Archive for August 11, 2015

Active surveillance of rectal colonization by carbapenemase-producing Enterobacteriaceae in hospitalized patients at the critical unit of private hospital in Santiago, Chile.

Rev Chilena Infectol. 2015 Apr;32(2):244-5.

[Article in Spanish]

Hervé B, Salas A, Corvalán V, Munizaga R.

Sr. Editor:

El año 2013, Gutiérrez y cois. publicaron en su prestigiosa revista, los resultados de su experiencia con vigilancia de portación de cepas productoras de carbapenemasas en Hospital Clínico de la Universidad Católica durante 20111.

Durante el período estudiado, no encontraron cepas productoras de carbapenemasas. Posteriormente, a partir del año 2012 en nuestro país se ha reportado la aparición de muestras clínicas con tales cepas, importadas desde el extranjero y también autóctonas23.

Concomitantemente, el ISP emitió la Norma Técnica “Vigilancia nacional de resistencia a antimicrobianos en bacterias que pueden producir infecciones asociadas a atención en salud”, en que frente a un hallazgo de laboratorio de una cepa sospechosa de tener este mecanismo de resistencia, debe ser derivada para su confirmación al ISP (Circular N° 11, mayo de 2012).

En enero de 2014, el mismo ISP difundió las “Recomendaciones para inclusión de pruebas de screening para carbapenemasas en Klebsiella spp”, que incluyen la realización de test de Hodge modificado (THM) y test de ácido borónico.

Las cepas con screening positivo, deben ser enviadas a confirmación al ISP (circular N° 160, enero de 2014)…..

PDF

http://www.scielo.cl/pdf/rci/v32n2/art19.pdf

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August 11, 2015 at 10:13 pm

Candidemia, and infections by Clostridium difficile and carbapenemase-producing Enterobacteriaceae: new enteropathogenetic opportunistic syndromes?

Infez Med. 2015 Jun 1;23(2):105-16.

De Rosa FG1, Corcione S1, Raviolo S1, Montrucchio C1, Aldieri C1, Pagani N1, Di Perri G1.

Author information

1Department of Medical Sciences, Infectious Diseases at Amedeo di Savoia Hospital, University of Turin, Turin, Italy.

Abstract

In this paper we analyze three enteropathogenetic opportunistic infections represented by Candida spp., C. difficile and carbapenemase-producing K. pneumoniae.

The common pathogenetic pathway is based on an alteration of the intestinal flora, now mainly referred as the human microbiome, with secondary opportunism for infections caused by Candida, C. difficile and carbapenemase-producing Enterobacteriaceae (“CCC”).

We highlight the epidemiology, risk factors, clinical syndromes associated with the pathogens and we propose some new issues related to the epidemiology and diagnosis of candidemia, also using hierarchical cluster analysis, definitions of levels of interventions in patients colonized or infected by carbapenemase-producing bacteria.

The “enteropathogenetic” opportunistic syndromes are best prevented with antimicrobial stewardship programs aiming at increasing diagnostic specificity of infectious syndromes to reduce the antimicrobial use and costs.

Appropriate guidelines for infection control should also be implemented to reduce the nosocomial spread of enteropathogenetic microbes.

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http://www.infezmed.it/VisualizzaUnArticolo.aspx?Anno=2015&numero=2&ArticoloDaVisualizzare=Vol_23_2_2015_2

August 11, 2015 at 10:11 pm

Increase of serotypes 15A and 23B in IPD in Germany in the PCV13 vaccination era

BMC Infectious Diseases May 5, 2015 V.15 P.207

Mark van der Linden, Stephanie Perniciaro, Matthias Imöhl

Background

This study presents an analysis of 1,491 serogroup 23 and 762 serogroup 15 isolates from invasive pneumococcal disease (IPD) in children and adults before and after the general recommendation for childhood pneumococcal conjugate vaccination in Germany in July 2006. Vaccination formulations used were PCV7 (from July 2006), PCV10 (from April 2009) and PCV13 (from December 2009, replacing PCV7).

Methods

The German National Reference Center for Streptococci (GNRCS) has conducted surveillance of IPD since 1992. Isolates were serotyped and tested for antibiotic susceptibility. Selected isolates were characterized using MLST.

Results

In an analysis of 23,957 isolates from IPD in children and adults sent to the GNRCS between July 1992 and June 2014, we found a strongly significant increase of non-PCV13 serotypes in the late vaccination (PCV13) period (2010-2014). Among these, the proportions of serotypes 15A and 23B were the most strongly significantly increasing. After the recommendation for pneumococcal conjugate childhood vaccination in 2006 and the introduction of higher-valent vaccines in 2009, the proportion of 15A increased significantly from 0.5% in the early vaccination period (2007-2010) to 2.4% in the late vaccination period (2010-2014, p=3.14×10-22). The proportion of serotype 23B increased from 0.5% to 2.8% in the same period (p=1.55×10-29). Penicillin non-susceptibility levels of the serotype 15A (47.4%) and serotype 23B (46.5%) isolates were high, with MIC values ranging from 0.12-2 μg/ml (15A) and 0.12-0.5 μg/ml (23B). MLSTs of serotype 23B isolates grouped in two clonal complexes (CC): CC439, with sequence type (ST) 439 as the main representative and CC338 (linked to CC156), with ST1349 as most prevalent clone. Both CCs have been present over almost the whole surveillance period. All penicillin non-susceptible isolates occurred in CC338. Serotype 15A isolates appeared to be more diverse. Six CCs, one group of three STs and two singletons were found among 20 isolates. Most prevalent was CC63, with ST63 as most prominent representative (n=5). Most penicillin non-susceptible isolates were found among CC63 isolates.

Conclusions

The prevalence of non-PCV13 serotypes in Germany has increased significantly between July 2007 and June 2014, with 15A and 23B being the most strongly increasing serotypes of all. Both serotypes show a high proportion of penicillin non-susceptibility.

PDF

http://www.biomedcentral.com/content/pdf/s12879-015-0941-9.pdf

August 11, 2015 at 3:23 pm

Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

N Engl J Med July 20, 2015

The INSIGHT START Study Group

Background

Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter.

Methods

We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non–AIDS-related event, or death from any cause.

Results

A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12,759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 person-years), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non–AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P=0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions.

Conclusions

The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter. (Funded by the National Institute of Allergy and Infectious Diseases and others; START ClinicalTrials.gov number, NCT00867048.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1506816

August 11, 2015 at 3:22 pm

A trial of early antiretrovirals and isoniazid preventive therapy in Africa

N Engl J Med July 20, 2015

The TEMPRANO ANRS 12136 Study Group.

Background

In sub-Saharan Africa, the burden of human immunodeficiency virus (HIV)–associated tuberculosis is high. We conducted a trial with a 2-by-2 factorial design to assess the benefits of early antiretroviral therapy (ART), 6-month isoniazid preventive therapy (IPT), or both among HIV-infected adults with high CD4+ cell counts in Ivory Coast.

Methods

We included participants who had HIV type 1 infection and a CD4+ count of less than 800 cells per cubic millimeter and who met no criteria for starting ART according to World Health Organization (WHO) guidelines. Participants were randomly assigned to one of four treatment groups: deferred ART (ART initiation according to WHO criteria), deferred ART plus IPT, early ART (immediate ART initiation), or early ART plus IPT. The primary end point was a composite of diseases included in the case definition of the acquired immunodeficiency syndrome (AIDS), non–AIDS-defining cancer, non–AIDS-defining invasive bacterial disease, or death from any cause at 30 months. We used Cox proportional models to compare outcomes between the deferred-ART and early-ART strategies and between the IPT and no-IPT strategies.

Results

A total of 2056 patients (41% with a baseline CD4+ count of ≥500 cells per cubic millimeter) were followed for 4757 patient-years. A total of 204 primary end-point events were observed (3.8 events per 100 person-years; 95% confidence interval [CI], 3.3 to 4.4), including 68 in patients with a baseline CD4+ count of at least 500 cells per cubic millimeter (3.2 events per 100 person-years; 95% CI, 2.4 to 4.0). Tuberculosis and invasive bacterial diseases accounted for 42% and 27% of primary end-point events, respectively. The risk of death or severe HIV-related illness was lower with early ART than with deferred ART (adjusted hazard ratio, 0.56; 95% CI, 0.41 to 0.76; adjusted hazard ratio among patients with a baseline CD4+ count of ≥500 cells per cubic millimeter, 0.56; 95% CI, 0.33 to 0.94) and lower with IPT than with no IPT (adjusted hazard ratio, 0.65; 95% CI, 0.48 to 0.88; adjusted hazard ratio among patients with a baseline CD4+ count of ≥500 cells per cubic millimeter, 0.61; 95% CI, 0.36 to 1.01). The 30-month probability of grade 3 or 4 adverse events did not differ significantly among the strategies.

Conclusions

In this African country, immediate ART and 6 months of IPT independently led to lower rates of severe illness than did deferred ART and no IPT, both overall and among patients with CD4+ counts of at least 500 cells per cubic millimeter. (Funded by the French National Agency for Research on AIDS and Viral Hepatitis; TEMPRANO ANRS 12136 ClinicalTrials.gov number, NCT00495651.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1507198

 

August 11, 2015 at 3:20 pm


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