Archive for May 9, 2017

Guidelines – Recommendations on hepatitis C screening for adults

Canadian Medical Journal Association April 24, 2017 V.189 N.16

Canadian Task Force on Preventive Health Care

An estimated 0.64%–0.71% of Canadians (220 000–245 000 people) have chronic hepatitis C virus (HCV) infection,1 and approximately 44%2 of those may be undiagnosed. HCV can be transmitted directly through percutaneous exposure (e.g., through inadequately sterilized medical equipment) or through receipt of contaminated blood products.3 People who inject drugs are at highest risk, but recipients of unscreened blood products, tissues or organs and patients undergoing long-term hemodialysis are also at increased risk.3 Less common modes of transmission include vertical transmission, high-risk sexual contact, unsterilized tattoo or piercing equipment, and occupational exposure.3 Not all people with chronic HCV infection will develop cirrhosis or signs or symptoms indicative of liver disease.4 It is estimated that approximately 84% of people infected with HCV do not develop cirrhosis 20 years after acute infection, and 59% after 30 years.5,6 Progression of liver fibrosis is variable and influenced by factors such as alcohol consumption, age at time of infection, male sex and HIV coinfection.7

PDF

http://www.cmaj.ca/content/189/16/E594.full.pdf+html

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May 9, 2017 at 3:35 pm

Use of azithromycin and risk of ventricular arrhythmia

Canadian Medical Journal Association April 18, 2017 V.189 N.15

Gianluca Trifirò, Maria de Ridder, Janet Sultana, Alessandro Oteri, Peter Rijnbeek, Serena Pecchioli, Giampiero Mazzaglia, Irene Bezemer, Edeltraut Garbe, Tania Schink, Elisabetta Poluzzi, Trine Frøslev, Mariam Molokhia, Igor Diemberger, and Miriam C.J.M. Sturkenboom

BACKGROUND

There are conflicting findings from observational studies of the arrhythrogenic potential of azithromycin. Our aim was to quantify the association between azithromycin use and the risk of ventricular arrhythmia.

METHODS

We conducted a nested case–control study within a cohort of new antibiotic users identified from a network of 7 population-based health care databases in Denmark, Germany, Italy, the Netherlands and the United Kingdom for the period 1997–2010. Up to 100 controls per case were selected and matched by age, sex and database. Recency of antibiotic use and type of drug (azithromycin was the exposure of interest) at the index date (occurrence of ventricular arrhythmia) were identified. We estimated the odds of ventricular arrhythmia associated with current azithromycin use relative to current amoxicillin use or nonuse of antibiotics (≥ 365 d without antibiotic exposure) using conditional logistic regression, adjusting for confounders.

RESULTS

We identified 14 040 688 new antibiotic users who met the inclusion criteria. Ventricular arrhythmia developed in 12 874, of whom 30 were current azithromycin users. The mean age of the cases and controls was 63 years, and two-thirds were male. In the pooled data analyses across databases, azithromycin use was associated with an increased risk of ventricular arrhythmia relative to nonuse of antibiotics (adjusted odds ratio [OR] 1.97, 95% confidence interval [CI] 1.35–2.86). This increased risk disappeared when current amoxicillin use was the comparator (adjusted OR 0.90, 95% CI 0.48–1.71). Database-specific estimates and meta-analysis confirmed results from the pooled data analysis.

INTERPRETATION

Current azithromycin use was associated with an increased risk of ventricular arrhythmia when compared with nonuse of antibiotics, but not when compared with current amoxicillin use. The decreased risk with an active comparator suggests significant confounding by indication.

PDF

http://www.cmaj.ca/content/189/15/E560.full.pdf+html

May 9, 2017 at 3:34 pm

Synovial Fluid Cell Count for Diagnosis of Chronic Periprosthetic Hip Infection.

Journal of Bone & Joint Surgery – American May 3, 2017 V.99 N.9 P.753-759

Higuera, Carlos A.; Zmistowski, Benjamin; Malcom, Tennison…

Background

There is a paucity of data regarding the threshold of synovial fluid white blood-cell (WBC) count and polymorphonuclear cell (neutrophil) percentage of the WBC count (PMN%) for the diagnosis of chronic periprosthetic joint infection (PJI) after total hip arthroplasty. Despite this, many organizations have provided guidelines for the diagnosis of PJI that include synovial fluid WBC count and PMN%. We attempted to define a threshold for synovial fluid WBC count and PMN% for the diagnosis of chronic PJI of the hip using a uniform definition of PJI and to investigate any variations in the calculated thresholds among institutions.

Methods

From 4 academic institutions, we formed a cohort of 453 patients with hip synovial fluid cell count analysis as part of the work-up for revision total hip arthroplasty. Using the definition of PJI from the Musculoskeletal Infection Society (MSIS), 374 joints were diagnosed as aseptic and 79, as septic. Intraoperative aspirations were performed as routine practice, regardless of the suspicion for infection, in 327 (72%) of the patients. Using receiver operating characteristic curves, the optimal threshold values for synovial WBC count and PMN% were identified.

Results

For the diagnosis of chronic PJI of the hip, the threshold for the overall cohort was 3,966 cells/μL for WBC count and 80% for PMN%. Despite the high predictive accuracy for the cohort, there was notable institutional variation in fluid WBC count and PMN%. Furthermore, the rate of PJI was 14% (4 of 28) for patients with a WBC count of 3,000 to 5,000 cells/μL compared with 91% (20 of 22) for patients with a WBC count of >50,000 cells/μL. Similarly, the rate of PJI was 29% (14 of 49) for patients with a PMN% of 75% to 85% compared with 69% (33 of 48) for patients with a PMN% of >95%.

Conclusions

Using the MSIS criteria, the optimal synovial fluid WBC count and PMN% to diagnose chronic PJI in the hip is closer to thresholds for the knee than those previously reported for the hip. This study validates the diagnostic utility of synovial fluid analysis for the diagnosis of periprosthetic hip infection; however, we also identified a clinically important “gray area” around the threshold for which the presence of PJI may be unclear.

Level of Evidence

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

FULL TEXT

http://journals.lww.com/jbjsjournal/Fulltext/2017/05030/Synovial_Fluid_Cell_Count_for_Diagnosis_of_Chronic.6.aspx

May 9, 2017 at 3:34 pm

Sexually acquired Zika virus: a systematic review

Clinical Microbiology and Infection May 2017 V.23 N.5

Moreira, T.M. Peixoto, A.M. Siqueira, C.C. Lamas

1) Instituto Nacional de Infectologia Evandro Chagas, Fundaçao Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil ~

2) Universidade do Grande Rio (Unigranrio), Rio de Janeiro, Brazil

3) Unidade de pesquisa cardiovascular, Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil

Background:

Zika virus (ZIKV) is transmitted to humans primarily by Aedes mosquito bites. However, circumstantial evidence points to a sexual transmission route.

Objectives:

To assess the sexually acquired ZIKV cases and to investigate the shedding of ZIKV in genital fluids.

Data sources:

PubMed, Scopus, Pro-MED-mail and WHO ZIKV notification databases from inception to December 2016.

Selection criteria:

Reports describing ZIKV acquisition through sex and studies reporting the detection or isolation of ZIKV in the genital fluids were included.

Risk-of-bias assessment:

The risk of bias was assessed using the National Institute of Health Tool.

Results:

Eighteen studies reporting on sex-acquired ZIKV and 21 describing the presence of ZIKV in genital fluids were included. The overall risk of bias was moderate. Sexual transmission was male efemale (92.5%), femaleemale (3.7%) and maleemale (3.7%). Modes of sexual transmission were unprotected vaginal (96.2%), oral (18.5%) and anal (7.4%) intercourse. The median time between onset of symptoms in the index partner and presumed sexual transmission was 13 days (range 4e44 days). ZIKV RNA was detected in semen as late as 188 days (range 3e188 days) following symptom onset, and infectious virus was isolated in semen up to 69 days after symptom onset. No study reported ZIKV isolation from female genital samples, but detection did occur up to 13 days after symptom onset.

Conclusions:

ZIKV is potentially sexually transmitted and persists in male genital secretions for a prolonged period after symptom onset

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)30659-0/pdf

May 9, 2017 at 8:26 am

Corticosteroids in treating CAP – has the time really come.

Clinical Microbiology and Infection May 2017 V.23 N.5

Blot, A. Salmon-Rousseau, P. Chavanet, L. Piroth*

Departement d’Infectiologie, Centre Hospitalier Universitaire, Dijon, France

Whether corticosteroids should be used in the treatment of severe community-acquired pneumonia (CAP) is still a matter of debate.

This question is all the more relevant as pneumonia remains a leading cause of death worldwide.

Severe CAP is associated with an increase in pulmonary and circulatory cytokines, which may be associated with treatment failure, especially in bacteraemic pneumococcal pneumonia.

Thus corticosteroids, which suppress inflammatory reactions and prevent the migration of inflammatory cells to tissues, may be of particular interest in the treatment of such severe pneumonias …

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)30388-3/pdf

May 9, 2017 at 8:25 am

Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates

Journal of Clinical Microbiology May 2017 V.55 N.5 P.1276-1284

Cynthia Y. Truong, Saurabh Gombar, Richard Wilson, Gopalakrishnan Sundararajan, Natasa Tekic, Marisa Holubar, John Shepard, Alexandra Madison, Lucy Tompkins, Neil Shah, Stan Deresinski, Lee F. Schroeder, and Niaz Banaei

aDepartment of Pathology, Stanford University School of Medicine, Stanford, California, USA

bDigital Solutions, Stanford Health Care, Stanford, California, USA

cDivision of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA

dInfection Control and Prevention, Stanford Health Care, Stanford, California, USA

eStanford Antimicrobial Safety and Sustainability, Stanford Health Care, Stanford, California, USA

fDepartment of Pathology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA

gClinical Microbiology Laboratory, Stanford Health Care, Stanford, California, USA

Health care-onset health care facility-associated Clostridium difficile infection (HO-CDI) is overdiagnosed for several reasons, including the high prevalence of C. difficile colonization and the inability of hospitals to limit testing to patients with clinically significant diarrhea. We conducted a quasiexperimental study from 22 June 2015 to 30 June 2016 on consecutive inpatients with C. difficile test orders at an academic hospital. Real-time electronic patient data tracking was used by the laboratory to enforce testing criteria (defined as the presence of diarrhea [≥3 unformed stools in 24 h] and absence of laxative intake in the prior 48 h). Outcome measures included C. difficile test utilization, HO-CDI incidence, oral vancomycin utilization, and clinical complications. During the intervention, 7.1% (164) and 9.1% (211) of 2,321 C. difficile test orders were canceled due to absence of diarrhea and receipt of laxative therapy, respectively. C. difficile test utilization decreased upon implementation from an average of 208.8 tests to 143.0 tests per 10,000 patient-days (P < 0.001). HO-CDI incidence rate decreased from an average of 13.0 cases to 9.7 cases per 10,000 patient-days (P = 0.008). Oral vancomycin days of therapy decreased from an average of 13.8 days to 9.4 days per 1,000 patient-days (P = 0.009). Clinical complication rates were not significantly different in patients with 375 canceled orders compared with 869 episodes with diarrhea but negative C. difficile results. Real-time electronic clinical data tracking is an effective tool for verification of C. difficile clinical testing criteria and safe reduction of inflated HO-CDI rates.

PDF

http://jcm.asm.org/content/55/5/1276.full.pdf+html

May 9, 2017 at 8:23 am

Commentaries – Strategies for Optimizing the Diagnostic Predictive Value of Clostridium difficile Molecular Diagnostics

Journal of Clinical Microbiology May 2017 V.55 N.5 P.1244-1248

Larry K. Kociolek

Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA

Because nucleic acid amplification tests (NAATs) do not distinguish Clostridium difficile infection (CDI) and asymptomatic C. difficile carriage, the diagnostic predictive value of NAATs is limited when used in patients with a low probability of CDI. In this issue of the Journal of Clinical Microbiology, Truong et al. (J. Clin. Microbiol., 55:1276–1284, 2017, https://doi.org/10.1128/JCM.02319-16) report significant reductions in hospital-onset CDI and oral vancomycin utilization at their institution following implementation of a novel intervention that leveraged their clinical bioinformatics resources to prevent C. difficile testing of stools from patients without clinically significant diarrhea and in patients with recent laxative use….

PDF

http://jcm.asm.org/content/55/5/1244.full.pdf+html

May 9, 2017 at 8:22 am

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