Neuroinvasive St. Louis Encephalitis Virus Infection in Solid Organ Transplant Recipients.

In summer 2015, three unrelated solid organ transplant recipients in Phoenix, Arizona, had meningoencephalitis suggestive of West Nile virus (WNV) infection. Testing was inconclusive but was later confirmed as St. Louis encephalitis (SLE). We retrospectively reviewed clinical manifestations, treatment, and outcomes of these transplant recipients. Common symptoms were fever, rigors, diarrhea, headache, and confusion. One patient died 3 days after hospitalization. Therapy for the other two patients was initiated with interferon α-2b (IFN) and intravenous IgG (IVIG; IFN plus IVIG in combination). Both patients tested positive for WNV by serologic assay, but SLE virus (SLEV) infection was later confirmed by plaque reduction neutralization test at a reference laboratory. Clinical improvement was observed within 72 h after initiation of IFN plus IVIG. SLEV has been an uncommon cause of neuroinvasive disease in the United States. Accurate, timely diagnosis is hindered because of clinical presentation similar to neuroinvasive WNV and SLE, serologic cross-reactivity, and lack of a commercially available serologic assay for SLEV. There is currently no approved therapy for flaviviral neuroinvasive disease. Anecdotal reports indicate varying success with IFN, IVIG, or IFN plus IVIG in WNV neuroinvasive disease. The same regimen might be of value for immunocompromised persons with neuroinvasive SLEV infection.

Successful colonoscopic fecal transplant for severe acute Clostridium difficile pseudomembranous colitis.

Clostridium difficile-associated diarrhea has become one of the most common healthcare-associated infections, with significant morbidity and mortality, especially among the elderly in the inpatient setting. The standard approach with metronidazole and vancomycin is not very effective in treating patients with severe colitis and hence other alternatives have been explored. We herein describe the first successful experience of colonoscopic fecal transplant in a case of severe refractory C. difficile pseudomembranous colitis.

Risk factors for urinary lithotripsy-associated sepsis.

OBJECTIVES: To identify risk factors for sepsis following urinary extracorporeal shock wave lithotripsy (ESWL). DESIGN: Retrospective case-control study with two control groups. SETTING: A rural, 570-bed, regional referral center. RESULTS: Six cases (four bacteremias and two fungemias) were compared with two sets of 18 controls. Cases had a higher frequency and number of urinary tract infections prior to the procedure and tended to have larger stone size. CONCLUSIONS: Patients undergoing ESWL who are at high risk for infectious complications may be identified by preprocedure evaluation. Such patients may require alternative prophylactic regimens and close postprocedure follow-up.

Do protective devices prevent needlestick injuries among health care workers?

OBJECTIVES: To determine the effectiveness and direct of two protective devices-a shielded 3 ml safety syringe (Safety-Lok; Becton Dickinson and Co., Becton Dickinson Division, Franklin Lakes, N.J.) and the components of a needleless IV system (InterLink; Baxter Healthcare Corp., Deerfield, Ill.)--in preventing needlestick injuries to health care workers. DESIGN: Twelve-month prospective, controlled, before-and-after trial with a standardized questionnaire to monitor needlestick injury rates. SETTING: Six hospital inpatient units, consisting of three medical units, two surgical units (all of which were similar in patient census, acuity, and frequency of needlesticks), and a surgical-trauma intensive care unit, at a 900-bed urban university medical center. PARTICIPANTS: All nursing personnel, including registered nurses, licensed practical nurses, nursing aides, and students, as well as medical teams consisting of an attending physician, resident physician, interns, and medical students on the study units. INTERVENTION: After a 6-month prospective surveillance period, the protective devices were randomly introduced to four of the chosen study units and to the surgical-trauma intensive care unit. RESULTS: Forty-seven needlesticks were reported throughout the entire study period, 33 in the 6 months before and 14 in the 6 months after the introduction of the protective devices. Nursing staff members who were using hollow-bore needles and manipulating intravenous lines accounted for the greatest number of needlestick injuries in the pre-intervention period. The overall rate of needlestick injury was reduced by 61%, from 0.785 to 0.303 needlestick injuries per 1000 health care worker-days after the introduction of the protective devices (relative risk = 1.958; 95% confidence interval, 1.012 to 3.790; p = 0.046). Needlestick injury rates associated with intravenous line manipulation, procedures with 3 ml syringes, and sharps disposal were reduced by 50%; however, reductions in these subcategories were not statistically significant. No seroconversions to HIV-1 or hepatitis B virus seropositivity occurred among those with needlestick injuries. The direct cost for each needlestick prevented was $789. CONCLUSIONS: Despite an overall reduction in needlestick injury rates, no statistically significant reductions could be directly attributed to the protective devices. These devices are associated with a significant increase in cost compared with conventional devices. Further studies must be concurrently controlled to establish the effectiveness of these devices.

HIV treatment-associated hepatitis.

Combination antiretroviral therapy, as well as a variety of other medications prescribed, places patients with HIV disease at high risk for adverse drug reactions and interactions. Sever hepatitis has been reported with all of the currently available classes of antiretroviral agents. Physicians should be aware of the risk of hepatocellular injury in patients receiving antiretroviral therapy and monitor transaminase levels in those at risk. This article reviews the incidence, clinical features, risk factors, and etiology of drug-induced hepatitis with various combinations used in clinical practice.

Hepatitis C virus and human immunodeficiency virus co-infection in women.

Women account for almost one of four newly diagnosed cases of the human immunodeficiency virus (HIV) infection in the United States. It is believed that up to 20% of them are co-infected with hepatitis C virus (HCV). AIDS is now the third leading cause of death in women aged 25 to 44 years in the United States. The ability to better control the HIV infection and improve survival among the co-infected population will make managing chronic liver disease due to hepatitis C the next clinical challenge for these women. This article reviews the available data and summarizes the primary care approach to the female patient with HCV-HIV co-infection.

The benefits and limitations of needle protectors and needleless intravenous systems.

Needleless and needle protector intravenous systems have taken the place of 80% of needles used in i.v. therapy. Although these new systems are marketed as safe, many have not been widely tested and are not fail-safe. Each of the needleless i.v. systems and needle protector systems has limitations and potential benefit when applied in the appropriate circumstances. The benefits and limitations of these devices in today's healthcare market are discussed.

Bacterial complications of strongyloidiasis: Streptococcus bovis meningitis.

We report the case of a 64-year-old veteran who had Streptococcus bovis meningitis as a result of a long latent Strongyloides infection that became acute when he was treated with prednisone. We reviewed 38 reported cases of serious bacterial infections associated with strongyloidiasis. Patients most frequently had nonspecific gastrointestinal symptoms. Of these 38 patients, 21 (55%) had meningitis, and 28 (73%) had bacteremia that was polymicrobial in 3 cases (8%). Other sites of infection included lung, bone marrow, ascites, mitral valve, and lymph node. Most infections were due to enteric gram-negative bacteria. There is one previously reported case of S bovis meningitis. Thirty-four of the patients (89%) were immunosuppressed; 21 of these (55%) were taking pharmacologic doses of adrenal corticosteroids. Thirty-three of the 38 (87%) patients died. Patients with enteric bacterial infection without an obvious cause should be tested for the presence of strongyloidiasis.

Antibiotics and pancreatitis.

Despite improvements in the general supportive care of patients with acute pancreatitis, the morbidity of infectious complications remains high and bacterial infections account for most deaths. The role of antibiotics in reducing infectious morbidity and mortality has been debated for decades because of a lack of supportive clinical data. Research completed over the past decade has helped to define the microbiology, establish the risk factors, and improve the understanding of the pathogenesis of infectious complications in patients with acute pancreatitis. Patients with acute necrotizing pancreatitis are at the greatest risk of developing an infection with enteric gram-negative or gram-positive bacteria translocated from the bowel lumen into the necrotic pancreatic tissue. The most effective antimicrobial agents are the fluoroquinolones, imipenem-cilastatin, and metronidazole, which achieve adequate penetration into pancreatic juice and necrotic tissue and inhibit the growth of enteric bacteria. Animal and human studies support the use of antibiotics for the prevention of infectious morbidity and mortality in severe acute pancreatitis. Recent clinical trials have assessed the role of both systemic antibiotic prophylaxis and selective bowel decontamination with nonabsorbable oral antimicrobials in high-risk patients with acute necrotizing pancreatitis. This article provides an overview of our current knowledge of pancreatic infections and a critical analysis of studies on the role of antibiotics in this disease.

Urinary tract infections in adults.

Urinary tract infections remain a significant cause of morbidity in all age groups. Recent studies have helped to better define the population groups at risk for these infections, as well as the most cost-effective management strategies. Initially, a urinary tract infection should be categorized as complicated or uncomplicated. Further categorization of the infection by clinical syndrome and by host (i.e., acute cystitis in young women, acute pyelonephritis, catheter-related infection, infection in men, asymptomatic bacteriuria in the elderly) helps the physician determine the appropriate diagnostic and management strategies. Uncomplicated urinary tract infections are caused by a predictable group of susceptible organisms. These infections can be empirically treated without the need for urine cultures. The most effective therapy for an uncomplicated infection is a three-day course of trimethoprim-sulfamethoxazole. Complicated infections are diagnosed by quantitative urine cultures and require a more prolonged course of therapy. Asymptomatic bacteriuria rarely requires treatment and is not associated with increased morbidity in elderly patients.