A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults.

BACKGROUND: The incidence and severity of herpes zoster and postherpetic neuralgia increase with age in association with a progressive decline in cell-mediated immunity to varicella-zoster virus (VZV). We tested the hypothesis that vaccination against VZV would decrease the incidence, severity, or both of herpes zoster and postherpetic neuralgia among older adults. METHODS: We enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine ("zoster vaccine"). Herpes zoster was diagnosed according to clinical and laboratory criteria. The pain and discomfort associated with herpes zoster were measured repeatedly for six months. The primary end point was the burden of illness due to herpes zoster, a measure affected by the incidence, severity, and duration of the associated pain and discomfort. The secondary end point was the incidence of postherpetic neuralgia. RESULTS: More than 95 percent of the subjects continued in the study to its completion, with a median of 3.12 years of surveillance for herpes zoster. A total of 957 confirmed cases of herpes zoster (315 among vaccine recipients and 642 among placebo recipients) and 107 cases of postherpetic neuralgia (27 among vaccine recipients and 80 among placebo recipients) were included in the efficacy analysis. The use of the zoster vaccine reduced the burden of illness due to herpes zoster by 61.1 percent (P<0.001), reduced the incidence of postherpetic neuralgia by 66.5 percent (P<0.001), and reduced the incidence of herpes zoster by 51.3 percent (P<0.001). Reactions at the injection site were more frequent among vaccine recipients but were generally mild. CONCLUSIONS: The zoster vaccine markedly reduced morbidity from herpes zoster and postherpetic neuralgia among older adults.

Infection versus colonization in the critical care unit.

Serious infections in the critical care unit are commonplace. However, distinguishing true infection from mere colonization is a difficult and often uncertain process that has been shown to result in both over- and under-treatment of patients. Antimicrobial agents used in the CCU setting are expensive and not without toxicities. This article discusses methods to differentiate colonization from infection.

New perspectives on the management of septic shock in the cancer patient.

Septic shock is a common life-threatening problem, usually presenting with fever, tachycardia, tachypnea, and often a source of infection. The cardiac index is increased, with a decreased systemic vascular resistance, and a reversibly decreased ejection fraction with an increased end diastolic volume. The myocardial depression is most likely caused by a circulating humoral substance that depresses myocardial contractility. The initial treatment of septic shock is aggressive fluid resuscitation and antibiotic therapy, with vasopressors and inotropes being indicated in those patients who do not respond adequately to fluids. Therapy directed against the mediators of septic shock is theoretically promising, but to date has not been successful.

Liver abscess following blunt trauma: a case report and review of the literature.

We report a case of Haemophilus paraphrophilus causing primary liver abscesses after blunt nonpenetrating trauma. A 32-year-old previously healthy white man sustained a back injury 2 months prior to admission with fever, chills, and night sweats. A computed tomography (CT) scan-directed needle aspirate of several hypoechoic hepatic lesions grew H paraphrophilus. Recent blunt trauma to the lower back may have contributed to the localization of this infection to an area of contusion or hematoma within the liver, followed by an episode of bacteremia that seeded the injury.

Pelvicobdominal actinomycosis associated with an intrauterine contraceptive device. A case of liver dissemination mimicking metastatic ovarian cancer.

A rare case of pelvicoabdominal actinomycosis with liver dissemination is reported in a patient with an intrauterine contraceptive device (IUCD) in place for 10 years. Her initial preoperative diagnosis of metastatic ovarian cancer emphasizes the slow indolent destructive nature of actinomycosis mimicking a malignancy. A history of an indwelling IUCD for several years along with a pelvic mass should prompt consideration of actinomycosis as a possible etiology.

Oral ciprofloxacin treatment of infections in geriatric patients.

The efficacy and safety of oral ciprofloxacin (750 mg every 12 hours) in the treatment of infections was evaluated in 84 geriatric patients. Duration of treatment ranged from three to 42 days (for a mean of 10.45 days). Satisfactory responses (cured or improved) were noted in 33 of 34 cases of urinary tract infections (97%); in 11 of 13 cases of lower respiratory tract infections (85%); in four of nine cases of skin and skin structure infections (44%); and in both cases of bone infection and bacteremia. Bacteriological cure rates were 91% of 33 urinary tract infections; 83% of 12 lower respiratory tract infections; 62% of eight skin and skin structure infections; and in both cases of bone infection and bacteremia. Three patients evaluable for clinical purposes were bacteriologically unevaluable. Overall clinical efficacy and bacteriological cure rates were 86% and 85%, respectively. Of the 78 evaluable pathogens isolated, 70 (90%) were eradicated. Adverse reactions occurred in 24 patients (29%) and included candida colonization in eight, gastrointestinal upset in six, dermatologic symptoms in five, and vaginal candidiasis, chest pain, renal failure, tremors, monocytosis, thrombocytosis, and increased serum theophylline level in one patient each. Ciprofloxacin appears to be a safe and effective treatment for infections in geriatric patients. Advantages of the oral form include cost effectiveness and decreased length of hospitalization.

Comparative evaluation of safety and efficacy of cefmetazole and cefoxitin in lower respiratory tract infections.

The efficacy and safety of cefmetazole and cefoxitin were compared in a randomized open-label parallel trial in 68 hospitalized adult patients with lower respiratory tract infections. Of 40 patients evaluable for efficacy, 23/25 (92%) in the cefmetazole group and 13/15 (87%) in the cefoxitin group demonstrated a favourable clinical response. The causative bacteria were eradicated in 30/32 (94%) and 13/14 (93%) of isolates in the cefmetazole and cefoxitin groups, respectively. A total of 51 adverse events was noted in 68 patients: 36 in 26 patients (55%) in the cefmetazole group and 15 in 12 patients (57%) in the cefoxitin group. These events were reversible, and except in one patient who was treated for oral candidiasis, did not require any therapeutic intervention or prolonged hospitalization. Cefmetazole appears to be as safe and effective as cefoxitin in the treatment of lower respiratory tract infections of hospitalized patients.