Archive for June, 2019

Efficacy and accuracy of qSOFA and SOFA scores as prognostic tools for community-acquired and healthcare-associated pneumonia

International Journal of Infectious Diseases July 2019 V.84 P.89-96

Nobuhiro Asai, Hiroki Watanabe, Arufumi Shiota, Hideo Kato, Daisuke Sakanashi, Mao Hagihara, Yusuke Koizumi, Yuka Yamagishi, Hiroyuki Suematsu, Hiroshige Mikamo

Highlights

  • The Japanese Respiratory Society recently updated the prognostic guidelines for pneumonia in 2017.
  • The new guidelines recommend that pneumonia severity be evaluated using the sequential organ failure assessment (SOFA) and the quick SOFA (qSOFA) scoring systems in a therapeutic strategy flowchart.
  • The combination of qSOFA and SOFA score could be an independent prognostic factor for 30-day mortality among patients with community-onset pneumonia.

Background

The Japanese Respiratory Society recently updated its prognostic guidelines for pneumonia, recommending that pneumonia severity be evaluated using the sequential organ failure assessment (SOFA) and quick SOFA (qSOFA) scoring systems in a therapeutic strategy flowchart. However, the efficacy and accuracy of these tools are still unknown.

Methods

All patients with community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) who were admitted to the study institution between 2014 and 2017 were enrolled in this study. Pneumonia severity on admission was evaluated by A-DROP, CURB-65, PSI, I-ROAD, qSOFA, and SOFA scoring systems. Prognostic factors for 30-day mortality were also analyzed.

Results

This study included 406 patients, 257 male (63%) and 149 female (37%). The median age was 79 years (range 19–103 years). The 30-day and in-hospital mortality rates were both 5%. With respect to the diagnostic value of the predictive assessments for 30-day mortality, the area under the receiver operating characteristic curve (AUROC) value for the SOFA score was 0.769 for CAP patients and 0.774 for HCAP patients. Further, the AUROC values for the SOFA score in CAP and HCAP patients with a qSOFA score ≥2 were 0.829 and 0.784, respectively, for 30-day mortality.

Conclusions

qSOFA and SOFA scores were able to correctly evaluate the severity of CAP and HCAP.

FULL TEXT

https://www.ijidonline.com/article/S1201-9712(19)30190-0/fulltext

PDF

https://www.ijidonline.com/article/S1201-9712(19)30190-0/pdf

June 30, 2019 at 9:25 pm

Antibiotic penetration into bone and joints: An updated review

International Journal of Infectious Diseases April 2019 V.81 N.4 P.128-136

Abrar K. Thabit, Dania F. Fatani, Maryam S. Bamakhrama, Ola A. Barnawi, Lana O. Basudan, Shahad F. Alhejaili

Highlights

  • Despite the rigid structure of bone, many antibiotics demonstrated a good penetration profile.
  • Diffusion into synovial fluid was exhibited by many antibiotics despite their variation in pharmacokinetic properties.
  • Only penicillin, flucloxacillin, and metronidazole showed lower than optimum penetration profiles.
  • Antibiotics with good penetration profiles in bone and joints represent potential options for the treatment of osteomyelitis and septic arthritis.

Treatment of bone and joint infections can be challenging as antibiotics should penetrate through the rigid bone structure and into the synovial space. Several pharmacokinetic studies measured the extent of penetration of different antibiotics into bone and joint tissues. This review discusses the results of these studies and compares them with minimum inhibitory concentrations (MIC) of common pathogens implicated in bone and joint infections in order to determine which antibiotics may have a greater potential in the treatment of such infections. Clinical outcomes were also evaluated as data were available. More than 30 antibiotics were evaluated. Overall, most antibiotics, including amoxicillin, piperacillin/tazobactam, cloxacillin, cephalosporins, carbapenems, aztreonam, aminoglycosides, fluoroquinolones, doxycycline, vancomycin, linezolid, daptomycin, clindamycin, trimethoprim/sulfamethoxazole, fosfomycin, rifampin, dalbavancin, and oritavancin, showed good penetration into bone and joint tissues reaching concentrations exceeding the MIC90 and/or MIC breakpoints of common bone and joint infections pathogens. Few exceptions include penicillin and metronidazole which showed a lower than optimum penetration into bones, and the latter as well as flucloxacillin had poor profiles in terms of joint space penetration. Of note, studies on joint space penetration were fewer than studies on bone tissue penetration. Although clinical studies in osteomyelitis and septic arthritis are not available for all of the evaluated antibiotics, these pharmacokinetic results indicate that agents with good penetration profiles would have a potential utilization in such infections.

FULL TEXT

https://www.ijidonline.com/article/S1201-9712(19)30069-4/fulltext

PDF

https://www.ijidonline.com/article/S1201-9712(19)30069-4/pdf

June 30, 2019 at 12:23 pm

Group B Streptococcus in surgical site and non-invasive bacterial infections worldwide: A systematic review and meta-analysis

International Journal of Infectious Diseases June 2019 V.83 P.116-129

Simon M. Collin, Nandini Shetty, Rebecca Guy, Victoria N. Nyaga, Ann Bull, Michael J. Richards, Tjallie I.I. van der Kooi, Mayke B.G. Koek, Mary De Almeida, Sally A. Roberts, Theresa Lamagni

Highlights

  • This review obtained data on group B Streptococcus infection from 67 countries.
  • Group B Streptococcus is implicated in a small proportion of non-invasive infections.
  • Group B Streptococcus causes 10% of caesarean section invasive surgical infections.

Objectives

The epidemiology of disease caused by group B Streptococcus (GBS; Streptococcus agalactiae) outside pregnancy and the neonatal period is poorly characterized. The aim of this study was to quantify the role of GBS as a cause of surgical site and non-invasive infections at all ages.

Methods

A systematic review (PROSPERO CRD42017068914) and meta-analysis of GBS as a proportion (%) of bacterial isolates from surgical site infection (SSI), skin/soft tissue infection (SSTI), urinary tract infection (UTI), and respiratory tract infection (RTI) was conducted.

Results

Seventy-four studies and data sources were included, covering 67 countries. In orthopaedic surgery, GBS accounted for 0.37% (95% confidence interval (CI) 0.08–1.68%), 0.87% (95% CI 0.33–2.28%), and 1.46% (95% CI 0.49–4.29%) of superficial, deep, and organ/space SSI, respectively. GBS played a more significant role as a cause of post-caesarean section SSI, detected in 2.92% (95% CI 1.51–5.55%), 1.93% (95% CI 0.97–3.81%), and 9.69% (95% CI 6.72–13.8%) of superficial, deep, and organ/space SSI. Of the SSTI isolates, 1.89% (95% CI 1.16–3.05%) were GBS. The prevalence of GBS in community and hospital UTI isolates was 1.61% (1.13–2.30%) and 0.73% (0.43–1.23%), respectively. GBS was uncommonly associated with RTI, accounting for 0.35% (95% CI 0.19–0.63%) of community and 0.27% (95% CI 0.15–0.48%) of hospital RTI isolates.

Conclusions

GBS is implicated in a small proportion of surgical site and non-invasive infections, but a substantial proportion of invasive SSI post-caesarean section.

FULL TEXT

https://www.ijidonline.com/article/S1201-9712(19)30187-0/fulltext

PDF

https://www.ijidonline.com/article/S1201-9712(19)30187-0/pdf

 

 

June 30, 2019 at 12:21 pm

American trypanosomiasis and Chagas disease – Sexual transmission

International Journal of Infectious Diseases April 2019 V.81 N.4 P.81-84

Clever Gomes, Adriana B. Almeida, Ana C. Rosa, Perla F. Araujo, Antonio R.L. Teixeira

Highlights

  • Trypanosoma cruzi infection can be transmitted sexually from males and females to naïve mates.
  • T. cruzi parasites were detected in semen ejaculates from individuals with Chagas disease by nucleic acid techniques.
  • Semen aliquots from humans with Chagas disease instilled into the vagina of naïve female mice resulted in T. cruzi infections.
  • Breeding T. cruzi-infected male and female mice vertically transmitted the infection to progeny mice.

Objective

To contribute to the discussion on the research findings indicating the sexual transmission of American trypanosomiasis and Chagas disease in humans.

Methods

A review of the literature was performed to investigate the routes of transmission of Trypanosoma cruzi parasites and to evaluate the distribution of Chagas disease, which is now found across five continents.

Results

The epidemiological profile of American trypanosomiasis, which is still considered a neglected disease of the poor people of Latin America, has changed over time. A family-based study demonstrated that the blood protozoan T. cruzi can be transmitted sexually from infected males and females to naïve mates.

Conclusions

Evidence that Chagas disease can be transmitted sexually, coupled with the migration of individuals with Chagas disease to previously non-endemic countries and increased travel to endemic countries, has implications for public health. Improved screening of blood supplies and prenatal care are required to prevent congenital spread.

FULL TEXT

https://www.ijidonline.com/article/S1201-9712(19)30032-3/fulltext

PDF

https://www.ijidonline.com/article/S1201-9712(19)30032-3/pdf

June 30, 2019 at 12:18 pm

Pyoderma gangrenosum – a guide to diagnosis and management.

Clin Med (Lond). May 2019 V.19 N.3 P.224-228.       

George C1, Deroide F2, Rustin M2.

1 Royal Free Hospital, London, UK cgeorge2@nhs.net.

2 Royal Free Hospital, London, UK.

Abstract

Pyoderma gangrenosum (PG) is a reactive non-infectious inflammatory dermatosis falling under the spectrum of the neutrophilic dermatoses.

There are several subtypes, with ‘classical PG’ as the most common form in approximately 85% cases. This presents as an extremely painful erythematous lesion which rapidly progresses to a blistered or necrotic ulcer.

There is often a ragged undermined edge with a violaceous/erythematous border. The lower legs are most frequently affected although PG can present at any body site.

Other subtypes include bullous, vegetative, pustular, peristomal and superficial granulomatous variants.

The differential diagnosis includes all other causes of cutaneous ulceration as there are no definitive laboratory or histopathological criteria for PG.

Underlying systemic conditions are found in up to 50% of cases and thus clinicians should investigate thoroughly for such conditions once a diagnosis of PG has been made.

Treatment of PG remains largely anecdotal, with no national or international guidelines, and is selected according to severity and rate of progression.

Despite being a well-recognised condition, there is often a failure to make an early diagnosis of PG.

This diagnosis should be actively considered when assessing ulcers, as prompt treatment may avoid the complications of prolonged systemic therapy, delayed wound healing and scarring.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542232/pdf/clinmed-19-3-224.pdf

June 27, 2019 at 8:18 am

CIM City: the Game Continues for a Better Carbapenemase Test

Clin. Microbiol. July 2019 V.57 N.7 P.1-5

The Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing agree that carbapenemase testing is not necessary for clinical care, provided that the laboratory is up to date with current breakpoints. Nonetheless, publication on the development and modification of carbapenemase tests continues, as is the case in this issue of the Journal of Clinical Microbiology (R. W. Beresford and M. Maley, J Clin Microbiol 57:e01852-18, 2019, https://doi.org/10.1128/JCM.01852-18). This commentary explores modifications to the carbapenem inactivation method—but is this the right focus for clinical laboratories?

PDF

https://jcm.asm.org/content/jcm/57/7/e00353-19.full.pdf

June 26, 2019 at 4:19 pm

Gentamicin as an alternative treatment for gonorrhoea

LANCET June 22, 2019 V.393 N.10190 P.2474-2475

COMMENT

A high gonorrhoea disease burden, increasing rates, and growing antimicrobial resistance portend a developing global public health crisis.1 Gonorrhoea can cause reproductive complications such as pelvic inflammatory disease and infertility, blindness in infants born to infected mothers, and can facilitate HIV acquisition and transmission. Effective treatment prevents sequelae and transmission. Yet Neisseria gonorrhoeae has developed resistance to each antimicrobial used for treatment.2 Development of new antimicrobials has not kept pace…..

FULL TEXT

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30244-2/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2819%2930244-2

 

LANCET June 22, 2019 V.393 N.10190 P.2511-2520

Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): a randomised non-inferiority trial

Background

Gonorrhoea is a common sexually transmitted infection for which ceftriaxone is the current first-line treatment, but antimicrobial resistance is emerging. The objective of this study was to assess the effectiveness of gentamicin as an alternative to ceftriaxone (both combined with azithromycin) for treatment of gonorrhoea.

Methods

G-ToG was a multicentre, parallel-group, pragmatic, randomised, non-inferiority trial comparing treatment with gentamicin to treatment with ceftriaxone for patients with gonorrhoea. The patients, treating physician, and assessing physician were masked to treatment but the treating nurse was not. The trial took place at 14 sexual health clinics in England. Adults aged 16–70 years were eligible for participation if they had a diagnosis of uncomplicated genital, pharyngeal, or rectal gonorrhoea. Participants were randomly assigned to receive a single intramuscular dose of either gentamicin 240 mg (gentamicin group) or ceftriaxone 500 mg (ceftriaxone group). All participants also received a single 1 g dose of oral azithromycin. Randomisation (1:1) was stratified by clinic and performed using a secure web-based system. The primary outcome was clearance of Neisseria gonorrhoeae at all initially infected sites, defined as a negative nucleic acid amplification test 2 weeks post treatment. Primary outcome analyses included only participants who had follow-up data, irrespective of the baseline visit N gonorrhoeae test result. The margin used to establish non-inferiority was a lower confidence limit of 5% for the risk difference. This trial is registered with ISRCTN, number ISRCTN51783227.

Findings

Of 1762 patients assessed, we enrolled 720 participants between Oct 7, 2014, and Nov 14, 2016, and randomly assigned 358 to gentamicin and 362 to ceftriaxone. Primary outcome data were available for 306 (85%) of 362 participants allocated to ceftriaxone and 292 (82%) of 358 participants allocated to gentamicin. At 2 weeks after treatment, infection had cleared for 299 (98%) of 306 participants in the ceftriaxone group compared with 267 (91%) of 292 participants in the gentamicin group (adjusted risk difference −6·4%, 95% CI −10·4% to −2·4%). Of the 328 participants who had a genital infection, 151 (98%) of 154 in the ceftriaxone group and 163 (94%) of 174 in the gentamicin group had clearance at follow-up (adjusted risk difference −4·4%, −8·7 to 0). For participants with a pharyngeal infection, a greater proportion receiving ceftriaxone had clearance at follow-up (108 [96%] in the ceftriaxone group compared with 82 [80%] in the gentamicin group; adjusted risk difference −15·3%, −24·0 to −6·5). Similarly, a greater proportion of participants with rectal infection in the ceftriaxone group had clearance (134 [98%] in the ceftriaxone group compared with 107 [90%] in the gentamicin group; adjusted risk difference −7·8%, −13·6 to −2·0). Thus, we did not find that a single dose of gentamicin 240 mg was non-inferior to a single dose of ceftriaxone 500 mg for the treatment of gonorrhoea, when both drugs were combined with a 1 g dose of oral azithromycin. The side-effect profiles were similar between groups, although severity of pain at the injection site was higher for gentamicin (mean visual analogue pain score 36 of 100 in the gentamicin group vs 21 of 100 in the ceftriaxone group).

Interpretation

Gentamicin is not appropriate as first-line treatment for gonorrhoea but remains potentially useful for patients with isolated genital infection, or for patients who are allergic or intolerant to ceftriaxone, or harbour a ceftriaxone-resistant isolate. Further research is required to identify and test new alternatives to ceftriaxone for the treatment of gonorrhoea.

Funding

UK National Institute for Health Research.

FULL TEXT

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32817-4/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2932817-4

 

 

June 22, 2019 at 7:59 pm

Listeriosis in Spain based on hospitalisation records, 1997 to 2015: need for greater awareness

Eurosuveillance

Listeriosis is an infectious disease caused by bacteria of the genus Listeria spp. L. monocytogenes is the major pathogenic species in both animals and humans. L. monocytogenes is a Gram-positive, rod-shaped organism that can grow in aerobic and anaerobic conditions [1], is widely distributed in the environment and is able to contaminate a wide variety of foods or beverages (soft cheese, deli meats, unpasteurised milk, refrigerated smoked seafood, etc.) [2]. The bacteria can multiply at refrigerator temperatures [3]; therefore, contaminated products are often kept for several days or even weeks, e.g. in the household/restaurants, and may be eaten on multiple occasions, which can complicate the identification of the incriminated food source [4].

The clinical syndromes of listeriosis include: febrile gastroenteritis, sepsis, central nervous system (CNS) involvement in the form of encephalitis, meningoencephalitis and focal infections such as pneumonia myo-endocarditis and septic arthritis, etc [5]. Invasive listeriosis most commonly affects pregnant women, neonates, elderly people and people with chronic conditions or weakened immune response [6]. Listeriosis has one of the highest case fatality rates among all food-borne infections; when it affects the CNS, the mortality rate is above 50% and neurological sequelae are present in more than 60% of survivors [2]. Listeriosis is also associated with fetal and neonatal death.

Worldwide, listeriosis is an emerging infection of public health concern [7]. In Europe, human listeriosis peaked in incidence during the 1980s, showed a general decline during the 1990s and stabilised in the 2000s [8]. More recent data show an increasing trend since 2008 [9]. This increase seems to be related to the ageing of the population and the increase in life expectancy of immunocompromised patients, but also to changes in the ways food is produced, stored, distributed and consumed around the world [10]. Although listeriosis is often a sporadic disease [11], large food-borne outbreaks have occurred during the last decade in Europe and the United States (US) [12]. In South Africa, an outbreak with more than 1,024 laboratory-confirmed listeriosis cases, as at 2 May 2018, has been ongoing since the start of 2017, with a 28.6% case fatality rate [13].

In Spain, food safety criteria (FSC) for L. monocytogenes follow European Commission (EC) regulations [14,15]. Before 2015, when it was added to the list of mandatory notifiable diseases, regions could voluntarily report listeriosis to the Microbiological Information System (Sistema de Información Microbiológica, SIM) [16]. Using the centralised hospital discharge database (Conjunto Mínimo Básico de Datos, CMBD), we aimed to describe the epidemiology of listeriosis in Spain from 1997–2015.

FULL TEXT

https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2019.24.21.1800271

PDF (CLIC en DOWNLOAD PDF)

June 21, 2019 at 7:49 am

Review – Clostridium difficile infection.

European Journal of Clinical Microbiology & Infectious Diseases. June 2019 V.38 N.7

Clostridium difficile (C. difficile) is a Gram-positive, spore-forming, anaerobic bacillus, which is widely distributed in the intestinal tract of humans and animals and in the environment.

In the last decade, the frequency and severity of C. difficile infection has been increasing worldwide to become one of the most common hospital-acquired infections. Transmission of this pathogen occurs by the fecal-oral route and the most important risk factors include antibiotic therapy, old age, and hospital or nursing home stay.

The clinical picture is diverse and ranges from asymptomatic carrier status, through various degrees of diarrhea, to the most severe, life threatening colitis resulting with death. Diagnosis is based on direct detection of C. difficile toxins in feces, most commonly with the use of EIA assay, but no single test is suitable as a stand-alone test confirming CDI.

Antibiotics of choice are vancomycin, fidaxomicin, and metronidazole, though metronidazole is considered as inferior. The goal of this review is to update physicians on current scientific knowledge of C. difficile infection, focusing also on fecal microbiota transplantation which is a promising therapy.

FULL TEXT

https://link.springer.com/article/10.1007/s10096-019-03539-6?wt_mc=alerts.TOCjournals&utm_source=toc&utm_medium=email&utm_campaign=toc_10096_38_7

PDF

https://link.springer.com/content/pdf/10.1007%2Fs10096-019-03539-6.pdf

June 20, 2019 at 7:04 pm

Delay of appropriate antibiotic treatment is associated with high mortality in patients with community-onset sepsis in a Swedish setting

European Journal of Clinical Microbiology & Infectious Diseases. June 2019 V.38 N.7

Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important.

Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock.

A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012–2013. The criterion “early appropriate antibiotic treatment” was defined as administration of the first dose of adequate antibiotics within 1 h, and the second dose given with less than 25% delay after the recommended dose interval.

A high-risk patient was defined as a septic patient with either shock within 24 h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality.

Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment.

Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.

FULL TEXT

https://link.springer.com/article/10.1007/s10096-019-03529-8?wt_mc=alerts.TOCjournals&utm_source=toc&utm_medium=email&utm_campaign=toc_10096_38_7

PDF

https://link.springer.com/content/pdf/10.1007%2Fs10096-019-03529-8.pdf

June 20, 2019 at 7:01 pm

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