Ami Neuberger

Lack of Evidence for Chloroquine- Resistant Plasmodium falciparum Malaria, Leogane, Haiti

Plasmodium falciparum malaria in Haiti is considered chloroquine susceptible, although resistance transporter alleles associated with chloroquine resistance were recently detected. Among 49 patients with falciparum malaria, we found neither parasites carrying haplotypes associated with chloroquine resistance nor instances of chloroquine treatment failure. Continued vigilance to detect emergence of chloroquine resistance is needed.

Treatment of Carbapenem-Resistant Acinetobacter baumannii Ventilator-Associated Pneumonia: Retrospective Comparison Between Intravenous Colistin and Intravenous Ampicillin-Sulbactam.

Carbapenem-resistant Acinetobacter baumannii has been increasingly reported as the causative agent of ventilator-associated pneumonia (VAP) among patients in the intensive care units. However, there are insufficient data to guide the appropriate treatment for such infection. Our aim was to compare the outcome of carbapenem-resistant A. baumannii VAP treated with colistin or with ampicillin–sulbactam. We conducted a retrospective study of patients diagnosed with carbapenem-resistant A. baumannii VAP during 2008 and 2009. Clinical and microbiologic cure rates, 30-day mortality, and change in renal function were compared between patients treated with colistin versus those treated with ampicillin–sulbactam. The association between treatment and mortality was examined through multivariable logistic regression analysis. Of the 98 patients diagnosed with carbapenem-resistant A. baumannii VAP, 66 were treated with colistin and 32 with ampicillin–sulbactam. Baseline characteristics of patients were similar, except for a longer intensive care unit stay and lower creatinine clearance test before VAP diagnosis among patients treated with colistin. Clinical cure rates were similar in the 2 groups. In the colistin group, microbiologic failure rates were higher at 7 days [16/33 (48%) vs. 3/17 (18%); P = 0.03]; patients had a more significant elevation in creatinine (+0.2 ± 1.0 mg/dL vs. −0.3 ± 1.1 mg/dL; P = 0.021), and treatment was associated with an increased 30-day mortality (adjusted-odds ratio, 6.5; 95% confidence interval, 1.348–31.342; P = 0.02). In conclusion, patients treated with colistin or ampicillin–sulbactam had similar clinical cure rates. However, colistin was associated with higher rates of microbiologic failure, reduction in renal function, and an increased 30-day mortality. A prospective study comparing high-dose colistin and ampicillin–sulbactam for the treatment of carbapenem-resistant A. baumannii VAP is warranted.

Infectious Diseases Seen in a Primary Care Clinic in Leogane, Haiti

All diseases diagnosed in a primary healthcare clinic situated in Leogane, Haiti, were recorded prospectively during a 7-month period. Among the patients in this cohort, 2,821 of 6,631 (42.6%) presented with an infectious disease. The three most common syndromes among the patients presenting with infections were respiratory tract infections (33.5%), suspected sexually transmitted diseases--mostly among females with recurrent disease (18.1%)--and skin and soft tissue infections, including multiple cases of tinea capitis (12.8%). Of the 255 patients presenting with undifferentiated fever, 76 (29.8%) were diagnosed with falciparum malaria. Other vector-borne diseases included 13 cases of filariasis and 6 cases of dengue fever. Human immunodeficiency virus infection was diagnosed in 19 patients. Four cases of mumps were detected among unimmunized children. A large proportion of these infections are preventable. Concerted efforts should be made to create large-scale preventive medicine programs for various infectious diseases.

The Changing Epidemiology of Human African Trypanosomiasis among Patients from Nonendemic Countries –1902–2012

Background Although human African trypanosomiasis (HAT) is uncommon among patients from non-endemic countries (NEC), there has been an increase in the number of cases reported in recent years. Methods A systematic review of the literature was performed. The number of incoming tourists to HAT endemic countries was obtained from the United Nations World Tourism Organization. All HAT cases diagnosed in patients from NEC were included. Immigrants and refugees were excluded. We compared patients during and after the colonial period, and analyzed the relationship between the number of incoming travellers and the number of HAT cases. Results Between 1902 and 2012, HAT was reported in 244 patients. Most HAT cases were reported before 1920, and after the year 2000. In the colonial era the average age of patients was lower (32.5±7.8 vs. 43.0±16.1 years, P<0.001), the proportion of females was lower (10.0% vs. 23.9%, P<0.01], most cases were diagnosed in expatriates, missionaries and soldiers (74.3%), and Gambian trypanosomiasis accounted for 86/110, (78%) of cases. In the post-colonial era most patients 91/125 (72.8%) were short-term tourists to game parks in Eastern and South-Eastern Africa (mainly in Tanzania); Rhodesian trypanosomiasis accounted for 94/123 (76.4%) of cases. Between 1995 and 2010 there has been a constant linear increase in the number of incoming tourists to Tanzania, and HAT cases occurred in small outbreaks rather than following a similar linear pattern. Conclusions In recent decades HAT patients from NEC are older, and more likely to be tourists who acquired the disease while visiting game-parks in Eastern and South-Eastern Africa. While Rhodesian trypanosomiasis is relatively uncommon among Africans, it now accounts for most cases reported among patients from NEC. Returning febrile travellers without an alternative diagnosis should be evaluated for HAT. Cases among travellers may serve as sentinels for Rhodesian trypanosomiasis “hot spots” in Africa.

Pros and cons of circumcision: an evidence-based overview

Based on three large randomized controlled trials (RCTs) conducted in Africa, it can clearly be stated that circumcision lowers the risk of infection with the human immunodeficiency virus (HIV) and some sexually transmitted infections (STIs) among males in settings of high HIV and STI endemicity. Similar effects on STI risk may exist for females, although this may result from an indirect effect of decreasing risk of infection among male partners. It is unknown whether circumcision prevents HIV acquisition in men who have sex with men (MSM), although there might be a protective effect for men who engage mainly in insertive anal intercourse. When the effects of adult circumcision on sexual function and satisfaction of men are examined, high-quality evidence strongly supports lack of harm. Whether circumcision alters sexual satisfaction of female partners is not known as fewer and smaller studies reported conflicting results. Circumcision rarely causes serious complications if practiced by trained practitioners, in a sterile setting, and with a proper follow-up. These conclusions are limited by the lack of high-quality data from areas outside of Africa. RCTs have not been conducted to assess the effects of circumcising infants or MSM. Circumcision has well-proven benefits for people residing in areas with high prevalence of STIs, including HIV, and is not unethical for those who choose to be circumcised or have their children circumcised on religious, social, or cultural grounds. For many others, a definite pro or con recommendation, based on a risk-benefit ratio, cannot be made.

Japanese encephalitis among patients with acute encephalitic syndrome admitted to a tertiary hospital in Chitwan, Nepal--a prospective observational study.

Introduction The reported incidence of JE among patients with acute encephalitic syndrome (AES) in Nepal ranges between 20% to 62%. In light of the lack of up-to-date data, we sought to describe the epidemiology of JE in Chitwan, Nepal. Methods A prospective observational study was conducted during 2010–2012 in the College of Medical Science in the Chitwan District. Patients with suspected JE were tested for anti-JE IgM in serum and cerebrospinal fluid (CSF). Results Of 227 all patients tested, 18 (7.9%) were found positive for JE. 17/202 (8.4%) patients with AES had JE. All, with the exception of two patients, were diagnosed on the basis of positive a serologic test, both in serum and CSF samples. Patients with JE were significantly older (42.1±27.6 years) than patients without JE (25.6±25.2 years, p = 0.02). Half of JE cases occurred in adults older than 50. More of the JE cases (11/18, 61.1%) occurred during the rainy season when compared to the JE negative patients [71/209, (34%), p = 0.01]. None of the JE patients had a relevant travel history, and one recalled having been immunized against JE. There was a variation in the geographic distribution of cases across the districts of the central Terai. Conclusions In this cohort, the proportion of patients with AES who had JE was lower than in previous studies. In addition, most patients were adults, and cases were not distributed uniformly across the central Terai region. The risk of acquiring JE by short-term travelers in the area is likely to be low. Vector-control programs and the promotion of mosquito avoidance behavior in the Terai region should continue. The high proportions of adults among patients with JE may suggest recent changes in the epidemiology of JE in the central Terai region, and routine immunization of all adults should be considered.

Epidemiologic profile of patients seen in primary care clinics in an urban and a rural setting in Haiti, 2010–11

BACKGROUND This study examined the demographic and epidemiological differences between patient populations presenting to a rural and an urban clinic in Haiti. METHODS A primary health clinic was established in urban Leogane, and a once-weekly clinic was established in Magandou, a rural village. Patient data were recorded for all individuals presenting to each clinic. RESULTS Over 7 months, 6632 patients (median age 25) were seen in the urban clinic, and 567 (median age 47) in the rural clinic. There was a female majority at both sites. Hypertension was diagnosed in 41.9% (238/567) of the rural population over 40 years of age, while 29.5% (1956/6632) of patients in the urban setting had the same diagnosis (p<0.001). Among women of reproductive age, 20.4% (1353/6632) were diagnosed with STDs in the urban setting versus 8.6% (49/567) at the rural clinic (p=0.004). Eighty-eight patients at the urban clinic had a vector-borne disease, while none were diagnosed among the rural population. CONCLUSIONS Screening and treatment of hypertension in Haiti must address the wide rural prevalence. STDs are a major urban health issue requiring treatment for both patients and their partners. Vector-borne disease was unseen in the rural clinic, despite an altitude insufficient to prevent mosquito-borne illness.

Clostridium difficile infection after malaria chemoprophylaxis with doxycycline: Is there an association?

Malaria chemoprophylaxis with doxycycline is commonly used in the United Kingdom and in many other countries. It is considered to be associated with an increased risk of Clostridium difficile associated diarrhea (CDAD). We describe a case of diarrhea and a positive stool assay for C. difficile in a returning traveler, and review available literature. The commonly held concept of an association between doxycycline chemoprophylaxis and CDAD is not supported by available data.

Histoplasmosis in Israeli Travelers

Histoplasmosis is a common endemic human mycoses acquired mostly in the Americas. We reviewed 23 cases of histoplasmosis in Israeli travelers; 22 had traveled to Central or South America and one to North America. Fourteen cases had been exposed to bat habitats and were symptomatic, presenting ≤ 3 months after their return. Asymptomatic patients (N = 9) were diagnosed during the evaluation of incidental radiological findings or because a travel partner had been suspected of Histoplasma infection, 16-120 months after their return. Serological testing was positive in 75% of symptomatic cases but only 22% of asymptomatic cases. Histoplasmosis should be considered in travelers returning from the Americas with respiratory or febrile illness within weeks of return, particularly if exposed to bat habitats. Travel history is essential in patients presenting with pulmonary nodules, even years after travel to endemic countries.

Prolonged Fever and Splinter Hemorrhages in an Immunocompetent Traveler With Disseminated Histoplasmosis

We present a case of progressive disseminated histoplasmosis in an immunocompetent traveler. Histoplasmosis was acquired in South America; its manifestations included prolonged fever, splinter hemorrhages, erythema multiforme, arthritis, and mediastinal lymphadenopathy. To the best of our knowledge no splinter hemorrhages had previously been reported in a patient with histoplasmosis.