Screening Pneumocystis carinii pneumonia in non–HIV-infected immunocompromised patients using polymerase chain reaction

We evaluated the clinical value of polymerase chain reaction (PCR) for screening Pneumocystis carinii pneumonia (PCP) in non–HIV-infected immunocompromised patients. We retrospectively analyzed PCR and Grocott's methenamine silver (GMS) staining on 1044 clinical specimens obtained from 756 patients. Positive rates of PCR and GMS staining in sputum specimens were 21.1% and 9.5%, respectively (P < 0.01), and in bronchoalveolar lavage (BAL), specimens were 31.9% and 25.5%, respectively. Among 5 patient groups, the highest GMS staining and PCR positive rates were observed in immunosuppressed patients. In 28 GMS staining-positive patients, positive rates of PCR and GMS staining after a short anti-PCP treatment were 39.3% and 17.9%, respectively. In 5 patients with positive PCR but negative GMS staining results in initial sputum examination, GMS staining result turned positive in subsequent BAL specimens. In conclusion, PCR is sensitive for detection of Pneumocystis in sputum specimens and is useful for screening PCP in non–HIV-infected high-risk patients.     

Aerosolized pentamidine prophylaxis against AIDS-related Pneumocystis carinii pneumonia and its short- and long-term effects on pulmonary function in the Japanese

 We evaluated the incidence of prophylaxis failure with aerosolized pentamidine (AP) for Pneumocystis carinii pneumonia (PCP) in Japanese patients with human immunodeficiency virus (HIV) infection, and we examined the short- and long-term effects of AP on pulmonary function. The patients inhaled 300 mg of pentamidine by ultrasonic nebulizer, after the inhalation of procaterol (80 μg), every 4 weeks. PCP developed in 2 of 16 patients receiving primary prophylaxis with AP, and in 4 of 13 patients with secondary prophylaxis. The CD4⁺ T-lymphocyte count was very low in the patients with prophylaxis failure. The chest radiographic presentations were atypical in 4 of the 6 patients with prophylaxis failure. There were no significant changes in the vital capacity (VC), VC/predictive VC (%VC), forced expiratory volume in 1 s (FEV_1.0), FEV_1.0/forced vital capacity (FEV_1.0%), and maximum expiratory flow rate at 25% of vital capacity (MEF₂₅)/height comparing values before and after initial AP treatment. However, a reduction of oxygen saturation (SpO₂) of over 3% was noted in 4 patients during the initial AP administration. In 9 patients receiving AP prophylaxis for more than 36 months, we compared the pulmonary function parameters between the baseline and final observations (mean, 52.7 months). There were no changes in VC, %VC, FEV_1.0, FEV_1.0%, and SpO₂, but there was a statistically significant decline in MEF₂₅/height after long-term AP treatment. We concluded that the incidence of prophylaxis failure with AP for PCP in Japanese patients was similar to that in Western patients, and that long-term AP treatment affected MEF₂₅/height in spite of the safe pulmonary effects in short-term AP inhalation. Received: October 17, 2002 / Accepted: January 9, 2003     

Continuous positive airway pressure by face mask or mechanical ventilation in patients with human immunodeficiency virus infection and severePneumocystis carinii pneumonia

We reviewed the records of 44 patients with AIDS who had 45 episodes of severePenumocystis carinii pneumonia (PCP). While 9 patients required intubation and mechanical ventilation (MV) on admission, continuous positive airway pressure (CPAP) by face mask was the initial measure in 36 episodes. There were 25 patients managed with CPAP alone, 23 of whom survived. Among the reasons for delayed intubation and MV (11 patients) was that treatment failure was strongly associated with non-survival, since all 6 such patients died. The in-hospital mortality for severe PCP in this study was 33% overall, and reached 65% for mechanically ventilated patients. The 1-year survival was 43% (95% confidence interval, 28%–58%). These data confirm the improved prognosis for patients with AIDS and severe PCP, and suggest that mask CPAP may be an adequate mean of ventilatory support in this setting.     

Immunodiagnosis in cerebrospinal fluid of cerebral toxoplasmosis and HIV-infected patients using Toxoplasma gondii excreted/secreted antigens

Cerebral toxoplasmosis is the most common neurologic opportunistic infection in HIV-infected patients. Excretory–secretory antigens (ESA) are the majority of the circulating antigens in sera from hosts with acute toxoplasmosis, and their usefulness as antigens has been shown. This study considered whether it could find anti-ESA antibodies in cerebrospinal fluid (CSF) and whether these antibodies can be markers of active infection. Samples of CSF from 270 HIV-infected patients were analyzed and divided into 3 groups according to the presence or absence of active toxoplasmosis. Group I: 99 patients with cerebral toxoplasmosis; group II: 112 patients with other opportunistic neurologic diseases and seropositive for toxoplasmosis; and group III: 59 patients with other opportunistic neurologic diseases and seronegative for toxoplasmosis. Toxoplasma gondii ESA and a crude tachyzoite antigen were used as antigens using ELISA and immunoblotting. The statistical analysis was done using the F test and unpaired Student's t test. Crude tachyzoite antigen: mean ELISA-relative values ± standard error for CSF of groups I and II were 7.0 ± 0.27 and 3.9 ± 0.19, respectively. Variance analysis revealed that results of both groups of patients were statistically different (1.80, P = 0.0025). The difference between the mean results was 3.0 ± 0.3, and the Student's t test value was 9.41 (P = 0.0001). Samples from groups I and II were reactive by immunoblotting, with similar intensities. In ESA-ELISA, the mean for group I was 9.0 ± 0.39. Group II showed a mean value of 2.7 ± 0.12. Both groups were statistically different (9.16, P < 0.001). However, in ESA, the difference between the mean results was higher (6.2 ± 0.39) and the Student's t test value was 16.04 (P < 0.0001). Similar results were shown in immunoblotting where a CSF sample from group I reacted well with ESA, and the sample from a group II patient failed to do so. The mean ELISA-relative value of the control group (group III) was 0.5 ± 0.09 for the first antigen and 0.4 ± 0.22 for the second. ESA-ELISA and/or immunoblotting of CSF samples can be used for diagnosis of cerebral toxoplasmosis in association with clinical, serologic, and radiological information, thus providing a simple straightforward methodology, particularly suitable in countries with high prevalence of latent toxoplasmosis in the general population.     

Efficacy of rabeprazole in patients with reflux esophagitis: A single-center, open-label, practice-based, postmarketing surveillance investigation

Background: The efficacy of rabeprazole sodium 20 mg/d for the treatment of reflux esophagitis has been demonstrated in several studies in Japan. However, studies of rabeprazole sodium 10 mg/d are lacking.Objective: This study was conducted to assess the efficacy and tolerability of rabeprazole 10 mg/d for the treatment of reflux esophagitis.Methods: Patients diagnosed with reflux esophagitis in routine clinical practice were enrolled in this single-center, open-label, practice-based, post-marketing surveillance investigation. Patients were to receive 10 mg of rabeprazole once daily for 8 weeks. The efficacy of rabeprazole was assessed on the basis of symptoms and endoscopic findings in accordance with the modified Los Angeles classification. Tolerability was assessed using subjective symptoms recorded before, during, and after treatment.Results: Of a total of 61 patients enrolled in this study, 47 (77%; 29 men, 18 women; mean age, 63 years) were included in the efficacy and tolerability analyses. Fourteen (23%) patients, including 5 (8.2%) patients who were treated with rabeprazole 20 mg/d, were excluded from the analyses. Endoscopic examinations were performed before and after treatment in 32 of 47 (68.1%) patients; mucosal lesions were healed in 20 of 32 (62.5%) patients after rabeprazole treatment. In patients with mild mucosal lesions prior to treatment, complete remission was achieved in 17 of 24 (70.8%) patients after treatment. Rates of improvement of symptoms were as follows: epigastralgia, 76%; heartburn, 76.7%; dull pain in the esophagus, 86.7%; and belching, 72.2%. Rabeprazole was well tolerated throughout the study; no serious symptomatic adverse events were reported. Although 1 case each of elevated alkaline phosphatase and gamma-glutamyltranspeptidase levels were reported, these changes were mild and improved after continuous treatment with rabeprazole.Conclusion: In this study, rabeprazole 10 mg/d was well tolerated and was shown to have satisfactory efficacy in the healing of esophagitis and the relief of the symptoms of esophagitis.     

Effectiveness and safety of lower dose sulfamethoxazole/trimethoprim therapy for Pneumocystis jirovecii pneumonia in patients with systemic rheumatic diseases: A retrospective multicenter study

Objectives

To evaluate the effectiveness and safety of lower-dose sulfamethoxazole/trimethoprim therapy (SMX/TMP) for Pneumocystis jirovecii pneumonia (PCP) in patients with systemic rheumatic diseases.

Comparison between ImmunoCard STAT! and real-time PCR as screening tools for both O157:H7 and non-O157 Shiga toxin-producing Escherichia coli in Southern Alberta,Canada

An increasing number of non-O157 Shiga toxin-producing Escherichia coli (STEC) infections and outbreaks have been reported. In this study, we evaluated the performance of ImmunoCard STAT!^® (Meridian Bioscience, Inc., Cincinnati, OH, USA) as a method to screen stool specimens for STEC (O157 and non-O157). An in-house real-time PCR method was used as the “gold standard”. We also evaluated the prevalence and clinical characteristics of STEC infections in the Alberta South West Zone. From July to November 2011, 819 stool specimens submitted for routine stool culture were tested. With our in-house real-time PCR, 7 O157:H7 and 10 non-O157 STEC isolates were identified for a total of 17 STECs. In comparison, ImmunoCard STAT!^® identified a total of 6, resulting in a sensitivity and specificity of 35% and 99%, respectively (P < 0.05). Because of the low sensitivity, ImmunoCard STAT!^® cannot be recommended as a routine screening test for STEC from enriched stool specimens. The rate of STEC positivity as detected by PCR was 2.08%, of which 0.86% was O157:H7 and 1.22% non-O157 STEC. Five of the 7 cases of STEC O157 infection experienced bloody diarrhea, and 1 developed hemolytic uremic syndrome.     

Evaluation of two real-time PCR chemistries for the detection of Chlamydophila pneumoniae in clinical specimens

Chlamydophila pneumoniae is an atypical bacterial respiratory pathogen that is responsible for 3–10% of community-acquired pneumonia cases. We report the evaluation of two distinct real-time PCR assays for rapid and specific detection of C. pneumoniae. We tested 401 clinical specimens, finding 5.7% positive, and confirmed a localized outbreak.     

左氧氟沙星序贯疗法与头孢呋辛联合阿奇霉素治疗社区获得性肺炎的多中心、随机对照临床和药物经济学研究

目的对左氧氟沙星的序贯疗法治疗社区获得性肺炎（CAP）进行临床疗效观察及药物经济学分析评价。方法以头孢呋辛联合阿奇霉素为对照药，采用多中心随机、开放、阳性对照研究方法。结果378例CAP患者中左氧氟沙星序贯疗法治疗（190例）的痊愈率和有效率分别为67．37％和96．84％，细菌阴转率高达96．77％，药物不良反应发生率为10．53％；对照药治疗（188例）的痊愈率和有效率分别为64、36％和96、28％。细菌阴转率为96．67％，药物不良反应发生率为7．98％；两组比较差异无统计学意义，平均疗程、住院天数和住院费用差异亦无统计学意义，试验组的成本-效果比为32．01，低于对照组（38．51）。结论左氧氟沙星的序贯疗法治疗CAP临床疗效较好，药物不良反应率较低，成本-效果比较低。     

Unrecognized cervical spinal epidural abscess associated with metastatic Klebsiella pneumoniae bacteremia and liver abscess in nondiabetic patients

We describe a Klebsiella pneumoniae-related liver abscess and unrecognized epidural abscess with or without endophthalmitis in 2 nondiabetic patients, both of whom suffered neurologic complications after invasive procedure. Although rare, we should keep these types of cases in mind when making a diagnosis in patients with both liver abscess and complaint of neck pain.     

Therapeutic efficacies of penicillin G,cefotaxime, and imipenem/cilastatin against penicillin-resistant pneumococcal pneumonia in CBA/J mice

We compared the therapeutic efficacies of penicillin G (PCG), cefotaxime (CTX), and imipenem/cilastatin (IPM/CS) against penicillin-resistantStreptococcus pneumoniae pneumonia in CBA/J mice. In pneumonia induced by strain TUH39 (PCG MIC; 0.063 μg/mL), eight 2.5 mg/kg doses of PCG administered at 1.5 hour intervals beginning 36 hours after infection reduced the number of bacteria in the lungs below the limit of detection. In contrast, a similar regimen failed to lower the number of organisms following infection with strain TUM741 (PCG MIC; 1 μg/mL); however, PCG doses of 8 × 10 and 8 × 40 mg/kg reduced bacterial numbers in a dose-dependent manner. CTX (MIC; 0.5 μg/mL) and IPM/CS (MIC; 0.125 μg/mL) at 6 × 40 mg/kg were more effective than PCG at the same dose against strain TUM741 pneumonia; these antibiotics eradicated bacteria in lungs of 2 out of 5 and 5 out of 5 mice, respectively. In accord with the pulmonary clearance results, survival of mice treated with PCG (6 × 40 and 6 × 160 mg/kg), CTX (6 × 40 mg/kg) and IPM/CS (6 × 40 mg/kg) were 30%, 80%, 40% and 100%, respectively. Pharmacokinetic analysis in lungs revealed that IPM/CS was superior to CTX and PCG in several parameters. These results demonstrate therapeutic responses to CTX, IPM/CS and high-dose PCG in a CBA/J mouse model of penicillin-resistant pneumococcal pneumonia. Results with IPM/CS were particularly favorable, suggesting this antibiotic combination as a potential first-line treatment for penicillin-resistantS. pneumoniae pneumonia.     

Cefepime vs. Ampicillin/Sulbactam and Aztreonam as antibiotic prophylaxis in neurosurgical patients with external ventricular drain: result of a prospective randomized controlled clinical trial

INTRODUCTION: We aimed to find out whether single board spectrum antibiotic prophylaxis was as good as dual specific antibiotic prophylaxis in neurosurgical patients with external ventricular drain (EVD) in situ. METHOD: In a 2-year period, 255 eligible patients were recruited. Patients were randomized into two groups of antibiotic prophylaxis as long as the ventricular catheter in situ. Group A employed Cefepime 2G 12 hourly and Group B employed dual antibiotics as Ampicillin/Sulbactam 3 g 8 hourly and Aztrenam 2 g 8 hourly. RESULTS: There was no statistically significant difference in cerebrospinal fluid (CSF) infection rate with 14 patients (11.5%) in group A (Cefepime prophylaxis) and eight patients (6.0%) in group B (dual prophylaxis with Ampicillin/Sulbactam and Aztrenam) had CSF infection (P=0.18). There was also no statistical significant difference between wound infection rate happened in eight patients (6.6%) in Group A and three patients (2.3%) in Group B (P=0.17). There was no statistical significant difference in extracranial infection rate between both groups (P=0.70). CONCLUSION: Single board spectrum antibiotic prophylaxis with Cefepime was an effective alternative regimen for neurosurgical patients with an EVD in situ.     

IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care

Background

Cardiovascular disease (CVD) is the leading cause of death, and principal reason for the large difference in life expectancy between indigenous Māori and the non-indigenous population in New Zealand. CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin, blood pressure lowering and lipid lowering therapies. However, prescribing and adherence rates are low and CVD events remain high.

Aim

To assess whether a medication strategy using a fixed dose combination pill (‘polypill’) could improve prescribing and adherence to recommended medications, lower blood pressure and improve lipids compared with current care over 12 months.

Methods

IMProving Adherence using Combination Therapy (IMPACT) is an open-label randomised controlled trial comparing a once-daily polypill containing four preventive medications with usual care. Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled, including 300 Māori. Participants are identified, enrolled and prescribed either the polypill or current medications at their usual primary health care practice, with medications (including the polypill) dispensed through local community pharmacies. The polypill contains 75 mg aspirin, 40 mg simvastatin, 10 mg lisinopril and either 12.5 mg hydrochlorothiazide or 50 mg atenolol. Primary outcomes are adherence to guidelines-recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months. Secondary outcomes include other lipids, medication dispensing, barriers to adherence, CVD and other serious adverse events, quality of life and prescriber acceptability. The trial is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12606000067572).     

Rapid detection of Mycobacterium tuberculosis in sputum by Patho-TB kit in comparison with direct microscopy and culture

The usefulness of a new rapid diagnostic test (Patho-TB) using antibodies specific to mycobacterial antigens was evaluated for the rapid discrimination between pulmonary tuberculosis (TB) and non-TB pulmonary diseases on sputa. One hundred sputa collected from 79 active TB patients and from 21 patients with non-TB pulmonary diseases (asthma and chronic obstructive pulmonary disease) were enrolled into the study and tested for the presence of Mycobacterium tuberculosis by Ziehl–Neelsen smear, Patho-TB kit, and Löwenstein–Jensen culture. The sensitivity, specificity, positive predictive value, and negative predictive value of the Patho-TB test were 95%, 100%, 100%, and 84%, respectively. Patho-TB test is simple, quick, and easy to perform. Its sensitivity, specificity, and positive predictive value are satisfactory. Therefore, it could be used as a screening test in poorly equipped laboratories of TB endemic areas.     

A simple PCR-based genotyping method for M105I mutation of alpha-SNAP enhances the study of early pathological changes in hyh phenotype

α-SNAP is an essential component of the protein machinery responsible for membrane fusion events in different cell types. The hyh (hydrocephalus with hop gait) mouse carries a missense mutation in Napa gene that results in a point mutation (M105I) in α-SNAP protein. Homozygous animals for the mutant allele have been identified by the clinical and/or neuropathological phenotype, or by direct sequencing of PCR products. The aims of the present study were (i) to develop a high-throughput technique to genotype hyh mice, (ii) to correlate genotype-phenotype, and (iii) to analyze the earliest pathological changes of hyh mutant mice. As no restriction sites are affected by the hyh mutation, we resolved this problem by creating a BspHI restriction site with a modified (mismatch) polymerase chain reaction (PCR) primer in wild-type allele. This artificially created restriction site (ACRS)–PCR technique is a simple, rapid and reliable method to genotype hyh mice in a day-work procedure. Biochemical and histological analysis of genotyped hyh embryos at different developmental stages allowed us to identify and characterize the earliest brain pathological changes of the hyh phenotype, including the first signs of neuroepithelial disruption and neuronal ectopia. In addition, genotype-phenotype analysis of 327 animals confirmed that (i) hyh is a single-gene autosomal recessive disorder, and (ii) the disorder has 100% penetrance (i.e., the mutation was only present in affected mice). The genotyping method described here enhances the potentiality of hyh mouse as a unique in vivo model to study the role of membrane trafficking in different developmental and physiological processes.     

Chlamydia trachomatis ompA genotypes in male patients with urethritis in Greece: conservation of the serovar distribution and evidence for mixed infections with Chlamydophila abortus

PCR amplification and nucleotide sequencing of the ompA gene of Chlamydia trachomatis were used to determine the prevalence and distribution of genotypes in 51 urine and urethral specimens from Greek male patients with urethritis, that were positive by the COBAS Amplicor test. A single C. trachomatis serovar was identified in 43 of the 51 amplified samples. Serovars F and E were the most prevalent (both 12, 28%), followed by D (9, 21%), G (4, 9%), B and K (both 2, 5%) and H and J (both 1, 2%). Over one third of the samples bared a variant ompA genotype that had been previously identified in other areas worldwide. Two results in this study, both observed for the first time, were of particular interest. First, the emergence of the unique variant genotype D/Ep6 (X77364.2) identified in 3 urethral samples. Second, the ompA genotype OCLH196 of the animal pathogen Chlamydophila abortus as well as a 23S rRNA gene fragment of this species detected by the assay ArrayTube™ was found in 7 urethral samples. The implications resulting from this observation for the health of the general population are discussed.     

Do in situ forming PLG/NMP implants behave similar in vitro and in vivo? A non-invasive and quantitative EPR investigation on the mechanisms of the implant formation process

Electron paramagnetic resonance (EPR) spectroscopy was applied to monitor non-invasively the formation of in situ forming implants in vitro and in vivo after the administration of poly(lactide-co-glycolide) (PLGA)/N-methyl-pyrrolidone (NMP) solutions. The nitroxide spin probe 4-benzoyloxy-2,2,6,6-tetramethylpiperidine-1-oxyl (TB) was incorporated in polymer solutions and samples were incubated in 0.1 M phosphate buffer (pH 7.4) at 37 °C or injected subcutaneously in the femoral of BALB/c mice. EPR permitted the direct and continuous determination of the NMP-water exchange during implant formation both in vitro and in living mice. The formation of the implant structure followed a two phase mechanism: over 75% of the polymer precipitated immediately after injection within the first 30 min and formed a solid shell. The subsequent moderate solidification of the implants was governed by diffusion and was completed after 24 h. The replacement of the organic solvent NMP by water was determined by polarity shifts within the implant and could be quantified. Both the kinetic of NMP-water exchange and polymer precipitation showed good in vitro–in vivo correlation.