RESUMO
BACKGROUND: We report a case of prosthetic hip joint infection in a heart transplant recipient due to Anaerobiospirillum succiniciproducens, a genus of spiral-shaped curved anaerobic gram-negative rod which colonizes the gastrointestinal tract of cats and dogs. Invasive infections in humans are rare and typically occur in immunocompromised hosts. CASE PRESENTATION: A 65-year-old male dog breeder with a history of rheumatoid arthritis, bilateral hip arthroplasties, and non-ischemic cardiomyopathy with a heart transplant 10 years ago presented with a three month history of progressive left hip pain and frank purulence on hip aspiration. He underwent irrigation and debridement of the left hip and one-stage revision with hardware exchange. Although gram stain and culture from synovial fluid and intraoperative cultures were initially negative, anaerobic cultures from tissue specimens later grew a spiral-shaped gram-negative rod, identified as Anaerobiospirillum spp. by 16S rRNA gene sequencing. The patient was treated with ceftriaxone 2 g daily for 6 weeks with a good response to treatment. A similar organism was unable to be isolated from culture of 2 of the patient's dogs, however, they were thought to be the most likely source of his infection. CONCLUSION: Anaerobiospirillum spp. should be considered in immunocompromised patients with exposure to dogs or cats who present with bacteremia, gastrointestinal infection, pyomyositis, or prosthetic joint infections, especially in cases of culture-negative or with anaerobic culture growth.
Assuntos
Anaerobiospirillum/isolamento & purificação , Microbioma Gastrointestinal , Infecções por Bactérias Gram-Negativas/microbiologia , Hospedeiro Imunocomprometido , Infecções Relacionadas à Prótese/microbiologia , Idoso , Anaerobiospirillum/imunologia , Animais , Cães , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Infecções por Bactérias Gram-Negativas/imunologia , Infecções por Bactérias Gram-Negativas/transmissão , Transplante de Coração/efeitos adversos , Humanos , Imunossupressores/efeitos adversos , Masculino , Infecções Relacionadas à Prótese/imunologia , Infecções Relacionadas à Prótese/transmissãoRESUMO
Pneumonia remains one of the major disease entities practicing physicians must manage. It is a leading cause of infection-related morbidity and mortality in all age groups, and a leading cause of death in those older than 65 years of age. Despite its frequency and importance, clinical questions have remained in the therapy of community-acquired pneumonia including when to start antibiotics, when to stop them, who to treat, and what agents to use. Answers to these questions have involved historical practice, mythology, and science-sometimes good science, and sometimes better science. How clinical decisions are made for patients with community-acquired pneumonia serves as an illustrative model for other problem areas of medicine and allows for insight as to how clinical decisions have been made and clinical practice established.
Assuntos
Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/história , Pneumonia Bacteriana/diagnóstico , Pneumonia Bacteriana/história , Antibacterianos/uso terapêutico , Biomarcadores , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/terapia , Surtos de Doenças , História do Século XXI , Humanos , Pneumonia Bacteriana/epidemiologia , Pneumonia Bacteriana/terapiaRESUMO
OBJECTIVE/BACKGROUND: Cytomegalovirus (CMV) reactivation remains a serious complication after allogeneic hematopoietic cell transplantation (HCT) occurring in approximately 60-70% of CMV-seropositive HCT recipients. CMV reactivation leads to adverse outcomes including end-organ damage, graft-versus-host disease, and graft failure. METHODS: Ganciclovir was administered pretransplant at 5 mg/kg twice daily intravenously from the start of conditioning to Day T-2 to CMV-seropositive patients receiving their first allogeneic HCT. CMV DNA was monitored weekly until at least Day 100 posttransplant. RESULTS: A total of 109 consecutive patients were treated, median age 57 (range 20-73) years. Of these, 36 (33%) patients had a CMV reactivation within the first 105 days posttransplant with a median time of reactivation of 52.5 (range 36-104) days posttransplant. The cumulative incidence of CMV reactivation at Day 105 posttransplant was 33.1% (95% confidence interval: 24.4-42.0). One patient developed CMV disease. CONCLUSION: The use of pretransplant ganciclovir was associated with low incidence of CMV reactivation and disease. These data suggest that pretransplant ganciclovir with preemptive therapy for viral reactivation may be a useful strategy to reduce CMV reactivation. Future prospective trials are needed to compare strategies for CMV prophylaxis.
Assuntos
Infecções por Citomegalovirus , Doença Enxerto-Hospedeiro , Transplante de Células-Tronco Hematopoéticas , Humanos , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Ganciclovir/uso terapêutico , Citomegalovirus , Infecções por Citomegalovirus/etiologia , Infecções por Citomegalovirus/prevenção & controle , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Doença Enxerto-Hospedeiro/etiologiaRESUMO
BACKGROUND: Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process. OBJECTIVE: To characterize resident sign-out process and identify effective strategies for quality improvement. DESIGN: Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. PARTICIPANTS: Internal medicine residents (n = 89). INTERVENTIONS: An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies. MAIN MEASURES: Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach. KEY RESULTS: The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication. CONCLUSIONS: Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.
Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Eficiência Organizacional , Medicina Interna/educação , Internato e Residência/organização & administração , Modelos Organizacionais , Planejamento de Assistência ao Paciente/organização & administração , Avaliação de Processos em Cuidados de Saúde/normas , Adulto , Idoso , Coleta de Dados , Feminino , Humanos , Masculino , Sistemas Computadorizados de Registros Médicos , Pessoa de Meia-Idade , Estudos Prospectivos , VirginiaRESUMO
BACKGROUND: Invasive aspergillosis is an important cause of morbidity and mortality in immunocompromised patients. Current treatments provide limited benefit. Posaconazole is an extended-spectrum triazole with in vitro and in vivo activity against Aspergillus species. METHODS: We investigated the efficacy and safety of posaconazole oral suspension (800 mg/day in divided doses) as monotherapy in an open-label, multicenter study in patients with invasive aspergillosis and other mycoses who were refractory to or intolerant of conventional antifungal therapy. Data from external control cases were collected retrospectively to provide a comparative reference group. RESULTS: Cases of aspergillosis deemed evaluable by a blinded data review committee included 107 posaconazole recipients and 86 control subjects (modified intent-to-treat population). The populations were similar and balanced with regard to prespecified demographic and disease variables. The overall success rate (i.e., the data review committee-assessed global response at the end of treatment) was 42% for posaconazole recipients and 26% for control subjects (odds ratio, 4.06; 95% confidence interval, 1.50-11.04; P=.006). The differences in response between the modified intent-to-treat treatment groups were preserved across additional, prespecified subsets, including infection site (pulmonary or disseminated), hematological malignancy, hematopoietic stem cell transplantation, baseline neutropenia, and reason for enrollment (patient was refractory to or intolerant of previous antifungal therapy). An exposure-response relationship was suggested by pharmacokinetic analyses. CONCLUSIONS: Although the study predates extensive use of echinocandins and voriconazole, these findings demonstrate that posaconazole is an alternative to salvage therapy for patients with invasive aspergillosis who are refractory to or intolerant of previous antifungal therapy.
Assuntos
Antifúngicos/uso terapêutico , Aspergilose/tratamento farmacológico , Terapia de Salvação , Triazóis/uso terapêutico , Antifúngicos/administração & dosagem , Antifúngicos/farmacocinética , Aspergilose/microbiologia , Aspergillus/classificação , Aspergillus/isolamento & purificação , Humanos , Modelos Logísticos , Resultado do Tratamento , Triazóis/administração & dosagem , Triazóis/farmacocinéticaRESUMO
BACKGROUND: Patients with persistent fever and neutropenia often receive empirical therapy with conventional or liposomal amphotericin B for the prevention and early treatment of invasive fungal infections. Caspofungin, a member of the new echinocandin class of compounds, may be an effective alternative that is better tolerated than amphotericin B. METHODS: In this randomized, double-blind, multinational trial, we assessed the efficacy and safety of caspofungin as compared with liposomal amphotericin B as empirical antifungal therapy. At study entry, patients were stratified according to risk and according to whether they had previously received antifungal prophylaxis. A successful outcome was defined as the fulfillment of all components of a five-part composite end point. RESULTS: Efficacy was evaluated in 1095 patients (556 receiving caspofungin and 539 receiving liposomal amphotericin B). After adjustment for strata, the overall success rates were 33.9 percent for caspofungin and 33.7 percent for liposomal amphotericin B (95.2 percent confidence interval for the difference, -5.6 to 6.0 percent), fulfilling statistical criteria for the noninferiority of caspofungin. Among patients with baseline fungal infections, a higher proportion of those treated with caspofungin had a successful outcome (51.9 percent vs. 25.9 percent, P=0.04). The proportion of patients who survived at least seven days after therapy was greater in the caspofungin group (92.6 percent vs. 89.2 percent, P=0.05). Premature study discontinuation occurred less often in the caspofungin group than in the amphotericin B group (10.3 percent vs. 14.5 percent, P=0.03). The rates of breakthrough fungal infections and resolution of fever during neutropenia were similar in the two groups. Fewer patients who received caspofungin sustained a nephrotoxic effect (2.6 percent vs. 11.5 percent, P<0.001), an infusion-related event (35.1 percent vs. 51.6 percent, P<0.001), or a drug-related adverse event or discontinued therapy because of drug-related adverse events. CONCLUSIONS: Caspofungin is as effective as and generally better tolerated than liposomal amphotericin B when given as empirical antifungal therapy in patients with persistent fever and neutropenia.
Assuntos
Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Micoses/tratamento farmacológico , Peptídeos Cíclicos , Peptídeos/uso terapêutico , Adolescente , Adulto , Idoso , Anfotericina B/administração & dosagem , Anfotericina B/efeitos adversos , Antifúngicos/efeitos adversos , Caspofungina , Método Duplo-Cego , Equinocandinas , Feminino , Febre/etiologia , Humanos , Nefropatias/induzido quimicamente , Lipopeptídeos , Lipossomos , Masculino , Pessoa de Meia-Idade , Micoses/etiologia , Micoses/prevenção & controle , Neoplasias/complicações , Neoplasias/mortalidade , Neoplasias/terapia , Neutropenia/etiologia , Peptídeos/efeitos adversos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Patients with neutropenia and persistent fever are often treated empirically with amphotericin B or liposomal amphotericin B to prevent invasive fungal infections. Antifungal triazoles offer a potentially safer and effective alternative. METHODS: In a randomized, international, multicenter trial, we compared voriconazole, a new second-generation triazole, with liposomal amphotericin B for empirical antifungal therapy. RESULTS: A total of 837 patients (415 assigned to voriconazole and 422 to liposomal amphotericin B) were evaluated for success of treatment. The overall success rates were 26.0 percent with voriconazole and 30.6 percent with liposomal amphotericin B (95 percent confidence interval for the difference, -10.6 to 1.6 percentage points); these rates were independent of the administration of antifungal prophylaxis or the use of colony-stimulating factors. There were fewer documented breakthrough fungal infections in patients treated with voriconazole than in those treated with liposomal amphotericin B (8 [1.9 percent] vs. 21 [5.0 percent], P=0.02). The voriconazole group had fewer cases of severe infusion-related reactions (P<0.01) and of nephrotoxicity (P<0.001). The incidence of hepatotoxicity was similar in the two groups. Patients receiving voriconazole had more episodes of transient visual changes than those receiving liposomal amphotericin B (22 percent vs. 1 percent, P<0.001) and more hallucinations (4.3 percent vs. 0.5 percent, P<0.001). Parenteral voriconazole was changed to the oral formulation in 22 percent of the voriconazole group, with a reduction in the mean duration of hospitalization by one day in all patients (P=0.17) but by two days in patients at high risk (P=0.03). CONCLUSIONS: Voriconazole is a suitable alternative to amphotericin B preparations for empirical antifungal therapy in patients with neutropenia and persistent fever.
Assuntos
Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Febre/tratamento farmacológico , Micoses/prevenção & controle , Neutropenia/tratamento farmacológico , Pirimidinas/uso terapêutico , Triazóis/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Antifúngicos/efeitos adversos , Antifúngicos/farmacocinética , Doença Hepática Induzida por Substâncias e Drogas , Criança , Doença Crônica , Feminino , Febre/etiologia , Humanos , Infusões Intravenosas/efeitos adversos , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Neoplasias/terapia , Neutropenia/etiologia , Estudos Prospectivos , Pirimidinas/efeitos adversos , Pirimidinas/farmacocinética , Triazóis/efeitos adversos , Triazóis/farmacocinética , VoriconazolRESUMO
Pneumonia in the elderly remains a major source of morbidity and mortality in an age group that is growing in numbers. It remains unclear whether the propensity of older adults to develop community-acquired pneumonia represents an aging of host defenses, secondary effects of comorbid disease, or both. The signs and symptoms of pneumonia in the elderly are more subtle than in younger populations, which may lead to a delay in diagnosis. Although therapy for community-acquired pneumonia in the elderly is the same as for younger populations, mortality is higher, leading to an important role for prevention.
Assuntos
Pneumonia Bacteriana/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas , Saúde Global , Humanos , Prevalência , Fatores de Risco , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND: Therapy with an aminoglycoside and a beta-lactam remains common empirical therapy for febrile neutropenic patients. Concerns of aminoglycoside-induced ototoxicity and nephrotoxicity have led to studies of alternate regimens. OBJECTIVE: To determine whether ciprofloxacin-piperacillin is equivalent to tobramycin-piperacillin as empirical therapy for neutropenic fever. DESIGN: Randomized, double-blind multicenter trial. SETTING: Seven U.S. university-affiliated hospitals and one private research center. PATIENTS: Febrile (temperature >/= 38 degrees C), neutropenic (neutrophil level < 1 x 10(9) cells/L) hospitalized patients who had leukemia, lymphoma, or solid tumors, or were undergoing bone marrow transplantation. INTERVENTIONS: Patients received piperacillin, 50 mg/kg of body weight intravenously every 4 hours, and ciprofloxacin, 400 mg intravenously every 8 hours, or tobramycin, 2 mg/kg intravenously every 8 hours. MEASUREMENTS: Success was defined as resolution of infection and previously positive cultures without the need to give additional antimicrobial agents. RESULTS: 543 febrile episodes were evaluated, of which 471 were clinically evaluable (234 in the ciprofloxacin-piperacillin group and 237 in the tobramycin-piperacillin group). Success rates in the ciprofloxacin-piperacillin group (63 of 234 febrile episodes) and tobramycin-piperacillin group (52 of 237 episodes) were similar (27% vs. 22%, respectively; difference, 5.0 percentage points [95% CI, -2.3 to 12.8 percentage points]), as was survival (96.2% of patients receiving ciprofloxacin-piperacillin versus 94.1% of patients receiving tobramycin-piperacillin; difference, 2.1 percentage points [CI, -2.2 to 6.4 percentage points]). Additions to the initial antimicrobial regimen were the most common reason for treatment failure in both groups (accounting for 67% of failures in the ciprofloxacin-piperacillin group and 72% in the tobramycin-piperacillin group; difference, 5.0 percentage points [CI, -13.8 to 3.7 percentage points]). Fevers resolved faster in patients receiving ciprofloxacin-piperacillin than in patients receiving tobramycin-piperacillin (mean, 5 vs. 6 days) (P = 0.005). No significant differences in adverse events or toxicity were noted (P = 0.083). CONCLUSION: Ciprofloxacin-piperacillin is as safe and effective as tobramycin-piperacillin for empirical therapy of neutropenic fever.
Assuntos
Ciprofloxacina/uso terapêutico , Quimioterapia Combinada/uso terapêutico , Febre/tratamento farmacológico , Neutropenia/tratamento farmacológico , Piperacilina/uso terapêutico , Tobramicina/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/efeitos adversos , Antibacterianos/uso terapêutico , Anti-Infecciosos/efeitos adversos , Anti-Infecciosos/uso terapêutico , Transplante de Medula Óssea/efeitos adversos , Ciprofloxacina/efeitos adversos , Método Duplo-Cego , Feminino , Febre/etiologia , Humanos , Leucemia/complicações , Linfoma/complicações , Masculino , Pessoa de Meia-Idade , Neutropenia/complicações , Neutropenia/etiologia , Infecções Oportunistas/tratamento farmacológico , Infecções Oportunistas/etiologia , Penicilinas/efeitos adversos , Penicilinas/uso terapêutico , Piperacilina/efeitos adversos , Tobramicina/efeitos adversosRESUMO
Cryptococcus neoformans is an opportunistic yeast present in the environment. Practitioners are familiar with the presentation and management of the most common manifestation of cryptococcal infection, meningoencephalitis, in patients with AIDS or other conditions of immunocompromise. There is less awareness, however, of uncommon presentations where experience rather than evidence guides therapy. We report a case of primary cutaneous cryptococcosis (PCC) in a patient who had been immunosuppressed by chronic high-dose corticosteroid for the treatment of severe asthma. This case highlights the importance of early recognition of aggressive cellulitis that fails standard empiric antibiotic treatment in an immunocompromised patient. It also demonstrates successful treatment of PCC with a multispecialty approach including local debridement and fluconazole monotherapy.
RESUMO
We investigated the clinical characteristics and treatment of patients with a distinctive triad of acute infusion-related reactions (AIRRs) to liposomal amphotericin B (L-AMB) via single-center and multicenter analyses. AIRRs occurred alone or in combination within 1 of 3 symptom complexes: (1) chest pain, dyspnea, and hypoxia; (2) severe abdomen, flank, or leg pain; and (3) flushing and urticaria. The frequency of AIRRs in the single-center analysis increased over time. Most AIRRs (86%) occurred within the first 5 min of infusion. All patients experienced rapid resolution of symptoms after intravenous diphenhydramine was administered. The multicenter analysis demonstrated a mean overall frequency of 20% (range, 0%-100%) of AIRRs among 64 centers. A triad of severe AIRRs to L-AMB may occur in some centers; most of these reactions may be effectively managed by diphenhydramine administration and interruption of L-AMB infusion.
Assuntos
Anfotericina B/efeitos adversos , Antifúngicos/efeitos adversos , Dor Abdominal/etiologia , Adulto , Anfotericina B/administração & dosagem , Antifúngicos/administração & dosagem , Dor no Peito/etiologia , Combinação de Medicamentos , Dispneia/etiologia , Feminino , Rubor/etiologia , Humanos , Hipóxia/etiologia , Lipossomos , Masculino , Fosfatidilcolinas/efeitos adversos , Fosfatidilgliceróis/efeitos adversos , Fatores de RiscoAssuntos
Ética em Pesquisa , Jornais como Assunto/ética , Má Conduta Profissional/ética , Antifúngicos/administração & dosagem , Antifúngicos/efeitos adversos , Caspofungina , Aprovação de Drogas/métodos , Equinocandinas , Comitês de Ética em Pesquisa/ética , Humanos , Lipopeptídeos , Los Angeles , Estudos Multicêntricos como Assunto/ética , Estudos Multicêntricos como Assunto/métodos , Seleção de Pacientes , Peptídeos Cíclicos/administração & dosagem , Peptídeos Cíclicos/efeitos adversos , Pesquisa/normas , Estados UnidosRESUMO
BACKGROUND: Although cystic echinococcus (CE) is a common disorder worldwide, few cases are treated in the United States and other industrialized countries. Migration and tourism have caused an increase in the incidence of this parasitic infection in industrialized countries, and physicians must be familiar with its management. METHODS: We report successful therapy of CE in an immigrant from Afghanistan. RESULTS: The patient presented with a large epigastric mass that was initially misdiagnosed as gastric gastrointestinal stromal tumor. The mass was removed, together with partial gastrectomy, splenectomy, and resection of the left lateral segments of the liver, and diagnosis of CE was made. The patient recovered from surgery, albendazole was started, and at five months follow up, he is recurrence free. CONCLUSIONS: Echinococcus granulosus must be considered in immigrants and travelers presenting with a cystic mass.