Showing papers in "Clinical Infectious Diseases in 1995"
TL;DR: Since brucellosis is now rare in the United States, physicians may be unfamiliar with the clinical manifestations, methods for diagnosis, and options for treatment of this zoonotic infection.
Abstract: Not long ago a farmer in rural Texas presented to a local practitioner complaining of fever, night sweats, fatigue, and back pain. He mentioned that his cattle were under quarantine for Bang's disease (bovine brucellosis) and that he believed he too had the disease. When he was found to be afebrile and to have no other objective signs of disease, his complaints were dismissed as a likely case of the "flu." Several months later he was admitted to a hospital because of vertebral osteomyelitis, and Brucella abortus was isolated from bone tissue. Since brucellosis is now rare in the United States, physicians may be unfamiliar with the clinical manifestations, methods for diagnosis, and options for treatment of this zoonotic infection.
801 citations
TL;DR: Methods for rapid detection, such as the measurement of mannan (the major cell-wall polysaccharide of Candida), may be useful for diagnosing invasive candidiasis and for monitoring the response of this infection to antifungal therapy.
Abstract: Currently, about 180 hospitals participate in the National Nosocomial Infections Surveillance (NNIS) system. From January 1980 through April 1990, 27,200 fungal isolates causing nosocomial infections were reported from these hospitals; Candida species accounted for 19,621 (72.1%) of these isolates. Immunocompromised patients are at particularly high risk for candidemia. In patients with acute lymphocytic leukemia, treatment with vancomycin and/or imipenem appears to be an independent risk factor for candidemia; colonization of stool by Candida species may be another important predisposing factor in these patients. Rapid detection of invasive candidemia in these high-risk patients is particularly important to the improvement of rates of survival. Methods for rapid detection, such as the measurement of mannan (the major cell-wall polysaccharide of Candida), may be useful for diagnosing invasive candidiasis and for monitoring the response of this infection to antifungal therapy. Further studies of risk factors and the development of new methods for rapid diagnosis and monitoring should help decrease the morbidity and mortality associated with nosocomial fungal infections.
635 citations
TL;DR: The perception that, over time, a greater proportion of candida infections have been caused by non-albicans species was not borne out and the wide variability in reported findings was striking, due in part to differences in the underlying disease affecting the patients described.
Abstract: A number of surveys have documented increased rates of candida infection over the past several decades In this assessment of the frequency and distribution of non-albicans Candida species among patients with cancer, 37 reports that were published between 1952 and 1992 and that described 1,591 cases of systemic candida infection were reviewed Species other than Candida albicans accounted for 46% of all systemic candida infections in patients with cancer; specifically, Candida tropicalis accounted for 25%, Candida glabrata for 8%, Candida parapsilosis for 7%, and Candida krusei for 4% Other species were uncommon C tropicalis was the predominant pathogenic Candida species in five reports, C glabrata in two, C krusei in two, and Candida stellatoidea in one The perception that, over time, a greater proportion of candida infections have been caused by non-aolbicans species was not borne out The wide variability in reported findings was striking and was due in part to differences in the underlying diseases affecting the patients described For example, patients with leukemia were more likely to be infected by C albicans or C tropicalis but less likely to be infected by C glabrata than patients with other types of cancer The recent increase in the rate of bone marrow transplantation may also have contributed to discrepancies among reports Bone marrow transplant recipients were more likely to be infected by C krusei or C lusitaniae The other factors partially responsible for the variability among reports included common-source contamination and the pressures imposed by antimicrobial measures
537 citations
TL;DR: The USPHS/IDSA Prevention of Opportunistic Infections Working Group has recently formulated disease-specific recommendations for 17 opportunistic infections or groups of OIs in HIV-infected persons as mentioned in this paper.
Abstract: The USPHS/IDSA Prevention of Opportunistic Infections Working Group has recently formulated disease-specific recommendations for 17 opportunistic infections (OIs) or groups of OIs in HIV-infected persons [1]. The purpose of this article is to synthesize these recommendations and to offer the health care provider an organized approach to the prevention of OIs in this population. The authors recognize that preventing all exposures to opportunistic pathogens or all disease due to these pathogens is not possible. The avoidance of all behaviors and environments that can result in exposure to opportunistic pathogens would excessively restrict the patient's lifestyle. Furthermore, drugs active against many opportunistic pathogens are not available; even if they were, the multitude of agents required to reduce the risk of all OIs-with the attendant problems of toxicities, interactions, cost, and adherence to chemoprophylactic regimens-would render a complete preventive strategy impossible. This article is therefore intended to guide the provider in establishing priorities for the various preventive measures available.
535 citations
TL;DR: Differences in the BCG strains used in efficacy trials on humans may be responsible for the wide range in levels of protection from tuberculosis reported in those trials, and limited data available from human studies suggest that theBCG strain used for vaccination is not a significant determinant of the overall efficacy in the prevention of tuberculosis.
Abstract: Bacille Calmette-Guerin (BCG) vaccination for the prevention of tuberculosis has been used in humans since 1921. Furthermore, for > 60 years it has been possible to separate BCG strains (defined here as a BCG vaccine maintained in a particular laboratory and used in a particular trial or set of trials) on the basis of in vitro and in vivo tests. Investigators have concluded that differences in the BCG strains used in efficacy trials on humans may be responsible for the wide range in levels of protection from tuberculosis reported in those trials. We review the development of the separate strains used in the trials included in a recent meta-analysis and examine data for and against the protective efficacy of different BCG strains. The difficulties in correlating results of in vitro and in vivo tests with protective efficacy in humans are discussed. The limited data available from human studies suggest that the BCG strain used for vaccination is not a significant determinant of the overall efficacy in the prevention of tuberculosis.
511 citations
TL;DR: In this article some of the challenges posed by the management of nosocomial candidemia are presented in three case studies and the results of several investigations at the University of Iowa Hospitals and Clinics are reviewed.
Abstract: Over the past decade, the incidence of hospital-acquired bloodstream infections caused by Candida species has risen and the species associated with such infections have changed. The incidence of candidemia is dramatically higher in high-risk, critical-care units than in other parts of the hospital. Certain underlying physical conditions including acute leukemia, leukopenia, burns, gastrointestinal disease, and premature birth predispose patients to nosocomial candidemia. Independent risk factors include prior treatment with multiple antibiotics, prior Hickman catheterization, isolation of Candida species from sites other than the blood, and prior hemodialysis. In this article some of the challenges posed by the management of nosocomial candidemia are presented in three case studies. In addition, the results of several investigations of nosocomial candidemia at the University of Iowa Hospitals and Clinics are reviewed.
505 citations
TL;DR: A bibliographic search was conducted of English-language articles dealing with chronic hepatitis B virus (HBV) infection to evaluate the risk of chronicity following acute infection, finding the highest risk was found to be among infected neonates born to hepatitis B e antigen-positive carrier mothers.
Abstract: A bibliographic search was conducted of English-language articles dealing with chronic hepatitis B virus (HBV) infection to evaluate the risk of chronicity following acute infection. Chronic HBV infection was defined as carriage of hepatitis B surface antigen (HBsAg) for at least 6 months. On the basis of incidence studies employing standard serological test methods, the highest risk (80%-90%) of chronic infection was found to be among infected neonates born to hepatitis B e antigen-positive carrier mothers. Of children infected before 6 years of age, chronic infection was reported to develop in approximately 30%. A relatively wide range of risks (< 1%-12%) was found among diverse populations of older children and adults. However, most of the 10 identified incidence studies of generally healthy adults indicated that the risk of chronicity is very low: < or = 5% in eight studies. In addition, the pooled incidence of chronicity was < 5% among two different adult population groups: initially uninfected subjects, who usually experienced asymptomatic infection, and patients presenting with acute hepatitis B. In addition to the primary influence of age, the studies revealed a higher risk of chronic HBV infection among males and among patients with impaired immunity due to various causes.
496 citations
TL;DR: An outbreak of vancomycin-resistant Enterococcus faecium (vanA phenotype) bacteremia on the oncology ward of a tertiary care community hospital is described and the use of antimicrobial agents with significant activity against anaerobes are found to be risk factors.
Abstract: We describe an outbreak of vancomycin-resistant Enterococcus faecium (vanA phenotype) bacteremia on the oncology ward of a tertiary care community hospital. In 10 of the 11 cases the patients had leukemia and were neutropenic (median duration of neutropenia, 21 days) at the time of bacteremia. On average, patients received six antibiotic agents for a total of 61 agent-days prior to development of vancomycin-resistant E. faecium bacteremia. The mortality rate was 73%. Molecular typing of 22 isolates revealed that the majority (83%) represented a common strain, indicating nosocomial spread. When the 11 cases were compared to 22 matched control patients, gastrointestinal colonization with vancomycin-resistant E. faecium (odds ratio [denominator, 0] infinity, P = .005) and the use of antimicrobial agents with significant activity against anaerobes (metronidazole, clindamycin, and imipenem; odds ratio infinity, P = .02) were found to be risk factors for the development of vancomycin-resistant E. faecium bacteremia. Since no proven therapy for such infection exists, there is an urgent need to identify effective measures to prevent and control the development of vancomycin-resistant E. faecium bacteremia.
496 citations
TL;DR: A population-based register of cases of cryptococcosis in patients treated in Victoria, Australia, over a 10-year period was established for studying the epidemiologic and clinical features of infection with Cryptococcus neoformans and its two varieties.
Abstract: A population-based register of cases of cryptococcosis in patients treated in Victoria, Australia, over a 10-year period was established for studying the epidemiologic and clinical features of infection with Cryptococcus neoformans and its two varieties, gattii and neoformans. One hundred thirty-three cases of cryptococcosis were entered on the register; the incidence was 3.0 cases per 1 million population per year, a rate that increased to 5.0 cases per 1 million population per year over the decade as a result of the AIDS epidemic. There was a distinct association between immune status and C. neoformans variety: all C. neoformans variety gattii infections occurred in healthy hosts and 90% of C. neoformans variety neoformans infections occurred in immunosuppressed hosts. Meningitis was the commonest manifestation, with focal CNS and pulmonary lesions occurring primarily in healthy hosts with C. neoformans variety gattii infection; isolation of C. neoformans from blood and urine was associated with immunosuppression and C. neoformans variety neoformans infection. The mortality among patients with C. neoformans variety neoformans infection was high, while none of those patients with C. neoformans variety gattii died but often had neurological sequelae that required surgery and prolonged therapy. These findings appear to be related to variety-specific interactions between host and parasite and warrant further epidemiologic and immunologic study.
457 citations
TL;DR: A model relating the phenotypic characteristics of S. aureus SCVs with the clinical pattern of persistent and relapsing infection is proposed.
Abstract: Small-colony variants (SCVs) of Staphylococcus aureus were cultured from five patients with persistent and relapsing infections. All five SCV strains were nonhemolytic and nonpigmented and grew very slowly on routine culture media in an ambient atmosphere. In several instances, these phenotypic characteristics led to the initial misidentification of the organisms in the clinical microbiology laboratory. All four strains available for further analysis were shown to be auxotrophs that reverted to normal growth and morphology in the presence of menadione, hemin, and/or a CO2 supplement. Similarly, these isolates were resistant to aminoglycosides under routine conditions but susceptible in the presence of the metabolic supplements. For two patients, the large and small colony forms isolated concurrently were indistinguishable when analyzed by pulsed field gel electrophoresis and thus represented phenotypic variants within individual clones. We propose a model relating the phenotypic characteristics of S. aureus SCVs with the clinical pattern of persistent and relapsing infection.
425 citations
Agency for Healthcare Research and Quality1, Centers for Disease Control and Prevention2, American Foundation for AIDS Research3, Boston University4, Brown University5, Case Western Reserve University6, Council of State and Territorial Epidemiologists7, Dalhousie University8, Duke University9, Emory University10, Food and Drug Administration11, Gay Men's Health Crisis12, Rutgers University13, Harlem Hospital Center14, Harvard University15, Howard University16, Johns Hopkins University17, Maryland Department of Health18, Mount Auburn Hospital19, Icahn School of Medicine at Mount Sinai20, National Institutes of Health21, Northwestern University22, Rush University Medical Center23, St. Jude Children's Research Hospital24, Stony Brook University25, Tulane University26, University of Alabama27, University of Arizona28, University of California, San Francisco29, University of Minnesota30, University of Southern California31, University of Washington32, Washington University in St. Louis33
TL;DR: Research should be directed at reducing the carriage of E. coli O157:H7 at its bovine source, minimizing the microbial content of food and water, and averting systemic microangiopathic hemolytic anemia after infection with this pathogen.
Abstract: E coli O157:H7 is one of many E coli organisms that contain genes encoding one or more toxins similar in structure and function to Shiga toxin E coli O157:H7 is the most frequently isolated diarrheagenic type of E coli isolated in North America today; this pathogen can cause serious, even fatal disease Syndromes caused by E coli O157:H7 include diarrhea, hemorrhagic colitis, and HUS Poorly cooked ground beef has been the most frequently implicated vehicle of transmission, but additional vehicles are being identified Treatment consists of rehydration during hemorrhagic colitis and support of the patient during the multiple systemic complications of HUS A policy of routine screening for E coli O157:H7 in clinical microbiology laboratories, without reliance on the physician to request that this organism be sought or the technician to notice blood in the stool, is the most effective way to find cases Timely and accurate diagnosis can prevent secondary transmission, avert unnecessary and possibly dangerous procedures and/or therapies, and detect continuing outbreaks SLTEC strains other than E coli O157:H7 may cause diseases similar to or less severe than those caused by E coli O157:H7 At present, however, screening for such pathogens in clinical laboratories is too labor-intensive to be practical Education and legislation should promote safe food-preparation and food-handling practices Research should be directed at reducing the carriage of E coli O157:H7 at its bovine source, minimizing the microbial content of food and water, and averting systemic microangiopathic hemolytic anemia after infection with this pathogen
TL;DR: Pretransplantation determination of recipient EBV and CMV serostatus can identify a subgroup of patients whose risk for severe PTLD may preclude transplantation.
Abstract: Posttransplantation lymphoproliferative disorder (PTLD) is an uncommon but often fatal complication of solid organ transplantation that occurs in approximately 3% of patients. To determine the relative importance and relationship of potential risk factors for PTLD before transplantation (i.e., Epstein-Barr virus [EBV] serostatus of the recipient and the cytomegalovirus [CMV] sero-status of the recipient and the potential donor) and the principal risk factor after transplantation (immunosuppression with antilymphocyte antibody), we analyzed the findings for the first 381 consecutive adult nonrenal transplant recipients seen at Mayo Clinic. In the absence of the other risk factors, the incidence rate of PTLD for EBV-seronegative recipients was 24 times higher (95% confidence interval [CI]: 6.2, 89) than that for EBV-seropositive recipients. The additional risk factors of therapy with OKT3 for rejection and CMV seromismatch (i.e., a negative recipient and a positive donor) each further amplified this risk four- to sixfold. Together, all three risk factors acted synergistically to increase the incidence rate of fatal and/or CNS PTLD by a factor of 654 (CI: 368, 1,162) compared with the low incidence rate (.458 cases per 100 person years) when none of these risk factors were present. Pretransplantation determination of recipient EBV and CMV serostatus can identify a subgroup of patients whose risk for severe PTLD may preclude transplantation.
TL;DR: Dental health was a significant predictor of coronary events when controlled for the following factors: age, sex, socioeconomic status, smoking, hypertension, the number of previous myocardial infarctions, diabetes, body mass index, and serum lipids.
Abstract: Several recent studies have suggested that dental infections are associated with coronary artery disease. To further elucidate this association, we conducted a prospective 7-year follow-up study of 214 individuals (182 males and 32 females; mean age, 49 years) with proven coronary artery disease who had undergone a dental examination and evaluation for the classic coronary risk factors at entry. The main outcome measures were the incidence of fatal and nonfatal coronary events and overall mortality. Fifty-two patients met the endpoint criteria during follow-up. Dental health was a significant predictor of coronary events when controlled for the following factors: age, sex, socioeconomic status, smoking, hypertension, the number of previous myocardial infarctions, diabetes, body mass index, and serum lipids. Other significant predictors were the presence of diabetes, the number of previous myocardial infarctions, and the body mass index. Our results give further support to the hypothesis that dental infections are a risk factor for coronary events.
TL;DR: A retrospective review of cases of cerebral cryptococcosis among patients admitted to 12 Australian teaching hospitals between 1985 and 1992 found that the latter tended to occur in healthy hosts whose residence or job was located in a rural area, and cerebral mass lesions and/or hydrocephalus and pulmonary mass lesions were more common.
Abstract: We performed a retrospective review of cases of cerebral cryptococcosis among patients admitted to 12 Australian teaching hospitals between 1985 and 1992. Of 118 cases identified, 35 occurred in immunocompetent hosts. When cases due to Cryptococcus neoformans variety neoformans were compared with those due to Cryptococcus neoformans variety gattii, we found that the latter tended to occur in healthy hosts whose residence or job was located in a rural area, and cerebral mass lesions and/or hydrocephalus and pulmonary mass lesions were more common. For a subgroup of patients with infection due to C. neoformans variety gattii, multiple enhancing lesions were observed on cerebral computed tomograms, and papilledema, high CSF and serum cryptococcal antigen titers, and a worse prognosis (despite prolonged amphotericin B therapy and intraventricular shunt insertion) were also noted. No significant difference in clinical course or outcome in terms of variety of C. neoformans was noted for patients with cryptococcal meningitis whose computed tomographic scans appeared normal on presentation.
TL;DR: This review will provide a brief overview of current knowledge regarding the antimicrobial activity of NO and the possible importance of this activity in infection, particularly with regard to intracellular pathogens.
Abstract: The past decade has witnessed a veritable explosion of interest in the simple molecule nitric oxide (NO) as a vasodilator, neurotransmitter, and antimicrobial agent. NO and other reactive nitrogen intermediates exhibit cytostatic or cytocidal activity against a remarkable breadth of pathogenic microorganisms. Mammalian cells, including human cells, produce nitric oxide both constitutively and inducibly in response to inflammatory stimuli. This review will provide a brief overview of current knowledge regarding the antimicrobial activity of NO and the possible importance of this activity in infection, particularly with regard to intracellular pathogens.
TL;DR: A comparative analysis of the clinical characteristics and mortality rates among patients with nosocomial bacteremia caused by MRSA or methicillin-susceptible S. aureus in the authors' hospital over a 4-year period showed a relationship between mortality and the following variables: methamphetamineicillin resistance, meningitis, and inadequate treatment.
Abstract: We prospectively studied all cases of Staphylococcus aureus bacteremia that occurred during an extensive outbreak of methicillin-resistant S. aureus (MRSA) in our hospital over a 4-year period (January 1990 through September 1993). We report the results of a comparative analysis of the clinical characteristics and mortality rates among patients with nosocomial bacteremia caused by MRSA (84 cases) or methicillin-susceptible S. aureus (MSSA; 100 cases). The patients with MRSA bacteremia were older than those with MSSA bacteremia (69 years vs. 54 years, respectively; P < .01) and were more likely than those with MSSA bacteremia to have the following predisposing factors: a prolonged hospitalization (32 days vs. 14 days, respectively; P < .01); prior antimicrobial therapy (61% vs. 34%, respectively; P < .01); urinary catheterization (58% vs. 27%, respectively; P < .01); nasogastric tube placement (31% vs. 13%, respectively; P < .01); and prior surgery (45% vs. 31%, respectively; P = .05). Multivariate analysis with use of the stepwise logistic regression method showed a relationship between mortality and the following variables: methicillin resistance (odds ratio [OR], 3), meningitis (OR, 13), and inadequate treatment (OR, 11).
TL;DR: The clinical and epidemiological features of visitors to the Milwaukee area in whom cryptosporidiosis developed, and a telephone survey of Milwaukee County households to evaluate the risk of recurrent illness and secondary transmission, merit further investigation.
Abstract: Contamination of the public water supply in Milwaukee during March and April 1993 resulted in a massive outbreak of cryptosporidium infection. We investigated the clinical and epidemiological features of visitors to the Milwaukee area in whom cryptosporidiosis developed, and we conducted a telephone survey of Milwaukee County households to evaluate the risk of recurrent illness and secondary transmission. Cryptosporidium infection during this outbreak generally seemed more severe than cases described in previous reports of large case series. The risk of secondary transmission within a household was low (5%) when the index case involved an adult. The recurrence of watery diarrhea after apparent recovery was a frequent occurrence among visitors with laboratory-confirmed cryptosporidium infection (39%) and among visitors and Milwaukee County residents with clinical infection (21%). The interval between the initial recovery and the onset of recurrence was prolonged (> or = 5 days) in 6%-8% of persons. This pattern of recurrence and its impact on transmission and our understanding of the pathophysiological mechanisms of cryptosporidium infection merit further investigation.
TL;DR: It is proposed that for every pathogen there exists an antibody that will modify the infection to the benefit of the host, and such antibodies are potential antimicrobial agents.
Abstract: In the preantibiotic era, passive antibody administration (serum therapy) was useful for the treatment of many infectious diseases. The introduction of antimicrobial chemotherapy in the 1940s led to the rapid abandonment of many forms of passive antibody therapy. Chemotherapy was more effective and less toxic than antibody therapy. In this last decade of the 20th century the efficacy of antimicrobial chemotherapy is diminishing because of the rapidly escalating number of immunocompromised individuals, the emergence of new pathogens, the reemergence of old pathogens, and widespread development of resistance to antimicrobial drugs. This diminishment in the effectiveness of chemotherapy has been paralleled by advances in monoclonal antibody technology that have made feasible the generation of human antibodies. This combination of factors makes passive antibody therapy an option worthy of serious consideration. We propose that for every pathogen there exists an antibody that will modify the infection to the benefit of the host. Such antibodies are potential antimicrobial agents. Antibody-based therapies have significant advantages and disadvantages relative to standard chemotherapy. The reintroduction of antibody-based therapy would require major changes in the practices of infectious disease specialists.
TL;DR: Cases of nontuberculous mycobacterial lymphadenitis were analyzed in a prospective study spanning 32 years, from 1958 to 1990, and positive tuberculin skin tests were the rule, and reactivity was long lasting.
Abstract: Cases of nontuberculous mycobacterial lymphadenitis were analyzed in a prospective study spanning 32 years, from 1958 to 1990. The results are based on personal observations and long-term follow-up. There were 105 cases, all of which occurred in children aged 9 1/2 months to 12 years (median age, 2.92 years). The patients were predominantly female, and the cases occurred more often in the winter and spring. The cervical or facial nodes were involved in 96 cases. An abrupt change in the predominant etiologic agent (from Mycobacterium scrofulaceum to Mycobacterium avium complex) was noted in the 1970s. Positive tuberculin skin tests were the rule, and reactivity was long lasting. Complications included a prolonged initial phase of infection (n = 6) and recurrences 3 1/2 months to 7 years later (n = 5). Resection during the early stage of infection produced the most satisfactory healing.
TL;DR: The clinical presentation may mimic that of bacterial or other viral CNS infections, a circumstance making laboratory diagnosis of paramount importance for reducing unnecessary hospitalization and therapy.
Abstract: Infections of the CNS with the nonpolio enteroviruses are common and important causes of morbidity in both children and adults. Studies have recently defined the short-term and long-term outcomes of aseptic meningitis due to the enteroviruses. Focal encephalitis is increasingly recognized as a complication of enterovirus infection. Patients at greatest risk for sequelae of CNS enteroviral disease include neonates and those who are immunocompromised. The clinical presentation may mimic that of bacterial or other viral CNS infections, a circumstance making laboratory diagnosis of paramount importance for reducing unnecessary hospitalization and therapy. Recent advances in PCR technology, including its adaptation to a colorimetric microwell plate format, promise to greatly facilitate diagnosis of enteroviral infections. Promising antiviral drugs for CNS disease and other serious manifestations of enteroviral infections are under development.
TL;DR: This review summarizes the current knowledge on the pathogenesis, diagnosis, and treatment of herpes simplex virus infections of the brain.
Abstract: Herpes simplex virus infections of the central nervous system remain a significant cause of morbidity and mortality, in spite of safe and efficacious antiviral therapy Advances in the treatment of neonatal herpes and herpes simplex encephalitis with acyclovir have improved outcome The application of polymerase chain reaction has allowed for the prompt and specific diagnosis of herpes simplex virus infections of the brain This review summarizes our current knowledge on the pathogenesis, diagnosis, and treatment of herpes simplex virus infections of the brain Opportunities for the future will be defined
TL;DR: Patients with travel-associated dermatosis are advised on how to avoid exposure to the agents and vectors of infectious dermatoses and travel first-aid kits should include insect repellents and antibiotics effective against bacterial skin infections.
Abstract: The full spectrum of skin diseases related to travel in tropical areas is unknown. We prospectively studied 269 consecutive patients with travel-associated dermatosis who presented to our tropical disease unit in Paris during a 2-year period. The median age of these patients was 30 years; 137 patients were male; 76% of the patients were tourists; 38% had visited sub-Saharan Africa; and 85% had been appropriately vaccinated against tetanus. Cutaneous lesions appeared while the patient was still abroad in 61% of cases and after the patient's return to France in 39%. The diagnosis was definite in 260 cases; 137 of these cases (53%) involved an imported tropical disease. The most common diagnoses were cutaneous larva migrans (25%); pyodermas (18%); pruritic arthropod-reactive dermatitis (10%); myiasis (9%); tungiasis (6%); urticaria (5%); fever and rash (4%); and cutaneous leishmaniasis (3%). Hospitalization was necessary in 27 cases (10%), with a median duration of 5 days (range, 2-21 days). Travelers should be advised on how to avoid exposure to the agents and vectors of infectious dermatoses. Travel first-aid kits should include insect repellents and antibiotics effective against bacterial skin infections.
TL;DR: The ehrlichioses are emerging zoonotic infections that are caused by obligate intracellular bacteria in the genus Ehrlichia that occur in the United States and are associated with secondary or opportunistic infections and delayed therapy.
Abstract: The ehrlichioses are emerging zoonotic infections that are caused by obligate intracellular bacteria in the genus Ehrlichia. Two human ehrlichioses occur in the United States: monocytic ehrlichiosis (HME), which is caused by Ehrlichia chaffeensis that infects mononuclear phagocytes in blood and tissues, and granulocytic ehrlichiosis (HGE), an infection of granulocytes that is due to a phylogenetically distinct organism. Both infections cause undifferentiated fever with leukopenia, thrombocytopenia, and elevations in serum aminotransferase levels. Rash is an infrequent sign, and vasculitis is exceedingly rare. Severe or fatal ehrlichiosis is associated with secondary or opportunistic infections and delayed therapy. Ticks are the likely vectors, and deer are the likely reservoirs. HGE is associated with Ixodes species ticks and Lyme disease, a finding suggesting concurrent infection. In cases of HME, ehrlichial inclusions (morulae) are rarely detected; however, they are often seen in neutrophils of patients with HGE. A clinical diagnosis is confirmed with use of the polymerase chain reaction during the infection or by serology during convalescence. Therapy with doxycycline is highly efficacious.
TL;DR: This report is the first to examine the published experience with pylephlebitis during the era of antibiotics and modern imaging and is also theFirst to review critically the role of anticoagulation in the management of this disease.
Abstract: Pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system. We describe a case of pylephlebitis at our institution and examine 18 other cases culled from the literature since 1979, reviewing diagnostic and management issues. A precipitating focus of infection (most commonly diverticulitis) was identified in 13 (68%) of the cases. Bacteremia (often polymicrobial) was present in 88% of the patients. The most common blood isolate was Bacteroides fragilis. Overall mortality was 32%, but most of the patients who died had severe sepsis prior to the initiation of antibiotic therapy. In no case was improvement in a patient's clinical status clearly attributable to the use of heparin, but some beneficial effect of anticoagulation could not be ruled out. This report is the first to examine the published experience with pylephlebitis during the era of antibiotics and modern imaging and is also the first to review critically the role of anticoagulation in the management of this disease.
TL;DR: Most community MRSA isolate studied had distinct PFGE patterns, as did many nosocomial MRSA isolates, and multiple MRSA strains were demonstrated among both community and hospital isolates.
Abstract: An increase in methicillin-resistant Staphylococcus aureus (MRSA) infections prompted a study of MRSA during a 21-month period in a 600-bed university hospital in southern Texas. MRSA cases were classified as community, nosocomial, or transfer cases. A case-control study of risk factors for community MRSA compared with community methicillin-susceptible S. aureus (MSSA) was performed. Pulsed field gel electrophoresis (PFGE) of whole cell DNA typing was used as a marker of strain identity for 31 consecutive isolates collected during the last 8 months of the study. During the 21 months there were 170 patients with MRSA infection or colonization, an incidence of 0.2 per 1,000 patient-days. Ninety-nine (58%) of 170 isolates were from community cases ; the community to nosocomial case ratio was 2 :1. No significant risk factors differentiated patients with community MRSA compared with community MSSA. Most community MRSA isolates studied (15 [68%] of 22) had distinct PFGE patterns, as did many nosocomial MRSA isolates (4 [44%] of 9). MRSA isolates were commonly present on admission to the hospital, and multiple MRSA strains were demonstrated among both community and hospital isolates.
TL;DR: The acquisition of A. baumannii was associated not only with high mortality but also with a length of stay on the intensive care unit in excess of that due to the underlying disease alone; specifically, the attributable mortality was 25%, with a risk ratio for death of 2.0 (95% confidence interval, 1.11-3.62).
Abstract: To identify risk factors for and prognostic indicators of the nosocomial acquisition of multiresistant Acinetobacter baumannii in an intensive care unit, we prospectively studied 40 patients: 13 who were infected with this organism and 27 who were colonized. Isolates were identified by pulsed-field gel electrophoresis; the infected/colonized patients were compared with 348 noninfected, noncolonized patients by logistic regression analysis and with matched historical controls in a cohort study. The severity of illness (evaluated by the APACHE II score; P < .05) and previous infection (P < .001) were retained as independent risk factors for acquiring A. baumannii. Logistic regression analysis selected a high APACHE II score (P < .01) and the acquisition of A. baumannii (P < .01) as factors independently associated with death. The acquisition of A. baumannii was associated not only with high mortality but also with a length of stay on the intensive care unit in excess of that due to the underlying disease alone; specifically, the attributable mortality was 25%, with a risk ratio for death of 2.0 (95% confidence interval, 1.11-3.62), and the duration of stay for infected/colonized patients was 10.3 days longer than that for controls (P < .001).
TL;DR: Removal and replacement of all intravascular catheters without exchange over a guidewire from a preexisting line on or before the first day the study drug was administered were associated with a reduction in the subsequent mean duration of candidemia.
Abstract: During a comparative trial of amphotericin B vs. fluconazole for treatment of candidemia in nonneutropenic patients, data on the management of intravascular catheters were collected. Complete records were available for 91% of the 206 study patients. For the subset of patients with a catheter in place at the time of their first positive blood culture, removal and replacement of all intravascular catheters without exchange over a guidewire from a preexisting line on or before the first day the study drug was administered were associated with a reduction in the subsequent mean duration (+/- SE) of candidemia, from 5.6 +/ -0.8 days to 2.6 +/- 0.5 days (P < .001).
TL;DR: Azithromycin therapy is superior to ciprofloxacin in decreasing the excretion of Campylobacter species and as effective in shortening the duration of illness.
Abstract: We evaluated the use of azithromycin (500 mg) or ciprofloxacin (500 mg) daily for 3 days for the treatment of acute diarrhea among United States military personnel in Thailand. Stool cultures were obtained and symptoms were recorded on study days 0, 1, 2, 3, and 10. Campylobacter species were the most common pathogen isolated (44 isolates from 42 patients). All Campylobacter isolates were susceptible to azithromycin; 22 were resistant to ciprofloxacin. Among the 42 patients with campylobacter infection, there were 2 clinical and 6 bacteriologic treatment failures in the ciprofloxacin group and no treatment failures in the azithromycin group (P = .021 for bacteriologic failures). Overall, azithromycin was as effective as ciprofloxacin in decreasing the duration of illness (36.9 hours vs. 38.2 hours, respectively) and the number of stools (6.4 vs. 7.8, respectively). Among those not infected with Campylobacter species (n = 30), the duration of illness was 32.9 hours vs. 20.7 hours (P = .03) for the azithromycin and ciprofloxacin groups, respectively. Azithromycin is superior to ciprofloxacin in decreasing the excretion of Campylobacter species and as effective as ciprofloxacin in shortening the duration of illness. Azithromycin therapy may be an effective alternative to ciprofloxacin therapy in areas where ciprofloxacin-resistant Campylobacter species are prevalent.
TL;DR: The epidemic strain, defined by phage typing, was isolated in three-quarters of the listerial cases observed during the epidemic period and did not appear to differ significantly from the nonepidemic strains in terms of virulence.
Abstract: This article describes 57 cases of listeriosis that occurred in adults in western Switzerland during an outbreak associated with the consumption of a soft cheese. Twenty-one percent of the cases were of bacteremia, 40% were of meningitis, and 39% were of meningoencephalitis. Overall, 42% of the patients had an underlying disease and 54% were > 65 years of age. Patients with bacteremia were significantly older than those with meningitis or meningoencephalitis (median ages, 75, 69, and 55 years, respectively). The epidemic strain, defined by phage typing, was isolated in three-quarters of the listerial cases observed during the epidemic period and did not appear to differ significantly from the nonepidemic strains in terms of virulence. The overall mortality associated with the 57 cases was 32%. Among the patients' characteristics, age and type of clinical presentation were independent predictors of death in a multivariate logistic regression model (pseudo-r2 [coefficient of determination], .26; both P values < .05), and a presentation of meningoencephalitis was associated with an increased death risk (odds ratio, 6.5; 95% confidence interval, 1.1-39.5; P < .05). Neurological sequelae developed in 30% of the survivors of CNS listeriosis.