BACKGROUND:Robinsoniella peoriensis is an anaerobic gram-positive bacilli first isolated from swine manure in 2003 but has since been associated with human infections.METHODS:We describe a pediatric case of R. peoriensis infection following a below-knee amputation for a limb injury and its treatment. Methods of identifying R. peoriensis and reported in vitro antimicrobial minimum inhibitory concentrations from the literature are reviewed.RESULTS:R. peoriensis is readily identifiable via 16S rRNA gene sequencing and Matrix-Assisted Laser Desorption Ionization-Time of Flight. There is variability in the antibiotic susceptibility profiles reported in the literature, but antibiotics with low in vitro minimum inhibitor concentrations against R. peoriensis include beta-lactam/beta-lactamase inhibitors, carbapenems, vancomycin, and metronidazole.CONCLUSION:This is the first reported case of R. peoriensis infection following a traumatic injury in Canada to our knowledge and highlights the importance of recognizing this organism and other anaerobes in settings where wounds are grossly contaminated with soil.

A 25-year-old Somali-born female was admitted to the hospital in active labour. Following post-partum hemorrhage, Brucella melitensis grew from a blood culture and the placenta. Identification and relatedness were determined through reverse transcriptase polymerase chain reaction (RT-PCR), single nucleotide polymorphism (SNP), and whole genome sequencing. The patient and her child were completely asymptomatic at their initial assessment.

Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening clinical syndrome caused by uncontrolled activation of lymphocytes and histiocytes resulting in high levels of cytokines. Acquired HLH occurs in autoimmune, inflammatory, infectious, and immunosuppressive disorders. Prompt identification and treatment of an underlying triggering cause improves clinical outcome.

This study evaluated the performance of direct mecA polymerase chain reaction (PCR) from blood culture bottles growing Gram-positive cocci in clusters and its role in optimization of antibiotic therapy. A total of 266 blood cultures including 121 methicillin-resistant and 122 methicillin-susceptible Staphylococci were tested for mecA. Compared to phenotypic testing, the overall performance of direct mecA PCR was 99% for sensitivity, specificity, positive predictive value, and negative predictive value, respectively. Assessment of antibiotic therapy upon microbiology reporting of direct mecA PCR results from 38 patients prior to (phase I) and 48 patients after implementation of testing and reporting (phase II) showed that the mean time to antibiotic optimization in phase II (0.9 ± 0.9 day) was significantly shorter than that in phase I (2.2 ± 3.2 days) (P < 0.05). Methicillin-susceptible staphylococcal bacteremias had significantly higher frequency of antibiotic adjustment upon direct mecA reporting, compared to methicillin-resistant staphylococcal bacteremias. Our study indicated that direct mecA PCR improved timely antibiotic optimization.

A 72-year-old Caucasian female had been diagnosed with chronic lymphocytic leukaemia (CLL) 4 years earlier and received the most recent dose of oral chlorambucil 1 month before presentation. She was admitted to a local hospital for treatment of febrile neutropenia with a blood culture positive for Klebsiella pneumoniae. Ten days later, she was transferred to a tertiary care hospital intensive care unit (ICU) for further diagnosis and treatment. She had fever, fluctuating loss of consciousness and clinical manifestations consistent with septic shock. Laboratory investigations showed a pancytopenia with a normocytic anaemia, haemoglobin concentration 93 g/l, thrombocytopenia (platelet count <10 × 109/l) and severe neutropenia (neutrophil count below detectable limits). Lactate dehydrogenase (LDH) was significantly elevated at 2134 iu/l (reference 100–205 iu/l). Chest radiography showed moderate to severe pulmonary oedema with bibasal atelectasis. A computerized tomography scan of the abdomen and pelvis demonstrated hepatosplenomegaly and lymphadenopathy consistent with the known diagnosis of CLL, and multiple small hypodense lesions in the spleen suggestive of lymphomatous deposits or splenic abscesses (left). The patient was treated with piperacillin-tazobactam, vancomycin, fluconazole and filgrastim. Microscopic evaluation of a peripheral blood film revealed rare neutrophils, a relative but not absolute lymphocytosis, smear cells and lymphocytes with clumped chromatin, compatible with CLL. A giant reactive monocyte with multiple intracellular yeast-like organisms was discovered at the feather-edge of the film. These organisms were about 2–4 μm in diameter and were eccentric within a typical clear pseudocapsule, findings diagnostic of Histoplasma capsulatum (right). Careful scrutiny of the whole film demonstrated a neutrophil with one organism inside the cytoplasm, which had the same morphological features. Only 10 neutrophils and/or monocytes were observed in the film, and of these, 3 (30%) contained 1–9 intracellular organisms per cell. Following the diagnosis of disseminated histoplasmosis, liposomal amphotericin was added to the treatment regimen. Additional histoplasmosis-specific workup was implemented, including fungal culture from both blood and tracheal aspirate and serological tests. Next day, the patient displayed evidence of respiratory failure and required urgent intubation. She deteriorated quickly and died 3 d after admission to ICU. Fungal culture from both blood and tracheal aspirate isolated Histoplasma capsulatum, confirming that patient had disseminated histoplasmosis. Disseminated histoplasmosis is a progressive haematogenous extra-pulmonary infection. It may occur in patients during the acute infection before cellular immunity develops or by reactivation in immunocompromised patients. In our patient, the clinical presentation of histoplasmosis, including lymphadenopathy and hepatosplenomegaly, was somewhat masked by the underlying CLL and febrile neutropenia that could be attributed to Klebsiella pneumoniae infection. But several clues existed for the diagnosis of histoplasmosis besides the peripheral blood film examination. One clue was the multiple hypodense areas in the spleen, which may have represented histoplasma abscesses. This case emphasizes the importance of microscopic examination of peripheral blood films.

Cardiac device infections (CDIs) are recognized complications of device implantation. Most CDIs are caused by skin flora but can also result from hematogenous seeding of the device. A case involving Streptococcus pneumoniae CDI, which is rare, potentially vaccine preventable and may not be associated with overt antecedent pneumococcal infection, is reported.

Here we present the first case of a patient from Ottawa Canada, presenting with leprosy-like illness associated with Mycobacterium lepromatosis. The patient had no history of travel to leprosy-endemic areas or any obvious risk factors. Clinically, the patient presented with an anesthetic maculopapular rash on the trunk, back, and extremities. A skin biopsy of a lesion revealed a dermal lymphohistiocytic infiltration involving the vessels with an inflammatory process extending to the nerves. A neurological exam also identified a severe sensorimotor polyneuropathy. Concurrently, the patient was diagnosed with non-resectable, non small cell carcinoma of the lung, further complicating his clinical presentation. A Kinyoun stain of nasal blows and a Fite stain of the skin biopsy revealed few to moderate acid fast bacilli respectively. Cultures of the skin biopsy and multiple nasal blows were negative. Molecular studies of a skin biopsy sample including sequence analysis of a 765 bp region of the 16s rRNA gene eventually identified the organism with 100% homology to M. lepromatosis. The patient was treated for leprosy and appeared to improve slightly on therapy but died as a result of his malignancy approximately five months after the initiation of therapy. This represents the first case of a patient with M. lepromatosis like illness outside of Mexico and Singapore.

This is the second edition of the text that was first published in 2003. The organization of the text is essentially the same as the first edition, with the addition of two chapters dealing with Pneumocystis and anomalous fungal and fungal-like infections. A very useful feature is the inclusion of a CD that contains the images from the text. The editors and many of the senior authors are leaders in their fields. The first edition was a useful reference text that provided more information than could be obtained from the standard reference texts on infectious diseases. The purpose of the second edition is to update the clinician with modern tools in the diagnosis, prevention, and treatment of fungal infections in various patient populations. A weakness of the first edition was the use of black and white images and tables throughout the text, as well as color plates not being included in their related chapters. These shortcomings have all been corrected in the current edition, thus improving the readability and use of the book as a reference. There is increased content to many chapters related to new information on pathogens, e.g. Cryptococcus gattii, and better understanding of the pathogenesis and treatment of invasive Aspergillus infections. The chapters dealing with antifungal therapy are an excellent resource with expanded content related to drug resistance and drug–drug interactions. Clinical problems can be addressed looking at them in the context of the infecting organism. Unknown clinical syndromes can be approached based on involved organ systems or based on the host's status. An improvement to the text that would be helpful to the clinician is to have linkages of chapters dealing with the organisms to those that deal with the clinical syndromes as the material is additive. The ability to export images provides excellent quality images that are useful for teaching purposes. The inclusion of key tables and algorithms would be a benefit for teaching. I have loaned the text to infectious disease colleagues and they have been enthusiastic about it. I would recommend this text to trainees and specialists in infectious diseases and microbiology. The text is also useful to clinicians who care for patients at increased risk of invasive fungal infections. The added information and improved presentation makes purchase of the second edition a worthwhile investment for those who already have the first.

ABSTRACT Klebsiella pneumoniae isolates from three patients admitted to the Ottawa Hospital, a 1,040-bed teaching hospital, were found to contain the plasmid-borne K. pneumoniae carbapenemase (KPC)-producing bla gene ( bla KPC ) . There was evidence of person-to-person transmission for two patients. Screening of 186 clinical isolates revealed no additional bla KPC -containing isolates.

Background: Streptococcus pyogenes can cause severe disease in the individual patient and dramatic hospital outbreaks.Objective: To describe the epidemiology of hospital outbreaks of invasive group A streptococcal infection in order to understand the potential benefit of proposed outbreak investigation and management strategies.Design: Prospective, population-based surveillance. Setting: Short-term care hospitals in Ontario, Canada.Patients: Persons with a positive culture for group A streptococcus from a normally sterile site between 1 January 1992 and 31 December 2000.Measurements: Laboratory-based surveillance identified patients with nosocomial invasive group A streptococcal infection. Epidemiologic and microbiological investigations were used to detect transmission.Results: Of 2351 cases of invasive group A streptococcal disease, 291 (12%) were hospital acquired. Twenty-nine (10%) nosocomial cases occurred as part of 20 outbreaks. Seventy percent (14 of 20) of outbreaks involved nonsurgical, nonobstetric patients. Community-acquired cases initiated 25% of outbreaks; most were cases of necrotizing fasciitis in patients admitted to the intensive care unit. outbreaks were small (median, 2 cases [range, 2 to 10 cases]) and short (median duration, 6 days [range, 0 to 30 days]). The median time between the first 2 cases was 4.5 days. The most common mode of propagation was patient-to-patient transmission. A staff carrier was the primary mode of transmission in 2 (10%) outbreaks, but 1 or more health care workers were colonized with the outbreak strain in 6 of 18 (33%) other outbreaks.Limitations: Some outbreaks with 1 case of invasive disease may have been missed; advice provided to participating hospitals may have reduced the number and size of outbreaks.Conclusions: Practices to prevent hospital transmission of group A streptococci should include isolation of patients admitted to the intensive care unit with necrotizing fasciitis, investigation after a single nosocomial case, and emphasis on identifying and treating health care worker carriers on surgical and obstetric services and patient reservoirs on other wards.

revised) Background: MRSA screening by culture requires 48-72 hours compared to 1 hr for the BMA. At the Ottawa Hospital, nasal and rectal swabs are pooled in a selective broth prior to testing. To improve turnaround times (TAT) we evaluated the performance of the BMA using a flocked swab and a liquid Stuart's (LS) transport system. Method: Flocked swabs dipped in a 0.5 McFarland saline suspension of CMRSA-2, -7 and -10 clinical isolates were placed in the LS and incubated at room temperature (RT) for 1 hr, 2 hr, and overnight. To simulate a rectal swab, CMRSA-2 an inoculated swab was dipped in a MRSA negative stool and incubated in LS at RT for 1hr, 2 hr and overnight. For the simulated nasal swab, nares of a negative volunteer were swabbed prior to dipping in a CMRSA-2 suspension and incubated 1hr, 2hr and overnight at RT. For BMA testing, swabs were vortexed in the LS and a 50ul aliquot was transferred to the sample diluents buffer and processed according to manufacturers instructions. All runs were performed in triplicate. Serial dilutions of 5 different C-MRSA clinical isolates were used in order to determine the limit of detection for the BMA in both LS and 0.45 % sodium chloride solution (NaCl). Duplicate runs were performed using both the BMA kit (mechanical) lysis and achromopeptidase lysis procedures. Results: All 0.5 McFarland inoculated flocked swabs transported in LS including simulated rectal and nasal specimens were detected by BMA. Using both LS and NaCl as the transport medium the BMA had a limit of detection of 10 4 CFU/mL. The BMA runs using the achromopeptidase lysis procedure were able to reach the same limit of sensitivity using NaCl but not LS as the transport medium. Conclusion: Flocked swabs transported in LS have the potential to be used with the BMA for screening of MRSA colonized patients. Achromopeptidase lysis procedure did not perform as well as the BMA kit lysis procedure using LS as the transport medium. Pooling of nasal and rectal specimens collected on flocked swabs and transported in LS could be used with the BMA for direct testing eliminating the use of the selective broth and potentially reducing TAT.

BACKGROUND A significant proportion of invasive group A streptococcal infections are hospital acquired. No large, prospective studies have characterized this subgroup of cases and evaluated the risk of transmission in hospitals. METHODS We conducted prospective, population-based surveillance of invasive group A streptococcal infections in Ontario, Canada, from 1992 to 2000. Epidemiologic and microbiologic investigations were conducted to identify cross-transmission. RESULTS We identified 291 hospital-acquired cases (12.4%) among 2351 cases of invasive group A streptococcal disease. Hospital-acquired invasive group A streptococcal infections are heterogeneous, including surgical site (96 cases), postpartum (86 cases), and nonsurgical, nonobstetrical infections (109 cases). Surgical site infections affected 1 of 100,000 surgical procedures and involved all organ systems. Postpartum infections occurred at a rate of 0.7 cases per 10,000 live births and exhibited an excellent prognosis. Nonsurgical, nonobstetrical infections encompassed a broad range of infectious syndromes (case-fatality rate, 37%). Nine percent of cases were associated with in-hospital transmission. Transmission occurred from 3 of 142 patients with community-acquired cases of necrotizing fasciitis requiring intensive care unit (ICU) admission, compared with 1 of 367 patients with community-acquired cases without necrotizing fasciitis admitted to the ICU and 1 of 1551 patients with other cases (P<.001). Fifteen outbreaks were identified; 9 (60%) involved only 2 cases. Hospital staff were infected in 1 of 15 outbreaks, but colonized staff were identified in 6 (60%) of 10 investigations in which staff were screened. CONCLUSIONS Presentation of hospital-associated invasive group A streptococcal infections is diverse. Cross-transmission is common; illness occurs in patients but rarely in staff. Isolation of new cases of necrotizing fasciitis and intervention after a single nosocomial case may also prevent transmission.

BACKGROUND:Asymptomatic catheter-associated urinary tract infections (CAUTIs) are common in hospitalized patients. They are associated with a low incidence of sequelae and morbidity, and in most patients resolve spontaneously on removal of the catheter. As a result, it is not recommended that asymptomatic catheter-associated bacteriuria or candiduria be treated with antimicrobial agents while the catheter remains in place because it may lead to the evolution of resistant flora.OBJECTIVE:To assess the current management of patients with CAUTIs with respect to antimicrobial therapy at The Ottawa Hospital and the University of Ottawa Heart Institute, Ottawa, Ontario.METHODS:A prospective observational study over a period of 26 consecutive days was conducted at The Ottawa Hospital (General and Civic campuses) and the University of Ottawa Heart Institute. Inpatients with an indwelling catheter, a positive urine culture and the absence of UTI signs or symptoms were assessed. Patients were followed for five days to determine whether antimicrobials were prescribed.RESULTS:From March 3 to March 28, 2003, 29 of 119 patients screened met inclusion criteria. Of these 29 patients, 15 (52%) were prescribed antimicrobials and were therefore considered to be inappropriately managed. Differences were observed between the appropriate and inappropriate management groups in terms of duration of stay to positive urine culture and whether yeast or bacteria were isolated from the culture.CONCLUSION:Antimicrobial agents were prescribed in over one-half of CAUTI cases, contrary to recommendations from the literature. Education is required to bring this strongly supported recommendation into clinical practice.

Background: Salmonella spp. with reduced susceptibility to fluoroquinolones have higher than usual MICs to these agents but are still considered "susceptible" by NCCLS criteria. Delayed treatment response to fluoroquinolones has been noted, especially in cases of enteric fever due to such strains. We reviewed the ciprofloxacin susceptibility and clinical outcome of our recent enteric fever cases.Methods: Salmonella enterica Serotype Typhi ( S. Typhi) and Serotype Paratyphi ( S. Paratyphi) blood culture isolates ( 1998 - 2002) were tested against nalidixic acid by disk diffusion ( DD) and agar dilution ( AD) and to ciprofloxacin by AD using NCCLS methods and interpretive criteria. Reduced fluoroquinolone susceptibility was defined as a ciprofloxacin MIC of 0.125 - 1.0 mg/L. The clinical records of patients treated with ciprofloxacin for isolates with reduced fluoroquinolone susceptibility were reviewed.Results: Seven of 21 (33%) S. Typhi and S. Paratyphi isolates had reduced susceptibility to fluoroquinolones ( MIC range 0.125 - 0.5 mg/L). All 7 were nalidixic acid resistant by DD ( no zone) and by AD ( MIC 128- > 512 mg/L). The other 14 isolates were nalidixic acid susceptible and fully susceptible to ciprofloxacin ( MIC range 0.015 - 0.03 mg/L).Five of the 7 cases were treated initially with oral ciprofloxacin. One patient remained febrile on IV ciprofloxacin until cefotaxime was added, with fever recurrence when cefotaxime was discontinued. Two continued on oral or IV ciprofloxacin alone but had prolonged fevers of 9 - 10 days duration, one was switched to IV beta-lactam therapy after remaining febrile for 3 days on oral/IV ciprofloxacin and one was treated successfully with oral ciprofloxacin. Four of the 5 required hospitalization.Conclusions: Our cases provide further evidence that reduced fluoroquinolone susceptibility of S. Typhi and S. Paratyphi is clinically significant. Laboratories should test extra-intestinal Salmonella spp. for reduced fluoroquinolone susceptibility.