Updates-By Carol A. Kemper, MD, FACP
Updates-By Carol A. Kemper, MD, FACP
Sex and E coli
Source: Eschenbach DA, et al. J Infect Dis. 2001;183:913-918.
Condom use is being encouraged as an effective means to reduce STDs and HIV. And, yet, vaginal intercourse with condoms has been associated with an increased risk of urinary tract infections (UTIs) in female partners. Eschenbach and colleagues from Seattle examined the effect of a single episode of sex on the vaginal flora in women randomly assigned to sex with or without a lubricated condom without nonoxynol-9. Each woman served as her own control; clinical examinations and cultures of vaginal flora and urine were obtained 1 month and 1-2 days before the episode of sex, and 8-12 hours, 2-3 days, and 6-8 days after.
During the month before sex, each woman’s vaginal flora remained remarkably stable. As expected, lactobacilli were the predominate organism. Within 8-12 hours after an episode of sex in both condom and noncondom users, there was a significant increase in the numbers of women with ³ 105 cfu/mL E coli and other enteric bacteria in vaginal fluid. Although this effect appeared to be somewhat less in condom users, logistic regression analysis showed no difference between the 2 groups. In addition, no difference was observed in the physical or colposcopic appearance of the vagina and cervix, and no change in pH was found. The number of enteric bacteria in the vagina rapidly decreased within 2-3 days.
Cultures of urine also showed a transient increase in E coli within hours after sex, although colony counts were < 105 in all but 1 patient, which quickly disappeared in most patients. This effect was observed in both condom and noncondom users, although somewhat unexpectedly, was significant only in those who did not use a condom. While the mechanical effect (sic) of vaginal intercourse forces the introduction of E coli and other enterics into the vaginal canal and lower urinary tract, this effect appears to be transient, lasting less than a day in most patients. Although sex with condoms reportedly increases your risk of UTI, apparently having sex only once wasn’t enough.
Treatment of MDR-TB Meningitis
Source: Berning S, et al. Clin Infect Dis. 2001;32:643-646.
Berning and colleagues at the National Jewish Medical Center in Denver describe an unusual case of widely disseminated multi-drug resistant tuberculosis (MDR-TB) resulting in meningitis in an HIV-positive man. The patient ultimately responded to the intrathecal administration of levofloxacin and amikacin, in addition to systemic therapy.
During initial treatment with a 5-drug regimen including INH, ethambutol, pyrazinamide, cycloserine, and capreomycin, the patient developed progressive central nervous system disease with positive cerebrospinal fluid cultures, despite evidence of improvement in the lungs. Initial attempts at treatment with parenterally administered levofloxacin and amikacin were not successful. Ultimately, intrathecal treatment via an Omaya reservoir with both levofloxacin (maximal dose 1.5 mg) and azithromycin (maximal dose 5 mg), titrated to patient tolerance, on alternate days, resulted in improvement in CSF parameters within 8 days. Although CSF levels of the 2 agents were lower than target levels, they exceeded the MIC of each agent. CSF:serum ratios of both agents were higher (82-99%) for levofloxacin and 43% to > 200% for amikacin than published reports. The patient was doing well 12 months later, still on therapy. Therapeutic drug monitoring of CSF and serum levels proved helpful in making dosage adjustments.
Parenteral Therapy vs. Implants for CMV Retinitis
Source: Am J Ophthalmol. 2001;131: 457-467.
While the newer antiretrovi-ral therapies have resulted in improved immune system function in many patients with HIV infection, increasing numbers of patients are experiencing failure of their regimens and progression of their disease. The optimal treatment of opportunistic infections, such as cytomegalovirus (CMV), therefore remains of continued concern. Since the introduction of the ganciclovir ocular implant, many patients have opted for this convenient and effective option.
The investigators examined the relative efficacy of the ganciclovir implant plus orally administered ganciclovir (1 gm 3 times daily) vs. intravenous cidofovir (5 mg/kg every other week) in a group of 61 patients with AIDS and CMV retinitis. Both agents were similarly effective with regard to retinitis progression (P = .72) and loss of visual acuity (P = .28). Loss of visual acuity occurred at a rate of 0.78 in the implant group vs. 0.47 per person-year in patients receiving cidofovir. There was a trend toward greater loss of visual fields in patients with the implant. However, side effects between the 2 different treatment arms were extremely different. While renal dysfunction and uveitis was more common in patients receiving cidofovir, vitreous hemorrhage was more common in the implant group. These data suggest that cidofovir is an effective treatment option for patients with CMV retinitis, presuming the renal toxicity can be appropriately managed.
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