No abstract

The clinical and neurophysiological findings in six Australian children with generalized tick paralysis are described. Paralysis is usually caused by the mature female of the species Ixodes holocyclus. It most frequently occurs in the spring and summer months but can be seen at any time of year. Children aged 1-5 years are most commonly affected. The tick is usually found in the scalp, often behind the ear. The typical presentation is a prodrome followed by the development of an unsteady gait, and then ascending, symmetrical, flaccid paralysis. Early cranial nerve involvement is a feature, particularly the presence of both internal and external ophthalmoplegia. In contrast to the experience with North American ticks, worsening of paralysis in the 24-48 h following tick removal is common and the child must be carefully observed over this period. Death from respiratory failure was relatively common in the first half of the century and tick paralysis remains a potentially fatal condition. Respiratory support may be required for > 1 week but full recovery occurs. This is slow with several weeks passing before the child can walk unaided. Anti-toxin has a role in the treatment of seriously ill children but there is a high incidence of acute allergy and serum sickness. Neurophysiological studies reveal low-amplitude compound muscle action potentials with normal motor conduction velocities, normal sensory studies and normal response to repetitive stimulation. The biochemical structure of the toxin of I. holocyclus has not been fully characterized but there are many clinical, neurophysiological and experimental similarities to botulinum toxin.

Healing of poorly vascularized and venous stasis ulcers is often refractory to therapy, particularly when they are infected. Systemic antibiotic therapy may be of little benefit in this setting because of poor penetration of the antibiotic into the wound and the frequent associated emergence of bacterial strains resistant to common antimicrobial agents. Given the clinical significance of these problems, there is a need to explore alternative management approaches for these difficult-to-treat wounds. PhagoBioDerm is a novel wound-healing preparation consisting of a biodegradable polymer impregnated with an antibiotic and lytic bacteriophages, which was recently licensed for sale in the Republic of Georgia (one of the former Soviet Union republics). In 1999-2000, in Tbilisi, Georgia, 107 patients who had ulcers that had failed to respond to conventional therapy were treated with PhagoBioDerm alone or in combination with other interventions. The wounds/ulcers healed completely in 67 (70%) of 96 patients for whom follow-up data were available. In 22 cases in which microbiologic data were available, healing was associated with the concomitant elimination of, or a reduction in, specific pathogenic bacteria in the ulcers. Our findings suggest that this slow-release biopolymer is safe and of possible benefit in the management of refractory wounds, and they support the apparent utility of bacteriophages in this setting. Further studies, including carefully designed clinical trials, will be required to rigorously evaluate the efficacy of this novel wound dressing preparation.

We performed a prospective cohort study to quantify the number of cases of patient-to-patient transmission of extended-spectrum b-lactamase-producing Klebsiella species on perianal surveillance culture. Among 27 patients who acquired Klebsiella pneumoniae infection, 14 had infections (52%) that were due to patient-to-patient transmission, and 6 (22%) had a subsequent positive extended-spectrum blactamase clinical culture results.Antibiotic-resistant gram-negative bacteria are an emerging problem. Although extended-spectrum b-lactamase (ESBL) enzymes are emerging in a number of bacterial species, they are most common in Klebsiella species and Escherichia coli [1,2]. ESBL-producing bacteria cause adverse patient outcomes and limit effective antibiotic options [2][3][4][5].Much of the present literature suggests that the increasing incidence of ESBL-producing bacteria can be controlled by antibiotic stewardship programs and by limiting certain classes of antibiotics [6][7][8][9]. However, optimal control of antibioticresistant bacteria requires the understanding of the relative causal importance (i.e., attributable fraction) of the organismspecific proportion of antibiotic resistance that is attributable to antibiotic use and the proportion that is due to patient-topatient transmission. To our knowledge, no study has quantified the amount of patient-to-patient transmission in the acquisition of Klebsiella-species gut colonization. The objective of this study was to quantify the amount of patient-to-patient transmission among patients who acquire an ESBL-producing Klebsiella, with use of surveillance cultures in an intensive-careunit (ICU) population.Methods. This study was approved by the Institutional Review Board of the University of Maryland (Baltimore). We created a prospective cohort of all adult patients admitted to the medical ICU (MICU) and surgical ICU (SICU) of the University of Maryland Medical Center between 1 September 2001 and 1 September 2004. During the study period, the MICU was a 10-bed, private-room unit, and the SICU was a 19-bed, private-room unit.During the study period, patients in the MICU and SICU had perianal cultures performed at the time of admission and discharge and weekly during stay in the ICU and that were analyzed for vancomycin-resistant enterococci as part of hospital infection-control practices. As part of our research project, the same swabs were analyzed for ESBL-producing Klebsiella species. There were no infection-control precautions for those patients whose clinical culture results were positive for ESBLproducing bacteria. ESBL-surveillance culture results were not provided to physicians or nurses.We defined admission-positive patients as those who had admission cultures that were positive for ESBL-producing Klebsiella bacteria. We defined acquisition-positive patients as those who had an admission culture negative for ESBL-producing Klebsiella and had either a subsequent weekly or a discharge culture positive for ESBL-producing Klebsiella.Microbiological methods for the is...