Case of Extensively Drug-Resistant Shigella sonnei Infection, United States.

We report extensively drug-resistant (XDR) Shigella sonnei infection in an immunocompromised patient in Texas, USA. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry failed to identify XDR Shigella, but whole-genome sequencing accurately characterized the strain. First-line antimicrobials are not effective against emerging XDR Shigella. Fosfomycin, carbapenems, and tigecycline are potential alternatives.

Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-Site Product Supply Quality Improvement Project.

OBJECTIVE: Blood culture contamination above the national threshold has been a consistent clinical issue in the ED setting. Two commercially available devices were examined that divert an initial small volume of the specimen before the collection of blood culture to reduce skin contamination. METHODS: Prospectively, 2 different blood culture-diversion devices were made available in the unit supplies to ED clinicians at a single site during 2 different periods of time as a follow-up strategy to an ongoing quality improvement project. Blood samples were collected in the emergency department over a period of 16 months. A retrospective record review study was conducted comparing the use of the 2 specimen-diversion devices with no device (control group) for blood culture contamination rates. The main outcome of monthly blood culture contamination per device was tested using a Bayesian Poisson multilevel regression model. RESULTS: A total of 4030 blood samples were collected and analyzed from November 2017 to February 2019. The model estimated that the mean incidence of contaminated blood draws in the device A group was 0.29 (0.14-0.55) times the incidence of contaminated draws in the control group. The mean incidence of contaminated blood draws in the device B group was 0.23 (0.13-0.37) times the incidence of contaminated draws in the control group, suggesting that initial-diversion methods reduced blood culture contamination. CONCLUSION: Initial specimen-diversion devices supplement present standard phlebotomy protocols to bring down the blood culture contamination rate.

Impact of improper sample handling on Cobas CT/NG testing platform with dual swab sample collection kit for detecting Chlamydia trachomatis and Neisseria gonorrhoeae.

IMPORTANCE: The importance of this observation lies in its potential to directly impact testing outcomes and patient care. By identifying improper sample handling as a contributing factor to a substantial number of invalid results, we emphasize the need for meticulous adherence to recommended protocols during sample collection. Laboratories that overlook or are unaware of such deviations may inadvertently compromise the reliability and efficacy of their diagnostic processes, leading to misdiagnoses, delayed treatment, and patient dissatisfaction.

Multifocal pneumonia caused by Bordetella bronchiseptica: Insights from a human case study.

This case report describes a 43-year-old man who presented with respiratory distress and was diagnosed with an exacerbation of congestive heart failure and multifocal pneumonia caused by Bordetella bronchiseptica. Microbiological work up of a respiratory sample identified the causative organism, prompting antibiotic treatment and recommending vaccination for his dog. This case emphasizes the need to consider diverse origins in respiratory infections for effective clinical management.

Skin abscess caused by Trueperella bernardiae: Case report and literature review.

We investigated a skin abscess caused by Trueperella bernardiae in a patient with comorbidities. Initial empirical therapy with Clindamycin did not yield a response, and follow-up culture revealed the presence of T. bernardiae through MALDI-TOF and NGS. Since no CLSI or FDA breakpoints have been published for this strain, resistant gene screening of the genetic sequence showed the presence of the erm(X) gene (with 95 % identity). This gene confers resistance to erythromycin, clindamycin, lincomycin, pristinamycin, quinupristin, and virginiamycin. Subsequent therapy with oral amoxicillin/clavulanate led to complete healing.

Evolution of a Distinct SARS-CoV-2 Lineage Identified during an Investigation of a Hospital Outbreak.

The SARS-CoV-2 virus steadily evolves, and numerous antigenically distinct variants have emerged over the past three years. Tracking the evolution of the virus would help us understand the process that generates the diverse variants and predict the future evolutionary trajectory of SARS-CoV-2. Here, we report the evolutionary trajectory of a unique Omicron lineage identified during an outbreak investigation that occurred in a residence unit in the healthcare system. The new lineage had four distinct non-synonymous and two distinct synonymous mutations apart from its parental lineage. Since this lineage of virus was exclusively found during the outbreak, we were able to track the detailed evolutionary history of the entire lineage along the transmission path. Furthermore, we estimated the evolutionary rate of the SARS-CoV-2 Omicron variant from the analysis of the evolution of the lineage. This new Omicron sub-lineage acquired 3 mutations in a 12-day period, and the evolutionary rate was estimated as 3.05 × 10-3 subs/site/year. This study provides more insight into an ever-evolving virus.

MRI confirms loss of blood-brain barrier integrity in a mouse model of disseminated candidiasis.

Disseminated candidiasis primarily targets the kidneys and brain in mice and humans. Damage to these critical organs leads to the high mortality associated with such infections, and invasion across the blood-brain barrier can result in fungal meningoencephalitis. Candida albicans can penetrate a brain endothelial cell barrier in vitro through transcellular migration, but this mechanism has not been confirmed in vivo. MRI using the extracellular vascular contrast agent gadolinium diethylenetriaminepentaacetic acid demonstrated that integrity of the blood-brain barrier is lost during C. albicans invasion. Intravital two-photon laser scanning microscopy was used to provide the first real-time demonstration of C. albicans colonizing the living brain, where both yeast and filamentous forms of the pathogen were found. Furthermore, we adapted a previously described method utilizing MRI to monitor inflammatory cell recruitment into infected tissues in mice. Macrophages and other phagocytes were visualized in kidney and brain by the administration of ultrasmall iron oxide particles. In addition to obtaining new insights into the passage of C. albicans across the brain microvasculature, these imaging methods provide useful tools to study further the pathogenesis of C. albicans infections, to define the roles of Candida virulence genes in kidney versus brain infection and to assess new therapeutic measures for drug development.

Diagnostic performance of DNA probe-based and PCR-based molecular vaginitis testing.

Vaginitis is usually diagnosed empirically, microscopically, via cultures, or by molecular testing for the detection of bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), or Trichomonas vaginalis (TV). The DNA probe-based technique detects BV by identifying Gardnerella vaginalis, VVC by identifying Candida spp., while real-time PCR-based detection methods identify BV by algorithmic analysis of the absence or presence of known vaginal flora. We examined 8,878 total orders placed for DNA probe-based identification (ID) and 10,464 total orders placed for molecular panel ID. We found that PCR-based BV test positivity reduced from 30% to 23% compared with the population tested with DNA probe-based testing. We also found that PCR-based testing VVC positivity increased from 6.3% and 11.6% when compared with DNA probe-based testing. Bayesian generalized linear analysis estimated a lower mean proportion of positive tests for BV in PCR-based molecular panels than DNA probe testing suggesting an under-call of BV. The same models estimated a higher mean proportion of positive tests for molecular vaginal panels than DNA probe testing suggesting an increased detection of candidal vaginitis. In addition, the mean (SD) age for patients with Candida albicans was 40.5 (40.0-41.1) years. Patients with Candida glabrata (now N. glabrata) were 5.2-8.1 (mean 6.7) years older than patients with Candida albicans. Our retrospective data analysis found that BD Max MVP's ability to discriminate between vaginal candidiasis versus other yeast will help to implement CDC (Centers for Disease Control and Prevention)-recommended treatment options. We also believe that providers' inattention to non-albicans treatment could be an issue nationwide. IMPORTANCE Using retrospective data from U.S. Food and Drug Administration-approved/cleared molecular vaginal panels, molecular methods were found to have higher detection for Candida vaginitis and lower detection for bacterial vaginitis when compared to probe-based methods. In addition, the differentiation of Candida and non-Candida yeast has not reached the physician community as we observed noncompliance in recommended therapy. Furthermore, the pros and cons of migrating to molecular testing from conventional microscopy for identifying bacterial vaginitis and fungal vaginitis have been examined and reported in this paper. Interestingly, the mean (SD) age for patients with Candida albicans was 40.5 (40.0-41.1) years. Patients with N. glabrata were 5.2-8.1 (mean 6.7) years older than patients with Candida albicans.

Campylobacter coli bacteremia associated with diarrhea.

Campylobacter coli (C. coli) is a gram negative, non-spore forming, mobile, curved, or spiral-shaped rod organisms and one of the most common gastrointestinal human pathogens. Campylobacter very rarely causes bacteremia. However, there are reports of bloodstream infection of C. coli and most of the Campylobacterbacteremia have been found among immunocompromised patients. In this study, a case of C. coli blood stream infection that was associated with diarrhea in an immunocompetent patient.

Presumptive positive with the Cepheid Xpert Xpress SARS-CoV-2 assay due to N mutations in the Delta variant.

The Cepheid Xpert® Xpress SARS-CoV-2 assay is 1 of the several real-time reverse transcription polymerase chain reaction (RT-PCR) assays that received Emergency Use Authorization from the United States Food and Drug Administration (FDA) for detection of SARS-CoV-2. Here we report 4 SARS-CoV-2 samples that were reported as presumptive positives on the Cepheid platform while reported as positives on alternative RT-PCR platforms. Whole genome sequencing indicated that the samples were Delta variants and had point mutations in the N gene which potentially interfered with SARS-CoV-2 detection. Two types of point mutations were found in these samples in the US CDC 2019-nCoV Real time PCR N2 Probe region: C29203T and C29200T. C29203T is a novel point mutation, and C29200T has not been previously reported in the Delta variants. This underlines the fact that mutations in the real-time RT-PCR assay target region could hinder accurate detection of SARS-CoV-2.

Extended Remdesivir Infusion for Persistent Coronavirus Disease 2019 Infection.

Persistent severe acute respiratory syndrome coronavirus 2 infection is difficult to treat. Here, we report a case of 5-month persistent coronavirus disease 2019 in an immunocompromised patient who was successfully treated with 30 consecutive days of remdesivir. Prolonged remdesivir infusion with concurrent cycle threshold monitoring might provide a potential solution to cure these patients with difficult-to-treat infections.

Dur3 is the major urea transporter in Candida albicans and is co-regulated with the urea amidolyase Dur1,2.

Hemiascomycetes, including the pathogen Candida albicans, acquire nitrogen from urea using the urea amidolyase Dur1,2, whereas all other higher fungi use primarily the nickel-containing urease. Urea metabolism via Dur1,2 is important for resistance to innate host immunity in C. albicans infections. To further characterize urea metabolism in C. albicans we examined the function of seven putative urea transporters. Gene disruption established that Dur3, encoded by orf 19.781, is the predominant transporter. [(14)C]Urea uptake was energy-dependent and decreased approximately sevenfold in a dur3Δ mutant. DUR1,2 and DUR3 expression was strongly induced by urea, whereas the other putative transporter genes were induced less than twofold. Immediate induction of DUR3 by urea was independent of its metabolism via Dur1,2, but further slow induction of DUR3 required the Dur1,2 pathway. We investigated the role of the GATA transcription factors Gat1 and Gln3 in DUR1,2 and DUR3 expression. Urea induction of DUR1,2 was reduced in a gat1Δ mutant, strongly reduced in a gln3Δ mutant, and abolished in a gat1Δ gln3Δ double mutant. In contrast, DUR3 induction by urea was preserved in both single mutants but reduced in the double mutant, suggesting that additional signalling mechanisms regulate DUR3 expression. These results establish Dur3 as the major urea transporter in C. albicans and provide additional insights into the control of urea utilization by this pathogen.

Draft Genome Sequence of a Multidrug-Resistant Klebsiella pneumoniae Isolate from a Prosthetic Joint Infection.

Extended-spectrum ß-lactamase (ESBL)-producing Klebsiella pneumoniae strain 9120005127 was isolated from a wound infection. We describe the draft genome sequence and antibiotic susceptibility of this strain.

Rare Lelliottia nimipressuralis from a wound infection case report using whole genome sequencing-based bacterial identification.

Identification of clinical bacterial isolates is an essential first step to provide guidelines for treatment of pathogenic bacterial infection. Infection occurred in a laceration along the medial aspect of left upper arm of a 71-year-old female. Conventional biochemical testing and MALDI-TOF MS identification failed to correctly identify a bacterial isolate. Using whole genome sequencing, the isolate was identified as Lelliottia nimipressuralis. WGS can overcome the limitations of conventional phenotypic and molecular identification methods and successfully identified a rare pathogen. This case is the first report of a human infection of L. nimipressuralis.

Understanding false positives and the detection of SARS-CoV-2 using the Cepheid Xpert Xpress SARS-CoV-2 and BD MAX SARS-CoV-2 assays.

Several real-time RT-PCR assays have received Emergency Use Authorization from the United States Food and Drug Administration. The BD MAX™ SARS-CoV-2 assay, run by the BD MAX™ system, is a qualitative test that detects the SARS-CoV-2 specific nucleocapsid phosphoprotein gene regions, N1 and N2. The human RNase P gene is used as the endogenous nucleic acid extraction control. The Cepheid Xpert® Xpress SARS-CoV-2 assay, run by the GeneXpert system, detects the pan-sarbecovirus E gene and the N2 region of the N gene. We evaluated the performance characteristics of the BD and Cepheid assays using matched patient samples. We also analyzed comparative Ct values for both assays using 183 positive samples tested at this facility. In addition, we mitigated reporting false positive results without relying on interpretive software. We found that both systems showed comparable sensitivity. We found an approximately 3.5% false positive rate from the BD MAX™ system results.

Evolutionary aspects of urea utilization by fungi.

The higher fungi exhibit a dichotomy with regard to urea utilization. The hemiascomycetes use urea amidolyase (DUR1,2), whereas all other higher fungi use the nickel-containing urease. Urea amidolyase is an energy-dependent biotin-containing enzyme. It likely arose before the Euascomycete/Hemiascomycete divergence c. 350 million years ago by insertion of an unknown gene into one copy of a duplicated methylcrotonyl CoA carboxylase (MccA). The dichotomy between urease and urea amidolyase coincides precisely with that for the Ni/Co transporter (Nic1p), which is present in the higher fungi that use urease and is absent in those that do not. We suggest that the selective advantage for urea amidolyase is that it allowed the hemiascomycetes to jettison all Ni(2+)- and Co(2+)-dependent metabolisms and thus to have two fewer transition metals whose concentrations need to be regulated. Also, the absence of MccA in the hemiascomycetes coincides with and may explain their production of fusel alcohols.

Draft Genome Sequence of an Unusually Multidrug-Resistant Strain of Achromobacter xylosoxidans from a Blood Isolate.

Achromobacter xylosoxidans strain DN2019 was isolated from blood of a septicemia patient. We describe the draft genome and antibiotic susceptibility of this strain.

Clade-specific variation in susceptibility of Candida auris to broad-spectrum ultraviolet C light (UV-C).

BACKGROUND: Candida auris is an emerging and often multidrug-resistant fungal pathogen with an exceptional ability to persist on hospital surfaces. These surfaces can act as a potential source of transmission. Therefore, effective disinfection strategies are urgently needed. We investigated the efficacy of ultraviolet C light (UV-C) disinfection for C. auris isolates belonging to 4 different clades. METHODS: In vitro testing of C. auris isolates was conducted using 106 colony-forming units (CFU) spread on 20-mm diameter steel carriers and exposed to a broad-spectrum UV-C light source for 10, 20, and 30 minutes at a 1.5 m (5 feet) distance. Post-UV survivors on the coupons were subsequently plated. Colony counts and log reductions were recorded, calculated, and compared to untreated control carriers. Identification of all isolates were confirmed by MALDI-TOF and morphology was visualized by microscopy. RESULTS: We observed an increased susceptibility of C. auris to UV-C in 8 isolates belonging to clades I, II and IV with increasing UV exposure time. The range of log kill (0.8-1.19) was highest for these isolates at 30 minutes. But relatively no change in log kill (0.04-0.35) with increasing time in isolates belonging to clade III were noted. Interestingly, C. auris isolates susceptible to UV-C were mostly nonaggregating, but the isolates that were more resistant to UV exposure formed aggregates. CONCLUSIONS: Our study suggests variability in susceptibility to UV-C of C. auris isolates belonging to different clades. More studies are needed to assess whether a cumulative impact of prolonged UV-C exposure provides additional benefit.

Arginine-induced germ tube formation in Candida albicans is essential for escape from murine macrophage line RAW 264.7.

The opportunistic fungal pathogen Candida albicans is a part of the normal flora but it also causes systemic candidiasis if it reaches the bloodstream. Upon being phagocytized by macrophages, an important component of innate immunity, C. albicans rapidly upregulates a set of arginine biosynthetic genes. Arginine, urea, and CO2 induced hyphae in a density-dependent manner in wild-type, cph1/cph1, and rim101/rim101 strains but not in efg1/efg1 or cph1/cph1 efg1/efg1 strains. Arginase (Car1p) converts arginine to urea, which in turn is degraded by urea amidolyase (Dur1,2p) to produce CO2, a signal for hyphal switching. We used a dur1,2/dur1,2 mutant (KWN6) and the complemented strain, KWN8 (dur1,2/dur1,2::DUR1,2/DUR1,2) to study germ tube formation. KWN6 could not make germ tubes in the presence of arginine or urea but did in the presence of 5% CO(2), which bypasses Dur1,2p. We also tested the effect of arginine on the interaction between the macrophage line RAW 264.7 and several strains of C. albicans. Arginine activated an Efg1p-dependent yeast-to-hypha switch, enabling wild-type C. albicans and KWN8 to escape from macrophages within 6 h, whereas KWN6 was defective in this regard. Additionally, two mutants that cannot synthesize arginine, BWP17 and SN152, were defective in making hyphae inside the macrophages, whereas the corresponding arginine prototrophs, DAY286 and SN87, formed germ tubes and escaped from macrophages. Therefore, metabolism of arginine by C. albicans controls hyphal switching and provides an important mechanism for escaping host defense.