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What's new in infectious diseases

Last literature review version 18.2: May 2010 | This topic last updated: June 18, 2010 (More)

The following represent additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.

ANTIBIOTICS AND ANTIMICROBIAL RESISTANCE

Antibiotics and warfarin — Among patients age 66 and above taking warfarin who require antimicrobial therapy for treatment of urinary tract infection, trimethoprim-sulfamethoxazole and ciprofloxacin appear to be associated with increased risk of upper gastrointestinal tract bleeding (OR 3.84; 95% CI 2.33-6.33 and OR 1.94; 95% CI 1.28-2.95, respectively) [1]. In such patients an alternative antibiotic agent of a different class should be prescribed if feasible. (See "Therapeutic use of warfarin", section on 'Antibiotics'.)

BACTERIAL INFECTIONS

Endocarditis — Routine cerebral magnetic resonance imaging (MRI) may be useful in patients with definite or suspected endocarditis. In one study including 53 patients, early use of cerebral MRI led to the reclassification from possible to definite infective endocarditis in one-third of cases [2]. (See "Diagnostic approach to infective endocarditis", section on 'Cerebral imaging'.)

C. difficile — Symptomatic patients may play a role in airborne dispersal of C. difficile. In a study including 50 patients with confirmed C. difficile infection, air sampling for one hour demonstrated C. difficile organisms in 12 percent of cases [3]. (See "Prevention and control of Clostridium difficile in hospital and institutional settings", section on 'Infection control'.)

New clinical practice guidelines for Clostridium difficile infection in adults have been released by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Disease Society of America (ISDA) [4]. (See "Clinical manifestations and diagnosis of Clostridium difficile infection in adults" and "Treatment of antibiotic-associated diarrhea caused by Clostridium difficile in adults".)

Orbital cellulitis — In a retrospective cohort study of otherwise healthy children who had an orbital abscess, proptosis, pain with external ocular movement, and ophthalmoplegia were associated with the presence of an orbital abscess, although 51 percent of patients who had an abscess did not have these findings [5]. Other factors associated with orbital abscess were a peripheral absolute neutrophil count (ANC) >10,000 per microL, absence of conjunctivitis, periorbital edema, age >3 years, and previous antibiotic therapy. The authors concluded that in children who lack the usual high risk signs of ophthalmoplegia and proptosis, the presence of edema beyond the eyelid or an ANC >10,000 cell/microL qualifies the patient as high risk for an orbital abscess, and should necessitate an expedited evaluation including emergent CT scanning. (See "Preseptal (periorbital) and orbital cellulitis", section on 'Orbital cellulitis'.)

PARASITIC INFECTIONS

Artemisinin resistance and P. falciparum — Results of malaria blood smears performed three days after treatment initiation may be used as a screening tool for artemisinin resistance [6]. Artemisinin resistance is highly unlikely if the proportion of patients with parasite density <100,000 parasites/microL following a three-day course of therapy with an artemisinin combination regimen is <3 percent. (See "Treatment of uncomplicated falciparum malaria", section on 'Resistance'.)

Pyronaridine-artesunate — Pyronaridine-artesunate is an excellent addition to the artemisinin combination therapy armamentarium for treatment of uncomplicated falciparum malaria [7]. In a randomized trial including 1272 children and adults, patients on pyronaridine-artesunate had a significantly lower rate of subsequent infection at day 28 and day 42 than patients on artemether-lumefantrine, likely due to the prolonged half-life of the pyronaridine component. (See "Treatment of uncomplicated falciparum malaria", section on 'Comparing ACTs'.)

PNEUMONIA

Community-acquired pneumonia and antipsychotics — In a case-control study, current use of atypical or typical antipsychotics was associated with a dose-dependent increased risk for community-acquired pneumonia (CAP) compared with past use [8]. Atypical antipsychotic use was also associated with an increase in the risk of fatal CAP. (See "Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults", section on 'Drugs'.)

SEXUALLY TRANSMITTED DISEASES

Human papillomavirus and HIV acquisition — In a study of 2168 HIV-seronegative men in Kenya (n = 2168) who were participating in a placebo-controlled randomized trial of circumcision, HPV infection at baseline was correlated with an increased risk of HIV acquisition over a four-year period, independent of subsequent circumcision status and behavioral risk factors [9]. (See "Epidemiology of human papillomavirus infections".)

IMMUNIZATIONS AND TRAVEL

Influenza immunization

Universal immunization — In 2010, the US Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded the recommendation for influenza vaccination to include all individuals six months of age and older [10]. This represents a change for adults from previous guidelines, which recommended influenza vaccination for individuals over age 50 and for those at increased risk of influenza complications and close contacts of such individuals. (See "Seasonal influenza vaccination in adults", section on Indications for immunization.)

Vaccine composition — Starting with the 2010 influenza season in the southern hemisphere and the 2010-2011 season in the northern hemisphere, the trivalent influenza vaccine includes antigen from the 2009 pandemic H1N1 influenza A virus [11,12]. (See "Seasonal influenza vaccination in adults", section on 'Vaccine design'.)

High-dose vaccine — In December 2009, the US Food and Drug Administration approved a high-dose inactivated influenza vaccine for individuals ≥65 years of age [13]. The approval was based on data showing increased immunogenicity of the high-dose vaccine in older adults. However, the Advisory Committee on Immunization Practices has not stated a preference for this vaccine over the standard dose vaccine in older adults since there are no data demonstrating greater protection against influenza illness. (See "Seasonal influenza vaccination in adults", section on 'Vaccine formulation'.)

Japanese encephalitis — New recommendations for Japanese encephalitis vaccines have been released by the Advisory Committee on Immunization Practices (ACIP) [14]. (See "Japanese encephalitis: Epidemiology, diagnosis, treatment and prevention".)

Measles mumps rubella (MMR) — Monovalent vaccines are no longer available in the United States for measles, mumps or rubella [15]. Their use unnecessarily delays administration of the three vaccine components, leaving individuals susceptible for a longer period of time to serious, life-threatening diseases. (See "Standard childhood immunizations", and other related topics).

Meningococcal vaccine — In 2010, a new quadrivalent meningococcal conjugate vaccine (Menveo, MenACWY) was approved in the United States for use in individuals from 11 to 55 years of age as an alternative to the older quadrivalent conjugate vaccine (Menactra, MCV4) [16]. Both formulations protect against the same serogroups (A, C, Y, and W135), are immunogenic, and have comparable safety profiles. (See "Meningococcal vaccines".)

Herpes zoster vaccine — Early uptake of herpes zoster vaccine has been approximately 2 to 7 percent in the United States. A survey among general internists and family practice physicians found that the most frequently reported barrier to immunization was financial; only 45 percent of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D [17]. (See "Prevention of varicella-zoster virus infection: Herpes zoster".)

MYCOBACTERIA

HIV and tuberculosis — In a prospective, open-label, randomized trial (CAPRISA) in South Africa, 642 HIV-infected patients with CD4 counts of <500 cells/microL, and sputum smears positive for acid fast bacilli, were randomly assigned to either integrated TB/HIV treatment (ART initiation during TB therapy) or sequential treatment (ART initiation after completion of TB therapy) [18]. The trial was stopped early since all-cause mortality was 56 percent lower in the integrated treatment arm compared with the sequential treatment arm. Furthermore, mortality was lower in the integrated therapy group within all CD4 count strata while rates of adverse events were similar in both arms. The optimal timing of overlapping therapy, however, is still unknown. (See "Treatment of pulmonary tuberculosis in the HIV-infected patient".)

Buruli ulcer — Antimicrobial therapy for Buruli ulcer disease has traditionally consisted of rifampin and streptomycin. A randomized trial including 151 patients demonstrated that the number of streptomycin injections can be reduced by employing a regimen of four weeks of streptomycin and rifampicin followed by four weeks of rifampicin and clarithromycin [19]. Surgery was avoided in the majority of patients demonstrating that generous excision margins including healthy tissue are not necessary; prior to this study aggressive debridement was believed to be necessary for cure. (See "Buruli ulcer (Mycobacterium ulcerans infection)", section on 'Treatment'.)

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