Archive for April, 2009

Dengue infection in pregnancy: prevalence, vertical transmission, and pregnancy outcome.

Obstetrics & Gynecology May 2008 V.111 N.5 p.1111-7

Tan PC, Rajasingam G, Devi S, Omar SZ.

Department of Obstetrics & Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.

OBJECTIVE: To estimate prevalence rate of recent dengue infection in parturients, as well as the vertical transmission rate, and to compare pregnancy outcomes among infected women.

METHOD: A prospective cohort study was performed. Maternal and paired umbilical cord bloods were taken at delivery. A brief questionnaire on febrile illness and dengue in pregnancy was completed by participants. The samples were sent to a World Health Organization Collaborating Center for Arbovirus Reference and Research. Maternal sera were tested with a dengue-specific immunoglobulin M (IgM) capture test. The paired umbilical cord serum was tested to determine when the maternal sample was positive. Dengue reverse transcriptase polymerase chain reaction (PCR) was performed on all dengue IgM-positive sera. Pregnancy outcome was extracted from delivery records.

RESULTS: A total of 2,958 parturients were enrolled, and 2,531 paired maternal-umbilical cord blood samples were available for testing. Dengue-specific IgM was positive in 63 of 2,531 (2.5%, 95% confidence interval [CI] 1.9-3.2%) maternal samples. Only 1 of 64 (1.6%, 95% CI 0.0-9.5%) of the paired umbilical cord sera was IgM-positive. All reverse transcriptase PCR tests were negative. Fifty-six of 63 (88.9%) of dengue IgM-positive women did not report a febrile illness in pregnancy. Apart from a higher mean age in dengue IgM-positive women of 30.6+/-5.2 compared with 29.2+/-4.9 years (P=.025) compared with dengue IgM-negative women, all other characteristics were similar. Rates of preterm birth, mode of delivery, postpartum hemorrhage, low birth weight, and neonatal outcomes were not different.

CONCLUSION: Recent dengue infection was demonstrated in 2.5% of parturients, with a vertical transmission rate of 1.6%. Pregnancy outcome of recently infected women was not different. LEVEL OF EVIDENCE: II.


April 22, 2009 at 11:51 pm Leave a comment

Vertical dengue infection: case reports and review.

Pediatric Infectious Disesase Journal Nov. 2004 V.23 N.11 p.1042-7.

Sirinavin S, Nuntnarumit P, Supapannachart S, Boonkasidecha S, Techasaensiri C, Yoksarn S.

Division of Infectious Diseases and Clinical Epidemiology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand.

Two vertical dengue infection cases are presented, and 15 others are reviewed. Twelve mothers had fever 0-9 (median, 2) days antepartum. The fevers of 17 neonates occurred at 1-11 (median, 4) days of life and lasted for 1-5 (median, 3) days. Neonatal thrombocytopenia was detected at 1-11 (median, 6) days of life and lasted for 3-18 (median, 6) days; the lowest platelet counts were 5-75 × 103 (median, 19 × 103)/mm3. One neonate died.


April 22, 2009 at 11:48 pm Leave a comment

Risk for Opportunistic Disease and Death after Reinitiating Continuous Antiretroviral Therapy in Patients with HIV Previously Receiving Episodic Therapy

Annals of Internal Medicine 2 Sept 2008 V.149 N.5 p.289-299

A Randomized Trial

The SMART Study Group*

From Harlem Hospital Center, Columbia University, New York, New York; University of Minnesota, Minneapolis, Minnesota; Community Research Initiative of New England, Boston, Massachusetts; Medical Research Council, Clinical Trials Unit, London, United Kingdom; National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia; and Rigshospitalet and University of Copenhagen, Copenhagen, Denmark.

Background: Episodic use of antiretroviral therapy guided by CD4+ cell counts is inferior to continuous antiretroviral therapy.

Objective: To determine whether reinitiating continuous antiretroviral therapy in patients who received episodic treatment reduces excess risk for opportunistic disease or death.

Design: Randomized, controlled trial.

Setting: Sites in 33 countries.

Patients: 5472 HIV-infected individuals with CD4+ cell counts greater than 0.350 x 109 cells/L enrolled from January 2002 to January 2006.

Intervention: Episodic or continuous antiretroviral therapy initially, followed by continuous therapy in participants previously assigned to episodic treatment.

Measurements: Opportunistic disease or death was the primary outcome.

Results: Eighteen months after the recommendation to reinitiate continuous therapy, mean CD4+ cell counts were 0.152 x 109 cells/L (95% CI, 0.136 to 0.167 x 109 cells/L) less in participants previously assigned to episodic treatment (P < 0.001). The proportion of follow-up time spent with CD4+ cell counts of 0.500 x 109 cells/L or more and HIV RNA levels of 400 copies/mL or less was 29% for participants initially assigned to episodic therapy and 66% for those assigned to continuous therapy. Participants who reinitiated continuous therapy experienced rapid suppression of HIV RNA levels (89.7% with HIV RNA levels 400 copies/mL after 6 months), but CD4+ cell counts after 6 months remained 0.140 x 109 cells/L below baseline. The hazard ratio (episodic versus continuous treatment) for opportunistic disease or death decreased after the recommendation to reinitiate continuous therapy (from 2.5 [CI, 1.8 to 3.5] to 1.4 [CI, 1.0 to 2.0]; P = 0.033 for difference). The residual excess risk was attributable to failure to reinitiate therapy by some participants and slow recovery of CD4+ cell counts for those who reinitiated therapy.

Limitation: Follow-up was too short to assess the full effect of switching from episodic to continuous antiretroviral therapy.

Conclusion: Reinitiating continuous antiretroviral therapy in patients previously assigned to episodic treatment reduced excess risk for opportunistic disease or death, but excess risk remained. Episodic antiretroviral therapy, as used in the SMART study, should be avoided.



April 22, 2009 at 12:48 pm Leave a comment

Swine Influenza A (H1N1) Infection in Two Children

MMWR Dispatch April 21, 2009 V.58 p.1-3

Southern California, March–April 2009

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April 22, 2009 at 12:47 pm Leave a comment

Update on Leprosy in Immigrants in the United States: Status in the Year 2000

Clinical Infectious Diseases 15 March 2001 V.32 N.6 p.930-7.


Winnie W. Ooi1 and Samuel L. Moschella2

1Department of Internal Medicine and the 2Department of Dermatology, Lahey Clinic Medical Center, Burlington, Massachusetts

The World Health Organization established a goal in 1991 of “elimination of leprosy as a public health problem by the year 2000.” Although prevalence rates of leprosy have decreased in many geographic areas, it is clear that in some countries where leprosy is endemic, such as Brazil and India, this goal will not be reached. Leprosy is rare in the United States, but 85% of detected cases are in immigrants in whom the disease may mimic many common dermatologic and neurological entities, leading to delay of diagnosis. The statuses of polymerase chain reaction analysis, serological testing, and vaccines are reviewed. Effective multidrug therapy and prevention of permanent damage to nerves by early recognition and treatment will help prevent residual disabilities. This update reviews what is known about the pathophysiology and treatment of leprosy. Increased awareness will lead to earlier recognition, diagnosis, and treatment.



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April 21, 2009 at 11:09 pm Leave a comment

Clinical Overview of Gram-Positive Bloodstream Infections

Clinical Infectious Diseases 15 May 2009 V.48 N.S4


S 231 Staphylococcus aureus Bacteremia: Epidemiology, Pathophysiology, and Management Strategies

S 238 The Clinical Importance of Microbiological Findings in the Diagnosis and Management of Bloodstream Infections

S 246 Patients at Risk of Complications of Staphylococcus aureus Bloodstream Infection

S 254 Staphylococcus aureus Bloodstream Infections: Definitions and Treatment

S 260 Clinical Consensus Conference: Survey on Gram‐Positive Bloodstream Infections with a Focus on Staphylococcus aureus

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April 19, 2009 at 5:19 pm Leave a comment

Empirical Treatment of Community-Acquired Pneumonia and the Development of Fluoroquinolone-Resistant Tuberculosis

Clinical Infectious Diseases 15 May 2009 V.48 N.10 p.1354–1360

Richard Long,1 Huey Chong,3 Vernon Hoeppner,5 Hareishun Shanmuganathan,6 Kinga Kowalewska-Grochowska,4

Cary Shandro,4 Jure Manfreda,7 Ambikaipakan Senthilselvan,2 Abeer Elzainy,1 and Thomas Marrie1

Departments of 1Medicine and 2Public Health Sciences, University of Alberta, 3Capital Health Region, and 4Provincial Laboratory for Public Health, Edmonton, Alberta, 5Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, and Departments of 6Medicine and 7Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba

Background. Fluoroquinolone (FLQ) antibiotics are not uncommonly prescribed for community-acquired pneumonia that is later proven to be pulmonary tuberculosis (TB). Such FLQ monotherapy may result in FLQ-resistant pulmonary TB.

Methods. To assess outpatient FLQ use by patients with culture-proven pulmonary TB before diagnosis, TB registries in Alberta and Saskatchewan, Canada, were linked with provincial and federal drug benefit plans. To assess FLQ resistance, a case-control study was performed.

Results. Of 428 patients with pulmonary TB who were covered by a drug benefit plan, 74 (17.3%) had received 1 FLQ prescription during the 6 months immediately before receipt of the diagnosis. Older patients (age, >64 years) were more likely than younger patients (age, 15–64 years) to be prescribed an FLQ ( ). Patients who were prescribed an FLQ received a total of 103 prescriptions. Most (54 [73.0%] of 74) patients who were prescribed an FLQ received a single prescription. Most (69 [67.0%] of 103) FLQ prescriptions were written within 90 days before the diagnosis of pulmonary TB. Patients who were prescribed an FLQ were not statistically significantly more likely than matched patients who were not prescribed an FLQ (control subjects) to be infected with FLQ-resistant Mycobacterium tuberculosis. Of 148 isolates of M. tuberculosis from patients and control subjects, 3 were FLQ resistant; all of these isolates were from patients who had received multiple FLQ prescriptions. Patients who had received multiple FLQ prescriptions were more likely than patients who had received a single FLQ prescription to be infected with FLQ-resistant M. tuberculosis (15.0% vs. 0.0%; odds ratio, 11.4; ).

Conclusions. Outpatient FLQ use, ostensibly for community-acquired pneumonia, is not uncommon among patients with pulmonary TB, especially older patients. Single FLQ prescriptions were not associated with FLQ-resistant M. tuberculosis, whereas multiple FLQ prescriptions were associated with FLQ resistance.




Fluoroquinolones for Treatment of Community-Acquired Pneumonia and Tuberculosis: Putting the Risk of Resistance into Perspective

Donald E. Low

Ontario Agency for Health Protection and Promotion and Department of Microbiology, Mount Sinai Hospital–University Health Network, Toronto, Ontario, Canada

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April 19, 2009 at 12:19 am Leave a comment

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