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1.
Medicine (Baltimore) ; 100(29): e26682, 2021 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-34398037

RESUMO

RATIONALE: Nocardiosis is an uncommon and potentially life-threatening infection that usually affects immunocompromised hosts. No clinical guidelines have been established for managing this rare disease, and the optimal treatment modality remains unclear. Nocardia farcinica, a relatively infrequent pathogen of nocardiosis, causes a clinically aggressive infection. In addition to our patient data, our search of the literature for patients who presented with empyema caused by N. farcinica will provide fundamental information for optimal treatment modalities. PATIENT CONCERNS: A 64-year-old man was diagnosed with empyema, 4 days following surgery for sigmoid colon cancer. Brain lesions were evaluated only after N. farcinica was isolated and identified as the causative pathogen through repeated culture tests. DIAGNOSES: N. farcinica was isolated from the pleural effusion and confirmed as the pathogen through 16S rRNA sequencing. INTERVENTIONS: The patient was successfully treated with tube thoracotomy, neurosurgical evacuation, and a combination of trimethoprim/sulfamethoxazole plus imipenem. Long-term antibiotic therapy was required to prevent recurrence. OUTCOMES: Pyothorax showed a good clinical response to antimicrobial therapy and drainage of pleural effusion, whereas brain abscess did not respond to medical therapy and required surgery. The patient eventually recovered and continued chemotherapy as treatment for sigmoid colon cancer. LESSONS: Although extremely rare, this report demonstrates the importance of considering Nocardia infection as the differential diagnosis in immunocompromised patients who present with empyema. In particular, because of the N. farcinica infection's tendency to spread and the resistance of the organism to antibiotics, aggressive evaluation of metastatic lesions and standardized support from microbiological laboratories are important. Surgery may be required in some patients with brain abscesses to improve the chance of survival.


Assuntos
Adenocarcinoma , Abscesso Encefálico/diagnóstico , Neoplasias do Colo , Empiema/diagnóstico , Nocardiose/diagnóstico , Nocardia/isolamento & purificação , Anti-Infecciosos/uso terapêutico , Abscesso Encefálico/complicações , Abscesso Encefálico/diagnóstico por imagem , Abscesso Encefálico/tratamento farmacológico , Diagnóstico Diferencial , Empiema/complicações , Empiema/diagnóstico por imagem , Empiema/tratamento farmacológico , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , Nocardiose/complicações , Nocardiose/diagnóstico por imagem , Nocardiose/tratamento farmacológico , Tomografia Computadorizada por Raios X , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
2.
BMC Infect Dis ; 21(1): 664, 2021 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-34238239

RESUMO

BACKGROUND: Pneumocystis pneumonia (PCP) is a potentially life-threatening infection. Trimethoprim-sulfamethoxazole (TMP-SMX) is considered as the first regimen for PCP prophylaxis according to several guidelines. The recommended prophylactic dose of TMP-SMX has been determined based on patients with normal renal function, but the appropriate dosage for patients undergoing hemodialysis is unknown. The aim of this study was to investigate the efficacy and safety of low-dose TMP-SMX in patients undergoing hemodialysis. METHODS: HIV-uninfected adult patients who were undergoing hemodialysis and administered TMP-SMX for PCP prophylaxis, were included, and divided into standard-dose (≥6 single strength (SS, TMP-SMX 80 mg/400 mg tablets/week) and low-dose groups (< 6 SS tablets/week). The endpoints were cumulative incidence of PCP and cumulative discontinuation rate of TMP-SMX due to adverse events. For comparison of the groups, we employed the chi-squared test for categorical variables and the Mann-Whitney U test for continuous variables. Risk factors for the endpoints were evaluated using the Cox Fine and Gray method. RESULTS: The median age of the 81 patients included in the study was 67 years (IQR: 60-76 years), and 52 patients (64.2%) were men. No patients in either group developed PCP during the observation period. The yearly cumulative incidence of discontinuation was 12.1% (95% confidence interval [CI]: 0.027-0.29) in the low-dose group and 35.6% (95% CI: 0.20-0.52) in the standard-dose group (P = 0.019). The adjusted hazard ratio of the low-dose group compared to standard-dose group was 0.18 (95% CI: 0.04-0.86, P = 0.032). CONCLUSIONS: None of the study patients developed PCP, and the cumulative discontinuation rate of TMP-SMX due to adverse events was significantly lower in the low-dose group compared to that in the standard-dose group (P = 0.032). These results indicate that low-dose TMP-SMX is an appropriate regimen to maintain a balance between PCP prophylaxis and prevention of adverse events due to TMP-SMX administration. These findings can guide health care professionals to determine TMP-SMX dosage when considering PCP prophylaxis for patients undergoing hemodialysis.


Assuntos
Anti-Infecciosos Urinários/uso terapêutico , Antibioticoprofilaxia , Pneumonia por Pneumocystis/prevenção & controle , Diálise Renal , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Idoso , Relação Dose-Resposta a Droga , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/epidemiologia , Estudos Retrospectivos , Fatores de Risco
3.
Cochrane Database Syst Rev ; 7: CD012997, 2021 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-34219224

RESUMO

BACKGROUND: Haemolytic uraemic syndrome (HUS) is a common cause of acquired kidney failure in children and rarely in adults. The most important risk factor for development of HUS is a gastrointestinal infection by Shiga toxin-producing Escherichia coli (STEC). This review addressed the interventions aimed at secondary prevention of HUS in patients with diarrhoea who were infected with a bacteria that increase the risk of HUS. OBJECTIVES: Our objective was to evaluate evidence regarding secondary preventative strategies for HUS associated with STEC infections. In doing so, we sought to assess the effectiveness and safety of interventions as well as their potential to impact the morbidity and death associated with this condition. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 12 November 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: Studies were considered based on the methods, participants, and research goals. Only randomised controlled trials were considered eligible for inclusion. The participants of the studies were paediatric and adult patients with diarrhoeal illnesses due to STEC. The primary outcome of interest was incidence of HUS. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as recommended by Cochrane. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: We identified four studies (536 participants) for inclusion that investigated four different interventions including antibiotics (trimethoprim-sulfamethoxazole), anti-Shiga toxin antibody-containing bovine colostrum, Shiga toxin binding agent (Synsorb Pk: a silicon dioxide-based agent), and a monoclonal antibody against Shiga toxin (urtoxazumab). The overall risk of bias was unclear for selection, performance and detection bias and low for attrition, reporting and other sources of bias. It was uncertain if trimethoprim-sulfamethoxazole reduced the incidence of HUS compared to no treatment (47 participants: RR 0.57, 95% CI 0.11-2.81, very low certainty evidence). Adverse events relative to this review, need for acute dialysis, neurological complication and death were not reported. There were no incidences of HUS in either the bovine colostrum group or the placebo group. It was uncertain if bovine colostrum caused more adverse events (27 participants: RR 0.92, 95% CI 0.42 to 2.03; very low certainty evidence). The need for acute dialysis, neurological complications or death were not reported. It is uncertain whether Synsorb Pk reduces the incidence of HUS compared to placebo (353 participants: RR 0.93, 95% CI 0.39 to 2.22; very low certainty evidence). Adverse events relevant to this review, need for acute dialysis, neurological complications or death were not reported. One study compared two doses of urtoxazumab (3.0 mg/kg and 1.0 mg/kg) to placebo. It is uncertain if either 3.0 mg/kg urtoxazumab (71 participants: RR 0.34, 95% CI 0.01 to 8.14) or 1.0 mg/kg urtoxazumab (74 participants: RR 0.95, 95% CI 0.79 to 1.13) reduced the incidence of HUS compared to placebo (very low certainty evidence). Low certainty evidence showed there may be little or no difference in the number of treatment-emergent adverse events with either 3.0 mg/kg urtoxazumab (71 participants: RR 1.00, 95% CI 0.84 to 1.18) or 1.0 mg/kg urtoxazumab (74 participants: RR 0.95, 95% CI 0.79 to 1.13) compared to placebo. There were 25 serious adverse events reported in 18 patients: 10 in the placebo group, and 9 and 6 serious adverse events in the 1.0 mg/kg and 3.0 mg/kg urtoxazumab groups, respectively. It is unclear how many patients experienced these adverse events in each group, and how many patients experienced more than one event. It is uncertain if either dose of urtoxazumab increased the risk of neurological complications or death (very low certainty evidence). Need for acute dialysis was not reported. AUTHORS' CONCLUSIONS: The included studies assessed antibiotics, bovine milk, and Shiga toxin inhibitor (Synsorb Pk) and monoclonal antibodies (Urtoxazumab) against Shiga toxin for secondary prevention of HUS in patients with diarrhoea due to STEC. However, no firm conclusions about the efficacy of these interventions can be drawn given the small number of included studies and the small sample sizes of those included studies. Additional studies, including larger multicentre studies, are needed to assess the efficacy of interventions to prevent development of HUS in patients with diarrhoea due to STEC infection.


Assuntos
Diarreia/complicações , Infecções por Escherichia coli/terapia , Síndrome Hemolítico-Urêmica/prevenção & controle , Prevenção Secundária/métodos , Escherichia coli Shiga Toxigênica , Adulto , Animais , Anticorpos Monoclonais Humanizados/efeitos adversos , Anticorpos Monoclonais Humanizados/uso terapêutico , Viés , Bovinos , Criança , Colostro/imunologia , Diarreia/microbiologia , Diarreia/terapia , Síndrome Hemolítico-Urêmica/epidemiologia , Humanos , Incidência , Compostos de Organossilício/efeitos adversos , Compostos de Organossilício/uso terapêutico , Placebos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Trissacarídeos/efeitos adversos , Trissacarídeos/uso terapêutico
4.
Transplant Proc ; 53(5): 1576-1582, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33962778

RESUMO

BACKGROUND: Pneumocystis jiroveci pneumonia (PCP) is a life-threatening pulmonary infection after kidney transplantation (KTx). Its onset in the current era of modern immunosuppression and of routine use of universal PCP prophylaxis seems to differ from its onset in previous decades in terms of late onset with subtle clinical presentation, indicating a need for increased vigilance. METHODS: We retrospectively studied all KTx recipients from our center who underwent bronchoscopy and bronchoalveolar lavage (BAL) between 2009 and 2018. Of these, all cases with confirmed PCP any time after the first post-KTx year were included in the analysis. RESULTS: Among 60 patients with KTx who had undergone bronchoscopy and BAL, 12 cases with late-onset PCP were identified. PCP appeared late at a median of 10.8 (interquartile range, 2.4-15.8) years after transplantation. Patients' mean age was 59 years, and all were receiving stable low-dose immunosuppression. Most of the patients (67%) had received PCP prophylaxis after KTx. Five out of 12 patients (42%) had concomitant cytomegalovirus (CMV) reactivation at the time of PCP. In almost all cases, clinical presentation was mild. Treatment consisted of trimethoprim-sulfamethoxazole (TMP-SMX) and intravenous corticosteroid administration, and concomitant immunosuppression was temporarily reduced or withdrawn. Outcome was generally good. None of the patients developed respiratory insufficiency or required mechanical ventilation. One patient died as a result of sepsis, and 3 more with preexisting advanced chronic kidney disease subsequently lost their grafts. CONCLUSION: Renal transplant recipients are at risk of late-onset PCP, even at a steady state of low-dose maintenance immunosuppression. Because of its subtle clinical presentation, high suspicion of the disease is warranted. Its early recognition and proper management are essential for a successful outcome.


Assuntos
Imunossupressão/efeitos adversos , Transplante de Rim/efeitos adversos , Pneumocystis carinii , Pneumonia por Pneumocystis/imunologia , Complicações Pós-Operatórias/microbiologia , Adulto , Idoso , Feminino , Humanos , Imunossupressão/métodos , Masculino , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/induzido quimicamente , Pneumonia por Pneumocystis/tratamento farmacológico , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/tratamento farmacológico , Estudos Retrospectivos , Fatores de Tempo , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
5.
Dtsch Med Wochenschr ; 146(9): 603-607, 2021 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-33931838

RESUMO

HISTORY AND CLINICAL FINDINGS: A 68-year-old male patient with psorias and a bullous pemphigoid as an underlying disease developed bilateral groundglass opacities on chest CT under longer-term, higher-dose immunosuppressive therapy with methylprednisolone with clinical symptoms of dry cough, progressive dyspnea and fever. DIAGNOSIS AND THERAPY: After the exclusion of COVID-19, Pneumocystis jirovecii pneumonia (PCP) was detected and a corresponding high-dose therapy with trimethoprim-sulfamethoxazole was initiated promptly. COURSE: Nonetheless, a complicated course with bacterial superinfection and pulmonary aspergillosis as well as ARDS developed. DISCUSSION AND CONCLUSION: In contrast to COVID-19, the typical course, diagnosis and therapy of Pneumocystitis jirovecii pneumonia are discussed. It is particularly emphasized that not all ground glass infiltrates in the CT chest image can be traced back to a COVID-19, even in a pandemic situation. Possible differential diagnoses should always be considered and taken into account in the diagnosis.


Assuntos
Pneumocystis carinii , Pneumonia por Pneumocystis , Idoso , Antifúngicos/administração & dosagem , Antifúngicos/uso terapêutico , COVID-19 , Diagnóstico Diferencial , Humanos , Masculino , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/patologia , Combinação Trimetoprima e Sulfametoxazol/administração & dosagem , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
6.
JAMA ; 325(18): 1841-1851, 2021 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-33974018

RESUMO

Importance: Alteration in lung microbes is associated with disease progression in idiopathic pulmonary fibrosis. Objective: To assess the effect of antimicrobial therapy on clinical outcomes. Design, Setting, and Participants: Pragmatic, randomized, unblinded clinical trial conducted across 35 US sites. A total of 513 patients older than 40 years were randomized from August 2017 to June 2019 (final follow-up was January 2020). Interventions: Patients were randomized in a 1:1 allocation ratio to receive antimicrobials (n = 254) or usual care alone (n = 259). Antimicrobials included co-trimoxazole (trimethoprim 160 mg/sulfamethoxazole 800 mg twice daily plus folic acid 5 mg daily, n = 128) or doxycycline (100 mg once daily if body weight <50 kg or 100 mg twice daily if ≥50 kg, n = 126). No placebo was administered in the usual care alone group. Main Outcomes and Measures: The primary end point was time to first nonelective respiratory hospitalization or all-cause mortality. Results: Among the 513 patients who were randomized (mean age, 71 years; 23.6% women), all (100%) were included in the analysis. The study was terminated for futility on December 18, 2019. After a mean follow-up time of 13.1 months (median, 12.7 months), a total of 108 primary end point events occurred: 52 events (20.4 events per 100 patient-years [95% CI, 14.8-25.9]) in the usual care plus antimicrobial therapy group and 56 events (18.4 events per 100 patient-years [95% CI, 13.2-23.6]) in the usual care group, with no significant difference between groups (adjusted HR, 1.04 [95% CI, 0.71-1.53; P = .83]. There was no statistically significant interaction between the effect of the prespecified antimicrobial agent (co-trimoxazole vs doxycycline) on the primary end point (adjusted HR, 1.15 [95% CI 0.68-1.95] in the co-trimoxazole group vs 0.82 [95% CI, 0.46-1.47] in the doxycycline group; P = .66). Serious adverse events occurring at 5% or greater among those treated with usual care plus antimicrobials vs usual care alone included respiratory events (16.5% vs 10.0%) and infections (2.8% vs 6.6%); adverse events of special interest included diarrhea (10.2% vs 3.1%) and rash (6.7% vs 0%). Conclusions and Relevance: Among adults with idiopathic pulmonary fibrosis, the addition of co-trimoxazole or doxycycline to usual care, compared with usual care alone, did not significantly improve time to nonelective respiratory hospitalization or death. These findings do not support treatment with these antibiotics for the underlying disease. Trial Registration: ClinicalTrials.gov Identifier: NCT02759120.


Assuntos
Antibacterianos/uso terapêutico , Doxiciclina/uso terapêutico , Fibrose Pulmonar Idiopática/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Idoso , Antibacterianos/efeitos adversos , Doxiciclina/efeitos adversos , Feminino , Hospitalização , Humanos , Fibrose Pulmonar Idiopática/mortalidade , Pulmão/microbiologia , Masculino , Pessoa de Meia-Idade , Testes de Função Respiratória , Infecções Respiratórias/prevenção & controle , Resultado do Tratamento , Combinação Trimetoprima e Sulfametoxazol/efeitos adversos
8.
Transplant Cell Ther ; 27(4): 292-300, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33840441

RESUMO

Infection due to the protozoa Toxoplasma gondii can be life-threatening in hematopoietic stem cell transplantation (HSCT) recipients. Most cases of toxoplasmosis in HSCT recipients result from reactivation of latent infection in individuals who were Toxoplasma-seropositive before transplantation and did not receive appropriate prophylaxis. Pretransplantation screening with Toxoplasma IgG and IgM antibodies is suggested for all allogeneic HSCT recipients and their donors and all autologous HSCT recipients. Prevention of toxoplasmosis in T. gondii-seropositive HSCT recipients requires primary prophylaxis, preemptive screening, or both. Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent for Toxoplasma prophylaxis and should be continued for 6 months or until the patient is no longer receiving immunosuppression, whichever is longer, assuming that immune reconstitution has occurred. Preemptive weekly screening with whole blood Toxoplasma PCR should be considered for seropositive HSCT recipients if prophylaxis cannot be given or if prophylaxis other than TMP-SMX is used. The signs, symptoms, and radiographic findings of toxoplasmosis in HSCT recipients can be nonspecific, and the diagnosis requires a high degree of suspicion. Common presentations include fever, encephalopathy with mental status changes or seizures, and pneumonia. A Toxoplasma PCR analysis from whole blood (and other body fluids/tissues according to clinical symptoms) should be obtained in patients in whom there is a concern for toxoplasmosis. Treatment with oral pyrimethamine, sulfadiazine, and leucovorin for at least 6 weeks is the first-line therapy and should be followed by secondary prophylaxis. In this article, we review the published literature regarding the epidemiology, clinical presentation, treatment, and prevention of toxoplasmosis in HSCT recipients.


Assuntos
Transplante de Células-Tronco Hematopoéticas , Toxoplasma , Toxoplasmose , Criança , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Toxoplasmose/diagnóstico , Transplantados , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
9.
J Zoo Wildl Med ; 52(1): 389-395, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33827203

RESUMO

A primiparous white rhinoceros (Ceratotherium simum) gave birth to a calf overnight after approximately 16 mo of gestation. The calf was found dead in the morning. Necrosuppurative placentitis with bacterial inclusions suggestive of coxiellosis was diagnosed histologically, and Coxiella burnetii was identified in fetal tissues and placenta by polymerase chain reaction and immunohistochemistry. Another primiparous female from the same herd aborted later that year after approximately 15 mo of gestation, and coxiellosis was similarly diagnosed in fetal tissues and on vaginal shedding. Estimates of exposure time, duration of vaginal shedding, and phase I and phase II antibody dynamics were determined retrospectively and prospectively for the two confirmed cases. Biosecurity measures were put in place to prevent guests, staff, and conspecific exposure to the organism. No other confirmed cases have occurred in the collection 3 yr after the initial cases. Coxiellosis outbreaks could represent an emerging threat to conservation efforts and ex situ white rhinoceros breeding programs.


Assuntos
Coxiella burnetii/isolamento & purificação , Perissodáctilos/microbiologia , Complicações Infecciosas na Gravidez/veterinária , Febre Q/veterinária , Animais , Animais Recém-Nascidos , Evolução Fatal , Feminino , Gravidez , Complicações Infecciosas na Gravidez/microbiologia , Complicações Infecciosas na Gravidez/patologia , Febre Q/diagnóstico , Febre Q/patologia , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Zoonoses
11.
J Infect Chemother ; 27(8): 1238-1243, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33722464

RESUMO

Although a variety of microorganisms have caused infective endocarditis, Nocardia species have rarely been reported as a causative agent of the disease. We describe a case of nocardial endocarditis, occurring to a 22-year-old Japanese woman during long-term corticosteroid therapy for adult-onset Still's disease and diagnosed after the rupture of cerebral mycotic aneurysm. Echocardiography showed that the causative organism, isolated from the blood and identified as Nocardia nova with an analysis of 16S ribosomal RNA sequences, affected the posterior papillary muscle of the left ventricle. Nocardia-like organisms were also detected in the pus around the raptured aneurysm. After treatment with imipenem/cilastatin plus amikacin for 3 months followed by oral trimethoprim/sulfamethoxazole for 1 year, no relapse of nocardiosis occurred during a follow-up for 3 years. To our knowledge, the present case is the first reported endocarditis due to N. nova.


Assuntos
Endocardite Bacteriana , Nocardiose , Nocardia , Adulto , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/tratamento farmacológico , Feminino , Humanos , Nocardia/genética , Nocardiose/diagnóstico , Nocardiose/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Adulto Jovem
12.
RMD Open ; 7(1)2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33688083

RESUMO

OBJECTIVES: To investigate short-term prognosis and prognostic factors for connective tissue disease-associated pneumocystis pneumonia (CTD-PCP) using the Japanese nationwide diagnosis procedure combination (DPC) inpatient database. METHODS: The present retrospective cohort study from April 2014 to March 2016 included data of patients with CTD-PCP extracted from the DPC database using the 10th revision of International Classification of Diseases and Injuries codes. RESULTS: In 15 901 766 cases registered from 1329 hospitals, 333 of 67 890 patients who were admitted with PCP were diagnosed with CTD-PCP and included in the study. The median age was 71.0 years, and 214 (64.3%), 80 (24.0%), and 29 (8.7%) patients received sulfamethoxazole/trimethoprim (ST) monotherapy and pentamidine-containing and atovaquone-containing therapy, respectively. There were 114 (34.2%) in-hospital deaths, and the 30-day and 60-day in-hospital survival rates after PCP treatment initiation were 66.0% and 53.7%, respectively. Older age (HR 1.06, 95% CI 1.03 to 1.08) and concomitant interstitial lung disease (ILD) (HR 1.65, 95% CI 1.12 to 2.42) were poor prognostic factors. Patients who completed PCP treatment with ST monotherapy had a significantly higher survival rate than those treated with those not treated with ST monotherapy (p=0.015; log-rank test). Pentamidine versus atovaquone as second-line therapy was significantly higher with atovaquone (p=0.012; log-rank test). CONCLUSION: Older age and concomitant ILD were poor prognostic factors for CTD-PCP. ST was a reasonable first-line therapy in patients with CTD-PCP, and patients with inadequate response to ST treated with atovaquone tended to have a better prognosis than those treated with pentamidine.


Assuntos
Doenças do Tecido Conjuntivo , Pneumonia por Pneumocystis , Idoso , Doenças do Tecido Conjuntivo/complicações , Doenças do Tecido Conjuntivo/diagnóstico , Doenças do Tecido Conjuntivo/tratamento farmacológico , Humanos , Pneumonia por Pneumocystis/complicações , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/tratamento farmacológico , Prognóstico , Estudos Retrospectivos , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
13.
PLoS One ; 16(3): e0247646, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33661970

RESUMO

BACKGROUND: Despite the necessity of early recognition for an optimal outcome, sepsis often remains unrecognized. Available tools for early recognition are rarely evaluated in low- and middle-income countries. In this study, we analyzed the spectrum, treatment and outcome of sepsis at an Ethiopian tertiary hospital and evaluated recommended sepsis scores. METHODS: Patients with an infection and ≥2 SIRS criteria were screened for sepsis by SOFA scoring. From septic patients, socioeconomic and clinical data as well as blood cultures were collected and they were followed until discharge or death; 28-day mortality was determined. RESULTS: In 170 patients with sepsis, the overall mortality rate was 29.4%. The recognition rate by treating physicians after initial clinical assessment was low (12.4%). Increased risk of mortality was significantly associated with level of SOFA and qSOFA score, Gram-negative bacteremia (in comparison to Gram-positive bacteremia; 42.9 versus 16.7%), and antimicrobial regimen including ceftriaxone (35.7% versus 19.2%) or metronidazole (43.8% versus 25.0%), but not with an increased respiratory rate (≥22/min) or decreased systolic blood pressure (≤100mmHg). In Gram-negative isolates, extended antimicrobial resistance with expression of extended-spectrum beta-lactamase and carbapenemase genes was common. Among adult patients, sensitivity and specificity of qSOFA score for detection of sepsis were 54.3% and 66.7%, respectively. CONCLUSION: Sepsis is commonly unrecognized and associated with high mortality, showing the need for reliable and easy-applicable tools to support early recognition. The established sepsis scores were either of limited applicability (SOFA) or, as in the case of qSOFA, were significantly impaired in their sensitivity and specificity, demonstrating the need for further evaluation and adaptation to local settings. Regional factors like malaria endemicity and HIV prevalence might influence the performance of different scores. Ineffective empirical treatment due to antimicrobial resistance is common and associated with mortality. Local antimicrobial resistance statistics are needed for guidance of calculated antimicrobial therapy to support reduction of sepsis mortality.


Assuntos
Antibacterianos/uso terapêutico , Bactérias/efeitos dos fármacos , Candida/efeitos dos fármacos , Plasmodium/efeitos dos fármacos , Sepse/tratamento farmacológico , Adolescente , Adulto , Idoso , Bactérias/classificação , Bactérias/isolamento & purificação , Candida/isolamento & purificação , Clindamicina/uso terapêutico , Estudos Transversais , Resistência a Medicamentos , Etiópia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Plasmodium/isolamento & purificação , Prognóstico , Estudos Prospectivos , Sepse/microbiologia , Sepse/parasitologia , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Adulto Jovem
14.
Rheumatology (Oxford) ; 60(8): 3553-3564, 2021 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-33752235

RESUMO

OBJECTIVES: To assess available evidence from randomized controlled trials (RCTs) and observational studies including a control group regarding the role of trimethoprim/sulfametoxazole (TMP/SMX) in reducing the relapse rate in patients with granulomatosis with polyangiitis (GPA) and the risk of infections in patients with ANCA-associated vasculitis (AAV). METHODS: MEDLINE, EMBASE, The Cochrane Library databases, Scopus, Web of Science and ClinicalTrials.gov were searched from inception until 15 January 2020 to identify controlled studies assessing the role of TMP/SMX in reducing the rate of relapse in patients with GPA (primary outcome) and the number and/or severity of infections in patients with AAV (secondary outcome). Two reviewers independently selected eligible studies and extracted data. Cumulative risk ratios (RRs) with 95% CI were calculated using a random effect meta-analysis. RESULTS: Eight studies were selected out of 2907 records. Seven studies (520 patients) (of which two were RCTs) assessed the role of TMP/SMX in the relapse rate in patients with GPA. TMP/SMX was not associated with a reduced risk of relapse (RR = 1.15, 95% CI: 0.51, 2.55; I2 = 78.5%; P < 0.001). Sensitivity analysis according to the dose of TMP/SMX (960 mg twice daily vs three times/week) confirmed the results. One retrospective cohort study (192 patients) was identified demonstrating a significant reduction of severe infections in patients with AAV receiving prophylaxis with TMP/SMX in association with rituximab. CONCLUSION: TMP/SMX was not associated with a reduced risk of relapse in patients with GPA. TMP/SMX might be useful in the reduction of infectious complications. PROSPERO DATABASE REGISTRATION CODE: CRD42019118983.


Assuntos
Antibacterianos/uso terapêutico , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/prevenção & controle , Prevenção Secundária , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Humanos
15.
J Pediatric Infect Dis Soc ; 10(6): 745-748, 2021 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-33693793

RESUMO

We describe the presentation and treatment of a patient who developed ongoing fever and diagnosed with disseminated toxoplasmosis post-hematopoietic stem cell transplantation. He was initially treated with trimethoprim-sulfamethoxazole (TMP-SMX) and there was dramatic improvement in his fever curve. He successfully completed a modified course of therapy.


Assuntos
Transplante de Células-Tronco Hematopoéticas , Toxoplasmose , Criança , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Toxoplasmose/diagnóstico , Toxoplasmose/tratamento farmacológico , Transplantados , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
17.
BMC Infect Dis ; 21(1): 277, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33740906

RESUMO

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease associated with neurological complications, including cerebral abscesses (CA). They tend to be unique, supratentorial and lobar. While the surgical intervention is a rule of thumb when treating and diagnosing the etiology of these lesions, this is not always possible due to dangerous or inaccessible locations. We report the case of a patient solely treated with empiric antibiotics without stereotaxic intervention and satisfactory results. CASE PRESENTATION: We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance. CONCLUSION: Carefully tailored antibiotic-only regime and vigilance of its adverse effects and close radiological following is a good treatment approach when surgery is not an option.


Assuntos
Antibacterianos/uso terapêutico , Abscesso Encefálico/diagnóstico , Veias Pulmonares/anormalidades , Telangiectasia Hemorrágica Hereditária/patologia , Encéfalo/diagnóstico por imagem , Abscesso Encefálico/tratamento farmacológico , Abscesso Encefálico/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Telangiectasia Hemorrágica Hereditária/complicações , Tomografia Computadorizada por Raios X , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Adulto Jovem
18.
Medicine (Baltimore) ; 100(10): e24890, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725845

RESUMO

RATIONALE: Cystoisosporiasis is an intestinal infectious disease caused by a coccidian protozoa, Cystoisospora belli (C. belli). It can cause prolonged and refractory diarrhea most commonly in immunocompromised patients, while immunocompetent individuals usually exhibit no symptoms or self-limited diarrhea. PATIENT CONCERNS: We herein report a case of chronic cystoisosporiasis in an immunocompetent patient. A 62-year-old man, who had been first diagnosed with cystoisosporiasis 15 years ago and had been treated with oral administration of trimethoprim-sulfamethoxazole (TMP-SMX), complained of persistent watery diarrhea. He was negative for anti-human immunodeficiency virus antibody and anti-human T-cell leukemia virus type 1 (HTLV-1) antibody. DIAGNOSIS: Biopsy specimens from the duodenum revealed oocysts in the atrophic absorptive epithelium and protozoa were detected through stool examination, indicating the recurrence of cystoisosporiasis. Capsule endoscopy showed diffuse atrophic mucosa with white villi in the entire small intestine. We diagnosed him with chronic cystoisosporiasis that occurred in an immunocompetent adult. INTERVENTIONS: Since oral administration of TMP-SMX and ciprofloxacin were ineffective, the intravenous administration of TMP-SMX was initiated. OUTCOMES: Intravenous TMP-SMX exhibited a significant improvement. LESSONS: This case indicates that even immunocompetent individuals may develop recurrent and refractory cystoisosporiasis. Furthermore, intravenous treatment of antibiotic agents should be considered when the impaired absorptive ability from the small intestine is suspected.


Assuntos
Antiprotozoários/administração & dosagem , Enteropatias Parasitárias/diagnóstico , Enteropatias Parasitárias/tratamento farmacológico , Isosporíase/diagnóstico , Isosporíase/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/administração & dosagem , Administração Intravenosa , Administração Oral , Antiprotozoários/uso terapêutico , Endoscopia por Cápsula , Doença Crônica , Diarreia/parasitologia , Humanos , Imunocompetência , Masculino , Pessoa de Meia-Idade , Recidiva , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
19.
Medicine (Baltimore) ; 100(10): e24970, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725864

RESUMO

ABSTRACT: The aim of this study was to discuss the correlation between the sulfamethoxazole-trimethoprim resistance of Shigella flexneri (S. flexneri) and the antibiotic resistance genes sul1, sul2, and sul3 and SXT element.From May 2013 to October 2018, 102 isolates of S. flexneri were collected from the clinical samples in Jinan. The Kirby-Bauer (K-B) test was employed to determine the antibiotic susceptibility of the S. flexneri isolates. The antibiotic resistance rate was analyzed with the WHONET5.4 software. The isolates were subject to the PCR amplification of the sul genes (sul1, sul2, and sul3) and the SXT element. On the basis of the sequencing results, the correlation between the sulfamethoxazole-trimethoprim resistance of the S. flexneri isolates and the sul genes was analyzed.The antibiotic resistance rates of the 102 S. flexneri isolates to ampicillin, streptomycin, chloramphenicol, tetracycline, and sulfamethoxazole-trimethoprim were 90.2%, 90.2%, 88.2%, 88.2%, and 62.7%, respectively. The antibiotic resistance rates of these isolates to cefotaxime, ceftazidime, and ciprofloxacin varied between 20% and 35%. However, these isolates were 100% susceptible to cefoxitin. Positive fragments were amplified from 59.8% (61/102) of the 102 S. flexneri isolates, the sizes of the sul1 and sul2 genes being 338 bp and 286 bp, respectively. The sequence alignment revealed the presence of the sul1 and sul2 genes encoding for dihydrofolate synthase. The carrying rate of the sul1 gene was 13.7% (14/102), and that of the sul2 gene was 48.0% (49/102). No target gene fragments were amplified from the 3 isolates resistant to sulfamethoxazole-trimethoprim. The sul3 gene and SXT element were not amplified from any of the isolates. The testing and statistical analysis showed that the resistance of the S. flexneri isolates to sulfamethoxazole-trimethoprim correlated to the sul1 and sul2 genes.The acquired antibiotic resistance genes sul1 and sul2 were closely associated with the resistance of the 102 S. flexneri isolates to sulfamethoxazole-trimethoprim.


Assuntos
Proteínas de Bactérias/genética , Proteínas de Transporte/genética , Disenteria Bacilar/tratamento farmacológico , Shigella flexneri/genética , Resistência a Trimetoprima/genética , Combinação Trimetoprima e Sulfametoxazol/farmacologia , Elementos de DNA Transponíveis/genética , DNA Bacteriano/genética , DNA Bacteriano/isolamento & purificação , Disenteria Bacilar/microbiologia , Fezes/microbiologia , Humanos , Testes de Sensibilidade Microbiana , Reação em Cadeia da Polimerase , Shigella flexneri/efeitos dos fármacos , Shigella flexneri/isolamento & purificação , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
20.
BMJ Case Rep ; 14(3)2021 Mar 23.
Artigo em Inglês | MEDLINE | ID: mdl-33758048

RESUMO

A 36-year-old African American man with no medical history presented with a recent history of cough and dyspnoea. Initial chest imaging revealed diffuse bilateral lung infiltrates. A subsequent HIV test resulted positive, and he was presumptively diagnosed with AIDS, later confirmed by a CD4 of 88 cells/mm3 Empiric therapy with trimethoprim-sulfamethoxazole was initiated for presumed Pneumocystis jirovecii pneumonia. The patient's clinical status deteriorated despite treatment. Further workup with chest CT, bronchoscopy and skin biopsy led to a diagnosis of Kaposi sarcoma with pulmonary involvement. Highly active antiretroviral therapy therapy was initiated, along with plans to start chemotherapy. However, the patient's clinical status rapidly declined, leading to respiratory failure and eventual death. This case underlines the importance of maintaining a broad differential in immunocompromised patients presenting with respiratory symptoms.


Assuntos
Síndrome de Imunodeficiência Adquirida , Pneumocystis carinii , Pneumonia por Pneumocystis , Sarcoma de Kaposi , Síndrome de Imunodeficiência Adquirida/complicações , Síndrome de Imunodeficiência Adquirida/tratamento farmacológico , Adulto , Terapia Antirretroviral de Alta Atividade , Humanos , Masculino , Pneumonia por Pneumocystis/complicações , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
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