. Rapid point-of-care tests are available to aid in accurate diagnosis of infectious vaginitis. Atrophic vaginitis, a form of vaginitis caused by estrogen deficiency, produces symptoms of vaginal dryness, itching, irritation, discharge, and dyspareunia. Both systemic and topical estrogen treatments are effective. Allergic and irritant contact forms of vaginitis can also occur.


    Skin and soft tissue infections in immunocompetent patients.

    Am Fam Physician 2010; 81 (7): 893-9

    The increasing incidence of skin and soft tissue infections requires family physicians to be familiar with the management of these conditions. Evidence of systemic infection, such as fever, tachycardia, and hypotension, is an indication for inpatient management. Urgent surgical referral is imperative for those with life-threatening or rapidly advancing infections. In patients with uncomplicated abscesses measuring less than 5 cm in diameter, surgical drainage alone is the primary therapeutic intervention. Wound irrigation using tap water has similar outcomes as irrigation using sterile water. When antimicrobials are indicated, choice of agents depends on local resistance and susceptibility patterns. In settings where suspicion of methicillin-resistant Staphylococcus aureus (MRSA) is low, beta-lactam antibiotics are the first-line treatments for uncomplicated skin and soft tissue infections without focal coalescence or trauma. When empiric coverage for MRSA is indicated and the infection is uncomplicated, oral agents, such as tetracyclines, trimethoprim/sulfamethoxazole, and clindamycin, are preferred. Vancomycin is the first-line agent for MRSA in hospitalized patients, and newer agents, such as linezolid, daptomycin, and tigecycline, should be reserved for patients who do not respond to or cannot tolerate vancomycin therapy. There are insufficient data to support eradicating the carrier state in patients with MRSA or their contacts with nasal mupirocin or antibacterial body washes. Standard infection-control precautions, including proper and frequent handwashing, are a mainstay of MRSA prevention.


    Diabetic foot infection.

    Am Fam Physician 2008; 78 (1): 71-9

    Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extremity amputation. Diabetic foot infections are classified as mild, moderate, or severe. Gram-positive bacteria, such as Staphylococcus aureus and beta-hemolytic streptococci, are the most common pathogens in previously untreated mild and moderate infection. Severe, chronic, or previously treated infections are often polymicrobial. The diagnosis of diabetic foot infection is based on the clinical signs and symptoms of local inflammation. Infected wounds should be cultured after debridement. Tissue specimens obtained by scraping the base of the ulcer with a scalpel or by wound or bone biopsy are strongly preferred to wound swabs. Imaging studies are indicated for suspected deep soft tissue purulent collections or osteomyelitis. Optimal management requires aggressive surgical debridement and wound management, effective antibiotic therapy, and correction of metabolic abnormalities (mainly hyperglycemia and arterial insufficiency). Treatment with antibiotics is not required for noninfected ulcers. Mild soft tissue infection can be treated effectively with oral antibiotics, including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be initially treated intravenously with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin. The risk of methicillin-resistant S. aureus infection should be considered when choosing a regimen. Antibiotic treatment should last from one to four weeks for soft tissue infection and six to 12 weeks for osteomyelitis and should be followed by culture-guided definitive therapy.


    Diagnosis and treatment of otitis media.

    Am Fam Physician 2007; 76 (11): 1650-8

    Diagnostic criteria for acute otitis media include rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. Fever, otalgia, headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are common, but nonspecific symptoms. Detection of middle ear effusion by pneumatic otoscopy is key in establishing the diagnosis. Observation is an acceptable option in healthy children with mild symptoms. Antibiotics are recommended in all children younger than six months, in those between six months and two years if the diagnosis is certain, and in children with severe infection. High-dosage amoxicillin (80 to 90 mg per kg per day) is recommended as first-line therapy. Macrolide antibiotics, clindamycin, and cephalosporins are alternatives in penicillin-sensitive children and in those with resistant infections. Patients who do not respond to treatment should be reassessed. Hearing and language testing is recommended in children with suspected hearing loss or persistent effusion for at least three months, and in those with developmental problems.


    Prevention of group B streptococcal disease in the newborn.

    Am Fam Physician 2005; 71 (5): 903-10

    Group B streptococcus (GBS) is a leading cause of morbidity and mortality among newborns. Universal screening for GBS among women at 35 to 37 weeks of gestation is more effective than administration of intrapartum antibiotics based on risk factors. Lower vaginal and rectal cultures for GBS are collected at 35 to 37 weeks of gestation, and routine dindamycin and erythromycin susceptibility testing is performed in women allergic to penicillin. Women with GBS bacteriuria in the current pregnancy and those who previously delivered a GBS-septic newborn are not screened but automatically receive intrapartum antibiotics. Intrapartum chemoprophylaxis is selected based on maternal allergy history and susceptibility of GBS isolates. Intravenous penicillin G is the preferred antibiotic, with ampicillin as an alternative. Penicillin G should be administered at least four hours before delivery for maximum effectiveness. Cefazolin is recommended in women allergic to penicillin who are at low risk of anaphylaxis. Clindamycin and erythromycin are options for women at high risk for anaphylaxis, and vancomycin should be used in women allergic to penicillin and whose cultures indicate resistance to clindamycin and erytbromycin or when susceptibility is unknown. Asymptomatic neonates born to GBS-colonized mothers should be observed for at least 24 hours for signs of sepsis. Newborns who appear septic should have diagnostic work-up including blood culture followed by initiation of ampicillin and gentamicin. Studies indicate that intrapartum prophylaxis of GBS carriers and selective administration of antibiotics to newborns reduce neonatal GBS sepsis by as much as 80 to 95 percent.


    Diagnosis and treatment of acne.

    Am Fam Physician 2004; 69 (9): 2123-30

    Acne can cause significant embarrassment and anxiety in affected patients. It is important for family physicians to educate patients about available treatment options and their expected outcomes. Topical retinoids, benzoyl peroxide, sulfacetamide, and azelaic acid are effective in patients with mild or moderate comedones. Topical erythromycin or clindamycin can be added in patients with mild to moderate inflammatory acne or mixed acne. A six-month course of oral erythromycin, doxycycline, tetracycline, or minocycline can be used in patients with moderate to severe inflammatory acne. A low-androgen oral contraceptive pill is effective in women with moderate to severe acne. Isotretinoin is reserved for use in the treatment of the most severe or refractory cases of inflammatory acne. Because of its poor side effect profile and teratogenicity, isotretinoin (Accutane) must by prescribed by a physician who is a registered member of the manufacturer's System to Manage Accutane-Related Teratogenicity program.


    Peritonsillar abscess: diagnosis and treatment.

    Am Fam Physician 2002; 65 (1): 93-6

    Peritonsillar abscess, the most common deep infection of the head and neck that occurs in adults, is typically formed by a combination of aerobic and anaerobic bacteria. The presenting symptoms include fever, throat pain, and trismus. Ultrasonography and computed tomographic scanning are useful in confirming a diagnosis. Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy (including penicillin, clindamycin, cephalosporins, or metronidazole) must be initiated. In advanced cases, incision and drainage or immediate tonsillectomy may be required.


    When to suspect and how to monitor babesiosis.

    Am Fam Physician 2001; 63 (10): 1969-74

    In the past decade, cases of babesiosis in humans have been reported with increasing frequency, especially in the northeastern United States. Babesia microti (in the United States) and bovine strains (in Europe) cause most infections in humans. Most cases are tick-borne, although cases of transfusion-associated and transplacental/perinatal transmission have also been reported. Factors associated with more severe disease include advanced age, previous splenectomy and immunodeficient states. Symptoms include high fever, chills, diaphoresis, weakness, anorexia and headache. Later in the course of the illness, the patient may develop jaundice. Congestive heart failure, renal failure and acute respiratory distress syndrome are the most common complications. Therapy using the combination of quinine sulfate and clindamycin was the most commonly used treatment; however, atovaquone suspension plus azithromycin was recently reported an equally effective and less toxic therapy. Exchange transfusion, together with antibabesial chemotherapy, may be necessary in critically ill patients.


    Drug treatment of common STDs: Part II. Vaginal infections, pelvic inflammatory disease and genital warts.

    Am Fam Physician 1999; 60 (6): 1716-22

    The Centers for Disease Control and Prevention (CDC) released new guidelines for the treatment of sexually transmitted diseases (STDs) in 1998. Several treatment advances have been made since the previous guidelines were published. Part II of this two-part series on STDs describes recommendations for the treatment of diseases characterized by vaginal discharge, pelvic inflammatory disease, epididymitis, human papillomavirus infection, proctitis, proctocolitis, enteritis and ectoparasitic diseases. Single-dose therapies are recommended for the treatment of several of these diseases. A single 1-g dose of oral azithromycin is as effective as a seven-day course of oral doxycycline, 100 mg twice a day, for the treatment of chlamydial infection. Erythromycin and ofloxacin are alternative agents. Four single-dose therapies are now recommended for the management of uncomplicated gonococcal infections, including 400 mg of cefixime, 500 mg of ciprofloxacin, 125 mg of ceftriaxone or 400 mg of ofloxacin. Advances in the treatment of bacterial vaginosis also have been made. A seven-day course of oral metronidazole is still recommended for the treatment of bacterial vaginosis in pregnant women, but intravaginal clindamycin cream and metronidazole gel are now recommended in nonpregnant women. Single-dose therapy with 150 mg of oral fluconazole is a recommended treatment for vulvovaginal candidiasis. Two new topical treatments, podofilox and imiquimod, are available for patient self-administration to treat human papillomavirus infection. Permethrin cream is now the preferred agent for the treatment of pediculosis pubis and scabies.


    Bacterial vaginosis: an update.

    Am Fam Physician 1998; 57 (6): 1285-9, 1291

    Bacterial vaginosis is the most common cause of vaginal discharge. Recent studies have confirmed its association with pelvic inflammatory disease and adverse pregnancy outcomes. Bacterial vaginosis is treated with oral metronidazole (given either as a single dose or a seven-day course) or clindamycin. Treatment with topical clindamycin or metronidazole is also effective in returning the vaginal flora to normal but may be less effective in preventing the increased incidence of adverse pregnancy outcomes.


    Prevention of neonatal group B streptococcal infection.

    Am Fam Physician 1998; 57 (11): 2713-20, 2725

    Neonatal group B streptococcal infection is the primary cause of neonatal morbidity related to infection. It can often be prevented by identifying and treating pregnant women who carry group B streptococci or who are at highest risk of transmitting the bacteria to newborns. Increasing evidence and expert opinion support intrapartum treatment of women at relatively high risk of delivering an infant with group B streptococcal infection. Such women can be identified through the use of an anogenital culture for group B streptococci obtained at 35 to 37 weeks of gestation and by the presence of at least one of many risk factors associated with neonatal infection. These risk factors include preterm labor or rupture of the membranes at less than 37 weeks of gestation, previous delivery of an infant with invasive group B streptococcal disease, group B streptococcal bacteriuria during the present pregnancy, maternal intrapartum fever of 38 degrees C (100.4 degrees F) or higher and rupture of the fetal membranes for 18 hours or more. The recommended agent for intrapartum chemoprophylaxis is intravenous penicillin G; clindamycin is used in penicillin-allergic women. The use of risk markers alone to guide the administration of intrapartum antibiotics is much more cost-effective than other preventive strategies, but it exposes more women and infants to antibiotic-associated risks. Management of the infants of treated mothers is empiric and is currently guided by expert opinion.


    Preventing bacterial endocarditis: American Heart Association guidelines.

    Am Fam Physician 1998; 57 (3): 457-68

    The American Heart Association recently revised its guidelines for the prevention of bacterial endocarditis. These guidelines are meant to aid physicians, dentists and other health care providers, but they are not intended to define the standard of care or to serve as a substitute for clinical judgment. In the guidelines, cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on the potential outcome if endocarditis develops. Procedures that may cause bacteremia and for which prophylaxis is recommended are clearly specified. In addition, an algorithm has been developed to more clearly define when prophylaxis is recommended in patients with mitral valve prolapse. For oral and dental procedures, the standard prophylactic regimen is a single dose of oral amoxicillin (2 g in adults and 50 mg per kg in children), but a follow-up dose is no longer recommended. Clindamycin and other alternatives are recommended for use in patients who are allergic to penicillin. For gastrointestinal and genitourinary procedures, the prophylactic regimens have been simplified. The new recommendations are meant to more clearly define when prophylaxis is or is not recommended, to improve compliance, to reduce cost and the incidence of gastrointestinal side effects, and to approach more uniform worldwide recommendations.


    Clindamycin: An Unusual Cause of Acute Kidney Injury.

    Am J Case Rep 2019; 20 (): 248-251

    BACKGROUND Medications are one of the most common causes of acute kidney injury (AKI). Elderly patients with diabetes mellitus and chronic kidney disease seem to be at particularly high risk for development of medication-induced AKI. Among antibiotics, the most commonly implicated agents are aminoglycosides, cephalosporins, trimethoprim-sulfamethoxazole, acyclovir, and amphotericin. Despite its widespread use, clindamycin has been rarely associated with AKI. CASE REPORT A 52-year-old male patient with type II insulin dependent diabetes mellitus without diabetic nephropathy was treated with clindamycin for chronic osteomyelitis. Five days following initiation of therapy, he developed nausea, poor appetite, decrease in urine output, and profound generalized weakness. His symptoms were initially attributed to gastrointestinal side effects of clindamycin and he was advised to take it with food and to hydrate himself vigorously. Despite this change, his symptoms progressed and he developed hematuria and AKI which prompted hospital admission. Extensive workup for AKI that included evaluation for pre-renal, intrinsic renal, and post-renal etiologies failed to point to other etiologies apart from clindamycin-induced AKI. Following cessation of medication and temporary renal replacement therapy (RRT), his renal function returned to baseline. CONCLUSIONS We present a case of clindamycin-induced AKI that was diagnosed after a delay due to uremia symptoms being mistakenly attributed to gastrointestinal side effects of clindamycin. Although rare, clindamycin can be a cause of AKI and clinician should be aware of this association in order to recognize and treat it in timely manner.


    A Case of Levo fl oxacin-Induced Hepatotoxicity.

    Am J Case Rep 2018; 19 (): 272-276

    BACKGROUND Levo fl oxacin covers a broad spectrum of pathogens and is readily prescribed by clinicians. Hepatotoxicity is a known but unusual complication of levo fl oxacin use. Here, we present a case of severe transaminitis caused by levofloxacin. CASE REPORT A young man in his thirties with a history of asthma, chronic alcoholism, methamphetamine intravenous drug abuse (IVDA), and non-compliant insulin-dependent diabetes mellitus (IDDM) presented to an emergency department with suicidal ideation. Vital signs were stable and the patient was noted to have cellulitis of the right forearm, for which cultures were drawn, and he received IV clindamycin. He was admitted to behavioral medicine for further care. Blood cultures were positive for gram-negative rods and he was transferred to the medicine ward. Cultures eventually grew Brevundimonas diminuta. Clindamycin was discontinued and he was started on levofloxacin. Transaminase levels measured soon after levo fl oxacin administration showed aminotransferase levels raised to approximately 50 times baseline within a few days. Levo fl oxacin was discontinued due to concern about drug-induced hepatotoxicity. After discontinuation, transaminase levels decreased immediately. Work-up for other causes of transaminitis revealed no other etiology. CONCLUSIONS Clinicians should remain mindful that levo fl oxacin can induce hepatotoxicity in rare cases. In patients presenting with acute liver injury who have recently taken levo fl oxacin, it would be wise to remain cognizant of the possibility of levo fl oxacin-induced hepatotoxicity.


    When Epidemiology Is the Clue to a Positive Outcome: A Case of Malaria During Pregnancy.

    Am J Case Rep 2018; 19 (): 128-132

    BACKGROUND Malaria infection during pregnancy is associated with increased perinatal and maternal morbidity and mortality. CASE REPORT A 29-year-old primigravida at 37 weeks of gestation, with no significant medical history, presented complaining of fever, chills, and generalized body aches. She had been living in Malawi for 1 year and was on atovaquone/proguanil prophylaxis until she was found to be pregnant. Prophylaxis was changed to mefloquine and discontinued upon her return to the US. Six weeks prior to presentation, she traveled to Malawi for 1 month when she was off prophylaxis. On admission, vital signs and physical exam results were normal. Given epidemiologic findings, a malaria smear was performed and showed 4% parasitemia. She was treated with mefloquine and discharged. Two days after discharge, she again presented with fever, chills, and body aches. A malaria smear showed <0.01% parasitemia, with 2 ring forms. Serologies for dengue, chikungunya, leptospira, and blood cultures were negative. These symptoms were deemed secondary to early recrudescence. The species was later identified as P. falciparum. The patient was treated with quinine sulfate and clindamycin. She delivered at full term without complication. CONCLUSIONS Pregnant women are more susceptible to severe forms of malaria, such as P. falciparum. A high index of suspicion and early identification of malaria are vital to prevent deleterious outcomes.


    Chromobacterium Violaceum Sepsis: Rethinking Conventional Therapy to Improve Outcome.

    Am J Case Rep 2015; 16 (): 740-4

    BACKGROUND: Chromobacterium violaceum (C. violaceum) is a facultative anaerobic gram-negative bacterium found in soil and water, especially in tropical and subtropical areas. Although infection in humans is rare, it is associated with significant morbidity. The bacterium is known for its resistance to multiple antimicrobials, and the possibility of relapse and reinfection. Presence of bacteremia, disseminated infection, and ineffective antimicrobial agents are predictors of mortality. CASE REPORT: We report the case of a previously healthy 11-year-old male with C. violaceum sepsis who was exposed to stagnant water. He presented with severe septic shock and developed multi-organ system failure. Initial presumptive diagnosis was staphylococcal infection secondary to presence of skin abscesses resulting in antibiotic coverage with vancomycin, clindamycin, nafcillin and ceftriaxone. He also had multiple lung and liver abscesses. Once C. violaceum was identified, he received meropenem and ciprofloxacin, and was later discharged on ertapenem and trimethoprim-sulfamethoxazole (TMP-SMX) to complete a total of six months of antibiotics. He was diagnosed with chronic granulomatous disease (CGD) and is currently on prophylactic TMP-SMX and itraconazole. He has not had any relapses since his initial presentation. CONCLUSIONS: This case highlights the importance of considering C. violaceum as a relevant human pathogen, and considering it early in temperate regions, particularly in cases of fulminant sepsis associated with multi-organ abscesses. Once C. violaceum is identified, appropriate antimicrobial therapy should be started promptly, and sufficient duration of treatment is necessary for successful therapy.


    Acute generalized exanthematous pustulosis with multiple organ dysfunction syndrome.

    Am J Crit Care 2013; 22 (3): 270-3

    Acute generalized exanthematous pustulosis is a rare condition characterized by sterile pustules on erythematous and edematous tissue. Mostly drug induced, this condition can also be caused by other factors. Cases due to vancomycin are rare. A 67-year-old woman with cellulitis of the left lower extremity was admitted with marked bilateral lymphedema of the lower extremities and diffuse erythema of the left lower extremity from foot to knee. She was given clindamycin and then vancomycin. On day 5, her condition worsened, with erythema involving the entire back. Although treatment with clindamycin and vancomycin was discontinued, acute generalized exanthematous pustulosis developed. After successful treatment of other complications, the skin condition improved. Because vancomycin is frequently used, clinicians should be aware of the possibility of acute generalized exanthematous pustulosis. Because the pustulosis decreases after withdrawal of the causative drug, being able to diagnose and differentiate the abnormality from other conditions is prudent.


    Antibiotic resistance in Staphylococcus aureus-containing cutaneous abscesses of patients with HIV.

    Am J Emerg Med 2009; 27 (3): 344-7

    PURPOSE: The aim of this study was to document the resistance patterns found in exudates from cutaneous abscesses of HIV-infected persons. BASIC PROCEDURES: Patient records were reviewed on 93 culture and sensitivity tests performed on exudates taken from incised and drained abscesses of HIV-infected persons. MAIN FINDINGS: Of the specimens, 84.6% were Staphylococcus aureus. Of these, 93.5% were penicillin resistant, 87% oxacillin resistant, 84.4% cephazolin resistant, 84.4% erythromycin resistant, 52.2% ciprofloxacin resistant, and 15.6% tetracycline resistant. Fifty-eight specimens were tested for clindamycin with 29.3% found resistant; 85.7% were methicillin-resistant S aureus (MRSA) (defined as resistant to both penicillin G and oxacillin). All specimens were resistant to multiple antibiotics including antimicrobials that might be considered for use in MRSA. No specimens were resistant to trimethoprim-sulfamethoxazole, rifampin, or vancomycin. CONCLUSIONS: Empiric antimicrobial therapy of HIV-infected persons with cutaneous abscesses must be tailored to the high frequency of antimicrobial drug resistance including MRSA in this population.


    Osteonecrosis of the jaw associated with pamidronate therapy.

    Am J Hematol 2006; 81 (1): 73-5

    Bisphosphonates are commonly used in the treatment and prevention of osteoporosis, and they are also an important therapeutic adjunct in multiple myeloma and other cancers metastatic to bone. Bisphosphonates are generally well tolerated and associated with minimal adverse effects; however, there exists a growing concern that intravenous bisphosphonate use is associated with osteonecrosis of the jaw (ONJ). We report the occurrence of osteonecrosis of the jaw associated with pamidronate therapy in 12 patients diagnosed with multiple myeloma, breast carcinoma, or renal cell carcinoma, all involving bone. At the onset of jaw osteonecrosis, pamidronate therapy was the single medication common to all 12 patients. The duration of therapy varied from 12 to 77 months before osteonecrosis was observed; 92% (11/12) of cases involved the posterior mandible and all cases have been refractory to a variety of medical therapies, including surgical debridement and systemic antibiotics. Available tissue biopsies revealed inflammation consistent with osteomyelitis. In one biopsy, Actinomyces spp. were recovered from culture, but treatment with an extended course of clindamycin conferred no clinical benefit. The persistence of exposed bone remains a significant source of morbidity and pain for each surviving patient. Discontinuation of pamidronate therapy has not helped reverse the presence of osteonecrosis, and surgical manipulation of the involved site appears to worsen the underlying bone pathology. ONJ is an important adverse outcome associated with bisphosphonate therapy, and physicians prescribing pamidronate or zoledronate must be aware of the association between these drugs and this serious clinical entity. Failure to recognize the signs of ONJ can lead to unnecessary surgical procedures, which ultimately exacerbate the condition and impact quality of life. The unremitting nature of this clinical development, and the long-lasting morbidity associated with it suggests that patients should be counseled regarding the possible occurrence of ONJ prior to initiating therapy with pamidronate.


    Preferred treatment and prevention strategies for recurrent community-associated methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: a survey of adult and pediatric providers.

    Am J Infect Control 2010; 38 (4): 324-8

    Among pediatric and adult providers, 70% preferred trimethoprim-sulfamethoxazole for directed treatment of community-associated methicillin-resistant Staphylococcus aureus skin and soft-tissue infections, although a higher proportion of pediatric compared with adult providers favored clindamycin (36% vs 8%, respectively, P < .0001). For recurrent infections, 88% of providers employed at least 1 topical decolonization strategy.


    Serious bleeding events due to warfarin and antibiotic co-prescription in a cohort of veterans.

    Am J Med 2014; 127 (7): 657-663.e2;

    BACKGROUND: Antibiotics may interact with warfarin, increasing the risk for significant bleeding events. METHODS: This is a retrospective cohort study of veterans who were prescribed warfarin for 30 days without interruption through the US Department of Veterans Affairs between October 1, 2002 and September 1, 2008. Antibiotics considered to be high risk for interaction with warfarin include: trimethoprim/sulfamethoxazole (TMP/SMX), ciprofloxacin, levofloxacin, metronidazole, fluconazole, azithromycin, and clarithromycin. Low-risk antibiotics include clindamycin and cephalexin. Risk of bleeding event within 30 days of antibiotic exposure was measured using Cox proportional hazards regression, adjusted for demographic characteristics, comorbid conditions, and receipt of other medications interacting with warfarin. RESULTS: A total of 22,272 patients met inclusion criteria, with 14,078 and 8194 receiving high- and low-risk antibiotics, respectively. There were 93 and 36 bleeding events in the high- and low-risk groups, respectively. Receipt of a high-risk antibiotic (hazard ratio [HR] 1.48; 95% confidence interval [CI], 1.00-2.19) and azithromycin (HR 1.93; 95% CI, 1.13-3.30) were associated with increased risk of bleeding as a primary diagnosis. TMP/SMX (HR 2.09; 95% CI, 1.45-3.02), ciprofloxacin (HR 1.87; 95% CI, 1.42-2.50), levofloxacin (HR 1.77; 95% CI, 1.22-2.50), azithromycin (HR 1.64; 95% CI, 1.16-2.33), and clarithromycin (HR 2.40; 95% CI, 1.16-4.94) were associated with serious bleeding as a primary or secondary diagnosis. International normalized ratio (INR) alterations were common; 9.7% of patients prescribed fluconazole had INR value >6. Patients who had INR performed within 3-14 days of co-prescription were at a decreased risk of serious bleeding (HR 0.61; 95% CI, 0.42-0.88). CONCLUSIONS: Warfarin users who are prescribed high-risk antibiotics are at higher risk for serious bleeding events. Early INR evaluation may mitigate this risk.


    Clindamycin-induced acute kidney injury: large biopsy case series.

    Am J Nephrol 2013; 38 (3): 179-83

    BACKGROUND: While clindamycin-induced acute kidney injury (AKI) is uncommon, it has occurred more frequently in recent years. SUMMARY: We investigated 24 patients diagnosed with clindamycin-induced AKI retrospectively. The dosage of clindamycin was 1.0-1.5 g/day. Fifteen patients had episodes of gross hematuria, but fever, skin rash and eosinophilia were rare. Urine analysis revealed mild proteinuria and severe tubular dysfunction. Twenty-three patients were diagnosed with AKI stage 3 upon admission. The clindamycin lymphocyte transformation assay was positive for 63.2% of the patients. Acute interstitial nephritis (AIN) and acute tubular necrosis (ATN) were proven by renal biopsy, and renal insufficiency appeared to result from tubular toxicity and drug crystals. In the majority (87.5%) of the patients, AKI was severe and required renal replacement therapy, but all of their renal function recovered significantly 2 months after discharge. Clindamycin-induced AKI is largely reversible and has episodes of gross hematuria. Renal biopsies confirmed AIN or ATN in these patients.


    Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and metaanalysis.

    Am J Obstet Gynecol 2011; 205 (3): 177-90

    The purpose of this study was to determine whether the administration of clindamycin to women with abnormal vaginal flora at <22 weeks of gestation reduces the risk of preterm birth and late miscarriage. We conducted a systematic review and metaanalysis of randomized controlled trials of the early administration of clindamycin to women with abnormal vaginal flora at <22 weeks of gestation. Five trials that comprised 2346 women were included. Clindamycin that was administered at <22 weeks of gestation was associated with a significantly reduced risk of preterm birth at <37 weeks of gestation and late miscarriage. There were no overall differences in the risk of preterm birth at <33 weeks of gestation, low birthweight, very low birthweight, admission to neonatal intensive care unit, stillbirth, peripartum infection, and adverse effects. Clindamycin in early pregnancy in women with abnormal vaginal flora reduces the risk of spontaneous preterm birth at <37 weeks of gestation and late miscarriage. There is evidence to justify further randomized controlled trials of clindamycin for the prevention of preterm birth. However, a deeper understanding of the vaginal microbiome, mucosal immunity, and the biology of BV will be needed to inform the design of such trials.


    A diagnosis of Stevens-Johnson Syndrome (SJS) in a patient presenting with superficial keratitis.

    Am J Ophthalmol Case Rep 2018; 11 (): 167-169

    Purpose: To describe a case of Stevens-Johnson syndrome (SJS) diagnosed in a patient presenting with primarily ocular findings where SJS had not been initially suspected. Observations: A 23-year-old female presented with a 2 day history of bilateral eye pain, conjunctival injection, decreased visual acuity, and photophobia in the context of a 4 day history of fever, headache, and sore throat. She was found to have bilateral superficial keratitis and treated for suspected early infectious keratitis secondary to extended contact lens wear. She returned the next day with worsening visual symptoms, a new macular rash over her upper torso, and new ulcerating lesions over her buccal and perioral tissue. The patient was diagnosed with SJS. She was successfully treated using systemic cyclosporine with antibiotics and steroid eye drops. Conclusions and importance: Ophthalmologists may be the first physicians to diagnose SJS, a life-threatening condition that can initially present with non-specific viral prodromal symptoms and ocular signs alone. This case emphasizes the importance of considering a patient's entire clinical history, especially when the presentation is atypical and the diagnosis is not obviously apparent.


    Congenital Plasmodium falciparum Malaria in Washington, DC.

    Am J Trop Med Hyg 2017; 96 (1): 167-169;

    Congenital malaria is rare in the United States, but is an important diagnosis to consider when evaluating febrile infants. Herein, we describe a case of congenital Plasmodium falciparum malaria in a 2-week-old infant born in the United States to a mother who had emigrated from Nigeria 3 months before delivery.


    Antimicrobial Disk Susceptibility Testing of Leptospira spp. Using Leptospira Vanaporn Wuthiekanun (LVW) Agar.

    Am J Trop Med Hyg 2015; 93 (2): 241-243

    Leptospira Vanaporn Wuthiekanun (LVW) agar was used to develop a disk diffusion assay for Leptospira spp. Ten pathogenic Leptospira isolates were tested, all of which were susceptible to 17 antimicrobial agents (amoxicillin/clavulanic acid, amoxicillin, azithromycin, cefoxitin, ceftazidime, ceftriaxone, chloramphenicol, ciprofloxacin, clindamycin, doripenem, doxycycline, gentamicin, linezolid, nitrofurantoin, penicillin, piperacillin/tazobactam, and tetracycline). All 10 isolates had no zone of growth inhibition for four antimicrobials (fosfomycin, nalidixic acid, rifampicin, and trimethoprim/sulfamethoxazole). Of the ten Leptospira, seven had a growth inhibition zone of


    Nasal carriage of resistant Staphylococcus aureus in a medical student community.

    An Acad Bras Cienc 2016; 88 (3): 1501-9

    Staphylococcus aureus can cause a variety of infections due to its high transmissibility, high pathogenic potential and resistance to multiple drugs, factors that contribute to the relevance of infections in healthcare services. The aim of this study was to document phenotypic and genotypic resistance factors of Staphylococcus aureus strains, isolated from nasal mucosa of medical students. A nasal swab was collected from the nares (nostrils) of 222 medical students. After collection, the samples were submitted to isolation and identification procedures. From 204 valid samples, 20.6% (42 samples) were positive for S. aureus. For the assessment of phenotypic resistance by disk-diffusion technique, from 42 samples, 95.2% showed resistance to erythromycin, 42.8% to clindamycin, 16.6% to cephoxitin and 9.5% to oxacillin. The D test showed that 26.2% of samples were resistant to macrolides, lincosamides and streptogramin B. A PCR assay allowed for the evaluation of a genotypic resistance profile, in which 16.6% of the samples were positive for the mecA gene, 35.7% positive for the ermC gene or ermA gene and 28.5% were positive for both genes. These results demonstrate that medical students can enter the healthcare service previously colonized by multidrug resistant strains and become potential spreaders in the hospital environment.


    Antibiotic resistance and enterotoxin genes in Staphylococcus sp. isolates from polluted water in Southern Brazil.

    An Acad Bras Cienc 2014; 86 (4): 1813-20

    The aim of this study was to evaluate the species distribution, antibiotic-resistance profile and presence of enterotoxin (SE) genes in staphylococci isolated from the Diluvio stream in South Brazil. Eighty-eight staphylococci were identified, 93.18% were identified as coagulase-negative (CNS) and 6.82% coagulase-positive (CPS). Fourteen Staphylococcus species were detected and the most frequently were Staphylococcus cohnii (30.48%) and S. haemolyticus (21.95%). Resistance to erythromycin was verified in 37.50% of the strains, followed by 27.27% to penicillin, 12.50% to clindamycin, 6.81% to trimethoprim-sulfamethoxazole, 5.68% to chloramphenicol and 2.27% to norfloxacin. None of the investigated strains showed gentamicin and ciprofloxacin resistance. The strains were tested for the presence of sea, seb, sec, sed and see genes by PCR and only CNS strains (43.18%) showed positive results to one or more SE genes. The scientific importance of our results is due to the lack of data about these topics in polluted waters in Brazil. In conclusion, polluted waters from the Diluvio stream may constitute a reservoir for disseminating antibiotic-resistance and enterotoxin into the community. In addition, the detection of staphylococci in the polluted waters of the Diluvio stream indicated a situation of environmental contamination and poor sanitation conditions.


    Antimicrobial resistance profile of Staphylococcus aureus isolates obtained from skin and soft tissue infections of outpatients from a university hospital in Recife -PE, Brazil.

    An Bras Dermatol 2012; 87 (6): 857-61

    BACKGROUND: Staphylococcus aureus has a notable ability to acquire resistance to antibiotics, and methicillin resistance represents a growing public health problem. Methicillin-resistant S. aureus (MRSA) has also become important outside the hospital environment, particularly in the United States. In Brazil, since 2005, cases of community skin infections caused by MRSA have been reported, but resistance studies involving outpatients are scarce. OBJECTIVE: To know the resistance profile of S. aureus involved in skin and soft tissue infections of patients seen at the Dermatology outpatient clinic of a university hospital in Recife, Pernambuco State, northeastern Brazil. METHODS: Prospective study involving 30 patients with skin and soft tissue infections, seen at the Dermatology outpatient clinic from May until November 2011. To evaluate the susceptibility of S. aureus to antibiotics, the disk diffusion method and oxacillin screening agar were used. RESULTS: From a total of 30 samples of skin lesions, 19 (63%) had positive culture for S. aureus. The following resistance patterns of S. aureus were observed: penicillin, 95%; tetracycline, 32%; erythromycin, 21%; gentamicin, 16%; cefoxitin, 11%; oxacillin, 11%; trimethoprim-sulfamethoxazole, 11%; chloramphenicol, 11%; clindamycin, 5% ; and ciprofloxacin, 0%. One of the identified MRSA was obtained from a patient without risk factors for its acquisition, and was resistant, beyond to the beta-lactams, only to tetracycline. CONCLUSIONS: With regard to the resistance patterns of S. aureus, resistances to tetracycline, erythromycin and gentamicin were the highest. It was documented, for the first time in Pernambuco, a case of skin infection caused by community-associated MRSA.


    Efficacy of topical combination of benzoyl peroxide 5% and clindamycin 1% for the treatment of progressive macular hypomelanosis: a randomized, doubleblind, placebo-controlled trial.

    An Bras Dermatol 2011; 86 (1): 50-4

    BACKGROUND: Progressive macular hypomelanosis is a dermatosis without definite etiology. There is no consensus or first-line therapy in the treatment of progressive macular hypomelanosis, and the treatment options used are very little effective. OBJECTIVE: To evaluate the therapeutic efficacy of the topical combination of benzoyl peroxide 5% and clindamycin 1% associated with sun exposure for the treatment of progressive macular hypomelanosis. MATERIALS AND METHODS: This is a randomized, double-blind, placebo-controlled study in which patients were divided into two groups. Group A used the topical combination of benzoyl peroxide 5% and clindamycin 1% and Group B used gel cream as a placebo. Patients were advised to expose themselves to the sun on a daily basis and were systematically evaluated and photographed. The collected data were entered and analyzed using Epi Info. A p value < 0.05 was considered statistically significant. RESULTS: Out of the 23 patients included in the study, 13 were in group A and 10 in group B. Eleven patients (85%) in group A had significant clinical improvement and only two patients (20%) in group B showed an equivalent clinical improvement (p = 0.003). Side effects were more frequent in group A (p = 0.003). CONCLUSION: The topical combination of benzoyl peroxide 5% and clindamycin 1% is effective in the treatment of progressive macular hypomelanosis.


    Documento de consenso SEIP-AEPAP-SEPEAP sobre la etiologia, el diagnostico y el tratamiento de las infecciones cutaneas bacterianas de manejo ambulatorio.

    An Pediatr (Barc) 2016; 84 (2): 121.e1-121.e10

    Skin infections are a common cause for dermatological consultations in the paediatric setting. A review is presented of the clinical manifestations, diagnosis and treatment of the main bacterial skin infections, as well as the diagnosis and treatment of super-infected puncture and bite wounds. The most prevalent bacteria in skin infections are Staphylococcus aureus and Streptococcus pyogenes. Treatment is usually empirical, since microbiological studies are only recommended under certain circumstances or lack of improvement with common therapies. Superficial skin infections can be treated with local antiseptics or antibiotics (mupirocin or fusidic acid). Systemic treatment is usually reserved for patients with extensive or severe disease or with other risk factors. Systemic treatment depends on the suspected infecting bacteria, with penicillin, amoxicillin, amoxicillin-clavulanic acid and first or second generation cephalosporin being the most frequently used drugs. Due to the low incidence of community-acquired methicillin-resistant infection by S. aureus in Spain, the use of clindamycin or co-trimoxazole is only recommended after severe disease, relapses or a clear epidemiological background.


    Utilidad de una tecnica antigenica rapida en el diagnostico de faringoamigdalitis por Streptococcus pyogenes.

    An Pediatr (Barc) 2012; 77 (3): 193-9

    INTRODUCTION: Streptococcus pyogenes is the most frequent bacterial cause of acute tonsillopharyngitis. The validity of the rapid antigen test was analysed for its diagnosis in a Paediatric Primary Care setting. The clinical profile with better diagnostic yield was also identified. The unnecessary use of antibiotics was quantified when the rapid antigen test or only the clinical diagnosis was used. The sensitivity of the assay to penicillin, erythromycin and clindamycin was also determined. PATIENTS AND METHODS: Cross-sectional study was conducted on children between 2 to 14 years with acute tonsillitis and/or pharyngitis seen in five Primary Care Centres, from January 2008 to May 2010. After a clinical diagnosis, two swabs were taken for pharyngotonsillar smears: the first was used for a rapid antigen test, and the second one for a culture and a study of antibiotic sensitivity, with its analysis being blind to the rapid test result. A total sample of 546 consecutive was envisaged and with consecutive sampling. RESULTS: A total 192 patients were included. The prevalence of Streptococcus pyogenes was 38.7% (95% CI: 31.4-45.7). Odynophagia and scarlatiniform rash were most likely with positive cultures, the Streptococcus pyogenes was sensitive to penicillin in 100%, to erythromycin in 97.3% and to clindamycin in 86.3%. The specificity of the rapid antigen test was 91.5% and with a Negative Predictive Value of 91.5%. About half (49.2%) of those who would have receive antibiotics for clinical suspicion would have been treated unnecessarily, with this decreasing to at least in 29.5% when using the rapid antigen test. CONCLUSIONS: The rapid antigen test can lead to a better use of antibiotics. Its use in Paediatric Primary Health Care could be useful when, as when the result is negative, there would be no need to confirm by a culture, in those Health Centres with difficult access to laboratory.


    Enfermedad por Staphylococcus aureus resistente a meticilina en Panama

    An Pediatr (Barc) 2011; 75 (2): 103-9

    INTRODUCTION: Infections due to methicillin-resistant Staphylococcus aureus (MRSA) are increasing worldwide. The clinical spectrum of the disease ranges from nasal colonization to superficial and invasive infections. OBJECTIVES: To describe the frequency, clinical characteristics and risk factors associated with MRSA disease in children under 15 years old. To establish the prevalence of colonization and antimicrobial susceptibility of isolates. MATERIAL AND METHODS: Retrospective study. Included subjects; aged 1 month to 15 years old treated in the Hospital del Nino in Panama with invasive or superficial infection by S. aureus in the period from June 1, 2009 to June 30, 2010. Carrier status was assessed by performing nasal swabs. Demographic, clinical features, treatment of disease and antimicrobial resistance patterns. RESULTS: A total of 146 subjects were collected with S.aureus infections, of which 8.9% (13/146) were infected by MRSA. Community-acquired MRSA accounted for 38.5% of the isolates. We did not identify any risk factors for developing MRSA infections. The prevalence of nasal carriage was 8.3%. The resistance rates to erythromycin and clindamycin were 15.4%. CONCLUSIONS: The incidence of MRSA infections was low compared with other regions. We recommend active surveillance in order to establish measures to prevent nosocomial infections and treatment guidelines based on local epidemiological criteria.


    Revision de los casos de paludismo de los ultimos 12 anos en el Hospital Universitario de Getafe.

    An Pediatr (Barc) 2009; 71 (3): 196-200

    INTRODUCTION: Malaria has increased in Spain, and is potentially severe in children. Information on pediatric malaria in Spain is scarce. The aim is to evaluate the clinical, therapeutic and epidemiological characteristics of children diagnosed with malaria in our hospital. PATIENTS AND METHODS: A retrospective descriptive study was performed on all pediatric cases of malaria diagnosed in Getafe University Hospital, from January 1995 to November 2006. Epidemiological and clinical features, as well as diagnostic methods, treatments and outcome were studied. An analysis of two comparative periods (before and after January 2000) was carried out. RESULTS: Eighteen cases of confirmed malaria were identified, twelve girls and six boys. The age range was from 13 months to 13 years with a median age of 60 months. All patients had recently travelled to or from endemic countries. Despite having a stable number of admissions to hospital over time, all but two patients were diagnosed in the second period (P<0.01). Fever and gastrointestinal symptoms were the most common symptoms, with liver or spleen enlargement in 75%. Thrombocytopenia and anemia were common. No cases of complicated malaria or death occurred. Plasmodium identification by microscopic examination was used in all cases. Identification of Plasmodium species with PCR was carried out in 16 children. P. falciparum was found in 89% of these cases. Quinine-sulphate and clindamycin were used in 72%. CONCLUSIONS: The incidence of pediatric malaria is increasing in the southern area of Madrid, with P. falciparum as the most frequently identified species. Microscopic visualization or identification of its antigen are gold-standard diagnostic methods, however, identification with PCR is essential upon admission to determine the species and discard possible multiple infestations. Pediatricians must learn to suspect this potentially severe disease, in order to establish an early treatment that may improve the prognosis.


    Fascitis necrosante por Staphylococcus aureus resistente a la meticilina adquirido en la comunidad productor de leucocidina de Panton-Valentine.

    An Pediatr (Barc) 2009; 70 (4): 374-8

    Community-Acquired Methicillin-Resistant Staphylococcus aureus (CA-MRSA) is a worldwide emerging pathogen that is able to produce serious skin and soft- tissue infections such as necrotizing fasciitis, as well as pneumonia and osteomyelitis. We present a 14 month child with necrotizing fasciitis, confirmed by magnetic resonance imaging, produced by CA-MRSA Panton-Valentine leukocidin producer. The clinical outcome was good after early surgical treatment and the administration of intravenous clindamycin for two weeks. We review microbiological aspects and treatment guidelines of these infections.


    Sindrome de escaldadura estafilococica.

    An Pediatr (Barc) 2008; 68 (2): 124-7

    INTRODUCTION: Staphylococcal scalded skin syndrome is a rare disease caused by Staphylococcus aureus that produces exfoliative toxins. There are few epidemiological data in our environment. PATIENTS AND METHODS: We present an observational cohort study. We review the cases of staphylococcal scalded skin syndrome monitored at La Paz Children Hospital during the last ten years (January 1997 to December 2006). RESULTS: We obtained 26 patients, 7 in the first 5 years and 19 more in the following years. The mean age at diagnosis was 19 months. Four cases (15%) occurred during the neonatal period. Sixty-seven percent of the cases were diagnosed during spring and summer. Main clinical signs were: erythroderma with blisters and posterior desquamation (100%), perioral fissures (54%), fever (46%), conjunctivitis (42%) and palpebral edema (31%). No significant increases in leukocytes (mean: 11,341/.l) or C-reactive protein (mean: 9 mg/l) were found on blood analysis. Diagnosis was made by clinical findings. S. aureus was isolated in nasal or conjunctival samples on 59% of cases. All strains were sensitive to cloxacillin, clindamycin and vancomycin. The patients were treated with cloxacillin with good progress. CONCLUSIONS: Staphylococcal scalded skin syndrome seems to be more common in the last few years. It must be suspected in children with acute erythroderma and perioral or conjunctival lesions. Treatment with cloxacillin leads to healing without sequelae.


    Tratamiento de la infeccion periamigdalina.

    An Pediatr (Barc) 2006; 65 (1): 37-43

    OBJECTIVE: To evaluate the clinical and epidemiologic characteristics in children with peritonsillar infections. PATIENTS AND METHODS: A longitudinal retrospective study was performed through a review of the clinical histories of patients attending the emergency unit in the previous 6 years. The variables gathered were age, sex, recurrent tonsillitis, previous upper airway infection, antibiotic administration, and therapeutic approach. RESULTS: Twenty-nine children were admitted, with a mean age of 7.4 +/- 1.6 years (boys 1.6:1). Twenty-seven percent had recurrent tonsillitis. At the visit, 57.8 % had an upper respiratory infection and 65 % were taking antibiotic treatment, especially macrolides. The treatment selected at our center consisted of the association of penicillin or amoxicillin-clavulanate acid with clindamycin, including corticosteroids. Ten children underwent computed tomography and nine underwent fine-needle aspiration. Drainage was performed in 20.6 % of confirmed abscesses. The mean length of hospital stay was 5.6 +/- 1.6 days. Delayed tonsillectomy was performed in 31 %, except in one patient who developed a parapharyngeal abscess. Currently, 18.9 % of all peritonsillar infections occur in the pediatric population. CONCLUSIONS: The increase in these infections is probably related to inappropriate use of antibiotics in respiratory diseases. Diagnosis is clinical, and infections are often resolved by intravenous administration of beta-lactams with clindamycin and an expectant attitude. When an abscess is suspected or there is no clinical improvement, fine-needle aspiration or computed tomography is warranted and drainage should be performed if an abscess is confirmed. Tonsillectomy, usually delayed, is only indicated in patients with recurrent tonsillitis.


    Clindamicina como terapia adyuvante en el sindrome de piel escaldada estafilococica.

    An Sist Sanit Navar 2014; 37 (3): 449-53

    Staphylococcal scalded skin syndrome (SSSS) is a dermatologic disease caused by exotoxins produced by Staphylococcus aureus. The disease presents as a painful cutaneous rash that culminates with the detachment of the superficial dermis. The usual treatment is antibiotics with beta-lactamase resistant penicillin. We report the case of a patient who presented with SSSS with initial torpid evolution despite antibiotic treatment and after the introduction of clindamycin IV experienced a very significant improvement. Concerns about the increase of methicillin resistant Staphylococcus aureus (MRSA) and the pathophysiology of this disease make bacteriostatic spectrum antistaphylococcal antibiotics, such as clindamycin, strong candidates for consideration as a first-line therapeutic arsenal for the treatment of SSSS.


    In vitro activity of tigecycline and comparators against a European collection of anaerobes collected as part of the Tigecycline Evaluation and Surveillance Trial (T.E.S.T.) 2010-2016.

    Anaerobe 2018; 51 (): 78-88;

    The Tigecycline Evaluation and Surveillance Trial (T.E.S.T.) is a global program that aims to monitor the in vitro antimicrobial activities of current therapeutic agents against clinical isolates. This study presents surveillance data for Gram-positive and Gram-negative anaerobic isolates (N=7008) collected from nine European countries between 2010 and 2016. Presented in this study are antimicrobial susceptibility data, according to the European Committee for Antimicrobial Susceptibility Testing (EUCAST) breakpoints, and minimum inhibitory concentration (MIC) distributions. The antimicrobial agents tested were cefoxitin (Gram-negative isolates only), clindamycin, meropenem, metronidazole, penicillin (Gram-positive isolates only), piperacillin-tazobactam and tigecycline. Among all Gram-positive and Gram-negative anaerobes, the lowest rates of resistance were to meropenem and metronidazole (0.0%-1.7% and 0.0%-1.9%, respectively). High rates of resistance were reported to clindamycin, in particular among isolates of the Bacteroides fragilis group (22.1%-48.1%) and Prevotella spp. (10.9%-32.2%). The majority of MIC distributions were unimodal, with the exception of clindamycin, which were mostly bimodal. Fifty percent of Gram-negative isolates gave tigecycline MICs between 0.06 and 1mg/L, and 50% of Gram-positive isolates exhibited tigecycline MICs between 0.06 and 0.25mg/L. The findings of this study suggest that the majority of anaerobic isolates were susceptible to meropenem and metronidazole, and that tigecycline remained active, but clindamycin resistance is a cause for concern in Europe. Surveillance studies, such as T.E.S.T., provide information on changes in the susceptibility of clinically important pathogens to commonly prescribed antimicrobial agents, and can highlight problems of antimicrobial resistance that need to be addressed.


    Susceptibility of bacterial vaginosis (BV)-associated bacteria to secnidazole compared to metronidazole, tinidazole and clindamycin.

    Anaerobe 2017; 47 (): 115-119;

    Secnidazole, a 5-nitroimidazole with a longer half-life, is structurally related to metronidazole and tinidazole. For treatment of bacterial vaginosis (BV), secnidazole is a suitable single-dose oral drug having a longer serum half-life than metronidazole. The objective of this study was to evaluate the antimicrobial susceptibility of vaginal isolates of facultative and anaerobic bacteria to secnidazole, metronidazole, tinidazole and clindamycin. A total of 605 unique BV-related bacteria and 108 isolates of lactobacilli recovered from the human vagina of US women during the years 2009-2015 were tested for antimicrobial susceptibility by the agar dilution CLSI reference method to determine the minimal inhibitory concentration (MIC). The MIC90 (mug/mL) for secnidazole was similar to metronidazole and tinidazole for Anaerococcus tetradius (secnidazole: MIC90 2; metronidazole: MIC90 2; tinidazole: MIC90 4), Atopobium vaginae (32; >128; 128), Bacteroides species (2; 2; 2), Finegoldia magna (2; 2; 4), Gardnerella vaginalis (128; 64; 32), Mageeibacillus indolicus (2; 2; 2), Megasphaera-like bacteria (0.5; 0.25; 0.5), Mobiluncus curtisii (128; >128; >128) and Mobiluncus mulieris (>128; >128; >128), Peptoniphilus lacrimalis (4; 4; 4) and Peptoniphilus harei (2; 2; 4), Porphyromonas species (0.25; 0.5; 0.25), Prevotella bivia (8; 8; 8), Prevotella amnii (2; 1; 2) and Prevotella timonensis (2; 2; 2). In this evaluation, 14 (40%) of 35 P. bivia, 5 (14%) of 35 P. amnii and 21 (58%) of 36 P. timonensis isolates were resistant to clindamycin with MIC values of >128 mug/mL. Secnidazole, like metronidazole, was superior to clindamycin for Prevotella spp., Bacteroides spp., Peptoniphilus spp., Anaerococcus tetradius and Finegoldia magna. Clindamycin had greater activity against Atopobium vaginae, Gardnerella vaginalis and Mobiluncus spp. compared to the nitroimidazoles. All 27 Lactobacillus crispatus, 26 (96%) of 27 L. jensenii, 5 (19%) of 27 L. gasseri and 18 (67%) of 27 L. iners isolates were susceptible to clindamycin (MIC 128 mug/mL for secnidazole, metronidazole and tinidazole. Secnidazole has similar in vitro activity against the range of microorganisms associated with BV compared to metronidazole or tinidazole. Further, secnidazole spares lactobacilli, a characteristic which is desirable in drugs used to treat bacterial vaginosis.


    Evaluation of the routine antimicrobial susceptibility testing results of clinically significant anaerobic bacteria in a Slovenian tertiary-care hospital in 2015.

    Anaerobe 2017; 47 (): 64-69;

    The aim of our study was to determined antimicrobial susceptibility profiles of 2673 clinically significant anaerobic bacteria belonging to the major genera, isolated in 2015 in a large tertiary-care hospital in Slovenia. The species identification was performed by MALDI-TOF mass spectrometry. Antimicrobial susceptibility was determined immediately at the isolation of the strains against: penicillin, co-amoxiclav, imipenem, clindamycin and metronidazole, using gradient diffusion methodology and EUCAST breakpoints. The most frequent anaerobes were Bacteroides fragilis group with 31% (n = 817), Gram positive anaerobic cocci (GPACs) with 22% (n = 589), Prevotella with 14% (n = 313) and Propionibacterium with 8% (n = 225). Metronidazole has retained full activity (100%) against all groups of anaerobic bacteria intrinsically susceptible to it. Co-amoxiclav and imipenem were active against most tested anaerobes with zero or low resistance rates. However, observed resistance to co-amoxiclav (8%) and imipenem (1%) is worrying especially among B. fragilis group isolates. High overall resistance (23%) to clindamycin was detected in our study and was highest among the genera Prevotella, Bacteroides, Parabacteroides, GPACs and Clostridium. Routine testing of antimicrobial susceptibility of clinically relevant anaerobic bacteria is feasible and provides good surveillance data.


    Improving the reproducibility of the NAP1/B1/027 epidemic strain R20291 in the hamster model of infection.

    Anaerobe 2016; 39 (): 51-3

    Comparative analysis of the Clostridium difficile BI/NAP1/027 strain R20291 and ClosTron-derived ermB mutants in the hamster infection model are compromised by the clindamycin susceptibility of the parent. Mutants can appear more virulent. We have rectified this anomaly by genome engineering. The variant created (CRG20291) represents an ideal control strain for virulence assays of ClosTron mutants.


    The non-toxigenic Clostridium difficile CD37 protects mice against infection with a BI/NAP1/027 type of C. difficile strain.

    Anaerobe 2015; 36 (): 49-52

    Clostridium difficile CD37, a clinical isolate from the USA, does not produce toxin A, B or binary toxin. The aim of this study was to determine whether strain CD37 can protect mice against infection from a challenge with a toxigenic C. difficile strain. Three groups of mice (n = 10) were pretreated with a antibiotics cocktail for 5 days, switched to sterile water for 2 days, and given one dose of clindamycin (10 mg/kg) one day (day-1) before challenge (day 0) with a toxigenic C. difficile strain. Group 1 (CD37 + UK6) was given 10(7)C. difficile CD37 vegetative cells by gavage twice a day on days -1 and -2, followed by challenge with 10(6) spores of the toxigenic C. difficile UK6 (BI/NAPI/027) on day 0; Group 2 (UK6) was infected with 10(6)C. difficile UK6 spores on day 0; Group 3 (CD37) was challenged with 10(6) CD37 vegetative cells on day 0. Our data show that pre-inoculation of strain CD37 provided mice significant protection (survival, p < 0.001 between groups CD37 + UK6 and UK6) against subsequent infection with the strain UK6, while mice infected with CD37 only did not develop any symptoms of C. difficile infection (CDI). Our results highlight the potential use of CD37 as a therapeutic strain for the prevention of primary and recurrent CDI in humans.


    Streptoccocus pyogenes: a forgotten cause of severe community-acquired pneumonia.

    Anaesth Intensive Care 2000; 28 (1): 87-90

    We report a case of severe community-acquired pneumonia caused by Streptococcus pyogenes (Lancefield Group A streptoccocus) that was complicated by a streptococcal toxic shock syndrome. Although this micro-organism is an uncommon cause of community-acquired pneumonia, previously well individuals may be infected and the clinical course may be fulminant. A household contact was the likely point of infection. Invasive group A streptococcal disease continues to remain an important cause of morbidity and mortality in the community and therefore will continue to be encountered by intensive care physicians. Treatment of Group A streptococcal infection remains penicillin; however, clindamycin should be added in severe infection.


    Prolongation of neuromuscular blocking effect of vecuronium by antibiotics.

    Anaesthesia 1987; 42 (8): 858-60

    A case is described of prolonged neuromuscular block in a patient who was given the muscle relaxant vecuronium followed by bolus injections of the antibiotics gentamycin and clindamycin.


    Study of in-vitro metabolism of selected antibiotic drugs in human liver microsomes by liquid chromatography coupled with tandem mass spectrometry.

    Anal Bioanal Chem 2016; 408 (29): 8273-8287;

    High performance liquid chromatography coupled with triple-quadrupole mass spectrometry was applied in the determination of in vitro metabolism products of selected antibiotic drugs (cefotaxime, ciprofloxacin, fluconazole, gentamicin, clindamycin, linezolid, and metronidazole). The analytes were separated on a reversed phase C18 column, with acetonitrile and 0.1 % aqueous formic acid as the mobile phase. Tandem mass spectrometry with positive electrospray ionization was used to facilitate the structural characterization of the potential metabolites. Metabolism studies on human liver microsomes were performed via cytochromes P450 (phase I) and via NADPH/UDP-glucuronosyltransferase (phase II) mediated reactions. LC-MS/MS experiments allowed potential metabolite peaks, including sum formulae suggestions, to be identified; high resolution MS/MS experiments led to the identification of various oxidative and reductive modifications of target compounds in phase I biotransformation, and conjugation products with glucuronic acid in phase II reactions. A total of 11 potential metabolites and their proposed structures were characterized during the incubation of human liver microsomes by comparing their retention times and spectral patterns with those of the parent drug. Dehydrogenation and reactions of side chains such as hydroxylation and hydrolysis of ester bonds constituted the major metabolic pathways. Finally, LC-MS/MS spectrometry was revealed to be a suitable analytical tool to procure a feasible analytical base for the envisioned in vivo experiments. Graphical Abstract Workflow overview of in vitro drug metabolism studies.


    Simultaneous Identification and Susceptibility Determination to Multiple Antibiotics of Staphylococcus aureus by Bacteriophage Amplification Detection Combined with Mass Spectrometry.

    Anal Chem 2015; 87 (13): 6769-77

    The continued advance of antibiotic resistance in clinically relevant bacterial strains necessitates the development and refinement of assays that can rapidly and cost-effectively identify bacteria and determine their susceptibility to a panel of antibiotics. A methodology is described herein that exploits the specificity and physiology of the Staphylococci bacteriophage K to identify Staphylococcus aureus (S. aureus) and determine its susceptibility to clindamycin and cefoxitin. The method uses liquid chromatography-mass spectrometry to monitor the replication of bacteriophage after it is used to infect samples thought to contain S. aureus. Amplification of bacteriophage K indicates the sample contains S. aureus, for it is only in the presence of a suitable host that bacteriophage K can amplify. If bacteriophage amplification is detected in samples containing the antibiotics clindamycin or cefoxitin, the sample is deemed to be resistant to these antibiotics, respectively, for bacteriophage can only amplify in a viable host. Thus, with a single work flow, S. aureus can be detected in an unknown sample and susceptibility to clindamycin and cefoxitin can be ascertained. This Article discusses implications for the use of bacteriophage amplification in the clinical laboratory.


    A Case of Recalcitrant Actinomycosis Unresponsive to Antibiotic Therapy.

    Ann Acad Med Singapore 2016; 45 (10): 475-476


    Anaerobic bacteraemia revisited: species and susceptibilities.

    Ann Acad Med Singapore 2015; 44 (1): 13-8

    INTRODUCTION: This retrospective study was performed to evaluate the frequency of anaerobic bacteraemia over a 10-year period, and to provide updated antibiotic susceptibilities for the more clinically relevant anaerobes causing blood stream infection. MATERIALS AND METHODS: Data were retrieved from the laboratory information system for the period 2003 to 2012. During this time, blood cultures were inoculated in Bactec Plus vials (BD, USA) and continuously monitored in the Bactec 9000 blood culture system (BD, USA). Anaerobic organisms were identified using commercial identification kits, predominantly API 20 A (bioMerieux, France) supplemented with Vitek ANC cards (bioMerieux, France) and AN-Ident discs (Oxoid, United Kingdom). A representative subset of isolates were retrieved from 2009 to 2011 and antimicrobial susceptibilities to penicillin, amoxicillin-clavulanate, clindamycin, imipenem, moxifloxacin, piperacillin-tazobactam and metronidazole were determined using the Etest method. RESULTS: Anaerobes comprised 4.1% of all positive blood culture with 727 obligate anaerobes recovered over the 10-year period, representing a positivity rate of 0.35%. The only significant change in anaerobe positivity rates occurred between 2003 and 2004, with an increase of 0.2%. The Bacteroides fragilis group (45%) were the predominant anaerobic pathogens, followed by Clostridium species (12%), Propioniobacterium species (11%) and Fusobacterium species (6%). The most active in vitro antibiotics were imipenem, piperacillin-tazobactam, amoxicillin-clavulanate and metronidazole, with susceptibilities of 95.0%, 93.3%, 90.8% and 90.8% respectively. Resistance was high to penicillin, clindamycin and moxifl oxacin. However, there were apparent differences for antibiotic susceptibilities between species. CONCLUSION: This study indicates that the anaerobes comprise a small but constant proportion of bloodstream isolates. Antibiotic resistance was high to some antibiotics, but metronidazole, the beta-lactam/beta-lactamase inhibitors and carbapenems retained good in vitro activity.


    Anaerobic culture of diabetic foot infections: organisms and antimicrobial susceptibilities.

    Ann Acad Med Singapore 2008; 37 (11): 936-9

    INTRODUCTION: The prevalence of diabetes mellitus is high in Singapore. Infections of the lower limb are significant causes of morbidity in this population. Although the aerobic bacteriology of these infections is well-documented, there is less data available on the anaerobic pathogens involved. This study sets out to describe the anaerobic bacteria associated with diabetic foot infections, and evaluates the susceptibility to 3 antimicrobials with anaerobic activity. MATERIALS AND METHODS: Anaerobic culture was performed on operative samples taken from diabetic foot infections. Organisms were identified through standard microbiological methods and commercial identification kits. Antimicrobial susceptibility testing to clindamycin, metronidazole and imipenem was performed by agar dilution. RESULTS: One hundred and two strains of strict anaerobic bacteria were isolated from 30 unique specimens. The predominant anaerobic isolates were Peptostreptococcus spp. (46%) and Bacteroides fragilis group (19%). Antibiotic resistance was detected for clindamycin (18%), metronidazole (1%) and imipenem (2%). CONCLUSION: Multiple anaerobic species can be isolated from diabetic foot infections. A significant proportion of isolates are resistant to clindamycin, while resistance to imipenem and metronidazole remains low.


    Streptococcus agalactiae maternal colonization, antibiotic resistance and serotype profiles in Africa: a meta-analysis.

    Ann Clin Microbiol Antimicrob 2019; 18 (1): 14;

    BACKGROUND: Maternal rectovaginal colonization with Streptococcus agalactiae (Group B Streptococcus or GBS) is the most common route for the GBS disease in the perinatal period. The knowledge of maternal colonization, antibiotic resistance and serotype profiles is substantially needed to formulate the broad vaccine. However, it has not been estimated in Africa. This meta-analysis was aimed to determine the pooled prevalence of colonization, antibiotic resistance and serotype profiles of GBS reported in Africa. METHODS: Potentially relevant studies from 1989 to 31th January, 2019 were retrieved from the Medline/PubMed, EMBASE, HINARI online databases, periodicals and by requesting authors. Unpublished studies retrieved from grey literature through Google and Google Scholar. Pooled estimates were calculated using the random effect model. Subgroup analysis was done to investigate the burden of colonization across sub-regions, sampling site and countries. Summary estimates were presented using words, Forest plots and Tables. Heterogeneity was assessed using the I(2) statistic. RESULTS: Eighty-three articles were assessed, of which 57 studies conducted in five sub-regions with 21 countries (22,206 pregnant women) met pre-specified inclusion criteria. The overall estimate of recto-vaginal colonization was 19.3% (95% CI 16.9, 21.7). The highest estimate was observed in Southern Africa, 23.8% (95% CI 18.7, 28.9), followed by Northern Africa, 22.7% (95% CI 18.2, 27.2) while the lowest was driven from the Eastern Africa, 15.4% (95% CI 12.1, 18.7). Considerable heterogeneity across and within regions, sampling site, screening methods and countries (I(2) > 75%); and the publication bias were observed (p = 0.031). GBS showed the highest resistance to tetracycline. Resistance to penicillin, amoxicillin, chloramphenicol, ampicillin, ceftriaxone, ciprofloxacin, erythromycin, vancomycin and clindamycin also observed. The V, III, Ia, Ib, and II serotypes altogether were accounted 91.8% in the African studies. CONCLUSIONS: The pooled estimate of the maternal colonization with GBS was 19.3% which is equivalent with other many primary and review reports worldwide. The most antibiotic resistance estimate was recorded in the tetracycline followed by penicillin. Five serotypes were the most prevalent in Africa and more data on the antibiotic resistance and serotype distribution patterns are needed from developing countries to devise the effective preventive measures. In addition, the antibiotic susceptibility test methods used in the Africa shall be assessed for its quality. Trial registration Prospero Registration Number CRD42018094525.


    Streptococcus agalactiae from Ethiopian pregnant women; prevalence, associated factors and antimicrobial resistance: alarming for prophylaxis.

    Ann Clin Microbiol Antimicrob 2019; 18 (1): 3;

    BACKGROUND: Maternal Streptococcus agalactiae (Group B Streptococcus, GBS) colonization rates and its antibiotic resistance patterns provide important information useful in guiding prevention strategies. There is a paucity of evidence about GBS in the Amhara National Regional State, Ethiopia. OBJECTIVE: To determine colonization prevalence, associated risk factors, and antibiotics resistance including inducible clindamycin resistance patterns of GBS among Ethiopian pregnant women. METHODS: A prospective cross-sectional study was conducted from 1st December 2016 to 30th November 2017 at the University of Gondar Referral hospital delivery ward. Combined recto-vaginal swabs were collected from 385 pregnant women and analyzed at the University of Gondar Bacteriology Laboratory by using LIM broth and 5% defibrinated sheep blood agar culture methods. Isolates were identified by using colony morphology, gram reaction, hemolysis, and CAMP test. Antibiotic susceptibility test was done using the disc diffusion method. Double disc diffusion method was used to identify inducible clindamycin resistance isolates. Data were analyzed by SPSS version 20 software. p


    Characterization of the clonal profile of methicillin resistant Staphylococcus aureus isolated from patients with early post-operative orthopedic implant based infections.

    Ann Clin Microbiol Antimicrob 2019; 18 (1): 8;

    BACKGROUND: To analyze the molecular epidemiology and to compare between the major methicillin resistant Staphylococcus aureus biotypes for association with patient characteristics who had an implant for closed fracture and developed early post-operative wound infections (POWI) in a tertiary care hospital of India. METHODS: Pulsed-field gel electrophoresis (PFGE), antimicrobial resistance, accessory gene regulator (agr) and staphylococcal cassette chromosome mec (SCCmec) types, Paton-Valentine leukocidin (PVL) gene, toxin gene profiling, biofilm formation and patient demographics were correlated with MLST clonal complexes (CC). FINDINGS: Overall eight different sequence types (STs) were detected with a predominance of ST239 (66%), ST22 (18%) and some minor types ST772, ST30 (4% each) ST1, ST642, ST6, ST107 (2% each). All ST239 isolates belong to CC239 and SCCmec III whereas ST22 isolates belong to CC22 and SCCmec IV. The isolates varied in the distribution of various toxin genes. With 63.63% biofilm formers ST239 were all multidrug resistant with frequent resistance to erythromycin, clindamycin, gentamicin, cefuroxime, amoxyclav and ciprofloxacin indicating doxycycline, amikacin, vancomycin and linezolid can be the drug of choice. CONCLUSION: This study shows that ST239 MRSA is still most prevalent strain with new emergence of ST642 and ST107 isolates in association with orthopedic implant based POWI. As compare to other ST types ST239 strain was associated with adverse treatment outcomes. This highlights the importance of improving nosocomial infection control measures in this unit.


    Clindamycin suppresses virulence expression in inducible clindamycin-resistant Staphylococcus aureus strains.

    Ann Clin Microbiol Antimicrob 2018; 17 (1): 38;

    Clindamycin is a protein synthesis inhibitory agent that has the ability to suppress the expression of virulence factors in Staphylococcus aureus. Recent guidelines recommend the use of clindamycin for the treatment of toxin-mediated infections. Clindamycin modulates virulence expression at sub-inhibitory concentrations (sub-MICs) in clindamycin-susceptible S. aureus strains but previous report shown that this effect was supressed for constitutive clindamycin resistant strains. However, no data are currently available on the impact of clindamycin at sub-MICs on the virulence of inducible clindamycin-resistant S. aureus strains. Here, we show that sub-MICs of clindamycin decrease Panton-Valentine leucocidin, toxic-shock-staphylococcal toxin (TSST-1) and alpha-haemolysin (Hla) expression in six inducible clindamycin-resistant isolates cultivated in vitro in CCY medium. These results suggest that the clindamycin anti-toxin effect is retained for inducible clindamycin-resistant S. aureus isolates; therefore, its usage should be considered within the treatment regimen of toxin related infections for inducible clindamycin-resistant S. aureus.


    The draft genomes and investigation of serotype distribution, antimicrobial resistance of group B Streptococcus strains isolated from urine in Suzhou, China.

    Ann Clin Microbiol Antimicrob 2018; 17 (1): 28;

    BACKGROUND: The group B Streptococcus (GBS) is a human commensal bacterium, which is capable of causing several infectious diseases in infants, and people with chronic diseases. GBS has been the most common cause of infections in urinary tract of the elders, but relatively few studies reported the urine-isolated GBS and their antimicrobial susceptibilities. Hence, we decided to investigate GBS specially isolated from urine in Suzhou, China. METHODS: 27 GBS samples were isolated from urine in Suzhou, China. The PCR and agarose gel electrophoresis were used to identify the serotype distribution. Susceptibility tests were based on MIC test and Kirby-Bauer test. Genome were sequenced via Illumina Hiseq platform and assembled by SPAdes. Genomes of five isolates were sequenced and submitted to NCBI genome database. The sequencing files in fastq format were submitted to NCBI SRA database. RESULTS: Five serotypes were identified. The resistant rates measured for tetracycline, erythromycin, clindamycin and fluoroquinolones were 74.1, 63.0, 44.4 and 48.1%, respectively. 18.5% of the isolates were nonsusceptible to nitrofurantoin. The resistance to tetracycline was mainly associated with the gene tetM. The erythromycin resistance was mainly associated with the genes ermB and mefE. The genes ermB and lnuB were the prevalent genes in cMLSB type. No known nitrofurantoin resistance gene was found in nitrofurantoin-nonsusceptible GBS. CONCLUSIONS: Five serotypes were identified in our study. High rates of GBS isolates were resistant to tetracycline, erythromycin, clindamycin and fluoroquinolones. The genes ermB and lnuB occupied high rates in cMLSB phenotype.


    Antimicrobial susceptibility pattern, and associated factors of Salmonella and Shigella infections among under five children in Arba Minch, South Ethiopia.

    Ann Clin Microbiol Antimicrob 2018; 17 (1): 1;

    BACKGROUND: Diarrheal diseases continue to be the major cause of morbidity and mortality among children under 5 years. Salmonella and Shigella specious are the major enteric pathogen causing diarrhea among children worldwide. Examination of stool sample is the most sensitive method to diagnose diarrheal disease in children. This study aimed to determining the prevalence, antimicrobial susceptibility pattern and associated factor of Salmonella and Shigella infection among under five children. METHODS: A cross sectional study was conducted on under 5 years children attending Arba Minch town. Pre-tested and structured questionnaire was used for collecting data about socio-demographic characteristics and associated factors. Stool sample was used to isolate and identified the pathogen. Antimicrobial susceptibility test was performed for isolated Salmonella and Shigella specious. A logistic regression analysis was used to see the association between different variables and outcome variable. Odds ratio with 95% CI was computed to determine the presence and strength of the association. RESULTS: A total of 167 under five children were included in the study. About 57% of participants were males with the mean age of 32 months. The overall prevalence of Salmonella and Shigella species infection was 17.45% with 12.6% Salmonella species. The isolates were resistant to common antibiotics such as Amoxicillin, Erythromycin, Chloramphenicol, Clindamycin, Norfloxacin, Ciprofloxacin, Cotrimoxazole, and Gentamycin. Urban resident [AOR = 7.11; 95% CI (2.3, 22.2)], month income < 1000 Ethiopian birr [AOR = 6.5; 95% CI (2.0, 21.4)], absence of waste disposal system [AOR = 3.3; 95% CI (1.2, 9.3)], poor hand washing habit [AOR = 6.0; 95% CI (2.0, 18.2)], untrimmed finger nail [AOR = 3.7; 95% CI (1.4, 10.6)], and use of napkin [AOR = 3.2; 95% CI (1.1, 9.3)] had significant association with Salmonella and Shigella infection. CONCLUSION: Salmonella and Shigella species infections were higher as compared the national prevalence. This study also revealed that the enteric infection were significantly associated with finger nail status, residence, hand washing practice, month income of parents, usage of napkin after toilet, and absence of waste disposal system. Therefore, working on identified associated factors and regular drug susceptibility test is mandatory to reduce the problem.


    Antibiotic resistance and biofilm production among the strains of Staphylococcus aureus isolated from pus/wound swab samples in a tertiary care hospital in Nepal.

    Ann Clin Microbiol Antimicrob 2017; 16 (1): 15;

    BACKGROUND: The increasing drug resistance along with inducible clindamycin resistance, methicillin resistance and biofilm production among the strains of Staphylococcus aureus are present as the serious problems to the successful treatment of the infections caused by S. aureus. So, the main objectives of this study were to determine the antimicrobial susceptibility patterns along with the rates of inducible clindamycin resistance, methicillin resistance and biofilm production among the strains of S. aureus isolated from pus/wound swab samples. METHODS: A total of 830 non-repeated pus/wound swab samples were processed using standard microbiological techniques. The colonies grown were identified on the basis of colony morphology, Gram's stain and biochemical tests. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion technique. Detection of inducible clindamycin resistance was performed by D test, while detection of methicillin resistant S. aureus (MRSA) was performed by determination of minimum inhibitory concentration of oxacillin by agar dilution method. Similarly, detection of biofilm formation was performed by microtiter plate method. Strains showing resistance to three or more than three different classes of antibiotics were considered multidrug resistant. RESULTS: Total 76 samples showed the growth of S. aureus, among which 36 (47.4%) contained MRSA and 17 (22.4%) samples were found to have S. aureus showing inducible clindamycin resistance. Among the S. aureus isolated from outpatients, 41.9% were MRSA. Highest rates of susceptibility of S. aureus were seen toward linezolid (100%) and vancomycin (100%). Similarly, S. aureus isolated from 35 (46.1%) samples were found to be biofilm producers. Higher rate of inducible clindamycin resistance was seen among MRSA in comparison to methicillin susceptible S. aureus (MSSA). Similarly, higher rates of multidrug resistance and methicillin resistance were found among biofilm producing strains in comparison to biofilm non producing strains. CONCLUSIONS: The rate of isolation of MRSA from community acquired infections was found to be high in Nepal. Increased rate of inducible clindamycin resistance as compared to previous studies in Nepal was noted. So for the proper management of the infections caused by S. aureus, D test for the detection of inducible clindamycin resistance should be included in the routine laboratory diagnosis. Further, detection of biofilm production should also be included in the routine tests. Linezolid and vancomycin can be used for the preliminary treatment of the serious infections caused by S. aureus.


    Comparison of Clinical Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines for the interpretation of antibiotic susceptibility at a University teaching hospital in Nairobi, Kenya: a cross-sectional study.

    Ann Clin Microbiol Antimicrob 2016; 15 (): 21;

    BACKGROUND: The Clinical Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines are the most popular breakpoint guidelines used in antimicrobial susceptibility testing worldwide. The EUCAST guidelines are freely available to users while CLSI is available for non-members as a package of three documents for US $500 annually. This is prohibitive for clinical microbiology laboratories in resource poor settings. We set out to compare antibiotic susceptibility determined by the two guidelines to determine whether adoption of EUCAST guidelines would significantly affect our susceptibility patterns. METHODS: We reviewed minimum inhibitory concentrations (MIC) of various antibiotics routinely reported for Escherichia coli (E. coli), Staphylococcus aureus (S. aureus) and Pseudomonas aeruginosa (P. aeruginosa) isolates from an automated microbiology identification system (VITEK-2) at the Aga Khan University Hospital Nairobi's Pathology department. These MICs were then analyzed using both CLSI 2015 and EUCAST 2015 guidelines and classified as resistant, intermediate or susceptible. We compared the susceptibility and agreement between the CLSI and EUCAST categorizations. RESULTS: Susceptibility data from a total of 5165 E. coli, 1103 S. aureus and 532 P. aeruginosa isolates were included. The concordance rates of the two guidelines for E. coli, S. aureus and P. aeruginosa ranged from 78.2 to 100 %, 94.6 to 100 % and 89.1 to 95.5 % respectively. The kappa statistics for E. coli MICs revealed perfect agreement between CLSI and EUCAST for cefotaxime, ceftriaxone and trimethoprim-sulfamethoxazole, almost perfect agreement for ampicillin, ciprofloxacin, cefuroxime, gentamicin and ceftazidime, substantial agreement for meropenem, moderate agreement for cefepime and amoxicillin-clavulanate, fair agreement for nitrofurantoin and poor agreement for amikacin. For S. aureus the kappa statistics revealed perfect agreement for penicillin, trimethoprim-sulfamethoxazole, levofloxacin, oxacillin, linezolid and vancomycin, almost perfect agreement for clindamycin, erythromycin and tetracycline and moderate agreement for gentamicin. For P. aeruginosa the kappa analysis revealed moderate to almost perfect agreement for all the anti-pseudomonal antibiotics. CONCLUSION: The results show comparable antibiotic susceptibility patterns between CLSI and EUCAST breakpoints. Given that EUCAST guidelines are freely available, it makes it easier for laboratories in resource poor settings to have an updated and readily available reference for interpreting antibiotic susceptibilities.


    Clinical characteristics and antimicrobial susceptibility of Bacillus cereus blood stream infections.

    Ann Clin Microbiol Antimicrob 2015; 14 (): 43;

    BACKGROUND: Bacillus cereus is one of the pathogens causing nosocomial bloodstream infections (BSIs). However, few reports have documented the antimicrobial susceptibility and clinical characteristics of Bacillus cereus BSI and the importance of empirical therapy. The aim of this study was to investigate the clinical characteristics and antimicrobial susceptibility of B. cereus isolates from patients with BSI and to analyze the impact of appropriate empirical therapy on the outcome of patients with B. cereus BSI. METHODS: All adult cases of bacteremia between April 2003 and March 2012 in a teaching hospital in Tokyo, Japan were reviewed retrospectively. Clinical data were collected from the patients' medical records and charts. Antimicrobial susceptibility testing was performed by broth microdilution method. The patients with B. cereus BSI were divided into an appropriate empirical therapy group and an inappropriate empirical therapy group. The primary outcome was all-cause mortality at 4 weeks after the start of BSI. The secondary outcome was early defervescence within 2 days after starting empirical therapy. RESULTS: There were 29 B. cereus bloodstream infection cases. No vancomycin, gentamicin, and imipenem-resistant isolates were found. However, 65.5 % were resistant to clindamycin and 10.3 % were resistant to levofloxacin. The main etiology was venous catheter-related (69 %). All-cause mortality at 4 weeks was not significantly different between the appropriate empirical therapy group (9 cases) and the inappropriate group (20 cases) in this study. However, early defervescence within 2 days after starting empirical therapy was significantly different (p = 0.032). CONCLUSIONS: The BSI of B. cereus is mostly caused by venous catheter-related infections. Appropriate empirical therapy is important to achieve early clinical resolution in B. cereus BSI. Vancomycin is one of the appropriate selections of empirical therapy for B. cereus BSI.


    Clonality and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus at the University Hospital Zurich, Switzerland between 2012 and 2014.

    Ann Clin Microbiol Antimicrob 2015; 14 (): 14

    BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a global epidemic threat. The aim of this study was to determine which globally known MRSA lineages are currently present at our tertiary care hospital in Switzerland, a hospital with low MRSA prevalence. In light of the increasing prevalence of multi drug resistance including vancomycin resistance we also assessed antibiotic susceptibilities. METHODS: The 146 MRSA strains collected over two years (March 2012 until February 2014) at the University Hospital Zurich, Switzerland, were analyzed by PFGE analysis of SmaI digests in combination with spa-typing. In addition, representative isolates were analyzed by multi locus sequence typing (MLST). Susceptibilities to eight antibiotics were assessed using the Kirby-Bauer disc diffusion method. RESULTS: Isolates showed resistance to erythromycin (48%), ciprofloxacin (43%), clindamycin (31%), tetracycline (22%), and gentamicin (16%). All isolates were susceptible to vancomycin, 95% were susceptible to sulfamethoxazole/trimethoprim and rifampicin, respectively. PFGE analysis revealed 22 different patterns, with four major patterns that accounted for 53.4% of all MRSA isolates, and seven sporadic patterns. Spa typing revealed 50 different spa types with the predominant types being t008 (14%), t002 (10%), and t127 (9%). 82% of the MRSA isolates could be assigned to six clonal complexes (CCs) namely CC1 (10%), CC5 (23%), CC8 (18%), CC22 (17%), CC30 (11%), and CC45 (3%) based on spa-types, PFGE patterns, and MLST. Two isolates could not be typed by either PFGE analysis or spa-typing and three isolates had spa-types that have not yet been described. CONCLUSIONS: The combination of the two typing methods was more discriminatory as compared to the use of a single method. Several of the lineages that are predominant in Europe are present in our hospital. Resistances to antibiotics have decreased in comparison to a study conducted between 2004 and 2006.


    Study of the frequency of Clostridium difficile tcdA, tcdB, cdtA and cdtB genes in feces of Calves in south west of Iran.

    Ann Clin Microbiol Antimicrob 2014; 13 (): 21

    BACKGROUND: Clostridium difficile (C. difficile) is a gram-positive, toxin-producing bacillus which is an intestinal pathogen in both humans and animals and causes a range of digestive disorders including inflammation of the bowel, abdominal pain, fever and diarrhea. C. difficile toxins include enterotoxin (Toxin A), cytotoxin (Toxin B) and a binary toxin. Two large protein toxins A and B are encoded by separate genes, tcdA and tcdB. Clostridium difficile infection (CDI) mainly caused by the activity of the genes tcdA and tcdB. The binary toxin is encoded by the genes cdtA and cdtB. The binary toxin caused increased adherence of bacteria to intestinal epithelium. The aim of the present study was isolation of C. difficile from feces of calves, and study of the frequency of C. difficile virulence genes. METHODS: 150 samples of fresh feces from calves were collected and C. difficile was isolated from feces of calves using bacterial culture methods. DNA was extracted by a genomic DNA purification kit. Then PCR method was used for definitive diagnosis of C. difficile. Multiplex PCR method performed for identification of tcdA, tcdB, cdtA and cdtB genes. In the final stage antimicrobial resistance determining was carried out by standard Bauer-Kirby disk diffusion method. RESULTS: C. difficile was isolated from 90 samples (60%). The tcdA was observed in 8 isolates (8.8%), tcdB in 16 isolates (17.7%), cdtA in 8 isolates (8.8%) and cdtB in 14 isolates (15.5%). Only 1 isolated (1.1%) was containing all four genes tcdA, tcdB, cdtA and cdtB, 2 isolates (2.2%) only had both tcdA and tcdB genes, and there was no sample positive only for both cdtA and cdtB. The highest rate of drug resistance was against clindamycin (100%) and the highest rate of drug sensitivity was against ciprofloxacin (50%). CONCLUSION: The results showed high incidence of C. difficile and also high antibiotic resistance of this bacterium, but frequency of strains containing virulence genes (tcdA, tcdB, cdtA and cdtB) was low.


    Prevalence of antibiotic resistance in multi-drug resistant coagulase-negative staphylococci isolated from invasive infection in very low birth weight neonates in two Polish NICUs.

    Ann Clin Microbiol Antimicrob 2013; 12 (): 41

    BACKGROUND: Multi-drug resistant coagulaso-negative staphylococci (CNS) have become an increasing problem in nosocomial infections connected with the presence of medical devices. The paper aimed to analyze the prevalence of antibiotic resistance in CNS isolated from invasive infection in very low birth weight (VLBW) neonates. METHODS: Continuous prospective target surveillance of infections was conducted in 2009 at two Polish NICUs that participated in the Polish Neonatology Surveillance Network (PNSN). The study covered 386 neonates with VLBW (


    Variable antibiotic susceptibility patterns among Streptomyces species causing actinomycetoma in man and animals.

    Ann Clin Microbiol Antimicrob 2011; 10 (): 24

    BACKGROUND: Drug therapy is recommended in conjunction with surgery in treatment of actinomycetoma. The specific prescription depends on the type of bacteria (actinomycetoma) or fungi (eumycetoma) causing the disease and their in vitro antimicrobial susceptibility. OBJECTIVES: To investigate the antimicrobial susceptibility among isolates of Streptomyces spp. isolated from cases of actinomycetoma in man and animals in Sudan. METHODS: Streptomyces strains (n = 18) isolated from cases of actinomycetoma were tested in vitro against 15 commonly prescribed antibacterial agents using MIC agar dilution method as per standard guidelines. RESULTS: Streptomyces strains isolated from actinomycetoma fall into various phenotypic groups. All of the strains were inhibited by novobiocin (8 mug/mL), gentamycin (8, 32 mug/mL) and doxycycline (32 mug/mL). Fusidic acid (64 mug/mL) inhibited 94.4% of the strains; bacitracin, streptomycin, cephaloridine, clindamycin, ampicillin, rifampicin and tetracycline (64 mug/mL) inhibited between 61.1 and 77.8% of the strains. All strains were found resistant to amphotericin B (64 mug/mL), penicillin (20 mug/mL) and sulphamethoxazole (64 mug/mL). CONCLUSIONS: Saprophytic Streptomyces spp. cause actinomycetoma in man and animal belong to separate phenotypes and have a wide range of susceptibility patterns to antimicrobial agents, which pose a lot of difficulties in selecting effective in vivo treatment for actinomycetoma.


    The dissemination of ST80-SCCmec-IV community-associated methicillin resistant Staphylococcus aureus clone in Kuwait hospitals.

    Ann Clin Microbiol Antimicrob 2010; 9 (): 31

    BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a global healthcare problem. The purpose of this study was to characterize CA-MRSA clones and their distribution in Kuwait hospitals. METHODS: In total, 135 CA-MRSA isolates, carrying the SCCmec IV or V genetic elements, isolated in eight hospitals were characterized using antibiogram, pulsed-field gel electrophoresis, multilocus sequence typing, and carriage of genes for Panton-Valentine Leukocidin (PVL), capsular polysaccharides types (cap) 5 and 8, accessory genes regulators (agr), Staphylococcal enterotoxins (SE) and toxic shock syndrome toxin 1 (tst). RESULTS: They were susceptible to vancomycin, teicoplanin and linezolid but resistant to kanamycin (62%), fusidic acid (42.2%), tetracycline (39.3%), erythromycin and clindamycin (21.5%), gentamicin (5.9%), streptomycin (6.7%), trimethoprim (5.9%), mupirocin (6.6%) and cadmium acetate (82.2%). They consisted of 10 pulsotypes with the majority belonging to PFGE type I (51.1%), type II (22.2%), type IV (13.3%) and type III (3.7%). They belonged to 10 sequence types (ST) comprising ST80 (51.1%), ST30 (22.2%), ST5 (14.1%), ST1 (4.45), ST6 (3.7%), ST88 (1.5%), ST834 (1.5%), ST8 (0.7%), ST46 (0.7%) and ST950 (0.7%). Genes for PVL, cap 8, cap 5 and agr III, agr I and agr II were detected in 61.5%, 77.3%, 20.7% and 62.2%, 17% and 8.1% of the isolates respectively. Nine (6.7%) isolates contained tst while 103 isolates were positive for SE genes with sei (63.0%), seg (41.5%) and sed (29.6%) as the common SE genes. CONCLUSIONS: ST80-SCCmecIV was the most common CA-MRSA clone in Kuwait hospitals presenting new challenges for infection control.


    The need for continued monitoring of antibiotic resistance patterns in clinical isolates of Staphylococcus aureus from London and Malta.

    Ann Clin Microbiol Antimicrob 2010; 9 (): 20

    BACKGROUND: Antibiotic resistance is an increasing problem in isolates of Staphylococcus aureus (S. aureus) worldwide. In 2001 The National Health Service in the UK introduced a mandatory bacteraemia surveillance scheme for the reporting of S. aureus and methicillin-resistant S. aureus (MRSA). This surveillance initiative reports on the percentage of isolates that are methicillin resistant. However, resistance to other antibiotics is not currently reported and therefore the scale of emerging resistance is currently unclear in the UK. In this study, multiple antibiotic resistance (MAR) profiles against fourteen antimicrobial drugs were investigated for 705 isolates of S. aureus collected from two European study sites in the UK (London) and Malta. RESULTS: All isolates were susceptible to linezolid, teicoplanin and vancomycin. Multiple antibiotic resistance profiles from both countries were determined, a total of forty-two and forty-five profiles were seen in the UK cohort (MRSA and MSSA respectively) and comparatively, sixty-two and fifty-two profiles were shown in the Maltese group. The largest MAR profile contained six antibiotics (penicillin G, methicillin, erythromycin, ciprofloxacin, clindamycin and clarithromycin) and was observed in the MRSA isolates in both the UK and Maltese cohorts. CONCLUSION: The data presented here suggests that the monitoring of changing resistance profiles locally in maintaining treatment efficacy to resistant pathogens.


    A population-based study examining the emergence of community-associated methicillin-resistant Staphylococcus aureus USA300 in New York City.

    Ann Clin Microbiol Antimicrob 2006; 5 (): 29

    BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a serious pathogen in several regions in the United States. It is unclear which populations are at high risk for the emergence of these strains. METHODS: All unique patient isolates of S. aureus were collected from hospitals in Brooklyn, NY over a three-month period. Isolates of MRSA that were susceptible to clindamycin underwent SCCmec typing. Isolates with the SCCmec type IV (characteristic of CA-MRSA strains) underwent ribotyping. Demographic information involving the neighborhoods of Brooklyn was also gathered and correlated with the prevalence of CA-MRSA strains. RESULTS: Of 1316 isolates collected during the surveillance, 217 were MRSA susceptible to clindamycin. A total of 125 isolates possessed SCCmec type IV; 72 belonged to the USA300 strain and five belonged to the USA400 strain. Hospitals in the eastern part of the city had the highest prevalence of USA300 strain. Individuals in the eastern region, when compared to the western region, were more likely to be Black, Hispanic, female, and < 18 years of age, and to have households of > or = 3 persons. In addition, the median household income was lower, and the proportion of individuals on public assistance was higher, for the population in the eastern region. CONCLUSION: The USA300 strain of CA-MRSA is emerging in New York City. In this population-based study, urban regions of lower socioeconomic status and with evidence of overcrowding appear to be at higher risk for the emergence of this pathogen.


    Mutation at the position 2058 of the 23S rRNA as a cause of macrolide resistance in Streptococcus pyogenes.

    Ann Clin Microbiol Antimicrob 2004; 3 (): 5

    BACKGROUND: In streptococci, three macrolide resistance determinants (erm(B), erm(TR) and mef(A)) have been found. In addition, certain mutations at the ribosomal 23S RNA can cause resistance to macrolides. Mutation at the position 2058 of the 23S rRNA of the Streptococcus pyogenes as a cause of macrolide resistance has not been described before. METHODS: Antibiotic resistance determinations for the clinical S. pyogenes strain ni4277 were done using the agar dilution technique. Macrolide resistance mechanisms were studied by PCR and sequencing. All six rRNA operons were amplified using operon-specific PCR. The PCR products were partially sequenced in order to resolve the sequences of different 23S rRNA genes. RESULTS: One clinical isolate of S. pyogenes carrying an adenine to guanine mutation at the position 2058 of the 23S rRNA in five of the six possible rRNA genes but having no other known macrolide resistance determinants is described. The strain was highly resistant to macrolides and azalides, having erythromycin and azithromycin MICs > 256 microgram/ml. It was resistant to lincosamides (clindamycin MIC 16 microgram/ml) and also MIC values for ketolides were clearly elevated. The MIC for telithromycin was 16 microgram/ml. CONCLUSION: In this clinical S. pyogenes strain, a mutation at the position 2058 was detected. No other macrolide resistance-causing determinants were detected. This mutation is known to cause macrolide resistance in other bacteria. We can conclude that this mutation was the most probable cause of macrolide, lincosamide and ketolide resistance in this strain.


    Prevalence and characterization of integrons in blood culture Enterobacteriaceae and gastrointestinal Escherichia coli in Norway and reporting of a novel class 1 integron-located lincosamide resistance gene.

    Ann Clin Microbiol Antimicrob 2004; 3 (): 12

    BACKGROUND: Class 1 integrons contain genetic elements for site-specific recombination, capture and mobilization of resistance genes. Studies investigating the prevalence, distribution and types of integron located resistance genes are important for surveillance of antimicrobial resistance and to understand resistance development at the molecular level. METHODS: We determined the prevalence and genetic content of class 1 integrons in Enterobacteriaceae (strain collection 1, n = 192) and E. coli (strain collection 2, n = 53) from bloodstream infections in patients from six Norwegian hospitals by molecular techniques. Class 1 integrons were also characterized in 54 randomly selected multiresistant E. coli isolates from gastrointestinal human infections (strain collection 3). RESULTS: Class 1 integrons were present in 10.9% of the Enterobacteriaceae blood culture isolates of collection 1, all but one (S. Typhi) being E. coli. Data indicated variations in class 1 integron prevalence between hospitals. Class 1 integrons were present in 37% and 34% of the resistant blood culture isolates (collection 1 and 2, respectively) and in 42% of the resistant gastrointestinal E. coli. We detected a total of 10 distinct integron cassette PCR amplicons that varied in size between 0.15 kb and 2.2 kb and contained between zero and three resistance genes. Cassettes encoding resistance to trimethoprim and aminoglycosides were most common. We identified and characterized a novel plasmid-located integron with a cassette-bound novel gene (linF) located downstream of an aadA2 gene cassette. The linF gene encoded a putative 273 aa lincosamide nucleotidyltransferase resistance protein and conferred resistance to lincomycin and clindamycin. The deduced LinF amino acid sequence displayed approximately 35% identity to the Enterococcus faecium and Enterococcus faecalis nucleotidyl transferases encoded by linB and linB' CONCLUSIONS: The present study demonstrated an overall low and stable prevalence of class 1 integron gene cassettes in clinical Enterobacteriaceae and E. coli isolates in Norway. Characterization of the novel lincosamide resistance gene extends the growing list of class 1 integron gene cassettes that confer resistance to an increasing number of antibiotics.


    Antibiotic Susceptibility of Staphylococcus aureus in Atopic Dermatitis: Current Prevalence of Methicillin-Resistant Staphylococcus aureus in Korea and Treatment Strategies.

    Ann Dermatol 2015; 27 (4): 398-403

    BACKGROUND: Staphylococcus aureus is a well-known microbe that colonizes or infects the skin in atopic dermatitis (AD). The prevalence of methicillin-resistant S. aureus (MRSA) in AD has recently been increasing. OBJECTIVE: This study aimed to determine the antimicrobial susceptibility patterns in AD skin lesions and evaluate the prevalence of MRSA in Korea. We also recommend proper first-line topical antibiotics for Korean patients with AD. METHODS: We studied S. aureus-positive skin swabs (n=583) from the lesional skin of infants, children, and adults who presented to our outpatient clinic with AD from July 2009 to April 2012. RESULTS: S. aureus exhibited high susceptibility against most antimicrobial agents. However, it exhibited less susceptibility to benzylpenicillin, erythromycin, clindamycin, and fusidic acid. The prevalence of MRSA was 12.9% among 583 S. aureus isolates, and the susceptibility to oxacillin was significantly lower in infants in both acute and chronic AD lesions. CONCLUSION: S. aureus from AD has a high prevalence of MRSA and multidrug resistance, especially in infants. In addition, the rate of fusidic acid resistance is high among all age groups, and mupirocin resistance increases with age group regardless of lesional status. This is the first study comparing the antimicrobial susceptibility rates of S. aureus isolates from AD cases with respect to age and lesion status in Korea.


    The Prevalence, Genotype and Antimicrobial Susceptibility of High- and Low-Level Mupirocin Resistant Methicillin-Resistant Staphylococcus aureus.

    Ann Dermatol 2012; 24 (1): 32-8

    BACKGROUND: Mupirocin has been used for the treatment of skin infections and eradication of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). The increased use of this antibiotic has been accompanied by outbreaks of MRSA that are resistant to mupirocin. OBJECTIVE: This study aims to determine the prevalence, genotype and antimicrobial susceptibility of mupirocin-resistant MRSA from 4 Korean hospitals. METHODS: A total 193 MRSA clinical isolates were collected from four university hospitals. Antimicrobial susceptibility tests, including mupirocin, and pulsed-field gel electrophoresis (PFGE) pattern analysis were performed. RESULTS: Overall, 27 of the 193 (14.1%) MRSA isolates were resistant to mupirocin. All of the (A) hospital isolates showed high-level (HL) mupirocin resistance and the low-level (LL) mupirocin resistant strains were from three other hospitals. The PFGE patterns of 16 mupirocin-resistant isolates were divided into 5 clusters (1-5), and the nine HL mupirocin-resistant isolates belonged to cluster 1. Both the HL and LL mupirocin-resistant MRSA isolates were susceptible to vancomycin and rifampin, but they were resistant to ciprofloxacin, clindamycin and tetracycline. The erythromycin and fusidic acid resistance rates were different between the HL and LL resistant isolates. CONCLUSION: HL mupirocin-resistant isolates that could transfer this resistance to other bacteria were detected and these isolates were clonally related. The emergence of mupirocin resistant isolates emphasizes the importance of using antibiotics judiciously and carefully monitoring the prevalence of mupirocin resistance.


    Blunt trauma as a risk factor for group A streptococcal necrotizing fasciitis.

    Ann Epidemiol 2007; 17 (11): 878-81

    PURPOSE: Anecdotal reports suggest that blunt trauma and seemingly innocuous musculoskeletal injuries (e.g., muscle strains) are risk factors for developing necrotizing fasciitis (NF) and myositis caused by group A Streptococcus and other bacteria; however, this hypothesis has not been tested in analytic epidemiologic studies of invasive group A streptococcal (GAS) disease. We conducted two case-control studies to determine whether nonpenetrating trauma is a risk factor for either NF or severe cellulitis caused by GAS. METHODS: A secondary analysis of patients who were hospitalized throughout Florida for invasive GAS disease during a 4-year period was conducted. Two case series were used. The first series comprised patients who had severe GAS cellulitis. The second were patients who had GAS NF. Case-patients were compared to a single control series composed of patients with invasive GAS disease not including either NF or cellulitis (e.g., primary bacteremia, septic arthritis). RESULTS: After we adjusted for age, race, and clindamycin usage, GAS NF cases were 5.97 times as likely as controls to have a recent history of blunt trauma (p = 0.04). Patients with severe cellulitis were not more likely than controls to have associated blunt trauma. CONCLUSIONS: Nonpenetrating trauma is significantly associated with the development of GAS NF.


    Antimicrobial Susceptibility Patterns of Anaerobic Bacterial Clinical Isolates From 2014 to 2016, Including Recently Named or Renamed Species.

    Ann Lab Med 2019; 39 (2): 190-199;

    BACKGROUND: Anaerobic bacterial resistance trends may vary across regions or institutions. Regional susceptibility patterns are pivotal in the empirical treatment of anaerobic infections. We determined the antimicrobial resistance patterns of clinically important anaerobic bacteria, including recently named or renamed anaerobes. METHODS: A total of 521 non-duplicated clinical isolates of anaerobic bacteria were collected from a tertiary-care hospital in Korea between 2014 and 2016. Anaerobes were isolated from blood, body fluids, and abscess specimens. Each isolate was identified by conventional methods and by Bruker biotyper mass spectrometry (Bruker Daltonics, Leipzig, Germany) or VITEK matrix-assisted laser desorption ionization time-of-flight mass spectrometry (bioMerieux, Marcy-l'Etoile, France). Antimicrobial susceptibility was tested using the agar dilution method according to the CLSI guidelines. The following antimicrobials were tested: piperacillin-tazobactam, cefoxitin, cefotetan, imipenem, meropenem, clindamycin, moxifloxacin, chloramphenicol, tetracycline, and metronidazole. RESULTS: Most Bacteroides fragilis isolates were susceptible to piperacillin-tazobactam, imipenem, and meropenem. The non-fragilis Bacteroides group (including B. intestinalis, B. nordii, B. pyogenes, B. stercoris, B. salyersiae, and B. cellulosilyticus) was resistant to meropenem (14%) and cefotetan (71%), and Parabacteroides distasonis was resistant to imipenem (11%) and cefotetan (95%). Overall, the Prevotella and Fusobacterium isolates were more susceptible to antimicrobial agents than the B. fragilis group isolates. Anaerobic gram-positive cocci exhibited various resistance rates to tetracycline (6-86%). Clostridioides difficile was highly resistant to penicillin, cefoxitin, imipenem, clindamycin, and moxifloxacin. CONCLUSIONS: Piperacillin-tazobactam, cefoxitin, and carbapenems are highly active beta-lactam agents against most anaerobes, including recently named or renamed species.


    Molecular Epidemiological Features and Antibiotic Susceptibility Patterns of Streptococcus dysgalactiae subsp. equisimilis Isolates from Korea and Japan.

    Ann Lab Med 2018; 38 (3): 212-219

    BACKGROUND: The molecular characterization of Streptococcus dysgalactiae subsp. equisimilis (SDSE) has not yet been performed in Korea. This study aimed to find the differences or similarities in the clinical features, molecular epidemiological findings, and antimicrobial resistance patterns of SDSE from two countries (Korea and Japan). METHODS: SDSE isolates were collected from Korea (N=69) from 2012-2016 and Japan (N=71) from 2014-2016. Clinical characteristics, emm genotypes, and sequence types (STs) were compared. Microdilution tests were performed using different antimicrobials, and their resistance determinants were screened. RESULTS: Median ages were 69 years in Korea and 76 years in Japan. The most common underlying diseases were diabetes and malignancy. Blood-derived isolates comprised 36.2% and 50.7% of Korean and Japanese isolates, respectively; mortality was not different between the two groups (5.8% vs 9.9%, P=0.53). Among Korean isolates with 20 different combined ST-emm types, ST127-stG245 (N=16), ST128-stG485 (N=10), and ST138-stG652 (N=8) were prevalent. Among Japanese isolates with 29 different combined types, ST17-stG6792 (N=11), ST29-stG485 (N=7), and ST205-stG6792 (N=6) were prevalent. Resistance rates to erythromycin, clindamycin, and minocycline were 34.8%, 17.4%, and 30.4% in Korea and 28.2%, 14.1%, and 21.4% in Japan, respectively. CONCLUSIONS: SDSE infections commonly occurred in elderly persons with underlying diseases. There was a significant difference in the distribution of ST-emm types between the two countries. Antimicrobial resistance rates were comparable with different frequencies of resistance determinants in each country.


    Multicenter study of antimicrobial susceptibility of anaerobic bacteria in Korea in 2012.

    Ann Lab Med 2015; 35 (5): 479-86

    BACKGROUND: Periodic monitoring of regional or institutional resistance trends of clinically important anaerobic bacteria is recommended, because the resistance of anaerobic pathogens to antimicrobial drugs and inappropriate therapy are associated with poor clinical outcomes. There has been no multicenter study of clinical anaerobic isolates in Korea. We aimed to determine the antimicrobial resistance patterns of clinically important anaerobes at multiple centers in Korea. METHODS: A total of 268 non-duplicated clinical isolates of anaerobic bacteria were collected from four large medical centers in Korea in 2012. Antimicrobial susceptibility was tested by the agar dilution method according to the CLSI guidelines. The following antimicrobials were tested: piperacillin, piperacillin-tazobactam, cefoxitin, cefotetan, imipenem, meropenem, clindamycin, moxifloxacin, chloramphenicol, metronidazole, and tigecycline. RESULTS: Organisms of the Bacteroides fragilis group were highly susceptible to piperacillin-tazobactam, imipenem, and meropenem, as their resistance rates to these three antimicrobials were lower than 6%. For B. fragilis group isolates and anaerobic gram-positive cocci, the resistance rates to moxifloxacin were 12-25% and 11-13%, respectively. Among B. fragilis group organisms, the resistance rates to tigecycline were 16-17%. Two isolates of Finegoldia magna were non-susceptible to chloramphenicol (minimum inhibitory concentrations of 16-32 mg/L). Resistance patterns were different among the different hospitals. CONCLUSIONS: Piperacillin-tazobactam, cefoxitin, and carbapemems are highly active beta-lactam agents against most of the anaerobes. The resistance rates to moxifloxacin and tigecycline are slightly higher than those in the previous study.


    Characterization of Mucoid and Non-Mucoid Streptococcus pneumoniae Isolated From Outpatients.

    Ann Lab Med 2015; 35 (4): 410-5

    BACKGROUND: Streptococcus pneumoniae causes pneumonia, sepsis, and meningitis. This study aimed to investigate the clinical characteristics of mucoid and non-mucoid isolates of S. pneumoniae, and to explore the relationship between the isolate phenotypes and their antibiotic susceptibility. METHODS: Clinical isolates from 3,453 non-repetitive S. pneumoniae (189 mucoid and 3,264 non-mucoid) infections obtained between January 2008 and December 2012 from outpatients at the Kimitsu-Central Hospital were evaluated. RESULTS: Compared to the non-mucoid isolates, the mucoid phenotypes were more susceptible to certain antibiotics such as erythromycin, clarithromycin, and tetracycline as opposed to clindamycin, chloramphenicol, and rifampicin. The mucoid phenotype was isolated more frequently from schoolchildren, adults, and elderly adults in a variety of clinical sites, including otorrhea, genitalia, pus, and eye discharge than the non-mucoid phenotype. This suggested that mucoid isolates are more likely to be involved than non-mucoid isolates in various local infections. Systemic infection, which indicates invasiveness, was not associated with the mucoid or non-mucoid phenotype. CONCLUSIONS: The results of this study suggest that mucoid isolates tend to have higher susceptibility than non-mucoid isolates to antibiotics. To the best of our knowledge, mucoid and non-mucoid S. pneumoniae isolates considerably differ in terms of clinical isolation site and age-specific prevalence.


    Antimicrobial susceptibility of clinical isolates of Bacteroides fragilis group organisms recovered from 2009 to 2012 in a Korean hospital.

    Ann Lab Med 2015; 35 (1): 94-8

    BACKGROUND: Periodic monitoring of antimicrobial resistance trends of clinically important anaerobic bacteria such as Bacteroides fragilis group organisms is required. We determined the antimicrobial susceptibilities of clinical isolates of B. fragilis group organisms recovered from 2009 to 2012 in a tertiary-care hospital in Korea. METHODS: A total of 180 nonduplicate clinical isolates of B. fragilis group organisms were collected in a tertiary care hospital. The species were identified by conventional methods: the ATB 32A rapid identification system (bioMerieux, France) and the Vitek MS matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (bioMerieux). Antimicrobial susceptibility was determined by the CLSI agar dilution method. RESULTS: Imipenem and meropenem resistance rates were 0-6% for B. fragilis group isolates. The rate of resistance to piperacillin-tazobactam was 2% for B. fragilis and 0% for other Bacteroides species, but 17% for B. thetaiotaomicron isolates. High resistance rates to piperacillin (72% and 69%), cefotetan (89% and 58%), and clindamycin (83% and 69%) were observed for B. thetaiotaomicron and other Bacteroides spp. The moxifloxacin resistance rate was 27% for other Bacteroides spp. The MIC50 and MIC90 of tigecycline were 2-4 microg/mL and 8-16 microg/mL, respectively. No isolates were resistant to chloramphenicol or metronidazole. CONCLUSIONS: Imipenem, meropenem, chloramphenicol, and metronidazole remain active against B. fragilis group isolates. Moxifloxacin and tigecycline resistance rates are 2-27% and 8-15% for B. fragilis group isolates, respectively.


    Detection of the efflux-mediated erythromycin resistance transposon in Streptococcus pneumoniae.

    Ann Lab Med 2015; 35 (1): 57-61

    BACKGROUND: The present analysis focuses on phenotypic and genotypic characterizations of efflux-mediated erythromycin resistance in Streptococcus pneumoniae due to an increase in macrolide resistance in S. pneumoniae worldwide. METHODS: We investigated the prevalence of efflux-mediated erythromycin resistance and its relevant genetic elements from 186 specimens of S. pneumonia isolated from clinical and normal flora from Tehran, Iran. The presence of erythromycin resistance genes was tested by PCR with two sets of primers, specific for erm(B) and mef(A/E), and their genetic elements with tetM, xis, and int genes. Isolates were typed with the BOX PCR method and tested for resistance to six antibiotics. RESULTS: Antibiotic susceptibility tests revealed that 100% and 47% isolates were resistant to tetracycline and erythromycin, respectively. The erythromycin and clindamycin double-disc diffusion test for macrolide-lincosamide-streptograminB (MLSB) resistance phenotype showed 74 (84%) isolates with the constitutive MLSB phenotype and the remaining with the M phenotype. BOX PCR demonstrated the presence of 7 types in pneumococci with the M phenotype. Fourteen (16%) isolates with the M phenotype harbored mef(A/E), tetM, xis, and int genes. CONCLUSIONS: The present results suggest dissemination of polyclonal groups of S. pneumoniae with the M phenotype carrying resistance genes attributed to transposon 2009.


    First report of neutrophil involvement of exflagellated Plasmodium vivax microgametes.

    Ann Lab Med 2014; 34 (6): 481-3


    Comparison of supplemented Brucella agar and modified Clostridium difficile agar for antimicrobial susceptibility testing of Clostridium difficile.

    Ann Lab Med 2014; 34 (6): 439-45

    BACKGROUND: Antimicrobial susceptibility testing (AST) of Clostridium difficile is increasingly important because of the rise in resistant strains. The standard medium for the AST of C. difficile is supplemented Brucella agar (sBA), but we found that the growth of C. difficile on sBA was not optimal. Because active growth is critical for reliable AST, we developed a new, modified C. difficile (mCD) agar. C. difficile grew better on mCD agar than on sBA. METHODS: C. difficile isolates were collected from patients with healthcare-associated diarrhea. sBA medium was prepared according to the CLSI guidelines. Homemade mCD agar containing taurocholate, L-cysteine hydrochloride, and 7% horse blood was used. For 171 C. difficile isolates, we compared the agar dilution AST results from mCD agar with those from sBA. RESULTS: No significant differences were observed in the 50% minimal inhibitory concentration (MIC50) and 90% minimal inhibitory concentration (MIC90) of clindamycin (CLI), metronidazole (MTZ), moxifloxacin (MXF), piperacillin-tazobactam (PTZ), and rifaximin (RIX), but the values for vancomycin (VAN) were two-fold higher on mCD agar than on sBA. The MICs of CLI, MXF, and RIX were in 100% agreement within two-fold dilutions, but for MTZ, VAN, and PTZ, 13.7%, 0.6%, and 3.1% of the isolates, respectively, were outside the acceptable range. CONCLUSIONS: The MIC ranges, MIC50 and MIC90, were acceptable when AST was performed on mCD agar. Thus, mCD agar could be used as a substitute medium for the AST of C. difficile.


    Are we under-estimating basic first line drug regimes of beta-lactam antibiotics clindamycin and metronidazole in dental oral and maxillofacial infections?

    Ann Maxillofac Surg 2013; 3 (1): 104-5


    Evaluation of bacterial spectrum of orofacial infections and their antibiotic susceptibility.

    Ann Maxillofac Surg 2012; 2 (1): 46-50

    INTRODUCTION: The inappropriate use of antibiotics has contributed to a worldwide problem of antimicrobial resistance. The objective of present study is to assess the most common microorganisms causing orofacial infections and their antimicrobial susceptibility to routinely used antibiotics in this part of India. MATERIALS AND METHODS: Sixty eight patients with orofacial infection were selected on the basis of a series of predefined inclusion and exclusion criteria. Samples were collected under aseptic conditions and subjected to culture and antibiotic susceptibility testing. Descriptive statistics were provided. RESULTS: A total of 64 aerobic and 87 anaerobic strains were isolated. The predominant bacteria were Streptococci viridans (64%), Prevotella (43%), Peptostreptococcus (26%), Porphyromonas (7%), and Fusobacterium (14%). The isolated strains seemed to be highly sensitive to the routinely used antibiotics such as amoxicillin - clavulanate and amoxicillin alone, clindamycin, and levofloxacin. In contrast, more resistance to erythromycin was observed. CONCLUSION: Amoxicillin still possesses powerful antimicrobial activity against major pathogens in orofacial odontogenic infections. Amoxicillin/clavulanate and clindamycin would also be advocated as being useful alternatives for the management of severe orofacial infections. However, the findings of this study indicate that erythromycin is of questionable benefit in the treatment of severe orofacial odontogenic infections.


    Necrotising soft tissue infection in a UK metropolitan population.

    Ann R Coll Surg Engl 2015; 97 (1): 46-51

    INTRODUCTION: Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice. METHODS: Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated. RESULTS: Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1-17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality. CONCLUSIONS: In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.


    Maternal colonization of group B streptococcus: prevalence, associated factors and antimicrobial resistance.

    Ann Saudi Med 2015; 35 (6): 423-7

    BACKGROUND AND OBJECTIVES: Group B streptococcus (GBS, Streptococcus agalactiae) can be transferred during delivery to neonates from mothers who are colonized with GBS in the genital tract. GBS can cause sepsis and meningitis in newborns. This study was conducted to determine GBS colonization rates among pregnant women and the antibiotic sensitivity patterns. DESIGN AND SETTING: Prospective descriptive study at the Maternity and Children Hospital, Makkah. PATIENTS AND METHODS: Vaginal swabs from 1328 pregnant women (>=35 weeks of gestation) attending antenatal clinic were cultured in Todd-Hewitt broth supplemented with gentamicin and nalidixic acid. After 36 hours of incubation, subculture was made onto sheep blood agar and incubated in 5% carbon dioxide for 18 to 24 hours. A Microscan Walk Away system was used for the identification and antibiotic susceptibility of GBS isolates. Each isolate was also tested for group B by using latex slide agglutination test. Information such as maternal age, gestational age and parity was collected using a predesigned questionnaire. RESULTS: The study population ranged between ages 17-47 years. The GBS colonization in all age groups was found to be 13.4%. A higher colonization rate was seen in pregnant women > 40 years of age (27.4%). Women with gestational age > 42 weeks were colonized (25%) more frequently that women with a gestational age from 41-42 weeks (20.2%). An increased rate of colonization was found in women who delivered > 5 times and no colonization in women who delivered once. All GBS isolates were 100% sensitive to penicillin G, ampicillin and vancomycin. Erythromycin and clindamycin showed resistance-15.7% and 5.1%, respectively. CONCLUSION: The high prevalence of GBS colonization in pregnant women demands for screening in women attending an antenatal clinic so that intrapartum antimicrobial prophylaxis can be offered to all women who are colonized with GBS, thus preventing its transfer to the newborn.


    Methicillin-resistant Staphylococcus aureus nosocomial infection trends in Hospital Universiti Sains Malaysia during 2002-2007.

    Ann Saudi Med 2010; 30 (5): 358-63

    BACKGROUND AND OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen that causes severe morbidity and mortality in many hospitals worldwide. The aim of the present study was to assess the burden of MRSA nosocomial infection, its association with factors of interest, and its antimicrobial susceptibility. METHODS: This was a retrospective analysis of a database of all S aureus that were cultured from patients admitted to the different wards of Hospital Universiti Sains Malaysia (HUSM) over a period of 6 years. RESULTS: The MRSA infections rate was 10.0 per 1000 hospital admissions. The incidence density rate of MRSA infections during the study period was 1.8 per 1000 patient-days, with annual rates ranging from 0.95 to 3.47 per 1000 patient-days. Duration of hospitalization, previous antibiotic use, and bedside invasive procedures were significantly higher among MRSA than methicillin-sensitive S aureus patients (P>.05). The highest number of MRSA infections were found in orthopedic wards (25.3%), followed by surgical wards (18.2%) and intensive care units (ICUs) (16.4%). All MRSA isolates were resistant to erythromycin (98.0%), co-trimoxazole (94.0%) and gentamicin (92.0%). Clindamycin was the best antibiotic with only 6% resistance. All MRSA isolates were sensitive to vancomycin. CONCLUSION: The rate of nosocomial MRSA infection per 1000 admissions was higher than that in other studies. The three factors associated most significantly with acquired MRSA infections included duration of hospitalization, antibiotic use, and bedside invasive procedures. This study confirmed that vancomycin-resistant S aureus has not yet been established in HUSM.


    Results of a multicenter trial comparing imipenem/cilastatin to tobramycin/clindamycin for intra-abdominal infections.

    Ann Surg 1990; 212 (5): 581-91

    We designed a multicenter study to compare tobramycin/clindamycin to imipenem/cilastatin for intra-abdominal infections. We included the Acute Physiology and Chronic Health Evaluation (APACHE II) index of severity and excluded patients without established infection. Two hundred ninety patients were enrolled, of whom 162 were evaluable. Using logistic regression to analyze both outcome at the abdominal site of infection and outcome as mortality, we found a significant correlation for both with APACHE II score (p less than 0.0001 for both). Next we analyzed the residual effect of treatment assignment and found a significant improvement in outcome for imipenem/cilastatin-treated patients (p = 0.043). The differences in outcome were explained by a higher failure rate for patients with gram-negative organisms for tobramycin/clindamycin-treated patients (p = 0.018). This was reflected in a significantly higher incidence of fasciitis requiring reoperation and prosthetic fascial replacement. Maximum peak tobramycin levels were analyzed for 63 tobramycin/clindamycin patients harboring gram-negative organisms. For failures the maximum peak was 6.4 +/- 1.9 micrograms/mL, and time to maximum peak was 4.6 +/- 5.2 days. For successes the maximum peak was 6.1 +/- 1.7 micrograms/mL, occurring at 3.8 +/- 2.6 days. This study supports inclusion of severity scoring in statistical analyses of outcome results and supports the notion that imipenem/cilastatin therapy improves outcome at the intra-abdominal site of infection as compared to a conventionally prescribed amino-glycoside-based regimen.


    Beyond PubMed : called unfree

    Prophylactic Antibiotic Management of Surgical Patients Noted as "Allergic" to Penicillin at Two Academic Hospitals.

    A A Case Rep 2016; 6 (9): 263-7

    We studied prophylactic antibiotics administered at 2 academic medical centers during a 6-year period where a cephalosporin was indicated but an "allergy" to penicillin was noted. Another drug (typically vancomycin or clindamycin) was substituted approximately 80% of the time; this occurred frequently even when symptoms unrelated to acute hypersensitivity were listed. In >50% of cases, the reaction was either omitted or vague (e.g., simply "rash"). Given the estimated 1% cross-reactivity between penicillins and cephalosporins with similar R1 side chains, many of these patients could have received either the prescribed cephalosporin or another cephalosporin with a different R1 side chain.


    Treatment of methicillin-resistant Staphylococcus aureus surgical site infections.

    AACN Adv Crit Care 2011; 22 (1): 5-12; quiz 14


    Transfersomal Nanoparticles for Enhanced Transdermal Delivery of Clindamycin.

    AAPS PharmSciTech 2016; 17 (5): 1067-74;

    The aim of this work was to study the potential of delivering clindamycin phosphate, as an efficient antibiotic drug, into a more absorbed, elastic ultradeformable form, transfersomes (TRSs). These vesicles showed an enhanced penetration through ex vivo permeation characters. TRSs were prepared using thin-film hydration method. Furthermore, they were evaluated for their entrapment efficiency, size, zeta potential, and morphology. Also, the prepared TRSs were converted into suitable gel formulation using carbopol 934 and were evaluated for their gel characteristics like pH, viscosity, spreadability, homogeneity, skin irritation, in vitro release, stability, and ex vivo permeation studies in rats. TRSs were efficiently formulated in a stable bilayer vesicle structure. Furthermore, clindamycin phosphate showed higher entrapment efficiency within the TRSs reaching about 93.3% +/- 0.8 and has a uniform particle size. Moreover, the TRSs surface had a high negative charge which indicated the stability of the produced vesicles and resistance of aggregation. Clindamycin phosphate showed a significantly higher in vitro release (p < 0.05; ANOVA/Tukey) compared with the control carbopol gel. Furthermore, the transfersomal gel showed a significantly higher (p < 0.05; ANOVA/Tukey) cumulative amount of drug permeation and flux than both the transfersomal suspension and the control carbopol gel. In conclusion, the produced results suggest that TRS-loaded clindamycin are promising carriers for enhanced dermal delivery of clindamycin phosphate.


    Erratum to: Transfersomal Nanoparticles for Enhanced Transdermal Delivery of Clindamycin.

    AAPS PharmSciTech 2016; 17 (6): 1507;


    Calcium Phosphate Nanoparticles as Intrinsic Inorganic Antimicrobials: The Antibacterial Effect.

    ACS Appl Mater Interfaces 2018; 10 (40): 34013-34028

    Cheap and simple to make, calcium phosphate (CP), thanks to its unusual functional pleiotropy, belongs to the new wave of abundant and naturally accessible nanomaterials applicable as a means to various technological ends. It is used in a number of industries, including the biomedical, but its intrinsic antibacterial activity in the nanoparticle form has not been sufficiently explored to date. In this study, we report on this intrinsic antibacterial effect exhibited by two distinct CP phases: an amorphous CP (ACP) and hydroxyapatite (HAp). The effect is prominent against a number of regular bacterial species, including Staphylococcus aureus, Staphylococcus epidermis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa, but also their multidrug-resistant (MDR) analogues. Although ACP and HAp displayed similar levels of activity against Gram-negative organisms, ACP proved to be more effective against the Gram-positive ones, with respect to which HAp was mostly inert, yet this trend became reversed for the MDR strains. In addition to the intrinsic antimicrobial effect of CP nanoparticles, we have also observed a synergistic effect between the nanoparticles and certain antibiotics. Both forms of CP were engaged in a synergistic relationship with a variety of concomitantly delivered antibiotics, including ampicillin, kanamycin, oxacillin, vancomycin, minocycline, erythromycin, linezolid, and clindamycin, and enabled even antibiotics completely ineffective against particular bacterial strains to significantly suppress their growth. This relationship was complex; depending on a particular CP phase, bacterial strain and antibiotic, the antibacterial activity (i) intensified proportionally to the nanoparticle concentration, (ii) plateaued immediately after the introduction of nanoparticles in minute amounts, or (iii) exhibited concentration-dependent minima due to stress-induced biofilm formation. These findings present grounds for the further optimization of CP properties and maximization of this intriguing effect, which could in the long run make this material comparable in activity to the inorganics of choice for this application, including silver, copper, or zinc oxide, while retaining its superb safety profile and positive eukaryotic versus prokaryotic cell selectivity.


    Human Milk Oligosaccharides (HMOs) Sensitize Group B Streptococcus to Clindamycin, Erythromycin, Gentamicin, and Minocycline on a Strain Specific Basis.

    ACS Chem Biol 2018; 13 (8): 2020-2026

    Human milk oligosaccharides (HMOs) possess antimicrobial and antibiofilm activity against Group B Streptococcus (GBS). HMOs were screened for their ability to potentiate antibiotic activity. We observed that HMOs potentiate the function of aminoglycosides, lincosamides, macrolides, and tetracyclines on a strain specific basis but not beta-lactams or glycopeptides that inhibit cell wall synthesis. These findings are notable as GBS has evolved high levels of resistance toward aminoglycosides, macrolides, and tetracyclines. Finally, HMOs potentiate the function of aminoglycosides against both Staphylococcus aureus and Acinetobacter baumannii. On the basis of these observations, we hypothesized that HMOs act by increasing membrane permeability. This hypothesis was evaluated using a bacterial membrane permeability assay which revealed that HMOs increase membrane permeability toward propidium iodide.


    Assessing Antibiotic Permeability of Gram-Negative Bacteria via Nanofluidics.

    ACS Nano 2017; 11 (7): 6959-6967

    While antibiotic resistance is increasing rapidly, drug discovery has proven to be extremely difficult. Antibiotic resistance transforms some bacterial infections into deadly medical conditions. A significant challenge in antibiotic discovery is designing potent molecules that enter Gram-negative bacteria and also avoid active efflux mechanisms. Critical analysis in rational drug design has been hindered by the lack of effective analytical tools to analyze the bacterial membrane permeability of small molecules. We design, fabricate, and characterize the nanofluidic device that actively loads more than 200 single bacterial cells in a nanochannel array. We demonstrate a gigaohm seal between the nanochannel walls and the loaded bacteria, restricting small molecule transport to only occur through the bacterial cell envelope. Quantitation of clindamycin translocation through wild-type and efflux-deficient (DeltatolC) Escherichia coli strains via nanofluidic-interfaced liquid chromatography mass spectrometry shows higher levels of translocation for wild-type E. coli than for an efflux-deficient strain. We believe that the assessment of compound permeability in Gram-negative bacteria via the nanofluidic analysis platform will be an impactful tool for compound permeation and efflux studies in bacteria to assist rational antibiotic design.


    Occurrence of metronidazole and imipenem resistance among Bacteroides fragilis group clinical isolates in Hungary.

    Acta Biol Hung 2001; 52 (2-3): 271-80

    During the period between 1987 and 1997, various surveillances of the antibiotic resistance of B. fragilis group isolates revealed that practically all the isolates tested were susceptible to imipenem, metronidazole and chloramphenicol; very few isolates (2.5%) exhibited resistance to amoxicillin/clavulanic acid. However, similarly as in some southern European countries, the percentages of the isolates that were resistant to ampicillin, tetracycline and clindamycin were high throughout this period, and the resistance to cefoxitin increased from 6% to 16%. In 2000, isolates with intermediate or high resistance to imipenem and isolates with increased MICs to metronidazole were emerging among the clinical isolates of B. fragilis. The presence of the cfiA gene was demonstrated by PCR in 7 of 242 isolates (2.9%); 2 of them with high MICs to carbapenems harboured the IS942 element immediately upstream of the resistance genes. In the 2 B. fragilis isolates with increased MICs to metronidazole, the nim gene could be detected by PCR. The IS1186 element was found in these isolates upregulating the metronidazole resistance gene.


    Cefepime/clindamycin vs. ceftriaxone/clindamycin for the empiric treatment of poisoned patients with aspiration pneumonia.

    Acta Biomed 2008; 79 (2): 117-22

    Different antimicrobial treatments have proved to be effective in patients with aspiration pneumonia. However, resistant bacterial strains are commonly observed in hospital settings challenging the empirical treatment of these patients. In this study, we aimed to compare the efficacy of cefepime/clindamycin and ceftriaxone/clindamycin for empiric therapy of poisoned patients with aspiration pneumonia. In an open, randomized, prospective design, 140 consecutive patients aged more than 13 years, with radiographic signs of infiltration in chest radiography and dullness on percussion or pulmonary rales or ronchi in combination with at least two of the following clinical criteria were considered as eligible: fever > or = 37 degrees C (axillary), or hypothermia < 35 degrees C (axillary) and leukocytosis (> 10 cells/mm3), or leukopenia (< 3,000 cells/mm3), a left-shift of > 10%, or purulent sputum or secretion from trachea or bronchi. Participants received intravenously either ceftriaxone 1 g q12 h and clindamycin 900 mg q8 h (group 1) or cefepime 1 g q12 h and clindamycin 900 mg q8 h (group 2). On day 5 of treatment, the number of improved/cured patients was not different between groups (OR 0.86; 95% CI 0.24 to 2.90) nor at 14 days of the study (OR 0.66; 95% CI 0.12 to 3.29). Six patients died in group 1 and 5 in group 2 (RR 0.83; 95% CI 0.28 to 2.46). In conclusion, efficacy of empiric treatment of poisoned patients with aspiration pneumonia with ceftriaxone/clindamycin was comparable to treatment with cefepime/clindamycin.


    Calciphylaxis in a cardiac patient without renal disease.

    Acta Cardiol 2009; 64 (1): 91-3

    Calciphylaxis is a rare complication that occurs in 1% of patients with end-stage renal disease (ESRD) each year. Extensive microvascular calcification and occlusion/thrombosis lead to violaceous skin lesions, which progress to nonhealing ulcers with secondary infection, often leading to sepsis and death. The lower extremities are predominantly involved (roughly 90% of patients). Although most calciphylaxis patients have abnormalities of the calcium-phosphate axis or elevated levels of parathyroid hormone, these abnormalities do not appear to be fundamental to the pathophysiology of the disorder. We report on a case of histologically proven calciphylaxis in a 54-year-old woman with normal renal function and normal calcium-parathyroid homeostasis. She had a history of alcoholic cardiomyopathy, and was treated with warfarin anticoagulation. She has been successfully treated with antibiotics, i.v. biophosphonates and intensive local wound care. We recorded a complete wound healing in contrast to what is reported in other series.


    An atypical case of necrotizing fasciitis of the breast.

    Acta Chir Belg 2014; 114 (3): 215-8

    Necrotizing fasciitis is a rare and aggressive soft tissue infection involving the fascia and subcutaneous tissues. It carries a high mortality and morbidity rate. In literature, the few case reports on necrotizing fasciitis of the breast, describe the need for a mastectomy in 90% of the cases. We report on a case of a 72-year old Caucasian women with an atypical presentation of necrotizing fasciitis of the breast in combination with an acute abdomen, successfully treated with breast-conserving debridement and secondary wound closure.


    Necrotizing fasciitis: case report and review of literature.

    Acta Chir Belg 2007; 107 (1): 29-36

    We report a case of necrotizing fasciitis of the lower limb. This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles. Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to clinical findings. Paucity of cutaneous findings early in the course of the disease makes diagnosis challenging. The confirmation of the diagnosis is often made after surgical debridement. Delay in diagnosis and/or treatment correlates with poor outcome, leading to sepsis and/or multiple organ failure. Radiologic studies including plain radiographs, CT-scan or MRI may help to diagnose necrotizing fasciitis. Prompt surgical debridement, intravenous antibiotics, fluids and electrolytes management and analgesia are mainstays of the therapy. Adjuvant treatments like clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed.


    Piperacillin-tazobactam treatment for severe intra-abdominal infections.

    Acta Chir Belg 1995; 95 (3): 162-5

    In this limited series of 23 patients suffering from severe or life-threatening intra-abdominal infection, piperacillin + tazobactam, together with adequate surgical drainage and resections, cured 78% of our patients and eradicated almost all the pathogens. Side effects included essentially eosinophilia and elevation of transaminases but was never severe. Piperacillin + tazobactam seem thus to be an acceptable treatment, associated with correct surgical drainage. This regimen has to be compared in appropriate trial versus gold standard therapy, such as imipenem, a beta-lactam with aminoglucoside and imidazole or clindamycin or with broad spectrum beta-lactam and other inhibitors or beta-lactamases, but our rate of cure is impressive in such a population.


    La cefamandole comme antibiotique phophylactique en chirurgie abdominale. Etude comparee cefamandole versus clindamycine/tobramycine.

    Acta Chir Belg 1980; 79 (5): 321-6

    A prospective, randomized and controlled study of prophylactic A.B. was made in 100 patients prior to abdominal surgery. Fifty patients received 3 x 2 g of cefamandole I.V. within 24 hrs, the first dose being given at the time of anesthetic induction. Postoperative infections occurred in 2% of this group. Fifty patients received the association Clindamycin-Tobramycin (clindamycin 600 mg - tobramycin 80 mg/8 hrs) for 24 hrs, the first dose also at the induction of anesthesia. The complication rate in this group was 18%. The difference between those 2 groups is statistically significant (p less than 0.01). Cefamandole used as a prophylactic antibiotic in abdominal surgery reduces the incidence of postoperative wound infections when compared to the association clindamycin-tobramycin.


    Single-dose parenteral antibiotic prophylaxis in gastrointestinal surgery.

    Acta Chir Belg 1980; 79 (1): 27-33

    In the course of two consecutive, double-blind and prospective studies, the authors evaluated the prophylactic effect of a single peroperative intravenous dose of gentamicin (this study included 166 patients) or the combination gentamicin and clindamycin (this study included 127 patients), on the wound infection rate following interventions involving the incision of an abdominal hollow viscus. Antibiotic prophylaxis lowered the post-operative wound sepsis rate, especially following clinically contaminated interventions, but this reduction did not reach statistical significance. It is concluded that a single peroperative parenteral dose of antibiotics does not constitute an entirely satisfactory means of wound infection prophylaxis in digestive surgery.


    Smislena uporaba antibiotikov po kirurskih posegih v trebusni votlini.

    Acta Chir Iugosl 1982; 29 (2): 165-72

    Surgical drainage is the most important treatment of infections of the abdomen. In severe cases supplementary antibiotic treatment is needed. Rational selection of antimicrobial therapy is based on a thorough knowledge of the invading pathogens. It should be taken into account that most abdominal infections are polymicrobic from which both aerobes, mainly enterobacteria, and anaerobes, mainly bacteria of the genus Bacteroides, are isolated. Such infections are synergistic processes, in which multiple bacteria act together to produce the disease. A group of 75 patients with infections following abdominal surgery was entered into the study. The in vitro results demonstrated that cefoxitin with or without an aminoglycoside or clindamycin plus an aminoglycoside was effective against the isolated bacteria. Cefoxitin was active against 94.7% of strains Bacteroides, against 98.1% of strains E. coli and against the majority of other (less frequent) bacteria, except against Pseudomonas aeruginosa, Enterococci and Peptococci. Clindamycin was active against anaerobic bacteria, and against some aerobic bacteria too; but it had no effect against E. coli and the majority of other enterobacteria. The aminoglycoside were effective against enterobacteria but they showed no activity against Gram-negative non-sporing anaerobes. The clinical outcome demonstrated that clindamycin plus an aminoglycoside and cefoxitin without or (sometimes) with an aminoglycoside were effective in the therapy of mixed abdominal infections.


    Septicka sakroiliitida komplikovana pseudoaneuryzmatem arteria iliaca interna - kazuistika.

    Acta Chir Orthop Traumatol Cech 2016; 83 (1): 50-4

    The case of a 67-year-old woman with a combination of pelvic pyomyositis and left-sided sacroiliitis is reported. After a failed two-week antibiotic therapy, CT-guided percutaneous drainage of psoas muscle abscesses was performed and methicillin-resistant Staphylococcus aureus (MRSA) was isolated. Subsequently, a regression of symptoms was observed. At 6.5 weeks after the onset of symptoms, progression of sacroiliac joint (SI) destruction was again observed and an open revision of the SI joint was indicated (posterior approach, drainage and lavage). This again was followed by symptom regression. At 9.5 weeks after the patient was admitted, her condition markedly deteriorated and a large gluteal abscess was detected on CT examination. The second revision surgery was complicated by massive bleeding and, due to a septic pseudoaneurysm, internal iliac artery ligation was necessary. A significant subsidence of inflammatory changes and no pseudoaneurysm were shown on the follow-up CT scan. The intravenous antibiotic therapy with clindamycin was continued. At follow-up, repeated microbiological cultures from both tissue samples and drained secretions were all negative and CT scanning detected neither any fluid around the SI joint nor a pseudoaneurysm.


    Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 3-year follow-up.

    Acta Chir Scand 1984; 150 (8): 689-92

    Conventional incision and drainage was compared with incision plus curettage and primary suture of abscess cavity under antibiotic cover in a prospective, randomized trial of 83 patients with acute anorectal abscess with or without low fistula. All the patients were followed up for three years. The time to healing was on average three weeks less after suture than after incision alone. The difference was statistically significant. Primary healing was obtained in 32 of 42 cases after suture. Recurrence of abscess tended to be more frequent after suture, but the time to healing of initial and recurrent abscesses and fistulas in the three-year observation period continued to be three weeks less after suture than after incision alone, making suture the most attractive treatment.


    The effect of one prophylactic dosage of antibiotics on experimentally induced lethal intraabdominal sepsis.

    Acta Chir Scand 1984; 150 (3): 239-44

    In order to study the effect of one preoperative dosage of antibiotic on the mortality rate, incidence of abscesses, adhesions and intraperitoneal fluid, a previously described reproducible experimental model of intraabdominal infections in rats has been used. Preoperatively, the rats were fed with lean ground beef for two weeks in order to change the intestinal microflora into a microflora similar to humans. The antibiotics tested were: doxycycline (1 mg), cefoxitin (40 mg), tinidazole (8 mg) + netilmicin (5 mg), clindamycin (150 mg) + netilmicin (5 mg) and trimethoprimsulfa (76.8 mg) + tinidazole (8 mg). The results indicate that one preoperative dosage of the antibiotic(s) significantly reduces the mortality rate in rats with intraabdominal sepsis. Intraperitoneal fluid was observed in all non-surviving rats, whereas in the surviving animals no fluid was present regardless of the type of antibiotic. The rate of intraabdominal abscesses was significantly higher in the doxycycline group compared with the other treated groups, indicating an inadequate anaerobic cover of doxycycline. The incidence of intraabdominal postoperative adhesions was similar in all groups except the trimethoprimsulfa + tinidazole group, which had a significantly lower number of rats with adhesions.


    Diffuse peritonitis treated with tobramycin and clindamycin. Bacteria in relation to preoperative duration of illness.

    Acta Chir Scand 1983; 149 (6): 573-8

    Twenty consecutive patients, mean age 71 years, with a peroperative diagnosis of diffuse peritonitis were treated with clindamycin and tobramycin. The aim of this open prospective study was to correlate bacterial findings at operation to the duration of illness. The effectiveness of the treatment was also evaluated. The number of aerobic strains from peritoneal cultures outnumbered anaerobes when duration of illness was less than three days, while the opposite was evident when duration was longer. All isolates were fully susceptible to the antibiotic combination except for four anaerobic strains with MIC greater than 1 mg/l for clindamycin. The response to treatment was good in 18 patients, fair in one and poor in one.


    High-dose tobramycin combined with clindamycin or lincomycin in the treatment of septic peritonitis and intraabdominal sepsis.

    Acta Chir Scand 1981; 147 (5): 339-46

    Tobramycin in combination with clindamycin or lincomycin were used as systemic antibiotics in the treatment of 20 consecutive patients with septic peritonitis or intraabdominal sepsis, 10 of which were in septic shock. Doses were: tobramycin 1.5 mg/kg body weight every 8 hours, with prolonged dosage interval in patients with reduced renal function, clindamycin 0.9 g every 8 hours and lincomycin 1.2 g every 8 hours. Therapy was monitored by means of tobramycin serum concentration determinations and renal function tests. Eventual cure of the infection was obtained in 19 patients. In 2 of these, the effects of the antibiotics were doubtful. Side effects were observed on 8 occasions: One patient had a slight and temporary subjective hearing loss, coinciding with raised trough levels of tobramycin. Diarrhoea occurred in 3 cases and skin reactions in 3 cases. Superinfection with Candida albicans fungemia occurred in one patient. From the overall results it is concluded that the antibiotic regimen is of value in serious life-threatening infections. Although the tobramycin dose was higher than customarily used in Scandinavia at the time, 0 hour and 1 hour serum concentrations remained stable during therapy in patients whose renal function was normal at onset of therapy. Serum creatinine (S-Cr) levels in these patients were also essentially unchanged. Temporary reductions in osmolality (Osm) ratio Osm-urine/Osm-serum occurred in 11 patients despite normal S-Cr, but it was hard to attribute these impairments of renal function to tobramycin specifically. It was also doubtful whether tobramycin further aggravated renal function in those patients where it was impaired at onset of therapy. Thus, no conclusive evidence of clinically important tobramycin-induced nephrotoxicity were found. We suggest that the dosage schedule of tobramycin used in this study is applied when treating serious intraabdominal infections.


    Lemierre's syndrome: a case study with a short review of literature.

    Acta Clin Belg 2019; 74 (3): 206-210

    OBJECTIVE AND IMPORTANCE: Lemierre's syndrome (LS) is a rare condition that typically starts with a bacterial oropharyngeal infection complicated by a thrombophlebitis of the internal jugular vein and septic emboli to the lungs or other organs. The most common organism isolated is Fusobacterium necrophorum, although other causative organisms are isolated in rare cases. CASE PRESENTATION: We discuss a case of LS in a 44-year-old, previously healthy man presenting with an oropharyngeal infection. F. necrophorum was isolated from blood cultures and Computed tomography of the chest demonstrated septic emboli in the lungs. Magnetic resonance imaging showed a thrombophlebitis of the sigmoid and transverse vein with continuity to the internal jugular vein. METHODS: Case report and literature review. RESULTS: F. necrophorum isolates show in vitro susceptibility to metronidazole, clindamycin, beta-lactam/beta-lactamase inhibitor combinations and carbapenems with no signs of resistance or reduced sensitivity. Anticoagulation is believed to play a favourable role in recovery of the disease because of the potential for faster resolution of thrombophlebitis and bacteraemia. Conflicting results exist in literature with many studies or reviews indicating a favourable outcome both with and without anticoagulation. Anticoagulation for LS consists in most cases of Warfarin or Low molecular weight heparins, with the last being the first choice in children. Indications for the use of anticoagulation in literature are significant clot burden, complication of septic emboli, arterial ischemic stroke, poor response to antibiotics, thrombophilia and cerebral infarction. CONCLUSIONS: Antibiotics are considered the mainstay of treatment, although statistically valid trials to evaluate optimal treatment regimens have not yet been conducted due to the low incidence of the infection. The use of anticoagulation in LS is still heavily debated as a result of conflicting results in literature. Due to the disease's low incidence, statistically valid trials that evaluate anticoagulation are lacking. Further prospective and randomized research is needed to establish the benefit of anticoagulation in the treatment of LS.


    A plethora of manifestations following a Mycoplasma pneumoniae infection: a case report.

    Acta Clin Belg 2019; (): 1-6

    Mycoplasma pneumoniae infection can present with a plethora of symptoms and result in a systemic vasculitis by activating a cascade of autoimmune reactions. In this case report, a young man without relevant past medical history was admitted to the hospital with diarrhea, abdominal pain and spiking fever. A CT-scan showed terminal ileitis. A 5-day broad spectrum antibiotic treatment (ciprofloxacin/clindamycin) did not result in any clinical improvement. On the contrary, the patient developed a cholestatic hepatitis, bilateral anterior uveitis and a dry cough. Extensive serological testing finally led to the diagnosis of a M. pneumoniae infection by paired serology (>/=4-fold rise in IgG titer). In the diagnostic work-up, a PET-CT was performed and showed increased tracer uptake in the carotids and vertebral arteries, suggesting the diagnosis of vasculitis. After start of azithromycin and low-dose corticosteroids (0.5 mg/kg/day), a gradual clinical and biochemical improvement was observed. But subsequently, the patients relapsed and presented with an acute coronary syndrome. Coronary angiography revealed aneurysmatic deformation of the three coronary arteries, leading to the assumption of coronary vasculitis. Clinical improvement was achieved with high-dose corticosteroids (1 mg/kg/day). This case shows that M. pneumoniae is not merely a pulmonary infection, but that its primary symptoms can be diverse and misleading. All clinicians should be aware of its extrapulmonary manifestations.


    Streptococcal toxic shock syndrome in a returning traveller.

    Acta Clin Belg 2018; (): 1-5

    BACKGROUND: A patient presenting with fever and purpura after a stay in the tropics tempts a physician to make a differential diagnosis mainly focusing on imported diseases. Although the importance of considering a tropical disease is obvious, the fact that cosmopolitan infections account for one third of the cases in a febrile returning traveler must not be overseen. Toxic Shock Syndrome is amongst the most notorious diseases due to the high mortality when inappropriately managed and the association with necrotizing fasciitis. Methods : We present a 60-year old female with fever, shock syndrome and progressive appearance of painful purpura on the lower legs after a 2-week holiday in Zanzibar. Results : The patient was diagnosed with Streptococcal Toxic Shock Syndrome. Treatment focusing on aggressive fluid resuscitation, prompt administration of antibiotics (ceftriaxon, doxycycline and one dose of amikacin) and adjunctive treatment by clindamycin and immunoglobulin was initiated. She was also immediately taken into surgery for a bilateral fasciotomy and surgical exploration of the lower legs. Histology appeared compatible with purpura fulminans, thereby excluding necrotizing fasciitis. No source of infection could be identified. Conclusion:Toxic Shock Syndrome remains a challenging diagnosis and even more in a returning traveler with an extensive differential diagnosis containing both tropical and cosmopolitan diseases. Cornerstones for the treatment of Streptococcal Toxic Shock Syndrome are abrupt administration of antimicrobial therapy comprising beta-lactam antibiotics and clindamycin and surgical exploration to apply source control when indicated.


    Sweet's or not: a cutaneous presentation of a severe disease.

    Acta Clin Belg 2016; 71 (2): 114-6


    A forgotten disease in a returning traveler from Thailand.

    Acta Clin Belg 2013; 68 (5): 382-3;

    Cutaneous diphteria is a forgotten disease. We must consider this in our differential diagnosis, not only when a patient presents with a cutaneous ulcer and has travelled to tropical areas, but also in patients who subsist in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse. Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future. We report a case of a foot infection with a non toxigenic C. diptheriae biovar gravis in a 16 year old girl, who has travelled to Thailand.


    Stimulation of the i.v. to oral switch of bioavailable drugs by phone calls in a Belgian tertiary care hospital.

    Acta Clin Belg 2013; 68 (3): 179-82

    INTRODUCTION: Early switch from intravenous to oral administration of drugs with an almost complete oral bioavailability, can have important benefits. Drugs with almost complete bioavailability, like clindamycin (Dalacin), levofloxacin (Tavanic) and paracetamol (Perfusalgan/Dafalgan), are very suitable for an early intravenous to oral switch in patients whose gastrointestinal absorption is intact. The aim of this study was to investigate the impact of direct phone contact between pharmacist and clinician on the intravenous to oral switch and to evaluate the reasons, mentioned by clinicians, that prevented an early switch. MATERIALS & METHODS: The project was initiated in a Belgian 1900-bed tertiary care hospital with a poster, communicated through the hospital's intranet and spread to every hospital ward. During one month, all prescriptions for intravenous clindamycin, levofloxacin and paracetamol were evaluated. The treating clinician was contacted by phone to evaluate if an intravenous to oral switch was possible. RESULTS: Clinicians were contacted concerning 377 patients. For 58.7% of patients, the switch from intravenous to oral administration was made. In case of refusal, several reasons were mentioned by the clinician, some more appropriate than others. CONCLUSION: Despite several appropriate reasons preventing an early intravenous to oral switch, there are still some aberrant opinions circulating in the hospital environment. Active interventions of pharmacists to stimulate intravenous to oral switch, using phone contact with the treating clinicians, can possibly be an adequate technique to stimulate intravenous to oral switch, but this needs to be further optimized.


    Vertebral osteomyelitis with spinal epidural abscess in two patients with Bacteroides fragilis bacteraemia.

    Acta Clin Belg 2008; 63 (3): 193-6

    We report 2 cases of vertebral osteomyelitis and contiguous epidural abscess due to Bacteroides fragilis with no concomitant or past intra-abdominal infection. Decompressive surgery with laminectomy was required for both patients due to the occurrence of neurologic deficits. Clinical recovery was achieved after 8 weeks of antibiotic therapy. It included 3 weeks of intravenous therapy with clindamycin followed by an oral regimen of clindamycin for 1 patient and oral metronidazole for the other. In both cases, magnetic resonance imaging (MRI) has proved to be essential for diagnostic. The primary source of infection remained unknown despite careful investigations.


    Surveillance of antibiotic resistance in non invasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winters 2003 and 2004.

    Acta Clin Belg 2006; 61 (2): 49-57

    A total of 391 and 424 non-invasive isolates of Streptococcus pneumoniae collected by 15 laboratories during the 2003 and 2004 survey were tested for their susceptibility by a microdilution technique following NCCLS recommendations. Insusceptibility rates (IR) in the two surveys (2003/2004) were as follows: penicillin 15.0/14.7% [8.4/6.4% Resistance (R)], ampicillin 17.4/14.6% (R 9.0/7.1%), amoxicillin +/- clavulanic acid 2.6/1.2 % (R 0/0%), cefaclor 14.3/14.1% (R 11.5/13.4%), cefuroxime 13.6/12.7% (R 10.5/11.8%), cefuroxime-axetil 10.5/11.8% (R 10.0/9.2%) (breakpoints based on 250 mg), cefotaxime 4.9/6.2% (R 1.3/2.4%), ceftazidime NotTested (NT)/6.4 (R NT/2.6%), cefepime NT/6.4 (R NT/2.6%), imipenem 7.7/8.9 % (R 1.8/1.4%), ertapenem 0.8/NT% (R O/NT%), ciprofloxacin 13.8/9.0% (R 4.3/2.4%), levofloxacin 3.3/2.8% (R 1.5/0.2%), moxifloxacin 0.6/0.2% (R 0.3/0%), ofloxacin 13.5/9.0% (R 4.3/2.4%), erythromycin 26.1/24.7% (R 25.3/24.5%), azithromycin 25.4/24.7% (R 24.6/24.5%), telithromycin 0.8/0.2% (R 0.5/0%), clindamycin 21.2/18.4% (R 19.2/17.7%) and tetracycline 32.3/22.1% (R 29.2/19.3%). There were only minor differences in resistance rates according to age, sample site, admission type (i.e. ambulatory, hospitalized or long-term care facility patients), gender and geographic origin. Overall, telithromycin (MIC50, MIC90 in 2003/2004: 0.015 microg/ml, 0.12 microg/ml/ 0.008,0.06 respectively), ertapenem (0.03; 0.25/NT), moxifloxacin (0.06; 0.25/0.06, 0.12), and amoxicillin +/- clavulanic acid (0.03; 0.25/0.015, 0.5) were the most active compounds in both surveys. In 2003, the most common resistance phenotype was isolated insusceptibility to tetracycline (10.5%) followed by combined insusceptibility to erythromycin and tetracycline (9.3%). Erythromycin-tetracycline resistance (10.4%) was the most common in 2004. Isolates showing resistance to an antibiotic were significantly more present in 2003 than in 2004 (50.4% versus 40.8%). In penicillin-insusceptible isolates, MICs of all beta-lactams were increased but cross-resistance between penicillin and other beta-lactams in the penicillin-insusceptible isolates was not complete. In the 2003 survey, most of these isolates remained fully susceptible to ertapenem (94.9%) and amoxicillin +/- clavulanic acid (83.1%). In the 2004 survey, 91.9% of the penicillin insusceptible isolates remained susceptible to amoxicillin +/- clavulanic acid. In both surveys, the most common serotypes in penicillin insusceptible isolates were 14, 23,19 and 9 (20.0%, 20.0%, 16.4% and 10.9% respectively in 2003; 41.6%, 11.7%, 15.0% and 18.3% respectively in 2004).


    Antimicrobial susceptibility of group B streptococci collected in two Belgian hospitals.

    Acta Clin Belg 2005; 60 (4): 180-4

    OBJECTIVE: to determine the in vitro susceptibility of group B streptococci (GBS) to antibiotics, used for intrapartum chemoprophylaxis and treatment of infections; to determine the rate of resistance to erythromycin and clindamycin and the phenotype distribution of GBS strains. METHODS: 262 GBS strains from pregnant women at 35-37 weeks' gestation were collected in University Hospital Gasthuisberg (Leuven) and Imelda Hospital (Bonheiden). The minimum inhibitory concentrations (MICs) of penicillin G, amoxicillin, cefazolin, cefotaxime, erythromycin, clindamycin, gentamicin, vancomycin and linezolid were determined by the agar dilution method, according to NCCLS guidelines. RESULTS: all isolates were susceptible to penicillin, amoxicillin, cefazolin, cefotaxime, vancomycin and linezolid. We found resistance rates of 16.7% to erythromycin and 11.0% to clindamycin. Of all erythromycin-resistant strains, 63.6% had the cMLSB phenotype, 20.5% the iMLSB phenotype and 15.9% the M-phenotype. For 25% of erythromycin-resistant strains, the resistance was of a very high level (MICs ranging from 128 microg/mL to 256 microg/mL). All these isolates belong to the cMLSB phenotype. For the remaining 75% the resistance to erythromycin was of low level (MICs ranging from 1 microg/mL to 4 microg/mL). These isolates had the cMLSB phenotype (38.6%), the iMLSB phenotype (20.5%) and the M-phenotype (15.9%). CONCLUSION: the susceptibility of GBS to the beta-lactam antibiotics supports the continued use of penicillin for intrapartum chemoprophylaxis. For women who are allergic to penicillin, clindamycin or erythromycin are considered to be the alternatives, however resistance rates to these antibiotics are significant.


    Surveillance of antibiotic resistance in clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2000-2001.

    Acta Clin Belg 2003; 58 (2): 111-9

    A total of 314 isolates of Streptococcus pneumoniae collected by 10 different laboratories were tested for their susceptibility by using a microdilution technique following NCCLS recommendations. The following antibiotics were included: penicillin, ampicillin, amoxicillin, amoxicillin/clavulanate, cefaclor, cefuroxime, cefotaxime, imipenem, ciprofloxacin, gemifloxacin, levofloxacin, erythromycin, clarithromycin, azithromycin, miocamycin, clindamycin and tetracycline. The insusceptibility rate (IR) to penicillin was 21.0% [10.8% intermediate (> or = 0.12-1 microgram/mL) and 10.2% high-level (> or = 2 micrograms/mL)], to cefotaxime 7.3% [3.5% intermediate (> or = 1 microgram/mL) and 3.8% high-level (> or = 2 micrograms/mL)], to imipenem 3.8% [3.8% intermediate (> or = 0.25-0.5 microgram/mL) and 0% high-level (> or = 1 microgram/mL)], to ciprofloxacin 11.2% [8.3% intermediate (2 micrograms/mL) and 3.9% high-level (> or = 4 micrograms/mL)], to erythromycin 30.3% [3.5% intermediate (0.5 microgram/mL) and 26.8% high-level (> or = 1 microgram/mL)] and to tetracycline 38.5% [0.9% intermediate (4 micrograms/mL) and 37.6% high-level (> or = 8 micrograms/mL)]. No decreased susceptibility was found for gemifloxacin (> or = 0.5 microgram/mL). This compound was the most active with MIC50, MIC90 and an IR of 0.015 microgram/mL, 0.03 microgram/mL and 0% respectively, followed by amoxicillin/clavulanate, amoxicillin and imipenem (MIC50, MIC90 and IR: 0.015 microgram/mL, 1 microgram/mL, 1.6%/0.015 microgram/mL, 1 microgram/mL, 1.9%/0.008 microgram/mL, 0.12 microgram/mL, 3.8% respectively). Compared to the 1999 surveillance, penicillin and tetracycline-insusceptibility increased with 4.9% and 15.6% respectively, while cefotaxime, erythromycin and ciprofloxacin insusceptibility decreased with 5.4%, 5.8% and 4.4% respectively. MICs of all beta-lactams rose with those of penicillin for penicillin-insusceptible isolates. Imipenem, cefotaxime, amoxicillin and amoxicillin/clavulanate were generally 4, 2, 1 and 1 doubling dilutions respectively more potent than penicillin on these isolates while ampicillin, cefuroxime and cefactor were generally 1, 2 and 4 dilutions respectively [table: see text] less potent. Most penicillin-insusceptible isolates remained fully susceptible to amoxicillin/clavulanate (92.4%), amoxicillin (90.9%) and imipenem (81.8%). Erythromycin-tetracycline insusceptibility was the most common resistance phenotype (14.3%). Three- and four-fold resistance was found in 12.4% and 1.6% respectively of the isolates. Most penicillin-insusceptible isolates were of capsular types 14 (22.7%), 23 (21.2%), 6 (18.2%), 9 (13.6%) and 19 (12.1%).


    In vitro activity of the new ketolide telithromycin and other antibiotics against Streptococcus pneumoniae in Belgium.

    Acta Clin Belg 2001; 56 (6): 349-53

    In Belgium more than 17% of the invasive pneumococci are not susceptible to penicillin, and more than 38% not to macrolides. The most prevalent mechanism of macrolide resistance in Europe is modification of the drug target site leading to cross-resistance to lincosamides and group B streptogramines (MLSB resistance). Telithromycin is the first antibiotic of the family of ketolides, which differ from erythromycin by having a 3-keto group instead of the neutral sugar L-cladinose. We tested the susceptibility of 637 pneumococci, recently isolated from patients in Belgium, to telithromycin and five other antibiotics. Data generated by this study show that telithromycin inhibits 98.4% of pneumococci at a breakpoint concentration of 1 mg/L in spite of a high percentage (> 30%) of strains with the MLSB constitutive type of resistance. Susceptibilities to the five comparator drugs were: penicillin (81.8%), tetracycline (67.0%), levofloxacin (98.9%), erythromycin (61.5%) and clindamycin (66.6%). Consequently telithromycin looks to have considerable potential for the empiric treatment of community-acquired respiratory tract infections.


    In vitro study on the antimicrobial activity of various antibiotics against clinical isolates of Streptococcus pneumoniae from Belgium collected during winter 1998-1999.

    Acta Clin Belg 2000; 55 (6): 312-22

    A total of 205 isolates of Streptococcus pneumoniae obtained from 10 different centres were included in this study. The susceptibilities to penicillin, ampicillin, amoxicillin, amoxicillin/clavulanic acid, cefaclor, cefuroxime, cefotaxime, imipenem, ciprofloxacin, gemifloxacin, grepafloxacin, levofloxacin, trovafloxacin, erythromycin, clarithromycin, miocamycin, clindamycin and tetracycline were determined by a microdilution technique following NCCLS recommendations. Decreased susceptibility to penicillin was 16.1% [6.8% intermediate (0.12-1 microgram/mL) and 9.3% high-level (> or = 2 micrograms/mL)], cefotaxime insusceptibility (> or = 1 microgram/mL) 12.7%, ciprofloxacine insusceptibility (> or = 2 micrograms/mL) 15.6% with 1.5% of high level resistance (> or = 4 micrograms/mL), erythromycin insusceptibility (> or = 0.5 microgram/mL) 36.1% and tetracycline insusceptibility (> or = 4 micrograms/mL) 22.9%. Decreased susceptibility to cefotaxime was found in 78.8% of the penicillin-insusceptible isolates. No decreased susceptibility was found for gemifloxacin (> or = 0.5 microgram/mL) and trovafloxacin (> or = 1 microgram/mL). Compared to the 1996-1997 surveillance, penicillin, cefotaxime and erythromycin insusceptibility rose by 3.8%, 5.2% and 5.0% respectively, while tetracycline insusceptibility decreased with 8.2%. MICs of all beta-lactams rose with those of penicillin for penicillin-insusceptible isolates. Amoxicillin +/- clavulanate, cefotaxime and imipenem were generally 1, 1 and 5 doubling dilutions respectively more potent than penicillin on these isolates. Penicillin, ampicillin and cefuroxime were equally active while cefaclor was generally 5 dilutions less potent. Most penicillin-insusceptible isolates remained fully susceptible to amoxicillin +/- clavulanate and imipenem. The penicillin-insusceptible isolates were 36.4%, 27.3% and 3.0% co-insusceptible to erythromycin, erythromycin plus tetracycline and tetracycline respectively. A subpopulation of 52 isolates obtained from children aged < or = 3 years was also studied. Compared to the other isolates we found a statistically significant increase in insusceptibility for penicillin, cefaclor, cefuroxime, erythromycin, clarithromycin and tetracycline while a significant decrease was found for ciprofloxacin.


    In vitro activity of amoxycillin/clavulanate and ticarcillin/clavulanate compared with that of other antibiotics against anaerobic bacteria: comparison with the results of the 1987 survey.

    Acta Clin Belg 1996; 51 (2): 70-9

    The activity of amoxycillin/clavulanate (Augmentin) and ticarcillin/ clavulanate (Timentin) was tested against 351 strict anaerobic clinical isolates collected from September 1993 to April 1994 in eight Belgian university hospitals and compared with that of 8 other antibiotics using the NCCLS reference agar dilution procedure. Production of beta-lactamase was detected by the nitrocefin test in 48% of the isolates. At NCCLS-recommended breakpoints, more than 90% of isolates were susceptible to amoxycillin/clavulanate, ticarcillin/clavulanate, piperacillin/tazobactam, imipenem, chloramphenicol and metronidazole but only 77%, 72% and 48% to cefoxitin, clindamycin and penicillin, respectively. In comparison with the results of a similar survey conducted in 1987 no major changes in susceptibility were observed except for the susceptibility to clindamycin that declined from 83% to 72% overall, and from 83% to 66% in the B. fragilis group. Furthermore one isolate of Clostridium clostridioforme was found produce beta-lactamase and few B. fragilis group isolates showed reduced susceptibility to metronidazole.


    Intrathoracic infections with bacteraemia due to Eikenella corrodens as a complication of peritonsillar abscesses: report of a case and review of the literature.

    Acta Clin Belg 1992; 47 (2): 124-8

    A 52-year-old man, without previous disease, presented with dysphagia, dyspnoea, high fever and sore throat after peritonsillar abscesses drainage. Physical and complementary examinations were consistent with pericarditis, mediastinitis, pneumonia and pleuritis. Blood cultures grew Eikenella corrodens resistant to clindamycin and amikacin. We emphasize the pathogenic potential of Eikenella corrodens. To the best of our knowledge, this is the first reported case of this organism as a pathogen in intrathoracic infections after peritonsillar abscesses drainage.


    Streptococcal myositis. A report of two cases.

    Acta Clin Belg 1991; 46 (2): 82-8

    Two patients are described with acute streptococcal myositis. One of them died after a brief duration of illness in multiple organ failure; the other survived extensive muscular damage complicated by diffuse intravascular coagulation, acute renal failure, adult respiratory distress syndrome, bronchopneumonia, Pseudomonas septicaemia and probably streptococcal toxic shock syndrome. Both patients received nonsteroidal antiphlogistics, purportedly involved in the pathogenesis of this syndrome. Based on a mouse model, clindamycin would seem to be the antibiotic of choice.


    In vitro activity of amoxycillin plus clavulanic acid and ticarcillin plus clavulanic acid compared with that of other antibiotics against anaerobic bacteria.

    Acta Clin Belg 1989; 44 (4): 228-36

    The activity of amoxycillin/clavulanic acid (Augmentin) and ticarcillin/clavulanic acid (Timentin) was tested against 303 unselected clinical anaerobic isolates recently collected in seven Belgian university hospitals and compared with that of 11 other antimicrobial agents. Bacteroides spp. accounted for 52.1% of the isolates, Clostridium spp. for 23.4%, anaerobic cocci for 15.5%, nonsporeforming gram-positive bacilli for 4.6% and Fusobacterium spp. for 3.3%. Ticarcillin/clavulanic acid (fixed clavulanic acid concentration of 2 mg/l) was the most active drug with an overall susceptibility rate of 99.7%. Amoxycillin/clavulanic acid (fixed ratio of 2:1) and chloramphenicol inhibited 97.4% of the isolates, metronidazole 95.4%, piperacillin 92.4%, ticarcillin 91.4%, clindamycin 87.8%, cefotetan 81.2%, cefazolin 63.0%, cefuroxime 60.4%, erythromycin 57.8%, penicillin 57.1% and doxycycline 52.1%. beta-lactamases were detected exclusively in Bacteroides spp. isolates (79.1% positive).


    In vitro evaluation of the antibiotic susceptibility of Streptococcus pneumoniae: pneumococci relatively resistant to penicillin in Brussels.

    Acta Clin Belg 1980; 35 (6): 343-8


    Therapeutic efficacy of clindamycin gel as an adjunct to scaling and root planing therapy in chronic periodontal disease.

    Acta Clin Croat 2015; 54 (1): 46-51

    Clindamycin, a lincosamide antibiotic, has been under-recognized as an antimicrobial agent for use in dentistry. The aim of the present work was to evaluate clinical efficacy of 2% clindamycin gel in addition to the basic mechanical periodontal therapy. At baseline, scaling and root planing (SRP) was performed at all 50 subjects (control group and test group). Clindamycin gel was applied after SRP only in the test group. Clinical measurements including periodontal pocket depth (PPD), clinical attachment level (CAL), bleeding on probing (BOP) and plaque index (PI) were done at baseline, and at 3 and 6 months after treatment. Compared to baseline, the PPD and CAL values significantly decreased in the test group (p < 0.05) and were statistically lower (p < 0.05) compared to control group. PPD reduction of 2.42 mm was obtained in the test group and could be generally considered as clinically significant. A PPD reduction greater than 2 mm indicated that clindamycin gel could be used efficiently as an adjunct to SRP. Also, between-group difference in BOP and PI scores was statistically significant 6 months after treatment. In conclusion, the application of clindamycin gel in combination with SRP enhanced the efficacy of non surgical periodontal therapy in reducing pocket depth and improving attachment levels in chronic periodontitis subjects and had additional benefits over mechanical therapy alone.


    Clindamycin hydrochloride monohydrate and its ethanol solvate.

    Acta Crystallogr C 2010; 66 (Pt 2): o97-100

    Clindamycin hydrochloride, an antibiotic of the lincomycin family, was crystallized as the monohydrate, namely (2S,4R)-2-(N-{(1S,2S)-2-chloro-1-[(3R,4S,5R,6R)-3,4,5-trihydroxy-6-(methylsulfany l)perhydropyran-2-yl]propyl}aminocarbonyl)-4-propylpyrrolidinium chloride monohydrate, C(18)H(34)ClN(2)O(5)S(+).Cl(-).H(2)O, (I), and as the monohydrate ethanol solvate, C(18)H(34)ClN(2)O(5)S(+).Cl(-).H(2)O.C(2)H(6)O, (II). The conformation of the clindamycin molecule in both crystal structures is the same and is found to be similar to that in enzyme-bound clindamycin. The simultaneous presence of free chloride ions and water molecules in (I) and of additional ethanol molecules in (II) provides an interesting network of hydrogen bonds. The significance of this study lies in the interactions in these structures and the aggregations occurring via hydrogen bonds in the hydrated and solvated crystalline forms of the title compound.


    A double-blind comparison of topical clindamycin and oral minocycline in the treatment of acne vulgaris.

    Acta Derm Venereol 1990; 70 (6): 534-7

    Sixty-six patients with moderate to severe facial acne vulgaris were entered in a 12-week double-blind study to compare the efficacy of topical clindamycin phosphate 1% twice daily and oral minocycline 50 mg twice daily. Both treatments gave significant overall improvements from baseline observations in acne grade and inflamed lesion counts, but not in noninflamed lesion counts. There were no significant differences between the two treatment groups in respect of acne grade, inflamed or non-inflamed lesion counts. Both treatment regimes were well tolerated. This study has shown that topical clindamycin twice daily is an effective alternative to oral minocycline 50 mg twice daily in the treatment of moderate to severe facial acne vulgaris.


    Antibiotic sensitivity of comedonal Propionibacterium acnes.

    Acta Derm Venereol 1979; 59 (6): 552-54

    Previous studies on antibiotic MIC levels for P. acnes and P. granulosum have shown them generally sensitive to therapeutic levels in both blood and surface lipids. The clinical response of acne vulgaris to antibiotic therapy is slower than one would anticipate from in vitro studies. It is also delayed well beyond the time tetracycline is known to appear in surface lipids. The concentration of antibiotics in comedonal material could be important, but it is not known. To determine the sensitivity level required for such an assay, MIC studies on P. acnes and P. granulosum from comedonal material were carried out from 0.05 to 25 microgram/ml. The assay would need to detect 0.05 microgram/ml or less in comedonal material. Interestingly, two organisms were found to be resistant to one or more antibiotics at the 25 microgram/ml level and another had a MIC level of 12.5 microgram/ml for tetracycline.


    On therapeutic approaches to some special types of acne.

    Acta Derm Venereol Suppl (Stockh) 1985; 120 (): 39-42

    The aim of the present study was to evaluate different treatment schedules in some different types of acne using a quantitative counting technique. Systemic treatment with erythromycine 0.5 g daily and topical treatment with clindamycin phosphate solution 1% was found to be optimal from the efficacy/side effect ratio. The combined treatment was tried in heat-provoked and cosmetic acne with favourable results. Doubling of erythromycine dosage could not prevent premenstrual exacerbation of acne. Diazepam 4 mg daily for two weeks followed by an antihistamine in addition to erythromycine 0.5 g daily gave relatively good results in female patients with acne excorie. In acne coexisting with pronounced seborrhoic dermatitis of the face the addition of hydrocortisone cream 1% was of benefit, although Roaccutane may here be the drug of choice. In female postpubertal acne, the effect of cyproteronacetate-etynilestradiol (Diane) was not superior to treatment with erythromycine 0.5 g daily. By treating special subtypes differently, one could be able to improve the results of acne therapy.


    General considerations by a clinical bacteriologist regarding antibiotic therapy in acne.

    Acta Derm Venereol Suppl (Stockh) 1980; Suppl 89 (): 83-5


    Topical antibiotics and topical antimicrobial agents in acne therapy.

    Acta Derm Venereol Suppl (Stockh) 1980; Suppl 89 (): 75-82


    Awareness, knowledge, and practice patterns of general practitioner residents and specialists toward hidradenitis suppurativa: a survey study.

    Acta Dermatovenerol Alp Pannonica Adriat 2019; 28 (2): 61-63

    INTRODUCTION: Hidradenitis suppurativa (HS) is an unrecognized chronic inflammatory and debilitating disease with severe consequences for patients' quality of life. METHODS: A survey was performed among general practitioner (GP) residents and consultants in order to determine awareness, knowledge, and attitudes about HS. RESULTS: Among 372 respondents, 74% were GP residents in the first 2 years, 22% GP residents in the 3rd and 4th year, and 4% consultants. For a patient with boils and/or recurrent abscesses in folds, 90% considered a diagnosis of HS with no significant difference according to years of experience. These patients were referred to dermatology by 273 residents (80%) and eight consultants (53%), and this difference is statistically significant (p < 0.05). Regarding acute treatment, 84% prescribed topical antibiotics and 76% oral antibiotics. Respecting therapeutic approach, we observed that treatment with non-steroidal anti-inflammatory drugs is higher among older residents (51%) compared to younger ones (36%, p < 0.02) and the prescription of oral clindamycin is higher among consultants (31%) compared to residents (12%, p < 0.04). CONCLUSIONS: Our survey demonstrates that knowledge of HS is lacking among primary care physicians. Communication channels between GPs and dermatologists are often hampered, and so we recommend incorporating medical education into GP residency programs on how to treat mild HS, when to refer, and how to approach HS.


    Successful Treatment with Fusidic Acid in a Patient with Folliculitis Decalvans.

    Acta Dermatovenerol Croat 2019; 27 (1): 49-50

    Dear Editor, Folliculitis decalvans (FD) is a rare form of primary neutrophilic cicatricial alopecia. It is a highly distressing disease that affects young and middle-aged adults, with a slight male predominance (1). The most frequent clinical manifestations are follicular pustules and diffuse and perifollicular erythema that heal with centrifugal scarring. Follicular tufting, erosions, and hemorrhagic crusts can also be present, and this alopecia is most often located at the vertex and occipital area. Patients frequently complain about pain, itching, or burning sensations, and the involvement of other body areas is rare (2). The pathogenesis of this disease remains unclear. Staphylococcus aureus and other hair follicle bacteria can often be isolated from the pustules, suggesting the role of a bacterial infection in its etiology. A defect in the host's immune response can also be postulated by reports of familial cases and the appearance of FD in patients with immunity dysfunctions. Other mechanical factors have been suggested, such as structural abnormalities of the follicle or local inflammation (2). Management of this alopecia is difficult and its course is typically chronic and relapsing. The treatment aim is to stop inflammation and further irreversible destruction of hair follicles. Antibiotics remain the first-line therapy, due both to their anti-inflammatory and antimicrobial properties (1). Although topical fusidic acid is widely used as adjuvant treatment, there are few data regarding its oral use. We report a case of folliculitis decalvans successfully treated with oral fusidic acid. Our patient was a 41-year old Cape Verdean woman with a two month history of alopecia with painful, purulent discharge at the vertex of the scalp. The patient was diagnosed with human immunodeficiency virus type 1 (HIV-1) infection 5 years prior and was stable on her regimen of efavirenz, tenofovir, and emtricitabine, with undetectable viral load. She denied application of topical or capillary products. Dermatological examination revealed a patch of cicatricial alopecia with crusts and follicular pustules (Figure 1). Direct microscopic examination and mycological culture showed no fungal element. A diagnosis of folliculitis decalvans was established and the patient was started on oral fusidic acid at a dose of 500 mg three times a day. Betamethasone dipropionate 0.05% and salicylic acid 3% lotion as well as azelaic acid 5% lotion were also applied to the affected area once daily. After two months of treatment, the patient showed clinical improvement, with less erythema and suppuration of the affected scalp. A partial hair regrowth was noted, mainly at the periphery. Subsequently the patient maintained only topical therapy, and no recurrences were observed after 6-months of follow-up. Fusidic acid is useful in the treatment of skin and soft tissue infections, particularly those due to S. aureus, as shown by randomized controlled studies (3). The clinical efficacy of fusidic acid in the treatment of folliculitis decalvans has been reported previously. Bogg was the first to describe this useful effect (4). Sutter also reported good results with fusidic acid used both topically and orally (500 mg three times a day) (5). However, both failed to report the treatment duration or the outcome on discontinuation. Abeck described three patients that responded to a three week oral course of fusidic acid (500 mg three times a day) and to a maintenance treatment with zinc sulfate (4). During the following year, recurrence was observed in only one patient after ending zinc sulfate therapy. Oral antibiotics are frequently used to treat folliculitis decalvans. Tetracyclines and the combination of clindamycin with rifampicin are the most commonly used (2). However, the disease usually progresses when treatment is stopped. Fusidic acid is an anti-staphylococcal drug with few adverse effects. It is highly bioavailable orally, and has a long plasma half-life. Despite years of clinical use in numerous countries, resistance rates remain at low levels to date (6). Since clinical series or cases including ours have shown good results, this drug should not be forgotten when considering treatment options for folliculitis decalvans.


    Tatami Mats: A Source of Pitted Keratolysis in a Martial Arts Athlete?

    Acta Dermatovenerol Croat 2018; 26 (1): 68-70

    Dear Editor, Pitted keratolysis (PK), also known as keratosis plantaris sulcatum, is a non-inflammatory, bacterial, superficial cutaneous infection, characterized by many discrete superficial crateriform ''pits'' and erosions in the thickly keratinized skin of the weight-bearing regions of the soles of the feet (1). The disease often goes unnoticed by the patient, but when it is noticed it is because of the unbearable malodor and hyperhidrosis of the feet, which are socially unacceptable and cause great anxiety to many of the patients. PK occurs worldwide, with the incidence rates varying based on the environment and occupation. The prevalence of this condition does not differ significantly based on age, sex, or race. People who sweat profusely or wash excessively, who wear occlusive footwear, or are barefoot especially in hot and humid weather are extremely prone to this condition (2). Physicians commonly misdiagnose it as tinea pedis or plantar warts. Treatment is quite simple and straightforward, with an excellent expected outcome if treated properly. We report a case of a 32-year-old male patient with skin changes of approximately one-year duration diagnosed as plantar verrucae, who was referred to our Department for cryotherapy. The patient presented with asymptomatic, malodorous punched-out pits and erosions along with hyperkeratotic skin on the heel and metatarsal region of the plantar aspect of both feet. The arches, toes, and sides of the feet were spared (Figure 1). Except for these skin changes, the patient was healthy and denied any other medical issues. He was an athlete active in martial arts and had a history of sweating of feet and training barefoot on the tatami mat for extended periods of time. The diagnosis of PK was established based on the clinical findings (crateriform pitting and malodor), negative KOH test for hyphae, and a history of prolonged sweating in addition to contact of the skin with tatami mats, which are often a source of infection if hygiene measures are not adequately implemented. Swabs could have been helpful to identify causative organisms, but they were not crucial for the diagnosis and treatment. The patient was prescribed with general measures to prevent excessive sweating (cotton socks, open footwear, and proper hygiene), antiseptic potassium permanganate foot soaks followed by clindamycin 1% and benzoyl peroxide 5% in a gel vehicle twice daily. At the one-month follow-up visit, the skin changes, hyperhidrosis, and malodor were entirely resolved (Figure 2). Pitted keratolysis is common among athletes (3,4). The manifestations of PK are due to a superficial cutaneous infection caused by several bacterial Gram-positive species including Corynebacterium species, Kytococcus sedentarius, Dermatophilus congolensis, Actynomices keratolytica, and Streptomyces that proliferate and produce proteinase and sulfur-compound by-products under appropriate moist conditions (5-7). Proteinases digest the keratin and destroy the stratum corneum, producing the characteristic skin findings, while sulfur compounds (sulfides, thiols, and thioesters) are responsible for the malodor. Athletes and soldiers who wear occlusive footwear for prolonged periods of time or even barefooted people that sweat extensively and spend time on wet surfaces such as laborers, farmers, and marine workers are more prone to this problem (3,4,8-11). Martial arts athletes are at greater risk of skin infections due to the constant physical contact that can lead to transmission of viral, bacterial, and fungal pathogens directly but also indirectly through contact with the mat and the skin flora of an another infected individual. A national survey of the epidemiology of skin infections among US high school athletes conducted by Ashack et al. supported the prevalent theory that contact sports are associated with an increased risk of skin infections. In this study, wrestling had the highest skin infection rate of predominantly bacterial origin (53.8%), followed by tinea (35.7%) and herpetic lesions (6.7%), which is consistent with other literature reporting (12). Being barefoot on the tatami mat in combination with excessive sweating and non-compliance with hygiene measures makes martial arts athletes more susceptible to skin infections, including PK. The diagnosis is clinical, by means of visual examination and recognition of the characteristic odor. Dermoscopy can be useful, revealing abundant pits with well-marked walls that sometimes show the bacterial colonies (13). Cultures, if taken, show Gram-positive bacilli or coccobacilli. Because of the ease of diagnosis on clinical findings, biopsy of pitted keratolysis is rarely performed. Skin scraping is often performed to exclude tinea pedis, which is one of the main differential diagnosis, the others including verrucae, punctate palmoplantar keratoderma, keratolysis exfoliativa, circumscribed palmoplantar hypokeratosis, and basal cell nevus syndrome. If unrecognized and left untreated, skin findings and smelly feet can last for many years. Sometimes, if unrecognized, PK can be mistreated with antifungals, or even with aggressive treatment modalities such as cryotherapy. Appropriate treatment includes keeping feet dry with adequate treatment of hyperhidrosis, preventive measures, and topical antibiotic therapy. Topical forms of salicylic acid, sulfur, antibacterial soaps, neomycin, erythromycin, mupirocin, clindamycin and benzoyl peroxide, clotrimazole, imidazoles, and injectable botulinum toxin are all successful in treatment and prevention of PK (14,15). Topical antibiotics are the first line of medical treatment, among which fusidic acid, erythromycin 1% (solution or gel), mupirocin 2%, or clindamycin are the most recommended (14). As in our case, a fixed combination of two approved topical drugs - clindamycin 1%-benzoyl peroxide 5% gel, had been already demonstrated by Vlahovich et al. as an excellent treatment option with high adherence and no side-effect (16). The combined effect of this combination showed signi fi cantly greater effect due to the bactericidal and keratolytic properties of benzoyl peroxide. Additionally, this combination also lowers the risk of resistance of causative microorganisms to clindamycin. Skin infections are an important aspect of sports-related adverse events. Due to the interdisciplinary nature, dermatologists are not the only ones who should be aware of the disease, but also family medicine doctors, sports medicine specialists, and occupational health doctors who should educate patients about the etiology of the skin disorder, adequate prevention, and treatment. Athletes must enforce the disinfecting and sanitary cleaning of the tatami mats and other practice areas. Keeping up with these measures could significantly limit the spread of skin infections that can infect athletes indirectly, leading to significant morbidity, time loss from competition, and social anxiety as well.


    Clindamycin-induced Maculopapular Exanthema with Preferential Involvement of Striae Distensae: A Koebner phenomenon?

    Acta Dermatovenerol Croat 2018; 26 (1): 61-63

    Clindamycin is a lincomycin-derived antibiotic useful for the treatment of anaerobic and Gram-positive aerobic bacterial infections. Cutaneous adverse reactions are usually maculopapular exanthemas, although hypersensitivity syndrome, acute generalized exanthematous pustulosis, and Stevens-Johnson syndrome have also been reported (1). We report the case of a patient with a maculopapular rash triggered by clindamycin who developed cutaneous lesions on striae distensae (SD). A 47-year-old woman was referred to our clinic for pruritic cutaneous lesions which had started 6 days earlier. Her past clinical history included hypertension, hypothyroidism, hyperuricemia, cholecystectomy, caesarean section, and endometriosis-related abdominal surgery, and she was taking levothyroxine, allopurinol, imidapril, and omeprazole. The skin rash first developed on her neck and back on the 3rd day of clindamycin oral treatment (300 mg every 6 hours), which was prescribed as antibiotic prophylaxis for a tooth implant. General malaise (but not fever) was also reported. Physical examination revealed an erythematous maculopapular eruption symmetrically distributed on the neck, abdomen, and back (Figure 1, A), with isolated lesions involving the proximal upper and lower limbs (Figure 1, B). There was a striking vertical distribution of skin lesions along the SD on the lateral sides of the abdomen (Figure 1, C). No mucosal involvement was found, and laboratory studies showed no abnormalities. Clindamycin withdrawal was followed by prescription of a course of oral deflazacort, starting at 30 mg daily and tapering down during a 9-day period. On the 5th day of treatment, the rash had almost cleared with minimal desquamation (Figure 1, D). Eight weeks after clearance of the skin rash, informed consent was obtained in order to perform an allergological evaluation of clindamycin, including prick and intradermal (ID) tests on the forearm and patch tests on the upper back (2). For patch testing, powder of the commercial capsules (Dalacin(R)) was diluted in petrolatum (pet.) and water (aq.), resulting in a final 1% clindamycin dilution. Parenteral clindamycin preparations were used in therapeutic concentrations for prick tests (150 mg/mL) and dilutions in saline of 1/100 and 1/10 for the ID test. Other authors have reported that these concentrations do not seem to irritate the skin (3-6). Prick and ID tests were assessed after 20 min and 24 hours, respectively. Patch tests were removed after the 2nd day, and late reactions were evaluated on day 2 and day 4. Prick and ID test results after 20 min were negative. Late results of ID tests with clindamycin (1.5 and 15 mg/mL) were positive: erythematous infiltrated papules about 7x7 mm and 18x15 mm were observed at 24 hours and lasted until the 8th day. Patch tests with clindamycin 1% in pet. and 1% in aq. were also positive (+ on day 2 and day 4). Positive late skin tests suggested delayed-type non-IgE-mediated allergic clindamycin hypersensitivity. Oral challenge tests are considered to be the gold standard to establish or exclude drug hypersensitivity. Due to the positive result of late skin test to clindamycin, oral challenge was not performed in our patient (3,5). The Koebner isomorphic phenomenon has been described in cutaneous reactions induced by drugs, such as antibiotics and chemotherapy. Chronic pressure on the skin is probably involved in the onset of skin lesions in hand-foot eruptions induced by tyrosine kinase inhibitors (sorafenib and sutinib). Solar exposure and cutaneous trauma also seem to play a role in the location of papulopustular eruptions caused by endothelial growth factor receptor inhibitors (erlotinib) (7). More frequent involvement in traumatized skin and surgical scars has been reported in the context of linear IgA bullous dermatosis and leukocytoclastic vasculitis triggered by vancomycin and cefuroxime (8). SD are produced by non-penetrating physical trauma, similar to friction or pressure. Different dermatoses can develop along SD skin lesions (like plaque psoriasis, pustular psoriasis, lichen planus, vitiligo, discoid lupus erythematosus, lupus vasculitis, urticarial vasculitis, or chronic graft-versus-host disease) (9). Bevacizumab, etretinate, and corticosteroid-induced ulcers, hyperpigmentation caused by bleomycin, and urticariform lesions triggered by diclofenac are examples of different type of drug-induced abnormalities involving SD (10). In summary, we identified clindamycin as the cause of the cutaneous reactions that occurred in our patient on the basis of the results of the skin tests and clinical history. Our findings confirmed a delayed-type hypersensitivity reaction, possibly involving a T-cell-mediated immunologic mechanism. Intradermal and patch tests were found to be useful in order to confirm the diagnosis (4,5). We did not find reports in the literature of drug-induced cutaneous eruptions along the SD as a manifestation of a Koebner phenomenon. Clinical underreporting of this phenomenon could explain the scarce literature on this cutaneous adverse reaction.


    Boils at Frictional Locations in a Patient with Hidradenitis Suppurativa.

    Acta Dermatovenerol Croat 2016; 24 (4): 303-304;

    Dear Editor, Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin disease. The primary clinical presentation are painful inflamed nodules or boils of inverse areas, i.e. the axillary and anogenito-crural regions, but it can also involve the infra- and inter-mammary regions (1,2). The etiology of HS is not clearly defined. Obesity, smoking, and genetic factors are considered important risk factors. In addition, it has also been suggested that friction may contribute to the development of HS, especially in the obese, but this is based on highly anecdotal reports (3-5). We describe a case with classic HS, obesity, and HS-like lesions at the position of the bra strap, suggesting that mechanical stress was an external pathogenic factor for HS development. A 33-year old woman presented with an 18-year history of chronic, recurrent, inflammatory nodules in the axillae, the groin, the pubic region, and to a lesser extent the abdomen and buttocks. She was obese with as result of 33.2 kg/m-2 of 33.2, had a positive family history of two first grade family members with HS, and was a smoker (19 Pack years). There were no other known comorbidities. The inflamed lesions had been treated with several courses of oral antibiotics (minocycline, erythromycin, and combination therapy of clindamycin and rifampicine) and surgical treatments: lancing, deroofing, and excisions (2,6). On examination, there were nodules, folliculitis, cysts, and depressed scars in the axillae and groins, including the inner thighs (Figure 1). On the chest, corresponding to where the lower edge of the patient's bra was usually located, a superficial nodule and follicular papules were observed, exactly coinciding with the red stripe caused by mechanical stress (friction and pressure) of the bra edge. There was no skin fold present on the location of the HS lesions, and there were no lesions observed in the intermammary region or on the side of the breasts in contact with the skin of the thorax (skin to skin contact) (Figure 2). Cultures from skin swabs showed commensal skin flora and moderate mixed anaerobic bacteria, as would be expected in a HS lesion. It is well documented that HS is a disease of the obese. However, the role of friction as an environmental factor is poorly documented. Patients report that environmental factors such as tight-fitting clothing or friction could cause flares in the disease (2). Furthermore, it has been postulated that friction may contribute to the development of HS by stimulating interfollicular hyperplasia (7). HS lesions arranged in a linear pattern suggest an environmental influence and suggests an etiopathogenic role for mechanical stress. Waistline, or as in this case the chest line, distribution indicates that wearing of tight waistbands, wide belts, or bras may induce HS in predisposed individuals. To our knowledge, there is only one case report describing an obese patient with classic HS (typical lesions in predilection areas) who developed HS like lesions on the upper abdomen (waist) at the height of the waistband as well as under the lower abdominal apron (skin on skin contact) (8). Two other reports suggesting a pathogenic role for mechanical stress are flawed, however, as neither of the cases showed signs of concomitant classic HS or had a family history, bringing into question the implied association of HS (9,10). In summary, we presented a case with classic HS locations (typical lesions on typical locations, i.e. the axillae and inguino-crural regions) developing inflammatory lesions on the chest at the location closely corresponding to where the bra strap was exerting mechanical pressure and friction on the skin. The lesions were clinically and microbiologically compatible with ectopic HS lesions. The chest is an atypical HS location free of apocrine sweat glands. It is postulated that these lesions may have been induced by mechanical stress, additionally triggered by the pro-inflammatory state of the obese body. Patients are encouraged to avoid friction from environmental factors such as tight clothing.


    Acneiform eruption induced by cetuximab.

    Acta Dermatovenerol Croat 2007; 15 (4): 246-8

    Cetuximab is a recombinant human/mouse chimeric monoclonal antibody that targets the extracellular domain of the epidermal growth factor receptor (EGFR). Cetuximab is approved by the US Food and Drug Administration for the treatment of EGFR-expressing metastatic colorectal cancer as monotherapy in patients who are intolerant to irinotecan-based chemotherapy, or in combination with irinotecan in patients who are refractory to irinotecan-based chemotherapy. Due to the important role of the EGFR in skin homeostasis, cutaneous reactions are a common adverse effect of cetuximab, mainly as acneiform follicular eruption seen in almost 85% of patients. We report on a 46-year-old female Caucasian patient with metastatic colorectal cancer, referred to our department for acneiform eruption induced by cetuximab in combination with irinotecan. Four days after the first infusion the patient developed intense acneiform eruption consisting of erythematous follicular papules and pustules spread to the face, neck and upper part of the trunk, accompanied by intense pruritus and fever (38.0 degrees C). There were no comedones. Biopsy specimen revealed superficial and florid neutrophilic suppurative folliculitis. She was treated with erythromycin tablet 600 mg, three times a day for 1 month, and topical clindamycin solution 3%. After 1 month of treatment, the lesions consistently faded, and the patient continued receiving immunochemotherapy.


    An appraisal of cephalexin and clindamycin concentration in seminal plasma.

    Acta Eur Fertil 1981; 12 (4): 319-21


    A case of Clindamycin-induced aphagia.

    Acta Gastroenterol Belg 2018; 81 (4): 540-541


    Campylobacter pylori-associated gastritis: attempts to eradicate the bacteria by various antibiotics and anti-ulcer regimens.

    Acta Gastroenterol Belg 1988; 51 (4-5): 329-37

    The efficacy of various antimicrobial and anti-ulcer agents on the eradication of Campylobacter pylori in patients with antral gastritis or duodenal ulcers was investigated by several open studies or double-blind, placebo-controlled protocols. Among the anti-ulcer agents, ranitidine, cimetidine or sucraflate had no effect on C. pylori. Colloidal bismuth subcitrate achieved clearance of C. pylori in 40% of treated patients at the end of therapy but a high relapse rate (14/16 patients) was observed after a 6-month follow-up period. The antibacterial agents doxycycline, minocycline, ofloxacin, clindamycin, paromomycin and nifuroxazide failed to eradicate C. pylori in most patients. By contrast, short term elimination of C. pylori could be achieved in more than 90% of patients treated with amoxycillin. However, relapse occurred as a rule in all amoxycillin-treated patients within one month after therapy. Overall, we observed no correlation between the in-vitro activity of the different antibacterial agents and their in vivo efficacy. Development of resistance during therapy does not seem to account for this discrepancy since it occurred only with ofloxacin. On the basis of these results, we conclude that long term eradication of C. pylori from the gastric antrum cannot be achieved after monotherapy either with antibiotics or with bismuth salts.


    Im Auftrag der Osterreichischen Kardiologischen Gesellschaft veroffentlichen wir die Empfehlungen zur Prophylaxe bakterieller Endokarditiden. Herausgegeben von der Kommission fur Klinische Kardiologie der Deutschen Gesellschaft fur Herz- und Kreislaufforschung.

    Acta Med Austriaca 1987; 14 (3-4): 102-3


    Nekrotizirajuca infekcija mekih cesti ruke uz razvoj sindroma toksicnog soka--klinicki tijek i lijecenje.

    Acta Med Croatica 2008; 62 (5): 505-10

    Necrotizing soft tissue infections (NSTI) are uncommon infections associated with considerable morbidity and mortality (20%-40%). They are characterized by rapidly progressive necrosis of soft tissue that primarily involves subcutaneous fat and fascia with variable involvement of the overlying skin and muscle. Extensive soft tissue necrosis is often accompanied by systemic toxicity. Establishing the diagnosis in the early stage of the infection can be difficult, which leads to a delay in surgical treatment and a poor outcome. The principles of treatment are early and aggressive surgical debridement, broad spectrum antimicrobial therapy administered empirically and reassessed pending culture and sensitivity results, and intensive care management. We report a case of NSTI of the arm in a 64-year-old female patient caused by group A Streptococcus and Staphylococcus aureus complicated with toxic shock-like syndrome with emphasis on the pathophysiology of toxic shock-like syndrome and treatment modalities. NSTI developed 10 days after a knife cut wound of the thumb. The patient had no significant comorbidity. Treatment included aggressive surgical debridement with removal of necrotic tissue and extensive fasciotomies 24 h of admission, cardiovascular stabilization and monitoring at intensive care unit, and repeat surgical debridement at 72 h of admission. Early triple drug antimicrobial therapy included high-dose clindamycin, which inhibits protein synthesis and bacterial exotoxin production that is responsible for inflammatory response and toxic shock-like syndrome. In addition, the patient received hyperbaric oxygen therapy (8 treatments in total). The above management led to control of the infective process. Prolonged surgical wound care followed by thin split-skin grafting and placement of secondary sutures on day 36 of admission preserved the extremity with good functional and cosmetic result.


    Sepsa uzrokovana bakterijom Fusobacterium necrophorum (Lemierreov sindrom): rijetka komplikacija akutnog tonzilofaringitisa.

    Acta Med Croatica 2006; 60 (5): 509-12

    Lemierre syndrome is defined as an acute pharyngotonsillar infection that has spread into the lateral pharyngeal space causing thrombophlebitis of the internal jugular vein with consecutive metastatic emboli. The syndrome is most often caused by Fusobacterium (F.) necrophorum and usually involves young, previously healthy people. We present a healthy 20-year-old man who suddenly developed with high fever and sore throat followed by dyspnea, tachypnea and cough on the third day of illness. His condition worsened despite outpatient intramuscular penicillin therapy (1600 000 IU/day). He was admitted to Dr. Fran Mihaljevic University Hospital for Infectious Diseases, Zagreb, on the sixth day of his illness with clinical signs of sepsis. Chest radiograph showed bilateral multiple infiltrates. F. necrophorum was isolated from blood culture. Swelling of the neck was also observed on the fourteenth day of illness, however, thrombophlebitis of the jugular vein was not diagnosed on ultrasound examination. The patient was treated with clindamycin for five weeks and recovered completely.


    Razlikovanje rezistentnih fenotipova medu eritromicin rezistentnim streptokokima.

    Acta Med Croatica 2004; 58 (4): 301-6

    Although macrolide antibiotics have proved to be a valuable alternative to beta-lactam antibiotics in the treatment of respiratory tract infections, resistance to these agents is now becoming established in streptococci, especially among Streptococcus pneumoniae isolates. Of particular concern is the emergence of cross-resistance to 14-, 15- and 16-membered macrolides, licosamides and group B streptogramins (MLSb phenotype). MLS resistance can be expressed either constitutively (cMLS phenotype) or inducibly (iMLS phenotype). MLS resistance is mediated by two classes of methylase genes--the conventional erm(B) and recently described erm(A) determinants. A new macrolide efflux mechanism has been described for streptococci, in which it is associated with a new resistance pattern (M phenotype) characterized by resistance to 14- and 15-membered macrolides, and susceptibility to 16-membered macrolides, lincosamides and streptogramin B. The recognition of the prevalence of M phenotype in streptococci has implications for sensitivity testing and may have an impact on the choice of antibiotic therapy in clinical practice. While M resistance is similar in S. pyogenes and S. pneumoniae being mediated by mef(A) and mef(E), respectively, MLS resistance in both species appears to be genotypically and phenotypically more varied. Differentiation of M and MLS phenotypes of erythromycin-resistant strains can be performed using the erythromycin-clindamycin double-disc method (ECDD). Distinguishing not only M resistance but also constitutively or inducibly MLS phenotype by ECDD in S. pyogenes is easily and reliably achieved. Inducible MLS phenotype S. pyogenes strain is genotypically and phenotypically heterogeneous and is further subdivided into three recently described subtypes, iMLS-A, iMLS-B and iMLS-C, by a triple-disk test with erythromycin plus clindamycin and josamycin. While distinguishing M from MLS resistance in S. pneumoniae by ECDD test is easily and reliably achieved, the differentiation between constitutive and inducible MLS resistance is by far more uncertain. The meaning of inducible MLS resistance appears to be different in S. pneumoniae from that in S. pyogenes. In order to easily differentiate, within erythromycin-resistant pneumococci, not only the strains of the M phenotype from those with MLS resistance but also among the latter, cMLS from iMcLS strains, a triple-disk test has been set up by adding a rokitamycin disk to the conventional


    Hematogenous Candida spondylitis. A case report.

    Acta Med Scand 1984; 215 (1): 85-7

    A 58-year-old patient with neutropenia due to SLE developed spondylitis of the lumbar region caused by Candida albicans. The spondylitis was probably superinfected with Staphylococcus aureus. The initial one month's intravenous combination therapy with amphotericin B and flucytosine was discontinued because of fever reactions to amphotericin B, suspected myelosuppressive effect of flucytosine and insufficient clinical response. This therapy was followed by four months of oral ketoconazole and clindamycin with good results and without any side-effects.


    Changes of the serum antibiotic levels during open heart surgery (ceftazidim, ciprofloxacin, clindamycin).

    Acta Medica (Hradec Kralove) 2000; 43 (1): 23-7

    BACKGROUND: Wound, mediastinal and intracardiac infections are still very serious complications of open-heart surgery. The incidence of it is still in the range of 0.4%-5%. The aims of our study were to assess the adequacy of regimen using ceftazidim (CTZ), ciprofloxacin (CPF) and clindamycin (CLIN) as prophylactic antibiotics and to verify whether cardiopulmonary bypass (CPB) can modify the time of antibiotic serum concentrations. That is why the serum levels of them were measured during open heart procedures. METHODS: The prospective study comprised 75 consequent coronary patients randomized in to three groups receiving 1 g of CTZ or 400 mg of CPF or 900 mg of CLIN i.v. with anesthesia induction. Routine coronary surgery with left internal mammary artery harvesting, moderate body hypothermic (30 degrees C) CPB with crystaloid cardioplegia was performed. Serum antibiotic levels were determined before application, with skin incision, prior CPB induction, after cardioplegia infusion, every 20 minutes of CPB, prior end of CPB, in time of chest closure. Conventional cylinder-plate microbiological assay was used for antibiotic level measurement. RESULTS: All serum antibiotic concentrations showed a sharp decrease immediately after starting CPB and lasted until CPB ended. After initiating of CPB after cardioplegia administration serum concentrations of CTZ (105 min after initial dose) decreased by, on average 55%, CPF (97 min) by 42% and CLIN (116 min) by 78%. CONCLUSION: CPB can modify the time course of antibiotic serum concentrations. The serum levels of CTZ at the end of the longest procedures were found to be below the MICs for some of the suspected pathogens. We recommend to use higher antibiotic doses for prophylaxis and to administer the second dose with protamin sulphate to obtain maximum concentration in newly formed blood clots.


    Distribution of genes encoding resistance to macrolides, lincosamides, and streptogramins among methicillin-resistant Staphylococcus aureus strains isolated from burn patients.

    Acta Microbiol Immunol Hung 2019; (): 1-12

    The increasing resistance to macrolide, lincosamide, and streptogramin B agents among methicillin-resistant Staphylococcus aureus (MRSA) is a worldwide problem for the health community. This study aimed to investigate the prevalence of ermA, ermB, ermC, and msrA in MRSA strains isolated from burn patients in Ahvaz, southwest of Iran. A total of 76 isolates of S. aureus were collected from January to May 2017 from Taleghani Burn Hospital in Ahvaz. Among 76 S. aureus strains collected, 60 (78.9%) isolates were MRSA. The antimicrobial susceptibility testing for MRSA showed extreme high resistance rate to clarithromycin (100%) and azithromycin (100%), followed by erythromycin (98.3%). The PCR assay revealed that the frequency rates of msrA, ermA, and ermC genes were 23 (38.3%), 28 (46.7%), and 22 (36.7%), respectively. In addition, none of the MRSA isolates had the ermB gene. Because of the high prevalence of macrolide and lincosamide resistance found in MRSA isolates from infections of burn patients in Ahvaz, southwest of Iran, it is recommended that local periodic survey be performed for controlling the dissemination of antimicrobial resistance.


    High prevalence of Staphylococcus aureus nasal carriage among children in Szolnok, Hungary.

    Acta Microbiol Immunol Hung 2018; 65 (1): 59-72

    We collected nasal samples from 1,390 healthy 3-7 years old children in Szolnok city, Hungary, in 2012. We detected 476 Staphylococcus aureus isolates from 474 children. In two occasions, two different S. aureus were isolated, based on hemolysis type and pulsed-field gel electrophoresis pattern. S. aureus carriage rate was calculated to be 34.1% similar to others studies. Male gender was found to be a risk factor for carriage by statistical analysis. Altogether, four methicillin-resistant S. aureus (MRSA) strains were detected by mecA polymerase chain reaction, which means 0.8% community-acquired MRSA prevalence among the S. aureus isolates. All MRSA strains harbored the SCCmec type IV cassette (typical for CA-MRSA) and belonged to ST45 by multilocus sequence typing. During antibiotic susceptibility testing, we measured the following resistance rates: 0.0% for mupirocin, 0.2% for ciprofloxacin, 0.6% for gentamicin and oxacillin, 3.4% for tetracycline, 9.5% for clindamycin, 10.3% for erythromycin, and 91.4% for penicillin, which are generally lower compared with Hungarian clinical isolates.


    Influence of subinhibitory antibiotic concentration on Streptococcus pyogenes adherence and biofilm production.

    Acta Microbiol Immunol Hung 2018; 65 (2): 229-240

    In this study, the focus was on the effects of sub-MICs of the antibiotics on adherence, hydrophobicity, and biofilm formation by two groups of Streptococcus pyogenes strains, which were responsible for different clinical cases. The aim of this study was to explore the effects of sub-MICs of penicillin, ceftriaxone, erythromycin, and clindamycin on adherence, surface hydrophobicity, and biofilm biomass in two selected collections of group A streptococcus (GAS): strains isolated from carriers (CA) and strains isolated from patients with tonsillopharyngitis (TPh). Isolates were tested for hydrophobicity to xylene, adherence, and biofilm production in uncoated microtiter plates before and after treatment with 1/2 and 1/4 MICs of antibiotics. Penicillin reduced adherence and biofilm production in TPh strains, whereas ceftriaxone diminished adherence and biofilm formation in CA group. On the contrary, clindamycin enhanced adherence and biofilm production in both groups of strains. Erythromycin did not significantly alter adherence, but triggered biofilm production in both groups of isolates. Hydrophobicity of both groups of strains was significantly reduced after exposure to all antibiotics. Beta-lactams displayed anti-biofilm activity; penicillin diminished both adherence and biofilm production in TPh strains, whereas ceftriaxone reduced it in strains isolated from CA.


    Characterization of macrolide-resistant non-invasive pneumococci in the pre-vaccine era in Serbia.

    Acta Microbiol Immunol Hung 2018; 65 (4): 477-488

    Numerous reports have confirmed that increased macrolide use in the treatment of respiratory tract infection has contributed to the emergence of antibiotic resistance worldwide. Studies have also shown that pneumococcal vaccine can reduce pneumococcal resistance. The aim of this study was to determine the prevalence of co-resistance to penicillin and other antibiotics in macrolide-resistant (MR) non-invasive pneumococcal isolates and to evaluate serotype distribution in resistant strains in the pre-vaccine era in Serbia. About 80% of MR isolates expressed the MLS phenotype with very high resistance to both erythromycin and clindamycin. A total of 132 (84.1%) MR isolates were multiresistant, i.e., they were resistant to erythromycin, penicillin, tetracycline, and trimethoprim-sulfamethoxazole. Among 157 MR pneumococci, 11 different serotypes were found. Four serotypes, 19F, 14, 6B, and 23F, accounted for 77.7% of all MR pneumococcal isolates. Among isolates with the cMLS phenotype, serotypes 19F and 14 were predominant, whereas serotype 6A was the most common among those with the M phenotype, followed by 14. In conclusion, co-resistance to macrolides and penicillin in our non-invasive pneumococcal isolates is high. The majority of tested strains ( approximately 80%) belonged to the four serotypes (19F, 14, 6B, and 23F) that are included in all conjugate vaccine formulations.


    The first characterized carbapenem-resistant Bacteroides fragilis strain from Croatia and the case study for it.

    Acta Microbiol Immunol Hung 2018; 65 (3): 317-323

    An imipenem-resistant Bacteroides fragilis strain was isolated from the blood of a 72-year-old male patient with a urinary bladder tumor in Osijek, Croatia. This strain was also resistant to ampicillin, piperacillin/tazobactam, cefoxitin, clindamycin, tetracycline, and harbored cfiA, ermF, and tetQ genes where the high-level expression of the cfiA carbapenem-resistant gene was driven by an IS1187 element. Interestingly, despite the carbapenem-resistant feature of the B. fragilis from blood, the patient relatively easily recovered from the bacteremia. It was the first characterized imipenem-resistant B. fragilis isolate with its case report from Croatia, which confirmed the appearance of carbapenem-resistant B. fragilis strains, that continues worldwide with low incidence and the molecular characteristics vary temporally and geographically.


    Epidemiology and antibiotic sensitivity of Staphylococcus aureus nasal carriage in children in Hungary.

    Acta Microbiol Immunol Hung 2017; 64 (1): 51-62

    The aim of this study was to assess the Staphylococcus aureus nasal carriage rate in healthy children all over Hungary and to specify some risk factors, the antibiotic resistance patterns of the bacteria, and their genetic relatedness. In total, 878 children (aged 3-6 years) were screened at 21 day-care centers in 16 different cities in Hungary, between February 2009 and December 2011. Samples taken from both nostrils were cultured on blood agar, and suspected S. aureus isolates were identified by beta-hemolysis, catalase positivity, clump test, and nucA PCR. Methicillin-resistant strains were screened by mecA and mecC PCR. Antibiotic susceptibility was determined by agar dilution or gradient test strips. Pulsed-field gel electrophoresis was used for genotyping. S. aureus carriage rate was found to be 21.3%, which correlates well with international data. We found no statistically significant correlation between the gender or the sibling status and S. aureus carriage. All isolates were sensitive to oxacillin, trimethoprim-sulfamethoxazole, and mupirocin. The resistance rates for erythromycin, ciprofloxacin, clindamycin, gentamicin, and tetracycline were 7.5%, 0.5%, 1.1%, 3.7%, and 4.3%, respectively. The isolates showed very high genetic diversity. In summary, carried S. aureus isolates are more sensitive to antibiotics compared with clinical isolates in Hungary, and methicillin-resistant S. aureus carriage rate is very low yet.


    Does Staphylococcus Saprophyticus Cause Acute Cystitis only in Young Females, or is there more to the Story? A One-Year Comprehensive Study Done in Budapest, Hungary.

    Acta Microbiol Immunol Hung 2016; 63 (1): 57-67

    Staphylococcus saprophyticus is a well-known urinary pathogen in acute cystitis in young females. We completed a retrospective overview of the distribution of urinary tract infections (UTIs) occurring in 2014, at Semmelweis University hospitals and at Heim Pal Children's Hospital. Six age-groups (ages 0-100) were examined, with the frequency of S. saprophyticus in females being: 0.1% (0-4), 0.7%, (5-15), 7.4% (16-24), 1.2% (25-39), 0.4% (40-59) and 0.1% (60-100), and S. saprophyticus being the 3(rd) most common pathogen in females aged 16-24. In males, S. saprophyticus was only isolated from those aged 5-15. Seasonal distribution of UTIs caused by S. saprophyticus showed that most infections occurred during the months of January, June, August and November. Antibiotic-resistance rates of amoxicillin, clindamycin, doxycycline, erythromycin, gentamicin and sulfamethoxazole- trimethoprim varied as follows: 0.9%, 32.7%, 19.6%, 34.6%, 0.9% and 0.9%, respectively. Thirty randomly selected samples were analysed by pulsed-field gelelectrophoresis, and 28 different genotypes were identified. S. saprophyticus is involved in the pathogenesis of acute cystitis not only in young females, but also in other age-groups, and in young males as well. We did not find any significant seasonal occurrence in S. saprophyticus-caused UTIs. The infective strains were genetically diverse. Antibiotic-resistance does not pose any issue as of yet.


    Virulence factors, antimicrobial susceptibility and molecular characterization of Streptococcus agalactiae isolated from pregnant women.

    Acta Microbiol Immunol Hung 2014; 61 (4): 425-34

    Forty-one Streptococcus agalactiae isolates collected from pregnant women at 35-37 weeks of gestation were analysed for their capsular types, antimicrobial resistance determinants, distribution of virulence factors and genetic relatedness using PCR and multiplex PCR. Capsular type III was predominant (65.8%), followed by capsular type II (14.6%), Ib (7.3%), and V(4.9%). All isolates were susceptible to penicillin, vancomycin, linezolid and quinupristin-dalfopristin. Resistance to tetracycline, erythromycin and clindamycin were found in 97.6%, 24.4%, and 14.6% of isolates, respectively. The most common antimicrobial resistance gene was tetM found in 97.6% of the isolates followed by ermTR and ermB found in 12% and 7.3% of isolates, respectively. The most common virulence gene was hly (100%), followed by scpB (97.6%), bca (97.6%), rib (53.65%) and bac (4.9%). The insertion sequence IS1548 was found in 63.4% of isolates. By multi locus variable number of tandem repeat analysis (MLVA) typing, 30 different allelic profiles or MLVA types (MTs) were identified. The most frequent was the MT1 (5/41, 12.2%) and followed by MT2 (4/41, 9.75%). Our data revealed that population structure of these isolates is highly diverse and indicates different MLVA types.


    Nasal carriage of methicillin resistant Staphylococcus aureus and their antibiotic susceptibility patterns in children attending day-care centers.

    Acta Microbiol Immunol Hung 2011; 58 (3): 227-34

    Nasal colonization with community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is being increasingly reported, especially in places where people are in close contact and in reduced hygiene, such as day-care centers. In this study we investigated the frequency of MRSA colonization and their antibiotic susceptibility patterns in 1-6 years old children of day-care centers in Hamadan, West of Iran.Five hundred nasal swabs were collected from children of 27 day-care centers that had no risk factors for colonization by S. aureus. The specimens were cultured for isolation of S. aureus by standard methods. Antimicrobial susceptibility testing was performed according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. For evaluation of the frequency of erythromycin induced clindamycin resistance, disk approximation test (D-test) was applied.Totally, 148 (29.6%) children were colonized by S. aureus. Out of 260 male, 94 (36.2%) and of 240 female, 54 (22.5%) cases were nasal carriers of S. aureus (P value = 0.001). Six (4.1%) of the 148 S. aureus isolated from children were MRSA strains. None of MRSA and methicillin susceptible S. aureus (MSSA) was resistant to vancomycin and clindamycin. Three of the 6 strains of MRSA and 7 (4.9%) of the 142 MSSA strains were resistant to erythromycin, and D-test was positive in all of them.We conclude that the rate of colonization by S. aureus is high in children attending day-care centers but colonization with MRSA is not common in our areas. Clindamycin or trimethoprim-sulfamethoxazol could be used in mild to moderataly severe diseases caused by CA-MRSA. However, if the CA-MRSA isolates are erythromycin resistant, D-test should be carried out for detection of inducible clindamycin resistance.


    Characterization of Staphylococcus aureus strains isolated from raw milk of bovine subclinical mastitis in Tehran and Mashhad.

    Acta Microbiol Immunol Hung 2011; 58 (2): 113-21

    Staphylococcus aureus is considered one of the most important food borne pathogens. A total of 111 isolates of S. aureus were cultured from raw milk samples during January 2009 to June 2009 from Tehran and Mashhad. The coagulase gene polymorphism and the prevalence of classical enterotoxin genes of S. aureus strains were determined by PCR-RFLP (restriction fragment length polymorphism) and Multiplex-PCR. Disk diffusion method was used to determine the susceptibility of isolates to antimicrobial agents as instructed by Clinical and Laboratory Standards Institute. Sixty-seven % of the isolates harboured one or more enterotoxin genes. The most prevalent gene was sec, found in 59 % of the isolates. Approximately 8% of the isolates were positive for sea, seb and sed genes. Only one isolate had see gene. The rate of coexistence of enterotoxin genes was 14%. All S. aureus isolates were susceptible to ciprofloxacin, gentamicin, imipenem, minocycline, oxacillin and vancomycin. They were resistant to ampicillin (64%), penicillin (56%), clindamycin (22%), tetracycline (22%), doxycycline (19%), teicoplanin (13%), rifampin (2%) and trimethoprim-sulfamethoxazole (2%). On the basis of coagulase gene analysis of 111 S. aureus isolates, the PCR products of 56 isolates were digested with Alu I that produced three distinct patterns. These data indicate the high prevalence of enterotoxigenic S. aureus in raw bovine milk in Tehran and Mashhad, and highlight the importance of proper quality control of dairy products for public health.


    Incidence of Staphylococcus aureus isolated from patients treated at the Clinical Center of Skopje, Macedonia, with special attention to MRSA.

    Acta Microbiol Immunol Hung 2005; 52 (3-4): 373-84

    The distribution of 3497 Staphylococcus aureus strains according to methicillin resistance, specimens, departmental profession and antibiotic resistance patterns was analysed. The strains were cultured from the patients of the Clinical Center of Skopje, Macedonia, between 1 January 2002 and 31 December 2004. The majority of the isolates was obtained from suppurated wounds (28.5%), nares (21%), intratracheal tubes (13%) and blood cultures (11.8%). Overall 1100 (31.4%) of the isolates was methicillin-resistant with 1 microg oxacillin disc. Of these 35.5%, 30.5% and 10.4% were cultured from wounds, intratracheal tubes and blood samples, respectively. The prevalence of MRSA strains was 78.6%, 75%, 44.2% and 37.3% in specimens of ICU, Coma Center, General Surgery and Haematology patients. There were extremely big differences in the frequency of MRSA between departments with particular specialisation. The 2397 MSSA isolates belonged to practically one antibiotic resistance pattern characterised with penicillin resistance and susceptibility to other antistaphylococcal drugs. The 1100 MRSA isolates distributed to four antibiotic resistance patterns on the basis of their resistance to oxacillin, penicillin, amoxicillin+clavulanic acid, azithromycin, clindamycin, amikacin, gentamicin, ciprofloxacin, trimethoprim+sulphamethoxasole, vancomycin and teicoplanin. All the MRSA isolates were multidrug resistant but sensitive to glycopeptides.


    Effectiveness of antibiotics on the autochthonous Escherichia coli of mice in the intestinal biofilm versus its planktonic phase.

    Acta Microbiol Immunol Hung 1994; 41 (2): 189-95

    The effectiveness of antibiotics was tested on the autochthonous Escherichia coli in biofilm mode of growth in large bowel pieces as well as on the predominant faecal E. coli isolated from the same SPF mice in planktonic phase of growth. Aminoglycoside antibiotics, chloramphenicol, oxytetracycline, erythromycin and lincomycin-clindamycin treatment had a very limited effect in the intestinal biofilm. Surprising ineffectiveness was found with polymyxins: polymyxin B showed a Minimal Bactericidal Dose of 0.78 microgram in planktonic phase, while it was 400 micrograms for E. coli incorporated in the biofilm matrix. In contrast to the above groups of antibiotics, the beta-lactam drugs were effective both in the biofilm and in the planktonic phase growth of E. coli and their derivatives with broad or broader spectrum exerted an increased biofilm activity. Polymyxin B showed no sign of penetration into the colonic mucus, but on the other side ampicillin concentrated about three-four times in the intestinal matrix.


    Influence of clindamycin, metronidazole and polymyxin B on the expression of cell adhesion molecules stimulated by endotoxin and enterotoxin of Bacteroides fragilis.

    Acta Microbiol Pol 2003; 52 (4): 361-72

    The aim of this study was to compare the influence of antimicrobials (clindamycin, metronidazole and polymyxin B) on the expression of adhesion molecules (VCAM-1, ICAM-1 and E-selectin) on the HMEC-1 cell line stimulated by LPS and enterotoxin of B. fragilis. LPS was extracted from two reference: ATCC 43858 and NCTC 11295 and one isolated in our laboratory (W2) enterotoxigenic strains, and one nonenterotoxigenic reference strain--IPL E 323. Enterotoxin preparations (Tox 1 and Tox 2) were isolated from supematant of B. fragilis ATCC 43858 culture and purified. HMEC-1 cell line was stimulated with bacterial preparations at concentration of 10 mg/ml. For measuring the expression of adhesion molecules we used ELISA test. Clindamycin, metronidazole and polymyxin B supressed the ICAM-1 expression when endothelium was stimulated with B. fragilis LPS and augmented ICAM-1 expression by Tox 1 and Tox 2. The expression of VCAM-1 was augmented by antimicrobials when endothelium was stimulated with LPS or enterotoxin preparations. The expression of E-selectin was differentiated.


    Antibiotic susceptibility patterns of respiratory isolates of Staphylococcus aureus in a Turkish university hospital.

    Acta Microbiol Pol 2003; 52 (2): 143-8

    A total of 391 respiratory isolates of Staphylococcus aureus in Sivas (Turkey) were studied between January 1999-2002. The organisms were cultured from the following specimens: throat (43%), sputum (28%), transtracheal/endotracheal aspirates (27%), and bronchial lavage (2%). The isolates were tested against 11 different antibiotics by a disk diffusion method or standardized microdilution technique. Methicillin-resistant isolates constituted 76.9% of all isolates. Most of the methicillin-resistant isolates (95.1%) were isolated from inpatients. The rate of methicillin-resistant isolates in throat, sputum, and tracheal aspirates was 17.2%, 60.1%, and 68.9%, respectively. The resistance of methicillin-resistant isolates in throat to teicoplanin was 3.4%. The methicillin-sensitive isolates were susceptible to most agents tested, while most methicillin-resistant isolates were resistant to these agents. Overall resistance to erythromycin was 61.9%, tetracycline 56.6%, gentamicin 50.7%, ofloxacin 42.0%, rifampin 40.8%, clindamycin 38.9%, chloramphenicol 19.0%, co-trimoxazole 10.2%, and vancomycin 0%.


    In vitro antibiotic susceptibility of Bacteroides fragilis strains isolated from excised appendix of patients with phlegmonous or gangrenous appendicitis.

    Acta Microbiol Pol 2000; 49 (2): 171-5

    Out of 34 studied after-appendectomy tissues of adult and child patients 86 different strains of anaerobes were isolated. The antibiotic susceptibility of 30 isolated B. fragilis strains was tested using E tests. All studied strains were sensitive to imipenem, clindamycin and penicillin/tazobactam. Sensitivity to penicillin and cefoxitin was variable among these strains. One strain resistant to metronidazole (MIC--256 mg/L) and 3 strains with increased MIC to metronidazole were detected. Most of isolated strains were beta-lactamase producers.


    Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters.

    Acta Neurochir (Wien) 2011; 153 (3): 647-51

    INTRODUCTION: Many strategies have been developed with the aim of reducing external ventricular drain-related infections. Antibiotic-impregnated catheters are one of them. MATERIAL AND METHODS: We report 648 cases of external ventricular drain from a total of 534 patients treated at the Virgen del Rocio Hospital between 1995 and 2006. Three subgroups were considered: group 1 included patients treated between 1995 and 2000, as well as a total of 190 external ventricular drains and 59 cases of infection (31.05%); group 2, with patients treated between 2000 and 2004 and managed with a minimal handling protocol, included 210 external ventricular drains and nine cases of infection (4.29%); and group 3, treated between 2004 and 2006, with 248 external ventricular drains and six cases of infection (2.41%). This latter subgroup included patients managed with a minimal handling protocol and antibiotic-impregnated catheters. RESULTS: Infection rate was 17% when non-antibiotic-impregnated catheters were employed and 2.41% when antibiotic-impregnated catheters were inserted (p < 0.001). This difference was statistically significant before and after the introduction of a minimal handling protocol, with percentages of 5.31% and 3.27%, respectively (p < 0.001; odds ratio 0.08; absolute risk reduction 27.26%). However, no statistically significant difference was observed in infection rate when the impact of a minimal handling protocol was considered: 4.29% when only the protocol was introduced and 2.41% when both the protocol and antibiotic-impregnated catheters were used (p > 0.05). CONCLUSION: Minimal handling protocols constitute an essential strategy in the reduction of external ventricular drain-related infections. Besides that, the use of antibiotic-impregnated catheters may reduce infection-related hospital costs.


    The impact of silver nanoparticle-coated and antibiotic-impregnated external ventricular drainage catheters on the risk of infections: a clinical comparison of 95 patients.

    Acta Neurochir Suppl 2012; 114 (): 347-50

    BACKGROUND: Infection, i.e. meningitis or ventriculitis, is a major complication of external ventricular drainage (EVD). In order to prevent this complication rifampin-impregnated and clindamycin-impregnated silicone catheters and EVDs impregnated with nanoparticles of silver and an insoluble silver salt have been developed. Sparse data are published concerning the efficacy of these catheters in reducing bacterial colonization. METHODS: Between July 2003 and June 2006, 95 patients (age range 12-84 years, mean 53.6 years) underwent implantation of an EVD catheter for CSF diversion for several indications. All surgeries were performed in a standardized way at a single medical center. We used standard polyurethane catheters in 32 patients, Codman Bactiseal silicone catheters in 31 patients, and Spiegelberg Silverline catheters in 32 patients. Samples of the cerebrospinal fluid (CSF) were taken at the time of implantation, every 10 days and at the time of removal. The samples were microbiologically analyzed. RESULTS: In 32 standard catheters we saw infections in 5 patients (15.6%). By contrast, 2 of the 31 patients with a Bactiseal catheter (6.5%) and 3 with a Silverline catheter (9.4%) developed an infection. CONCLUSION: Rifampin-impregnated and clindamycin-impregnated EVDs as well as silver-impregnated EVDs decreased the infection rate. Randomized studies are needed to assess the advantage of these catheters compared with standard polyurethane catheters.


    Cerebral toxoplasmosis and AIDS. Clinical, neuroradiological and immunological findings in 15 patients.

    Acta Neurol (Napoli) 1992; 14 (4-6): 493-502

    Cerebral toxoplasmosis is the most common cause of focal CNS disease complicating AIDS and its incidence ranges from 3% to 40% of such patients. This opportunistic infection is generally due to reactivation of chronic toxoplasmosis as a consequence of severe immune deficiency. We present the clinical, neuroradiological and immunological findings of 15 AIDS patients with cerebral toxoplasmosis. All patients had focal neurological signs. CT-scan (13 cases) and NMR (2 cases) showed single or multiple mass lesions and edema. Serum IgG anti-Toxoplasma antibodies were positive in 14 patients; CSF specific IgG were positive in 5 out of 7 studied patients, while serum and CSF specific IgM were negative in all subjects. The intrathecal synthesis of anti-Toxoplasma antibodies were high in all 7 patients. A presumptive diagnosis of cerebral toxoplasmosis is based on the focal cerebral signs and neuroradiological findings. It is more frequently confirmed by the improvement of the clinical and neuroradiological picture during the treatment with pyrimethamine-sulphadiazine or clindamycin.


    Long-term course and outcome in AIDS patients with cerebral toxoplasmosis.

    Acta Neurol Scand 1999; 100 (3): 178-84

    OBJECTIVES: We compared clinical long-term course and outcome in all AIDS patients admitted to our outpatient department from January, 1989 to June, 1998 with toxoplasma encephalitis (TE) as first AIDS-defining infection (n= 106) and in 106 patients with Pneumocystis carinii pneumonia (PCP) as first AIDS-defining disease. MATERIAL AND METHODS: The 2 groups were matched with respect to age, sex, risk group, degree of immunodeficiency as measured by CD4 cell counts and duration of HIV-1-positivity. TE was diagnosed radiologically and by response to treatment. RESULTS: Forty-three TE patients surviving the first TE symptoms > 14 months developed dementive symptoms, leucoencephalopathy in imaging procedures and died from dementia. In contrast only 5 patients surviving PCP for an equally long period showed dementive symptoms. CONCLUSION: Cerebral infections like toxoplasma encephalitis (TE) may negatively influence HIV-1-activity so far latent in the brain.


    Antibiotic treatment for patients with amniotic fluid "sludge" to prevent spontaneous preterm birth: A historically controlled observational study.

    Acta Obstet Gynecol Scand 2019; ():

    INTRODUCTION: Amniotic fluid "sludge" has been associated with an increased rate of spontaneous preterm delivery before 35 weeks, a higher frequency of clinical and histologic chorioamnionitis in a high-risk population. Only one study evaluating the use of antibiotics in the presence of amniotic fluid "sludge" showed reduced rates of spontaneous preterm birth at <34 weeks. The objective of this study was to evaluate routine antibiotic treatment in the presence of amniotic fluid "sludge" for prevention of preterm delivery. MATERIAL AND METHODS: A historically controlled observational study was performed between October 2010 and January 2015, including a total of 86 pregnant women with singleton pregnancies and the presence of amniotic fluid "sludge" at ultrasound. Women admitted from October 2010 to September 2012 received no treatment with antibiotics, whereas those admitted from October 2012 to January 2015, received routinely clindamycin and first-generation cephalosporin. The groups were compared considering the incidence of spontaneous preterm delivery. The effect of antimicrobials was also compared in the subgroup of women at high risk for spontaneous preterm birth (ie, cervical length


    Prevalence of and risk factors for abnormal vaginal flora and its association with adverse pregnancy outcomes in a rural district in north-east Bangladesh.

    Acta Obstet Gynecol Scand 2019; 98 (3): 309-319

    INTRODUCTION: The role of screening and treatment for abnormal vaginal flora (AVF) on adverse pregnancy outcomes remains unclear. Using data from women who participated in a population-based cluster randomized trial who were screened and treated for AVF, we report risk factors for AVF and association of persistent AVF with adverse perinatal outcomes. MATERIAL AND METHODS: Pregnant women (n = 4221) <19 weeks of gestation provided self-administered mid-vaginal swabs; smears were Nugent-scored. AVF was treated with oral clindamycin; if AVF was present 3 weeks after treatment, persistent AVF was re-treated. We examined risk factors for AVF and the association of persistent AVF with adverse pregnancy outcomes. RESULTS: The prevalence of AVF was 16.5%: 9.8% of women had bacterial vaginosis and 6.8% had intermediate flora. Lower economic and educational status of women were associated with increased risk of AVF. One-third of women with AVF had persistent abnormal flora; these women had a higher risk of a composite measure of adverse pregnancy outcomes from 20 to <37 weeks (preterm live birth, preterm still birth, late miscarriage) (relative risk [RR] 1.33, 95% confidence interval [CI] 1.07-1.65) and of late miscarriage alone (RR 4.15, 95% CI 2.12-8.12) compared to women without AVF. CONCLUSIONS: In this study in Sylhet District, Bangladesh, rates of AVF and persistent AVF were high and persistent AVF was associated with adverse pregnancy outcomes, with an especially high associated risk for late miscarriage. Further characterization of the microbiome and relative bacterial species density associated with persistent AVF is needed.


    The treatment of bacterial vaginosis in pregnancy with clindamycin to reduce the risk of infection-related preterm birth: a response to the Danish Society of Obstetrics and Gynecology guideline group's clinical recommendations.

    Acta Obstet Gynecol Scand 2017; 96 (2): 139-143

    Preterm birth is the major cause of perinatal mortality and morbidity worldwide. Infection/inflammation is responsible for a significant percentage of preterm birth, particularly at early gestations. A recent clinical recommendation by a guidelines group of the Danish Society of Obstetrics and Gynecology advised against the use of clindamycin for the treatment of bacterial vaginosis in pregnancy to reduce the risk of spontaneous preterm birth based on lack of evidence of efficacy. We believe that the evidence for the use of clindamycin for this indication is robust and that this recommendation was reached erroneously on the basis of flawed inclusion criteria: the inclusion of an unpublished study with poorly diagnosed bacterial vaginosis and the exclusion of an important pivotal study on the use of clindamycin in early pregnancy for the prevention of preterm birth. Had these errors been corrected, the conclusions would have been different.


    Treatment of bacterial vaginosis in pregnancy in order to reduce the risk of spontaneous preterm delivery - a clinical recommendation.

    Acta Obstet Gynecol Scand 2016; 95 (8): 850-60

    INTRODUCTION: Bacterial vaginosis (BV) is characterized by a dysbiosis of the vaginal microbiota with a depletion of Lactobacillus spp. In pregnancy, prevalence's between 7 and 30% have been reported depending on the study population and the definition. BV may be associated with an increased risk of spontaneous preterm delivery (sPTD). However, it is controversial whether or not BV-positive pregnant women will benefit from treatment to reduce the risk of sPTD. We could not identify any good-quality guideline addressing this issue. Consequently we aimed to produce this clinical recommendation based on GRADE. MATERIAL AND METHODS: Systematic literature searches were conducted in the following databases: Guidelines International Network: G-I-N, Medline, Embase, The Cochrane Database of Systematic Reviews, Web of Science and from 1999 to 3 October 2014. Hence, nine guidelines, 34 reviews, 18 randomized controlled trials and 12 observational studies were included. RESULTS: The GRADE quality of evidence was consistently low or very low, primarily because none of the risk ratios (RR) for the risk of sPTD at <37 weeks were statistically significant. Concerning treatment with metronidazole, RR was 1.11 (95% CI 0.93-1.34) in low-risk pregnancies and 0.96 (95% CI 0.78-1.18) in high risk pregnancies. Concerning treatment with clindamycin at any gestational age, the RR was 0.87 (95% CI 0.73-1.05). CONCLUSION: This systematic review gives a strong recommendation against treatment with metronidazole and a weak recommendation against treatment with clindamycin to reduce the sPTD rate in both high-risk and low-risk pregnancies with BV.


    Prevalence of maternal group B streptococcal colonisation in European countries.

    Acta Obstet Gynecol Scand 2008; 87 (3): 260-71

    BACKGROUND: Group B streptococcus (GBS) is a leading cause of neonatal sepsis in many industrialised countries. However, the burden of perinatal GBS disease varies between these countries. We undertook a systematic review to determine the prevalence of maternal group B streptococcal colonisation, one of the most important risk factor for early onset neonatal infection, and to examine the serotype distribution of the GBS strains isolated and their susceptibility to antibiotics in European countries. METHODS: We followed the standard methodology for systematic reviews. We prepared a protocol and a form for data extraction that identifies key characteristics on study and reporting quality. The search was conducted for the years 1996-2006 including electronic, hand searching and screening of reference lists. RESULTS: Twenty-one studies presented data on 24,093 women from 13 countries. Among all studies, GBS vaginal colonisation rates ranged from 6.5 to 36%, with one-third of studies reporting rates of 20% or greater. The regional carriage rates were as follows: Eastern Europe 19.7-29.3%, Western Europe 11-21%, Scandinavia 24.3-36%, and Southern Europe 6.5-32%. GBS serotypes III, II and Ia were the most frequently identified serotypes. None of the GBS isolates were resistant to penicillin or ampicillin, whereas 3.8-21.2% showed resistance to erythromycin and 2.7-20% showed resistance to clindamycin. CONCLUSION: Although there is variation in the proportion of women colonised with GBS, the range of colonisation, the serotype distribution and antimicrobial susceptibility reported from European countries appears to be similar to that identified in overseas countries.


    Group B streptococcal carriage in Sweden: a national study on risk factors for mother and infant colonisation.

    Acta Obstet Gynecol Scand 2008; 87 (1): 50-8

    BACKGROUND: To study group B streptococcus (GBS) colonisation in parturients and infants in relation to obstetric outcome and to define serotypes and antibiotic resistance in GBS isolates acquired. METHODS: A population-based, national cohort of parturients and their infants was investigated. During 1 calendar week in 2005 all women giving birth (n=1,754) were requested to participate in the study. RESULTS: A total of 1,569 mother/infant pairs with obstetric and bacteriological data were obtained. Maternal carriage rate was 25.4% (95% confidence interval (CI): 23.3-27.6). In GBS-positive mothers with vaginal delivery and no intrapartum antibiotics, the infant colonisation rate was 68%. Some 30% of infants were colonised after acute caesarean section, and 0% were colonised after an elective procedure. Duration of transport of maternal recto/vaginal swabs of more than 1 day impeded culture sensitivity. Infant mMales were more frequently colonised than females (76.9 versus 59.8%, odds ratio (OR): 2.16; 95% CI: 1.27-3.70), as were infants born after rupture of membranes > or =24 h (p =0.039). Gestational age, birth weight and duration of labor did not significantly influence infant colonisation. Some 30% of parturients with at least one risk factor for neonatal disease received intrapartum antibiotics. The most common GBS serotypes were type III and V. Some 5% of the isolates were resistant to clindamycin and erythromycin, respectively. CONCLUSIONS: Maternal GBS prevalence and infant transfer rate were high in Sweden. Males were more frequently colonised than females. The sensitivity of maternal cultures decreased with the duration of sample transport. Clindamycin resistance was scarce. The use of intrapartum antibiotics was limited in parturients with obstetric risk factors for early onset group B streptococcal disease.


    Use of pH/whiff test or QuickVue Advanced pH and Amines test for the diagnosis of bacterial vaginosis and prevention of postabortion pelvic inflammatory disease.

    Acta Obstet Gynecol Scand 2006; 85 (7): 837-43

    BACKGROUND: Untreated bacterial vaginosis (BV) is a risk factor for postabortion pelvic inflammatory disease (PID). METHODS: Eight hundred and eight women who requested therapeutic abortion were consecutively examined for the presence of BV, using either pH/whiff test or QuickVue Advanced pH and Amines test. All patients who tested positive to BV were treated with clindamycin or metronidazole prior to abortion. RESULTS: Based on the wet smear examination, the incidence of BV was 21.6%. Positive pH and whiff test had a sensitivity of 53%, specificity of 98% and Kappa index 0.59 (n=239). Values for QuickVue Advanced pH and Amines test were 53%, 97%, and 0.58 respectively (n=508). The incidence of PID among all patients was 2.4% after pharmacological abortion and 4.9% after surgical abortion. Among the patients with microscopic presence of BV diagnosed positive by the pH/whiff test or QuickVue Advanced pH and Amines test and treated with antibiotics, no PID occurred. Patients with negative pH/whiff test or QuickVue pH and amines test who consequently did not receive preoperative antibiotics, but who later demonstrated microscopic presence of BV, had an incidence of 14.3% (5/35) postoperative PID compared to women with normal lactobacilli flora 4.3% (10/234) (OR 3.73; 95% CI 1.21-9.21). CONCLUSIONS: Although the pH/whiff test and QuickVue pH and Amines test failed to ascertain BV in almost half of the participants later found to have BV, we found that preabortal screening and subsequent treatment of those who test clinically positive does lower the incidence of postabortion PID.


    Cost-effectiveness of screening and treatment for bacterial vaginosis in early pregnancy among women at low risk for preterm birth.

    Acta Obstet Gynecol Scand 2004; 83 (1): 27-36

    BACKGROUND: Bacterial vaginosis (BV) is an important risk factor for preterm birth. BV is detected in 10-30% of pregnant women and is often asymptomatic. Treatment of BV during pregnancy seems to reduce the risk of preterm delivery among high-risk women. We performed a cost-effectiveness analysis of screening and treatment for BV in early pregnancy among asymptomatic women at low risk for preterm delivery. METHODS: A decision tree was built with two arms. For the screening (and treatment) arm the probabilities were derived from our earlier randomized trial on screening and treatment for BV, consisting of BV-positive women treated with intravaginal clindamycin cream or placebo and also of BV-negative pregnant women. The probabilities of outcomes among these women were collected from antenatal clinic records and hospital records, and for the no-screening arm mainly from the Finnish Perinatal Statistics. The outcomes considered were preterm delivery, mode of delivery, peripartum infections and postpartum complications. The unit costs associated with these outcomes were mainly based on disease-related groups (DRGs). No-screening was compared with two screening programs (one with clindamycin, the other with metronidazole treatment) and subjected to sensitivity analyses. RESULTS: There was no significant difference between screening and no-screening strategies in the costs and in the rate of preterm deliveries but the screening strategy produced significantly fewer peripartum infections and postpartum complications. Sensitivity analyses suggested that the screening strategy may become cost-saving if the rate of preterm deliveries exceeds 3%. CONCLUSION: Screening and treatment for BV in early pregnancy may not reduce costs compared to no-screening in a population at low risk for preterm birth but would produce, at the same cost, more health benefits in terms of fewer peripartum infections and postpartum complications. However, it may be cost-saving if the rate of preterm deliveries is higher than 3%.


    Antibiotic treatment for threatened abortion during the early first trimester in women with previous spontaneous abortion.

    Acta Obstet Gynecol Scand 2001; 80 (8): 753-6

    BACKGROUND: We retrospectively examined the usefulness of antibiotic therapy for management of first-trimester threatened abortion in women with previous spontaneous abortion. METHODS: From 1993 through 1999, women with first-trimester threatened abortion received antibiotic therapy. Only those with gestational age less than 9 weeks and previous spontaneous abortion were included in this analysis. Women with mild abdominal cramping received amoxicillin plus erythromycin for 1 week; those with severe abdominal pain received amoxicillin plus clindamycin for 1 week. Recurrence was documented on the basis of either lower abdominal pain or vaginal bleeding. RESULTS: Of the 23 women included, 15 (65%) had abnormal vaginal flora (a score above 4, Nugent's criteria). Seven of 16 women who received amoxicillin plus clindamycin and three of seven who received amoxicillin plus erythromycin had complete resolution of lower abdominal pain and vaginal bleeding without recurrence (p=1). The recurrence rate was higher, though not significantly, in women with abnormal bacterial vaginal flora (8/15 vs. 2/8, p=0.379). Twenty-two (96%) of the 23 pregnancies were carried to term, with no identifiable neonatal anomalies. CONCLUSIONS: These results suggest the usefulness of early antibiotic therapy in preventing pregnancy loss in women with threatened abortion early in the first trimester, and warrant further clinical trials.


    Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study.

    Acta Obstet Gynecol Scand 2000; 79 (5): 390-6

    BACKGROUND: Bacterial vaginosis (BV) and intermediate flora is known risk-factor for postoperative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy. AIM: To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion. DESIGN: Prospective, double-blinded, placebo-controlled, multicenter study. MATERIAL AND METHODS: Consecutive women attending for surgical termination prior to 11+4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables. RESULTS: Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal flora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group. CONCLUSION: Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora).


    Treatment of Bartholin's abscess. Marsupialization versus incision, curettage and suture under antibiotic cover. A randomized study with 6 months' follow-up.

    Acta Obstet Gynecol Scand 1992; 71 (1): 59-62

    Conventional marsupialization was compared with incision plus curettage and primary suture of the abscess cavity under antibiotic (Clindamycin) cover in a prospective, randomized study of 32 patients with Bartholin's abscess. The median time to healing was 5 days less after suture than after marsupialization alone. The difference was statistically significant. 29 patients were followed up for 6 months. Recurrence of abscesses tended not to be more frequent after suture, making suture an attractive, safe and convenient alternative treatment for Bartholin's abscess.


    Comparative evaluation of clindamycin/gentamicin and cefoxitin/doxycycline for treatment of pelvic inflammatory disease: a multi-center trial. The European Study Group.

    Acta Obstet Gynecol Scand 1992; 71 (2): 129-34

    The clinical efficacy and safety of clindamycin-gentamicin versus doxycycline-cefoxitin in the treatment of acute pelvic inflammatory disease was evaluated in a comparative, randomized, prospective, multicenter study. Ten investigators enrolled 170 patients. Those judged to be eligible for efficacy were 60/88 (68%) who received the clindamycin-gentamicin regimen and 55/82 (67%) of those treated with cefoxitin-doxycycline. A successful clinical outcome was attained for 52/60 (87%) and 46/55 (84%) for patients treated with clindamycin-gentamicin and cefoxitin-doxycycline, respectively, a difference that was not statistically significant. In the clindamycin-gentamicin series, 8/8 (100%) of patients with positive C. trachomatis culture at baseline were culture negative at the late follow-up 21-35 days after treatment. For those given cefoxitin-doxycycline, 9/11 (82%) who had C. trachomatis at pretreatment showed eradication at follow-up. Neisseria gonorrhoeae was present at baseline in 8/60 (13%) of the clindamycin-gentamicin patients and in 9/55 (16%) of those treated with cefoxitin-doxycycline. Of those who had appropriate follow-up cultures performed, 6 in the clindamycin-gentamicin group and 8 in the cefoxitin-doxycycline series, all showed eradication of the organism. It is concluded that clindamycin-gentamicin and cefoxitin-doxycycline have similar clinical cure rates for acute pelvic inflammatory disease, and based on this limited experience, it is suggested that the clindamycin-gentamicin combination will satisfactorily eradicate Chlamydia trachomatis and Neisseria gonorrhoeae when either or both of these pathogens are present.


    Preoperative clindamycin treatment and vaginal drainage in hysterectomy.

    Acta Obstet Gynecol Scand 1989; 68 (3): 241-5

    In a randomised study, comprising 166 patients, aged 25-75 years, the effect of a single preoperative dose of Clindamycin was compared with no antibiotic treatment at all in patients undergoing elective abdominal hysterectomy with drainage of the upper part of the vagina. Febrile Morbidity, frequency of postoperative infections, the amount of secretion and the number of hospital days were recorded. Preoperative administration of clindamycin resulted in a reduction (from 24% to 14%) in the febrile morbidity, and in the amount of secretion (from 24 to 12.5 ml) both of marginal statistical significance, whereas the reduction in the frequency of postoperative infections (from 19 to 10%) was without statistical significance. A statistically significant reduction in the hospitalisation period (from 8.4 to 7.9 days) was observed. The frequency of urinary tract infections was similar in the two groups. No adverse reactions occurred in connection with the clindamycin treatment.


    Ruptured episiotomia resutured primarily.

    Acta Obstet Gynecol Scand 1987; 66 (2): 163-4

    In a randomized study, 35 patients with ruptured episiotomy were treated in two ways. One group, treated with Clindamycin and primary resuture, did better than the other group, not resutured but spontaneously healed.


    Treatment of abscesses in the vulva. Conventional open treatment versus primary suture under antibiotic cover.

    Acta Obstet Gynecol Scand 1986; 65 (5): 459-61

    Seventy patients were treated for a subcutaneous abscess in the vulva. In 35 consecutive patients the abscess was treated conventionally with deroofing of the abscess and wet dressings. In the other 35 consecutive patients the abscess was treated by incision, curettage and primary suture under antibiotic cover with a single dose of clindamycin. In the conventionally treated group the median stay in hospital was 7 days and the median healing time 18 days. In the group treated by primary suture the median stay in hospital was 2 days and the median healing time 7 days (P less than 0.0001). Recurrence of abscess was observed in one patient in each group. No other complications were observed in either group. It is concluded that vulvar abscesses may be treated safely and advantageously by primary suture under antibiotic cover.


    Bacteriocins in S. mutans strains isolated from children with and without dental caries: biotypes and sensitivity to antibiotics.

    Acta Odontol Latinoam 2008; 21 (1): 97-104

    The aim of this study was to determine the production of bacteriocins in the Streptococcus mutans strains isolated from children with and without dental caries. With this purpose the dmft index was determined and non-stimulated saliva was collected from 53 3- to 5-year-old children. The samples were cultured on Mitis Salivarius Bacitracin agar and incubated anaerobically for two days at 37 degrees C. The isolates were biotyped using the Api-ZYM enzymatic system (bioMerieux; Marcy-lE'toile, France). Bacteriocin was detected using the double layer onto brain heart infusion agar technique and the minimal inhibitory concentrations of the isolates were evaluated against penicillin, amoxycillin, cefazolin, erythromycin, clindamycin, imipenem and vancomycin using an agar dilution method. The dental caries experience in these children was 66% (35/53) and dmft index average was 3.2 (range 2-6). S. mutans was found in the saliva of 33 children (62%). In the 33 strains of S. mutans, 10 biotypes were found. Eight (24%) of the 33 strains evaluated produced bacteriocins, 6 of these strains came from patients with dental caries and the other two from patients without dental caries. All isolates were highly sensitive to the antibiotics tested.


    Determination and identification of antibiotic-resistant oral streptococci isolated from active dental infections in adults.

    Acta Odontol Scand 2018; 76 (4): 229-235

    OBJECTIVE: To determine and identify antibiotic-resistant bacteria (ARB) of oral streptococci from active dental infections in adults and its association with age and gender. MATERIAL AND METHODS: This cross-sectional study included 59 subjects from 18 to 62 years old. Ninety-eighth samples obtained from the subjects were cultivated in agar plates containing antibiotics amoxicillin/clavulanic acid (A-CA), clindamycin, and moxifloxacin (concentrations of 16, 32 or 64 microg/ml). PCR assay was performed to identify bacterial species. RESULTS: The bacterial species that showed more antibiotic-resistance (AR) was S. mutans (45.9%), followed by S. gordonii (21.6%), S. oralis (17.6%), S. sanguinis (9.5%), S. salivarius (5.4%) and S. sobrinus (0%). Moreover, clindamycin (59.4%) showed the highest frequency of AR. Moxifloxacin and A-CA showed an susceptibility >99.1%, while clindamycin showed the lowest efficacy (93.3%); there was a significant statistically difference (p < .01). The age group between 26 and 50 years old (32.2%) and females (28.8%) showed more multiresistance. Clindamycin showed a statistical difference (p < .05) when comparing groups by gender. CONCLUSIONS: Clindamycin was the antibiotic with the highest frequency of ARB and lower bactericidal effect. Moxifloxacin and A-CA showed the highest efficacy and the lowest ARB frequency. Streptococcus mutans was the bacterial specie that showed an increased frequency of AR.


    Radiography-based score indicative for the pathogenicity of bacteria in odontogenic infections.

    Acta Odontol Scand 2014; 72 (7): 530-6

    OBJECTIVE: 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. MATERIALS AND METHODS: 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 (1) 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. CONCLUSIONS: 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.


    Odontogenic infections: an 8-year epidemiologic analysis in a dental emergency outpatient care unit.

    Acta Odontol Scand 2013; 71 (3-4): 518-24

    OBJECTIVES: The purpose of this investigation was to analyze epidemiological patterns, clinical features and the management of odontogenic infections in patients undergoing treatment in a dental emergency outpatient care unit. STUDY DESIGN: A retrospective analysis of 58 161 case records of patients presenting to an emergency outpatient unit in Hamburg, Germany between 2000-2007 was performed. From this pool, patients with odontogenic infections were identified using an ICD-10 code, analyzing age, gender, medical co-morbidities, duration of pain, ratio of infiltrates/abscesses, affected teeth, management of infection and administered antibiotics. RESULTS: Of the 58 161 patients, 5357 (9.2%) were identified as having odontogenic infections, with 2689 (50.2%) inflammatory infiltrates and 2668 (49.8%) abscesses. Mean age was 34.8 +/- 16.8 years. As the primary site of odontogenic infection, the most significantly affected teeth were the maxillary and mandibular first molars. Patients in age-group 20-29 years (25.1%) utilized the emergency care unit more frequently than other age groups. Clindamycin was the most frequently administered antibiotic. CONCLUSIONS: Early recognition, diagnosis and management of odontogenic infections are requisite for avoiding or minimizing the development of potential complications. Strategies and evidence-based protocols should be developed within the dental ambulatory care sector, advancing interdisciplinary cooperation between general dentists and oral or maxillofacial surgeons.


    Aggressive toxoplasma retinitis.

    Acta Ophthalmol (Copenh) 1992; 70 (6): 795-800

    Toxoplasma infection is a common cause of infectious uveitis. It usually produces a characteristic fundal appearance, with evidence of previous inflammation. However, it may occur in an atypical and aggressive form. Steroids administered to salvage vision may then worsen the clinical course. Retinal biopsy may be diagnostic in cases where doubt exists. We illustrate these points with two cases.


    Clindamycin and sulphonamides in the treatment of ocular toxoplasmosis.

    Acta Ophthalmol (Copenh) 1983; 61 (1): 51-7

    Eight patients with active toxoplasmic retinochoroiditis were treated with clindamycin and a triple sulphonamide combination for a period of up to 6 weeks. In addition systemic prednisone was administered when the optic nerve or the macula was involved (6 of the 8 cases). In all cases we observed clinical improvement within 2 weeks. Visual acuity improved in all cases. Side effects of the treatment were observed in 2 cases. The follow-up period ranged from 8 to 22 months.


    Low relapse with oral antibiotics and two-stage exchange for late arthroplasty infections in 40 patients after 2-9 years.

    Acta Orthop 2007; 78 (4): 511-9

    BACKGROUND AND PURPOSE: Exchange surgery in late arthroplasty infection is directed against bacteria adhering to implants. Therapies based on antibiotics that are effective intracellularly have been proposed recently. We have combined both strategies to improve the cure rate. METHODS: 40 consecutive patients (16 hips, 24 knees) were diagnosed with late arthroplasty infection. The organisms isolated were 35 Staphylococcus, 19 of which were methicillin-resistant, 4 Enterococcus, 6 Gram-negative bacilli, and 4 Corynebacterium. The infections were managed by a combined therapy consisting of two-stage exchange surgery and two oral intracellularly-effective antibiotics. The antibiotics were selected according to bacterial sensitivity and intracellular and biofilm effectiveness. Second re-implantation surgery was delayed until clinical and analytical normalization. Patients were in hospital for only 1 week after each surgery, and were followed up prospectively on an outpatient basis (2-9 years). Cure of the infection was defined as absence of clinical, serological, and radiographic signs of infection during the whole follow-up. RESULTS: The infection was resolved in 38/40 patients (15/16 hips and 23/24 knees). INTERPRETATION: Oral antibiotics that are effective intracellularly in combination with two-stage exchange surgery is a promising alternative for treating late arthroplasty infections. Oral antibiotics shorten hospitalization and reduce patient discomfort.


    Cancellous bone as an antibiotic carrier.

    Acta Orthop Scand 2000; 71 (1): 80-4

    We compared the release characteristics of antibiotics from in vivo and in vitro processed morselized cancellous bone. The bone was impregnated with 7 antibiotics and compressed into a wire-mesh cylinder. In vitro, the bone was processed by daily transfer of the cylinder with its contents into test tubes with broth. The amount of antibiotic eluted from the bone was measured after 1, 3 and 7 days. In vivo, the cylinder was implanted intramuscularly in the interscapular region in rats. After 1, 3 and 7 days, the cylinder was removed and the amount of antibiotic eluted in broth was measured. The results showed that morselized cancellous bone can act as a carrier of antibiotics in vitro and in vivo. The elution profiles of netilmicin-, vancomycin-, clindamycin- and rifampicin-impregnated cancellous bone processed in vitro and in vivo were similar.


    Adsorption and release of antibiotics from morselized cancellous bone. In vitro studies of 8 antibiotics.

    Acta Orthop Scand 1999; 70 (3): 298-304

    We studied the basic release patterns of antibiotics from cancellous bone in vitro. Antibiotic-impregnated bone was compressed into a wire-mesh cylinder and the release of antibiotic was assessed by two different in vitro methods: agar diffusion and broth elution. The zones of inhibition were measured on seeded agar and the amounts of antibiotics released in elution tubes were assessed by a bioassay. The study continued for 21 days with daily transfer of the cylinders. The results indicated that benzylpenicillin, dicloxacillin, cephalotin, netilmicin, clindamycin, vancomycin, ciprofloxacin and rifampicin were adsorbed to cancellous bone in vitro. Compared to broth elution, agar diffusion showed a prolonged period of release, owing to the small amounts of antibiotic leaking out of the cylinder into the agar. The betalactams had antibacterial activity in broth for a shorter time than the other antibiotics. The release patterns of the betalactams were similar, in spite of their differences in thermal stability. Only rifampicin showed a concentration higher than MIC for longer than 21 days.


    Antibiotic penetration into the infected knee. A rabbit experiment.

    Acta Orthop Scand 1987; 58 (3): 256-9

    We investigated the diffusion of penicillin-G, cloxacillin, clindamycin, and netilmicin into synovial fluid and membrane in rabbits. Purulent arthritis was induced in the right knee of each rabbit by inoculation of Staphylococcus aureus phage type 3C, whereas sterile saline was injected into the left knee to serve as a control. Two days later, concentrations of antibiotics were determined in serum, synovial fluid, and membrane after an intramuscular single dose. All four drugs diffused readily into infected joints, whereas the corresponding concentrations in the normal joints were 2-3 times lower. Clindamycin showed the highest intraarticular penetration, cloxacillin the lowest. The lower penetration of cloxacillin corresponded to its higher protein binding in rabbit serum. Considering the sufficient local concentrations achieved, parenteral treatment obviates the need for local instillation of these antibiotics.


    Clindamycin in recurrent group A streptococcal pharyngotonsillitis--an alternative to tonsillectomy?

    Acta Otolaryngol 1997; 117 (4): 618-22

    Fifty-three patients with bacterial treatment failure after a 10-day course of treatment with phenoxymethyl penicillin (pcV) for group A streptococcal (GAS) pharyngotonsillitis were randomly assigned to continued treatment with pcV, or to treatment with clindamycin instead. The patients were then followed for 1 year with throat cultures and clinical examination every third month and in the event of symptoms of sore throat. In the first 3-month period, 15/22 patients in the pcV group yielded one or more positive cultures for GAS, all of the same T-type as in the original throat culture, as compared to 3/26 in the clindamycin group (p < 0.001). All three cases in the clindamycin group were due to a new T-type and thus were re-infections. In the pcV group, owing to repeated treatment failure, 12/22 patients were switched to treatment with clindamycin within the 3-month period following the second treatment. During the remainder of the 1-year follow-up period, sporadic cases of GAS-positive throat cultures occurred in both groups, but there was no significant difference in frequency between the two groups. It is concluded that, in patients with GAS pharyngotonsillitis and failure after pcV treatment, a 10-day course of clindamycin can protect the patient from recurrence for at least 3 months and might be an alternative to tonsillectomy.


    Pharyngeal flora in patients undergoing head and neck oncologic surgery.

    Acta Otorhinolaryngol Belg 1999; 53 (3): 237-40

    In order to specify the correlation between pharyngeal flora and the onset of surgical wound infection, we conducted two prospective studies on patients undergoing oncologic surgical procedures with expected contamination by pharyngeal secretions. In the first study, an oropharyngeal swab and a specific swab of the tumour were collected the day before, or on the day of surgery. As potential pathogens were always isolated in the oropharyngeal swab, it was considered that the tumour is not infected but is colonised by the oropharyngeal flora. A second pharyngeal swab was collected at day 5-7 in the second study. Preliminary results in the second study showed that 50% (11/22) of patients were orpharyngeal carriers of pathogens before surgery. This rate is 70% (15/22) in the post-operative period with a higher rate of gram negative rods. WSI occurred in 7/22 patients (32%), mainly with isolated rods similar to those observed in the oropharyngeal post-operative flora and potential pathogens in 5/7 patients. More patients are necessary to establish a link between pre-operative ropharyngeal pathogens and the occurrence of SWI.


    De rol van de anaerobe bacterien bij sinusitis

    Acta Otorhinolaryngol Belg 1975; 29 (4): 613-20

    The purpose of the present study is to determine the role of the anaerobic bacteria in the chronic paranasal sinusitis. We cultured both aerobically and anaerobically, 80 specimen of pus we obtained by antral puncture. Fourteen per cent of the specimen were sterile (11 cases); we found a pure aerobic growth in 51% (41 cases), a mixed aerobic-anaerobic growth in 25% (20 cases) and a pure anaerobic growth in 10% (8 cases). This means that anaerobic organismes were isolated in 35% (28 cases): in 22% (18 cases) the anaerobic bacteria can be considered as the only pathogenes. These results show the great importance of the anaerobic bacteria in chronic and subacute paranasal sinusitis. The anaerobes live as saprofytes on the entire body but they become pathogene in certain conditions such as a low oxidation-reduction potential and a reduced oxygen tension. These conditions are found in the chronically infected paranasal sinuses. Probably the anaerobes do not initiate a sinusitis (except in the sinusitis from dental origine) but the primary infection is superinfected by anaerobes; once they have found ideal growth conditions, it's very difficult to destroy them: despite of several antral washings, a surgical intervention is often the only way. The best antibiotics against anaerobic sinusitis are clindamycin and tetracycline in general administration, and lincomycin, thiamfenicol and tetracycline for local application.


    Le infezioni batteriche ed il loro trattamento nella chirurgia demolitiva bucco-faringo-laringea.

    Acta Otorhinolaryngol Ital 1987; 7 (1): 53-65


    Actinomicosis lingual: dificultad de diagnostico. Revision de la bibliografia.

    Acta Otorrinolaringol Esp 2000; 51 (1): 80-4

    Actinomycosis of the cervicofacial area is a rare infection with a difficult clinical diagnosis. We report a case of lingual actinomycosis which was diagnosed after a long remission with empirical antibiotic treatment, two years after onset. The clinical characteristics, differential diagnosis, and therapeutic options in this unusual infection are discussed.


    Rinoescleroma. A proposito de un caso.

    Acta Otorrinolaringol Esp 1999; 50 (4): 321-3

    Rhinoscleroma is a chronic, specific, inflammatory granulomatous condition of the nose and other structures of the upper respiratory tract. It is caused by the bacterium Klebsiella rhinoscleromatis. We report a case in a 29-year-old black male emigrant who consulted for a 2-year history of hoarseness, cough, and nasal discharge. The diagnosis was scleroma with nasal, laryngeal, tracheal, and bronchial involvement and ulcerating and necrotizing lesions that caused respiratory obstruction. Bacterial over-infection responded to treatment with third-generation cephalosporins and clindamycin. The sclerotic lesions responded well to treatment with ciprofloxacin. We review the clinical findings at different stages, diagnostic options, and several treatments.


    Absceso lingual con presentacion clinica atipica.

    Acta Otorrinolaringol Esp 1999; 50 (1): 72-4

    Lingual abscesses have become extremely rare since the discovery of antibiotics, with only about 200 cases reported in the last 160 years. Diagnosis on the basis of clinical symptoms alone is quite difficult. Imaging studies are essential for the diagnosis of lingual abscesses and for their differentiation from related pathologies with similar clinical symptoms. We report a case of lingual abscess with otherwise unremarkable clinical findings that was diagnosed by CT scan. The etiology, pathophysiology, bacteriology, diagnosis, and treatment of these uncommon infections is discussed.


    Estudio comparativo de dos protocolos de profilaxis antibiotica en cirugia oncologica de faringe y laringe.

    Acta Otorrinolaringol Esp 1998; 49 (5): 397-9

    The use of antibiotic prophylaxis in oncological pharyngeal and laryngeal surgery has reduced the risk of postoperative wound infection, which decreases morbidity and health-care costs. We report the results of a prospective randomized study in our hospital comparing the effectiveness of two antibiotic protocols, amoxicillin-clavulanate and clindamycin plus gentamicin, both given for 24 hours, in patients who underwent clean-contaminated oncological surgery of the pharynx or larynx.


    Eikenella corrodens como patogeno de un absceso laterocervical.

    Acta Otorrinolaringol Esp 1993; 44 (1): 51-2

    We show a case of right neck abscess, in which the Eikenella corrodens, acted as pathogen together which other microorganism. We call attention to this germ that has a slow growing in culture and generally intervene in infections in which it is assumed the presence of anaerobic germs (intrathoracic abscess, neck abscess, etc.) and the are habitually treated with clindamycin, antibiotic which Eikenella corrodens is systematically resistant (to this antibiotic).


    Analisis de las modificaciones en la flora de la cavidad bucal tras el uso de antibioticos topicos orales. Importancia en la profilaxis antimicrobiana en cirugia de cabeza y cuello.

    Acta Otorrinolaringol Esp 1990; 41 (5): 347-50

    A pilot study using 5 healthy adults was performed to assess the influence of topical antibiotics and antiseptics on oral flora. Samples of saliva were cultured before and after rinsing the mouth with several solutions: clindamycin, amoxyciclin + clavulanic, povidone-iodine and placebo. The results of this study suggest that, by reducing concentrations of oral flora, topical oral antibiotic prophylaxis is justified for patients having a high risk of developing a surgical infectious complications.


    Case 2: An unusual presentation of an unusual condition (Case Presentation).

    Acta Paediatr 2008; 97 (6): 694


    Characteristics of Streptococcus pyogenes strains isolated from Chinese children with scarlet fever.

    Acta Paediatr 2008; 97 (12): 1681-5

    AIM: To analyse the characteristics of Streptococcus pyogenes isolates from Chinese children with scarlet fever. METHODS: Minimal inhibitory concentration with nine antibiotics was performed on 145 Streptococcus pyogenes isolates acquired from Beijing and Shanghai in 2007. Their macrolide-resistant genes (mefA, ermB and ermA- a subclass of ermTR), superantigens (speA and speC), and en-coding mature M protein gene (emm gene) were amplified by PCR. RESULTS: A total of 97.9% of the isolates exhibited resistance to the macrolides, while 96.6% manifested resistance to tetracycline. All isolates were sensitive to chloramphenicol, penicillin, cefradine, and ofloxacin. Moreover, 94.5% exhibited a cMLSB phenotype, while 90.3% had the ermB gene. Five emm types (emm1.0, emm4.0, emm12.0, emm22.0 and st5240) were discovered, of which 9.7% carried the superantigen speA, 35.9% carried the speC, 42.8% carried both speA and speC and 11.7% carried neither speA nor speC. Finally, 85.5% of emm1.0 and 15.5% of emm12.0 isolates carried speA, while 79.0% of emm1.0 and 75.9% of emm12.0 isolates carried speC. CONCLUSION: The Streptococcus pyogenes isolates had high resistance rates against macrolides and tetracycline. They mainly expressed the ermB gene type and cMLSB phenotype. Their common emm types are emm1.0 and emm12.0, which have different frequencies of speA and speC.


    Evaluation of clindamycin in group A beta haemolytic streptococcal infections in children.

    Acta Paediatr Belg 1973; 27 (5): 329-33


    Interaction of phagocytic cells with antibiotics: uptake and intracellular killing activity.

    Acta Paediatr Hung 1988; 29 (1-2): 153-8


    Flavobacterium meningosepticum infections in a neonatal intensive care unit.

    Acta Paediatr Scand 1989; 78 (1): 51-5

    An outbreak of nosocomial infections by Flavobacterium meningosepticum in a neonatal intensive care unit is described. During a period of eleven weeks two patients presented with septicaemia and meningitis. In addition, nine patients were found to be colonized and three of these neonates developed septicaemia. The infected patients were treated with clindamycin and piperacillin. All the patients survived, but the neonates with meningitis developed hydrocephalus. An extensive bacteriological screening of the staff was negative, but in the ward environment, F. meningosepticum was found around sinks, on rubber stoppers for milk bottles and on "cleaned" teats. Several infection control measures were instituted. Established routines were revised, with particular emphasis on the handling of objects containing or in regular contact with water.


    Case report. Clindamycin associated pseudomembranous colitis.

    Acta Paediatr Scand 1981; 70 (1): 129-30

    Pseudomembranous colitis is rare in children. We describe a case associated with clindamycin in which Clostridium difficile and its enterotoxin were isolated from the stool. Treatment with oral vancomycin brought about a prompt and complete recovery.


    In vitro antibiotic susceptibility of lactobacilli isolated from commercial products containing active lactobacilli.

    Acta Paediatr Taiwan 2004; 45 (3): 141-4

    To survey the antibiotic susceptibility patterns of some commercially available Lactobacillus, we collected four commercial products that contain active Lactobacillus. We incubated individual product and identified these colonies by the methods of API50 CH test kit and RAPID ID 32A kit. Strains of Streptococcus thermophilus, Bifidobacterium infantis, Lactobacillus acidophilus and Lactobacillus casei were collected. By agar dilution method, each identified strain was inoculated to Brucella blood agar-MIC plates. Each plate contained one of the following antibiotics with different concentrations: amoxicillin, cephalothin, gentamicin, vancomycin, erythromycin, rifampin, tetracyclin and penicillin G, clindamycin, chloramphenicol, cefmetazole, metronidazole, ampicillin/sulbactum, cefoxtin, etc. After incubation, the growth condition of each Brucella blood agar-MIC plate was observed and the breakpoint of each antibiotic to different Lactobacillus products determined. The MICs of amoxicillin, ampicillin/sulbactum and penicillin-G to all identified strains were < or =2 microg/ml and those of vancomycin, clindamycin, erythromycin, metronidazole, cefmetazole and cefoxtin for L. casei were >32 microg/ml. L. casei was more resistant to all the testing antibiotics than the other strains. According to the MICs of the above antibiotics, proper active lactobacillus products could be chosen to prevent antibiotic-associated diarrhea in the pediatric field.


    Group B streptococcus infection in infancy: 21-year experience.

    Acta Paediatr Taiwan 2002; 43 (6): 326-9

    In this hospital-based review, clinical presentations associated with Group B streptococcus (GBS) infections in children occurring between January 1980 and March 2000 were analyzed. Among the 25 infants with invasive group B streptococcal infections, 9 (36%) were early onset diseases (EOD), 12 (48%) were late onset diseases (LOD), and 4 (16%) occurred beyond the third month of life. Eight of the nine (89%) EOD cases manifested during the first day of life and three (33%) were premature births. Common presentations in GBS infection were fever (75%), poor activity (25%), respiratory distress (25%), lethargy (20%), and irritability (20%). Seizure occurred in 31% of infants with meningitis. Pneumonia (66%) and case-fatality rate (33.3%) were significantly higher in EOD than in LOD. Meningitis was the major manifestation (77%) of LOD and had severe sequelae in 40% of cases. Eight strains were assayed for antibiotic sensitivity and they were all susceptible to penicillin, ampicillin, cefotaxime, and vancomycin. The susceptibilities to erythromycin and clindamycin were 62% and 75%, respectively. Most of the strains from blood or cerebrospinal fluid were type III.


    Isolation of Eikenella corrodens from polymicrobial hepatic abscess: report of one case.

    Acta Paediatr Taiwan 1999; 40 (1): 50-2

    Eikenella corrodens is a rare cause of hepatic abscess. We report a case of a hepatic abscess caused by (1) Bacteroides fragilis, (2) Streptococcus constellatus and (3) E. corrodens, which illustrates potential problems of antibiotic coverage due to the presence of Eikenella species. The infection followed an episode of acute gastroenteritis and the clinical course appeared indolent evolving over one week. Besides empirical antibiotics, initial percutaneous aspiration was performed and yielded pus which grew E. corrodens concomitantly with Streptococcus species. E. corrodens was sensitive to penicillin but resistant to clindamycin and metronidazole. But B. fragilis was resistant to penicillin. So the antibiotics were switched to amoxicillin/clavulanate. Unfortunately fever persisted and the abscess increased in size. Therefore echo-guided percutaneous drainage with pigtail catheter was installed. Fever subsided 5 days later. After 21 days treatment of antibiotics, the patient was discharged in good condition despite having some sterile fluid in the residual abscess cavity. Two months after discharge the follow-up echogram confirmed complete resolution of the residual abscess. This patient shows us the existence of E. corrodens in pediatric patients, especially when the hepatic abscess is very likely from the spread of an oral or abdominal infection.


    Antibiotics and human monocyte function. I. Chemotaxis.

    Acta Pathol Microbiol Immunol Scand B 1987; 95 (5): 293-6

    The influence of thirteen commonly used antibacterial drugs on the chemotactic responsiveness of human blood monocytes in vitro was investigated. Tetracyklin, trimethoprim and fusidic acid at high concentrations produced a significant inhibition of the monocyte response, whereas normal therapeutic concentrations produced insignificant inhibition. Benzylpenicillin, ampicillin, tobramycin, chloramphenicol, metronidazole, rifampicin, clindamycin, sulfametoxazole, cefotaxime and ofloxacin did not alter monocyte migration. From these observations it can be expected that at normal dosages none of the tested drugs will affect monocyte chemotaxis in vivo.


    In vitro susceptibility of Campylobacter jejuni and Campylobacter coli isolated in Denmark to fourteen antimicrobial agents.

    Acta Pathol Microbiol Immunol Scand B 1987; 95 (3): 189-92

    The in vitro susceptibility of 95 recent Danish human clinical isolates of Campylobacter jejuni and Campylobacter coli to 14 antimicrobial agents was determined by an agar dilution technique. C. jejuni and C. coli were considered together. Doxycycline, ciprofloxacin, gentamicin, clindamycin, nitrofurantoin and erythromycin were the most active drugs. 2% of the strains tested were resistant to erythromycin (MIC greater than 3.1 micrograms/ml). Therefore susceptibility testing is suggested if antimicrobial therapy with erythromycin is considered to be indicated. Ciprofloxacin might prove to be an alternative to erythromycin. Susceptibility testing in a CO2 atmosphere affected the determination of MICs of doxycycline, erythromycin, gentamicin and clindamycin, probably reflecting pH-changes in the media during incubation under increased CO2 tension.


    Susceptibility testing of 7 antibiotics against anaerobic bacteria: comparison of 2 different media and carbon dioxide concentrations.

    Acta Pathol Microbiol Immunol Scand B 1987; 95 (1): 65-73

    Anaerobic agar (AA) and Danish Blood agar (DBA) were evaluated by a standardized agar diffusion and agar dilution test in 5% CO2. The activity of seven antibiotics (tetracycline, clindamycin, metronidazole, rifamycin, chloramphenicol, penicillin, erythromycin) was tested against 40 anaerobic bacteria, including 3 control strains (Cl.perfringens ATCC 13124, B.fragilis ATCC 25285, B.thetaiotaomicron ATCC 29741). 70% of the strains were resistant to erythromycin in 10% CO2, only 30% in 5% CO2. No evident CO2-effect could be seen with the other antibiotics. Mean MIC for tetracycline was twice as great on AA than DBA. In spite of that, tablet sensitivity testing with tetracycline on AA proved to be more accurate and completely separated the resistant and susceptible strains. For penicillin, the mean MIC was one dilution step higher on AA. No major differences could be seen with the other antibiotics. AA was superior to DBA in providing growth of anaerobes. Measurement on AA was easier, and it was more precise. Except for tetracycline. MIC on control strains fell well within range set by The National Committee for Clinical Laboratory Standards (NCCLS) on AA. Acceptable correlation coefficients were recorded between agar diffusion and agar dilution. Prediction of susceptibility based on zone diameter measurements was very good on AA. Only one discrepancy that could cause change of susceptibility status occurred on AA, while there were 12 on DBA. On DBA, there was poor correlation between MIC, compared with earlier results on the same agar. The 50% inhibitory concentration (IC50) was also measured, but offered no advantage over MIC.


    Antimicrobial susceptibility of Flavobacterium meningosepticum strains identified by DNA-DNA hybridization.

    Acta Pathol Microbiol Immunol Scand B 1987; 95 (2): 95-101

    Antimicrobial susceptibilities of 52 strains of Flavobacterium meningosepticum were determined by an agar plate dilution technique and by a tablet diffusion method. No useful susceptibility differences between the two main DNA relatedness groups within F. meningosepticum were found. All strains produced beta-lactamase and were resistant to most beta-lactam antibiotics. Ciprofloxacin, rifampicin and clindamycin appear to be the most promising for treating infections caused by F. meningosepticum.


    Chlamydia trachomatis: in vitro susceptibility to antibiotics singly and in combination.

    Acta Pathol Microbiol Immunol Scand B 1986; 94 (5): 329-32

    Decreased susceptibility in vitro to erythromycin has been demonstrated for few C. trachomatis isolates outside Scandinavia, making local susceptibility-screening indicated. Eleven recent isolates of C. trachomatis found in a Danish hospital have been examined for susceptibility, expressed as minimal inhibitory concentration (MIC) to antibacterial agents commonly used in genito-urinary infections. Full susceptibility to doxycycline and erythromycin was demonstrated. Clindamycin and ampicillin showed moderate activity, and sulfamethizole had a MIC value in the border area of what is needed for therapeutic effect in non-urinary infections. C. trachomatis, being a major pathogen in pelvic inflammatory disease, makes combination chemotherapy desirable in order to protect against resistance development, to obtain synergistic effect and to ensure effect in infections of mixed etiology - provided antagonism could not be anticipated. In three checkerboard trials, with the combinations doxycycline plus ampicillin, erythromycin plus sulfamethizole and ampicillin plus sulfamethizole, using MIC as end-point, neither synergism nor antagonism could be demonstrated in the concentration range from 1/8 to 4 times the MIC values of each drug.


    Coumermycin: in vitro activity against 251 clinical isolates of bacteria compared with the activities of eight other antibacterial agents.

    Acta Pathol Microbiol Immunol Scand B 1986; 94 (2): 85-8

    The in vitro activity of coumermycin has been compared with those of ampicillin, clindamycin, cloxacillin, doxycycline, erythromycin, netilmicin, penicillin G and vancomycin. A total of 251 clinical isolates of Gram-positive cocci were examined. The minimal inhibitory concentration (MIC) was determined by an agar dilution method. Clindamycin, coumermycin and erythromycin were the most active drugs against Staphylococcus aureus and S. epidermidis on a weight-for-weight basis. All the staphylococcal isolates were inhibited by coumermycin at a concentration of 0.12 mg/l or less. Netilmicin seemed to be somewhat more active against S. epidermidis than against S. aureus. The MICs of vancomycin for the staphylococcal isolates were clustered around 1 mg/l. Streptococcus pneumoniae, S. pyogenes and S. agalactiae were highly susceptible to penicillin G and erythromycin; most isolates were inhibited by 0.03 mg/l or less of either drug. Coumermycin showed poor activity against S. pyogenes, S. agalactiae and enterococci. Most of the S. pneumoniae isolates had also high MICs, although a wide range of sensitivities was found.


    The influence of antimicrobial agents on macrophage-associated Staphylococcus aureus.

    Acta Pathol Microbiol Immunol Scand B 1985; 93 (3): 189-94

    Macrophages obtained by culturing human blood monocytes were incubated with Staphylococcus aureus for phagocytosis to occur and exposed to gentamicin, rifampin, clindamycin or trimethoprim/sulphamethoxazole. The macrophage-associated bacteria were protected against gentamicin at low concentrations (1 mg/l) and trimethoprim/sulphamethoxazole. However, high concentrations of gentamicin and clindamycin reduced the number of bacteria, indicating that these drugs penetrated into human macrophages and killed phagocytosed bacteria. Rifampin, even at low concentrations (0.5 mg/l), caused a marked reduction in macrophage-associated bacteria, implying that the drug penetrated into the phagocytes and retained its effect in the cells most effectively.


    Antibiotic sensitivity pattern of recent clinical isolates of Streptococcus pneumoniae.

    Acta Pathol Microbiol Scand B 1981; 89 (1): 25-8

    Antimicrobial susceptibility of 180 recent isolates of Streptococcus pneumoniae was determined by microdilution technic. There was a high degree of susceptibility to both penicillin G and cefuroxime, except for one strain which required 0.25 microgram/ml. All strains were inhibited by 0.06 microgram/ml of ampicillin, clindamycin and erythromycin. When tested against doxycycline 97.2% of the strains were inhibited by 1.0 microgram/ml. 8 microgram/ml inhibited all strains. Three of the strains were chloramphenicol-resistant with MIC more than 8 microgram/ml. These strains could be shown to inactivate chloramphenicol. All strains but three were susceptible to 20/l microgram/ml of sulfamethoxazole/trimethoprim.


    In vitro antibiotic sensitivity testing of Vibrio alginolyticus.

    Acta Pathol Microbiol Scand B 1980; 88 (6): 307-10

    V. alginolyticus from environmental sources of different geographical areas and some human pathogenic strains were investigated for their sensitivity to 29 different antimicrobial agents, using the agar diffusion method. All strains were sensitive to Gentamicin, Neomycin, Sulfaisodimidin, Sulfamethoxazole-Trimethoprim, Rifamycin, Nalidixan and Linco-Spectin and all except one to Trimethoprim, Tetracycline, Chloramphenicol, Nitrofurantoin and Tobramycin. Between 80 and 94% of tested strains were sensitive to Clindamycin, Cephalotin, Kanamycin, Tylosin and Spiramycin, while Ampicillin, Vancomycin and Novobiocin were effective to approximately 50%. A high percentage of resistance was found to Meticillin, Carbenicillin and Lincomycin. All strains were resistant to Penicillin and Fucidin. No variation in sensitivity pattern between environmental strains isolated from different areas was detected. Great correlation was found among environmental and human pathogenic strains, which could be helpful as guidance in therapy.


    Micellar liquid chromatographic analysis of benzyl alcohol and benzaldehyde in injectable formulations.

    Acta Pharm 2007; 57 (2): 231-9

    An accurate, sensitive and selective reversed-phase micellar liquid chromatographic method was developed for simultaneous determination of benzyl alcohol and benzaldehyde. This method was applied in different injectable formulations containing diclofenac, piroxicam, lincomycin and clindamycin. The method showed excellent linearity in the range of 10-100 microg mL(-1) and 1-20 microg mL(-1) with the limit of detection (S/N = 3) 0.25 microg mL(-1) (2.3 x 10(-6) mol L(-1)) and 0.12 microg mL(-1) (1.13 x 10(-6) mol L(-1)) for benzyl alcohol and benzaldehyde, respectively. The suggested method was successfully applied to the analysis of the studied drugs in bulk with average recoveries of 100.1 +/- 1.0% for benzyl alcohol and 100.4 +/- 1.6% for benzaldehyde, and to the determination of benzyl alcohol and benzaldehyde in injectable formulations with the respective average recoveries of 99.8 +/- 0.3 and 100.0 +/- 0.4%.


    Sites and mechanisms of antibiotic-induced neuromuscular block: a pharmacological analysis using quantal content, voltage clamped end-plate currents and single channel analysis.

    Acta Physiol Pharmacol Ther Latinoam 1999; 49 (4): 242-50

    Since the original observation of Vital Brazil and Corrado (1957) concerning the antibiotic induced neuromuscular block produced by streptomycin, there has been considerable interest in the mechanisms responsible for not only neuromuscular block but also the effects of antibiotics on different systems. We used the voltage clamped end-plate of transacted skeletal muscle to examine the concentration-dependent actions of several groups of antibiotics. The aminoglycoside antibiotics, neomycin and streptomycin, were both more effective at reducing quantal release of acetylcholine (ACh) than interacting with the postjunctional ACh receptor-channel complex. Neomycin was approximately 10 X more potent prejunctionally than streptomycin and the prejunctional effects of each antibiotic were reversed competitively by raising extracellular calcium. Both neomycin and streptomycin also had postjunctional actions at higher concentrations. Neomycin interacted with the open state of the ACh receptor ion channel complex while streptomycin blocks the ACh receptor. The lincosamide antibiotics, lincomycin and clindamycin produced their neuromuscular block postjunctionally by interacting with the open state of the ACh-receptor channel complex. Clindamycin is approximately 20 X more effective at blocking the open channel than was lincomycin. Using cell attached patch clamp recordings in cultured rat myotubes, we demonstrated a lincosamide-induced block of open ion channels with clindamycin having a much slower unblocking rate than lincomycin. Using epimers of the lincosamides, we demonstrated that lipophilicity of the molecule, rather than stereochemical considerations, is important for open channel blockade affecting primarily the "off" rate of channel blocking. This mechanism appears important for not only the lincosamide antibiotics but also for the postjunctional actions of the aminoglycoside antibiotics, particularly neomycin.


    Antimicrobiele profylaxis door clindamycine in de oncologische chirurgie van hoofd en hals.

    Acta Stomatol Belg 1986; 83 (2): 121-8


    Current treatment of ocular toxoplasmosis in immunocompetent patients: a network meta-analysis.

    Acta Trop 2018; 185 (): 52-62

    Ocular toxoplasmosis (OT) is the most frequent form of infectious posterior uveitis caused by the protozoan parasite Toxoplasma gondii. To evaluate the available evidence in peer-reviewed publications about the most effective therapy for OT in immunocompetent patients, herein a systematic literature search was conducted using Embase, PubMed, Google Scholar, and the Cochrane Central Register of Controlled Trials (CENTRAL) database from January 1987 to October 2017, with search terms "OT", "retinochoroiditis", "treatment", and "immunocompetent"; search filters "controlled clinical trial", "randomized clinical trial", and "clinical trial". The included studies were performed to evaluate the various treatment modalities of OT. Different treatment regimens were compared with regard to the improvement of visual acuity, the resolution of vitreous inflammation, recurrence, and side-effects. We independently extracted data and assessed eligibility and risk of bias using the preferred reporting items for systematic reviews and meta-analysis, and resolved any disagreement through discussion. A Bayesian network meta-analysis model was used to evaluate the interesting outcomes of all the interventions. Total 10 trials of treatments for OT were found to meet the inclusion criteria. Six trials of treatments including clindamycin, azithromycin, and trimethoprim-sulfamethoxazole (TMP-SMX) were compared with conventional therapy (the combination of pyrimethamine, sulfadiazine, and corticosteroids) for evaluation of the effect on visual acuity, vitreous inflammation, recurrence of OT, and side-effects. Two trials were compared TMP-SMX with placebo. One trial was compared azithromycin with TMP-SMX. And another trial was compared among treatments with clindamycin, P-S, TMP-SMX, and placebo. Based on our network meta-analysis, therapy with TMP-SMX seems to be an alternative treatment of OT in immunocompetent patients.


    Causative agents and antimicrobial resistance patterns of human skin and soft tissue infections in Bagamoyo, Tanzania.

    Acta Trop 2018; 186 (): 102-106;

    Few epidemiological studies have been carried out to assess the aetiology and antimicrobial susceptibility patterns of pathogens giving rise to skin and soft tissue infections (SSTIs) in sub-Saharan Africa. In the present study from six healthcare facilities in Bagamoyo, Tanzania, wound swabs from outpatients with SSTIs were analysed by a suite of methods, including microbiological culture techniques, matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry and resistance testing. Among 185 patients with SSTIs, 179 (96.8%) swabs showed microbiological growth. In total, 327 organisms were found, of which 285 were of potential aetiological relevance. Staphylococcus aureus was the predominant pathogen (prevalence: 71.4%), followed by the Gram-negative bacteria Enterobacter cloacae complex (14.6%), Klebsiella pneumoniae (12.4%) and Pseudomonas aeruginosa (11.8%). While one out of three isolates of S. aureus showed resistance to macrolides, tetracyclines, cotrimoxazole and clindamycin, only a single methicillin-resistant S. aureus (MRSA) strain was found. In Gram-negative bacteria, resistance to ampicillin and cotrimoxazole was common, while extended-spectrum beta-lactamases were rarely detected (<1%). We conclude that S. aureus was the most frequently detected pathogen in community-acquired SSTIs in Bagamoyo, Tanzania. Resistance to commonly prescribed oral antibiotics was considerable, but multi-resistant strains were rarely encountered. Monitoring of antibiotic susceptibility patterns in SSTIs is important to provide specific data for tailoring treatment recommendations.


    Meta-analysis of prevention and treatment of toxoplasmic encephalitis in HIV-infected patients.

    Acta Trop 2013; 127 (3): 236-44

    Toxoplasmic encephalitis (TE) is one of the most common central nervous system (CNS) opportunistic infections in HIV-infected patients. It can be prevented and treated through drug regimen. However, drugs have serious adverse effects sometimes. The purpose of this review is to determine the most effective therapy for TE in HIV-infected patients. Different primary prophylaxis and treatment regimens have been compared with regard to episodes of TE, clinical response, morbidity, and serious adverse events. In September 2012, we searched PubMed, Google Scholar, EMBASE, and CENTRAL (the Cochrane Central Register of Controlled Trials) database for randomized and quasi-randomized controlled trials of any drug regimen for primary prophylaxis and treatment of TE in HIV-infected patients. We independently extracted data and assessed eligibility and risk of bias using a standardized data collection form, and resolved any disagreement through discussion. We combined dichotomous outcomes using odds ratio (OR), presenting with 95% confidence interval (CI). Eleven trials were found to meet the inclusion criteria. Six trials compared trimethoprim-sulfamethoxazole (TMP-SMX) with dapsone-pyrimethamine (D-P) were analyzed together for the outcome of episodes of TE, morbidity, and serious adverse events. The two treatment arms did not differ for episodes of TE (OR=0.98; 95% CI: 0.48-2.00). Compared with D-P, TMP-SMX showed a beneficial trend in terms of mortality despite a lack of statistical significance (OR=0.75; 95% CI: 0.53-1.06). However, TMP-SMX is still associated with substantial toxicity and intolerance (OR=1.47; 95% CI: 0.91-2.38). Three trials compared pyrimethamine-sulfadiazine (P-S) with pyrimethamine-clindamycin (P-C) were analyzed together for the outcome of clinical response, morbidity, and serious adverse events. Compared with P-C, P-S showed a beneficial trend in terms of clinical response (OR=1.63; 95% CI: 1.05-2.51); P-S also showed a beneficial trend in terms of mortality despite a lack of statistical significance (OR=0.66; 95% CI: 0.37-1.17). However, P-S is still associated with substantial toxicity and intolerance (OR=3.08; 95% CI: 1.82-5.24). Two trials compared P-S with TMP-SMX were analyzed together for the outcome of clinical response, morbidity, and serious adverse events. The two treatment arms did not differ for clinical response (OR=0.90; 95% CI: 0.39-2.06). Compared with TMP-SMX, P-S showed a beneficial trend in terms of mortality despite a lack of statistical significance (OR=0.12; 95% CI: 0.01-1.39). However, P-S is still associated with substantial toxicity and intolerance (OR=2.91; 95% CI: 0.99-8.55). The available evidence fails to identify any one superior regimen for the primary prophylaxis and treatment of TE. The choice of therapy will often be directed by available therapy. Although current evidence does not allow a definitive recommendation, administration of TMP-SMX for primary prophylaxis and treatment of TE in patients with HIV infection is consistent with the available data.


    Therapeutic responses to antimalarial and antibacterial drugs in vivax malaria.

    Acta Trop 2004; 89 (3): 351-6

    Plasmodium vivax is the most prevalent malaria infection and is an important cause of morbidity in Central and South America and Asia. P. vivax is generally sensitive to the common antimalarial drugs but high level resistance to chloroquine and/or pyrimethamine has been documented in some geographic locations. In the studies reviewed here, the therapeutic responses to antimalarial and antibacterial drugs in vivax malaria have been assessed in the Bangkok Hospital for Tropical Diseases. The evaluated drugs consisted of the eight most widely used antimalarial drugs and anti-bacterial drugs that possess antimalarial activities (tetracycline, doxycycline, clindamycin or azithromycin). The activities of these drugs in descending order of parasite clearance times were artesunate, artemether, chloroquine, mefloquine, quinine, halofantrine, primaquine, followed by the antibacterial drugs and lastly sulfadoxine-pyrimethamine. Clinical responses to sulfadoxine-pyrimethamine were also poor with evidence of high grade resistance in 42% of the patients. Of the four antibacterial drugs, clindamycin was more effective than azithromycin and can be an alternative to the tetracyclines. Except for chloroquine and mefloquine which have long plasma half lives and may therefore suppress first relapses, the cumulative cure rates for the short acting antimalarial drugs were similar. Double infection with Plasmodium falciparum was common and usually manifested 3-4 weeks following clearance of vivax malaria. The prevalence of cryptic falciparum malaria was 8-15% and was higher in patients treated with less potent antimalarial drugs. Follow-up studies have revealed that the relapse time in Thai patients with vivax malaria is on average only 3 weeks, but can be suppressed by the slowly eliminated antimalarial drugs such as chloroquine and mefloquine. For accurate comparison of relapse/recrudescence rates in vivax malaria, at least 2 month's follow-up is required. It can be concluded that in malarious areas of Thailand, double infection with P. falciparum and P. vivax is common affecting at least 25% of the patients and usually manifests as sequential illnesses. P. vivax in Thailand is sensitive to chloroquine but has acquired high grade resistance to sulfadoxine-pyrimethamine.


    Serum protein concentrations in Plasmodium falciparum malaria.

    Acta Trop 1992; 52 (2-3): 121-8

    In patients with uncomplicated Plasmodium falciparum infection cytokine-mediated serum protein levels of C-reactive protein (CRP), coeruloplasmin (COE), beta 2-microglobulin (B2M), alpha 1-acid glycoprotein (AAG), alpha 1-antitrypsin (AAT), haptoglobin (HPT), prealbumin (PRE), retinol binding protein (RBP), albumin (ALB) and transferrin (TRF) were measured in an endemic area of the Amazonian rain forest. Semi-immune (SI) and nonimmune (NI) patients were investigated. In both patient groups the serum concentrations of CRP, COE and B2M were elevated on admission. In addition AAG and AAT concentrations were increased in NI patients compared to control subjects. Significantly lower serum concentrations of HPT, PRE, RBP, ALB and TRF were seen in both patient groups during the acute phase of the disease, and were more pronounced in NI patients. After a 28-day follow-up, AAT and B2M were normal in SI patients but HPT, AAT and B2M were still significantly altered in NI patients.


    Immunological alterations in uncomplicated Plasmodium falciparum malaria. Relationship between parasitaemia and indicators of macrophage activation.

    Acta Trop 1989; 46 (5-6): 351-9

    Numerical alterations of circulating lymphocytes were investigated in 37 Brazilian patients with uncomplicated Plasmodium falciparum malaria and in a group of 15 healthy controls. The number of CD4+ T helper/inducer cells was significantly lower in patients than controls, whereas absolute numbers of CD8+ suppressor/cytotoxic T cells did not differ between the groups. TNF and neopterin levels were markedly increased in the plasma of patients and remained slightly elevated after chemotherapy with clindamycin. Neopterin, but not TNF levels, were significantly correlated with parasitaemia. TNF was inversely related to monocyte counts. Interferon gamma could not be detected in the plasma of control subjects and was observed in only one patient. We conclude that in uncomplicated falciparum malaria the distribution of phenotypes of circulating lymphocytes are altered slightly and that the high plasma levels of TNF and neopterin indicate excessive release of these molecules by activated macrophages and the activation of cellular immune mechanisms during the infection.


    Antimicrobial susceptibility of Bacillus anthracis strains from Hungary.

    Acta Vet Hung 2016; 64 (2): 141-7

    The susceptibility of 29 Bacillus anthracis strains, collected in Hungary between 1933 and 2014, was tested to 10 antibiotics with commercially available minimum inhibitory concentration (MIC) test strips. All strains were susceptible to amoxicillin, ciprofloxacin, clindamycin, doxycycline, gentamicin, penicillin, rifampicin, and vancomycin. Intermediate susceptibility to erythromycin and cefotaxime was detected in 17.2% (5/29) and 58.6% (17/29) of the strains, respectively. Correlations were not observed between the isolation date, location, host species, genotype, and antibiotic susceptibility profile of strains.


    Investigation of the antibiotic resistance and biofilm formation of Staphylococcus aureus strains isolated from gangrenous mastitis of ewes.

    Acta Vet Hung 2012; 60 (2): 189-97

    In this study, Staphylococcus aureus strains (n = 110) isolated from seven ewe flocks in Sanliurfa, Turkey were screened for antibiotic resistance and biofilmforming ability as well as for genes associated with antibiotic resistance and biofilm-forming ability. All isolates were found to be susceptible to oxacillin, gentamicin, clindamycin, cefoxitin, tetracycline, vancomycin, amoxicillin-clavulanic acid, ciprofloxacin and sulphamethoxazole-trimethoprim. The percent proportions of strains resistant to penicillin G, ampicillin and erythromycin were 27.2% (n = 30), 25.4% (n = 28) and 6.3% (n = 7), respectively. Regarding the antibiotic resistance genes, 32 (29%) isolates carried the blaZ and 8 (7.2%) the ermC gene. Other resistance genes were not detected in the isolates. All isolates showed biofilm-forming ability on Congo red agar (CRA), while 108 (98.18%) and 101 (91.81%) of them were identified as biofilm producers by the use of standard tube (ST) and microplate (MP) methods, respectively. All isolates carried the icaA and icaD genes but none of them harboured the bap gene. The results demonstrated that S. aureus isolates from gangrenous mastitis were mainly resistant to penicillins (which are susceptible to the staphylococcal beta-lactamase enzyme), and less frequently to erythromycin. Furthermore, all of the S. aureus isolates produced biofilm which was considered a potential virulence factor in the pathogenesis of staphylococcal mastitis.


    Tricomicosis axilar: diagnostico en imagenes, clinica, luz de Wood y dermatoscopia.

    Actas Dermosifiliogr 2017; 108 (3): 264-266;


    Hipomelanosis macular progresiva resuelta con peroxido de benzoilo y clindamicina topicos.

    Actas Dermosifiliogr 2010; 101 (6): 565-7


    Efectos cutaneos adversos causados por erlotinib.

    Actas Dermosifiliogr 2008; 99 (1): 54-60

    INTRODUCTION: Erlotinib is an inhibitor of human epidermal growth factor approved for treating non-small cell lung cancer. The aim of this prospective observational study was to determine the prevalence of adverse cutaneous reactions caused by erlotinib and assess the management of such effects. METHODS: Eleven patients with lung cancer and 1 with ovarian cancer received erlotinib at a dose of 150 mg/d. The prevalence, severity, and time course of the adverse cutaneous reactions were assessed. RESULTS: The most frequent cutaneous reaction was acneiform eruption (10 cases). The patients were treated with topical erythromycin and clindamycin, or with doxycycline. Also reported were seborrheic dermatitis (5), paronychia (4), xerosis (3), mouth blisters (3), blepharitis (2), cheilitis (1), and fissures on the hands and feet (1). The first reactions to appear were seborrheic dermatitis (9.8 days until onset) and acneiform eruption (11.8 days), whereas the paronychia presented latest (65.3 days). One patient with acneiform eruption and another with paronychia suspended treatment until the lesions improved. CONCLUSIONS: Erlotinib induces adverse effects in most patients treated. Acneiform eruption, seborrheic dermatitis, and paronychia are the most frequently reported reactions and can lead to temporary suspension of erlotinib administration.


    Infeccion subcutanea necrotizante por Streptococcus agalactiae.

    Actas Dermosifiliogr 2006; 97 (10): 644-6

    Necrotizing soft tissue infections constitute some of the most potentially threatening infections that may be acquired in the community or in the hospital milieu as they are associated with a high mortality rate. In most cases they are produced by Streptococcus pyogenes. We report a case of a necrotizing soft tissue infection caused by Streptococcus agalactiae (group B beta hemolytic streptococcus) that involved the leg of an elderly man with chronic lymphatic leukemia and diabetes mellitus. The lesions notably improved after initiating intravenous antibiotic treatment with amoxicillin-clavunate and clindamycin.


    Acne fulminans.

    Actas Dermosifiliogr 1981; 72 (3-4): 149-52


    Infectious exanthems and unusual infections.

    Adolesc Med 2000; 11 (2): 327-58

    Invasive disease due to group A beta-hemolytic streptococci (GABHS) can be divided into 3 categories of disease: streptococcal toxic shock syndrome (strepTSS), necrotizing fasciitis, and other invasive GABHS disease. Patients with strepTSS may have multiorgan failure within hours of presentation. Clindamycin and penicillin G should be used in combination for treatment of invasive GABHS disease. The mortality rate for menstrual staphylococcal toxic shock syndrome has decreased with early recognition and treatment, and removal of hyperabsorbent tampons from the market. Kawasaki syndrome (KS) is the most common cause of acquired heart disease in children in the U. S., and atypical forms have a higher mortality rate than typical KS. Hantavirus pulmonary syndrome is a zoonosis with an 80% mortality rate if the diagnosis is not made on first presentation and patients return to the hospital in shock. Children and adolescents with Lyme disease have an excellent prognosis and respond well to antimicrobial therapy. Cat scratch disease (CSD) is caused by Bartonella henselae and is transmitted by flea-infested kittens. CSD lymphadenopathy typically resolves spontaneously in 2n3 months; however, there is a 50% likelihood of resolution in 1 month if patients receive a 5-day treatment course with azithromycin.


    An Old Disease Makes a Comeback.

    Adolesc Med 1996; 7 (3): 413-416

    A 15-year-old African-American female was hospitalized following 7 days of fever, pharyngitis, and neck pain. Physical exam revealed enlarged tonsils. A rapid group A streptococcus antigen test was negative, and the throat culture showed no streptococci. The blood culture grew Fusobacterium necrophorum. Lumbar puncture results were negative. Chest CT scan showed apical cavitary lesions of the lungs. Doppler and CT scan of the neck showed narrowing of the right internal jugular vein, compatible with thrombophlebitis. The diagnosis of Lemierre's disease was made and patient improved rapidly following intravenous therapy of clindamycin, ceftriaxone, and heparin.


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