Archive for August 26, 2008

Opt-Out Testing for Human Immunodeficiency Virus in the United States: Progress and Challenges

JAMA  August 27, 2008  V.300  N.8  p.945-951

Special Communications

John G. Bartlett; Bernard M. Branson; Kevin Fenton; Benjamin C. Hauschild; Veronica Miller; Kenneth H. Mayer

Johns Hopkins University, School of Medicine, Baltimore, Maryland (Dr Bartlett); Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Branson and Fenton); Forum for Collaborative HIV Research and George Washington University, Washington, DC (Mr Hauschild and Dr Miller); and Department of Medicine, Brown University, and Miriam Hospital, Providence, Rhode Island (Dr Mayer).

The Centers for Disease Control and Prevention (CDC) has recommended human immunodeficiency virus (HIV) testing for all persons aged 13 to 64 years in all health care settings. Signed consent would not be required and counseling with referral would be managed as it is for other serious conditions. The goal of the recommendations is to promote earlier entry into care to reduce unnecessary mortality and facilitate prevention by behavioral changes that accompany knowledge of serostatus. Concerns about the change include laws in some states that mandate signed consent and counseling, a perception that counseling is an effective prevention strategy, variability in payment coverage for the test, concerns about the stigma and discrimination that may accompany the HIV diagnosis, and the possibility that other testing policies would be more effective. Eleven of 16 states have changed legislation to reduce barriers to testing, 35 of 74 national professional societies have endorsed the new recommendations, and multiple demonstration projects have shown feasibility. Metrics to evaluate the health outcomes of the CDC’s recommendations for HIV testing have been defined, but the data necessary to determine the effects on early entry into care, the actual reduction in disease incidence, and the unanticipated consequences are not yet available.


August 26, 2008 at 11:49 pm Leave a comment

Delay of Active Antimicrobial Therapy and Mortality among Patients with Bacteremia: Impact of Severe Neutropenia

Antimicrobial Agents and Chemotherapy  1 Sept 2008  V.52  N.9  p.3188-3194

Michael Y. Lin,1,2* Robert A. Weinstein,1,2 and Bala Hota1,2

Section of Infectious Diseases, Rush University Medical Center, Chicago, Illinois,1 Division of Infectious Diseases, John H. Stroger, Jr. (Cook County) Hospital, Chicago, Illinois2

Increasing bacterial antimicrobial resistance has prompted physicians to choose broad-spectrum antimicrobials in order to reduce the likelihood of inactive empirical therapy. However, for bacteremic patients already receiving supportive care, it is unclear whether delay of active antimicrobial therapy significantly impacts patient outcomes. We performed a retrospective cohort study of patients with monomicrobial bloodstream infections at a large urban hospital in the United States from 2001 to 2006. We assessed the impact of delay of active antimicrobial therapy on mortality by using multivariable logistic regression modeling with and without propensity score methodology. We evaluated 1,523 episodes of monomicrobial bacterial bloodstream infections at our institution. Nine hundred eighty-three bacteremic episodes (64.5%) were treated with an active antimicrobial agent within 24 h of the index blood culture; the remaining 540 episodes (35.5%) were considered to have delay of active antimicrobial therapy. In adjusted analysis, among patients in the non-intensive-care-unit setting with an absolute neutrophil count (ANC) of <100 cells/µl, delay was associated with increased mortality (odds ratio [OR], 18.0; 95% confidence interval [CI], 2.84 to 114.5; P < 0.01); among intensive-care-unit patients with an ANC of <100 cells/µl, the effect of delay on mortality was nearly significant (OR, 5.56; 95% CI, 0.85 to 36.3; P = 0.07). However, for patients who were nonneutropenic (ANC, >500 cells/µl) or had ANCs of 100 to 500 cells/µl, delay was not associated with increased mortality. While the delay of active antimicrobial therapy was not significantly associated with higher mortality for most patients in this cohort, patients with severe neutropenia appeared to be vulnerable.


August 26, 2008 at 11:46 pm Leave a comment

Bloodstream Infections Caused by Extended-Spectrum-β-Lactamase- Producing Escherichia coli: Risk Factors for Inadequate Initial Antimicrobial Therapy

Antimicrobial Agents and Chemotherapy  1 Sept 2008  V.52  N.9  p.3244-3252

Mario Tumbarello,1* Michela Sali,2 Enrico Maria Trecarichi,1 Fiammetta Leone,2 Marianna Rossi,1 Barbara Fiori,2 Gennaro De Pascale,1 Tiziana D’Inzeo,2 Maurizio Sanguinetti,2 Giovanni Fadda,2 Roberto Cauda,1 and Teresa Spanu2

Institute of Infectious Diseases,1 Institute of Microbiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy2

Extended-spectrum-β-lactamase (ESBL)-producing strains of Escherichia coli are a significant cause of bloodstream infections (BSI) in hospitalized and nonhospitalized patients. We previously showed that delaying effective antimicrobial therapy in BSI caused by ESBL producers significantly increases mortality. The aim of this retrospective 7-year analysis was to identify risk factors for inadequate initial antimicrobial therapy (IIAT) (i.e., empirical treatment based on a drug to which the isolate had displayed in vitro resistance) for inpatients with BSI caused by ESBL-producing E. coli. Of the 129 patients considered, 56 (43.4%) received IIAT for 48 to 120 h (mean, 72 h). Independent risk factors for IIAT include an unknown BSI source (odds ratios [OR], 4.86; 95% confidence interval [CI], 1.98 to 11.91; P = 0.001), isolate coresistance to 3 antimicrobials (OR, 3.73; 95% CI, 1.58 to 8.83; P = 0.003), hospitalization during the 12 months preceding BSI onset (OR, 3.33; 95% CI, 1.42 to 7.79; P = 0.005), and antimicrobial therapy during the 3 months preceding BSI onset (OR, 2.65; 95% CI, 1.11 to 6.29; P = 0.02). IIAT was the strongest risk factor for 21-day mortality and significantly increased the length of hospitalization after BSI onset. Our results underscore the need for a systematic approach to the management of patients with serious infections by ESBL-producing E. coli. Such an approach should be based on sound, updated knowledge of local infectious-disease epidemiology, detailed analysis of the patient’s history with emphasis on recent contact with the health care system, and aggressive attempts to identify the infectious focus that has given rise to the BSI.


August 26, 2008 at 11:44 pm Leave a comment


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