Monkeypox in Montréal: Epidemiology, Phylogenomics, and Public Health Response to a Large North American Outbreak.

BACKGROUND: Monkeypox, a viral zoonotic disease, is causing a global outbreak outside of endemic areas. OBJECTIVE: To characterize the outbreak of monkeypox in Montréal, the first large outbreak in North America. DESIGN: Epidemiologic and laboratory surveillance data and a phylogenomic analysis were used to describe and place the outbreak in a global context. SETTING: Montréal, Canada. PATIENTS: Probable or confirmed cases of monkeypox. MEASUREMENTS: Epidemiologic, clinical, and demographic data were aggregated. Whole-genome sequencing and phylogenetic analysis were performed for a set of outbreak sequences. The public health response and its evolution are described. RESULTS: Up to 18 October 2022, a total of 402 cases of monkeypox were reported mostly among men who have sex with men (MSM), most of which were suspected to be acquired through sexual contact. All monkeypox genomes nested within the B.1 lineage. Montréal Public Health worked closely with the affected communities to control the outbreak, becoming the first jurisdiction to offer 1 dose of the Modified Vaccinia Ankara-Bavarian Nordic vaccine as preexposure prophylaxis (PrEP) to those at risk in early June 2022. Two peaks of cases were seen in early June and July (43 and 44 cases per week, respectively) followed by a decline toward near resolution of the outbreak in October. Reasons for the biphasic peak are not fully elucidated but may represent the tempo of vaccination and/or several factors related to transmission dynamics and case ascertainment. LIMITATIONS: Clinical data are self-reported. Limited divergence among sequences limited genomic epidemiologic conclusions. CONCLUSION: A large outbreak of monkeypox occurred in Montréal, primarily among MSM. Successful control of the outbreak rested on early and sustained engagement with the affected communities and rapid offer of PrEP vaccination to at-risk persons. PRIMARY FUNDING SOURCE: None.

Laboratory Features of Trichinellosis and Eosinophilia Threshold for Testing, Nunavik, Quebec, Canada, 2009-2019.

Prolonged eosinophilia is characteristic of trichinellosis. To determine the optimal eosinophil threshold for reflex Trichinella testing, we examined all 43 cases in Nunavik, Quebec, Canada, during 2009-2019. Using receiver operating characteristic analysis, we determined that eosinophil counts >0.8 × 109 cells/L should prompt consideration of trichinellosis and testing to rapidly identify potential outbreaks.

Efficacy, immunogenicity, and safety of a plant-derived, quadrivalent, virus-like particle influenza vaccine in adults (18-64 years) and older adults (≥65 years): two multicentre, randomised phase 3 trials.

BACKGROUND: Seasonal influenza remains a substantial public health threat despite the availability of egg-derived and other vaccines. Plant-based manufacturing might address some of the limitations of current vaccines. We describe two phase 3 efficacy studies of a recombinant quadrivalent virus-like particle (QVLP) influenza vaccine manufactured in plants, one in adults aged 18-64 years (the 18-64 study) and one in older people aged 65 years and older (the 65-plus study). METHODS: We did two randomised, observer-blind, multinational studies in the northern hemisphere in the 2017-18 (the 18-64 study) and 2018-19 (the 65-plus study) influenza seasons. The 18-64 study was done at 73 sites and the 65-plus study was done at 104 sites, both across Asia, Europe, and North America. In the 18-64 study, inclusion criteria were body-mass index less than 40 kg/m2; age 18-64 years at screening visit; and good health. In the 65-plus study, inclusion criteria were body-mass index of maximum 35 kg/m2; aged 65 years or older at screening visit; not living in a rehabilitation centre or care home; and no acute or evolving medical problems. Participants in the 18-64 study were randomly assigned (1:1) to receive either QVLP vaccine (30 µg haemagglutinin per strain) or placebo. Participants in the 65-plus study were randomly assigned (1:1) to receive QVLP vaccine (30 µg haemagglutinin per strain) or quadrivalent inactivated vaccine (QIV; 15 µg haemagglutinin per strain). The primary outcome in the 18-64 study was absolute vaccine efficacy to prevent laboratory-confirmed, respiratory illness caused by antigenically matched influenza strains. The primary outcome in the 65-plus study was relative vaccine efficacy to prevent laboratory-confirmed influenza-like illness caused by any influenza strain. The primary analyses were done in the per-protocol population and safety was assessed in all participants who received the assigned treatment. These studies are registered with ClinicalTrials.gov (18-64 study NCT03301051; 65-plus study NCT03739112). FINDINGS: In the 18-64 study, between Aug 30, 2017, and Jan 15, 2018, 10 160 participants were randomly assigned to receive either QVLP vaccine (5077 participants) or placebo (5083 participants). The per-protocol population consisted of 4814 participants in the QVLP group and 4812 in the placebo group. The study did not meet its primary endpoint of 70% absolute vaccine efficacy for the QVLP vaccine (35·1% [95% CI 17·9 to 48·7]) against respiratory illness caused by matched strains. 55 (1·1%) of 5064 participants in the QVLP group versus 51 (1·0%) of 5072 in the placebo group had a serious adverse event. Four (0·1%) and six [0·1%] participants had severe treatment-related treatment-emergent adverse events. In the 65-plus study, between Sept 18, 2018, and Feb 22, 2019, 12 794 participants were randomly assigned to receive either QVLP vaccine (6396 participants) or QIV (6398 participants). The per-protocol population consisted of 5996 participants in the QVLP group and 6026 in the QIV group. The study met its primary non-inferiority endpoint with a relative vaccine efficacy of the QVLP vaccine for the prevention of influenza-like illness caused by any strain of 8·8% (-16·7 to 28·7). 263 (4·1%) of 6352 participants in the QVLP group versus 266 (4·2%) of 6366 in the QIV group had serious adverse events (one [<0·1%] vs two [<0·1%] were considered treatment-related); one (<0·1%) versus three (<0·1%) participants had severe treatment-related treatment-emergent adverse events. INTERPRETATION: These efficacy studies are the first large-scale studies of any plant-derived human vaccine. Together, they show that the plant-derived QVLP vaccine can provide substantial protection against respiratory illness and influenza-like illness caused by influenza viruses in adults. QVLP vaccine was well tolerated and no major safety signal arose in participants who received QVLP vaccine across the two studies. FUNDING: Medicago.

First Human Case of Metacestode Infection Caused by Versteria sp. in a Kidney Transplant Recipient.

Cestodes are emerging agents of severe opportunistic infections among immunocompromised patients. We describe the first case of human infection, with the recently-proposed genus Versteria causing an invasive, tumor-like hepatic infection with regional and distant extension in a 53-year-old female kidney transplant recipient from Atlantic Canada.

Decision Tool for Herpes B Virus Antiviral Prophylaxis after Macaque-Related Injuries in Research Laboratory Workers.

Macaque-related injuries among primate workers can lead to a potentially fatal B virus encephalomyelitis. We describe a decision tool for evaluating the need for antiviral postexposure prophylaxis and provide a retrospective review of the injuries assessed in our center after its implementation in 2010. Among the injuries studied (n = 251), 40.6% were categorized as high-risk (prophylaxis recommended), 44.2% moderate-risk (consider prophylaxis), and 15.1% low-risk (prophylaxis not recommended). Ten percent of low-risk and 98% of high-risk injuries received prophylaxis (p<0.001). Compared with using universal postexposure prophylaxis, using a decision tool can lead to a standardization of practice and a reduction in prescriptions for antiviral medication.

Travel-Related Infections Among Pregnant Travellers to the Tropics: An Overview.

Infectious diseases acquired during travel pose a significant health risk to pregnant travellers, who are more susceptible to both acquiring certain infections and developing severe complications. A review of the literature focusing on recent evidence-based guidelines was conducted with attention to tropical infections in the pregnant patient. A summary meant to serve as a succinct reference for health care professionals caring for pregnant women is presented. Magnitude of risk, clinical features, management, and preventive strategies of major travel-acquired infections of pertinence to the pregnant traveller are summarized, including malaria, arboviral infections, foodborne infections, helminthic infections, and influenza. Tables with details on specific infections within each group and guidance for reducing travel-related health risks in the pregnant patient are presented.

GeoSentinel surveillance of illness in returned travelers, 2007-2011.

BACKGROUND: International travel continues to increase, particularly to Asia and Africa. Clinicians are increasingly likely to be consulted for advice before travel or by ill returned travelers. OBJECTIVE: To describe typical diseases in returned travelers according to region, travel reason, and patient demographic characteristics; describe the pattern of low-frequency travel-associated diseases; and refine key messages for care before and after travel. DESIGN: Descriptive, using GeoSentinel records. SETTING: 53 tropical or travel disease units in 24 countries. PATIENTS: 42 173 ill returned travelers seen between 2007 and 2011. MEASUREMENTS: Frequencies of demographic characteristics, regions visited, and illnesses reported. RESULTS: Asia (32.6%) and sub-Saharan Africa (26.7%) were the most common regions where illnesses were acquired. Three quarters of travel-related illness was due to gastrointestinal (34.0%), febrile (23.3%), and dermatologic (19.5%) diseases. Only 40.5% of all ill travelers reported pretravel medical visits. The relative frequency of many diseases varied with both travel destination and reason for travel, with travelers visiting friends and relatives in their country of origin having both a disproportionately high burden of serious febrile illness and very low rates of advice before travel (18.3%). Life-threatening diseases, such as Plasmodium falciparum malaria, melioidosis, and African trypanosomiasis, were reported. LIMITATIONS: Sentinel surveillance data collected by specialist clinics do not reflect healthy returning travelers or those with mild or self-limited illness. Data cannot be used to infer quantitative risk for illness. CONCLUSION: Many illnesses may have been preventable with appropriate advice, chemoprophylaxis, or vaccination. Clinicians can use these 5-year GeoSentinel data to help tailor more efficient pretravel preparation strategies and evaluate possible differential diagnoses of ill returned travelers according to destination and reason for travel. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Zoonotic infections in communities of the James Bay Cree territory: An overview of seroprevalence.

The Cree communities of James Bay are at risk for contracting infectious diseases transmitted by wildlife. Data from serological testing for a range of zoonotic infections performed in the general population (six communities), or trappers and their spouses (one community), were abstracted from four population-based studies conducted in Cree territory (Quebec) between 2005 and 2009. Evidence of exposure to Trichinella species, Toxoplasma gondii, Toxocara canis, Echinococcus granulosus, Leptospira species, Coxiella burnetii and Francisella tularensis was verified in all communities, whereas antibodies against Sin Nombre virus and California serogroup viruses (Jamestown Canyon and snowshoe hare viruses) were evaluated in three and six communities, respectively. Seroprevalence varied widely among communities: snowshoe hare virus (1% to 42%), F tularensis (14% to 37%), Leptospira species (10% to 27%), Jamestown Canyon virus (9% to 24%), C burnetii (0% to 18%), T gondii (4% to 12%), T canis (0% to 10%), E granulosus (0% to 4%) and Trichinella species (0% to 1%). No subject had serological evidence of Sin Nombre virus exposure. These data suggest that large proportions of the Cree population have been exposed to at least one of the targeted zoonotic agents. The Cree population, particularly those most heavily exposed to fauna, as well as the medical staff living in these regions, should be aware of these diseases. Greater awareness would not only help to decrease exposures but would also increase the chance of appropriate diagnostic testing.

Les communautés cries de la Baie James sont vulnérables aux maladies infectieuses transmises par les animaux sauvages. Les données tirées des tests sérologiques sur une série de zoonoses effectués dans la population générale (six communautés) ou chez les trappeurs et leur conjointe (une communauté) ont été extraites de quatre études en population menées en territoire cri, au Québec, entre 2005 et 2009. Les manifestations d'exposition aux espèces de Trichinella, au Toxoplasma gondii, au Toxocara canis, à l'Echinococcus granulosus, aux espèces de Leptospira, au Coxiella burnetii et au Francisella tularensis ont été vérifiées dans toutes les communautés, tandis que les anticorps contre le virus Sin Nombre et les virus du sérogroupe Californie (virus Jamestown Canyon et snowshoe hare) ont été évalués dans trois et six communautés, respectivement. La séroprévalence variait considérablement selon les communautés, comme suit : virus snowshoe hare (1 % à 42 %), F tularensis (14 % à 37 %), espèces de Leptospira (10 % à 27 %), virus Jamestown Canyon (9 % à 24 %), C burnetii (0 % à 18 %), T gondii (4 % à 12 %), T canis (0 % à 10 %), E granulosus (0 % à 4 %) et espèces de Trichinella (0 % à 1 %). Aucun sujet n'avait de manifestation sérologique d'exposition au virus Sin Nombre. Ces données laissent supposer que de fortes proportions de la population crie ont été exposées à au moins l'un des agents zoonotiques ciblés. La population crie, notamment les peuples les plus exposés aux animaux sauvages, ainsi que le personnel médical qui habite dans ces régions, devrait connaître ces maladies. Une meilleure sensibilisation contribuerait non seulement à réduire les expositions, mais accroîtrait également la possibilité de tests diagnostiques pertinents.

Intravenous Liposomal Amphotericin B Efficacy and Safety for Cutaneous and Mucosal Leishmaniasis: A Systematic Review and Meta-analysis.

Background: Tegumentary leishmaniasis is often subject to limited funding, underpowered studies, and a paucity of high-quality interventional studies. Intravenous liposomal amphotericin B (L-AmB) has been increasingly used to treat cutaneous and mucosal leishmaniasis (CL and ML, respectively) despite the lack of well-conducted interventional studies. We conducted a systematic review to consolidate the descriptive evidence on the efficacy and safety of L-AmB in treating CL and ML. Methods: Several online databases and the reference lists of included studies were searched to extract data from 132 studies comprising both case reports and case series. The population, intervention, comparison, outcome, and study design strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Results: Of 132 studies included, 92 were case reports and 40 were case series. Of the 92 cases, 65 (82.3%) were considered cured after receiving L-AmB as part of their treatment regimen. Twenty-one of the 92 (22.8%) cases reported adverse reactions to L-AmB. A pooled cure rate of 87.0% (95% CI, 79.0%-92.0%) was reported for the 38 case series that reported on treatment efficacy; 40.7% of the cases were associated with an adverse reaction. Conclusions: Observational data on cure rates using L-AmB suggest efficacy between 80% and 90%, similar to rates reported for other antileishmanial drugs. The highest efficacy rates were observed when a single cycle of L-AmB was administered to patients with mild-moderate CL and ML. The limitations of this study include the heterogeneity observed among the included studies and the increased likelihood of publication bias associated with the inclusion of case reports and case series. This systematic review further illustrates the need for high-quality comparative trials of intravenous L-AmB for the treatment of tegumentary leishmaniasis.

Rapid diagnostic testing for syphilis in Arctic communities (the STAR study): a multisite prospective field diagnostic accuracy study in an intended-use setting.

OBJECTIVES: We evaluated the field diagnostic accuracy of a syphilis rapid test (RDT), using serum and whole blood by non-laboratorians in two Canadian Arctic communities. METHODS: We implemented a multisite prospective field evaluation wherein patients were screened by an RDT containing treponemal and non-treponemal components (Chembio DPP® Syphilis Screen & Confirm) between January 2020 and December 2021. Venous whole blood and serum were collected for rapid testing and compared with laboratory-based serology reference testing using a reverse sequence algorithm of treponemal and rapid plasma reagin (RPR) testing. RESULTS: Overall, 135 whole blood and 139 serum specimens were collected from 161 participants during clinical encounters. Treponemal-RDT sensitivity against a treponemal-reference standard (38/161 confirmed cases) was similar for serum (78% [95% CI: 61-90%]) and whole blood (81% [95% CI: 63-93%]). In those with RPR titres ≥1:8 (i.e. suggestive of recent/active infection), sensitivity increased to 93% (95% CI: 77-99%) for serum and 92% (95% CI: 73-99%) for whole blood. Treponemal-RDT specificity was excellent (99% [95% CI: 95-100%]) for both specimen types. Non-treponemal-RDT sensitivity against RPR was 94% (95% CI: 80-99%) for serum and 79% (95% CI: 60-92%) for whole blood. Sensitivity increased to 100% (95% CI: 88-100%) for serum and 92% (95% CI: 73-99%) for whole blood when RPR titres ≥1:8. RDT performance with whole blood was similar to that with serum. DISCUSSION: Non-laboratorians using the RDT accurately identified individuals with infectious syphilis under real-world conditions in an intended-use setting at the point of care. Implementing the RDT can eliminate treatment delays and may enhance disease control.

Dengue outbreak amongst travellers returning from Cuba-GeoSentinel surveillance network, January-September 2022.

Increasing numbers of travellers returning from Cuba with dengue virus infection were reported to the GeoSentinel Network from June to September 2022, reflecting an ongoing local outbreak. This report demonstrates the importance of travellers as sentinels of arboviral outbreaks and highlights the need for early identification of travel-related dengue.

Evaluation of Strongyloides Awareness and Knowledge among Canadian Physicians Caring for Patients At Risk for Severe Strongyloidiasis: A National Cross-sectional Survey.

In Canada, a substantial proportion of migrants come from strongyloidiasis-endemic regions. Systematic screening for Strongyloides is not performed in immunocompromised patients in whom this infection could be potentially fatal. We aim to assess the level of Strongyloides awareness and knowledge among Canadian physicians caring for immunocompromised patients and identify factors currently associated with screening. Using an online survey distributed through Canadian medical associations, we collected information on physicians' demographics, practice setting, overall awareness and knowledge of Strongyloides, and current practices. Descriptive analysis and logistic regression models were performed to identify the factors associated with Strongyloides screening. Nineteen national and provincial medical associations agreed to participate. Between November 2020 and August 2021, 368 of 5,194 (7%) physicians that were contacted responded to our survey. Quebec (46%) and Ontario (24%) were the most responsive. Sixty-nine percent of respondents practiced medicine in academic settings. Infectious disease (ID) specialists/medical microbiologists (38%) followed by nephrologists (33%) were the most represented. Most respondents (95%) had heard about Strongyloides. However, 36% of non-ID specialists considered themselves unfamiliar. Forty percent of respondents did not or rarely performed screening for strongyloidiasis in high-risk populations. Screening was associated with younger-aged physicians (odds ratio [OR] 2.35; 95% confidence interval [CI] 1.07-5.18), physicians who frequently served migrants (OR 3.33; 95% CI 1.44-7.66), or those who had training in global health and ID/medical microbiology (OR 3.71; 95% CI 1.21-11.34 and OR 46.42; 95% CI 15.89-135.59, respectively). Our survey suggests a general lack of knowledge of Strongyloides among Canadian physicians that is associated with low rates of screening in high-risk populations.

Cutaneous leishmaniasis in travellers and migrants: a 10-year case series in a Canadian reference centre for tropical diseases.

BACKGROUND: Cutaneous leishmaniasis is increasingly encountered in returned travellers and migrants to nonendemic countries. We sought to describe the clinical characteristics and treatment outcomes of cases of cutaneous leishmaniasis diagnosed at our reference centre over a 10-year period. METHODS: This case series included all laboratory-confirmed cases of cutaneous leishmaniasis in travellers and migrants for whom complete clinical data were available, diagnosed between January 2008 and October 2018 at the J.D. MacLean Centre for Tropical Diseases in Montréal. We examined the number of cases each year. We used descriptive statistics to summarize variables (e.g., demographic characteristics, travel history, clinical presentation, diagnostic methods, treatments, adverse events) extracted from the patients' electronic medical records. The primary outcome for evaluating clinical response to treatment was defined as the complete re-epithelialization of the wound surface at 1 year. RESULTS: We identified 48 patients who received diagnoses of cutaneous leishmaniasis in the 10-year study period, including 33 exposed in the Americas and 15 exposed in other regions (median age 43.5 [range 1-75] yr); 28 [58%] males). The annual number of cases increased from 9 in 2008/09 to 16 in 2017/18. The median time from onset to diagnosis was 89 (IQR 58-134) days. Liposomal amphotericin B was the most commonly used initial treatment (20 [53%] patients). Thirty-five patients completed their follow-up, and 11 had successful response to 1 course of liposomal amphotericin B. Adverse events (including acute kidney injury, increased pancreatic enzymes and fatigue) were reported in 6 (30%) patients. Clinical cure was achieved within 1 year for 32 (91%) of the 35 patients who completed follow-up. INTERPRETATION: This study showed an increase in the number of cases of cutaneous leishmaniasis seen in our centre over the study period, likely because of increased travel and migration. This diagnosis should be considered in travellers and migrants with a chronic cutaneous lesion.

Patterns of illness in travelers visiting Mexico and Central America: the GeoSentinel experience.

BACKGROUND: Mexico and Central America are important travel destinations for North American and European travelers. There is limited information on regional differences in travel related morbidity. METHODS: We describe the morbidity among 4779 ill travelers returned from Mexico and Central America who were evaluated at GeoSentinel network clinics during December 1996 to February 2010. RESULTS: The most frequent presenting syndromes included acute and chronic diarrhea, dermatologic diseases, febrile systemic illness, and respiratory disease. A higher proportion of ill travelers from the United States had acute diarrhea, compared with their Canadian and European counterparts (odds ratio, 1.9; P < .0001). During the 2009 H1N1 influenza outbreak from March 2009 through February 2010, the proportionate morbidity (PM) associated with respiratory illnesses in ill travelers increased among those returned from Mexico, compared with prior years (196.0 cases per 1000 ill returned travelers vs 53.7 cases per 1000 ill returned travelers; P < .0001); the PM remained constant in the rest of Central America (57.3 cases per 1000 ill returned travelers). We identified 50 travelers returned from Mexico and Central America who developed influenza, including infection due to 2009 H1N1 strains and influenza-like illness. The overall risk of malaria was low; only 4 cases of malaria were acquired in Mexico (PM, 2.2 cases per 1000 ill returned travelers) in 13 years, compared with 18 from Honduras (PM, 79.6 cases per 1000 ill returned travelers) and 14 from Guatemala (PM, 34.4 cases per 1000 ill returned travelers) during the same period. Plasmodium vivax malaria was the most frequent malaria diagnosis. CONCLUSIONS: Travel medicine practitioners advising and treating travelers visiting these regions should dedicate special attention to vaccine-preventable illnesses and should consider the uncommon occurrence of acute hepatitis A, leptospirosis, neurocysticercosis, acute Chagas disease, onchocerciasis, mucocutaneous leishmaniasis, neurocysticercosis, HIV, malaria, and brucellosis.

Hospitalization for trichinellosis and echinococcosis in Canada, 2001-2005: the tip of the iceberg?

OBJECTIVES: This study was undertaken to measure the incidence of echinococcosis and trichinellosis hospitalization in Canada, and to compare these incidence rates between residents of northern regions and the rest of the Canadian population. METHODS: Cases hospitalized in 2001-2005 for either echinococcosis or trichinellosis were retrieved from the hospital morbidity database (HMDB) held by the Canadian Institute for Health Information. Crude and standardized incidence rates were calculated by province and by latitude range. RESULTS: A total of 108 echinococcosis and 14 trichinellosis hospitalizations were found, yielding incidence rates of 0.72 and 0.09 per million per year, respectively. There was a clear south-north gradient in the incidence of echinococcosis hospitalization, the highest incidence (2.9 per million per year) being found north of the 55th parallel. The risk of echinococcosis hospitalization was also significantly higher in women than in men (RR 1.92, 95% CI 1.29-2.87). For trichinellosis, the highest incidence (42 per million per year) was found in Nunavut and Northern Quebec. CONCLUSION: Incidence of hospitalization for echinococcosis and trichinellosis is low at the national level. However, significantly higher rates have been measured in northern regions of Canada despite the fact that both diseases are theoretically preventable and that a Trichinella control program is in place in Nunavik. Further efforts, probably educational in nature, will be required to reduce the incidence of these infections in high-risk areas.

Prolonged empirical antibiotic therapy is correlated with bloodstream infections and increased mortality in a tertiary care hospital in Ethiopia: bacteriology testing matters.

BACKGROUND: Hospital-associated infection (HAI) and antimicrobial resistance (AMR) are major health threats in low- and middle-income countries (LMICs). Because diagnostic capacity is lacking throughout most of Africa, patients are commonly managed with prolonged empirical antibiotic therapy. Our goal was to assess mortality in relation to HAI and empirical therapy in Ethiopia's largest referral hospital. METHODS: Cohort study of patients with suspected HAI at Tikur Anbessa Specialized Hospital from October 2016 to October 2018. Blood culture testing was performed on an automated platform. Primary outcomes were proportion of patients with bloodstream infection (BSI), antibiotic resistance patterns and 14 day mortality. We also assessed days of therapy (DOT) pre- and post-blood culture testing. RESULTS: Of 978 enrolled patients, 777 had blood culture testing; 237 (30%) had a BSI. Enterobacteriaceae were isolated in 49%; 81% of these were cephalosporin resistant and 23% were also carbapenem resistant. Mortality at 14 days was 31% and 21% in those with and without BSI, respectively. Ceftriaxone resistance was strongly correlated with mortality. Patients with BSI had longer DOT pre-blood culture testing compared with those without BSI (median DOT 12 versus 3 days, respectively, P < 0.0001). After testing, DOT were comparable between the two groups (20 versus 18 days, respectively). CONCLUSIONS: BSI are frequent and fatal among patients with suspected HAI in Ethiopia. Highly resistant blood isolates are alarmingly common. This study provides evidence that investing in systematic blood culture testing in LMICs identifies patients at highest risk of death and that empirical management is frequently inappropriate. Major investments in laboratory development are critical to achieve better outcomes.

A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality.

BACKGROUND: In March 2003, several hospitals in Quebec, Canada, noted a marked increase in the incidence of Clostridium difficile-associated diarrhea. METHODS: In 2004 we conducted a prospective study at 12 Quebec hospitals to determine the incidence of nosocomial C. difficile-associated diarrhea and its complications and a case-control study to identify risk factors for the disease. Isolates of C. difficile were typed by pulsed-field gel electrophoresis and analyzed for binary toxin genes and partial deletions in the toxin A and B repressor gene tcdC. Antimicrobial susceptibility was evaluated in a subgroup of isolates. RESULTS: A total of 1703 patients with 1719 episodes of nosocomial C. difficile-associated diarrhea were identified. The incidence was 22.5 per 1000 admissions. The 30-day attributable mortality rate was 6.9 percent. Case patients were more likely than matched controls to have received fluoroquinolones (odds ratio, 3.9; 95 percent confidence interval, 2.3 to 6.6) or cephalosporins (odds ratio, 3.8; 95 percent confidence interval, 2.2 to 6.6). A predominant strain, resistant to fluoroquinolones, was found in 129 of 157 isolates (82.2 percent), and the binary toxin genes and partial deletions in the tcdC gene were present in 132 isolates (84.1 percent). CONCLUSIONS: A strain of C. difficile that was resistant to fluoroquinolones and had binary toxin and a partial deletion of the tcdC gene was responsible for this outbreak of C. difficile-associated diarrhea. Exposure to fluoroquinolones or cephalosporins was a risk factor.

Seroprevalence of zoonoses in a Cree community (Canada).

Cree trappers and hunters are at risk for contracting infectious diseases conveyed by wildlife. We performed a study in a Cree community (Canada) to determine the seroprevalence of 8 zoonotic infections among hunters and trappers for evidence of exposure to Trichinella sp., Toxoplasma gondii, Toxocara canis, Echinococcus granulosus, Leptospira sp., Coxiella burnetii, Francisella tularensis, and Sin Nombre virus. A total of 50 participants (28 women and 22 men) were included in this study. Results indicate no or infrequent exposure to the Sin Nombre virus (0%) and 3 of the 4 parasites investigated (0-4%). Exposure to T. gondii (10%) and some bacteria appeared to be more prevalent (range, 4-18%). Overall, seropositivity was related to fishing, hunting, and trapping activities. Physicians should be aware of these infections in this population, particularly Q fever, tularemia, and leptospirosis.