Archive for September, 2012

Case 30-2012 — A 54-Year-Old Woman with HIV Infection, Dyspnea, and Chest Pain

N Engl J of Medic September 27, 2012 V.367  P.1246-1254



Steven G. Deeks, M.D., Rajesh T. Gandhi, M.D., Claudia U. Chae, M.D., and Kent B. Lewandrowski, M.D.

From the Department of Medicine, San Francisco General Hospital, San Francisco (S.G.D.); and the Departments of Medicine (R.T.G., C.U.C.) and Pathology (K.B.L.), Massachusetts General Hospital; the Ragon Institute of MGH, MIT, and Harvard (R.T.G.); and the Departments of Medicine (R.T.G., C.U.C.) and Pathology (K.B.L.), Harvard Medical School — all in Boston.


A 54-year-old woman with human immunodeficiency virus (HIV) infection was admitted to this hospital because of dyspnea and chest pain.

The patient had been in her usual health until approximately 10 days before admission, when episodes of increasing dyspnea on exertion developed. Approximately 1 hour before presentation, substernal chest pain developed during sexual intercourse, associated with dyspnea, nausea, and diaphoresis. She came to the emergency department at this hospital….



September 30, 2012 at 4:05 pm

Once versus multiple daily dosing of aminoglycosides for patients with febrile neutropenia: a systematic review and meta-analysis

Journal of Antimicrobial Chemotherapy  Feb. 2011 V.66 N.2 P.251-259

Systematic review

Michael N. Mavros1, Konstantinos A. Polyzos1, Petros I. Rafailidis1,2 and Matthew E. Falagas1,2,3,*

1Alfa Institute of Biomedical Sciences, Athens, Greece

2Department of Medicine, Henry Dunant Hospital, Athens, Greece

3Department of Medicine, Tufts University School of Medicine, Boston, MA, USA


Once daily dosing (ODD) of aminoglycosides has become a standard of care for most patient populations. However, the use of ODD of aminoglycosides has not been clarified in febrile neutropenia.


We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effectiveness and safety of ODD versus multiple daily dosing (MDD) of aminoglycosides in patients with febrile neutropenia. We searched the PubMed, Scopus, Cochrane Central Register of Trials and databases up to July 2010.


A total of five and eight RCTs were included in the effectiveness and safety analyses, respectively. We observed a trend towards better effectiveness of the ODD regimen in the clinically evaluable population {five RCTs, 403 patient-episodes, risk ratio (RR)=1.18 [95% confidence interval (95% CI): 0.98, 1.42]}, but not in the microbiologically evaluable population [three RCTs, 119 patient-episodes, RR=1.11 (95% CI: 0.84, 1.48)]. The occurrence of nephrotoxicity was similar between the two groups [seven RCTs, 1643 patient-episodes, RR=0.74 (95% CI: 0.36, 1.50)], as was ototoxicity [six RCTs, 862 patient-episodes, RR=1.05 (95% CI: 0.51, 2.19)]. There was no difference in mortality [four RCTs, 403 patient-episodes, RR=0.77 (95% CI: 0.21, 2.78)].


Although the generalization of our findings may be restricted by the relatively small sample size and other methodological limitations of the included RCTs, ODD appears to be at least as effective and as safe as MDD in patients with febrile neutropenia. RCTs comparing ODD versus MDD in patients with bacteraemia and profound or prolonged neutropenia would be of additional value.


September 30, 2012 at 3:55 pm

Emerging antiretroviral drug interactions

Journal of Antimicrobial Chemotherapy  Feb. 2011 V.66 N.2 P.235-239

Paul A. Pham1,* and Charles Flexner2

1Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, MD 21287, USA

2Division of Clinical Pharmacology, Johns Hopkins University, School of Medicine, Baltimore, MD 21287, USA

With HIV-infected patients living longer and recommendations to initiate antiretrovirals (ARVs) being made earlier, the likelihood for potential drug–drug interactions between ARVs and concurrent medications used to manage co-morbid conditions will increase. In order to maximize the clinical benefit and minimize potential toxicity of ARVs and co-administered medications, it is important for clinicians to recognize significant drug–drug interactions. This article highlights clinically significant drug–drug interactions with antituberculosis agents, antimalarials, anticoagulants, chemotherapeutic agents and pulmonary antihypertensive agents when they are co-administered with newer ARVs (e.g. darunavir, raltegravir, maraviroc and etravirine).


September 30, 2012 at 3:51 pm

Changes in the classification and management of skin and soft tissue infections

Journal of Antimicrobial Chemotherapy  Feb. 2011 V.66 N.2 P.232-234

Roland Koerner1,* and Alan P. Johnson2

1Department of Microbiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK

2Department of Healthcare-associated Infection and Antimicrobial Resistance, Health Protection Agency Centre for Infection, London NW9 5EQ, UK

Although skin and soft tissue infections (SSTIs) are extremely common in both primary and secondary care, there is a lack of validated evidence-based schemes for the classification of clinical presentation or severity, and there are few data available on treatment outcomes. The commonly used ‘Eron classification’ is based on the consensus views of an expert panel, while the Clinical Resource Efficiency Support Team (CREST) ‘Guidelines on the Management of Cellulitis in Adults’ have not been validated in clinical trials. In the current issue of JAC, investigators at NinewellsHospital in Dundee, Scotland, report a retrospective study of patients with SSTIs who were treated with antibiotics. The patients were stratified into four classes of clinical severity, based on the presence or absence of sepsis and co-morbidity, and their standardized early warning score. The empirical treatment received by patients in each class was compared with the recommendations of the CREST guidelines. The findings do not make comfortable reading. Overall, 43% of patients (and 65% at the mildest end of the clinical spectrum) were overtreated, while mortality (at 30 days) and inadequate antimicrobial therapy increased with severity class. Strikingly, 35 different empirical antimicrobial prescribing regimens were noted. These findings, which are likely to reflect the situation in many hospitals, show that SSTIs remain a significant cause of mortality and that empirical therapy is bordering on the haphazard, with significant under treatment of severely ill patients.


September 30, 2012 at 3:50 pm

Carbapenem Resistance in Klebsiella pneumoniae Due to the New Delhi Metallo-β-lactamase

Clin Infect Dis  Feb. 2011 V.52 N.4 P.481-484


Hanna Sidjabat1, Graeme R. Nimmo1,2, Timothy R. Walsh5, Enzo Binotto2,3, Anthony Htin3, Yoshiro Hayashi1, Jian Li4, Roger L. Nation4, Narelle George2, and David L. Paterson1,2

1University of Queensland Centre for Clinical Research

2Pathology Queensland, Royal Brisbane and Women’s Hospital Campus, Brisbane

3Cairns Base Hospital, Cairns

4Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia

5Cardiff University, Cardiff, United Kingdom

Carbapenem resistance in Klebsiella pneumoniae is most notably due to the K. pneumoniae carbapenemase (KPC) β-lactamase. In this report, we describe the occurrence of a newly described mechanism of carbapenem resistance, the NDM-1 β-lactamase, in a patient who received medical attention (but was not hospitalized) in India.




September 30, 2012 at 3:48 pm

Preexposure Prophylaxis for HIV Prevention — Polling Results

N Engl J of Medic September 27, 2012

Clinical Decisions

James A. Colbert, M.D.

In early August, we presented two cases involving persons who were potential candidates for preexposure prophylaxis (PrEP) for HIV in Clinical Decisions, an interactive feature designed to assess how readers would manage a clinical problem for which there may be more than one appropriate approach to the care of the patients. The two cases involved a 46-year-old man from New York City who has sex with multiple male partners and an 18-year-old, single, heterosexual woman from South Africa who has recently become sexually active. Two experts in the prevention of HIV infection presented arguments, one in favor of the use of PrEP in these two patients and one opposed. We asked our readers to decide between these two approaches and to share their thoughts on this controversial topic….


September 30, 2012 at 3:47 pm

Comparative Effectiveness and Toxicity of Statins Among HIV-Infected Patients

Clin Infect Dis  Feb. 2011 V.52 N.3 P.387-395

Sudershan Singh1, James H. Willig2, Michael J. Mugavero2, Paul K. Crane1, Robert D. Harrington1, Robert H. Knopp1,a, Bradley W. Kosel1, Michael S. Saag2, Mari M. Kitahata1, and Heidi M. Crane1

1Department of Medicine, University of Washington, Seattle, WA

2Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama


Dyslipidemia is common and is often treated with 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins). Little is known about the comparative effectiveness of statins among human immunodeficiency virus (HIV)–infected patients. This study compared the effectiveness and toxicity of statins among HIV-infected patients in clinical care.


We conducted a retrospective cohort study of patients starting their initial statin medications at 2 large HIV clinics (N = 700). The primary observation was change in lipid levels during statin therapy. Secondary observations included whether individualized National Cholesterol Education Program (NCEP) goals for low density lipoprotein cholesterol (LDL-C) and non–high density lipoprotein cholesterol (non-HDL-C) levels were reached, and toxicity rates. We used linear regression to examine change in lipid levels, controlling for baseline lipid values and demographic and clinical characteristics. We conducted secondary analyses using propensity scores to address confounding by indication.


The most commonly prescribed statins were atorvastatin (N = 303), pravastatin (N = 280), and rosuvastatin (N = 95). One year after starting a statin therapy, patients who received atorvastatin or rosuvastatin had significantly greater decreases in total cholesterol, LDL-C, and non-HDL-C than patients on pravastatin. The likelihood of reaching NCEP goals for LDL-C levels was higher with the use of rosuvastatin (OR 2.1; P = .03) and atorvastatin (odds ratio [OR], 2.1; P = .001) compared with that of pravastatin. The likelihood of reaching NCEP goals for non-HDL-C levels was higher for rosuvastatin (OR 2.3; P = .045) but not atorvastatin (OR, 1.5; P = .1) compared with pravastatin. Toxicity rates were similar for all 3 statins: 7.3% for atorvastatin, 6.1% for pravastatin, and 5.3% for rosuvastatin.


Our findings suggest that atorvastatin and rosuvastatin are preferable to pravastatin for treatment of HIV-infected patients with dyslipidemia, due to greater declines in total cholesterol, LDL-C, and non-HDL-C, with similar lower toxicity rates.


September 28, 2012 at 12:19 pm

Removal of nail polish and finger rings to prevent surgical infection.

Cochrane Database Syst Rev. 2012 May 16;5:CD003325.

Arrowsmith VA, Taylor R.

School of Health and Social Welfare, Open University, Milton Keynes, UK.



Surgical wound infections may be caused by the transfer of bacteria from the hands of surgical teams to patients during operations. Surgical scrubbing prior to surgery reduces the number of bacteria on the skin, but wearing rings and nail polish on the fingers may reduce the efficacy of scrubbing, as bacteria may remain in microscopic imperfections of nail polish and on the skin beneath rings.


To assess the effect of the presence or absence of rings and nail polish on the hands of the surgical scrub team on postoperative wound infection rates.


For this update, we searched The Cochrane Wounds Group Specialised Register (searched 27 January 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1); Ovid MEDLINE (2010 to January Week 2 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, January 26, 2012); Ovid EMBASE (2010 to 2012 Week 03); and EBSCO CINAHL (2010 to January 6 2012).


Randomised controlled trials (RCTs) evaluating the effect of wearing or removing finger rings and nail polish on the efficacy of the surgical scrub and postoperative wound infection rate.


All abstracts were checked against a checklist to determine whether they fulfilled the inclusion criteria. Full reports of relevant studies were obtained. Excluded trial reports were checked by all authors to ensure appropriate exclusion.


We identified: no new trials; no RCTs that compared wearing of rings with the removal of rings; and no trials of nail polish versus no nail polish that measured surgical infection rates. We found one small RCT (102 scrub nurses) that evaluated the effect of nail polish on the number of bacterial colony forming units left on hands after pre-operative surgical scrubbing. Nurses had either unpolished nails, freshly-applied nail polish (less than two days old), or old nail polish (more than four days old). There were no significant differences in the number of bacteria on hands between the groups before and after surgical scrubbing.


No trials have investigated whether wearing nail polish or finger rings affects the rate of surgical wound infection. There is insufficient evidence to determine whether wearing nail polish affects the number of bacteria on the skin post-scrub.

FULL TEXT;jsessionid=A857C2A7218F4AD0DE0EA8BACA83BCE9.d03t01

Update of Cochrane Database Syst Rev. 2001;(4):CD003325.



September 28, 2012 at 12:16 pm

Hepatitis E

N Engl J of Medic September 27, 2012 V.367  P.1237-1244

Review Article

Jay H. Hoofnagle, M.D., Kenrad E. Nelson, M.D., and Robert H. Purcell, M.D.

From the Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases (J.H.H.), and the Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases (R.H.P.), National Institutes of Health, Bethesda; and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (K.E.N.) — both in Maryland.

Hepatitis E, the fifth known form of human viral hepatitis, is probably the most common cause of acute hepatitis and jaundice in the world. Yet in the United States and other developed nations, hepatitis E is uncommon, and its role in causing liver disease is not well defined. This disease was initially identified in 1980 as “epidemic, non-A, non-B hepatitis,” an infectious, waterborne illness similar to hepatitis A that was common in the developing countries but rare elsewhere. Three years later, Mikhail Balayan visualized the hepatitis E virus (HEV) using immune electron microscopy to examine his own stool samples, which he collected prospectively after self-administration of infectious material. The viral genome was subsequently isolated and sequenced with the use of bile samples obtained from experimentally infected cynomolgus macaques….


September 28, 2012 at 12:14 pm

Unpredictable and Difficult to Control — The Adolescence of West Nile Virus

N Engl J of Medic September 27, 2012


Lyle R. Petersen, M.D., M.P.H., and Marc Fischer, M.D., M.P.H.

From the Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, CO.

Disturbingly unpredictable, disagreeable, and difficult to control — West Nile virus, first identified in the United States in 1999, has entered adolescence. In this year’s tally, 3142 cases of West Nile virus disease in humans in 45 states had been reported to the Centers for Disease Control and Prevention as of September 18, 2012, including 1630 cases of resulting neuroinvasive disease (meningitis, encephalitis, acute flaccid paralysis) and 134 deaths. Almost 40% (1225) of all cases were reported in Texas, mostly in Dallas and surrounding counties (see maps Incidence of West Nile Virus Neuroinvasive Disease. To judge from past reporting trends, these figures suggest that this year’s West Nile virus outbreak will be among the largest ever recorded…



September 28, 2012 at 12:12 pm

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