Archive for April 4, 2015

Rapid urine antigen testing for Streptococcus pneumoniae in adults with community-acquired pneumonia: clinical use and barriers.

Diagn Microbiol Infect Dis. 2014 Aug;79(4):454-7.

Harris AM1, Beekmann SE2, Polgreen PM2, Moore MR3.

1Respiratory Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia. Electronic address: ieo9@cdc.gov 

2University of Iowa Carver College of Medicine, Iowa City, Iowa.

3Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.

Abstract

Streptococcus pneumoniae (pneumococcus) is the most common bacterial etiology of community-acquired pneumonia (CAP) in adults, a leading cause of death.

The majority of pneumococcal CAP is diagnosed by blood culture, which likely underestimates the burden of disease.

The 2007 CAP guidelines recommend routine use of the rapid pneumococcal urinary antigen (UAg) test.

To assess the how pneumococcal UAg testing is being used among hospitalized adult CAP patients and what barriers restrict its use, a Web-based survey was distributed in 2013 to 1287 infectious disease physician members of the Emerging Infectious disease Network of the Infectious Disease Society of America.

Of 493 eligible responses, 65% use the pneumococcal UAg test. The primary barrier to UAg use was availability (46%).

UAg users reported ordering fewer other diagnostic tests and tailoring antibiotic therapy.

Increased access to UAg tests could improve pneumonia management and pneumococcal CAP surveillance.

abstract

http://www.dmidjournal.com/article/S0732-8893(14)00200-4/abstract

PDF

http://www.dmidjournal.com/article/S0732-8893(14)00200-4/pdf

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April 4, 2015 at 7:18 pm

Drug Combinations against Borrelia burgdorferi Persisters In Vitro: Eradication Achieved by Using Daptomycin, Cefoperazone and Doxycycline.

PLoS One. 2015 Mar 25;10(3):e0117207.

Feng J1, Auwaerter PG2, Zhang Y1.

1Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.

2Fisher Center for Environmental Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America.

Abstract

Although most Lyme disease patients can be cured with antibiotics doxycycline or amoxicillin using 2-4 week treatment durations, some patients suffer from persistent arthritis or post-treatment Lyme disease syndrome.

Why these phenomena occur is unclear, but possibilities include host responses, antigenic debris, or B. burgdorferi organisms remaining despite antibiotic therapy.

In vitro, B. burgdorferi developed increasing antibiotic tolerance as morphology changed from typical spirochetal form in log phase growth to variant round body and microcolony forms in stationary phase.

B. burgdorferi appeared to have higher persister frequencies than E. coli as a control as measured by SYBR Green I/propidium iodide (PI) viability stain and microscope counting.

To more effectively eradicate the different persister forms tolerant to doxycycline or amoxicillin, drug combinations were studied using previously identified drugs from an FDA-approved drug library with high activity against such persisters.

Using a SYBR Green/PI viability assay, daptomycin-containing drug combinations were the most effective.

Of studied drugs, daptomycin was the common element in the most active regimens when combined with doxycycline plus either beta-lactams (cefoperazone or carbenicillin) or an energy inhibitor (clofazimine).

Daptomycin plus doxycycline and cefoperazone eradicated the most resistant microcolony form of B. burgdorferi persisters and did not yield viable spirochetes upon subculturing, suggesting durable killing that was not achieved by any other two or three drug combinations.

These findings may have implications for improved treatment of Lyme disease, if persistent organisms or detritus are responsible for symptoms that do not resolve with conventional therapy.

Further studies are needed to validate whether such combination antimicrobial approaches are useful in animal models and human infection.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4373819/pdf/pone.0117207.pdf

April 4, 2015 at 7:16 pm

Repeat or persistent Lyme disease: persistence, recrudescence or reinfection with Borrelia Burgdorferi?

F1000Prime Rep. 2015 Jan 5;7:11.

Shapiro ED1.

1Departments of Pediatrics, Epidemiology of Microbial Diseases and Investigative Medicine, Yale University Schools of Medicine and of Public Health and Graduate School of Arts and Sciences New Haven, CT USA.

Abstract

Whether or not Borrelia burgdorferi can persist after conventional treatment with antimicrobials has been a very controversial issue.

Two recent studies took different approaches to try to answer this question.

In one, investigators showed that, in each of 22 instances in 17 patients with two consecutive episodes of culture-proved erythema migrans, the strains of B. burgdorferi were different based on their genotypes. This indicated that the repeat episodes were due to new infections rather than recrudescence of the original infection.

In another study, in which persistence of B. burgdorferi was assessed by using xenodiagnosis, no viable B. burgdorferi were cultured from ticks fed on any of the patients.

There continues to be no evidence that viable B. burgdorferi persist in humans after conventional treatment with antimicrobials.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311275/pdf/medrep-07-11.pdf

April 4, 2015 at 7:13 pm

Antibiotic Treatment Strategies for Community-Acquired Pneumonia in Adults

N Engl J of Med April 2, 2015, V.372 N.14 P.1312-1323

Douwe F. Postma, M.D., Cornelis H. van Werkhoven, M.D., Leontine J.R. van Elden, M.D., Ph.D., Steven F.T. Thijsen, M.D., Ph.D., Andy I.M. Hoepelman, M.D., Ph.D., Jan A.J.W. Kluytmans, M.D., Ph.D., Wim G. Boersma, M.D., Ph.D., Clara J. Compaijen, M.D., Eva van der Wall, M.D., Jan M. Prins, M.D., Ph.D., Jan J. Oosterheert, M.D., Ph.D., and Marc J.M. Bonten, M.D., Ph.D., for the CAP-START Study Group*
From the Julius Center for Health Sciences and Primary Care (D.F.P., C.H.W., M.J.M.B.) and the Departments of Internal Medicine and Infectious Diseases (D.F.P., A.I.M.H., J.J.O.) and Medical Microbiology (M.J.M.B.), University Medical Center Utrecht, and the Departments of Internal Medicine (D.F.P.), Pulmonology (L.J.R.E.), and Medical Microbiology (S.F.T.T.), Diakonessenhuis Utrecht, Utrecht, the Department of Medical Microbiology, Amphia Ziekenhuis Breda, Breda (J.A.J.W.K.), the Department of Pulmonology, Medisch Centrum Alkmaar, Alkmaar (W.G.B.), the Department of Internal Medicine, Kennemer Gasthuis Haarlem, Haarlem (C.J.C.), the Department of Pulmonology, Spaarne Ziekenhuis, Hoofddorp (E.W.), and the Department of Internal Medicine, Academic Medical Center Amsterdam, Amsterdam (J.M.P.) — all in the Netherlands. Address reprint requests to Dr. van Werkhoven at the University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, P.O. Box 85500, 3508 GA Utrecht, the Netherlands, or at c.h.vanwerkhoven@umcutrecht.nl

BACKGROUND
The choice of empirical antibiotic treatment for patients with clinically suspected community-acquired pneumonia (CAP) who are admitted to non–intensive care unit (ICU) hospital wards is complicated by the limited availability of evidence. We compared strategies of empirical treatment (allowing deviations for medical reasons) with beta-lactam monotherapy, beta-lactam–macrolide combination therapy, or fluoroquinolone monotherapy.

METHODS
In a cluster-randomized, crossover trial with strategies rotated in 4-month periods, we tested the noninferiority of the beta-lactam strategy to the beta-lactam–macrolide and fluoroquinolone strategies with respect to 90-day mortality, in an intention-to-treat analysis, using a noninferiority margin of 3 percentage points and a two-sided 90% confidence interval.

RESULTS
A total of 656 patients were included during the beta-lactam strategy periods, 739 during the beta-lactam–macrolide strategy periods, and 888 during the fluoroquinolone strategy periods, with rates of adherence to the strategy of 93.0%, 88.0%, and 92.7%, respectively. The median age of the patients was 70 years. The crude 90-day mortality was 9.0% (59 patients), 11.1% (82 patients), and 8.8% (78 patients), respectively, during these strategy periods. In the intention-to-treat analysis, the risk of death was higher by 1.9 percentage points (90% confidence interval [CI], −0.6 to 4.4) with the betalactam–macrolide strategy than with the beta-lactam strategy and lower by 0.6 percentage points (90% CI, −2.8 to 1.9) with the fluoroquinolone strategy than with the beta-lactam strategy. These results indicated noninferiority of the beta-lactam strategy. The median length of hospital stay was 6 days for all strategies, and the median time to starting oral treatment was 3 days (interquartile range, 0 to 4) with the fluoroquinolone strategy and 4 days (interquartile range, 3 to 5) with the other strategies.

CONCLUSIONS
Among patients with clinically suspected CAP admitted to non-ICU wards, a strategy of preferred empirical treatment with beta-lactam monotherapy was noninferior to strategies with a beta-lactam–macrolide combination or fluoroquinolone monotherapy with regard to 90-day mortality. (Funded by the Netherlands Organization for Health Research and Development; CAP-START ClinicalTrials.gov number, NCT01660204.)

PDF
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1406330

April 4, 2015 at 5:27 pm


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