Daptomycin and Ceftaroline Combination Therapy in Complicated Endovascular Infections Caused by Methicillin-Resistant Staphylococcus epidermidis

Background In complicated endovascular infections by methicillin-resistant Staphylococcus aureus (MRSA) or Staphylococcus epidermidis (MRSE), when first-line therapy with vancomycin (VAN) or daptomycin (DAP) fails, combination therapy with ceftaroline (CFT) and DAP has been shown to be a useful approach as salvage therapy for persistent MRSA bacteremia. Objectives This study aimed to describe experience with daptomycin and ceftaroline combination therapy in MRSE-complicated endovascular infections. Methods A single-center retrospective review of consecutive patients with MRSE-complicated endovascular infections treated with ≥72 hours of DAP+CFT at any time during the course of treatment, from January 1, 2016 to December 31, 2020, at Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal, was conducted. The exclusion criteria were known resistance to daptomycin or ceftaroline, total time of combination therapy <72 hours and loss to follow-up. Results We identified seven cases that matched our criteria: five endocarditis and two central venous catheter infections. Six patients switched to combination therapy due to treatment failure with first-line agents - three due to persistent bacteremia and three due to progression of infection despite negative blood cultures. Effective surgical source control took one to four weeks to occur. Three patients died during the treatment, one from progression of the disease and two due to another infection. Conclusions We consider the DAP+CFT combination therapy to be a valid and safe therapeutic choice in complicated patients, such as those with severe infection, poor functional status, and impossibility or delay of surgical source control. However, conclusions on the role of combination therapy should be careful due to the low number of patients and the several confounding factors.

EPI-Net One Health reporting guideline for antimicrobial consumption and resistance surveillance data: a Delphi approach

Strategic and standardised approaches to analysis and reporting of surveillance data are essential to inform antimicrobial resistance (AMR) mitigation measures, including antibiotic policies. Targeted guidance on linking full-scale AMR and antimicrobial consumption (AMC)/antimicrobial residues (AR) surveillance data from the human, animal, and environmental sectors is currently needed. This paper describes the initiative whereby a multidisciplinary panel of experts (56 from 20 countries-52 high income, 4 upper middle or lower income), representing all three sectors, elaborated proposals for structuring and reporting full-scale AMR and AMC/AR surveillance data across the three sectors. An evidence-supported, modified Delphi approach was adopted to reach consensus among the experts for dissemination frequency, language, and overall structure of reporting; core elements and metrics for AMC/AR data; core elements and metrics for AMR data. The recommendations can support multisectoral national and regional plans on antimicrobials policy to reduce resistance rates applying a One Health approach.

Corynebacterium striatum cardiac device-related endocarditis: A case report

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Diagnosis of cardiac device-related endocarditis may be complex.

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Corynebacterium striatum has been increasingly associated with severe infections.

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Antimicrobial treatment is difficult, especially in the presence of resistance.

Corynebacterium striatum is an emerging Gram-positive bacillus associated with invasive infection in both immunocompetent and immunocompromised patients, especially associated with medical devices. Its ability to form biofilms has been demonstrated and it has been occasionally associated with cardiac device-related infective endocarditis with few cases described in literature. We report a case of C. striatum cardiac device-related infective endocarditis of complex management.

Late Hepatitis B reactivation after treatment with rituximab

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Patients with past hepatitis B virus (HBV) infections that undergo immunosuppression are in risk of HBV reactivation.

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Antiviral prophylaxis in patient with previous contact with HBV treated with rituximab is recommended by current guidelines.

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The duration of antiviral prophylaxis in patients with hematologic malignancies treated with rituximab remains controversial.

There is a large reservoir of individuals with past hepatitis B virus (HBV) infection that are in risk for HBV reactivation when immunosuppressed. On the setting of hematologic malignancy, the malignancy itself and currently used treatments, especially anti-CD20 agents, have risk of HBV reactivation. Antiviral prophylaxis is recommended by some international societies. We present a case of HBV reactivation more than 12 months after stopping rituximab containing treatment and 6 months of antiviral prophylaxis with entecavir, in a patient with HBV functional cure. The patient was restarted on antivirals and again obtain functional cure. The antiviral was stopped 1 year after seroconversion and the patient followed for another year without evidence of new reactivation. Most literature supports the use of antiviral prophylaxis in patients treated with rituximab. However, there are still conflicting indications and no consensus regarding the duration of prophylaxis. This clinical case and review of the literature supports a longer prophylaxis duration (more than 18 months after finishing rituximab treatments) instead of standard 12 months prophylaxis.

Post Vaccine Rubella During a Measles Outbreak: Clinical Case

Rubella is a vaccine preventable infection, and congenital rubella the most feared complication of this disease. Although young adult women are at greatest risk of post-vaccine rubella, this is also the group who potentially benefits the most from vaccine protection. Since post-vaccine disease has a mild and self-limited course, the benefit clearly exceeds the risk. During a measles outbreak in the north of Portugal, a 38-year-old woman presented with cervical posterior lymphadenopathies, fever and a maculo-papular rash one week after the administration of the measles, mumps and rubella vaccine. Measles was discarded and rubella viremia was demonstrated. Symptoms of rubella are non-specific and laboratory confirmation is essential. This is particularly relevant during a measles outbreak.

Panton-Valentine Leukocidin-Producing Staphylococcus aureus Infection: A Case Series

Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-SA) is associated with relapsing multifocal skin and soft tissue infections (SSTI), necrotizing pneumonia (NP) and severe musculoskeletal infections. Epidemiology is underknown and underdiagnosis is likely. Recent travel abroad, case clustering and relapsing disease are often reported. We reviewed all cases of PVL-SA infection diagnosed at our center, and found 21 cases over a 43-month period. Most patients were adult males, had relevant travel history, reported recurrent disease and presented with SSTI. Etiologic diagnosis took up to five years; meanwhile, 42% of patients had antibiotic treatments. Draining procedures were required in 43% of patients and intensive care support in 19%. All patients recovered. Methicillin-resistance prevalence was 24%. Only 2/13 decolonized patients had posterior relapsing SSTI, both with likely infected contacts. PVL-SA infection’s severity and impact are clear, even in small case series as ours. Physician awareness and active PVL-gene search are crucial for an adequate management.

Validation of a semi-automated surveillance system for surgical site infections: Improving exhaustiveness, representativeness, and efficiency

OBJECTIVES

To assess whether electronic records data could improve the efficiency, exhaustiveness, and representativeness of SSI surveillance by selecting a group of high-risk patients for manual review.

METHODS

Colorectal surgeries (2016-2018) and cholecystectomies (2017-2018) were selected. Post-surgical antibiotic use, positive culture, C-reactive protein (CRP) values, body temperature, leukocyte count, surgical re-intervention, admission to the emergency room, and hospital readmission were retrieved. For representativeness, procedures registered in HAI-Net were compared with non-included procedures, and the validity of each variable (or combination) was tested considering the presence of SSI as the gold standard. The proportion of procedures flagged for manual review by each criterion was estimated.

RESULTS

Little more than 50% of procedures were included in HAI-Net (SSI risk: 10.6% for colorectal and 2.9% for cholecystectomies). Non-included procedures showed higher proportions of infection markers. Antibiotic use and CRP >100 mg/dl presented the highest sensitivity for both surgical groups, while antibiotic use achieved the highest positive predictive value in both groups (22% and 21%, respectively) and flagged fewer colorectal procedures (47.7%).

CONCLUSIONS

Current SSI surveillance has major limitations. Thus, the reported incidence seems unreliable and underestimated. Antibiotic use appears to be the best criterion to select a sub-sample of procedures for manual review, improving the exhaustiveness and efficiency of the system.

Pleural aspergillosis in a patient with recurrent spontaneous pneumothorax: The challenge of an optimal therapeutic approach

Pleural aspergillosis (PA) is a rare but potentially fatal disease. Most cases are secondary to bronchopleural fistulae or pleural intervention and can occur in the absence of immunosuppression.

We report a case of PA in a young patient after pleurodesis for recurrent pneumothorax. Clinical resolution was achieved with systemic and local antifungal therapy combined with surgical debridement. Hepatotoxicity led to a switch from voriconazole to isavuconazole, with a successful outcome.

Portraying infective endocarditis: results of multinational ID-IRI study

Infective endocarditis is a growing problem with many shifts due to ever-increasing comorbid illnesses, invasive procedures, and increase in the elderly. We performed this multinational study to depict definite infective endocarditis. Adult patients with definite endocarditis hospitalized between January 1, 2015, and October 1, 2018, were included from 41 hospitals in 13 countries. We included microbiological features, types and severity of the disease, complications, but excluded therapeutic parameters. A total of 867 patients were included. A total of 631 (72.8%) patients had native valve endocarditis (NVE), 214 (24.7%) patients had prosthetic valve endocarditis (PVE), 21 (2.4%) patients had pacemaker lead endocarditis, and 1 patient had catheter port endocarditis. Eighteen percent of NVE patients were hospital-acquired. PVE patients were classified as early-onset in 24.9%. A total of 385 (44.4%) patients had major embolic events, most frequently to the brain (n = 227, 26.3%). Blood cultures yielded pathogens in 766 (88.4%). In 101 (11.6%) patients, blood cultures were negative. Molecular testing of vegetations disclosed pathogens in 65 cases. Overall, 795 (91.7%) endocarditis patients had any identified pathogen. Leading pathogens (Staphylococcus aureus (n = 267, 33.6%), Streptococcus viridans (n = 149, 18.7%), enterococci (n = 128, 16.1%), coagulase-negative staphylococci (n = 92, 11.6%)) displayed substantial resistance profiles. A total of 132 (15.2%) patients had cardiac abscesses; 693 (79.9%) patients had left-sided endocarditis. Aortic (n = 394, 45.4%) and mitral valves (n = 369, 42.5%) were most frequently involved. Mortality was more common in PVE than NVE (NVE (n = 101, 16%), PVE (n = 49, 22.9%), p = 0.042).

Mononeuritis multiplex: an uncommon neurological manifestation of cytomegalovirus reactivation in an HIV-infected patient

Background

Cytomegalovirus (CMV) reactivation with neurological involvement in patients with acquired immunodeficiency syndrome (AIDS) is increasingly rare since the introduction of antiretroviral therapy (ART). Manifestations include encephalitis, myelitis, polyradiculopathy and, less commonly, mononeuritis multiplex (MNM). We report a case of disseminated CMV disease with gastrointestinal and peripheral and central nervous system involvement in a patient with AIDS, manifesting primarily as MNM.

Case presentation

A 31-year old woman with AIDS presented with a clinical picture of MNM. Electromyography confirmed the clinical findings. CMV DNA was detected in cerebrospinal fluid (CSF) and blood. Gastrointestinal involvement was histologically documented. HIV RNA was also detected in CSF and brain MRI was consistent with HIV encephalopathy. A diagnosis of disseminated CMV disease (with esophagitis, colitis, encephalitis and MNM) and HIV encephalopathy was made. Treatment consisted of ganciclovir and foscarnet, followed by maintenance therapy with valganciclovir. Evolution was favorable and valganciclovir was stopped after sustained immune recovery following ART initiation.

Conclusion

We discuss the diagnostic approach to CMV neurological disease, with a focus on MNM and CMV encephalitis. Combination therapy with ganciclovir and foscarnet should be considered for all forms of neurological involvement, although available data are scarce. Since there is significant overlap between CMV encephalitis and HIV encephalopathy, ART drugs with higher CSF penetration may have to be considered. ART and immune recovery are essential to improve outcomes.

Routine CD4 monitoring in HIV patients with viral suppression: Is it really necessary? A Portuguese cohort

PURPOSE

CD4 cell-count has been regarded as the key surrogate marker for prognostic staging and therapeutic monitoring of HIV-infected individuals. Our purpose was to assess the probability of maintaining a CD4 count >200 cells/μL in patients with continuous viral suppression and CD4 cell counts >200 cells/μL.

METHODS

Retrospective cohort study of HIV-infected patients, treatment naïve, who started antiretroviral therapy between 2007 and 2011. We estimated the probability of maintaining CD4 counts >200 cells/μL during continuous viral suppression using the Kaplan-Meier method. The hazard ratios of a CD4 count <200 cells/μL were estimated and compared using Cox proportional hazards regression.

RESULTS

401 patients were included: 70.1% men; median age 37 years; 98.8% HIV-1 infected. The median duration of continuous viral suppression with CD4 counts >200 cells/μL was 40.5 months. Ninety-three percent of patients maintained CD4 counts ≥200 cells/μL during the period of continuous viral suppression. Compared with those with an initial CD4 count ≥350 cells/μL, patients with initial CD4 count <300 cells/μL had a significantly higher risk of a CD4 count <200 cells/μL. Patients with viral suppression and CD4 counts ≥350 cells/μL had a 97.1% probability of maintaining CD4 cell counts ≥200 cells/μL for 48 months.

CONCLUSIONS

The probability of a CD4 count <200 cells/μL in an HIV-infected patient with viral suppression and CD4 ≥350 cells/μL was very low. These data suggests less frequent monitoring of CD4 counts in these patients.

Artemether-lumefantrine and liver enzyme abnormalities in non-severe Plasmodium falciparum malaria in returned travellers: a retrospective comparative study with quinine-doxycycline in a Portuguese centre

Background

Artemisinin-based therapy is the current standard treatment for non-severe malaria due to Plasmodium falciparum. The potential for asymptomatic liver toxicity of this therapy and its implication in clinical practice is currently unknown. The aim of this study is to assess the hepatic function in patients treated with a standard three-day artemisinin-based regimen and to compare it with the quinine-doxycycline regimen.

Methods

Retrospective and comparative study of returned adult travellers admitted with non-severe P. falciparum malaria. Fifty-seven patients were included: 19 treated with artemisinin-based therapy and 38 with quinine-doxycycline therapy.

Results

During treatment, when compared with quinine-doxycycline group, the artemisinin-lumefantrine group presented a higher proportion of significant liver enzyme abnormalities (42 vs. 5%, p < 0.01) and a higher peak value of aspartate aminotransferase (131 vs. 64 U/L, p < 0.01) and alanine aminotransferase (99 vs. 75 U/L, p = 0.05). None of the patients was symptomatic, there were no treatment interruptions and all patients achieved clinical cure.

Conclusions

Treatment of uncomplicated falciparum malaria with artemisinin-based therapy might cause asymptomatic liver enzyme abnormalities in the first days of treatment. Nevertheless, these liver enzyme abnormalities seem to be harmless, asymptomatic and self-limited.

Interactions between liposomes and hydroxypropylmethylcellulose

The characteristics of the adsorption process of hydroxypropylmethylcellulose (HPMC) of molecular weight 35400 Da and nominal viscosity 100 cps onto liposomes prepared with different egg lecithin-cholesterol molar ratios were examined. Adsorption isotherms were constructed and analysed to investigate the mechanisms implicated in the incorporation of the polymer to the interface. Only the isotherms obtained with cholesterol-free liposomes were fitted with Langmuir model. When cholesterol is present in the composition they present a sigmoidal slope. The mechanism of adsorption depends on liposome composition being the main force that drives polymer adsorption of hydrophobic nature. The apparent volumes of HPMC indicate that the conformation of the adsorbed macromolecules depends on liposome composition. Hydration enthalpy values show that adsorbed polymers do not give more hydrophilic systems after freeze-drying as expected with the hydrophilic characteristics of the HPMC.

Interfacial adsorption of polymers and surfactants: implications for the properties of disperse systems of pharmaceutical interest

This review considers basic aspects of the interfacial adsorption of polymers and surfactants, with particular reference to the relevance of these processes for the formulation of pharmaceutical disperse systems. First, we discuss different approaches to the interpretation of adsorption isotherms, paying particular attention to systems containing more than one adsorbate. Second, we consider the implications of adsorption for the properties of suspensions, emulsions, and colloidal systems, particularly as regards the use of polymers and surfactants for stabilizing disperse systems, for controlling flocculation, and for modifying the biopharmaceutical behavior of colloidal drug carriers. Finally, we present a number of representative examples of the importance of adsorption of macromolecules in pharmaceutical systems.

Degradation of hydroxypropylcellulose by Rhizomucor: effects on release from theophylline-hydroxypropylcellulose tablets

The stability of several varieties of hydroxypropylcellulose was monitored during 3 years of storage (1) under the conditions recommended by manufacturers and official pharmacopoeias (simple storage in closed containers) and (2) at zero relative humidity. After 1 year, severe degradation of the varieties with lower initial pH and particle size stored at ambient relative humidity was shown by changes in their molecular weight and in the pH and apparent viscosity of 2% aqueous dispersions. Microbiological analyses showed the observed degradation to be attributable to the action of fungi of the genus Rhizomucor. The changes in apparent viscosity significantly affected the release of theophylline from direct compression tablets formulated with the degraded excipients.

The adsorption of cellulose ethers in aqueous suspensions of pyrantel pamoate: effects on zeta potential and stability

This work examined the physico-chemical phenomena induced in aqueous suspensions of pyrantel pamoate by two varieties of hydroxypropylmethylcellulose (HPMC) and sodium carboxymethylcellulose (NaCMC) of different molecular weights, and the effects of these phenomena on the physical stability of the suspension. The mechanism of the interfacial adsorption of the polymer was investigated by constructing adsorption isotherms: for the two HPMC varieties, the isotherms were of type L and were fitted with the Langmuir model; of the NaCMCs, only the variety with higher molecular weight was adsorbed, its adsorption isotherm being of type S (sigmoidal). The resulting monolayer films were characterized viscosimetrically, determining their thickness and the number of polymer molecules adsorbed per unit area. The nonionic polymers formed thinner, more continuous monolayers than the NaCMC. Only the nonionic polymers significantly altered the zeta potential of the systems. In the range of conditions studied, all the polymers stabilized the initially flocculated systems, decreasing sedimentation volume and increasing the time necessary to redisperse them (the redispersability value). This stabilization occurred either by the steric mechanism (HPMCs and the high-molecular-weight NaCMC) or by depletion mechanisms (low-molecular-weight NaCMC). Owing to the complexity of these mechanisms, sedimentation volume was not found to be a useful index of the consistency of the sediments obtained from the suspensions.

[Acquired factor VIII inhibitor in a patient with rheumatoid arthritis]

In the present report we describe a 66 year-old-woman, diagnosed of rheumatoid arthritis, who suffered a severe haemorrhagic syndrome caused by the presence of a circulating inhibitor to factor VIII. Inhibitor quantitation was measured with Bethesda test. After treatment with corticosteroids and high-dose immunoglobulin, a good clinical response was obtained; factor VIII:C activity increased with the disappearance of detectable inhibitor. This response was observed more effectively and rapidly than with prednisone treatment alone.

[Alkyl derivatives of isoquinoline. III. Synthesis and pharmacologic activity of dialkylaminoalkyl amides of 1-chloro- and 1-methoxy-3-carboxy-4-methylisoquinoline and of 3-carboxy-2,4-dimethyl-1,2-dihydro-1-oxoisoquinoline]

The synthesis of a series of dialkylaminoalkylic amides of 1-chloro-3-carboxy-4-methylisoquinoline (VIII), of 1-methoxy-3-carboxy-4-methylisoquinoline (VI) and of 3-carboxy-2,4-dimethyl-1-oxoisoquinoline (XIII) is described. In addition a series of 1-amino-substituted 3-carboxymethyl-4-methylisoquinolines (II) was synthesized. The pharmacological activity of some of these compounds was studied. The compounds (XIIIa), (VIa) and (VIIIa) showed a clear local anaesthetic activity, a little lower than that of lidocaine; the same compounds also showed fairly good antispasmodic properties.