Fungal Prophylaxis in Preemies
Source: Kaufman D, et al. N Engl J Med. 2001;345:1660-1666.
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On the heels of a recent Infectious Disease Alert discussing the frequency and risks of invasive candidiasis in neonates, (Infectious Disease Alert. 2001;21:40) Kaufman and colleagues report the effectiveness of fluconazole prophylaxis in 100 preterm infants with birth weights under 1000 grams. Fifty infants were randomly assigned to receive IV fluconazole 3 mg/kg every third day for 2 weeks, and then every other day during weeks 3 and 4, and then daily during weeks 5 and 6, and 50 matching control subjects received blinded placebo. During the 6-week study, none of the infants who received fluconazole developed invasive fungal infection, defined as a positive culture from a usually sterile site (eg, blood, urine, CSF), compared with 10 (20%) control subjects (P = .008). Fungal colonization in treated subjects was still common (22%), but significantly less than in controls (60%) (P = .002).
The reduction in colonization was most frequently observed for stools, skin, and nasopharynges, but most of this was due to a decrease in Candida albicans. There was no effect on the frequency of colonization with C parapsilosis and other yeasts between the 2 groups. In patients receiving fluconazole, 83% of all isolates were C parapsilosis and 9.5% were T glabrata. In contrast, nearly half (43.5%) of the isolates from control subjects were C albicans. There was no evidence of increased fungal MICs in patients receiving fluconazole.
Fluconazole, at these dosages, was remarkably well-tolerated in these preterm infants. The frequency of abnormal hepatic transaminases was ~6% in each group. While there was no statistically significant difference in mortality (4 infants receiving fluconazole and 10 in the placebo group died), 4 of 10 control subjects who developed invasive candidiasis died. Interestingly, fewer patients receiving fluconazole developed necrotizing enterocolitis and intestinal perforation.
Probing the Cause of Nongonococcal Urethritis
Source: Homer P, et al. Clin Infect Dis. 2001;32:995-1003.
Homer and colleagues conducted an in-depth examination of the etiology and natural history after treatment of 114 heterosexual men with acute, symptomatic nongonococcal urethritis (NGU) compared with 64 patients without NGU. All of the men underwent urinalysis, gram stains of urethral smears, and cultures. Patients with acute NGU received a 2-week course of doxycycline 100 mg twice daily.
Taking into consideration age, race, number of sexual partners, and coinfection, only C trachomatis and M genitalium were significantly associated with acute urethritis. There was no association between the presence of ureaplasmas in the genital tract and acute NGU. However, both M genitalium and ureaplasmas were significantly associated with the development of chronic NGU in symptomatic men, but not in asymptomatic men with evidence of chronic NGU nor in symptomatic men without evidence of chronic urethritis. Within 1 month of treatment, 48 men returned with evidence of urethritis (42%), 23 of whom were symptomatic. Between 30 and 92 days posttreatment, chronic urethritis was diagnosed in 28 men (25%), 16 of whom were symptomatic. The detection of either ureaplasmas or M genitalium 30-92 days after treatment was associated with urethritis (P = .028).
These results confirm the role of M genitalium in NGU in men. On the other hand, while the presence of ureoplasmas in the genital tract of both men and women is fairly common and associated with the number of lifetime sexual partners, its association with acute urethritis in men is less certain. While ureaplasmas may cause acute urethritis in some patients, most men appear to be asymptomatic carriers. However, there does appear to be an association between chronic, symptomatic NGU and ureaplasmas. Molecular tests for M genitalium and ureaplasmas may prove clinically useful, especially in symptomatic individuals.
Hepatitis E in Rats and the Homeless?
Source: ProMED-mailpost, Nov. 22, 2001. www.promedmail.org.
Following the identification of a hepatitis E-like virus in rats captured in Los Angeles and Orange County, California, researchers suspect they may have hit upon a source of occult hepatitis E virus infection in the United States. Because hepatitis E virus is probably a group of closely related viruses that infect both humans and animals, researchers are working to determine whether the virus found in rats could be responsible for infection in humans. Hepatitis E is endemic throughout Asia, Africa, and South America, where it is an important cause of hepatitis. The infection usually lasts from 1-4 weeks, is not usually life threatening, and does not result in chronic infection. Although clinically recognized hepatitis E disease is rare in the United States, serosurveys suggest previous exposure in up to 1-5% of US blood donors. Recent data suggest that 15% of the homeless in southern California have been infected, piquing interest in the possible source (or sources) of this enteric infection.
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