We report, in a clinical setting, the tigecycline concentration and area under the concentration-time curve (AUC) - both in blood and in cerebrospinal fluid (CSF) - of a patient with a ventriculo-atrial shunt infection. Tigecycline weakly penetrates CSF the CSF-to-serum concentration ratio was 0.079 and CSF-to-serum AUC(0-12) ratio was 0.067.

Hepatitis B virus (HBV) infection constitutes a serious global health problem. Nowadays there are divergent data regarding the use of antiviral drugs to treat acute hepatitis B. We present here a case of a 62-year-old man affected by severe acute hepatitis B with progressive worsening of clinical and hepatic function. The patient was treated with entecavir without critical side effects. We observed rapid clinical and laboratory improvements and the disappearance of hepatitis B surface antigen (HBsAg). The treatment with entecavir was protracted until 17th week when the antibody anti-HBs appeared. Entecavir should be carefully considered for the treatment of severe acute hepatitis B cases.

BackgroundThere is no clear relationship between in vitro bactericidal activity tests and clinical outcome. We studied bactericidal activity of oxacillin, vancomycin and teicoplanin against Staphylococcus aureus isolates in patients with endocarditis and then we sought to determine if there was a relationship between in vitro bactericidal activity and clinical outcome.MethodsMinimal bacteriostatic and minimal bactericidal concentrations were determined for Staphylococcus aureus strains isolated from patients with endocarditis following standardized methods. Medical records were reviewed retrospectively to collect data on antimicrobial susceptibility at admission, antimicrobial therapy, need for surgery, embolic events and outcome.Results and DiscussionSixty-two Staphylococcus aureus strains were studied in 62 patients with endocarditis. Overall, 91.9% definite, 21% methicillin resistant and 72.6% cured. Surgery was performed in 32.3% and embolic events were documented in 64.5%. Tolerance to oxacillin and teicoplanin was more common than vancomycin tolerance among methicillin susceptible Staphylococcus aureus. Among methicillin resistant Staphylococcus aureus teicoplanin was shown to have a higher rate of tolerance than vancomycin. No statistically significant differences on clinical outcome between oxacillin tolerant and oxacillin non tolerant Staphylococcus aureus infections were observed. Tolerance to oxacillin did not adversely affect clinical outcomes of patients with methicillin susceptible Staphylococcus aureus endocarditis treated with a combination of antimicrobials including oxacillin. The cure rate was significantly lower among patients with methicillin resistant Staphylococcus aureus endocarditis.ConclusionsIn vitro bactericidal test results were not valid predictors of clinical outcome. Physicians need to use additional parameters when treating patients with staphylococcal endocarditis.

Durable virological suppression during HAART is associated with immunological recovery in patients with HIV infection. Current guidelines recommend to initiate HAART when CD4+ cell count falls <350/μl. However, recent studies have shown a higher immune restoration when HAART was started at CD4+ baseline level > 350 cells/μl. We retrospectively assessed the long-term immunological outcome in patients with sustained virological suppression during HAART, for up to 8 years. MethodsHIV-infected consecutive patients attending to our clinic were included, with the following inclusion criteria: follow-up >1 year while on HAART and sustained virologic suppression (HIV-RNA <400 copies/ml) for at least 6 consecutive months. We analyzed the immunological outcome by of annual determination of: 1) CD4+ cell count; and 2) change in CD4+ cell count from baseline. Complete immunological recovery was defined as CD4+ cell count ≥700/μl. Patients were stratified according to baseline CD4+ cell (counts of <200/μl, 200-350/μl and >350/ μl), age, HIV risk group, HCV co-infection, HAART regimen, sex, and race. A statistical analysis was performed by linear regression. Summary of results352 patients were observed: 172, 85 and 95 patients had baseline CD4+ cell count <200/μl, 200-350/μl and >350/ μl, respectively. After 5 years of therapy, 29%, 69% and 82% of patients with baseline CD4+ cell count, respectively, <200/μl, 200-350/μl and >350/μl, exceeded the threshold of 500 cells/μl (p = 0.034).Among patients with baseline CD4+ cell count >350/μl, mean CD4+ cell count reached a plateau with a complete immunological recovery by 4 years of suppressive HAART. CD4+ cell count increased even after 8 years without ever reaching a full immunological recovery in patients with baseline CD4+ cell count <200/μl. Patients aged ≥50 years had a slower but similar immune recovery (p > 0.05). We found no significant differences in immunological response according to baseline viral load, HIV risk factor, sex, HCV co-infection and HAART regimen. ConclusionIn our study, patients with sustained viral suppression experienced a significant immune recovery over 8 years of HAART. We found that complete immune recovery was achieved only in patients with baseline CD4+ cell count >350/μl. This observation strengthens the hypothesis that starting HAART at CD4+ cell counts < 50/μl could not be adequate to obtain a complete immunological recovery.

We report pharmacokinetic data on two gastrectomized, patients affected by tuberculosis. Drugs plasmatic concentrations were measured after seven days of oral therapy by a validated high performance liquid chromatography-mass spectrometry (HPLC-MS) method and the area under the concentration-time-curve (AUC) over 24 hours (AUC0–24) was calculated. A sub-therapeutic level of isoniazid was found in a patient with total gastrectomy with a Cmax of 0,395 mg\L and AUC0–24 level of 4.75 hr*mg/L. The level of the other antitubercular drugs was adequate. These findings support the need to monitor anti tubercular drug levels to facilitate early detection of therapeutic failure, above all in patients treated with isoniazid and with potential problems on oral drugs absorption.