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The effectiveness of newer macrolides in acute Q fever for 113 patients was recorded. The mean times to defervescence were 2.9 days for doxycycline and 3.3, 3.9, 3.9, and 6.4 days for clarithromycin, roxithromycin, erythromycin, and β-lactams, respectively ( P < 0.01 for macrolides versus β-lactams). We conclude that macrolides may be an adequate empirical antibiotic therapy for acute Q fever.

The in vitro susceptibility to linezolid shown by nine Greek isolates of Coxiella burnetii derived from patients with acute Q fever was investigated. MICs of linezolid were compared with those of pefloxacin, ciprofloxacin, ofloxacin, trovafloxacin, doxycycline, and clarithromycin using the shell vial assay. MICs of linezolid and clarithromycin ranged from 2 to 4 μg/ml; those of doxycycline, trovafloxacin, and ofloxacin ranged from 1 to 2 μg/ml; those of pefloxacin ranged from 1 to 4 μg/ml; and those of ciprofloxacin ranged from 4 to 8 μg/ml. Linezolid was effective in controlling intracellular parasites in cultures of Vero cells infected by C . burnetii . No bactericidal activity by linezolid was obtained against C . burnetii at 8 μg/ml.

Murine typhus, also known as endemic typhus, is a flea-borne infectious disease with a worldwide distribution, caused by an obligate intracellular, gram-negative microorganism, Rickettsia typhi [1]. The transmitting agent of R. typhi is the rat flea, Xenopsylla cheopis, although the cat flea, Ctenocephalides felis, has also been implicated [1–4]. Main reservoirs are rats, house mice, opossums, skunks and cats [1–3]. The actual incidence of murine typhus is unclear, as the common clinical manifestations of the disease are non-specific [1,2]. In children, only a small number of studies have focused on the occurrence and on clinical profiles of the disease [3–5]. The aim of this study was to confirm the presence and to assess the clinical and laboratory characteristics of R. typhi infection among children in the area of Chania, Crete, Greece. Forty-one children were hospitalised with acute R. typhi infection in the Pediatric Department of the General Hospital of Chania, from 2001 through to 2006. All other causes included in the differential diagnosis were ruled out. Diagnosis of acute R. typhi infection was considered positive by the combination of compatible clinical features and an indirect immunofluorescence test (Biomerieux, Lyon, France), when specific IgM and ⁄ or IgG titres on admission were >1 ⁄ 400 and >1 ⁄ 960, respectively. All cases were reviewed retrospectively for demographic, clinical and laboratory findings, treatment and outcome. Most admissions (87.8%) occurred between May and October. The mean age was 9.8 years old (range, 1–15 years old). Twenty children (48.8%) were males. History of recent contact with animals was positive in 13 children (31.7%); all 13 children reported contact with cats and 10 ⁄ 13 reported contact with dogs. On admission all patients had fever. Common clinical characteristics were fever, rash, hepatomegaly, splenomegaly and anorexia. Main laboratory features included elevated aspartate aminotransferase and alanine aminotransferase, abnormal chest radiography, thrombocytopenia and leucopenia. CSF analysis in one patient with confusion did not reveal any abnormalities. Clinical and laboratory manifestations found on admission are presented in Table 1. Serologic testing through IFA performed on admission was diagnosed for all 41 children, with a median IgM titre of 1 ⁄ 3200 (range, 1 ⁄ 400 to 1 ⁄ 31200) and a median IgG titre of 1 ⁄ 2880 (range, 1 ⁄ 480 to 1 ⁄ 30720). All children were treated upon admission. Combination therapy was administered to two of them. Antibiotics administered were doxycycline in 19 children (46.3%), chloramphenicol in 12 (29.3%), quinolones in five (12.2%), cephalosporins in three children (7.3%), and a combination of trimethoprim ⁄ sulfamethoxazole and b-lactams in two children (4.9%). The outcome was favourable for all 41 patients; apyrexia was recorded on a mean of 4.9 days after admission (range, 2–12 days). The mean total duration of fever was 9.1 days (range, 3–17 days). No complication or relapse was observed within 1 month of follow-up.

Laboratory of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine, WHO Collaborating Center for Mediterranean Zoonoses, University of Crete, Greece, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece, Department of Internal Medicine, University General Hospital ‘Attikon’, Athens, Greece and 4 Department of Pathophysiology, Athens University Medical School, Athens, Greece

To determine the radiographic features of Q fever pneumonia.Chest radiographs in 85 patients admitted to the hospital during a 7-year period with Q fever pneumonia were retrospectively reviewed by two observers.The most commonly recorded abnormalities were segmental (n = 53 [62%]) and lobar (n = 15 [18%]) areas of opacity. Segmental pneumonia was observed as a unilateral single area of opacity in 38 (72%) patients. It was more frequently located in the upper lobes. The left upper lobe was involved in 31% of patients, the right upper lobe, in 23%; and the right lower lobe, in 27%. Lobar pneumonia was less frequently observed as a single lesion in eight (53%) of 15 patients; It was located in the left upper lobe in 31% and in the right middle lobe in 27% of patients. There was no correlation between the extent of pulmonary involvement and the course of the disease; the outcome was favorable in all patients. Complete resolution of the radiographic findings occurred in a mean of 39 days.The radiographic differentiation of Q fever pneumonia from the other community-acquired pneumonias is not possible. Clinical, serologic, and epidemiologic data provide the best basis for diagnosis.

Bartonella henselae are aerobic, Gram-negative, rod shaped bacteria responsible for the disease known as cat-scratch disease (CSD), which encompasses a worldwide distribution. Cats, the main reserv...

Coxiella burnetii is the etiologic agent of Q fever. Two major forms of the disease are known: acute and chronic (1). The acute form of the disease is usually a self-limiting acute febrile illness, during which pneumonia or hepatitis may occur. However, the chronic form is a severe disease in which endocarditis predominates (8). Whereas acute C. burnetii infections respond to antibiotic therapy, chronic infections are hard to cure (3, 12). The efficacies of quinolones against these types of infection have yet to be established. In this paper we studied the activity of a new quinolone, trovafloxacin, against C. burnetii, using Vero cell tissue cultures. We also compared its bacteriostatic effect with those of five other antibiotic compounds on eight Greek isolates derived from human samples. Stock solutions of trovafloxacin (20 mg/ml; kindly provided by Pfizer Inc., New York, N.Y.), pefloxacin (400 mg/5 ml; Rhone Poulenc S.A., Paris, France), ciprofloxacin (100 mg/50 ml; Bayer AG, Leverkuzen, Germany), and ofloxacin (220 mg/100 ml; Hoechst AG, Frankfurt am Main, Germany) were prepared. For doxycycline (Pfizer Inc.) and clarithromycin (Abbott Laboratories, Chicago, Ill.), stock solutions at 6 mg/ml were prepared by using methanol. All strains were grown in Vero cells as previously described (10). The bacteriostatic and bactericidal effects on C. burnetii were tested by the shell vial assay. For this purpose an acute-infection model with the Nine-Mile strain and a chronic-infection model with the Q212 strain were employed (1, 10). In addition, the concentration of the inoculum that was previously determined to infect 30 to 50% of Vero cells was used to infect the shell vials for the antibiotic challenge (10). Bacterial growth was evaluated after 6 days of incubation by indirect immunofluorescence, and the results were scored as follows: R for resistance, with growth comparable to that of the control; I for intermediate susceptibility, with less than 10% infected cells; and S for susceptibility, with the absence of infected cells (10). The bactericidal activity of trovafloxacin was assessed by the quantitative method described by Maurin and Raoult (6). Trovafloxacin was added to the culture medium at 4 μg/ml. Viable organisms were identified after 6 days in the culture, and bactericidal activity corresponded to a significant reduction in bacterial titer (at least 2 to 3 dilutions) after antibiotic exposure, compared with that in the primary inoculum dose (5, 6). Trovafloxacin showed bacteriostatic activity toward C. burnetii. Complete bacterial growth inhibition was obtained with 1 μg per ml in tests with the Nine-Mile isolate and with seven of eight Greek isolates. Inhibition was also obtained with 2 μg/ml in tests with the Q212 strain and the last Greek isolate (Table ​(Table1).1). These concentrations are below those achieved in human serum with the recommended single oral dose of 200 mg of trovafloxacin (2.2 μg/ml). TABLE 1 Susceptibilities of C. burnetii strains to trovafloxacin determined by the shell vial technique Vero cells were persistently infected with the Nine-Mile and Q212 C. burnetii strains for 5 months before being tested. Only these two strains were tested in bactericidal experiments with trovafloxacin. No bactericidal activity was demonstrated with 4 μg of trovafloxacin per ml when these cells were examined. All MICs recorded were compared with each other and with the peak concentration of each antibiotic in serum. The MICs of all the antibiotics tested are summarized in Table ​Table2.2. TABLE 2 Antibiotic susceptibilities of C. burnetii isolates At the concentrations tested, trovafloxacin, ofloxacin, and doxycycline showed improved bacteriostatic activities in vitro in tests with the Greek C. burnetii isolates as well as the tested reference strains. However, the same isolates were less susceptible to pefloxacin and clarithromycin. Ciprofloxacin presented higher MICs for all tested strains. Two major problems are associated with the evaluation of the antibiotic treatment of acute Q fever. First, it is usually a self-limited disease and mostly retrospectively diagnosed and in the chronic form, an evaluation of the success of therapy requires prolonged follow-up due to late relapses (3–5, 7–9). Second, the experimental evaluation of antibiotic therapy is problematic because C. burnetii is a strictly intracellular pathogen and no successful animal model of chronic Q fever has been described so far (9). In cases of acute Q fever, a bacteriostatic effect is sufficient for enabling recovery, whereas in cases of chronic Q fever, a bacteriostatic regimen is not curative (9). Tetracycline has been the mainstay therapy for endocarditis (8, 9). However, recovery of viable C. burnetii from valve tissue after 4 years of therapy with doxycycline has been reported (8). The use of cotrimoxazole alone has failed to cure Q fever endocarditis (8, 9). Combinations of rifampin with either doxycycline or cotrimoxazole have been used in treating Q fever endocarditis, with apparent success (9). Clinical data on the efficacies of macrolides are lacking (4). More recently, a combination of doxycycline with the lysosomotropic agent chloroquine displayed bactericidal activity in vitro, but no definitive clinical data were presented (4). Quinolones exhibit in vitro activities against rickettsiae and have produced encouraging clinical results in Q fever patients (2, 3). In our study, trovafloxacin showed bacteriostatic activities (MIC, 1 to 2 μg/ml) in tests with C. burnetii strains that were better than those obtained with pefloxacin, clarithromycin, and ciprofloxacin. The bacteriostatic activities of doxycycline and ofloxacin were comparable to those of trovafloxacin. A comparison between its MIC and peak concentration in serum cannot be used as evidence of trovafloxacin’s clinical efficacy, since C. burnetii is an intracellular pathogen. It is, however, interesting that the intracellular concentrations of ciprofloxacin for all the tested strains and those of pefloxacin for two strains (Q212 and CP1) needed to be higher than their peak concentrations in serum in order to achieve bacteriostatic levels. This was not true for the other quinolones tested. The same type of comparison produced favorable results for clarithromycin and doxycycline (Table ​(Table2).2). However, the determination of the activities of trovafloxacin against C. burnetii strains showed that at a concentration of 4 μg/ml, it was not bactericidal to either tested strain. In conclusion, our results indicate that trovafloxacin possesses promising in vitro activities against bacteria of the C. burnetii species. Careful clinical studies are now required to evaluate it for the treatment of Q fever infection.

The causative organisms, clinical manifestations, factors influencing prognosis, and other epidemiological characteristics of 81 episodes of bacteremia due to gram-negative organisms, in non-neutropenic patients, were studied retrospectively during a 3-year period (1992-1994) at the Department of Internal Medicine of the University Hospital of Heraklion, Crete, Greece. The gram-negative bacteremia incidence was 2% and the overall mortality 12%. All 81 patients had fever; Escherichia coli was the most frequent organism isolated (from 47 patients--58%) and was associated with shock (9/47), disseminated intravascular coagulation (DIC) (8/47), anuria (5/47), adult respiratory distress syndrome (ARDS) (3/47), and pneumonia (1/47). Other less frequent gram-negative microorganisms were Klebsiella spp. (ten patients; 12%), Pseudomonas spp. (7; 7%), Salmonella spp. (5; 6%), Enterobacter spp. (5; 6%), Proteus spp. (3; 3.4%), Stenotrophomonas spp. (3; 3.4%), and Acinetobacter spp. (1; 1.2%). ARDS. shock, DIC, anuria, presence of central venous catheter, urinary catheter, unknown origin of infection and inappropriate treatment were significantly associated with a higher death rate. Early initiation of appropriate therapy was the most important intervention that favorably affected the outcome of gram-negative bacteremias in this patient population.

A retrospective study was undertaken in Crete, Greece, to investigate the epidemiologic, clinical, and therapeutic aspects of Q fever. Over a period of 5 years (1989-1993), 1,298 patients were examined and 98 cases were identified. Individuals who were aged 20-29 years and 30-39 years appeared to have an increased risk of infection. Contact with animals was found to be a major risk factor for acquisition of Q fever. The predominant clinical manifestations of the infection were fever (91.7% of patients) and respiratory disease (88.5%), whereas hepatitis was the dominant feature in only a minority (7.1%) of patients. Chest radiographs frequently revealed pulmonary interstitial changes (36.4% of patients) and alveolar changes (34.4%). Abnormal echocardiographic findings were also observed. There was no difference in the duration of fever whether the patient received therapy with tetracycline or erythromycin, a finding that may be explained by the delay in initiating tetracycline therapy.

We report two children with Rickettsia typhi infection presenting with mild central nervous system manifestations and pleocytosis in cerebrospinal fluid. Murine typhus should be included in the differential diagnosis of meningoencephalitis in children who are residents of endemic areas. (J Child Neurol 2002;17:156-157).

Cases of murine typhus were described in Chalkis, capital town of the island Evia in Greece. In the present work a prospective study on murine typhus was carried out in Chalkis General Hospital in 1985, is presented. During this year 49 cases, serologically confirmed using indirect fluorescence assay, were diagnosed. Signs and symptoms of the patients as well as preliminary epidemiological data are reported in this paper.

Summary Objectives To document and evaluate the clinico-epidemiological profile of murine typhus during the re-emergence of the disease in a previously endemic focus in central Greece. Methods This was a 5-year, hospital-based, observational study, in which 90 adult patients with murine typhus were prospectively identified and studied. Results Most cases of the disease occurred in rural (52%) and semi-urban (34%) settings, with a seasonal frequency peak during the late summer. The triad of fever, headache, and rash was present in 64% of the patients within 2 days of hospital admission. Normal white blood cell counts (63%), thrombocytopenia (81%), and a high erythrocyte sedimentation rate (93%) were the main hematological findings upon presentation. Elevated aminotransferases (>84%), hypoalbuminemia (81%), and hyponatremia (36%) were prominent biochemical abnormalities. Pulmonary, neurological, and renal complications were noted in 26% of the patients and subsided after specific treatment. The duration of fever was shorter in patients treated with doxycycline (median 3 days) compared to ofloxacin ( p =0.001) or doxycycline plus ofloxacin ( p =0.009). Conclusions Murine typhus has the potential to cause significant morbidity. Awareness of the disease in endemic areas, early recognition of its clinical and laboratory features, and prompt administration of effective treatment are key factors to prevent potentially severe complications.

The activities of clarithromycin, sulfisoxazole, and rifabutin against three virulent strains of Mycobacterium avium complex isolated from patients with acquired immunodeficiency syndrome were evaluated in a model of intracellular infection. Human monocyte-derived macrophages were infected at day 6 of culture with M. avium complex. Intracellular bacteria were counted 60 min after inoculation. Extra- and intracellular bacteria were counted at days 4 and 7 after inoculation. The concentrations used were 4 micrograms of clarithromycin per ml (MICs for the three strains, 4, 4, and 4 micrograms/ml), 50 micrograms of sulfisoxazole per ml (MICs, 50, 25, and 25 micrograms/ml), and 0.5 micrograms of rifabutin per ml (MICs, 2, 0.5, and 0.5 micrograms/ml). Compared with controls, clarithromycin and rifabutin slowed the intracellular replication of the three strains (at day 7 after inoculation, P was less than 0.01 for the first strain and less than 0.001 for the two others). Sulfisoxazole was ineffective against the three strains. Clarithromycin was as effective as rifabutin. Clarithromycin plus rifabutin was as effective as each single agent. Clarithromycin plus sulfisoxazole was as effective as clarithromycin alone.

The profile and temporal trends of antimicrobial use were investigated at a university hospital. Aggregate data were analyzed according to the ATC/DDD methodology. During 1998-2002, hospital-wide antimicrobial use increased by 22%, from 86.97 to 106.24 defined daily doses per 100 bed-days [DDD/100BD]. Pooled usage rates in DDD/100BD, overall percentage increases and annual average increase rates were respectively 109.97, 35.6%, 8.1 for Medical wards, 98.21, 48.7%, 9.1 for Intensive Care Units and 74.46, 34.3%, 5.7 for Hemato-oncology wards. Surgical wards had a fairly constant usage rate (98.36). A shift towards the newer broad-spectrum antibiotics, to the detriment of the older penicillins and cephalosporins, was noted in all hospital areas. Surveillance of antimicrobial consumption using the ATC/DDD system provided a clear picture of its profile. Monthly rates over a sufficient surveillance period allowed the assessment of temporal trends. Stratification of rates according to clinical service allowed areas of concern to be specified and targeted antibiotic policy changes to be initiated.

A 27-year-old woman was admitted on 14 May 2007, into the hospital of Famagusta (Cyprus) with an 11-day fever (up to 39.5 C). She reported no direct contact with domestic animals or ticks; however, she lived in a rural area, where sheep and goats are abundant. On physical examination, hepatosplenomegaly and an enlarged lymph node were observed. Initial laboratory examination demonstrated moderate anaemia (Hb 11.5 g ⁄dL), thrombocytopenia (PLT 95000), increased transaminases (AST 178 u ⁄L, ALT 313 u ⁄L), cGT (79 u ⁄L), LDH (698 u ⁄L) and increased CRP (10.4 mg ⁄L) and ESR (80 mm ⁄h). The electrocardiogram and the chest axial tomography were negative, as were blood cultures, antibody tests against CMV, EBV, hepatitis, HIV, mycoplasma, coxackievirus, adenovirus and parvovirus and tests for rheumatoid disease. The patient was treated with doxycycline (200 mg ⁄day for 11 days), ceftriaxone (2 g ⁄day for 5 days) and imipenem-cilastatin (1500 mg ⁄day for 1 day), recovered and was discharged 17 days after hospitalisation. Blood samples were taken from the patient on admission into the hospital, and 7 days and 3 months later.

In this study we investigate the demographic, clinical and laboratory features of six human cases of human granulocytic anaplasmosis (HGA) in Crete, Greece. Six patients, residents of the city of Chania, Crete, were hospitalised in the General Hospital of Chania with clinical manifestations and laboratory findings suggestive of acute A. phagocytophilum infection. Blood samples were taken from all patients on admission before the administration of antibiotics. Acute-phase serum samples were tested using an indirect immunofluorescence assay (IFA) for the presence of IgG and IgM antibodies against A. phagocytophilum antigen (Focus Diagnostics, CA, USA), according to the manufacturer’s recommendations (cut-off for positivity IgG‡1 ⁄ 64 and IgM‡1 ⁄ 20). Whole blood samples were tested by PCR-sequencing analysis of the 16s rRNA gene. DNA extraction was carried out using the QIAamp DNA blood mini kit (Qiagen, Hilden, Germany). PCR reactions were carried out using the primer set EHR16SD– EHR16SR targeting a fragment of 345 bp of the 16s rRNA gene of Anaplasmataceae using the conditions previously described [4]. Positive PCR products were directly sequenced using the sequencer CEQ 8000 Beckman Coulter. Three consecutive blood samples were taken for culture from each patient. Serological testing for suspected potential pathogens that are endemic in the area was also performed. Six patients were diagnosed as having acute A. phagocytophilum infection. Four infections were acquired in September 2006, one in August 2007 and one in September 2007. The mean age was 46.7 years old, ranging from 17 to 69 years old. Five patients were males. Three out of six patients reported contact with wild animals within 1 month before the onset of symptoms. None of the patients had travelled recently. Demographic characteristics, clinical presentation and laboratory findings are presented in Table 1. Symptoms persisted for 2–6 days before presentation. On admission, fever was present in all of the six patients and was accompanied by chills in two patients. Other symptoms observed were a maculopapular rash of the trunk (3 ⁄ 6), headache (2 ⁄ 6), malaise (2 ⁄ 6), splenomegaly (2 ⁄ 6), cervical lymphadenopathy (1 ⁄ 6), and gastrointestinal disturbances (1 ⁄ 6 patients). Common laboratory abnormalities found were high lactate dehydrogenase titres (all patients), elevated transaminases (5 ⁄ 6), elevated serum C-reactive protein (4 ⁄ 6), thrombocytopenia (4 ⁄ 6), and leucopenia (2 ⁄ 6 patients). All blood cultures were negative for common pathogens. Acute infection by other suspected pathogens included in the differential diagnosis was ruled out. All patients revealed IgM antibodies with titres ranging from 1 ⁄ 20 to 1 ⁄ 40. Only one patient revealed both IgM and IgG antibodies against Anaplasma phagocytophilum (IgG 1 ⁄ 128, IgM 1 ⁄ 40). DNA sequences of the PCR products in all patients (Genbank number EU448142), when compared using nucleotide Blast (National Center for Biotechnology Information) (http:// www.ncbi.nlm.nih.gov/BLAST), revealed 100% identity with each other and 98% identity with Anaplasma sp deposited sequences (EU448141, Anaplasma sp. panagCy 16S ribosomal RNA gene; Corresponding author and reprint requests: A. Psaroulaki, Laboratory of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine, Voutes, Heraklion, Crete 71100, Greece E-mail: annapsa@med.uoc.gr