Matthew E. Falagas

Toxoplasmosis snapshots: Global status of Toxoplasma gondii seroprevalence and implications for pregnancy and congenital toxoplasmosis

Toxoplasma gondiis importance for humans refers mainly to primary infection during pregnancy, resulting in abortion/stillbirth or congenital toxoplasmosis. The authors sought to evaluate the current global status of T. gondii seroprevalence and its correlations with risk factors, environmental and socioeconomic parameters. Literature published during the last decade on toxoplasmosis seroprevalence, in women who were pregnant or of childbearing age, was retrieved. A total of 99 studies were eligible; a further 36 studies offered seroprevalence data from regions/countries for which no data on pregnancy/childbearing age were available. Foci of high prevalence exist in Latin America, parts of Eastern/Central Europe, the Middle East, parts of south-east Asia and Africa. Regional seroprevalence variations relate to individual subpopulations religious and socioeconomic practices. A trend towards lower seroprevalence is observed in many European countries and the United States of America (USA). There is no obvious climate-related gradient, excluding North and Latin America. Immigration has affected local prevalence in certain countries. We further sought to recognise specific risk factors related to seropositivity; however, such risk factors are not reported systematically. Population awareness may affect recognition of said risks. Global toxoplasmosis seroprevalence is continuingly evolving, subject to regional socioeconomic parameters and population habits. Awareness of these seroprevalence trends, particularly in the case of women of childbearing age, may allow proper public health policies to be enforced, targeting in particular seronegative women of childbearing age in high seroprevalence areas.

Antibiotic treatment of infections due to carbapenem-resistant Enterobacteriaceae: systematic evaluation of the available evidence

ABSTRACT We sought to evaluate the effectiveness of the antibiotic treatment administered for infections caused by carbapenemase-producing Enterobacteriaceae. The PubMed and Scopus databases were systematically searched. Articles reporting the clinical outcomes of patients infected with carbapenemase-producing Enterobacteriaceae according to the antibiotic treatment administered were eligible. Twenty nonrandomized studies comprising 692 patients who received definitive treatment were included. Almost all studies reported on Klebsiella spp. In 8 studies, the majority of infections were bacteremia, while pneumonia and urinary tract infections were the most common infections in 12 studies. In 10 studies, the majority of patients were critically ill. There are methodological issues, including clinical heterogeneity, that preclude the synthesis of the available evidence using statistical analyses, including meta-analysis. From the descriptive point of view, among patients who received combination treatment, mortality was up to 50% for the tigecycline-gentamicin combination, up to 64% for tigecycline-colistin, and up to 67% for carbapenem-colistin. Among the monotherapy-treated patients, mortality was up to 57% for colistin and up to 80% for tigecycline. Certain regimens were administered to a small number of patients in certain studies. Three studies reporting on 194 critically ill patients with bacteremia showed individually significantly lower mortality in the combination arm than in the monotherapy arm. In the other studies, no significant difference in mortality was recorded between the compared groups. Combination antibiotic treatment may be considered the optimal option for severely ill patients with severe infections. However, well-designed randomized studies of specific patient populations are needed to further clarify this issue.

Treatment of Acinetobacter infections

Importance of the field: Acinetobacter baumannii has emerged as a major cause of healthcare-associated infections. It commonly presents resistance to multiple antimicrobial agents, occasionally including carbapenems and polymyxins, and hence, it is considered the paradigm of multidrug-resistant (MDR) or pandrug-resistant (PDR) bacterium. MDR A. baumannii is a rapidly emerging pathogen, especially in the intensive care setting, causing infections including bacteremia, pneumonia/ventilator-associated pneumonia (VAP), meningitis, urinary tract infection, central venous catheter-related infection, and wound infection. Areas covered in this review: All potential antimicrobial agents that are available for the treatment of Acinetobacter infections are presented. Emphasis was given to the management of nosocomial infections due to MDR A. baumannii and its close relatives, spp. 3 and 13TU. Areas covered include bloodstream infections, pneumonia or VAP, meningitis, urinary tract infection, skin and soft-tissue or wound infections due to Acinetobacter. What the reader will gain: The antibiotics that are usually effective against A. baumannii infections include carbapenems, polymyxins E and B, sulbactam, piperacillin/tazobactam, tigecycline and aminoglycosides. Carbapenems (imipenem, meropenem, doripenem) are the mainstay of treatment for A. baumannii, though carbapenem-resistant Acinetobacter strains have increasingly been reported worldwide in recent years. However, although well-designed trials of new therapeutic approaches are certainly required, the most important factor necessary to guide clinicians in their choice of empirical or targeted therapy should be knowledge of the susceptibility patterns of strains present in their own geographical area. Take home message: Pooled data suggest that infections caused by A. baumannii, especially those with inappropriate treatment, are associated with considerable attributable mortality. The optimal treatment for A. baumannii nosocomial infections has not been established, especially for MDR strains. Therefore, well-designed clinical studies are necessary to guide clinicians on decisions regarding the best therapeutic approach for patients with MDR A. baumannii infections. In addition, new experimental studies are warranted to evaluate the activity and safety of peptides and other novel antibacterial agents for A. baumannii infections.

Acinetobacter infections: a growing threat for critically ill patients

There has been increasing concern regarding the rise of Acinetobacter infections in critically ill patients. We extracted information regarding the relative frequency of Acinetobacter pneumonia and bacteraemia in intensive-care-unit (ICU) patients and the antimicrobial resistance of Acinetobacter isolates from studies identified in electronic databases. Acinetobacter infections most frequently involve the respiratory tract of intubated patients and Acinetobacter pneumonia has been more common in critically ill patients in Asian (range 4-44%) and European (0-35%) hospitals than in United States hospitals (6-11%). There is also a gradient in Europe regarding the proportion of ICU-acquired pneumonias caused by Acinetobacter with low numbers in Scandinavia, and gradually rising in Central and Southern Europe. A higher proportion of Acinetobacter isolates were resistant to aminoglycosides and piperacillin/tazobactam in Asian and European countries than in the United States. The data suggest that Acinetobacter infections are a growing threat affecting a considerable proportion of critically ill patients, especially in Asia and Europe.

Pandemic A(H1N1) 2009 influenza: review of the Southern Hemisphere experience

We sought to systematically review the published literature describing the epidemiological aspects of the first wave of pandemic A(H1N1) 2009 influenza in the Southern Hemisphere. Fifteen studies were included in this review, originating from South America, Australia or New Zealand, and Africa. Across the different studies, 16·8-45·3% of the laboratory-confirmed cases were admitted to hospital, and 7·5-26·0% of these cases were admitted to intensive care units (ICUs). The fatality rate was 0·5-1·5% for laboratory-confirmed cases in 6/8 studies reporting specific relevant data, and 14·3-22·2% for cases admitted to ICUs in 5/7 studies, respectively. In 4/5 studies the majority of laboratory-confirmed cases were observed in young and middle-aged adults, the percentage of older adults increased the higher the level of healthcare the cases received (e.g. laboratory confirmation, hospitalization or ICU admission) or for fatal cases. Many of the cases had no prior comorbidity, including conditions identified as risk factors for seasonal influenza. Pregnant women represented 7·4-9·1% and 7·1-9·1% of unselected laboratory-confirmed cases and of those admitted to ICUs, respectively. Obesity and morbid obesity were more commonly reported as the level of healthcare increased.

Worldwide research productivity in critical care medicine

IntroductionThe number of publications and the impact factor of journals are accepted estimates of the quantity and quality of research productivity. The objective of the present study was to assess the worldwide scientific contribution in the field of critical care medicine.MethodAll research studies published between 1995 and 2003 in medical journals that were listed in the 2003 Science Citation Index (SCI®) of Journal Citation Reports under the subheading critical care and also indexed in the PubMed database were reviewed in order to identify their geographical origin.ResultsOf 22,976 critical care publications in 14 medical journals, 17,630 originated from Western Europe and the USA (76.7%). A significant increase in the number of publications originated from Western European countries during the last 5 years of the study period was noticed. Scientific publications in critical care medicine increased significantly (25%) from 1995 to 2003, which was accompanied by an increase in the impact factor of the corresponding journals (47.4%). Canada and Japan had the better performance, based on the impact factor of journals.ConclusionSignificant scientific progress in critical care research took place during the period of study (1995–2003). Leaders of research productivity (in terms of absolute numbers) were Western Europe and the USA. Publications originating from Western European countries increased significantly in quantity and quality over the study period. Articles originating from Canada, Japan, and the USA had the highest mean impact factor.. Canada was the leader in productivity when adjustments for gross domestic product and population were made.

Safety of Hepatitis B, Pneumococcal Polysaccharide and Meningococcal Polysaccharide Vaccines in Pregnancy

Immunization during pregnancy has the potential to protect the mother and the newborn from preventable diseases. Current recommendations suggest that inactivated vaccines might be considered during pregnancy when the benefits outweigh the risks.In this review, we aimed to evaluate the safety of hepatitis B (HB) vaccine, pneumococcal polysaccharide vaccine (PPSV) and meningococcal polysaccharide vaccine (MPSV) administration during pregnancy by systematically reviewing the available evidence in PubMed and Scopus databases, as well as postmarketing surveillance data (including the Vaccine Adverse Event Reporting System [VAERS] database). A total of 18 studies were eligible for inclusion in the review. Six studies provided data on HB vaccine, six on PPSV and three on MPSV; three additional studies compared PPSV with MPSV. Additionally, 91 reports on vaccinations of pregnant women were identified from postmarketing surveillance data (88 on HB vaccine, 2 on PPSV, 1 on MPSV). The most common complaints were local reactions, including tenderness and swelling. Overall, immunization during pregnancy did not seem to be associated with a teratogenic effect on the fetus, preterm labour or spontaneous abortion. However, the lack of randomized, placebo-controlled trials, or even large cohort studies, in addition to the inherent limitations of the reviewed observational studies with small statistical power, precluded safe conclusions. Large, prospective, population-based cohort studies are needed to elucidate this issue.

Decreasing the incidence and impact of infections in neutropenic patients : evidence from meta-analyses of randomized controlled trials

ABSTRACT Backgound: Neutropenia is a common complication of intensive chemotherapy in patients with solid organ or hematologic malignancies that is associated with a high risk for life-threatening infections. Many interventions have been employed in order to limit the incidence of these infections or to treat them when the prophylactic measures fail. Scope: The commonest characteristic of the randomized controlled trials (RCTs) conducted on this issue was the small sample size. In addition, if RCTs studying the prophylactic interventions were excluded, the aim of most of the rest of relevant RCTs was to prove the equal effectiveness of the tested interventions in terms of treatment success. We searched PubMed and Cochrane database to identify meta-analyses of RCTs in the field of febrile neutropenia. Results: The most prominent findings of these meta-analyses were the promising effect, although based on open label RCTs, of antimicrobial prophylaxis with fluoroquinolones on the mortality of all neutropenic patients and the beneficial effect of antifungal prophylaxis on mortality of neutropenic patients with allogeneic hematopoetic stem cell transplantation. Another noteworthy finding was the higher mortality associated with empiric cefepime treatment when compared with other β-lactams. In other cases, the findings of the published meta-analyses either confirmed or consolidated the results of individual RCTs. Conclusion: Meta-analyses are very useful for obtaining a better overview and to provide some general qualitative and quantitative conclusions, but are not always a substitute for appropriately powered, well-designed RCTs. In addition, the reported findings should be interpreted with caution taking into account the limitations of various methodological aspects of meta-analysis in general, as well as the limitations of the individual meta-analyses in this field.

Unique Author Identification Number in Scientific Databases: A Suggestion

There is an increasing trend toward the use of electronic databases of scientific information, such as the PubMed database of the National Library of Medicine and the various databases of the Institute for Scientific Information (ISI). These databases are frequently used nowadays for various purposes, including the peer-review process of papers submitted for publication in scientific journals. Most of the scientific journals now use a Web-based peer-review system that offers editors, peer reviewers, and publishers the capability to check the previous papers published by authors submitting a manuscript for consideration for publication [ 1]. In addition, these databases are frequently searched in an attempt to select potential speakers for scientific conferences and to obtain data for possible collaborators for a multicenter study, as well as in the process of evaluating the research productivity of scientists—which is being used for various purposes. n nHowever, it is widely known that a considerable proportion of authors share the same last name and first initial. This seems to be the case for people of most ethnic heritages. In addition, authors of scientific publications do not frequently use their middle initial, which contributes to the confusion regarding the assignment of publications to the appropriate author. Frequently, it takes considerable effort and time to assign publications to the appropriate authors, particularly if there are authors that share the same last name and first initial (with or without the middle initial). This is usually based on the pattern of research interests, as well as the institutional affiliations of the various authors with the same name. In fact, this task is often impossible. n nIn order to decrease the problems arising from authors with identical names, I suggest the introduction of a unique author identification number (UAIN) in modern electronic databases of scientific information. I further suggest that such an identification number may be hidden in the electronic databases, i.e., it is not necessary for the UAIN to appear when reviewing the record of a publication. This function of the electronic databases could start operating after the providers of the databases are given a reasonable time to prepare. To avoid the resources needed to update the electronic databases with the appropriate assignment of publications to each author, I suggest that the UAIN not be used retrospectively. In this case, the record of publications for a specific author would be divided into two parts. The publications that are prospectively connected to a given author with a specific UAIN would have an indicator denoting this, while older publications (before the introduction of the UAIN) would not have such an indicator.

Unusual climatic conditions and infectious diseases: observations made by Hippocrates.

About 2500 years ago, Hippocrates made noteworthy observations about the influence of climate on public health. He believed that people living in cities with different climate may suffer from different diseases. Hippocrates also observed that abrupt climatic changes or unusual weather conditions affect public health, especially the incidence and severity of various infectious diseases, including gastrointestinal infections, tuberculosis, and central nervous system infections. We believe that Hippocrates scientific observations are great early historic examples that stress to modern infectious diseases researchers and clinicians the need to study intensively the effect of the occurring global climate changes to infectious diseases in order to help in the prevention of possible epidemics of infections.