Infectious Disease Alert Updates
By Carol A. Kemper, MD, FACP
Borrelia Miyamotoi in My Backyard! Who Knew?
SOURCE: Salkeld DJ, et al. Disease risk and landscape attributes of tick-borne Borrelia pathogens in the San Francisco Bay Area, California. PLoS ONE 10 (8), e0134812. Doi:10.1371/journal.pone.0134812.
Reading the local Woodside Almanac (Woodside, CA), my attention was captured by an article describing Lyme-infected ticks found in “all kinds of (local) habitats.” But the really interesting part of the article was the observation that Borrelia miyamotoi–carrying local ticks were as common in our area as B. burgdorferi-infected ticks.
Salkeld and colleagues at the Woods Institute for the Environment at Stanford University examined the prevalence of Borrelia-carrying nymphs and ticks at 20 sites within six different San Francisco Bay Area counties, including San Mateo, Santa Clara, Marin, Sonoma, Napa, and Santa Cruz counties. Ticks were collected in May 2012 and May 2013 by dragging a white flannel blankie around various local county and state parks and open space preserves. The number of nymphal ticks and adults collected was recorded every 30 meters. In the immediate vicinity, Palo Alto-exclusive Foothills Park, Wunderlich Park in Woodside (my favorite local county park), and the infamous Windy Hill Preserve (try hiking straight up this 1900-ft elevation- baby on a weekend) made the list. The blanket was dragged through a variety of habitats, through any leaf litter or vegetation, and included coastal live oak forests, coastal redwoods, madrones, blackberries, scrub and coyote brush, and grasslands. Both nymphs and adults were collected, and all Ixodes pacificus ticks were tested for Borrelia spp.
Ticks were individually tested using quantitative PCR for 16 gene Borrelia spp DNA, followed by species-specific hybridization. The overall frequency of infected nymphal and adult ticks was determined, and the density of infected ticks was calculated in 30-meter segments throughout the parks.
Borrelia spp were found in 37/349 (10.6%) nymphs and 22/273 (8.1%) adult ticks. B. miyamotoi was found in 3.7% of nymphal ticks (which were found at eight different sites), and 1.8% of adults (found at three different sites). B. burgdorferi was observed in 2% of all nymphs, and was found at five sites.
And the site with the highest prevalence of infected ticks? Our very own Windy Hill Preserve, where we locals hike on weekends. But an interesting finding was that not only did tick density vary considerably within the Bay Area, but the infected tick density varied between habitats, even within the same park. While no infected ticks were found in the grassland area of Windy Hill, the nearby Coastal Oak Trail had the highest density of infected ticks (10/100 m2) of anywhere in the Bay Area. Infected nymphs seemed to be more prevalent in coastal live oak woodlands and semi-arid/scrub areas than other areas.
The taxonomy of Borrelia are becoming increasingly complex, with at least 12 different species possibly being associated with Lyme disease — but more is being learned of other species, such as B. miyamotoi, which more closely resembles the B. recurrentis group of spirochetes. Clinically, the symptoms of B. miyamotoi infection resemble infection with Anaplasma phagocytophilum (previously known as granulocytic Ehrlichiosis), and may be almost as common in certain areas of the country. Dean Winslow, MD, previously summarized the results of a recent retrospective survey (see Infectious Disease Alert, September 2015) of patients in New England with fever and suspected tick-borne disease, 0.8% of whom had a positive PCR for B. miyamotoi DNA. (By comparison, 3.1% were positive for B. microti DNA, 1.4% were positive for A. phagocytophilum DNA, and 1.7% were positive for B. burgdorferi DNA.) Nearly one-fourth required hospitalization, and 96% had fever and severe headache. Interestingly, only 16% of these initially had a positive EIA (using a B. miyamotoi recombinant rGlpQ antigen), but 78% of convalescent serum was positive. Ten percent of the patients also had a positive immunoblot to B. burgdorferi, suggesting possible co-infection.
Seroprevalence studies for B. miyamotoi in our area would be of interest.
Fecal Microbiota Transplantation — Patients Need No Convincing
SOURCE: Drekonja D, et al. Fecal microbiota transplantation for Clostridium difficile infection. A systemic review. Ann Intern Med 2015;12:630-638; Surawicz CM. Fecal microbiota transplantation: What we know and what we need to know. Ann Intern Med 2015;162;662-663.
Relapsing and refractory Clostridium difficile infection (CDI) has become a real challenge for clinicians and affected patients alike. Some patients wind up in a seemingly never-ending cycle of illness, gradual improvement, followed by a prolonged vancomycin taper, and eventual relapse. Relapse occurs in 15% to 30% of patients following an initial (successfully treated) episode, and further relapse occurs in more than 50% of those with second or subsequent episodes. Reports of successful resolution of this nasty infection using fecal microbiota transplantation (FMT) has generated enthusiasm. But available studies vary in their approach, their timing, the frequency of treatment (single dose vs. multiple doses over several days), and several guidelines now have been proposed for screening of potential donors. Some recommend FMT for those with two or more episodes, whereas the American College of Gastroenterology suggests FMT can be considered in those with three or more episodes.
These authors performed a systematic review of the available literature related to FMT. Two randomized, controlled trials, 28 case series, and five case reports were identified for a total of 561 FMT subjects. Combining the results of the two randomized clinical trials, 27 of 36 patients treated with FMT had resolution of symptoms (75%). One of these studies administered material via nasogastric (NG) tubes, with successful resolution of symptoms in 81% at 3 months. In contrast, less than 30% of patients in the two comparator arms receiving vancomycin treatment or vancomycin lavage had sustained resolution of symptoms at 3 months. In the first study, FMT was administered following 4-5 days of orally administered vancomycin (500 mg four times daily). Interestingly, 8 of the 43 patients included in this study were enrolled after their first episode of CDI. In the second randomized, controlled study, FMT was administered via NG vs. colonoscopy in 20 patients, with resolution of symptoms in 60% vs. 80% (P = 0.63). FMT was administered 3 days following completion of anti-CDI treatment.
In the various case series, FMT was performed in 480 patients with a history of 3-12 relapses over a 3-27 month period. Although none of these studies included a comparator arm, 85% reportedly remained disease-free following administration of FMT. In addition to these, there were seven smaller non-comparator studies for patients with refractory CDI, all using various methods, with an overall resolution rate of 55%. Symptomatic improvement was observed in 0% to 100%.
A third randomized, controlled trial, not published in time to be included in this analysis, demonstrated successful resolution of symptoms in 90% of patients treated with FMT vs. 26% in a vancomycin-treatment group; the study was halted prematurely because of this substantial difference in favor of FMT.
In conclusion, FMT appears effective in approximately 55% to 90% of patients with relapsing and refractory CDI, and will prove a blessing to those who have been in a miserable cycle of recurrent disease. Observed side effects were minimal and included complaints of cramping, bloating, nausea, transient fever, and dizziness. One patient receiving FMT by an erroneously placed NG tube developed pneumoperitoneum and polymicrobial bacteremia.
Many questions remain, including who, what, and how. Various protocols are used to screen donors, and methods for administration of FMT differ. For those without access to stool, one company is marketing frozen stool from pre-screened healthy donors. I’ve had several enterprising patients who have tried various approaches, including small home tap water enemas mixed with stool (strained to remove the peas and carrots), to capsules stuffed with a spouse’s stool, kept refrigerated, and swallowed the day following completion of orally administered vancomycin. A couple of patients have tried 10 capsules twice a day for 1-2 days, one of whom relapsed a week later, and tried it again with success. I guess if you can share food and other substances with your husband, his stool is probably OK. While initial reluctance was expressed, patients were quick to embrace this approach following yet another relapse. One of the randomized, controlled trials above indicated that patients were initially squeamish, but when contacted 3 months later, 97% said they would do it again.
It’s amazing that such a simple procedure — administration of a small amount of fecal material — can effect such an important change in your bowel flora. But I guess that is how we develop our flora, with ingestion of fecal material from the world around us, bit by bit. As one of my favorite instructors is fond of saying, “Think of the world as covered by a thin layer of feces.”
Borrelia Miyamotoi in My Backyard! Who Knew?
Fecal Microbiota Transplantation — Patients Need No Convincing
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