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Objective Aeromonas sp. infections are a recognized complication of medical leech therapy (MLT). In patients requiring MLT, ciprofloxacin or trimethoprim–sulphamethoxazole are commonly used to prevent such nosocomial infections. After a patient at our institution developed a MLT-associated multi-drug resistant (MDR) Aeromonas infection, we developed and evaluated a joint antimicrobial stewardship and infection prevention protocol for MLT at our institution. Methods We describe a case of a surgical site infection with MDR Aeromonas following MLT that was resistant to typically prescribed prophylactic antimicrobials, and development of a new leech culture protocol to proactively monitor for antimicrobial resistance among our institution’s leech supply. We also report the rates of MLT-associated infections prior to and following implementation of this protocol and the antimicrobial susceptibility profiles detected in leech culture at our institution. Results Between October 2014 and February 2018, 46 patients received MLT at our institution. Other than the case described in this report, no other instances of MLT-related infections were noted during this time period. Culture results from 22 leeches in six batches since February 2018 showed that all were susceptible to ciprofloxacin, TMP-SMX, and ceftriaxone. Since initiation of a leech culture protocol, no further cases of MLT-associated infections have been reported at our institution. Conclusions In light of increasing antimicrobial resistance and the potentially devastating consequences of MLT-associated infections, institutions offering MLT should be aware of these risks and ensure that protocols are in place to minimize infection risks for patients.

A 51 year old man with active follicular lymphoma presented with several days of erythematous skin nodules on all extremities two weeks after a self-limited diarrheal illness. All serum immunoglobulin levels were found to be low. Blood cultures grew Campylobacter jejuni. The patient was given one week of azithromycin with complete resolution of his skin nodules. The literature of skin manifestations seen in active Campylobacter jejuni infection are reviewed. The majority of cases occur in immunocompromised hosts, many with low or no serum immunoglobulin levels. Postulated mechanisms include a lack of secretory IgA in intestinal mucosa predisposing susceptible patients to translocated enteric pathogens however the precise pathogenesis underlying cutaneous manifestations are unknown.

Mycobacterium arupense is a member of the Mycobacterium terrae complex (MTC) that is implicated in bone and joint infections, among others. This group of environmental pathogens can be found in soil, reclaimed and drinking water systems, rodents, fish tanks and bioaerosols in duck houses. Interestingly, while M. arupense is genotypically closely related to the other agents in the MTC, antibiotic susceptibility of these mycobacteria can vary widely and empiric antibiotic therapy is controversial. Our case report contributes to the very limited literature on M. arupense tenosynovitis—as only six cases have been reported since 2008—and sheds light on different courses of treatment. While previous cases have been successfully treated, a streamlined course of therapy for M. arupense tenosynovitis is still needed.

Background Ganciclovir-resistant cytomegalovirus (GCV-R CMV) is an emerging challenge among solid organ transplant (SOT) recipients. The literature suggests that about 1% of abdominal transplant recipients develop GCV-R CMV infection. The epidemiology and outcome of GCV-R CMV in SOT recipients who have received alemtuzumab induction is not well described. Methods After Institutional Review Board approval, a single-center, retrospective review of 2148 abdominal SOT recipients between January 2006 and July 2011 at our institution (n = 2148) was conducted to identify patients with proven or empirically treated GCV-R CMV. Descriptive statistics on collected demographics, clinical course, and therapeutic outcomes were performed. Results Of 116 SOT recipient treated for CMV, 14 patients (12.1% of cases; 0.65% of all SOT patients) had proven or suspected GCV-R CMV. Eight (50%) developed GCV-R CMV while receiving valganciclovir (valGCV) prophylaxis. The remainder developed late-onset disease, after having completed an average 212 days (range 83–353) of prophylaxis. Resistance was clinically suspected an average of 103 days (range 10–455) after CMV infection was initially identified; 10 patients had confirmed genotypic resistance. Foscarnet therapy was associated with resolution of CMV in 13. Conclusion Suboptimal dosing of valGCV is associated with development of GCV-R CMV. Our observed rate of GCV-R CMV in alemtuzumab-induced patients is similar to rates seen to historical data for other induction agents.

Vaccines are an integral part of routine preventative health care for persons of all ages and play an integral role in protecting individuals against vaccine-preventable diseases. This handbook provides easy-to-understand, practical information on routinely recommended preventative vaccines for persons of all ages. It is written to be an informative, easily accessible, quick resource that addresses common vaccine issues that may be encountered by busy health-care providers in different specialties and at all different levels of training and practice. The “Did you know that” sections at the beginning of each chapter provide interesting facts on vaccines and vaccine preventable diseases. The FAQ section at the end of each chapter provides answers to commonly encountered situations in clinical practice involving vaccines. Exploring the different sections of this handbook will arm the reader with the tools needed to discuss the importance of vaccines and recommend the appropriate vaccines for their patients in order to optimally protect them against vaccine preventable diseases.

Vaccines for travelers visiting countries or regions in which vaccine preventable infectious disease is endemic are discussed. This chapter also discusses vaccination recommendations for health-care workers, animal handlers, veterinarians, and others who are in regular contact with bodily fluids, human waste, live animals, or animal parts. Specific illnesses such as yellow fever, typhoid fever, cholera, and rabies are discussed in detail relating to their geographic sites, clinical courses, incubation periods, transmissibilities, treatments, and vaccine prophylaxes. Typhoid fever history in the US is discussed. The need and usefulness of certified Travel Clinics are emphasized. Each illness has specific FAQs providing useful responses to patient concerns.

Immunization schedules for infants, children, adolescents, and adults help clinicians ensure that they are administering vaccines in a timely and appropriate manner. Specific, current CDC schedules for infants, children, adolescents, and adults are presented Special attention is paid to recommendations and contraindications for the vaccination of pregnant women and women who are trying to conceive. Details for the specific illnesses, their influences on the pregnant woman and the fetus, vaccination recommendations in the pre-pregnancy, various trimesters, and post-partum periods are given. Safety concerns and Frequently Asked Questions are given significant space as patients and their families are appropriately concerned. Health Care Professionals and their staff needs are included in the recommendations.

The natural history, signs and symptoms, prevention, and treatment of common vaccine preventable infectious diseases are introduced. Dosing, immunization schedules, contraindications, precautions, and administration of vaccines are discussed for patients of all ages. Frequently asked question sections at the end of each chapter summarize issues that clinicians commonly encounter in their practices. This chapter details each of the diseases and specific vaccines that are recommended throughout life. The clinical presentations, clinical courses, complications, and post-exposure and pre-exposure managements are detailed. Differences in the disease in childhood and adult ages are noted. International variations of the diseases and vaccine requirements of individual countries are noted. The transmissions, incubation periods of the diseases, natural, and vaccine-induced durations of immunity are discussed. FAQs offer helpful answers to many of the questions that this wide variety of conditions present.

Objective Sacroiliac joint injections are frequently performed procedures in the management of acute and chronic low-back pain, including patients with various immunocompromised states. Infectious complications following these procedures along with other spinal injections are rarely reported, but the true incidence is unknown. The purpose of this report is to highlight the devastating neurologic sequela that can occur, and to discuss potential future management strategies. Case Report We present a patient who developed diskitis, osteomyelitis, spinal epidural abscess, meningitis, and endocarditis from Staphylococcus aureus, all of which developed shortly after a sacroiliac joint injection. The patient was on treatment for hepatitis C virus, and the resulting immunocompromised state likely contributed to the outcome. Conclusions Immunocompromised patients should be identified prior to treatment, and the small possibility of devastating complications should be thoughtfully weighed against the potential benefit of the procedure. Conservative management should be maximized initially, and if a procedure is done, strict asepsis must be maintained. Prophylaxis for S. aureus should be considered for immunocompromised patients undergoing interventional spine procedures.

Virologic suppression was well maintained when HIV patients receiving 3TC/ABC with a boosted protease inhibitor were switched to emtricitabine/tenofovir disoproxil fumarate (FTC/TDF). Subjects randomized to FTC/TDF) had fewer virologic failures; in addition, improvements in lipids and Framingham risk scores were noted, while slight declines in estimated GFR were observed., Background. In the United States, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a preferred nucleoside reverse transcriptase inhibitor (NRTI) backbone with lamivudine/abacavir (3TC/ABC) as a commonly used alternative. For patients infected with human immunodeficiency virus (HIV-1) virologically suppressed on a boosted protease inhibitor (PI) + 3TC/ABC regimen, the merits of switching to FTC/TDF as the NRTI backbone are unknown. Methods. SWIFT was a prospective, randomized, open-label 48-week study to evaluate efficacy and safety of switching to FTC/TDF. Subjects receiving 3TC/ABC + PI + ritonavir (RTV) with HIV-1 RNA < 200 c/mL ≥3 months were randomized to continue 3TC/ABC or switch to FTC/TDF. The primary endpoint was time to loss of virologic response (TLOVR) with noninferiority measured by delta of 12%. Virologic failure (VF) was defined as confirmed rebound or the last HIV-1 RNA measurement on study drug ≥200 c/mL. Results. In total, 311 subjects were treated in this study (155 to PI + RTV + FTC/TDF, 156 to PI + RTV + 3TC/ABC). Baseline characteristics were similar between the arms: 85% male, 28% black, median age, 46 years; and median CD4 532 cells/mm3. By TLOVR through week 48, switching to FTC/TDF was noninferior compared to continued 3TC/ABC (86.4% vs 83.3%, treatment difference 3.0% (95% confidence interval, −5.1% to 11.2%). Fewer subjects on FTC/TDF experienced VF (3 vs 11; P = .034). FTC/TDF showed greater declines in fasting low-density lipoproteins (LDL), total cholesterol (TC), and triglycerides (TG) with significant declines in LDL and TC beginning at week 12 with no TC/HDL ratio change. Switching to FTC/TDF showed improved NCEP thresholds for TC and TG and improved 10-year Framingham TC calculated scores. Decreased epidermal growth factor receptor (eGFR) was observed in both arms with a larger decrease in the FTC/TDF arm. Conclusions. Switching to FTC/TDF from 3TC/ABC maintained virologic suppression, had fewer VFs, improved lipid parameters and Framingham scores but decreased eGFR. ClinicalTrials.gov identifier. NCT00724711.

Objective To investigate the pharmacokinetics, safety/tolerability and antiviral activity of enfuvirtide administered once-daily (QD) versus twice-daily (BID). Design An open-label, randomized, multiple dose, two-period crossover study comparing 180 mg enfuvirtide, two injections QD versus 90 mg enfuvirtide, two injections, BID. Methods Steady-state intensive pharmacokinetic samples were obtained on days 7 and 14. Results Thirty-seven subjects received at least one dose of enfuvirtide. Thirty-three subjects completed both dosing periods. The regimens were bioequivalent based on the ratio of geometric mean area under the curve (AUC)0-tau [112 +/- 6.2 microg x h/ml QD; 115 +/- 6.4 microg x h/ml 2 x BID; QD/BID 0.98; 90% confidence interval (CI) 0.89,1.07]. The maximum observed plasma concentration within a dosing interval (Cmax) was 49% higher for QD (9.5 +/- 2.7 microg/ml) versus BID (6.3 +/- 1.7 microg/ml) and the pre-dose plasma concentration (Ctrough) was 57% lower for QD (1.6 +/- 1.1 microg/ml) versus BID (3.8 +/- 1.3 microg/ml). The LSM decrease in viral load from baseline to day 7 was 1.0 +/- 0.14 log10 (n = 18) for QD and 1.4 +/- 0.2 log10 (n = 17) for BID (LSM difference 0.385; P = 0.07). Linear regression analysis suggested that decline in viral load up to day 7 was associated with Ctrough but not Cmax or AUC. There were no significant differences in adverse events between the two dosing regimens. Conclusions Administration of enfuvirtide 180 mg QD results in bioequivalence compared with 90 mg BID based on AUC with a similar short-term safety profile, but a trend towards a weaker antiretroviral effect. Larger and longer-term studies are needed to determine if 180 mg once daily is an effective dosing alternative for enfuvirtide.

OBJECTIVE To describe 2 instances of breakthrough Candida infection in 2 patients on treatment doses of voriconazole. CASE SUMMARIES A 27-year-old woman with systemic lupus erythematosus was receiving high-dose voriconazole (400 mg twice daily) for central nervous system lesions of unknown origin and developed oral thrush. The patient was receiving concomitant therapy with phenytoin 400 mg/day. The voriconazole dose was increased to 400 mg 3 times daily, and the thrush resolved. A 50-year-old man with HIV infection was receiving enfuvirtide, lamivudine, tenofovir, and efavirenz 600 mg/day, as well as prophylactic trimethoprim/sulfamethoxazole and azithromycin. He was started on voriconazole 200 mg twice daily for pulmonary aspergillosis and developed esophageal candidiasis. The voriconazole dose was increased to 350 mg twice daily, and the thrush eventually resolved. DISCUSSION Both reactions were probable according to the Naranjo probability scale. Significant drug interactions may have played a role in the development of breakthrough infections in these patients, specifically with phenytoin and efavirenz. Voriconazole is metabolized primarily by CYP2C19, as well as CYP2C9 and CYP3A4. Voriconazole is also known to inhibit these enzymes, and the manufacturer reports an extensive list of drugs that interact with voriconazole. CONCLUSIONS Although requiring systematic evaluation, there may be a role for voriconazole serum concentration monitoring to ensure therapeutic efficacy when significant drug interactions are suspected.

Objective: To assess the efficacy of tenofovir disoproxil fumarate (TDF) monotherapy by following the initial rate of decline in plasma viral load, which is a measure of the efficacy of therapy in blocking viral replication. Design: An open-label, single-site study of TDF monotherapy in 10 antiretroviral drug-naive chronically HIV-1-infected individuals. Methods: Antiviral responses were assessed at baseline and during 21 days of monotherapy with TDF by measuring plasma HIV-1 RNA levels. The rate of change in HIV-1 RNA from baseline was determined both by linear regression and by fitting to a published model. Slopes were compared with those previously determined for ritonavir monotherapy. Results: Over 21 days, mean plasma HIV-1 RNA levels in the TDF-treated patients fell 1.5 log10 copies/ml (range, 0.7–2.0). The initial rates of decline in plasma HIV-1 RNA in the 10 TDF-treated patients and in 25 protease inhibitor-naive subjects treated with ritonavir monotherapy were nearly identical. Conclusions: The reduction in plasma HIV-1 RNA with TDF montherapy was comparable with the decline observed in previous studies of protease inhibitor monotherapy. TDF is a potent antiretroviral agent and has comparable inherent antiviral activity with that of ritonavir, a potent protease inhibitor. These data support further study of TDF-based regimens in simplified combinations of antiviral agents as initial treatment for chronic HIV-1 infection.

The drug–drug interaction (DDI) potential between the fixed‐dose combinations of ledipasvir/sofosbuvir 90/400 mg for hepatitis C virus and emtricitabine/rilpivirine/tenofovir alafenamide (TAF) 200/25/25 mg for HIV was evaluated in a randomized, open‐label, single‐center, multiple‐dose, 3‐way, 6‐sequence, crossover Phase 1 study in 42 healthy subjects. Emtricitabine/rilpivirine/TAF had no relevant effect on the pharmacokinetic parameters of maximum concentration [C max] and area under the concentration versus time curve over the dosing interval [AUC tau] for ledipasvir, sofosbuvir, and the metabolites GS‐566500 and GS‐331007. Ledipasvir/sofosbuvir had no effect on the C max and AUC tau for rilpivirine and emtricitabine. The C max and AUC tau of tenofovir, the major metabolite of TAF, were increased by 62% and 75%, respectively. However, the resulting absolute tenofovir exposures were markedly lower than the historical tenofovir exposures following tenofovir disoproxil fumarate (TDF) and, as such, were not considered to be clinically relevant. In contrast, additional adverse effect monitoring is recommended upon coadministration of ledipasvir and TDF due to elevated tenofovir exposures resulting from the DDI. This difference is explained by the fact that TAF 25 mg results in markedly lower (~90%) plasma tenofovir exposure compared to TDF 300 mg. Ledipasvir/sofosbuvir and emtricitabine/rilpivirine/TAF were generally well tolerated when administered alone or in combination. HIV/hepatitis C virus‐coinfected patients can coadminister ledipasvir/sofosbuvir and emtricitabine/rilpivirine/TAF without dosage adjustments.

Legionellae are Gram-negative bacteria which are capable of causing disease, most commonly in the form of pneumonia. We describe a case of native valve endocarditis caused by a Legionella strain which by genotypic (16S rRNA and mip gene sequencing) and phenotypic analyses is unlike previously described strains of Legionella .

Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistantStaphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based sur veillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

A 73-year-old African American female presented to our clinic with painful lower extremity lesions of 2 weeks duration. She was in her usual state of health until 3 months prior to presentation when she reported symptoms of fatigue and weakness. She also noticed an enlarging mass on the left side of her neck. She denied fevers, chills, night sweats or cough. Her symptoms were unresponsive to a course of oral dicloxacillin. The neck mass enlarged over 8 weeks and she was referred to our institution for evaluation. CT scan of the neck showed an enlarged lymph node. Ten days prior to her presentation in dermatology, a fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas. Tissue was sent for routine mycobacterial and fungal cultures. Routine blood work, chest radiograph, and a tuberculin skin test were also performed. At the time of her dermatology visit she described the development of multiple new painful, non-pruritic lesions, bilaterally on the lower extremities. She also reported a red crusted area that appeared at the site of her tuberculin test that was placed subsequent to the development of her lower extremity lesions. Her past medical history was significant for Parkinson's disease, hypothyroidism and hypertension. Her current medications included l-thyroxine, estrogen and diltiazem. Her travel history was only remarkable for a trip to Jamaica the previous spring. She was born and raised in Haiti. She reported a history of a positive tuberculin skin test 20 years ago, but received no therapy. Physical examination revealed a 2 x 3 centimeter firm, nontender left lateral neck mass (Fig. 1). Her right forearm revealed an erythematous, ulcerated, indurated plaque 1.5 cm in diameter (Fig. 2.). Her lower extremities revealed tender 0.5 to 1 cm erythematous nodules below the knees bilaterally (Fig. 3). A punch biopsy of a lower extremity nodule revealed a mild pervisacular dermal infiltrate. Within the subcutaneous tissue there was septal widening. There was also a lymphohistiocytic infiltrate with a slight admixture of neutrophils within the septa of the fat lobules. There was no evidence of necrotizing vasculitis or collagen necrosis. An acid-fast stain was not performed. The histologic findings were consistent with a diagnosis of erythema nodosum. Her laboratory evaluation including CBC, electrolytes, thyroid studies, angiotensin converting enzyme level and chest radiograph were normal. Approximately 1 week after her dermatological evaluation, the fine-needle aspirate culture grew Mycobacterium tuberculosis. A diagnosis of tuberculous lymphadenitis associated with erythema nodosum was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol and pyrazinamide. Her lower limb skins lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.

Conflicting data exist regarding the effect of pregnancy on steady-state nevirapine pharmacokinetics (PK), although steady-state nevirapine concentrations during pregnancy have never been characterized in sub-Saharan Africa.This was a longitudinal intensive PK study in Ugandan pregnant women receiving nevirapine-based antiretroviral therapy. Participants underwent intensive 12-hour PK sampling during the second trimester (T2; n = 4), third trimester (T3; n = 15) and 6 weeks postpartum (PP; n = 15). HIV-1 RNA was performed within 2 weeks of each visit. Nevirapine C12 above 3000 ng/mL was classified as optimal based on the suggested value for therapeutic drug monitoring.The pharmacokinetics of nevirapine were influenced by pregnancy, demonstrated by a 20% reduction in the maximum concentration, minimum concentration (C12), and area under the curve between T3 and PP visits (P = 0.001, P = 0.011 and P = 0.005, respectively). Ten subjects (66.7%) had C12 values3000 ng/mL during T3. Of these participants, 7 partcipant's C12 concentrations increased to3000 ng/mL during the PP visit. HIV-1 RNA were1000 copies per milliliter at T3 and400 copies per milliliter at PP in all patients.Nevirapine exposure was reduced in Ugandan women during their third trimester compared with the same women PP, however, HIV RNA remained1000 copies per milliliter. The long-term impact of intermittent suboptimal nevirapine concentrations during pregnancy is unknown.

Xenotropic murine leukemia virus-related virus has been detected in blood cells of patients with chronic fatigue syndrome and in 3.7% of healthy controls from the same geographic region. We evaluated 996 men who were participants in the Multicenter AIDS Cohort Study for xenotropic murine leukemia virus-related virus sequences in blood cells by means of a real-time quantitative PCR assay. Xenotropic murine leukemia virus-related virus was detected in none of the men on the basis of the absence of xenotropic murine leukemia virus-related virus DNA, suggesting that infection may be population-specific.

Objectives: To evaluate a potential pharmacodynamic/pharmacokinetic interaction between abacavir (ABC) and tenofovir disoproxil fumarate (TDF). Design and methods: This randomized trial compared 7 days of ABC or TDF monotherapy, separated by a 35-day washout, with 7 days of ABC + TDF dual-therapy in treatment-naive, HIV-1-infected patients. During each 7-day course, the slope of the phase I viral decay was estimated and steady-state intracellular concentrations of carbovir triphosphate (CBV-TP), deoxyguanosine triphosphate (dGTP), tenofovir diphosphate (TFV-DP) and deoxyadenosine triphosphate (dATP) were determined. Results: Twenty-one participants were randomized to initial monotherapy with ABC (n = 11) or TDF (n = 10). The addition of TDF did not increase the slope of viral decay compared to ABC alone (-0.15 log 10 per day vs. -0.16 log 10 per day, respectively). No decrease in CBV-TP or TFV-DP between monotherapy and dual-therapy was observed. However, intracellular dATP concentrations increased between monotherapy and dual-therapy [median dATP (fmol/10 6 cells) 3293 vs. 4638; P=0.08], although this difference was significant only among patients randomized to TDF [median dATP (fmol/ 10 6 cells) 3238 vs. 4534; P= 0.047]. A lower TFV-DP-to-dATP ratio was associated with reduced viral decay during dual-therapy (p=-0.5 29 ; P=0.04 5 ). Conclusion: In this study, the viral decay during ABC and TDF dual-therapy was similar to that during ABC therapy alone, suggesting a nonadditive antiviral effect. This negative pharmacodynamic interaction was not explained by changes in CBV-TP or TFV-DP concentrations. Rather, modest increases in endogenous dATP pools were associated with reduced antiviral potency of TDF during co-administration with ABC.

The pharmacokinetics of perioperative systemic antibiotics and the microbiological effectiveness of oral nonabsorbable antibiotics started immediately prior to surgery were studied in 18 adult patients undergoing liver transplantation. All patients received cefotaxime, 2 g intravenously, at 6-h intervals during surgery and then at 8-h intervals thereafter for 48 h; eight patients also received ampicillin at the same dose and schedule. This regimen produced levels of antibiotics in blood that appeared appropriate for prophylaxis. The first dose peak (68 +/- 18 micrograms/ml) and trough (6.9 +/- 4.7 micrograms/ml) levels of cefotaxime in serum and the first dose peak (73 +/- 22 micrograms/ml) and trough (4.1 +/- 2.3 micrograms/ml) levels of ampicillin in serum, which were assayed by high-performance liquid chromatography, were similar to levels reported in normal volunteers, despite mean intraoperative blood loss of 3.3 liters and fluid replacement of 21 liters. On postoperative days 1 and 2, the levels of cefotaxime and ampicillin were maintained at or above 0.9 and 1.3 micrograms/ml, respectively, with little accumulation. By random assignment, 8 patients received systemic antibiotics alone and 10 patients received systemic antibiotics plus a 3-week regimen of oral nonabsorbable antibiotics (gentamicin, polymyxin E, and nystatin) beginning when a donor liver was procured. Pre- and postoperative cultures of rectum, throat, and gastric aspirate samples showed persistence of aerobic gram-negative bacilli for the first 2 postoperative weeks in about half of the patients in each group. Failure of the regimen of oral nonabsorbable antibiotics to supplement cefotaxime in eradicating aerobic gram-negative bacilli from stools probably results from impaired peristalsis during and after surgery and warrants earlier initiation of the regimen.

Evaluate the impact of switching from twice-daily zidovudine/lamivudine (AZT/3TC) to once-daily tenofovir DF plus emtricitabine (TDF/FTC) with efavirenz (EFV).Prospective, multicenter, single-arm 24-week trial.Patients on EFV + AZT/3TC foror =8 weeks with HIV-1 RNA400 copies/mL were switched to EFV + TDF/FTC and assessed for safety/tolerability, virologic and immunologic responses, adherence, and quality of life at 4, 12, and 24 weeks.Of 402 patients, 2% discontinued for an adverse event (AE) and 1 patient for virologic failure. At 24 weeks, 87% had HIV RNA400 copies/mL, and 74% versus 71% at baseline had undetectable (HIV RNA50 copies/mL) viral load (ITT; M=F). Treatment-emergent AEs were infrequent (or = 5%) with gastrointestinal complaints being the most common. At 24 weeks compared to baseline, hemoglobin (Hb) increased by a median of 0.6 g/dL (p.001), and a decrease in creatinine clearance of 7.6 mL/min (p.001) was observed. Fasting lipids decreased slightly (p.02) in a subset of patients studied (n = 160). A higher percentage of patients reported being "very satisfied" with treatment and the absence of regimen side effects at 24 weeks versus baseline (p.001). At 24 weeks, 86% of patients tookor = 95% of doses versus 78% at baseline (p = .002).Patients switched to EFV + TDF/FTC maintained virologic suppression and the regimen was well tolerated. Patients reported increased satisfaction with treatment and fewer were bothered by side effects.

We report a case of multiple brain abscesses due to Actinomyces species in a 35-year-old immunocompetent man who presented with a 2-month history of headache, diplopia, fever, and weight loss. Despite receipt of broad-spectrum antibiotics for over a month, he continued to have headaches and diplopia. He subsequently underwent right anterior temporal lobectomy and evacuation of abscesses. The diagnosis was aided by identification of sulfur granule on histopathological examination of cerebral cavitary lesion and Gram-positive filamentous rods seen on tissue-Gram stain.

According to American Cancer Society estimates, leukemias and lymphomas accounted for only 7% of male and 6% of female cancers diagnosed and 8% of cancer deaths; the remaining cancers were solid tumors [1]. Although solid tumors account for the vast majority of cancer in adults, severe infectious complications in these patients are far less common than in patients with hematologic malignancies. For instance, Elting et al. [2] reported that polymicrobial sepsis was 16 times less common per patient admission in patients with solid tumors than patients with acute leukemia. Similarly, Mayo and Wenzel [3] found that nosocomial bloodstream infections were 15 times less likely in solid tumor patients than leukemia patients. Nevertheless, patients with solid tumors complicated by infection are not unusual. We reviewed the last 100 cancer patients seen by our infectious disease inpatient consultation service and the majority (62) had underlying solid tumors (J. P. Flaherty, unpublished observation). Common scenarios included wound infection, pneumonia, intravascular catheter-related sepsis, and fever and neutropenia following intensive chemotherapy.

Infection complicates the treatment of malignancy either as a direct result of the neoplastic process (e.g., postobstructive pneumonia in a patient with lung cancer) or more commonly, as a result of treatment (e.g., Gram-negative sepsis in a neutropenic patient following high-dose chemotherapy). As our understanding of the pathogenesis of infection in cancer patients has grown and the availability of effective antimicrobial therapy has improved, cancer treatment has become more intensive and antimicrobial resistance has kept pace with the development of new antimicrobial agents. The management of infectious complications in oncology patients requires continued vigilance for evidence of infection in susceptible patients, an awareness of trends in emerging antimicrobial resistance, and knowledge of the appropriate place for newer antimicrobial agents.

Clinicians caring for patients with vancomycin-resistant Enterococcus faecium (VREF) infections face severe constraints in the selection of treatment. Quinupristin/dalfopristin (Synercid) is active in vitro against VREF, with a MIC(90) of 1.0 microg/mL. We investigated the clinical efficacy and safety of this agent in a multicenter, prospective, noncomparative, emergency-use study of 396 patients. Patients were included if they had signs and symptoms of active infection, including bacteremia of unknown origin, intra-abdominal infection, and skin and skin-structure infection, with no alternative antibiotic therapy available. The mean duration of treatment was 20 days (range, 4-40 days). The clinical response rate was 68.8% in the evaluable subset, and the overall response rate was 65.6%. The most common adverse events related to quinupristin/dalfopristin were arthralgias and myalgias. Related laboratory abnormalities were rare. In this severely ill patient population, quinupristin/dalfopristin was efficacious and demonstrated an acceptable safety profile in the treatment of VREF infection.

Nosocomial infections complicate the hospital course of 20% or more of intensive care unit (ICU) patients resulting in substantial mortality, prolonged length of stay, and increased utilization of resources (1,2). Is the development of nosocomial infection an inevitable consequence of modern intensive medical care or can traditional infection control practices reduce the risk of hospital-acquired infection? Reports of surprisingly poor compliance with traditional infection control procedures by healthcare workers in ICUs raise questions about the perceived value, and the practicality of these measures. Do handwashing, barrier precautions, and traditional isolation procedures provide enough value in reducing infection risk to warrant more strenuous efforts to improve compliance or do we need to develop new methods of infection control? In this chapter we review the value of these and other common control measures.

Suggested citation for this article: Reddy P, Flaherty JP. Plasmodium vivax malaria relapses after primaquine prophylaxis [letter]. Emerg Infect Dis [serial on the Internet]. 2006 Nov [date cited]. http://dx.doi.org/10.3201/eid1211.060613

ostensibly due to improved diagnostic imaging, but in a contemporaneous series the proportion was 24%. In our hospital neoplasia, in particular lymphoma, remains an important cause of FUO. The role of certain individual diseases has changed considerably. For example, rheumatic fever and systemic lupus erythematosus (SLE) were common in early series but are unusual today, probably because of the sharp decline in rheumatic fever in the developed world and the wide availability of accurate tests for SLE that permit early diagnosis. Infective endocarditis has decreased in frequency since the 1950s as blood culture techniques have improved, but new pathogens that are difficult to isolate (eg, Bartonella quintana) ensure that it will not disappear as a cause of FUO. A few diagnoses in recent series were unknown four decades ago, including Lyme disease, acute HIV infection, Sweet’s syndrome, and Bartonella endocarditis. Early series also failed to report drug fever as a cause of FUO.

To investigate an outbreak of gram-negative bacteremia in an outpatient hemodialysis unit and to identify the source of contaminating bacteria and the route by which bacteria gained access to the bloodstream.A matched-pair, case-control study and a bacteriologic investigation of the hemodialysis unit and the implicated dialyzers.A university outpatient hemodialysis unit.Eleven patients receiving long-term hemodialysis who had a total of 12 episodes of primary gram-negative bacteremia and 12 matched controls.Clinical and demographic data were obtained for patients and controls. Dialysis unit procedures were observed for compliance with aseptic technique. Cultures of potential environmental sources of bacteria were obtained. Hemodialyzers from bacteremic and nonbacteremic patients were dismantled, and the component parts were cultured. Inoculation of O-rings (from Hemoflow F-80 dialyzer) with bacteria and simulated dialysis were done.During January to October 1988, 12 episodes of primary gram-negative bacteremia caused by Pseudomonas cepacia, Xanthomonas maltophilia, Citrobacter freundii, Acinetobacter calcoaceticus var. anitratus, or Enterobacter cloacae occurred in 11 patients. In 11 episodes, symptoms developed within 3 hours of starting hemodialysis. Intravenous antibiotics were administered for 11 episodes, 3 episodes resulted in hospitalization, and all patients recovered. Case patients were more likely to have received high-flux dialysis with Hemoflow F-80 dialyzers (odds ratio congruent to 11) than were controls. O-rings from dialyzers used by bacteremic patients were culture positive for the organism responsible for bacteremia. Three of the four dialyzers were disinfected using the standard automated method and were recultured 72 hours later; the O-rings of all three dialyzers remained culture positive. Simulated dialysis using dialyzers with contaminated O-rings caused blood pathway contamination despite intervening reprocessing. When the disinfection method for F-80 dialyzers included removal and complete disinfection of the O-rings, O-ring and blood pathway cultures were consistently negative. After this procedure was made routine, no episodes of primary gram-negative bacteremia occurred during the next 6 months.Because dialyzers with removable headers and O-rings are widely used in patients receiving long-term hemodialysis, disinfection procedures should include measures to ensure adequate disinfection of O-rings.

The optimal management of the febrile neutropenic patient continues to be controversial (Pizzo and Meyers 1989). There are numerous factors which must be taken into account when making recommendations for empiric therapy (Talcott et al. 1988; Pizzo et al. 1984). These factors include the age of the patient and the underlying diagnosis, the type of induction regimen used to treat the underlying disease, the presence of concomitant illnesses (i.e., renal/cardiac/hepatic), the expected duration of neutropenia, the nature and duration of prior infectious episodes, the clinical clues which exist to suggest a source for the neutropenic fever, and the expected organisms and their resistance patterns within that particular hospital. Clearly, if prospective clinical trials of antibiotic regimens are available, patients should be entered into such trials (Table 1).

Bacillus species are increasingly recognized as agents of infection in humans. These organisms are ubiquitous in nature and can cause clinical illness ranging from transient bacteremia to serious systemic infection. We describe a pregnant intravenous drug abuser with fever, constitutional symptoms, and premature labor. Her blood cultures yielded gram-positive bacilli, and her clinical course was consistent with systemic listeriosis of pregnancy. Pathological examination of the placenta revealed acute villitis, and Bacillus species grew from cultures of both placenta and blood. Through biochemical testing the isolate was identified as Bacillus pumilis. To our knowledge, this is the first reported case of premature labor induced by Bacillus species infection.

A case of septic endarteritis that occurred in the femoral artery following percutaneous transluminal coronary angioplasty (PTCA) is reported, and nine previously reported cases of this complication are reviewed. In each case Staphylococcus aureus was identified as the pathogen. For all cases in which a complete clinical description was available, endarteritis occurred following repeated PTCA or repuncture PTCA (i.e., a second catheterization at the original site of insertion for diagnostic purposes). The characteristic manifestations of endarteritis in this setting included bacteremia (all 10 cases), the formation of a pseudoaneurysm (six), distal emboli (five), and regional septic arthritis or osteomyelitis (five of six cases that included the information needed to determine the presence of these conditions). In each case, treatment included 4-6 weeks of iv antibiotics and surgery, most frequently resection of the pseudoaneurysm and vascular bypass. We recommend surveillance for the signs of endarteritis, especially after repeated catheterization, and use of the contralateral site when repeated catheterization is indicated. When the ipsilateral site is used, the administration of prophylactic antibiotics should be considered.

Selective decontamination of the oropharynx and gastrointestinal tract with nonabsorbable antimicrobials and sucralfate, a stress ulcer prophylactic that maintains the normal gastric acid bacterial barrier, were compared for prevention of pneumonia in a cardiac surgery intensive care unit. Over 8 months, 51 patients received selective decontamination and 56 received sucralfate. The selective decontamination regimen included polymyxin, gentamicin, and nystatin given as an oral paste and as a solution; patients also received standard antacid or histamine2 blocker stress ulcer prophylaxis. Patients in the selective decontamination group had significantly less colonization of the oropharynx and stomach by gram-negative bacilli (12% vs. 55%, P less than .001), significantly fewer infections due to gram-negative bacilli (6% vs. 20%, P = .02), and fewer infections overall (12% vs. 27%, P = .04). There was one episode of pneumonia in the selective decontamination group and five in the sucralfate group. Mortality and length of stay did not differ between the groups, but those receiving selective decontamination had less than one-third as many days of systemic antibiotic therapy with no increase in colonization or infection with resistant gram-negative bacilli. Thus, selective decontamination appeared to reduce both extrapulmonary and pulmonary infections.