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Corticosteroids for acute bacterial meningitis.

Cochrane Database Syst Rev Start a Discussion »

Jun 052013

Corticosteroids for acute bacterial meningitis.

Cochrane Database Syst Rev. 2013 Jun 4;6:CD004405

Authors: Brouwer MC, McIntyre P, Prasad K, van de Beek D

Abstract
BACKGROUND: In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response. OBJECTIVES: To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis. SEARCH METHODS: We searched CENTRAL 2012, Issue 12, MEDLINE (1966 to January week 2, 2013), EMBASE (1974 to January 2013), Web of Science (2010 to January 2013), CINAHL (2010 to January 2013) and LILACS (2010 to January 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis. DATA COLLECTION AND ANALYSIS: We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality. MAIN RESULTS: Twenty-five studies involving 4121 participants were included. Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events. AUTHORS' CONCLUSIONS: Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.

PMID: 23733364 [PubMed - as supplied by publisher]

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Surveillance of avian influenza A(H7N9) virus infection in humans and detection of the first imported human case in Taiwan, 3 April to 10 May 2013.

Euro Surveill Start a Discussion »

Jun 042013

Surveillance of avian influenza A(H7N9) virus infection in humans and detection of the first imported human case in Taiwan, 3 April to 10 May 2013.

Euro Surveill. 2013;18(20)

Authors: Lo Y, Chen W, Huang W, Lin Y, Liu M, Kuo H, Chuang J, Yang J, Liu M, Wu H, Yang C, Chou J, Chang F

Abstract

PMID: 23725865 [PubMed - as supplied by publisher]

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Preliminary inferences on the age-specific seriousness of human disease caused by avian influenza A(H7N9) infections in China, March to April 2013.

Euro Surveill Start a Discussion »

Jun 042013

Preliminary inferences on the age-specific seriousness of human disease caused by avian influenza A(H7N9) infections in China, March to April 2013.

Euro Surveill. 2013;18(19)

Authors: Cowling B, Freeman G, Wong J, Wu P, Liao Q, Lau E, Wu J, Fielding R, Leung G

Abstract

PMID: 23725807 [PubMed - as supplied by publisher]

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Association between adverse clinical outcome in human disease caused by novel influenza A H7N9 virus and sustained viral shedding and emergence of antiviral resistance.

Lancet Start a Discussion »

Jun 042013

Association between adverse clinical outcome in human disease caused by novel influenza A H7N9 virus and sustained viral shedding and emergence of antiviral resistance.

Lancet. 2013 May 29;

Authors: Hu Y, Lu S, Song Z, Wang W, Hao P, Li J, Zhang X, Yen HL, Shi B, Li T, Guan W, Xu L, Liu Y, Wang S, Zhang X, Tian D, Zhu Z, He J, Huang K, Chen H, Zheng L, Li X, Ping J, Kang B, Xi X, Zha L, Li Y, Zhang Z, Peiris M, Yuan Z

Abstract
BACKGROUND: On March 30, a novel influenza A subtype H7N9 virus (A/H7N9) was detected in patients with severe respiratory disease in eastern China. Virological factors associated with a poor clinical outcome for this virus remain unclear. We quantified the viral load and analysed antiviral resistance mutations in specimens from patients with A/H7N9. METHODS: We studied 14 patients with A/H7N9 disease admitted to the Shanghai Public Health Clinical Centre (SPHCC), China, between April 4, and April 20, 2013, who were given antiviral treatment (oseltamivir or peramivir) for less than 2 days before admission. We investigated the viral load in throat, stool, serum, and urine specimens obtained sequentially from these patients. We also sequenced viral RNA from these specimens to study the mutations associated with resistance to neuraminidase inhibitors and their association with disease outcome. FINDINGS: All patients developed pneumonia, seven of them required mechanical ventilation, and three of them further deteriorated to become dependent on extracorporeal membrane oxygenation (ECMO), two of whom died. Antiviral treatment was associated with a reduction of viral load in throat swab specimens in 11 surviving patients. Three patients with persistently high viral load in the throat in spite of antiviral therapy became ECMO dependent. An Arg292Lys mutation in the virus neuraminidase (NA) gene known to confer resistance to both zanamivir and oseltamivir was identified in two of these patients, both also received corticosteroid treatment. In one of them, wild-type sequence Arg292 was noted 2 days after start of antiviral treatment, and the resistant mutant Lys292 dominated 9 days after start of treatment. INTERPRETATION: Reduction of viral load following antiviral treatment correlated with improved outcome. Emergence of NA Arg292Lys mutation in two patients who also received corticosteroid treatment led to treatment failure and a poor clinical outcome. The emergence of antiviral resistance in A/H7N9 viruses, especially in patients receiving corticosteroid therapy, is concerning, needs to be closely monitored, and considered in pandemic preparedness planning. FUNDING: National Megaprojects of China for Infectious Diseases, Shanghai Municipal Health and Family Planning Commission, the National Key Basic Research Program of China, Ministry of Science and Technology, and National Natural Science Foundation of China.

PMID: 23726392 [PubMed - as supplied by publisher]

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Impact of Age and Comorbidity on Etiology and Outcome in Community-Acquired Pneumonia.

Chest Start a Discussion »

May 152013

Impact of Age and Comorbidity on Etiology and Outcome in Community-Acquired Pneumonia.

Chest. 2013 May 9;

Authors: Cillóniz C, Polverino E, Ewig S, Aliberti S, Gabarrús A, Menéndez R, Mensa J, Blasi F, Torres A

Abstract
ABSTRACT BACKGROUND: Prolonged life expectancy has currently increased the proportion of the very elderly among patients with community-acquired pneumonia (CAP). The aim of this study was to determine the influence of age and comorbidity on microbial patterns in CAP patients over 65 years of age. METHODS: Prospective observational study of adult CAP patients (excluding nursing home) over a 12-year period. We compared patients aged 65-74 years, 75-84 years and >85 years for potential differences in clinical presentation, comorbidities, severity on admission, microbial investigations, etiologies, antimicrobial treatment, and outcomes. RESULTS: We studied a total of 2149 patients: 759 (35.3%) patients aged 65-74 years, 941 (43.7%) aged 75-84 years, and 449 (20.8%) patients aged >85 years. At least one comorbidity was present in 1710 (79.6%) patients. Streptococcus pneumoniae was the most frequent pathogen in all age groups, regardless of comorbidity. Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa accounted for 9.1% of isolates and Haemophilus influenzae, 6.4%. All these pathogens were isolated only in patients with ≥1 comorbidity. Mortality increased with age (65-74 y, 6.9%; 75-84 y, 8.9%; >85 y, 17.1%; p<0.001) and was associated with increased comorbidities (neurological, OR: 2.1, 95% CI: 1.5-2.1), PSI IV-V (OR: 3.2, 95% CI: 1.8-6.0), bacteremia (OR: 1.7, 95% CI: 1.1-2.7), the presence of a potential MDR pathogen (S. aureus, P. aeruginosa, Enterobacteriaceae; OR: 2.4, 95% CI: 1.3-4.3) and ICU admission (OR: 4.2, 95% CI: 2.9-6.1) on multivariate analysis. CONCLUSIONS: Age does not influence microbial etiology itself, while comorbidities are associated with specific etiologies such as H. influenzae and potential MDR pathogens. Mortality in the elderly is mainly driven by the presence of comorbidities and potential MDR.

PMID: 23670047 [PubMed - as supplied by publisher]

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Mortality differences among hospitalized patients with community-acquired pneumonia in three world regions: Results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study.

Respir Med Start a Discussion »

May 112013

Mortality differences among hospitalized patients with community-acquired pneumonia in three world regions: Results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study.

Respir Med. 2013 May 6;

Authors: Arnold FW, Wiemken TL, Peyrani P, Ramirez JA, Brock GN, CAPO authors

Abstract
BACKGROUND: Community-acquired pneumonia (CAP) causes considerable worldwide mortality, but limited data compare the mortality in different regions of the world. Our objective was to determine if there was a difference in mortality among hospitalized patients with CAP in three continental regions of the world. METHODS: This was a cohort study of patients hospitalized for CAP between November 2001 and December 2011 from 70 institutions in 16 countries in US/Canada, Europe and Latin America; the Community-Acquired Pneumonia Organization (CAPO) international database. The primary outcome was mortality, and factors of interest included world region, processes of care, severity of disease, associated pathogen, specific comorbidities, and antimicrobial therapy. Multivariable logistic regression was performed to adjust for confounding effects on differences in mortality between regions. Patients were analyzed separately based on their intensive care unit admission status. RESULTS: A total of 6371 patients were reviewed. Latin America had the highest mortality (13.3%) followed by Europe (9.1%) and the USA/Canada (7.3%) (P < 0.001 for differences between regions). Important confounding variables included comorbidities (i.e., congestive heart failure, cerebrovascular disease), elevated blood urea nitrogen level, antimicrobial therapy (macrolide or fluoroquinolone use), and whether the patient had prior vaccinations (influenza, pneumococcal). After adjustment for confounding variables, estimated differences in mortality between the three regions were significantly reduced for both patients in the ICU and the ward. CONCLUSIONS: There was an observed discrepancy in CAP mortality between three world regions. Identified factors that contributed to these differences included incidence of H1N1 infection, elevated BUN, cerebrovascular disease, macrolide use, fluoroquinolone use, and vaccinations. Treatment regimen (fluoroquinolone and macrolide use) and preventive measures (vaccinations) were variables that may be modified to help alleviate the differences.

PMID: 23660396 [PubMed - as supplied by publisher]

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