Mapping Proximity to Infectious Disease Physicians Across the United States.

Enduring shortages of infectious disease physicians across the United States continue despite efforts to mitigate the problem. The recent fellowship match results underscore the difficulty in rectifying that shortage. Our report sheds light on the current geographic distribution of US infectious disease physicians and highlights the challenges faced by rural communities.

Unravelling the mystery of a rare infection: a challenging case of pulmonary sequestration with Mycobacterium avium complex and the importance of a thorough microbiological investigation.

Pulmonary sequestration is a rare congenital condition. It is a dysplastic lung tissue with a separate systemic blood supply and without a bronchial tree connection. The emergence of a superimposed infection can lead to its diagnosis, such as Staphylococcus aureus, Pseudomonas aeruginosa, Nocardia asteroids and Aspergillus sp pneumonia. Mycobacterium avium complex (MAC) superimposed disease is exceedingly rare. We report a case of a man in his third decade without known medical disorders presenting with a persistent cough. After an extensive microbiological workup, an MAC infection was diagnosed. An elevated carbohydrate antigen 19-9 (CA 19-9) was also noted. He was treated with antimycobacterial therapy and lobectomy resulting in clinical improvement and CA19-9 normalisation. This case illustrates the value of comprehensive microbiological investigations in patients with chronic respiratory symptoms and imaging findings that are not typical of bacterial pneumonia. Clinical studies remain needed to investigate the utility of CA 19-9 in a scoring system to guide MAC therapy.

Rapid Onset Severe Immune Thrombocytopenia following mRNA COVID-19 Vaccine in a Young Patient.

The coronavirus disease 2019 (COVID-19) pandemic has affected millions of people around the world. Vaccination against COVID-19 has been approved for the following three vaccines in the United States: Pfizer-BioNTech, Moderna, and Janssen. Hematological complications of vaccination have been reported in the literature but remain as a rare phenomenon. We present the case of a patient who developed severe thrombocytopenia within twenty-four hours following the Pfizer-BioNTech vaccination. Commonly encountered differentials including heparin-induced thrombocytopenia and common viral etiologies were ruled out, and other causes such as drug reactions deemed unlikely as the etiology of this presentation after a broad workup. Nucleocapsid antibodies against COVID-19 were found to be positive which indicated that vaccination was at least the second encounter with this virus for our patient, which has been reported previously as the cause of immune thrombocytopenia (ITP), and this might be the culprit for sudden onset. He responded to the first-line ITP treatment with corticosteroids and intravenous immunoglobulin (IVIG) as evidenced by the fast recovery of platelet count and lack of recurrence of thrombocytopenia.

Efficacy of Tocilizumab in Patients Hospitalized with Covid-19.

BACKGROUND: The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear. METHODS: We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses. RESULTS: We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo. CONCLUSIONS: Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).

Opportunities to Improve Antibiotic Appropriateness in U.S. ICUs: A Multicenter Evaluation.

OBJECTIVES: To use a standardized tool for a multicenter assessment of antibiotic appropriateness in ICUs and identify local antibiotic stewardship improvement opportunities. DESIGN: Pilot point prevalence conducted on October 5, 2016; point prevalence survey conducted on March 1, 2017. SETTING: ICUs in 12 U.S. acute care hospitals with median bed size 563. PATIENTS: Receiving antibiotics on participating units on March 1, 2017. INTERVENTIONS: The Centers for Disease Control and Prevention tool for the Assessment of Appropriateness of Inpatient Antibiotics was made actionable by an expert antibiotic stewardship panel and implemented across hospitals. Data were collected by antibiotic stewardship program personnel at each hospital, deidentified and submitted in aggregate for benchmarking. hospital personnel identified most salient reasons for inappropriate use by category and agent. MEASUREMENTS AND MAIN RESULTS: Forty-seven ICUs participated. Most hospitals (83%) identified as teaching with median licensed ICU beds of 70. On March 1, 2017, 362 (54%) of 667 ICU patients were on antibiotics (range, 8-81 patients); of these, 112 (31%) were identified as inappropriate and administered greater than 72 hours among all 12 hospitals (range, 9-82%). Prophylactic antibiotic regimens and PICU patients demonstrated a statistically significant risk ratio of 1.76 and 1.90 for inappropriate treatment, respectively. Reasons for inappropriate use included unnecessarily broad spectrum (29%), no infection or nonbacterial syndrome (22%), and duration longer than necessary (21%). Of patients on inappropriate antibiotic therapy in surgical ICUs, a statistically significant risk ratio of 2.59 was calculated for noninfectious or nonbacterial reasons for inappropriate therapy. CONCLUSIONS: In this multicenter point prevalence study, 31% of ICU antibiotic regimens were inappropriate; prophylactic regimens were often inappropriate across different ICU types, particularly in surgical ICUs. Engaging intensivists in antibiotic stewardship program efforts is crucial to sustain the efficacy of antibiotics and quality of infectious diseases care in critical care settings. This study underscores the value of standardized assessment tools and benchmarking to be shared with local leaders for targeted antibiotic stewardship program interventions.

Oxacillin-induced leukocytoclastic vasculitis.

Leukocytoclastic vasculitis (LCV) refers to a histopathological pattern of neutrophil predominant inflammatory process of small vessels associated with fibrinoid necrosis. Cutaneous LCV usually presents as symmetrically distributed palpable purpuric nodules of the lower extremities with or without systemic involvement. Although 50% of LCV cases are idiopathic, it can be secondary to identifiable causes such as malignancy, autoimmune conditions, infections, and medications. Medications have been implicated in up to 25% of cases; sulfonamides, NSAIDs, and beta-lactams have the most frequent association. We herein present a 32-year-old female who developed palpable purpura over hands and lower limbs 12 days after exposure to oxacillin administered for infective endocarditis. Punch biopsy from the skin lesions confirmed the diagnosis of LCV. Given the temporal relationship between oxacillin administration and development of skin findings, the diagnosis of oxacillin-associated LCV was suspected. Discontinuation of drug resulted in resolution of the lesions confirming the diagnosis. To our knowledge, this is the second case of oxacillin-induced cutaneous LCV described in literature.

Streptococcus pluranimalium infective endocarditis and brain abscess.

Infective endocarditis is an infection of the endocardium of the heart typically seen in individuals with underlying risk factors. We report a rare case of Streptococcus pluranimalium bacteremia causing infective endocarditis and brain abscess. Only 3 cases were reported in the literature on infective endocarditis in patients secondary to S. pluranimalium.

Microbiological evaluation of infected pelvic lymphocele after robotic prostatectomy: potential predictors for culture positivity and selection of the best empirical antimicrobial therapy.

OBJECTIVES: To examine symptomatology and microbiology of infected lymphocele (LC) post-robotic-assisted radical prostatectomy and pelvic lymph node dissection (PLND) and to assess for potential predictors for LC fluid culture positivity. Secondly, to provide general recommendations about use of select antimicrobial therapy. METHODS: This was a single-center, IRB-approved, retrospective, case series review conducted between October 2008 and October 2014. Data included symptomatology, microbiology of symptomatic LC in men post-robotic prostatectomy and PLND. Those with infected LC were compared to those men with symptomatic LC in the absence of infection. RESULTS: Symptomatic LC was seen in 7% of men, and among those, infected LC was seen in 42%. Infected LC cultures showed predominance of G+ cocci such as S. aureus, coagulase-negative Staphylococcus species, S. pyogenes, S. fecalis and S. viridans. Monomicrobial infection was seen in 85%. Multivariate logistic regression showed leukocytosis [Odds: 12.3, p = 0.03, 95% CI (1.2-125)] was significant predictor for culture positivity, whereas trend toward significance for factors such CT findings of thickened walls around the LC +/- air. CONCLUSIONS: LC infection following PLND for prostate cancer is usually monomicrobial and caused by Gram+ cocci. GI tract and skin flora are the main habitat. High index of suspicion of infected LC is undertaken in the presence of leukocytosis, fever and abnormal CT findings. Based upon our local hospital antibiogram, combination of IV ampicillin/sulbactam and vancomycin is suggested as the best initial empiric therapy in treating these patients.

Anaphylactoid reaction considered ciprofloxacin related: a case report and literature review.

BACKGROUND: Although ciprofloxacin is a generally well-tolerated fluoroquinolone antibiotic, serious and life-threatening adverse events such as anaphylaxis and pulmonary edema have been described with its use. However, there is a lack of data in the scientific literature regarding these events. OBJECTIVES: This report describes a case of an anaphylactoid reaction, considered probably ciprofloxacin related, that manifested as angioedema and later as pulmonary edema. This report also summarizes the available scientific evidence regarding the epidemiology, pathogenesis, and outcome of ciprofloxacin-associated anaphylactoid reactions. METHODS: Previously reported cases were identified using a search of MEDLINE and EMBASE (years: 1960-June 2009; English-language articles; search terms: ciprofloxacin, anaphylactoid reaction, anaphylaxis, angioedema, and pulmonary edema). The references cited in these articles were examined to identify additional reports. CASE SUMMARY/RESULTS: A 25-year-old healthy white woman with a weight of 65 kg and normal renal function presented with pyelonephritis. She was administered ciprofloxacin 500 mg BID PO and ibuprofen 400 mg q6h PO as needed for pain control. The following day, angioedema and pulmonary edema developed and were thought to be probably associated with ciprofloxacin use (Naranjo adverse drug reaction probability scale score, 6). Ciprofloxacin treatment was discontinued and supportive care with ceftriaxone 1 g/d IV was provided, and the patient recovered after 1 week of hospitalization. The adverse drug reactions associated with the intake of fluoroquinolones most commonly affect the gastrointestinal system, central nervous system, and skin. The literature search identified 64 cases of anaphylactoid reaction considered probably ciprofloxacin related. Forty-two of these cases were described in large studies, with no detailed data reported. Detailed information on the dose of ciprofloxacin, the time period between ciprofloxacin administration and anaphylactoid reaction, clinical manifestations, and outcomes of these reactions was available in 22 cases described in case reports. Twelve of these cases were described in HIV- patients; 10 cases were described in HIV+ patients. All of the patients recovered, with the exception of 2 patients with HIV infection, who died (unknown cause of death in 1 case and toxoplasma encephalitis in the other case). Fourteen patients (including all of the patients with HIV infection) required hospitalization in the intensive care unit. According to the manufacturer of ciprofloxacin, pulmonary edema has been described as an adverse event associated with ciprofloxacin in <1% of treated patients. However, a search of the MEDLINE and EMBASE databases did not identify any documented reports of ciprofloxacin-associated pulmonary edema. CONCLUSIONS: The patient described in this case report experienced an anaphylactoid reaction likely associated with ciprofloxacin use. Although anaphylactoid/ anaphylactic reactions are uncommon (<5% of cases) adverse events associated with ciprofloxacin and other fluoroquinolones, clinicians should be aware of this potentially life-threatening event, which might also lead to pulmonary edema even in the setting of normal renal function.

Listeria endocarditis in a patient with psoriatic arthritis on infliximab: are biologic agents as treatment for inflammatory arthritis increasing the incidence of Listeria infections?

The use of anti-tumor necrosis factor agents such as infliximab as treatment modalities of inflammatory joint diseases has widely spread over the past few years. However, increasing numbers of reports of infectious complications during TNF-a blockade have also highlighted the fact that an increased rate of sometimes life-threatening complications may be the price paid for superior therapeutic efficacy. We report the first case report of Listeria endocarditis associated with infliximab use and the second published case of Listeria infection associated with infliximab in patients with psoriatic arthritis. We also summarize the literature regarding the association of Listeria infection with use of infliximab. Further studies are needed to elucidate the contribution of anti-TNF-a therapy to development of listeriosis. Physicians should be aware of the possibility of Listeria infection in individuals receiving anti-TNF therapy.

Cytomegalovirus pseudotumor of the duodenum in a patient with AIDS: an unrecognized and potentially treatable clinical entity.

BACKGROUND: Cytomegalovirus (CMV) is a common pathogen affecting the gastrointestinal tract in patients with AIDS. We report a case of CMV-induced pseudotumor of the duodenum in a patient with AIDS and review other reported cases of CMV-induced pseudotumors in the gastrointestinal tract. CMV-induced pseudotumor in patients with AIDS is an exceptionally rare clinical entity, and to our knowledge no reports have previously summarized this clinical entity. METHODS: All previous cases included in our literature review were found using a PubMed search (1980-November 2008) of the English-language medical literature applying the terms 'CMV infection', 'inflammatory mass', 'pseudotumor', and 'gastrointestinal tract'. The references cited in these articles were examined to identify additional reports. RESULTS: Although CMV-induced duodenitis has been described in patients with HIV infection, to our knowledge CMV-induced pseudotumor of the duodenum has not been previously reported in the literature. We describe the first case of an AIDS patient with CMV pseudotumor responding to oral treatment with valganciclovir with complete resolution of the CMV mass. Among reports of non-duodenal pseudotumor reported in the English literature, we found only 14 cases of CMV-induced gastrointestinal pseudotumors in HIV-positive patients. The clinical manifestations, pathologic findings of the CMV pseudotumors, as well as the treatment and outcome of these HIV patients are reviewed. CONCLUSION: CMV pseudotumor should be included in the differential diagnosis of gastrointestinal mass lesions in AIDS patients and in other immunocompromised patients. The tumor often responds to antiviral therapy, but resolution of a CMV mass as a result of oral antiviral therapy has not been previously described. Since pseudotumors secondary to CMV often respond to medical treatment, it is important that the physicians treating severely immunocompromised patients are aware of this entity.

Underestimation of HIV-1 plasma viral burden in patients who acquire infection abroad: the experience in a community hospital clinic.

In a suburban teaching hospital clinic, we diagnosed human immunodeficiency virus type 1 (HIV-1) infection in 10 patients who acquired the infection in Africa or Asia. All the patients had low viral plasma HIV RNA levels. This finding likely represents underestimation of true plasma viral burden in patients infected with non-B serotypes of HIV-1. Clinicians caring for immigrants with HIV infection need to be aware of the limitations of current commercial assays for the quantification of HIV-1 plasma viral burden, and better assays are needed for non-B HIV-1 serotypes.