Efficacy and Safety of Mycophenolate Mofetil and Tacrolimus as Second-line Therapy for Patients With Autoimmune Hepatitis.

BACKGROUND & AIMS: Predniso(lo)ne, alone or in combination with azathioprine, is the standard-of-care (SOC) therapy for autoimmune hepatitis (AIH). However, the SOC therapy is poorly tolerated or does not control disease activity in up to 20% of patients. We assessed the efficacy of mycophenolate mofetil (MMF) and tacrolimus as second-line therapy for patients with AIH. METHODS: We performed a retrospective study of data (from 19 centers in Europe, the United States, Canada, and China) from 201 patients with AIH who received second-line therapy (121 received MMF and 80 received tacrolimus), for a median of 62 months (range, 6-190 mo). Patients were categorized according to their response to SOC. Patients in group 1 (n = 108) had a complete response to the SOC, but were switched to second-line therapy as a result of side effects of predniso(lo)ne or azathioprine, whereas patients in group 2 (n = 93) had not responded to SOC. RESULTS: There was no significant difference in the proportion of patients with a complete response to MMF (69.4%) vs tacrolimus (72.5%) (P = .639). In group 1, MMF and tacrolimus maintained a biochemical remission in 91.9% and 94.1% of patients, respectively (P = .682). Significantly more group 2 patients given tacrolimus compared with MMF had a complete response (56.5% vs 34%, respectively; P = .029) There were similar proportions of liver-related deaths or liver transplantation among patients given MMF (13.2%) vs tacrolimus (10.3%) (log-rank, P = .472). Ten patients receiving MMF (8.3%) and 10 patients receiving tacrolimus (12.5%) developed side effects that required therapy withdrawal. CONCLUSIONS: Long-term therapy with MMF or tacrolimus generally was well tolerated by patients with AIH. The agents were equally effective in previous complete responders who did not tolerate SOC therapy. Tacrolimus led to a complete response in a greater proportion of previous nonresponder patients compared with MMF.

Case report: severe cytomegalovirus primary infection in an immunocompetent adult with disseminated intravascular coagulation treated with valganciclovir.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a very rare complication of disseminated cytomegalovirus (CMV) infection. So far it is mainly described for immunocompromised patients. CASE PRESENTATION: A 49-year-old immunocompetent Caucasian male presented with sudden onset of fever and DIC due to primary CMV infection, which was treated with Valganciclovir. CMV-specific IgG-avidity and epithelial cell-specific neutralisation-capacity developed five weeks after onset of symptoms. We describe the first case of an immunocompetent patient suffering from DIC due to a CMV primary infection successfully treated with Valganciclovir. CONCLUSIONS: Primary CMV infection can occur accompanied with life threatening complications even in immunocompetent patients. Immediate treatment with Valganciclovir should be considered as an early treatment of choice in severe cases since specific neutralisation capacity might need several weeks to develop.

Trimeric autotransporter adhesin-dependent adherence of Bartonella henselae, Bartonella quintana, and Yersinia enterocolitica to matrix components and endothelial cells under static and dynamic flow conditions.

Trimeric autotransporter adhesins (TAAs) are important virulence factors of Gram-negative bacteria responsible for adherence to extracellular matrix (ECM) and host cells. Here, we analyzed three different TAAs (Bartonella adhesin A [BadA] of Bartonella henselae, variably expressed outer membrane proteins [Vomps] of Bartonella quintana, and Yersinia adhesin A [YadA] of Yersinia enterocolitica) for mediating bacterial adherence to ECM and endothelial cells. Using static (cell culture vials) and dynamic (capillary flow chambers) experimental settings, adherence of wild-type bacteria and of the respective TAA-negative strains was analyzed. Under static conditions, ECM adherence of B. henselae, B. quintana, and Y. enterocolitica was strongly dependent on the expression of their particular TAAs. YadA of Y. enterocolitica did not mediate bacterial binding to plasma or cellular fibronectin under either static or dynamic conditions. TAA-dependent host cell adherence appeared more significant under dynamic conditions although the total number of bound bacteria was diminished compared to the number under static conditions. Dynamic models expand the methodology to perform bacterial adherence experiments under more realistic, bloodstream-like conditions and allow dissection of the biological role of TAAs in ECM and host cell adherence under static and dynamic conditions.

Infection Risk in Sterile Operative Procedures.

BACKGROUND: The main objective of hospital hygiene and infection prevention is to protect patients from preventable nosocomial infections. It was recently stated that the proper goal should be for zero infection rates in sterile surgical procedures. In this article, we attempt to determine whether this demand is supported by the available literature. METHODS: We systematically searched the Medline and EMBASE databases for studies published in the last 10 years on the efficacy of infection control measures and carried out a meta-analysis according to the PRISMA tool. We used the following search terms: "aseptic surgery," "intervention," "surgical site infection," "nosocomial infection," "intervention," and "prevention." RESULTS: 2277 articles were retrieved, of which 204 were acquired in full text and analyzed. The quantitative analysis included 7 prospective cohort studies on the reduction of nosocomial infection rates after aseptic surgery. The measures used included training sessions, antibiotic prophylaxis, and operative-site disinfection and cleaning techniques. These interventions succeeded in reducing postoperative wound infections (relative risk (RR] 0.99 [0.98; 1.00]). Subgroup analyses on antibiotic prophylaxis (RR 0.99 [0.98; 1.01]) and noncontrolled trials (RR 0.97 [0.92; 1.02]) revealed small, insignificant effects. CONCLUSION: A multimodal approach with the participation of specialists from various disciplines can further reduce the rate of postoperative infection. A reduction to zero is not realistic and is not supported by available evidence.

[Sometimes a liver can cause you headaches]. / Warum die Leber manchmal Kopfschmerzen bereitet - Fall 4/2014.

HISTORY AND ADMISSION FINDINGS: We report on a 41-year-old patient who was taken over from an outside hospital with headache, fever, polydipsy and profound sweating. INVESTIGATIONS: Blood cultures revealed an infection due to Klebsiella pneumonia. CT exhibited a large liver abscess in segments VI and VII (7,6 x 7,2 x 9,9 cm). DIAGNOSIS, TREATMENT AND COURSE: We started an empiric antibiotic treatment with meropenem, linezolid and fluconazole. After susceptibility testing the antibiotic treatment was adapted to ciprofloxacin and continued for 4 weeks. Furthermore, we placed a CT-guided drainage of the abscess. In follow-up visits, his lab values normalized and the size of the abscess decreased. CONCLUSIONS: A pyogenic liver abscess is a rare but severe inflammatory disease. The etiology is often unclear. Depending on localisation a conservative, a surgical or a treatment with a targeted drainage is necessary. However, an isolation of the pathogen for antibiotic testing should be achieved and long term antibiotic treatment should be performed.