Archive for May, 2011

Bacterial Meningitis in the United States, 1998–2007

N Engl J of Medicine May 26, 2011 V.364  P.2016-2025

Michael C. Thigpen, M.D., Cynthia G. Whitney, M.D., M.P.H., Nancy E. Messonnier, M.D., Elizabeth R. Zell, M.Stat., Ruth Lynfield, M.D., James L. Hadler, M.D., M.P.H., Lee H. Harrison, M.D., Monica M. Farley, M.D., Arthur Reingold, M.D., Nancy M. Bennett, M.D., Allen S. Craig, M.D., William Schaffner, M.D., Ann Thomas, M.D., Melissa M. Lewis, M.P.H., Elaine Scallan, Ph.D., and Anne Schuchat, M.D. for the Emerging Infections Programs Network


The rate of bacterial meningitis declined by 55% in theUnited Statesin the early 1990s, when the Haemophilus influenzae type b (Hib) conjugate vaccine for infants was introduced. More recent prevention measures such as the pneumococcal conjugate vaccine and universal screening of pregnant women for group B streptococcus (GBS) have further changed the epidemiology of bacterial meningitis.


We analyzed data on cases of bacterial meningitis reported among residents in eight surveillance areas of the Emerging Infections Programs Network, consisting of approximately 17.4 million persons, during 1998–2007. We defined bacterial meningitis as the presence of H. influenzae, Streptococcus pneumoniae, GBS, Listeria monocytogenes, or Neisseria meningitidis in cerebrospinal fluid or other normally sterile site in association with a clinical diagnosis of meningitis.


We identified 3188 patients with bacterial meningitis; of 3155 patients for whom outcome data were available, 466 (14.8%) died. The incidence of meningitis changed by −31% (95% confidence interval [CI], −33 to −29) during the surveillance period, from 2.00 cases per 100,000 population (95% CI, 1.85 to 2.15) in 1998–1999 to 1.38 cases per 100,000 population (95% CI 1.27 to 1.50) in 2006–2007. The median age of patients increased from 30.3 years in 1998–1999 to 41.9 years in 2006–2007 (P<0.001 by the Wilcoxon rank-sum test). The case fatality rate did not change significantly: it was 15.7% in 1998–1999 and 14.3% in 2006–2007 (P=0.50). Of the 1670 cases reported during 2003–2007, S. pneumoniae was the predominant infective species (58.0%), followed by GBS (18.1%), N. meningitidis (13.9%), H. influenzae (6.7%), and L. monocytogenes (3.4%). An estimated 4100 cases and 500 deaths from bacterial meningitis occurred annually in theUnited Statesduring 2003–2007.


The rates of bacterial meningitis have decreased since 1998, but the disease still often results in death. With the success of pneumococcal and Hib conjugate vaccines in reducing the risk of meningitis among young children, the burden of bacterial meningitis is now borne more by older adults. (Funded by the Emerging Infections Programs, Centers for Disease Control and Prevention.)



May 29, 2011 at 2:09 pm Leave a comment

How Staphylococcus aureus Adapts to Its Host

N Engl J of Medicine May 26, 2011 V.364  P.1987-1990


Franklin D. Lowy, M.D.

As a pathogen, Staphylococcus aureus is well adapted to humans. It can live as a commensal but, provided a suitable opportunity, can initiate severe infection at various body sites. Structural components functioning in concert with secreted products of S. aureus can efficiently target human tissues and evade host defense mechanisms. As a result, S. aureus continues to cause diverse invasive, life-threatening infections despite the availability of effective antimicrobial agents …



May 29, 2011 at 2:08 pm Leave a comment

A potential role for daptomycin in enterococcal infections: what is the evidence?

Journal of Antimicrobial Chemotherapy June 2010 V.65 N.6 P.1126-1136

Rafael Canto´n1,2*, Patricia Ruiz-Garbajosa1,2, Ricardo L. Chaves3 and Alan P. Johnson4

1Servicio de Microbiologı´a, Hospital Universitario Ramo´n y Cajal and Instituto Ramo´n y Cajal de Investigacio´n Sanitaria (IRYCIS), Madrid, Spain; 2CIBER en Epidemiologı´a y Salud Pu´ blica (CIBERESP), Madrid, Spain; 3Novartis Pharma AG, Novartis Campus, CH-4056 Basel, Switzerland; 4Department of Healthcare-Associated Infection and Antimicrobial Resistance, Health Protection Agency Centre for Infections, London NW9 5EQ, UK


Nosocomial infections caused by enterococci present a challenge for clinicians because treatment options are often limited due to the widespread occurrence of strains resistant to multiple antibiotics, including vancomycin. Daptomycin is a first-in-class cyclic lipopeptide that has proven efficacy for the treatment of Gram-positive infections. Although methicillin-resistant Staphylococcus aureus has been the most prominent target in the clinical development of daptomycin, this agent has demonstrated potent bactericidal activity in enterococcal infection models and has been used for the treatment of enterococcal infections in humans. In recent years, large-scale susceptibility studies have shown that daptomycin is active against >98% of enterococci tested, irrespective of their susceptibility to other antibacterial agents. This lack of cross-resistance reflects the fact that daptomycin has a mode of action distinct from those of other antibiotics, including glycopeptides. While there are limited data available from randomized controlled trials, extensive clinical experience with daptomycin in enterococcal infections (including bacteraemia, endocarditis, skin and soft tissue infections, bone and joint infections and urinary tract infections) has been reported. This growing body of evidence provides useful insights regarding the efficacy of daptomycin against enterococci in clinical settings.



May 28, 2011 at 11:57 pm Leave a comment

Outbreak of Group A Streptococcal Pneumonia Among Marine Corps Recruits — California, November 1–December 20, 2002

MMWR Feb 14, 2003  V.52  N.6  P.106-109

During November 1–December 20, 2002, atotal of 163 Marine Corps personnel from the Marine Corps Recruit Depot (MCRD) in San Diego, California, including 160 new recruits, were admitted to the Naval Medical Center San Diego (NMCSD) for possible pneumonia. For 128 (79%) patients, pneumonia was confirmed by chest radiograph; of these 128 cases, 31 (24%) were definitely or probably caused by group A streptococci (GAS). This is the first outbreak of serious GAS-associated illness at a San Diego military training facility since the 1987 outbreak of rheumatic fever (1) and the largest outbreak of GAS pneumonia in the United States since 1968 (2). This report summarizes the results of the investigation of this outbreak, which indicate that GAS infection can occur
among military recruit populations despite routine chemoprophylaxis administered to incoming recruits. Instituting routine surveillance for noninvasive GAS disease in military training facilities might prevent future invasive GAS outbreaks…..

Full Text


May 28, 2011 at 11:52 pm Leave a comment

Invasive Group A Streptococcus Infections

Clinical Infectious Diseases 1 January 1992 V.14 N.1 P.2-13

Dennis L. Stevens

From the Department of Medicine, University of Washington School of Medicine, Seattle, Washington; and the Veterans Affairs Medical Center. Infectious Diseases Section, Boise, Idaho


The late 1980s have witnessed the emergence of severe group A streptococcus (GAS) infection; shock, bacteremia, and acute
respiratory distress syndrome are common features, and death has been associated with this infection in 30% of patients. Such infections have now been described in all parts of the United States, Europe, and Australia and have occurred predominantly in otherwise healthy adolescents and adults. The characteristic clinical and laboratory features of the streptococcal toxic shock syndrome include deep-seated infection associated with shock and multiorgan failure. Strains of GAS isolated from patients with invasive disease have been predominantly M types 1 and 3, which produce pyrogenic exotoxin A or B or both. In this report, the clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis will be presented and compared with those of streptococcal toxic shock syndrome. Current concepts of the pathogenesis of invasive streptococcal infection will also be presented in terms of the interaction between virulence factors of GAS and host defense mechanisms. Finally, new concepts for future treatment of serious streptococcal infections will be proposed.



May 28, 2011 at 11:46 pm Leave a comment

Metronidazole Is Still the Drug of Choice for Treatment of Anaerobic Infections

Clin Inf Dis 1 February 2010 V.50 Suppl.1 P.16-23

Sonja Löfmark, Charlotta Edlund, and Carl Erik Nord

Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden


Metronidazole has been used for the treatment of infections for >45 years and is still successfully used for the treatment of trichomoniasis, amoebiasis, and giardiasis. Anaerobic bacterial infections caused by Bacteroides species, fusobacteria, and clostridia respond favorably to metronidazole therapy. Good clinical results in the treatment of vaginosis due to Gardnerella vaginalis have also been reported. Rates of resistance to metronidazole are still generally low; however, several studies have reported decreased susceptibility among Bacteroides species, as well as different mechanisms of resistance. Metronidazole-resistant Helicobacter pylori strains have been described, but combination therapy (eg, metronidazole, amoxicillin, or clarithromycin plus omeprazole) is still recommended for eradication of this pathogen in patients with gastroduodenal ulcers. Metronidazole is considered to be a cost-effective drug because of its low cost, good activity against pathogenic anaerobic bacteria, favorable pharmacokinetic and pharmacodynamic properties, and minor adverse effects. Metronidazole is still the criterion standard for therapy of anaerobic infections, as was described by Tally and colleagues 35 years ago.



May 27, 2011 at 1:45 am Leave a comment

Combating Antimicrobial Resistance: Policy Recommendations to Save Lives, Infectious Diseases Society of America (IDSA)

Clin Infect Dis 5 May 2011 Suppl 5 397-428


Antimicrobial resistance is recognized as one of the greatest threats to human health worldwide [ 1]. Drug-resistant infections take a staggering toll in the United States (US) and across the globe. Just one organism, methicillin-resistant Staphylococcus aureus (MRSA), kills more Americans every year (∼19,000) than emphysema, HIV/AIDS, Parkinson’s disease, and homicide combined [ 2]. Almost 2 million Americans per year develop hospital-acquired infections (HAIs), resulting in 99,000 deaths [ 3], the vast majority of which are due to antibacterial (antibiotic)-resistant pathogens. Indeed, two common HAIs alone (sepsis and pneumonia) killed nearly 50,000 Americans and cost theUShealth care system more than $8 billion in 2006 [ 4]. In a recent survey, approximately half of patients in more than 1,000 intensive care units in 75 countries suffered from an infection, and infected patients had twice the risk of dying in the hospital as uninfected patients [ 5]. Based on studies of the costs of infections caused by antibiotic-resistant pathogens versus antibiotic-susceptible pathogens [ 6– 8], the annual cost to the US health care system of antibiotic-resistant infections is $21 billion to $34 billion and more than 8 million additional hospital days.

The discovery of antibiotics in the 1930s fundamentally transformed the way physicians care for patients, shifting their approach from a focus on diagnoses without means to intervene to a treatment-focused approach that saves lives. Seven decades of medical advances enabled by antibiotics are now seriously threatened by the convergence of relentlessly rising antibiotic resistance and the alarming and ongoing withdrawal of most major pharmaceutical companies from the antibiotic market. Without effective antibiotics, diverse fields of medicine will be severely hampered, including surgery, the care of premature infants, cancer chemotherapy, care of the critically ill, and transplantation medicine, all of which are feasible …



May 27, 2011 at 1:41 am Leave a comment

Purulent pericarditis caused by the Streptococcus milleri group: a case report and review of the literature.


Internal Medicine 2009 V.48  N.12  P.1073-8.

Hirokazu Tokuyasu1), Yuhei Saitoh2), Tomoya Harada1), Hirokazu Touge1), Yuji Kawasaki1), Ryo Maeda3), Noritaka Isowa3) and Eiji Shimizu4)

1) Division of Respiratory Medicine, Matsue Red Cross Hospital

2) Division of Cardiovascular Surgery, Matsue Red Cross Hospital

3) Division of Thoracic Surgery, Matsue Red Cross Hospital

4) Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University

SourceDivision of Respiratory Medicine, Matsue Red Cross Hospital.


A 69-year-old woman with a history of diabetes mellitus presented at our emergency room with chest pain and dyspnea. A chest computed tomography revealed a pericardial effusion. Pericardiocentesis was performed; strains of the Streptococcus milleri group were detected on culture of the fluid thus obtained. Therefore, purulent pericarditis was diagnosed. Despite treatment with panipenem/betamipron, the pericarditis worsened leading to the development of cardiac tamponade. Emergency pericardial drainage was performed, after which the condition resolved without any complications. We report an extremely rare case of purulent pericarditis caused by a strain of the Streptococcus milleri group. In addition, we review 5 previously reported cases of purulent pericarditis caused by strains



May 27, 2011 at 1:39 am Leave a comment

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children: Executive Summary

Clin Infect Diseases  1 February 2010 V.52 N.3  P.285-292

Catherine Liu1, Arnold Bayer3,5, Sara E. Cosgrove6, Robert S. Daum7, Scott K. Fridkin8, Rachel J. Gorwitz9, Sheldon L. Kaplan10, Adolf W. Karchmer11, Donald P. Levine12, Barbara E. Murray14, Michael J. Rybak12,13, David A. Talan4,5, and Henry F. Chambers1,2

1Department of Medicine, Division of Infectious Diseases, University of California-San Francisco, San Francisco, California

2Division of Infectious Diseases, San Francisco General Hospital, San Francisco, CA

3Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, CA

4Divisions of Emergency Medicine and Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA

5Department of Medicine, David Geffen School of Medicine at University of California- Los Angeles

6Division of Infectious Diseases, Johns Hopkins Medical Institutions, Baltimore, Maryland

7Department of Pediatrics, Section of Infectious Diseases, University of Chicago, Chicago, Illinois


9Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

10Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas

11Division of Infectious Diseases, Beth Israel Deaconess Medicine Center, Harvard Medical School, Boston, Massachusetts

12 Department of Medicine, Division of Infectious Diseases, Wayne State University, Detroit Receiving Hospital and University Health Center, Detroit, Michigan

13Deparment of Pharmacy Practice, Wayne State University, Detroit Michigan

14Division of Infectious Diseases and Center for the Study of Emerging and Re-emerging Pathogens, University of Texas Medical School, Houston, Texas


Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.



May 24, 2011 at 12:39 am Leave a comment

Brief Communication: Treatment of Enterococcus faecalis Endocarditis with Ampicillin plus Ceftriaxone

Annals of Internal Medicine 17 April 2007 V.146 N.8 P.574-579

Joan Gavaldà, MD; Oscar Len, MD; José M. Miró, MD; Patricia Muñoz, MD; Miguel Montejo, MD; Aristides Alarcón, MD; Julián de la Torre-Cisneros, MD; Carmen Peña, MD; Xavier Martínez-Lacasa, MD; Cristina Sarria, MD; Germán Bou, MD; José M. Aguado, MD; Enrique Navas, MD; Joan Romeu, MD; Francesc Marco, MD; Carmen Torres, MD; Pilar Tornos, MD; Ana Planes, MD; Vicenç Falcó, MD; Benito Almirante, MD; and Albert Pahissa, MD

From the Hospital Universitari Vall d’Hebron, Institut d’Investigacions Biomediques August Pi i Sunyer, Hospital de Bellvitge, Mutua de Terrassa, and Hospital Germans Tries i Pujol, Barcelona, Spain; Hospital Gregorio Marañón, Hospital Universitario de La Princesa, Hospital Doce de Octubre, and Hospital Ramón y Cajal, Madrid, Spain; Hospital de Cruces, Barakaldo, Spain; Hospital Virgen del Rocío, Seville, Spain; Hospital Reina Sofía, Córdoba, Spain; Hospital Juan Canalejo, La Coruña, Spain; and Universidad de La Rioja, Logroño, Spain.



High-level aminoglycoside resistance (HLAR) that precludes bactericidal synergism with penicillins or glycopeptides and nephrotoxicity related to aminoglycoside treatment are major problems in treating Enterococcus faecalis endocarditis.


To evaluate the efficacy and safety of ampicillin plus ceftriaxone for treating endocarditis due to E. faecalis with and without HLAR.


Observational, open-label, nonrandomized, multicenter clinical trial.


13 centers inSpain.


21 patients with HLAR E. faecalis endocarditis and 22 patients with non-HLAR E. faecalis endocarditis. All were at risk for nephrotoxicity related to aminoglycoside use.


6-week course of intravenous ampicillin,2 gevery 4 hours, plus intravenous ceftriaxone,2 gevery 12 hours.


Clinical and microbiological outcomes.


The clinical cure rate at 3 months was 67.4% (29 of 43 patients) among all episodes. During treatment, 28.6% of patients with HLAR E. faecalis endocarditis and 18.2% of patients with non-HLAR E. faecalis endocarditis died of infection-related causes. The rate of clinical and microbiological cure in patients who completed the protocol was 100% in the HLAR E. faecalis endocarditis group. No episodes of breakthrough bacteremia occurred, although there were 2 relapses in the non-HLAR E. faecalis endocarditis group. Treatment was withdrawn in 1 case because of fever and skin rash.


The study had a small sample and was observational.


The combination of ampicillin and ceftriaxone is effective and safe for treating HLAR E. faecalis endocarditis and could be a reasonable alternative for patients with non-HLAR E. faecalis endocarditis who are at increased risk for nephrotoxicity.



May 23, 2011 at 11:37 am Leave a comment

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