Local Transmission of Zika Virus--Puerto Rico, November 23, 2015-January 28, 2016.

Zika virus, a mosquito-borne flavivirus, spread to the Region of the Americas (Americas) in mid-2015, and appears to be related to congenital microcephaly and Guillain-Barré syndrome (1,2). On February 1, 2016, the World Health Organization (WHO) declared the occurrence of microcephaly cases in association with Zika virus infection to be a Public Health Emergency of International Concern.* On December 31, 2015, Puerto Rico Department of Health (PRDH) reported the first locally acquired (index) case of Zika virus disease in a jurisdiction of the United States in a patient from southeastern Puerto Rico. During November 23, 2015-January 28, 2016, passive and enhanced surveillance for Zika virus disease identified 30 laboratory-confirmed cases. Most (93%) patients resided in eastern Puerto Rico or the San Juan metropolitan area. The most frequently reported signs and symptoms were rash (77%), myalgia (77%), arthralgia (73%), and fever (73%). Three (10%) patients were hospitalized. One case occurred in a patient hospitalized for Guillain-Barré syndrome, and one occurred in a pregnant woman. Because the most common mosquito vector of Zika virus, Aedes aegypti, is present throughout Puerto Rico, Zika virus is expected to continue to spread across the island. The public health response in Puerto Rico is being coordinated by PRDH with assistance from CDC. Clinicians in Puerto Rico should report all cases of microcephaly, Guillain-Barré syndrome, and suspected Zika virus disease to PRDH. Other adverse reproductive outcomes, including fetal demise associated with Zika virus infection, should be reported to PRDH. To avoid infection with Zika virus, residents of and visitors to Puerto Rico, particularly pregnant women, should strictly follow steps to avoid mosquito bites, including wearing pants and long-sleeved shirts, using permethrin-treated clothing and gear, using an Environmental Protection Agency (EPA)-registered insect repellent, and ensuring that windows and doors have intact screens.

Adiposity and Muscle Strength in Men With Prostate Cancer and Cardiovascular Outcomes.

Background: There are limited data on the physical effects of androgen deprivation therapy (ADT) for prostate cancer (PC), and on the relationships of such measures of adiposity and strength to cardiovascular outcomes. Objectives: The primary objective of this study was to evaluate the relationships of measures of adiposity and strength to cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, heart failure, arterial revascularization, peripheral arterial disease, and venous thromboembolism) in patients with PC. A secondary objective was to characterize the relationships between ADT use and 12-month changes in these physical measures. Methods: This international, prospective cohort study included 3,967 patients with PC diagnosed in the prior 12 months or being treated with ADT for the first time. Median follow-up duration was 2.3 years. Results: Participants' mean age was 68.5 years, and 1,731 (43.6%) were exposed to ADT. ADT was associated with a 1.6% increase in weight, a 2.2% increase in waist circumference, a 1.6% increase in hip circumference, a 0.1% increase in waist-to-hip ratio, a 27.4% reduction in handgrip strength, and a 0.1% decrease in gait speed. High waist circumference and low handgrip strength were associated with adverse cardiovascular outcomes. Adjusting for age, education, race, tobacco and alcohol use, physical activity, cardiovascular disease, glomerular filtration rate, and ADT use, waist circumference above the highest quartile (110 cm) and handgrip strength below the lowest quartile (29.5 kg) were associated with higher likelihoods of a future cardiovascular event, with respective HRs of 1.40 (95% CI: 1.03-1.90; P = 0.029) and 1.59 (95% CI: 1.14-2.22; P = 0.006). Conclusions: ADT was associated with increased adiposity and reduced strength over 12-month follow-up. High waist circumference and low baseline strength were associated with future adverse cardiovascular outcomes.

Strongyloides Stercoralis Infection in Hispanic Veterans Living in Puerto Rico: A Tropical Issue or a Global One?

OBJECTIVE: Strongyloidiasis is a parasitic infection classified by the World Health Organization as a neglected tropical disease. Although predominantly asymptomatic, it can become a life-threatening disease in an immunocompromised host. Epidemiologic studies in the Western Hemisphere are scarce, but even more scarce are descriptions of the natural course of this disease. Our objectives were to identify the different manifestations and outcomes of Strongyloides stercoralis infection in the Hispanic veteran population in Puerto Rico. We also discuss the importance of pursuing a timely diagnosis in high-risk patients migrating from or traveling to endemic areas, regardless of their symptomatic status. METHODS: This was a single-center, retrospective record review study involving patients diagnosed with S. stercoralis via serology, stool samples, or organ biopsies, from 2008 through 2014. RESULTS: A total of 270 patients tested positive; 210 (77.8%) were asymptomatic. The mean age at diagnosis was 75.4 years old. Symptomatic patients had pulmonary (n = 25), gastrointestinal (n = 21), and dermatologic (n = 5) symptoms; 9 had multiple symptoms. Five had hyperinfection, mostly after treatment with systemic steroids or preexisting immunosuppression. The most common laboratory abnormality was eosinophilia. Reasons for testing were eosinophilia, asthma, diarrhea, screening for parasites, and unexplained skin rash. CONCLUSION: Our study highlights the importance of being aware of this potentially fatal infection, especially when treating patients traveling from endemic countries. It also highlights the importance of timely screening, diagnosis, and treatment of S. stercoralis infection in order to prevent potentially fatal outcomes, especially when considering immunosuppressive drugs.

Zika virus infection in the Veterans Health Administration (VHA), 2015-2016.

BACKGROUND: Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection. METHODOLOGY: Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed. PRINCIPAL FINDINGS: Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6-244.7), congestive heart failure (OR, 6; CI, 2-18.5), dementia (OR, 3.6; CI, 1.1-11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7-9.2), leukocytosis (OR, 11.8; CI, 4.5-31), thrombocytopenia (OR, 7.8; CI, 3.3-18.6), acute kidney injury (OR, 28.9; CI, 5.8-145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3-133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13-0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9-12.2), cerebrovascular disease (OR 4.9; CI 1.7-14.4), and dementia (OR 2.8; CI 1.2-6.6). CONCLUSION: Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

An unusual presentation of actinomycosis in a young woman, after surgery.

Actinomycosis is an unusual, chronic granulomatous disease. Actinomyces israelli has been found to be related to infectious processes in those patients with affected skin integrity leading to abscess formation, fistulae or mass lesions. Actinomycosis mainly presents in three forms cervicofacial (50%), abdominal (20%) and thoracic (15%). Pelvic cases have been rarely reported and are usually associated with the use of intrauterine devices. We describe a case of a 23 y/o female without history of intrauterine device use, who was admitted with an ovarian cyst following an appendectomy. An ovarian abscess was drained. The pathology showed a granuloma and focal sulfur granules like particles compatible with Actinomyces. This is a case of pelvic Actinomyces, not related to the use of an intrauterine device.

Phenotypic confirmation of extended-spectrum B-lactamases (ESBL) in clinical isolates of Escherichia coli and Klebsiella pneumoniae at the San Juan Veterans Affairs Medical Center.

Extended-spectrum Beta (beta)-lactamases (ESBLs) have emerged as an important mechanism of resistance to B-lactam antibiotics in gram-negative bacteria (GNB). They are enzymes that hydrolyze older B-lactam antibiotics as well as broad-spectrum cephalosporins and monobactams. ESBL producers have been reported in many bacteria but special attention has been paid to the ones in E.coli and Klebsiella spp. Detection of the ESBLs by the clinical laboratory is a special challenge. Surveillance to monitor resistance is important to decide when detection of ESBLs must be started. This study determined the prevalence of ESBL producers in the strains E.coli and K.pneumoniae at the San Juan VA Medical Center, and characterized their phenotypes to evaluate the importance to identify these bacteria as a standard routine procedure in the institution. All E.coli and K.pneumoniae isolated from Jan 1 to Mar 31, 2003 were evaluated according to National Committee for Clinical Laboratory Standards (NCCLS) screening criteria for suspected ESBL producers. Phenotypic confirmation of the ESBL production was performed using the Etest method. A total of 112/253 (44%) E.coli and 72/137 (53%) K.pneumoniae were identified as suspected ESBL producers. Etest was performed in 60% of the E.coli and 57% of the K.pneumoniae suspected to be ESBL producers. The overall ESBL prevalence for E.coli was 25% and in K.pneumoniae was 26%. Most E.coli ESBL-producers were from urine while the K.pneumoniae were from sputum. ESBL-producers were isolated from different sources including pleural and synovial fluids, blood, and skin besides urine and sputum. According to susceptibility results, the most reliable antibiotic in predicting a negative ESBL was cefpodoxime (CPD), and in the strains studied, the ESBL producers were consistently resistant to aztreonam (ATM). A large proportion (95%) of ESBL producing K.pneumoniae were susceptible to cefepime (CEP). Of the ESBL producing E.coli, 24% were susceptible. In the case of E.coli ESBLproducers, Cefepime can be considered as a therapeutic option if susceptibilities are available. Automated identification and sensitivity systems are valid alternatives for routine evaluation of B-lactam resistance but when increased resistance is documented in GNB and/or ESBL prevalence is high, ESBL detection should be performed. All confirmed ESBL producers should be reported resistant to all penicillins, cephalosporins, and aztreonam in spite of having susceptible ranges with routine susceptibility tests. Inappropriate antibiotic selection in infections caused by these organisms is associated with treatment failures, poor clinical outcomes, increased mortality and longer hospital stays.

Potentially serious infections in the aging person: diagnosis, treatment and prevention.

Infections in the elderly patient are a challenge, since the classical signs of infection are absent or ill defined. The present paper describes the presentation, diagnosis, clinical manifestations and treatment for a selected group of potential serious infections including influenza, bacterial pneumonia, urinary tract infections as well as infections caused by multiresistant bacteria, like vacomycin-resistant enterococcus and methicillin resistant S. aureus. We conclude with the need for prevention in the older person with the use of vaccines, specifically the influenza and pneumococcal vaccine as well as the prevention of urinary infections. Influenza is a significant cause of morbidity, whose ill effects can be prevented in many older persons with the use of a vaccine. The use in prophylaxis and treatment of antiviral agents like amantadine, rimatadine, and oseltamivir is presented. Bacterial pneumonia is one of the leading causes of death in the USA among the older persons. The emergence of drug resistant Streptococcus pneumoniae leads to the consideration as empiric therapy the newer fluoroquinolones or the use of third or fourth generation cephalosporis. Of importance is the use of pneumococcal vaccine among people age 60 or above. The frequency of urinary tract infections among the elderly is of primary although in many instances important do not require treatment. When infection of the urinary tract is diagnosed, most authors use a fluoroquinolone as empiric theraphy. The emergence of multiresistant bacteria like methicillin resistant S. aureus and or vancomycin resistant enterococci leads to the need to consider new agents like quinipristin-dalfopristin, linezolid and deptomycin in the management of such patients.

Antibiotics in older adults.

Antibiotics are frequently prescribed in the older person, the dosification needs special care, since the pharmacokinetic parameters changes with aging and the side effects can be different in the older person. The creatinine clearance changes and we must modify the way we prescribe such antibiotics to the elderly, calculating. The variety of antibiotics now available led us to consider this paper in which we have presented the antimicrobial agents that can be considered in the treatment of the older person. We present several groups: the penicillins, cephalosporins, monobactams, carbapenems and betalactamase inhibitors or the great betalactam group. Other trimetroprin-sulfame-thoxazole, the newer macrolides (azithromycin and clarithromycin) as well as the aminoglycosides, vancomycin, clindamycin, metroridazole. The indications and contraindications are presented and reviewed.

Management of urinary tract infections, decubitus ulcer and pneumonia in the aging person.

Infections in the older person are common and a significant cause of morbidity and mortality. Infections of the urinary tract, skin and soft tissue infections including decubitus ulcers, antibiotics associated diarrhea and lower respiratory tract infections are particularly important in the elderly because of their frequency. While most initial antibiotic therapy is empiric, its important before treatment to try to document the etiology for better use of antibiotics. Infections of the urinary tract are frequently and potentially serious in the elderly, they must be separated from asymptomatic bacteriuria that requires no therapy. Upper and lower urinary tract infections are frequently caused by aerobic gram negative bacilli and or enterococci. Most authors prefer the use of fluoroquinolones to manage such infections. The elderly with decubitus ulcer presents a problem in management, since these are frequent polymicrobic infections in which anaerobes play an important role. The initial therapy usually involves the combination of a fluoroquinolone plus an antianaerobic agent like clindamycin. C. difficile diarrhea as frequent in nursing home residents as well as the older person with prior antibiotics. The treatment should be with metronidazole and avoid the use of vancomycin. Pneumonias in the elderly can be acquired in the community, the nursing home or during a hospitalization. The etiologic agents that predominate change from S. pneumoniae and atypicals in those from the community to an increase in gram negative pneumonia. The initial treatment as started by most authors as well as guidelines include the use of a new fluoroquinolone like gatifloxacin alone or in combination with a beta-lactamic agent like ceftriaxone. For those infections acquired in the hospital therapy with third or fourth generation cephalosporins, carbapenems, beta-lactams with betalactamase inhibitors alone or in combination with an aminoglucoside and or vancomycin if MRSA is suspected is accepted therapy.

Hiperinfección por Strongyloides stercoralis en un paciente con infección por virus HTVL-1 / Hiper-infection by Strongyloides stercoralis in a patient with HTLV-1 infection

Strongyloides stercolarisen un nemátodo endémico en países de clima tropical y subtropical, la infección suele manifestarse por síntomas predominantemente digestivos, en los casos de hiperinfestación produce una strongiloidiasis diseminada con sobreinfecciones bacterianas sistémicas que provocan una disfunción multiorgánica. Los factores de riesgo más importantes para que una infección en principio intestinal adquiera características de gravedad son la inmunosupresión así como la infección por HTVL-1. Presentamos un caso de síndrome de hiperinfección por S. stercolaris en un paciente con HTLV-1.

Strongyloides stercolarisis an endemic nematode in tropical and subtropical climates. Infection is predominantly manifested by gastrointestinal symptoms, and in cases of hyper-infestation causes a disseminated strongyloidiasis with a systemic bacterial over infection causing multiple organ dysfunctions with fatal outcome. The most important risk factors for intestinal infection to acquire gravity features include immunosuppression and HTVL-1 infection. The case presented corresponds to S. stercoralis hyperinfection syndrome in a patient with HTVL-1 infection.

Abscesos pulmonares: conceptos actuales y tratamiento / Pulmonary abscess: actual concepts and treatment

La incidencia de abscesos pulmonares ha aumentado en los últimos años. Esto se ha correlacionado al aumento en poblaciones de pacientes alcohólicos e inmunocomprometidos quienes están a mayor riesgo de aspiración debido a alteraciones en el estado de conciencia. Los orgnaismos encontrados más comunmente causando estos abscesos son bacterias anaeróbicas de las vías respiratorias altas acompañados de otras bacterias que son parte de la flora indígena nasofaringeal. El tratamiento actual de estos pacientes es médico, siendo el antibiótico de elección la penicilina o la clindamicina. En circustancias especiales hay que recurir a tratamiento quirúrgico

Norfloxacin in urinary tract infections: cost effectiveness analysis

Norfloxacin es un nuevo antibiótico perteneciente a los quinolonas con un amplio espectro de actividad antimicrobiona. El presente estudio reporta el uso de norfloxacin 400 mg por via oral dos veces al día por una duración promedio de 15 días (8-30 días) en el tratamiento de 25 pacientes con infecciones de tracto urinario, de las cuales 20 tenían infecciones complicadas. Todas las cepas bacterianas recobradas eran susceptibles a norfloxacin a concentraciones de 8 ug/ml o menos. Una semana después de terminar el tratamiento el 86 porciento de las infecciones fueron erradicadas y a 4 semanas de terminar el tratamiento fue solamente el 50 porciento, con un 9 porciento de reinfección y 27 porciento de recaída. El estudio de la efectividad de costo demostró que norfloxacin fue efectivo para infecciones complicadas y severos causadas per cepas multiresistentes, pero no fue efectivo desde el punto de vista de costo para infecciones del tracto urinario causada por los patógenos usuales. Norfloxacin resultó ser seguro y efectivo en el tratamiento de infecciones complicadas del tracto urinario causadas por patogenos susceptibles a norfloxacin

Disseminated histoplasmosis

We have presented the microbiology, pathogenesis, clinical presentation, diagnosis and treatment of disseminated histoplasmosis. Emphasis is presented on the manifestations in the HIV infected patient