Blood infections

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  • La microbiologie médicale est l'étude des micro-organismes pathogènes pour l'homme. Elle a pour principal objectif le diagnostic spécifique des infections, mais embrasse également l'épidémiologie, la pathogenèse, le traitement et la prévention des maladies infectieuses. Bien que l'incidence des maladies microbiennes ne soit pas très élevée dans les pays développés, les épidémies d'infections restent encore inquiétantes. Dans les pays en voie de développement, les maladies microbiennes font un grand nombre de victimes, en terme de morbidité comme de mortalité....

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  • Vascular device–related infection is suspected on the basis of the appearance of the catheter site or the presence of fever or bacteremia without another source in patients with vascular catheters. The diagnosis is confirmed by the recovery of the same species of microorganism from peripheral-blood cultures (preferably two cultures drawn from peripheral veins by separate venipunctures) and from semiquantitative or quantitative cultures of the vascular catheter tip.

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  • Site of Infection The location of the infected site may play a major role in the choice and dose of antimicrobial drug. Patients with suspected meningitis should receive drugs that can cross the blood-CSF barrier; in addition, because of the relative paucity of phagocytes and opsonins at the site of infection, the agents should be bactericidal. Chloramphenicol, an older drug but occasionally useful in the treatment of meningitis, is bactericidal for common organisms causing meningitis (i.e.

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  • Sweet's syndrome, or febrile neutrophilic dermatosis, was originally described in women with elevated white blood cell (WBC) counts. The disease is characterized by the presence of leukocytes in the lower dermis, with edema of the papillary body. Ironically, this disease now is usually seen in neutropenic patients with cancer, most often in association with acute leukemia but also in association with a variety of other malignancies. Sweet's syndrome usually presents as red or bluish-red papules or nodules that may coalesce and form sharply bordered plaques.

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  • Harrison's Internal Medicine Chapter 118. Infective Endocarditis Infective Endocarditis: Introduction The prototypic lesion of infective endocarditis, the vegetation (Fig. 118-1), is a mass of platelets, fibrin, microcolonies of microorganisms, and scant inflammatory cells. Infection most commonly involves heart valves (either native or prosthetic) but may also occur on the low-pressure side of the ventricular septum at the site of a defect, on the mural endocardium where it is damaged by aberrant jets of blood or foreign bodies, or on intracardiac devices themselves.

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  • The roles of bacteremia and echocardiographic findings in the diagnosis of endocarditis are appropriately emphasized in the Duke criteria. The requirement for multiple positive blood cultures over time is consistent with the continuous low-density bacteremia characteristic of endocarditis (≤100 organisms/mL). Among patients with untreated endocarditis who ultimately have a positive blood culture, 95% of all blood cultures are positive; in 98% of these cases, one of the initial two sets of cultures yields the microorganism.

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  • Primary Bacterial Peritonitis: Treatment Treatment for PBP is directed at the isolate from blood or peritoneal fluid. Gram's staining of peritoneal fluid often gives negative results in PBP. Therefore, until culture results become available, therapy should cover gram-negative aerobic bacilli and gram-positive cocci. Third-generation cephalosporins such as cefotaxime (2 g q8h, administered IV) provide reasonable initial coverage in moderately ill patients. Broad-spectrum antibiotics, such as penicillin/β-lactamase inhibitor combinations (e.g., piperacillin/tazobactam, 3.

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  • Epididymitis Acute epididymitis, almost always unilateral, produces pain, swelling, and tenderness of the epididymis, with or without symptoms or signs of urethritis. This condition must be differentiated from testicular torsion, tumor, and trauma. Torsion, a surgical emergency, usually occurs in the second or third decade of life and produces a sudden onset of pain, elevation of the testicle within the scrotal sac, rotation of the epididymis from a posterior to an anterior position, and absence of blood flow on Doppler examination or 99m Tc scan.

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  • Kingella kingae Because of improved microbiologic methodology, isolation of K. kingae is increasingly common. Inoculation of clinical specimens (e.g., synovial fluid) into aerobic blood culture bottles enhances recovery of this organism. In recent series, K. kingae has been the third most common cause of septic arthritis in children

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  • Other Gram-Negative Bacteria Achromobacter xylosoxidans A. xylosoxidans (previously Alcaligenes xylosoxidans) is probably part of the endogenous intestinal flora and has been isolated from water sources. Immunocompromised hosts, including patients with cancer and post- chemotherapy neutropenia, cirrhosis, and chronic renal failure, are at increased risk. Nosocomial outbreaks of A. xylosoxidans infection have been attributed to contaminated fluids, and clinical illness has been associated with isolates from many sites, including blood (often in the setting of intravascular devices).

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  • Antimicrobial Therapy for Selected Settings For uncomplicated skin and soft tissue infections, the use of oral antistaphylococcal agents is usually successful. For other infections, parenteral therapy is indicated. S. aureus endocarditis is usually an acute, life-threatening infection. Thus prompt collection of blood for cultures must be followed immediately by empirical antimicrobial therapy. For S. aureus native-valve endocarditis, a combination of antimicrobial agents is often used.

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  • Infection with Viridans Streptococci: Treatment Isolates from neutropenic patients with bacteremia are often resistant to penicillin; thus these patients should be treated presumptively with vancomycin until the results of susceptibility testing become available. Viridans streptococci isolated in other clinical settings usually are sensitive to penicillin. Abiotrophia Species (Nutritionally Variant Streptococci) Occasional isolates cultured from the blood of patients with endocarditis fail to grow when subcultured on solid media.

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  • Infection control in health care continues to be the subject of intensive research and debate. Implementing safe and realistic infection control procedures requires the full compliance of the whole dental team. These procedures should be regularly monitored during clinical sessions and discussed at practice meetings. The individual practitioner must ensure that all members of the dental team understand and practice these procedures routinely. Every practice must have a written infection control policy, which is tailored to the routines of the individual practice and regularly updated.

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  • Sexually transmitted infections (STIs) are defined as infections that spread primarily through person-to-person sexual contact. However, several of these infections, in particular HIV, syphilis and hepatitis B, can also be transmitted via mother-to-child-transmission during pregnancy and childbirth, blood products or tissue transfer.

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  • Like prophylaxis, preemptive treatment, which targets patients with polymerase chain reaction (PCR) evidence of CMV entails the unnecessary treatment of many individuals (on the basis of a laboratory test that is not highly predictive of disease) with drugs that have adverse effects. Currently, because of the neutropenia associated with ganciclovir in HSCT recipients, a preemptive approach—that is, treatment of those patients in whose blood CMV is detected by an antigen or nucleic acid amplification test—is used at most centers.

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  • Diagnosis The diagnosis of clostridial disease, in association with positive cultures, must be based primarily on clinical findings. Because of the presence of clostridia in many wounds, their mere isolation from any site, including the blood, does not necessarily indicate severe disease. Smears of wound exudates, uterine scrapings, or cervical discharge may show abundant large gram-positive rods as well as other organisms. Cultures should be placed in selective media and incubated anaerobically for identification of clostridia.

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  • Outer-Membrane Components Associated with Virulence Meningococcal strains are characterized by the expression of capsular polysaccharide and other outer-membrane structures, including LOS (endotoxin). Outer-membrane blebbing, meningococcal autolysis, molecular mimicry, genome plasticity, horizontal DNA exchange, and phase and/or antigenic variation are all important in meningococcal virulence. Capsule The polysaccharide capsule is a major—if not the major—virulence factor of N. meningitidis.

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  • Host Defense Mechanisms Preventing meningococcal growth in blood requires bactericidal and opsonic antibodies, complement, and phagocytes (Fig. 136-3). The major bactericidal antibodies are IgM and IgG, which (except for serogroup B) bind to the capsular polysaccharide. Immunity to meningococci is therefore serogroup specific. Antibodies to other surface (subcapsular) antigens may confer crossserogroup protection. PorA, PorB, Opc, and LOS appear to be major targets of cross-reactivity and of serogroup B bactericidal antibodies.

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  • Other Moraxella Species Other Moraxella species are occasional causes of a wide range of infections, including bronchitis, pneumonia, empyema, endocarditis, meningitis, conjunctivitis, endophthalmitis, urinary tract infection, septic arthritis, and wound infection. In a report on all Moraxella isolates submitted to the Centers for Disease Control and Prevention between 1953 and 1980, certain clinical associations were apparent (Table 138-2). M. osloensis and M.

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  • Specific Infections Caused by S. Pneumoniae S. pneumoniae causes infections of the middle ear, sinuses, trachea, bronchi, and lungs (Table 128-2) by direct spread from the nasopharyngeal site of colonization. Infections of the central nervous system (CNS), heart valves, bones, joints, and peritoneal cavity usually arise by hematogenous spread. Peritoneal infection may also result from ascent via the fallopian tubes. The CNS may also be infected by drainage from nasopharyngeal lymphatics or veins or by contiguous spread of organisms (e.g., through a tear in the dura).

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