Clinical Infectious Diseases最新文献

Background: World Health Organization (WHO) tuberculosis (TB) screening guidelines recommend computer-aided detection (CAD) software for chest radiograph (CXR) interpretation. However, studies evaluating their diagnostic and prognostic accuracy are limited.

Methods: We conducted a prospective cohort study of household contacts of rifampicin-resistant TB in South Africa. Participants underwent baseline CXR and sputum investigation (routine [single spontaneous] and enhanced [additionally 2-3 induced]) for prevalent TB and follow-up for incident TB. Three CXR-CAD software products (CAD4TBv7.0, qXRv3.0.0, and Lunit INSIGHT v3.1.4.111) were compared. We evaluated their performance to detect routine and enhanced prevalent and incident TB, comparing performance with blood tests (Xpert MTB host-response, erythrocyte sedimentation rate, C-reactive protein, QuantiFERON) in a subgroup.

Results: 483 participants were followed up for 4.6 years (median). There were 23 prevalent (7 routinely diagnosed) and 38 incident TB cases. The AUC ROCs (95% CIs) to identify prevalent TB for CAD4TBv7.0, qXRv3.0.0, and Lunit INSIGHT v3.1.4.111 were .87 (.77-.96), .88 (.79-.97), and .91 (.83-.99), respectively. More than 30% with scores above recommended CAD thresholds who were bacteriologically negative on routine baseline sputum were subsequently diagnosed by enhanced sputum investigation or during follow-up. The AUC performance of baseline CAD to identify incident cases ranged between .60 and .65. Diagnostic performance of CAD for prevalent TB was superior to blood testing.

Conclusions: Our findings suggest that the potential of CAD-CXR screening for TB is not maximized as a high proportion of those above current thresholds, but with a negative routine confirmatory sputum, have true TB disease that may benefit intervention.

Background: Limited data exist regarding outcomes of cryptococcosis in patients without HIV with few studies having compared outcomes of Cryptococcus gattii, versus C. neoformans, infection.

Methods: We conducted a retrospective study in 46 Australian and New Zealand hospitals to determine the outcomes of cryptococcosis in patients without HIV diagnosed between 2015 and 2019, and compared outcomes of C. gattii versus C. neoformans infections. Multivariable analysis identified predictors of mortality within one year.

Results: Of 426 patients, one-year all-cause mortality was 21%. C. gattii infection was associated with a lower mortality than C. neoformans (adjusted odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.23-0.95), whilst severe neurological symptoms at presentation was the strongest predictor of death (adjusted OR: 8.46, 95% CI: 2.99-23.98). Almost all (99.5%) patients with central nervous system (CNS) infection received induction antifungal therapy versus 27.7% of isolated pulmonary cryptococcosis. The commonest regimen in CNS disease was liposomal amphotericin B with flucytosine (93.8%, mean duration 31 ± 13 days). Among patients with CNS cryptococcosis, C. gattii infection was associated with higher risk of immune reconstitution inflammatory response (C-IRIS) than C. neoformans (21% versus 3%, p<0.001). Nineteen patients received amphotericin B-based re-induction therapy for suspected relapse but none had microbiological relapse. Serum cryptococcal antigen positivity and lung imaging abnormalities resolved slowly (resolution at one year in 25% and 34% of patients, respectively).

Conclusion: Compared with C. neoformans, C. gattii infection demonstrated lower mortality but higher C-IRIS risk in CNS infection. Severe neurological symptoms were the strongest predictor of mortality.

Background: Given the known relationship between human immunodeficiency virus (HIV), antiretroviral therapies, and excess visceral adipose tissue (VAT), this review sought to characterize risk of negative health outcomes associated with excess VAT and increased waist circumference (WC) in people with HIV (PWH).

Methods: Comprehensive targeted literature searches were conducted in Medline/Embase (27 June 2022), identifying peer-reviewed articles and conference abstracts reporting on cohorts of PWH. Screening was guided by PECOS (Population, Exposure, Comparator, Outcomes, Study design) criteria. From the included studies, outcomes of interest including mortality and morbidity risk by VAT area and WC were extracted, overall, and by sex, race/ethnicity, and duration of HIV. Relationships between outcome and exposure variables were summarized.

Results: Thirty-five studies were included (sample size range: 31-1748 PWH). Twenty-five studies characterized the relationship between increased WC and negative health outcomes-cardiovascular disease (CVD), arteriosclerosis, hypertension, diabetes, hepatic fat and fibrosis, and cognitive impairment-among PWH. Fifteen studies reported on increased VAT and negative health outcomes: all-cause mortality, CVD, atherosclerosis, hepatic fat, and fibrosis. Importantly, there was a 2.1-times higher odds of 5-year all-cause mortality among PWH with the highest amount of VAT in the only study identified reporting on mortality. Among the studies characterizing the relationship between morbidity and VAT, for example, 1 found that, for each 10-cm2 increase in VAT, the risk of prevalent CVD increased by 1.05 (95% CI: 1.0-1.1) times.

Conclusions: WC may be a useful and cost-effective surrogate for visceral adiposity, which is an important marker of morbidity and mortality among PWH.

Despite widespread adoption of "high-dose" glucocorticoid definitions across international immunisation guidelines (i.e., prednisone-equivalent dosing >20 mg/day, or >2 mg/kg/day in children), the rationale remains unclear. Literature searches were performed through academic databases for this narrative review to identify relevant evidence regarding glucocorticoid dosing on vaccine responses and safety. In people receiving prednisone <7 mg/day, vaccine responses are maintained. In people on 'high-dose' glucocorticoids (>20 mg/day), antibody titres and seropositivity are reduced, whereas the impact of low- to medium-dose glucocorticoids (7 to 20 mg/day) on vaccine efficacy remains inconclusive. Due to inconsistent paediatric dosing regimens, data is insufficient to support a unified "high-dose" glucocorticoid threshold. Non-live vaccines are well tolerated in patients receiving glucocorticoids with rheumatic/inflammatory disorders, but enhanced reactogenicity after live vaccination may occur in those with severe immunodeficiencies. Clinicians should consider individual risk-benefit profiles, rather than following strict dosing thresholds, when curating immunisation programs for patients prescribed glucocorticoids.

Background: The increased prevalence of antimicrobial-resistant (AMR) infections is a significant global health threat, resulting in increased disease, deaths, and costs. The drivers of AMR are complex and potentially impacted by socioeconomic factors. We investigated the relationships between geographic and socioeconomic factors and AMR.

Methods: We collected select patient bacterial culture results from 2015 to 2020 from electronic health records of 2 expansive healthcare systems within the Dallas-Fort Worth, Texas, metropolitan area. Among individuals with electronic health records who resided in the 4 most populous counties in Dallas-Fort Worth, culture data were aggregated. Case counts for each organism studied were standardized per 1000 persons per area population. Using residential addresses, the cultures were geocoded and linked to socioeconomic index values. Spatial autocorrelation tests identified geographic clusters of high and low AMR organism prevalence and correlations with established socioeconomic indices.

Results: We found significant clusters of AMR organisms in areas with high levels of deprivation, as measured by the area deprivation index (ADI). We found a significant spatial autocorrelation between ADI and the prevalence of AMR organisms, particularly for AmpC β-lactamase and methicillin-resistant Staphylococcus aureus, with 14% and 13%, respectively, of the variability in prevalence rates being attributable to their relationship with the ADI values of the neighboring locations.

Conclusions: We found that areas with a high ADI are more likely to have higher rates of AMR organisms. Interventions that improve socioeconomic factors such as poverty, unemployment, decreased access to healthcare, crowding, and sanitation in these areas of high prevalence may reduce the spread of AMR.