Archive for April, 2011

The diagnosis and management of prosthetic joint infections

Journal of Antimicrobial Chemotherapy  NOV.2010 V.65 N.Suppl.3  P.45-54

E. Moran1,2,*, I. Byren1,2 and B. L. Atkins1,2

1Department of Microbiology and Infectious Disease, John Radcliffe Hospital, Oxford OX3 9DU, UK

2Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK

Abstract

A host of technical and operative improvements have seen the rates of infection associated with joint replacement reach historic lows. However, the increasing number of operations being performed means that the absolute number of such infections remains significant. Diagnosis may be challenging and delaying appropriate treatment can lead to reduced joint function and the need for more complex, perhaps multiple, procedures. Individual centres tend to see small numbers of such cases, and in the absence of large clinical trials management varies. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Such packages of care are best delivered by a multidisciplinary team composed of orthopaedic and plastic surgeons, microbiologists, infectious disease physicians, specialist nurses, physiotherapists and occupational therapists. Each treatment plan must be developed in consultation with the patient, taking into account their aims and realistic goals. This review provides an overview of current understanding regarding diagnosis and treatment of prosthetic joint infections and suggests a treatment algorithm.

abstract

http://jac.oxfordjournals.org/content/65/suppl_3/iii45.abstract?etoc

PDF

http://jac.oxfordjournals.org/content/65/suppl_3/iii45.full.pdf+html

April 16, 2011 at 12:07 am Leave a comment

A CD4+ Cell Count <200 Cells per Cubic Millimeter at 2 Years After Initiation of Combination Antiretroviral Therapy Is Associated With Increased Mortality in HIV-Infected Individuals With Viral Suppression

JAIDS  Journal of Acquired Immune Deficiency Syndromes 1 Dec 2010  V.55  N.4  P.451-459

Clinical Science

Loutfy, Mona R; Genebat, Miguel; Moore, David; Raboud, Janet; Chan, Keith; Antoniou, Tony; Milan, David; Shen, Anya; Klein, Marina B; Cooper, Curtis; Machouf, Nima; Rourke, Sean B; Rachlis, Anita; Tsoukas, Chris; Montaner, Julio S G; Walmsley, Sharon L; Smieja, Marek; Bayoumi, Ahmed; Mills, Edward; Hogg, Robert S; and the CANOC Collaboration

Abstract:

Objective

To determine the long-term impact of immunologic discordance (viral load <50 copies/mL and CD4 count ≤200 cells/mm) in antiretroviral-naive patients initiating combination antiretroviral therapy (cART).

Methods

Our analysis included antiretroviral-naive individuals from a population-based Canadian Observational Cohort that initiated cART after January 1, 2000, and achieved virologic suppression. Multivariable Cox proportional hazards regression was used to examine the association between 1-year and 2-year immunologic discordance and time to death from all-causes. Correlates of immunologic discordance were assessed with logistic regression.

Results

Immunologic discordance was observed in 19.9% (404 of 2028) and 10.2% (176 of 1721) of individuals at 1 and 2 years after cART initiation, respectively. Two-year immunologic discordance was associated with an increased risk of death [adjusted hazard ratio = 2.69; 95% confidence interval (CI): 1.26 to 5.78]. One-year immunologic discordance was not associated with death (adjusted hazard ratio = 1.12; 95% CI: 0.54 to 2.30). Two-year immunologic discordance was associated with older age (aOR per decade = 1.23; 95% CI: 1.03 to 1.48), male gender (aOR = 1.86; 95% CI: 1.09 to 3.16), injection drug use (aOR = 2.75; 95% CI: 1.81 to 4.17), and lower baseline CD4

count (aOR per 100 cells = 0.24; 95% CI: 0.19 to 0.31) and viral load (aOR per log copies/mL = 0.46; 95% CI: 0.33 to 0.65).

Conclusions

Immunologic discordance after 2 years of cART in antiretroviral-naive individuals was significantly associated with an increased risk of mortality.

abstract

http://journals.lww.com/jaids/toc/2010/12010

April 16, 2011 at 12:04 am Leave a comment

Human Rabies – Michigan, 2009

MMWR Weekly April 15, 2011  V.60  N.14 P.437-440

REPORTS 

On November 9, 2009, aMichiganhospital informed CDC of suspected rabies in a man aged 55 years. The patient reportedly had awakened with a bat on his arm 9 months earlier but had not sought medical evaluation. He went to a local emergency department (ED) on October 30 and soon after was hospitalized; he died 12 days later. On November 14, CDC confirmed infection with a rabies virus variant that commonly infects the silver-haired bat (Lasionycteris noctivagans). This report summarizes the patient’s clinical course and the associated public health investigation. The report highlights the importance of public awareness of rabies, particularly among persons who might be at risk for wildlife exposures. Persons who experience contact with a bat and cannot confidently rule out a bite or scratch should seek prompt medical attention……

Full Text

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6014a1.htm?s_cid=mm6014a1_e&source=govdelivery

PDF

http://www.cdc.gov/mmwr/pdf/wk/mm6014.pdf

April 16, 2011 at 12:02 am Leave a comment

Spondylodiscitis: update on diagnosis and management

Journal of Antimicrobial Chemotherapy  NOV.2010 V.65 N.Suppl.3  P.11-24

Theodore Gouliouris*, Sani H. Aliyu and Nicholas M. Brown

Clinical Microbiology and Public Health Laboratory, Addenbrooke’s Hospital, Cambridge CB2 0QW, UK

Abstract

Spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis, is the main manifestation of haematogenous osteomyelitis in patients aged over 50 years. Staphylococcus aureus is the predominant pathogen, accounting for about half of non-tuberculous cases. Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. In this review of the published literature, we found no randomized trials on treatment and studies were too heterogeneous to allow comparison. Improvements in surgical and radiological techniques and the discovery of antimicrobial therapy have transformed the outlook for patients with this condition, but morbidity remains significant. Randomized trials are needed to assess optimal treatment duration, route of administration, and the role of combination therapy and newer agents.

abstract

http://jac.oxfordjournals.org/content/65/suppl_3/iii11.abstract?etoc

PDF

http://jac.oxfordjournals.org/content/65/suppl_3/iii11.full.pdf+html

April 11, 2011 at 1:04 pm Leave a comment

Increasing burden of liver disease in patients with HIV infection

LANCET  02 Apr 2011  V.377 N.9772 P.1198 – 1209

Deepak Joshi MRCP a, John O’Grady MD a, Prof Doug Dieterich MD b, Prof Brian Gazzard MD c, Dr Kosh Agarwal MD

Summary

Introduction of effective combined antiretroviral therapy has made HIV infection a chronic illness. Substantial reductions in the number of AIDS-related deaths have been accompanied by an increase in liver-related morbidity and mortality due to co-infection with chronic hepatitis B and C viruses. Increases in non-alcoholic fatty liver disease and drug-induced hepatotoxicity, together with development of hepatocellular carcinoma, also potentiate the burden of liver disease in individuals with HIV infection. We provide an overview of the key causes, disease mechanisms of pathogenesis, and recommendations for treatment options including the evolving role of liver transplantation.

abstract

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2962001-6/abstract?elsca1=TL-010411&elsca2=email&elsca3=segment

April 11, 2011 at 1:02 pm Leave a comment

Viral pneumonia

Lancet 9 April 2011 V.377 N.9773 P.1264 – 1275

Prof Olli Ruuskanen MD a , Elina Lahti MD a, Lance C Jennings PhD b, Prof David R Murdoch MD b

Summary

About 200 million cases of viral community-acquired pneumonia occur every year—100 million in children and 100 million in adults. Molecular diagnostic tests have greatly increased our understanding of the role of viruses in pneumonia, and findings indicate that the incidence of viral pneumonia has been underestimated. In children, respiratory syncytial virus, rhinovirus, human metapneumovirus, human bocavirus, and parainfluenza viruses are the agents identified most frequently in both developed and developing countries. Dual viral infections are common, and a third of children have evidence of viral-bacterial co-infection. In adults, viruses are the putative causative agents in a third of cases of community-acquired pneumonia, in particular influenza viruses, rhinoviruses, and coronaviruses. Bacteria continue to have a predominant role in adults with pneumonia. Presence of viral epidemics in the community, patient’s age, speed of onset of illness, symptoms, biomarkers, radiographic changes, and response to treatment can help differentiate viral from bacterial pneumonia. However, no clinical algorithm exists that will distinguish clearly the cause of pneumonia. No clear consensus has been reached about whether patients with obvious viral community-acquired pneumonia need to be treated with antibiotics. Apart from neuraminidase inhibitors for pneumonia caused by influenza viruses, there is no clear role for use of specific antivirals to treat viral community-acquired pneumonia. Influenza vaccines are the only available specific preventive measures. Further studies are needed to better understand the cause and pathogenesis of community-acquired pneumonia. Furthermore, regional differences in cause of pneumonia should be investigated, in particular to obtain more data from developing countries.

Abstract

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961459-6/abstract?elsca1=TL-080411&elsca2=email&elsca3=segment

April 11, 2011 at 1:00 pm Leave a comment

Colistin-Tobramycin Combinations Are Superior to Monotherapy Concerning the Killing of Biofilm Pseudomonas aeruginosa

Journal of Infectious Diseases 15 Nov  2010  V.202  N.10 P.1585-1592

Gloria Herrmann1, Liang Yang3, Hong Wu4, Zhijun Song4, Hengzhuang Wang4, Niels Høiby4, Martina Ulrich1, Søren Molin3, Joachim Riethmüller2 and Gerd Döring1

1Institute of Medical Microbiology and Hygiene, Tübingen, Germany

2Childrens Hospital, Universitätsklinikum, University of Tübingen, Tübingen, Germany

3Department of Systems Biology, Technical University of Denmark, Lyngby

4Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark

Abstract

Background

Antibiotic combination therapy might be more efficient than single antibiotics to combat Pseudomonas aeruginosa biofilms in the airways of patients with cystic fibrosis. We tested the ability of colistin sulphate-tobramycin combinations and single antibiotics to kill P. aeruginosa biofilms.

Methods

P. aeruginosa biofilms were generated in vitro and in rat lungs. In a pilot study, 5 patients with cystic fibrosis inhaled colistin and then tobramycin for 4 weeks. The changes in P. aeruginosa counts and lung function were assessed before and after therapy.

Results

Antibiotic combination therapy significantly reduced the number of P. aeruginosa cells in P. aeruginosa biofilm models in vitro. When rats were challenged with 1 × 107 cfu of P. aeruginosa, which was embedded in alginate beads, mortality rates, lung pathologic findings, and bacterial colony-forming unit counts were significantly lower after 7 days in animals receiving antibiotic combination than in animals receiving single antibiotics. In patients with cystic fibrosis, inhaled colistin-tobramycin was well tolerated and resulted in a mean decrease of 2.52 ± 2.5 log10 cfu of P. aeruginosa per milliliter of sputum (P = .027). Measurements of forced expiratory volume in 1 s, obtained both before and after the study, did not differ significantly.

Conclusion

Colistin-tobramycin combinations are more efficient than respective single antibiotics for killing P. aeruginosa in biofilms in vitro, and they significantly reduced P. aeruginosa cell counts in a rat lung infection model and in patients with cystic fibrosis.

abstract

http://jid.oxfordjournals.org/content/202/10/1585.abstract

April 11, 2011 at 12:57 pm Leave a comment

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