Archive for July, 2017

Editorial – Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin

Clinical Orthopaedics and Related Research July 2017 V.475 N.7 P.1762-1766


Daniel Wongworawat MD


July 30, 2017 at 3:00 pm

Risk Factors for 30-Day Mortality in Patients with Methicillin-Resistant Staphylococcus aureus Bloodstream Infections

International Journal of Infectious Diseases August 2017 V.60 N.8 P.3-6

Pedro Ayau, Ana C. Bardossy, Guillermo Sanchez, Ricardo Ortiz, Daniela Moreno, Pamela Hartman, Khulood Rizvi, Tyler C. Prentiss, Mary B. Perri, Meredith Mahan, Vanthida Huang, Katherine Reyes, Marcus J. Zervos


  • The aim of this study was to identify risk factors associated with 30-day mortality in patients with MRSA BSI.
  • 1,168 patients with confirmed MRSA BSI were identified over a 9-year period in which 30-day all-cause mortality was 16%.
  • There was no significant variability in 30-day mortality over our 9-year study period.
  • Our study showed that age, cancer, heart disease, neurologic disease, nursing home residence and Charlson score >3 are risk factors for 30-day mortality in patients with MRSA BSI.
  • Diabetes, PVD and readmission because of infection have statistically significant protective effects on 30-day mortality


Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections (BSI) are a major health care problem accounting for a large percentage of nosocomial infections. The aim of this study was to identify risk factors associated with 30-day mortality in patients with MRSA BSI.


This was a retrospective study performed in Southeast Michigan. Over a 9- year period, a total of 1,168 patients were identified with MRSA BSI. Patient demographics and clinical data were retrieved and evaluated using electronic medical health records.


30-day mortality during the 9-year study period was 16%. Significant risk factors for 30-day mortality were age, cancer, heart disease, neurologic disease, nursing home residence and Charlson score >3 with Odds Ratio (OR) of 1.03 (CI 1.02–1.04), 2.29 (CI 1.40–3.75), 1.78 (CI 1.20–2.63), 1.65 (CI 1.08–2.25), 1.66 (CI 1.02 − 2.70) and 1.86 (CI 1.18 − 2.95) correspondingly. Diabetes mellitus, peripheral vascular disease (PVD), and readmission were protective factors for 30-day mortality with OR of 0.53 (CI 0.36–0.78), 0.46 (CI 0.26–0.84) and 0.13 (CI0.05 − 0.32) respectively.


Our study identified significant risk factors for 30-day mortality in patients with MRSA BSI. Interestingly, diabetes mellitus, PVD and readmission were protective effects on 30-day mortality. There was no statistically significant variability in 30-day mortality over the 9-year study period.


July 30, 2017 at 12:57 pm

Efficacy of indefinite chronic oral antimicrobial suppression for prosthetic joint infection in the elderly: a comparative study

International Journal of Infectious Diseases July 2017 V.60 N.7 P.57-60


  1. Prendki, P. Sergent, A. Barrelet, E. Oziol, E. Beretti, M. Berlioz-Thibal, F. Bouchand, F.A. Dauchy, E. Forestier, G. Gavazzi, C. Ronde-Oustau, J. Stirnemann, A. Dinh


  • Antimicrobial suppression appears to be effective for prosthetic joint infection (PJI).
  • Antimicrobial suppression appears safe for PJI.
  • Antimicrobial suppression is an adequate option for elderly patients with PJI.


During prosthetic joint infection (PJI), surgical management is sometimes impossible and indefinite chronic oral antimicrobial suppression (ICOAS) may be the only option. The outcomes of elderly patients who benefited from ICOAS with strictly palliative intent were evaluated.


A national retrospective cohort study was performed in France, involving patients aged >75 years with a PJI who were managed with planned life-long ICOAS from 2009 to 2014. Patients who experienced an event were compared to those who did not. An event was defined as a composite outcome in patients undergoing ICOAS, including local or systemic progression of the infection, death, or discontinuation of antimicrobial therapy because of an adverse drug reaction.


Twenty-one patients were included, with a median age of 85 years (interquartile range 81–88 years). Eight of the 21 patients experienced an event: one had an adverse drug reaction, three had systemic progression of sepsis, and two had local progression. Two of the 21 patients died. No death was related to ICOAS or infection. There was no significant difference between the population with an event and the population free of an event with regard to demographic, clinical, and microbiological characteristics (p > 0.05).


ICOAS appeared to be an effective and safe option in this cohort.



July 30, 2017 at 12:54 pm

Staphylococcus aureus soft tissue infection may increase the risk of subsequent staphylococcal soft tissue infections

International Journal of Infectious Diseases July 2017 V.60 N.7 P.44-48

Cindy Bouvet, Shpresa Gjoni, Besa Zenelaj, Benjamin A. Lipsky, Elif Hakko, Ilker Uçkay


Staphylococcus aureus is the most common cause of soft tissue infections. It is unknown, however, if a patient who has had such an infection is at greater risk for future soft tissue infections with S. aureus.


We conducted an epidemiological survey of adult patients hospitalized in the only public hospital in Geneva for treatment (usually combined surgical and medical) of a soft tissue infection caused by S. aureus. By reviewing nursing and medical records from the emergency department and hospital wards, we assessed whether or not they developed any other soft tissue infections (excluding a recurrence) after or before the index one.


Among 1023 index episodes of soft tissue infections, 670 (65%) were caused by S. aureus, of which 47 were caused by methicillin-resistant strains (30 healthcare-associated and 17 community-acquired). The patients’ median age was 51 years and 334 (34%) were immune-compromised. The median time span between the patient’s first and last consultation (for any reason) in our hospital was 21.4 years (interquartile range, 10-30 years). In addition to their index infection, 124 patients (12%) developed a new nosocomial or community-acquired soft tissue infection. Among the index cases with an S. aureus infection, 92 (14%) had another soft tissue infection, compared to 32 (9%) who had a non-staphylococcal index infection (Pearson-χ2-test; p = 0.03). Similarly, patients with an index S. aureus infection, compared to those with a non-S. aureus infection, had a higher rate of another soft tissue infection caused by S. aureus (χ2-test; p < 0.01). In multivariate analysis, an index infection due to S. aureus shows a high association to further S. aureus soft tissue infections (logistic regression; odds ratio 2.5, 95% confidence interval 1.4-4.6).


Among adult patients hospitalised for a soft tissue infection, those infected with S. aureus (compared with other pathogens) may be at higher risk of a subsequent soft tissue infection, particularly with S. aureus.


July 30, 2017 at 12:52 pm

Evaluation of the variability and safety of serum trough concentrations of vancomycin in patients admitted to the intensive care unit

International Journal of Infectious Diseases July 2017 V.60 N.7 P.17-22

Xiaodan Qian, Guantao Du, Chunmei Weng, Haijun Zhou, Xianju Zhou


  • The vancomycin trough concentration varies significantly in intensive care unit (ICU) patients.
  • Sex, age, and the estimated glomerular filtration rate are independent factors affecting the trough concentration.
  • The fixed-dose regimen of 2 g/day may be inappropriate in ICU patients.
  • The dose should be individualized based on weight, age, and renal function.


To examine the variability and safety of serum trough concentrations of vancomycin in patients admitted to the intensive care unit (ICU) and to analyze the factors influencing the trough concentration.


Data were collected retrospectively from ICU patients receiving vancomycin treatment at a fixed dose of 2 g/day due to unobtainable weight data, at Changzhou No. 2 People’s Hospital, between 2012 and 2015. Vancomycin trough concentrations were compared between groups stratified by sex, age, and estimated glomerular filtration rate (eGFR).


The vancomycin trough concentration varied significantly among ICU patients on a fixed dose of 2 g/day. Only 16.9% of ICU patients met the concentration target of 15–20 mg/l, while 25% of patients showed supratherapeutic concentrations. A higher proportion of female patients than male patients showed supratherapeutic concentrations (40.4% vs. 15.5%). The trough concentration was positively correlated with age (y = 0.279 x − 2.085; R2 = 0.186) and negatively correlated with eGFR (y = −0.2 x + 33.776; R2 = 0.366). Vancomycin-related nephrotoxicity occurred at an incidence of 5.9%.


These results suggest that the fixed-dose regimen is not appropriate for ICU patients in view of the low incidence of target trough concentrations and the high incidence of supratherapeutic concentrations. The dose should be individualized based on weight, age, and renal function to improve outcomes and patient safety.


July 30, 2017 at 12:49 pm

Changing patterns in leptospirosis: a three-decade study in Brazil

International Journal of Infectious Diseases July 2017 V.60 N.7 P.4-10

Elizabeth De Francesco Daher, Gabriela Studart Galdino de Carvalho, Douglas de Sousa Soares, Matheus Henrique Mendes, Sérgio Luiz Arruda Parente Filho, Hermano Alexandre Lima Rocha, Geraldo Bezerra da Silva Junior


This study was conducted to investigate changes in the clinical pattern of leptospirosis over time, analyzing its clinical and laboratory presentations in a metropolitan city of Brazil.


This was a retrospective study including all patients with leptospirosis admitted to tertiary care hospitals in Fortaleza in the northeast of Brazil, between 1985 and 2015. Patients were divided into three groups according to the year of hospital admission: group I for the years 1985–1995, group II for 1996–2005, and group III for 2006–2015. Demographic, clinical, and laboratory data were compared between the groups.


A total of 507 patients were included. Their mean age was 37.3 ± 15.9 years and 82.4% were male. The mean time between symptom onset and admission was 7 ± 4 days. There was a linear decrease in the levels of serum urea (190.1 ± 92.7, 135 ± 79.5, and 95.6 ± 73.3 mg/dl, respectively, p < 0.0001) and creatinine (5.8 ± 2.9, 3.8 ± 2.6, and 3.0 ± 2.5 mg/dl, respectively, p < 0.0001) in each decade, while levels of hemoglobin (10.31 ± 1.9, 10.8 ± 2.0, and 11.5 ± 2.1 g/dl, respectively, p < 0.0001) and platelets (57.900 ± 52.650, 80.130 ± 68.836, and 107.101 ± 99.699 × 109/l, respectively, p < 0.0001) increased. There was a tendency towards a linear decrease in mortality (22%, 14%, and 11.6%, respectively, p = 0.060).


Leptospirosis showed significant changes over time in this region. The main changes point to a decrease in disease severity and complications, such as acute kidney injury. Mortality has decreased, being close to 11%.


July 30, 2017 at 12:47 pm

A new paradigm in pneumococcal conjugate vaccination: moving from individual to herd protection

International Journal of Infectious Diseases July 2017 V.60 N.7 P.96-97


Gail L. Rodgers, Keith P. Klugman

Immunization programs incorporating pneumococcal conjugate vaccines (PCV) have led to a dramatic decrease in invasive pneumococcal disease (IPD) due to vaccine serotypes, pneumonia, and otitis media in children receiving these vaccines. Consistent with the conjugate Haemophilus influenzae type B vaccine (Hib) experience (Moulton et al., 2000), decreased nasopharyngeal (NP) carriage resulting in decreased transmission and the herd or indirect effect (decrease in disease in the unvaccinated) has also been seen with PCV, but the magnitude of this benefit has far surpassed initial expectations (Lexau et al., 2005, Pilishvili et al., 2010, Moore et al., 2015, Von Gottberg et al., 2014). Two years following the introduction of PCV7 into the routine vaccination program in the USA using a 3 + 1 schedule (three infant doses at 2, 4, and 6 months of age and one toddler dose at 12–15 months of age), a profound effect was found in the unvaccinated: PCV7 prevented more than twice as many invasive cases through indirect effects than through its direct effect of protecting vaccinated children (CDC, 2005). This has been documented in other countries, including those using reduced dosing schedules such as 2 + 1, as well as in countries using the extended serotype vaccines, PCV10 and PCV13 (Shiri et al., 2017). A reduction in NP carriage of vaccine serotypes, a precursor of the herd effect, was documented in the original 3 + 0 study of conjugate vaccination of infants in Africa (Mbelle et al., 1999) and was confirmed in countries using 3 + 0 schedules (Hammitt et al., 2014). The mechanism for protection in the unvaccinated is due to the decrease and/or near elimination of vaccine serotypes from the nasopharynx. This in turns leads to decreased transmission of these serotypes and decreased disease. Thus, the effect on NP carriage, a non-disease state and critical precursor to disease, is key to the control of pneumococcal disease in countries unlikely to have immunization programs able to immunize all of their children.



July 30, 2017 at 12:44 pm

Time to re-evaluate the effect of the adolescent booster of hepatitis B vaccine

International Journal of Infectious Diseases July 2017 V.60 N.7 P.88-90

Editorial –

Ellie Carmody

Division of Infectious Diseases and Immunology, New York University School of Medicine, New York, New York, USA

Neutralizing antibodies (anti-HBs) conferred by immunization with hepatitis B virus (HBV) vaccine against HBV surface antigen (HBsAg) have been found to wane or reach undetectable levels in many individuals after 10–15 years of the vaccination (Wainwright et al., 1997, Dentinger et al., 2005).

It is uncertain whether individuals with low or absent levels of anti-HBs remain protected against HBV infection.

HBV vaccine does elicit immunologic memory, in which memory B cells can appropriately generate a robust anamnestic response to HBsAg even if the anti-HBs titer falls below 10 mIU/mL (West and Calandra, 1996, Watson et al., 2001, van der Sande et al., 2007).

However, the duration and uniformity of this immunologic memory after primary vaccination at infancy is unclear. HBV breakthrough infection in young adults may occur if the immunologic memory to HBsAg is absent upon sexual, parenteral, or horizontal (household) HBV exposure….


July 30, 2017 at 12:41 pm

The antibiotic course has had its day

British Medical Journal July 2017


Martin J Llewelyn, professor of infectious diseases1 2, Jennifer M Fitzpatrick, specialist registrar in infection2, Elizabeth Darwin, project manager3, SarahTonkin-Crine, health psychologist4, Cliff Gorton, retired building surveyor5, John Paul, consultant in microbiology6, Tim E A Peto, professor of infectious diseases7, Lucy Yardley, professor of health psychology8, Susan Hopkins, consultant in infectious diseases and microbiology9, Ann Sarah Walker, professor of medical statistics and epidemiology3

1Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, BN1 9PS, UK

2Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK

3Nuffield Department of Medicine, University of Oxford, UK

4Nuffield Department of Primary Care Health Sciences, Oxford, UK

5Oxford, UK

6Public Health England, Royal Sussex County Hospital, Brighton, UK

7Oxford Biomedical Research Centre, Oxford, UK

8Faculty of Human and Social Sciences, University of Southampton, UK

9Royal Free London NHS Foundation Trust, London, UK

Correspondence to: M Llewelyn

With little evidence that failing to complete a prescribed antibiotic course contributes to antibiotic resistance, it’s time for policy makers, educators, and doctors to drop this message, argue Martin Llewelyn and colleagues

Antibiotics are vital to modern medicine and antibiotic resistance is a global, urgent threat to human health.

The relation between antibiotic exposure and antibiotic resistance is unambiguous both at the population level1 and in individual patients.

Reducing unnecessary antibiotic use is therefore essential to mitigate antibiotic resistance…..



July 29, 2017 at 11:25 am

Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure — United States (Including U.S. Territories), July 2017

MMWR July 28, 2017 V.66 N.29 P.781-793


Titilope Oduyebo, MD1; Kara D. Polen, MPH1; Henry T. Walke, MD1; Sarah Reagan-Steiner, MD1; Eva Lathrop, MD1; Ingrid B. Rabe, MBChB1; Wendi L. Kuhnert-Tallman, PhD1; Stacey W. Martin, MSc1; Allison T. Walker, PhD1; Christopher J. Gregory, MD1; Edwin W. Ades, PhD1; Darin S. Carroll, PhD1; Maria Rivera, MPH1; Janice Perez-Padilla, MPH1; Carolyn Gould, MD1; Jeffrey B. Nemhauser, MD1; C. Ben Beard, PhD1; Jennifer L. Harcourt, PhD1; Laura Viens, MD1; Michael Johansson, PhD1; Sascha R. Ellington, MSPH1; Emily Petersen, MD1; Laura A. Smith, MA1; Jessica Reichard, MPA1; Jorge Munoz-Jordan, PhD1; Michael J. Beach, PhD1; Dale A. Rose, PhD1; Ezra Barzilay, MD1; Michelle Noonan-Smith1; Denise J. Jamieson, MD1; Sherif R. Zaki, MD1; Lyle R. Petersen, MD1; Margaret A. Honein, PhD1; Dana Meaney-Delman, MD1

CDC has updated the interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure in response to 1) declining prevalence of Zika virus disease in the World Health Organization’s Region of the Americas (Americas) and 2) emerging evidence indicating prolonged detection of Zika virus immunoglobulin M (IgM) antibodies.

Zika virus cases were first reported in the Americas during 2015–2016; however, the incidence of Zika virus disease has since declined.

As the prevalence of Zika virus disease declines, the likelihood of false-positive test results increases. In addition, emerging epidemiologic and laboratory data indicate that, as is the case with other flaviviruses, Zika virus IgM antibodies can persist beyond 12 weeks after infection.

Therefore, IgM test results cannot always reliably distinguish between an infection that occurred during the current pregnancy and one that occurred before the current pregnancy, particularly for women with possible Zika virus exposure before the current pregnancy.

These limitations should be considered when counseling pregnant women about the risks and benefits of testing for Zika virus infection during pregnancy.

This updated guidance emphasizes a shared decision-making model for testing and screening pregnant women, one in which patients and providers work together to make decisions about testing and care plans based on patient preferences and values, clinical judgment, and a balanced assessment of risks and expected outcomes…..


July 28, 2017 at 5:17 pm

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