Archive for December, 2013

Modern management of pyogenic hepatic abscess: a case series and review of the literature.

BMC Res Notes. 2011 Mar 24;4:80.

Heneghan HM, Healy NA, Martin ST, Ryan RS, Nolan N, Traynor O, Waldron R.


Department of Surgery, Mayo General Hospital, Castlebar, Mayo, Ireland.



Pyogenic hepatic abscesses are relatively rare, though untreated are uniformly fatal. A recent paradigm shift in the management of liver abscesses, facilitated by advances in diagnostic and interventional radiology, has decreased mortality rates. The aim of this study was to review our experience in managing pyogenic liver abscess, review the literature in this field, and propose guidelines to aid in the current management of this complex disease.


Demographic and clinical details of all patients admitted to a single institution with liver abscess over a 5 year period were reviewed. Clinical presentation, aetiology, diagnostic work-up, treatment, morbidity and mortality data were collated.


Over a 5 year period 11 patients presented to a single institution with pyogenic hepatic abscess (55% males, mean age 60.3 years). Common clinical features at presentation were non-specific constitutional symptoms and signs. Aetiology was predominantly gallstones (45%) or diverticular disease (27%). In addition to empiric antimicrobial therapy, all patients underwent radiologically guided percutaneous drainage of the liver abscess at diagnosis and only 2 patients required surgical intervention, including one 16-year old female who underwent hemi-hepatectomy for a complex and rare Actinomycotic abscess. There were no mortalities after minimum follow-up of one year.


Pyogenic liver abscesses are uncommon, and mortality has decreased over the last two decades. Antimicrobial therapy and radiological intervention form the mainstay of modern treatment. Surgical intervention should be considered for patients with large, complex, septated or multiple abscesses, underlying disease or in whom percutaneous drainage has failed.


December 26, 2013 at 1:30 pm

Epidemiology and Outcome of Pneumonia Caused by Methicillin-Resistant Staphylococcus aureus (MRSA) in Canadian Hospitals.

PLoS One. 2013 Sep 17;8(9):e75171.

Tadros M, Williams V, Coleman BL, McGeer AJ, Haider S, Lee C, Iacovides H, Rubinstein E, John M, Johnston L, McNeil S, Katz K, Laffin N, Suh KN, Powis J, Smith S, Taylor G, Watt C, Simor AE.


University of Toronto, Toronto, Ontario, Canada.



MRSA remains a leading cause of hospital-acquired (HAP) and healthcare-associated pneumonia (HCAP). We describe the epidemiology and outcome of MRSA pneumonia in Canadian hospitals, and identify factors contributing to mortality.


Prospective surveillance for MRSA pneumonia in adults was done for one year (2011) in 11 Canadian hospitals. Standard criteria for MRSA HAP, HCAP, ventilator-associated pneumonia (VAP), and community-acquired pneumonia (CAP) were used to identify cases. MRSA isolates underwent antimicrobial susceptibility testing, and were characterized by pulsed-field gel electrophoresis (PFGE) and Panton-Valentine leukocidin (PVL) gene detection. The primary outcome was all-cause mortality at 30 days. A multivariable analysis was done to examine the association between various host and microbial factors and mortality.


A total of 161 patients with MRSA pneumonia were identified: 90 (56%) with HAP, 26 (16%) HCAP, and 45 (28%) CAP; 23 (14%) patients had VAP. The mean (± SD) incidence of MRSA HAP was 0.32 (± 0.26) per 10,000 patient-days, and of MRSA VAP was 0.30 (± 0.5) per 1,000 ventilator-days. The 30-day all-cause mortality was 28.0%. In multivariable analysis, variables associated with mortality were the presence of multiorgan failure (OR 8.1; 95% CI 2.5-26.0), and infection with an isolate with reduced susceptibility to vancomycin (OR 2.5, 95% CI 1.0-6.3).


MRSA pneumonia is associated with significant mortality. Severity of disease at presentation, and infection caused by an isolate with elevated MIC to vancomcyin are associated with increased mortality. Additional studies are required to better understand the impact of host and microbial variables on outcome.


December 26, 2013 at 1:28 pm

For an Influenza Vaccine, Are Two Bs Better Than One?

N Engl J of Medic Dec 26, 2013 V.369 P.2547-2549


Lindsey R. Baden, M.D

Every year, influenza causes epidemic disease. Periodically, antigenic drift and shift enable influenza viruses to evade human immunity from prior seasons, increasing the severity of the associated illnesses.

Since the 1918 pandemic, circulating influenza A viruses have had several antigenic shifts, resulting, for example, in the emergence of the A/H2N2 (1957–1958) and A/H3N2 (1968–1969) strains, but influenza more often drifts with modest antigenic changes.

A recent analysis has shown that a few specific point mutations near the hemagglutinin-receptor binding site of A/H3N2 and both circulating B lineages (B/Yamagata and B/Victoria) allow evasion of immunity.

A central part of the strategy to prevent disease caused by influenza has been annual vaccination with a trivalent influenza vaccine that contains A/H1N1 and A/H3N2 plus a single B antigen, with the antigens determined on the basis of the likely, or “best guess,” influenza strains that will circulate later in the year.

In the Northern Hemisphere, the seed vaccine strains are typically selected in the first quarter of the year for the upcoming influenza season, given the time that it has traditionally taken to make the seasonal egg-based influenza vaccine. Developing the vaccine on the basis of the best-guess strains incurs the risk that the vaccine will not “match” the influenza strains that will actually circulate …



December 25, 2013 at 9:36 pm

Vaccine for Prevention of Mild and Moderate-to-Severe Influenza in Children

N Engl J of Medic Dec 26, 2013 V.369 P.2481-2491

Varsha K. Jain, M.D., M.P.H., Luis Rivera, M.D., Khalequ Zaman, M.B., B.S., Ph.D., Roberto A. Espos, Jr., M.D., M.H.S.A., Chukiat Sirivichayakul, M.D., Beatriz P. Quiambao, M.D., Doris M. Rivera-Medina, M.D., Pirunghul Kerdpanich, M.D., Mehmet Ceyhan, M.D., Ener C. Dinleyici, M.D., Alejandro Cravioto, M.D., Ph.D., Mohammed Yunus, M.B., B.S., Pornthep Chanthavanich, M.D., Kriengsak Limkittikul, M.D., Zafer Kurugol, M.D., Ph.D., Emre Alhan, M.D., Adrian Caplanusi, M.D., Ph.D., Serge Durviaux, B.A., Philippe Boutet, D.V.M., Ph.D., Opokua Ofori-Anyinam, Ph.D., Vijayalakshmi Chandrasekaran, M.Sc., Ghassan Dbaibo, M.D., and Bruce L. Innis, M.D.


Commonly used trivalent vaccines contain one influenza B virus lineage and may be ineffective against viruses of the other B lineage. We evaluated the efficacy of a candidate inactivated quadrivalent influenza vaccine (QIV) containing both B lineages.


In this multinational, phase 3, observer-blinded study, we randomly assigned children 3 to 8 years of age, in a 1:1 ratio, to receive the QIV or a hepatitis A vaccine (control). The primary end point was influenza A or B confirmed by real-time polymerase chain reaction (rt-PCR). Secondary end points were rt-PCR–confirmed, moderate-to-severe influenza and rt-PCR–positive, culture-confirmed influenza. The vaccine efficacy and the effect of vaccination on daily activities and utilization of health care resources were assessed in the total vaccinated cohort (2584 children in each group) and the per-protocol cohort (2379 children in the QIV group and 2398 in the control group).


In the total vaccinated cohort, 62 children in the QIV group (2.40%) and 148 in the control group (5.73%) had rt-PCR–confirmed influenza, representing a QIV efficacy of 59.3% (95% confidence interval [CI], 45.2 to 69.7), with efficacy against culture-confirmed influenza of 59.1% (97.5% CI, 41.2 to 71.5). For moderate-to-severe rt-PCR–confirmed influenza, the attack rate was 0.62% (16 cases) in the QIV group and 2.36% (61 cases) in the control group, representing a QIV efficacy of 74.2% (97.5% CI, 51.5 to 86.2). In the per-protocol cohort, the QIV efficacy was 55.4% (95% CI, 39.1 to 67.3), and the efficacy against culture-confirmed influenza 55.9% (97.5% CI, 35.4 to 69.9); the efficacy among children with moderate-to-severe influenza was 73.1% (97.5% CI, 47.1 to 86.3). The QIV was associated with reduced risks of a body temperature above 39°C and lower respiratory tract illness, as compared with the control vaccine, in the per-protocol cohort (relative risk, 0.29 [95% CI, 0.16 to 0.56] and 0.20 [95% CI, 0.04 to 0.92], respectively). The QIV was immunogenic against all four strains. Serious adverse events occurred in 36 children in the QIV group (1.4%) and in 24 children in the control group (0.9%).


The QIV was efficacious in preventing influenza in children. (Funded by GlaxoSmithKline Biologicals; number, NCT01218308.)


December 25, 2013 at 9:31 pm

Preserving Antibiotics, Rationally

N Engl J of Medic Dec 26, 2013 V.369 P.2474-2476


Aidan Hollis, Ph.D., and Ziana Ahmed, B.A.Sc.

Antimicrobial resistance is a critical threat to public health. The value of antibiotics for human health is immeasurable, but were one to try to measure, a plausible estimate of the increase in life expectancy attributable to antibiotics might be 2 to 10 years.1 If we multiply this increase by 300 million Americans and a dollar value of, say, $100,000 per life-year, we arrive at an estimate for the worth of the current stock of antibiotics of $60 trillion to $300 trillion in the United States alone. Unfortunately, this stock is being gradually depleted owing to genetic mutations in bacteria and the selective pressure caused by the flood of antibiotics released into the environment. A total of 51 tons of antibiotics are consumed daily in the United States alone, so the selective pressure in favor of resistant pathogens is strong…..


December 25, 2013 at 9:27 pm

CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management

MMWR Recommendations and Reports December 20, 2013 V.62 N.RR 10 P.1-19

Hepatitis B (HBV) has long been recognized as an occupational risk for health-care personnel (HCP), including HCP trainees. The virus remains infectious for prolonged periods on environmental surfaces and is transmissible in the absence of visible blood.

HCP do not recognize all exposures to potentially infectious blood or body fluids and even if exposures are recognized, often do not seek postexposure prophylactic management for recognized exposures. In serologic studies conducted in the United States during the 1970s, HCP had a prevalence of HBV infection approximately 10 times greater than the general population.

This report provides CDC guidance for persons working, training, or volunteering in health-care settings who have documented HepB vaccination years before hire or matriculation (e.g., when HepB vaccination was received as part of routine infant [recommended since 1991] or catch-up adolescent [recommended since 1995] vaccination).



December 24, 2013 at 7:45 am

A 10-year retrospective analysis of clinical profiles, laboratory characteristics and management of pyogenic liver abscesses in a chinese hospital.

Gut Liver. 2011 Jun;5(2):221-7.

Zhu X, Wang S, Jacob R, Fan Z, Zhang F, Ji G.


Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.



Pyogenic liver abscess (PLA) is a serious, life threatening condition with a high mortality rate that represents a diagnostic and therapeutic challenge. The aim of this study was to collect demographic data and clinical, laboratory and microbiological characteristics of PLA patients treated between 2000 and 2010. We also aimed to collect information regarding our management experience of these cases.


As a retrospective review, 47 patients with PLA in a tertiary referral center were examined to determine their demographic characteristics, clinical features, and laboratory, imaging, and microbiologic findings as well as the treatment outcome.


Cryptogenic PLA was the most frequently identified type of PLA, while benign biliary tract disease was the most frequently identifiable cause of PLA (18/47 patients; 38.3%). Leukocytosis and elevated alanine transaminase were common laboratory findings and were observed in 35 (74.5%) and 22 (46.8%) patients, respectively. Increased fibrinogen was also detected in 11 of 15 investigated cases (73.3%). Notably, infection-induced thrombocytopenia occurred in 8 patients (17%). Diabetes mellitus was associated with the occurrence of infection induced shock when compared to the non-diabetic group (p<0.05). Patients with two or more comorbid diseases had longer hospitalizations when compared to patients with one comorbid disease or those without comorbidities (p<0.001). The number of days needed to establish diagnosis was correlated with the length of hospitalization (p<0.001). The overall hospital mortality rate was 2.1% (1/47).


Characteristics of PLA patients from the past 10 years are presented. The number of days needed to establish a PLA diagnosis was correlated with the length of the hospital stay. The hospital stay of PLA patients can be further improved by early diagnosis and effective treatments during the early stages of PLA progression.


December 23, 2013 at 11:20 am

Knowledge and perceptions about community-acquired staphylococcal infections among health care workers in Hawai’i.

Hawaii J Med Public Health. 2013 Sep;72(9):311-6.

Dunn BS, Tice AD, Hurwitz EL, Katz AR.


Department of Public Health Sciences, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI.


Since the early 1990, national rates of methicillin-resistant Staphylococcus aureus (MRSA) infections have increased dramatically.

Initially identified in health care settings, community-acquired MRSA is now a major public health concern.

With Hawai’i’s expanding S. aureus and MRSA epidemic closely approximating the national trend in inpatient and outpatient settings, a high level of knowledge and awareness among health care workers is essential to successfully control this evolving epidemic. Health care and related workers were surveyed to assess their knowledge and perceptions about staphylococcal and MRSA infections.

Knowledge was estimated by demonstrated ability to correctly identify risk factors including diabetes and obesity, as well as to demonstrate awareness of a growing staphylococcal and MRSA epidemic. Perceptions were estimated by level of concern of antibiotic resistance as well as of the severity of the staphylococcal and MRSA epidemic.

Variations in knowledge and perception concerning basic principles associated with S. aureus infections as well as characteristics of the evolving S. aureus and MRSA epidemic were observed among various occupations (advance clinical practitioners, nurses, public health professionals, athletic trainers, and non-medical workers) as well as work locations (hospital, community, and non-clinical community).

Overall, health care and related workers in community settings demonstrated disparities in knowledge regarding S. aureus and MRSA infections. They were also more likely to misperceive this growing threat.

These findings provide support for focused educational interventions targeting community health care and related workers to improve awareness of staphylococcal infections in order to successfully address and combat this evolving epidemic.


December 23, 2013 at 11:16 am

The hantaviruses causing hemorrhagic fever with renal syndrome and pulmonary syndrome.

Salud Publica Mex. 2008 Jul-Aug;50(4):334-40.

[Article in Spanish]

Ramos C.


Departamento de Arbovirus, Centro de Investigaciones sobre Enfermedades Infecciosas, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México.


The goal of this review is to provide basic information on hantaviruses as causative agents of Hemorrhagic Fever with Renal Syndrome (HFRS) and Hantavirus Pulmonary Syndrome (HPS), two zoonotic diseases widely distributed in Asia/Europe, and the American continent, respectively.

Hantaviruses are rodent-borne and transmitted to humans by direct contact with infected rodents or their secretions (urine, feces and saliva). Both, HFRS and HPS share some clinical aspects, however, hemorrhage and renal failure are the hallmark of HFRS, while respiratory problems are distinctive signs and symptoms of patients with HPS.

Studies on hantavirus infection in rodents from Mexico are included, some recomendations to prevent or avoid contact with rodents are mentioned, and some determinant ecologic factors of hantaviruses distribution and their natural rodents, are also included.


December 23, 2013 at 11:09 am

DALI: Defining Antibiotic Levels in Intensive care unit patients: a multi-centre point of prevalence study to determine whether contemporary antibiotic dosing for critically ill patients is therapeutic

BMC Infect Dis. 2012 Jul 6;12:152. doi: 10.1186/1471-2334-12-152.

Jason A Roberts1,2*, Jan J De Waele3, George Dimopoulos4, Despoina Koulenti4, Claude Martin5,

Philippe Montravers6, Jordi Rello7, Andrew Rhodes8, Therese Starr2, Steven C Wallis1 and Jeffrey Lipman1,2



The clinical effects of varying pharmacokinetic exposures of antibiotics (antibacterials and antifungals) on outcome in infected critically ill patients are poorly described. A large-scale multi-centre study (DALI Study) is currently underway describing the clinical outcomes of patients achieving pre-defined antibiotic exposures. This report describes the protocol.


DALI will recruit over 500 patients administered a wide range of either beta-lactam or glycopeptide antibiotics or triazole or echinocandin antifungals in a pharmacokinetic point-prevalence study. It is anticipated that over 60 European intensive care units (ICUs) will participate. The primary aim will be to determine whether contemporary antibiotic dosing for critically ill patients achieves plasma concentrations associated with maximal activity. Secondary aims will compare antibiotic pharmacokinetic exposures with patient outcome and will describe the population pharmacokinetics of the antibiotics included. Various subgroup analyses will be conducted to determine patient groups that may be at risk of very low or very high concentrations of antibiotics.


The DALI study should inform clinicians of the potential clinical advantages of achieving certain antibiotic pharmacokinetic exposures in infected critically ill patients.


December 21, 2013 at 11:00 am

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