Replacement of Administration Sets Used to Administer Blood, Blood Products, or Lipid Emulsions for the Prevention of Central Line-Associated Bloodstream Infection

To the Editor—Given our particular interest in the field of evidence-based guidelines for infection prevention, 1-3 we were delighted to welcome the publication of the journal’s October 2008 Supplement 1, which contained a compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Indeed, in addition to supplying the healthcare worker with a very useful and excellent update of the existing recommendations, this compendium provides enlightening information regarding implementation strategies and performance measures for internal and external reporting. The paper’s executive summary states that the updated recommendations are not meant to supplant the existing, more-detailed guideline documents but aim to provide practical guidance. 4 Nevertheless, while reading the guidelines for the prevention of central line–associated bloodstream infections, 5 some questions arose. Therefore, we gratefully take this opportunity to address these questions, which concern the management of intravenous administration sets, and we thank the authors in advance for their interest and clarification. The article by Marschall et al. 5 recommends replacement

Novel Relationship between Tuberculosis Immune Reconstitution Inflammatory Syndrome and Antitubercular Drug Resistance

Tuberculosis (TB) immune reconstitution inflammatory syndrome (IRIS) is emerging as an important early complication of combination antiretroviral therapy in patients with TB in developing countries. The differential diagnosis of TB IRIS includes deterioration caused by other human immunodeficiency virus-related morbidities and drug-resistant TB.

Changes in Cancer Mortality among HIV‐Infected Patients: The Mortalité 2005 Survey

The goal of the current study was to describe the distribution and characteristics of malignancy related deaths among human immunodeficiency virus (HIV)-infected patients with use of data obtained from a national survey conducted in France in 2005 and to compare with results obtained from a similar survey conducted in 2000.

Dominant‐Negative Tumor Necrosis Factor Protects fromMycobacterium bovisBacillus Calmette‐Guérin (BCG) and Endotoxin‐Induced Liver Injury without Compromising Host Immunity to BCG andMycobacterium tuberculosis

Tumor necrosis factor (TNF) is associated with the development of inflammatory pathologies. Antibodies and soluble TNF (solTNF) receptors that neutralize excessive TNF are effective therapies for inflammatory and autoimmune diseases. However, clinical use of TNF inhibitors is associated with an increased risk of infections.

Genotype of 88Toxoplasma gondiiIsolates Associated with Toxoplasmosis in Immunocompromised Patients and Correlation with Clinical Findings

We report the genotyping analysis of Toxoplasma gondii isolates in samples collected from 88 immunocompromised patients, along with clinical and epidemiological data. Most of these samples were collected in France during the current decade by the Toxoplasma Biological Resource Center. Lack of specific anti-Toxoplasma treatment, pulmonary toxoplasmosis, and involvement of multiple organs were the 3 main risk factors associated with death for this patient group. Genotyping results with 6 microsatellite markers showed that type II isolates were predominant among patients who acquired toxoplasmic infection in Europe. Non-type II isolates included 13 different genotypes and were mainly collected from patients who acquired toxoplasmosis outside Europe. Type III was the second most common genotype recovered from patients, whereas type I was rare in our population. Three nonarchetypal genotypes were repeatedly recovered from different patients who acquired the infection in sub-Saharan Africa (genotypes Africa 1 and Africa 2) and in the French West Indies (genotype Caribbean 1). The distribution of genotypes (type II vs. non-type II) was not significantly different when patients were stratified by underlying cause of immunosuppression, site of infection, or outcome. We conclude that in immunocompromised patients, host factors are much more involved than parasite factors in patients' resistance or susceptibility to toxoplasmosis.

Meningococcal Factor H–Binding Protein Variants Expressed by Epidemic Capsular Group A, W‐135, and X Strains from Africa

Meningococcal epidemics in Africa are generally caused by capsular group A strains, but W-135 or X strains also cause epidemics in this region. Factor H-binding protein (fHbp) is a novel antigen being investigated for use in group B vaccines. Little is known about fHbp in strains from other capsular groups.

Neurologic Manifestations of Paradoxical Tuberculosis‐Associated Immune Reconstitution Inflammatory Syndrome: A Case Series

Paradoxical neurologic tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a potentially life-threatening condition that occurs within 3 months after starting combination antiretroviral therapy (ART). The reports in the published literature are anecdotal, and the prevalence and outcomes of neurologic TB-IRIS are unknown.

Reply to Gómez‐Marín

Serum Cross‐Reactivity withAspergillusGalactomannan and Cryptococcal Antigen during Fatal DisseminatedTrichosporon dermatisInfection

Hospital Costs in Patients with Nosocomial Methicillin-Resistant or Methicillin-Susceptible Staphylococcus aureus Bloodstream Infection

To the editor.—Given our interest in health economics in the field of infectious disease research, we read with interest the article by Dr Ben-David and colleagues published in the May 2009 issue of the journal. 1-5 The authors examined the attributable impact of methicillin resistance among patients with nosocomial methicillin-resistant Staphylococcus aureus bloodstream infection on hospital mortality, length of stay, and costs, compared with patients with nosocomial methicillin-susceptible S. aureus bloodstream infection. Their initial results suggested increased resource use in terms of hospital costs and length of stay associated with methicillin resistance; however, after they had accounted for potential confounders by means of a propensity score analysis, their final results did not reveal increased resource use. 3 Although we agree with the conclusion of Dr Ben-David and colleagues, we have some suggestions regarding the additional study that they propose. In their propensity score, which was assessed for each individual case patient, the authors did not include prior use of antibiotic agents (appropriateness of therapy, number of antibiotics administered, and duration of antibiotic use) and whether the patients were cared for in a long-term care facility prior to hospital admission—both variables that are associated with acquisition of antibiotic resistance. 6-8 As such, important bias may remain, because the propensity score adjusted for in their analysis may not satisfactorily correct for existing differences between patients with nosocomial bloodstream infection caused by methicillin-resistant S. aureus and patients with nosocomial bloodstream infection caused by methicillin-susceptible S. aureus. 9 In an aim to increase the generalizability of a propensity score to other settings or institutions, however, it is important to keep such a “probability model” as simple as possible, which means retaining only the most clinically relevant variables in the final analysis. In this regard, we do not completely comprehend why some characteristics that seem not to have any relationship to methicillin resistance were included (eg, presence of cirrhosis or diabetes mellitus [P p ]; see their Table 4), while other characteristics were excluded .7 (eg, residence in a long-term care facility), even though they were statistically and clinically relevant. We would like to kindly invite Dr Ben-David and colleagues to clarify the decision process by which potential confounders were included or excluded from the final model on which the propensity score was based.