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….

Full Text

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

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