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Background: The goal of this study was to describe the clinical and epidemiologic manifestations of a syphilis outbreak in downtown Madrid, Spain. Because human immunodeficiency virus (HIV)-positive patients may be at increased risk of serologic failure during syphilis treatment, analysis of factors determining the response to treatment was performed in a cohort of HIV-positive and HIV-negative patients with syphilis., Methods: We performed a longitudinal, retrospective study of patients with syphilis who received the diagnosis at a university-affiliated hospital in Madrid from 2003 through 2007., Results: Three hundred forty-seven cases of syphilis were identified and treated (30 primary, 164 secondary, 77 early latent, and 76 late cases of syphilis). Forty-one percent of patients were immigrants, mostly from South America and the Caribbean, and 49.3% were known to be HIV positive. Syphilis incidence increased from 15.6 to 35 cases per 100,000 person-years from 2003 to 2007. Most patients were men, and 50.4% were men who had sex with other men. Meningitis (4.9%) and uveitis (2.9%) were the complications most frequently observed, and their frequency did not differ between HIV-positive and HIV-negative patients. Serologic failure was observed in 44 (23.5%) patients: 37 (29.6%) of 125 HIV-positive patients and 7 (11.2%) of 62 HIV-negative patients (odds ratio, 3.3; 95% confidence interval, 1.38-7.93; P < .05). Men (hazard ratio [HR], 0.38), patients in the late stage of syphilis (HR, 0.46), and HIV-positive persons (HR, 0.61) demonstrated slower serological responses to treatment. HIV-negative patients responded more frequently to treatment, but after 2 years of follow-up, both groups shared similar response rates. Antiretroviral treatment reduced the time to serologic response (HR, 2.08; 95% confidence interval, 1.35- 3.20; P < .001)., Conclusion: Syphilis incidence rose 223% from 2003 to 2007, affecting mostly HIV-positive men, men who have sex with men, and immigrants. Men, patients in the late stages of syphilis, and HIV-positive persons may be at increased risk of serologic failure. Antiretroviral therapy significantly reduced the time to achieve response to syphilis treatment in HIV-positive patients.

Background: Dengue fever is the most common arboviral disease in travelers. In countries where dengue virus is endemic, sequential (secondary) infections with different dengue virus serotypes are associated with disease severity. Data on severity and secondary infection rates in a population of travelers are lacking., Methods: Intensified surveillance of dengue fever in travelers was performed within the European Network on Surveillance of Imported Infectious Diseases. Data were collected at 14 European clinical referral centers between 2003 and 2005., Results: A total of 219 dengue virus infections imported from various regions of endemicity were reported. Serological analysis revealed a secondary immune response in 17%. Spontaneous bleeding was observed in 17 (8%) patients and was associated with increased serum alanine and aspartate aminotransferase levels and lower median platelet counts. Two (0.9%) patients fulfilled the World Health Organization (WHO) case definition for dengue hemorrhagic fever. However, 23 (11%) travelers had severe clinical manifestations (internal hemorrhage, plasma leakage, shock, or marked thrombocytopenia). A secondary immune response was significantly associated with both spontaneous bleeding and other severe clinical manifestations., Conclusions: In travelers, severe dengue virus infections are not uncommon but may be missed if the WHO classification is strictly applied. High liver enzyme levels and low platelet counts could serve as indicators of disease severity.

Objectives: To compare the activity of cloxacillin and vancomycin against methicillin-susceptible Staphylococcus aureus and to determine how rapidly their bactericidal activity occurs in cardiac vegetations., Methods: In vitro and in vivo studies using an experimental model of endocarditis in rabbits. Animals were treated for 1, 2 or 3 days with cloxacillin 200 mg/kg intramuscularly three times a day or vancomycin 25 mg/kg intravenously twice a day., Results: Cloxacillin and vancomycin at concentrations 4- and 16-fold the MIC produced a modest decrease in the number of microorganisms at 4 h. After 24 h, cloxacillin produced a decrease in the counts of staphylococci from 2.19 to 4.84 log10 cfu/mL of inoculum. Only concentrations of vancomycin from 16- to 32-fold the MIC resulted in equivalent decreases. After 24 h of treatment, both antibiotics were equally effective in preventing mortality of rabbits. Cloxacillin produced a greater decrease in the number of staphylococci than vancomycin (3.50+/-2.18 log10 cfu/g vegetation and 6.25+/-1.28 log10 cfu/g vegetation, respectively; P<0.05) and 41% of rabbits had sterile vegetations in comparison with none with vancomycin (P=0.035). After 48 and 72 h of treatment, both antimicrobials exhibited equivalent activity., Conclusions: Vancomycin was less rapidly bactericidal than cloxacillin in vivo.

Background: Whether asymptomatic human immunodeficiency virus (HIV)-infected patients can interrupt treatment remains unknown., Methods: We performed a prospective, observational study of 46 patients who started therapy with >300 CD4+ cells/mm3 and/or <70,0000 HIV-1 RNA copies/mL. Patients had been receiving highly active antiretroviral therapy (HAART) for at least 6 months. HAART was discontinued, and plasma HIV-1 RNA loads and CD4+ cell counts were determined at 4-month intervals., Results: At the time of HAART discontinuation, the median CD4+ cell count was 793 cells/mm3, and all patients had undetectable viral loads. A rapid decrease of 173 cells/mm3 in the median CD4+ cell count was observed during the first 4 months after HAART was stopped, followed by a slower decrease of 234 cells/mm3 between months 5 and 20. The decrease in the median CD4+ cell count early after HAART discontinuation was inversely correlated with the increase that occurred during receipt of therapy (r=-0.653) and with the count at the time of HAART discontinuation (r=-0.589). The decrease in the median CD4+ cell count after the fourth month without HAART was correlated with the nadir count before HAART initiation (r=-0.349) and the increase during treatment (r=-0.322). The median follow-up duration was 20 months. After 12, 24, and 36 months of observation, 33 patients (71.7%), 22 patients (47.8%), and 16 patients (34.7%), respectively, remained free of therapy. Adverse clinical events were not seen, and all patients who reinitiated HAART responded rapidly., Conclusion: Selected asymptomatic HIV-infected patients can safely discontinue therapy for prolonged periods of time.

Background: Simplified highly active antiretroviral therapy (HAART) regimens are becoming widely used, particularly as a result of the side effects of and difficult compliance with protease inhibitor (PI) therapy. However, the long-term efficacy of HAART has not been properly assessed., Methods: We performed a prospective study of 110 patients infected with human immunodeficiency virus type 1 (HIV-1) with undetectable virus load who discontinued PI therapy and initiated therapy with nevirapine without changing nucleoside analogues. Reasons for switching were treatment simplification (45%), lipodystrophy (24%), renal problems (23%), and dyslipidemia (8%). HIV-1 load, CD4 cell count, and fasting biochemistry profiles were performed at the time of switching (baseline) and every 3-4 months thereafter. The aim of the study was to evaluate the long-term efficacy and safety of this combination., Results: Sixty-eight patients (61.8%) had a duration of follow-up of 3 years. The mean increase in the CD4 cell count after 3 years was 90 cells/microL (13.8% from baseline). Virus loads remained undetectable in all patients but 9 (8.2%). Triglyceride levels dramatically improved at 12 months (a 75% decrease; P<.02) and remained statistically significant over time (P<.04). The same occurred with serum cholesterol levels: there was an initial reduction of 25% (P<.02) and at the end of the follow-up period (P<.015). However, at the long-term evaluation, complete normalization of mean serum cholesterol and triglyceride levels could not be achieved. Sixteen patients (14.5%) had to stop therapy as a result of nevirapine-associated side effects., Conclusions: The switching of a PI to nevirapine is a safe and well-tolerated option for maintaining long-term virological suppression and immunological control. Three years after starting nevirapine therapy, rates of hypercholesterolemia and hypertriglyceridemia improved, although normal cholesterol and triglyceride values were not achieved.

Bacteremia due to non-typhi Salmonella is frequent in human immunodeficiency virus (HIV)-infected patients; however, focal complications rarely have been reported. Ten of 38 HIV-infected patients (26.3%) with salmonellosis documented over a period of 9 years had focal suppurative complications; only 19 (3.9%) of 490 adults without HIV infection who were seen during the same period had focal complications (P = .001). Infections of the urinary tract, lungs, and soft tissue, followed by arthritis, endocarditis, and meningitis were most frequently seen. Although salmonellosis occasionally heralded HIV infection, most patients were severely immunocompromised and had CD4 cell counts of <100/mm3. The mortality rate was 50%, equivalent to that observed among patients with other immunosuppressive disorders (52.6%). Major emphasis must be put on intensive therapy for salmonella bacteremia and prevention of its complications.

To assess the most relevant features of hospital-acquired endocarditis, we conducted a retrospective study of cases of infectious endocarditis at a single university hospital from 1978 through 1992. During this period 248 episodes of infectious endocarditis were documented; 23 (9.3%) of these episodes were hospital-acquired and were not associated with cardiac surgery. (This figure represented a remarkable rise in the frequency of nosocomial endocarditis, only one case of which was identified among 101 cases of endocarditis treated at the same institution between 1960 and 1975.) In each of the 23 nosocomial cases, endocarditis was the result of bacteremia associated with a hospital-based procedure: intravenous catheterization (15 cases), instrumentation of a diseased urogenital tract (seven cases), or liver biopsy (one case). Staphylococcus aureus and Enterococcus faecalis were the predominant organisms isolated from intravenous catheters and the urogenital tract, respectively. Two of seven enterococcal isolates were highly resistant to gentamicin (MIC, > 2,000 micrograms/mL). Overall mortality was 56%. Two subsets of at-risk patients with different anatomic and clinical manifestations were identified. Our results emphasize that infectious endocarditis must be considered a serious nosocomial hazard against which preventive measures must be implemented.

The optimal therapy for visceral leishmaniasis in patients with AIDS is unknown. We describe herein three patients with advanced AIDS and disseminated leishmaniasis who were treated with meglumine antimoniate plus interferon-gamma. The conditions of the three patients rapidly improved, and the therapeutic combination drastically reduced the parasite burden; after administration of antiprotozoal therapy for 4 weeks, cultures of bone marrow were negative for two of the three patients. Interferon-gamma was well tolerated. Because the patients died of other AIDS-related diseases in the months following therapy, the efficacy of the combination of meglumine antimoniate and interferon-gamma for preventing relapses remains unknown.