Archive for December 8, 2005

AGING AND INFECTIOUS DISEASES INVITED ARTICLE – Surgical Site Infection in the Elderly Population

Source: Clinical Infectious Diseases 2004;39:1835-1841

Kevin P. High, Section Editor

Keith S. Kaye,1,3 Kenneth E. Schmader,1,2,3 and Robert Sawyer4

1Division of Infectious Diseases, 2Division of Geriatrics, Department of Medicine, and 3Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina; and 4Department of Surgery, University of Virginia Health System, Charlottesville, Virginia

Surgical site infections (SSIs) account for 11% of nosocomial infections among older patients. This report reviews the available data and presents medical and surgical perspectives on the epidemiology, outcomes, and prevention of SSI in the elderly population. The risk for SSI does not seem to increase after the age of 65 years. Several risk factors for SSI are similar among elderly patients and younger patients, but financial factors and factors related to health services may differ between the groups. The clinical presentation of infection and the pathogens that cause infection are similar among elderly patients and younger patients. However, the mortality rate, the duration of hospitalization, and the costs associated with hospital care are greater for elderly patients with SSI than for younger patients with SSI. Several modalities for SSI prevention have been well studied in the general surgical population but have not been specifically evaluated in the elderly surgical population. Insights and opinions pertaining to modalities for SSI prevention in the elderly population and areas of import for future research are discussed.
 

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December 8, 2005 at 10:03 pm Leave a comment

MAJOR ARTICLE – A Randomized, Double-Blind Study to Assess the Optimal Duration of Doxycycline Treatment for Human Brucellosis

Source: Clinical Infectious Diseases 2004;39:1776-1782

Javier Solera,1 Paloma Geijo,3 Jose Largo,4 Manuel Rodriguez-Zapata,6 Julio Gijón,7 Elisa Martinez-Alfaro,1 Elena Navarro,2 and Miguel Angel Macia5, for the Grupo de Estudio de Castillala Mancha de Enfermedades Infecciosas (GECMEI)a 1Servicio de Medicina Interna and 2Unidad de Investigación, Hospital General Universitario, Albacete, 3Unit of Infectious Diseases, Hospital Virgen de la Luz, Cuenca, 4Servicio de Medicina Interna, Hospital Virgen de la Salud, and 5Servicio de Epidemiologia Consejeria de Sanidad, Junta de Castilla La Mancha, Toledo, 6Servicio de Medicina Interna, Hospital General Universitario, Guadalajara, and 7Servicio de Medicina Interna, Complejo Hospitalario, Ciudad Real, Spain

Background. Human brucellosis is usually treated with a combination of tetracyclines and aminoglycosides. However, the optimal duration of therapy has not been clearly determined.

Methods. We conducted a prospective, double-blind, randomized, multicenter study comparing treatment with doxycycline (100 mg po b.i.d.) for 30 days (30-day group) with the same dosage of doxycycline for 45 days (45-day group) in patients with brucellosis without endocarditis, spondylitis, or neurobrucellosis. All patients were treated with gentamicin (240 mg im once daily) for the first 7 days. Therapeutic outcome was evaluated by measuring relapse rates and drug safety.

Results. Seventy-three patients were included in each group. During the first 45 days after treatment, the percentage of patients with relapse was significantly higher in the 30-day group than in the 45-day group (12.3% vs. 1.37%; relative risk, 9.00; 95% confidence interval [CI], 1.1769.2; P = .017). Between day 45 after treatment and 12 months after treatment, no further significant differences were found in relapse rates between groups (9.38% in the 30-day group vs. 11.11% in the 45-day group; relative risk, 0.84; 95% CI, 0.312.30; P = .78). Overall, relapses occurred in 15 (20.55%) of 73 patients in the 30-day group and in 9 (12.33%) of 73 patients in the 45-day group (relative risk, 1.67; 95% CI, 0.783.56; P = .264). Compliance and adverse effects were comparable in the 2 groups.

Conclusions. Doxycycline treatment for 45 days significantly decreased early relapse rates among adults with brucellosis without increasing adverse effects.

a Members of the study group are listed at the end of the text.

 

December 8, 2005 at 9:58 pm Leave a comment

Is there evidence for an increase in the death rate from liver-related disease in patients with HIV?.

Source: AIDS. 19(18):2117-2125, December 2, 2005.

Mocroft, Amanda a; Soriano, Vincent b; Rockstroh, Jurgen c; Reiss, Peter d; Kirk, Ole e; de Wit, Stephane f; Gatell, Jose g; Clotet, Bonaventura h; Phillips, Andrew N a; Lundgren, Jens D e; for the EuroSIDA Study Group *

Abstract:

Background: Increases in deaths due to liver-related disease (LRD) among HIV-infected individuals have been reported although the influence of combination antiretroviral therapy (cART) on LRD is controversial.

Aims: To determine changes over time in the death rate from LRD and if longer exposure to cART was associated with an increased death rate from LRD in 10 937 patients from EuroSIDA, an observational longitudinal cohort study.

Results: A total of 184 (1.7%) died from LRD during 52 236 person-years of follow-up (PYFU). The death rate from LRD declined from 6.9 per 1000 PYFU before 1995 [95% confidence interval (CI), 3.9-9.9] to 2.6 at/after 2004 (95% CI, 1.6-4.0). When the current CD4 cell count and other factors were taken into account, there was a 13% increase in the death rate from LRD per year (95% CI, 5-20%, P = 0.0008). In patients who had started cART, there was a 12% increase in the death rate from LRD per additional year exposure to cART (95% CI, 4-20%, P = 0.022) after adjustment for current CD4 cell count and other factors.

Conclusions: Death rates from LRD appeared to decrease across Europe. However after adjustment for the current CD4 cell count, and therefore increases in CD4 cell counts in patients taking cART, there was a significant increase over time in death rates from LRD. In patients with similar CD4 cell counts, longer exposure to cART was associated with an increased death rate from LRD. This may be due to direct liver toxicity of antiretrovirals, progression of liver disease due to hepatitis B virus or hepatitis C virus over time as patients survive longer, or some other factor.

 

December 8, 2005 at 9:56 pm Leave a comment

Immune reconstitution inflammatory syndrome in HIV-infected patients with disseminated histoplasmosis

Source: AIDS. 20(1):119-121, January 2, 2006.

Breton, Guillaume a; Adle-Biassette, Homa b; Therby, Audrey c; Ramanoelina, Jacky d; Choudat, Laurence e; Bissuel, Francois f; Huerre, Michel g; Dromer, Francoise h; Dupont, Bertrand c; Lortholary, Olivier c,h

Abstract:

Four HIV-1-infected patients presented with unusual clinical manifestations in the course of disseminated histoplasmosis, including liver abscesses, compressive lymphadenitis, intestinal obstruction, uveitis and arthritis within a median of 45 days after initiation of highly active antiretroviral therapy (HAART). They had a median increase of 106 CD4 cells/[mu]l and granulomas with caseation in three. Partial immune reconstitution induced by HAART during disseminated histoplasmosis either related to the variety capsulatum or duboisii may be associated with immune reconstitution inflammatory syndrome.

December 8, 2005 at 9:53 pm Leave a comment

Increased risk of pre-eclampsia and fetal death in HIV-infectedpregnant women receiving highly active antiretroviral therapy.

Source: AIDS. 20(1):59-66, January 2, 2006.

Suy, Anna a; Martinez, Esteban b; Coll, Oriol a; Lonca, Montserrat b; Palacio, Montserrat a; de Lazzari, Elisa b; Larrousse, Maria b; Milinkovic, Ana b; Hernandez, Sandra a; Blanco, Jose L b; Mallolas, Josep b; Leon, Agathe b; Vanrell, Juan A a; Gatell, Jose M b,*

Abstract:

Background: Pre-eclampsia and/or fetal death have increased sharply in HIV-infected pregnant women receiving HAART.

Methods: The occurrence of pre-eclampsia or fetal death was analysed in women who delivered after at least 22 weeks of gestation for all women (January 2001 until July 2003) and for HIV-infected women (November 1985 until July 2003).

Results: In 2001, 2002 and 2003, the rates per 1000 deliveries of pre-eclampsia and fetal death, respectively, remained stable in all pregnant women at 25.4, 31.9 and 27.7 (P = 0.48) and 4.8, 5.8, and 5.0 (P = 0.89) (n = 8768). In 1985-2000 (n = 390) to 2001-2003 (n = 82), rates per 1000 deliveries in HIV-infected women rose from 0.0 to 109.8 (P Conclusions: HIV infection treated with HAART prior to pregnancy was associated with a significantly higher risk for pre-eclampsia and fetal death.

 

December 8, 2005 at 9:52 pm Leave a comment

Survival and prognostic factors of HIV-infected patients with HCV-related end-stage liver disease.

Source: AIDS. 20(1):49-57, January 2, 2006.

Merchante, Nicolas a; Giron-Gonzalez, Jose A b; Gonzalez-Serrano, Mercedes c; Torre-Cisneros, Julian d; Garcia-Garcia, Jose A a; Arizcorreta, Ana b; Ruiz-Morales, Josefa c; Cano-Lliteras, Pilar d; Lozano, Fernando a; Martinez-Sierra, Carmen b; Macias, Juan a; Pineda, Juan A a; for the Grupo Andaluz para el Estudio de las Enfermedades Infecciosas (GAEI)

Abstract:

Objective: To find the survival and the predictors of death of HIV-infected patients with hepatitis C virus (HCV)-related end-stage liver disease (ESLD).

Design and methods: A prospective cohort study set in the infectious diseases units of four tertiary care public hospitals in Andalucia, Spain. From a multicentric cohort of 2664 HIV/HCV-co-infected patients, all consecutive patients with HCV-related cirrhosis who presented with the first hepatic decompensation from January 1997 to June 2004 were followed-up and 153 patients were included. The survival and the demographic, HIV-related and liver-related factors associated with death were evaluated.

Results: Ninety-five (62%) patients died during the follow-up. In 79 (85%) individuals, the cause of death was liver related. The median survival time was 13 months. Independent predictors of survival were Child score [hazard ratio (HR), 1.2; 95% confidence interval (CI), 1.08-1.37; P = 0.001], CD4+ cell count at decompensation lower than 100 cells/[mu]l (HR, 2.48; 95% CI, 1.52-4.06; P Conclusions: The survival of HIV/HCV-co-infected patients with ESLD is extremely poor. Immunosuppression and markers of severe liver disease predict liver-related mortality in these patients. HAART seems to be associated with a reduced liver-related mortality.

 

December 8, 2005 at 9:50 pm Leave a comment

Redefining Lipodystrophy Syndrome: Risks and Impact on Clinical Decision Making.

Source: JAIDS Journal of Acquired Immune Deficiency Syndromes. 39(4):395-400, August 1, 2005.

Lichtenstein, Kenneth A MD

Abstract:

Summary: Lipodystrophy syndrome comprises several conditions (lipoatrophy; lipohypertrophy; mixed syndrome, often associated with dyslipidemia; and insulin resistance). These conditions, though sometimes occurring together, may occur independently, suggesting a complex, multifactorial cause. To elucidate the relative contribution of risk factors of drug, disease, and host to fat redistribution, large epidemiologic studies using multivariate analysis were reviewed. In studies assessing lipoatrophy, the most common statistically significant risk factors were use of specific nucleoside analogues, increasing age, presence of markers of disease severity (CD4/HIV RNA), duration of therapy, and white race. In studies assessing lipohypertrophy, the most common statistically significant risk factors were duration of therapy, markers of disease severity, and protease inhibitor use. The pathogenesis of these disorders is complex, but recent hypotheses and evidence suggest that impairment to adipocyte differentiation, impairment of adipokine regulation, unopposed production of proinflammatory cytokines, dysregulation of 11-[beta]-hydroxysteroid dehydrogenase, and mitochondrial toxicity may play a role.

December 8, 2005 at 6:05 pm Leave a comment

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