Archive for July, 2014

Case 20-2014 — A 65-Year-Old Man with Dyspnea and Progressively Worsening Lung Disease

N Engl J Med June 26, 2014 V.370 P.2521-2530


Kathleen M. Finn, M.D., Leo C. Ginns, M.D., Gregory K. Robbins, M.D., Carol C. Wu, M.D., and John A. Branda, M.D.

From the Departments of Medicine (K.M.F., L.C.G., G.K.R.), Radiology (C.C.W.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (K.M.F., L.C.G., G.K.R.), Radiology (C.C.W.), and Pathology (J.A.B.), Harvard Medical School — both in Boston.


Dr. Gregory K. Robbins: A 65-year-old man with a history of emphysema and inflammatory colitis was admitted to this hospital because of dyspnea, hypoxemia, and worsening lung disease.

The patient had been well until approximately 3 years before admission, when herpes zoster infection (shingles) occurred; shortly thereafter, episodes of bloody diarrhea developed, after which a diagnosis of inflammatory colitis was made at another hospital.

Two years before admission, mesalamine was administered for treatment of the colitis, with improvement of his symptoms. During the next 2 years, progressive dyspnea on exertion occurred.

One year before this admission, pulmonary-function tests were performed, and diagnoses of chronic obstructive pulmonary disease (COPD) and advanced emphysema were made. Tiotropium bromide was administered by inhalation.

During the 6 months before this admission, numerous episodes of worsening dyspnea occurred.

Supplemental oxygen (2 liters per minute through a nasal cannula, as needed), multiple courses of antibiotics, and tapering courses of prednisone were administered, with transient improvement.

Approximately 5 months before this admission, cough with sputum production developed….


July 30, 2014 at 2:39 pm

Clinical Microbiology Costs for Methods of Active Surveillance for Klebsiella pneumoniae Carbapenemase–Producing Enterobacteriaceae

Infection Control & Hospital Epidemiology April 2014 V.35 N.4 P.350-355

Amy J. Mathers, MD,1,2 Melinda Poulter, PhD,2 Dawn Dirks, MS,2 Joanne Carroll, BS,2 Costi D. Sifri, MD,1 and Kevin C. Hazen, PhD2,a

  1. Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
  2. Department of Pathology, University of Virginia Health System, Charlottesville, Virginia

a Present affiliation: Clinical Microbiology Laboratory, Department of Pathology, Duke University Health System, Durham, North Carolina

Address correspondence to Amy J. Mathers, MD, Division of Infectious Diseases and International Health, University of Virginia Health System, PO Box 801361, Charlottesville, VA 22908 (


To compare direct laboratory costs of different methods for perirectal screening for carbapenemase-producing Enterobacteriaceae (CPE) colonization.


Cost-benefit analysis.


A university hospital and affiliated long-term acute care hospital (LTACH).


Inpatients from the hospital or LTACH.


Perirectal samples were collected from inpatients at risk for exposure to CPE. In 2009, we compared the accuracy of the Centers for Disease Control and Prevention (CDC)–recommended CPE screening method with similar methods incorporating a chromogenic agar (CA). We then performed a cost projection analysis using 2012 screening results for the CA method, the CDC method, and a molecular assay with wholesale pricing based on the 2009 analysis. Comparisons of turnaround and personnel time were also performed.


A total of 185 (2.7%) of 6,860 samples were confirmed as CPE positive during 2012. We previously found that the CDC protocol had a lower sensitivity than the CA method and predicted that the CDC protocol would have missed 92 of the CPE-positive screening results, whereas the modified protocol using CA would have missed 26, assuming similar prevalence and performance. Turnaround time was 3 days using the CDC and CA-modified protocols compared with 1 day for molecular testing. The estimated annual total program cost and total technologist’s hours would be the following: CA-modified protocol, $37,441 and 376 hours; CDC protocol, $22,818 and 482 hours; and molecular testing, $224,596 and 343 hours.


The CDC screening protocol appeared to be the least expensive perirectal screening method. However, expense must be weighed against a lower sensitivity and extra labor needed for additional work-up of non-CPE isolates. The molecular test has the shortest turnaround time but the greatest expense.




July 30, 2014 at 2:35 pm

Addressing the Emergence and Impact of Multidrug-Resistant Gram-Negative Organisms: A Critical Focus for the Next Decade

Infection Control & Hospital Epidemiology April 2014 V.35 N.4 P.333-335

Ebbing Lautenbach, MD, MPH, MSCE1 and Eli N. Perencevich, MD, MS2

  1. Division of Infectious Diseases, Department of Medicine, Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
  2. Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, and Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Administration Health Care System, Iowa City, Iowa

Address correspondence to Ebbing Lautenbach, MD, MPH, MSCE, Center for Clinical Epidemiology and Biostatistics, 825 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021 (

Approximately 10% of hospitalizations are complicated by a healthcare-associated infection, and up to 75% of these are due to organisms resistant to first-line antimicrobial therapy.

Furthermore, antimicrobial-resistant bacterial infections are associated with significant increases in morbidity and mortality and incur upward of $20 billion in annual healthcare costs.

Antimicrobial resistance has increased significantly in all spheres of patient care: acute care hospitals, long-term acute care hospitals, long-term care, and the community. Despite these sobering facts, we remain woefully unprepared to address both current and future resistant organisms.

Although antimicrobial resistance has been noted in nearly all bacterial pathogens, multidrug resistance among gram-negative bacteria represents a unique and immediate threat.

In the past decade, there has been a dramatic increase in the prevalence of various types of antimicrobial-resistant gram-negative bacteria, including extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant strains of Pseudomonas aeruginosa and Acinetobacter baumannii.

Infections due to these organisms have been associated with significantly worse clinical outcomes, with mortality rates up to 4 times higher than infections caused by susceptible strains.

Furthermore, the potential for widespread and rapid transmission of these pathogens and/or the underlying genetic determinants of their resistance is of great concern….



July 30, 2014 at 2:32 pm


MEDICINA (Buenos Aires) 2014 V.74 P.189-197


  1. Daniel D. Siciliani, Graciela Cabral, Verónica Pingray, María Elena Borda, Alicia Aranaz, Isabel N.P. Miceli

1 Sector Epidemiología, 2 Laboratorio de Virología, Hospital Nacional Profesor Alejandro Posadas, Argentina

En el Hospital Nacional Profesor Alejandro Posadas se estudiaron la incidencia de influenza, las características de casos y tipos y subtipos de virus circulantes de enero a agosto de 2013 inclusive, semanas epidemiológicas (SE) 1-35, y se compararon con los años 2009-2012. De fin de mayo a agosto inclusive de 2013 (SE 18 a 35) se observó un aumento del porcentaje de consulta por enfermedades respiratorias, enfermedad tipo influenza e internación por neumonía y se diagnosticaron 207 casos: 153 influenza A (FLU-A)(H1N1pdm09), 46 A(H3), ocho A(sin subtipificar). La mayor frecuencia fue en menores de 5 años, seguida por el grupo de 60 a 64.La chance de tener la enfermedad fue tres veces mayor en el grupo de 40-64 años versus 15-39 o > 64 años. La letalidad, que aumentó con la edad, fue de 7.2% y la chance de morir fue seis veces mayor en los > 64 años. El porcentaje de vacunación entre los casos fue11.6%. Ninguno de los fallecidos estaba vacunado. Luego de la pandemia de 2009 el porcentaje de consultas anuales disminuyó hasta 2012, con un aumento en el período invernal de 2013 de 52.0% con respecto a 2012. La circulación viral en 2013 fue más temprana que en los años anteriores. En 2009 y 2013 la mayor circulación fue FLU-A (H1N1pdm), en 2011 FLU-A(H3) y en 2010 y 2012 FLU-A(H3) y FLU-B.


July 27, 2014 at 6:21 pm

Enterococcal endocarditis – A multicenter study of 76 cases.

Enferm Infecc Microbiol Clin. 2009 Dec;27(10):571-9.

Article in Spanish

Martínez-Marcos FJ1, Lomas-Cabezas JM, Hidalgo-Tenorio C, de la Torre-Lima J, Plata-Ciézar A, Reguera-Iglesias JM, Ruiz-Morales J, Márquez-Solero M, Gálvez-Acebal J, de Alarcón-González A; Grupo para el Estudio de las Infecciones Cardiovasculares de la Sociedad Andaluza de Enfermedades Infecciosas.

Author information

1Unidad de Enfermedades Infecciosas, Hospital Juan Ramón Jiménez, Huelva, España.



Although enterococci occupy the third position among microorganisms producing infectious endocarditis (IE) following streptococci and Staphylococcus aureus, few multicenter studies have provided an in-depth analysis of enterococcal IE.


Description of the characteristics of 76 cases of enterococcal left-sided infectious endocarditis (LSIE) (native: 59, prosthetic: 17) retrieved from the database of the Cardiovascular Infections Study Group of the Andalusian Society of Infectious Diseases, with emphasis on the comparison with non-enterococcal LSIE.


Enterococci were the causal agent in 76 of the 696 episodes of LSIE (11%). Compared with non-enterococcal LSIE, enterococcal LSIE was more commonly seen in patients older than 65 (47.4% vs. 27.6%, P<0.0005), and those with chronic diseases (75% vs. 54.6%, P<0.001), calcified valves (18.6% vs. 10%, P<0.05), and previous urinary (30.3% vs. 2.1%, P<0.00001) or abdominal (10.5% vs. 3.1%, P<0.01) infections, and produced a higher rate of relapses (6.6% vs. 2.3%, P<0.05). Enterococcal LSIE was associated with fewer peripheral vascular or skin manifestations (14.5% vs. 27.1%, P<0.05) and fewer immunological phenomena (10.5% vs. 24%, P<0.01). Among the total of patients with enterococcal LSIE, 36.8% underwent valve surgery during hospitalization. In-hospital mortality was 32.9% for enterococcal LSIE, 9.3% for viridans group streptococci (VGS) LSIE and 48.6% for S. aureus LSIE (enterococci vs VGS: P<0.0001; enterococci vs S. aureus: P=0.02). Enterococcal LSIE patients treated with the combination of a penicillin or vancomycin plus an aminoglycoside (n=60) and those treated with ampicillin plus ceftriaxone (n=6) showed similar in-hospital mortality (26.7% vs 33.3%, P=0.66). High-level resistance to gentamicin was detected in 5 of 38 episodes of enterococcal LSIE (13.1%).


Enterococcal LSIE appears in patients with well-defined clinical characteristics, and causes few peripheral vascular or skin manifestations and few immunological phenomena. The relapse rate is higher than in non-enterococcal LSIE. Mortality due to enterococcal LSIE is lower than that of S. aureus LSIE, and much higher than that of VGS LSIE. Mortality due to enterococcal LSIE is similar in patients treated with ampicillin plus ceftriaxone or with a combination of penicillin or vancomycin plus an aminoglycoside. High-level resistance to gentamicin remains uncommon in enterococci causing LSIE.



July 27, 2014 at 6:20 pm

VIRUS CHIKUNGUNYA – Preparación y respuesta ante la eventual introducción en las Américas

CDC-OPS 148 págs.

La fiebre chikungunya (CHIK) es una enfermedad emergente transmitida por mosquitos y causada por un alfavirus, el virus chikungunya (CHIKV). Esta enfermedad es transmitida principalmente por los mosquitos Aedes aegypti y Ae. albopictus, las mismas especies involucradas en la transmisión del dengue.

Las epidemias de CHIKV han mostrado históricamente una presentación cíclica, con períodos interepidémicos que oscilan entre 4 y 30 años. Desde el año 2004, el CHIKV ha expandido su distribución geográfica mundial, provocando epidemias sostenidas de magnitud sin precedentes en Asia y África. Si bien algunas zonas de Asia y África se consideran endémicas para esta enfermedad, el virus produjo brotes en muchos territorios nuevos de las islas del Océano Índico y en Italia. Esta reciente reemergencia del CHIKV ha aumentado la preocupación y el interés respecto al impacto de este virus sobre la salud pública mundial…..


July 26, 2014 at 9:41 am

Detection of the Middle East Respiratory Syndrome Coronavirus Genome in an Air Sample Originating from a Camel Barn Owned by an Infected Patient

mBio July 2014 V.5 N.4

Esam I. Azhar, Anwar M. Hashem, Sherif A. El-Kafrawy, et al

Special Infectious Agents Unit, King Fahd Medical Research Center,a Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences,b Department of Medical Microbiology and Parasitology, Faculty of Medicine,c Environmental Science Department, Faculty of Metrology,d Department of Medicine, Faculty of Medicine,e and Scientific Chair of Mohammad Hussein Alamoudi for Viral Hemorrhagic Fever, King Fahd Medical Research Center,f King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel betacoronavirus that has been circulating in the Arabian Peninsula since 2012 and causing severe respiratory infections in humans.

While bats were suggested to be involved in human MERS-CoV infections, a direct link between bats and MERS-CoV is uncertain….


July 24, 2014 at 9:10 am

Diagnóstico microbiológico de las infecciones por Chlamydia spp. y especies relacionadas

Enf Infecc y Microb Clínica Junio – Julio 2014 V.32 N.06


Microbiological diagnosis of infections due to Chlamydia spp. and related species

Mario Rodríguez-Domínguez a, Sara Sanbonmatsu b, Jesús Salinas c, Roberto Alonso d, José Gutiérrez be, Juan Carlos Galán af,

a Servicio de Microbiología y CIBER en Epidemiología y Salud Pública (CIBERESP), Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España

b Área de Microbiología, Hospital Universitario Virgen de las Nieves, Granada, España

c Departamento de Sanidad Animal, Facultad de Veterinaria, Universidad de Murcia, Campus Universitario de Espinardo, Murcia, España

d Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, España

e Facultad de Medicina, Universidad de Granada, Granada, España

f Unidad de Resistencia a Antibióticos y Virulencia Bacteriana (RYC-CSIC), Madrid, España

Hasta fechas muy recientes eran muy pocos los genomas de Chlamydia trachomatis disponibles, a pesar de su importancia en salud pública. Actualmente se están secuenciando 66 genomas completos de C. trachomatis.

Esta revolución genómica está permitiendo comprender su biología, mejorar la sensibilidad y especificidad en el diagnóstico o desarrollar herramientas epidemiológicas no solo de C. trachomatis sino también de especies relacionadas, como C. pneumoniae o C. psittaci.

El diagnóstico basado en cultivo celular, serología o microinmunofluorescencia está siendo progresivamente sustituido por técnicas de amplificación de ácidos nucleicos, al superarse los inconvenientes de escaso rendimiento o reacciones cruzadas y mejorar la estandarización entre laboratorios.

Por otra parte, el desarrollo de técnicas de tipificación (MLST y VNTR) aplicadas a Chlamydiae ha aumentado el conocimiento de la epidemiología local y global aportando información sobre cómo esas bacterias evolucionan, causan brotes o adquieren mecanismos de resistencia.

Esta revisión se centra en los grandes avances alcanzados en el conocimiento de las diferentes especies de Chlamydia, en parte debido a la innovación tecnológica aplicada a la genómica como una aproximación para explicar la revolución que, tanto en el diagnóstico como en su epidemiología, se ha observado en este grupo de bacterias en los últimos años…..



July 23, 2014 at 7:52 pm

Human adenovirus – Viral pathogen with increasing importance.

Eur J Microbiol Immunol (Bp). 2014 Mar;4(1):26-33.

Ghebremedhin B.


The aim of this review is to describe the biology of human adenovirus (HAdV), the clinical and epidemiological characteristics of adenoviral epidemic keratoconjunctivitis and to present a practical update on its diagnosis, treatment, and prophylaxis.

There are two well-defined adenoviral keratoconjunctivitis clinical syndromes: epidemic keratoconjunctivitis (EKC) and pharyngoconjunctival fever (PCF), which are caused by different HAdV serotypes. The exact incidence of adenoviral conjunctivitis is still poorly known. However, cases are more frequent during warmer months.

The virus is endemic in the general population, and frequently causes severe disease in immunocompromised patients, especially the pediatric patients. Contagion is possible through direct contact or fomites, and the virus is extremely resistant to different physical and chemical agents.

The clinical signs or symptoms of conjunctival infection are similar to any other conjunctivitis, with a higher incidence of pseudomembranes. In the cornea, adenoviral infection may lead to keratitis nummularis.

Diagnosis is mainly clinical, but its etiology can be confirmed using cell cultures, antigen detection, polymerase chain reaction or immunochromatography. Multiple treatments have been tried for this disease, but none of them seem to be completely effective. Prevention is the most reliable and recommended strategy to control this contagious infection.


July 23, 2014 at 7:47 pm

Postoperative endophthalmitis.

Clin Infect Dis. 2004 Feb 15;38(4):542-6.

Hanscom TA.

Author information

Jules Stein Eye Institute, University of California-Los Angeles School of Medicine, and Saint John’s Hospital, Santa Monica, California, USA.


Postoperative endophthalmitis remains a serious clinical problem in ophthalmology, with an incidence of approximately 0.5%. Prognosis is largely determined by the virulence of the offending organism.

The Endophthalmitis Vitrectomy Study (EVS) was a prospective, randomized trial comparing various diagnostic and treatment modalities in cases of endophthalmitis that followed cataract surgery. The EVS found that vitrectomy was only beneficial for patients presenting with very poor visual acuity and that intravenous antibiotic treatments had no additional benefit, compared with intravitreal antibiotic therapy alone.

However, weaknesses of the EVS leave these conclusions open to modification in the future. Preoperative application of povidone-iodine preparation to the skin and conjunctiva is the only proven endophthalmitis prophylaxis.

Endophthalmitis may be chronic and may follow glaucoma surgery and intravitreal injection of gas and drugs. The EVS did not study these issues, although they are associated with specific features that may require alterations in patient management.


July 23, 2014 at 7:44 pm

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