Another Strategy for Hepatitis B Vaccine Non-responders

In a small study of subjects who did not respond to hepatitis B vaccine, re-vaccination with a double-dose of combined hepatitis A and B vaccine greatly improved response rates. Out of 44 non-responders, 59 percent had protective levels of antibody to hepatitis B virus after the first double-dose of combined vaccine, and 95 percent responded after three doses. The authors speculate that the addition of the hepatitis A vaccine, the increased dose of hepatitis B vaccine, or both could be responsible for the improved response rate. (Cardell et al., J Infect Dis. 2008;198:299-304; editorial commentary by Diepolder, J Infect Dis. 2008;198:297-298.)

HIV Scars GALT, Inhibits ART Recovery

HIV infection appears to scar gut-associated lymphoid tissue (GALT) early in infection and to a greater extent than it does other tissues, which may help explain why CD4+ T cell counts do not recover as well in the gut following antiretroviral therapy (ART). Researchers found greater areas of collagen deposition in GALT biopsies from HIV-positive subjects compared to HIV-negative subjects. In biopsies from early-acute HIV-infected subjects, researchers found greater areas of collagen deposition in GALT than in lymph node tissue. Greater areas of collagen deposition correlated with lower levels of CD4+ cells. Beginning ART earlier may help reduce GALT damage and improve immune recovery. (Estes et al., J Infect Dis. 2008;198:456-464; editorial commentary by Read and Sereti, J Infect Dis. 2008;198:453-455.)

Predicting Need for Intensive Care Unit Management in Community-acquired Pneumonia 

From the Australian Community-acquired Pneumonia Study, the authors devised a tool—SMART-COP—to predict which patients would require intensive respiratory or vasopressor support. By assessing features such as low systolic blood pressure, multilobar chest radiograph involvement, low albumin level, high respiratory rate, tachycardia, confusion, poor oxygenation, and low arterial pH, they were able to identify 92 percent of the patients who required intensive respiratory or vasopressor support. In comparison, the sensitivity of the pneunomia severity index was 74 percent, and that of the CURB-65 score was 39 percent. (Charles et al., Clin Infect Dis. 2008;47:375-384.)

XDR TB in California  

Using case reports submitted to the California tuberculosis (TB) registry during 1993–2006, Banerjee and colleagues investigated the characteristics and magnitude of extensively drug-resistant (XDR) TB. Of 424 multidrug-resistant TB cases, 4 percent were XDR and 18 percent were “pre-XDR,” the latter being defined as TB with resistance to isoniazid and rifampin and either a fluoroquinolone or second-line injectable agent, but not both. The proportion of pre-XDR TB cases increased over time, from 7 percent in 1993 to 32 percent in 2005. Among patients with XDR TB, 83 percent were foreign born and 43 percent received a diagnosis of XDR TB within 6 months of arrival in the United States. (Banerjee et al., Clin Infect Dis. 2008;47:450-457.)

Management of MDR and XDR TB

Recent guidelines have varied considerably in their therapeutic recommendations for multidrug-resistant (MDR) tuberculosis. This Korean study of 155 patients with MDR TB found that the use of at least 4 drugs to which the organisms were susceptible was associated with a favorable outcome. The treatment success rates were similar between the patients with MDR TB and those who had XDR TB, although the patients with XDR TB were more likely than the patients with MDR TB to have had surgical resection (48 percent vs. 17 percent). (Kwon et al., Clin Infect Dis. 2008;47:496-502.)

More from the literature: the IDSA Journal Club

Don’t miss this feature to help you stay up to date on the infectious diseases literature. Each month, the IDSA Journal Club features brief summaries of key infectious diseases studies in the previous month’s major journals chosen by the new IDSA Literature Review Panel.

In addition, the “In This Issue” section of each issue of Clinical Infectious Diseases (CID) highlights several important studies from that journal. (Click for September 1 or September 15.) For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, in each issue of CID.

Sept. 1

• Active Surveillance for Detection of Colonization with Methicillin-Resistant Staphylococcus aureus (MRSA)

Sept. 15

• CNS Vasculopathy and Varicella Zoster Virus (VZV)
• Monogamous Couples and a Promiscuous Virus
• Possible Protection against Group A Streptococcal (GAS) Infection Associated with Influenza Vaccination

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