Archive for May, 2010

Helicobacter pylori Infection

N England J of Medicine 29 April 2010 V.362 N.17 p.1597-1604

Clinical Practice

Kenneth E.L. McColl, M.D.

A 29-year-old man presents with intermittent epigastric discomfort, without weight loss or evidence of gastrointestinal bleeding. He reports no use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). Abdominal examination reveals epigastric tenderness. A serologic test for Helicobacter pylori is positive, and he receives a 10-day course of triple therapy (omeprazole, amoxicillin, and clarithromycin). Six weeks later, he returns with the same symptoms. . . .



May 30, 2010 at 4:50 pm Leave a comment

Pandemic 2009 Influenza A(H1N1) Virus Illness Among Pregnant Women in the United States

JAMA April 21, 2010  V.303  N.15 p.1517-1525

Alicia M. Siston, PhD; Sonja A. Rasmussen, MD; Margaret A. Honein, PhD; Alicia M. Fry, MD; Katherine Seib, BS; William M. Callaghan, MD; Janice Louie, MD; Timothy J. Doyle, MPH; Molly Crockett, MPH; Ruth Lynfield, MD; Zack Moore, MD; Caleb Wiedeman, MPH; Madhu Anand, MPH; Laura Tabony, MPH; Carrie F. Nielsen, PhD; Kirsten Waller, MD; Shannon Page, BS; Jeannie M. Thompson, MPH; Catherine Avery, CFNP; Chasisity Brown Springs, MSPH; Timothy Jones, MD; Jennifer L. Williams, MSN; Kim Newsome, MPH; Lyn Finelli, DrPH; Denise J. Jamieson, MD; for the Pandemic H1N1 Influenza in Pregnancy Working Group

Epidemic Intelligence Service (Drs Siston and Nielsen), National Center for Immunization and Respiratory Diseases, (Drs Siston, Fry, and Finelli), National Center on Birth Defects and Developmental Disabilities (Drs Rasmussen and Honein, and Mss Seib, Williams, and Newsome), National Center for Chronic Disease Prevention and Health Promotion (Drs Callaghan and Jamieson), Centers for Disease Control and Prevention, Atlanta, Georgia; California Department of Public Health, Richmond (Dr Louie); Florida Department of Health, Tallahassee (Mr Doyle); Massachusetts Department of Public Health, Boston (Ms Crockett); Minnesota Department of Health, St Paul (Dr Lynfield); North Carolina Department of Health and Human Services, Raleigh (Dr Moore); Arizona Department of Health Services, Phoenix (Mr Wiedeman); New York State Department of Health, Albany (Ms Anand); Texas Department of State Health Services, Austin (Ms Tabony); Wisconsin Department of Health Services, Madison (Dr Nielsen); Pennsylvania Department of Health, Harrisburg (Dr Waller); Ohio Department of Health, Columbus (Ms Page); Oklahoma State Department of Health, Oklahoma City (Ms Thompson); New Mexico Department of Health, Santa Fe (Ms Avery); South Carolina Department of Health and Environmental Control, Columbia (Ms Brown Springs); Tennessee Department of Health, Nashville (Dr Jones).


Early data on pandemic 2009 influenza A(H1N1) suggest pregnant women are at increased risk of hospitalization and death.


To describe the severity of 2009 influenza A(H1N1) illness and the association with early antiviral treatment among pregnant women in the United States.

Design, Setting, and Patients 

Surveillance of 2009 influenza A(H1N1) in pregnant women reported to the Centers for Disease Control and Prevention (CDC) with symptom onset from April through December 2009.

Main Outcome Measures 

Severity of illness (hospitalizations, intensive care unit [ICU] admissions, and deaths) due to 2009 influenza A(H1N1) among pregnant women, stratified by timing of antiviral treatment and pregnancy trimester at symptom onset.


We received reports on 788 pregnant women in the United States with 2009 influenza A(H1N1) with symptom onset from April through August 2009. Among those, 30 died (5% of all reported 2009 influenza A[H1N1] influenza deaths in this period). Among 509 hospitalized women, 115 (22.6%) were admitted to an ICU. Pregnant women with treatment more than 4 days after symptom onset were more likely to be admitted to an ICU (56.9% vs 9.4%; relative risk [RR], 6.0; 95% confidence interval [CI], 3.5-10.6) than those treated within 2 days after symptom onset. Only 1 death occurred in a patient who received treatment within 2 days of symptom onset. Updating these data with the CDC’s continued surveillance of ICU admissions and deaths among pregnant women with symptom onset through December 31, 2009, identified an additional 165 women for a total of 280 women who were admitted to ICUs, 56 of whom died. Among the deaths, 4 occurred in the first trimester (7.1%), 15 in the second (26.8%), and 36 in the third (64.3%);


Pregnant women had a disproportionately high risk of mortality due to 2009 influenza A(H1N1). Among pregnant women with 2009 influenza A(H1N1) influenza reported to the CDC, early antiviral treatment appeared to be associated with fewer admissions to an ICU and fewer deaths.


May 30, 2010 at 4:48 pm Leave a comment

Exposure to Children as a Risk Factor for Bacteremic Pneumococcal Disease

Arch Intern Med 8 April 2010 V.170 N.8 p.725-731

Changes in the Post–Conjugate Vaccine Era

Joshua P. Metlay, MD, PhD; Ebbing Lautenbach, MD, MPH, MSCE; Yimei Li, MS; Justine Shults, PhD; Paul H. Edelstein, MD

Departments of Medicine (Drs Metlay and Lautenbach), Biostatistics and Epidemiology (Drs Metlay, Lautenbach, and Shults and Ms Li), and Pathology and Laboratory Medicine (Dr Edelstein), and the Centers for Education and Research on Therapeutics (Drs Metlay and Lautenbach), University of Pennsylvania School of Medicine, Philadelphia.


The introduction of a pneumococcal conjugate vaccine has been associated with a shift in the serotypes responsible for bacteremic pneumococcal disease. We examined recent trends in serotypes responsible for disease and current risk factors among adults.


Data were obtained from 48 acute care hospitals in the 5-county region surrounding Philadelphia, Pennsylvania, from October 1, 2002, through September 30, 2008, on all hospitalized adult patients with community-acquired bacteremic pneumococcal disease. Isolates were serotyped and patient characteristics were compared with data from a household survey of the adult population in the region.


During the study period, the annual rate of disease due to vaccine serotypes declined by 29% per year, but the rate of disease due to nonvaccine serotypes increased 13% per year, yielding an overall 7% increase in the annual rate of disease among adults. Advanced age was a risk factor for infection with nonvaccine serotypes compared with vaccine serotypes. Comparing all patients with the source population, African Americans were at increased risk of infection, and the presence of additional children in the home was associated with decreased risk of disease. Smoking, advanced age, and diabetes mellitus remained important risk factors in adults.


New serotypes are replacing the serotypes covered in the conjugate vaccine. While some risk factors for pneumococcal disease remain unchanged, the observation that exposure to children in the home is associated with lower risk of disease suggests that the changing epidemiology of pneumococcal disease may be altering the dominant modes of transmission in the community.


May 30, 2010 at 4:46 pm Leave a comment

New directly acting antivirals for hepatitis C: potential for interaction with antiretrovirals

J. Antimicrob. Chemother. June 2010 V.65  N.6 p.1079-1085

Kay Seden1,*, David Back2 and Saye Khoo2

1 NIHR Biomedical Research Centre, Royal Liverpool & Broadgreen University Hospitals Trust, Liverpool, UK 2 Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK

Recent advances in the development of agents that act specifically to inhibit hepatitis C virus (HCV) are set to fundamentally change the way that patients will be treated. New directly acting anti-HCV agents such as protease and polymerase inhibitors will initially be added to standard of care with pegylated interferon- and ribavirin. However, future therapy is likely to constitute combinations of agents which act at distinct stages of viral replication and have differing resistance profiles. While directly acting anti-HCV agents will undoubtedly improve treatment outcomes, the introduction of combination therapy may not be without complications in some patient groups. HIV-positive patients who are receiving antiretrovirals (ARVs) are relatively highly represented among those with HCV infection, and are at high risk of drug–drug interactions (DDIs). As combination anti-HCV treatment gradually evolves to resemble anti-HIV therapy, it is essential to consider the increased potential for DDIs in patients receiving combination anti-HCV therapy, and particularly in HCV/HIV-co-infected individuals. Therapeutic drug monitoring is likely to play a role in the clinical management of such interactions.



May 29, 2010 at 7:07 pm Leave a comment

Detection and treatment options for Klebsiella pneumoniae carbapenemases (KPCs): an emerging cause of multidrug-resistant infection

J. Antimicrob. Chemother. June 2010 V.65  N.6 p.1119-1125


Elizabeth B. Hirsch1,2 and Vincent H. Tam1,2,*

1 University of Houston College of Pharmacy, Houston, TX, USA 2 St Luke’s Episcopal Hospital, Houston, TX, USA

Bacteria producing Klebsiella pneumoniae carbapenemases (KPCs) are rapidly emerging as a cause of multidrug-resistant infections worldwide. Bacterial isolates harbouring these enzymes are capable of hydrolysing a broad spectrum of β-lactams including the penicillins, cephalosporins, carbapenems and monobactam. Detection of isolates harbouring carbapenemases can be inconsistent using automated systems, often requiring subsequent confirmatory tests. Phenotypic methods utilizing boronic acid disc tests have demonstrated promising results and appear practical for use in clinical microbiology laboratories. Treatment of infection caused by KPC bacteria is particularly worrisome as the carbapenems are often agents of the last resort for resistant Gram-negative infections. The optimal treatment of infections caused by KPC bacteria is not well established and clinical outcome data remain sparse. We reviewed the current literature regarding clinical outcomes following KPC infections, with a specific effort to summarize the clinical data available for specific antimicrobial agents. A total of 15 papers involving 55 unique patient cases were reviewed. While the total number of patients is relatively small, some useful insights could still be gathered to guide clinicians in the management of KPC infections. Tigecycline and the aminoglycosides were associated with positive outcomes in the majority of cases. Clinical success rates were low when the polymyxins were used as monotherapy, but were much higher when they were used in combination. Studies examining combination therapy and well-controlled clinical trials are needed to ascertain the optimal treatment of infections caused by KPC bacteria.  


May 29, 2010 at 7:03 pm Leave a comment

Antibiotic use and impact on outcome from bacteraemic critical illness: the Bacteraemia Study in Intensive Care (BASIC)

J. Antimicrob. Chemother. June 2010 V.65  N.6 p.1276-1285

Alberto Corona1, Guido Bertolini2, Jeff Lipman3, A. Peter Wilson4 and Mervyn Singer1,*

1 Bloomsbury Institute of Intensive Care Medicine, Department of Medicine and Wolfson Institute of Biomedical Research, University College London, Gower Street, London WC1E 6BT, UK 2 Laboratory of Clinical Epidemiology, GiViTI Coordinating Centre, Istituto di Ricerche Farmacologiche Mario Negri, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Ranica (BG), Italy 3 Burns Trauma and Critical Care Research Centre, Royal Brisbane and Women’s Hospital and the University of Queensland, Brisbane, Australia 4 Department of Microbiology, University College London Hospitals NHS Foundation Trust, Windeyer Building, 46 Cleveland St, London W1, UK


The lack of prospective, randomized, controlled trial data to guide optimal antibiotic use in bacteraemic critically ill patients has led to a wide variety of strategies and major issues with drug resistance. We therefore prospectively investigated the epidemiology of bacteraemia and fungaemia in intensive care units (ICUs); and the impact of timing, type and appropriateness of antibiotic intervention.


We conducted a multinational, multicentre, prospective observational study in 132 ICUs from 26 countries with no interventions.


1702 patients [European (69.6%), Australasian (12.2%), South American (8.3%) and Asian (9.9%)] developed 1942 bacteraemic episodes over the study period. Mortality rates were similar for those receiving empirical (40.5%), semi-targeted (37.6%) or fully targeted (33.3%) antibiotic therapy (P = 0.40), and in those initially receiving broad- (39.3%) or restricted-spectrum (39.1%) therapy (P = 0.94). First-line therapy was effective in terms of the antibiogram (where available) in 70.4% of cases. This in vitro susceptibility ranged from 76.3% for broad-spectrum antibiotics to 46.3% for restricted-spectrum antibiotics (P < 0.0001). However, no antibiotic policy-associated variable, including in vitro susceptibility (odds ratio 0.89, 95% confidence interval 0.61–1.30), was a statistically significant predictor of mortality.


We could not show an impact of antibiotics on mortality in critically ill patients, despite in vitro activity and early commencement. Randomized, multicentre trials are urgently needed to establish the appropriate duration, timing and combinations of antibiotics that will both optimally treat infection and minimize development of resistance and other complications.


May 29, 2010 at 7:01 pm Leave a comment

FDA Licensure of Quadrivalent Human Papillomavirus Vaccine (HPV4, Gardasil) for Use in Males and Guidance from the Advisory Committee on Immunization Practices (ACIP)

MMWR  May 28, 2010  V.59 N.20 p.630-632

On October 16, 2009, the Food and Drug Administration licensed quadrivalent human papillomavirus vaccine (HPV4; Gardasil, Merck & Co. Inc.) for use in males aged 9 through 26 years for prevention of genital warts caused by human papillomavirus (HPV) types 6 and 11. HPV4 had been licensed previously for use in females aged 9 through 26 years for prevention of HPV 6, 11, 16, and 18-related outcomes (i.e., vaginal, vulvar, and cervical precancers and cancers and genital warts). The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of females at age 11 or 12 years and catch-up vaccination for females aged 13 through 26 years (1). On October 21, 2009, ACIP provided guidance that HPV4 may be given to males aged 9 through 26 years to reduce their likelihood of acquiring genital warts; ACIP does not recommend HPV4 for routine use among males. This report presents the ACIP policy statement and summarizes background data. Issues reviewed by ACIP included efficacy, immunogenicity, and safety of the HPV4 vaccine in males, epidemiology of HPV and burden of HPV-associated diseases and cancers in males, cost-effectiveness of male vaccination, and programmatic considerations….

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May 28, 2010 at 5:58 pm Leave a comment

FDA Licensure of Bivalent Human Papillomavirus Vaccine (HPV2, Cervarix) for Use in Females and Updated HPV Vaccination Recommendations from the Advisory Committee on Immunization Practices (ACIP)

MMWR  May 28, 2010  V.59 N.20 p.626-629

On October 16, 2009, the Food and Drug Administration (FDA) licensed bivalent human papillomavirus vaccine (HPV2; Cervarix, GlaxoSmithKline) for use in females aged 10 through 25 years. Cervarix is the second human papillomavirus (HPV) vaccine licensed for use in females in the United States. Quadrivalent HPV vaccine (HPV4; Gardasil, Merck & Co, Inc.) was licensed in 2006 for use in females aged 9 through 26 years, and the Advisory Committee on Immunization Practices (ACIP) recommended routine HPV4 vaccination of females aged 11 or 12 years, and catch-up vaccination for females aged 13 through 26 years (1). This report provides updated recommendations for routine and catch-up vaccination of females with either HPV2 or HPV4…..

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May 28, 2010 at 5:57 pm Leave a comment

Novel Influenza A(H1N1) Virus Among Gravid Admissions

Archives of Internal Medicine May 24, 2010  V.170  N.10 p.868-873

Andrew C. Miller, MD; Farnaz Safi, MD; Sadia Hussain, BS; Ramanand A. Subramanian, PhD; Elamin M. Elamin, MD, MSc; Richard Sinert, DO

Departments of Internal Medicine (Dr Miller), Emergency Medicine (Drs Miller, Subramanian, and Sinert), and Obstetrics and Gynecology (Dr Safi), State University of New York Downstate Medical Center and Kings County Hospital Center, Brooklyn; State University of New York Downstate College of Medicine, Brooklyn (Ms Hussain); and Pulmonary, Critical Care, and Sleep Medicine Section, James A. Haley Veterans Hospital, Tampa, Florida (Dr Elamin).


Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population.


We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957.


Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17% (n = 3). Demographically, 2 patients were health care workers (11%); 15 were black (83%); 2, Hispanic (11%); and 1, white (6%). None reported recent travel. Half of the patients presented with gastrointestinal or abdominal complaints; 13 patients met sepsis criteria (72%). The most common comorbidities were asthma, sickle cell disease, and diabetes. Fourteen patients tested positive for H1N1 on DAT (initial or repeated) (78%); in the other 4 cases, H1N1 was identified by viral culture or rRT-PCR (22%). Seven patients delivered during hospitalization (39%), 6 prematurely and 4 via emergency cesarean delivery. There were 2 fetal deaths (11%). No maternal mortality was recorded.


Admitted pregnant patients with H1N1 are at risk for obstetrical complications including fetal distress, premature delivery, emergency cesarean delivery, and fetal death. A high number of patients presented with gastrointestinal and abdominal complaints. Early antiviral treatment may improve maternal outcomes.



May 26, 2010 at 5:05 pm Leave a comment

Differing Symptom Patterns in Early Pandemic vs Seasonal Influenza Infections

Archives of Internal Medicine May 24, 2010  V.170  N.10 p.861-867

Julian Wei-Tze Tang, PhD, MRCP, MRCPath; Paul A. Tambyah, MBBS; Florence Yuk Lin Lai, MSc; Hong Kai Lee, BSc; Chun Kiat Lee, BSc; Tze Ping Loh, MD; Lily Chiu, MSc; Evelyn Siew-Chuan Koay, PhD, FRCPath

Molecular Diagnosis Centre, Department of Laboratory Medicine, National University Hospital (Drs Tang, Loh, and Koay, Messrs H. K. Lee and C. K. Lee, and Ms Chiu), Departments of Medicine (Dr Tambyah) and Pathology (Dr Koay), Yong Loo Lin School of Medicine, National University of Singapore, and Communicable Diseases Division, Ministry of Health (Ms Lai), Singapore.


Singapore is a tropical country with a temperature range of 23°C to 35°C and relative humidity of 48% to 100% throughout the year. Influenza incidence peaks in June through July and November through January, though influenza cases can be detected throughout the year.


Between May 1 and July 28, 2009, a novel dual-gene diagnostic polymerase chain reaction assay targeting the hemagglutinin (HA) and nucleoprotein (NP) genes of the new influenza A(H1N1/2009) virus was specifically designed for enhanced influenza surveillance using nasopharyngeal swabs collected from symptomatic patients (including their close contacts) and returning travelers returning from influenza A(H1N1/2009)–affected areas, presenting to affiliated primary care clinics as well as the main hospital emergency department.


From the week of June 16 to June 23, 2009, this pandemic influenza A(H1N1/2009) displaced and then replaced the seasonal influenzas (H3N2, H1N1, and B). Of 2683 samples tested during this 12-week surveillance period, 742 (27.6%) were positive for any influenza virus using this assay, with 547 cases of A(H1N1/2009) (20.4%), 167 cases of A(H3N2) (6.2%), 14 cases of A(H1N1) (0.5%), and 12 cases of influenza B (0.4%). Results of multivariate analysis showed that age (P < .001), fever (P < .001), cough (P < .001), sore throat (P = .002), rhinorrhea (P = .001), and dyspnea (P < .001) were significantly different among these groups.


From this large prospective study, there was a lower incidence of fever and dyspnea in patients with pandemic influenza A(H1N1/2009) infection. Similar to reports from elsewhere, it was also found that this pandemic virus tends to infect younger people, though with fewer symptoms, on average, than seasonal influenza. Early pandemic influenza A(H1N1/2009) infections appeared to be slightly milder than seasonal influenza as indicated by different symptom patterns in the presentation of more than 500 cases of influenza A(H1N1/2009) during April through July to a large teaching hospital in Singapore.


May 26, 2010 at 5:00 pm Leave a comment

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