High Rate of Acquisition but Short Duration of Carriage of Multidrug-Resistant Enterobacteriaceae After Travel to the Tropics.

BACKGROUND: Multidrug-resistant Enterobacteriaceae (MRE) are widespread in the community, especially in tropical regions. Travelers are at risk of acquiring MRE in these regions, but the precise extent of the problem is not known. METHODS: From February 2012 to April 2013, travelers attending 6 international vaccination centers in the Paris area prior to traveling to tropical regions were asked to provide a fecal sample before and after their trip. Those found to have acquired MRE were asked to send fecal samples 1, 2, 3, 6, and 12 months after their return, or until MRE was no longer detected. The fecal relative abundance of MRE among all Enterobacteriaceae was determined in each carrier. RESULTS: Among 824 participating travelers, 574 provided fecal samples before and after travel and were not MRE carriers before departure. Of these, 292 (50.9%) acquired an average of 1.8 MRE. Three travelers (0.5%) acquired carbapenemase-producing Enterobacteriaceae. The acquisition rate was higher in Asia (142/196 [72.4%]) than in sub-Saharan Africa (93/195 [47.7%]) or Latin America (57/183 [31.1%]). MRE acquisition was associated with the type of travel, diarrhea, and exposure to ß-lactams during the travel. Three months after return, 4.7% of the travelers carried MRE. Carriage lasted longer in travelers returning from Asia and in travelers with a high relative abundance of MRE at return. CONCLUSIONS: MRE acquisition is very frequent among travelers to tropical regions. Travel to these regions should be considered a risk factor of MRE carriage during the first 3 months after return, but not beyond. CLINICAL TRIALS REGISTRATION: NCT01526187.

Update in treatment of Chagas disease.

PURPOSE OF REVIEW: This review discusses the recent data about the pathogenesis of Chagas disease, tolerance of drugs, and follow-up of patients impacting the treatment of Chagas disease in immunocompetent and immunocompromised patients. RECENT FINDINGS: The role of the parasite to promote direct or indirect organ damage in the chronic phase of the disease as well as the usefulness of antiparasitic treatment to slow or prevent the deterioration of cardiac function and the aggravation of Chagasic cardiomyopathy lead to an extension of the indications of treatment. Tolerance is poor for the two drugs, benznidazole and nifurtimox. The rates of adverse events and treatment discontinuation before 60 days are higher with nifurtimox. PCR, and in the near future immunologic tests, might allow assessment of the early success or failure of the antiparasitic treatment. SUMMARY: Assessment of alternative drugs, such as posaconazole, and of new strategies of treatment (combination of two antiparasitic drugs, association of antiparasitic and immunomodulatory drugs, and re-treatment), and follow-up are a global health priority.

A public policy approach to local models of HIV/AIDS control in Brazil.

OBJECTIVES: We investigated involvement and cooperation patterns of local Brazilian AIDS program actors and the consequences of these patterns for program implementation and sustainability. METHODS: We performed a public policy analysis (documentary analysis, direct observation, semistructured interviews of health service and nongovernmental organization [NGO] actors) in 5 towns in 2 states, São Paulo and Pará. RESULTS: Patterns suggested 3 models. In model 1, local government, NGOs, and primary health care services were involved in AIDS programs with satisfactory response to new epidemiological trends but a risk that HIV/AIDS would become low priority. In model 2, mainly because of NGO activism, HIV/AIDS remained an exceptional issue, with limited responses to new epidemiological trends and program sustainability undermined by political instability. In model 3, involvement of public agencies and NGOs was limited, with inadequate response to epidemiological trends and poor mobilization threatening program sustainability. CONCLUSIONS: Within a common national AIDS policy framework, the degree of involvement and cooperation between public and NGO actors deeply impacts population coverage and program sustainability. Specific processes are required to maintain actor mobilization without isolating AIDS programs.

community-acquired infection with healthcare-associated methicillin-resistant Staphylococcus aureus: the role of home nursing care.

OBJECTIVE: To better understand the role of indirect transmission in community-acquired infection with methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Prospective case-control study. SETTING: A French teaching hospital. PATIENTS: A total of 198 case patients and 198 control patients with MRSA or methicillin-susceptible S. aureus infection diagnosed between April 2002 and July 2003. RESULTS: Multivariate analysis showed a highly significant independent link between MRSA infection at admission and prior receipt of home nursing care (odds ratio [OR], 3.7; P<.001). Other independent risk factors were prior hospitalization (OR, 3.8; P<.001), transfer from another institution (OR, 2.3; P=.008), and age older than 65 years (OR, 1.6; P=.04). Prior home nursing care showed a frequency dose-response relationship. Eleven MRSA-infected patients had had home nursing procedures but no hospital stay in the previous 3 years. These patients' MRSA strains were related to the prevalent MRSA clone currently spreading in French hospitals. CONCLUSION: Home nursing care appears to be an independent risk factor for MRSA acquisition in the community. The reservoir probably consists of MRSA carriers discharged from the hospital. Community nurses seem to be a potential vector.

Consequences of HIV infection on malaria and therapeutic implications: a systematic review.

Despite recent changes in the epidemiology of HIV infection and malaria and major improvements in their control, these diseases remain two of the most important infectious diseases and global health priorities. As they have overlapping distribution in tropical areas, particularly sub-Saharan Africa, any of their clinical, diagnostic, and therapeutic interactions might have important effects on patient care and public health policy. The biological basis of these interactions is well established. HIV infection induces cellular depletion and early abnormalities of CD4+ T cells, decreases CD8+ T-cell counts and function (cellular immunity), causes deterioration of specific antigen responses (humoral immunity), and leads to alteration of innate immunity through impairment of cytolytic activity and cytokine production by natural killer cells. Therefore, HIV infection affects the immune response to malaria, particularly premunition in adolescents and adults, and pregnancy-specific immunity, leading to different patterns of disease in HIV-infected patients compared with HIV-uninfected patients. In this systematic review, we collate data on the effects of HIV on malaria and discuss their therapeutic consequences. HIV infection is associated with increased prevalence and severity of clinical malaria and impaired response to antimalarial treatment, depending on age, immunodepression, and previous immunity to malaria. HIV also affects pregnancy-specific immunity to malaria and response to intermittent preventive treatment. Co-trimoxazole (trimethoprim-sulfamethoxazole) prophylaxis and antiretroviral treatment reduce occurrence of clinical malaria; however, these therapies interact with antimalarial drugs, and new therapeutic guidelines are needed for concomitant use.

Chagas disease: changes in knowledge and management.

More than 100 years after the discovery of human American trypanosomiasis by Carlos Chagas, our knowledge and management of the disease are profoundly changing. Substantial progress made by disease control programmes in most endemic areas contrasts with persisting difficulties in the Gran Chaco region in South America and the recent emergence of the disease in non-endemic areas because of population movements. In terms of pathogenesis, major discoveries have been made about the life cycle and genomics of Trypanosoma cruzi, and the role of the parasite itself in the chronic phase of the disease. From a clinical perspective, a growing number of arguments have challenged the notion of an indeterminate phase, and suggest new approaches to manage patients. New methods such as standardised PCR will be necessary to ensure follow-up of this chronic infection. Although drugs for treatment of Chagas disease are limited, poorly tolerated, and not very effective, treatment indications are expanding. The results of the Benznidazole Evaluation For Interrupting Trypanosomiasis (BENEFIT) trial in 2012 will also help to inform treatment. Mobilisation of financial resources to fund research on diagnosis and randomised controlled trials of treatment are international health priorities.

[Chagas disease: clinical aspects and treatment in non-endemic countries]. / Maladie de Chagas: formes cliniques et prise en charge en zone non endémique.

International migration has led to the emergence of Chagas disease in industrialized countries, notably France. Clinicians should consider and test for Chagas disease in several situations: chronic cardiac and digestive manifestations in patients who lived (or whose parents lived) in an endemic area; pregnant woman who come from an endemic area and in the infant if the mother's serologic tests are positive; and more rarely, patients with a persistent fever who recently visited an endemic area. During the acute phase, diagnosis is confirmed by parasitological testing. During the chronic phrase, diagnosis remains serologic. The usefulness of PCR has not been determined. The recent recognition of the parasite's pathogenic role during the chronic phase has enlarged the indications for treatment. Today, all patients younger than 50 years with Chagas disease in the acute, chronic symptomatic or chronic asymptomatic phases should receive treatment, except for pregnant women, patients with hepatic or renal failure, or advanced cardiac or digestive manifestations. Treatment must be considered on an individual basis in patients older than 50 years. The frequency and seriousness of potential adverse events due to treatment require careful monitoring of the patient throughout treatment.