Archive for July, 2010

One Health Approach to Influenza: Assessment of Critical Issues and Options

EID August 2010  V.16  N.8

Conference Summary

Thomas F. Powdrill, Terry L. Nipp, and Jennifer L. Rinderknecht

Texas A&M University, College Station, Texas, USA

A task force of experts on influenza, public health, and animal health met at the conference One Health Approach to Influenza: Assessment of Critical Issues and Options in Washington, DC, on December 1–2, 2009. These experts discussed the role of the One Health approach in preparing for and responding to an influenza pandemic or other emerging zoonotic disease by using pandemic (H1N1) 2009 as a case study. The meeting was convened by the US Department of Homeland Security National Center for Foreign Animal and Zoonotic Disease Defense, and the National Institute of Allergy and Infectious Diseases/National Institutes of Health Western Regional Center of Excellence for Biodefense and Emerging Infectious Diseases….

Full Text

http://www.cdc.gov/eid/content/16/8/e1.htm

July 31, 2010 at 6:10 pm Leave a comment

Lethal Necrotizing Pneumonia Caused by an ST398 Staphylococcus aureus Strain

EID August 2010  V.16  N.8 p.1330

Letter

PJean-Philippe Rasigade, Frederic Laurent, Philippe Hubert, François Vandenesch, and Jerome Etienne

Hospices Civils de Lyon, Lyon, France (J.P. Rasigade, F. Laurent, J. Etienne, F. Vandenesch); and Assistance Publique–Hôpitaux de Paris, Paris, France (P. Hubert)

To the Editor: Several recent studies have shown massive colonization of livestock (especially pigs) and livestock workers by methicillin-resistant Staphylococcus aureus (MRSA) in western Europe, Canada, and the United States…

Full Text

http://www.cdc.gov/eid/content/16/8/1330.htm

PDF

http://www.cdc.gov/eid/content/16/8/pdfs/1330.pdf

July 31, 2010 at 6:02 pm Leave a comment

Leptospira Serovar as Prognostic Factor

EID August 2010  V.16  N.8 p.1333

Letter

To the Editor: Herrmann-Storck et al. (1) investigated prognostic factors of leptospirosis and concluded that infection with Leptospira interrogans serovar Icterohemorrhagiae was linked to severe outcomes. We have concerns about this conclusion….

Full Text

http://www.cdc.gov/eid/content/16/8/1333.htm     

PDF

http://www.cdc.gov/eid/content/16/8/pdfs/1333.pdf

July 31, 2010 at 5:57 pm Leave a comment

Early versus Standard Antiretroviral Therapy for HIV-Infected Adults in Haiti

N Engl J of Medicine Jul.15, 2010 V.363  N.3  p.257-265

Patrice Severe, M.D., Marc Antoine Jean Juste, M.D., Alex Ambroise, M.D., Ludger Eliacin, M.D., Claudel Marchand, M.D., Sandra Apollon, B.S., Alison Edwards, M.S., Heejung Bang, Ph.D., Janet Nicotera, R.N., Catherine Godfrey, M.D., Roy M. Gulick, M.D., Warren D. Johnson, Jr., M.D., Jean William Pape, M.D., and Daniel W. Fitzgerald, M.D.

ABSTRACT

Background

For adults with human immunodeficiency virus (HIV) infection who have CD4+ T-cell counts that are greater than 200 and less than 350 per cubic millimeter and who live in areas with limited resources, the optimal time to initiate antiretroviral therapy remains uncertain.

Methods

We conducted a randomized, open-label trial of early initiation of antiretroviral therapy, as compared with the standard timing for initiation of therapy, among HIV-infected adults in Haiti who had a confirmed CD4+ T-cell count that was greater than 200 and less than 350 per cubic millimeter at baseline and no history of an acquired immunodeficiency syndrome (AIDS) illness. The primary study end point was survival. The early-treatment group began taking zidovudine, lamivudine, and efavirenz therapy within 2 weeks after enrollment. The standard-treatment group started the same regimen of antiretroviral therapy when their CD4+ T-cell count fell to 200 per cubic millimeter or less or when clinical AIDS developed. Participants in both groups underwent monthly follow-up assessments and received isoniazid and trimethoprim–sulfamethoxazole prophylaxis with nutritional support.

Results

Between 2005 and 2008, a total of 816 participants — 408 per group — were enrolled and were followed for a median of 21 months. The CD4+ T-cell count at enrollment was approximately 280 per cubic millimeter in both groups. There were 23 deaths in the standard-treatment group, as compared with 6 in the early-treatment group (hazard ratio with standard treatment, 4.0; 95% confidence interval [CI], 1.6 to 9.8; P=0.001). There were 36 incident cases of tuberculosis in the standard-treatment group, as compared with 18 in the early-treatment group (hazard ratio, 2.0; 95% CI, 1.2 to 3.6; P=0.01).

Conclusions

Early initiation of antiretroviral therapy decreased the rates of death and incident tuberculosis. Access to antiretroviral therapy should be expanded to include all HIV-infected adults who have CD4+ T-cell counts of less than 350 per cubic millimeter, including those who live in areas with limited resources. (ClinicalTrials.gov number, NCT00120510 [ClinicalTrials.gov].)

abstract

http://content.nejm.org/cgi/content/full/363/3/257?query=TOC

PDF

http://content.nejm.org/cgi/reprint/363/3/257.pdf

July 27, 2010 at 6:47 pm Leave a comment

Meropenem dosing in critically ill patients with sepsis and without renal dysfunction: intermittent bolus versus continuous administration? Monte Carlo dosing simulations and subcutaneous tissue distribution.

J Antimicrob Chemother July 2009 V.64 N.1 p.142–50.

Jason A. Roberts1,2,3,*, Carl M. J. Kirkpatrick4, Michael S. Roberts5, Thomas A. Robertson5, Andrew J. Dalley1 and Jeffrey Lipman1,3

1 Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia 2 Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, Australia 3 Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, Australia 4 School of Pharmacy, The University of Queensland, Brisbane, Australia 5 Therapeutics Research Unit, The University of Queensland, Brisbane, Australia

Objectives

To compare the plasma and subcutaneous tissue concentration–time profiles of meropenem administered by intermittent bolus dosing or continuous infusion to critically ill patients with sepsis and without renal dysfunction, and to use population pharmacokinetic modelling and Monte Carlo simulations to assess the cumulative fraction of response (CFR) against Gram-negative pathogens likely to be encountered in critical care units.

Patients and methods

We randomized 10 patients with sepsis to receive meropenem by intermittent bolus administration (n = 5; 1 g 8 hourly) or an equal dose administered by continuous infusion (n = 5). Serial subcutaneous tissue concentrations were determined using microdialysis and compared with plasma data for first-dose and steady-state pharmacokinetics. Population pharmacokinetic modelling of plasma data and Monte Carlo simulations were then undertaken with NONMEM®.

Results

It was found that continuous infusion maintains higher median trough concentrations, in both plasma (intermittent bolus 0 versus infusion 7 mg/L) and subcutaneous tissue (0 versus 4 mg/L). All simulated intermittent bolus, extended and continuous infusion dosing achieved 100% of pharmacodynamic targets against most Gram-negative pathogens. Superior obtainment of pharmacodynamic targets was achieved using administration by extended or continuous infusion against less susceptible Pseudomonas aeruginosa and Acinetobacter species.

Conclusions

This is the first study to compare the relative concentration–time data of bolus and continuous administration of meropenem at the subcutaneous tissue and plasma levels. We found that the administration of meropenem by continuous infusion maintains higher concentrations in subcutaneous tissue and plasma than by intermittent bolus dosing. Administration by extended or continuous infusion will achieve superior CFR against less-susceptible organisms in patients without renal dysfunction.

abstract

http://jac.oxfordjournals.org/cgi/content/abstract/64/1/142

PDF

http://jac.oxfordjournals.org/cgi/reprint/64/1/142

July 27, 2010 at 6:39 pm Leave a comment

Outcomes with daptomycin in the treatment of Staphylococcus aureus infections with a range of vancomycin MICs

J. Antimicrob. Chemother. August 2010  V.65  N.8  p.1784-1791

Jason A. Crompton1, Donald S. North1, MinJung Yoon1, Judith N. Steenbergen1, Kenneth C. Lamp1,* and Graeme N. Forrest2

1 Cubist Pharmaceuticals, 65 Hayden Ave, Lexington, MA 02421, USA 2 Portland VA Medical Center, 3701 SW US Veterans Hospital Rd, P3-ID, Portland, OR 97239, USA

Objectives

Recent recommendations by the Infectious Diseases Society of America for the treatment of Staphylococcus aureus suggest the use of alternative agents when vancomycin MIC values are 2 mg/L. This study examines the outcome of patients treated with daptomycin for S. aureus infections with documented vancomycin MICs.

Patients and methods

All patients with skin, bacteraemia and endocarditis infections due to S. aureus with vancomycin MIC values in CORE 2005–08, a retrospective, multicentre, observational registry, were studied. The outcome (cure, improved, failure or non-evaluable) was the investigator assessment at the end of daptomycin therapy. Success was defined as cure or improved.

Results

Five hundred and forty-seven clinically evaluable patients were identified with discrete vancomycin MIC values [MIC <2 mg/L: 451 (82%); MIC 2 mg/L: 96 (18%)]. The vancomycin MIC groups were well matched for patient characteristics, types of infections, first-line daptomycin use (19%) and prior vancomycin use (58%). Clinical success was reported in 94% of patients. No differences were detected in the daptomycin success rate by the vancomycin MIC group overall or by the infection type. A multivariate logistic regression also failed to identify vancomycin MIC as a predictor of daptomycin failure. Adverse event (AE) rates were not different when analysed by MIC group; both groups had 17% of patients with one AE.

Conclusions

In this diverse population, daptomycin was associated with similar outcomes for patients, regardless of whether the vancomycin MIC was categorized as <2 or 2 mg/L. Further studies are warranted.

abstract

http://jac.oxfordjournals.org/cgi/content/abstract/65/8/1784?etoc

PDF

http://jac.oxfordjournals.org/cgi/reprint/65/8/1784

July 27, 2010 at 12:03 pm Leave a comment

A rifampicin-containing antibiotic treatment improves outcome of staphylococcal deep sternal wound infections

J. Antimicrob. Chemother. August 2010  V.65  N.8  p.1799-1806

Bettina Khanlari1,, Luigia Elzi1,, Laura Estermann1, Maja Weisser1, Wolfgang Brett2, Martin Grapow2, Manuel Battegay1, Andreas F. Widmer1 and Ursula Flückiger1,*

1 Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland 2 Department of Cardiovascular Surgery, University Hospital Basel, Basel, Switzerland

Background

Deep sternal wound infection (DSWI) is a severe complication after cardiac surgery, mostly caused by staphylococci. Little is known about the optimal antibiotic management.

Methods

A 10 year retrospective analysis of 100 patients with staphylococcal DSWI after cardiac surgery in a tertiary hospital. Treatment failure was defined as sternal wound dehiscence or fistula at the end of the prescribed antibiotic therapy, 12 months later, or DSWI-related death.

Results

Most patients were male (83%) and the median age was 72 years [interquartile range (IQR) 63–76]. Coronary artery bypass was the most frequent preceding procedure (93%). The median time to diagnosis of DSWI was 13 days (IQR 10–18) after surgery. Clinical presentation consisted of wound discharge in 77% of patients. Coagulase-negative staphylococci were isolated in 54 and Staphylococcus aureus in 46 patients. All patients received antibiotics and 95% underwent surgical debridement. The median duration of antibiotic treatment was 47 days (IQR 41–78). During follow-up, 21 out of 100 patients experienced treatment failure. Of these, 8/21 patients (38%) died from DSWI after a median of 12 days (IQR 8–30). In the multivariate analysis, a rifampicin-containing antibiotic regimen was the only factor associated with lower risk of treatment failure (hazard ratio 0.26, 95% confidence interval 0.10–0.64, P = 0.004). Prolonged treatment (12 weeks instead of 6 weeks) did not alter outcome (P = 0.716) in patients without prosthetic valve endocarditis.

Conclusions

Treatment of rifampicin-susceptible staphylococcal DSWI with a rifampicin-containing antibiotic regimen may improve the outcome. After surgical debridement an antibiotic treatment of 6 weeks may be adequate for staphylococcal DSWI.

abstract

http://jac.oxfordjournals.org/cgi/content/abstract/65/8/1799?etoc

July 27, 2010 at 12:02 pm Leave a comment

Carbapenem-resistant Acinetobacter baumannii and Klebsiella pneumoniae across a hospital system: impact of post-acute care facilities on dissemination

J. Antimicrob. Chemother. August 2010  V.65  N.8  p.1807-1818

Federico Perez1,2,3, Andrea Endimiani1,3, Amy J. Ray2,3, Brooke K. Decker3, Christopher J. Wallace1, Kristine M. Hujer1, David J. Ecker4, Mark D. Adams5, Philip Toltzis6, Michael J. Dul6, Anne Windau7, Saralee Bajaksouzian7, Michael R. Jacobs7, Robert A. Salata2,3 and Robert A. Bonomo1,3,8,9,*

1 Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, 10701 East Blvd, Cleveland, OH 44106, USA 2 Division of Infectious Diseases and HIV Medicine, University Hospitals Case Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA 3 Department of Medicine, Case Western Reserve School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA 4 Ibis Biosciences, Abbott Molecular, 1896 Rutherford Rd, Carlsbad, CA 92024, USA 5 Department of Genetics, Case Western Reserve School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA 6 Rainbow Babies and Children’s Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA 7 Department of Pathology, Case Western Reserve School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA 8 Department of Molecular Biology and Microbiology, Case Western Reserve School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA 9 Department of Pharmacology, Case Western Reserve School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA

Background

Resistance to carbapenems among Acinetobacter baumannii and Klebsiella pneumoniae presents a serious therapeutic and infection control challenge. We describe the epidemiology and genetic basis of carbapenem resistance in A. baumannii and K. pneumoniae in a six-hospital healthcare system in Northeast Ohio.

Methods

Clinical isolates of A. baumannii and K. pneumoniae distributed across the healthcare system were collected from April 2007 to April 2008. Antimicrobial susceptibility testing was performed followed by molecular analysis of carbapenemase genes. Genetic relatedness of isolates was established with repetitive sequence-based PCR (rep-PCR), multilocus PCR followed by electrospray ionization mass spectrometry (PCR/ESI-MS) and PFGE. Clinical characteristics and outcomes of patients were reviewed.

Results

Among 39 isolates of A. baumannii, two predominant genotypes related to European clone II were found. Eighteen isolates contained blaOXA-23, and four isolates possessed blaOXA-24/40. Among 29 K. pneumoniae isolates with decreased susceptibility to carbapenems, two distinct genotypes containing blaKPC-2 or blaKPC-3 were found. Patients with carbapenem-resistant A. baumannii and K. pneumoniae were elderly, possessed multiple co-morbidities, were frequently admitted from and discharged to post-acute care facilities, and experienced prolonged hospital stays (up to 25 days) with a high mortality rate (up to 35%).

Conclusion

In this outbreak of carbapenem-resistant A. baumannii and K. pneumoniae across a healthcare system, we illustrate the important role post-acute care facilities play in the dissemination of multidrug-resistant phenotypes.

abstract

http://jac.oxfordjournals.org/cgi/content/abstract/65/8/1807?etoc

July 27, 2010 at 12:00 pm Leave a comment

Antiretroviral Treatment of Adult HIV Infection – 2010 Recommendations of the International AIDS Society–USA Panel

JAMA 14 July 2010  V.304  N.2  p.321-333

CLINICIAN’S CORNER

Melanie A. Thompson, MD; Judith A. Aberg, MD; Pedro Cahn, MD; Julio S. G. Montaner, MD; Giuliano Rizzardini, MD; Amalio Telenti, MD, PhD; José M. Gatell, MD, PhD; Huldrych F. Günthard, MD; Scott M. Hammer, MD; Martin S. Hirsch, MD; Donna M. Jacobsen, BS; Peter Reiss, MD, PhD; Douglas D. Richman, MD; Paul A. Volberding, MD; Patrick Yeni, MD; Robert T. Schooley, MD

AIDS Research Consortium of Atlanta, Atlanta, Georgia (Dr Thompson); University of California San Diego, La Jolla (Dr Schooley); New York University School of Medicine, New York (Dr Aberg); Hospital Juan Fernandez/University of Buenos Aires Medical School and Fundacion Huesped, Argentina (Dr Cahn); Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain (Dr Gatell); University Hospital Zurich, Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland (Dr Günthard); Columbia University College of Physicians and Surgeons, New York, New York (Dr Hammer); Harvard Medical School, Boston, Massachusetts (Dr Hirsch); International AIDS Society–USA, San Francisco, California (Ms Jacobsen); BC-Centre for Excellence in HIV/AIDS, Providence Health Care and University of British Columbia, Vancouver, Canada (Dr Montaner); Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (Dr Reiss); University of California San Diego and Veterans Affairs San Diego Healthcare System (Dr Richman); Luigi Sacco Hospital, Milan, Italy (Dr Rizzardini); University Hospital of Lausanne, Lausanne, Switzerland (Dr Telenti); University of California San Francisco and San Francisco Veterans Affairs Medical Center (Dr Volberding); and Hôpital Bichat-Claude Bernard and Xavier Bichat Medical School, Paris, France (Dr Yeni).

Context

Recent data regarding the consequences of untreated human immunodeficiency virus (HIV) infection and the expansion of treatment choices for antiretroviral-naive and antiretroviral-experienced patients warrant an update of the International AIDS Society–USA guidelines for the use of antiretroviral therapy in adults with HIV infection.

Objectives

To provide updated recommendations for management of HIV-infected adults, using antiretroviral drugs and laboratory monitoring tools available in the international, developed-world setting. This report provides guidelines for when to initiate antiretroviral therapy, selection of appropriate initial regimens, patient monitoring, when to change therapy, and what regimens to use when changing.

Data Sources and Study Selection

A panel with expertise in HIV research and clinical care reviewed relevant data published or presented at selected scientific conferences since the last panel report through April 2010. Data were identified through a PubMed search, review of scientific conference abstracts, and requests to antiretroviral drug manufacturers for updated clinical trials and adverse event data.

Data Extraction and Synthesis

New evidence was reviewed by the panel. Recommendations were drafted by section writing committees and reviewed and edited by the entire panel. The quality and strength of the evidence were rated and recommendations were made by full panel consensus.

Conclusions

Patient readiness for treatment should be confirmed before initiation of antiretroviral treatment. Therapy is recommended for asymptomatic patients with a CD4 cell count 500/µL, for all symptomatic patients, and those with specific conditions and comorbidities. Therapy should be considered for asymptomatic patients with CD4 cell count >500/µL. Components of the initial and subsequent regimens must be individualized, particularly in the context of concurrent conditions. Patients receiving antiretroviral treatment should be monitored regularly; treatment failure should be detected and managed early, with the goal of therapy, even in heavily pretreated patients, being HIV-1 RNA suppression below commercially available assay quantification limits.

abstract

http://jama.ama-assn.org/cgi/content/abstract/304/3/321

July 23, 2010 at 12:28 pm Leave a comment

Triatoma infestans Bugs in Southern Patagonia, Argentina

Emerging Infectious Diseases May 2010  V.16  N.5  p.887-889

Letter

Romina V. Piccinali,  Delmi M. Canale, Alejandra E. Sandoval, Marta V. Cardinal, Oscar Jensen, Uriel Kitron, and Ricardo E. Gürtler

Universidad de Buenos Aires, Buenos Aires, Argentina (R.V. Piccinali, M.V. Cardinal, R.E. Gürtler); Coordinación Nacional de Control de Vectores, Córdoba, Argentina (D.M. Canale); Secretaría de Salud de Chubut, Chubut, Argentina (A.E. Sandoval, O. Jensen); and Emory University, Atlanta, Georgia, USA (U. Kitron)

To the Editor: Triatoma infestans bugs, the main vector of Chagas disease, historically occupied a large area from northeastern Brazil to Chubut Province in Patagonia, Argentina (1). Large-scale insecticide spraying during the 1980s and 1990s reduced its geographic range and abundance and interrupted transmission of Trypanosoma cruzi, mainly in Uruguay, Chile, and Brazil (2). However, T. infestans and transmission of T. cruzi persist in the Gran Chaco, a large ecoregion in Argentina, Bolivia, and Paraguay …

Full Text

http://www.cdc.gov:80/eid/content/16/5/887.htm  

PDF

http://www.cdc.gov/eid/content/16/5/pdfs/887.pdf

July 22, 2010 at 6:20 pm Leave a comment

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