Management and choice of antibiotics for patients with an allergy to penicillin

Allergic reactions to penicillin occur in 0.7-8% of treatments. Management of bacterial infections in patients allergic to penicillin depends on the availability of alternative antibiotics and on the type of allergy. Skin tests can be used to exclude the risk of IgE-mediated reactions (e.g. anaphylaxis) to subsequent penicillin administration. If penicillin is the first choice for treatment and the patient has an IgE-mediated allergy (on the basis of a positive skin test), desensitization therapy to the drug can be performed.     

Determination of ionisation chamber collection efficiency in a swept electron beam by means of thermoluminescent detectors and the "two-voltage" method

Two methods for determining the collection efficiency of a 0.6 cm3 thimble ionisation chamber exposed to the swept electron beam of a linear accelerator Therac 20 Saturne (CGR MeV) have been compared. In one method the chamber signal has been compared to that of simultaneously exposed thermoluminescent LiF dosemeters (TLD), in the other the "two-voltage" method of Boag, adapted for swept beams, has been used. By variation of the electron energy between 20 and 13 MeV, of the focus-skin-distance (FSD) between 200 and 100 cm and of the monitor rate between 400 monitor units (m.u.) and 100 m.u. per minute, different values could be produced for the peak charge density M. The collection efficiency of the chamber, operating at a standard voltage of 250 V, decreases from 0.99 to 0.84 for a charge density increasing from 0.3 X 10(-4) C/m3 to 7.5 X 10(-4) C/m3, respectively. The maximum deviation observed between the TLD and the "two-voltage" method adopted for similar M is never more than 2% and mostly smaller than 1%. It can be concluded that, under the present experimental conditions, the calculated ionisation chamber collection efficiency is confirmed by the experimental method using TL dosimetry.     

Persistent Transmission of HCV among Men Who Have Sex with Men despite Widespread Screening and Treatment with Direct-Acting Antivirals

Background: In the Netherlands, unrestricted access to direct-acting antivirals (DAAs) halved the incidence of acute hepatitis C virus (HCV) infections among HIV-infected men who have sex with men (MSM). To develop strategies that can further reduce the spread of HCV, it is important to understand the transmission dynamics of HCV. We used phylogenetic analysis of a dense sample of MSM to provide insight into the impact of unrestricted access to DAAs on HCV transmission in the Netherlands and in Belgium. Methods: We included 89 MSM that were recently infected with HCV genotype 1a in ten Dutch and one Belgian HIV treatment centers. Sequences were generated using next gene sequencing and Sanger sequencing. Maximum likelihood phylogenetic analysis (general time reversible model) was performed on concatenated NS5A and NS5B sequences and a reference set of 389 highly similar control sequences selected from GenBank. A cluster was based on a minimum bootstrap support of 90% and a 3% genetic distance threshold. Results: We found that 78 (88%) of individuals were part of seven major clusters. All clusters included individuals from across the study region, however, different cities were part of different clusters. In three clusters, HIV-negative MSM clustered with sequences from HIV-positive MSM. All clusters that were observed before the introduction of DAAs persisted after unrestricted access to DAAs became available. Conclusion: Recently acquired HCV infections among MSM in the Netherlands and Belgium are strongly clustered and therefore highly suitable for targeted prevention strategies, such as contact tracing and partner notification. Importantly, despite an HCV incidence reduction after high DAA uptake and continuously monitoring, HCV transmission persisted in the same clusters.     

Frequency of transient streptococcal bacteremia following urgent orotracheal intubation in critically ill patients

OBJECTIVES: To examine whether urgent orotracheal intubation (OI) can induce bacteremia. To find predictive factors for post-intubation bacteremia. DESIGN: Prospective observational study. SETTING: Seventeen-bed medical intensive care unit in a university hospital. PATIENTS: Sixty-eight adult intensive care patients undergoing urgent OI. MEASUREMENTS AND RESULTS: Patients in need of OI could be included if no cardiopulmonary resuscitation was performed. A blood culture was taken immediately before, as soon as possible after, and 60 min after intubation. The indication for intubation, ease of intubation, and the antibiotics used before intubation were registered. Six patients (6/68 or 9%) had streptococcal bacteremia immediately (mean 10.8 min) after intubation. No patient (0/62) had streptococcal bacteremia 60 min after intubation (P = 0.01). Four of the six patients showing streptococcal bacteremia after intubation were intubated by a second doctor because of difficulties during intubation, whereas this was the case in only 9/62 in those without streptococcal bacteremia (P = 0.01). Four of the 13 patients (31%) who needed to be intubated by a second doctor showed transient streptococcal bacteremia. Of the 20 patients not receiving antibiotics at the time of intubation, four (20%) had streptococcal bacteremia compared with 2/47 (4.2%) patients receiving antibiotics (P = 0.06). CONCLUSIONS: Urgent intubation can cause transient bacteremia with streptococci in a significant proportion of intensive care patients. The observed frequency of bacteremia is higher than previously reported after elective intubation. The difficulty of intubation is probably a predisposing factor.