Mary Jane Burton

Risk of hospitalized bacterial infections associated with biologic treatment among US veterans with rheumatoid arthritis

The comparative risk of infection associated with non–anti–tumor necrosis factor (anti‐TNF) biologic agents is not well established. Our objective was to compare risk for hospitalized infections between anti‐TNF and non–anti‐TNF biologic agents in US veterans with rheumatoid arthritis (RA).

Community-acquired methicillin-resistant Staphylococcus aureus as a cause of Fournier's gangrene.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has become an important pathogen in aggressive skin and soft-tissue infections in patients without risk factors for nosocomial infections. We describe a case of a previously healthy adult who developed fulminant sepsis from Fourniers gangrene caused by a strain of CA-MRSA containing the Panton-Valentine leukocidin genes.

Adult Immunizations: Update on Recommendations

The Advisory Committee for Immunization Practices recommends universal influenza vaccination for 2010-2011. Older adults should be offered protection against herpes zoster, and younger adults should receive immunization against human papilloma virus and pertussis. Hepatitis B vaccination should be encouraged in non-immune adults. Recommendations also address vaccinations for tetanus/diphtheria, hepatitis A, pneumococcus, measles/mumps/rubella, and meningococcus.

Misidentification of Candida parapsilosis as C famata in a Clinical Case of Vertebral Osteomyelitis

A case of vertebral osteomyelitis involving misidentification of Candida parapsilosis as C famata by the VITEK 2 compact is described. Species-specific primers were used in the polymerase chain reaction to correctly identify the clinical isolate. When uncommon species of Candida are reported using automated systems, heightened clinical suspicion is warranted.

Infective Endocarditis Prevention: Update on 2007 Guidelines

Antibiotic prophylaxis for preventing infective endocarditis is unproven. The recently issued American Heart Association guidelines for endocarditis prevention call for restricting the use of preprocedure antibiotics. We discuss how these revisions apply to clinical practice in patients undergoing elective medical and dental procedures.

Telaprevir and boceprevir in African Americans with genotype 1 chronic hepatitis C: implications for patients and providers.

Telaprevir and boceprevir have received US Food and Drug Administration approval for use as triple therapy with pegylated interferon and ribavirin in genotype 1 chronic hepatitis C virus (HCV) infection. Clinical trials of these agents included few African Americans, despite the overwhelming need for improved therapies in this racial group. Although African Americans are predicted to have improved response rates with this new treatment paradigm, clinical trials illustrate lower rates of sustained virologic response for this racial group versus whites. African Americans with genotype 1 HCV infection appear to require longer durations of therapy than do whites to achieve a sustained virologic response. Further investigation is required to adequately counsel African Americans with genotype 1 chronic HCV infection on the efficacy of telaprevir and boceprevir in their racial group. Increased participation of this racial group in HCV clinical trials is needed to improve therapies in this difficult-to-treat population.

Safety of biologic and nonbiologic disease-modifying antirheumatic drug therapy in veterans with rheumatoid arthritis and hepatitis B virus infection: a retrospective cohort study

IntroductionWe evaluated the safety of current treatment regimens for patients with RA and HBV in a large US cohort.MethodsWe identified biologic and nonbiologic treatment episodes of RA patients using 1997 to 2011 national data from the US Veterans Health Administration. Eligible episodes had evidence of HBV infection (HBV surface antigen, HBV core antibody, HBV e-antibody and/or HBV DNA) and had a baseline alanine aminotransferase (ALT) <1.5 times the upper limit of laboratory normal within 90 days prior to initiation of a new biologic or nonbiologic DMARD. The main outcome of interest was hepatotoxicity, defined as ALT elevation >100 IU/mL. Results were reported as the cumulative incidence of treatment episodes achieving hepatotoxicity at 3, 6 and 12 months post biologic exposure.ResultsFive hundred sixty-six unique RA patients with HBV contributed 959 treatment episodes. Mean age was 62.1 ± 10.3 years; 91.8% were male. Hepatotoxicity was uncommon, with 26 events identified among 959 episodes (2.7%) within 12 months. Hepatotoxicity was comparable between biologic and nonbiologic DMARDs (2.6% vs. 2.8%, P = 0.87). The median time between HBV screening and starting a new RA drug was 504 days (IQR 144, 1,163). Follow-up HBV testing occurred among 14 hepatotoxicity episodes (53.8%) at a median of 202 days (IQR 82, 716) from the date of ALT elevation. A total of 146 (15.2%) treatment episodes received at least one test for HBV DNA at any point in the observation period.ConclusionsAmong US veterans with RA and HBV the risk of hepatotoxicity is low (2.7%), and comparable between biologic and nonbiologic DMARDS (2.8% vs. 2.6%, P = 0.87). HBV testing associated with DMARD initiation or hepatotoxicity was infrequent.

Characteristics of Hepatitis C Virus Coinfection in a Human Immunodeficiency Virus-Infected Population With Lower Reported Rates of Injection Drug Use

Background:Injection drug use (IDU) is considered the major risk factor for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection. We examined risk factors for HIV/HCV coinfection in a region with a low reported rate of IDU. Methods:We identified 146 HIV/HCV coinfected patients in Jackson, Mississippi. Medical records were reviewed for demographics, social history, and risk factors for HIV and HCV acquisition. A randomly selected group of HIV-monoinfected patients from the same clinic served as a control group. Results:History of IDU (P < 0.0001), crack cocaine use (P < 0.0001), incarceration (P < 0.0001), and syphilis (P < 0.0001) were significantly associated with HCV infection in this cohort of HIV patients. However, the reported rate of IDU (32.5%) is lower than other published HIV/HCV–infected cohorts. Conclusions:HIV/HCV patients in Mississippi are less likely to report a history of IDU than other coinfected populations, suggesting an alternative means of HCV transmission. Further studies are needed to examine the role of syphilis, crack cocaine use, and incarceration as risk factors for HCV infection in this population of HIV patients.

Prognostic value of cardiac troponin levels in infective endocarditis

http://tac.sagepub.com 45 Recent analyses suggest that early surgery is associated with improved 6-month mortality in infective endocarditis (IE), emphasizing the need to identify patients who would benefit from early intervention. Although well established as a marker for myocardial injury and increased mortality in the setting of acute coronary syndromes [Heidenreich et al. 2001], cardiac-specific troponins (Tn) have also been found to associate with clinical outcomes in other noncardiac diseases [Dispenzieri et al. 2004]. Isolated reports suggest that elevated cardiac troponin I (TnI) and/or T (TnT) serum concentrations associate with poor prognosis in patients with IE. We performed a systematic review of this subject. An electronic literature search of the National Library of Medicine database using PubMed (all listings through 30 September 2012) was performed using the search terms ‘endocarditis’ and ‘troponin’, limited to human studies and English language articles. After excluding case reports (four) and letters to the editor (one), six original reports remained for inclusion in this analysis (Table 1).

Women with chronic hepatitis C virus infection: recommendations for clinical practice.

Abstract The natural history of hepatitis C virus infection differs between women and men. Women demonstrate a slow rate of disease progression until menopause. Older women are more likely to develop fibrosis and are less responsive than younger women to pegylated interferon and ribavirin. Women of childbearing age have higher rates of sustained virologic response, but current therapies are contraindicated during pregnancy. Vertical transmission of hepatitis C virus occurs, but data supporting recommendations for prevention of mother-to-infant transmission are limited.