Can you pick up a bac...

Robert Morrell Jr. bmorrell at ISNET.IS.WFU.EDU
Mon Oct 24 19:48:52 EST 1994


On Mon, 24 Oct 1994 BCapstone at aol.com wrote:

> Bob, I enjoy are little debates about this case.  Are you seeing it from the
> patient's perspective?

Most definitely. Worrying about the choice of antibiotics is a major part 
of my job. See  Amer Journ of Hosp Pharm, Oct. 93

> He has sepsis and and a gram negative rod in his
> blood.

This thread has been going on for =weeks=. If he has been septic all this 
time I am surprised he is still alive. The key point that you did not 
answer: you have the cloacae =from the blood=. You have the antibiogram. 
Even if, and I think that this is unlikely, the prostate was the source, 
its susceptibilities would not be different. How has the patient 
responded to the therapy based on the blood culture isolate's antibiogram?

> One looks for where the source of the sepsis is.

True, but this is still largely an academic concern, since treatment will
supposedly hit the organism in the blood and at the source. From the
patient's point of view, the sepsis is the problem, not where it came from.

> It's likely to be
> in the prostate because the patient has clinical prostatitis, rods are
> present in semen and no other source of infection has been found. 

The patient, according to the data you sent to me has classic non-bacterial 
prostatitis, where at most, coagulase negative staph are isolated. In 
bacterial prostatitis, enterics, such as E. cloacae are routinely 
isolated (showing no ill effects from the "hostile" prostate environment.)
Thus, if this were the source of the sepsis organism, you would have a 
bacterial prost. case, with numerous isolations of the organism from that 
source.

> I think
> this suggests that the standard laboratory protocol does not pick up the
> pathogen.

It suggests that the standard laboratory protocol does not get the rod 
being seen microscopically. It does not even indicate that the rod is 
real, or that if it is some obscure fastidious organism, that it is "a" as 
opposed to "the" pathogen. The pathogen, by right of its isolation from 
=blood= is E. cloacae.

> This needs to be investigated as the patient's outcome depends on
> accurate diagnosis.

The patient's outcome depends upon the proper treatment of sepsis, which 
has already been diagnosed.

> Since my
> hospital's lab uses EMB modified instead of MacConkey I will discuss this
> with them as per your last post.  Currently, it is my understanding that both
> kinds of agar are suitable for gram negative rods.

That is correct. Had the E. cloacae been there, it would have grown, 
perfectly isolated from the CNS on that plate. It did not. Even casual 
experience with this organism would lead one to conclude that it did not 
because it was not there.

> You will forgive me, as I know a lot about the prostatitis literature, but
> little about what goes on in the microbiology laboratories.

This has become increasingly clear. However, please remember that all 
bacterial/nonbacterial controversies demand a lot of knowledge about 
laboratory techniques. I would suggest that the whole framework upon which 
your understanding of bacterial/non bacterial prostatitis exists is 
called into question. 
 
*                     Bob Morrell                       *
*               bmorrell at isnet.is.wfu.edu               *
*       Taking offense is the last refuge of denial.    *




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