Difference between SARS-CoV-2, seasonal coronavirus, influenza, and respiratory syncytial virus infection in solid organ transplant recipients.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been raging since the end of 2019 and has shown worse outcomes in solid organ transplant (SOT) recipients. The clinical differences as well as outcomes between respiratory viruses have not been well defined in this population. METHODS: This is a retrospective cohort study of adult SOT recipients with nasopharyngeal swab or bronchoalveolar lavage PCR positive for either SARS-CoV-2, seasonal coronavirus, respiratory syncytial virus (RSV) or influenza virus from January 2017 to October 2020. The follow up period was 3 months. Clinical characteristics and outcomes were evaluated. RESULTS: A total of 377 recipients including 157 SARS-CoV-2, 70 seasonal coronavirus, 50 RSV and 100 influenza infections were identified. The most common transplanted organ was kidney 224/377 (59.4%). Lower respiratory tract infection (LRTI) was found in 210/377 (55.7%) and the risk factors identified with multivariable analysis were SARS-CoV-2 infection, steroid use, and older age. Co- and secondary infections were seen in 77/377 (20.4%) recipients with bacterial pathogens as dominant. Hospital admission was seen in 266/377 (67.7%) recipients without significant statistical difference among viruses, however, ICU admission, mechanical ventilation and mortality were higher with SARS-CoV-2 infection. In the multivariable model, the risk factors for mortality were SARS-CoV-2 infection and older age. CONCLUSIONS: We found higher incidence of ICU admission, mechanical ventilation, and mortality among SARS-CoV-2 infected recipients. Older age was found to be the risk factor for lower respiratory tract infection and mortality for SARS-CoV-2, coronaviruses, RSV and influenza virus groups.

Cefazolin plus ertapenem and heart transplantation as salvage therapy for refractory LVAD infection due to methicillin-susceptible Staphylococcus aureus: A case series.

The use of left ventricular assist devices (LVADs) is increasingly more common as the availability of donor organs in relation to failing hearts is outstandingly limited. Infections are the most common complications in LVAD recipients, particularly those caused by Staphylococcus spp. Refractory LVAD-related infections are not uncommon as achieving adequate source control is often not feasible before heart transplantation. Evidence suggest that cefazolin plus ertapenem is effective in refractory methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, but this approach has not been described in LVAD recipients. In this article, we report two cases of refractory MSSA bacteremia in LVAD recipients that were successfully treated with salvage therapy with cefazolin plus ertapenem and subsequent heart transplantation. This treatment strategy should be considered in patients with refractory LVAD-associated infection due to MSSA that are not responding to standard treatment.

Initial Assessment of the Molecular Epidemiology of blaNDM-1 in Colombia.

We report complete genome sequences of four blaNDM-1-harboring Gram-negative multidrug-resistant (MDR) isolates from Colombia. The blaNDM-1 genes were located on 193-kb Inc FIA, 178-kb Inc A/C2, and 47-kb (unknown Inc type) plasmids. Multilocus sequence typing (MLST) revealed that these isolates belong to sequence type 10 (ST10) (Escherichia coli), ST392 (Klebsiella pneumoniae), and ST322 and ST464 (Acinetobacter baumannii and Acinetobacter nosocomialis, respectively). Our analysis identified that the Inc A/C2 plasmid in E. coli contained a novel complex transposon (Tn125 and Tn5393 with three copies of blaNDM-1) and a recombination "hot spot" for the acquisition of new resistance determinants.

[Prevalence and risk factors for extended-spectrum ß-lactamase-producing Escherichia coli causing community-onset urinary tract infections in Colombia]. / Prevalencia y factores de riesgo para infecciones del tracto urinario de inicio en la comunidad causadas por Escherichia coli productor de betalactamasas de espectro extendido en Colombia.

INTRODUCTION: Urinary tract infections (UTI) are common in the community. However, information of resistant isolates in this context is limited in Latin America. This study aims to determine the prevalence and risk factors associated with community-onset UTI (CO-UTI) caused by extended-spectrum ß-lactamase (ESBL)-Producing Escherichia coli in Colombia. MATERIALS AND METHODS: A case-control study was conducted between August and December of 2011 in three Colombian tertiary-care institutions. All patients who were admitted to the Emergency Department with a probable diagnosis of CO-UTI were invited to participate. All participating patients were asked for a urine sample. ESBL confirmatory test, antibiotic susceptibility, and molecular epidemiology were performed in these E.coli isolates (Real Time-PCR for bla genes, repetitive element palindromic PCR [rep-PCR], multilocus sequence typing [MLST] and virulence factors by PCR). Clinical and epidemiological information was recorded, and a statistical analysis was performed. RESULTS: Of the 2124 recruited patients, 629 had a positive urine culture, 431 of which grew E.coli; 54 were positive for ESBL, of which 29 were CTX-M-15. The majority of ESBL isolates were susceptible to ertapenem, phosphomycin and amikacin. Complicated UTI was strongly associated with ESBL-producing E.coli infections (OR=3.89; 95%CI: 1.10-13.89; P=.03). CTX-M-15-producing E.coli showed 10 different pulsotypes, 65% were PT1 or PT4, and corresponded to ST131. Most of these isolates had 8 out of the 9 analysed virulence factors. DISCUSSION: E.coli harbouring blaCTX-M-15 associated with ST131 is still frequent in Colombia. The presence of complicated CO-UTI increases the risk of ESBL-producing E.coli, and must be taken into account in order to provide an adequate empirical therapy.

Characteristics and clinical manifestations of monkeypox among people with and without HIV in the United States: a retrospective cohort.

OBJECTIVES: To compare characteristics and clinical manifestations of monkeypox (MPX) between people with and without HIV in the United States. DESIGN: Retrospective cohort study using TriNetX, a federated research network. METHODS: Patients 18 years and older with MPX were identified based on the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code B04 and divided into two groups: people with HIV (PWH) and people without HIV. Differences in baseline characteristics, clinical manifestations, and all-cause healthcare utilization were examined between groups. Outcomes were reported before and after propensity score matching. RESULTS: Of 322 cases of MPX included, 29% ( n  = 93) were PWH. Baseline characteristics were similar, but PWH were more likely to identify as Black or African American persons (24% vs. 11%, P  = 0.0303) or as Hispanic or Latino persons (24% vs. 11%, P  = 0.0345) and more likely to report lifestyle factors affecting health status. Rash and rectal pain were more common in PWH (25% vs. 11%, P  < 0.01, and 25% vs. 10%, P  < 0.001, respectively). In addition, PWH had higher rates of anal or rectal abscesses (11% vs. 0%, P  < 0.0001), phimosis (11% vs. 0%, P  < 0.0001), and pneumonia (11% vs. 0%, P  < 0.0001). More PWH required urgent care visits (53% vs. 29%, P  < 0.0001) and hospitalizations (11% vs. 4%, P  = 0.0314), but not emergency department visits (42% vs. 58%, P  = 0.0085). CONCLUSION: PWH had higher rates of clinical manifestations and required greater utilization of healthcare resources for any reason compared with those without HIV.

Clinical Spectrum and Outcomes of Cryptogenic Klebsiella pneumoniae Liver Abscess in the Americas: A Scoping Review.

(1) Background: Cryptogenic Klebsiella pneumoniae liver abscesses are an invasive infection with or without extra hepatic involvement in the absence of hepatobiliary disease or abdominal malignancy. Most of the evidence has emanated from reports from Asia, and previous studies in the Americas have limited clinical characterization. (2) Methods: To understand this syndrome's characteristics on our continent, we conducted a scoping review to identify adult cases of idiopathic, community-acquired monomicrobial K. pneumoniae liver abscess in the Americas. (3) Results: We identified 144 cases spanning 1978-2022. Most cases were reported in males that had traveled or migrated from Southeast or East Asia with diabetes mellitus. Extrahepatic involvement and bacteremia were common, including seeding to the lungs, ocular structures, and central nervous system. Although limited by sample size, the most commonly reported genes were magA or rmpA. Concomitant percutaneous drainage and third generation cephalosporins (alone or in combination with other antibiotics) were frequently used, yet pooled fatality occurred in 9% of the reported cases. (4) Conclusions: The features of cryptogenic K. pneumoniae liver abscess in the Americas mirror those described in Asia, confirming its global dissemination. This condition is increasingly being reported in our continent and carries significant clinical impact due to its systemic invasiveness.

Dasatinib-Induced Bilateral Pleural Effusions.

Fluid accumulation in the form of pleural effusions and ascites may be attributed to a single etiology. Diagnosis depends on a thorough clinical history as well as fluid analysis. We present the case of a 60-year-old man with chronic myeloid leukemia (CML) on dasatinib, recent right-sided ischemic stroke, alcohol-associated liver disease, cocaine and alcohol use disorders in early remission, and hypertension who presented with subacute-onset of bilateral pleural effusions and ascites. Pleural fluid analysis showed an exudative effusion, while ascitic fluid analysis showed a transudative collection. After an extensive workup, the bilateral effusions were attributed to dasatinib therapy, which was also suspected to play an unclear role in the worsening ascites. Although peripheral edema and pleural effusions are well-recognized and common side effects of tyrosine kinase inhibitors (TKIs), this case represents the first description of a patient presenting with bilateral TKI-induced pleural effusions as well as concomitant ascites of unclear origin.

Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review.

Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.

Disseminated cryptococcosis in a patient with newly diagnosed HTLV-1 infection.

Infection by human T-lymphotropic virus 1 (HTLV-1) is often seen as the cause of chronic infection or lymphoproliferative disorders, but many clinicians do not recognise its association with severe immunosuppression. We report the case of a woman in her 70s from the Caribbean who sought care at the emergency department for weakness, fatigue and weight loss. Further work-up showed atypical lymphocytosis with floral lymphocytes and smudge cells in the peripheral blood smear and hypercalcaemia. Chest CT demonstrated a moderate right pleural effusion. Results of HIV testing were negative, and screening and confirmatory tests for HTLV-1 were positive. Empiric antibiotic therapy was administered, and the patient was discharged home. Five days later, she was readmitted with shortness of breath and severe abdominal pain. A disseminated infection with Cryptococcus neoformans was diagnosed. Despite aggressive intravenous antifungal therapy, the patient died on day 7 of hospitalisation.

Impact of Preoperative Testing on Patients Undergoing Ophthalmologic Surgery: A Retrospective Cohort Study.

OBJECTIVE: Routine medical testing is not recommended before cataract surgery, but no consensus exists about preoperative testing before general ophthalmologic surgery. We aimed to assess the impact of preoperative testing on patients undergoing ophthalmologic surgery by analyzing their surgical outcomes and complications. METHODS: We retrospectively reviewed electronic health records of patients who had preoperative evaluations before cataract or noncataract ophthalmologic surgery at a tertiary care center from January 1, 2015, through December 31, 2019. RESULTS: The cohort consisted of 2268 patients (1270 [56.0%] women). The most frequent ophthalmologic procedure was cataract extraction (n = 1450 [63.9%]). Laboratory tests results were available for 489 patients (33.7%) in the cataract group; of these, 275 results (56.2%) had abnormal values, and 18 patients (6.5%) required preoperative interventions. Preoperative test results were available for 772 out of 818 patients (94.4%) having noncataract procedures. Of these, 384 results (49.7%) had abnormal values, and 10 patients (2.6%) required additional intervention. No significant differences were observed for the rate of surgery cancellations between the cataract and noncataract patient groups (0.6% vs 1.0%; P = .24). Of the 12 patients (0.5%) who had complications, all had undergone preoperative testing. CONCLUSIONS: No differences in outcomes and complications were observed among patients who underwent cataract or noncataract surgery. It is reasonable to consider avoiding preoperative testing in patients undergoing ophthalmologic surgery.

Tuberculous peritonitis masquerading as carcinomatosis.

Tuberculous peritonitis may debut with unspecific symptoms that can pose a diagnostic challenge for clinicians. We present a patient with tuberculous peritonitis masquerading as carcinomatosis. High clinical suspicion, appropriate identification of bacterial isolates of the Mycobacterium tuberculosis complex, and susceptibility testing are crucial to select target therapy.

Increased cryptococcal meningitis mortality among HIV negative, non-transplant patients: a single US center cohort study.

Cryptococcal meningitis (CM) is an opportunistic fungal infection associated with human immunodeficiency virus (HIV) and other forms of immunosuppression. We lack a clear understanding of CM associated mortality among HIV-negative, non-transplant patients in the United States (US). This article compares clinical features and outcomes across HIV status in patients with laboratory-confirmed CM. METHODS: A retrospective cohort study was performed that included adult patients with laboratory-confirmed CM treated at an academic tertiary hospital between January 2000 and September 2018. Those with a history of organ transplant or non-meningeal infections were excluded. Data were gathered on demographics, HIV status, clinical presentation, cerebrospinal fluid (CSF) profiles, neurological outcomes, hospital course, and mortality. RESULTS: A total of 70 patients with cryptococcal disease were identified. Our final sample included 36 CM patients, mean age was 48.8 ± 13.2 years; of this group, 66.7% (n = 24) had HIV. Median [interquartile range (IQR)] absolute CD4 count for the HIV group was 35 cells/µl (10-80 cells/µl). Non-HIV/non-transplant patients were significantly older (p < 0.001) and had higher rates of altered mental status (AMS) on presentation (58.3% versus 25%, p = 0.05). Non-HIV patients/non-transplant patients had significantly higher CSF white blood cell (WBC) count (p = 0.02), lower CSF glucose (p = 0.005), and higher CSF protein (p < 0.001) compared with HIV patients. There was no significant variation in temperature, blood pressure, WBC count, serum sodium, CSF opening pressure, length of stay, intensive care unit admission, or neurological outcomes. Overall, 90-day all-cause mortality was 19.4%: mortality rates were significantly higher in non-HIV/non-transplant patients at both 90 days (41.7% versus 8.3%, p = 0.017) and 1 year (41.7% versus 12.5%, p = 0.047). CONCLUSION: Compared with HIV-infected individuals, non-HIV/non-transplant CM patients have a higher CSF WBC count at the time of diagnosis, higher rates of AMS on presentation, and higher rates of 90-day and 1-year all-cause mortality. Further prospective research is needed to identify the hallmarks of CM in non-HIV/non-transplant patients to facilitate early identification and intervention.

Use of Procalcitonin to Guide Discontinuation of Antimicrobial Therapy in Patients with Persistent Intra-Abdominal Collections: A Case Series.

OBJECTIVE: Limited evidence exists for the use of procalcitonin (PCT) to guide the duration of antimicrobial therapy in patients with intra-abdominal abscesses (IAA). In this case series, we describe clinical presentations and outcomes using PCT to guide cessation of antimicrobial therapy in patients with persistent IAA who exhibited clinical improvement. METHODS: A retrospective analysis of patients with IAA who had PCT levels available to review was performed in a tertiary academic teaching institution in the United States between 2017 and 2018. Demographics, clinical characteristics, and outcomes were obtained from the medical records. Patients were followed up for a minimum of 180 days after completion of antimicrobial therapy to determine if evidence of recurrence or mortality was present. RESULTS: We identified four patients with IAA. They underwent early drainage of the source of infection and received empiric antimicrobial therapy according to individual risk factors and clinical scenarios. Antimicrobials were discontinued after clinical and radiographic improvement and evidence of normal PCT levels, regardless of the persistence of fluid collections. No evidence of recurrence or mortality was observed during the follow-up period. CONCLUSIONS: We found PCT to be a useful aid in the medical decision-making process to safely discontinue antimicrobial therapy in a series of patients with persistent intra-abdominal collections despite early drainage and appropriate course of antimicrobial therapy.

In Search of Congenital Chagas Disease in the Sierra Nevada de Santa Marta, Colombia.

Chagas disease remains a major impediment to sustainable socioeconomic development in Latin America. Transplacental transmission explains the persistence of transmission in urban areas, in non-endemic regions, and in areas with an established interrupted vectorial transmission. One of every five cases of congenital Chagas disease in the world occurs in Colombia and Venezuela. The massive migration of impoverished populations from neighboring Venezuela has worsened the situation creating a humanitarian crisis in Northeastern Colombia, including the Sierra Nevada de Santa Marta. The prevalence of Chagas infection among pregnant women in these areas is higher than the national average, and the public health resources are insufficient. This perspective discusses the associated increased morbidity and mortality of congenital Chagas in this region, where stigmatization contributes to the impression among health authorities and the general population that it affects indigenous communities only. The monitoring and control of congenital Chagas disease in the Sierra Nevada of Santa Marta is a public health necessity that demands urgent and effective interventions.

Anaerobic Bacteremias in Left Ventricular Assist Devices and Advanced Heart Failure.

Left ventricular assisted devices (LVADs) have revolutionized the treatment of advanced heart failure, providing meaningful increases in survival, functional capacity, and quality of life. There are two categories of LVADs patients: (1) bridge-to-transplant and (2) destination therapy. Advanced heart failure and destination LVADs often carry a poor prognosis. The overall 1-year mortality rate remains as high as 30%. LVAD-specific infections, LVAD-related infections, and non-LVAD-related infections represent important emerging clinical problems in this setting. With an incidence ranging from 30 to 50%, these lead to high rates of hospitalization, morbidity, and mortality. Bacteremias caused by anaerobic pathogens in patients with LVAD are underreported. Herein, we describe the microbiological findings, treatment, and clinical outcome of four patients with LVADs and advanced heart failure with anaerobic bacteremias. Fusobacterium species was the most frequent etiological agent. Most patients had a relatively favorable short-term outcome with survival rates of 100% at 30 days and of 50% at 90 days. However, due to other multiple long-term complications, overall mortality remains at 50% during the first year and increases to 75% beyond the first year. Anaerobic bacteremia sources included the oral cavity from odontogenic infections and aspiration pneumonia. Anaerobic bacteremia constitutes an unfavorable mortality prognostic factor in patients with destination LVADs. We recommend implementing preventive strategies with a comprehensive dental care evaluation in patients with LVADs and advanced heart failure.

[Clinical impact of ertapenem de-escalation in critically-ill patients with Enterobacteriaceae infections]. / Impacto clínico del desescalamiento a ertapenem en pacientes críticos con infecciones por Enterobacteriaceae.

BACKGROUND: Ertapenem has proven to be effective for extended-spectrum beta-lactamases-producing Enterobacteriaceae but lacks activity against non-fermenters; de-escalation to this antibiotic may reduce the selection of resistance to Pseudomonas aeruginosa and improve clinical outcomes. AIM: To evaluate the clinical impact of de-escalation from broad-spectrum anti-pseudomonal agents to ertapenem, a non-pseudomonal antibiotics for Enterobacteriaceae infections in critically-ill patients. METHODS: We conducted a prospective cohort study in adult patients admitted to intensive care units (ICUs) who had Enterobacteriaceae infections and were de-escalated from empiric anti-pseudomonal coverage to non-pseudomonal antibiotics. Cox proportional hazards models were performed comparing all-cause mortality and length of hospital stay between patients who remained on anti-pseudomonal coverage versus those who were de-escalated to ertapenem. RESULTS: 105 patients in the anti-pseudomonal group were compared to 148 patients in the ertapenem de-escalation group. De-escalation was associated with lower all-cause mortality compared to patients who remained on anti-pseudomonal coverage (adjusted Hazard Ratio 0.24; 95% CI: 0.12-0.46). The length of ICU stay was similar between the groups. DISCUSSION: ICU patients with Enterobacteriaceae infections de-escalated to ertapenem therapy had better outcomes compared to patients who remained on broad-spectrum, anti-pseudomonal therapy, suggesting that de-escalation is a safe approach amongst ICU patients.

Epidemiology of Candida isolates from Intensive Care Units in Colombia from 2010 to 2013.

BACKGROUND: The frequency of Candida isolates as a cause of hospital infections has risen in recent years, leading to high rates of morbidity and mortality. The knowledge of the epidemiology of those hospital acquired fungal infections is essential to implement an adequate antifungal therapy. AIMS: To describe the epidemiology of Candida infections in Intensive Care Units (ICUs) from a surveillance network in Colombia. METHODS: Information was collected from the microbiology laboratories of 20 tertiary healthcare institutions from 10 Colombian cities using the Whonet® software version 5.6. A general descriptive analysis of Candida species and susceptibility profiles focusing on fluconazole and voriconazole was completed between 2010 and 2013, including a sub-analysis of healthcare associated infections (HAIs) during the last year. RESULTS: Candida isolates made up 94.5% of the 2680 fungal isolates considered, with similar proportions for Candida albicans and non-C. albicans Candida species (48.3% and 51.7%, respectively). Among the latter, Candida tropicalis (38.6%) and Candida parapsilosis (28.5%) were the most frequent species. Of note, among the blood isolates C. albicans was not the main species. Most of the species isolated were susceptible to fluconazole and voriconazole. From the HAIs reported, 25.5% were caused by Candida; central line-associated bloodstream infection was the most common HAI (58.8%). There were no statistically significant differences regarding length of hospital stay and device days among HAIs. CONCLUSIONS: In ICUs of Colombia, non-C. albicans Candida species are as frequent as C. albicans, except in blood samples where non-C. albicans Candida isolates predominate. Further studies are needed to evaluate Candida associated risk factors and to determine its clinical impact.