Archive for August, 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.

abstract
http://jama.ama-assn.org/cgi/content/abstract/300/8/945?etoc

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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.

abstract
http://aac.asm.org/cgi/content/abstract/52/9/3188

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.

abstract
http://aac.asm.org/cgi/content/abstract/52/9/3244

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

Clinical Features of Viral Meningitis in Adults: Significant Differences in Cerebrospinal Fluid Findings among Herpes Simplex Virus, Varicella Zoster Virus, and Enterovirus Infections

Clinical Infectious Diseases 15 September 2008  V.47  N.6  p.783–789 

Ugo K. Ihekwaba,1 Goura Kudesia,2 and Michael W. McKendrick1

Departments of 1Infection and Tropical Medicine and 2Virology, Sheffield Teaching Hospitals, National Health Service Foundation Trust, Sheffield, United Kingdom

Background.  In this retrospective study, our objective was to review the epidemiology of viral meningitis and to compare clinical features associated with enterovirus, herpes simplex virus (HSV), and varicella zoster virus (VZV) infections in immunocompetent adults.

Methods.  Data on cerebrospinal fluid (CSF) samples submitted to the Trust Virology Laboratory (Sheffield, UK) from April 2004 through April 2007 were reviewed. Notes on immunocompetent adults who were polymerase chain reaction (PCR) positive for enterovirus, HSV type 2, or VZV and who had presented to local clinical departments were scrutinized (4 patients were positive for HSV type 1 and did not meet the inclusion criteria).

Results.  A total of 2045 samples were analyzed for viral pathogens during the 3-year period. Of the 109 PCR-positive samples, 38 (35%) were from immunocompetent adults, of whom 22 were infected with enterovirus, 8 were infected with HSV type 2, and 8 were infected with VZV. The median ages were 32 years (range, 16–39 years), 39 years (range, 22–53 years), and 47.5 years (range, 26–80 years), respectively. Rash occurred after the meningitis symptoms in 5 patients infected with VZV (median time from meningitis symptoms to rash, 6 days). Protein levels were significantly higher in CSF samples from patients infected with HSV type 2 (median, 1205 mg/L) and in samples from those infected with VZV (median, 974 mg/L) than in samples from those infected with enterovirus (median, 640 mg/L; P=.001 and P=.01, respectively). White blood cell counts were significantly higher in CSF samples from patients infected with HSV type 2 (median, 240 x106 cells/L) than in samples from those infected with enterovirus (median,  51 x 106 cells/L; P=.01).

Conclusions.  Enterovirus infection was the most common cause of viral meningitis in immunocompetent adults in this study. White blood cell counts and protein levels were significantly higher in CSF samples from patients infected with HSV type 2 than in samples from patients with enterovirus infection. Zoster rash often occurs after meningitis. PCR testing provides a rapid and specific etiological diagnosis.

abstract
http://www.journals.uchicago.edu/doi/abs/10.1086/591129

PDF
http://www.journals.uchicago.edu/doi/pdf/10.1086/591129

August 24, 2008 at 1:47 pm Leave a comment

Emergency Department Visits for Antibiotic-Associated Adverse Events

Clinical Infectious Diseases 15 September 2008  V.47  N.6  p.735–743 

Nadine Shehab, Priti R. Patel, Arjun Srinivasan, and Daniel S. Budnitz

Division of Healthcare Quality Promotion, National Center for Detection, Preparedness, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

Background.  Drug-related adverse events are an underappreciated consequence of antibiotic use, and the national magnitude and scope of these events have not been studied. Our objective was to estimate and compare the numbers and rates of emergency department (ED) visits for drug-related adverse events associated with systemic antibiotics in the United States by drug class, individual drug, and event type.

Methods.  We analyzed drug-related adverse events from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project (2004–2006) and outpatient prescriptions from national sample surveys of ambulatory care practices, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2004–2005).

Results.  On the basis of 6614 cases, an estimated 142,505 visits (95% confidence interval [CI], 116,506–168,504 visits) annually were made to US EDs for drug-related adverse events attributable to systemic antibiotics. Antibiotics were implicated in 19.3% of all ED visits for drug-related adverse events. Most ED visits for antibiotic-associated adverse events were for allergic reactions (78.7% of visits; 95% CI, 75.3%–82.1% of visits). One-half of the estimated ED visits were attributable to penicillins (36.9% of visits; 95% CI, 34.7%–39.2% of visits) and cephalosporins (12.2%; 95% CI, 10.9%–13.5%). Among commonly prescribed antibiotics, sulfonamides and clindamycin were associated with the highest rate of ED visits (18.9 ED visits per 10,000 outpatient prescription visits [95% CI, 13.1–24.7 ED visits per 10,000 outpatient prescription visits] and 18.5 ED visits per 10,000 outpatient prescription visits [95% CI, 12.1–25.0 ED visits per 10,000 outpatient prescription visits], respectively). Compared with all other antibiotic classes, sulfonamides were associated with a significantly higher rate of moderate-to-severe allergic reactions (4.3% [95% CI, 2.9%–5.8%] vs. 1.9 % [95% CI, 1.5%–2.3%]), and sulfonamides and fluoroquinolones were associated with a significantly higher rate of neurologic or psychiatric disturbances (1.4% [95% CI, 1.0%–1.7%] vs. 0.5% [95% CI, 0.4%–0.6%]).

Conclusions.  Antibiotic-associated adverse events lead to many ED visits, and allergic reactions are the most common events. Minimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events in individual patients.
abstract
http://www.journals.uchicago.edu/doi/abs/10.1086/591126

PDF
http://www.journals.uchicago.edu/doi/pdf/10.1086/591126

EDITORIAL COMMENTARY

Antibiotics for Treatment of Acute Respiratory Tract Infections: Decreasing Benefit, Increasing Risk, and the Irrelevance of Antimicrobial Resistance

Jeffrey A. Linder

Division of General Medicine and Primary Care, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

http://www.journals.uchicago.edu/doi/full/10.1086/591149

PDF
http://www.journals.uchicago.edu/doi/pdf/10.1086/591149

August 24, 2008 at 1:29 pm Leave a comment

Q Fever — California, Georgia, Pennsylvania, and Tennessee, 2000–2001

MMWR  Oct.18, 2002  V.51  N.41  p.924-927

Q Fever — California, Georgia, Pennsylvania, and Tennessee, 2000–2001

FULL TEXT
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5141a2.htm

August 24, 2008 at 1:26 pm Leave a comment

Q Fever During Pregnancy: A Public Health Problem in Southern France

Clinical Infectious Diseases  Sept 1998  V.27  N.3  p.592–596

Andreas Stein – Didier Raoult

From the Unite des Rickettsies, Faculte de Medecine, Universite de la Mediterranee, Marseille, France

We describe five cases of Q fever in pregnant women that were diagnosed during the last 3 years in the town of Martigues in Southern France. Analysis of our cases and the 18 other published cases shows that Q fever is a significant cause of morbidity and mortality in pregnancy. The disease may present as an acute or chronic infection and can be reactivated during subsequent pregnancies, as is seen with other mammals. In Martigues, Q fever is present in at least one per 540 pregnancies and constitutes the most significant public health problem related to intrauterine infections.
abstract
http://www.journals.uchicago.edu/doi/abs/10.1086/514698

PDF
http://www.journals.uchicago.edu/doi/pdf/10.1086/514698

August 23, 2008 at 7:08 pm Leave a comment

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