Prevention of Nosocomial Infections in Critically Ill Patients With Lactoferrin: A Randomized, Double-Blind, Placebo-Controlled Study.

OBJECTIVE: To obtain preliminary evidence for the efficacy of lactoferrin as a preventative measure for nosocomial infections and inform the conduct of a definitive study. DESIGN: Phase 2, multicenter, randomized, double-blind, placebo-controlled study. SETTING: Medical-surgical ICUs. PATIENTS: Adult, critically ill patients receiving invasive mechanical ventilation. INTERVENTIONS: Randomized, eligible, consenting patients expected to require invasive mechanical ventilation more than 48 hours received lactoferrin both enterally and via an oral swab or a placebo of sterile water for up to 28 days. MEASUREMENTS AND MAIN RESULTS: Of the 214 patients who were randomized, 212 received at least one dose of the intervention and were analyzed (107 lactoferrin and 105 placebo). Protocol adherence was 87.5%. Patients receiving lactoferrin were older (mean [SD], 66.3 [13.5] vs 62.5 [16.2] yr), had a higher Acute Physiology and Chronic Health Evaluation II score (26.8 [7.8] vs 23.5 [7.9]), and need for vasopressors (79% vs 70%). Antibiotic-free days (17.3 [9.0] vs 18.5 [7.1]; p = 0.91) and nosocomial infections (0.3 [0.7] vs 0.4 [0.6] per patient; p = 0.48) did not differ between lactoferrin and placebo groups, respectively. Clinical outcomes for lactoferrin versus placebo were as follows: ICU length of stay (14.5 [18.0] vs 15.0 [37.3] d; p = 0.82), hospital length of stay (25.0 [25.9] vs 28.1 [44.6] d; p = 0.57), hospital mortality (41.1% vs 30.5%; p = 0.11), and 90-day mortality (44.9% vs 32.4%; p = 0.06). Biomarker levels did not differ between the groups. CONCLUSIONS: Lactoferrin did not improve the primary outcome of antibiotic-free days, nor any of the secondary outcomes. Our data do not support the conduct of a larger phase 3 trial.

Fulminating varicella despite prophylactic immune globulin and intravenous acyclovir in a renal transplant recipient: should renal patients be vaccinated against VZV before transplantation?

We describe a case of fulminating varicella despite prophylactic immune globulin and intravenous acyclovir in a renal transplant recipient. This promoted a survey of all 383 adult patients awaiting a renal transplant in Scotland, which showed a low level of Varicella zoster virus (VZV) awareness but a willingness to consider vaccination if non immune. 359/363 serum samples tested were seropositive for VZV antibody giving a susceptibility to VZV of 1.2%. Although data on vaccination in adults with chronic kidney disease are limited, expert opinion is of the view that the benefits of vaccinating immunocompetent seronegative patients before transplantation are likely to outweigh the risks. We believe that adult patients awaiting a transplant in the UK should be tested for their susceptibility to VZV and that early vaccination should be offered to those who are both immunocompetent and seronegative.

The development of amphids and amphidial glands in adult Syngamus trachea (Nematoda: Syngamidae).

Nematode amphids are a pair of lateral cephalic sense organs, each comprising a group of sensory endings terminating in a cuticle-lined pit. In Syngamus trachea, a parasite of birds, each amphid is surrounded by two non-nervous supporting elements, a large gland cell basally and a smaller supporting cell anteriorly. The amphidial glands display high levels of secretory activity from five to six days postinfection. Secretory material is discharged through the lumen of the sense organ onto host tissue. The ultrastructure of amphids and amphidial glands has been investigated in newly moulted, immature and mature adults to trace the development of glandular activity and its effect on amphid-amphidial gland relationships. In newly moulted adults, the glands have very low levels of secretory activity and appear to act only as supporting cells to the amphids. As secretory activity increases, the gland cell membrane surrounding the sensory endings is elaborated into a reticulum which probably forms the secretory surface. In mature adults the amphid pit is swollen and filled with secretion; the sensory endings are relegated to the periphery of the lumen. It is suggested that amphidial glands develop from typical supporting cells, but acquire a new role possibly associated with parasite attachment.