Soldier’s Death from Rabies Underscores Infection Danger Overseas

by U.S. Medicine

June 7, 2012

For the first time in nearly 40 years, a U.S. servicemember died last year from rabies because of an overseas exposure to an infected dog, according to the national Centers for Disease Control, which emphasized that overseas travelers, including deployed military, need to be warned of the risks.

In a recent issue of the Morbidity and Mortality Weekly Report (MMWR), CDC said the case “highlights the importance of rabies risk awareness for all travelers, including servicemembers, and the need for prompt medical care, including [ post-exposure prophylaxis (PEP)], for potential exposures.” 1

Last August, a soldier with progressive right arm and shoulder pain, nausea, vomiting, ataxia, anxiety and dysphagia was admitted to an emergency department in New York for suspected rabies. An Afghanistan canine rabies virus variant was identified, and the patient told clinicians he had been bitten by a dog while deployed there. He had not received effective rabies PEP, however, and an experimental treatment protocol was tried unsuccessfully at the hospital in New York.

As a result, 29 close contacts and healthcare personnel received PEP because of proximity to the patient.

Canine rabies virus transmission is considered eliminated in the continental United States but still affects travelers to canine rabies-enzootic areas. During a 15-year time period ending in August 2011, 10 of 45 reported U.S. human rabies cases were associated with canine-variant viruses, and all resulted from dog exposures occurring overseas, the CDC noted.

Worldwide, CDC reports that canine rabies from dog bites in Africa and Asia make up more than 95% of all human rabies deaths.

“With the exception of transmission through transplantation, human-to-human rabies transmission has not been laboratory-documented but is possible theoretically because rabies virus can be present in saliva, CSF, neural tissue and tears,” according to the MMWR article. It recommended that caregivers of patients with suspected or confirmed rabies wear goggles, gowns, gloves and face masks, particularly during activities with risk for saliva contact, such as intubation and suctioning.

The article also said travelers should be informed of rabies risks in rabies-enzootic countries and encouraged to keep a safe distance from wild and feral animals. In the case of the soldier, who had traveled since exposure, local, state, federal and international parties collaborated to do risk assessments of anyone who potentially had contact with infectious secretions in transit. None of the potential contacts required PEP.

  1. Waleed J, Amzuta I, Amritpal N, Johnston T, et al.. Imported Human Rabies in a U.S. Army Soldier — New York, 2011. MMWR May 4, 2012 / 61(17);302-305.
Soldier’s Death from Rabies Underscores Infection Danger Overseas

Use of PPIs Modestly Associated with Veterans’ Pneumonia

Has the use of proton pump inhibitors (PPI) increased the risk of community-acquired pneumonia (CAP) in veterans? Research suggests a modest association.

“Among the veterans studied, current compared with past PPI exposures associated modestly with increased risks of CAP. However, our observations that recent treatment initiation and higher PPI doses were associated with greater risks, and the inconsistent PPI-CAP associations between patient subgroups, indicate that further inquiries are needed to separate out coincidental patterns of associations,” wrote the authors of a recent study of patients at the New England VA Healthcare System in Bedford, MA. 1

The retrospective, nested case-control study was done by a team of researchers from the VA Boston Healthcare System, Boston University and Harvard Medical School.

Using linked pharmacy and administrative databases of the New England VA system, researchers identified 71,985 outpatients who had been newly prescribed PPIs between 1998 and 2007. They then calculated crude and adjusted odds ratios comparing current with past PPI exposures for the entire and stratified samples.

The results showed a modest association between current PPI use and CAP (adjusted odds ratio 1.29, with a 95% confidence interval,, 1.15–1.45). While risks did not significantly change based on age or year of diagnosis, dementia and sedative/tranquilizer use appeared to increase the association, although some chronic medical conditions seemed to reverse PPI-associated CAP risks. Other factors increasing the risk were — PPI exposures between one and 15 days as compared with longer exposures and taking more than one dose a day.

The authors called for more studies to determine how strong the association actually might be.

1. Hermos JA, Young MM, Fonda JR, Gagnon DR, Fiore LD, Lawler EV. Risk of
community-acquired pneumonia in veteran patients to whom proton pump inhibitors were dispensed.
Clin Infect Dis. 2012 Jan 1;54(1):33-42. Epub 2011 Nov 18. PubMed PMID: 22100573.

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Soldier’s Death from Rabies Underscores Infection Danger Overseas

Antibiotics Often Overused in Asymptomatic Bacteriuria Cases

Asymptomatic bacteriuria (ABU) is often overtreated with antibiotics, especially in patients with pyuria, according to a new study.1

“Given the low incidence of infectious complications, efforts should be made to optimize the use of antibiotics in enterococcal bacteriuria,” according to the researchers from the Houston VA Research & Development Center of Excellence, the Michael E. DeBakey VA Medical Center and the Baylor College of Medicine.

A retrospective medical-record review looked at patients from two academic teaching hospitals over a three-month period during the fall of 2009. Patients were divided into two groups — those with a urinary tract infection (UTI) for whom antibiotic use was deemed appropriate, or those with asymptomatic ABU for whom antibiotic use was considered inappropriate. Appropriateness of antibiotic use was determined based on Infectious Diseases Society of America guidelines.

Medical records were reviewed for Enterococcus cultured from another sterile site within 30 days. Of 339 cases meeting inclusion criteria, 183 (54.0%) were classified as ABU and 156 (46.0%) as UTI. In 289 of those with urinalysis, pyuria was associated with UTI in 98 of 140 episodes (70.0%) compared with 63 of 149 episodes of ABU (42.3%).

Providers inappropriately treated 60 of 183 episodes of ABU (32.8%) with antibiotics, and, in multivariate analysis, only pyuria was associated with the inappropriate use of antibiotics.

The risks of withholding antibiotics turned out to be low. Only seven subsequent infections with Enterococcus occurred in the 339 episodes of bacteriuria overall (2.1%), with two of the 183 cases of ABU (1.1%) having distant infections.

1. Lin E, Bhusal Y, Horwitz D, Shelburne SA 3rd, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012 Jan 9;172(1):33-8. PubMed PMID:22232145.


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