On Tue, 25 Oct 1994 BCapstone at aol.com wrote:
>> The sepsis resolved on imipenem. The prostatitis did not.
This is yet another indication that the prostatitis was not the source of
the cloacae, for imipenem has good penetration in all tissues and should
have hit the organism there as well. E. cloacae is present in various
normal floras in the body. The dehibilitation of the patient by the
prostatitis might have enabled one of those sources to become
opportunistic.
> If you can be so > certain that prostatitis is not the source of the
sepsis without ever seeing > the patient then what is? Urologist and
Infectious Disease specialist both > feel it is prostatitis, that no other
source is present. >
What evidence do they have? You have cultures that are negative for an
organism that is easily recovered from such cultures. You also have a
differential response to therapy that should have cured both, were the
organism the causative agent in both. There is no rule that I know of that
says that we must have a clearly identifiable source of sepsis.
It sounds like you and the consult team have labeled a source (the I
hate blank spaces on the chart approach) and are now unwilling to back
down in the face of considerable evidence to the contrary. This is the
"I've made up my mind, and if the lab doesn't confirm it, the lab is
wrong" mentality.
>> How do you know coagulase negative staff are not the pathogen in so called
> "non-bacterial prostatitis." If in this case Enterobacter Cloacae is found
> in the semen or prostatitic fluid of this patient it would disprove many of
> your biases.
>This paragraph is rather befuddled. If the CNS is the pathogen, then why
are we talking about the cloacae? Your target keeps moving. The reason
CNS is not normally considered the pathogen, and why CNS isolation
indicates non-bacterial prostatitis is because patients do not typically
respond to treatment of the CNS, as I believe you said that this patient
did not.
E cloacae was =not= found in the semen or prostatic fluid, which proves
my "bias".
>> Exactly the point. Why not find out what the rods are and end the controvery?
Why not indeed? The problem is you seem to have E cloacae on your mind.
Classical microbiology technique: rule out possibilities. Let us consider
E cloacae in this case:
1. It did not grow on culture, despite being a hardy organism routinely
isolated in other prostatitis patients =using identical techniques=.
2. It did not respond to therapy that would hit an E. cloacae.
3. Rods observed in specimen did not stain well, where as E. cloacae
stains gram negative quite well.
In my book the above points take together would be enough to rule out E
cloacae as the rod supposedly being seen in the specimen. I would
certainly be interested in what that rod was, but I suspect it is in fact
a propionibacterium (if all the cocci you are seeing is normal skin
flora, then I would expect this organism) that will be hard to recover
apart from the staph, and then probably not be the pathogen.
> This conclusion is not logical. If the Enterobacter Cloacae is
> cultured or determined to be one of the rods, your "casual experience"
> will be proven worthless.
It certainly will, as will be my extensive experience with this organism.
If someone discovers that the germ theory of medicine is not true, my
whole career will be worthless. Somehow I am not worried. What I am
trying to do is save you a lot of trouble chasing something that may not
be there, or is almost certainly something else other than the cloacae.
>> I would suggest that you were taken in by Meares and Stamey, two urologist
> who became famous for publishing a flawed localization technique.
> I would suggest that you are failing to go over a lot of microbiological
ground that has already been covered. The key to non-bacterial prostatitis
is probably related to what we are culturing for more than how we collect
the specimen. This is why you should turn your attention away from easily
recovered organisms and towards more unusual, seldom cultured for
pathogens, such as Mycobacteria or other difficult to grow, poorly
staining organisms.
Bob Morrell
