Sepsis-2.5: Resolving Conflicts Between Payers and Providers.

Competing definitions of sepsis have significant clinical implications and impact both medical coding and hospital payment. Although clinicians may prefer Sepsis-2, payer use of Sepsis-3 to validate clinical diagnoses may result in denial of payment or requests to recoup previously paid funds from healthcare providers. The Sepsis-2.5 project was a cooperative effort between a hospital system and a private payer to develop a community-based, literature-supported consensus definition for sepsis characterized by the presence of clinical illness, a source of infection, and evidence of organ dysfunction. This new definition ("Sepsis-2.5") has been instrumental in resolving provider-payer conflicts in defining clinical sepsis and reimbursing care.

Severe scombroid poisoning and life-threatening hypotension.

Scombroid fish poisoning (SFP), the most common fish-related illness worldwide, is a histamine response caused by the heat stable toxin histamine. A healthy 48-year-old woman and co-author of this paper developed palpitations, tachycardia and hypotension 10 min after a tuna steak dinner. She subsequently developed numbness of her face, flushing, conjunctival erythema, abdominal pain, nausea, vomiting, diarrhoea, headache and chest pain. Her ECG revealed tachycardia with ST depression. Her hypotension did not respond to fluid resuscitation, and she required phenylephrine. Based on exposure history, clinical syndrome, exclusion of other diseases and consultation with poison control, a diagnosis of scombroid poisoning was established. The state health department was notified. The patient was weaned off vasopressors, dosed famotidine and discharged 43 hours after fish ingestion with no symptoms and normal ECG. SFP is an often misdiagnosed and underreported illness with the potential to cause life-threatening hypotension.

Lung nodules due to Candida parapsilosis in a person with cystic fibrosis.

We present the first reported case of Candida parapsilosis pulmonary infection presenting as lung nodules. The patient is a 31-year-old man with cystic fibrosis (CF) colonised with multidrug-resistant Escherichia coli and increased frequency of pulmonary exacerbations in the preceding months. While on intravenous antibiotics for a pulmonary exacerbation, he developed bilateral pulmonary nodules. Bronchoalveolar lavage cultures grew C. parapsilosis He was initially treated with dual antifungal therapy, voriconazole and micafungin. Discontinuation of voriconazole due to transaminitis resulted in the development of new nodules, and isavuconazonium was added. Repeat imaging revealed no progression of disease. Micafungin was eventually discontinued. Monotherapy with isavuconazonium is planned for 1 year post lung transplant. In the CF population, C. parapsilosis may be an opportunistic pathogen. The case highlights that frequent CF exacerbations and antibiotic exposure increase the risk for opportunistic infections including Candida species and the implications for lung transplantation in this setting.

Long-term remission in an adult heart transplant recipient with advanced Burkitt's lymphoma post-transplant lymphoproliferative disorder after anthracycline-free chemotherapy: A case report and literature review.

Incidence of Burkitt's lymphoma post-transplant lymphoproliferative disorder (BL-PTLD) in solid organ transplant (SOT) recipients in 1.4%-1.6% with unknown cure rate. We report a case of Epstein-Barr virus (EBV) positive, late-onset BL-PTLD in a 24-year-old EBV donor positive/recipient negative female. This is the first reported case of advanced BL-PTLD post-heart transplant in an adult. This is also the first reported case of treatment of advanced BL-PTLD in a heart transplant recipient with a combined chemotherapy regimen without anthracyclines to avoid cardiotoxicity. The patient received 6 cycles of R-COEP (rituximab with cyclophosphamide, vincristine, etoposide, prednisone) over 6 months and subsequently 3 cycles of high-dose methotrexate (MTX) over 3 months for CNS prophylaxis. She remains without evidence of disease at 19 months post-treatment. This case demonstrates that an anthracycline-free regimen can be the therapy option for patients with BL-PTLD after heart transplantation.

Multiple organ dysfunction syndrome and death secondary to Cyberlindnera fabianii.

Cyberlindnera fabianii is a yeast present in soil rarely associated with invasive infection. Due to advanced diagnostic and therapeutic techniques, pathogenicity is increasingly recognized. A 37-year-old male with B cell lymphoma on rituximab developed multiple organ dysfunction syndrome secondary to C. fabianii bacteremia. Specialized species identification techniques were required after failure of standard methods. Despite extracroporeal membrane oxygenation (ECMO) the patient died on day 26 after admission.

Single-center experience with use of letermovir for CMV prophylaxis or treatment in thoracic organ transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) infection is common in thoracic organ transplant recipients. Valganciclovir and ganciclovir are used for both prophylaxis and treatment of this infection, but intolerance and treatment failure are common. Letermovir has been demonstrated to reduce the risk of CMV infection when used for prophylaxis in allogeneic hematopoietic cell transplantation. However, there are no data on its efficacy in thoracic organ transplantation. METHODS: We examined the use of letermovir for either CMV prophylaxis (primary and secondary) or treatment in heart and lung transplant recipients at our institution from February 1, 2018, through December 31, 2018. RESULTS: Nine total patients received letermovir at our institution (8 lung transplant, 1 heart transplant) during the study period. Letermovir was prescribed for CMV prophylaxis in eight patients (primary prophylaxis in two patients and secondary prophylaxis in 6 patients), and for treatment of CMV DNAemia in two cases. One patient received letermovir for both secondary prophylaxis and treatment on separate occasions. Three out of 8 (37.5%) patients receiving letermovir for prophylaxis developed CMV DNAemia during prophylaxis. One patient treated for CMV disease had clinical failure with a sharp rise in serum CMV DNA PCR. The other patient treated for low-grade CMV DNAemia initially had a slight rise in CMV DNA PCR, but has since had a sustained response. No major side effects were experienced, and 2 patients reported minor side effects. CONCLUSION: Letermovir was well tolerated with only minor side effects reported; however, the rate of development of CMV DNAemia on prophylaxis was considerable. Further study of the dosing and efficacy of letermovir for CMV prophylaxis or treatment in thoracic organ transplant recipients is warranted.

Stroke and death risk in ventricular assist device patients varies by ISHLT infection category: An INTERMACS analysis.

BACKGROUND: Ventricular assist device (VAD) patients often experience infections, which increase the risk of stroke and mortality. Using the definitions of the International Society for Heart and Lung Transplantation (ISHLT), we have characterized differences in clinical outcomes for categories of infection: VAD-specific (e.g., pump component related); VAD-related (e.g., bloodstream infection, BSI); and non-VAD infections (e.g., pneumonia). METHODS: Querying of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) identified 16,597 continuous-flow VAD recipients. Categories of infection were tested in multivariate models to determine the risk of stroke and death. RESULTS: After implant, 7,046 patients (42%) developed an infection at a median of 69 (interquartile range 12 to 272) days. A majority were non-VAD infections (49%), followed by VAD-related (26%) and VAD-specific infections (25%). BSIs were the most common form of VAD-related infection (92%), and the majority (59%) had no associated infection, that is, idiopathic bacteremia. Internal pump component infections were rare (0.003 event per patient-year [EPPY]). Infected VAD patients had a higher prevalence of stroke compared to patients without an infection (18% vs 11%, p < 0.001). The lowest stroke rate occurred after a VAD-specific infection (0.11 EPPY) compared with VAD-related (0.17 EPPY) and non-VAD infections (0.15 EPPY, p < 0.001). Hemorrhagic strokes were more common than ischemic strokes in all infection groups and highest after a VAD-related infection (0.13 EPPY). One-year survival after an infection was 87% in VAD-specific infections, as compared with VAD-related (71%) and non-VAD infections (72%, p < 0.001). CONCLUSIONS: The ISHLT categorization of VAD infections unveils notable differences in associated risk of stroke and mortality. A re-assessment of transplant prioritization for eligible infected VAD patients may be useful to increase transplant-related survival benefit.

Transmission of Eastern Equine Encephalitis Virus From an Organ Donor to 3 Transplant Recipients.

BACKGROUND: In fall 2017, 3 solid organ transplant (SOT) recipients from a common donor developed encephalitis within 1 week of transplantation, prompting suspicion of transplant-transmitted infection. Eastern equine encephalitis virus (EEEV) infection was identified during testing of endomyocardial tissue from the heart recipient. METHODS: We reviewed medical records of the organ donor and transplant recipients and tested serum, whole blood, cerebrospinal fluid, and tissue from the donor and recipients for evidence of EEEV infection by multiple assays. We investigated blood transfusion as a possible source of organ donor infection by testing remaining components and serum specimens from blood donors. We reviewed data from the pretransplant organ donor evaluation and local EEEV surveillance. RESULTS: We found laboratory evidence of recent EEEV infection in all organ recipients and the common donor. Serum collected from the organ donor upon hospital admission tested negative, but subsequent samples obtained prior to organ recovery were positive for EEEV RNA. There was no evidence of EEEV infection among donors of the 8 blood products transfused into the organ donor or in products derived from these donations. Veterinary and mosquito surveillance showed recent EEEV activity in counties nearby the organ donor's county of residence. Neuroinvasive EEEV infection directly contributed to the death of 1 organ recipient and likely contributed to death in another. CONCLUSIONS: Our investigation demonstrated EEEV transmission through SOT. Mosquito-borne transmission of EEEV to the organ donor was the likely source of infection. Clinicians should be aware of EEEV as a cause of transplant-associated encephalitis.

A 24-Year-Old Woman With Precipitous Respiratory Failure After Lung Transplantation.

CASE PRESENTATION: A 24-year-old woman with ΔF508/Y1092X cystic fibrosis (CF) complicated by severe obstructive lung disease (FEV1 of 30% predicted) was admitted for IV antibiotics for planned sinus surgery resulting from severe chronic sinusitis causing frequent exacerbations and declining lung function. She had persistent airway infection with multidrug-resistant Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and growth of a fungus presumed to be an airway colonizer, identified as Stephanoascus ciferrii 1 year before presentation. Two days after surgery, she developed acute respiratory failure requiring mechanical ventilation. On day 4 of mechanical ventilation, venovenous-extracorporeal membrane oxygenation (VV-ECMO) was initiated for refractory respiratory failure. The following day, she was listed for bilateral lung transplant and was transplanted 4 days later. Following transplantation, she was decannulated from ECMO; however, over the next 12 hours, oxygenation deteriorated requiring reinstitution of VV-ECMO for presumed severe primary graft dysfunction. Despite treatment with broad spectrum antimicrobial coverage with piperacillin/tazobactam, ciprofloxacin, linezolid, micafungin, voriconazole, and ganciclovir, she failed to improve and developed complex bilateral pleural effusions.