Archive for June, 2014

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections – 2014 Update by the Infectious Diseases Society of America

Clinical Infectious Diseases July 15, 2014 V.59 N.2 P.


Dennis L. Stevens1, Alan L. Bisno2, Henry F. Chambers3, E. Patchen Dellinger4, Ellie J. C. Goldstein5, Sherwood L. Gorbach6, Jan V. Hirschmann7, Sheldon L. Kaplan8, Jose G. Montoya9, and James C. Wade10

1Division of Infectious Diseases, Department of Veterans Affairs, Boise, Idaho

2Medical Service, Miami Veterans Affairs Health Care System, Florida

3San Francisco General Hospital, University of California

4Division of General Surgery, University of Washington, Seattle

5University of California, Los Angeles, School of Medicine, and R. M. Alden Research Laboratory, Santa Monica, California

6Department of Community Health, Tufts University, Boston, Massachusetts

7Medical Service, Puget Sound Veterans Affairs Medical Center, Seattle, Washington

8Department of Pediatrics, Baylor College of Medicine, Houston, Texas

9Department of Medicine, Stanford University, California

10Geisinger Health System, Geisinger Cancer Institute, Danville, Pennsylvania

Correspondence: Dennis L. Stevens, PhD, MD, Infectious Diseases Section, VA Medical Center, 500 W Fort St, Bldg 45, Boise, ID 83702 (

A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs).

The panel’s recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections.

The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population.

These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.



June 29, 2014 at 7:39 pm

Lower Respiratory Tract Virus Findings in Mechanically Ventilated Patients With Severe Community-Acquired Pneumonia

Clinical Infectious Diseases July 1, 2014 V.59 N.1 P.62-70

J. Karhu1, T. I. Ala-Kokko1, T. Vuorinen4, P. Ohtonen2, and H. Syrjälä3

1Department of Anaesthesiology, Division of Intensive Care

2Department of Anaesthesiology and Surgery

3Department of Infection Control, Oulu University Hospital, Medical Research Center Oulu

4Department of Virology, University of Turku, Finland

Correspondence: Jaana Karhu, MD, Department of Anaesthesiology, Division of Intensive Care, PO Box 21, FI-90029 OUH, Finland (



The role of viral infections in the etiology of severe community-acquired pneumonia (SCAP) was prospectively evaluated from 2008 to 2012 at a university-level intensive care unit.


Clinical data and microbiological tests were assessed: blood cultures, urine pneumococcal and legionella antigens, Mycoplasma pneumoniae and Chlamydia pneumoniae antibodies from paired serums, and respiratory virus detection by multiplex, real-time polymerase chain reaction (PCR) from nasopharyngeal swabs and lower tracheal specimens via intubation tube.


Of 49 mechanically ventilated SCAP patients (21 men and 28 women; median age, 54 years), the etiology was identified in 45 cases (92%). There were 21 pure bacterial infections (43%), 5 probably pure viral infections (10%), and 19 mixed bacterial–viral infections (39%), resulting in viral etiology in 24 patients (49%). Of 26 viruses, 21 (81%) were detected from bronchial specimens and 5 (19%) from nasopharyngeal swabs. Rhinovirus (15 cases, 58%) and adenovirus (4 cases, 15%) were the most common viral findings. The bacterial–viral etiology group had the highest peak C-reactive protein levels (median, 356 [25th–75th percentiles, 294–416], P = .05), whereas patients with probably viral etiology had the lowest peak procalcitonin levels (1.7 [25th–75th percentiles, 1.6–1.7]). The clinical characteristics of pure bacterial and mixed bacterial–viral etiologies were comparable. Hospital stay was longest among the bacterial group (17 vs 14 days; P = .02).


Viral findings were demonstrated in almost half of the SCAP patients. Clinical characteristics were similar between the pure bacterial and mixed bacterial–viral infections groups. The frequency of viral detection depends on the availability of PCR techniques and lower respiratory specimens.



Editorial Commentary

What is the Real Role of Respiratory Viruses in Severe Community-Acquired Pneumonia?

Olli Ruuskanen1 and Asko Järvinen2

1Department of Pediatrics, Turku University Hospital

2Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Finland

Correspondence: Olli Ruuskanen, MD, PhD, Department of Pediatrics, Turku University Hospital, 20520 Turku, Finland (

The impact of respiratory virus infections (RVIs) on community-acquired pneumonia (CAP) in adults is increasingly recognized. The role of influenza A virus in causing pneumonia has been well known since its discovery in 1933 and was reinforced by the 2009 influenza A(H1N1) pandemic. However, the role of other RVIs in adults with CAP was long underestimated simply because available technologies such as virus culture or virus antigen detection lacked sensitivity in detecting the full range of respiratory viruses. The availability of nucleic acid amplification tests (NAATs) has greatly increased our ability to detect RVIs and characterize viral pneumonia. Recent studies employing a full set of tests suggest that a third of adult cases of CAP are associated with RVIs. In addition to influenza, rhinoviruses, respiratory syncytial virus (RSV), coronaviruses, and human metapneumovirus are most often detected among 30 viruses known as putative causative agents of CAP [1]. Viral–bacterial coinfections occur in 10%–15% of patients [1–3]. Although RVIs are often associated with CAP, the pathogenesis and clinical impact of viral lung infection is not well understood. In the most recent clinical practice article on adult CAP, only influenza viruses are recommended to be searched for during influenza season, and other RVIs viruses are not even mentioned [4].

In this issue of Clinical Infectious Diseases, Karhu and colleagues [5] from Oulu, Finland, report their observations on the role of viruses in severe community-acquired pneumonia (SCAP) in adults. Their article contains 3 interesting messages.

First, half of 49 patients with SCAP had evidence of RVI when both upper and lower respiratory sampling was used. Importantly, viruses were found most often in bronchial samples (bronchoalveolar lavage [BAL] or bronchial suction aspirate). Only …


June 29, 2014 at 7:36 pm

Crossing Borders: One World, Global Health

Clinical Infectious Diseases July 1, 2014 V.59 N.1

Clive M. Brown and Martin S. Cetron, Section Editors

Rotavirus Enteritis in Dadaab Refugee Camps: Implications for Immunization Programs in Kenya and Resettlement Countries

Maurice Ope, Steve B. Ochieng, Collins Tabu, Nina Marano.

Dadaab refugee camp, established in Kenya in 1991, is host to >500 000 refugees, most of whom are Somali in origin. Annually, the United States resettles approximately 11 000 refugees from Africa, 4000 of them from Kenya. Although substantial progress has been made to provide safe water and improve sanitation in Dadaab, diarrheal disease remains among the leading causes of morbidity and mortality. Several disease outbreaks, including hepatitis E virus, cholera, and wild poliovirus, have been attributed to poor sanitation in the camps.

Rotavirus enteritis is an acute viral infection that is transmitted by the fecal–oral route and affects nonimmune people, particularly children <5 years old. Rotavirus causes severe diarrhea in young children, particularly in developing countries, and contributes to high childhood mortality. Rotavirus infects nearly every child by the age of 3–5 years. Severe rotavirus enteritis is, however, preventable through vaccination early in life.

To date, 53 countries have implemented routine vaccination against rotavirus, including 12 in Africa (Botswana, Burkina Faso, Burundi, Ethiopia, The Gambia, Ghana, Malawi, Mali, Rwanda, South Africa, Tanzania, and Zambia). The role …


June 29, 2014 at 7:34 pm

Breastfeeding and HIV-Infected Women in the United States: Harm Reduction Counseling Strategies

Clinical Infectious Diseases July 15, 2014 V.59 N.2 P.304-309

Judy Levison1, Shannon Weber2, and Deborah Cohan2,3

1Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas

2National HIV/AIDS Clinical Consultation Center

3Department of Obstetrics and Gynecology, University of California, San Francisco

Correspondence: Judy Levison, MD, MPH, Baylor College of Medicine c/o Northwest Health Center, 1100 W 34th St, Houston, TX 77018 (


Social and cultural forces have led some human immunodeficiency virus (HIV)–infected women to question the recommendation in the United States not to breastfeed.

Without an open dialogue, women may choose to breastfeed exclusively or intermittently and not disclose this to their provider.

We review the evidence from global studies of the risks of breastfeeding among HIV-infected mothers and propose a harm reduction model for women considering breastfeeding.


June 29, 2014 at 7:32 pm

Impact of Risk Factors for Specific Causes of Death in the First and Subsequent Years of Antiretroviral Therapy Among HIV-Infected Patients

Clinical Infectious Diseases July 15, 2014 V.59 N.2 P.287-297

Suzanne M. Ingle1, Margaret T. May1, M. John Gill2, Michael J. Mugavero3, Charlotte Lewden4,5, Sophie Abgrall6,7,8, Gerd Fätkenheuer9, Peter Reiss10, Michael S. Saag3, Christian Manzardo11, Sophie Grabar7,12,13, Mathias Bruyand14, David Moore15, Amanda Mocroft16, Timothy R. Sterling17, Antonella D’Arminio Monforte18, Victoria Hernando19,20, Ramon Teira21, Jodie Guest22,23, Matthias Cavassini24, Heidi M. Crane25, and Jonathan A. C. Sterne1 for the Antiretroviral Therapy Cohort Collaboration

1School of Social and Community Medicine, University of Bristol, United Kingdom

2Division of Infectious Diseases, University of Calgary, Canada

3Division of Infectious Disease, Department of Medicine, University of Alabama, Birmingham

4INSERM, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux

5Université Bordeaux, Institut de Santé Publique, d’Epidémiologie et de Developpement (ISPED)

6UPMC Université Paris 06, UMR_S 943

7INSERM, UMR_S 943, Paris

8Service des maladies infectieuses et tropicales, AP-HP, Hôpital Avicenne, Bobigny, France

9Department of Internal Medicine, University of Cologne, Germany

10Stichting HIV Monitoring, and Division of Infectious Diseases and Department of Global Health, Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, The Netherlands

11Infectious Diseases Service, Hospital Clinic–IDIBAPS, Barcelona, Spain

12AP-HP, Hôpital Cochin, Unité de Biostatistique et Epidémiologie, Paris

13Université Paris Descartes

14INSERM, ISPED, Centre Inserm U897-Epidemiologie-Biostatistique, Bordeaux, France

15BC Centre for Excellence in HIV/AIDS, Department of Medicine, University of British Columbia, Vancouver, Canada

16Research Department of Infection and Population Health, University College London, United Kingdom

17Vanderbilt University School of Medicine, Nashville, Tennessee

18Clinic of Infectious Diseases and Tropical Medicine, San Paolo Hospital, University of Milan, Italy

19Red de Investigación en Sida, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid

20CIBER de Epidemiología y Salud Pública, Madrid

21Unit of Infectious Diseases, Hospital Sierrallana, Torrelavega, Spain

22HIV Atlanta VA Cohort Study, Atlanta

23Veterans Affairs Medical Center, Decatur, Georgia

24Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Switzerland

25Clinical Epidemiology and Health Services Research Core, Center for AIDS Research, University of Washington, Seattle

Correspondence: Suzanne M. Ingle, PhD, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK (


Patterns of cause-specific mortality in individuals infected with human immunodeficiency virus type 1 (HIV-1) are changing dramatically in the era of antiretroviral therapy (ART).


Sixteen cohorts from Europe and North America contributed data on adult patients followed from the start of ART. Procedures for coding causes of death were standardized. Estimated hazard ratios (HRs) were adjusted for transmission risk group, sex, age, year of ART initiation, baseline CD4 count, viral load, and AIDS status, before and after the first year of ART.


A total of 4237 of 65 121 (6.5%) patients died (median, 4.5 years follow-up). Rates of AIDS death decreased substantially with time since starting ART, but mortality from non-AIDS malignancy increased (rate ratio, 1.04 per year; 95% confidence interval [CI], 1.0–1.1). Higher mortality in men than women during the first year of ART was mostly due to non-AIDS malignancy and liver-related deaths. Associations with age were strongest for cardiovascular disease, heart/vascular, and malignancy deaths. Patients with presumed transmission through injection drug use had higher rates of all causes of death, particularly for liver-related causes (HRs compared with men who have sex with men: 18.1 [95% CI, 6.2–52.7] during the first year of ART and 9.1 [95% CI, 5.8–14.2] thereafter). There was a persistent role of CD4 count at baseline and at 12 months in predicting AIDS, non-AIDS infection, and non-AIDS malignancy deaths. Lack of viral suppression on ART was associated with AIDS, non-AIDS infection, and other causes of death.


Better understanding of patterns of and risk factors for cause-specific mortality in the ART era can aid in development of appropriate care for HIV-infected individuals and inform guidelines for risk factor management.


June 29, 2014 at 7:30 pm

Pneumococcal infection in adults: burden of disease

Clinical Microbiology and Infection May 2014 V.20 Suppl.5


J. J. C. Drijkoningen andG. G. U. Rohde*

Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands

* Corresponding author: G. G. U. Rohde, Department of Respiratory Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands    E-mail:

To overview the present global burden of pneumococcal disease is important because new preventive measures such as the pneumococcal conjugate vaccine 13 are currently being evaluated. Pneumococcal disease is roughly divided into non-invasive and invasive disease.

The burden of non-invasive pneumococcal disease in adults is mainly determined by community-acquired pneumonia. Pneumococcal pneumonia has high incidence rates and carries a high mortality risk, especially in the elderly.

Within the cluster of invasive pneumococcal diseases, pneumonia also represents the most common infectious source. Incidence and mortality rates of both non-invasive and invasive disease have changed as a result of pneumococcal vaccination in children.

However, especially elderly patients with comorbidities remain vulnerable to morbidity and mortality caused by pneumococcal disease.

The current review summarizes the current knowledge on the epidemiology including outcome of the main clinical forms of pneumococcal disease, with a special focus on elderly patients.

Furthermore, the economic burden and future vaccine strategies are briefly discussed.


June 28, 2014 at 11:41 am

Update on antifungal resistance in Aspergillus and Candida

Clinical Microbiology and Infection June 2014 V.20 Suppl S6


M. C. Arendrup*

Unit of Mycology and Parasitology, Department Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark

* Corresponding author: M. C. Arendrup, Unit of Mycology, Dept. Microbiology and Infection Control, Statens Serum Institut, Building 43/317, Copenhagen, Denmark   E-mail:

Antifungal resistance in Candida and Aspergillus may be either intrinsic or acquired and may be encountered in the antifungal drug exposed but also the antifungal drug-naïve patient.

Prior antifungal treatment confers a selection pressure and notoriously raises the awareness of possible resistance in patients failing therapy, thus calling for susceptibility testing.

On the contrary, antifungal resistance in the drug-naïve patient is less expected and therefore more challenging. This is particularly true when it concerns pathogens with acquired resistance which cannot be predicted from the species identification itself.

This scenario is particularly relevant for A. fumigatus infections due to the increasing prevalence of azole-resistant isolates in the environment. For Candida, infections resistance is most common in the context of increasing prevalence of species with intrinsic resistance.

Candida glabrata which has intrinsically reduced susceptibility to fluconazole is increasingly common particularly among the adult and elderly population on the Northern Hemisphere where it may be responsible for as many as 30% of the blood stream infections in population-based surveillance programmes.

Candida parapsilosis is prevalent in the paediatric setting, at centres with increasing echinocandin use and at the southern or pacific parts of the world. In the following, the prevalence and drivers of intrinsic and acquired resistance in Aspergillus and Candida will be reviewed.


June 28, 2014 at 11:39 am

Single-Dose Oritavancin in the Treatment of Acute Bacterial Skin Infections

N Engl J Med 2014; 370:2180-2190

G. Ralph Corey, M.D., Heidi Kabler, M.D., Purvi Mehra, M.D., Sandeep Gupta, M.D., J. Scott Overcash, M.D., Ashwin Porwal, M.D., Philip Giordano, M.D., Christopher Lucasti, M.D., Antonio Perez, M.D., Samantha Good, Ph.D., Hai Jiang, Ph.D., Greg Moeck, Ph.D., and William O’Riordan, M.D. for the SOLO I Investigators

From Duke University Medical Center, Durham, NC (G.R.C.); Sunrise Hospital and Medical Center, Las Vegas (H.K.); Sharp Chula Vista Medical Center, Chula Vista (P.M., W.O.), and Sharp Grossmont Hospital, San Diego (J.S.O.) — both in California; MV Hospital and Research Center, Lucknow (S. Gupta), and Inamdar Multispecialty Hospital, Pune (A. Porwal) — both in India; Orlando Health, Orlando, FL (P.G.); and South Jersey Infectious Disease, Somers Point (C.L.), and the Medicines Company, Parsippany (A. Perez, S. Good, H.J., G.M.) — both in New Jersey.

Address reprint requests to Dr. Corey at Duke University Medical Center, 310 Trent Dr., Box 90519, Durham, NC 27708, or at  

The economic burden of acute bacterial skin and skin-structure infections remains substantial and is driven by the high costs of hospitalization and by treatment with agents that require dosing once or twice daily for a duration of 7 to 10 days or more.

Treatment of these infections often requires agents that are active against methicillin-resistant Staphylococcus aureus (MRSA), which continues to be an important causative pathogen in many countries.

Even treatment in an outpatient setting cannot overcome the disadvantage of multiple administrations, incomplete adherence to medication regimens, and the complexity of monitoring therapeutic drug levels……



June 28, 2014 at 11:35 am

Antifungal pre-emptive strategy for high-risk neutropenic patients: why the story is still ongoing

Clinical Microbiology and Infection June 2014 V.20 Suppl S6


C. Cordonnier1,*, C. Robin1, A. Alanio2,3 andS. Bretagne2,3,4

1Haematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil, France

2Parasitology–Mycology Department, Saint-Louis Hospital, AP-HP and University Paris Diderot, Paris, France

3Institut Pasteur, Molecular Mycology Unit, CNRS URA 3012, Paris, France

4Institut Pasteur, Centre National de Référence des Mycoses Invasives et Antifongiques, Paris, France

* Corresponding author: C. Cordonnier, Haematology Department, Henri Mondor Hospital, 94000 Créteil, France


Neutropenic patients with haematological malignancies are at high risk of invasive fungal disease (IFD).

Due to limitations in specific procedures to establish an early diagnosis of IFD, two historical unpowered studies suggested, three decades ago, that giving an empirical antifungal treatment to patients with persistent or recurrent fever under broad-spectrum antibacterials, could reduce the risk of IFD.

For cost and toxicity reasons, this strategy became debated when modern imaging and indirect biological markers became available.

Different pre-emptive strategies, either based on lung imaging, galactomannan antigenaemia, fungal PCR, or a combination of several parameters, were designed with the goal of restricting the administration of antifungals to the more at-risk patients with early signs of IFD.

Almost all pre-emptive studies showed or suggested a reduction of administration and cost of antifungals during neutropenic phases. However, the clinical pertinence and safety of the strategy, and mainly its optimal design, are still pending.

This paper reviews the evolution of these strategies and how they may be implemented in the haematology ward.


June 26, 2014 at 7:41 pm

The role of primary antifungal prophylaxis in patients with haematological malignancies

Clinical Microbiology and Infection June 2014 V.20 Suppl S6


L. Pagano* andM. Caira

Istituto di Ematologia, Università Cattolica del Sacro Cuore, Rome, Italy

* Corresponding author: L. Pagano, Istituto di Ematologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, I-00168 Rome, Italy    E-mail:

Invasive fungal infections (IFIs) represent important complications in patients with haematological malignancies.

Chemoprevention of IFIs may play an important role in this setting, but in the past decades the majority of antifungal drugs utilized demonstrated poor efficacy, particularly in the prevention of invasive aspergillosis.

The new triazoles are very useful antifungal drugs, more suitable for prophylaxis of IFIs than amphotericin B and echinocandins.

In this review, the main clinical data about antifungal prophylaxis with fluconazole, itraconazole, voriconazole and posaconazole are analysed.

At present, posaconazole appears to be the most efficacious azole in antifungal prophylaxis, particularly in patients with acute myeloid leukaemia.


June 26, 2014 at 7:38 pm

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