Genital Herpes Disclosure Attitudes Among Men Who Have Sex with Men.

An abundance of literature interested in sexually transmitted infections-related disclosure attitudes among MSM (men who have sex with men) exists. However, comparatively few studies have examined these with respect to genital herpes. This cross-sectional study examined attitudes about herpes-related disclosure among Houston MSM. Convenience sampling at Houston-based MSM venues and events was conducted during December 2018 and January 2019 with 302 participants recruited. Participants were asked if an individual with genital herpes should disclose to others and if they would disclose to others if they had/have genital herpes. Factors associated with decreased belief that someone should disclose a genital herpes infection to others were history of genital herpes (OR 0.14, 95% CI [0.04, 0.55]) and race other than white, black, or Hispanic/Latino (OR 0.34, 95% CI [0.15, 0.77]). History of 0 to 1 sexual partner(s) in the past year was associated with increased belief that an individual should disclose (OR 2.43, 95% CI [1.19, 4.98]), while self-reported history of genital herpes was associated with decreased intent to disclose one's own infection to potential partners (OR 0.30, 95% CI [0.10, 0.91]). Self-reported history of genital herpes was associated with decreased belief that someone with genital herpes should tell others and with decreased likelihood to disclose one's own status. Lastly, race other than white, black, or Hispanic/Latino was associated with increased belief that someone with genital herpes should not tell others. Normalization of genital herpes could bolster intent to disclose genital herpes infection and improve sexual outcomes.

Hurricane-Associated Mold Exposures Among Patients at Risk for Invasive Mold Infections After Hurricane Harvey - Houston, Texas, 2017.

In August 2017, Hurricane Harvey caused unprecedented flooding and devastation to the Houston metropolitan area (1). Mold exposure was a serious concern because investigations after Hurricanes Katrina and Rita (2005) had documented extensive mold growth in flood-damaged homes (2,3). Because mold exposure can cause serious illnesses known as invasive mold infections (4,5), and immunosuppressed persons are at high risk for these infections (6,7), several federal agencies recommend that immunosuppressed persons avoid mold-contaminated sites (8,9). To assess the extent of exposure to mold and flood-damaged areas among persons at high risk for invasive mold infections after Hurricane Harvey, CDC and Texas health officials conducted a survey among 103 immunosuppressed residents in Houston. Approximately half of the participants (50) engaged in cleanup of mold and water-damaged areas; these activities included heavy cleanup (23), such as removing furniture or removing drywall, or light cleanup (27), such as wiping down walls or retrieving personal items. Among immunosuppressed persons who performed heavy cleanup, 43% reported wearing a respirator, as did 8% who performed light cleanup. One participant reported wearing all personal protective equipment (PPE) recommended for otherwise healthy persons (i.e., respirator, boots, goggles, and gloves). Immunosuppressed residents who are at high risk for invasive mold infections were exposed to mold and flood-damaged areas after Hurricane Harvey; recommendations from health care providers to avoid exposure to mold and flood-damaged areas could mitigate the risk to immunosuppressed persons.

Clinical failure with and without empiric atypical bacteria coverage in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis.

BACKGROUND: Both typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a ß-lactam) to a regimen without atypical antibiotic coverage (ß-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints). METHODS: We searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I 2 ) was observed. RESULTS: Five RCTs with a total of 2011 patients were retained. A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732-0.99; P = 0.037]; I 2  = 0%). The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259-1.165, P = 0.118], I 2  = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523-1.272, P = 0.369], I 2  = 0%), diarrhea (RR = 0.746 [95% CI, 0.311-1.790, P = 0.512], I 2  = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542-1.270, P = 0.39], I 2  = 0%). CONCLUSIONS: Empiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP. Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage. Our findings provide support for the current guidelines recommendations to include empiric atypical coverage.

Short versus long course of antibiotics for catheter-associated urinary tract infections in patients with spinal cord injury: a randomized controlled noninferiority trial.

OBJECTIVE: To assess the applicability of a short-course regimen of antibiotics for managing catheter-associated urinary tract infection (CA-UTI) in patients with spinal cord injury (SCI). DESIGN: Randomized, controlled, noninferiority trial. SETTING: Medical center. PARTICIPANTS: Patients with SCI who had CA-UTI (N=61). INTERVENTIONS: Patients were randomized to receive either a 5-day regimen of antibiotics after catheter exchange (experimental group) or a 10-day regimen of antibiotics with catheter retention (control group). Noninferiority was prespecified with a margin of 10%. MAIN OUTCOME MEASURE: Clinical cure at the end of therapy. RESULTS: Of the 61 patients enrolled in this study, 6 patients were excluded because of bacteremia or absence of urinary symptoms. All patients (100%) achieved clinical cure at the end of therapy. The rates of microbiologic response were 82.1% in the experimental group and 88.9% in the control group (upper boundary 95% confidence interval (CI) for difference, 26%). The rates of resolution of pyuria were 89.3% in the experimental group and 88.9% in the control group (upper boundary 95% CI for difference, 16%). Patients in the experimental group had higher rates of CA-UTI recurrence than the control group. The rates of new CA-UTI, diarrhea, and Clostridium difficile colitis were similar in the 2 treatment arms. CONCLUSIONS: The primary endpoint of the study was met, indicating that the 5-day regimen with catheter exchange was noninferior to the 10-day regimen with catheter retention on the basis of clinical cure. Criteria for noninferiority on the basis of microbiologic response and resolution of pyuria were not met.

Eosinophilia and associated factors in a large cohort of patients infected with human immunodeficiency virus.

OBJECTIVES: To determine the prevalence of eosinophilia among antiretroviral therapy (ART)-naïve patients infected with human immunodeficiency virus (HIV) and to identify variables associated with eosinophilia. METHODS: We included all ART-naïve HIV-infected patients entering into care at the Thomas Street Health Center (Houston, Texas) between February 2007 and January 2009. Eosinophilia was defined as absolute eosinophil count ≥ 400 cells per cubic millimeter. Patients with eosinophilia (cases) at baseline were matched to patients without baseline eosinophilia (controls). Clinical and laboratory data were collected for cases and controls. Variables associated with eosinophilia were evaluated by univariate and multivariate analyses. RESULTS: Sixty-five (9.7%) of 671 ART-naïve patients had eosinophilia. There was no difference in age, sex, race, or baseline CD4 count between patients with and without eosinophilia; however, patients with eosinophilia were more likely to have higher HIV RNA viral loads (5.05 vs 4.82 log10 copies per milliliter; P = 0.019). A total of 52 (80%) of 65 patients with eosinophilia (cases) had at least two follow-up clinic visits. They were matched to 104 controls. Skin rash was the only variable associated with eosinophilia (odds ratio 2.16, 95% confidence interval 1.04-4.47) in our multivariate analysis. Of eight cases tested, only one, from Central America, had a parasitic infection (hookworm). Thirty-eight (73.1%) patients experienced resolution of their eosinophilia by the end of the study (mean follow-up 1019 days). Resolution of eosinophilia did not differ between patients with and without HIV viral suppression. CONCLUSIONS: Eosinophilia is not an infrequent occurrence among ART-naïve HIV-infected patients. Patients with eosinophilia are more likely than patients without eosinophilia to present with a skin rash. HIV RNA viral suppression did not necessarily result in the resolution of eosinophilia. Extensive workup for eosinophilia may not be necessary in most cases.

The impact of direct inoculation of ascites into blood culture bottles on ascites culture positivity.

Objective: Assess whether direct inoculation of ascites into blood culture bottles would improve ascites culture yield. Design: Pre-post-study. Setting: The study was performed at a quaternary academic medical center in Houston, Texas, including all inpatient and emergency department encounters. Patients: Ascites cultures collected from November 2020 to December 2022 were reviewed and screened for spontaneous bacterial peritonitis. Patients were excluded if a prior ascites culture from the same patient was already included in the study or if there was evidence of secondary bacterial peritonitis. Intervention: In the pre-intervention period, ascites cultures were collected into a sterile container and inoculated onto/into solid and liquid media. In the post-intervention period, ascites cultures were instead directly inoculated into bioMérieux© blood culture bottles at the bedside. Results: 114 patients met inclusion and exclusion criteria, 61 pre-intervention and 53 post-intervention. Overall ascites culture positivity was 15.8% (18/114), 11.5% (7/61) pre-intervention vs 20.8% (11/53) post-intervention. After adjusting for confounders, the intervention had a trend toward a significant effect on ascites culture positivity (P = 0.077). No significant differences were seen in time to positivity, hospital length of stay, or 30-day readmission. Conclusions: Direct inoculation of ascitic fluid into blood culture bottles led to a small increase in culture yield but lacked statistical significance. This lack of significance may be due to the study being underpowered. Further studies are required to investigate if this is due to procedural inefficiencies (eg, inadequate inoculation volumes) or pragmatic clinical practice considerations (ie, high rates of pre-culture antibiotics).

Analyzing the relationship between socioeconomic deprivation and outpatient Medicare Part D fluoroquinolone claim rates in Texas.

Introduction: Only a few studies have assessed the relationship between deprivation and excessive antibiotic use. In Texas, antimicrobial prescription rates are particularly high compared with the rest of the US. This study analyzed the association between local area socioeconomic deprivation and providers' fluoroquinolone claim rates among beneficiaries 65 years and older in Texas. Methods: This ecological study utilized provider- and area-level data from Medicare Part D Prescribers and the Social Deprivation Index (SDI) repositories. Negative binomial regression models were employed to evaluate the relationship between provider- and area-level characteristics (prescriber's gender, specialty, rural-urban community area, beneficiaries' demographics, area-level population, and SDI) and fluoroquinolone claim rates per 1,000 beneficiaries. Results: A total of 11,996 providers were included. SDI (IRR 0.98, 95% CI 0.97-0.99) and male providers (IRR 0.96, 95% CI 0.94-0.99) were inversely associated with claim rates. In contrast, several factors were associated with higher claim rates, including non-metropolitan areas (1.04, 95% CI 1.00-1.09), and practices with a high proportion of male (IRR 1.12, 95% CI 1.10-1.14), Black (IRR 1.05, 95% CI 1.03-1.07), or Medicaid beneficiaries (IRR 1.15, 95% CI 1.12-1.17). Effect modification was observed between SDI and rurality, with higher SDI in non-metropolitan areas associated with higher claim rates, whereas SDI in metropolitan areas was inversely related to claim rates. Conclusion: Lower fluoroquinolone claim rates were observed among Texas Medicare providers in metropolitan areas with higher SDI. Conversely, higher rates were observed in rural areas with higher SDI. More studies are needed to understand the underlying causes of this variation and develop effective stewardship interventions.

Detection of invasive Bartonella infections with next-generation sequencing of microbial cell-free DNA.

We report 9 patients with invasive Bartonella infections, including 5 with endocarditis, who were diagnosed with microbial cell-free DNA next-generation sequencing and Bartonella serology studies. Diagnosis with plasma mcfDNA NGS enabled a faster clinical and laboratory diagnosis in 8 patients. Prompt diagnosis impacted antibiotic management in all 9 patients.

Clinical utility of metagenomic next-generation sequencing in fever of undetermined origin.

Background: Metagenomic next-generation sequencing (mNGS) is a novel diagnostic tool increasingly used in the field of infectious diseases. Little guidance is available regarding its appropriate use in different patient populations and clinical syndromes. We aimed to review the clinical utility of mNGS in patients with a specific clinical syndrome and identify factors that may increase its utility. Methods: We retrospectively reviewed charts of 72 non-immunocompromised adults hospitalized with the clinical syndrome of 'fever of undetermined origin' and underwent mNGS testing. Standardized criteria from a previously published study were used to determine the clinical impact of mNGS testing. We applied logistic regression to identify factors associated with a positive clinical impact. Results: Of the 72 patients identified, 62.5% were males with a median age of 56. All patients had a fever at the time of evaluation. At least one organism was identified in 65.3% of cases; most commonly were Epstein-Barr virus (13.9%), cytomegalovirus (12.5%), and Rickettsia typhi (11.1%). Of those determined to have an infectious etiology of their febrile syndrome, 89.5% (n = 34/38) had a positive mNGS. Consistency between the organism(s) on mNGS and the clinically determined infectious etiology was 82.4%. mNGS had a positive clinical impact in 40.3% of cases, a negative impact in 2.8%, and no impact in 56.9% of cases. Besides age, we did not identify other factors associated with a higher likelihood of positive clinical impact. Conclusion: In our review, mNGS had a positive clinical impact in a large proportion of adults with fever of undetermined origin, with minimal negative impact. However, mNGS results should be interpreted carefully given the high rate of detection of pathogens of unclear clinical significance. Randomized clinical trials are needed to assess the clinical utility of this novel diagnostic tool.

Clinical utility of metagenomic next-generation sequencing in fever of undetermined origin In this study, we evaluated the use of a new diagnostic tool, namely, metagenomic next generation sequencing (mNGS), in hospitalized, non-immunocompromised, adult patients with a fever that was otherwise unexplained. We reviewed the clinical utility of this tool in 72 patients and found that at least one organism was found in 65.3% of cases, with the 2 most common organisms being viruses. In patients who were found to have an infection as the cause of their fever, 89.5% had a positive mNGS study. In 82.4% of cases, the infectious organism(s) found on mNGS was the organism thought to be the cause of the fever. Based on definitions from another study, mNGS had a positive clinical impact in 40.3% of cases, a negative impact in 2.8%, and no impact in 56.9% of cases. This study suggests that mNGS has minimal negative impact and can be a useful tool in identifying a causative infectious organism in patients with unexplained fevers. Additional studies are needed to identify patients and clinical conditions that would most benefit from this tool.

Discontinuation of contact precautions in patients with hospital-acquired MRSA and VRE infections during the COVID-19 pandemic: A multi-center experience.

Variations in the literature support the benefit of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections in the hospital setting. During personal protective equipment shortages throughout the COVID-19 pandemic, contact precautions were discontinued for MRSA and VRE-infected patients. Rates of hospital-acquired MRSA and VRE infections were compared before and after this intervention, along with hand hygiene proportions. Contact precaution discontinuation did not lead to an increase in hospital-acquired MRSA or VRE infections.

Assessing clinicians' and trainees' knowledge and practice of the IDSA guidelines for asymptomatic bacteriuria in older adults.

A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.

Comparison of complication types in patients receiving vesicant intravenous antimicrobials or vasopressors via midlines and peripherally inserted central catheters.

We assessed adverse events in hospitalized patients receiving selected vesicant antibiotics or vasopressors administered through midline catheters or peripherally inserted central catheters (PICC). The rates of catheter-related bloodstream infections, thrombosis, and overall events were similar across the two groups, while occlusion was higher in the PICC group.

The impact of a blood-culture diagnostic stewardship intervention on utilization rates and antimicrobial stewardship.

Blood-culture overutilization is associated with increased cost and excessive antimicrobial use. We implemented an intervention in the adult intensive care unit (ICU), combining education based on the DISTRIBUTE algorithm and restriction to infectious diseases and ICU providers. Our intervention led to reduced blood-culture utilization without affecting safety metrics.

Clinical significance of Staphylococcus aureus bacteriuria at a tertiary care hospital.

OBJECTIVES: Staphylococcus aureus bacteriuria has been associated with invasive S. aureus disease. The current project describes the clinical significance of S. aureus bacteriuria. METHODS: We conducted a retrospective chart review of patients who had S. aureus bacteriuria at the Michael E. DeBakey Veterans Affairs Medical Center, 2008-2010. RESULTS: A total of 326 patients were included. Invasive S. aureus disease was documented within 12 months of bacteriuria in 56 patients (22.3% of methicillin-resistant S. aureus (MRSA) cases and 8.4% of methicillin-sensitive S. aureus (MSSA), p = 0.002). Multiple logistic regression indicated that MRSA bacteriuria (odds ratio (OR) 2.91, p = 0.010), absence of symptoms suggestive of a urinary tract infection (UTI) (OR 3.21, p = 0.019), inpatient status (OR 4.72, p = 0.003), and receipt of antibiotics active against S. aureus (OR 6.41, p < 0.001) were significantly associated with the presence of invasive S. aureus disease. Seventy-seven patients (23.6%) died within 12 months of the documented S. aureus bacteriuria. Age (OR 1.02, p = 0.025), absence of pyuria (OR 2.00, p = 0.029), the presence of invasive S. aureus disease (OR 2.05, p = 0.033), and inpatient status (OR 3.62, p < 0.001) were significantly associated with death. CONCLUSIONS: S. aureus bacteriuria is associated with significant morbidity and mortality. Patients without UTI symptoms, those with MRSA bacteriuria, and those without pyuria were more to likely to have worse outcomes (invasive S. aureus disease or death). Obtaining blood cultures should be considered in these cases.

Designing a Local Policy to Reduce HIV in Mexico City.

The Joint United Nations Program on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (Joint United Nations Program on HIV/AIDS, UNAIDS) has recommended 90-90-90 goals to increase the number of patients who are aware of their status, on antiretroviral therapy, and have undetectable viral loads. Mexico City has made several achievements to aid in prevention, early diagnosis, and treatment; however, the incidence of HIV has not decreased over the past decade. This article reviews global initiatives that were successful in achieving some or all these metrics and provide a road map for Mexico to reach the desired goals.

Understanding the Gap Between Nursing Workforce in the United States and Population Needs-A Policy Brief.

Purpose This report is intended to analyze the root causes for the current gap between the nursing workforce and population needs in the United States. It aims to consolidate what is known about these contributing reasons and provide evidence-based recommendations for action. Methods The report utilized the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework to develop the research question and the 5 Whys methodology for the root cause analysis. Results This report highlighted six major causative problems, including workforce market mismatch, poor financing design, inadequate governance, flawed technologies, insufficient research, and suboptimal service delivery. A detailed evaluation of root causes with supported evidence is presented. Conclusion The report provided seven actionable recommendations based on the analysis: (1) strengthening the nursing role in advancing equity, (2) investing in nursing well-being, (3) changing policies and payment structure, (4) including nursing in technology design, (5) strengthening nursing education, (6) developing a robust public health emergencies preparedness plan, and (7) investing in relevant research.

The Impact of Initial Specimen Diversion Systems on Blood Culture Contamination.

Blood culture contamination is associated with increased antimicrobial use, length of stay, and hospital cost. To address this problem, blood culture diversion has been developed as an additional measure to reduce contamination to targeted goals. Three different versions were proposed, including an open technique and 2 commercially available devices. This study aims to review the existing literature and analyze evidence for these 3 techniques.

The effect of a plasma next-generation sequencing test on antimicrobial management in immunocompetent and immunocompromised patients-A single-center retrospective study.

Objective: To describe the use of next-generation sequencing (NGS) and to determine whether NGS leads to changes in antimicrobial management. Design and setting: This retrospective cohort study included patients aged ≥18 years admitted to a single tertiary-care center in Houston, Texas, with an NGS test performed between January 1, 2017, and December 31, 2018. Patients: In total, 167 NGS tests were performed. Most patients were of non-Hispanic ethnicity (n = 129), white (n = 106), and male (n = 116), with a mean age of 52 years (SD, 16). Moreover, 61 patients were immunocompromised: solid-organ transplant (n = 30), patients with human immunodeficiency virus (n = 14), and rheumatology patients on immunosuppressive therapy (n = 12). Results: Of the 167 NGS tests performed, 118 (71%) were positive. Test results associated with a change in antimicrobial management were found in 120 (72%) of 167 cases, with an average of 0.32 (SD, 1.57) fewer antimicrobials after the test. The largest change in antimicrobial management was in glycopeptide use (36 discontinuations) followed by antimycobacterial drug use (27 additions among 8 patients). Also, 49 patients had negative NGS results, but only 36 patients had their antibiotics discontinued. Conclusions: Plasma NGS testing is associated with a change in antimicrobial management in most cases. We observed a decrease in glycopeptide use after NGS results, which highlights physicians' comfort in withdrawing methicillin-resistant Staphylococcus aureus (MRSA) coverage. In addition, antimycobacterial coverage increased, corresponding with early mycobacterial detection by NGS. Further studies are needed to determine effective ways to use NGS testing as an antimicrobial stewardship tool.

Impact of gastrointestinal polymerase chain reaction panels on antibiotic utilization in hospitalized adult patients.

Multiplex stool polymerase chain reaction (PCR) panels offer rapid comprehensive testing for patients with infectious diarrhea. We compared antibiotic utilization among hospitalized patients with suspected infectious diarrhea who underwent diagnostic testing with either a stool culture or stool PCR panel. No significant differences in antibiotic utilization were identified.

Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship.

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.