Archive for June, 2011

A 30-Year-Old Man with Diarrhea after a Trip to the Dominican Republic

N Engl J of Med June 30, 2011

Case 20-2011 —

Edward T. Ryan, M.D., Lawrence C. Madoff, M.D., and Mary Jane Ferraro, Ph.D., M.P.H.

Presentation of Case

Dr. Stephen M. Carpenter (Infectious Diseases): A 30-year-old man was seen in the emergency room at this hospital in January 2011 because of diarrhea.

The patient had been well 5 days earlier, when he traveled to a resort in theDominican Republicfor a social event. On his fourth day in theDominican Republic, 2 days before this presentation, he flew back to theUnited States, arriving at1 a.m. the day before presentation. Four hours later, he was awakened by the urge to defecate, and he had watery diarrhea. He reported having approximately 12 watery bowel movements during the next 35 hours. He consumed chicken broth and took bismuth solution, without improvement. The night before this presentation, relatives informed him that 13 other attendees of the event had diarrhea. On the day of this presentation, he noted that stool frequency and volume were decreasing. He took a combination of ampicillin and sulbactam (375 mg) orally, which he had obtained inSouth America. He called the Massachusetts Department of Public Health and was referred to the emergency department at this hospital….

FULL TEXT

http://www.nejm.org/doi/full/10.1056/NEJMcpc1100928?query=TOC

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMcpc1100928

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June 30, 2011 at 6:35 pm Leave a comment

Antitrypanosomal Therapy for Chronic Chagas’ Disease

New Engl J of Med June 30, 2011

Clinical Therapeutics

Caryn Bern, M.D., M.P.H.

A 42-year-old woman presents to her physician with a letter stating that after she made a recent blood donation, a serologic test of her donated blood was positive for Chagas’ disease. The patient was born inEl Salvadorand moved to theUnited Stateswhen she was 18 years of age. Her three children are 8, 13, and 16 years of age. Her medical history is remarkable only for a cholecystectomy 2 years earlier; she reports no cardiac or gastrointestinal symptoms. Her physical examination is unremarkable. Electrocardiography (ECG) shows sinus rhythm at a rate of 72 beats per minute and a complete right bundle-branch block. An echocardiogram shows mild left ventricular segmental wall-motion abnormalities, but a normal ejection fraction and left ventricular diameter. The patient is referred to an infectious-disease consultant, who recommends antitrypanosomal therapy….

FULL TEXT

http://www.nejm.org/doi/full/10.1056/NEJMct1014204

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMct1014204

June 30, 2011 at 6:33 pm Leave a comment

Lessons from Sickle Cell Disease in the Treatment and Control of Malaria

N Engl J of Med June 30, 2011

Clinical Implications of Basic Research

Philip J. Rosenthal, M.D.

Malaria, especially infection with Plasmodium falciparum, has exerted strong selective pressure on the human genome. In a well-characterized, balanced polymorphism, persons who are homozygous for the sickle hemoglobin mutation (in which valine replaces glutamic acid at position6 inthe β-globin chain of hemoglobin A, producing hemoglobin S) have serious hematologic illness, but those who are heterozygous for the mutation (and have hemoglobin AS) are asymptomatic and relatively protected against severe falciparum malaria as compared with those who have normal hemoglobin.1 A recent study by Ferreira and colleagues2 offers an improved understanding of how hemoglobin AS protects against malaria, thereby providing insight into potential means of treating and controlling this disease…

abstract

http://www.nejm.org/doi/full/10.1056/NEJMcibr1105118

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMcibr1105118

 

June 30, 2011 at 6:32 pm Leave a comment

Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone

Clinical Microbiology and Infection June 2011  V.17 N.6 P.862-867

C. A. Aboltins1, M. M. Dowsey2, K. L. Buising1, T. N. Peel1, J. R. Daffy1, P. F. M. Choong2, P. A. Stanley1

Abstract

Information is required about treatment outcomes of Gram-negative prosthetic joint infections treated with prosthesis retention and surgical debridement, especially where biofilm-active antibiotics such as fluoroquinolones are used. The outcome of 17 consecutive patients with an early Gram-negative prosthetic joint infection who had been treated with prosthesis retention and surgical debridement was analysed. Enterobacteriaceae were isolated in 16 patients and infections were mixed with other organisms in 13 (76%) patients. The median joint age was 17 days and the median duration of symptoms before debridement was 7 days. All patients initially received intravenous β-lactam antibiotic therapy and 14 patients were then treated with oral ciprofloxacin. Treatment failure occurred in two patients over a median period of follow-up of 28 months. In only one patient was a relapsed Gram-negative infection responsible for the failure and this patient had not been treated with ciprofloxacin. The 2-year survival rate free of treatment failure was 94% (95% CI, 63–99%). Prosthesis retention with surgical debridement, in combination with antibiotic regimens including ciprofloxacin, was effective and should be considered for patients with early Gram-negative prosthetic joint infection.

abstract

http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2010.03361.x/abstract

June 28, 2011 at 1:31 am Leave a comment

Mobile phone technology and hospitalized patients: a cross-sectional surveillance study of bacterial colonization, and patient opinions and behaviours

Clinical Microbiology and Infection June 2011  V.17 N.6 P.830-835

R. R. Brady1, A. C. Hunt2, A. Visvanathan1, M. A. Rodrigues1, C. Graham3, C. Rae2, P. Kalima2, H. M. Paterson1, A. P. Gibb2

Abstract

Healthcare workers’ mobile phones provide a reservoir of bacteria known to cause nosocomial infections. UK National Health Service restrictions on the utilization of mobile phones within hospitals have been relaxed; however, utilization of these devices by inpatients and the risk of cross-contamination are currently unknown. Here, we examine demographics and characteristics of mobile phone utilization by inpatients and phone surface microbial contamination. One hundred and two out of 145 (70.3%) inpatients who completed a questionnaire detailing their opinions and utilization of mobile phones, also provided their mobile phones for bacteriological analysis and comparative bacteriological swabs from their nasal cavities; 92.4% of patients support utilization of mobile phones by inpatients; indeed, 24.5% of patients stated that mobile phones were vital to their inpatient stay. Patients in younger age categories were more likely to possess a mobile phone both inside and outside hospital (p <0.01) but there was no gender association. Eighty-six out of 102 (84.3%) patients’ mobile phone swabs were positive for microbial contamination. Twelve (11.8%) phones grew bacteria known to cause nosocomial infection. Seven (6.9%) phones and 32 (31.4%) nasal swabs demonstrated Staphylococcus aureus contamination. MSSA/MRSA contamination of phones was associated with concomitant nasal colonization. Patient utilization of mobile phones in the clinical setting is popular and common; however, we recommend that patients are educated by clear guidelines and advice on inpatient mobile phone etiquette, power charging safety, regular cleaning of phones and hand hygiene, and advised not to share phones or related equipment with other inpatients in order to prevent transmission of bacteria.

abstract

http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2011.03493.x/abstract

June 28, 2011 at 1:29 am Leave a comment

Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess

Archives of Internal Medicine June 27, 2011 V.171 N.12 P.1072-1079

ONLINE FIRST

Timothy C. Jenkins, MD; Bryan C. Knepper, MPH, MSc; Allison L. Sabel, MD, PhD, MPH; Ellen E. Sarcone, MD; Jeremy A. Long, MD, MPH; Jason S. Haukoos, MD, MSc; Steven J. Morgan, MD; Walter L. Biffl, MD; Andrew W. Steele, MD, MPH, MSc; Connie S. Price, MD; Philip S. Mehler, MD; William J. Burman, MD

Department of Medicine (Drs Jenkins, Sarcone, Long, Price, Mehler, and Burman), Division of Infectious Diseases (Drs Jenkins, Price, and Burman), and Departments of Patient Safety and Quality (Mr Knepper and Drs Sabel and Mehler), Emergency Medicine (Dr Haukoos), Orthopaedic Surgery (Dr Morgan), General Surgery (Dr Biffl), and eHealth Services (Dr Steele), Denver Health Medical Center, Denver, Colorado; Department of Medicine (Drs Jenkins, Sarcone, Long, Steele, Price, Mehler, and Burman), Division of Infectious Diseases (Drs Jenkins, Price, and Burman), and Departments of Emergency Medicine (Dr Haukoos), Orthopaedic Surgery (Dr Morgan), and General Surgery (Dr Biffl), University of Colorado Denver, Aurora; and Departments of Biostatistics and Informatics (Dr Sabel) and Epidemiology (Dr Haukoos), Colorado School of Public Health, Aurora.

Background

Cellulitis and cutaneous abscess are among the most common infections leading to hospitalization, yet optimal management strategies have not been adequately studied. We hypothesized that implementation of an institutional guideline to standardize and streamline the evaluation and treatment of inpatient cellulitis and abscess would decrease antibiotic and health care resource utilization.

Methods

A retrospective preintervention-postintervention study was performed to compare management before and after implementation of the guideline (January 1, 2007–December 31, 2007, and July 9, 2009–July 8, 2010).

Results

A total of 169 patients (66 with cellulitis, 103 with abscess) were included in the baseline cohort, and 175 (82 with cellulitis, 93 with abscess) were included in the intervention cohort. The intervention led to a significant decrease in use of microbiological cultures (80% vs 66%; P = .003) and fewer requests for inpatient consultations (46% vs 30%; P = .004). The median duration of antibiotic therapy decreased from 13 days (interquartile range [IQR], 10-15 days) to 10 days (IQR, 9-12 days) (P < .001). Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). Clinical failure occurred in 7.7% and 7.4% of cases (P = .93), respectively.

Conclusion

Implementation of a guideline for the management of inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes.

abstract

http://archinte.ama-assn.org/cgi/content/abstract/171/12/1072?etoc

June 28, 2011 at 1:27 am Leave a comment

Telaprevir for Retreatment of HCV Infection

N Engl J of Medicine June 2011

Stefan Zeuzem, M.D., Pietro Andreone, M.D., Stanislas Pol, M.D., Eric Lawitz, M.D., Moises Diago, M.D., Stuart Roberts, M.D., Roberto Focaccia, M.D., Zobair Younossi, M.D., Graham R. Foster, F.C.R.P., Andrzej Horban, M.D., Peter Ferenci, M.D., Frederik Nevens, M.D., Beat Müllhaupt, M.D., Paul Pockros, M.D., Ruben Terg, M.D., Daniel Shouval, M.D., Bart van Hoek, M.D., Ola Weiland, M.D., Rolf Van Heeswijk, Pharm.D., Sandra De Meyer, Ph.D., Don Luo, Ph.D., Griet Boogaerts, M.Sc., Ramon Polo, Pharm.D., Gaston Picchio, Ph.D., and Maria Beumont, M.D. for the REALIZE Study Team

Background

Up to 60% of patients with hepatitis C virus (HCV) genotype 1 infection do not have a sustained virologic response to therapy with peginterferon alfa plus ribavirin.

Methods

In this randomized, phase 3 trial, we evaluated the addition of telaprevir to peginterferon alfa-2a plus ribavirin in patients with HCV genotype 1 infection who had no response or a partial response to previous therapy or who had a relapse after an initial response. A total of 663 patients were assigned to one of three groups: the T12PR48 group, which received telaprevir for 12 weeks and peginterferon plus ribavirin for a total of 48 weeks; the lead-in T12PR48 group, which received 4 weeks of peginterferon plus ribavirin followed by 12 weeks of telaprevir and peginterferon plus ribavirin for a total of 48 weeks; and the control group (PR48), which received peginterferon plus ribavirin for 48 weeks. The primary end point was the rate of sustained virologic response, which was defined as undetectable HCV RNA 24 weeks after the last planned dose of a study drug.

Results

Rates of sustained virologic response were significantly higher in the two telaprevir groups than in the control group among patients who had a previous relapse (83% in the T12PR48 group, 88% in the lead-in T12PR48 group, and 24% in the PR48 group), a partial response (59%, 54%, and 15%, respectively), and no response (29%, 33%, and 5%, respectively) (P<0.001 for all comparisons). Grade 3 adverse events (mainly anemia, neutropenia, and leukopenia) were more frequent in the telaprevir groups than in the control group (37% vs. 22%).

Conclusions

Telaprevir combined with peginterferon plus ribavirin significantly improved rates of sustained virologic response in patients with previously treated HCV infection, regardless of whether there was a lead-in phase. (Funded by Tibotec and Vertex Pharmaceuticals; REALIZE ClinicalTrials.gov number, NCT00703118.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1013086

June 23, 2011 at 12:14 am Leave a comment

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