Fecal transplant (FMT) is increasingly used to treat recurrent clostridium difficile infections (rCDI) with reported cure rates of 70-90%. FMT’s efficacy has been studied in prospective and observation studies, however, it is unclear how it performs against fidoxamicin, a newer antibiotic used in the initial presentation and recurrence of CDI.
FMT is probably more efficacious than fidoxamicin and vancomycin for rCDI. My main concern with this study is that it was unblinded as to who received the FMT and could potentially influence the difference in microbiologic vs symptomatic cures with FMT. Interestingly, more patients treated with antibiotics had microbiologic cures than symptomatic cures, (vancomycin 31% microbiologic cure while only 19% clinical cure).
Among patients discharged with OPAT for complicated staph infections, 1/3 had an adverse event and nearly 2/3 were re-admitted within 90 days. Patients discharged to a skilled nursing facility (SNF) were lost to follow up at higher rates than those discharged with home care services (HCS) and had higher incidence of line complications. What surprised me was that the ID clinic only received labs from 44% of patients at SNF and 53% at HCS. But at the end of the day, both discharge locations had similar rates of “favorable outcomes”, 61% vs 70%. The SNF vs home care comparison maybe confounded because older and sicker patients are more likely to be sent to SNF/SAR
We often discharge patients on long courses of parenteral antibiotics for Staphyloccus auerus infections and we must recognize they are likely to face significant adverse events and complications. It is unclear if this is due to the severity of the underlying infection, and more importantly, could it have been prevented with closer inpatient monitoring. This study should give you pause when sending patients to SAR/SNF on long term IV antibiotics.
HHV-6 reactivation is one of the most common causes (in 30-70% of patients) of encephalitis in allo-SCT. It is a ubiquitous viral infection that remains latent and can reactivate after transplant.
Risk factors: HLA mismatch, T-cell depletion therapy, treatment with glucocorticoids, and the use of cord blood as a source of stem cells; 90% of cases of HHV-6 reactivation occur in patients who with cord-blood transplants.
Encephalitis presents as subacute confusion, but some may have a more progressive course. Anterograde amnesia, personality changes, irritability and seizures. SIADH is common.
CSF analysis shows mild lymphocytic pleocytosis and protein elevation.
Treatment is based on in-vitro susceptibility testing and foscarnet is therapy of choice. Can add ganciclovir if not clinically improving. But need to monitor closely for side effects including bone marrow suppression and electrolyte derangement which can predispose to seizures. Alternative therapy is cidofovir, but watch out for nephrotoxicity. Duration is 3-6 weeks and you shouldn’t monitor PCR levels to shorten treatment duration.
16 studies were included – significant heterogeneity, but of 2359 patients. Heterogeneity was assessed graphically and with a Q test. The Q test should only be used once in a data set to exclude outliers. The reference standard, we considered it to be of high quality if based on CT alone or when it consisted of a final diagnosis made by experts using an integrated synthesis of radiology and laboratory or microbiological data (or both).
The highest risk of bias stemmed from the flow of patients within each study because of an uneven application of the reference test (differential verification bias).
The dispersion of studies in the ROC plane suggests marked heterogeneity.
The 95% CI of the overall effect indicates a sensitivity of approximately 80% to 90% and a specificity of 70% to 90%.
Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis – Ana M. Llamas-Álvarez, MD; Eva M. Tenza-Lozano, MD; and Jaime Latour-Pérez, MD, PhD; . Chest 2017; 151(2):374-382
Baseline rates of treatment failure have varied in studies and rates have ranged from 8.5 to 17% in the best case scenarios to 43-75% in other studies. So even at baseline, we know that a significant number of patients will fail antibiotics and require surgery. Risk factors include diabetes mellitus, leukocytosis greater than 12.5, positive blood cultures, and C-reactive protein greater than 115. One risk factor increases failure rates for to 35.4%, two risk factors increases failure to 40.2%, and three or more risk factors increases failure rates to 76.9%. So basically, most patients should ideally managed with surgery and barring that we should advocate for surgery in patients who have risk factors.
STOP-IT trial: In patients with intraabdominal infections WITH source control, outcomes were similar between fixed duration (4 days) vs. duration guided by clinical improvement – 2 days after the resolution of fever, leukocytosis, and ileus (mean 8 days). Both intention to treat and per-protocol analysis found no difference. However, the study was terminated early due to funding, and only enrolled half the intended patients.
Concern over overlapping toxicities, pill burden, and drug interactions led some clinicians to delay ART initiation in patients with AIDS-related OI. This study demonstrates that initiating early ART is beneficial.
282 patients with CD4 <200 and AIDs-related OI or severe bacterial infection randomized to early ART within 14 days or deferred ART that started after 4 weeks. Improved AIDs illnesses or deaths. The study population consisted predominantly of patients with Pneumocystis pneumonia (63%), cryptococcal meningitis (12%), and AIDS-associated bacterial infections (12%).
The actual timing of when ARTs were started was 12 vs 45 days, which argues for starting ARTs within 2 weeks and not immediately.
No difference in the occurrence of IRIS (6 vs 9%).
Early Antiretroviral Therapy Reduces AIDS Progression/ Death in Individuals with Acute Opportunistic Infections: A Multicenter Randomized Strategy Trial – Zolopa AR, Andersen J, Komarow L, Sanne I, Sanchez A, et al. PLoS ONE 2009 4(5): e5575.