Prevalence of HIV indicator conditions in late presenting patients with HIV: a missed opportunity for diagnosis?

AIM

To evaluate prior prevalence of HIV indicator conditions in late-presenters with HIV infection.

DESIGN

Retrospective cohort study between 2000 and 2014 in a healthcare network in Melbourne, Australia comparing patients presenting with late diagnosis of HIV infection (CD4 < 350 cells/ml) to those patients who had a CD greater than or equal to 350 cells/ml at presentation.

METHOD

The European AIDS Clinical Society guidelines on HIV indicator guided testing were used to assess for any indicator conditions in their prior medical history which may have represented a missed opportunity for earlier diagnosis. Main outcome measures: Descriptive statistics and prevalence of HIV indicator conditions.

RESULTS

Of 436 patients with HIV infection, 82 were late presenters. Late presenters were more commonly male (83% vs. 75%, P = 0.11), older (mean age 45 vs. 39 years), born overseas (61% vs. 58%, P = 0.68) and report heterosexual transmission as their exposure risk (51% vs. 31%, P < 0.001). Of 80 patients with late presentation of HIV infection, 54 (55%) had at least one, 29 (36%) at least 2, 12 (15%) at least 3 and 5 (6%) had 4 or more previous HIV indicator conditions which would have triggered HIV testing according to guidelines. The most common indicator conditions were: unexplained loss of weight (31%), herpes zoster (10%), thrombocytopenia or leukopenia (10%), oral or oesophageal candidiasis (10%) and community acquired pneumonia (9%). Twenty patients (25%) had HIV indicator conditions diagnosed at least 12 months before the eventual diagnosis of HIV infection.

DISCUSSION/ CONCLUSION

Patients diagnosed with late-presenting HIV often had an HIV indicator condition prior to presentation, presenting a missed opportunity for earlier diagnosis.

Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand

The incidence of Clostridium difficile infection (CDI) continues to rise, whilst treatment remains problematic due to recurrent, refractory and potentially severe nature of disease. The treatment of C. difficile is a challenge for community and hospital-based clinicians. With the advent of an expanding therapeutic arsenal against C. difficile since the last published Australasian guidelines, an update on CDI treatment recommendations for Australasian clinicians was required. On behalf of the Australasian Society of Infectious Diseases, we present the updated guidelines for the management of CDI in adults and children.

Low rates of endocarditis in healthcare-associated Staphylococcus aureus bacteremia suggest that echocardiography might not always be required

Healthcare-associated Staphylococcus aureus bacteremia (HA-SAB) is an increasingly frequently observed complication of medical treatment. Current guidelines recommend evaluation with echocardiography and preferably transesophageal echocardiography for the exclusion of infectious endocarditis (IE). We performed a retrospective analysis of all patients with HA-SAB between 1 January 2007 and 31 July 2012. Patients were divided into those with a high degree of clinical suspicion of IE (prosthetic intracardiac device, hemodialysis or positive blood cultures for 4 days or more) or those with a low degree of clinical suspicion of IE (absence of high-risk features based on previous literature as strong indicators of endocarditis). Three hundred and fifty-eight patients with HA-SAB were evaluated to determine the prevalence of IE, including 298 (83 %) who had echocardiography. Fourteen patients (4 %) had a final diagnosis of IE after echocardiography. In the group with a high degree of clinical suspicion 11 out of 84 patients (13 %) had IE. In the group with a low degree of clinical suspicion group 3 out 274 patients (1.1 %) had IE. HA-SAB has a low rate of IE, especially in the absence of high-risk features such as prolonged bacteremia, intracardiac prosthetic devices, and hemodialysis. Echocardiographic imaging in this low-risk population of patients is rarely helpful and may generally be avoided, although careful clinical follow-up is warranted. Patients with HA-SAB who have mechanical valves, intracardiac devices, prolonged bacteremia or dialysis dependency have a high incidence of IE and should be evaluated thoroughly using echocardiography.

Mucormycosis in Australia: contemporary epidemiology and outcomes

Mucormycosis is the second most common cause of invasive mould infection and causes disease in diverse hosts, including those who are immuno-competent. We conducted a multicentre retrospective study of proven and probable cases of mucormycosis diagnosed between 2004-2012 to determine the epidemiology and outcome determinants in Australia. Seventy-four cases were identified (63 proven, 11 probable). The majority (54.1%) were caused by Rhizopus spp. Patients who sustained trauma were more likely to have non-Rhizopus infections relative to patients without trauma (OR 9.0, p 0.001, 95% CI 2.1-42.8). Haematological malignancy (48.6%), chemotherapy (42.9%), corticosteroids (52.7%), diabetes mellitus (27%) and trauma (22.9%) were the most common co-morbidities or risk factors. Rheumatological/autoimmune disorders occurred in nine (12.1%) instances. Eight (10.8%) cases had no underlying co-morbidity and were more likely to have associated trauma (7/8; 87.5% versus 10/66; 15.2%; p <0.001). Disseminated infection was common (39.2%). Apophysomyces spp. and Saksenaea spp. caused infection in immuno-competent hosts, most frequently associated with trauma and affected sites other than lung and sinuses. The 180-day mortality was 56.7%. The strongest predictors of mortality were rheumatological/autoimmune disorder (OR = 24.0, p 0.038 95% CI 1.2-481.4), haematological malignancy (OR = 7.7, p 0.001, 95% CI 2.3-25.2) and admission to intensive care unit (OR = 4.2, p 0.02, 95% CI 1.3-13.8). Most deaths occurred within one month. Thereafter we observed divergence in survival between the haematological and non-haematological populations (p 0.006). The mortality of mucormycosis remains particularly high in the immuno-compromised host. Underlying rheumatological/autoimmune disorders are a previously under-appreciated risk for infection and poor outcome.

Who really knows their patients' penicillin adverse drug reaction status? A cross-sectional survey

This cross-sectional survey of patients with adverse drug reactions (ADR) to penicillin and their treating doctor, nurse and pharmacist was undertaken to identify the extent of healthcare workers (HCW) awareness of their patients' ADR, and antibiotic use in hospital. There were 23 (38%) doctors, 53 (87%) nurses and 40 (66%) pharmacists who were aware of their patient's penicillin ADR, despite more than half of their patients receiving antibiotics. Interventions encouraging 'double checking' may improve antibiovigilance.

Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012

We describe an Australia-wide Clostridium difficile outbreak in 2011 and 2012 involving the previously uncommon ribotype 244. In Western Australia, 14 of 25 cases were community-associated, 11 were detected in patients younger than 65 years, 14 presented to emergency/outpatient departments, and 14 to non-tertiary/community hospitals. Using whole genome sequencing, we confirm ribotype 244 is from the same C. difficile clade as the epidemic ribotype 027. Like ribotype 027, it produces toxins A, B, and binary toxin, however it is fluoroquinolone-susceptible and thousands of single nucleotide variants distinct from ribotype 027. Fifteen outbreak isolates from across Australia were sequenced. Despite their geographic separation, all were genetically highly related without evidence of geographic clustering, consistent with a point source, for example affecting the national food chain. Comparison with reference laboratory strains revealed the outbreak clone shared a common ancestor with isolates from the United States and United Kingdom (UK). A strain obtained in the UK was phylogenetically related to our outbreak. Follow-up of that case revealed the patient had recently returned from Australia. Our data demonstrate new C. difficile strains are an on-going threat, with potential for rapid spread. Active surveillance is needed to identify and control emerging lineages.

New HIV diagnosis after occupational exposure screening: the importance of reporting needlestick injuries

We describe three new diagnosis of HIV infection as a direct result of testing following occupational exposures (NSIs) in a low-prevalence setting. In each case the finding was unexpected. Our series provides a reminder of the importance of prompt reporting of NSIs by healthcare workers, access to rapid HIV testing and post-exposure prophylaxis with antiretrovirals to prevent transmission.

Rat-bite fever septic arthritis: illustrative case and literature review

Rat-bite fever is a rare zoonotic infection caused by Streptobacillus moniliformis or Spirillum minus, which is characterised by fever, rash and arthritis. The arthritis has previously been described as non-suppurative and isolation of the organism from synovial fluid as very uncommon. This article reports a case of septic arthritis diagnosed as rat-bite fever when the organism was cultured from synovial fluid and reviews another 15 cases of S. moniliformis septic arthritis reported in the worldwide literature since 1985. Articles were included in this review if S. moniliformis was cultured from synovial fluid. Of the published cases, 88% presented with polyarthritis, affecting small and large joints although two had monoarticular hip sepsis. Fever was present in 88%, rash in 25% and 56% had extra-articular features. Synovial fluid analysis revealed high cell counts in all cases (mean 51,000 x 10(9)/l) with a predominance of polymorphonuclear leucocytes, and organisms were found on Gram stain in only 50%. Penicillin was used for treatment in 56% of cases and surgery was required in 30%. All patients recovered. Rat-bite fever arthritis can be suppurative and attempts should be made to isolate the organism from synovial fluid. The diagnosis should be considered when there is arthritis and a high synovial fluid cell count but no apparent organism, especially when the patient has had contact with rats.

Management of Aspergillus osteomyelitis: report of failure of liposomal amphotericin B and response to voriconazole in an immunocompetent host and literature review

Presented here is a case of Aspergillus osteomyelitis in an immunocompetent patient that progressed despite surgery and prolonged treatment with liposomal amphotericin B; the report is followed by a review of the literature. The review of this case and 41 similar cases found an overall cure rate of 69%. The importance of surgery when amphotericin B is used as first-line therapy is indicated by a 14% cure rate when amphotericin B is used alone compared to 75% when combined with surgery. When therapy is failing or surgery is contraindicated, dose escalation using a lipid formulation was not effective. On review, the addition of another agent, in particular 5-fluorocytosine, appears to be more beneficial. The patient reported here responded rapidly to voriconazole, a promising new antifungal agent for Aspergillus infections.

Bacteraemia due to Stenotrophomonas maltophilia: an analysis of 45 episodes

OBJECTIVE

Stenotrophomonas maltophilia is an important nosocomial pathogen and a therapeutic challenge. A ten-year review of episodes of bacteraemia due to S. maltophilia was undertaken in light of reports of an increasing frequency of infection.

METHODS

A retrospective analysis of bloodstream infections due toS. maltophilia at a tertiary care hospital in Melbourne, Australia. Cases were identified via microbiology laboratory reports, and relevant clinical data were collected from the medical record of each patient.

RESULTS

Eighty per cent of these 45 episodes were nosocomial. The most common characteristics in cases of bacteraemia were the presence of an indwelling central venous catheter (CVC) (38/45, 84%) and previous antibiotic therapy (33/45, 73%). There were 8 deaths (8/44, 18%) within 7 days of bacteraemia. A significant correlation was found between deaths and a failure to remove the CVC (P = 0.01) or treat with appropriate antimicrobials (P = 0.01). Antibiotic susceptibility testing revealed that isolates were most sensitive to sulphamethoxazole (80%), chloramphenicol (75.5%) and ceftazidime (64.5%).

CONCLUSIONS

S. maltophilia is an important pathogen especially in the highly compromised host. Isolation of this organism from a blood culture should prompt a careful review of the patient with particular emphasis on removal of indwelling CVCs and commencement of appropriate antibiotic therapy.

Vancomycin and teicoplanin use in Victorian hospitals. The Victorian Drug Usage Evaluation Group

OBJECTIVE

To determine patterns of prescribing of glycopeptide antibiotics (vancomycin and teicoplanin) in Victorian hospitals and identify areas for targeted intervention.

DESIGN

A concurrent, observational, multisite evaluation of drug use.

SETTING

Thirty-five Victorian hospitals, 1-14 September 1997.

STUDY POPULATION

Patients commencing a glycopeptide antibiotic course.

MAIN OUTCOME MEASURES

Rate of glycopeptide antibiotic use; indications; duration of use; main hospitals using glycopeptide antibiotics.

RESULTS

293 patients (269 adults and 24 neonates) commenced on 302 glycopeptide antibiotic courses: 296 intravenous (i.v.) vancomycin courses and three each of oral vancomycin and parenteral teicoplanin. The overall rate of use was 10.3 courses per 1000 inpatient separations. Of 271 i.v. vancomycin courses for adults, 176 (65%) were for treatment--120 empirically. The median duration of treatment courses was 4.7 days (interquartile range, 2.0-8.2 days). A flucloxacillin-resistant organism was confirmed for 44% of treatment courses. Ninety-five i.v. vancomycin courses were for prophylaxis, including for cardiac (54%) and vascular surgery (21%); 82% of prophylactic courses were administered for less than 24 hours. Of all the glycopeptide antibiotic courses, 69% were administered at five major metropolitan hospitals.

CONCLUSIONS

Glycopeptide antibiotic use in Victoria is concentrated in the major metropolitan hospitals. Prolonged durations of vancomycin therapy, including for surgical prophylaxis and empirical therapy not subsequently confirmed by microbiology findings, would be suitable targets for interventional strategies.

The clinical efficacy of continuous-infusion flucloxacillin in serious staphylococcal sepsis

Since the efficacy of beta-lactams against pathogens such as methicillin-susceptible Staphylococcus aureus (MSSA) is related to the time for which serum drug concentrations exceed the MIC for the pathogen, administration of anti-staphylococcal beta-lactams by continuous infusion may provide a more suitable means of drug delivery than intermittent dosing. To assess the clinical efficacy of continuous-infusion therapy, we reviewed the outcomes for 20 consecutive patients with proven serious MSSA sepsis (three with endocarditis, ten osteomyelitis, one endocarditis plus osteomyelitis and six deep abscess) treated with continuous-infusion flucloxacillin (8-12 g/day). Patients initially receiving routine intermittent-dose flucloxacillin therapy were changed to continuous-infusion flucloxacillin (mean duration 29 days; range 4-60 days) for completion of their treatment course. In the majority of cases this was given at home. Serum flucloxacillin concentrations during continuous-infusion flucloxacillin 12 g/day were 11.5->40 mg/L (ten patients) and those during continuous-infusion flucloxacillin 8 g/day were 8->40 mg/L (five patients), these concentrations being well above the expected MIC of flucloxacillin for MSSA. Continuous-infusion flucloxacillin was well tolerated by most patients, and 14/17 patients (82%) who completed their course of continuous-infusion flucloxacillin were judged clinically and microbiologically cured at long-term follow-up (mean 67 weeks; range 4-152 weeks). These preliminary data suggest that, following initial intermittent-dose flucloxacillin therapy, continuous-infusion flucloxacillin is an effective treatment option for serious MSSA sepsis, and forms a feasible and possibly preferable alternative to glycopeptides when considering home-based parenteral therapy for these infections. Further studies are needed to identify whether continuous-infusion flucloxacillin can entirely replace intermittent-dose therapy for such infections.

Three cases of Anaerobiospirillum succiniciproducens bacteremia confirmed by 16S rRNA gene sequencing

We describe three cases of Anaerobiospirillum succiniciproducens bacteremia from Australia. We believe one of these cases represents the first report of A. succiniciproducens bacteremia in a human immunodeficiency virus (HIV)-infected individual. The other two patients had an underlying disorder (one patient had bleeding esophageal varices complicating alcohol liver disease and one patient had non-Hodgkin's lymphoma). A motile, gram-negative, spiral anaerobe was isolated by culturing blood from all patients. Electron microscopy showed a curved bacterium with bipolar tufts of flagella resembling Anaerobiospirillum spp. Sequencing of the 16S rRNA genes of the isolates revealed no close relatives (organisms likely to be in the same genus) in the sequence databases, nor were any sequence data available forA. succiniciproducens. This report presents for the first time the 16S rRNA gene sequence of the type strain of A. succiniciproducens, strain ATCC 29305. Two of the three clinical isolates have sequences identical to that of the type strain, while the sequence of the other strain differs from that of the type strain at 4 nucleotides.

Acute glomerulonephritis associated with acute Q fever: case report and review of the renal complications of Coxiella burnetii infection

We report a case of acute glomerulonephritis associated with acute Q fever. An abattoir worker with a nonspecific febrile illness and pneumonia and abnormal liver function test results developed hematuria, proteinuria, and acute renal failure that resolved with appropriate antimicrobial therapy. Renal biopsy demonstrated diffuse proliferative and exudative glomerulonephritis. Serological tests confirmed recent infection with Coxiella burnetii, with a fourfold rise in the titer of phase II antibody, positive phase II IgM antibody, and negative phase I antibody. Other known causes of glomerulonephritis were excluded. Most reports of renal complications of C. burnetii infection describe glomerulonephritis associated with endocarditis due to chronic Q fever. Renal involvement in patients with acute C. burnetii infection has been rarely described. Glomerulonephritis should be recognized as a complication of acute C. burnetii infection and endocarditis due to chronic Q fever.

Fatal Legionella longbeachae infection following heart transplantation

A case of fatal Legionella longbeachae infection following heart transplantation is described. Gram stains of respiratory secretions on day 17 posttransplant revealed leucocytes and gram-negative bacilli, but there was no growth on routine bacterial culture. Legionella longbeachae serogroup 1 was isolated from respiratory specimens, blood, and postmortem lung tissue. Legionella longbeachae is a common cause of legionellosis in Australia, and infection has been associated with exposure to potting mixes. Specific culture for Legionella spp. should be performed for any patient who develops pneumonia following organ transplantation.

Anaerobic meningitis due to Peptostreptococcus species: case report and review

We describe a patient with postsurgical anaerobic meningitis due to Peptostreptococcus magnus. In cases of meningitis associated with Peptostreptococcus species reported in the literature, the most common predisposing factors are meningorectal fistulae and head-and-neck surgery. Most patients respond well to appropriate antimicrobial therapy. Surgical intervention may be required in some instances.

Neurological complications of chlamydial infections: case report and review

We describe a patient with Chlamydia pneumoniae infection who presented with cerebellar dysfunction, followed by respiratory failure requiring mechanical ventilation. C. pneumoniae is an important respiratory pathogen, and other clinical manifestations, including neurological syndromes, are being increasingly recognized. Meningoencephalitis and other neurological complications have also been described in patients with infections due to Chlamydia psittaci and Chlamydia trachomatis. Chlamydial infections should be included in the differential diagnosis of neurological syndromes, including cerebellar dysfunction.

Acute hepatitis associated with Campylobacter jejuni bacteraemia

A case of acute hepatitis associated with Campylobacter jejuni bacteraemia is reported. Transaminase levels were increased over 50-fold in a patient with clinical features of enteritis and septicaemia. Campylobacter jejuni was isolated from blood and faecal cultures. Other infective and noninfective causes of acute hepatitis were excluded. The patient's symptoms and liver function values improved after antimicrobial therapy. Hepatitis should be considered as a complication of human Campylobacter jejuni infection.

Risk factors for adverse cutaneous reactions associated with intravenous vancomycin

We retrospectively studied adverse cutaneous reactions associated with intravenous vancomycin therapy over a 14-month period when two different brands of vancomycin were used. Of 224 adults, 12 (5.4%) had infusion-related reactions; ten of 174 patients who received more than one day of vancomycin (5.7%) had delayed cutaneous reactions. Age less than 40 years was a risk factor for both infusion-related and delayed reactions by both univariate and multivariate analysis. Duration of therapy greater than 7 days was a risk factor for delayed reactions. There was a significant increase in adverse cutaneous reactions associated with the use of a particular batch of vancomycin, although analytical testing of this batch failed to identify any difference from other batches associated with routine rates of adverse reactions. Awareness of vancomycin-associated infusion-related and delayed cutaneous reactions is necessary, and the risk factors associated with these reactions may have important clinical implications.

Treatment of urinary tract infections

Urinary tract infections (UTIs) are common conditions in clinical practice. For uncomplicated UTIs, the causative organisms and their antimicrobial susceptibility profiles are generally predictable, and empiric short course (3 day) antibiotic therapy after an abbreviated laboratory workup is advocated. Acute pyelonephritis requires a 2 week antibiotic course, often with initial parenteral therapy. Women with frequent recurrences of UTIs may require intermittent self-treatment or continuous or postcoital antibiotic prophylaxis. Catheter-associated UTIs generally only require treatment if the patient shows signs of systemic infection. Treatment of asymptomatic bacteriuria is only recommended in certain circumstances. Careful consideration of the clinical circumstances, the patient's known or predicted urinary tract anatomy, and the antibiotic susceptibility of the bacterial pathogen(s) are critical factors in the choice of appropriate therapy for urinary tract infections.