Early initiation of antiretroviral therapy (ART) within 6 months of HIV infection contributes to the normalization of CD8 T-cell counts. The study found that:
1) CD8 counts decreased significantly from 797 to 588 cells/μL over 24 months in individuals who started ART early, reaching lower levels than those without ART or with delayed ART.
2) CD4 T-cell recovery was more prominent in individuals who started ART early compared to those with delayed ART.
3) ART initiated early in HIV infection is associated with improved resolution of elevated CD8 T-cell counts compared to long-term ART initiated in chronic infection, which may help reduce non-AIDS related events.
1) Antibiotic de-escalation refers to narrowing or reducing the spectrum of antibiotics administered to critically ill patients once culture results are available.
2) Observational studies have found de-escalation therapy to be safely practiced in ICU patients and possibly associated with lower mortality and shorter hospital stays.
3) However, randomized trials have found possible higher risks of reinfection with de-escalation, without effects on mortality. Overall, de-escalation appears to be a well-tolerated strategy but is not widely adopted in practice.
This document summarizes the principles of tuberculosis treatment. It notes that while effective treatment has been available for 60 years, treatment takes at least 6 months. The standard treatment involves a 2-month induction phase with at least 3 drugs (isoniazid, rifampin, and pyrazinamide), followed by a 4-month consolidation phase with at least 2 drugs (isoniazid and rifampin). Challenges to treatment include bacterial populations with differing drug susceptibilities, sequestration of bacteria in tissues where drugs cannot reach, and factors influencing drug absorption and metabolism.
This study found that CMV coinfection is associated with higher CD8 T-cell counts, lower CD4/CD8 ratios, and increased systemic inflammation in ART-treated HIV-infected individuals. The key findings were:
1) Median CD8 counts were significantly higher in HIV/CMV coinfected patients compared to HIV monoinfected or healthy controls.
2) HIV/CMV coinfection resulted in significantly lower CD4/CD8 ratios.
3) Levels of inflammatory markers IP-10, TNF-RII, and D-dimer were higher in HIV/CMV coinfected individuals.
CMV coinfection may contribute to the risk of morbid outcomes in treated HIV infection by driving
Echinocandins remain the preferred treatment for invasive Candida infections. While mutations in FKS genes can cause reduced echinocandin susceptibility, overall rates of resistance remain low outside of certain high-risk settings. Susceptibility testing and detection of FKS mutations have limited roles in routine clinical practice due to low prevalence, testing uncertainties, and unclear relationships with treatment outcomes. These tools may be most useful for patients with prior echinocandin exposure who develop new infections or do not respond to treatment.
Treatment of hospital acquired, ventilator-associated, and healthcare-associa...Christian Wilhelm
This document discusses the treatment of hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) in adults. It emphasizes the importance of appropriate antibiotic therapy based on risk factors for multidrug-resistant pathogens. For patients at higher risk, empiric broad-spectrum multidrug therapy is recommended. Once culture results are available, therapy should be narrowed based on susceptibility. Adherence to treatment guidelines has been shown to improve outcomes in some studies, but guidelines may fail to identify some patients at risk of drug-resistant bacteria.
Dexamethasone is a corticosteroid that has shown promise in improving outcomes for patients with bacterial meningitis. However, previous studies have found conflicting results on whether it benefits all patients or only certain subgroups. This study conducted a meta-analysis of individual patient data from 5 randomized controlled trials involving 2029 patients to identify which patients are most likely to benefit from dexamethasone treatment. The analysis found that dexamethasone did not significantly reduce death rates or neurological disability overall. It also did not provide significant benefits within any prespecified subgroups based on factors like causative organism, pre-treatment with antibiotics, HIV status, or age. The only benefit seen was a reduction in hearing loss among survivors.
Early initiation of antiretroviral therapy (ART) within 6 months of HIV infection contributes to the normalization of CD8 T-cell counts. The study found that:
1) CD8 counts decreased significantly from 797 to 588 cells/μL over 24 months in individuals who started ART early, reaching lower levels than those without ART or with delayed ART.
2) CD4 T-cell recovery was more prominent in individuals who started ART early compared to those with delayed ART.
3) ART initiated early in HIV infection is associated with improved resolution of elevated CD8 T-cell counts compared to long-term ART initiated in chronic infection, which may help reduce non-AIDS related events.
1) Antibiotic de-escalation refers to narrowing or reducing the spectrum of antibiotics administered to critically ill patients once culture results are available.
2) Observational studies have found de-escalation therapy to be safely practiced in ICU patients and possibly associated with lower mortality and shorter hospital stays.
3) However, randomized trials have found possible higher risks of reinfection with de-escalation, without effects on mortality. Overall, de-escalation appears to be a well-tolerated strategy but is not widely adopted in practice.
This document summarizes the principles of tuberculosis treatment. It notes that while effective treatment has been available for 60 years, treatment takes at least 6 months. The standard treatment involves a 2-month induction phase with at least 3 drugs (isoniazid, rifampin, and pyrazinamide), followed by a 4-month consolidation phase with at least 2 drugs (isoniazid and rifampin). Challenges to treatment include bacterial populations with differing drug susceptibilities, sequestration of bacteria in tissues where drugs cannot reach, and factors influencing drug absorption and metabolism.
This study found that CMV coinfection is associated with higher CD8 T-cell counts, lower CD4/CD8 ratios, and increased systemic inflammation in ART-treated HIV-infected individuals. The key findings were:
1) Median CD8 counts were significantly higher in HIV/CMV coinfected patients compared to HIV monoinfected or healthy controls.
2) HIV/CMV coinfection resulted in significantly lower CD4/CD8 ratios.
3) Levels of inflammatory markers IP-10, TNF-RII, and D-dimer were higher in HIV/CMV coinfected individuals.
CMV coinfection may contribute to the risk of morbid outcomes in treated HIV infection by driving
Echinocandins remain the preferred treatment for invasive Candida infections. While mutations in FKS genes can cause reduced echinocandin susceptibility, overall rates of resistance remain low outside of certain high-risk settings. Susceptibility testing and detection of FKS mutations have limited roles in routine clinical practice due to low prevalence, testing uncertainties, and unclear relationships with treatment outcomes. These tools may be most useful for patients with prior echinocandin exposure who develop new infections or do not respond to treatment.
Treatment of hospital acquired, ventilator-associated, and healthcare-associa...Christian Wilhelm
This document discusses the treatment of hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) in adults. It emphasizes the importance of appropriate antibiotic therapy based on risk factors for multidrug-resistant pathogens. For patients at higher risk, empiric broad-spectrum multidrug therapy is recommended. Once culture results are available, therapy should be narrowed based on susceptibility. Adherence to treatment guidelines has been shown to improve outcomes in some studies, but guidelines may fail to identify some patients at risk of drug-resistant bacteria.
Dexamethasone is a corticosteroid that has shown promise in improving outcomes for patients with bacterial meningitis. However, previous studies have found conflicting results on whether it benefits all patients or only certain subgroups. This study conducted a meta-analysis of individual patient data from 5 randomized controlled trials involving 2029 patients to identify which patients are most likely to benefit from dexamethasone treatment. The analysis found that dexamethasone did not significantly reduce death rates or neurological disability overall. It also did not provide significant benefits within any prespecified subgroups based on factors like causative organism, pre-treatment with antibiotics, HIV status, or age. The only benefit seen was a reduction in hearing loss among survivors.
This document discusses issues in selecting appropriate non-inferiority margins or "deltas" in clinical trials comparing a new drug to an active control drug. It examines challenges in setting deltas for acute bacterial meningitis and hospital-acquired pneumonia based on historical data, disease severity, and practical trial considerations. For both conditions, the magnitude of benefit from antibiotics over placebo is unclear from old studies. A smaller delta reflecting less acceptable inferiority is preferable for severe diseases, but may require impractically large trials.
1. This document provides guidelines for the diagnosis, management, and treatment of hepatitis C virus (HCV) infection based on a formal review of recent literature and expert consensus.
2. It recommends screening high-risk groups for HCV infection, including current and former injection drug users, those with HIV, and prior blood transfusion recipients.
3. It also provides guidance on counseling HCV-infected individuals, including advising them to avoid behaviors that may spread the virus and informing them that properly performed tattooing and piercing pose a very low risk of transmission.
Necessity of COVID-19 vaccination in previously infected individualsMattisHallsteinVolla
This study examined the incidence of COVID-19 among 52,238 employees in an American healthcare system over 5 months. The study found:
1) The cumulative incidence of COVID-19 remained almost zero among those previously infected who remained unvaccinated, those previously infected who were vaccinated, and those not previously infected who were vaccinated.
2) In contrast, there was a steady increase in cumulative incidence among those not previously infected who remained unvaccinated.
3) Not one of the 1,359 previously infected subjects who remained unvaccinated had COVID-19 over the duration of the study.
The results suggest individuals who have had COVID-19 are unlikely to benefit from vaccination, and vaccines
This study analyzed serious non-AIDS events (SNAs) among HIV-infected adults in Latin America. The researchers identified 130 patients with SNA events out of 6007 patients in the cohort, representing an incidence rate of 0.86 events per 100 person-years. Risk factors like hepatitis B/C coinfection, diabetes, and alcohol abuse were associated with SNA events. Lower CD4 cell counts prior to and at the index date were significantly associated with SNA events occurring, even in patients receiving antiretroviral treatment. The study found HIV-associated immune deficiency increased the risk of SNA events.
This document provides an updated practice guideline from the American Association for the Study of Liver Diseases (AASLD) for the treatment of genotype 1 chronic hepatitis C virus infection. The guideline is based on a formal review of recent literature and considers new direct-acting antiviral agents and genetic markers associated with treatment response. Major advances since the previous guideline include the development of direct-acting antiviral protease inhibitors and identification of single-nucleotide polymorphisms related to hepatitis C virus clearance. The guideline provides recommendations for treating genotype 1 infection with current standard of care therapies as well as newer protease inhibitor regimens, noting that additional data is still needed as treatments continue to evolve.
This study examined the risk of serious infection in patients with rheumatoid arthritis (RA) and interstitial lung disease (ILD). The study identified 181 RA patients with ILD between 1998-2014. It found that these patients faced a high risk of serious infections requiring hospitalization, with an overall rate of 7.4 infections per 100 person-years. The risk was highest for patients with organizing pneumonia ILD (27.1 per 100 person-years) and lower for nonspecific interstitial pneumonia and usual interstitial pneumonia. Use of high-dose prednisone (>10mg per day) was also linked to greater infection risk. Identifying patients at highest risk could help reduce infection-related morbidity.
Who 2019-n cov-corticosteroids-2020.1-engCIkumparan
This document provides recommendations from the WHO on the use of corticosteroids for the treatment of COVID-19. It recommends the use of systemic corticosteroids for patients with severe or critical COVID-19 based on moderate certainty evidence showing benefits. It conditionally recommends against the use of corticosteroids for non-severe COVID-19 based on low certainty evidence. The document was developed in collaboration with experts and reviews evidence on corticosteroid use from multiple clinical trials. It provides the background, methods, evidence and practical considerations regarding the recommendations.
This document provides guidelines from the Infectious Diseases Society of America for the use of antimicrobial agents in neutropenic patients with cancer. Key points include:
1) Patients should be assessed for risk of infection and categorized as high or low risk to guide treatment approach. High risk patients require hospitalization and IV antibiotics.
2) Initial evaluation should include blood cultures and tests to assess organ function. Imaging is indicated if respiratory symptoms are present.
3) High risk patients require broad-spectrum IV antibiotics targeting both gram-positive and gram-negative bacteria. Antifungal therapy or investigation should be considered if fever persists after 4-7 days of antibiotics.
4) Treatment duration depends on infection status and marrow
ABSTRACT- Invasive fungal infections have become a major source of morbidity and mortality in post operative
patients. Critically ill patients after extended surgical procedure are more risk to post surgical fungal infections. Life
saving devices like central venous catheters can increases risk for fungal infections. Surgical infections are infections of
the tissues, organs or spaces exposed by surgeons during performances of surgical procedure. Mold infection is
increasingly common in post operative patients. Postoperative surgical infection represents an uncommon but potentially
devastating complication of surgery. Unfortunately, medical community is not much aware of such secondary infections
due to fungi in post operative patients leading to grave consequences. Better diagnostic methods are needed to improve
the outcome of successful surgery and better health care for public. The diagnosis of invasion and dissemination in the
majority of cases requires the acquisition and proper interpretation of clinical evidence.
Key-words- Postoperative, Surgical infections, Secondary infections, Diagnostic method
1) Empirical antibiotic therapy is initiated prior to determining the specific infecting microorganism in patients with septic shock. Inappropriate empirical therapy is associated with increased mortality.
2) Therapies should be broad-spectrum and cover likely pathogens based on infection site and patient risk factors. They should be reassessed and narrowed once culture results are available.
3) Antibiotics should be administered within 1 hour of recognizing septic shock, as delays in treatment are associated with increased mortality. Prompt administration of appropriate empirical therapy improves survival in septic shock.
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
This document summarizes a study of 82 patients with pneumonia who were treated as outpatients and re-evaluated after 14 days in an emergency department in Spain. The average age was 49 years old, and most patients had mild symptoms. Bacteria were detected in 29% of cases, most commonly Streptococcus pneumoniae and Mycoplasma pneumoniae. All patients recovered without deaths, though two needed further hospital consultation. The study concludes that outpatient treatment can be effective for mildly ill pneumonia patients when monitored in the emergency department.
Knowledge and Attitude of Prosthodontic Post Graduates on COVID 19: A Qualita...DrHeena tiwari
This document summarizes a study that surveyed 60 prosthodontic post-graduate students regarding their knowledge and attitudes about COVID-19. The results found that 80% felt they received adequate training on COVID-19 prevention and control, while over 60% were confident in managing patients with required precautions. However, only around 63% knew who to contact if they encountered a suspected COVID-19 patient. Nearly all (96.6%) agreed that the pandemic has affected their academic activities. The study concludes that understanding aerosol transmission in dentistry can help identify risks and improve practices to prevent disease spread.
This case report describes a 35-year-old male with acute myeloid leukemia who presented with ptosis of both eyes after receiving aminoglycosides for a chest infection. He was initially diagnosed with a post-synaptic neuromuscular junction disorder but later developed progressive symmetrical weakness and respiratory difficulty, confirming a diagnosis of myasthenic crisis. Treatment with high-dose steroids was started. Further evaluation ruled out thymoma or central nervous system involvement. The case report discusses myasthenic crisis as exacerbation of muscle weakness that can lead to respiratory failure and highlights common precipitating factors like infection.
This document provides guidelines from the American Association for the Study of Liver Diseases (AASLD) for the management of chronic hepatitis B infection. It summarizes recommendations for screening high-risk populations to identify those infected with hepatitis B virus (HBV), including people born in areas with high HBV prevalence and those with risk factors like injection drug use or multiple sexual partners. The guidelines are based on a review of medical literature on HBV and aim to provide a data-supported approach to treating chronic HBV patients.
This study retrospectively reviewed 133 pediatric patients treated for acute osteomyelitis between 2002-2012 at two universities to identify factors associated with treatment failure and evaluate optimal antibiotic treatment. The majority (106 patients) were successfully treated, defined as treatment under 14 weeks without recurrence within 30 days of stopping antibiotics. Seventeen patients were treated with trimethoprim-sulfamethoxazole with comparable cure rates. Factors like pre-existing bone defects, high initial erythrocyte sedimentation rate, extensive soft tissue involvement, and skull osteomyelitis were associated with higher failure rates. On average, patients transitioned to low bioavailability oral antibiotics at 3.5 weeks, and transitioning before this time did not decrease cure
Fungal infections can occur due to the increasing use of broad-spectrum antibiotics and patients with immunodeficiency. Some pathogens, such as Cryptococcus, Candida,and Fusarium, rarely cause serious diseases in the normal host, while other endemic fungi, such as Histoplasmosis, Coccidiodes,and Paracoccidiodes can cause disease in a normal host, but has a tendency to be aggressive on immunocompromise.
Candida species are normal flora that may be an apportunistic pathogen. Candidiasis occurs in some diseases such as gastrointestinal mucosal esophagitis, a fungal disease associated with the use of catheters and in - patients who have mucosal damage or obtain broad – spectrum antibiotics. Other candidiasis consist of skin candidiasis, funguria candidiasis, disseminated candidiasis and endocarditis candidiasis. Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in many of the developed country. Invasive candidiasis has a significant impact on patient outcomes, and it has been estimated that the mortality of invasive candidiasis is as high as 47%. The mortality rates are 15%-25% for adults and 10%-15% for neonates and children. Diagnostic approach to fungal infection is a priority. The knowledge of the changes in epidemiology and risk factors for fungal infections, has become the main reference to measure optimal treatment of fungal infections.
Clinical presentation and outcomes of HIV positive patients with diagnosis of...Oscar Malpartida-Tabuchi
This document summarizes a study on tuberculosis (TB) in HIV-positive patients at a hospital in Lima, Peru in 2014. It finds that:
- 22 HIV+ patients were diagnosed with TB, most were male with low CD4 counts. Extra-pulmonary TB was most common.
- 21 cases were microbiologically confirmed, with high rates of drug resistance including 30% MDR and 5% XDR.
- Outcomes differed by HIV treatment group: no mortality in groups receiving HIV drugs >6 months or <6 months, but 18.2% mortality in group not receiving HIV drugs.
E twinning is 5 (nx powerlite) (nxpowerlite)ivanabrabcova
eTwinning is a community for schools in Europe to collaborate using information and communication technology tools. Teachers and students can connect with other schools to work together on projects, share ideas and best practices. The program has been running for 15 years and has brought over 250,000 schools together from across Europe.
This document discusses issues in selecting appropriate non-inferiority margins or "deltas" in clinical trials comparing a new drug to an active control drug. It examines challenges in setting deltas for acute bacterial meningitis and hospital-acquired pneumonia based on historical data, disease severity, and practical trial considerations. For both conditions, the magnitude of benefit from antibiotics over placebo is unclear from old studies. A smaller delta reflecting less acceptable inferiority is preferable for severe diseases, but may require impractically large trials.
1. This document provides guidelines for the diagnosis, management, and treatment of hepatitis C virus (HCV) infection based on a formal review of recent literature and expert consensus.
2. It recommends screening high-risk groups for HCV infection, including current and former injection drug users, those with HIV, and prior blood transfusion recipients.
3. It also provides guidance on counseling HCV-infected individuals, including advising them to avoid behaviors that may spread the virus and informing them that properly performed tattooing and piercing pose a very low risk of transmission.
Necessity of COVID-19 vaccination in previously infected individualsMattisHallsteinVolla
This study examined the incidence of COVID-19 among 52,238 employees in an American healthcare system over 5 months. The study found:
1) The cumulative incidence of COVID-19 remained almost zero among those previously infected who remained unvaccinated, those previously infected who were vaccinated, and those not previously infected who were vaccinated.
2) In contrast, there was a steady increase in cumulative incidence among those not previously infected who remained unvaccinated.
3) Not one of the 1,359 previously infected subjects who remained unvaccinated had COVID-19 over the duration of the study.
The results suggest individuals who have had COVID-19 are unlikely to benefit from vaccination, and vaccines
This study analyzed serious non-AIDS events (SNAs) among HIV-infected adults in Latin America. The researchers identified 130 patients with SNA events out of 6007 patients in the cohort, representing an incidence rate of 0.86 events per 100 person-years. Risk factors like hepatitis B/C coinfection, diabetes, and alcohol abuse were associated with SNA events. Lower CD4 cell counts prior to and at the index date were significantly associated with SNA events occurring, even in patients receiving antiretroviral treatment. The study found HIV-associated immune deficiency increased the risk of SNA events.
This document provides an updated practice guideline from the American Association for the Study of Liver Diseases (AASLD) for the treatment of genotype 1 chronic hepatitis C virus infection. The guideline is based on a formal review of recent literature and considers new direct-acting antiviral agents and genetic markers associated with treatment response. Major advances since the previous guideline include the development of direct-acting antiviral protease inhibitors and identification of single-nucleotide polymorphisms related to hepatitis C virus clearance. The guideline provides recommendations for treating genotype 1 infection with current standard of care therapies as well as newer protease inhibitor regimens, noting that additional data is still needed as treatments continue to evolve.
This study examined the risk of serious infection in patients with rheumatoid arthritis (RA) and interstitial lung disease (ILD). The study identified 181 RA patients with ILD between 1998-2014. It found that these patients faced a high risk of serious infections requiring hospitalization, with an overall rate of 7.4 infections per 100 person-years. The risk was highest for patients with organizing pneumonia ILD (27.1 per 100 person-years) and lower for nonspecific interstitial pneumonia and usual interstitial pneumonia. Use of high-dose prednisone (>10mg per day) was also linked to greater infection risk. Identifying patients at highest risk could help reduce infection-related morbidity.
Who 2019-n cov-corticosteroids-2020.1-engCIkumparan
This document provides recommendations from the WHO on the use of corticosteroids for the treatment of COVID-19. It recommends the use of systemic corticosteroids for patients with severe or critical COVID-19 based on moderate certainty evidence showing benefits. It conditionally recommends against the use of corticosteroids for non-severe COVID-19 based on low certainty evidence. The document was developed in collaboration with experts and reviews evidence on corticosteroid use from multiple clinical trials. It provides the background, methods, evidence and practical considerations regarding the recommendations.
This document provides guidelines from the Infectious Diseases Society of America for the use of antimicrobial agents in neutropenic patients with cancer. Key points include:
1) Patients should be assessed for risk of infection and categorized as high or low risk to guide treatment approach. High risk patients require hospitalization and IV antibiotics.
2) Initial evaluation should include blood cultures and tests to assess organ function. Imaging is indicated if respiratory symptoms are present.
3) High risk patients require broad-spectrum IV antibiotics targeting both gram-positive and gram-negative bacteria. Antifungal therapy or investigation should be considered if fever persists after 4-7 days of antibiotics.
4) Treatment duration depends on infection status and marrow
ABSTRACT- Invasive fungal infections have become a major source of morbidity and mortality in post operative
patients. Critically ill patients after extended surgical procedure are more risk to post surgical fungal infections. Life
saving devices like central venous catheters can increases risk for fungal infections. Surgical infections are infections of
the tissues, organs or spaces exposed by surgeons during performances of surgical procedure. Mold infection is
increasingly common in post operative patients. Postoperative surgical infection represents an uncommon but potentially
devastating complication of surgery. Unfortunately, medical community is not much aware of such secondary infections
due to fungi in post operative patients leading to grave consequences. Better diagnostic methods are needed to improve
the outcome of successful surgery and better health care for public. The diagnosis of invasion and dissemination in the
majority of cases requires the acquisition and proper interpretation of clinical evidence.
Key-words- Postoperative, Surgical infections, Secondary infections, Diagnostic method
1) Empirical antibiotic therapy is initiated prior to determining the specific infecting microorganism in patients with septic shock. Inappropriate empirical therapy is associated with increased mortality.
2) Therapies should be broad-spectrum and cover likely pathogens based on infection site and patient risk factors. They should be reassessed and narrowed once culture results are available.
3) Antibiotics should be administered within 1 hour of recognizing septic shock, as delays in treatment are associated with increased mortality. Prompt administration of appropriate empirical therapy improves survival in septic shock.
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
This document summarizes a study of 82 patients with pneumonia who were treated as outpatients and re-evaluated after 14 days in an emergency department in Spain. The average age was 49 years old, and most patients had mild symptoms. Bacteria were detected in 29% of cases, most commonly Streptococcus pneumoniae and Mycoplasma pneumoniae. All patients recovered without deaths, though two needed further hospital consultation. The study concludes that outpatient treatment can be effective for mildly ill pneumonia patients when monitored in the emergency department.
Knowledge and Attitude of Prosthodontic Post Graduates on COVID 19: A Qualita...DrHeena tiwari
This document summarizes a study that surveyed 60 prosthodontic post-graduate students regarding their knowledge and attitudes about COVID-19. The results found that 80% felt they received adequate training on COVID-19 prevention and control, while over 60% were confident in managing patients with required precautions. However, only around 63% knew who to contact if they encountered a suspected COVID-19 patient. Nearly all (96.6%) agreed that the pandemic has affected their academic activities. The study concludes that understanding aerosol transmission in dentistry can help identify risks and improve practices to prevent disease spread.
This case report describes a 35-year-old male with acute myeloid leukemia who presented with ptosis of both eyes after receiving aminoglycosides for a chest infection. He was initially diagnosed with a post-synaptic neuromuscular junction disorder but later developed progressive symmetrical weakness and respiratory difficulty, confirming a diagnosis of myasthenic crisis. Treatment with high-dose steroids was started. Further evaluation ruled out thymoma or central nervous system involvement. The case report discusses myasthenic crisis as exacerbation of muscle weakness that can lead to respiratory failure and highlights common precipitating factors like infection.
This document provides guidelines from the American Association for the Study of Liver Diseases (AASLD) for the management of chronic hepatitis B infection. It summarizes recommendations for screening high-risk populations to identify those infected with hepatitis B virus (HBV), including people born in areas with high HBV prevalence and those with risk factors like injection drug use or multiple sexual partners. The guidelines are based on a review of medical literature on HBV and aim to provide a data-supported approach to treating chronic HBV patients.
This study retrospectively reviewed 133 pediatric patients treated for acute osteomyelitis between 2002-2012 at two universities to identify factors associated with treatment failure and evaluate optimal antibiotic treatment. The majority (106 patients) were successfully treated, defined as treatment under 14 weeks without recurrence within 30 days of stopping antibiotics. Seventeen patients were treated with trimethoprim-sulfamethoxazole with comparable cure rates. Factors like pre-existing bone defects, high initial erythrocyte sedimentation rate, extensive soft tissue involvement, and skull osteomyelitis were associated with higher failure rates. On average, patients transitioned to low bioavailability oral antibiotics at 3.5 weeks, and transitioning before this time did not decrease cure
Fungal infections can occur due to the increasing use of broad-spectrum antibiotics and patients with immunodeficiency. Some pathogens, such as Cryptococcus, Candida,and Fusarium, rarely cause serious diseases in the normal host, while other endemic fungi, such as Histoplasmosis, Coccidiodes,and Paracoccidiodes can cause disease in a normal host, but has a tendency to be aggressive on immunocompromise.
Candida species are normal flora that may be an apportunistic pathogen. Candidiasis occurs in some diseases such as gastrointestinal mucosal esophagitis, a fungal disease associated with the use of catheters and in - patients who have mucosal damage or obtain broad – spectrum antibiotics. Other candidiasis consist of skin candidiasis, funguria candidiasis, disseminated candidiasis and endocarditis candidiasis. Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in many of the developed country. Invasive candidiasis has a significant impact on patient outcomes, and it has been estimated that the mortality of invasive candidiasis is as high as 47%. The mortality rates are 15%-25% for adults and 10%-15% for neonates and children. Diagnostic approach to fungal infection is a priority. The knowledge of the changes in epidemiology and risk factors for fungal infections, has become the main reference to measure optimal treatment of fungal infections.
Clinical presentation and outcomes of HIV positive patients with diagnosis of...Oscar Malpartida-Tabuchi
This document summarizes a study on tuberculosis (TB) in HIV-positive patients at a hospital in Lima, Peru in 2014. It finds that:
- 22 HIV+ patients were diagnosed with TB, most were male with low CD4 counts. Extra-pulmonary TB was most common.
- 21 cases were microbiologically confirmed, with high rates of drug resistance including 30% MDR and 5% XDR.
- Outcomes differed by HIV treatment group: no mortality in groups receiving HIV drugs >6 months or <6 months, but 18.2% mortality in group not receiving HIV drugs.
E twinning is 5 (nx powerlite) (nxpowerlite)ivanabrabcova
eTwinning is a community for schools in Europe to collaborate using information and communication technology tools. Teachers and students can connect with other schools to work together on projects, share ideas and best practices. The program has been running for 15 years and has brought over 250,000 schools together from across Europe.
Mistä ne puhuu? Mikä on some ja mikä twiitti?Pasi Siltakorpi
Tuntuuko GoogleDrivet, SkyDrivet, Sosiaaliset mediat, Twiittaukset, Streamaukset saatikka Pilvipalvelut vierailta ? Kurssin aikana kerrotaan ja näytetään mistä on kyse ja hieman saatetaan kokeillakin.
This document provides information and resources for creating and using wikis in education, including examples of wikis, how to create wikis, and apps that can be used. It discusses topics like how wikis can help students learn, provides a list of top ten apps for education, and contact information for the author.
With web users often leaving a site if it doesn't load in less than three seconds, having a slow blog not only harms your traffic, but it can have a detrimental effect on your business too.
This presentation shows you three simple steps to optimize your blog's load time, to ensure you not only keep new visitors happy, but ensure they join your existing community and keep coming back.
This document discusses different categories of NoSQL databases and provides examples. It also introduces the Membase distributed key-value store and describes how it is simple, fast, and elastic. Details are given on getting involved with the open source project, including using pre-built packages, platform porting opportunities, and contact information.
- Replay Solutions automates 30% of the software lifecycle using its patented ReplayDIRECTOR technology which records application executions at runtime with minimal overhead.
- ReplayDIRECTOR provides automated issue reproduction, bridging development, operations, QA and support teams. It allows issues to be reproduced instantly on any workstation without requiring application servers, databases or load.
- The presentation highlights how ReplayDIRECTOR can be used across various teams and use cases like development, operations, customer support to automate issue diagnosis and rapidly locate root causes.
The song "Let It Be" was composed by Paul McCartney in 1970 and inspired by a dream he had of his mother telling him "let it be." It was written during a period of internal troubles within The Beatles as the band was disbanding. The main message of the song is to stay calm and let things happen naturally. It encourages having faith that even in hard times, there will eventually be resolution or answers if you "let it be."
Un canale "storico". Una piattaforma acquistata da Yahoo per più di 1 miliardo di dollari. Una community vispa e stimolante ma soprattutto un network ricco di creativi e opportunità.
Per sapere tutto su Tumblr, aprire il proprio canale e integrarlo nella strategia personale.
This document discusses geotourism as a pathway for regional development in Australia. It defines geotourism as tourism focused on an area's geology and landscape. National Landscapes and geoparks are discussed as models, with some challenges to adopting geoparks in Australia noted. Geotrails are presented as a way to enhance regional development through geotourism by linking geological and landscape features along existing tourist routes. Several examples of potential geotrails in Australian National Landscapes are described. The document concludes geotourism has potential to boost regional development in Australia if tourism infrastructure is expanded and geotrails are established to provide early geotourism opportunities.
Quick prototyping apps using JS - Ciklum, VinnitsaYuriy Silvestrov
The document discusses quick prototyping of applications using JavaScript. It provides biographies of Yuriy V. Silvestrov and Mikhail Valkov, and then discusses topics like when quick prototyping is useful, how to quickly prototype an app, JavaScript techniques like MVC, jQuery, AngularJS and RequireJS, design tips including responsive design, and includes links to example applications and code on BitBucket and GitHub.
ArenaFlowers.com is an online flower retailer that launched in 2006 and now operates multiple websites across Europe, including ArenaFlowers.com, ArenaBloemen.nl, and ArenaFleurs.fr. With a team of 40 employees working in the UK and Netherlands, ArenaFlowers.com is the number one independent online flower retailer and top five in the flowers category overall in Europe. The company has won awards and maintains high customer ratings.
This document discusses bubbles in economics, the role of central banks like the Federal Reserve in managing bubbles, and debates around regulating versus deregulating financial markets. It notes that bubbles involve trading assets at inflated prices and post-bubble economies are difficult to manage. While some deny bubbles occur, others think they stem from price coordination or social norms. Regulating financial markets could limit risky behavior but models would need to accurately map interlinkages, while deregulation allows economic freedom but risks bubbles. The Federal Reserve uses tools like adjusting interest rates and quantitative easing to stimulate or constrain the economy as needed to prevent overheating or recession.
Tilitoimiston laajentunut palvelutarjooma_160410ValueFrame Oy
TietoAkselin Sanna Vähäkomin esitys nykyaikaisen taloushallintopalvelun tarjoamista mahdollisuuksista. Kuittien raahaamisen aika on ohi! Modernien, sähköisten ratkaisujen avulla yritykset voivat keskittyä omaan liiketoimintaansa ja kääntää tarkastelun kohti nykyhetkeä ja tulevaa peräpeiliin tuijottamisen sijaan. Esitetty ValueFramen ja TietoAkselin aamiaisseminaarissa 16.4.2010.
La ley de inclusión escolar establece un nuevo marco regulatorio para el sistema educativo chileno que garantiza mayores recursos económicos, protege los derechos de la comunidad educativa, y fomenta la gratuidad progresiva mediante la subvención escolar preferencial y el aporte de gratuidad. Asimismo, permite que los actuales sostenedores mantengan sus proyectos educativos y facilita que puedan adquirir definitivamente los inmuebles donde funcionan los establecimientos a través de créditos hipotecarios garant
This study evaluated the diagnostic validity of cerebrospinal fluid (CSF) parameters for distinguishing tuberculous meningitis (TBM) from other causes of meningitis. The study assessed CSF analyses of adenosine deaminase activity, protein and glucose levels, and lymphocyte count in 157 patients in Peru, which has a high tuberculosis incidence. Adenosine deaminase activity above 6 U/l had the best performance, with 95% specificity and a positive likelihood ratio of 10.7, but only 55% sensitivity. No combination of CSF parameters achieved good performance for ruling out TBM. The study found that an elevated CSF adenosine deaminase level strongly supports a diagnosis of TBM
This research paper evaluated the efficacy of fine needle aspiration cytology (FNAC) in diagnosing Bacillus Calmette-Guérin (BCG)-induced lymphadenitis in children. The study analyzed 17 cases of children presenting with enlarged lymph nodes after BCG vaccination who underwent FNAC. Most cases involved the left axillary lymph node and presented between 2-6 months of age. Pus was aspirated in most cases. Microscopic examination found diffuse necrosis and degenerated cells in over half of cases. Acid-fast bacilli were detected via ZN staining in 88% of cases. FNAC is a useful diagnostic tool for BCG lymphadenitis, with characteristic cytological patterns including necrosis and
This document provides guidelines from the Infectious Diseases Society of America (IDSA) for the diagnosis and management of skin and soft tissue infections (SSTIs) updated in 2014. It summarizes recommendations for evaluating and treating common SSTIs like impetigo, ecthyma, and cutaneous abscesses. Gram stains and cultures are recommended for diagnostic purposes but treatment can begin without these in typical cases. Incision and drainage is the primary treatment for purulent SSTIs like abscesses along with antibiotics for systemic signs of infection. The guidelines provide recommendations for appropriate antibiotic therapy based on infection severity and whether methicillin-resistant Staphylococcus aureus is a concern.
Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-...fahmi khan
The main purpose of this study was to describe the demographic and clinical features of cryptic disseminated TB; it was also aimed to shed light on diagnostic test, procedure results, organ involvement, and outcomes of cryptic disseminated TB in patients with confirmed disseminated TB.
This study characterized dengue infections in Pakistan by analyzing hematological and serological markers in 154 suspected dengue cases and 146 control patients with other febrile illnesses. NS1 antigen was detected in 55% of dengue cases, IgM antibodies in 30%, and both in 15%. Control groups primarily had malaria (71%) and enteric fever (20%). Hematological markers (platelet count, hematocrit, WBC) measured before and after treatment showed significant differences for platelet count and hematocrit but not WBC count between the groups. Analysis of clinical symptoms and serological/hematological markers helps diagnose dengue, assess prognosis, and inform prevention efforts to reduce morbidity, mortality and spread of the disease.
Diagnostic Approaches to Chronic Fungal and Tuberculous Meningitisinventionjournals
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
This document summarizes guidelines for the management of febrile neutropenia. It describes definitions of fever and neutropenia and risk factors. Initial evaluation involves blood cultures, site-specific cultures as indicated, and monitoring. Risk is stratified using tools like the MASCC index. Prophylaxis includes hand hygiene, oral care, and sometimes antibiotics or antifungals. Empiric antibiotic therapy is recommended, with modifications based on risk and response. Therapy typically continues until resolution of fever and recovery of neutrophils. Empiric antifungals may be considered for persistent fever.
This study aimed to establish a cerebrospinal fluid (CSF) white blood cell (WBC) count cutoff that could distinguish bacterial meningitis from viral and aseptic meningitis in children. The study retrospectively analyzed 295 children admitted with CSF pleocytosis between 2005-2009. Bacterial meningitis was diagnosed in 31 children (10.5%), viral meningitis in 156 (52.9%), and aseptic meningitis in 108 (36.6%). CSF WBC count was significantly higher in bacterial meningitis compared to the other groups. A cutoff of 321 WBC/μL provided the best balance of sensitivity (80.6%) and specificity (81.4%) for diagnosing bacterial
This study evaluated the validity of procalcitonin (PCT) for diagnosing bacterial infections in elderly patients aged 75 years or older. 161 patients were included in the study and divided into two groups: 95 patients with probable bacterial infections and 66 patients without infections. PCT levels above 0.5 ng/mL were found in 72% of patients with probable bacterial infections and 8% of patients without infections. The study found that PCT has a sensitivity of 72% and specificity of 92% for diagnosing bacterial infections in elderly patients using a cutoff of 0.5 ng/mL. The researchers concluded that PCT can be reliably used to diagnose bacterial infections in elderly patients due to its good sensitivity and high specificity.
Abstract—In Italy the hydatid disease is more prevalent and new cases are highlighted more frequently in Sicily, Sardinia, (Italy). Aim of this study is to put the indication in search of iaditea nature in both spleen swelling and muscle tendon.
Material and Method Patients observed during the period 2007-2009 at the Surgical Clinic III and Digestive Surgery, Policlinico G Rodolico were explored for Hydatid cyste at various sites. Diagnosis of cysts ecchinococcus occurred primarily for various four reasons either for compression of bodies involved or for eosinophilia or for instrumental investigation or for anaphylactic reaction to rupture of cysts. Biological diagnosis is based on serology rather than isolation of the parasite (indirect diagnosis);
Results Patients attended during the period 2007-2009 Hydatid cyst was found in 0.5% of all cases in liver along with 4 in the lung, 3 in splenic, 2 in the mammary and 2 in the chest wall No 2. The Surgical treatment with the complete removal of the cyst with a satisfactory postoperative course in the absence of cases of relapse of the disease and by following the therapeutic act, the assumption of mebendazole 50mg / kg / day for 3 weeks at a dose of 400mg for 4 months
Conclusions There is a need to define diagnostic methods with high specificity and sensitivity, which can provide a valid diagnostic aid for the cases clinically difficult to diagnose. And the final diagnosis must then also be based on the development of immunological methods that allow the determination of specific antibodies in the serum and their titration and / or the circulating antigen determination.
This document discusses sepsis, including definitions, causes, pathophysiology, diagnosis, and management. It defines sepsis, severe sepsis, and septic shock. Mortality from sepsis is high and increasing. Common causes are bacterial and fungal infections. The pathophysiology involves an excessive host immune response. Diagnosis requires identifying an infection and assessing for organ dysfunction. Management involves early antibiotic treatment, fluid resuscitation, vasopressor support if needed, and treating any infection source. Performance improvement efforts focusing on timely treatment can improve outcomes.
This document discusses Candida infections in the ICU, including epidemiology, risk factors, pathogenesis, diagnosis, and treatment. Some key points:
- Candida species are the most common fungal pathogens in hospitals and ICUs, responsible for 17% of healthcare-associated infections. Non-albicans Candida species now account for around 50% of infections.
- Risk factors for invasive Candida infections include prolonged ICU stay, broad-spectrum antibiotic use, surgery, and underlying conditions like diabetes that impair immunity. Heavy Candida colonization is an independent risk factor.
- Diagnosis is challenging as symptoms mimic bacterial infections. Culture-based methods are slow. Biomarkers like beta-D-
This study examined the prevalence of cryptococcal meningitis (CM) among people living with HIV/AIDS (PLHAs) at a hospital in southern Odisha, India. Of 112 clinically diagnosed CM patients, 16 cases were confirmed via cerebrospinal fluid analysis, showing a prevalence of 14.3%. Males aged 21-40 were most commonly affected. The most common symptoms were fever, headache, altered sensorium, and neck stiffness. CD4 T-lymphocyte counts were below 100 cells/μl in 93.7% of confirmed cases. All patients responded initially to antifungal therapy but 2 died during hospitalization and 4 were lost to follow up. Early diagnosis and treatment of CM is
Dengue fever in children 2019 by Dr KibogoyoGeorgeKibogoyo
This document provides an overview of dengue fever in children. It discusses the epidemiology, transmission, pathophysiology, classification, clinical presentation, investigations, differential diagnosis, management, prognosis, and prevention of dengue fever in children. Some key points include:
- Dengue is caused by one of four serotypes of dengue virus and is transmitted by Aedes mosquitoes.
- It is a major public health problem in many tropical and subtropical countries.
- Clinical presentation varies from mild fever to severe dengue with hemorrhage, plasma leakage, or organ involvement.
- Diagnosis involves IgM/IgG detection, NS1 antigen detection, PCR, or viral isolation from blood samples.
This document discusses septic arthritis in adults. It reviews the changing epidemiology of this medical emergency, which is becoming more common due to factors like an aging population and increased immunosuppression. Diagnosis is challenging but important, as timely treatment is needed to prevent joint damage and mortality. The document examines risk factors, pathogenesis, diagnostic approaches, and evolving treatment challenges like antibiotic resistance. Animal models and ongoing research aim to improve understanding and identify new treatment targets or adjunctive therapies.
Antibiotic resistance is increasing in Gram Negative organisms. It is important to know the antibiogram of the hospital to start empirical therapy. It can serve as a reference to clinician looking for information on antibiotic resistance. A retrospective analysis of the isolates obtained from January 2016 to December 2016 was performed. Samples were processed as per CLSI guideline. A total of 718 isolates were obtained. These were analysed for the prevalence
of MDR/XDR/PDR. It was found that XDR isolates are prevalent in our teaching hospital. The study showed an emergence in pan drug resistant isolates. The knowledge of local antibiogram
along with strong antibiotic stewardship program can help in guiding antibiotic therapy.This reduces antibiotic pressure among organisms and hence development of resistance.
This study was performed Department of Otor hinolaryngology, Jubilee Mission Medical College, thrissur, Kerala for a period of 2 years commencing from December 2012 to November 2014. To review our experience with deep neck space infections and to study changing trends. The objectives were to study clinical presentation, etiology, associated systemic diseases, bacteriology, radiology, management and outcome of deep neck space infections.40 Patients coming from both urban and rural areas irrespective of age and sex admitted in department of ENT with deep neck space infections which was confirmed either clinically or radiologically. Superficial skin abscesses and abscesses due to infections of external neck injuries were excluded from the study \r\n.
The value of real-world evidence for clinicians and clinical researchers in t...Arete-Zoe, LLC
In the midst of a rapidly spreading global pandemic, real-world evidence can offer invaluable insight into the most promising treatments, risk factors, and not only predict but suggest how to improve outcomes. Despite overwhelming news coverage, significant knowledge gaps regarding COVID-19 persist. The current uncertainties regarding incidence and the case fatality rate can only be addressed by widespread testing. But the paucity of testing, and diversity of approaches implemented in different countries, particularly among the general asymptomatic public, perpetuates a lack of understanding about spread and infectivity. The essential indicators that would describe the pandemic more accurately can be obtained using real-world data (RWD). To that purpose, we designed a data collection tool to collect data from hospitals that treat COVID-19 patients. The captured data will enhance our understanding of the COVID-19 pandemic, identify risk factors relevant for triage, relate to other similar seasonal infections and gain insight into the safety and efficacy of experimental and off-label therapies. Knowledge derived from a focused data collection effort will enable clinicians to adjust rapidly clinical protocols and discontinue interventions that turn out to be ineffective or harmful. By deploying our elegantly designed survey to capture routine clinical indicators, we avoid placing an additional burden on practitioners. Systematically generating real-world evidence can decrease the time to insight compared to randomized clinical trials, improving the odds for patients in rapidly changing conditions.
This document presents the protocol for an observational study examining the predictive value of cell-surface markers in identifying critically ill patients at risk of nosocomial infections. The study aims to validate previously identified markers of immune dysfunction - including low expression of CD88 on neutrophils, low HLA-DR on monocytes, and elevated regulatory T cells - and determine if combining these markers improves prediction of infection risk. It also aims to explore additional cell surface markers and immune cell subsets that may further predict infection risk. The multicenter study will collect blood samples from critically ill patients in the ICU to analyze immune cell markers using flow cytometry and correlate the results with rates of subsequent nosocomial infections.
1) The guideline provides recommendations for recognizing, diagnosing, and managing sepsis early. It outlines risk factors for sepsis and signs of clinical concern.
2) It recommends considering sepsis for anyone presenting with possible infection and assessing for risk factors and clinical concerns. It provides tools to stratify risk of severe illness from sepsis based on factors like vital signs.
3) Recommendations include considering anyone with altered mental status, respiratory distress, low blood pressure, or other concerning signs to be at high risk and warranting prompt treatment.
Un estudio sobre las caracteristicas del tratamiento sde la TB XDR en sudafrica y el pronostico de vida de los pacientes segun las estrategias terapeuticas
An 8-week regimen of sofosbuvir plus ledipasvir was found to be effective for many hepatitis C patients in real-world studies, even those who did not meet the official criteria for the shortened treatment. A review of five real-world studies involving over 600 patients found sustained viral response rates of 97% or higher with the 8-week regimen. The results provide reassurance that clinical trial results translate to real-world practice and suggest the criteria for the 8-week regimen could be expanded.
This randomized clinical trial compared two post-exposure prophylaxis (PEP) regimens for preventing HIV infection: tenofovir/emtricitabine plus ritonavir-boosted lopinavir versus tenofovir/emtricitabine plus raltegravir. The trial found that while overall PEP non-completion at 28 days was similar between the two regimens, the raltegravir-containing regimen had significantly fewer adverse events and better adherence. Specifically, the ritonavir-boosted lopinavir regimen was associated with higher rates of PEP non-completion, loss to follow up, and low adherence, as well as more reported adverse events.
The document presents new consensus definitions for sepsis and septic shock developed by an international task force. It summarizes limitations of previous definitions, which focused excessively on inflammation and lacked specificity. The task force developed updated definitions and clinical criteria through meetings, literature reviews, and consultation with international societies. The new definition of sepsis is "life-threatening organ dysfunction caused by a dysregulated host response to infection." Septic shock is defined as a subset of sepsis involving profound circulatory and metabolic abnormalities associated with higher mortality. Clinical criteria including changes in SOFA scores and vital signs were also developed to facilitate earlier recognition of at-risk patients. The task force aims to provide more consistency for research and management of sepsis.
This document discusses strategies for developing broad-spectrum antiviral agents (BSAA) that can treat multiple virus families. It identifies four promising categories: 1) nucleoside analogues, as viral polymerases share similarities allowing broad inhibition; 2) viral protease inhibitors, as proteases are somewhat conserved; 3) host-targeting drugs that modulate host cell factors viruses require; and 4) immune-modulating agents that exploit the immune system's natural antiviral functions. While progress has been made, the field of BSAA is still young, but developing such agents will be important for addressing future viral threats.
This study found that cytomegalovirus (CMV) coinfection is associated with higher CD8 T-cell counts, lower CD4/CD8 ratios, and increased systemic inflammation in HIV-positive individuals on antiretroviral therapy (ART). The study compared 158 HIV-positive individuals, of which 32 were CMV-negative and 126 were CMV-positive, to 21 HIV-negative controls. It found that CD8 T-cell counts were significantly higher in HIV-positive/CMV-positive individuals compared to HIV-positive/CMV-negative individuals or controls. Additionally, plasma levels of inflammatory markers IP-10, TNF-RII, and D-dimer were higher in HIV
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
1) The study compared the performance of the tuberculin skin test (TST) and interferon-gamma release assays (IGRA) in diagnosing latent tuberculosis infection (LTBI) in 60 contacts of active pulmonary tuberculosis patients in Sao Luis, Brazil.
2) Using a 5mm cutoff, the TST showed 67.9% sensitivity, 84.4% specificity, 79.1% positive predictive value, 75% negative predictive value, and 76.7% accuracy compared to the IGRA.
3) The prevalence of LTBI was 40% by TST and 46.7% by IGRA. The agreement between the two tests was moderate, with a kappa coefficient of 0
1. This document provides clinical practice guidelines from the Infectious Diseases Society of America (IDSA) for the management of candidiasis.
2. Key recommendations include using an echinocandin as initial therapy for candidemia in nonneutropenic patients, and considering removal of central venous catheters in candidemia when safely possible.
3. For candidemia in neutropenic patients, an echinocandin is also recommended as initial therapy, with lipid formulation amphotericin B as an alternative.
El documento describe la resistencia bacteriana a los antibióticos como una crisis global creciente que amenaza la eficacia de estos fármacos vitales. Explica que los genes de resistencia, elementos genéticos y clones bacterianos han contribuido a la propagación mundial de la resistencia en poco tiempo desde una perspectiva evolutiva. También menciona algunos ejemplos recientes de resistencia en patógenos humanos importantes y los factores que contribuyen a su propagación, así como posibles respuestas como el desarrollo continuo de nuevos antibiótic
This document provides a consensus on the management of urinary tract infections (UTIs) in solid organ transplant recipients from experts in Spain. It summarizes recommendations on screening and treatment of asymptomatic bacteriuria, prophylaxis and treatment of UTIs, management of recurrent UTIs, and interactions between antimicrobials and immunosuppressants. The recommendations are based on a systematic review of the literature and provide evidence levels for each. The goal is to support optimal care of this patient population by incorporating the latest scientific evidence on UTIs in transplant recipients.
Este estudio evaluó si una colaboración entre tres centros de atención primaria para aumentar la concienciación sobre la importancia de la detección temprana del VIH influyó en la proporción de pruebas de VIH solicitadas en pacientes con condiciones indicadoras de VIH. Los resultados mostraron que la solicitud de pruebas de VIH en pacientes con condiciones indicadoras aumentó del 3,9% al 11,8% después de la colaboración, pero aún no se solicitó en el 88% de los casos, lo que podría hab
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
2. from streptococcal etiology [9]. However, purulence has neither
been thoroughly evaluated nor is it a prominent sign in pure
cellulitis.
The aim of this study was to describe the etiological spectrum
of cellulitis and to investigate whether clinical and biochemical
markers were associated with, and predictive of, BHS etiology.
PATIENTS AND METHODS
Study Population
Haukeland University Hospital is a tertiary care hospital in
western Norway, and it also functions as a local hospital for ap-
proximately 300 000 inhabitants. Patients aged 18 years or older
and admitted with possible skin or soft tissue infection between
September 2010 and August 2014 were prospectively evaluated
for inclusion. The study was approved by the Regional Commit-
tee for Ethics in Medical Research (REC West; approval no.
2010/1406). Written informed consent was obtained from all
participants in the study.
Case Definition
Patients were eligible if they were hospitalized with acute diffuse
erythema of the skin of presumed bacterial origin and had the
following: (1) fever, chills, or reduced general condition; or (2)
facial infection site. Patients were excluded if they had postop-
erative surgical site infection, animal/human bite, impetigo,
necrotizing soft tissue infection, arthritis, osteomyelitis, masti-
tis, wound or ulcer with erythema extending <5 cm beyond
the skin defect, tenosynovitis, or nonbacterial disease underly-
ing the findings. Patients with drainable abscess, bursitis, or
other fluid/pus collection were also excluded, whereas patients
with progressive erythema after proper drainage of small puru-
lent lesions before admission were eligible.
Clinical Characteristics
Data were obtained by detailed clinical examination and history
by an infectious diseases physician (T.B., O.O., or S.S.), includ-
ing review of medical records. Age, gender, potential risk fac-
tors, symptoms and their duration, clinical findings on
admission (within 24 hours), clinical chemistry results, and an-
tibiotic treatment were registered.
Bacterial Culture and Identification
On admission, blood cultures and cutaneous swabs for bacterial
culture from ulcers, wounds, abrasions, fissured toe webs, or
other skin lesions were obtained. For some patients, samples
from normally sterile tissue were obtained for culture, either a
4 mm cutaneous punch biopsy or surgical subcutaneous sam-
ples in cases where surgical exploration was performed to rule
out necrotizing infection. Identification of the bacteria was per-
formed as part of the routine diagnostic service at the hospital.
Serogroups of BHS were identified using Streptococcal Group-
ing Kit (Oxoid, Cambridge, UK) on large β-hemolytic colonies
or bacterial species identification using mass spectrometry (ma-
trix-assisted laser desorption/ionization time of flight).
Streptococcal Serology
An acute serum sample for streptococcal serology was collected
during the hospital stay, and a convalescent serum was collected
approximately 1 week after the cessation of antimicrobial ther-
apy. Anti-streptolysin O (ASO) and anti-deoxyribonuclease B
(ADB) titers were measured using nephelometry (Siemens
Healthcare Diagnostics, Marburg, Germany). Titers <200 IU/
mL were considered normal. Seropositivity was defined as (1)
a 0.2 log10 rise in titer and a titer ≥200 IU/mL in the convales-
cent serum or (2) titers of both acute and convalescent sera
≥200 IU/mL [15].
Classification of β-Hemolytic Streptococcal Etiology
Confirmed BHS etiology was defined as ASO and/or ADB sero-
positivity and/or BHS in culture of blood or normally sterile tis-
sue. Probable BHS etiology was defined as BHS in cutaneous
swabs or a satisfactory response to penicillin monotherapy, de-
fined as clinical response at end of therapy in patients who were
not given other antibiotics during the course. Response was as-
sessed by a telephone consultation 1–2 weeks after cessation of
therapy.
Statistical Analysis
Data were analyzed using IBM SPSS Statistics, version 22, ex-
cept that diagnostic accuracy analyses were calculated using
an online calculator (www.medcalc.org). Categorical data were
analyzed using χ2
test or Fisher’s exact test. Continuous data
were presented as median with range and compared using the
Mann-Whitney U test. All statistical tests were 2-sided. P values
were considered significant below .05. For multivariate logistic
regression analysis, variables were dichotomized based on pre-
liminary analyses, and P values were calculated using the likeli-
hood test. Variables entered into the multivariate models were
chosen on the basis of low unadjusted P values, low multicolli-
nearity, and objectivity. In multivariate analysis of streptococcal
etiology, adjustment was also made for factors that may affect
serological sensitivity or admission findings. In order to have
probability measures that can be used in clinical practice inde-
pendently of prevalence, positive and negative likelihood ratios
(LR+
and LR−
) were calculated in addition to sensitivity, specif-
icity, and predictive values [16].
RESULTS
Patients
In total, 216 patients were included, 203 of whom were evalu-
able for β-hemolytic streptococcal etiology (Figure 1). Median
age was 54.5 years (range, 18–94 years); 58% were men.
Lower extremity was the most common location (57%) followed
by facial (24%), upper extremity (16%), and other sites (3%).
Culture and Serology Results
Of 127 cases with cutaneous swabs, 90 had growth of Gram-
positive pathogens and 5 had growth of Gram-negative bacteria
alone (Figure 2A). Among BHS, GCS/GGS were more prevalent
2 • OFID • Bruun et al
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3. Figure 1. Flow chart of patient enrollment and evaluation for β-hemolytic streptococcal etiology. a
One case with Staphylococcus aureus in culture of normally sterile tissue
and 2 positive (pos.) anti-streptolysin titers without significant rise were classified as negative (neg.) concerning confirmed β-hemolytic streptococcal (BHS) disease. b
Proportion
with local clinical improvement at end of therapy among cases treated with penicillin only. Abbreviations: GAS, group A streptococcus; GBS, group B streptococcus; GCS/GGS,
group C or G streptococcus.
Predicting Streptococcal Cellulitis • OFID • 3
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4. than GAS and GBS. Staphylococcus aureus was frequently iso-
lated, often in combination with BHS (Figure 2). No methicil-
lin-resistant S aureus isolates (MRSA) were found. β-hemolytic
streptococci were cultured in 40% (28 of 70) of cases with swabs
taken after antibiotics were started, compared with 49% (28 of
57) of cases with samples obtained before treatment (P = .30).
Blood cultures were positive in 6 (3%) of 197 cases (GAS 3,
GCS/GGS 2, GBS 1). Cultures of normally sterile tissue were
positive in 6 cases (GAS 1, GCS/GGS 2, GBS 2, S aureus 1)
and negative in 5 cases. Among the cases with tissue cultures,
only the GBS case did not receive antibiotics before sampling.
Acute and convalescent sera were available in 200 cases. Pos-
itive BHS serology was found in 71% of cases; 60% of cases were
positive for ASO, and 30% of cases were positive for ADB (Fig-
ure 2B). Seropositivity was 92% among cases positive for GAS
or GCS/GGS in cutaneous swabs cultures compared with 63%
among cases culture negative for these streptococci (P < .0005).
The GCS/GGS cases were associated with seropositivity just as
often as GAS cases (94% vs 89%) but were particularly associ-
ated with an ASO-positive/ADB-negative serological pattern.
This GCS/GGS-associated pattern was also predominant
among cases with cultures negative for BHS.
A multivariate analysis search for factors predicting low sero-
logical response during a streptococcal infection identified age
≥75 years (seropositivity odds ratio [OR], 0.026; 95% confi-
dence interval [CI], .001–.479; P = .007) and blood leucocytes
between 3.5 and 8 (OR, 0.008; 95% CI, .000–.220; P = 0.001)
as independently associated with seronegativity in cases with
GAS/GCS/GGS in culture. Immunosuppression (OR, 0.124;
95% CI, .005–2.840; P = .173) and area of erythema (percentage
of total body surface area [TBSA%]) (OR, 1.187; 95% CI, .008–
1.601; P = .266) were the nonsignificant factors in the model.
Among cases with antibiotic treatment before admission, 93%
had seropositivity compared with 88% among other cases.
Therefore, this factor was not included in the model.
Confirmed and Probable Streptococcal Etiology
Serology, blood culture, and samples of normally sterile tissue
confirmed BHS etiology in 146 (72%) of 203 evaluable cases (Fig-
ure 1). An additional 13% (27 of 203) had probable BHS defined
by penicillin response or BHS in superficial culture, giving a total
of 85% with confirmed or probable BHS etiology. Confirmed BHS
etiology was found in the majority of both cases with swabs taken
(92 of 121; 76%) and cases without such samples (54 of 82; 66%).
Of 35 cases with S aureus and/or Gram-negative bacteria as
the only cultured pathogens from swab samples, 21 (60%) had
BHS confirmed and 6 (17%) had probable BHS disease. Staph-
ylococcus aureus was cultured as a single pathogen from 24 pa-
tients, 18 (75%) of which had confirmed or probable BHS
infection. Twenty-one patients who had both penicillin-resis-
tant S aureus in swabs and confirmed BHS disease were started
on penicillin monotherapy. Thirteen of them continued penicil-
lin monotherapy with good clinical response. The remaining 8
cases changed to therapy also covering S aureus, 5 of them with-
in 2 days, ie, too early to indicate treatment failures.
Comorbidity and Risk Factors
Comorbidity and other risk factors were identified in the major-
ity of cases with and without confirmed BHS (Table 1). In each
subgroup of underlying factors, confirmed BHS etiology was
found in half or more of the cases. Confirmed BHS etiology
Figure 2. (A) Results of swab cultures of skin lesions in the affected body part. Coagulase-negative staphylococci, enterococci, and other bacteria interpreted as colonizers
are not presented. Cases with Staphylococcus aureus found in addition to β-hemolytic streptococci (BHS) are not shown. This concerns 13 of 18 group A streptococcus (GAS)
cases, 20 of 32 group C or G streptococcus (GCS/GGS) cases, and 4 of 8 group B streptococcus (GBS) cases. No Gram-negative bacteria were found in cases with BHS. (B)
Seropositivity (see the Patients and Methods section) for streptococcal antibodies in relation to swab culture results. The number of cases (shown in parentheses) in each
category of culture results is smaller than in A, because not all patients had 2 sets of serology. a
The anti-streptolysin O (ASO)-positive/anti-deoxyribonuclease B (ADB)-negative
serological pattern was specific for GCS/GGS among cases with BHS in culture. The titer rise was not significantly lower in cases with this pattern from whom GCS/GGS were
not cultured. (median log rise 0.40 vs 0.47, P = .369). b
Two of these cases also had growth of S aureus. c
Staphylococcus aureus and/or Gram-negative bacteria found without
other pathogens.
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5. was positively associated with male gender and skin barrier im-
pairment and negatively associated with older age, probably re-
flecting lower serological sensitivity in the elderly. Compared to
the cases that were culture-positive for GAS, the GCS/GGS
cases had more often male gender, obesity, chronic edema,
minor skin breaks, or previous cellulitis. Several risk factors
were significantly more frequent among patients with recurrent
cellulitis compared with patients experiencing their first episode
(Supplementary Table 1); however, in a multivariate analysis,
only chronic edema was independently associated with recur-
rence (P < .0005). Among cases with streptococcal seropositiv-
ity, a lower rise in antibody titer was significantly associated
with recurrence, also when adjusted for other factors, including
baseline antibody level (Supplementary Table 2).
Findings Upon Admission and Diagnostic Accuracy
Several clinical variables on admission were significantly associ-
ated with BHS in general or with GAS compared with GCS/
GGS (Table 2). β-hemolytic streptococcal etiology was not sig-
nificantly more common in cases with typical erysipelas signs.
In addition, among the cases without any typical erysipelas sign
and cases with an overlapping clinical presentation (erysipelas/
deeper cellulitis), two thirds or more had confirmed BHS
disease.
Diagnostic accuracy of clinical and biochemical parameters
in predicting confirmed BHS disease is shown in Supplementa-
ry Table 3. Several clinical variables significantly increased the
likelihood of BHS disease, but the increase was small; positive
likelihood rates (LR+
) ranged from 1.5 to 2.1, and the sensitivity
was low (30%–65%). A patient profile of rigors, percentage of
total body surface with erythema (TBSA%) ≥3, skin bruising,
and leucocytes ≥13.0 gave an LR+
of 4.0 but a sensitivity of 7%.
Independent Predictors of Etiology
Multivariate logistic regression analysis identified lower extrem-
ity location, TBSA% ≥3, and skin barrier impairment as the
Table 1. Demographics and Underlying Factors by Etiologya
Characteristic All Cases (n = 216)
BHS+
vs BHS−b
GCS/GGS vs GASc
BHS+
(n = 146) BHS−
(n = 57) P Value GAS (n = 22) GCS/GGS (N = 36) P Value
Demographics
Age ≥75 y 32 (15) 17 (12) 14 (25) .021 2 (9) 6 (17) .697
Male gender 126 (58) 92 (63) 27 (47) .042 10 (46) 27 (75) .023
Underlying condition
Cardiovascular disease 82 (38) 60 (41) 21 (37) .578 10 (46) 17 (47) .896
Diabetes mellitus 28 (13) 21 (14) 7 (12) .696 2 (9) 11 (31) .103
Previous or active malignancy 35 (16) 21 (14) 13 (23) .149 4 (18) 2 (6) .187
Immunosuppression 21 (10) 12 (8) 9 (16) .111 2 (9) 4 (11) .589
Other general somatic diseased
78 (36) 49 (34) 26 (46) .110 6 (27) 14 (39) .366
General somatic disease in total 134 (62) 90 (62) 40 (70) .255 15 (68) 23 (64) .739
IDU 13/214 (6) 4/144 (3) 4 (7) .227 0/21 (0) 1/35 (3) 1.000
Alcoholism 8/214 (4) 7/144 (5) 1 (2) .445 1/22 (5) 1/34 (3) 1.000
BMI ≥ 30 75 (35) 55 (38) 15 (27) .126 4 (18) 18 (50) .015
None of the conditions above 45 (21) 28 (19) 12 (21) .763 6 (27) 6 (17) .505
Skin barrier impairment
Chronic skin disease locally 60/215 (28) 46/145 (32) 11 (19) .077 5 (23) 9 (25) .844
Wound/ulcer before infection 87 (40) 64 (44) 19 (33) .171 17 (77) 21 (58) .141
Other skin barrier impairmente
106/215 (49) 74/145 (51) 25 (44) .359 6/21 (29) 22 (61) .018
No identified skin barrier impairment 40 (19) 22 (15) 16 (28) .033 1 (5) 2 (6) 1.000
Other local factors
Chronic edemaf
74/155 (48) 57/108 (53) 14/37 (38) .117 5/16 (31) 18/29 (62) .048
Peripheral vascular insufficiency 7 (3) 6 (4) 1 (2) .368 1 (5) 2 (6) 1.000
Previous local erysipelas/cellulitis/NSTI 62 (29) 37 (25) 19 (33) .252 1 (5) 11 (31) .021
Previous local radiation/surgery 51 (24) 32 (22) 15 (26) .504 5 (23) 8 (22) 1.000
None of the local factors above 100 (46) 67 (46) 28 (49) .678 15 (68) 13 (36) .018
Abbreviations: BHS+
, β-hemolytic streptococcal etiology confirmed; BHS−
, BHS not confirmed; BMI, body mass index; GAS, group A streptococcus; GCS, group C streptococcus; GGS, group G
streptococcus; IDU, previous or active intravenous drug use; NA, not applicable; NSTI, necrotizing soft tissue infection.
a
Data are presented as No. (%) or No./evaluable cases (%).
b
Cases with BHS etiology confirmed by serology or culture of blood or normally sterile tissue compared with cases with BHS not confirmed.
c
Cases with GCS/GGS compared with GAS cultured from blood, normally sterile tissue, or cutaneous swabs.
d
Rheumatic disease or chronic disease of lungs, gastrointestinal tract, liver, pancreas, kidney, or nervous system.
e
Includes fissured toe web/tinea pedis, intertrigo, excoriations.
f
Calculated for extremity infections only.
Predicting Streptococcal Cellulitis • OFID • 5
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6. only independent predictors of confirmed BHS etiology, when
adjusted for that may have affected admission findings and sensi-
tivity of serology (Table 3). For confirmed and probable BHS
combined, multivariate analysis identified intravenous drug use
as a negative predictor of BHS etiology (OR, 0.075; 95% CI,
.013–.438; P = .005). A multivariate analysis of GCS/GGS com-
pared with GAS etiology based on culture results (blood/tissue/
swabs) identified skin barrier impairment other than wound,
ulcer, or chronic skin disease (OR, 8.884; 95% CI, 1.479–53.347;
P = .009) as an independent predictor of GCS/GGS infection.
DISCUSSION
This comprehensive investigation demonstrates BHS as the
major etiological agents in a representative group of cellulitis
patients without drainable foci. By combining serology, culture,
and response to penicillin treatment, our results suggest that
more than 80% of the cases were of streptococcal origin, includ-
ing the majority of patients without typical signs of streptococ-
cal erysipelas and those with purulence and comorbidities such
as diabetes mellitus.
Previous studies including streptococcal serology have also
demonstrated a predominance of BHS in the etiology of cellulitis.
However, these studies were restricted to nonculturable or sharply
demarcated superficial cellulitis (erysipelas) [4, 6, 15, 17].
The relative importance of GCS/GGS (Streptococcus dysga-
lactiae subsp equisimilis) compared with GAS (S pyogenes) in
skin infections has been unclear. In general, invasive GCS/
GGS infections are increasing [18, 19], and in cellulitis other
than erysipelas a predominance of GCS/GGS bacteremia has
been demonstrated [8]. Such predominance has also been
Table 2. Symptoms, Signs, and Biochemical Findings by Etiologya
Characteristic All Cases (n = 216)
BHS+
vs BHS−b
GCS/GGS vs GASc
BHS+
(n = 146) BHS–
(n = 57) P Value GAS (n = 22) GCS/GGS (N = 36) P Value
Symptoms before admission
Symptom duration ≥3 d 83/214 (39) 58/144 (40) 22 (39) .826 9 (41) 17/35 (49) .572
Rigors 96/212 (45) 74/143 (52) 19/56 (34) .023 11 (52) 15 (43) .489
Affected site
Head 51 (24) 29 (20) 19 (33) .042 5 (23) 5 (14) .481
Upper extremity 35 (16) 14 (10) 16 (28) .001 5 (23) 0 (0) .011d
Lower extremity 123 (57) 97 (66) 21 (37) <.0005 12 (55) 30 (83) .017
Other 7 (3) 6 (4) 1 (2) .676 1 (0) 1 (3) 1.000
Signs at admission
Erythema sharply
demarcated
161/215 (75) 112/145 (77) 43 (75) .785 15 (68) 29 (81) .285
Erythema salmon red 142 (66) 105/146 (72) 33 (58) .054 14 (64) 28 (78) .242
Erythema salmon red and
sharply demarcated
121/215 (56) 90/145 (62) 27 (47) .057 12 (55) 24 (67) .356
Erythema with palpable
edge
109/209 (52) 76/141 (54) 31/55 (56) .756 9/21 (43) 19 (53) .470
No typical erysipelas signse
30/209 (14) 17/141 (12) 7/55 (13) .898 5/21 (24) 2 (6) .088
Erysipelas-cellulitis overlapf
95/209 (46) 58/136 (43) 29/57 (51) .295 8/21 (38) 19 (53) .284
TBSA%, median (range) 3 (1–40) 3 (1–21) 2 (1–40) .007 2 (1–20) 4 (1–20) .014
Skin bruising 52 (24) 43 (30) 8 (14) .023 5 (23) 14 (39) .203
Bullae 20 (9) 15 (10) 5 (9) .747 2 (9) 9 (25) .178
Pusg
27 (13) 17 (12) 7 (12) .900 8 (36) 4 (11) .042
Easily defined portal of entry 105 (49) 72 (49) 24 (42) .355 15 (68) 25 (69) .920
Biochemistry at admission
Leucocytes (×109
/L),
median (range)
11.7 (3.2–37.4) 12.1 (3.2–37.4) 10.9 (3.8–23.3) .014 15.5 (4.5–31.4) 13.1 (3.2–25.6) .177
CRP (mg/L), median (range) 97 (<1–426)h
108 (<1–426) 78 (4–399) .029 98 (3–426) 148 (6–407) .501
PCT (µg/L), median (range) 0.19 (<0.10–86.20) 0.27 (<0.10–86.20) 0.12 (<0.10–14.20) .011 0.13 (<0.10–36.00) 0.43 (<0.10–86.20) .038
Abbreviations: BHS+, β-hemolytic streptococcal etiology confirmed; BHS−, BHS not confirmed; CRP, C-reactive protein; GAS, group A streptococcus; GCS, group C streptococcus; GGS, group
G streptococcus; PCT, procalcitonin; TBSA%, percentage of total body surface with erythema.
a
Data are presented as No. (%) or No./evaluable cases (%) unless otherwise specified.
b
Cases with BHS etiology confirmed by serology or culture of blood or normally sterile tissue compared with cases with BHS not confirmed.
c
Cases with GCS/GGS compared with GAS cultured from blood, normally sterile tissue, or cutaneous swabs.
d
Fisher’s exact test was used, and 1 observation was added to each cell, due to 1 zero cell.
e
Sharply demarcated erythema, palpable edge, or salmon red erythema.
f
Neither all erysipelas signs (salmon red erythema, sharply demarcated erythema, palpable edge) nor none erysipelas signs.
g
Cases with drainable abscess or other drainable fluid collection were not included in the study.
h
Seven cases had CRP <5 mg/L at admission, but all except 1 case had CRP > 5 mg/L the day after.
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7. found for superficial cultures in some studies of cellulitis [20–
22]. However, in the latter studies, serology was not used, and
the causal role of GCS/GGS was therefore uncertain. In addi-
tion, GCS/GGS have primarily been associated with older age
or comorbidities [4, 18, 19, 21, 23, 24]. Our study supports
that GCS/GGS has a dominant role in cellulitis; they accounted
for the majority of BHS in culture and were strongly associated
with a serological profile predominant also among the culture
negative BHS infections. The GCS/GGS were not confined to
elderly or patients with comorbidities, underscoring the patho-
genic significance of these bacteria in cellulitis. It is interesting
to note that GCS/GGS were particularly associated with the
lower part of the body and GAS was associated with the
upper part, possibly related to differences in carriage, spread,
or pathogenicity of streptococci in carriage sites such as anus,
toe webs, and throat [21, 25–27].
Previous reports have suggested an important role also for S
aureus, and occasionally also Gram-negative bacteria, in cellu-
litis [7,8].These studies are hampered by retrospective design or
heterogeneous patient populations. Furthermore, these bacteria
are frequent colonizers of skin and common in abscesses, and in
a recent biopsy study of cellulitis patients, S aureus DNA was
also frequently detected in samples from uninfected tissue
[28]. In our study, cases with S aureus or Gram-negative bacte-
ria in swabs were common. However, the great majority, includ-
ing those with S aureus or Gram-negative bacteria as the only
detected pathogens, had confirmed or probable BHS disease.
This has also been reported previously for S aureus [6]. The re-
sults are in line with other studies demonstrating frequent col-
onization and dubious clinical significance of such pathogens
when detected in wounds, ulcers, or interdigital fissures of cel-
lulitis patients [26, 29]. Moreover, a recent randomized clinical
trial indicates that MRSA coverage is unnecessary in treatment
of uncomplicated nonpurulent cellulitis, adding to the evidence
that nonstreptococcal etiology in cellulitis is relatively rare [30].
The use of bedside cultures from nonsterile sites in the diag-
nostic work-up of cellulitis is usually not recommended [1, 3,
31]. Our findings support that S aureus or Gram-negative bac-
teria in swabs from cellulitis patients is of doubtful significance
and most often does not mandate antibiotic coverage against
these microbes. In contrast, we found a strong correlation be-
tween identification of both GAS and GCS/GGS in culture
and positive serology. A relative high proportion of “swab-pos-
itive” BHS infections was also documented, indicating that cu-
taneous swabs may be more useful in streptococcal cellulitis
than previously thought [17].
Our study also demonstrated that underlying factors known
to be associated with cellulitis, such as obesity and edema, were
common not only in patients with confirmed BHS disease, but
also among cases where other etiology is not unlikely. Some fac-
tors were particularly common in cases with recurrence, in line
with other studies [32]. Our data also support recent investiga-
tions that have found GCS/GGS to be more associated with re-
currence than GAS [21, 22].
To our knowledge, associations between bacterial etiology
and a detailed spectrum of clinical findings at admission previ-
ously have not been prospectively examined in cellulitis pa-
tients. We found that some signs, such as skin bruising and
extensive erythema, were related to BHS in this hospital setting.
However, as demonstrated by low positive likelihood ratios, the
Table 3. Clinical Predictors of Confirmed β-Hemolytic Streptococcal Etiologya
in Cellulitis
Characteristic
Unadjusted Models (n = 203b
) Adjusted Modelc
(n = 198)
OR (95% CI) P Value OR (95% CI) P Value
Age <75 yd
2.471 (1.125, 5.428) .021 3.523 (1.313, 9.455) .012
Male gender 1.893 (1.019, 3.516) .042 0.961 (.448, 2.065) .919
Skin barrier impairment 2.200 (1.055, 4.584) .033 2.419 (1.027, 5.699) .045
Antibiotics before admissione
0.561 (.286, 1.104) .092 0.343 (.147, 0.801) .012
Immunosuppression 0.478 (.189, 1.204) .111 0.179 (.146, 1.433) .184
Affected site <.0005 .031
Lower extremity 1.00 (Reference) 1.00 (Reference)
Upper extremity 0.189 (.080, 0.447) <.0005 0.255 (.092, 0.705) .008
Head 0.330 (.157, 0.697) .004 0.453 (.161, 1.274) .133
Other 1.299 (.148, 11.365) .813 1.737 (.141, 21.380) .667
TBSA% ≥3 2.754 (1.468, 5.166) .001 2.549 (1.044, 6.222) .038
Skin bruising 2.557 (1.117, 5.851) .023 1.495 (.521, 4.290) .450
Leucocytes (×109
/L) ≤3.5 or ≥8.0d
3.342 (1.491, 7.490) .002 2.426 (.950, 6.194) .065
Abbreviations: CI, confidence interval; OR, odds ratio; TBSA%, percentage of total body surface with erythema.
a
Defined by serology or culture of blood or normally sterile tissue.
b
For some variables, the number of evaluable cases were lower than 203 (see Tables 1 and 2 for details).
c
Adjustment was made for all factors listed in the table (Hosmer-Lemeshow’s χ2
= 13.166, df = 8, P = .068).
d
The association of this characteristic to confirmed BHS etiology is probably mainly due to increased serological sensitivity (see text).
e
Included in the adjusted model to correct for the possibility that antibiotics may have affected admission findings.
Predicting Streptococcal Cellulitis • OFID • 7
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8. correlation between clinical signature and BHS etiology was not
strong. This supports current recommendations using severity
and risk factors associated to specific microbes rather than the clin-
ical differentiation of erysipelas and deeper cellulitis as the basis for
empiric therapy [1]. However, a combination of some severe
symptoms and signs increased the positive likelihood ratio for
BHS etiology in our study. This suggests that severe cases in
some instances have a typical streptococcal profile that may justify
narrow-spectrum therapy. Low negative predictive values and high
LR−
values of BHS-related clinical signs implies that these markers
should be used to confirm rather than to disprove BHS disease.
The limitations of our study are mainly due to the lack of a
highly accurate “gold standard” for BHS etiology in nonbactere-
mic cellulitis [3, 9]. Biopsy studies have shown diverging results
[5, 7]. In addition, recent studies using current molecular tech-
nology have failed in defining the etiology of cellulitis [28, 33].
Furthermore, biopsy procedures are not feasible for a large rep-
resentative population. Likewise, culture of swab samples has
low sensitivity [6], and BHS in swabs of healthy controls do
occur, although rarely [26, 27]. We found serology to be the
most appropriate method for a large representative study. The
sensitivity is relatively good [9], but not optimal, as suggested
by streptococcal seronegativity in some of our cases with typical
erysipelas, BHS culture positivity, or penicillin response. As ob-
served, reduced sensitivity appears to be particularly related to
older age and low systemic response. Culture positive throat in-
fections with significant titer increases not reaching the stan-
dard upper limit of normal have demonstrated how sensitivity
is also dependent on the predefined diagnostic criteria [34]. In
addition, GBS infections are not detected by the serology assays
used. Sensitivity and specificity are also influenced by popula-
tion-dependent differences in normal values [35]. In a group
of healthy adults, the frequency of antibody levels above the
upper limit of normal (200 U/mL) was low, suggesting relatively
high specificity [15]. Nonetheless, recent or concurrent BHS in-
fections of the throat or other sites would influence serology re-
sults. Another concern recently pointed out is the lack of
specificity data regarding serology in skin and soft tissue infec-
tions [28]. Such specificity data were available from cases that
were noneligible in the cellulitis part of our study. Fifteen cases
with acute noncellulitis skin infection (abscess, bursitis, infectious
phlebitis, animal bite, osteomyelitis with skin infection, or viral
infection) with systemic illness and confirmed etiology other
than BHS had 2 sets of serology obtained. Streptococcal seropo-
sitivity was demonstrated (data not shown) in only 1 of these pa-
tients. These data as well as the strong correlation between
serological patterns and streptococcal species found in culture
suggest relatively high specificity. Our study was a single-center
cohort that was carried out in a population with low MRSA prev-
alence. Therefore, the results are not generalizable to all settings,
but the minor role of MRSA and other staphylococci suggested by
this and other studies increase the relevance [1, 9, 30, 36].
Strengths of our study include prospective design, low num-
ber of investigators, detailed and early registration of clinical
signs, and inclusion of cases representing the most important
subgroups of pure cellulitis. Finally, the combination of differ-
ent methods enabled us to evaluate the etiology in a large pro-
portion of patients.
CONCLUSIONS
In conclusion, this study confirms GAS and GCS/GGS as the
primary causes of cellulitis. This not only includes erysipelas
but also deeper cellulitis, overlapping conditions and cases
with S aureus cultured from cutaneous swabs. Knowledge of
the predominance of BHS in most subgroups of cellulitis con-
stitutes an important basis for empiric therapy. However, more
accurate tools are needed in the clinical setting to identify non-
streptococcal cases and establish etiological diagnoses. This may
also improve appropriate and pathogen-directed antibiotic ther-
apy for this large patient group.
Acknowledgments
We thank all of our coworkers at Haukeland University Hospital who
have contributed to the study. In particular, we thank Dr. Eivind Rath (De-
partment of Medicine) for review of the database.
Author contributions. T. B. designed the study, included cases, collect-
ed data, performed the data analyses, and drafted the manuscript. O. O. par-
ticipated in inclusion of cases, collection of data, and drafting the
manuscript. H. M. was responsible for the microbiological analyses and
helped draft the manuscript. B. R. K. and N. L. participated in the design
of the study and drafting the manuscript. S. S. participated in the design
of the study, inclusion of cases, collection of data, and drafting the
manuscript.
Financial support. This work was supported by a PhD grant from the
Department of Clinical Science, University of Bergen, Norway.
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest.
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