Posts filed under ‘Inmunizaciones’

A Therapeutic Strategy for All Pneumonia Patients: A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy

Clinical Infectious Diseases April 1, 2019 V.68 N.7 P.1080-1088 

EDITOR’S CHOICE

We applied a single algorithm to all forms of pneumonia, which was followed in 82.5% of a cohort of 1089 patients. Only 4.3% received inappropriate therapy; in multivariate analysis, site of pneumonia acquisition was not predictive of 30-day mortality.

Background

Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition.

Methods 

We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of  1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP).

Results

Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0–1 MDR risk (25.8% vs 5.3%, P < .001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0–1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P < .001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not.

Conclusions

Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality.

FULL TEXT

https://academic.oup.com/cid/article/68/7/1080/5063558

PDF (CLIC en PDF)

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May 4, 2019 at 12:14 pm

Measles in 2019 — Going Backward

N Engl J of Medic April 18, 2019

C.I. Paules, H.D. Marston, and A.S. Fauci

In 2000, the United States achieved a historic public health goal: the elimination of measles, defined by the absence of sustained transmission of the virus for more than 12 months. This achievement resulted from a concerted effort by health care practitioners and families alike, working to protect the population through widespread immunization…..

FULL TEXT

https://www.nejm.org/doi/full/10.1056/NEJMp1905099?query=TOC

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMp1905099?articleTools

 

April 21, 2019 at 11:39 am

Imported toxin-producing cutaneous diphtheria— Minnesota, Washington, and New Mexico, 2015–2018.

MMWR Morb Mortal Wkly Rep March 29, 2019 V.68 N.12 P.281-284

Griffith J et al.

Summary

What is already known about this topic?

Cutaneous diphtheria has not been notifiable in the United States since 1980, and U.S. disease incidence data are limited.

What is added by this report?

Toxin-producing Corynebacterium diphtheriae was identified in cutaneous wounds from four U.S. residents after return from international travel. Public health response for toxin-producing diphtheria includes treating patients, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage, and providing diphtheria toxoid–containing vaccine to incompletely immunized patients and close contacts.

What are the implications for public health practice?

Cutaneous toxin-producing diphtheria should be considered in travelers with wound infections who have returned from countries with endemic disease to permit prompt public health response and prevent disease transmission.

 

From September 2015 to March 2018, CDC confirmed four cases of cutaneous diphtheria caused by toxin-producing Corynebacterium diphtheriae in patients from Minnesota (two), Washington (one), and New Mexico (one). All patients had recently returned to the United States after travel to countries where diphtheria is endemic. C. diphtheriae infection was not clinically suspected in any of the patients; treating institutions detected the organism through matrix-assisted laser desorption/ionization–time-of-flight mass spectrometry (MALDI-TOF) testing of wound-derived coryneform isolates. MALDI-TOF is a rapid screening platform that uses mass spectrometry to identify bacterial pathogens. State public health laboratories confirmed C. diphtheriae through culture and sent isolates to CDC’s Pertussis and Diphtheria Laboratory for biotyping, polymerase chain reaction (PCR) testing, and toxin production testing. All isolates were identified as toxin-producing C. diphtheriae. The recommended public health response for cutaneous diphtheria is similar to that for respiratory diphtheria and includes treating the index patient with antibiotics, identifying close contacts and observing them for development of diphtheria, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage in the nose and throat, and providing diphtheria toxoid–containing vaccine to incompletely immunized patients and close contacts. This report summarizes the patient clinical information and response efforts conducted by the Minnesota, Washington, and New Mexico state health departments and CDC and emphasizes that health care providers should consider cutaneous diphtheria as a diagnosis in travelers with wound infections who have returned from countries with endemic diphtheria.

FULL TEXT

https://www.cdc.gov/mmwr/volumes/68/wr/mm6812a2.htm?s_cid=mm6812a2_w

PDF

https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6812a2-H.pdf

April 18, 2019 at 9:57 am

Cost-effectiveness analysis of quadrivalent seasonal influenza vaccines in England.

BMC Med. September 8, 2017 V.15 N.1 P.166.

Thorrington D1, van Leeuwen E2,3, Ramsay M4, Pebody R2, Baguelin M2,5.

Author information

1 Respiratory Diseases Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK. dominic.thorrington@phe.gov.uk

2 Respiratory Diseases Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.

3 Imperial College Faculty of Medicine, London, SW7 2AZ, UK.

4 Immunisation, Hepatitis & Blood Safety Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.

5 Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Abstract

BACKGROUND:

As part of the national seasonal influenza vaccination programme in England and Wales, children receive a quadrivalent vaccine offering protection against two influenza A strains and two influenza B strains. Healthy children receive a quadrivalent live attenuated influenza vaccine (QLAIV), whilst children with contraindications receive the quadrivalent inactivated influenza vaccine (QIIV). Individuals aged younger than 65 years in the clinical risk populations and elderly individuals aged 65+ years receive either a trivalent inactivated influenza vaccine (TIIV) offering protection from two A strains and one B strain or the QIIV at the choice of their general practitioner. The cost-effectiveness of quadrivalent vaccine programmes is an open question. The original analysis that supported the paediatric programme only considered a trivalent live attenuated vaccine (LAIV). The cost-effectiveness of the QIIV to other patients has not been established. We sought to estimate the cost-effectiveness of these programmes, establishing a maximum incremental total cost per dose of quadrivalent vaccines over trivalent vaccines.

METHODS:

We used the same mathematical model as the analysis that recommended the introduction of the paediatric influenza vaccination programme. The incremental cost of the quadrivalent vaccine is the additional cost over that of the existing trivalent vaccine currently in use.

RESULTS:

Introducing quadrivalent vaccines can be cost-effective for all targeted groups. However, the cost-effectiveness of the programme is dependent on the choice of target cohort and the cost of the vaccines: the paediatric programme is cost-effective with an increased cost of £6.36 per dose, though an extension to clinical risk individuals younger than 65 years old and further to all elderly individuals means the maximum incremental cost is £1.84 and £0.20 per dose respectively.

CONCLUSIONS:

Quadrivalent influenza vaccines will bring substantial health benefits, as they are cost-effective in particular target groups.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590113/pdf/12916_2017_Article_932.pdf

April 13, 2019 at 12:58 pm

A review of the value of quadrivalent influenza vaccines and their potential contribution to influenza control.

Hum Vaccin Immunother. July 3, 2017 V.13 N.7 P.1640-1652.

Ray R1, Dos Santos G2, Buck PO3, Claeys C1, Matias G1, Innis BL3, Bekkat-Berkani R1.

Author information

1 a GSK , Wavre , Belgium.

2 b Business & Decision Life Sciences , Brussels , Belgium (on behalf of GSK).

3 c GSK , Philadelphia , PA , USA.

Abstract

The contribution of influenza B to the seasonal influenza burden varies from year-to-year. Although 2 antigenically distinct influenza B virus lineages have co-circulated since 2001, trivalent influenza vaccines (TIVs) contain antigens from only one influenza B virus. B-mismatch or co-circulation of both B lineages results in increased morbidity and mortality attributable to the B lineage absent from the vaccine. Quadrivalent vaccines (QIVs) contain both influenza B lineages. We reviewed currently licensed QIVs and their value by focusing on the preventable disease burden. Modeling studies support that QIVs are expected to prevent more influenza cases, hospitalisations and deaths than TIVs, although estimates of the case numbers prevented vary according to local specificities. The value of QIVs is demonstrated by their capacity to broaden the immune response and reduce the likelihood of a B-mismatched season. Some health authorities have preferentially recommended QIVs over TIVs in their influenza prevention programmes.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5512791/pdf/khvi-13-07-1313375.pdf

 

April 13, 2019 at 12:57 pm

Safety and Immunogenicity of MF59-Adjuvanted Cell Culture-Derived A/H5N1 Subunit Influenza Virus Vaccine: Dose-Finding Clinical Trials in Adults and the Elderly.

 Open Forum Infect Dis. March 1, 2019 V.6 N.4 

Frey SE1, Shakib S2, Chanthavanich P3, Richmond P4, Smith T5, Tantawichien T6, Kittel C7, Jaehnig P7, Mojares Z8, Verma B9, Kanesa-Thasan N9, Hohenboken M10.

Author information

1 School of Medicine, Saint Louis University, St. Louis, Missouri.

2 CMAX Clinical Research Pty Ltd., Adelaide, SA, Australia.

3 Department of Tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

4 Division of Paediatrics, School of Medicine, University of Western Australia, and Vaccine Trials Group, Telethon Kids Institute, Subiaco, WA, Australia.

5 Mercy Health Research, St. Louis, Missouri.

6 Department of Medicine, Faculty of Medicine, Chulalongkorn University and Queen Saovabha Memorial Institute, Bangkok, Thailand.

7 GlaxoSmithKline Vaccines GmbH, Marburg, Germany.

8 GlaxoSmithKline Pte Ltd., Singapore, Singapore.

9 GlaxoSmithKline Vaccines LLC, Rockville, Maryland.

10 Seqirus Inc., Cambridge, Massachusetts.

Abstract

BACKGROUND:

A/H5N1 influenza viruses have high pandemic potential; consequently, vaccines need to be produced rapidly. MF59® adjuvant reduces the antigen required per dose, allowing for dose sparing and more rapid vaccine availability.

METHODS:

Two multicenter, phase II trials were conducted to evaluate the safety and immunogenicity of an MF59-adjuvanted, cell culture-derived, A/H5N1 vaccine (aH5N1c) among 979 adult (18-64 years old) and 1393 elderly (≥65 years old) subjects. Participants were equally randomized to receive 2 full-dose (7.5 μg of hemagglutinin antigen per dose) or 2 half-dose aH5N1c vaccinations 3 weeks apart. Outcomes were based on Center for Biologics Evaluation Research and Review (CBER) and Committee for Medicinal Products for Human Use (CHMP) licensure criteria (titers ≥1:40 and seroconversions on day 43). Solicited reactions and adverse events were assessed (www.clinicaltrials.gov: NCT01776541 and NCT01766921).

RESULTS:

CBER and CHMP criteria were met by both age groups. CBER criteria for hemagglutination titers were met for the full-dose formulation. Solicited reaction frequencies tended to be higher in the full-dose group and were of mild to moderate intensity. No vaccine-related serious adverse events occurred.

CONCLUSIONS:

In adult and elderly participants, the full-dose aH5N1c vaccine formulation was well tolerated and met US and European licensure criteria for pandemic vaccines.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446137/pdf/ofz107.pdf

April 13, 2019 at 12:56 pm

Microscopic Examination and Broth Culture of Cerebrospinal Fluid in Diagnosis of Meningitis

Journal of Clinical Microbiology June 1998 V.36 N.6 P.1617-1620

Dunbar SA et al

We reviewed the results of microscopic Gram stain examination and routine culture for 2,635 cerebrospinal fluid (CSF) samples processed in an adult hospital microbiology laboratory during 55 months. There were 56 instances of bacterial or fungal meningitis (16 associated with central nervous system [CNS] shunt infection), four infections adjacent to the subarachnoid space, four cases of sepsis without meningitis, and an additional 220 CSF specimens with positive cultures in which the organism isolated was judged to be a contaminant. Because 121 of these contaminants were isolated in broth only, elimination of the broth culture would decrease unnecessary work. However, 25% of the meningitis associated with CNS shunts would have been missed by this practice. The most common cause of meningitis was Cryptococcus neoformans, followed by Streptococcus pneumoniaeand Neisseria meningitidis. In 48 of 56 (88%) of cases, examination of the Gram-stained specimen revealed the causative organism. If patients who had received effective antimicrobial therapy prior to lumbar puncture are excluded, the CSF Gram stain is 92% sensitive. Microscopic examination incorrectly suggested the presence of organisms in only 3 of 2,635 (0.1%) CSF examinations. Thus, microscopic examination of Gram-stained, concentrated CSF is highly sensitive and specific in early diagnosis of bacterial or fungal meningitis.

Bacterial meningitis is a life-threatening infection. Although patients typically present with fever, headache, stiff neck, and altered mental status, these symptoms may be subtle in elderly or immunocompromised persons (1, 6, 7,18). Early implementation of appropriate antimicrobial therapy requires prompt identification of the infecting pathogen. Although culture is considered to be the definitive diagnostic test, microscopic examination of a Gram-stained specimen of cerebrospinal fluid (CSF) may provide immediate information about the causative microorganism. Previous studies have suggested that the sensitivity of this technique ranges from 60 to 90% and the specificity approaches 100% (1, 5,6, 8, 12, 18). Scheld concludes that the overall sensitivity is only 75% (14). It is often unclear whether earlier studies have stratified patients based upon their having received prior antimicrobial therapy. Further, the role of semiquantitative assessment of leukocytes (WBC) by microscopic examination as an indicator of infection (8, 12) is uncertain. The value of using broth culture in various populations is also questionable (9, 10,17). In the present study, we reviewed the results of microscopic examination and routine culture of 2,635 CSF specimens to establish the predictive value of the cytocentrifuged Gram stain and the usefulness of broth culture in a veteran population.

FULL TEXT

https://jcm.asm.org/content/36/6/1617

PDF

https://jcm.asm.org/content/jcm/36/6/1617.full.pdf

April 2, 2019 at 6:15 pm

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