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We report a retrospective, clinicopathologic study of 139 patients who died during treatment of a severe burn. Fifty-three percent of the patients had central nervous system (CNS) complications-infections, cerebral infarcts and hemorrhages, metabolic encephalopathies, central pontine myelinolysis, and cerebral trauma. Children and adults were equally affected. Sixteen percent of the patients had a CNS infection. Candida species, Staphylococcus aureus and Pseudomonas aeruginosa caused almost 80% of them. S. aureus and candida caused cerebral microabscesses and septic infarcts. P. aeruginosa caused meningitis and infarcts due to meningitis. CNS infections arose as a result of spread from a systemic source. The major risk factors for CNS infection were an extensive burn, S. aureus endocarditis, and a burn wound infection due to candida or P. aeruginosa. Patients with burns of less than 30% of the surface area of their body, those without a systemic infection, and those in the first week after their burn were at low risk. Eighteen percent of the patients had cerebral infarcts. In almost half the patients, the infarcts were caused by septic arterial occlusions or other complications of the burn, viz, disseminated intravascular coagulation (DIC) and septic shock. In only one-third of the patients were infarcts due to atherosclerosis, atrial fibrillation, or other causes prevalent in the general population. Intracranial hemorrhages were only one-fifth as frequent as infarcts and were due to DIC and thrombocytopenia, caused by bacteremia. Diagnosis during life was difficult, because the neurologic picture of focal cerebral lesions and meningitis was indistinguishable from that of metabolic encephalopathies, and because many patients had more than 1 neurologic complication. However, our results suggest that a clinical approach that includes analysis of risk factors for CNS infection, cerebral imaging, examination of cerebrospinal fluid, and tests for DIC can lead to a neurologic and microbiologic diagnosis in most patients.
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PMID:Central nervous system complications of thermal burns. A postmortem study of 139 patients. 152 3

Clostridial bacteremia is rare and has a variable presentation from asymptomatic to septic shock with disseminated intravascular coagulation (DIC), red cell hemolysis, and rapid death. In order to delineate the predisposing and prognostic factors in these patients, the authors reviewed 47 cases of clostridial bacteremia presenting over a seven year period at a major metropolitan teaching hospital. Predisposing factors included locally decreased oxidation reduction potential (Eh) in 43 per cent (including atherosclerosis, diabetes, and radiation therapy), systemic immunosuppression in 53 per cent (including alcohol abuse, chemotherapy, steroids, and malignancy), and a site of epithelial barrier disruption. The sites of clostridial invasion included: gastrointestinal tract (GI) (n = 22), pulmonary (n = 7), cutaneous (n = 7), undetermined (n = 7), and female genital tract (n = 4). Seven patients were found to have malignancy. Seventy-nine per cent of the blood culture isolates were histotoxic species (Clostridia perfringens and C. septicum). The overall mortality was 47 per cent. Significant differences between survivors and deaths included DIC, new onset renal failure, severe atherosclerotic disease, and age (P less than .05). The authors conclude that clostridial bacteremia is uncommon but highly lethal and may occur when decreased tissue Eh, systemic immunosuppression, and an epithelial barrier disruption are present. Poor outcome appears to be a reflection of advanced age, underlying illness, and presence of a histotoxic species.
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PMID:Clostridial bacteremia: implications for the surgeon. 204 53

While salmonellosis is often considered to affect primarily the gastrointestinal tract, infection at other sites may occur, producing characteristic clinical syndromes. We reviewed cases from our institutions and the literature on focal manifestations of salmonella infections. In the past, most extra-intestinal salmonella infections were caused by S. choleraesuis; however, we found S. typhimurium to be the predominant serotype. The mortality rate for patients in our series was considerably lower than the rate described for focal infections in other reviews. This may in part be due to lower proportion of infections due to S. choleraesuis, improved microbiologic and diagnostic techniques, increased use of ampicillin, and improved surgical techniques. Salmonella endocarditis usually occurs in patients with preexisting heart disease. Unlike other salmonella infections, S. choleraesuis is the most frequent serotype. Salmonella endocarditis is often very destructive, with a fatality rate of 70%. Nonvalvular (mural) endocarditis occurs in one-fourth of patients and survival has not been reported. While antibiotic therapy should be tried initially, if response is not prompt the clinician should look for an associated site of infection (intra- or extra-cardiac abscess), which will often require surgery. Salmonella pericarditis often presents with cardiac or pulmonary symptoms, but typical signs of pericardial disease (pulsus paradoxus, friction rub) or characteristic electrocardiographic changes (low voltage, elevated ST segments) are uncommon. Early diagnosis, before infection involves other areas of the heart, is crucial for survival. In addition to antibiotic therapy, pericardiocentesis or pericardiectomy is required. Salmonella may infect the peripheral or visceral arteries, but the abdominal aorta is the most frequent site of vascular infection. Most patients are men over age 50 with preexisting atherosclerosis of the aorta who do not have a previous history of gastroenteritis. About one-fourth of patients have associated lumbar osteomyelitis. No patients have been reported to survive with medical therapy alone. Specific guidelines for surgical removal of infected aneurysms have been proposed and these (in addition to increased use of ampicillin) may be responsible for higher survival rates in recent years. Due to the high incidence of relapses, postoperative blood cultures should be done routinely. Arterial infection should be considered in any elderly patient with salmonella bacteremia especially with prolonged fever or bacteremia after an "adequate course" of antibiotic therapy.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Extra-intestinal manifestations of salmonella infections. 330 60

Anaerobiospirillum succiniciproducens is a motile, spiral anaerobic bacterium with bipolar tufts of flagella. Reports of clinical illness due to A. succiniciproducens are rare. In a retrospective review of anaerobic isolates referred to the Centers for Disease Control (CDC) from January 1, 1975, through January 31, 1986, isolates of A. succiniciproducens from the blood of 21 patients were identified. A single patient whose blood isolate had not been received at CDC was included in the review. These 22 patients were from 15 states. Their mean age was 58.6 years. Underlying disorders included alcoholism, atherosclerosis, malignancy, surgery, diabetes mellitus, and dental caries. Clinical features included gastrointestinal tract signs and symptoms in 17 (77%) of 22, fever greater than 38 degrees C in seven (37%) of 19, and leukocytosis of more than 10,000 cells/mm3 in 11 (58%) of 19. Although 16 patients received antimicrobial therapy, its effect on outcome was unclear. A. succiniciproducens was reported to have contributed to the deaths of seven patients. Disorders predisposing patients to anaerobic infections may put them at increased risk for A. succiniciproducens bacteremia. The presence of antecedent gastrointestinal tract signs and symptoms suggests that the gastrointestinal tract might be the primary portal of entry.
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PMID:Bacteremia with Anaerobiospirillum succiniciproducens. 332 22

A case of bacteremic infection of a nonaneurysmal atherosclerotic infrarenal abdominal aorta by Arizona hinshawii that resulted in formation of a false aneurysm and secondary aortoduodenal fistula is reported and analyzed. Patients with bacteremia, gastroenteritis, or localized infectious processes due to Arizona species should be considered at risk for possible secondary arterial infection from transient bacteremia. In addition, patients over 50 years of age with atherosclerosis or patients with previously implanted cardiac and/or vascular prostheses who develop bacteremia or gastroenteritis because of Arizona species may be candidates for aggressive treatment with antimicrobial agents. The late diagnosis of primary arterial infections is associated with a high mortality rate, and an aggressive surgical posture is clearly indicated. Antimicrobial management should be instituted promptly in conjunction with, not in place of, aggressive surgical therapy.
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PMID:Mycotic aortic pseudoaneurysm with aortoenteric fistula caused by Arizona hinshawii. 689 1

From 1990 through 1994, we collected information on all cases of mycotic aneurysms due to non-typhi Salmonella that occurred at the Veterans General Hospital in Kaohsiung, Taiwan. All cases of salmonella bacteremia were reviewed to find any additional cases. A total of 16 cases of salmonella mycotic aneurysms occurred. The mortality rate was 100% among the three patients treated with medical therapy alone. Nine (70%) of the 13 patients who received surgical and medical therapy survived. Ten of the 16 cases were due to Salmonella choleraesuis. Diagnosis was established by computed tomography or aortography. Gallium scans were of no diagnostic utility. A culture of blood from a patient with underlying atherosclerosis that is positive for invasive Salmonella should prompt a search for a mycotic aneurysm. Treatment with a third-generation cephalosporin and resection of the infected vessel is usually successful.
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PMID:Mycotic aneurysm due to non-typhi salmonella: report of 16 cases. 890 37

This paper on periodontal disease as a potential risk factor for systemic diseases was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to provide information regarding the role of periodontal disease in systemic diseases, including bacteremia, infective endocarditis, cardiovascular disease and atherosclerosis, prosthetic device infection, diabetes mellitus, respiratory diseases, and adverse pregnancy outcomes.
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PMID:Position paper of The American Academy of Periodontology: periodontal disease as a potential risk factor for systemic diseases. 970 64

Cardiovascular diseases, including atherosclerosis and myocardial ischemia, occur as a result of a complex set of genetic and environmental factors. During periodontitis, dental plaque microorganisms may disseminate through the blood to infect the vascular endothelium and contribute to the occurrence of atherosclerosis and risk of myocardial ischemia and infarction. Myocardial ischemia and infarction are often preceded by acute thromboembolic events. In an in vitro model of thrombosis, certain dental plaque bacteria induce platelets to aggregate. Aggregation of platelets is induced by the platelet aggregation-associated protein [PAAPJ expressed on plaque bacteria, including Streptococcus sanguis and Porphyromonas gingivalis. Intravenous infusion of S. sanguis into rabbits has been shown previously to cause changes in the electrocardiogram (ECG), heart rate, blood pressure, and cardiac contractility. These changes are consistent with the occurrence of myocardial infarction. The ECG changes are now shown to begin within 30 seconds after infusion of PAAP+ S. sanguis, followed by alterations in blood pressure and respiratory rate. These changes occurred intermittently over a 30-minute period and changed within one heartbeat to a normal pattern and suddenly back to abnormal. Intermittent ECG abnormalities were seen in 13 of 15 rabbits, including left axis deviation, ST-segment depression, preventricular contractions, alternans, and bigemnia. Dose-dependent thrombocytopenia, accumulation of 111Indium-labeled platelets in the lungs, and tachypnea also occurred. No changes occurred with the PAAp- strain. The data indicated that PAPP+ S. sanguis interacts with circulating platelets, inducing thromboemboli to cause the pulmonary and cardiac abnormalities. During periodontitis, therefore, PAAP+ S. sanguis and P. gingivalis bacteremia may contribute to the chance of acute thromboembolic events.
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PMID:Dental plaque, platelets, and cardiovascular diseases. 972 99

This paper aimed to examine the literature for cases of coronary artery stent infection in order to provide comprehensive data to clinicians regarding its prevalence, clinical presentations, and possible treatments. Coronary artery stenting was initially reported in 1987. Stenting of the coronary arteries is now used in 40-60% of all interventional coronary artery procedures. The understanding of the pathophysiology of coronary artery disease is evolving. It has been suggested that atherosclerosis may be a complication of an infectious etiology. By using a stent to treat coronary artery disease, a foreign body is directly juxtaposed with an area of inflammation. The first reported case of an infected coronary artery stent was in 1993. Although this is an exceedingly rare event, the associated mortality is alarmingly high. Analysis of the literature reveals a total of four reported cases of coronary artery stent infection. Symptoms of stent infection present days to weeks after the initial coronary intervention. All four patients developed fevers and at least two patients developed postintervention angina. In patients who have had a coronary artery stented, the presence of angina and fevers should make the clinician suspicious for a stent-related infection. Two of the patients had infection with Pseudomonas aeruginosa, which seems to be an unusual organism for a catheter-related infection. Surgical removal of the infected stent and artery complex was performed on nearly all cases. Despite aggressive measures, the majority of patients died. Few data are available on the long-term risk for coronary artery stent infection. In a patient who has undergone coronary artery stent placement, the clinician must be very sensitive to fever, return of angina, and bacteremia. The complication rate at the present time does not warrant the use of prophylactic antibiotics prior to high-risk procedures (e.g., dental procedures). Furthermore, the low infection rate of coronary artery stents may be a result of the inflammatory nature of atherosclerosis, which may provide a protective benefit against bacterial infection of the stent.
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PMID:Coronary artery stent infection. 1109 26

Non-typhi Salmonella spp. are a common cause of gastroenteritis. In patients with a greater risk of bacteremia (those with immunosuppression, cardiovascular abnormalities, prostheses, those older than 50, especially those with atherosclerosis, and neonates) the need for antibiotic treatment may be affected by the presence of resistance. We retrospectively studied the evolution of antibiotic resistance of 917 strains isolated from feces, during the period between January 1992 and May 1998. Resistances of 32.1% to ampicillin, 14.6% to amoxicillin- clavulanic acid, 14.8% to chloramphenicol, 3.5% to trimethoprim-sulfamethoxazole and 1.8% to gentamicin were found. All the strains were susceptible to cefotaxime and ciprofloxacin. There was a distinct increase in the ampicillin resistance (12.9% in 1992 to 52.5% in 1998), amoxicillin-clavulanic acid (8.3% in 1992 to 23% in 1998), chloramphenicol (8.3% in 1994 to 23% in 1998) and trimethoprim-sulfamethoxazole (0% in 1992 to 6.6% in 1998). The typhimurium serotype showed higher resistance levels than the enteritidis serotype. Ciprofloxacin and trimethoprim-sulfamethoxazole (in children), used as first-choice antibiotics in patients with intestinal infections caused by non-typhi Salmonella spp., show excellent activity in our area.
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PMID:[Susceptibility of non-typhi Salmonella spp. at the Galdakao Hospital (1992-1998)]. 1137 50


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