Archive for December 23, 2009

Pediatric Hospitalizations Associated with 2009 Pandemic Influenza A (H1N1) in Argentina

N Engl J of Medicine  24 Dec. 2009  V.361  N.26

Romina Libster, M.D., Jimena Bugna, M.D., Silvina Coviello, M.S., Diego R. Hijano, M.D., Mariana Dunaiewsky, M.D., Natalia Reynoso, M.D., Maria L. Cavalieri, M.D., Maria C. Guglielmo, M.D., M. Soledad Areso, M.D., Tomas Gilligan, M.D., Fernanda Santucho, M.D., Graciela Cabral, M.D., Gabriela L. Gregorio, M.D., Rina Moreno, M.D., Maria I. Lutz, M.D., Alicia L. Panigasi, M.D., Liliana Saligari, M.D., Mauricio T. Caballero, M.D., Rodrigo M. Egües Almeida, M.D., Maria E. Gutierrez Meyer, M.D., Maria D. Neder, M.D., Maria C. Davenport, M.D., Maria P. Del Valle, M.D., Valeria S. Santidrian, M.D., Guillermina Mosca, M.D., Mercedes Garcia Domínguez, M.D., Liliana Alvarez, M.D., Patricia Landa, M.D., Ana Pota, M.D., Norma Boloñati, M.D., Ricardo Dalamon, M.D., Victoria I. Sanchez Mercol, M.D., Marco Espinoza, M.D., Juan Carlos Peuchot, M.D., Ariel Karolinski, M.D., Miriam Bruno, M.D., Ana Borsa, M.D., Fernando Ferrero, M.D., Ph.D., Angel Bonina, M.D., Margarita Ramonet, M.D., Lidia C. Albano, M.D., Nora Luedicke, M.D., Elias Alterman, M.D., Vilma Savy, Ph.D., Elsa Baumeister, Ph.D., James D. Chappell, M.D., Ph.D., Kathryn M. Edwards, M.D., Guillermina A. Melendi, M.D., and Fernando P. Polack, M.D

Background While the Northern Hemisphere experiences the effects of the 2009 pandemic influenza A (H1N1) virus, data from the recent influenza season in the Southern Hemisphere can provide important information on the burden of disease in children.

Methods We conducted a retrospective case series involving children with acute infection of the lower respiratory tract or fever in whom 2009 H1N1 influenza was diagnosed on reverse-transcriptase polymerase-chain-reaction assay and who were admitted to one of six pediatric hospitals serving a catchment area of 1.2 million children. We compared rates of admission and death with those among age-matched children who had been infected with seasonal influenza strains in previous years.

Results Between May and July 2009, a total of 251 children were hospitalized with 2009 H1N1 influenza. Rates of hospitalization were double those for seasonal influenza in 2008. Of the children who were hospitalized, 47 (19%) were admitted to an intensive care unit, 42 (17%) required mechanical ventilation, and 13 (5%) died. The overall rate of death was 1.1 per 100,000 children, as compared with 0.1 per 100,000 children for seasonal influenza in 2007. (No pediatric deaths associated with seasonal influenza were reported in 2008.) Most deaths were caused by refractory hypoxemia in infants under 1 year of age (death rate, 7.6 per 100,000).

Conclusions Pandemic 2009 H1N1 influenza was associated with pediatric death rates that were 10 times the rates for seasonal influenza in previous years.



December 23, 2009 at 10:59 pm Leave a comment

Severe 2009 H1N1 Influenza in Pregnant and Postpartum Women in California

N Engl J of Medicine  24 Dec. 2009  V.361  N.26

Janice K. Louie, M.D., M.P.H., Meileen Acosta, M.P.H., Denise J. Jamieson, M.D., M.P.H., Margaret A. Honein, Ph.D., M.P.H., for the California Pandemic (H1N1) Working Group

Background Like previous epidemic and pandemic diseases, 2009 pandemic influenza A (H1N1) may pose an increased risk of severe illness in pregnant women.

Methods Statewide surveillance for patients who were hospitalized with or died from 2009 H1N1 influenza was initiated by the California Department of Public Health. We reviewed demographic and clinical data reported from April 23 through August 11, 2009, for all H1N1-infected, reproductive-age women who were hospitalized or died — nonpregnant women, pregnant women, and postpartum women (those who had delivered 2 weeks previously).

Results Data were reported for 94 pregnant women, 8 postpartum women, and 137 nonpregnant women of reproductive age who were hospitalized with 2009 H1N1 influenza. Rapid antigen tests were falsely negative in 38% of the patients tested (58 of 153). Most pregnant patients (89 of 94 [95%]) were in the second or third trimester, and approximately one third (32 of 93 [34%]) had established risk factors for complications from influenza other than pregnancy. As compared with early antiviral treatment (administered 2 days after symptom onset) in pregnant women, later treatment was associated with admission to an intensive care unit (ICU) or death (relative risk, 4.3). In all, 18 pregnant women and 4 postpartum women (total, 22 of 102 [22%]) required intensive care, and 8 (8%) died. Six deliveries occurred in the ICU, including four emergency cesarean deliveries. The 2009 H1N1 influenza–specific maternal mortality ratio (the number of maternal deaths per 100,000 live births) was 4.3.

Conclusions 2009 H1N1 influenza can cause severe illness and death in pregnant and postpartum women; regardless of the results of rapid antigen testing, prompt evaluation and antiviral treatment of influenza-like illness should be considered in such women. The high cause-specific maternal mortality rate suggests that 2009 H1N1 influenza may increase the 2009 maternal mortality ratio in the United States.



December 23, 2009 at 10:56 pm Leave a comment

Clinical Features of the Initial Cases of 2009 Pandemic Influenza A (H1N1) Virus Infection in China

N Engl J of Medicine  24 Dec. 2009  V.361  N.26  p.2507-2517

Bin Cao, M.D., Xing-Wang Li, M.D., Yu Mao, M.D., Jian Wang, M.D., Hong-Zhou Lu, M.D., Yu-Sheng Chen, M.D., Zong-An Liang, M.D., Lirong Liang, M.D., Su-Juan Zhang, M.D., Bin Zhang, M.D., Li Gu, M.D., Lian-He Lu, M.D., Da-Yan Wang, Ph.D., Chen Wang, M.D., for the National Influenza A Pandemic (H1N1) 2009 Clinical Investigation Group of China

Background The first case of 2009 pandemic influenza A (H1N1) virus infection in China was documented on May 10. Subsequently, persons with suspected cases of infection and contacts of those with suspected infection were tested. Persons in whom infection was confirmed were hospitalized and quarantined, and some of them were closely observed for the purpose of investigating the nature and duration of the disease.

Methods During May and June 2009, we observed 426 persons infected with the 2009 pandemic influenza A (H1N1) virus who were quarantined in 61 hospitals in 20 provinces. Real-time reverse-transcriptase–polymerase-chain-reaction (RT-PCR) testing was used to confirm infection, the clinical features of the disease were closely monitored, and 254 patients were treated with oseltamivir within 48 hours after the onset of disease.

Results The mean age of the 426 patients was 23.4 years, and 53.8% were male. The diagnosis was made at ports of entry (in 32.9% of the patients), during quarantine (20.2%), and in the hospital (46.9%). The median incubation period of the virus was 2 days (range, 1 to 7). The most common symptoms were fever (in 67.4% of the patients) and cough (69.5%). The incidence of diarrhea was 2.8%, and the incidence of nausea and vomiting was 1.9%. Lymphopenia, which was common in both adults (68.1%) and children (92.3%), typically occurred on day 2 (range, 1 to 3) and resolved by day 7 (range, 6 to 9). Hypokalemia was observed in 25.4% of the patients. Duration of fever was typically 3 days (range, 1 to 11). The median length of time during which patients had positive real-time RT-PCR test results was 6 days (range, 1 to 17). Independent risk factors for prolonged real-time RT-PCR positivity included an age of less than 14 years, male sex, and a delay from the onset of symptoms to treatment with oseltamivir of more than 48 hours.

Conclusions Surveillance of the 2009 H1N1 virus in China shows that the majority of those infected have a mild illness. The typical period during which the virus can be detected with the use of real-time RT-PCR is 6 days (whether or not fever is present). The duration of infection may be shortened if oseltamivir is administered.



December 23, 2009 at 10:53 pm Leave a comment

Immunogenicity of a Monovalent 2009 Influenza A(H1N1) Vaccine in Infants and Children

JAMA 21 Dec. 2009  Early Release

A Randomized Trial

Terry Nolan, MBBS, PhD; Jodie McVernon, MBBS, PhD; Maryanne Skeljo, PhD; Peter Richmond, MBBS; Ushma Wadia, MBBS; Stephen Lambert, MBBS, MAppEpid; Michael Nissen, BMedSc, MBBS; Helen Marshall, MBBS, MPH; Robert Booy, MD, MSc; Leon Heron, MBChB, MPH; Gunter Hartel, MS, PhD; Michael Lai, MBBS, MMedSc; Russell Basser, MBBS, MD; Charmaine Gittleson, MBBCh; Michael Greenberg, MD, MPH

Vaccine and Immunization Research Group, School of Population Health, University of Melbourne, and Murdoch Children’s Research Institute, Victoria, Australia (Drs Nolan, McVernon, and Skeljo); School of Pediatrics and Child Health, University of Western Australia, and Telethon Institute for Child Health Research, Subiaco, Western Australia (Drs Richmond and Wadia); Queensland Pediatric Infectious Diseases Laboratory, Royal Children’s Hospital, Herston, Queensland, Australia (Drs Lambert and Nissen); Department of Pediatrics, University of Adelaide, and Women’s and Children’s Hospital, North Adelaide, South Australia (Dr Marshall); National Center for Immunization Research and Surveillance of Vaccine Preventable Diseases, University of Sydney, and Children’s Hospital at Westmead, New South Wales, Australia (Drs Booy and Heron); and Clinical Research and Development, CSL Limited, Parkville, Victoria, Australia (Drs Hartel, Lai, Basser, Gittleson, and Greenberg).

Context In the ongoing influenza pandemic, a safe and effective vaccine against 2009 influenza A(H1N1) is needed for infants and children.

Objective To assess the immunogenicity and safety of a 2009 influenza A(H1N1) vaccine in children.

Design, Setting, and Participants Randomized, observer-blind, age-stratified, parallel group study assessing 2 doses of an inactivated, split-virus 2009 influenza A(H1N1) vaccine in 370 healthy infants and children aged 6 months to less than 9 years living in Australia.

Intervention Intramuscular injection of 15 µg or 30 µg of hemagglutinin antigen dose of monovalent, unadjuvanted 2009 influenza A(H1N1) vaccine in a 2-dose regimen, administered 21 days apart.

Main Outcome Measures Hemagglutination inhibition assay to estimate the proportion of participants with antibody titers of 1:40 or greater, seroconversion, or a significant antibody titer increase, and factor increase in geometric mean titer. Assessments of solicited adverse events during 7 days and unsolicited adverse events for 21 days after each vaccination.

Results Following the first dose of vaccine, antibody titers of 1:40 or greater were observed in 161 of 174 infants and children in the 15-µg group (92.5%; 95% confidence interval [CI], 87.6%-95.6%) and in 168 of 172 infants and children in the 30-µg group (97.7%; 95% CI, 94.2%-99.1%). Corresponding seroconversion rates were 86.8% (95% CI, 80.9%-91.0%) and 94.2% (95% CI, 89.6%-96.8%), and factor increases in geometric mean titer were 13.6 (95% CI, 11.8-15.6) and 18.3 (95% CI, 15.7-21.4). All participants demonstrated antibody titers of 1:40 or greater after the second vaccine dose. Immune responses were robust regardless of age, baseline serostatus, or seasonal influenza vaccination status. The majority of adverse events were mild to moderate in severity.

Conclusion One 15-µg dose of vaccine was immunogenic in infants and children starting at 6 months of age and vaccine-associated reactions were mild to moderate in severity.


December 23, 2009 at 10:47 am Leave a comment

Nosocomial Acinetobacter baumannii infections: microbiological and clinical epidemiology

Ann Intern Med; Aug.1, 1998  Vol. 129  N.3  p.182-9.

Daniel Villers, MD; Eric Espaze, MD; Marianne Coste-Burel, PharmD; Frederic Giauffret, MD; Emmanuelle Ninin, MD; Francoise Nicolas, MD; and Herve Richet, MD

From the Institut de Biologie des Hopitaux de Nantes and Hotel Dieu, Nantes, France. Acknowledgments: The authors thank Jerome Tokars, MD, MPH, for manuscript review and assistance with data analysis and Dominique Gautreau, Anny Blin, and Michele Fleury for technical assistance. Grant Support: In part by grant 931305 from the Institut National de la Sante et de la Recherche Medicale. Requests for Reprints: Daniel Villers, MD, Service de Reanimation Medicale, Hotel Dieu, Centre Hospitalier Universitaire de Nantes, 44035 Nantes Cedex 01, France. Current Author Addresses: Drs. Villers, Giauffret, and Nicolas: Service de Reanimation Medicale, Hotel Dieu, Centre Hospitalier Universitaire de Nantes, 44035 Nantes Cedex 01, France. Drs. Espaze, Coste-Burel, Ninin, and Richet: Laboratoire de Bacteriologie, Virologie, Hygiene Hospitaliere, Institut de Biologie des Hopitaux de Nantes, 9, Quai Moncousu, 44035 Nantes Cedex 01, France.

Background: Acinetobacter baumannii is an important opportunistic pathogen that is rapidly evolving toward multidrug resistance and is involved in various nosocomial infections that are often severe. It is difficult to prevent A. baumannii infection because A. baumannii is ubiquitous and the epidemiology of the infections it causes is complex.

Objective: To study the epidemiology of A. baumannii infections and assess the relation between fluoroquinolone use and the persistence of multidrug-resistant clones.

Design: Three case–control studies and a retrospective cohort study.

Setting: A 20-bed medical and surgical intensive care unit.

Patients: Acinetobacter baumannii was isolated from 45 patients in urine (31%), the lower respiratory tract (26.7%), wounds (17.8%), blood (11.1%), skin (6.7%), cerebrospinal fluid (4.4%), and sinus specimens (2.2%). One death was due to A. baumannii infection.

Measurements: Antimicrobial resistance pattern and molecular typing were used to characterize isolates. The incidence of A. baumannii infection and the use of fluoroquinolones were calculated annually.

Results: Initially, 28 patients developed A. baumannii infection. Eleven isolates had the same antimicrobial susceptibility profile, genotypic profile, or both (epidemic cases), and 17 were heterogeneous (endemic cases). A surgical procedure done in an emergency operating room was the main risk factor for epidemic cases, whereas previous receipt of a fluoroquinolone was the only risk factor for endemic cases. The opening of a new operating room combined with the restriction of fluoroquinolone use contributed to a transitory reduction in the incidence of infection. When a third epidemiologic study was done, previous receipt of a fluoroquinolone was again an independent risk factor and a parallel was seen between the amount of intravenous fluoroquinolones prescribed and the incidence of endemic infection.

Conclusion: Epidemic infections coexisted with endemic infections favored by the selection pressure of intravenous fluoroquinolones.



– – –

Comments from Johns Hopkins: This review showed the following sites of infection in 45 cases: urine 31%, lung 27%, wounds 18%, blood 11%, CSF 4%. A major risk factor was prior treatment with a fluoroquinolone. The authors conclude A. baumannii is: 1)an important nosocomial pathogen; 2)may cause serious disease primarily in compromised host; 3)may be epidemic or endemic, esp in ICUs; 4)there may be multiply-resistant clones; 5)prior abx, esp fluoroquinolones, may be important risk factor.

December 23, 2009 at 10:44 am Leave a comment

Vertebral Osteomyelitis: Long-Term Outcome for 253 Patients from 7 Cleveland-Area Hospitals

Clin Infect Diseases  May 15, 2002  V.34  N.10  p.1342–1350

Martin C. McHenry,1 Kirk A. Easley,2 and Geri A. Locker2

Departments of 1Infectious Diseases and Biostatistics and 2Epidemiology, The Cleveland Clinic Foundation, Ohio

We report a retrospective study of 253 patients with vertebral osteomyelitis (VO) who had long-term follow-up. Eleven percent of the patients died, residual disability occurred in more than one-third of the survivors, and relapse occurred in 14%. Median duration of follow-up was 6.5 years (range, 2 days to 38 years). Independent risk factors for adverse outcome (death or qualified recovery) were neurologic compromise, time to diagnosis, and hospital acquisition of infection (p < .004). Surgical treatment resulted in recovery or improvement in 86 (79%) of 109 patients. Magnetic resonance images (110 patients) were often obtained late in the course of infection and did not significantly affect outcome. Often, relapse developed in individuals with severe vertebral destruction and abscesses, appearing some time after surgical drainage or debridement. Recurrent bacteremia, paravertebral abscesses, and chronically draining sinuses were independently associated with relapse (p<.001). An optimal outcome of VO requires heightened awareness, early diagnosis, prompt identification of pathogens, reversal of complications, and prolonged antimicrobial therapy.




December 23, 2009 at 10:38 am Leave a comment


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