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Khademi P, Tukmechi A, Sgroi G, Ownagh A, Enferadi A, Khalili M, Mardani K. Molecular and genotyping techniques in diagnosis of Coxiella burnetii: An overview. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2024; 123:105655. [PMID: 39116951 DOI: 10.1016/j.meegid.2024.105655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 07/26/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
Although we live in the genomic era, the accessibility of the complete genome sequence of Coxiella burnetii, the etiological agent of Q fever, has increased knowledge in the field of genomic diversity of this agent However, it is still somewhat of a "question" microorganism. The epidemiology of Q fever is intricate due to its global distribution, repository and vector variety, as well as absence of surveys defining the dynamic interaction among these factors. Moreover, C. burnetii is a microbial agent that can be utilized as a bioterror weapon. Therefore, typing techniques used to recognize the strains can also be used to trace infections back to their source which is of great significance. In this paper, the latest and current typing techniques of C. burnetii spp. are reviewed illustrating their advantages and constraints. Recently developed multi locus VNTR analysis (MLVA) and single-nucleotide polymorphism (SNP) typing methods are promising in improving diagnostic capacity and enhancing the application of genotyping techniques for molecular epidemiologic surveys of the challenging pathogen. However, most of these studies did not differentiate between C. burnetii and Coxiella-like endosymbionts making it difficult to estimate the potential role that ticks play in the epidemiology of Q fever. Therefore, it is necessary to analyze the vector competence of different tick species to transmit C. burnetii. Knowledge of the vector and reservoir competence of ticks is important for taking adequate preventive measures to limit infection risks. The significant prevalence observed for the IS1111 gene underscores its substantial presence, while other genes display comparatively lower prevalence rates. Methodological variations, particularly between commercial and non-commercial kit-based methods, result in different prevalence outcomes. Variations in sample processing procedures also lead to significant differences in prevalence rates between mechanical and non-mechanical techniques.
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Affiliation(s)
- Peyman Khademi
- Department of Microbiology and Food Hygiene, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran; Department of Microbiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Amir Tukmechi
- Department of Microbiology and Food Hygiene, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran.
| | - Giovanni Sgroi
- Department of Animal Health, Experimental Zooprophylactic Institute of southern Italy, Portici, Naples, Italy
| | - Abdulghaffar Ownagh
- Department of Microbiology and Food Hygiene, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran
| | - Ahmad Enferadi
- Department of Microbiology and Food Hygiene, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran
| | - Mohammad Khalili
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Karim Mardani
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, VIC, 3010, Australia
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Delahaye A, Eldin C, Bleibtreu A, Djossou F, Marrie TJ, Ghanem-Zoubi N, Roeden S, Epelboin L. Treatment of persistent focalized Q fever: time has come for an international randomized controlled trial. J Antimicrob Chemother 2024; 79:1725-1747. [PMID: 38888195 DOI: 10.1093/jac/dkae145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/15/2024] [Indexed: 06/20/2024] Open
Abstract
Q fever is a worldwide zoonosis due to Coxiella burnetii, responsible for endocarditis and endovascular infections. Since the 1990s, the combination hydroxychloroquine + doxycycline has constituted the curative and prophylactic treatment in persistent focalized Q fever. This combination appears to have significantly reduced the treatment's duration (from 60 to 26 months), yet substantial evidence of effectiveness remains lacking. Data are mostly based on in vitro and observational studies. We conducted a literature review to assess the effectiveness of this therapy, along with potential alternatives. The proposed in vitro mechanism of action describes the inhibition of Coxiella replication by doxycycline through the restoration of its bactericidal activity (inhibited in acidic environment) by alkalinization of phagolysosome-like vacuoles with hydroxychloroquine. So far, the rarity and heterogeneous presentation of cases have made it challenging to design prospective studies with statistical power. The main studies supporting this treatment are retrospective cohorts, dating back to the 1990s-2000s. Retrospective studies from the large Dutch outbreak of Q fever (>4000 cases between 2007 and 2010) did not corroborate a clear benefit of this combination, notably in comparison with other regimens. Thus, there is still no consensus among the medical community on this issue. However insufficient the evidence, today the doxycycline + hydroxychloroquine combination remains the regimen with the largest clinical experience in the treatment of 'chronic' Q fever. Reinforcing the guidelines' level of evidence is critical. We herein propose the creation of an extensive international registry, followed by a prospective cohort or ideally a randomized controlled trial.
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Affiliation(s)
- Audrey Delahaye
- Department of Infectious and Tropical Diseases, Andrée Rosemon Hospital, Cayenne, French Guiana
| | - Carole Eldin
- UMR UVE, Aix Marseille University, IRD 190 Inserm, 1207 EFS-IRBA, Marseille, France
| | - Alexandre Bleibtreu
- Department of Infectious and Tropical Diseases, University Hospitals Pitié Salpêtrière-Charles Foix, AP-HP, Paris, France
| | - Félix Djossou
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Thomas J Marrie
- Faculty of Medicine, Dalhousie University, 1459 Oxford Street, Halifax, NS B3H 4R2, Canada
| | - Nesrin Ghanem-Zoubi
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Sonja Roeden
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Loïc Epelboin
- Department of Infectious and Tropical Diseases, Andrée Rosemon Hospital, Cayenne, French Guiana
- Clinical Investigation Center Antilles Guyane, Inserm 1424, Centre Hospitalier de Cayenne Andrée Rosemon, Cayenne, French Guiana
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Lipman-Arens S, Finn T, Istomin V, Cohen R, Reisfeld S. The Prognostic Value of Serology in Persistent Q Fever Infection. Vector Borne Zoonotic Dis 2024; 24:293-298. [PMID: 38306181 DOI: 10.1089/vbz.2023.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
Background: Q fever has significant consequences for patients with persistent localized infection. A combination of doxycycline with hydroxychloroquine, for at least 18-24 months, is the first-line therapy. The use of serology as a prognostic marker during therapy is controversial. Methods: A retrospective, observational cohort study in two outpatient clinics in northern Israel. All adults with persistent Q fever (2015-2021) were included in the study. Clinical failure was defined as relapse or death related to Q fever after end of treatment (EOT). Serological cure was defined as phase 1 IgG ≤800 or a four-fold decrease at EOT. Results: Twenty-two patients were included in the study, with a median follow up of 40 months (IQR = 28.5-63.5), and median treatment duration of 28.5 months (IQR = 21.8-50.5). Clinical cure occurred in 18 patients (82%), serological cure in 10 (45%). Phase 1 IgG at presentation was significantly higher in the clinical failure group (median 9600 vs. 3200 in the clinical cure group, p = 0.019), and at 6-12 months after EOT (median 6400 vs. 800 respectively, p = 0.03). Phase 1 IgG levels at 1 year and EOT were similar in both groups. Positive phase 2 IgM after one year of therapy correlated with clinical failure (p = 0.038), but not at EOT or after EOT. Conclusion: Phase 1 IgG levels at presentation, phase 2 IgM at 1 year, and Phase 1 IgG 6-12 months after EOT were associated with clinical failure in patients with persistent Q fever.
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Affiliation(s)
- Shelly Lipman-Arens
- Infectious Diseases Unit, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Talya Finn
- Infectious Diseases Unit, Sanz Medical Center, Netanya, Israel
| | - Valery Istomin
- Internal Medicine Department C, Hillel Yaffe Medical Center, Hadera, Israel
| | - Regev Cohen
- Infectious Diseases Unit, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Sharon Reisfeld
- Infectious Diseases Unit, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Paul M. Which trial do we need? Doxycycline vs. doxycycline-hydroxychloroquine and treatment duration protocol for Q fever endovascular infections. Clin Microbiol Infect 2023; 29:1468-1470. [PMID: 37244465 DOI: 10.1016/j.cmi.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/20/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Mical Paul
- Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
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Dold C, Zhu H, Silva-Reyes L, Blackwell L, Linder A, Bewley K, Godwin K, Fotheringham S, Charlton S, Kim YC, Pollard AJ, Rollier CS. Immunisation with purified Coxiella burnetii phase I lipopolysaccharide confers partial protection in mice independently of co-administered adenovirus vectored vaccines. Vaccine 2023; 41:3047-3057. [PMID: 37037709 PMCID: PMC10914673 DOI: 10.1016/j.vaccine.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/25/2023] [Accepted: 04/04/2023] [Indexed: 04/12/2023]
Abstract
Q fever is a highly infectious zoonosis caused by the Gram-negative bacterium Coxiella burnetii. The worldwide distribution of Q fever suggests a need for vaccines that are more efficacious, affordable, and does not induce severe adverse reactions in vaccine recipients with pre-existing immunity against Q fever. Potential Q fever vaccine antigens include lipopolysaccharide (LPS) and several C. burnetii surface proteins. Antibodies elicited by purified C. burnetii lipopolysaccharide (LPS) correlate with protection against Q fever, while antigens encoded by adenoviral vectored vaccines can induce cellular immune responses which aid clearing of intracellular pathogens. In the present study, the immunogenicity and the protection induced by adenoviral vectored constructs formulated with the addition of LPS were assessed. Multiple vaccine constructs encoding single or fusion antigens from C. burnetii were synthesised. The adenoviral vectored vaccine constructs alone elicited strong cellular immunity, but this response was not correlative with protection in mice. However, vaccination with LPS was significantly associated with lower weight loss post-bacterial challenge independent of co-administration with adenoviral vaccine constructs, supporting further vaccine development based on LPS.
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Affiliation(s)
- Christina Dold
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Henderson Zhu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK.
| | - Laura Silva-Reyes
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Luke Blackwell
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Aline Linder
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Kevin Bewley
- UKHSA Porton Down, Medical Interventions Group, Salisbury, Wiltshire, UK
| | - Kerry Godwin
- UKHSA Porton Down, Medical Interventions Group, Salisbury, Wiltshire, UK
| | - Susan Fotheringham
- UKHSA Porton Down, Medical Interventions Group, Salisbury, Wiltshire, UK
| | - Sue Charlton
- UKHSA Porton Down, Medical Interventions Group, Salisbury, Wiltshire, UK
| | - Young Chan Kim
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Christine S Rollier
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK; Section of Immunology, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Brus IM, Spronk I, Haagsma JA, Erasmus V, de Groot A, Olde Loohuis AGM, Bronner MB, Polinder S. Prerequisites, barriers and opportunities in care for Q-fever patients: a Delphi study among healthcare workers. BMC Health Serv Res 2023; 23:319. [PMID: 37004033 PMCID: PMC10064509 DOI: 10.1186/s12913-023-09269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/10/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Q-fever is a zoonotic disease that can lead to illness, disability and death. This study aimed to provide insight into the perspectives of healthcare workers (HCWs) on prerequisites, barriers and opportunities in care for Q-fever patients. METHODS A two-round online Delphi study was conducted among 94 Dutch HCWs involved in care for Q-fever patients. The questionnaires contained questions on prerequisites for high quality, barriers and facilitators in care, knowledge of Q-fever, and optimization of care. For multiple choice, ranking and Likert scale questions, frequencies were reported, while for rating and numerical questions, the median and interquartile range (IQR) were reported. RESULTS The panel rated the care for Q-fever patients at a median score of 6/10 (IQR = 2). Sufficient knowledge of Q-fever among HCWs (36%), financial compensation of care (30%) and recognition of the disease by HCWs (26%) were considered the most important prerequisites for high quality care. A lack of knowledge was identified as the most important barrier (76%) and continuing medical education as the primary method for improving HCWs' knowledge (76%). HCWs rated their own knowledge at a median score of 8/10 (IQR = 1) and the general knowledge of other HCWs at a 5/10 (IQR = 2). According to HCWs, a median of eight healthcare providers (IQR = 4) should be involved in the care for Q-fever fatigue syndrome (QFS) and a median of seven (IQR = 5) in chronic Q-fever care. CONCLUSIONS Ten years after the Dutch Q-fever epidemic, HCWs indicate that the long-term care for Q-fever patients leaves much room for improvement. Facilitation of reported prerequisites for high quality care, improved knowledge among HCWs, clearly defined roles and responsibilities, and guidance on how to support patients could possibly improve quality of care. These prerequisites may also improve care for patients with persisting symptoms due to other infectious diseases, such as COVID-19.
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Affiliation(s)
- Iris M Brus
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands.
| | - Inge Spronk
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | - Juanita A Haagsma
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | - Vicki Erasmus
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | | | | | - Madelon B Bronner
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
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Swarath S, Maharaj N, Kawall T, Seecheran R, Seecheran V, Giddings S, Seecheran NA. Culture-Negative Endocarditis in an Immunocompromised Patient: A Case of Suspected Bartonella and Coxiella Co-Infection. J Investig Med High Impact Case Rep 2023; 11:23247096231192811. [PMID: 37559398 PMCID: PMC10413893 DOI: 10.1177/23247096231192811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023] Open
Abstract
We present the case of a 23-year-old man with a previous deceased-donor renal transplant maintained on tacrolimus and prednisone who developed culture-negative endocarditis (CNE) of the mitral and aortic valves. He was suspected of being co-infected with Bartonella henselae and Coxiella burnetii, confirmed with serology testing. He was successfully managed with appropriate antibiotics and dual valve replacement.
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Affiliation(s)
- Steven Swarath
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Nicole Maharaj
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Tiffany Kawall
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | | | - Valmiki Seecheran
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Stanley Giddings
- The University of the West Indies, Street Augustine, Trinidad and Tobago
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Buijs SB, Weehuizen JM, Jensen TK, Boye M, Hermans MH, Nooijen PT, Hoepelman AI, Bleeker-Rovers CP, Oosterheert JJ, Wever PC. Fluorescence in situ hybridization for detecting Coxiella burnetii in tissue samples from chronic Q fever patients. Clin Microbiol Infect 2022; 28:1502.e1-1502.e5. [PMID: 35724869 DOI: 10.1016/j.cmi.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/06/2022] [Accepted: 06/14/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Detection of the intracellular bacterium Coxiella burnetii, causative agent of chronic Q fever, is notoriously difficult. Diagnosis of and duration of antibiotic treatment for chronic Q fever is partly determined by detection of the bacterium with polymerase chain reaction (PCR). Fluorescence in situ hybridization (FISH) might be a promising technique for detecting C. burnetii in tissue samples from chronic Q fever patients, but its value in comparison with PCR is uncertain. We aim to assess the value of FISH for detecting C. burnetii in tissue of chronic Q fever patients. METHODS FISH and PCR were performed on tissue samples from Dutch chronic Q fever patients collected during surgery or autopsy. Sensitivity, specificity, and overall diagnostic accuracy were calculated. Additionally, data on patient and disease characteristics were collected from electronic medical records. RESULTS In total, 49 tissue samples from mainly vascular walls, heart valves, or placentas, obtained from 39 chronic Q fever patients, were examined by FISH and PCR. The sensitivity and specificity of FISH compared to PCR for detecting C. burnetii in tissue samples from chronic Q fever patients was 45.2% (95% CI, 27.3% - 64.0%) and 84.6% (95% CI, 54.6% - 98.1%), respectively. The overall diagnostic accuracy was 56.8% (95% CI, 42.2% - 72.3%). Two C. burnetii PCR negative placentas were FISH positive. Four FISH results (8.2%) were deemed inconclusive because of autofluorescence. CONCLUSION With an overall diagnostic accuracy of 57.8%, we conclude that FISH has limited value in the routine diagnostics of chronic Q fever.
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Affiliation(s)
- Sheila B Buijs
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jesper M Weehuizen
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Tim K Jensen
- National Veterinary Institute, Technical University of Denmark, Frederiksberg C, Denmark
| | - Mette Boye
- Norwegian Veterinary Institute, Ås, Norway
| | - Mirjam Ha Hermans
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Peet Tga Nooijen
- Department of Pathology, Pathologie-DNA, location Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Andy Im Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases, Radboud university medical center and Radboud Expertise Center for Q fever, Nijmegen, the Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter C Wever
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
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'Treatment of Coxiella burnetii endocarditis with hydroxychloroquine' – Author’s reply. Clin Microbiol Infect 2022; 28:1159-1160. [DOI: 10.1016/j.cmi.2022.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/27/2022] [Indexed: 11/22/2022]
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Stahl JP, Varon E, Bru JP. Treatment of Coxiella burnetii endocarditis with hydroxychloroquine. Is it evidence-based? Clin Microbiol Infect 2022; 28:637-639. [PMID: 35150877 DOI: 10.1016/j.cmi.2022.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/01/2022]
Affiliation(s)
- J P Stahl
- Grenoble Alpes University, CHUGA, Infectious Diseases, 38043, Grenoble, France.
| | - E Varon
- Intercommunal Hospital, Laboratory of Medical Biology, 94000, Créteil, France
| | - J P Bru
- Annecy Genevois Hospital, CHANGE, Infectious Diseases, 74374 Annecy, France
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Randomized Trial of Ciprofloxacin Doxycycline and Hydroxychloroquine Versus Budesonide in Active Crohn's Disease. Dig Dis Sci 2021; 66:2700-2711. [PMID: 32681228 DOI: 10.1007/s10620-020-06477-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Increased mucosa-associated E. coli are present in Crohn's disease, but their role in pathogenesis is uncertain. AIMS To assess efficacy and safety of an antibiotic/hydroxychloroquine combination effective against E. coli inside macrophages. METHODS Adults with moderately active disease (CDAI > 220-450 plus C reactive protein ≥ 5 mg/l and/or fecal calprotectin > 250 μg/g) were randomized to receive (open-label) oral budesonide (Entocort CR 9 mg/day 8 weeks, 6 mg/day 2 weeks, 3 mg/day 2 weeks) or oral ciprofloxacin 500 mg bd, doxycycline 100 mg bd, hydroxychloroquine 200 mg tds for 4 weeks, followed by doxycycline 100 mg bd and hydroxychloroquine 200 mg tds for 20 weeks. Primary endpoints were remission (CDAI ≤ 150) at 10 weeks, remission maintained to 24 weeks, and remission maintained to 52 weeks. Patients not responding (CDAI fall by > 70) by 10 weeks were invited to crossover onto the alternative therapy. RESULTS Fifty-nine patients were recruited across 8 sites. Including crossover, 39 patients received antibiotics/hydroxychloroquine and 39 received budesonide. At 10 weeks, 24 weeks, and 52 weeks on initial therapy, only 2/27, 2/27, and 1/27 were in remission on antibiotics/hydroxychloroquine compared with 8/32, 1/32, and 1/32 on budesonide (P = 0.092 at 10 weeks). Withdrawals by 10 weeks due to adverse events were seen in 15 receiving antibiotics/hydroxychloroquine and 6 budesonide. Results including crossover were more promising with 9/24 patients receiving antibiotics/hydroxychloroquine per protocol in remission by 24 weeks. No correlation was seen between response to antibiotics/hydroxychloroquine and ASCA/OmpC antibody status or disease location. CONCLUSION Overall results with this antibiotic/hydroxychloroquine combination were unimpressive, but long-term remission is seen in some patients and justifies further study.
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Buijs SB, Bleeker-Rovers CP, van Roeden SE, Kampschreur LM, Hoepelman AIM, Wever PC, Oosterheert JJ. Still new chronic Q fever cases diagnosed eight years after a large Q fever outbreak. Clin Infect Dis 2021; 73:1476-1483. [PMID: 34028546 DOI: 10.1093/cid/ciab476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chronic Q fever usually develops within two years after primary infection with Coxiella burnetii. We determined the interval between acute Q fever and diagnosis of chronic infection, assessed what factors contribute to a longer interval, and evaluated the long-term follow-up. METHODS From 2007-2018, patients with chronic Q fever were included from 45 participating hospitals. The interval between acute and chronic infection was calculated in patients with a known day of first symptoms and/or serological confirmation of acute Q fever. Chronic Q fever-related complications and mortality were assessed by two investigators based on predefined criteria. RESULTS In total, 313 (60.3%) proven, 81 (15.6%) probable and 125 (24.1%) possible chronic Q fever patients were identified. The date of acute Q fever was known in 200 patients: in 45 (22.5%) the interval was longer than two years with the longest observed interval being 9.2 years. Patients in whom serological follow-up was performed after acute Q fever were diagnosed less often after this two-year interval (OR 0.26, 95% CI 0.12-0.54). Chronic Q fever-related complications occurred in 216 patients (41.6%). Chronic Q fever-related mortality occurred in 83 (26.5%) of proven and 3 (3.7%) of probable chronic Q fever patients. CONCLUSIONS Chronic Q fever is still being diagnosed and mortality keeps occurring eight years after a large outbreak. Intervals between acute Q fever and diagnosis of chronic infection can reach over 9 years. We urge physicians to perform microbiological testing for chronic Q fever even many years after an outbreak or acute Q fever disease.
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Affiliation(s)
- Sheila B Buijs
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases, Radboud Expertise Centre for Q Fever, Radboud university medical center, Nijmegen, the Netherlands
| | - Sonja E van Roeden
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Linda M Kampschreur
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter C Wever
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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Körner S, Makert GR, Ulbert S, Pfeffer M, Mertens-Scholz K. The Prevalence of Coxiella burnetii in Hard Ticks in Europe and Their Role in Q Fever Transmission Revisited-A Systematic Review. Front Vet Sci 2021; 8:655715. [PMID: 33981744 PMCID: PMC8109271 DOI: 10.3389/fvets.2021.655715] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/22/2021] [Indexed: 01/09/2023] Open
Abstract
The zoonosis Q fever is caused by the obligate intracellular bacterium Coxiella burnetii. Besides the main transmission route via inhalation of contaminated aerosols, ticks are discussed as vectors since the first isolation of the pathogen from a Dermacentor andersonii tick. The rare detection of C. burnetii in ticks and the difficult differentiation of C. burnetii from Coxiella-like endosymbionts (CLEs) are questioning the relevance of ticks in the epidemiology of Q fever. In this review, literature databases were systematically searched for recent prevalence studies concerning C. burnetii in ticks in Europe and experimental studies evaluating the vector competence of tick species. A total of 72 prevalence studies were included and evaluated regarding DNA detection methods and collection methods, country, and tested tick species. Specimens of more than 25 different tick species were collected in 23 European countries. Overall, an average prevalence of 4.8% was determined. However, in half of the studies, no Coxiella-DNA was detected. In Southern European countries, a significantly higher prevalence was observed, possibly related to the abundance of different tick species here, namely Hyalomma spp. and Rhipicephalus spp. In comparison, a similar proportion of studies used ticks sampled by flagging and dragging or tick collection from animals, under 30% of the total tick samples derived from the latter. There was no significant difference in the various target genes used for the molecular test. In most of the studies, no distinction was made between C. burnetii and CLEs. The application of specific detection methods and the confirmation of positive results are crucial to determine the role of ticks in Q fever transmission. Only two studies were available, which assessed the vector competence of ticks for C. burnetii in the last 20 years, demonstrating the need for further research.
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Affiliation(s)
- Sophia Körner
- Institute of Bacterial Infections and Zoonoses (IBIZ), Friedrich-Loeffler-Institute, Federal Research Institute for Animal Health, Jena, Germany
| | - Gustavo R Makert
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Sebastian Ulbert
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Martin Pfeffer
- Institute of Animal Hygiene and Veterinary Public Health, University of Leipzig, Leipzig, Germany
| | - Katja Mertens-Scholz
- Institute of Bacterial Infections and Zoonoses (IBIZ), Friedrich-Loeffler-Institute, Federal Research Institute for Animal Health, Jena, Germany
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14
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Buijs SB, van Roeden SE, van Werkhoven CH, Hoepelman AIM, Wever PC, Bleeker-Rovers CP, Oosterheert JJ. The prognostic value of serological titres for clinical outcomes during treatment and follow-up of patients with chronic Q fever. Clin Microbiol Infect 2021; 27:1273-1278. [PMID: 33813120 DOI: 10.1016/j.cmi.2021.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/06/2021] [Accepted: 03/14/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We assessed the prognostic value of phase I IgG titres during treatment and follow-up of chronic Q fever. METHODS We performed a retrospective cohort study to analyse the course of phase I IgG titres in chronic Q fever. We used a multivariable time-varying Cox regression to assess our primary (first disease-related event) and secondary (therapy failure) outcomes. In a second analysis, we evaluated serological characteristics after 1 year of therapy (fourfold decrease in phase I IgG titre, absence of phase II IgM and reaching phase I IgG titre of ≤1:1024) with multivariable Cox regression. RESULTS In total, 337 patients that were treated for proven (n = 284, 84.3%) or probable (n = 53, 15.7%) chronic Q fever were included. Complications occurred in 190 (56.4%), disease-related mortality in 71 (21.1%) and therapy failure in 142 (42.1%) patients. The course of phase I IgG titres was not associated with first disease-related event (HR 1.00, 95% CI 0.86-1.15) or therapy failure (HR 1.02, 95% CI 0.91-1.15). Similar results were found for the serological characteristics for the primary (HR 0.97, 95% CI 0.62-1.51; HR 1.12, 95% CI 0.66-1.90; HR 0.99, 95% CI 0.57-1.69, respectively) and secondary outcomes (HR 0.86, 95% CI 0.57-1.29; HR 1.37, 95% CI 0.86-2.18; HR 0.80, 95% CI 0.48-1.34, respectively). DISCUSSION Coxiella burnetii serology does not reliably predict disease-related events or therapy failure during treatment and follow-up of chronic Q fever. Alternative markers for disease management are needed, but, for now, management should be based on clinical factors, PCR results, and imaging results.
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Affiliation(s)
- Sheila B Buijs
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Sonja E van Roeden
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Cornelis H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter C Wever
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases, Radboud Expert Centre for Q Fever, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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15
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Buijs SB, Weehuizen JM, Oosterheert JJ, van Roeden SE. Chronic Q fever vertebral osteomyelitis, an underrecognized clinical entity. Infect Dis (Lond) 2021; 53:241-242. [PMID: 33475041 DOI: 10.1080/23744235.2020.1871509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- S B Buijs
- Department of Internal Medicine, University Medical Centre Utrecht, Utecht, Netherlands
| | - J M Weehuizen
- Department of Internal Medicine, University Medical Centre Utrecht, Utecht, Netherlands
| | - J J Oosterheert
- Department of Internal Medicine, University Medical Centre Utrecht, Utecht, Netherlands
| | - S E van Roeden
- Department of Internal Medicine, University Medical Centre Utrecht, Utecht, Netherlands
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16
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Husayn SS, Brown JD, Presley CL, Boghean K, Waller JD. Hydroxychloroquine Alternatives for Chronic Disease: Response to a Growing Shortage Amid the Global COVID-19 Pandemic. J Pharm Pract 2020; 35:120-125. [PMID: 32734810 PMCID: PMC8819554 DOI: 10.1177/0897190020942658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
With the emergence of a novel severe acute respiratory syndrome coronavirus,
investigators worldwide are scrambling to identify appropriate treatment
modalities, develop accurate testing, and produce a vaccine. To date, effective
treatment remains elusive. Chloroquine phosphate and hydroxychloroquine sulfate
(HCQ), well-known antimalarial drugs effective in the treatment of systemic
lupus erythematosus, rheumatoid arthritis, porphyria cutanea tarda, and chronic
Q fever, are currently under investigation. The United States Food and Drug
Administration recently issued an Emergency Use Authorization for CQ and HCQ use
in the treatment of coronavirus disease 2019 (COVID-19). With spikes in HCQ use
and demand, ethical considerations encompassing appropriate use, patient
autonomy, nonmaleficence, and distributive justice abound. As drug experts,
pharmacists are uniquely positioned to advocate for patients with chronic
conditions necessitating HCQ use, assist in the appropriate prescribing of HCQ
for COVID-19, and ensure patients and health care professionals are continually
educated during this public health crisis. This review highlights the worldwide
pandemic, describes appropriate HCQ use for chronic conditions, highlights
available alternatives, and deliberates evolving ethical questions. With
assistance from colleagues, state boards of pharmacy, and national
organizations, pharmacists ensure the just distribution of valuable
pharmaceuticals to patients having COVID-19 while supporting the needs of
patients requiring HCQ for chronic conditions.
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Affiliation(s)
- Sameeha S Husayn
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Jeremy D Brown
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Colby L Presley
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Kelsey Boghean
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Jacquelyn D Waller
- Department of Biomedical Sciences, Rocky Vista University, Parker, CO, USA
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17
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Re: chronic Q-fever-related complications and mortality: data from a nationwide cohort. Clin Microbiol Infect 2019; 25:1433-1435. [DOI: 10.1016/j.cmi.2019.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 12/11/2022]
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18
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‘Chronic Q fever-related complications and mortality: data from a nationwide cohort’ – Author’s reply. Clin Microbiol Infect 2019; 25:1436-1437. [DOI: 10.1016/j.cmi.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 11/22/2022]
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19
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Jansen AFM, Raijmakers RPH, van Deuren M, Vonk MC, Bleeker-Rovers CP. Chronic Q fever associated with systemic sclerosis. Eur J Clin Invest 2019; 49:e13123. [PMID: 31077590 DOI: 10.1111/eci.13123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/21/2018] [Accepted: 04/26/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND After the Q fever outbreak in the Netherlands between 2007 and 2010, more than 300 patients with chronic Q fever have been identified. Some patients were also diagnosed with systemic sclerosis, a rare immune-mediated disease. We aimed to increase awareness of concomitant chronic Q fever infection and systemic sclerosis and to give insight into the course of systemic sclerosis during persistent Q fever infection. MATERIALS AND METHODS Chronic Q fever patients were identified after the Dutch Q fever outbreak in 2007-2010. Systemic sclerosis was diagnosed by a scleroderma expert and patients fulfilled the 2013 Classification Criteria for Systemic Sclerosis. RESULTS Four cases presented with chronic Q fever, persistent Coxiella burnetii infection, shortly preceded or followed by the diagnosis of limited cutaneous systemic sclerosis. The three male patients of 60 years or older developed a relatively mild systemic sclerosis, which did not require immunosuppressive therapy during adequate treatment of the chronic Q fever infection. The 58-year-old female patient used immunosuppressives for her newly diagnosed systemic sclerosis at the time she likely developed a chronic Q fever infection. CONCLUSIONS In this case series, chronic Q fever preceding systemic sclerosis was associated with a mild course of systemic sclerosis without the necessity of immunosuppressive drugs, while chronic Q fever development due to immunocompromised state was associated with a more deteriorating course of systemic sclerosis.
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Affiliation(s)
- Anne F M Jansen
- Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Expert Center for Q fever, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruud P H Raijmakers
- Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Expert Center for Q fever, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel van Deuren
- Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Expert Center for Q fever, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Madelon C Vonk
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Expert Center for Q fever, Radboud University Medical Center, Nijmegen, The Netherlands
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20
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van Roeden SE, Wever PC, Kampschreur LM, Gruteke P, van der Hoek W, Hoepelman AIM, Bleeker-Rovers CP, Oosterheert JJ. Chronic Q fever-related complications and mortality: data from a nationwide cohort. Clin Microbiol Infect 2018; 25:1390-1398. [PMID: 30543852 DOI: 10.1016/j.cmi.2018.11.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/12/2018] [Accepted: 11/26/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Chronic infection with Coxiella burnetii (chronic Q fever) can cause life-threatening conditions such as endocarditis, infected vascular prostheses, and infected arterial aneurysms. We aimed to assess prognosis of chronic Q fever patients in terms of complications and mortality. METHODS A large cohort of chronic Q fever patients was assessed to describe complications, overall mortality and chronic Q fever-related mortality. Chronic Q fever-related mortality was expressed as a case fatality rate (number of chronic Q fever-related deaths/number of chronic Q fever patients). RESULTS Complications occurred in 166 of 439 (38%) chronic Q fever patients: in 61% of proven (153/249), 15% of probable (11/74), and 2% of possible chronic Q fever patients (2/116). Most frequently observed complications were acute aneurysms (14%), heart failure (13%), and non-cardiac abscesses (10%). Overall mortality was 38% (94/249) for proven chronic Q fever patients (median follow-up 3.6 years) and 22% (16/74) for probable chronic Q fever patients (median follow-up 4.7 years). The case fatality rate was 25% for proven (63/249) chronic Q fever patients and 4% for probable (3/74) chronic Q fever patients. Overall survival was significantly lower in patients with complications, compared to those without complications (p <0.001). CONCLUSIONS In chronic Q fever patients, complications occur frequently and contribute to the mortality rate. Patients with proven chronic Q fever have the highest risk of complications and chronic Q fever-related mortality. Prognosis for patients with possible chronic Q fever is favourable in terms of complications and mortality.
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Affiliation(s)
- S E van Roeden
- University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - P C Wever
- Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | | | - P Gruteke
- Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - W van der Hoek
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
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21
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van Roeden SE, Reukers DFM, van Jaarsveld CHM, Kampschreur LM, Hoepelman IM, Wever PC, Bleeker-Rovers CP, Oosterheert JJ. Chronic Q fever: patient and treatment-related factors influencing long-term quality of life. QJM 2018; 111:791-797. [PMID: 30102400 DOI: 10.1093/qjmed/hcy171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Chronic Q fever is accompanied by high mortality and morbidity, and requires prolonged antibiotic treatment. Little is known on long-term quality of life (LQOL) in chronic Q fever patients treated with antibiotics. AIM To identify patient and treatment-related factors associated with impaired LQOL in chronic Q fever patients treated with antibiotics, and to assess patients' perception on treatment. DESIGN Cross-sectional study. METHODS LQOL was assessed with a validated questionnaire from the Nijmegen Clinical Screening Instrument. Patients' perception on treatment was measured with three newly developed questions. RESULTS We included 64 patients: LQOL was impaired in 55% (n = 35) after a median follow-up of 5 years. Median treatment duration was 27 months. In multivariable analysis, treatment duration was significantly associated with impaired LQOL (OR 1.07; 95%CI 1.02-1.12, P < 0.01 per month increase). Age, gender, number of antibiotic regimens, surgical intervention, complications, diagnostic classification, focus of infection or registration of side effects during treatment were not associated with impaired LQOL. After start of treatment, 17 patients (27%) perceived improvement of their condition. Disadvantages of treatment were experienced on a daily basis by 24 patients (69%) with impaired LQOL and 13 patients (46%) without impaired LQOL (P = 0.04). CONCLUSIONS LQOL in chronic Q fever patients treated with antibiotics is impaired in more than half of patients 5 years after diagnosis. Antibiotic treatment duration was the only variable associated with impaired LQOL. The majority of patients experienced disadvantages on a daily basis, highlighting the high burden of disease and treatment.
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Affiliation(s)
- S E van Roeden
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - D F M Reukers
- Department of Primary and Community Care, Academic Collaborative Center AMPHI, Radboud University Medical Center, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - C H M van Jaarsveld
- Department of Primary and Community Care, Academic Collaborative Center AMPHI, Radboud University Medical Center, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - L M Kampschreur
- Department of Internal Medicine and Infectious Diseases, Medical Center Leeuwarden, Henri Dunantweg 2, AD Leeuwarden, The Netherlands
| | - I M Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - P C Wever
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, Henri Dunantstraat 1, GZ 's-Hertogenbosch, The Netherlands
| | - C P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases and Radboud Expert Center for Q fever, Radboud University Medical Center, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - J J Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
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