Streptococcus pneumoniae. We conducted bloodstream infection surveillance in Thailand during November 2005–June 2008. Pre-culture antibiotic use was assessed by reported use and by serum antimicrobial activity. Of 35,639 patient blood cultures, 27% had reported pre-culture antibiotic use and 24%  had serum antimicrobial activity. Pathogen isolation was half as common in patients with versus without antibiotic use; S. pneumoniae isolation was 4- to 9-fold less common . Pre-culture antibiotic use by serum antimicrobial activity reduced pneumococcal bacteremia incidence by 32% overall and 39% in children < 5 years of age. Our findings highlight the limitations of culture-based detection methods to estimate invasive pneumococcal disease incidence in settings where pre-culture antibiotic use is common.No studies have quantified the impact of pre-culture antibiotic use on the recovery of individual blood-borne pathogens or on population-level incidence estimates for  Streptococcus pneumoniae.Antibiotic use is common among pediatric and adult patients presenting in both inpatient and outpatient settings.S. pneumoniae isolation and on estimates of the incidence of pneumococcal bacteremia requiring hospitalization.The World Health Organization (WHO) recommends that all countries prioritize the inclusion of the heptavalent pneumococcal conjugate vaccine (PCV7) in national vaccine programs.The International Emerging Infections Program (IEIP), a collaboration between the Thailand Ministry of Public Health and the U.S. Centers for Disease Control and Prevention (CDC), has conducted an active, population-based surveillance for pneumonia requiring hospitalization since 2002 in two rural provinces: Nakhon Phanom , on the border of Laos in northeastern Thailand, and Sa Kaeo , adjacent to Cambodia in eastern Thailand.Clinicians requested blood cultures from hospitalized patients as clinically indicated. Cultures were actively encouraged in all patients admitted with suspected pneumonia and patients < 5 years of age with suspected sepsis. To minimize potential confounding from patients with multiple blood cultures, data were limited to cultures performed at least 7 days apart ; cultures obtained from the same patient ≥ 7 days apart were treated as unique patient encounters. Detailed clinical and demographic information were available for the subset of patients with blood cultures who were also captured in the pneumonia surveillance system,Reported antibiotic use before blood culture was defined as antibiotics received within 72 hours before culture based on patient report and the nurse's review of medications received at the hospital. The name(s) of antibiotics received were determined by patient report or record review. The likely route of antibiotic administration  was classified by a Thai physician (S.T.) based on usual hospital practice in Thailand.Staphylococcus aureus (ATCC 9144). After 24 hours incubation at 35–37°C, growth inhibition around the disc was considered evidence of serum antimicrobial activity.Pre-culture antibiotic use was also assessed by measuring serum antimicrobial activity using a serum disc assay. At the time of blood collection, a filter paper disc was coated with 20 μL of patient serum and stored at −70°C. For testing, the filter paper was placed onto a Mueller-Hinton agar plate inoculated with antibiotic-sensitive s ATCC 914. After Streptococcus pneumoniae was performed at the reference laboratory of the Thailand Ministry of Public Health and CDC.Detailed methods have been described previously.S. pneumoniae isolation. For comparison, isolation rates of Escherichia coli and Burkholderia psuedomallei were examined, expecting the former to be inhibited by antimicrobial activity and the latter to be largely unaffected.Pearson's χS. pneumoniae isolation rate in patients without antibiotic use was applied to the total number of blood cultures. Differences between observed and adjusted incidence rates were considered statistically significant when the point estimate for the adjusted rate fell outside the range of the 95% CI around the observed rate. Analyses were conducted using SAS version 9.1  and SPSS version 15.0 .Age group-specific pneumococcal bacteremia incidence rates were calculated by dividing the number of cases by person-years under observation using corresponding population estimates from Thailand's National Economic and Social Development Board.These data were collected as part of the public health surveillance activities, which were determined not to require institutional review board review.P < 0.05).From November 2005 through June 2008, 35,639 blood cultures from 29,883 patients met our criteria for analysis; 6,114 (17%) cultures came from patients who had 2 or more cultures separated by ≥ 7 days. Among patients with > 1 culture, the median time between cultures was 106 days (interquartile range: 33–242 days). Antibiotic use in the 72 hours before blood culture was reported for 9,726 (27%) of 35,639 patient cultures. Similarly, 5,782  blood cultures were from patients with serum antimicrobial activity. Antibiotic use, both reported and by serum antimicrobial activity, differed slightly by province and hospital size . Among pP = 0.03), respiratory symptoms , and require supplemental oxygen or intubation . The case-fatality proportion was also higher among patients with antibiotic use . Human immunodeficiency virus (HIV) status was available for 5,523 (15.5%) of 35,642 patient cultures; HIV-positive patients had similar rates of pre-culture antibiotic use as HIV-negative patients .Detailed information was available for 19,838 patients included in the pneumonia surveillance system. Among these patients, reported antibiotic use prevalence was 28%, and the median age was 29 years. Compared with patients without reported pre-culture antibiotic use, those with antibiotic use were more likely to have fever  of patients with reported antibiotic use. The most commonly reported drugs used were third generation cephalosporins (38%) and penicillin/penicillin derivatives (34%), both in monotherapy or in combination; 1,742 (22%) received ≥ 2 antibiotics. We could determine the likely mode of antibiotic administration for 6,368 ; of those, 50%  had only antibiotics typically administered orally and 50%  had at least one IM or IV antibiotic.Correlation between serum antimicrobial activity and reported antibiotic use was moderate. After excluding patients missing antibiotic use data by either measure, 16% of patients were positive for antibiotic by both measures, 62% negative by both, and 23% discordant (Kappa = 0.42). Correlation increased slightly when reported antibiotics were limited to those administered IM or IV (Kappa = 0.48). Correlation was higher for patients aged 5 years and older (0.45) than for children less than 5 years of age (0.27). The major source of discordance, particularly in young children, was negative serum antimicrobial disc testing among patients with reported antibiotic use .E. coli was isolated more commonly from those without antibiotic use compared with those with pre-culture antibiotics. In contrast, B. pseudomallei yield was higher among patients with pre-culture antibiotic use compared with those without antibiotic use. Streptococcus pneumoniae was isolated more often in patients without antibiotics regardless of whether antibiotic use was determined by reported use, serum disc testing, or a combination of the two measures.Blood culture yields were significantly lower among patients with pre-culture antibiotic use compared with those without antibiotic use . This waS. pneumoniae, compared with 12 (0.4%) of 3,291 without serum antimicrobial activity (P = 0.09). Unexpectedly, E. coli isolation rates were higher among children < 5 years of age with positive serum disc testing  compared with negative serum disc tests .When analyses were limited to children < 5 years of age, trends in culture yields for both antibiotic use measures were similar but not statistically significant for pathogen isolation. None of the 554 children < 5 years of age with serum antimicrobial activity had a positive blood culture for S. pneumoniae, was significantly lower among children < 5 years of age compared with older patients , which may have been caused by lower blood volumes available for culture in children. Less than half (45%) of children < 5 years of age had the target 4 mL available for blood culture and 27.7% had less than 2 mL. Streptococcus pneumoniae yield was lowest among children < 5 years of age with < 2 mL collected compared with those with 2–3.99 mL collected and 4 mL or more: 0.1% (N = 4), 0.2% (N = 7), and 0.3% (N = 13), respectively. Streptococcus pneumoniae yield within blood volume strata among children < 5 years of age indicated non-significant reductions associated with pre-culture antibiotics, although these analyses are limited by small numbers: no S. pneumoniae isolated for both positive and negative serum antimicrobial activity with < 2 mL; 0  versus 0.4%  for 2–3.99 mL; and 0 versus 0.4% for 4 mL or more.Culture yield, as measured by alarm positivity, organism isolation, and pathogen isolation, including Figure 1 illustrates the potential impact of pre-culture antibiotic use on age-specific incidence rates of hospitalized pneumococcal bacteremia. The adjusted incidence rates were significantly greater than the overall observed rate , 60% higher when adjusted for antibiotic use defined as reported use or serum antimicrobial activity . The adjusted rates within each age category were similar across methods of defining antibiotic exposure, except for young children. Among children < 5 years of age, the adjusted incidence was 63% higher when antibiotic use was defined by serum antimicrobial activity , 9.6% higher when adjusted for reported antibiotic use, and 18% higher when adjusted for antibiotic exposure defined as either reported use or serum antimicrobial activity. When limited to children < 5 years of age with the targeted 4 mL blood volume, incidence was 40% higher after adjustment for serum antimicrobial activity: 13.0 versus 18.2 per 100,000 person-years.S. pneumoniae isolation in patients with reported pre-culture antibiotic use was one-fourth that in those without reported use. Differences in S. pneumoniae isolation were even greater when antibiotic use was defined by serum antimicrobial activity or by a combined measure of reported use or serum activity. This lower culture yield significantly reduced the estimated incidence of pneumococcal bacteremia overall and in children < 5 years of age, by 32% and 39%, respectively, when antibiotic use was defined by serum antimicrobial activity.This investigation used data from active, population-based surveillance for bacteremia and pneumonia to document high rates of pre-culture antibiotic use and show that the frequency of S. pneumoniae isolation was affected to a greater degree by pre-culture antibiotic use than pathogen yield overall. These observations are in line with previous studies showing the effects of pre-culture antibiotic use.E. coli was chosen as a positive control, because it is a frequently cultured organism with known susceptibility to commonly used antibiotics.E. coli yield overall. However, among children < 5 years of age, E. coli isolation was higher in patients with pre-culture antibiotic use, an unexpected finding driven by E. coli sepsis cases in young infants who were likely treated empirically before culture collection. In contrast, B. pseudomallei, an organism endemic in rural Thailand and refractory to one-time in vivo antibiotic treatment,B. pseudomallei recovery was actually higher among those with pre-culture antibiotic use, which may have resulted from patients with more severe disease being both more likely to receive antibiotics early and to have positive cultures. Overall, these findings strengthen the conclusion that differences in culture yield for S. pneumoniae by antibiotic use were caused by the antibiotic exposure and not to other factors, such as the amount of specimen collected or HIV status.4Our findings were consistent across numerous culture endpoints ; however, consistent with its fastidious nature, Our pre-culture antibiotic use rates  of 24% overall and 14% among children < 5 years of age compare with those of two Kenya studies showing urine antimicrobial activity in ~50% of adultsThis study benefited from the use of two measures of antibiotic use: reported use (based on patient report and nursing records) and serum antimicrobial activity. Although neither measure of antibiotic use is a true gold standard, we found consistent and significant associations across multiple culture endpoints. We found moderate agreement between the two measures with slightly better agreement among patients receiving IM/IV antibiotics and patients 5 years of age and older. Lack of agreement between measurements may have resulted from poor patient recall and/or serum antibiotic levels too low for detection. Testing urine may have been more sensitive than testing serum to detect antimicrobial activity, but urine is difficult to collect on demand at the time of blood culture, especially in children. Poorer correlation in patients < 5 years of age may have been caused by increased misclassification of the reported antibiotic use measure, because children taking antibiotics often miss doses (or do not receive full doses), and non-antimicrobial drugs may get reported as antibiotics. For these reasons, we believe that serum antimicrobial activity serves as the most accurate measure of pre-culture antibiotic use and should be the primary measure used to adjust pneumococcal disease incidence rates for children < 5 years of age .S. pneumoniae isolates were sensitive to penicillin,Our investigation would have benefited from additional data describing the context of antibiotic use . The analysis also relied on blood cultures collected at clinicians' discretion as opposed to standardized enrollment, limiting comparisons to other clinical settings where culture practices may differ. As another limitation, we were unable to stratify the impact of pre-culture antibiotics by degree of anti-pneumococcal activity. All The illustration of observed and adjusted pneumococcal bacteremia incidence  is not iS. pneumoniae. These findings underscore the limitations of exclusively culture-based methods to estimate S. pneumoniae bacteremia and IPD incidence. Our findings are also directly relevant to pneumococcal disease cost estimation and cost-effectiveness analyses of pneumococcal vaccine.S. pneumoniae, such as antigen detectionIn this study, we described pre-culture antibiotic use in rural Thailand, which has not been detailed for Thailand or other Southeast Asian countries. We showed that pre-culture antibiotics are associated with significantly lower culture yields for


East African countries have in the recent past experienced a tremendous increase in the volume of antiretroviral drugs. Capacity to manage these medicines in the region remains limited. Makerere University, with technical assistance from the USAID supported Rational Pharmaceutical Management Plus (RPM Plus) Program of Management Sciences for Health (MSH) established a network of academic institutions to build capacity for pharmaceutical management in the East African region. The initiative includes institutions from Uganda, Tanzania, Kenya and Rwanda and aims to improve access to safe, effective and quality-assured medicines for the treatment of HIV/AIDS, TB and Malaria through spearheading in-country capacity. The initiative conducted a regional assessment to determine the existing capacity for the management of antiretroviral drugs and related commodities.Heads and implementing workers of fifty HIV/AIDS programs and institutions accredited to offer antiretroviral services in Uganda, Kenya, Tanzania and Rwanda were key informants in face-to-face interviews guided by structured questionnaires. The assessment explored categories of health workers involved in the management of ARVs, their knowledge and practices in selection, quantification, distribution and use of ARVs, nature of existing training programs, training preferences and resources for capacity building.Inadequate human resource capacity including, inability to select, quantify and distribute ARVs and related commodities, and irrational prescribing and dispensing were some of the problems identified. A competence gap existed in all the four countries with a variety of healthcare professionals involved in the supply and distribution of ARVs. Training opportunities and resources for capacity development were limited particularly for workers in remote facilities. On-the-job training and short courses were the preferred modes of training.There is inadequate capacity for managing medicines and related commodities in East Africa. There is an urgent need for training in aspects of pharmaceutical management to different categories of health workers. Skills building activities that do not take healthcare workers from their places of work are preferred. Over the past few years, East African countries have experienced a tremendous increase in the volume of antiretroviral drugs. This is a direct result of the commendable global initiatives towards improving access to effective treatment of HIV/AIDS ,2. Lack To build in-country and regional capacity in pharmaceutical management, Uganda's Makerere University, with technical assistance from the USAID supported Rational Pharmaceutical Management Plus (RPM Plus) Program of Management Sciences for Health (MSH) established the Regional Technical Resource Collaboration (RTRC), a network of academic institutions to build capacity for pharmaceutical management. The initiative , which iA cross-sectional survey of fifty governmental and non-governmental institutions accredited to provide ART services in the four countries was conducted in the months of February and March 2005. One researcher from Makerere University and one in-country collaborator carried out the assessment. The assessment used a qualitative research methodology that included interviewing key informants, in-depth interviews of health care workers, and a survey of health facilities and programs.The survey covered both urban and rural areas and looked at different facets of healthcare provision including, public, private-for-profit, and private not-for-profit sectors. By convenience sampling, a minimum of 10 facilities were targeted in each country and at least three healthcare workers from each facility were interviewed.The assessment was standardized across the participating countries through a planning workshop, which brought together collaborators from Makerere University, Harvard Centre for International health, Management Sciences for Health, and two representatives of the AIDS Control Program from each of the four countries. The workshop reviewed the data collection tools, discussed the assessment logistics and process and agreed on time lines. Data collection tools were piloted at three health facilities and two programs in Uganda and their validity and reliability ascertained. These were later excluded from the main study. Permission to carry out the survey was obtained from the national HIV/AIDS control programs of the respective countries. Appointments with heads of the facilities and respondents were made by personnel from the national AIDS control program in each country.The heads of the National AIDS Control Programs, Ministry of Health Pharmacy Services, and HIV treatment programs were identified as key informants. Using the data collection tool information on; the general features of the country's ARV supply system , qualification and training of health care workers involved in supply management of ARVs and related commodities, and the training needs for the supply management of pharmaceuticals was sought in a face to face interview.The heads of the facilities providing ART services in the four countries were the key informants at the program level. The survey looked at the types of HIV/AIDS services provided, the existence of guidelines for management of ARVs and related commodities, the qualification of healthcare workers managing the supply of pharmaceuticals, existence of any ongoing skills building activities, and areas covered in ongoing training programs.Structured in-depth interviews of healthcare providers were held with physicians, pharmacists, pharmacy assistants, nurses and clinical officers. Information was sought on training background, knowledge of ARV supply management systems and the quality of the service provided.At the end of each survey, questionnaires were checked for completeness, accuracy and consistency. At the end of each assessment, analysis of the data involved discussion with various in-country stakeholders for more in-depth interpretation of perceptions and opinion on possible interventions to address identified problems. Quantitative data were analyzed using EPI INFO Version 3.3, while qualitative data were coded and manually analyzed. No statistical comparisons were made as this was a situational analysis survey without sufficient power for such analysis.National AIDS Control Programs were responsible for the development and implementation of HIV/AIDS treatment policies in all four countries. Public, private-not-for profit and private-for-profit institutions were involved in HIV/AIDS treatment and care in all the four countries. In the public institutions HIV/AIDS treatment was limited to district level facilities or higher at the time of the assessment.A total of 54 facilities involved in ART services were surveyed in the four countries, comprising of 27 public, 18 private not-for-profit, 5 private-for-profit, and 4 academic institutions  were delivering a series of training courses on managing procurement and logistics of HIV/AIDS drugs and related supplies . The tarEven though retail pharmacy outlets dispensed ARVs in Kenya, Uganda and Tanzania, clinical training programs on ART seldom included them. Future training initiative should include private pharmacies. In Kenya, policy makers believe that professional bodies such as the Kenya Pharmaceutical Society could contribute significantly to the training of community pharmacists providing ART services.Capacity for ARVs supply management in Uganda, Kenya, Tanzania, and Rwanda were found to be limited due many problems. These problems included poor human resource with inadequate skills and capacity to select, quantify and distribute the drugs, with irrational prescribing and dispensing. This calls for There is thus need to provide training in drug supply management in all four countries. Training processes that include local institutions are more sustainable and likely to cover wider geographical areas. The preferred modes of training are on-the-job training and short courses that do not draw participants away from their workplaces.The authors declare that they have no competing interests.PJW: Participated in designing the study, planning, data collection, data analysis and manuscript writing. ROA: Participated in designing the study, planning, data collection, data analysis and manuscript writing. CO: Participated in designing the study, planning, data collection, and manuscript writing. EO: Participated in designing the study, planning and data collection. WT: Participated in designing the study, planning and data collection. JO: Participated in designing the study, planning and data collection. WWA: Participated in designing the study, planning and data collection. LM: Participated in organizing funding, data analysis and manuscript writing. OA: Participated in applying for funding, designing the study, data collection, data analysis and manuscript writing.


For neurosurgery, the last decades have been a time of incredible improvement in areas such as imaging, microscopy, endoscopy, stereotactic guidance, navigation, radiosurgery and endovascular techniques. However, the efficacy of topical antibiotic prophylaxis in neurological operations remains to be established by neurosurgeons.The authors did an historical review of the literature regarding the utilization of topical antibiotic prophylaxis in neurological operations. The Pub Med database of the U.S. National Library of Medicine / National Institutes of Health was utilized as the primary source of the literature. The authors performed the search by using the following Mesh terms: “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibiotic prophylaxis”; “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibacterial agents.”In the last 70 years, we have poorly studied the use of topical antibiotics in neurosurgery. All the papers reported were Class III evidence.To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery. Evidence-based medicine may be defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. NeurosurFor neurosurgery, the last decades have been a time of incredible improvement in areas such as imaging, microscopy, endoscopy, stereotactic guidance, navigation, radiosurgery and endovascular techniques. However,The authors did an historical review of the literature regarding the utilization of topical antibiotic prophylaxis in neurological operations. The Pub Med database of the U.S. National Library of Medicine / National Institutes of Health was utilized as the primary source of the literature screened for development of this paper. The search was performed in January 2010, utilizing Pub Med files beginning in 1966 with no language limitation. The authors performed the search by using the following Mesh terms: “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibiotic prophylaxis”; “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibacterial agents.” The articles were reviewed by title, abstract or full text to identify relevant publications on this subject. The reference lists of textbook chapters, review articles and articles identified in the primary search were also examined. Undesired papers were excluded from the initial basis set to develop the final working set. These excluded publications, although found by the search strategy, were papers that did not discuss the main topic of this research. The intention of this search was to find articles that provided data on topical antibiotic prophylaxis in neurosurgery.The primary search identified only 4 articles after undesired papers were excluded.8917 The 89The articles were separated into 3 classes of evidence. Evidence from well-designed randomized controlled clinical trials, including overviews of trials, was classified as Class I. Evidence from well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies and other comparable studies, and from less well designed randomized controlled trials, was classified as Class II. Evidence from case series, comparative studies with historical controls, case reports, expert opinion and significantly flawed randomized controlled studies was classified as Class III.The search identified 2 articles that compared topical and parenteral antibiotics prophylaxis with controls .20 In anoTwo studies compared topical antibiotic prophylaxis with a historical control without antibiotic prophylaxis,11 and 1 7To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery .et al. were the first authors to report a historical control study about topical antibiotic prophylaxis in neurosurgery. They insufflated penicillin and sulfamethazene powder onto civilian wounds  and compared their infection rate of 0.9% with the previous rate of 4.4% when antibiotics were not used.[et al. reported a short successful case series  where they used topical prophylaxis with bacitracin and did not observe any infection.[vs. 7.2%, respectively). He concluded that the topical antibiotic spray was effective.[Topical application was the first drug-administration route utilized by surgeons to control infection. The Edwin-Smith papyrus 1700 BC) is thought to be the oldest book on surgery.700 BC is In 1944,not used. This earnfection. ProbablyDuring the 1960s, 1970s and early 1980s, better-designed studies were reported that evaluated the use of antibiotic prophylaxis in neurological procedures. The goal of these papers was to study the importance of antibiotic prophylaxis, and they did not separate parenteral from topical to compare with a control group without prophylaxis,619 or ju65Maybe, the most important publication on this subject is a case series reported by Malis in 1979. The Malis technique of antimicrobial prophylaxis proposed preoperative parenteral administration of a single dose of vancomycin (1 g) and 80 mg of gentamicin (later 80 mg of tobramicin) and continuous irrigation of the surgical site with streptomycin .8 The effi3Haines reported in 1982 an excellent critic review of the literature about topical antibiotics and concluded that no scientifically valid study to either confirm or refute the possible value of this prophylaxis in clean neurosurgical procedures exists, but the subject justifies a carefully designed randomized clinical trial.et al.[et al.[et al. reported a decrease of infection rate from 3.96% to 0.42%, and Yamamoto et al. reported complete abolition of infection. In line with all studies on topical antibiotics in neurosurgery, as pointed out by Maurice-Williams et al., these publications had some methodological flaws, such as historical control group and retrospective data collection.[In the 1990s, a greater number of papers were published on the subject. Maurice-Williams et al. and Yamal.[et al. each repllection.et al. reported 3 case series using topical and parenteral antibiotic prophylaxis with no case of infection.[th century and has developed most of the knowledge that neurosurgeons have on this subject.[7et al. are the antiseptic routine, the increasing resistance of coagulase-negative staphylococci causing nosocomial infections, and the efficacy of the prophylactic antibiotics. The potential sources of random contamination of the surgical wound, such as the flora of patient’s skin; flora of the skin and nares of the operating team; the surgical apparel; the surgeons’ gloves and the double-gloving importance; and the airborne organisms in the operating room, also have been studied by these authors.In the same decade, Savitz nfection.–17 The D subject. These ausubject.7–17 Some et al. reported a historical control study where they showed a significant reduction in stereotactic and functional neurosurgical hardware infection after local neomycin-polymyxin application in the wounds.[Recently, Miller e wounds. Even befNeurosurgeons have used topical antibiotics for several years in different forms, such as powder, spray, irrigation, wound local application, ointment after wound closure or combinations of these. Moreover, the drugs utilized and the sites where to apply the prophylaxis have varied in accord with generations and/ or neurosurgery departments. Some surgeons use topical antibiotics just before the wound closure; and others, during the whole procedure. There may be neurosurgeons that use topical antibiotics only in procedures with hardware. However, many neurosurgeons never use topical antibiotic prophylaxis. These differences reflect the insufficient knowledge about the subject.Are topical antibiotics effective in preventing infection in neurological procedures? What type of infection: superficial, deep or both? Which are the better drugs? Are they secure to use in neural tissue? Will we have problems with bacterial resistance or superinfection? Some authors, especially Savitz SI and Savitz MH, took the initiative to answer some of these questions.–17 TheirIn the last 70 years, we have poorly studied the use of topical antibiotics in neurosurgery, although it seems to be a common practice all around the world. All the papers reported were Class III evidence. The categorization as Class III does not imply erroneous or problematic information. These publications show that we need to study this subject better. Neurosurgeons are still without appropriate answers to questions formulated over the last two decades. Only with a better level of evidence, neurosurgeons will be able to integrate individual clinical expertise with the best available clinical evidence and practice evidence-based medicine. We are going (slowly) in the right direction, but neurosurgeons are still far from answers to questions about the appropriate use of topical antibiotics in neurological operations. The first step has been taken; it is time to take the second.All the publications identified by the search were Class III evidence. To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery.


While there has recently been significant medical advance in understanding and treating HIV, limitations in understanding the complex social dimensions of HIV/AIDS epidemics continue to restrict a host of prevention and development efforts from community through to international levels. These gaps are rooted as much in limited conceptual development as they are in a lack of empirical research.In this conceptual article, the authors compare and contrast the evolution of climate change and AIDS research. They demonstrate how scholarship and response in these two seemingly disparate areas share certain important similarities, such as the "globalization" of discourses and associated masking of uneven vulnerabilities, the tendency toward techno-fixes, and the polarization of debates within these fields. They also examine key divergences, noting in particular that climate change research has tended to be more forward-looking and longer-term in focus than AIDS scholarship.Suggesting that AIDS scholars can learn from these key parallels and divergences, the paper offers four directions for advancing AIDS research: (1) focusing more on the differentiation of risk and responsibility within and among AIDS epidemics; (2) taking (back) on board social justice approaches; (3) moving beyond polarized debates; and (4) shifting focus from reactive to forward-looking and proactive approaches. In the 27 years since the first cases of AIDS were recorded, HIV/AIDS has become one of most highly studied diseases in history. Epidemics continue to grow, albeit unevenly, and impacts are escalating, reaching beyond individuals and families to pose major challenges to development broadly. This is most obvious in southern Africa, where antenatal prevalence levels in some countries are over 30 percent. While there has been significant medical advance in understanding and treating HIV, the complex and place-specific social, economic, cultural, behavioural and psychological dimensions remain a puzzle.Limitations in understanding these social dimensions, which in turn restrict a range of HIV/AIDS prevention and response efforts, are rooted as much in limited conceptual development as in a lack of empirical research. HIV/AIDS scholars have tended to conceptualize "impacts" as sequential and short-term effects resulting from the virus, rather than considering the complexities and inter-generational dimensions of epidemics and their consequences ,2.Likewise, some AIDS researchers and advocates point to the limitations inherent in popular "techno-fix" responses , noting the continued challenges involved in understanding and changing the underlying social structures that fuel the uneven spread and burden of AIDS epidemics ,4. This Research on AIDS and on climate change share certain similarities. Scholars in both areas are struggling to understand phenomena that are unprecedented, complex and highly dynamic, and that have different impacts on different people and places. In both, "social vulnerability" is emerging as a key scholarly theme e.g., ,6). Rese. Rese6])This paper compares and contrasts the evolution of climate change and AIDS research, suggesting that scholars can learn from a comparative analysis of key debates and trends within climate change and AIDS scholarship. It addresses four conceptual limitations in the AIDS field: (1) the "globalization" of AIDS discourses and the associated masking of uneven vulnerabilities to infection and impact; (2) the highly medical framing of AIDS and tendency to seek technical solutions; (3) the polarization of debates within the field; and (4) the crisis-orientation that has characterized AIDS research and response.The paper outlines the evolution of, and current trends in, each area of study. It explores parallels and divergences between AIDS and climate change research, noting especially the forward-looking and longer-term focus of climate change research and the sophistication of social vulnerability concepts in this field. It ends by suggesting opportunities for advancing AIDS research. conceptual paper is suggesting that conceptual overlaps and differences within AIDS and climate change research may provide insights into future HIV/AIDS scholarship. It does not seek to study AIDS and climate change together in any substantive way, nor does it argue for links between HIV spread and climate change or vice versa.This To understand the central limitations within contemporary AIDS scholarship and, ultimately, suggest ways in which climate change research could inform these, a basic historiography is required. The history of AIDS research and response can be divided into the early years 1981-1996) and the later years (1996-2008). This is not an all-inclusive review ; rather981-1996 The unusual clustering of the disease that make up AIDS was first recognised in 1981 in the USA, and growing numbers of similar immune deficiency diseases were soon identified in Europe, Australia, New Zealand and Latin America. In central Africa, health workers were observing ailments not previously seen: reports of deaths from wasting in Uganda ; Kaposi'Early research was dominated first by the medical/life sciences, and then by public health and epidemiology. Scientists sought to understand what was causing the disease and how it was transmitted in order to prevent its further spread, alleviate symptoms, prolong lives and, ultimately, eradicate the virus. Early responses were scientific and technical (and prevention-oriented): improving blood safety, providing condoms, encouraging safe injection practices, and searching for potential treatments and vaccines.It quickly became apparent that medical/technical approaches were insufficient, as no cure or vaccine could be readily developed, and providing condoms did not lead to the widespread adoption of safer sexual practices. Thus, by the 1990s, AIDS research began to shift away from its initial medical, scientific and technical foundations: there was growing scholarly interest in the individual, social, and economic milieu that lead to vulnerability to HIV infection, and a recognition that social justice, poverty and equity issues were driving the uneven spread of the virus within and between communities and societies ,12.Among the pioneers of this shift was Dr. Jonathan Mann, head of the Global Programme on AIDS in the World Health Organisation (WHO). In 1986 he began deploying teams to developing countries, to start national AIDS programmes . This waThus the first 15 years of the epidemic may be summarised as follows:• The first response, combining an epidemiology and public health perspective, aimed at understanding transmission, who was at risk, and how the spread could be prevented.• Once the virus was identified, science sought treatments and biomedical answers. Alongside this were attempts to prevent the spread by promoting safer sex and injecting practices.why people are exposed to HIV. Despite growing numbers of deaths, however, there was little focus on broader social and economic impacts.• By the end of the period, human rights approaches were gaining ascendancy; attention turned to By 1996, there were major changes in response to HIV/AIDS, reflecting and reflected in much of the scholarship. There was a shift from the previous "science-epidemiology" focus to a proliferation of scholarship and institutional interest around understanding the social and economic dimensions of epidemics. The new UN agency charged with co-ordinating the response to the epidemic - UNAIDS - began operations in Geneva in 1996, acknowledging the need for comprehensive responses to AIDS epidemics, and recognizing that such multi-faceted  responses reached beyond realm of "health."This shift away from the medical/technical focus did not last long, however. The same year, at the XI International AIDS Conference in Vancouver, it was announced that effective new drugs to treat AIDS had become available. The result was a swell of interest in medical interventions; but with costs running at $12000 per patient per year concerns around unequal and inequitable access emerged. By the XIII International AIDS Conference in Durban in 2000, these issues were squarely on the agendas of all involved in HIV/AIDS.Responses to AIDS have since been dominated by new initiatives for making treatment accessible, especially in developing countries. This led to a re-medicalization of HIV/AIDS and increasing international pledging of resources . The globalization of AIDS discourses and the impetus for global response were further propelled by an international trend toward securitization and a language of "global threats". In 2000, United States vice president, Al Gore said: "it (HIV) threatens not just individual citizens, but the very institutions that define and defend the character of a society. ... It strikes at the military, and subverts the forces of order and peacekeeping." The US National Intelligence Council then produced its "The Global Infectious Disease Threat and Its Implications for the United States". Six monWhether based in sound evidence or not, this dialogue marked an important shift in thinking about HIV/AIDS as an epidemic that could potentially have widespread implications among even the most affluent and powerful. Most recently, with the continued pledging of large sums of money, this "globalization" in the conceptualization of AIDS impacts and responses has extended into concerns over "global governance" (to be discussed further in the section that follows).The hallmarks of the past 12 years were:• Treatment became available and prices of drugs plummeted. With this, scholarly concerns with social drivers and underlying vulnerabilities were largely overtaken by enthusiasm for treatment and renewed hope in medical intervention.• The level of resources grew rapidly and new global initiatives were announced.• The language of security and threat to global order was used, resulting in a further globalization of AIDS response and discourse.• However, the number of infections continued to rise, especially in southern Africa.The particular orientation of AIDS response and scholarship outlined above has in turn prompted a multidimensional and vibrant field of research and scholarly debates. Four current trends are outlined below; these will be revisited at the end of the paper in order to suggest future directions for AIDS research.pandemic". This globalized discourse, however, misses the differentiated nature of both the spread of the epidemic and its impact. There remains a tension faced by those working in the field of AIDS: finding a balance between overstating the case  and the risk of understating it (or limiting who feels compelled to take responsibility) and risking getting fewer resources [As discussed above, in HIV/AIDS arenas, discourses have become "globalized". This manifests in the language of "global threats" which is still used ). Issues of "global governance" have become central as large sums of money are pledged. Moreover, in AIDS research the "globalized" language is clearly captured in a shift that took place in the 1990's - the majority of international organizations shifted gear from an earlier focus on isolated "epidemics"  toward concerns for the "global AIDS esources .Also discussed above, with the development of effective treatments in the mid-1990s, the tendency towards a (re)-medicalisation of the epidemic gained momentum. This was further propelled by the decline in drug prices and the increased flow of resources. Besides the initial focus on antiretroviral treatment (ARV), the re-medicalization of AIDS research and response saw renewed hope placed on other potential medical and technological "solutions", such as vaccines, microbicides and circumcision. Although there has been continual expectation of breakthroughs, there are still no solutions. Resources keep on being poured into scientific/medical research through new avenues such as the International AIDS Vaccine Initiative and by the new philanthropies such as the Gates Foundation marking an overwhelming international desire for a scientific or technological "fix" to HIV/AIDS.versus prevention, as has happened among multilateral institutions, or the need for drugs versus nutrition, as has been the case in many African contexts, most notably in South Africa [Throughout the history of AIDS research and response, there has been a tendency toward polarized debates, depicted by a series of "either-or" framing of responses (i.e. debating the need for treatment h Africa ). In addh Africa .The evolving response of the AIDS field has focussed on intervening in developing crises. As new clusters of diseases emerged, the emphasis was on understanding the epidemiology and biology. As the syndrome began to spread, prevention and behaviour came into focus. As issues of equity and discrimination emerged, human rights were placed on the agenda. As treatment became available, discussion around costing, access and patenting grew. Most recently, as the magnitude of illness and death in parts of Africa is beginning to have society-wide effects, attention is turning toward understanding impacts. The overarching trend is that AIDS research been reactive, historically - it has focused predominantly on crisis intervention, not on understanding the complex and place-specific drivers of infection and impacts. Notable exceptions include Campbell and Stillwaggon ,22.Despite this tendency, some scholars have identified AIDS as a "long-wave event" recognizing that AIDS epidemics can take over 100 years to work through society. Thus, iClimate change research has also matured considerably over the past 27 years, although until very recently there have been limited interactions between climate change and HIV/AIDS communities. This section provides an overview of key concepts that have framed climate change research. The existence of anthropogenic climate change is now well established  thusThe creation of an international agency to address climate change occurred about eight years, prior to the creation of UNAIDS. With growing evidence that human activities were altering the Earth's climate throughout the 1980s, the Intergovernmental Panel on Climate Change (IPCC) was created in 1988 by the World Meteorological Organization (WMO) and the United Nations Environment Program (UNEP) with the mandate to assess scientific, technical and socio-economic information. IPCC is employed in this paper as a window into climatic change research; its four assessments, in 1990, 1995, 2001 and 2007, provide an effective mirror of research trends in this field ,26-30. Nfuture climate change has been a central theme since 1989.Figure Figure mitigation options - looking at how to reduce greenhouse gas (GHG) emissions or recapture and sequester carbon generated by human activities[impacts  and human adaptation  was underway. The uncertainties associated with future impacts on a wide range of economic activities were featured in the 1989 report, while the technical feasibility of both mitigation (reducing/limiting greenhouse gases (GHG)); and adaptation , only began to emerge by 1995.Although social science contributions lagged behind the development of the physical sciences, there has been a proliferation of this research recently. In the first two IPCC reports, the social sciences focused on climate ctivities. By the Since the mid-1990s, multiple calls to refocus social science contributions have sparked considerable research, especially in the areas of equity ,38 and sThese trends within the IPCC has directly contributed to the growing awareness that those most responsible for causing climate change are not the ones who are most likely to bear the greatest negative consequences. Indeed, a key finding from the Small Island States chapter in 2001 was as follows: "The small island states account for less than 1% of global GHG emissions but are among the most vulnerable of locations to the potential adverse impacts of climatic change and sea-level rise" .Climate Change Impacts, Adaptation and Vulnerability [Vulnerability to Climate Change and Reasons for Concern [With growing concerns around the inequitable distribution of potential impacts, came the need to better understand what makes certain groups and places particularly vulnerable and determines how effectively they respond to potential stresses. While the underlying (and uneven) social, economic, political and geographical factors driving what has become known as "social vulnerability" were virtually absent from the first two IPCC assessments, this has now emerged as a central issue in the field. This is reflected in a number of ways: the recent chapter title, rability ; each re Concern .Vulnerability is defined in the third assessment as "the degree to which a system is susceptible to, or unable to cope with, adverse effects of climatic change"  In the mMitigation of Climate Change [Although contemporary climate change science has not abandoned its physical science roots, it has clearly begun to recognize that a full understanding of climate change requires careful consideration of the interaction of human and climate systems. Nevertheless, even with growing attention to equity and social vulnerability in the research arena, the trend in climate change response continues to lean toward technological solutions. The section in the most recent report entitled e Change  focused worldwide impacts that may occur as average temperatures rise [Moreover, the "globalness" of climate change - the global-scale nature of the science and the discourses of global-scale threats - was a major factor leading to IPCC's creation in 1989 and remained a primary concern in 2007. This is evident in the most recent report, which assesses the extent to which "impacts may change at larger increases in global mean temperature," focusing on res rise . By focuIn summary, the research is based on science; and climate change research has always been forward-looking. Early social science contributions focused on mitigating (preventing) climate change itself, while understanding how communities might adapt to change took longer to come onto the agenda (at times with some polarization between these positions); in both cases, recourse to "techno-fix" solutions continues to dominate. Several new issues have emerged over the past decade with the most notable being:uneven capacities of human systems to adapt to climate change, and recognizing North-South equity issues; and• Understanding the vulnerabilities that put some individuals and communities in "harm's way".• Focusing on understanding and addressing underlying social Some commonalities and differences between climate change and HIV/AIDS scholarship clearly begin to emerge from the above discussion. Before turning specifically to an examination of these, this section highlights four current themes within the climate change field. As in the discussion around HIV/AIDS, we will revisit these themes in the analysis and conclusion sections of this paper.The uncertainty inherent in understanding climate change has important research, response and political implications. Given the complexities involved, it is unreasonable to expect firm predictions of future climates and climate-society relationships. It is in this context that climate change research is gradually placing more emphasis on living with uncertainty. For example, there has been a proliferation of "scenario" exercises designed to articulate future uncertainties about how human activities will alter GHG emissions and climate regimes . Among aThe uncertainty around climate change has also been used towards political ends - deploying it as a delaying or diversionary tactic to deter response efforts. This "denialism", not unlike the AIDS denialism discussed earlier , includes well-constructed arguments denying human activities are contributing climate change, as well as calls for more science to determine the extent to which the climate change reflects natural or human-induced variability. Denialism invariably commences with reference to the Earth's climate as dynamic  and suggests that climate science is in need of further development ,33,49. WThe "globalness" of climate change lies at the heart of the issue: even more so than HIV/AIDS, climate change is overwhelmingly framed as a "global threat." The prevailing belief that no one will escape its consequences has indeed prompted many affluent leaders to take action. Climate change is clearly a global issue requiring global solutions. Much like in the AIDS field, however, the continued globalized discourses around climate change stand in contrast to, and can even serve to mask, the uneven and inequitable vulnerabilities that are emerging as key concerns.Much of the social science-based research has focused on either reducing GHG emissions or sequestering atmospheric carbon in order to reduce the magnitude of future climate changes. Technical interventions such as carbon trading schemes, incentives to encourage a more efficient use of fossil fuels, and switching to non-carbon fuels have been thoroughly researched and are routinely included as key components in climate change programs.Attempts to alter human behaviours which underly the problem , or to enhance communities' capacities to adapt to climate change , have received less attention and are more controversial from a public policy perspective. As discussed in the HIV/AIDS field, technical solutions continue to dominate; however, attempts to bridge what has been a polarization between mitigation  and adaption  is giving way to a more balanced approach which does not pit mitigation against adaptation.As discussed above, climate change research has traditionally been framed in a forward-looking context (and here we are beginning to see a departure from the crisis-orientation that has characterized HIV/AIDS research and response). For example, paleoclimatology investigates past climates, but it is routinely framed as basic research into Earth system processes which provides a window into future climates. In addition, the use of scenarios to depict a range of futures has been and continues to be standard practice in climate change research and recognizes human activities are bound to change to many stimuli.Moreover, more recent social vulnerability research attempts to understand what present-day conditions cause certain people to be hardest hit by environmental changes and to be the least able to respond to these stresses. This too is forward-looking, in that it aims to find ways to prevent future climate change impacts by reducing present-day vulnerabilties.The above discussion reveals a number of the parallels and divergences in how researchers and practitioners have responded to and conceptualized HIV/AIDS and climate change. In this final section, we will explicitly summarize these key parallels and divergences, and then extend these points so as to suggest future conceptual directions for AIDS research."In this fanciful world, we're somehow all bobbing in 'the same boat', if not exactly equally than all equally-at-peril..." [Three parallel conceptual trends in HIV/AIDS and climate change research are pivotal for understanding current conceptual limitations in the AIDS field. The first is the tendency toward globalized discourses in both areas, which have often masked the differentiated risks and responsibilities associated with both HIV/AIDS epidemics and human-induced climate change. In the AIDS field, the shift to globalized language took place in the late 1990s, coinciding with the ascendancy of "global threats" and security discourses. While this "globalization" of AIDS discourses served to mobilize international actors, it also functioned to minimize massive inequalities in vulnerabilities within and between countries and communities. As Marais notes with respect to AIDS, In the climate change arena, we have seen the tendency to frame the 'threats' in a similarly homogenizing way. Reference to the Earth as a unified system reinforces similar images of "all bobbing in the same boat." . As in tThe second important parallel is that both AIDS and climate change research have developed from scientific perspectives: AIDS from life sciences, virology and epidemiology; and climate change from Earth and paleo-climatic sciences. In both cases, this leaning and continued emphasis  has resulted in tendencies to de-politicize the issues and focus on scientific or technical solutions. Just as focussing on vaccines, circumcision, and microbicides does not delve into the very difficult task of social change that will undoubtedly be required to curb the spread of HIV and mitigate the impacts of AIDS, carbon trading, alternative energy schemes, and projects to fortify dams are all part of a comprehensive response to climate change but still overlook the key question: who is consuming and who will pay the price? In both the climate change and AIDS arenas, there is a tendency to avoid tackling vested interests (such as removing power from oil lobbies) and difficult issues .The third parallel trend is the issue of "denialism". "Data debates" and "denialism" have taken place in both arenas: around AIDS, debates  have often focussed on scrutinizing prevalence levels, questioning the causes of AIDS, and being skeptical of the utility of ARVs; in the climate change arena, there has been ongoing debate as to the amount of change attributable to "natural" and "human-induced" causes, as well as skepticism that fossil fuel burning is at the core of the pending problem. It is difficult to understand why this "denialism" has taken place, though perhaps the unprecendented and uncertain nature of both phenomena, alongside not knowing what to do and attempting to protect the status quo, is partially to blame. The result has been a polarization within the debates in both fields, which distracts from the underlying issues and the associated inequities, and thus hinders mobilization for change that will improve the circumstances of those most vulnerable.root causes of the uneven impacts of AIDS (and of climate change) has not been (or has failed to remain) at the forefront of dominant research or development agendas. This analysis begins to shed light on one of the central conceptual limitations addressed in this paper and thus highlights ways in which scholars and practitioners in the AIDS field might begin to reorient their approaches - prioritizing the underlying, place- and time-specific drivers of uneven vulnerabilties.To summarize, three key parallel trends within AIDS and climate change research include: (1) the tendency toward globalized discourses and the masking of uneven vulnerabilities; (2) the dominance of scientific perspectives and continued grasping for "techno-fixes"; and (3) the polarized debates and resulting diversion away from equitable and comprehensive responses. Together, examining these parallels begin to elucidate why the task of understanding the There are also some obvious differences in the evolution of the AIDS and climate change fields. The key divergence discussed in this paper offers an important way AIDS scholars could learn from the work of their climate change colleagues. This major difference can be summarized as follows: while climate change research has always been forward-looking, attempting to predict and prevent future impacts, AIDS research has tended to be crisis-oriented, focusing on understanding impacts as they happened.AIDS research and response has followed the evolution of the disease and the epidemic. The key issues changed as the epidemic spread and treatment became available. This approach is retroactive - researchers, health care professionals and policy makers look backward to understand, and in some cases intervene in, AIDS impacts. Climate change research, by contrast, has focused on reducing future impacts. This has meant not only modeling predicted climate changes, but within a smaller cluster of the most recent social science research, moving beyond this to understanding present-day vulnerabilities in order to help vulnerable groups respond to future stresses ,52.now, before AIDS epidemics have fully run their course; thus, understanding these existing context-specific vulnerabilities gives opportunities to intervene in proactive ways.This forward-looking vulnerability approach is at the crux of the conceptual reorientation advocated in this paper. Growing in popularity among social scientists in the climate change field, the approach places emphasis on understanding the specific social, economic, political and geographical factors that currently make some people and groups vulnerable to any new shock or stress in their environment, including, but not limited to those caused by present-day and future climate change. It recognizes these vulnerabilities as exisiting now, before the worst of predicted climate change has hit; as Kelly and Adger  explain,Some, but only very few, AIDS scholars have stressed this need for proactive and preventive measures to understand and mitigate potential future impacts ,54. As iHowever, the projection depicted in Figure This paper was premised upon the notion that examining certain key parallels and divergences within and among AIDS and climate change research and response could offer new insights for AIDS scholarship. The overarching question must now be addressed: what can we really learn from how scholars have grappled with climate change and AIDS, and what does this mean for AIDS scholarship?The four key themes highlighted above, and examined throughout the discussion, are central to answering this question:because of this unevenness  that a global response is appropriate.1. We have seen parallels in the globalized framing of both HIV/AIDS and climate change. Yet, it is clear that AIDS epidemics (as well as climate change impacts) are uneven and differentiated. Nuance is needed: one approach could therefore be to frame HIV/AIDS epidemics in terms of their unevenness , while at the same time recognizing that it is in part what causes inequalities in infection levels, capacity for response, impacts and access to treatment.2. We have also seen a re-medicalization in the AIDS field, with a focus on treatment, resources and techno-fixes. This discussion hence suggests that AIDS scholars take back on board social justice approaches, which were more prominent a decade ago but have since been pushed to the margins of the field. This does not mean moving away from treatment, as treatment is also a social justice issue (particularly where access is concerned), and certainly medical interventions will need to be part of any comprehensive response. Rather, drawing on the work of colleagues in the climate change arena, this analysis suggests looking at and likelihood of bearing impacts? Can we intervene in underlying drivers common in all of these areas? Perhaps some of these crosscutting root causes are gender inequalities, social marginalization or livelihood insecurity? How are such root causes unique to specific places or similar across different communities? These complex questions pose a major challenge to social scientists in the field, but are crucial to consider in order to devise and implement effective and comprehensive responses.3. In both areas we have seen polarization and data debates. Clearly in the AIDS field there is a need to move beyond treatment versus prevention and other such "either-or" debates. What underlying issues cut across unequal access to treatment, risk of infection preventive rather than reactive way. We note AIDS epidemics have not yet run their course, and thus impacts will inevitably continue to unfold to decades; the magnitude and distribution of these future impacts depend, however, on existing vulnerabilities; and although major social and structural changes will almost certainly be required, these vulnerabilities can be reduced now in order to reduce or prevent hardships.4. Finally, one central lesson AIDS scholars can take from the climate change literature is a reorientation in the way they think about vulnerability and impact. As in recent social vulnerability research, it would make sense to push for an AIDS agenda that looks forward - an agenda that seeks to understand present-day vulnerabilities in order to reduce future impacts, in a By examining the conceptual similarities and differences within AIDS and climate change research, this paper has provided challenges toward an emerging AIDS research agenda. Many of the challenges facing the AIDS field are not dissimilar to those scholars are grappling with elsewhere. Indeed, there are opportunities to learn from climate change research, as we have demonstrated. There is a need to move beyond what often is constructed as "issues-based" silos to examine barriers within social inquiry more broadly.AIDS: Acquired Immune Deficiency Syndrome; ASCI: AIDS, Security and Conflict Initiative; ARV: Antiretroviral Treatment; GHG: Greenhouse gas; HIV: Human Imunodeficiency Virus; IPCC: Intergovernmental Panel on Climate Change; PEPFAR: Presidential Emergency Programme for AIDS Relief; RENEWAL: Regional Network on AIDS, Livelihoods and Food Security; SAVI: Southern Africa Vulnerability Initiative; UN: United Nations; UNAIDS: Joint United Nations Programme on HIV/AIDS; UNEP: United Nations Environment Program; WHO: World Health Organisation; WMO: World Meteorological Organization.The authors declare that they have no competing interests.MC conceived of this paper and engaged MB and AW in dialogue around their respective fields, climate change and HIV/AIDS. MC outlined the study in a presentation format; MB and AW contributed feedback and substantive intellectual input; and MC presented this preliminary version at the 2006 International AIDS Conference in Toronto, Canada. MC then drafted the manuscript; AW contributed to sections pertaining to HIV/AIDS; MB contributed to climatic change sections. All authors edited and proofread the final manuscript.


Reported symptoms were respiratory (68.9%), gastrointestinal (15.3%), fever (12.8%), and skin infection (2.8%). Medical attention was sought significantly more often among those with chronic illness, those born in the United States, and those with fever, runny nose, or skin infections . Antibiotics were taken significantly more often among those with poor health, those who spent more time at home, and those with fever and respiratory symptoms. Interventions to promote judicious use of antibiotics must include clinicians and the public, and for the Hispanic population such interventions must also be culturally relevant and provided in Spanish.Trained interviewers visited 631 inner city households to determine community prevalence and predictors of antibiotic use. Infectious disease symptoms were reported in 911 (33.2%) of 2,743 household members in the previous 30 days: medical attention was sought by 441  Evidence is overwhelming that antibiotic use is linked with increasing antimicrobial resistance in the community  was interviewed in a one-time home visit and prevalence survey from January 1999 to April 1999  had been present within the previous 30 days, and, if symptoms were present, whether medical treatment was sought, antibiotics were taken, or both, by any household member. Data regarding sore throat were obtained for persons The questionnaire used in the home interview underwent extensive psychometric assessment and pilot testing . In 93% of cases, directly verifying the presence of the reported symptoms was possible. Further, in 3% of visits a symptom was identified by the interviewer that had not been reported. Hence, the sensitivity and specificity of the symptom self-reports were 93% and 97%, respectively. To verify the accuracy of reporting of antibiotic usage, participants were asked to give the name of the antibiotic and, when available, the labeled bottle or envelope containing the antibiotic was examined by the interviewer. Interviewers only recorded that an antibiotic was taken when the informant was able to give the specific name or when the package label was examined and confirmed to be an antibiotic.Analyses were conducted only on Hispanic participants at the level of the individual household member. Chi square and Student t tests were used to compare demographic and illness variables between the two survey periods. Then, for all participants combined, logistic regression models were fit to identify predictors of seeking medical attention and taking an antibiotic among those with an infectious disease symptom. Independent variables used in the models included age, sex, health status (excellent/good vs. fair/poor), presence of chronic illness, household (since symptoms and practices were likely to be interdependent among members of the same household), type of symptom, time spent outside the home, and whether born outside the United States. A two-sided p value of <0.05 was considered statistically significant.>40 hours/week outside the household (35.3%), and another 35.1% spent >20 hours/week outside the household. No significant differences were found between survey 1 and survey 2 with regard to participants’ sex (p=0.09), mean ages , or proportion born outside the United States (p=0.16). Significantly more persons in survey 1 had fair/poor health (p<0.001), chronic disease (p=0.006), and spent >40 hours/week outside the home (p<0.001) than in survey 2.Characteristics of the participants  are summarized on Among the 2,743 household members, 911 (33.2%) reported 1,983 symptoms in the previous 30 days, the most common being respiratory , followed by gastrointestinal , fever (12.8%), and skin infection (2.8%). Approximately half of persons with infectious disease symptoms  sought medical attention for the symptoms, 42.5% received some type of treatment, and 38.9% took an antibiotic. Respondents in survey 1 reported significantly more symptoms than those in survey 2 (p<0.001) .>40 hours/week compared with 35.3% outside the home <20 hours/week had symptoms; p=0.006) and less likely to receive antibiotics .Among those with one or more infectious disease symptom, we found no significant differences in either seeking medical attention or taking antibiotics by age , gender , or by presence of gastrointestinal symptoms . As expected, household number was significantly associated with both seeking medical attention and taking an antibiotic. Those born in the United States were significantly more likely to seek medical attention  but not to take an antibiotic. Chronic illness or poor health status was a significant predictor of seeking medical attention and of taking an antibiotic. Finally, those who spent less time at home were significantly less likely to report symptoms of infection  but not to take antibiotics. Those with runny nose and fever were significantly more likely to seek medical attention and take antibiotics; those with cough and sore throat were also significantly more likely to take antibiotics. The regression models with the best fit for seeking medical attention and taking an antibiotic are summarized in The impact of illness with infectious disease symptoms in this community seemed high with about one third of household members reporting at least one symptom within the previous 30 days. However, determining how this compares with the prevalence of such symptoms in other generally healthy community populations is not possible since surveillance systems for infections are either hospital-based or physician-based . Households also informally reported sharing antibiotics between family members or among friends. Although the interviewers did not record the specific name of antibiotic after verifying that the medication was, in fact, an antibiotic, clearly, the antibiotics taken were frequently obtained without prescription. Another limitation of the study was that we were unable to examine differences between subgroups of the Hispanic population, since most respondents in this study were from a single country.As with all self-reported data, this survey contains the potential for recall bias and underreporting or overreporting. Although the answer would be useful to know, we chose not to ask respondents whether the antibiotics they took were obtained by prescription to discourage underreporting. One of the weaknesses of this study is that some participants were reluctant or unable to show the antibiotic container and label to the interviewer, perhaps because antibiotics were not always obtained by written prescription or were borrowed from others. In the study neighborhood, we verified that antibiotics were available over the counter in local Our findings have several important implications. First, estimates of antibiotic usage that are based on prescription data are likely to result in considerable underreporting of antibiotic usage in the community. Second, this generally unaccounted-for usage may be a major contributor to the ongoing problem of antibiotic resistance in the community. Few studies have investigated prevalence of use of unprescribed antibiotics. Among a Mexican immigrant population in Los Angeles, 28% reported obtaining medication, frequently antibiotics, in Mexico (To be effective within populations such as the one in this study, media and public health efforts to educate the public on the prudent use of antibiotics must be circulated widely in Spanish and other languages appropriate for recent immigrants, particularly those from countries where antibiotics are widely available without prescription. Further, the messages conveyed must be culturally meaningful for such targeted subgroups. The households in this study all spoke Spanish as their primary language. Language barriers, particularly among Hispanics, have been found to be associated with higher costs of care in the emergency department (Persons with poor health or a known chronic condition were more likely to receive medical attention and antibiotics. The fact that more U.S.-born persons sought medical attention may relate to insurance coverage or other access issues. Although we did not ask respondents about their insurance or immigration status in this study, in a previous survey of this community, Hispanics reported particularly low participation in insurance plans; 47% who had lived in the United States <5 years were uninsured, and the major reported reason for not seeking care was financial concern (On the one hand, this study showed a possible improvement in specific antibiotic-taking practices. A study conducted almost 10 years ago reported that 60% of patients seeing a physician for the common cold filled a prescription for an antibiotic (On the other hand, since a large proportion of persons in this study took an antibiotic for symptoms that were likely to be viral in origin, antibiotic overuse seems likely. A number of factors may contribute to a continued overuse of antibiotics. First, even though antibiotic prescribing for children with upper respiratory infection improved during the decade of the 1990s (Inappropriate use of antibiotics in this Hispanic population may also relate to practices in their country of origin. McKee et al. reported that persons from countries where antibiotics are readily available over the counter are more likely to use antibiotics not prescribed by clinicians; about one fourth of 192 persons surveyed in an ethnically diverse urban community in New York City obtained antibiotics from sources other than prescription (Interventions directed at providers and patients to promote more judicious use of antibiotics have met with variable success. Some trials have included both clinicians and patients or the patient’s parents (In summary, about one third of members of this Hispanic community reported infectious disease symptoms over a 30-day period, and antibiotics were taken by more than one third when a symptom was present. When controlled for other factors in the logistic regression analyses, age was not a predictor of seeking medical attention or of taking antibiotics. Persons with fever, runny nose, or skin infection; persons born in the United States; and those with chronic disease were significantly more likely to seek medical attention. Those with respiratory symptoms and poor health and those who spent more time at home were significantly more likely to take antibiotics. Continued interventions to promote judicious use of antibiotics must include both clinicians and the public; for the Hispanic population, such interventions must also be culturally relevant and provided in Spanish.


Advances in our understanding of human immunodeficiency virus (HIV) infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome (AIDS) remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis. Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) remains a critical world health issue and is a major cause of morbidity and mortality. More than 25 million people have died of AIDS since 1981. Africa has 11.6 million AIDS orphans.[there is an enhanced prevalence of bronchial hyperresponsiveness and dysfunction of the small airways.[The lungs are one of the chief target organs for HIV-associated disease, and almost 70% of the patients suffer at least one respiratory complication during the course of their illness.–4 In the airways.64+ cell count and HIV-related mortality both in adults[Mycobacterium tuberculosis (MTB), cytomegalovirus (CMV) and Pneumocystis carinii pneumonia (PCP), have been recently reported with HAART.[710Recently gained knowledge of the immunologic impact of HIV on disease progression has led to better care and incremental increase in survival. Better prophylaxis for opportunistic infections and the development of highly active antiretroviral therapy (HAART) has had a significant impact against HIV. HAART has had a significant impact on viral load, CDin adults and in pin adults  in a sick patient. In a relatively well patient, it likely represents a more indolent process such as lymphoproliferative disorder.–23Steroids may increase the degree of immune suppression and HAART can lead to various manifestations of immune restoration syndrome. A historMycobacterium avium complex (MAC), fungal infections and CMV[However, the level of immune compromise is the most important determinant in assessing the likelihood of various pulmonary complications. This is reflected in the CD4 count, with specific diseases occurring with increasing frequency as certain CD4 thresholds are reached. At CD4 levels above 400, patients are at risk of infection from relatively virulent organisms, such as bacteria and TB. Lung cancer may also occur at this stage. Between counts of 200 and 400, patients may suffer from recurrent infection as well as lymphoma. Opportunistic infections and KS are rare at CD4 levels >200 and indeed most cases of PCP occur at CD4 counts below 100, along with s and CMV [Table 2The conventional chest X-ray (CXR) is usually the first line and often only imaging investigation. Despite the variety of differential diagnoses, overlapping features, atypical manifestations and multifactorial disease, the CXR is accurate for diagnosing common complications, with reported accuracies of 64%, 75% and 84% for diagnosing bacterial pneumonia, PCP and MTB, respectively, in a blinded trial.High-resolution computed tomography (HRCT) is both more sensitive and more accurate, with an overall diagnostic accuracy of 92%, including 90% for KS and 94% for PCP. Furthermore, CT has a useful 93% negative predictive value in excluding active pulmonary disease.When comparing CXR and HRCT, Kang found that a confident diagnosis was made more often on CT than on CXR, and this confident diagnosis was more often correct on CT than on CXR. The correct confident interpretation was made more often in patients with lymphoma (100%), KS (91%) and PCP (87%). However,Clinical findings vary with the degree of immune suppression, ranging from an increased incidence of bronchitis and sinusitis, with CD4 counts above 500/µL, to PCP and KS, with CD4 counts below 200/µL.8 A simil27Infections are the most common pulmonary complication of AIDS, and bacteria are the most common cause of infection, superseding PCP at all levels of immune compromise.Streptococcus pneumoniae, Hemophilus influenzae, Pseudomonas and Staphylococcus aureus. Infection is frequently not pneumonic, the most common manifestation being acute bronchitis/bronchiolitis.[Multiorganism infection is common, involving hiolitis.–32 Patiehiolitis.The CXR in bacterial bronchiolitis may be normal or may reveal bilateral symmetrical lower lobar bronchial wall thickening appearing as ring shadows and “tram-tracks” Figure . AbnormaThe typical radiographic appearance of bacterial pneumonia CXR in AIDS is the same as that in an immune competent host with lobar or segmental consolidation but progressing rapidly, with frequent multilobar or bilateral disease3536 Fig35. Parapne35P. carinii remains the most common opportunistic and most common life-threatening pulmonary infection in AIDS.[ in AIDS.–39 PCP u in AIDS.41 Radiog in AIDS. The clas in AIDS. [Figures in AIDS.–7. If le in AIDS. [Figures in AIDS. and 9.HRCT is more sensitive, the hallmark being ground-glass attenuation, seen in over 90% of the cases. It often has a geographic or mosaic distribution. In this clinical setting, this is virtually diagnostic of PCP and is sufficient for commencement of empirical treatment Figures and 11. Cystic lung disease is a relatively common manifestation.40 Cysts 35Spontaneous pneumothorax is a well-recognised complication, particularly in patients with cysts . PneumotThe CXR may be normal in 10%, although this is uncommon in clinical practice42 Atypic35MTB is the most common pulmonary complication of HIV worldwide. Making tThe radiographic appearance of TB in AIDS differs from that in immune competent hosts, with more diffuse and lower zone disease, miliary disease and adenopathy as well as an increased incidence of a normal CXR.45The radiographic appearance generally reflects the CD4 count. When the CD4 level exceeds 200, the appearance is commonly that of typical reactivation MTB in a previously infected immune competent host. Classical primary TB can also be seen in patients without prior exposure. In contrast, patients with CD4 levels below 200 present with a pattern of primary TB, regardless of prior exposure.–45Features of reactivation MTB are patchy consolidation, including involvement at unusual sites, e.g. lower lobes, cavitation, nodularity, effusions and adenopathy . TB lymp“Primary” MTB manifests as focal unilateral, often lower lobe consolidation and adenopathy Figure . CavitatSerial CXRs are useful for monitoring response to treatment.–45 A parAlthough the time frame and clinical context of immune restoration syndrome are characteristic, radiographic findings are nonspecific, and this should only be diagnosed when other causes, such a poor compliance with treatment, drug resistance, drug reaction and concurrent disease, have been excluded. The latter, in particular, because almost 30% of the patients have been shown to develop new HIV-related lung disease during the first 3–6 months of TB treatment, most commonly PCP.MAC is the most common atypical mycobacterial infection.4748 It u47354735473547Cryptococcus is the fourth most common opportunistic infection in AIDS.48 The lu3535354935Aspergillosis occurs almost exclusively in association with neutropoenia, usually secondary to drug therapy.50 The in353535Ninety percent of HIV-positive patients are thought to carry latent CMV infection, although it is not considered a significant pulmonary pathogen in the majority. CMV pneuThe spectrum of radiographic findings is varied and overlaps other AIDS-related diseases, most notably PCP. FeaturesKS is by far the most common AIDS-related malignancy. The maleBilateral, perihilar and lower-zone reticulonodular infiltrates are characteristic . Septal 3535Thickening of bronchovascular bundles reflecting the bronchocentric distribution of disease is demonstrated on HRCT. Interlobular septal thickening due to lymphatic obstruction and tumor invasion is also seen4254 Fig42. Pleural3542AIDS-related lymphoma (ARL) is the second most common malignancy.55 The inNon-Hodgkin’s Lymphoma (NHL) accounts for 90% and the majority of cases are associated with Epstein-Barr virus. NHL is typically extranodal and usually disseminated at the time of diagnosis. Thoracic52Well-defined solitary or multiple parenchymal nodules are common . These a55Lymphadenopathy is a less common feature in AIDS-related NHL, and nodes are rarely significant according to size criteria. Effusions are common, may be unilateral or bilateral and are usually moderate to large in size.A rare form of ARL, called body cavity lymphoma, has been described, usually affecting homosexual males with advanced AIDS, manifest as pleural, pericardial or peritoneal effusions in the absence of any soft tissue tumor.–61There is conflicting data regarding the incidence of lung carcinoma in AIDS and, to date, there is no convincing evidence showing a significant rise.5862 It o5858585858A spectrum of polyclonal lymphoproliferative disorders affects the lungs of HIV-positive patients, the most common being lymphocytic interstitial pneumonitis.65 This i356567Bronchiolitis obliterans, with or without organizing pneumonia in the absence of infection, can be a feature of AIDS.–72 This Recently, work suggests that there may be a higher incidence of pulmonary emphysema among HIV-positive smokers. The prob+cell count and HIV-related mortality in HIV patients.[Better prophylaxis for opportunistic infections and the development of HAART has had a significant impact against HIV on viral load, CD4patients. With lonpatients.. A highepatients. A recentpatients. [Figure patients.. Finallypatients.. Lastly,patients..Limitations reflecting overlapping appearances, atypical manifestations and coexisting disease contribute to a relative lack of specificity of imaging. However, certain basic radiographic patterns can be recognized, which should raise the suspicion of certain underlying disease processes.Pulmonary nodules are a relatively common manifestation of AIDS-related pulmonary disease. The authors of two recent studies categorized nodules according to size and distribution and showed that nodules smaller than 1 cm, especially those with a random or centrilobular distribution, are more likely to be due to infection , whereas nodules larger than 1 cm are more likely neoplastic. Miliary nodularity is typically due to fungal infection or TB, although, rarely, it may be seen with PCP. KS tends to be peribronchovascular as opposed to lymphoma and lung cancer, which are more peripheral.Another study showed that cavitating lesions were universally infective in etiology. Eighty-five percent were polymicrobial, the majority involving bacteria (predominantly due to mixed infections often involving Staphylococcus and Pseudomonas). The remainder included MTB, PCP, fungi and CMV.–81Adenopathy is also most commonly due to infection. Although isolated lymphadenopathy can be seen in association with Cryptococcus, TB is by far the most common cause, accounting for about 85% of the cases. Both may be associated with low attenuation adenopathy. Lung cancer should also be included in the differential diagnosis. Calcified adenopathy has been described in PCP. KS may be associated with hyperattenuating lymphadenopathy due to vascular enhancement. This has been shown to have a 70% PPV.This is usually due to infection. A report in clinical radiology identified bacterial pneumonia as the most common cause of focal consolidation in AIDS, but showed that Pneumocystis was the most common individual pathogen to cause the appearance, usually as an upper lobe infiltrate. Consolidative PCP, however, rarely has a segmental pattern, helping in distinguishing it from bacterial infection. MTB, MAC, fungi , mixed infections and, rarely, neoplasms such as lymphoma and KS may also be responsible.838483The majority of effusions in AIDS are small, occurring with equal incidence in both infection and malignancy. The three main causes are bacterial infection, MTB and KS. Infective causes tend to be associated with unilateral effusions whereas those in KS tend to be bilateral. Non-AIDS-related conditions such as pulmonary embolism (PE) and organ failure should also be considered.6085–8760Despite the development of effective antiviral therapies and better prophylaxis of opportunistic infections, pulmonary complications of HIV/AIDS remain an important cause of morbidity and mortality. We have provided a pictorial assay of the lung afflictions seen in HIV/AIDS and have discussed the interpretation of imaging studies based on pattern recognition read in conjunction with demographic, clinical and laboratory data. Presently, a CXR remains the mainstay of thoracic imaging in HIV-infected patients, but CT/HRCT plays an increasingly important complementary role in establishing an accurate diagnosis when CXR findings are equivocal or nonspecific.