Archive for May, 2014

Atypical manifestations and poor outcome of herpes simplex encephalitis in the immunocompromised.

Neurology. 2012 Nov 20;79(21):2125-32.

Tan IL1, McArthur JC, Venkatesan A, Nath A.

1Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.



To characterize clinical features, neuroimaging, and outcomes of herpes simplex encephalitis (HSE) in immunocompromised individuals.


We performed a retrospective case control review of patients diagnosed with HSE. Adult patients were dichotomized into immunocompromised (n = 14) and immunocompetent groups (n = 15).


Fewer immunocompromised patients presented with prodromal symptoms and focal deficits. While the majority of CSF profiles in the immunocompromised patients were mononuclear cells predominant, 3 had polymorphonuclear predominance and another 3 had normal profiles. MRI showed widespread cortical involvement, with brainstem or cerebellar involvement in some. Two immunocompromised patients had recurrent HSE. The immunosuppressed state was associated with a decrease in Karnofsky Performance Status Scale (KPSS) score of 23.1 (p = 0.018). Every 1-day delay in initiation of acyclovir was associated with a decrease in KPSS of 10.2 (p = 0.002), and every 10 cell/mm(3) increase of CSF leukocytosis was associated with an increase in KPSS of 0.7 (p = 0.009). Mortality rate was 6 times higher in the immunocompromised patients.


Immunocompromised states may predispose to HSE with atypical clinical and neuroradiologic features. Immunocompromised individuals with HSE have significantly worse outcomes and mortality. Early diagnosis and treatment is associated with improved outcome. The findings are particularly important in light of the increasing use of potent immunosuppressive and immunomodulatory therapies.


May 31, 2014 at 9:14 am

Maintaining the Momentum of Change: The Role of the 2014 Updates to the Compendium in Preventing Healthcare-Associated Infections

Infection Control and Hospital Epidemiology May 2014  V.35 N.5


Edward Septimus, MD,1,a Deborah S. Yokoe, MD, MPH,2,a Robert A. Weinstein, MD,3 Trish M. Perl, MD, MSc,4 Lisa L. Maragakis, MD, MPH,4 and Sean M. Berenholtz, MD, MHS5

1. Hospital Corporation of America, Houston, Texas

2. Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

3. Stroger Hospital and Rush University Medical Center, Chicago, Illinois

4. Johns Hopkins University School of Medicine, Baltimore, Maryland

5. Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland

a These authors contributed equally to this work

Address correspondence to Deborah S. Yokoe, MD, MPH, 181 Longwood Avenue, Boston, MA 02115 (

Preventing healthcare-associated infections (HAIs) is a national priority. Although substantial progress has been achieved, considerable deficiencies remain in our ability to efficiently and effectively translate existing knowledge about HAI prevention into reliable, sustainable, widespread practice.

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates” is the product of a highly collaborative endeavor designed to support hospitals’ efforts to implement and sustain HAI prevention strategies.



May 31, 2014 at 9:12 am

Assessing the Burden of Healthcare-Associated Infections through Prevalence Studies: What Is the Best Method?

Infection Control and Hospital Epidemiology June 2014  V.35 N.6

Walter Zingg, MD,1 Benedikt D. Huttner, MD, MS,1 Hugo Sax, MD,1,a and Didier Pittet, MD, MS1

1. Infection Control Program and World Health Organization Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland

a Present affiliation: Division of Infectious Diseases and Infection Control, University Hospital of Zurich and Faculty of Medicine, Zurich, Switzerland

Address correspondence to Walter Zingg, MD, Infection Control Program, University of Geneva Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland (


To explore differences in the prevalence of healthcare-associated infections (HAIs) according to survey methodology.


Repeated point and period prevalence survey strategies.


University-affiliated primary and tertiary care center.


Analysis of data collected from 2006 to 2012 from annual HAI prevalence surveys using definitions proposed by the US Centers for Disease Control and Prevention. The study design allowed the analysis of the same data in the format of a point or a period prevalence survey.


Pooled point and period HAI prevalence was 7.46% and 9.84% (+32%), respectively. This additional 32% was mainly attributable to infections of the lower respiratory tract (2.42% vs 3.20% [+32%]) and the urinary tract (1.76% vs 2.62% [+49%]). Differences in surgical site infections (1.02% vs 1.20% [+19%]) and bloodstream infections (0.76% vs 0.86% [+13%]) were smaller. HAI prevalence for the point and period methodology in acute and long-term care were 7.47% versus 9.38 (+26%) and 8.37% versus 11.89% (+42%), respectively. Differences were stable over time. Focusing on the 4 major HAIs (respiratory tract, urinary tract, surgical site, and bloodstream infections) misses one-quarter of all HAIs.


More HAIs are identified by the period prevalence method, especially those of shorter duration (lower respiratory and urinary tract), which would make this method more suitable to be used in long-term care. Results of the 2 study methods cannot be benchmarked against each other.



May 31, 2014 at 9:10 am

Influenza in immunosuppressed populations: a review of infection frequency, morbidity, mortality, and vaccine responses.

Lancet Infect Dis. 2009 Aug;9(8):493-504.

Kunisaki KM1, Janoff EN.

1Pulmonary Section, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417, USA.


Patients that are immunosuppressed might be at risk of serious influenza-associated complications.

As a result, multiple guidelines recommend influenza vaccination for patients infected with HIV, who have received solid-organ transplants, who have received haemopoietic stem-cell transplants, and patients on haemodialysis.

However, immunosuppression might also limit vaccine responses. To better inform policy, we reviewed the published work relevant to incidence, outcomes, and prevention of influenza infection in these patients, and in patients being treated chemotherapy and with systemic corticosteroids.

Available data suggest that most immunosuppressed populations are indeed at higher risk of influenza-associated complications, have a general trend toward impaired humoral vaccine responses (although these data are mixed), and can be safely vaccinated–although longitudinal data are largely lacking.

Randomised clinical trial data were limited to one study of HIV-infected patients with high vaccine efficacy. Better trial data would inform vaccination recommendations on the basis of efficacy and cost in these at-risk populations.



May 30, 2014 at 6:47 pm

Implementation of a cost-effective strategy to prevent neonatal early-onset group B haemolytic streptococcus disease in the Netherlands.

BMC Pregnancy Childbirth. 2013 Jul 30;13:155.

Kolkman DG1, Rijnders ME, Wouters MG, van den Akker-van Marle ME, van der Ploeg CK, de Groot CJ, Fleuren MA.

1Department of Child Health, TNO, PO Box 2215, 2301 CE Leiden, The Netherlands.



Early-onset Group B haemolytic streptococcus infection (EOGBS) is an important cause of neonatal morbidity and mortality in the first week of life.

Primary prevention of EOGBS is possible with intra-partum antibiotic prophylaxis (IAP.) Different prevention strategies are used internationally based on identifying pregnant women at risk, either by screening for GBS colonisation and/or by identifying risk factors for EOGBS in pregnancy or labour.

A theoretical cost-effectiveness study has shown that a strategy with IAP based on five risk factors (risk-based strategy) or based on a positive screening test in combination with one or more risk factors (combination strategy) was the most cost-effective approach in the Netherlands.

IAP for all pregnant women with a positive culture in pregnancy (screening strategy) and treatment in line with the current Dutch guideline (IAP after establishing a positive culture in case of pre-labour rupture of membranes or preterm birth and immediate IAP in case of intra-partum fever, previous sibling with EOGBS or GBS bacteriuria), were not cost-effective.

Cost-effectiveness was based on the assumption of 100% adherence to each strategy. However, adherence in daily practice will be lower and therefore have an effect on cost-effectiveness.


The aims are to:

a.) implement the current Dutch guideline, the risk-based strategy and the combination strategy in three pilot regions and

b.) study the effects of these strategies in daily practice.

Regions where all the care providers in maternity care implement the allocated strategy will be randomised.

Before the introduction of the strategy, there will be a pre-test (use of the current guideline) involving 105 pregnant women per region. This will be followed by a post-test (use of the allocated strategy) involving 315 women per region.

The outcome measures are:

1.) adherence to the specific prevention strategy and the determinants of adherence among care providers and pregnant women,

2.) outcomes in pregnant women and their babies and

3.) the costs of each strategy in relation to the effects.


This study will provide recommendations for the implementation of the most cost-effective prevention strategy for EOGBS in the Netherlands on the basis of feasibility in daily practice.


May 30, 2014 at 4:19 pm

Measles — United States, January 1–May 23, 2014

MMWR May 29, 2014 V.63 P.1-4Early Release

Paul A. Gastañaduy, MD, Susan B. Redd, Amy Parker Fiebelkorn, MSN, et al.

Measles is a highly contagious, acute viral illness that can lead to serious complications and death.

Although measles elimination was declared in the United States in 2000, importations of measles cases from endemic areas of the world continue to occur, leading to secondary measles cases and outbreaks in the United States, primarily among unvaccinated persons.

To update national measles data in the United States, CDC evaluated cases reported by states from January 1 through May 23, 2014.

A total of 288 confirmed measles cases have been reported to CDC, surpassing the highest reported yearly total of measles cases since elimination….



May 30, 2014 at 4:15 pm


US Public Health Service



Preexposure Prophylaxis for HIV Prevention in the United States – 2013: A Clinical Practice Guideline provides comprehensive information for the use of daily oral antiretroviral preexposure prophylaxis (PrEP) to reduce the risk of acquiring HIV infection in adults.

The key messages of the guideline are …


May 29, 2014 at 8:51 am

Policy – An intergovernmental panel on antimicrobial resistance

NATURE May 22, 2014 V.509 N.7502

Mark Woolhouse& Jeremy Farrar

Drug-resistant microbes are spreading. A coordinated, global effort is needed to keep drugs working and develop alternatives, say Mark Woolhouse and Jeremy Farrar.

Last month, the World Health Organization (WHO) produced a global map1 of antimicrobial resistance, warning that a ‘post-antibiotic’ world could soon become a reality. In some ways, it already has….



May 29, 2014 at 8:48 am

Broad-Spectrum Anti-biofilm Peptide That Targets a Cellular Stress Response

Plos Pathogens May.22, 2014

César de la Fuente-Núñez, Fany Reffuveille, Evan F. Haney, Suzana K. Straus, Robert E. W. Hancock

César de la Fuente-Núñez, Fany Reffuveille, Evan F. Haney, Robert E. W. Hancock

Department of Microbiology and Immunology, Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, British Columbia, Canada

Suzana K. Straus

Department of Chemistry, University of British Columbia, Vancouver, British Columbia, Canada

Bacteria form multicellular communities known as biofilms that cause two thirds of all infections and demonstrate a 10 to 1000 fold increase in adaptive resistance to conventional antibiotics.

Currently, there are no approved drugs that specifically target bacterial biofilms.

Here we identified a potent anti-biofilm peptide 1018 that worked by blocking (p)ppGpp, an important signal in biofilm development.

At concentrations that did not affect planktonic growth, peptide treatment completely prevented biofilm formation and led to the eradication of mature biofilms in representative strains of both Gram-negative and Gram-positive bacterial pathogens including Pseudomonas aeruginosa, Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae, methicillin resistant Staphylococcus aureus, Salmonella Typhimurium and Burkholderia cenocepacia.

Low levels of the peptide led to biofilm dispersal, while higher doses triggered biofilm cell death.

We hypothesized that the peptide acted to inhibit a common stress response in target species, and that the stringent response, mediating (p)ppGpp synthesis through the enzymes RelA and SpoT, was targeted. Consistent with this, increasing (p)ppGpp synthesis by addition of serine hydroxamate or over-expression of relA led to reduced susceptibility to the peptide.

Furthermore, relA and spoT mutations blocking production of (p)ppGpp replicated the effects of the peptide, leading to a reduction of biofilm formation in the four tested target species.

Also, eliminating (p)ppGpp expression after two days of biofilm growth by removal of arabinose from a strain expressing relA behind an arabinose-inducible promoter, reciprocated the effect of peptide added at the same time, leading to loss of biofilm.

NMR and chromatography studies showed that the peptide acted on cells to cause degradation of (p)ppGpp within 30 minutes, and in vitro directly interacted with ppGpp.

We thus propose that 1018 targets (p)ppGpp and marks it for degradation in cells. Targeting (p)ppGpp represents a new approach against biofilm-related drug resistance.




May 28, 2014 at 3:47 pm

A Rare Presentation of Community Acquired Methicillin Resistant Staphylococcus aureus.

Case Rep Infect Dis. 2013;2013:543762.

Docekal J1, Hall J1, Reese B1, Jones J1, Ferguson T2.

1Department of Internal Medicine, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859, USA.

2Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859, USA.


Prostatic abscess is a rarely described condition and is commonly caused by gram-negative organisms such as enterobacteria.

However, as the prevalence of methicillin resistant Staphylococcus aureus (MRSA) increases in the community, unusual infections due to this organism have been recently published.

In this report, we describe a patient with diabetes mellitus type 2, who presents with diabetic ketoacidosis-later found to be due to a prostatic abscess from which MRSA was cultured.


May 27, 2014 at 3:38 pm

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