Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

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Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Infectious Diseases Society of America.

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 personyears), 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.)

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Initiation of antiretroviral therapy in early asymptomatic HIV infection

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Sexually transmitted diseases treatment guidelines, 2015.

Endocarditis por Erysipelothrix rhusiopathiae: una enfermedad profesional poco frecuente y de diagnóstico difícil

Objetivo La aparicion de nuevas poblaciones de riesgo y nuevas tecnicas diagnosticas y terapeuticas para el absceso cerebral en las ultimas decadas justifica una revision de sus caracteristicas epidemiologicas, clinicas, terapeuticas y pronosticas. Metodos Se reviso una cohorte retrospectiva de 79 pacientes adultos diagnosticados y tratados de absceso cerebral unico o multiple en el Hospital General Universitario “Gregorio Maranon” de Madrid en el periodo enero 1982 a diciembre 2000, obtenida a partir de las bases de datos de registros clinicos radiologicos, microbiologicos y quirurgicos del centro. Se evaluan sus caracteristicas epidemiologicas, clinicas, terapeuticas y pronosticas en terminos de impacto sobre la mortalidad y secuelas neurologicas persistentes. Resultados En el periodo referido fueron ingresados 101 pacientes diagnosticados de absceso cerebral por criterios clinico-radiologicos y/o microbiologicos (0.1 casos/1000 admisiones). Hemos tenido acceso a informacion completa de la historia clinica de 79 de ellos; 38 fueron admitidos en el Servicio de Neurocirugia y 41 en otros servicios medicos. La edad media fue de 47 anos (rango 20–81), siendo 55 varones y 24 mujeres (aprox. 2/1). La localizacion mas frecuente fue temporal; un tercio de los pacientes presentaban abscesos multiples. La forma de presentacion mas frecuente fue aguda (81 %), con fiebre, cefalea y alteracion del nivel de consciencia como combinacion de sintomas mas habitual. De los 38 admitidos en Neurocirugia, 34 (89%) fueron intervenidos (puncion-aspiracion y/o craneotomia) sin diferencias en la evolucion segun la tecnica quirurgica utilizada; se intervino a 15 (37%) de los ingresados en otros servicios. La mortalidad en los admitidos en el Servicio de Neurocirugia fue del 5.2%, frente a 44.7% en otras especialidades medicas, si bien existen un sesgo de seleccion debido a la patologia de base y criterios de indicacion quirurgica. La mortalidad global fiie del 25%. Conclusiones El absceso cerebral continua siendo a comienzos del siglo XXI una patologia con elevada morbimortalidad, incluso con tratamiento adecuado. A pesar de que algunos casos pueden manejarse con tratamiento antibiotico solo, creemos que el absceso cerebral continua siendo una patologia de tratamiento persistente quirurgico. Un alto indice de sospecha diagnostica y una actitud agresiva permitira reducir la mortalidad y las secuelas neurologicas persistentes.

2. Abscesos cerebrales piógenos en el adulto: experiencia en las dos últimas décadas

Idiopathic cutaneous ulcers, oesophageal ulcers and severe ulcerative ileocolitis occurred in a human immunodeficiency virus (HIV)-infected patient early after the initiation of combination antiretroviral therapy. This massive inflammatory process led to acute colonic perforation on two occasions. The disease was refractory to standard therapy, but responded successfully to thalidomide. Here, we discuss the potential benefits of thalidomide in refractory inflammatory processes in HIV-infected patients.

Idiopathic ileocolitis with perforation associated with HIV infection: thalidomide treatment.

Resumen La necesidad de conocer previamente el tropismo constituye un requisito imprescindible para el uso de los farmacos antagonistas de los correceptores CCR5. Un farmaco de esta clase, maraviroc, esta ya aprobado para el tratamiento de la infeccion por el virus de la inmunodeficiencia humana (VIH). Aunque en los ensayos de desarrollo de maraviroc, el tropismo se determino mediante pruebas fenotipicas (Trofile®), la realizacion de estas es compleja, tiene un coste elevado y su accesibilidad es limitada, lo que dificulta su utilizacion en la practica clinica. Los metodos genotipicos basados en el analisis de la tercera region variable (V3) de la envuelta del VIH utilizando algoritmos de interpretacion como geno2pheno y PSSM representan una alternativa rapida, barata y accesible en laboratorios diagnosticos para predecir el tropismo viral. En los analisis retrospectivos de los ensayos clinicos de maraviroc, las pruebas genotipicas realizadas mediante tecnicas de genotipo convencional (o poblacional) o mediante las nuevas plataformas de secuenciacion masiva (pirosecuenciacion por 454) fueron capaces de predecir la respuesta virologica al farmaco con una exactitud similar a las pruebas fenotipicas y, actualmente, las recomendaciones espanolas y europeas las incluyen como una alternativa aceptable para la determinacion del tropismo viral en la practica clinica.

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Félix Gutiérrez

Papers

Endocarditis por Erysipelothrix rhusiopathiae: una enfermedad profesional poco frecuente y de diagnóstico difícil

2. Abscesos cerebrales piógenos en el adulto: experiencia en las dos últimas décadas

Idiopathic ileocolitis with perforation associated with HIV infection: thalidomide treatment.

Tropismo del VIH. Técnicas disponibles y utilidad

Piomiositis pélvica con bacteriemia por Staphylococcus aureus en dos adolescentes sanos después de ejercicio intenso