Tranexamic acid in life-threatening military injury and the associated risk of infective complications.

BACKGROUND: Tranexamic acid (TXA) has been shown to reduce mortality from severe haemorrhage. Although recent data suggest that TXA has anti-inflammatory properties, few analyses have investigated the impact of TXA on infectious complications in injured patients. The aim was to examine the association between TXA administration and infection risk among injured military personnel. METHODS: Patients who received TXA were matched by Injury Severity Score with patients who did not receive TXA. Conditional logistic regression was used to examine risk factors associated with infections within 30 days. A Cox proportional analysis evaluated risk factors in a time-to-first-infection model. RESULTS: A total of 335 TXA recipients were matched with 626 patients who did not receive TXA. A greater proportion of TXA recipients had an infection compared with the comparator group (P < 0·001). Univariable analysis estimated an unadjusted odds ratio (OR) of 2·47 (95 per cent c.i. 1·81 to 3·36) for the association between TXA and infection risk; however, TXA administration was not significant in multivariable analysis (OR 1·27, 0·85 to 1·91). Blast injuries, intensive care unit (ICU) admission, and receipt of 10 units or more of blood within 24 h after injury were independently associated with infection risk. The Cox proportional model confirmed the association with ICU admission and blood transfusion. Traumatic amputations were also significantly associated with a reduced time to first infection. CONCLUSION: In life-threatening military injuries matched for injury severity, TXA recipients did not have a higher risk of having infections nor was the time to develop infections shorter than in non-recipients. Extent of blood loss, blast injuries, extremity amputations and ICU stay were associated with infection.

Combat trauma-associated invasive fungal wound infections: epidemiology and clinical classification.

The emergence of invasive fungal wound infections (IFIs) in combat casualties led to development of a combat trauma-specific IFI case definition and classification. Prospective data were collected from 1133 US military personnel injured in Afghanistan (June 2009-August 2011). The IFI rates ranged from 0·2% to 11·7% among ward and intensive care unit admissions, respectively (6·8% overall). Seventy-seven IFI cases were classified as proven/probable (n = 54) and possible/unclassifiable (n = 23) and compared in a case-case analysis. There was no difference in clinical characteristics between the proven/probable and possible/unclassifiable cases. Possible IFI cases had shorter time to diagnosis (P = 0·02) and initiation of antifungal therapy (P = 0·05) and fewer operative visits (P = 0·002) compared to proven/probable cases, but clinical outcomes were similar between the groups. Although the trauma-related IFI classification scheme did not provide prognostic information, it is an effective tool for clinical and epidemiological surveillance and research.

Longitudinal assessment of cardiac diastolic function in HIV-infected patients.

Asymptomatic isolated diastolic dysfunction (DD), with normal left ventricular systolic function, may be the first indication of underlying cardiac disease in HIV-negative populations. We previously reported a high prevalence (37%) of DD among asymptomatic HIV-infected patients at low risk for AIDS and cardiovascular disease (CVD). We performed a longitudinal assessment of interval echocardiographic changes in this cohort over a four-year period. Repeat transthoracic echocardiograms (TTEs) utilized standard techniques. Sixty (of the original 91) HIV-infected patients, predominately men, underwent repeat TTE (median follow-up 3.7 years, interquartile range [IQR] 3.5, 4.0). Cohort characteristics (median; IQR) include age 42.0 (36.5, 46.0) years, HIV duration 16.4 years (8.1, 18.9), current CD4 count 572.0 cells/mm(3) (436.5, 839.0), antiretroviral therapy (ART) duration 8.1 years (4.8, 13.4) and Framingham risk score 1.0 (0.0, 2.0). DD was observed in 28/60 patients on re-evaluation (47%, 95% confidence interval [CI] 34%, 60%); 31% (11/36) of patients had new onset DD for an overall incidence of 8.2/100 person-years. On follow-up, subjects with DD were older, had a trend towards higher body mass index, hypertension and longer duration of HIV infection compared with subjects without DD. We confirmed a high prevalence of DD (47%) in asymptomatic HIV-infected patients at low risk for AIDS and CVD.

Caught in the act: in vivo development of macrolide resistance to Campylobacter jejuni infection.

We report the first instance of macrolide resistance developing in vivo following appropriate antibiotic use in a healthy volunteer as a part of a controlled human infection with Campylobacter jejuni. In vivo development of macrolide resistance may be an important contributor to antibiotic resistance in C. jejuni.

Case series study of traveler's diarrhea in U.S. military personnel at Incirlik Air Base, Turkey.

Military personnel with traveler's diarrhea (n=202) while deployed to Incirlik Air Base, Turkey, from June to September 2002 were evaluated for pathogen-specific immune responses. Serologic and fecal immunoglobulin A (IgA) titers to enterotoxigenic Escherichia coli antigens (CS6, CS3, and LT) were quite low. In contrast, subjects with Campylobacter infections had high serologic and fecal IgA responses.

An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection.

Campylobacter is a leading cause of traveler's diarrhea in Thailand. Since resistance to quinolones is high among Campylobacter isolates, empiric therapy with quinolones for traveler's diarrhea may be ineffective in this region. We conducted an observational study among 169 U.S. military personnel with acute diarrhea and compared their microbiologic findings to those of 77 asymptomatic personnel deployed to Thailand in May 1998. Of 146 pathogenic bacterial isolates, the most common were nontyphoidal Salmonella (n = 31), enterotoxigenic Escherichia coli (n = 24), and C. jejuni/coli (n = 23). Campylobacter was strongly associated with disease (odds ratio = 5.9; 95% confidence interval = 1.3-37.3), with a more severe clinical presentation, and with a reduced functional ability at presentation (P = 0.02). In vitro resistance to ciprofloxacin was observed in 96% of the Campylobacter isolates. Sub-optimal treatment response to ciprofloxacin was observed in 17% of the cases of Campylobacter infection versus 6% due to other causes. These results highlight the importance of Campylobacter as a cause of severe traveler's diarrhea in Thailand and illustrates the ongoing problem with antibiotic-resistant strains and associated treatment problems.

Campylobacter jejuni enteritis.

We report the development of Campylobacter jejuni enteritis in a patient with preexisting humoral and cellular immune recognition of C. jejuni antigens. This is one of few studies in which the immunologic status of a person with regard to C. jejuni before and after C. jejuni infection is directly compared, and it is the only study of which we are aware that includes measurements of cellular immunity. The findings may be important to Campylobacter vaccine development efforts.

Diarrhea in the returned traveler.

Diarrhea in the returned traveler is a common problem that can be caused by a number of different pathogens. A history of the patient's travel and exposures, the duration of illness, the response to prior treatment, and the clinical syndrome can help to establish a good etiologic differential diagnosis on which further therapy can be based. Many of these patients can be treated empirically with antibiotics, either a fluoroquinolone or azithromycin, without further microbiologic evaluation. Those patients with severe or persistent disease or comorbid illnesses, or those who have failed empiric therapy, should undergo further microbiologic evaluation with directed stool cultures and ova and parasite screening. For those patients with negative evaluations, further empiric therapy may be warranted if syndromes are suggestive of specific agents of infection, such as by Giardia or Cyclospora species. Other patients may require endoscopic evaluation to exclude diagnoses such as tropical sprue or inflammatory bowel disease.

Comparative field evaluation of HIV rapid diagnostic assays using serum, urine, and oral mucosal transudate specimens.

BACKGROUND: Comparative field utility of selected HIV-1 assays using homologous collections of serum, urine and oral mucosal transudate (OMT) was determined in adult populations from a tuberculosis hospital and STD clinic in Djibouti, East Africa. STUDY DESIGN: Enzyme immunoassay with confirmatory Western blot was performed on all serum specimens for comparison with rapid, instrument-free assays (SUDS HIV-1, Murex: TestPack HIV-1/2. Abbott; and COMBAIDS HIV 1 + 2, SPAN Diagnostics) using various specimen sources. Delayed (48 h post-collection) testing was also performed on urine. Sensitivity and specificity for the rapid assays, in descending order, were as follows: serum SUDS HIV-1 assay (100%, 98.3%), serum COMBAIDS HIV-1/2 assay (98.4%, 99.6%), and OMT SUDS HIV-1 assay (98.4%, 94.5%). RESULTS: The OMT EIA optical density cutoff value was modified resulting in an improved specificity from 89.1 to 99.6%, however, sensitivity decreased from 100 to 98.5%. Urine EIA and rapid assays demonstrated unacceptable test performance for use as a screening test.

Short course chemotherapy with cefixime in children with multidrug-resistant Salmonella typhi Septicaemia.

Increasing prevalence of multidrug-resistant (MDR) Salmonella typhi strains in pediatric cases of typhoid fever and chemotherapy restrictions in children, such as fluoroquinolones, require ongoing clinical evaluations of different antibiotic regimens. Previously reported clinical trials with oral cefixime therapy given as a 12-day regimen (20-30 mg/kg divided twice daily) demonstrated both safety and efficacy. An open trial was undertaken to investigate a short course (8-day) regimen of oral cefixime in an Egyptian public fever hospital. Eighty children were initially enrolled with blood culture confirmation in 60 children. Clinical cure was documented in 57 (95 per cent) with three children requiring a change in antibiotic regimen due to therapeutic failure and one child with culture-confirmed relapsed 21 days post-therapy. All S. typhi isolates were sensitive to cefixime as measured by disk diffusion. Cefixime was well-tolerated with only mild side-effects, including nausea/vomiting (8 per cent) and abdominal cramping with loose stools (6 per cent), which may have been secondary to typhoid fever. Cefixime given in a short 8-day course is safe and effective in the management of MDR typhoid fever in children.

Gastrointestinal visceral motor complications of dermatomal herpes zoster: report of two cases and review.

Motor complications are uncommon manifestations of herpes zoster. This report describes two cases of gastrointestinal visceral motor manifestations associated with dermatomal herpes zoster and reviews the English-language literature since 1900. The 17 cases reviewed were divided clinically into two groups: colonic pseudo-obstruction and localized colonic spasm. Characteristics of the patients, radiographic study results, endoscopic findings, proposed pathogenesis, and management options are discussed. It is important to recognize this manifestation in order to institute proper management and avoid unnecessary surgery, given the complete resolution with conservative management in most cases.