Journal of Infection - Articles in Press

Influenza-associated illness is an important contributor to febrile convulsions in Danish children - Accepted Manuscript

Katja Majlund Harder, Kåre Mølbak, Steffen Glismann, Annette H. Christiansen — 2012-02-06

Abstract: Objective: To determine the burden of febrile convulsions attributed to influenza like illness in a western country during ten influenza seasons.Methods: Based on national Danish registries, we explored the association between influenza–like illness (ILI) activity and weekly number of hospital admittances for febrile convulsions in time-series analyses. We included data on 59,870 admissions for febrile convulsions in children between three months and five years of age in the period 1995-2005.Results: There was a significant relation between ILI-activity and number of children admitted for febrile convulsions with a systematic increase in admissions to pediatric wards about one week before the national surveillance system detected the corresponding rise in ILI- activity. The yearly number of admissions attributable to ILI varied from 11 to 47 % of admissions and was highest during influenza epidemics. This was in particular observed in seasons when a new strain of influenza A/H3N2 was circulating. During these epidemics, influenza contributed to 29 to 47 % of admissions.Conclusions: Influenza like illness is associated with a considerable burden of febrile convulsions in children, most pronounced in years with epidemics. As febrile convulsions are just one of many complications contributing to the burden of influenza in children, this should be taken into consideration when planning a vaccination strategy for preventing influenza-related morbidity in younger children.

Incidence and Predictors of Acute Kidney Injury Associated with Intravenous Polymyxin B Therapy - Accepted Manuscript

2012-02-06

Summary: Background: Increases in multidrug-resistance among gram-negative organisms have necessitated the use of polymyxins. To date, the incidence of acute kidney injury (AKI) associated with polymyxin B has not been evaluated using RIFLE criteria.Methods: Adult patients who received polymyxin B were retrospectively evaluated to determine the incidence of AKI during polymyxin B therapy using RIFLE criteria. Predictors of AKI were identified by comparing characteristics of patients with and without AKI.Results: A total of 73 patients were included. The incidence of AKI was 60%. Ten (14%) patients discontinued therapy due to nephrotoxicity. Median duration of polymyxin B was 11 days with a median cumulative dose of 18 mg/kg. Concomitant nephrotoxins were received in 69 (95%). Patients with AKI had a higher median cumulative dose (1578 mg vs. 800 mg; p=0.02), a higher body mass index (BMI) (27.2 vs. 24.5 kg/m2; p=0.03), and were more likely to receive vancomycin (82% vs. 55%; p=0.03) compared to those without AKI. After controlling for polymyxin B duration, independent predictors of AKI were higher BMI and concomitant vancomycin.Conclusions: The incidence of AKI during polymyxin B therapy was 60%. Further studies are needed to define dosing parameters that maximize efficacy and minimize nephrotoxicity.

Transmission of tuberculosis within family-households - Accepted Manuscript

2012-02-03

Summary: Objective: The introduction of molecular typing methods in the 1990s to study the epidemiology of tuberculosis (TB) has significantly improved the possibilities of quantifying transmission of Mycobacterium tuberculosis in different human settings. The purpose of this study was to investigate transmission of TB in 35 family-households in Poland.Methods: Two PCR-based genotyping methods: spoligotyping and mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR) typing were used.Results: Of 78 patients, 49 (63%), could be assigned to intra-household transmission on the basis of identical DNA fingerprints upon a combined typing approach. However, if a single spoligotype spacer or a single MIRU-VNTR locus variation was tolerated in the cluster definition, the intra-household transmission raised to 85% of all patients. For 12 patients in 6 households, the M. tuberculosis isolates were clearly distinct in either spoligotyping or VNTR typing or in both genotyping methods, suggesting that these patients were infected by the sources in the community.Conclusions: This study is the first to provide the results of a molecular epidemiological investigation performed within family-households in Poland. It shows the household setting as an important reservoir of M. tuberculosis transmission, and thus argues in favor of routine and extensive screening of the family contacts of TB patients.

Increase in primary drug resistance of Mycobacterium tuberculosis in younger birth cohorts in France - Accepted Manuscript

2012-02-03

Summary: Background: Monitoring of primary drug resistance is of interest for long-term evaluation of the efficacy of a national tuberculosis program. The objective was to describe changes over time in primary drug resistance among new tuberculosis patients.Methods: Stratified analysis by birth cohorts, region of birth, HIV-coinfection, of data from 14 610 culture-positive new tuberculosis patients diagnosed by a network of university hospitals between 1995 and 2008.Results: Half of the patients were foreign-born, and 9% HIV-coinfected. For foreign-born and French-born patients, there was an upward trend in resistance rates to streptomycin, isoniazid, and rifampicin from the oldest to the youngest cohorts. For a same age at tuberculosis diagnosis, the risk of isoniazid resistance was higher in younger cohorts, revealing a cohort effect. Among French-born patients, the only factor independently associated with primary resistance to streptomycin, or isoniazid was birth after 1950, and particularly after 1980. Risk of streptomycin resistance increased in youngest cohorts among European-born patients. HIV-coinfection was associated to rifampicin resistance among foreign-born and French-born patients.Conclusions: Theses results indicate that among French-born patients, isoniazid-resistant strains are currently circulating in younger patients that are more likely to be infected recently, and that among foreign-born patients, HIV-coinfection is a strong risk factor for primary resistance.

Should the methicillin-resistant Staphylococcus aureus carriage status be used as a guide to treatment for skin and soft tissue infections? - Accepted Manuscript

2012-02-03

Abstract: Objective: Previous skin carriage of methicillin-resistant Staphylococcus aureus (MRSA) leads frequently to empiric antibiotic MRSA coverage for skin & soft tissue infections.Methods: Retrospective cohort study of orthopaedic patients hospitalized at Geneva University Hospitals (MRSA prevalence; 30%); community-acquired MRSA excluded.Results: A total of 378 skin and soft tissue infections in 346 patients were retrieved. Overall cure was achieved in 330 episodes (87%) after a median antibiotic administration of 15 days. Among all episodes, 102 revealed a positive current MRSA status (during 2 weeks preceding infection; 27%) and 70 (19%) were MRSA carriers in the past. Sensitivity, specificity, positive and negative predictive values of current MRSA skin carriage to predict abscesses due to MRSA were 0.68, 0.77, 0.19, and 0.97, respectively. Fifty-four current MRSA carriers (54/102, 53%) and 30 past carriers (43%) were successfully treated with a non-MRSA antibiotic agent. In multivariate Cox regression analysis, anti-MRSA coverage (hazard ratio 1.2, 95%CI 0.5-2.8) and duration of antibiotic therapy (HR 1.0, 95%CI 0.96-1.02) did not influence treatment failure among patients with positive MRSA carriage.Conclusions: Current or past HA-MRSA skin carriage poorly predicts the need for anti-MRSA coverage for the antibiotic treatment of skin and soft tissue infections in hospitalized orthopaedic patients.

Melioidosis breast abscesses - Corrected Proof

Nardeen Mickail, Natalie C. Klein, Burke A. Cunha, Paul A. Schoch — 2012-01-24

Melioidosis is an infection with a myriad of clinical manifestations and is caused by Burkholderia pseudomallei. B. pseudomallei’s natural habitat is aquatic. Melioidosis is endemic in East Asia and northern Australia. The clinical spectrum of melioidosis ranges from asymptomatic seroconversion to acute fatal septicemia. Melioidosis may also be chronic. Melioidosis is histopathologically, characterized by abscess formation. Melioidosis may remain dormant and become clinically apparent years after initial exposure/infection. Melioidosis, originally called Pseudomonas pseudomallei, was derived from the Greek meaning “glanders-like” and was first described by Whitmore and Krishnaswami in Rangoon in 1911. They reported their experience with 38 cases of a previously undescribed infection characterized by widespread abscesses in the lungs, liver, spleen, kidneys, and skin. Common clinical presentations include septicemia or pneumonia which may be primary or secondary to hematogenous spread. Melioidosis abscesses in the liver, spleen, muscle, prostate, kidneys and in children may occur in the parotids. Rarely, melioidosis may present as isolated abscess or skin/subcutaneous abscesses.

Community-onset healthcare-related urinary tract infections: Comparison with community and hospital-acquired urinary tract infections - Uncorrected Proof

2012-01-24

Summary: Objectives: To analyze the characteristics of infection, adequacy of empirical treatment and outcome of patients with community-onset healthcare-associated (HCA) urinary tract infections (UTI) and compare them with hospital (HA) and community-acquired (CA) UTI.Methods: Prospective observational cohort study performed at a university 600-bed hospital between July 2009 and February 2010. Patients with UTI requiring hospital admission were included. Epidemiological, clinical and outcome data were recorded.Results: 251 patients were included. Patients with community-onset HCA UTI were older, had more co-morbidities and had received previous antimicrobial treatment more frequently than CA UTI (p = 0.02, p = 0.01 and p < 0.01). ESBL-Escherichia coli and Pseudomonas aeruginosa infections were more frequent in HCA than in CA UTI (p = 0.03 and p < 0.01). Inadequate empirical treatment was not significantly different between community-onset HCA and CA. Factors related to mortality were P. aeruginosa infection (OR 6.51; 95%CI: 1.01–41.73), diabetes mellitus (OR 22.66; 95%CI: 3.61–142.21), solid neoplasia (OR 22.48; 95%CI: 3.38–149.49) and age (OR 1.15; 95%CI 1.03–1.28).Conclusions: Epidemiological, clinical and microbiological features suggest that community-onset HCA UTI is different from CA and similar to HA UTI. However, in our series inadequate empirical antimicrobial therapy and mortality were not significantly higher in community-onset HCA than in CA UTI.

Markers of bacterial infection in the critically ill: A comparison of procalcitonin, C reactive protein and the neutrophil band count - Uncorrected Proof

2012-01-24

we read with interest the recent review of the role of procalcitonin in distinguishing infectious from non-infectious fever. However its place in the setting of a Critical Care Unit (CCU) was not mentioned.

Microhaemorrhages in Leptospirosis on susceptibility weighted imaging - Corrected Proof

Prashant S. Naphade, Abhijit A. Raut, Bhujang U. Pai — 2012-01-24

A 17year boy, diagnosed case of Leptospirosis (positive for leptospira by IgM ELISA), was admitted to out hospital for multiorgan failure and haematemesis. Platelet count was 34,000/microliter. He developed one episode of focal seizure involving face. MRI brain revealed patchy restriction of diffusion in bilateral posterior parietal and occipital lobes with gyriform enhancement on post contrast scan s/o subacute infarct secondary to prior hypoxic episode (A&B). Susceptibility weighted images reveals multiple foci of susceptibility in throughout the brain parenchyma, predominantly in supratentorial white matter, basal ganglia and corpus callosum (A&B). These microhaemorrhages appear to be secondary to Leptospirosis associated vasculitis rather than thrombocytopaenia. Such findings are not described in the leptospirosis.

Piperacillin–tazobactam as an initial empirical therapy of bacteremia caused by extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae - Corrected Proof

Cheol-In Kang, So Yeon Park, Doo Ryeon Chung, Kyong Ran Peck, Jae-Hoon Song — 2012-01-18

We read with interest the recent paper by Chen YH et al., which discussed antimicrobial susceptibility profiles of aerobic and facultative Gram-negative bacilli isolated from patients with intra-abdominal infections in the Asia-Pacific region. The efficacy of piperacillin–tazobactam (PTZ) for treating serious infection caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is controversial. Although carbapenems are considered the drugs of choice for treating such infections, some authors consider PTZ a useful alternative. Even though the random allocation of treatments would be the best way to compare PTZ and carbapenems for the treatment of such infections, there is a lot to learn from observational cohort studies. Herein, we report our experiences on PTZ for the treatment of ESBL-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK) bacteremia. We reviewed the medical records of individuals diagnosed with ESBL-EK bacteremia between January 2008 and December 2010 at Samsung Medical Center. Cases that were available from the database of nationwide bacteremia surveillance studies were also included in this analysis. A total of 114 patients (78 E. coli and 36 K. pneumoniae) were included to compare the outcomes of patients with ESBL-EK bacteremia who had been treated with PTZ or carbapenems. Of 114 patients, 36 received an initial empirical therapy with PTZ and 78 with a carbapenem. As for underlying diseases, diabetes mellitus was more common in the PTZ group than in the carbapenem group (13/36 [36.1%] vs. 15/78 [19.2%]; P = 0.052), while hematologic malignancy was less frequent in the PTZ group than in the carbapenem group (5/36 [13.9%] vs. 21/78 [26.9%]; P = 0.123). No significant differences between both groups were found in severity of illness assessed by McCabe and Jackson classification and Charlson weighted index of comorbidity, comorbid conditions except neutropenia, presence of severe sepsis or septic shock, and primary site of infection (all P > 0.1). The 30-day mortality was 25.4% (29/114) and no significant difference in the mortality rates was found between the PTZ group and the carbapenem group (8/36 [22.2%] vs. 21/78 [26.9%], P = 0.592). When early outcomes at 3 days and 7 days after treatment were assessed in evaluable cases, no significant differences were found between both groups (). A multivariable analysis showed that significant factors associated with mortality were high Pitt bacteremia score, pneumonia, and immunosuppressant use (all P < 0.05). After adjustment for confounders, no association was found between initial empirical therapy with PTZ and increased mortality (OR = 0.55; 95% CI = 0.16–1.88; P = 0.343). We calculated a propensity score for receiving empirical therapy with a carbapenem using logistic regression. After adjustment for the propensity score in the logistic regression model to evaluate an association with mortality, empirical therapy with PTZ showed adjusted OR of 0.63 (95% CI = 0.17–2.27). Because there were only 13 patients who received definitive therapy with PTZ, a comprehensive analysis regarding definitive antimicrobial therapy with PTZ could not be performed. Increased empirical use of carbapenems in response to an increased prevalence of ESBL-producing isolates may be accompanied by the rapid emergence of carbapenem resistance in other pathogens. Therefore, therapeutic options other than carbapenems would be attractive. It is unlikely that randomized controlled therapy trials for serious infections due to ESBL-producing organisms will be performed in the near future. Therefore, further clinical experience with antibiotics other than carbapenem is warranted to fully evaluate the potential usefulness of these antibiotics against serious infections due to ESBL-producing organisms. Our findings are consistent with a previous study by Rodriguez-Bano et al., strongly supporting their conclusions that PTZ could be alternative options for antimicrobial therapy of susceptible ESBL-producing pathogens, which could help prevent overuse of carbapenems. Our data also suggest that a more prudent use of carbapenems as the initial empirical antibiotic may be reasonable in Gram-negative bacteremia.

Fulminant fatal Streptococcus pneumoniae serotype 6C infection in two HIV infected individuals - Corrected Proof

Josephine Seale, Paul Flanagan — 2012-01-16

A recent article in your journal demonstrated the increasing incidence of invasive pneumococcal disease resulting from Serotype 19A in an elderly population. This serotype is not covered by the pneumococcal conjugate vaccine 7 (PCV7) and the polysaccharide pneumococcal vaccine (PPV), a situation which is considered to account for its increasing incidence. We would like to bring to the reader’s attention the emergence of another pneumococcal serotype currently not covered by any vaccine, serotype 6C. This serotype is traditionally regarded to have a lower potential to cause serious disease. However, we have witnessed two cases of fatal pneumococcal bacteremia due to 6C in HIV positive individuals who were sexual partners.

Staphylococcus aureus pyomyositis compared with non-Staphylococcus aureus pyomyositis - Corrected Proof

2012-01-16

Summary: Objectives: Pyomyositis is an acute bacterial infection of skeletal muscle not arising from contiguous infection. It is often hematogenous in origin and typically associated with abscess formation. Our objective was to determine if there were any differences in the clinical presentation of disease between Staphylococcus aureus (SA) and non-Staphylococcus aureus pyomyositis. We also sought to determine if methicillin-resistant SA (MRSA) occurred more frequently during the final years of the study period.Methods: A retrospective chart review study at three institutions in two cities.Results: Sixty cases of pyomyositis were identified between 1990 and 2010. Twenty-nine patients were infected with SA while 31 had other bacterial etiologies or were culture negative. Those with a traumatic event prior to the onset of infection were more likely to have a SA infection while SA infected patients were younger. Our first documented case of MRSA occurred in 2005, but the frequency of MRSA infection remained static over the following five years.Conclusions: Pyomyositis is an emerging infection that is underappreciated by many physicians. While MRSA has emerged as the foremost cause of SA infections in a majority of clinical conditions, in this series most patients still had methicillin-sensitive SA as their cause of pyomyositis. In light of the severity of pyomyositis and the potential for bacteremia (either as a source or complication of the infection), empiric SA therapy should be initiated in all patients until the culture results are available.

The patient presenting with acute dysentery – A systematic review - Corrected Proof

Margaret L. Pfeiffer, Herbert L. DuPont, Theresa J. Ochoa — 2012-01-16

Summary: Objectives: The etiologies, clinical presentations and diagnosis of acute pathogen-specific dysentery in children and adults in industrialized and developing regions is described to help develop recommendations for therapy.Methods: We conducted a systematic review of literature published between January 2000 and June 2011 to determine the frequency of occurrence of pathogen-specific dysentery.Results: Shigella, Salmonella, and Campylobacter remain the most frequent bacterial causes of dysentery worldwide. Shiga toxin-producing Escherichia coli (STEC) is potentially important in industrialized countries. Entamoeba histolytica must be considered in the developing world, particularly in rural or periurban areas. Clinicians should use epidemiological clues and knowledge of endemicity to suspect Vibrio spp., Aeromonas spp., Plesiomonas spp., Yersinia enterocolitica, Clostridium difficile, Cytomegalovirus or Schistosoma mansoni in cases presenting with dysentery. A single fecal sample studied for etiologic agents is the customary way to make an etiologic diagnosis.Conclusions: While a majority of dysenteric cases will not have an identifiable agent causing the illness, when an etiologic organism is identified, other than STEC, each has a specific recommended form of therapy, which is provided in this review.

Babesiosis mimicking Epstein Barr Virus (EBV) infectious mononucleosis: Another cause of false positive monospot tests - Corrected Proof

Burke A. Cunha, Nardeen Mickail, Marianne Laguerre — 2012-01-16

Babesiosis is a tickborne zoonotic infection that parasitized red blood cells; humans are accidental hosts. The clinical severity of babesiosis ranges from asymptomatic to severe depending upon the host’s immune status. In the United States, B. microti is the predominant species transmitted via Ixodid ticks. Patients with babesiosis present with a malaria-like illness characterized by headache, fever, chills, and fatigue which may be accompanied by sore throat or myalgias/arthralgias. If hepatosplenomegaly is not present on physical examination, there are no physical findings in babesiosis. We present a case of babesiosis mimicking Epstein Barr Virus (EBV) infectious mononucleosis with a false positive Monospot test.

Klebsiella pneumoniae: Emergence of multi-drug-resistant strains in Northwest Italy - Corrected Proof

2012-01-16

The emergence of drug resistant Klebsiella pneumoniae strains has became a public health problem globally. In particular the production of extended-spectrum β-lactamases (ESBLs), prevalently divided into three groups (TEM, SHV and CTX-M), has been increasingly described in Europe. Strains producing ESBLs often exhibit a multi-drug-resistance (MDR) phenotype, including resistance to aminoglycosides and fluoroquinolones, and are associated with increased morbidity, mortality and healthcare-associated costs. Thus carbapenems were often considered last resort antibiotics for the treatment of infections due to these organisms. However, during the last decade carbapenem resistance has been increasingly observed and largely attributed to the production of carbapenemase.

Stenotrophomonas maltophilia – The most worrisome threat among unusual non-fermentative gram-negative bacilli from hospitalized patients: A prospective multicenter study - Uncorrected Proof

2012-01-09

Summary: Objectives: Isolation rates of unusual non-fermentative Gram-negative bacilli (i.e. other than Pseudomonas aeruginosa and Acinetobacter baumannii) are increasing but studies are limited to few observations. We aimed at determining risk factors for infection and influence of antibiotic treatment on the outcome.Methods: A six-month (December 1, 2008–May 31, 2009) prospective multicenter cohort study was conducted in nine French teaching hospitals. Characteristics of patients colonized or infected by unusual NF-GNB, adequacy of antimicrobial therapies, and outcome were analyzed.Results: Analysis of 158 patients (median age, 62.7 years) was conducted. Stenotrophomonas maltophilia was the predominant bacterial species isolated (39%) followed by Achromobacter group (15%) and non-baumannii Acinetobacter species (13%). Compared to colonized patients, infected ones were more frequently immunocompromised [relative risk (RR) = 1.63, (95% confidence interval (CI) = 1.02–2.60, P = 0.05)], hospitalized within the last three months [RR 1.67 (95% CI 1.09–2.58, P = 0.02)], admitted in an intensive care unit with central venous catheter [RR 1.74 (95% CI 1.15–2.63, P = 0.01)]. The overall hospital mortality concerned 28 patients (18%) but no association with inadequate antimicrobial treatment was found except in the group of S. maltophilia infected cases [RR 2.81 (95% CI 1.01–7.83, P = 0.02)].Conclusion: Naturally carbapenems-resistant S. maltophilia is the main unusual NF-GNB pathogen in hospitalized patients, leading to inappropriate empirical antibiotic treatment at the time of emerging extended-spectrum β-lactamase-producing bacteria.

Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever: A case for procalcitonin - Corrected Proof

2012-01-09

Summary: Objectives: Fever suggests the presence of microbial infection in critically ill patients. The aim was to compare the role of old and new biomarkers in predicting absence or presence of microbial infection, its invasiveness and severity in critically ill patients with new onset fever.Methods: We prospectively studied 101 patients in the intensive care unit with new onset fever (>38.3 °C). Routine infection parameters, lactate, procalcitonin (PCT), midregional pro-adrenomedullin (MR proADM), midregional pro-atrial natriuretic peptide (MR proANP) and copeptin (COP) were measured daily for three days after inclusion. Likelihood, invasiveness (by bloodstream infection, BSI) and severity of microbial infection were assessed by cultures, imaging techniques and clinical courses.Results: All patients had systemic inflammatory response syndrome; 45% had a probable or proven local infection and 12% a BSI, with 20 and 33% mortality in the ICU, respectively. Only peak PCT (cutoff 0.65 ng/mL at minimum) was of predictive value for all endpoints studied, i.e. BSI, septic shock and mortality (high risk infection) and infection without BSI, shock and mortality (low risk infection), at areas under the receiver operating characteristic curves varying between 0.67 (P = 0.003) and 0.72 (P < 0.001). In multivariable analysis, the combination of C-reactive protein and lactate best predicted high risk infection, followed by PCT. For low risk infection, PCT was the single best predictor.Conclusions: In critically ill patients with new onset fever, plasma PCT as a single variable, among old and new biomarkers, best helps, to some extent, to predict ICU-acquired, high risk microbial infection when peaking above 0.65 ng/mL and low risk infection when peaking below 0.65 ng/mL.

Greatly increased risk for prostatic abscess following pyogenic liver abscess: A nationwide population-based study - Corrected Proof

Shiu-Dong Chung, Joseph Keller, Herng-Ching Lin — 2012-01-09

We read the article by Chung et al. with great interest. The incidence of extra-hepatic metastases from pyogenic liver abscess (PLA) has also increased over the last two decades, with the occurrence rising from 3 to 12% of all cases. Severe complications of PLA have been reported worldwide including septic endogenous endophthalmitis, metastatic infections of the brain and lungs, and necrotizing fasciitis. Some case reports have indicated that metastatic septic emboli arising from PLA may also contribute to the development of prostatic abscess (PA). However, data regarding the longitudinal risk for developing PA in patients with PLA are still lacking. Therefore, we examined the risk of PA among patients with PLA in comparison to a control population using a large-scale population-based database in Taiwan.

Recurrent Mycobacterium avium infection after seven years of latency in a HIV-infected patient receiving efficient antiretroviral therapy - Corrected Proof

2012-01-05

Summary: We report the first case of Mycobacterium avium reactivation, after prolonged latency, in a HIV-infected patient receiving highly active antiretroviral therapy with undetectable viral replication and normal CD4 cell count. The patient presented with a painful swollen shoulder seven years after initial M. avium bacteriaemia. Articular puncture grew M. avium. The isolates of the first and second infection were identical using repetitive-sequence-based Polymerase Chain Reaction analyses.

Risk factors for methicillin-resistant staphylococcal vascular graft infection in an 11-year cohort study - Corrected Proof

2012-01-05

Recently, we reported our experience concerning the management of prosthetic vascular graft infection in intensive care unit. In the literature, the optimal choice of antibiotic therapy for patients with PVGI remains unknown. Among unresolved questions is that of empirically covering methicillin-resistant (MR) Staphylococcus aureus and coagulase-negative staphylococci (CNS). The aim of our study was to identify factors associated with MR staphylococcal PVGI, and to propose adequate empirical antimicrobial treatment during the operative period. The cohort includes patients with a diagnosis of PVGI admitted from January 2000 to September 2010 to the Infectious Diseases and Surgical Vascular Departments of two referral centres for the PVGI (Lille and Tourcoing, France).

Corticosteroid therapy in patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza - Corrected Proof

2012-01-04

Summary: Objective: During the first pandemic, some patients with pandemic (H1N1) 2009 influenza were treated with corticosteroids. The objective of this study was to assess the effect on survival of corticosteroid therapy in patients with pandemic (H1N1) 2009 influenza.Methods: Prospective, observational, multicenter study performed in 148 ICU. Data were recorded in the GTEI/SEMICYUC registry. Adult patients with pandemic (H1N1) 2009 influenza confirmed by rt-PCR were included in the analysis. Database records specified corticosteroid type and reason for corticosteroid treatment.Results: 372 patients with the diagnosis of primary viral pneumonia and completed outcomes treated in an ICU were included in the database. Mechanical ventilation was used in 70.2% of the patients. 136 (36.6%) patients received corticosteroids after a diagnosis of primary viral pneumonia. Obesity (35.6% vs 47.8% p = 0.021) and asthma (7.6% vs 15.4% p = 0.018), were more frequent in the group treated with corticosteroids. A Cox regression analysis adjusted for severity and potential confounding factors found that the use of corticosteroid therapy was not significantly associated with mortality (HR = 1.06, 95% CI 0.626–1.801; p = 0.825).Conclusions: Corticosteroid therapy in a selected group of patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza does not improve survival.

Absence of occult HCV infection in HIV-positive patients - Corrected Proof

2012-01-04

Some authors have suggested the existence of occult Hepatitis C Virus (HCV) infection, defined by the presence of HCV RNA in the liver and/or in the Peripheral Blood Mononuclear Cells (PBMC) in the absence of circulating anti-HCV and HCV RNA, whereas other investigators failed to demonstrate this viro-immunological condition in subjects with abnormal aminotransferases, in kidney-transplant and onco-hematological patients. Recently, Barrill et al found that 45% of 109 anti-HCV-negative hemodialysis patients with abnormal serum aminotranferases had HCV RNA in PBMC, but no data are so far available on occult HCV infection in patients with Human Immunodeficiency Virus (HIV) infection.

The use of PCT, CRP, IL-6 and SAA in critically ill patients for an early distinction between candidemia and Gram positive/negative bacteremia - Corrected Proof

2012-01-04

Recently, Simion et al published an article on the Procalcitonin levels at risk of candidemia and concluded that PCT levels were lower in patients with candidemia (median 0.71 [IQR 0.5–1.1]) than those with bacteremia(12.9 [2.6–81.2]), p = 0.001. A cut-off value of PCT in 2 ng/mL with a sensitivity of 92% and a specificity of 93% can distinguish candidemia from bacteremia. Although the major microorganism of sepsis in ICU is bacterium, candidemia is a common phenomenon. According to Azoulay, candida infection rate in ICU could reach 17%, but the positive culture rate of monilia is less than 1%. Candidemia diagnosis has always been a marked clinical problem as confusing clinical symptoms, and clinicians can hardly distinguish candidemia from bacterial sepsis without microbiology evidence. Therefore, early and accurate identification is of paramount importance, as therapeutic schedules are totally different.

Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients - Corrected Proof

2012-01-03

Summary: Object: Although emergency department (ED) crowding has been shown to be associated with delayed antibiotics treatment in community-acquired pneumonia (CAP) patients, association between ED crowding with mortality has not been investigated. We hypothesized emergency department crowding is associated with 28-day mortality in CAP patients.Methods: A retrospective observational study using prospective database was performed on CAP patients who visited a single, urban, tertiary care hospital ED between April 1, 2008 and September 30, 2009. Main outcomes were 28-day mortality and timeliness of antibiotic therapy (within 2, 4, 6, and 8 h of arrival). ED crowding was measured by Emergency Department Occupancy (EDO) rate. A multivariate logistic regression was performed to determine the association of 28-day mortality with EDO rate after adjusting for factors such as time-to-first-antibiotic-dose (TFAD), pneumonia severity index and laboratory markers.Results: 477 cases were enrolled during the study period. 28-day mortality rate was 4.8%. EDO rate ranged from 37.2% to 162.8%, and median was 97.7% (IQR: 80.2%–116.3%). When categorized into tertiles by EDO rate, high crowding condition (EDO rate >109.3%) was significantly associated with a higher 28-day mortality (adjusted OR = 9.48, 95% CI 1.53–58.90). However, TFAD was not associated with 28-day mortality. ED crowding was not associated with delay of TFAD at various time intervals (2, 4, 6, and 8 h).Conclusions: ED crowding measured by EDO rate was associated with higher 28-day mortality in CAP patients after adjusting TFAD, pneumonia severity index (PSI), and laboratory markers, although there was no association between ED crowding and TFAD.

Breakthrough invasive mould infections in patients treated with caspofungin - Corrected Proof

2012-01-03

Summary: Objectives: To describe and estimate the rate of breakthrough invasive mould diseases (IMD) in patients receiving caspofungin.Methods: Retrospective, non-interventional study conducted in three University Hospitals.Results: Nineteen breakthrough infections have been identified including 13 aspergillosis, 2 mucormycosis, a fusariosis, a Hormographiella aspergillata infection and 2 possible IMD. Cases were equally distributed between the centres. Fourteen patients had a haematologic malignancy, four were transplant recipients (allogeneic haematopoietic stem cells in three, liver in one) and one had hepatic cirrhosis. Caspofungin has been prescribed as prophylaxis (n = 3), empirical therapy (n = 9) or directed therapy for candidemia (n = 5) or aspergillosis (n = 2). Aspergillus galactomannan was positive in serum or in bronchoalveolar lavage fluid in 10 of the 13 aspergillosis. Median duration of caspofungin treatment before breakthrough IMD was 15 days. Nine patients died within twelve weeks. Rate of breakthrough IMD in onco-haematology patients has been estimated to 7.3% for all mould infections and to 4.2% when restricted to documented aspergillosis.Conclusions: Our data call for Aspergillus galactomannan monitoring and close clinical and radiological examination in case of persistence or recurrence of infection signs in high-risk patients receiving caspofungin.

T-cell changes after a short-term exposure to maraviroc in HIV-infected patients are related to antiviral activity - Corrected Proof

2012-01-03

Summary: Objectives: Analyze the short-term immunological effect directly attributable to MRV without interference of other drugs.Methods: MRV group included experienced HIV-infected patients undergoing an 8-day MRV monotherapy. A comparison population included naïve HIV-infected patients starting combined antiretroviral therapy (cART group). Absolute CD4+ and CD8+ T-cells and T-lymphocyte subsets were determined at day 0 and 8.Results: Fifty-nine patients who underwent MRV monotherapy and 28 naïve patients were analyzed. Forty-one patients in the MRV group experienced a significant viral load decrease (MRV positive subgroup). Virological response and CD4+ T-cell change were comparable in the MRV positive and cART groups. CD8+ T-cell increase in the MRV positive subgroup showed a trend toward superiority when compared with the cART group. T-lymphocyte subset changes showed a similar profile in the MRV positive and cART groups with a differential effect in the TemRA cells related to MRV. No immunological effect (absolute lymphocyte counts or subsets) was observed in patients without virological response to MRV.Conclusions: MRV produced CD4+ and CD8+ T-cell gains related to antiviral activity and comparable or even superior in terms of CD8+ T-cells to naïve patients starting cART. No immunological effect occurred in subjects without virological response to MRV.

Risk of secondary cases of Clostridium difficile infection among household contacts of index cases - Corrected Proof

Jacques Pépin, Milagros Gonzales, Louis Valiquette — 2011-12-28

Summary: Objectives: We aimed to estimate the risk of secondary cases of Clostridium difficile infection (CDI) among household contacts of index cases.Methods: We reviewed all 2222 patients with confirmed CDI in a region of Quebec, Canada, during 1998–2009. Our laboratory serves a well-defined population for which it is the sole centre providing CDI testing, enabling us to calculate accurate population annual incidence rates of CDI. Cases with the same phone number were verified individually to determine whether they were indeed related. We considered as related two cases occurring in the same household within one year of each other.Results: We estimated that 1061 spouses and 501 children (<25 years-old) lived in the same household as the index cases, of which respectively 5 and 3 developed CDI. Among spouses and children, the attack rate was 4.71/1000 and 5.99/1000 respectively, and the relative risk was 7.61 (95%CI: 5.77–9.78) and 90.6 (95%CI: 33.89–487.64) for the three months after the diagnosis in the index case.Conclusions: Although the relative risk of CDI among household contacts is somewhat increased for a few months, the absolute risk is too low to justify interventions, apart from avoiding unnecessary courses of antimicrobials.

Hcv coinfection, an important risk factor for hepatotoxicity in pregnant women starting antiretroviral therapy - Corrected Proof

2011-12-26

Summary: Objectives: This retrospective cohort study evaluated the risk of hepatotoxicity in HIV-1 positive pregnant and non-pregnant women starting combined ART.Methods: Data were used from the ATHENA observational cohort. The study population consisted of HIV-1 infected, therapy naïve, pregnant and non-pregnant women, followed between January 1997 and February 2008. Demographic, treatment and pregnancy related data were collected. Risk of hepatotoxicity was determined using univariate and multivariate logistic regression. Analyses were adjusted for age, region of origin, baseline HIV-RNA levels and CD4 cell counts, cART regimen and hepatitis B and C coinfection. ALT and AST values of more than 5 times ULN were considered as hepatotoxicity.Results: Four-hundred and twenty-five pregnant and 1121 non-pregnant women were included. Independent risk factors of hepatotoxicity in all women were the presence of detectable HCV RNA (OR 5.48, 95% CI 2.25–13.38, p<0.001) and NVP use (OR 2.63, 95% CI 1.54–4.55, p<0.001). Stratified for pregnancy, the adjusted risk of hepatotoxicity was significantly associated with HCV coinfection only during pregnancy (OR 23.53, 95% CI 4.69–118.01, p<0.001). NVP use is related to hepatotoxicity in pregnant (OR 5.26, 95% CI 1.61–16.67, p<0.005) as well as in non-pregnant women (OR 2.13, 95% CI 1.11–4.00, p=0.02).Conclusion: HCV coinfection and NVP use are associated with a higher risk of cART induced hepatotoxicity in pregnant women.

Predictors of travel-related hepatitis A and B among native adult Danes: A nationwide case-control study - Corrected Proof

2011-12-26

Summary: Objectives: To assess journey length and other predictors of travel-related acute hepatitis A (HAV) and B (HBV) virus infection among native Danes and determine the sensitivity and specificity of current pre-travel vaccination guidelines.Methods: A nationwide case-control study was perfomed involving 60 Danes with HAV and 14 with HBV who acquired hepatitis in non-western countries from 2000 to 2010. Non-immune travellers from a nationwide survey (1188 HAV and 1709 HBV) served as controls.Results: The odds ratios (ORs) for HAV and HBV increased with increasing journey length (p<0.0001). However, 90% of HAV and 62% of HBV cases travelled for less than 4 weeks, and the daily infection rate did not increase with journey length; rather, for HAV it decreased. Increasing age (p<0.0001) and journeys to Africa (OR 6.1 (3.2–11)) raised the risk of acute HAV. Travelling alone or with friends as compared to travelling with a partner/family (OR: 15 (3.2–134)) strongly predicted HBV risk. Danish vaccination guidelines had HAV/HBV sensitivities of 86%/31%, and specificities of 27%/95%, respectively. Incidence rates were 12.8 (HAV) and 10.2 (HBV) per 100,000 non-immune travel months, and acute disease severity affected HAV and HBV cases equally.Conclusions: These results may support revision of current pre-travel vaccination guidelines.

Chronic Q fever: Review of the literature and a proposal of new diagnostic criteria - Corrected Proof

2011-12-26

Summary: A review was performed to determine clinical aspects and diagnostic tools for chronic Q fever. We present a Dutch guideline based on literature and clinical experience with chronic Q fever patients in The Netherlands so far. In this guideline diagnosis is categorized as proven, possible or probable chronic infection based on serology, PCR, clinical symptoms, risk factors and diagnostic imaging.

Actinobaculum schaalii: Review of an emerging uropathogen - Corrected Proof

Vincent Cattoir — 2011-12-23

Summary: Actinobaculum schaalii is a facultative anaerobic, Gram-positive rod-shaped species phylogenetically related to Actinomyces that is likely part of the commensal flora of the human genitourinary tract. Because of its fastidious growth under aerobic conditions and its resemblance to bacteria of the resident flora, A. schaalii is frequently overlooked or considered as a contaminant. It is also difficult to identify phenotypically, still requiring molecular identification. Note that the recent technology of matrix-assisted laser desorption/ionisation time-of-flight-mass spectrometry could be a promising tool for its identification. Recent studies using sensitive PCR assays showed that its clinical significance was largely underestimated. Since its first description in 1997, A. schaalii has been responsible for numerous urinary tract infections (UTIs), mainly in elderly (usually >60 years) and patients with underlying urological conditions. Infected urines usually show many Gram-positive rods with significant leukocyturia and a negative test for nitrites. Numerous cases of severe infections have also been described, such as urosepsis, bacteremia, cellulitis, spondylodiscitis, and endocarditis. In vitro, A. schaalii is highly susceptible to β-lactams but it is resistant to ciprofloxacin and cotrimoxazole, first-choice antimicrobials for the oral treatment of UTIs. A penicillin (e.g. amoxicillin) or a cephalosporin (e.g. cefuroxime, ceftriaxone) should be the preferred treatment.

Nosocomial bloodstream infections due to Acinetobacter baumannii, Acinetobacterpittii and Acinetobacternosocomialis in the United States - Corrected Proof

2011-12-22

Summary: Objectives: To compare the clinical features and antimicrobial susceptibilities of the clinically most important Acinetobacter species Acinetobacter baumannii, Acinetobacter pittii (formerly Acinetobacter genomic species 3) and Acinetobacter nosocomialis (formerly Acinetobacter genomic species 13TU).Methods: 295 Acinetobacter isolates collected prospectively from patients with bloodstream infections (BSI) in 52 US hospitals were identified to species level. Clinical and microbiological features were compared between species.Results: A. baumannii (63%) was the most prevalent species, followed by A. nosocomialis (21%), and A. pittii (8%). Intravascular catheters (15.3%) and the respiratory tract (12.9%) were the most frequent sources of BSI. A higher overall mortality was observed in patients with A. baumannii BSI than in patients with BSI caused by A. nosocomialis and A. pittii (36.9% vs. 16.4% and 13.0%, resp., p < 0.001). The most active antimicrobial agents as determined by broth microdilution were tigecycline (99.6% of isolates susceptible), colistin (99.3%), amikacin (98.5%), and imipenem (95.2%). 27 isolates (10.0%) were multi-drug resistant, all but one of these were A. baumannii.Conclusions: About one third of Acinetobacter BSI in our study were caused by A. nosocomialis or A. pittii. Patients with A. baumannii BSI had a less favorable outcome.

Apoptosis markers soluble Fas (sFas), Fas Ligand (FasL) and sFas/FasL ratio in patients with bacteremia: A prospective cohort study - Corrected Proof

2011-12-21

Summary: Background: Recent studies have shown that immunoparalysis and lymphocyte apoptosis play a critical role in severe bacteremia. Monitoring apoptosis on a routine basis in septic patients has proved challenging. We here studied the prognostic value of apoptosis markers human soluble Fas (sFas), Fas ligand (FasL) and sFas/FasL ratio in patients with bacteremia.Methods: sFas (ng/ml) and FasL (ng/ml) concentrations in plasma were determined using commercial quantitative enzyme immunoassays (Quantikine®, R&D Systems Inc., Minneapolis, MN, USA) in 132 patients with bacteremia caused by Staphylococcus aureus, Streptococcus pneumoniae, β-hemolytic streptococcae or Escherichia coli.Results: Maximum sFas, minimum FasL and high sFas/FasL ratio predicted high SOFA score in bacteremic patients (p < 0.001, p = 0.003 and p < 0.001, respectively). AUCROC`s in the prediction of high SOFA score for sFas, FasL and sFas/FasL ratio were 0.70 (CI 0.61–0.79), 0.65 (CI 0.56–0.75) and 0.72 (CI 0.63–0.80), respectively. High sFas concentrations and sFas/aFasL ratio, assessed using ROC curve as regards high SOFA (≥4) score, were associated with hypotension (p = 0.001 and p = 0.039, respectively). All of these markers predicted a high SOFA score independently in a logistic regression model. Maximum sFas, sFas/FasL ratio or minimum FasL during days 1–4 after blood culture were not associated with increased case fatality.Conclusions: Apoptosis markers sFas, FasL or sFas/FasL ratio are associated with high SOFA score in bacteremia.

Interferon-gamma release assay and Rifampicin therapy for household contacts of tuberculosis - Corrected Proof

2011-12-21

Summary: Objectives: Longitudinal studies in household contacts to identify subgroups at risk of active tuberculosis are lacking.Methods: Household contacts of pulmonary tuberculosis patients were prospectively enrolled to receive chest radiography, sputum studies, and T-SPOT.TB assay at initial visit. Repeat examinations every 6 months for 3 years, and 4-month rifampin preventive therapy for T-SPOT.TB-positive contacts were provided. We investigated factors predicting T-SPOT.TB-positivity and active pulmonary tuberculosis.Results: 583 contacts were enrolled with a follow-up duration of 20.7 ± 9.4 months. 176 (30.2%) were T-SPOT.TB-positive initially and 32 (18.2%) of them received preventive therapy. Old age, living in the same room/house with the index case, the index case having a high smear grade (3+ ∼ 4+) and pulmonary cavitation were associated with T-SPOT.TB-positivity. Active tuberculosis developed in 9 T-SPOT.TB-positive contacts; risk factors included T-SPOT.TB-positivity without preventive therapy, living in the same room, and the index case being ≤50 years or female. 108 (61.4%) T-SPOT.TB-positive contacts had repeat examinations. Forty-five had T-SPOT.TB reversion and none of them developed active tuberculosis.Conclusion: Household contacts who are T-SPOT.TB-positive and live in the same room as the index case are at risk of active tuberculosis and require preventive therapy and close follow-up.

Attitudes towards mandatory vaccination and vaccination coverage against vaccine-preventable diseases among health-care workers in tertiary-care hospitals - Corrected Proof

2011-12-16

Summary: Objective: To assess the attitudes about mandatory vaccination and vaccination coverage against vaccine-preventable diseases among health-care workers (HCWs) working in tertiary-care hospitals in Greece.Methods: A questionnaire was distributed to HCWs working in four tertiary-care hospitals.Results: In total, 505 HCWs participated in the survey. Self-reported completed vaccination rates were 18.8% against measles, 18.8% against mumps, 22.2% against rubella, 1.9% against varicella, 3.6% against hepatitis A, 56.5% against hepatitis B, and 35.7% against tetanus-diphtheria. Younger age groups had higher completed vaccination rates against measles, mumps, rubella, varicella, and hepatitis B compared with older HCWs (p-value < 0.001). Self-reported susceptibility rates were 12.7% for measles, 18.9% for mumps, 15.8% for rubella, 15.2% for varicella, 89.9% for hepatitis A, 34.2% for hepatitis B, and 64.3% for tetanus-diphtheria. Sixty three percent of 451 HCWs who answered this question supported mandatory vaccinations for HCWs, with significant differences per target disease. Physicians more frequently supported a mandatory vaccination policy compared to nurses and other professions (72.1% versus 61.9% and 54.2%, respectively; p-value = 0.028).Conclusions: Approximately two thirds of HCWs working in tertiary-care hospitals in Greece support mandatory vaccinations for HCWs, however suboptimal vaccination rates against vaccine-preventable diseases were recorded.

Multidrug-resistant gram-negative bacterial infections after liver transplantation – Spectrum and risk factors - Corrected Proof

2011-12-16

Summary: Objectives: Gram-negative bacilli infections, especially multidrug-resistant gram-negative bacilli infections, are the leading cause of high mortality after liver transplantation. This study sought to investigate the type of infection, infection rate, pathogenic spectrum, antibiotic-resistance profile, risk factors, and epidemiology of multidrug-resistant gram-negative bacterial infection.Methods: A retrospective cohort study was conducted and data of 217 liver transplant patients receiving cadaveric livers between January 2007 and April 2010 were analyzed. Antibiotic susceptibility was determined by minimum inhibitory concentration test. Extended-spectrum and metallo-β-lactamase assays were used to analyze β-lactamase-produced isolates, and repetitive-sequence polymerase chain reaction was used to differentiate bacterium subspecies.Results: Sixty-seven isolates of multidrug-resistant gram-negative bacteria were isolated from 66 infected liver transplant patients. Stenotrophomonas maltophilia (100%, 8/8), Klebsiella pneumoniae (61.5%, 8/13), Enterobacter cloacae (75%, 3/4) and Escherichia coli (81.3%, 13/16) were the most common extended-spectrum β-lactamase-producing bacilli. Metallo-β-lactamase expressing isolates were identified as S. maltophilia (100%, 8/8), Pseudomonas aeruginosa (83.3%, 5/6), Acinetobacter baumannii (95%, 19/20). Significant independent risk factors for multidrug-resistant gram-negative infection were extended use of pre-transplant broad-spectrum antibiotics (OR 9.027, P=0.001) and prolonged (≧72h) endotracheal intubation (OR 3.537, P=0.033).Conclusions: To reduce the risk of acquiring MDR gram-negative bacillus infections after liver transplant, control measures are required to limit the use of prophylactic antibiotic in preventing infection during liver transplant and to shorten endotracheal intubation time.

Clarithromycin has limited effects in non-elderly, non-severe patients with seasonal influenza virus A infection - Corrected Proof

2011-12-12

We read with interest the paper by Viasus and colleagues concerning the role of immunomodulatory therapies (corticosteroids, macrolides and statins) in severe cases with pandemic influenza A (H1N1) 2009. They concluded that these therapies used upon hospital admission did not prevent the development of severe disease in adults complicated by pneumonia. However, no study has determined the clinical role of immunomodulatory medicine in mild cases of influenza, including during pandemic influenza A 2009 virus infection.

Varicella zoster mimicking infectious tenosynovitis - Corrected Proof

Isaac I. Bogoch, Gregory K. Robbins — 2011-12-09

A 37-year male presented to the Emergency Department with five days of worsening right hand pain followed by three small, non-painful crusted lesions appearing on the volar aspect of his right wrist two days prior to admission. There was no associated fever, rash elsewhere, or other focal or constitutional symptoms. He denied any trauma, punctures, or bites to the area, and denied any sick contacts or travel exposures. He worked as a convenience store custodian. His exam was notable for Kanavel’s four cardinal signs of tenosynovitis including resting flexion of the affected digits, pain with passive extension, tenderness along the course of the tendon, and symmetric edema of the finger (). Three crusted lesions on an erythematous base, each 0.5 × 0.5 cm, were present on the volar aspect of his wrist. A hand X-ray did not demonstrate any abnormalities. The initial differential diagnosis included disseminated gonococcal infection, Staphylocccoal or Streptococcal infection which may have been introduced via an unnoticed inoculation or trauma, and non-infectious etiologies such as arthropod bites or inflammatory conditions like psoriatic arthritis presenting with “sausage digit”. He was empirically treated with vancomycin and ceftriaxone in the Emergency Department (ED). Interestingly, the direct fluorescent antigen test (DFA) was positive for varicella zoster virus (VZV). His antibiotics were discontinued prior to leaving the ED, and he was treated with valacyclovir 1 g PO TID for 7 days. At a one-week follow up appointment he noted absent pain and tenderness, and had a full range of motion of all digits.

Chronic Hepatitis E as a cause for cryptogenic cirrhosis in HIV - Corrected Proof

2011-12-07

Summary: Chronic Hepatitis E infection (HEV) is reported in immunocompromised patients. A 45-year-old HIV-infected man had no cause found for a persistent transaminitis which predated commencement of antiretroviral therapy. Hepatic elastography and liver biopsy revealed cirrhosis. In 2010, he tested positive for HEV IgM/IgG antibodies. Plasma HEV RNA was detected. Archived samples revealed HEV viraemia since 2000. A 24-week course of pegylated interferon was commenced and HEV RNA became undetectable at week 4 until week 27 post treatment cessation. Chronic HEV infection should be considered in HIV patients as a cause for unexplained transaminitis and cryptogenic liver cirrhosis.

First isolation of Tropheryma whipplei from bronchoalveolar fluid and clinical implications - Corrected Proof

2011-12-06

Summary: A patient presented diffuse pulmonary parenchymal micronodules. Tropheryma whipplei was detected in the saliva, a bronchial biopsy and bronchoalveolar fluid. PAS staining, immunohistochemistry and PCR for T. whipplei were negative in the duodenal biopsies. T. whipplei was isolated from the bronchoalveolar fluid, reinforcing its role as a respiratory pathogen.

Impact of fluoroquinolone consumption on resistance of healthcare-associated Pseudomonas aeruginosa - Corrected Proof

Wei-Lun Liu, Ping-Chin Chang, Yun-Ying Chen, Chih-Cheng Lai — 2011-12-05

Recently, Hsueh et al. reported that the treatment of complicate urinary tract infections (UTI) is a great challenge for physicians in Asia-Pacific region due to the increasing antimicrobial resistance. For example, nearly half of Escherichia coli isolates causing UTI were not susceptible to levofloxacin or ciprofloxacin in this region. In fact, the incidence of healthcare-associated infection (HCAI) caused by multidrug-resistant gram-negative bacteria, including Pseudomonas aeruginosa has gradually increased in acute hospital settings globally. Further, multidrug-resistant microorganisms related human infection would extend hospital stay and cause higher mortality. P. aeruginosa has been recognized as a major pathogen causing HCAI, especially for ventilator-associated pneumonia. However, P. aeruginosa can acquire antibiotic resistance during therapy in addition to the intrinsic resistance to lots of antibiotic. Therefore, antibiotic resistances among P. aeruginosa become a major concern while managing its associated infections. In one surveillance study of 2394 clinical isolates of P. aeruginosa in the United States, the antibiotic susceptible rate was 82% for imipenem, 80% for ceftazidime, 68% for ciprofloxacin, and 67% for levofloxacin, respectively.

High rate of Staphylococcus aureus oropharyngeal colonization in children - Corrected Proof

2011-12-05

We read with interest the article “Staphylococcus aureus bacteraemia – Nationwide assessment of treatment adequacy and outcome”, by Asgeirsson et al. We would like to discuss some aspects of S. aureus colonization since colonization can be a predisposing factor to bacteremia.

Dengue virus nonstructural protein NS1 binds to prothrombin/thrombin and inhibits prothrombin activation - Corrected Proof

2011-11-28

Summary: Objectives: Dengue virus (DENV) infection may result in severe dengue hemorrhage fever (DHF). However the mechanisms to cause hemorrhage during DENV infection are not fully understood. The sera level of secreted DENV nonstructural protein 1 (NS1) is correlated with the development of DHF. However, whether secreted NS1 can interfere with coagulation and contribute to the hemorrhage in DHF is unknown. Since thrombin plays a very important role in the activation of coagulation, we investigated whether NS1 can bind to thrombin and affect its formation or activity.Methods and results: We first demonstrated that NS1 could bind to thrombin and formed NS1/thrombin complex in dengue patients’ sera by enzyme-linked immunosorbent assay (ELISA). The ability of NS1 binding to prothrombin or thrombin was further confirmed using recombinant NS1 (rNS1) by ELISA, co-immunoprecipitation, and rNS1-affinity column purification. Even though the binding of rNS1 to thrombin showed no effect on thrombin activity, rNS1 could inhibit prothrombin activation and prolong activated partial thromboplastin time (APTT) of human platelet poor plasma.Conclusion: These results suggest secreted DENV NS1 may bind to prothrombin and inhibit it activation, which in turn, may contribute to the APTT prolongation and hemorrhage in DHF patients.

Lung and pharyngeal abscess caused by enterotoxin G- and I-producing Staphylococcus aureus - Corrected Proof

S.Y. Barnett, K.L. Hattotuwa, L. Teare — 2011-11-24

Summary: We report a particularly serious case of extensive meticillin sensitive Staphylococcal lung and pharyngeal abscess. Our patient had no significant risk factors for severe infection. The detection of enterotoxin G and I here suggest that when present together, these toxins work synergistically to produce a more virulent strain of Staphylococcus aureus.

Campylobacter fetus bacteremia in a young healthy adult transmitted by khat chewing - Corrected Proof

Carlos Martínez-Balzano, Patrick J. Kohlitz, Preeti Chaudhary, Housam Hegazy — 2011-11-24

Summary: Campylobacter fetus is a pathogen affecting almost exclusively patients with immunosuppression and chronic debilitating diseases. We report the case of a healthy young man with C. fetus bacteremia presenting with fever, hypotension and meningitis. The patient had no exposure to contaminated sources except from khat chewing, which we describe as a possible source of transmission for the first time.

Late hepatitis B virus reactivation after lamivudine prophylaxis interruption in an anti-HBs-positive and anti-HBc-negative patient treated with rituximab-containing therapy - Corrected Proof

2011-11-24

Summary: We describe a case of an anti-HBs-positive patient who experienced hepatitis B reactivation 18 months after the discontinuation of rituximab and after 12 months of lamivudine prophylaxis. The patient carried a hepatitis B genotype D virus harbouring a single immune escape mutation, sT118K. No consensus guidelines regarding the optimal length of treatment or the best elective drug have been defined for antiviral prophylaxis for HBsAg-negative, anti-HBc- and/or anti-HBs-positive patients undergoing immunosuppressive treatment.Screening based on HBV serological markers and HBV DNA testing is a critical issue to recognise hepatitis B reactivation as early as possible. Furthermore, it is of outstanding importance to identify alternative markers (e.g. cccDNA, HBV core related antigen, etc.), that could be predictive of HBV reactivation.

National guideline for the management of suspected viral encephalitis in children - Uncorrected Proof

2011-11-21

Summary: In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines.In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.

National guideline for the management of suspected viral encephalitis in adults - Uncorrected Proof

2011-11-21

Acute appendicitis, a rare complication of varicella: A report of three cases - Corrected Proof

2011-10-28

Summary: Acute appendicitis is a very rare complication of varicella, and is rarely reported in studies of complications of varicella or appendicitis. This report describes three cases of acute appendicitis in the course of varicella, diagnosed in Clinical Department of Infectious Diseases at Split University Hospital, Croatia between 1998 and 2010. Varicella was diagnosed clinically, and in two cases confirmed by positive serological tests for varicella-zoster virus (VZV). In addition to routine histopathological examination, testing for viral antigens or DNA in the appendix, omentum and peripheral blood by genetic and immunohistochemistry methods may be important to confirm whether VZV and appendicitis are etiopathogenetically connected.

Achromobacter xylosoxidans mesh related infection: A case of delayed diagnosis and management - Corrected Proof

Vishal Gupta, Suhas Nirkhiwale, Parul Gupta, Satish Phatak — 2011-09-23

Summary: We present the first case of mesh related infection caused by Achromobacter xylosoxidans after ventral hernia repair. After repair of a small paraumbilical hernia, the postoperative course was complicated by persistent discharging sinuses despite the removal of underlying polypropylene mesh. Removal of an intrabdominal omental inflammatory mass containing pus that showed growth of A. xylosoxidans led to the resolution of all the symptoms.