Cornwall & Isles of Scilly Devon, Plymouth and Torbay Peninsula Health Technology Commissioning Group Commissioning decision: Bevacizumab for diabetic macular oedema The Peninsula Health Technology Commissioning Group (PHTCG) has come to a decision on the use of bevacizumab for the treatment of diabetic macular oedema. This treatment will not be routinely commissioned.
Conversely, injection forms, though being painful and needing help of medical personnel for application, help to quickly achieve necessary concentration of preparation in blood buy antibiotics online Antibiotic is usually chosen in an empiric way (at random). But when choosing one is obligatory guided by definite rules.
9b infectolab co-infektionen engl 01.07.1BCA-clinic Betriebs GmbH & Co. KG Dr. med. Armin Schwarzbach Facharzt für Labormedizin
Increasing importance of co-infections for Lyme disease patients –
with or instead of a Lyme disease infection
An article by Armin Schwarzbach,M.D., PhD., laboratory medicine specialist
In the past months presentations of scientific conferences have shown a noticeable increase
of the importance of co-infections and all tick-born diseases and reactivated infections
respectively specific regarding laboratory diagnoses and resulting therapy decisions.
Prof. Sievers reported at the annual meeting of the German Borreliosis and FSME
Association that according to current research in Switzerland that the examined ticks had
42% Rickettsia and “only” 34% Borrelia and 1% Ehrlichia/Anaplasma. According to him in
Switzerland approximately 16% of all Lyme patients additionally suffer from Rickettsia (with
pericarditis and muscle pain) due to the high contamination of ticks with Rickettsia in
According to Dr. Lindauer, Tick-laboratory Weiden, in Germany, app. 6% of all ticks are
contaminated with Ehrlichia and Babesia. Babesiosis, Anaplasmosis and other co-infections
are increasingly considered in diagnosis and therapy in the USA as well. (Presentation JJ.
Burrascano “What´s new!” Sept. 2008).
In the BCA-clinic Augsburg (BCA) a laboratory test to check for co-infections is also
performed for patients who are diagnosed with Lyme disease because of their clinical results
and in case of a specific suspicion. It should be noted that many symptoms of co-infections
are the same as Lyme disease symptoms. Therefore, a precise decision of the therapists
about the antibiotic therapy cannot be made unless possible co-infections were checked for.
Not all co-infections are sensitive to all commonly used antibiotics for Lyme disease. Testing
for possible co-infections might result in an increase of the laboratory cost (up to € 950). But
these are justified by the additional reliability of the diagnosis and especially by choosing the
right antibiotic treatment, i.e. more success promising antibiotic therapies as well as
generally less extensive costs for the medication during the antibiotic treatment (vs. the
“classical” antibiotic treatment in case of chronic Lyme disease).
It has to be noted that in the meantime cellular activity tests, besides the Borrelia
Lymphocyte Transformation Test (LTT), have also been developed for Ehrlichia/Anaplasma,
Chlamydia pneumoniae and Chlamydia trachomatis via the Elispot-LTT-technique and in the
near future for Babesia, too. Actual cellular activity can be measured with Elispot-LTT-
technique. And – with the help of these new Elispot-LTT techniques numerous activities of
Chlamydia and Anaplasma were discovered in the BCA! Parallel to this, an examination of
antibodies in the serum regarding the co-infections is performed. By now there are very well
standardised antibody tests for Chlamydia, Mycoplasma, Ehrlichia, Bartonella, Rickettsia,
Babesia, Yersinia, etc. Here applies the same as for the Borrelia-LTT: antibodies alone do
not predict the disease activity as a single testing – the Elispot-LTT, however, can provide
evidence because with this test documents the interferon release against the particular co-
pathogens in the blood.
It should be noted that in some cases it is the co-infection pathogen itself that is responsible
for symptoms and not the Lyme infection: Chlamydia, for example, create disease patterns
Infectolab, ein Geschäftsbereich der BCA-clinic Betriebs GmbH & Co. KG Geschäftsführer: Dr. med. Carsten Nicolaus, Dr. med. Armin Schwarzbach Amtsgericht Augsburg HRA 15697 · Morellstraße 33 · 86159 Augsburg · Tel. +49/ 0821/ 455 074-0 · Fax +49/ 0821/ 455 074-1 www.infectolab.de · e-mail: [email protected] · Umsatzsteuer-Ident.-Nr. DE250941023 · Bankverbindung: Kreissparkasse Augsburg (BLZ 720 501 01) · Konto-Nr. 19885 · IBAN: DE48 7205 0101 0000 0198 85 · BIC: BYLANDEM1AUG such as Morbus Alzheimer, Multiple Sclerosis, Fibromyalgia, Chronic Fatigue Syndrome
(CFS), myocardinal infarct, strokes, blood vessel inflammations and visual disturbances.
The Lyme infection might have been successfully treated already with antibiotics, but the co-
infection has not yet been destroyed by the antibiotics. Therefore, a detailed anamnesis of
the symptoms needs to be documented before, during and after an infection with borrelia or
Not all possibly remaining symptoms are due to Lyme after an antibiosis, but could be
due to a co-infection!
Infectiology will gain a considerable dominant position in medicine – among others due to
climate change – and this does not only apply to tick-borne diseases.
A note on: Contamination of ticks in Switzerland (current data)
16 % Borrelia afzelii 11 % Borrelia garinii 5 % Borrelia sensu stricto (causes myalgia, pericarditis) 17 % of Borrelia contaminated ticks have additional Rickettsia! 14 out of 113 Lyme disease patients additionally have Rickettsia symptoms! Source: Presentation by Prof. Sievers, Hochschule Wädenswil, 5.4.2008 Bad Soden-Salmünster Overview of the most frequent co-infections of Lyme Disease
– Ehrlichia – Babesia – Bartonella – Rickettsia – Chlamydia – Mycoplasma –
Pathogen: Anaplasma phgocytophilum (gram-negative, obligatory intracellular in
Spectrum of hosts: wild animals (e.g. deer), domestic animals, productive livestock, humans Symptoms: (incubation period: days up to 4 weeks): Flu-like symptoms with fever, headaches and muscle pain with “sharp and stabbing, often located behind the eyes”, neurologic symptoms (duration 1 up to 60 days) up to lethal ending, sometimes diffuse erythema (reddening of the skin) including palms of hands and soles of feet Risk factors: elderly people, severe basic underlying diseases, immune suppression Activity test: Elispot®-LTT (Lymphocytes transformation test) Ehrlichia-PCR in blood (EDTA-blood): direct detection Antibodies for Ehrlichia-IgM and Ehrlichia-IgG: indirect detection – control of progression! Macrolides (Azithromycin, Clarythromycin) Tetracycline (Doxycycline, Minocycline) Quinolones (Ciprofloxacin, Levofloxacin) Rifampicin (During pregnancy!)
Pathogens: Babesia microti, Babesia divergens
Vector/Transmission: Ixodes ricinus, blood transfusion Spectrum of hosts: wild animals (e.g. deer), domestic animals, productive animals, humans Symptoms: (incubation period 5 days – 9 weeks): Sweating, neck stiffness, nausea, vomiting, loss of appetite, fatigue, feeling of weakness, constant exhaustion especially during stress, haemolytic anaemia, haemoglobinnuria, fever up to 40º C, shivering, sometimes hepatosplenomegaly, muscle pain, strong headaches, dizziness, coagulation dysfunction (blood-clotting disorder, hypercoagulability), stomach ache, emotional instability, mental dullness, kidney failure, dyspnoea, influenza-flu-like symptoms (up to a lethal level)! Risk factors: Splenectomia, HIV, immune suppression, organ transplantation, elderly people Babesia-PCR in blood (EDTA-blood): direct detection Antibodies of Babesia-IgM and Babesia-IgG: indirect detection – control of progression ! - Hamolytic anemia (erythrocytes, haptoglobin) - Thrombocytopenia - Leucocytopenia - Increase of liver parameters (sGOT, sGPT, sGGT) - Increase of Creatinine, Urea - Hemoglobinuria Clindamycin Malarone 250/200 mg 1x/day Malarone junior 65/25 mg 1x/day Atovaquone 750 mg 2x/day Lariam 250 mg
Bacteria: Bartonella henselae (gram-negative, optional intracellular in endothelial cells /
Erythrocytes) and/or BLO = Bartonella like organisms
Vector/Transmission: surface wounds/scratch from cats, Ixodes ricinus Symptoms (incubation period 3 – 38 days): headache (80%), fatigue (100%), muscle twitches, tremors, cramps, shivering, fever in the mornings (30%, in thrusts up to 6 weeks, otherwise 1 – 3 weeks), swollen lymph nodes, arthralgia (often), myalgia, insomnia, depression, agitation, amentia, concentration and attention disorder, dizziness, restlessness, gastritis, intestinal problems, sore feet soles (especially in the morning), hypodermic nodules along the extremities, no or minimal joint pain (important according to J.J. Burrascano) Severe progression: endocarditis, retinitis, epilepsy, aseptic meningitis, hepatosplenomegalia - PCR on Bartonella in blood (EDTA-blood): direct detection - Histology (hemangiome/lymphadenitis) - Antibodies on bartonella henselae-IgM and bartonella henselae-IgG: indirect detection evidence – control of progression ! - Elevated vascular endothelial growth factor (VEGF), only rarely increased, but if so Macrolides (Azithromycin, Clarythromycin) Tetracycline/Doxycycline Quinolones (Ciprofloxacin, Levofloxacin) Rifampicin Ceftriaxone/Cefotaxime
Pathogen: Rickettsia conorii, R. rickettsii, R. helvetica, R. slovaca, R. prowazekii (not gram-
stainable, obligatory intracellular in endothelial cells)
Vector/hosts: rodents, dogs, humans, Ixodes ricinus Symptoms: (incubation period 5 - 7 days): fever, lymphadenitis, exanthema (roseola to Complications (app. 13%): peri-/myocarditis, renal insufficiency, pneumonia, encephalitis, gastrointestinal bleedings, anemia, hepatitis, myalgia - PCR on Rickettsia in blood (EDTA-blood): direct detection Antibodies Rickettsia-IgM and -IgG: indirect detection – control of progression ! Doxycyclin/Tetracyclin Ciprofloxacin Chloramphenicol Erythromycin (Children)
Pathogen: Chlamydophila pneumoniae (gram-negative, intracellular)
Transmission: airborne infection (aerogen), human to human, affection of epithelial cells of Symptoms: slight throat pain, hoarseness, sinusitis, atypical pneumonia, meningoencephalitis, bronchiolitis obliterans, myocarditis, Guillain-Barre-Syndrom Post-infection (4-6 weeks): arthritis, tendovaginitis Associations: e.g. Morbus Alzheimer, Multiple Sclerosis, Fibromyalgia, Chronic Fatigue Syndrome (CFS), problems with prostate gland, heart attacks, apoplectic stroke, arteriosclerosis - Activity test: Elispot-LTT (Lymphocytes transformation test) - PCR on chlamydia pneumoniae in sputum/secretion of the throat: direct detection - Antibodies on chlamydia pneumoniae-IgA and chlamydia pneumoniae-IgG: indirect Macrolides (Azithromycin, Clarythromycin) Doxycycline Levofloxacin
Pathogen: Chlamydophila trachomatis (gram-negative, intracellular)
Transmission: sexual contact, human to human Symptoms: cervicitis, sterility, urethritis, trachoma, acute conjunctivitis („swimming pool conjunctivitis“), lymphogranuloma venereum After infection(4-6 weeks): arthritis, tendovaginitis - Activity determination: Elispot-LTT (Lymphocytes transformation test) - Chlamydia trachomatis PCR in urine/urogenital smear: direct detection - Antibodies on Chlamydia trachomatis-IgA and Chlamydia trachomatis-IgG: indirect Macrolides (Azithromycin, Clarythromycin) Doxycycline Tetracycline Quinolones (Levofloxacin, Ciprofloxain, Moxifloxacin) Mycoplasma
Pathogen: Mycoplasma pneumoniae/fermentans (gram-positive, intracellular)
Transmission: airborne infection (aerogen), human to human Symptoms: tiredness (100%), fever, joint pain, swollen joints, muscles pain, headache, insomnia, anxiety, emotional instability, lack of concentration, lack of alertness and memory, confusion Risk factors: immunosuppression (e.g. AIDS), Chronic Fatigue Syndrome (CFS), „Gulf War - Bacterial culture of special nutriment medium - PCR on chlamydia pneumoniae in sputum/secretion: direct detection - Antibodies on Mycoplasma pneumoniae-IgM, Mycoplasma pneumoniae-IgA and Mycoplasma pneumoniae-IgG: indirect detection – control of progression ! Macrolides (Azithromycin, Clarythromycin) Doxycycline Quinolones (Levofloxacin, Ciprofloxacin)
Other possible co-infections
SPECIAL ARTICLE Evidence-based guideline: Antiepileptic drugselection for people with HIV/AIDSReport of the Quality Standards Subcommittee of the American Academy ofNeurology and the Ad Hoc Task Force of the Commission on TherapeuticStrategies of the International League Against Epilepsy ABSTRACT Objective: To develop guidelines for selection of antiepileptic drugs (AEDs) among p