Limited role of antibiotics for acute rhinosinusitis
Most cases of acute rhinosinusitis are viral in origin. However, antibiotics are frequently prescribed for this condition. A systematic review evaluating 15 studies including over 3000 immunocompetent adults with uncomplicated acute rhinosinusitis found that nearly half of patients improved by one week, and two-thirds by two weeks, irrespective of antibiotic use* This review supports current recommendations to limit antibiotic use to a subset of patients who meet criteria for acute bacterial rhinosinusitis.
*Lemiengre MB, van Driel ML, Merenstein D, Liira H, Mäkelä M, De Sutter AI. Antibiotics for acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2018 Sep 10.
Meropenem versus piperacillin-tazobactam for ESBL-producing bacteria
Carbapenems (including meropenem) are the preferred antibiotics for treatment of serious infections with bacteria that produce an extended-spectrum beta-lactamase (ESBL). Although some ESBL isolates remain susceptible in vitro to piperacillin-tazobactam, observational studies evaluating outcomes with piperacillin-tazobactam compared with carbapenems have been equivocal. In an international randomized open-label trial of adults with bacteremia with ESBL-producing Escherichia coli or Klebsiella, the 30-day all-cause mortality rate was higher with directed therapy with piperacillin-tazobactam than with meropenem (12.3 versus 3.7 percent)*. Despite certain limitations, these findings support our suggestion not to use piperacillin-tazobactam for serious infections with ESBL-producing bacteria.
*Harris PNA, Tambyah PA, Lye DC, Mo Y, Lee TH, Yilmaz M, et al. MERINO Trial Investigators and the Australasian Society for Infectious Disease Clinical Research Network (ASID-CRN). Effect of Piperacillin-Tazobactam vs Meropenem on 30-Day Mortality for Patients With E coli or Klebsiella pneumoniae Bloodstream Infection and Ceftriaxone Resistance: A Randomized Clinical Trial. JAMA. 2018 Sep 11;320(10):984-994.
Outbreak of Candida auris infection in an intensive care unit in the United Kingdom
Candida auris is an emerging multidrug-resistant Candida species that has caused invasive health care-associated infections and is associated with high mortality rates. An outbreak of C. auris colonization and infection (including candidemia and central nervous system device-associated infection) in a neurologic intensive care unit in the United Kingdom was associated with reusable skin-surface axillary temperature probes that had been cleaned with wipes containing quaternary ammonium compound, which has poor activity against Candida species*. The incidence of new cases was reduced after removal of the temperature probes. Given concerns about resistance and transmission of C. auris in health care facilities, special attention should be paid to infection control precautions for patients who are colonized or infected with C. auris.
*Eyre DW, Sheppard AE, Madder H, Moir I, Moroney R, Quan TP, et al. A Candida auris Outbreak and Its Control in an Intensive Care Setting. N Engl J Med. 2018 Oct 4;379(14):1322-1331.
Oral versus intravenous antibiotics to complete therapy for left-sided endocarditis
Treatment of left-sided infective endocarditis (IE) consists of parenteral therapy for up to six weeks. In one study of 400 Danish patients who had completed at least 10 days of intravenous antibiotic therapy for native valve IE due to gram-positive organisms (excluding methicillin-resistant Staphylococcus aureus), patients in stable condition were randomized to continue intravenous treatment or switch to a two-drug oral antibiotic regimen; following randomization, the groups completed a similar duration of therapy*. Rates of a composite outcome (all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia) were not statistically different with intravenous versus oral therapy (12 versus 9 percent, respectively). However, the generalizability of these results is hampered by selection bias (only 20 percent of those assessed were randomized) and referral bias (all patients received care in tertiary centers). Therefore, these findings do not warrant alteration in the approach to treatment of IE; further study of oral antibiotic therapy for completing treatment of IE is needed.
*Iversen K, Ihlemann N, Gill SU, Madsen T, Elming H, Jensen KT, Bruun NE, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med. 2018 Aug 28.
Improved rates of HIV viral suppression over time in the United States
HIV suppression is a marker of successful antiretroviral therapy. In an observational cohort study of nearly 32,000 individuals with HIV receiving care across the United States, the rate of viral suppression (HIV RNA <400 copies/mL) increased from 32 to 86 percent over the 18-year period from 1997 to 2015*. Factors significantly associated with having an undetectable viral load included the use of a regimen containing an integrase strand transfer inhibitor, older age, Hispanic ethnicity, and years of follow-up. These findings are encouraging since a suppressed viral load improves clinical outcomes and reduces transmission of HIV to others.
*Nance RM, Delaney JAC, Simoni JM, Wilson IB, Mayer KH, Whitney BM, et al. Aunon FM,HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study. Ann Intern Med. 2018 Sep 18;169(6):376-384.
Autoimmune encephalitis after herpes simplex virus encephalitis
Individual cases of anti-N-methyl-D-aspartate (NMDA) receptor encephalitis have been described in the convalescent phase of herpes simplex virus encephalitis (HSVE) in both children and adults, but larger studies have been lacking. In a series of 58 patients with antibody-confirmed autoimmune encephalitis after HSVE (mostly attributable to NMDA receptor antibodies), the most common symptoms were change of behavior, decreased level of consciousness, choreoathetosis (all in children four years of age or younger), seizures, and dysautonomia*. Symptoms developed at a median of four to six weeks after HSVE diagnosis, and recurrent HSVE was excluded by HSV polymerase chain reaction testing in cerebrospinal fluid. Autoimmune encephalitis is important to recognize after HSVE, as patients may benefit from glucocorticoids and other immunosuppressive therapies.
Armangue T, Spatola M, Vlagea A, Mattozzi S, Cárceles-Cordon M, Martinez-Heras E, et al. Spanish Herpes Simplex Encephalitis Study Group. Frequency, symptoms, risk factors, and outcomes of autoimmune encephalitis after herpes simplex encephalitis: a prospective observational study and retrospective analysis. Lancet Neurol. 2018 Sep;17(9):760-772.
Source: Uptodate, 2018.