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1.
Antimicrob Agents Chemother ; 57(7): 3092-9, 2013 Jul.
Article in English | MEDLINE | ID: mdl-23612198

ABSTRACT

We studied clinical characteristics, appropriateness of initial antibiotic treatment, and other factors associated with day 30 mortality in patients with bacteremia caused by extended-spectrum-ß-lactamase (ESBL)-producing bacteria in eight Dutch hospitals. Retrospectively, information was collected from 232 consecutive patients with ESBL bacteremia (due to Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae) between 2008 and 2010. In this cohort (median age of 65 years; 24 patients were <18 years of age), many had comorbidities, such as malignancy (34%) or recurrent urinary tract infection (UTI) (15%). One hundred forty episodes (60%) were nosocomial, 54 (23%) were otherwise health care associated, and 38 (16%) were community acquired. The most frequent sources of infection were UTI (42%) and intra-abdominal infection (28%). Appropriate therapy within 24 h after bacteremia onset was prescribed to 37% of all patients and to 54% of known ESBL carriers. The day 30 mortality rate was 20%. In a multivariable analysis, a Charlson comorbidity index of ≥ 3, an age of ≥ 75 years, intensive care unit (ICU) stay at bacteremia onset, a non-UTI bacteremia source, and presentation with severe sepsis, but not inappropriate therapy within <24 h (adjusted odds ratio [OR], 1.53; 95% confidence interval [CI], 0.68 to 3.45), were associated with day 30 mortality. Further assessment of confounding and a stratified analysis for patients with UTI and non-UTI origins of infection did not reveal a statistically significant effect of inappropriate therapy on day 30 mortality, and these results were insensitive to the possible misclassification of patients who had received ß-lactam-ß-lactamase inhibitor combinations or ceftazidime as initial treatment. In conclusion, ESBL bacteremia occurs mostly in patients with comorbidities requiring frequent hospitalization, and 84% of episodes were health care associated. Factors other than inappropriate therapy within <24 h determined day 30 mortality.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacteremia/drug therapy , Enterobacteriaceae Infections/drug therapy , Enterobacteriaceae Infections/microbiology , beta-Lactams/therapeutic use , Aged , Bacteremia/microbiology , Comorbidity , Cross Infection/drug therapy , Cross Infection/microbiology , Enterobacter cloacae/drug effects , Enterobacteriaceae Infections/mortality , Escherichia coli/drug effects , Escherichia coli Infections/drug therapy , Escherichia coli Infections/microbiology , Escherichia coli Infections/mortality , Female , Humans , Intraabdominal Infections , Klebsiella Infections/drug therapy , Klebsiella Infections/microbiology , Klebsiella Infections/mortality , Klebsiella pneumoniae/drug effects , Male , Microbial Sensitivity Tests , Retrospective Studies , Treatment Outcome , beta-Lactam Resistance/genetics , beta-Lactamases/biosynthesis , beta-Lactams/pharmacology
2.
J Med Virol ; 81(3): 441-5, 2009 Mar.
Article in English | MEDLINE | ID: mdl-19152397

ABSTRACT

Occult hepatitis B virus (HBV) is defined by the presence of plasma HBV DNA in individuals with HBV core antibodies (anti-HBc), but without HBV surface antigen (HBsAg). The prevalence of occult HBV in HIV-infected patients remains controversial, and the risk factors, clinical significance and effect of highly active antiretroviral therapy (HAART) are unknown. The aim of this study was to determine prevalence, risk factors, and clinical significance of occult HBV in HIV-infected patients and to evaluate the effect of HAART. Plasma HBV DNA levels were determined in 191 HIV positive, antiretroviral naïve patients, who were anti-HBc positive and HBsAg negative. Quantitative HBV DNA was determined using a Taqman real-time nested PCR. Additionally, plasma HIV RNA levels, CD4 cell counts, anti-HBs-antibodies, anti-HCV-antibodies, ALT, AST, and gammaGT were determined. Occult HBV (a plasma HBV DNA level >50 copies/ml) was detected in 9/191 (4.7%) of the patients. Among 45 anti-HBs-negative patients (isolated anti-HBc positive), the prevalence was 11.1%. Patients with occult HBV had significantly lower CD4 count compared to anti-HBc-positive/HBsAg negative/HBV DNA-negative patients (105 +/- 157 (median +/- SD) vs. 323 +/- 299 cells/mm(3), P = 0.019). When HAART (including lamivudine) was initiated in the patients with occult HBV, HBV DNA was no longer detectable in any of the patients during 3 years of follow-up. In conclusion, occult HBV was associated with low CD4 counts and may be viewed as opportunistic reactivation of HBV that resolves as a consequence of HAART induced immune reconstitution and/or the effect of lamivudine.


Subject(s)
Antiretroviral Therapy, Highly Active , CD4-Positive T-Lymphocytes/immunology , HIV Infections/complications , HIV Infections/drug therapy , Hepatitis B virus/isolation & purification , Hepatitis B/virology , Plasma/virology , Adult , CD4 Lymphocyte Count , DNA, Viral/blood , Female , HIV Infections/immunology , Hepatitis B/epidemiology , Hepatitis B Core Antigens/blood , Hepatitis B Surface Antigens/blood , Humans , Liver Function Tests , Male , Middle Aged , Polymerase Chain Reaction/methods , Prevalence , Risk Factors , Viral Load
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