Simon Briggs

Gram-negative Bacillary Meningitis after Cranial Surgery or Trauma in Adults

In order to assess the clinical features, aetiology, treatment and outcome of post-neurosurgical and post-traumatic Gram-negative bacillary meningitis (GNBM) we performed a retrospective review of all adult patients admitted to the Department of Neurosurgery who had Gram-negative bacilli cultured from cerebrospinal fluid (CSF) following a neurosurgical procedure or traumatic head/spinal injury. During the 12 y of the review 33 patients had CSF isolates of Gram-negative bacilli that were thought to be significant. The median patient age was 47 y (range 22–77 y) and 21 (64%) were male. Klebsiella pneumoniae, Enterobacter cloacae and Escherichia coli were the most common isolates. Minimal inhibitory concentrations (MIC) measured for half the patients’ isolates resulted in 5 regimen changes, including 2 patients with E. cloacae meningitis in whom cephalosporin susceptibility decreased during cephalosporin treatment. Our recommended initial treatment was intravenous ceftriaxone and amikacin, subsequently tailored by susceptibility results; approximately half the patients remained on the antibiotics they started and half were changed to an alternate regimen, most often a carbapenem. Five patients (15%) died, 1 dying after cure of his GNBM. There were no failures in those who received more than 12 d of appropriate treatment: treatment for at least 14 d after the last positive CSF culture guaranteed cure. Initial ceftriaxone and amikacin subsequently changing to susceptibility driven alternatives, often a carbapenem, resulted in cure of 85% of our patients with GNBM.

Bone mineral density remains stable in HAART‐treated HIV‐infected men over 2 years

Objective  Recently we reported that human immunodeficiency virus (HIV)‐infected Caucasian men treated with highly active antiretroviral therapy (HAART) have normal weight‐adjusted bone mineral density (BMD), in contrast to most other cross‐sectional analyses, which have reported low BMD in HIV‐infected patients. We have now addressed the question of whether there is accelerated BMD loss over time in HIV‐infected men.

Effects of Intravenous Zoledronate on Bone Turnover and BMD Persist for at Least 24 Months

The duration of the antiresorptive effects of the intravenous bisphosphonate, zoledronate, is not known. Recently, we reported that two annual 4‐mg doses of zoledronate suppressed bone turnover and increased BMD in HIV‐infected men over 24 mo. We set out to determine the persistence of these effects after two doses of zoledronate. Thirty‐three HIV‐infected men who completed a randomized trial of 4 mg annual zoledronate (n = 17) or placebo (n = 16) were studied for a further 12 mo, during which time no skeletal therapy was administered. Participants received calcium (400 mg/d) and vitamin D supplements (50,000 IU/mo) for the first 24 mo of the study only. Biochemical markers of bone turnover and BMD were measured every 6 mo. Bone turnover markers were stably suppressed at 24 and 36 mo (12 and 24 mo after the second annual dose of zoledronate, respectively). There were no significant within‐group changes in urine N‐telopeptide, serum C‐telopeptide, and osteocalcin between 24 and 36 mo (p > 0.07), and at each time point, each of the turnover markers was significantly lower in the zoledronate group. There were also no significant between‐group differences in the changes in BMD at each site between 24 and 36 mo (p > 0.5), and at each time point, BMD at each site was significantly higher in the zoledronate group. These results suggest that the antiresorptive effects of zoledronate last >12 mo and raise the possibility that zoledronate could be administered less frequently than annually. Randomized trials that address this issue should be performed.

Bone mineral density is not reduced in HIV‐infected Caucasian men treated with highly active antiretroviral therapy

Objective   Recent studies have reported low bone mineral density (BMD) in patients infected with human immunodeficiency virus (HIV). Frequently these findings have been attributed to treatment with highly active antiretroviral therapy (HAART). We sought to determine whether BMD in HIV‐infected men treated with HAART for at least 3 months is different from that in healthy controls, and, if so, what HIV‐related factors might explain this finding.

Effects of Intravenous Zoledronate on Bone Turnover and Bone Density Persist for at Least Five Years in HIV-Infected Men

CONTEXT In HIV-infected men, the antiresorptive effects of zoledronate persist for at least 2 yr after the second annual dose. OBJECTIVE Our objective was to determine the duration of action of zoledronate in men. DESIGN AND SETTING This was 4-yr extension of a 2-yr, double-blind, randomized, placebo-controlled trial at an academic research center. PARTICIPANTS Participants included 43 HIV-infected men with bone mineral density (BMD) T score below -0.5, 35 of whom entered the extension study. INTERVENTION Intervention was annual administration of 4 mg iv zoledronate or placebo at baseline and 1 yr and no intervention subsequently. MAIN OUTCOME MEASURES We evaluated changes in the bone turnover markers, serum osteocalcin and serum C-telopeptide (CTx), and changes in BMD at the lumbar spine, total hip, and total body. RESULTS There was no time × treatment interaction between 1 and 5 yr after the second zoledronate dose for osteocalcin or CTx (P > 0.4) or any BMD site (P > 0.7). Between 1 and 5 yr after the second dose, on average, osteocalcin was 41% lower (95% confidence interval = 19-62%; P < 0.001), CTx 52% lower (33-71%; P < 0.001), lumbar spine BMD 3.7% greater (0.3-7.0%; P = 0.03), total hip BMD 2.3% greater (0.3-4.3%; P = 0.02), and total body BMD 2.5% greater (0.8-4.1%; P = 0.004) in the zoledronate group than the placebo group. Five years after the second dose, the between-groups differences were 38% (13-62%) for osteocalcin, 49% (20-77%) for CTx, 3.5% (0.7-6.7%) for lumbar spine BMD, 3.4% (1.4-5.4%) for total hip BMD, and 1.6% (0.2-3.1%) for total body BMD. CONCLUSION The effects of two annual 4-mg doses of zoledronate in men persist for at least 5 yr after the second dose. Larger trials assessing the antifracture efficacy of less frequent dosing of zoledronate are justified.

Emphysematous osteomyelitis: a case report and review of the literature

We report the case of a 15-year-old girl with pelvic and sacral emphysematous osteomyelitis caused by Fusobacterium necrophorum. This infection was cured following four surgical procedures and 4 weeks of intravenous then 4 weeks of oral antibiotics. We review our case alongside the 24 previously reported cases of emphysematous osteomyelitis in the literature. The 25 cases include 15 monomicrobial and 10 polymicrobial infections. The causative organism(s) in all but three cases included an anaerobe or a member of the Enterobacteriaceae family. A significant underlying comorbidity was reported in 18 cases. At least 15 cases required one or more surgical procedures. There was a significant associated mortality with eight (32%) patients dying in hospital at 7 to 56 days after the diagnosis of emphysematous osteomyelitis.

Stable bone mineral density over 6 years in HIV‐infected men treated with highly active antiretroviral therapy (HAART)

Objective  Most longitudinal studies of bone mineral density (BMD) in HIV‐infected cohorts have been of short duration, typically 1–2 years. Some studies, especially of cohorts treated with highly active antiretroviral therapy (HAART), report short‐term stable or increasing BMD, but other studies, often in cohorts initiating HAART, report short‐term losses in BMD. We assessed BMD changes over the medium term in HIV‐infected men already established on HAART at baseline.

Short course intravenous benzylpenicillin treatment of adults with meningococcal disease

Abstract

Actinomycotic vertebral osteomyelitis with spinal cord compression: A case report and review of the literature

Actinomycosis is a chronic suppurative condition caused by anaerobic or microaerophilic gram-positive bacteria of the genus Actinomyces. Actinomyces israelii is most commonly responsible for this condition but A. naeslundii, A. odontolyticus, A. meyeri, A. viscosus and A. gerencseriae may also cause disease in humans [1]. These organisms are part of the usual flora of the mouth, gastrointestinal tract and female genital tract. We report a case of vertebral actinomycosis with associated spinal cord compression.

An observational study of antiretroviral drug resistance in treatment-naïve patients with HIV infection in New Zealand, from 2007 to 2011.

UNLABELLED Background Genotypic testing for antiretroviral drug resistance is recommended for all patients newly diagnosed with HIV infection. This study sought to quantify the prevalence of antiretroviral drug resistance in treatment-naïve patients with HIV infection in New Zealand. METHODS All genotypic antiretroviral drug resistance testing in New Zealand is performed at LabPLUS, Auckland City Hospital. The clinicians who requested antiretroviral drug resistance testing during the period 2007-2011 were contacted and were asked to identify which patients with HIV infection were treatment-naïve at the time of testing. Results of the antiretroviral drug resistance tests for treatment-naïve patients with HIV infection were reviewed and the prevalence of resistance determined. RESULTS Two hundred and 10 treatment-naïve patients with HIV infection who had antiretroviral drug resistance testing performed were included; 20 (10%) were found to have a significant resistance mutation. Nine patients had virus resistant to one or more nucleoside reverse transcriptase inhibitors, 13 to non-nucleoside reverse transcriptase inhibitors and one to protease inhibitors. CONCLUSIONS The prevalence of antiretroviral drug resistance in treatment-naïve patients with HIV infection identified in this study is comparable to rates identified in studies from North America, the UK and Europe. This prevalence demonstrates the need for antiretroviral drug resistance testing for all treatment-naïve patients with HIV infection in New Zealand.