Sep 182014
 
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Use of Procalcitonin in Patients with Various Degrees of Chronic Kidney Disease Including Renal Replacement Therapy.

Clin Infect Dis. 2014 Sep 16;

Authors: Grace E, Turner RM

Abstract
Procalcitonin (PCT) has been shown to be a useful surrogate marker in identifying patients with various bacterial infections. PCT has been studied as a diagnostic marker in differentiating bacterial pneumonia from other respiratory conditions such as chronic obstructive pulmonary disease exacerbations or viral pneumonia. Differentiating bacterial from non-bacterial pneumonia using PCT has shown to reduce antibiotic usage, length of stay, and antibiotic-related adverse effects. PCT has also been studied in septic patients in effort to reduce unnecessary antibiotic usage and decrease the length of antibiotic therapy. This article focuses on the use of PCT in patients with various degrees of chronic kidney disease in addition to various forms of dialysis as chronic kidney disease may alter baseline levels of PCT and thus result in inappropriate use of PCT in this population.

PMID: 25228701 [PubMed - as supplied by publisher]

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Aug 292014
 
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Serum galactomannan-based early detection of invasive aspergillosis in hematology patients receiving effective anti-mold prophylaxis.

Clin Infect Dis. 2014 Aug 27;

Authors: Duarte RF, Sánchez-Ortega I, Cuesta I, Arnan M, Patiño B, Fernández de Sevilla A, Gudiol C, Ayats J, Cuenca-Estrella M

Abstract
BACKGROUND:  There is a practical need to investigate the performance of the serum galactomannan (GM) assay in hematology patients with a potentially low pre-test risk of invasive aspergillosis following effective anti-mold prophylaxis.
METHODS:  We present a four-year study with 262 unselected consecutive high-risk episodes, prospectively managed with posaconazole primary prophylaxis and a uniform diagnostic algorithm, including biweekly serum GM quantification for early detection of invasive aspergillosis.
RESULTS:  2972 serum GM tests were performed (median 11 per episode, 3-30); the vast majority was negative (96.7% tests; 83.6% episodes). The incidence of breakthrough invasive aspergillosis was 1.9% (5/262), all with true positive GM test results. Our study identified 30 false positive GM evaluable episodes (85.7%; 13.8% of all evaluable episodes), validating with real-life data the low positive predictive value of the assay in this setting (12%). In 26 out of these 30 episodes (86.7%), the false positive result/s occurred in tests performed as preemptive surveillance only. Conversely, in evaluable cases with positive GM tests and a clinical suspicion of invasive fungal disease, the performance of diagnostic-driven GM tests improved, with a positive predictive value of 89.6%.
CONCLUSIONS:  The low pre-test risk of invasive aspergillosis in the context of effective anti-mold prophylaxis renders serum GM surveillance of asymptomatic patients unreliable, as all results would be either negative or false positive. The test remains useful to diagnose patients with a clinical suspicion of invasive fungal disease, calling for a more efficient co-positioning of effective prophylaxis and GM testing in this clinical setting.

PMID: 25165088 [PubMed - as supplied by publisher]

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Aug 122014
 
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Failure of High-Dose Daptomycin for Bacteremia Caused by Daptomycin-Susceptible Enterococcus faecium Harboring LiaSR Substitutions.

Clin Infect Dis. 2014 Aug 8;

Authors: Munita JM, Mishra NN, Alvarez D, Tran TT, Diaz L, Panesso D, Reyes J, Murray BE, Adachi JA, Bayer AS, Arias CA

Abstract
A neutropenic patient with bloodstream infection caused by a daptomycin (DAP)-susceptible Enterococcus faecium (MIC 3 µg/mL) harboring genetic changes associated with DAP-resistance failed high-dose DAP therapy, with persistent bacteremia and selection of additional resistances. DAP monotherapy should be used cautiously against DAP-susceptible E. faecium strains with MICs>2 µg/mL.

PMID: 25107294 [PubMed - as supplied by publisher]

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Jul 252014
 

The Effect of Therapeutic Lumbar Punctures on Acute Mortality from Cryptococcal Meningitis.

Clin Infect Dis. 2014 Jul 23;

Authors: Rolfes MA, Hullsiek KH, Rhein J, Nabeta HW, Taseera K, Schutz C, Musubire A, Rajasingham R, Williams DA, Thienemann F, Muzoora C, Meintjes G, Meya DB, Boulware DR

Abstract
INTRODUCTION:  Cryptococcal meningitis is the most common cause of adult meningitis in sub-Saharan Africa. Raised intracranial pressure (ICP) is common in cryptococcosis. Prior studies suggest elevated ICP is associated with mortality, and guidelines recommend frequent lumbar punctures (LPs) to control ICP. However, the magnitude of the impact of LPs on cryptococcal-related mortality is unknown.
METHODS:  248 individuals with HIV-associated cryptococcal meningitis, screened for the Cryptococcal Optimal ART Timing (COAT) trial in Uganda and South Africa, were observed. Individuals received an LP to diagnose meningitis and subsequent therapeutic LPs were recommended for elevated ICP (>250 mmH2O) or new symptoms. We compared survival, through 11 days, between individuals receiving at least one therapeutic LP with individuals not receiving therapeutic LPs. The COAT trial randomized subjects at 7-11 days, thus follow-up stopped at time of death, randomization, or 11 days.
RESULTS:  75 (30%) individuals had at least one therapeutic LP. Individuals receiving therapeutic LPs had higher cerebrospinal fluid (CSF) opening pressures, higher CSF fungal burdens, and were more likely to have altered mental status at baseline than those with no therapeutic LPs. 31 deaths (18%) occurred among 173 individuals without a therapeutic LP and 5 deaths (7%) among 75 with at least one therapeutic LP. The adjusted relative risk of mortality was 0.31 (95% confidence interval: 0.12-0.82). The association was observed regardless of opening pressure at baseline.
CONCLUSIONS:  Therapeutic LPs were associated with a 69% relative improvement in survival, regardless of initial intracranial pressure. The role of therapeutic LPs should be re-evaluated.

PMID: 25057102 [PubMed - as supplied by publisher]

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Jul 232014
 

The Predictive Utility of Prior Positive Urine Cultures.

Clin Infect Dis. 2014 Jul 21;

Authors: MacFadden DR, Ridgway JP, Robicsek A, Elligsen M, Daneman N

Abstract
BACKGROUND:  A patient's prior urine cultures are often considered when choosing empiric antibiotic therapy for a suspected urinary tract infection. We sought to evaluate how well a patient's previous urine cultures predict the identity and susceptibility of subsequent urine cultures.
METHODS:  We conducted a multi-national, multi-centre, retrospective cohort study, including 22,019 pairs of positive urine cultures from 4,351 patients, across two healthcare systems in Toronto, Ontario and Chicago, Illinois. We examined the probability of the same organism being identified from the same patient's positive urine culture as a function of time elapsed from the previous positive urine specimen; in cases where the same organism was identified we also examined the likelihood of the organism exhibiting the same or better antimicrobial susceptibility profile.
RESULTS:  At 4-8 weeks between cultures, correspondence of isolate identity was 57%(95%CI: 55-59%), and at >32 weeks was 49%(95%CI:48-50%), still greater than expected by chance(p<0.001). At 4-8 weeks, a same or better susceptibility profile was found in 83%(95%CI:81-85%) of isolate pairs, and at >32 weeks 75%(95%CI:73-77%), still greater than expected by chance(p<0.001). Despite high local rates of ciprofloxacin resistance in urine isolates across all patients (40%,95%CI 39.5-40.5%), ciprofloxacin resistance was less than 20% among patients with a prior ciprofloxacin sensitive organism and no subsequent fluoroquinolone exposure.
CONCLUSIONS:  A patient's prior urine culture results are useful in predicting the identity and susceptibility of a current positive urine culture. In areas of high fluoroquinolone resistance, Ciprofloxacin can be used empirically when prior urine culture results indicate a ciprofloxacin-susceptible organism and no history of intervening fluoroquinolone use.

PMID: 25048850 [PubMed - as supplied by publisher]

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