Corynebacterium striatum is a commensal of human skin and has been recently recognized as an emerging pathogen. A case of nosocomial pacemaker lead endocarditis due to a multidrug-resistant C. striatum strain is described, highlighting the role of sonication as a diagnostic tool in cardiac device infections. CASE REPORTA 71-year-old woman, who underwent pacemaker replacement 2 months before, was admitted with a 15-day history of fever and generator site pain. She was febrile (core temperature, 38.5°C), her blood pressure was 120/80 mmHg, and her pulse rate was 76 beats/min. Erythema, warmth, tenderness, and purulent drainage were observed at the pocket site. Respiratory, abdominal, and neurological parameters were normal, and an examination of the heart showed a 2/6 systolic murmur. Laboratory analyses revealed a mild leukocytosis (11 ϫ 10 9 leukocytes/liter, 85% polymorphonuclear cells) and an erythrocyte sedimentation rate correspondent to 50 mm/h. A markedly increased C-reactive protein level (8 IU/liter) was observed.Two separate sets of blood and swab cultures obtained from purulent secretion at the pocket site yielded coagulase-negative Staphylococcus which showed resistance to methicillin and rifampin and susceptibility to vancomycin, teicoplanin, linezolid, and daptomycin.A transthoracic echocardiogram revealed a mobile mass adherent to the intracardiac lead in the absence of valve vegetations. Treatment with daptomycin (6 mg/kg body weight once daily) was started, leading to a rapid improvement, as determined by clinical and laboratory findings. Blood cultures and pocket swabs, performed 72 h after the beginning of antimicrobial therapy, were sterile. Serum bactericidal activity was Ͼ1:16 (4). After 7 days of daptomycin treatment, the patient developed renal failure (clearance of creatinine, Ͻ20 ml/min), and the antimicrobial therapy was switched to intravenous linezolid (600 mg twice daily). Following this therapy, the patient again became febrile (core temperature, 39°C). Blood cultures and pocket site swabs were negative. The patient underwent device removal, and a reimplantation of a new pacemaker was performed 8 days later. On macroscopic examination, the intracardiac portion of the electrode showed the presence of a mass adherent to the lead. Four samples of lead tips were collected: two of them were analyzed by following the traditional microbiological procedures without sonication, whereas the other two samples were submitted to device sonication and then cultured. Briefly, within 1 h from the removal, two lead tips were inoculated in Trypticase soy broth (TSB) which was incubated for 24 h and analyzed for bacterial growth. The other two lead tips were vortexed for 30 s and then sonicated in NaCl solution for 5 min at a frequency Ͼ20 kHz and finally vortexed again for another 30 s. The Ultrasonik 300 bath (Ney, BarkMeyer Division, Yucaipa, CA) was used for sonication. The resulting sonication fluid was centrifuged at 3,200 rpm for 15 min, and the sediment was used for microbiological cultures. A...

A survey of HIV coreceptor usage in cerebrospinal fluid (CSF) samples, peripheral blood mononuclear cells (PBMCs), and plasma samples from naïve seropositive patients was conducted. One hundred patients were enrolled in this study. Of the 100 patients, 36 had a primary or recent infection (P-RI), 31 had an early chronic infection (>350 CD4 cells) (ECI), and 33 had a late chronic infection (LCI). All 3 compartments were sampled in a subset of 33 participants, while the remaining 67 patients provided plasma samples and PBMCs only. Seventy-seven patients harbored the R5 virus in plasma samples and had a significantly higher median and percentage of CD4 ؉ T cells than patients with X4 virus (437 and 281 cells/l, respectively; P ‫؍‬ 0.0086; 20.6% and 18.6%, respectively). The X4 strain was detected more frequently in patients with LCI than in patients with P-RI or ECI (39.3%, 19.4%, and 9.6%, respectively; P ‫؍‬ 0.0063). PBMC and plasma tropism was concordant in 90 patients, and 73 had the R5 strain. Among patients with discordant results, 4 had the R5 virus in their plasma and the X4 virus in PBMCs; 6 showed the opposite profile. Plasma, PBMC, and CSF tropism determinations were concordant in 26/33 patients (21 patients had R5, and 5 had X4). The tropism was discordant in 5/33 patients, with the X4 virus in plasma and R5 in CSF; the HIV tropism in PBMCs was X4 in 3 patients. The remaining 2/33 patients had the R5 virus in plasma and PBMCs and the X4 virus in CSF; one of these patients had a P-RI. The discordant tropism in CSF and blood may have implications for chemokine (C-C motif) receptor 5 (CCR5) antagonist use in patients with limited response to antiretroviral therapy (ART) or in responding patients evaluated for simplification of treatment.

Only 6.2% of ART-responder patients presented the combination of three laboratory markers that identified them as full responders. These results indicate the high variability of the ART-responding population and lead us to suggest caution in the selection of patients for possible simplification regimens.

Simplified regimens containing protease-inhibitors (PI)-sparing combinations were used in patients with virological suppression after prolonged highly active antiretroviral therapy. This study evaluated the total HIV-1 DNA quantitation as a predictor of long-term success for PI-sparing simplified therapy. Sixty-two patients were enrolled in a prospective non-randomized cohort. All patients have been receiving a triple-therapy regimen, two nucleoside reverse transcriptase inhibitors (NRTIs) plus one PI, for at least 9 months and were characterized by undetectable plasma HIV-1 RNA levels (<50 cp/ml) for at least 6 months. Patients were changed to a simplified PI-sparing regimen to overcome PI-associated adverse effects. HIV-DNA levels in peripheral blood mononuclear cells (PBMCs) were evaluated at baseline and at the end of follow-up. Patients with proviral DNA levels below the median value (226 copies/10(6) PBMCs) had a significant higher CD4 cell count at nadir (P = 0.003) and at enrolment (P = 0.001) with respect to patients with HIV-DNA levels above the median value. At month 18, 53 out of 62 (85%) patients on simplified regimen showed virological success, 4 (6.4%) patients experienced virological failure and 5 (8%) patients showed viral blip. At logistic regression analysis, HIV-DNA levels below 226 copies/10(6) PBMCs at baseline were associated independently to a reduced risk of virological failure or viral blip during simplified therapy (OR 0.002, 95% CI 0.001-0.46, P = 0.025). The substitution of PI with NRTI or non-NRTIs may represent an effective treatment option. Indeed, treatment failure or viral blip were experienced by 6% and 8% of the patients on simplified therapy, respectively. In addition, sustained suppression of the plasma viral load was significantly correlated with low levels of proviral DNA before treatment simplification.

The association between human immunodeficiency virus (HIV) DNA load and immunologic parameters was investigated in 163 HIV-infected patients with undetectable plasma viremia during highly active antiretroviral therapy (HAART). Patients with HIV DNA below the 25th percentile (133 copies/10 6 peripheral blood mononuclear cells) had higher pre-HAART (P ‫؍‬ 0.001) and current (P ‫؍‬ 0.005) CD4 counts and a prolonged duration of treatment (P ‫؍‬ 0.001). At adjusted analysis, prolonged duration of treatment was independently associated with lower (P ‫؍‬ 0.006) and undetectable (P < 0.001) HIV DNA values.