W. Kemper Alston

African Trypanosomiasis in Two Travelers from the United States

African trypanosomiasis is a rare but well-documented cause of fever in United States travelers returning from areas where it is endemic. We report two recently diagnosed cases that involved tourists who went on safari in Tanzania. Review of these and 29 other published cases indicates that disease in returning United States travelers is nearly always of the East African form, a fulminant illness for which prompt diagnosis is necessary. In the United States, timely and appropriate therapy for this disease has resulted in favorable outcomes for most patients. Chemoprophylaxis for East African trypanosomiasis is not recommended, but travelers visiting areas of endemicity should practice appropriate preventive measures to prevent tsetse fly bites.

Childhood Cryptosporidiosis Is Associated with a Persistent Systemic Inflammatory Response

Cryptosporidiosis in young children prompts local inflammation in the intestinal tract. We studied a cohort of young children with cryptosporidiosis to determine whether systemic inflammatory responses occur and, if so, to evaluate whether inflammation persists after infection. Cryptosporidiosis was associated with increased levels of interleukin-8 and tumor necrosis factor- alpha systemically, which persisted at 6 months after enrollment. The level of intestinal tumor necrosis factor- alpha was elevated at enrollment, but elevated levels did not persist. Worsening of malnutrition, particularly stunting, was observed after infection. The association of cryptosporidiosis, inflammation, and stunting in children with cryptosporidiosis warrants further evaluation.

The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics.

CONTEXT Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. PURPOSE To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. METHODS This was a retrospective cohort study. FINDINGS Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm(3)-350/mm(3) vs 182 cells/mm(3)-379/mm(3)). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]). CONCLUSIONS This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.

Use of Longitudinal Surveillance Data to Assess the Effectiveness of Infection Control in Critical Care

A simple method for quantifying nosocomial infection and colonization with multidrug-resistant organisms is described. This method is applied to the intensive care unit of an academic medical center where longitudinal surveillance data have been used to assess the impact of infection control interventions and antibiotic use.

Risk Factors for Persistent Methicillin-Resistant Staphylococcus aureus Bacteremia Despite Treatment With Vancomycin

Persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia despite treatment with vancomycin is not uncommon. Factors that contribute to vancomycin failure remain poorly understood. A retrospective case-control study was performed to examine factors associated with persistent MRSA bacteremia. All episodes of MRSA bacteremia from 1998 to 2004 were reviewed. Case patients had at least 1 positive blood culture drawn 5 or more days after beginning vancomycin. Two controls for each case were randomly selected with negative blood cultures within 48 hours of starting vancomycin. Of 251 MRSA bloodstream infections, 20 patients met the case definition. The median number of foreign devices, an intravascular device or septic phlebitis as a site of infection, and a maximum vancomycin minimum inhibitory concentration of 2 μg/mL were significantly associated with persistent bacteremia. In a multivariate model, only the number of foreign devices present at the onset of the bacteremia was found to be an independent predictor.

When are Oral Antibiotics a Safe and Effective Choice for Bacterial Bloodstream Infections? An Evidence-Based Narrative Review.

Bacterial bloodstream infections (BSIs) are a major cause of morbidity and mortality in the United States. Traditionally, BSIs have been managed with intravenous antimicrobials. However, whether intravenous antimicrobials are necessary for the entirety of the treatment course in BSIs, especially for uncomplicated episodes, is a more controversial matter. Patients that are clinically stable, without signs of shock, or have been stabilized after an initial septic presentation, may be appropriate candidates for treatment of BSIs with oral antimicrobials. There are risks and costs associated with extended courses of intravenous agents, such as the necessity for long-term intravenous catheters, which entail risks for procedural complications, secondary infections, and thrombosis. Oral antimicrobial therapy for bacterial BSIs offers several potential benefits. When selected appropriately, oral antibiotics offer lower cost, fewer side effects, promote antimicrobial stewardship, and are easier for patients. The decision to use oral versus intravenous antibiotics must consider the characteristics of the pathogen, the patient, and the drug. In this narrative review, the authors highlight areas where oral therapy is a safe and effective choice to treat bloodstream infection, and offer guidance and cautions to clinicians managing patients experiencing BSI.