Teaching and Safety-Net Hospital Penalization in the Hospital-Acquired Condition Reduction Program.

Importance: The Hospital-Acquired Condition Reduction Program (HACRP) evaluates acute care hospitals on the occurrence of patient safety events and health care-associated infections. Since its implementation, several studies have raised concerns about the overpenalization of teaching and safety-net hospitals, and although several changes in the program's methodology have been applied in the last few years, whether these changes reversed the overpenalization of teaching and safety-net hospitals is unknown. Objective: To determine hospital characteristics associated with HACRP penalization and penalization reversal. Design, Setting, and Participants: This retrospective cross-sectional study assessed data from 3117 acute care hospitals participating in the HACRP. The HACRP penalization and hospital characteristics were obtained from Hospital Compare (2020 and 2021), the Inpatient Prospective Payment System impact file (2020), and the American Hospital Association annual survey (2018). Exposures: Hospital characteristics, including safety-net status and teaching intensity (no teaching and very minor, minor, major, and very major teaching levels). Main Outcomes and Measures: The primary outcome was HACRP penalization (ie, hospitals that fell within the worst quartile of the program's performance). Multivariable models initially included all covariates, and then backward stepwise variable selection was used. Results: Of 3117 hospitals that participated in HACRP in 2020, 779 (25.0%) were safety-net hospitals and 1090 (35.0%) were teaching institutions. In total, 771 hospitals (24.7%) were penalized. The HACRP penalization was associated with safety-net status (odds ratio [OR], 1.41 [95% CI, 1.16-1.71]) and very major teaching intensity (OR, 1.94 [95% CI, 1.15-3.28]). In addition, non-federal government hospitals were more likely to be penalized than for-profit hospitals (OR, 1.62 [95% CI, 1.23-2.14]), as were level I trauma centers (OR, 2.05 [95% CI, 1.43-2.96]) and hospitals located in the New England region (OR, 1.65 [95% CI, 1.12-2.43]). Safety-net hospitals with major teaching levels were twice as likely to be penalized as non-safety-net nonteaching hospitals (OR, 2.15 [95% CI, 1.14-4.03]). Furthermore, safety-net hospitals penalized in 2020 were less likely (OR, 0.64 [95% CI, 0.43-0.96]) to revert their HACRP penalization status in 2021. Conclusions and Relevance: Findings from this cross-sectional study indicated that teaching and safety-net hospital status continued to be associated with overpenalization in the HACRP despite recent changes in its methodology. Most of these hospitals were also less likely to revert their penalization status. A reevaluation of the program methodology is needed to avoid depleting resources of hospitals caring for underserved populations.

Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors.

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

Invasive Mold Infections Following Hurricane Harvey-Houston, Texas.

Background: Characterizing invasive mold infection (IMI) epidemiology in the context of large flooding events is important for public health planning and clinical decision making. Methods: We assessed IMI incidence (per 10 000 healthcare encounters) 1 year before and after Hurricane Harvey at 4 hospitals in Houston, Texas. Potential IMI cases were assigned as proven or probable cases using established definitions, and surveillance cases using a novel definition. We used rate ratios to describe IMI incidence and multivariable logistic regression to examine patient characteristics associated with IMI case status. Results: IMI incidence was significantly higher posthurricane (3.69 cases) than prehurricane (2.50 cases) (rate ratio, 1.48 [95% confidence interval, 1.10-2.00]), largely driven by surveillance IMI cases. Aspergillus was the most common species cultured (33.5% prehurricane and 39.9% posthurricane). About one-quarter (25.8%) of IMI patients lacked classical IMI risk factors such as hematologic malignancy and transplantations. Overall, 45.1% of IMI patients received intensive care, and in-hospital all-cause mortality was 24.2%. Conclusions: IMI incidence likely increased following Hurricane Harvey and outcomes for IMI patients were severe. Patient and clinician education on IMI prevention and identification is warranted, particularly as the frequency of extreme weather events increases due to climate change.

The Struggling Infectious Diseases Fellow: Remediation Challenges and Opportunities.

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors' Committee focused the 2018 National Fellowship Program Directors' Meeting at IDWeek on "Remediation of the Struggling Fellow." Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges.

Human Immunodeficiency Virus Pre-exposure Prophylaxis and Increased Incidence of Sexually Transmitted Infections in the United States.

BACKGROUND: Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) decreases HIV transmission. Some studies have raised concerns about a potential association between the implementation of HIV PrEP and the growing incidence rates of sexually transmitted infections (STIs) in the United States. METHODS: We conducted a quasi-experimental (interrupted time series) analysis of STI (syphilis, gonorrhea, and chlamydia) rates before (2000-2012) and after (2013-2017) the implementation of HIV PrEP. We also performed correlations between HIV PrEP utilization and STI cases at the national (2012-2017) and state (2017) levels. We defined HIV PrEP utilization as the number of people taking tenofovir disoproxil fumarate/emtricitabine for HIV prevention. RESULTS: HIV PrEP implementation was associated with 25% (relative risk [RR] 1.254, 95% confidence interval [CI] 1.245-1.263; P < .001) and 26% (RR 1.260, 95% CI 1.257-1.264; P < .001) increases in syphilis and gonorrhea rates, respectively, and a 12% reduction in chlamydia rates (RR: 0.884, 95% CI 0.883-0.885; P < .001). HIV PrEP utilization was correlated with the numbers of syphilis, gonorrhea, and chlamydia cases (spearman coefficients 1.00, 0.94, and 0.94, respectively; P < .001, P < .01, and P < .01, respectively). At the state level, HIV PrEP was also correlated with the number of cases of syphilis, gonorrhea, and chlamydia (spearman coefficients 0.85, 0.81, and 0.85, respectively; Ps < .001 for all correlations). CONCLUSIONS: The implementation and utilization of HIV PrEP in the United States were associated with increased rates of STIs. Further studies to confirm these associations and to elucidate potential causes are needed.

Tissue Parasites in HIV Infection.

PURPOSE OF REVIEW: The purpose of this review is to discuss the current knowledge of HIV and tissue parasite co-infection in the context of transmission enhancement, clinical characteristics, treatment, relapse, and clinical outcomes. RECENT FINDINGS: The pathophysiology and clinical sequelae of tissue parasites in people living with HIV (PLWH) have been well described for only a handful of organisms, primarily protozoa such as malaria and leishmaniasis. Available published data indicate that the interactions between HIV and tissue parasites are highly variable depending on the infecting organism and the degree of host immunosuppression. Some tissue parasites, such as Schistosoma species, are known to facilitate the transmission of HIV. Conversely, uncontrolled HIV infection can lead to the earlier and more severe presentation of a variety of tissue parasites and can make treatment more challenging. Although much investigation remains to be done to better understand the interactions between consequences of HIV and tissue parasite co-infection, it is important to disseminate the current knowledge on this topic to health care providers in order to prevent, treat, and control infections in PLWH.

Primary central nervous system lymphoma in patients with and without HIV infection: a multicenter study and comparison with U.S national data.

PURPOSE: Primary central nervous system lymphoma (PCNSL) in patients living with HIV (PLWH) is a distinct entity; however, the management is adopted from patients without HIV. The study aims to examine the differences in presentation, treatment, and outcomes of PCNSL patients with or without HIV. METHODS: We retrospectively compared the characteristics of 144 patients with PCNSL with and without HIV, and analyzed factors associated with overall and progression-free survival. Results were compared to the Central Brain Tumor Registry of the United States (CBTRUS) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) system. RESULTS: Among all patients with PCNSL, 19% had HIV. PLWH were younger (38 vs. 63 years; p < 0.01) and more likely to be African American (59% vs. 7%; p < 0.01) and male (74% vs. 49%; p = 0.02) than patients without HIV. PLWH were more likely to have multiple lesions (67% vs. 43%; p = 0.02), hemorrhage (59 vs. 37%; p = 0.03), and peripheral rim enhancement (57% vs. 7%; p < 0.01) on imaging; to receive palliative care (15% vs. 2%) or whole brain radiation (63% vs. 3%); and less likely to receive chemotherapy (22% vs. 95%) (p < 0.01). Twenty-four patients, none PLWH, underwent stem cell transplant. Not receiving transplant was an independent factor in mortality and disease progression. Our cohort of patients, compared to the national database, were younger (60 vs. 65 years), 58% were white vs. 75%, and had longer median overall survival 43 vs. 25 months. CONCLUSION: Epidemiology, imaging, and treatment options for patients with PCNSL with and without HIV differ, but HIV was not an independent factor of mortality or disease progression. More efforts are needed to improve access to research and treatment options for PLWH with PCNSL.

Brucellosis in Adults and Children: A 10-Year Case Series at Two Large Academic Hospitals in Houston, Texas.

OBJECTIVES: Brucellosis is one of the most common zoonoses worldwide. Most cases in the United States occur among travelers or immigrants from endemic regions, mostly Central America. In this study, we aimed at describing and comparing the epidemiology and clinical presentation of brucellosis in pediatric and adult patients at two large tertiary care centers in Houston, Texas. METHODS: We identified patients diagnosed as having brucellosis between January 2000 and December 2009 by searching electronic medical records and reviewing microbiology records for positive cultures. Cases were defined as those with a positive blood culture for Brucella sp, a serum agglutination titer ≥1:80 (or both positive blood culture and serum agglutination titer ≥1:80), along with an epidemiologic risk factor and clinical presentation that is consistent with brucellosis. RESULTS: Six adult and 12 pediatric cases were identified; 13 of 18 (72%) cases were immigrants, mostly from Central America. The median ages for adult and pediatric patients were 53 and 3 years old, respectively. Ingestion of unpasteurized milk products was frequently reported. Common clinical features included fever (83%), arthralgias or arthritis (67%), and hepatosplenomegaly (61%). Positive blood cultures were more frequently reported among children than adults (83% vs 33%, P = 0.03). The most common laboratory finding was mildly elevated transaminases. Three adults (50%) but no children developed thrombocytopenia (P = 0.02). Relapsed infection was a frequent occurrence. CONCLUSIONS: In the southern United States, brucellosis is an important consideration in the differential diagnosis of immigrants presenting with undifferentiated fever and joint complaints. A careful history often reveals an epidemiologic risk factor such as ingestion of unpasteurized dairy products.

Single Dose Versus 3 Doses of Intramuscular Benzathine Penicillin for Early Syphilis in HIV: A Randomized Clinical Trial.

Background: Patients coinfected with syphilis and human immunodeficiency virus (HIV) may have a slower decrease in rapid plasma reagin (RPR) titers. Currently a single dose of 2.4 million units of intramuscular benzathine penicillin G (BPG) is recommended for the treatment of early syphilis. Some observational studies have suggested that this regimen may lead to high failure rates in coinfected patients. Methods: We conducted an open-label randomized clinical trial to compare the efficacy of single-dose and 3-dose regimens of BPG for the treatment of early syphilis in HIV-infected individuals. RPR titers were monitored every 3 months. Treatment success was defined as a decrease in RPR titers of ≥2 dilutions (4-fold) during a 12-month follow-up period. Results: Sixty-four patients were included. In the intention-to-treat analysis, treatment success rates were 80% (28 of 35 subjects) and 93% (27 of 29 subjects) in the single-dose and 3-dose regimens, respectively (absolute difference, 13% [95% confidence interval {CI}, -5% to 30%; P = .17). In the per-protocol analysis, success rates were 93% (27 of 29) and 100% in the single-dose and 3-dose regimens, respectively (absolute difference, 7% [95% CI, -7% to 22%]; P = .49). CD4 T-cell count, RPR titer and syphilis stage did not affect treatment results. Conclusions: When compared with a single dose of BPG, a 3-dose regimen did not improve syphilis serological outcomes. Our results support the Centers for Disease Control and Prevention recommendation of a single dose of BPG in HIV-infected patients with early syphilis. Clinical Trials Registration: NCT02611765.

Eosinophilia in patients infected with human immunodeficiency virus.

Eosinophilia is not uncommonly encountered in patients infected with human immunodeficiency virus (HIV), particularly at initiation of care or among those with advanced disease. The clinical manifestation most commonly associated with eosinophilia in this patient population is skin rash. Management of these patients is challenging due to a paucity of data evaluating diagnostic testing and therapeutic strategies. Patients born in or with significant travel to parasite-endemic countries are more likely to have tissue-invasive helminthes, such as Strongyloides or Schistosoma. Patients without such risk factors are unlikely to have parasitic infections and frequently will have self-resolution of eosinophilia. When a detailed history, physical exam, and diagnostic work-up are unrevealing, we sometimes consider empirical therapy with ivermectin. Praziquantel may also be considered for those at risk for schistosomiasis.

Quantitative and Qualitative Antibody Responses to Immunization With the Pneumococcal Polysaccharide Vaccine in HIV-Infected Patients After Initiation of Antiretroviral Treatment: Results From a Randomized Clinical Trial.

BACKGROUND: Pneumococcal vaccination is recommended for human immunodeficiency virus-infected (HIV+) persons; the best timing for immunization with respect to initiation of antiretroviral therapy (ART) is unknown. METHODS: Double-blind, placebo-controlled trial in HIV+ with CD4(+) T cells/µL (CD4) ≥ 200 randomized to receive the 23-valent pneumococcal polysaccharide vaccine (PPV23) or placebo at enrollment, followed by placebo or PPV23, respectively, 9-12 months later (after ≥6 months of ART). Capsular polysaccharide-specific immunoglobin (Ig) G and IgM levels to serotypes 1, 3, 4, 6B, and 23F, and opsonophagocytic killing activity (OPA) to serotypes 6B and 23F were evaluated 1 month postvaccination. RESULTS: One hundred seven subjects were enrolled, 72 (67.3%) were evaluable (36/group). Both groups had significant increases in pre- to 1-month postvaccination IgG levels, but negligible to IgM, and significant increases in OPA titers to serotype 6B but not to 23F. There were no significant differences between groups in serotype-specific IgM or IgG levels or OPA titers. For the combined groups, there was a significant correlation between serotype-specific IgG and OPA titers to 23F but not to 6B. There was no correlation between CD4, viral load and IgG responses. CONCLUSIONS: In HIV+ with CD4 ≥ 200, delaying PPV23 until ≥6 months of ART does not improve responses and may lead to missed opportunities for immunization.

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.

Neurocysticercosis in the United States.

Neurocysticercosis (NCC) is typically considered a disease of the developing world. Nonetheless, NCC is also diagnosed in the developed world. The rise in the number of cases of NCC in developed countries, especially in the United States of America, has largely been driven by the influx of immigrants from endemic to non-endemic regions and the widespread access to neuroimaging. Cases of local transmission have also been documented particularly in the setting of a tapeworm carrier present in the household, which highlights the relevance of NCC as a public health problem in the USA. Although accurate incidence data in the USA are not available, estimates range from 0·2 to 0·6 cases per 100 000 general population and 1·5-5·8 cases per 100 000 Hispanics. We estimate that between 1320 and 5050 new cases of NCC occur every year in the USA. The number of NCC cases reported in the literature in the USA increased from 1494 prior to 2004 to 4632 after that date. Parenchymal cases remain the most commonly reported form of the disease; however, a slight increase in the percentage of extraparenchymal cases has been described in the most recent series. NCC is associated with significant morbidity resulting from hydrocephalus, cerebral edema, and seizures. Although uncommon, NCC is also a cause of premature death in the USA with a calculated annual age-adjusted mortality rate of at least 0·06 per million population.

Substance P causes seizures in neurocysticercosis.

Neurocysticercosis (NCC), a helminth infection of the brain, is a major cause of seizures. The mediators responsible for seizures in NCC are unknown, and their management remains controversial. Substance P (SP) is a neuropeptide produced by neurons, endothelial cells and immunocytes. The current studies examined the hypothesis that SP mediates seizures in NCC. We demonstrated by immunostaining that 5 of 5 brain biopsies from NCC patients contained substance P (SP)-positive (+) cells adjacent to but not distant from degenerating worms; no SP+ cells were detected in uninfected brains. In a rodent model of NCC, seizures were induced after intrahippocampal injection of SP alone or after injection of extracts of cysticercosis granuloma obtained from infected wild type (WT), but not from infected SP precursor-deficient mice. Seizure activity correlated with SP levels within WT granuloma extracts and was prevented by intrahippocampal pre-injection of SP receptor antagonist. Furthermore, extracts of granulomas from WT mice caused seizures when injected into the hippocampus of WT mice, but not when injected into SP receptor (NK1R) deficient mice. These findings indicate that SP causes seizures in NCC, and, suggests that seizures in NCC in humans may be prevented and/or treated with SP-receptor antagonists.

Riesgo de transmisión de la leptospirosis en la provincia Ciego de Ávila / Transmission risk of leptospirosis in Ciego de Ávila province

Se realizó un estudio observacional descriptivo de la serie de tiempo de la leptospirosis humana en la provincia Ciego de Ávila en el periodo 1980 a 2009 con el objetivo de estratificar el riesgo de transmisión del evento en el tiempo en la provincia. Se utilizó el método de estratificación de riesgo absoluto. El universo se constituyó con los 2035 casos confirmados de leptospirosis humana procedentes de los diez municipios de la provincia en el período referido. Los resultados obtenidos fueron: los municipios de Chambas y Florencia se designaron como Alto Riesgo de transmisión de leptospirosis en cinco de las seis mediciones realizadas, por consiguiente mantuvieron por más tiempo esta condición epidemiológica. El municipio de Bolivia con tres mediciones, el municipio de Baraguá con dos y los municipios de Morón y Ciego de Ávila clasificados como de Alto Riesgo en una medición fueron los designados en esta categoría de riesgo. En el resto de los municipios de la provincia (Primero de Enero, Ciro Redondo, Majagua y Venezuela) no se evidenció Alto Riesgo de Transmisión.

An observational descriptive study of human leptospirosis time serie was carried out in Ciego de Avila province from 1980 to 2009 with the aim of stratificating the transmission risk of the time event in this province.The absolute stratification risk method was used.The study Group was constituded by 2035 confirmed cases of human leptospirosis coming from the 10 municipalities of this province in the period mentioned before. It was obtained The following results : Chambas and Florencia municipality were designed as high risk of leptospirosis transmissión in five of the six measuring done, that´s why they kept this epidemiological condition for much longer. Bolivia municipality with three measures, Baraguá with two measures and Morón and Ciego de Avila clasified as high risk. They both were designed in this category of risk.The rest of municipalities (Primero de Enero, Ciro Redondo, Majagua, and Venezuela) wasn´t proved transmissión high risk.

Hemorrhagic cerebrovascular events and neurocysticercosis: a case report and review of the literature.

Cerebrovascular complications have been reported to occur in patients with neurocysticercosis (NCC). We report a patient who presented with relapsed subarachnoid hemorrhage possibly linked to NCC. In addition, we performed a literature review of all of the reported cases of aneurysmal and non-aneurysmal hemorrhagic cerebrovascular events associated with NCC. We identified 11 such cases. The majority of the individuals were young males (mean: 38 years; 70% males). Four cases (36%) had aneurysms. Four (36%) others had negative cerebral angiograms and therefore classified as non-aneurysmal, while the remaining three (28%) did not report sufficient information to classify them. All cases with aneurysmal hemorrhage underwent successful surgical repair of the aneurysms. Seven patients received albendazole (including three who had had surgery). Three patients died; all three presented in the pre-albendazole era. In summary, neurocysticercosis should be considered in the differential diagnosis of hemorrhagic cerebrovascular events in young patients without classical vascular risk factors who have lived or visited NCC-endemic areas.