Archive for January 2, 2006

ARTICLE – Changes in Invasive Pneumococcal Disease among HIV-Infected Adults Living in the Era of Childhood Pneumococcal Immunization

Source: Ann Inter Med 3 Jan 2006 Vol.144 N.1 p.1-9

Brendan Flannery, PhD; Richard T. Heffernan, MPH; Lee H. Harrison, MD; Susan M. Ray, MD; Arthur L. Reingold, MD; James Hadler, MD, MPH; William Schaffner, MD; Ruth Lynfield, MD; Ann R. Thomas, MD, MPH; Jianmin Li, DPE; Michael Campsmith, DDS, MPH; Cynthia G. Whitney, MD, MPH; and Anne Schuchat, MD

Background: Adults infected with HIV have high rates of invasive pneumococcal disease. Introduction of pneumococcal conjugate vaccine for children could affect disease among HIV-infected adults.

Objective: To compare invasive pneumococcal disease among HIV-infected adults before and after the introduction of a pediatric conjugate vaccine.

Design: Active laboratory-based surveillance in an adult population of 10.8 million, including 38 314 living with AIDS.

Setting: 7 Active Bacterial Core surveillance areas in the United States.

Patients: All surveillance-area residents 18 to 64 years of age with Streptococcus pneumoniae isolated from a sterile site between 1998 and 2003.

Measurements: Ratio of the number of cases of invasive pneumococcal disease among HIV-infected adults to the estimated number of adults 18 to 64 years of age living with AIDS; serotype-specific subset analyses; and comparison of periods before and after introduction of conjugate vaccine by using exact tests.

Results: Of 8582 cases of invasive pneumococcal disease in adults, 2013 (24%) occurred among persons infected with HIV. Between baseline (1998 to 1999) and 2003, the ratio of invasive pneumococcal disease in HIV-infected adults to the number of adults living with AIDS in the surveillance areas decreased from 1127 to 919 cases per 100 000 AIDS population, a reduction of 19% (P = 0.002). Among HIV-infected adults, the ratio for disease caused by pneumococcal serotypes included in the conjugate vaccine decreased 62% (P Limitations: Ratios are proxy measures of incidence rates. The denominator of surveillance-area residents living with HIV infection was not available.

Conclusions: Introduction of the pediatric conjugate vaccine was associated with an overall decrease in invasive pneumococcal disease among HIV-infected adults, despite increased disease caused by nonvaccine serotypes.
Editors’ Notes

Context

Routine pneumococcal conjugate vaccination for infants began in 2000. Its use markedly decreased invasive pneumococcal disease among children, but did it influence rates of disease among HIV-infected adults?

Contribution

Between 1998 and 2003, invasive pneumococcal disease among adults infected with HIV living in 7 surveillance areas in the United States decreased from 1127 to 919 cases per 100 000 adults with AIDS. Disease caused by serotypes in the vaccine decreased 62%, whereas disease caused by nonvaccine serotypes increased 44%.

Implications

Indirect evidence suggests that pediatric vaccine use is associated with a decreased incidence of pneumococcal disease among HIV-infected adults.

The Editors
Author and Article Information

From National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Connecticut Emerging Infections Program, Hartford, Connecticut; Maryland Emerging Infections Program and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Emory University School of Medicine and the Veterans Affairs Medical Center, Atlanta, Georgia; School of Public Health, University of California, Berkeley, California; Vanderbilt Medical Center, Nashville, Tennessee; Minnesota Emerging Infections Program, Minnesota Department of Health, Minneapolis, Minnesota; Oregon Emerging Infections Program, Department of Human Services, Portland, Oregon; and HIV Incidence and Case Surveillance Branch, Division of HIV/AIDS Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

Note: This paper was presented in part at the 4th International Symposium on Pneumococci and Pneumococcal Diseases, Helsinki, Finland, 9 to 13 May 2004 (abstract EPI-05), and at the 42nd Annual Meeting of the Infectious Diseases Society of America, Boston, Massachusetts, 30 September to 3 October 2004 (abstract 746).

Acknowledgments: The authors thank the study personnel from the following institutions: Centers for Disease Control and Prevention; the Active Bacterial Core surveillance sites; Minnesota Department of Health; and the University of Texas Health Science Center. They also thank the AIDS surveillance officers.

Grant Support: By the Emerging Infections Program of the Centers for Disease Control and Prevention.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Brendan Flannery, PhD, Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS C-23, Atlanta, GA 30333; e-mail, bflannery@cdc.gov.

Current Author Addresses: Drs. Flannery, Campsmith, Li, Whitney, and Schuchat: Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333.

Mr. Heffernan: Connecticut Emerging Infections Program, 410 Capital Avenue, Hartford, CT 06134.

Dr. Harrison: Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205.

Dr. Ray: Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303.

Dr. Reingold: University of California, Berkeley, 140 Warren, Berkeley, CA 94720-7360.

Dr. Hadler: Connecticut Department of Public Health, 410 Capital Avenue, MS 11 FDS, Hartford, CT 06134-0308.

Dr. Schaffner: Vanderbilt University Medical School, A-1124 MCN, Nashville, TN 37232.

Dr. Lynfield: Minnesota Department of Health, 717 Delaware Street SE, Minneapolis, MN 55414.

Dr. Thomas: Oregon Department of Human Services, 800 NE Oregon Street, Portland, OR 97212.

Author Contributions: Conception and design: B. Flannery, L.H. Harrison, A.L. Reingold, J. Hadler, A.R. Thomas, A. Schuchat.

Analysis and interpretation of the data: B. Flannery, R.T. Heffernan, A.L. Reingold, A.R. Thomas, J. Li, C.G. Whitney, A. Schuchat.

Drafting of the article: B. Flannery, A.L. Reingold, M. Campsmith.

Critical revision of the article for important intellectual content: L.H. Harrison, S.M. Ray, A.L. Reingold, J. Hadler, W. Schaffner, R. Lynfield, A.R. Thomas, J. Li, M. Campsmith, C.G. Whitney, A. Schuchat.

Final approval of the article: B. Flannery, L.H. Harrison, S.M. Ray, A.L. Reingold, J. Hadler, W. Schaffner, R. Lynfield, A.R. Thomas, J. Li, M. Campsmith, C.G. Whitney, A. Schuchat.

Provision of study materials or patients: J. Hadler, W. Schaffner, R. Lynfield.

Statistical expertise: J. Li.

Obtaining of funding: C.G. Whitney, A. Schuchat.

Administrative, technical, or logistic support: A.L. Reingold, W. Schaffner, R. Lynfield, C.G. Whitney.

Collection and assembly of data: R.T. Heffernan, S.M. Ray, J. Hadler, W. Schaffner, A.R. Thomas.

 

January 2, 2006 at 11:55 pm Leave a comment

Treatment of Infections Caused by Metronidazole-Resistant Trichomonas vaginalis

Source: Clinical Microbiology Reviews, Oct 2004 p.783-793 Vol.17 No.4

Sarah L. Cudmore, Kiera L. Delgaty, Shannon F. Hayward-McClelland, Dino P. Petrin, and Gary E. Garber*

Department of Biochemistry, Microbiology, and Immunology and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

Infections with the sexually transmitted protozoan Trichomonas vaginalis are usually treated with metronidazole, a 5-nitroimidazole drug derived from the antibiotic azomycin. Metronidazole treatment is generally efficient in eliminating T. vaginalis infection and has a low risk of serious side effects. However, studies have shown that at least 5% of clinical cases of trichomoniasis are caused by parasites resistant to the drug. The lack of approved alternative therapies for T. vaginalis treatment means that higher and sometimes toxic doses of metronidazole are the only option for patients with resistant disease. Clearly, studies of the treatment and prevention of refractory trichomoniasis are essential. This review describes the mechanisms of metronidazole resistance in T. vaginalis and provides a summary of trichomonicidal and vaccine candidate drugs.

* Corresponding author. Mailing address: Division of Infectious Diseases, Ottawa Hospital, General Campus, 501 Smyth Rd., Ottawa, ON, Canada K1H 8L6. Phone: (613) 737-8173. Fax: (613) 737-8099. E-mail: ggarber@ohri.ca.                                           
              

January 2, 2006 at 1:25 am Leave a comment

Trichomoniasis

Source: Clinical Microbiology Reviews, Oct 2004 p.794-803 Vol.17 No.4

Jane R. Schwebke1* and Donald Burgess2

Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama,1 Department of Protistology, American Type Culture Collection, Manassas, Virginia2

Trichomoniasis is perhaps the most common curable sexually transmitted disease worldwide, yet few resources are devoted to its control. It is associated with potentially serious complications such as preterm birth and human immunodeficiency virus acquisition and transmission. The immunology of a related organism, Tritrichomonas foetus, which causes disease in cattle, has been investigated to some extent, but more work is needed for the human strain, Trichomonas vaginalis. In addition, although trichomoniasis is easily treated with oral metronidazole, there is concern that the number of strains resistant to this antibiotic are increasing, and currently no alternative is licensed in the United States. As more is appreciated concerning the important public health implications of this common infection, more work will need to be done in understanding the diagnosis, treatment, and immunology of this organism.

* Corresponding author. Mailing address: Department of Medicine, Division of Infectious Diseases, 703 19th St. South, Zeigler Research Bldg. no. 239, Birmingham, AL 35294-0007. Phone: (205) 975-5665. Fax: (205) 975-7764. E-mail: Schwebke@uab.edu.                               

January 2, 2006 at 1:24 am Leave a comment

Aspergillus Infections in Transplant Recipients

Source: Clinical Microbiology Reviews, Jan 2005 p.44-69 Vol.18 No.1

Nina Singh* and David L. Paterson

University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Aspergillus infections are occurring with an increasing frequency in transplant recipients. Notable changes in the epidemiologic characteristics of this infection have occurred; these include a change in risk factors and later onset of infection. Management of invasive aspergillosis continues to be challenging, and the mortality rate, despite the use of newer antifungal agents, remains unacceptably high. Performing molecular studies to discern new targets for antifungal activity, identifying signaling pathways that may be amenable to immunologic interventions, assessing combination regimens of antifungal agents or combining antifungal agents with modulation of the host defense mechanisms, and devising diagnostic assays that can rapidly and reliably diagnose infections represent areas for future investigations that may lead to further improvement in outcomes.

* Corresponding author. Mailing address: VA Medical Center, Infectious Disease Section, University Dr. C, Pittsburgh, PA 15240. Phone: (412) 688-6179. Fax: (412) 688-6950. E-mail: nis5+@pitt.edu.

January 2, 2006 at 1:23 am Leave a comment

Combination Treatment of Invasive Fungal Infections

Source: Clinical Microbiology Reviews, Jan 2005 p.163-194 Vol.18 No.1

Pranab K. Mukherjee,1 Daniel J. Sheehan,2 Christopher A. Hitchcock,3 and Mahmoud A. Ghannoum1*

Center for Medical Mycology, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, Ohio,1 Pfizer Global Pharmaceuticals, Pfizer Inc., New York, New York,2 Exploratory Development, Pfizer Global Research & Development, Sandwich Laboratories, Sandwich, United Kingdom3

The persistence of high morbidity and mortality from systemic fungal infections despite the availability of novel antifungals points to the need for effective treatment strategies. Treatment of invasive fungal infections is often hampered by drug toxicity, tolerability, and specificity issues, and added complications often arise due to the lack of diagnostic tests and to treatment complexities. Combination therapy has been suggested as a possible approach to improve treatment outcome. In this article, we undertake a historical review of studies of combination therapy and also focus on recent studies involving newly approved antifungal agents. The limitations surrounding antifungal combinations include nonuniform interpretation criteria, inability to predict the likelihood of clinical success, strain variability, and variations in pharmacodynamic/pharmacokinetic properties of antifungals used in combination. The issue of antagonism between polyenes and azoles is beginning to be addressed, but data regarding other drug combinations are not adequate for us to draw definite conclusions. However, recent data have identified potentially useful combinations. Standardization of assay methods and adoption of common interpretive criteria are essential to avoid discrepancies between different in vitro studies. Larger clinical trials are needed to assess whether combination therapy improves survival and treatment outcome in the most seriously debilitated patients afflicted with life-threatening fungal infections.

* Corresponding author. Mailing address: Center for Medical Mycology, Department of Dermatology, Case Western Reserve University and University Hospitals of Cleveland, 11100 Euclid Ave., LKS-5028, Cleveland, OH 44106-5028. Phone: (216) 844-8580. Fax: (216) 844-1076. E-mail: mahmoud.ghannoum@case.edu.

January 2, 2006 at 1:22 am Leave a comment

Secondary Syphilitic Lesions

Source: Clinical Microbiology Reviews, Jan 2005 p.205-216 Vol.18 No.1
                                             
Robert E. Baughn1,2* and Daniel M. Musher2,3

Departments of Dermatology,1 Medicine,3 Baylor College of Medicine, and the Syphilis Research and Infectious Disease Laboratories, Veterans Affairs Medical Center, Houston, Texas2

An important theme that emerges from all early historical accounts is that in addition to the decreased virulence of Treponema pallidum, the incidence of secondary syphilis has decreased drastically over the past three centuries. Even in the early 20th century, most syphilologists were of the opinion that the disease had undergone changes in its manifestations and that they were dealing with an attenuated form of the spirochete. Such opinions were based primarily on the observations that violent cutaneous reactions and fatalities associated with the secondary stage had become extremely rare. The rate of primary and secondary syphilis in the United States increased in 2002 for the second consecutive year. After a decade-long decline that led to an all-time low in 2000, the recent trend is attributable, to a large extent, by a increase in reported syphilis cases among men, particularly homosexual and bisexual men having sex with men. The present review addresses the clinical and diagnostic criteria for the recognition of secondary syphilis, the clinical course and manifestations of the disease if allowed to proceed past the primary stage of disease in untreated individuals, and the treatment for this stage of the disease.

* Corresponding author. Mailing address: Syphilis Research Laboratory, Bldg. 109, Room 234A, VA Medical Center, 2002 Holcombe Blvd., Houston, TX 77030. Phone: (713) 791-1414 ext. 5876. Fax: (713) 794-7957. E-mail: rbaughn@bcm.tmc.edu.

January 2, 2006 at 1:20 am Leave a comment

Diagnosis and Management of Pediatric Urinary Tract Infections

Source: Clinical Microbiology Reviews, Apr 2005 p.417-422 Vol.18 No.2

Joseph J. Zorc,1* Darcie A. Kiddoo,2 and Kathy N. Shaw1

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania School of Medicine,1 Department of Urology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania2

Urinary tract infection (UTI) is among the most commonly diagnosed bacterial infections of childhood. Although frequently encountered and well researched, diagnosis and management of UTI continue to be a controversial issue with many challenges for the clinician. Prevalence studies have shown that UTI may often be missed on history and physical examination, and the decision to screen for UTI must balance the risk for missed infections with the cost and inconvenience of testing. Interpretation of rapid diagnostic tests and culture is complicated by issues of contamination, false test results, and asymptomatic colonization of the urinary tract with nonpathogenic bacteria. The appropriate treatment of UTI has been controversial and has become more complex with the emergence of resistance to commonly used antibiotics. Finally, the anatomic evaluation and long-term management of a child after a UTI have been based on limited evidence, and newer studies question some of the tenets of prior recommendations. The goal of this review is to provide an up-to-date summary of the literature with particular attention to practical questions about diagnosis and management for the clinician.

* Corresponding author. Mailing address: Division of Emergency Medicine, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399. Phone: (215) 590-1944. Fax: (215) 590-4454. E-mail: zorc@email.chop.edu.

January 2, 2006 at 1:19 am Leave a comment

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