Insights on the methodology for indoor microbial aerosol studies

Covid-19 has highlighted the need for reliable methods for airborne microbe control. Different microbes are suitable for different purposes, and the microbes are sensitive to collection methods used. We identified three safe-to-use microbes suitable for airborne microbial studies: MS2-bacteriophage virus, Staphylococcus simulans and Bacillus atrophaeus bacterial spores. We found that the sensitive microbes (MS2 and S. simulans) survive better, when collected directly in a liquid media. © 2022 17th International Conference on Indoor Air Quality and Climate, INDOOR AIR 2022. All rights reserved.

Ultra High-Throughput Screening Assays for Inhibitors of TMPRSS2 and SPIKE Interaction

SARS-CoV-2, the coronavirus that causes the disease COVID- 19, was identified over three years ago, yet current small molecule therapies have limited usefulness and resistance to therapies and vaccines is inevitable. Ultra high-throughput screening (uHTS) assays for novel and repurposed inhibitors of a protein-protein interaction in the viral life cycle could be used to screen a vast number of compounds with a specific target of action. In particular, the interaction between viral SPIKE protein and human TMPRSS2 is an understudied, yet critical step in viral entry. Thus, we aim to create uHTS assays to rapidly and affordably identify inhibitors of the TMPRSS2 and SPIKE interaction for further biochemical studies and therapeutic development for SARS-CoV-2.We first sought to create a Time Resolved-Forster/Fluorescence Energy Transfer (TR-FRET) assay which uses lysates of cells with overexpressed SPIKE and TMPRSS2 and fluorescently labeled antibodies to detect interactions between these proteins. Initially, we developed and optimized this TR-FRET assay in a 384-well plate then miniaturized to a 1536-well plate. We conducted a pilot screen of compounds with known biological activity to test this assay's screening capabilities. To further narrow the hits from this TR-FRET screen, we developed an orthogonal uHTS Nanoluciferase Binary Technology (NanoBiT) assay to detect the interaction between tagged SPIKE and TMPRSS2 in live cells.With these two assays in hand, we expanded our TR-FRET screen to over 100 000 compounds and identified several that were also positive in the orthogonal NanoBiT assay. Four of these compounds were found to potentially interact with either SPIKE or TMPRSS2 from thermal shift experiments, providing support for their action as SPIKE and TMPRSS2 interaction inhibitors. Thus, we have developed TR-FRET and NanoBiT orthogonal uHTS assays which have allowed for the discovery of several possible repurposed and novel inhibitors of the SPIKE/ TMPRSS2 interaction. These uHTS assays can be employed as a model for future drug discovery efforts and the compounds identified may be used as exciting starting points for development of inhibitors of SARS-CoV-2. This research was supported in part by The Emory School of Medicine COVID Catalyst-I3 award, the NCI Emory Lung Cancer SPORE (SR, HF;P50CA217691) Career Enhancement Program (AI, P50CA217691), Emory initiative on Biological Discovery through Chemical Innovation (AI) and R01AI167356 (SS).Copyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.

Photodynamic inactivation of Rhizopus oryzae - in vitro study

During the COVID-19 pandemic, several complications arose in infected patients, one of them being mucormycosis, which is an extremely aggressive fungal disease with a high mortality rate, especially in patients with compromised immune systems. Most cases of mucormycosis are caused by the fungus Rhizopus oryzae, also known as black fungus, with 90% of cases affecting the rhinocerebral site. The treatment tools used are based on high doses of amphotericin B and posaconazole, associated with surgical resections when possible. However, even with aggressive antifungal treatment, the estimated attributable mortality rate is high [1]. In the absence of surgical debridement of the infected tissue, antifungal treatment alone is not curative. So there is a need for development of adjuvant treatments. Antimicrobial Photodynamic Therapy (aPDT) may constitute an auxiliary therapeutic option for mucormycosis [2]. Due to the lack of reports on the photodynamic inactivation of R. oryzae, we investigated different protocols Photodithazine (PDZ) as a photosensitizer. The response on the fungus growing rate under distinct treatment parameters as photosensitizer concentration, incubation time, and association with surfactant, will be presented for both white and black hyphal phases, and infective spore phase. Preliminary results show the potential use of photodynamic therapy for the inactivation and growth control of the R. oryzae.Copyright © 2023

Diverse Presentation of Mucormycosis: A Post COVID Catastrophe - A Case Series

The corona virus disease-19 (COVID-19) produced by SARS-CoV-2 has resulted in a wide spectrum of illness ranging from mild to life-threatening conditions thus enhancing the incidence of opportunistic infections among individuals harbouring comorbidities. Mucormycosis is a dreadful angio-invasive opportunistic infection produced by zygomycetes fungus in an immunocompromised host. The clinical manifestations of mucormycosis include rhino-orbital-cerebral (ROC), pulmonary, cutaneous, gastrointestinal, with ROC accounting for around 40% of cases. Diabetes, neutropenia, iron overload, cancer, and organ transplant are all major culprits. Both Aspergillus and Candida have been identified as the primary fungal pathogens causing co-infection in COVID-19 preyed individuals. The most predominant variety, Rhizopus Oryzae, is responsible for roughly 60% of mucormycosis infections in humans, as well as 90% of the Rhino-orbital-cerebral (ROCM) variant. Mucormycosis is the most widespread ailment in India. Until lately, India was declared to be the world's diabetes capital, with the second-largest number of people suffering from diabetes mellitus (DM). Diabetes has been recognised as the most common predictive marker for mucormycosis which explains the dramatic rise in Mucor cases in India lately particularly during second wave of COVID-19. The inflammatory onslaught caused by COVID 19 has debilitated patients' immune systems, making individuals vulnerable to mucormycosis outbreaks. The possible explanation that Mucorales spores appear to be expediting germination in people with COVID-19 is due to the perfect scenario of oxygen deprivation (hypoxia), hyperglycemia (steroid-induced), acidic form of media (metabolic acidosis, diabetic ketoacidosis), increased iron levels (elevated ferritin), and significantly reduced phagocytic activity of white blood cells (WBC) due to immunosuppression (SARS-CoV-2 or steroid mediated or associated comorbidities). Copyright © 2022 International Medical Sciences Academy. All rights reserved.

A Report of Disseminated Histoplasmosis in an Immunocompromised Patient Following Covid-19 Infection

INTRODUCTION: Histoplasmosis results from spore inhalation of Histoplasma capsulatum, an endemic fungus in the soil of the Ohio and Mississippi River Valleys of the United States. While the majority of infections with H. capsulatum are asymptomatic and self-limited, immunosuppressed patients may develop severe, disseminated disease. Few reports have described disseminated histoplasmosis following SARS-CoV-2 (COVID-19) infection such as described in this case. DESCRIPTION: A 69-year-old female was evaluated for shortness of breath. Her medical history was significant for rheumatoid arthritis on methotrexate and recent COVID-19 infection treated with dexamethasone. Initial CT-angiography of the chest showed patchy bilateral ground glass opacities. She had leukopenia with white blood cell count of 1.3 K/uL and elevated procalcitonin of 5.88 ng/mL. Broad spectrum empiric antibiotics were initiated. On day 6, the patient decompensated and required ICU transfer. Urine histoplasma antigen, M and H precipitin bands, and serum galactomannan antigen returned positive. Amphotericin B was initiated. The patient underwent bronchoscopy with bronchoalveolar lavage showing atypical reactive macrophages with rare intracellular organisms suspicious for fungi. Repeat CT of the chest, abdomen, and pelvis showed extensive bilateral ground glass opacities, bilateral pulmonary calcifications consistent with granulomas, and calcifications in the spleen and liver. On hospital day 10, the patient required intubation due to hypoxemic respiratory failure. Despite appropriate antifungal therapy, she had worsening encephalopathy, leukocytosis, erythema nodosum, and renal failure. She passed away on day 19. DISCUSSION: This case highlights the development of disseminated histoplasmosis in an immunocompromised adult following COVID-19 infection. It was not until treatment with high dose glucocorticoids that the patient developed disseminated disease and declined. It is important to be aware of the impact that the COVID-19 pandemic has on the emergence of infectious disease and the role its treatment plays in immune suppression. Disseminated histoplasmosis is a consideration for immunocompromised patients in high risk, H. capsulatum endemic areas who are being treated for COVID-19 with high doses of steroids for prolonged periods.

Reducing Hospital-Onset C. diff with a Provider-Driven Emergency Department Ordering Algorithm

Background. Clostridoides difficile (C. diff) can cause diarrhea and inflammation of the colon. It is one of the most common causes of heathcare-associated infections (HAIs), estimated to cause almost half a million illnesses and thousands of deaths in the United States each year. Studies have estimated that this HAI costs up to $4.8 billion each year in excess healthcare costs for acute care facilities. Early identification, treatment and initiation of isolation precautions is crucial to patient care and transmission reduction, making the Emergency Department ideal partners in efforts to reduce C. diff infections. Methods. A C. diff testing algorithm was introduced specific to the Emergency Department in March, 2021, promoting earlier testing and isolation of patients suspected of having C. diff. Emergency medicine clinicians were awarded the "Golden Spore" Award weekly when appropriately initiating the C. diff testing and isolation, provided the patients met criteria, or were clinically suspected of having a C. diff infection. C. diff ordering algorithm Ordering algorithms were printed and placed in the clinician's work area to facilitate increased ordering of isolation and testing of potentially infected patients. GoldenSporeAward The Golden Spore is awarded weekly to emergency clinicians who successfully identify and isolate C. diff patients prior to admission. Results. As a result of the COVID-19 pandemic, there were varying degrees of challenges for implementation of the program. Emergency clinicians sent 199 C. diff tests pre-intervention (3/15/20-3/14/21) and 234 tests post-intervention (3/ 15/21-3/14/22). Pre-intervention, 44 patients were found to be C. diff positive prior to admission, compared to 62 post-intervention. Clinicians enjoyed the "golden spore" award and were excited to participate. Conclusion. The program is ongoing, though the initial results are encouraging. There was an immediate increase in the testing and subsequent isolation of patients while in the ED. Infection prevention and emergency medicine clinicians worked together to boost their numbers, and the "golden spore" continues to be awarded in weekly newsletters. Clinicians indicated they enjoyed the engagement, and found that the small change in a routine process improved their baseline awareness of potential C. diff patients, leading to an increase in the number of tests and subsequent discovery of C. diff positive patients. C. diff champions were also named and the algorithm will be shared with additional emergency departments within our system to continue to improve detection and prevention of hospital associated infections.

Evaluation of anti-Candida activity of Cinnamaldehyde using mice model

Objective: Vaginal candidiasis is a frequent infection afflicting the female population. Candida co-infections are reported in escalating frequency and can be associated with severe health hazards or even death. People with severe COVID-19, malig-nancies, AIDS, and organ transplants are particularly vulnerable to invasive vaginal candidiasis. Due to the high frequency of infections associated with recurrence, vaginal candidiasis poses a significant medical problem worldwide.Treatments of vaginal candidiasis are limited due to drug resistance, side effects, and toxicity. CIN is a natural compound and its antifungal activity is widely reported. The introduction of cinnamaldehyde (CIN) as the anti-Candidal agent will revolutionize the treatment of vaginal candidiasis. In this study, we investigated the anti-Candida activity of CIN against vaginal candidiasis in Swiss albino mice (C3HHC-Strain). Method(s): Vaginal candidiasis in mice (Swiss albino) was induced under conditions of pseudo-estrus. Persistent vaginal infection wasfound inestrogenized mice aftervaginal challenge withC.albicans.The mice weretreated orallyafter confirmation of infection in mice.The efficacy of CIN treatment was investigated phenotypically by colony-forming unit (CFU) counts in the vaginal smear, fungal load determination in the blood, the ovarian and vaginal tissues and periodic acid-Schiff (PAS) staining of histopathological sections of the vaginal tissues. The hematological parameters of the experimental mice were also evaluated. Result(s): The pseudohyphae and spores of C. albicans were present in the vaginal smear of experimentally infected mice. After treatment, no C. albicans colonies were found in the vaginal lavage of infected mice. The fungal burden was significantly higher inthe vaginaand the ovaries of infectedmice.However, a dose of262.5 mg/kgBW of CINreduced thenumber ofCFUin the vagina and ovaries in treated mice.The histopathology revealed the absence of C.albicans in the vaginal tissue of the treated mice. Nonetheless, the vaginal sections of infected mice exhibited pathological changes. The hematological parameters such as RBC count, WBC count, and percentage of hemoglobin showed significant differences in the treatment groups compared to the infected group. Conclusion(s): Cinnamaldehyde showed good in vivo antifungal potential against vaginal candidiasis. However, evaluation of its pharmacodynamic and pharmacokinetic parameters and complete elucidation of its mode of action are desirous.

Mucoromycosis: A Double Blow to the Country Amidst the Covid 19 Pandemic

INTRODUCTION: American pathologist R.D. Baker coined the term mucormycosis. Fungal infections are on a rise in the past 2 decades. It is defined as an insidious, broad aseptate ubiquitous fungal infection caused by members of mucorales and zygomcotic species.(1) It is colloquially termed as black fungus, when viewed through microscope it shows dark spherical spores and so the name. Earlier it was also known as zygomycetes, which means primitive fungi with broad, asepta including mucor, rhizopus, absidia and cunninghaemella. It is an opportunistic infection which is widely distributed in nature and predominantly in soil and thrives in dead and decaying substrates. It affects various organs involving the blood vessels causing thrombosis, infarction and necrosis of tissues and organs. As of 26th May 2021, India had noted approximately 12000 cases of mucor along with the Second wave of COVID 19, due to its fatality;it has become a notifiable disease under epidemic act.(2). Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

COVID-19-ASSOCIATED PULMONARY MUCORMYCOSIS PRESENTING AS SPONTANEOUS PNEUMOTHORAX: A RARE PRESENTATION

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Mucormycosis is an angio-invasive fungal infection with substantial morbidity and mortality. While diabetes and immune suppression remain well-known risk factors for mucormycosis, COVID-19 is now emerging as its independent predictor. CASE PRESENTATION: A 43-year-old male, with a history of hyperlipidemia and alcoholism, presented to the hospital with complaints of progressive dyspnea on exertion, productive cough, intermittent fever, anorexia, and chest pain over the course of 2 weeks. About 5 weeks prior to the current presentation, he was tested positive for COVID-19 by a polymerase chain reaction (PCR) based test and remained in quarantine at home. He was not vaccinated against COVID-19. He had no known immunosuppressive disease. On initial examination, he was ill-appearing and had a temperature of 101 F, blood pressure 138/83 mmHg, respiratory rate 22/minute, pulse 102/minute, and saturation of 91% on 2 L nasal cannula oxygen. A computerized tomography (CT) scan of the chest revealed small bilateral pneumothorax (2 cm and 5mm) along with extensive ground-glass opacifications in all lobes. In the next 24 hours, the right-sided pneumothorax progressed to tension pneumothorax requiring pigtail pleural drainage catheter placement. The drained pleural fluid had more than 100,000/uL total nucleated cells (91% neutrophils, 2% lymphocytes, and 1% eosinophils) and ultimately cultures grew Rhizopus spp. He was started on intravenous liposomal amphotericin-B infusion (5 mg/kg daily). On hospital discharge, he was switched to oral posaconazole (started with loading 300 mg delayed-release tablet twice a day, followed by 300 mg dosing of delayed-release posaconazole tablets daily) to complete the long term treatment course. DISCUSSION: Most of the reported cases of mucormycosis in COVID-19 were in patients with either diabetes or receiving steroids. This is a rare presentation of COVID-19–associated pulmonary mucormycosis (CAPM) as spontaneous pneumothorax, in the absence of known immunosuppression history. COVID-19 results in a considerable increase in cytokines, particularly interleukin-6 (IL-6), which increase free iron by increasing ferritin levels due to increased synthesis and decreased iron transport. Also, concomitant acidosis increases free iron by reducing the ability of transferrin to chelate iron and this available iron becomes a considerable resource for mucormycosis. [1] Also, Mucorales adheres to and invades endothelial cells by specific recognition of the host receptor glucose-regulator protein 78 (GRP-78). Acidosis associated with severe COVID-19 triggers GRP-78 and fungal ligand spore coating homolog (CotH) protein expression on endothelial cells, both contributing to angioinvasion, hematogenous dissemination, and tissue necrosis. [2] CONCLUSIONS: Mucormycosis can present as spontaneous pneumothorax after recent COVID-19 and clinicians should be aware of rare clinical presentation. Reference #1: Singh AK, Singh R, Joshi SR, et al. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021;15:102146. doi:10.1016/j.dsx.2021.05.019 Reference #2: Baldin C, Ibrahim AS. Molecular mechanisms of mucormycosis—The bitter and the sweet. PLOS Pathog 2017;13:e1006408. doi:10.1371/journal.ppat.1006408 DISCLOSURES: No relevant relationships by Faran Ahmad No relevant relationships by AYESHA BATOOL No relevant relationships by Zachary DePew No relevant relationships by Neil Mendoza

Redirection of T cells via chimeric antigen receptor (CAR) to control the invasive fungal infections

Invasive fungal infections (IFI) are associated with high rates of morbidity and mortality, and immunocompromised hosts are often affected. Candida albicans is among the main cause of IFIs in the last decades, and Paracoccidioides brasiliensis is found in most of the IFIs identified in the South America. Rhizopus oryzae causes mucormycosis that increased in the COVID-19 pandemic. Host immune response against IFIs depend of the effector activity of T cells, which is compromised in immunodeficient patients. However, chimeric antigen receptor (CAR) technology can redirect T cells to target any antigen inducing the cell activation, which can be applied in immunocompromised patient as done in cell therapy against cancer. We developed a CAR (M-CAR) specific to a carbohydrate on the fungal cell wall, and Jurkat cells expressing M-CAR after lentiviral transduction using a multiplicity of infection (MOI) of 1, 3, 5 or 10 had its recognition capacity evaluated against C. albicans, P. brasiliensis, and R. oryzae. CAR expression increased in a MOI dependent-manner, and M-CAR Jurkat cells produced high levels of IL-2 in the presence of hyphae form of C. albicans,P. brasiliensis yeast, and R. oryzae spores. These findings evidenced the capacity of M-CAR to recognize these fungi inducing T cell activation. This work opened new perspectives to evaluate the fungicidal activity of human T and NK cells expressing M-CAR in response to species of fungi studied. Keywords: Chimeric Antigen Receptor (CAR), T cells, invasive fungal infections.

A CASE OF MULTIFOCAL PNEUMONIA -A DIAGNOSTIC CHALLENGE

CASE: A 25 year old Vietnamese female initially presented to the emergency department (ED) with progressive dyspnea and cough for 2 weeks. Chest Xray (CXR) showed left lower lobe consolidation and was started on a 5-days of azithromycin. She returned to ED 3 days later with a worsening cough, yellowish sputum, dyspnea, pleuritic chest pain, chills, appetite loss, and a 6-pound weight loss. 7 years ago her pre-immigration screening was negative for tuberculosis. She worked in a nail salon and did gardening as a hobby. On exam, she was afebrile, appeared dyspneic with normal oxygen saturation, diminished breath sounds on left lower lobe with egophony. Labs showed leukocytosis of 22,300 with neutrophilia and negative COVID-19 test. Repeat CXR showed worsening left lower lobe opacity. On day 3, temperature peaked at 103.1F with worsening sputum production. Computed tomography (CT) chest showed complete consolidation of the left lower lobe with tree-in-bud opacities in bilateral upper lobes and right lower lobe. Antibiotics were switched from ceftriaxone and azithromycin to piperacillin-tazobactam and vancomycin. Bronchoalveolar lavage (BAL) gram stain, acid-fast bacilli stain and gomori stain, and blood cultures were negative. Follow-up CT chest was worse and repeat bronchoscopy with biopsy was done. On day 8, urinary blastomyces and histoplasma antigen tests were positive. BAL cytology showed budding yeast consistent with blastomycosis. IV voriconazole was added and her symptoms gradually improved. She was discharged on 6-month course of oral voriconazole. BAL and biopsy cultures came back positive for B. dermatitidis confirming the diagnosis. Outpatient follow-up with CXR after a month showed both clinical and radiological improvement. IMPACT/DISCUSSION: Blastomycosis is a fungal infection caused by thermally dimorphic fungi Blastomyces species, endemic in Ohio, Mississippi River Valleys, and the Great Lakes region in the United States. It commonly presents as a pulmonary infection following inhalation of spores. Severity varies from asymptomatic to life-threatening acute respiratory distress syndrome. Diagnosis delay is common with frequent misdiagnoses including bacterial pneumonia, malignancy, and tuberculosis. Pulmonary blastomycosis commonly presents as dense consolidation in the upper lobes but can have variable presentation. Serological tests, cultures and BAL studies can aid in diagnosis. Repeat bronchoscopies should be considered when the suspicion is high. Of note, blastomyces antigen can have cross-reactivity with histoplasma antigen which might be the case with our patient. CONCLUSION: This case highlights the resemblance of clinical and radiological presentation of blastomycosis with other respiratory conditions and the need for timely diagnosis, treatment, and antimicrobial stewardship. Practitioners need to keep a strong suspicion of this disease in patients with atypical presentation for pneumonia especially in endemic areas.

Clostridium perfringens Spores in Urology Hospital

Background: Clostridium spp. spores are resistant to many factors, including alcohol-based disinfectants. The presence of clostridial spores in a hospital environment may lead to infection outbreaks among patients and health care workers. Objective: This study is aimed to detect clostridial spores in the aurology hospital using C diff Banana Broth™ and assess the antibiotic sensitivity and toxinotypes of isolates. Methods: After diagnosing COVID-19 in medical staff and closing an 86-bed urology hospital in 2020 for H2O2 fogging, 58 swabs from the hospital environment were inoculated to C diff Banana Broth™, incubated at 37°C for 14 days, checked daily, and positive broths were sub-cultured anaerobically for 48 h at 37°C. After identification, multiplex PCR (mPCR) was performed for Clostridium perfringens, C. difficile toxin genes, and minimum inhibitory concentration (MIC) determination. Results: In this study, 16 out of 58 (~ 28%) strains of Clostridium spp. were cultured: 11-C. perfringens, 2-C. baratii, and 1 each of C. paraputrificum, C. difficile, and C. clostridioforme. 11 C. perfringens were positive for the cpa, 7-the cpb2, 2 – cpiA, and 1 – cpb toxin genes. All isolates were sensitive to metronidazole, vancomycin, moxifloxacin, penicillin/tazobactam, and rifampicin. Two out of the 11 C. perfringens strains were resistant to erythromycin and clindamycin. Conclusions: Regardless of the performed H2O2 fogging, antibiotic-resistant, toxigenic strains of C. perfringens (69%) obtained from the urology hospital environment were cultured using C diff Banana Broth™, indicating the need to develop the necessary sanitary and epidemiological procedures in this hospital.

A Case of Pulmonary Cryptococcosis After Severe COVID-19 Pneumonia T. Roesch

Introduction / Case Presentation:46yo female with a history of CKD, atrial flutter, bioprosthetic valve with mitral ring, and recent COVID-19 pneumonia who presented to the emergency department (ED) with shortness of breath, fevers, and fatigue. Three months prior, she had been diagnosed with severe COVID-19 pneumonia, for which she received dexamethasone, remdesivir, tocilizumab, anakinra, and IVIG. She was discharged to a nursing facility with a prolonged steroid taper, ending 1 month prior to admission.In the ED, the patient had a chest x-ray that demonstrated bibasilar atelectasis and opacification, and a CT chest revealed right lower lobe consolidation and surrounding ground glass opacities. A respiratory pathogen PCR swab was negative. Sputum culture was negative for bacterial and fungal growth. Blood cultures did not grow any organisms. Given recent immunosuppression and imaging findings, a serum Cryptococcal antigen was drawn, which was positive with a titer of 1:128. A transthoracic needle biopsy of the patient's right lower lung was then performed. The specimen did not grow any bacteria or fungi and AFB stain on the tissue was negative. Pathology demonstrated a collection of histiocytes, neutrophils, and necrotic debris. PAS, GMS, and mucicarmine stains were positive for fungal organisms consistent with Cryptococcus species. Discussion: Cryptococcosis is a fungal infection due predominately to one of two encapsulated yeasts, Cryptococcus neoformans or Cryptococcus gattii. C. neoformans is found in soil worldwide, and infection typically begins with spore inhalation. Clinically significant disease is seen mostly in immunocompromised patients.Corticosteroids and interleukin inhibitors, such as anakinra (IL-1) and tocilizumab (IL-6), are used in the treatment of COVID-19. These medications have been associated with increased risk for opportunistic infections, including invasive fungal infections. The diagnosis of pulmonary cryptococcosis may be challenging, as symptoms are often nonspecific and may radiographically resemble bacterial pneumonia, malignancy, or other infections. Serum cryptococcal antigen detection tests may be helpful in establishing the diagnosis, as well as histopathology showing narrow-based budding yeast. Conclusion: Patients with prior COVID-19 infection commonly return to healthcare settings with sequelae of their previous coronavirus infection. In our case, it was the prior treatment of COVID-19, which included immunomodulating therapy, that lead to a secondary pulmonary cryptococcal infection. When evaluating pulmonary processes that evolve after an acute infection with COVID-19, it is important to keep a broad differential, including uncommon and/or opportunistic infectious etiologies, particularly when a patient has received prolonged courses of steroids and tocilizumab.

A case of pulmonary mucormycosis in a post COVID patient treated in a different scenario

Background: Pulmonary Mucormycosis was rare pulmonary fungal disease ,which was difficult to diagnose early and lack effective treatment but during COVID-19 pandemic the testing modalities have become handy , usually it used to occur in immune compromised patients , present days post Covid pulmonary mucor has become common. Case Study: A case of 60yrs old male patient , hypertensive, post Covid presented with cough associated with black coloured sputum, also with streaky haemoptysis and sob on exertion ,CT chest revealed left upper lobe thick walled cavity with reverse halo sign with lower septated cavity , with post covid lung fibrosis. Discussion: Pulmonary Mucormycosis may develop by inhalation of spores or by hematogenous or lymphatic spread, mostly seen in immune compromised patient, the sequelae include angioinvasion and direct tissue injury it may cause severe morbidity and mortality sputum and BAL cultures and radiological investigations are the crucial modalities for diagnosis sputum and BAL cytology may be inconclusive however early diagnosis will prevent the patient from life threatening complications and at times alternative drugs in unavoidable situations can prevent patient from life threatening complications. Conclusion: Different scenarios may be challenging.

A rare case of pulmonary mucormycosis apparent as difficult to extract mucus-plug per bronchoscopy

Background: Pulmonary mucormycosis, a rare pulmonary fungal disease, is difficult to diagnose and lacks effective treatment. Diabetes mellitus, systemic corticosteroid therapy, neutropenia, hematologic malignancies, stem cell transplant, Covid-19 infection and immunocompromised state are the predisposing situations for mucormycosis. There are no reliable serological, PCR-based, or skin tests. Bronchoscopy guided biopsy proved to be effective for early diagnosis. Case Study: A 47 years old female patient, known Diabetic, presented with complains of Dry Cough and fever. Patient had past history of COVID-19 pneumonia. HRCT showed mucus plugging with collapse of left lower lobe. During Bronchoscopy, mucus plug was difficult to extract despite using mucolytics;then biopsy was taken which turned out to be MUCORMYCOSIS. Patient was treated with injectable Amphotericin B for 4-weeks and then Tablet Posaconazole. Patient was improved on follow up. Discussion: Pulmonary Mucormycosis is a rapidly progressive infection that occurs after inhalation of spores. Most patients are presented with fever, cough and hemoptysis. After Covid-19 pandemic, cases of mucormycosis are on rise. Pulmonary Mucormycosis is rare entity than Rhino-orbito-cerebral mucormycosis. Biopsy remains mainstay for diagnosis. Conclusion: Pulmonary Mucormycosis being rare lifethreatening opportunistic infection;early diagnosis and treatment is necessary for better outcome and survival.

Utilization and cost effectiveness of first-line yttrium-90 ibritumomab tiuxetan in lowgrade follicular and marginal zone lymphomas compared to standard of care bendamustine plus rituximab: A real-world experience

Background Yttrium-90 ibritumomab tiuxetan [(90)Y-IT;Zevalin] is a radio-immunoconjugate (RIC) which targets CD20. This study evaluates the utilization and cost-effectiveness of (90)Y-IT in the first line treatment for patients with previously untreated low-grade FL (UFL) and marginal zone lymphoma (UMZL) treated at our institution with (90)Y-IT. Methods We utilized the Advanced Text Explorer (ATE) and the Lymphoma SPORE databases to identify two groups of patients with UFL, WHO grade 1-2, and UMZL who received treatment with either (90)Y-IT or bendamustine plus rituximab (BR) at Mayo Clinic Cancer Center between January 2003 and December 2019. We excluded all patients who had >25% bone marrow involvement with lymphoma for the BR group as this was a requirement for (90)Y-IT treatment. Inverse propensity weighting was utilized to balance the groups for baseline patients and disease characteristics. We use progression-free survival (PFS) as a denominator for the cost effectiveness/utilization evaluation. We identified meaningful and retrospectively measurable outcomes to compare between the groups. we extracted the following data;number of clinic visits in the first year after therapy, emergency room visits, number of hospital admissions, number of hospitalization days, numbers of days on the floor and ICU, number of infections, number of neutropenic fever hospitalizations, number of C-difficile events, number of blood products transfusions, overall use of growth factors due to therapy induced neutropenia, average number of times a growth factor was used, and the number of therapeutic use days. We defined days of therapeutic use as the number of days a treatment was administered on. We also calculated the average cost of the induction treatment when utilizing either (90)Y-IT or BR. The therapeutic cost included only the cost of the medications/therapies and their administration. Results Our cohort consists of a total of 143 patients - 64% (92/143) received BR and 36% (51/143) received (90)Y-IT (see Table-1 for clinical characteristics).The median follow-up from the time of therapeutic administration for the (90)Y-IT group was 5.3 years (95% CI;4.2, 6.2) with one death and 4.7 years (95% CI;3.9, 4.9) for the BR group with 6 deaths. The ORR was 100% in (90)Y-IT group with 94% achieving complete response (CR) while ORR in the BR group was 98% with 95% achieving CR. Rituximab maintenance was utilized in 33% of BR patients compared to only 6% in patients who received (90)Y-IT, p=0.002. After utilizing inverse propensity weighting (Figure-1), 5 years PFS was 76% for the (90)Y-IT group and 75% for the BR group, p=0.63 (Figure-2). We evaluated the average treatment effect of (90)Y-IT compared to BR on utilization outcomes, Table-2. (90)Y-IT required an average of 4.5 clinic visits less within the first year after treatment compared to BR group, p<0.001. (90)Y-IT patients had an average of 10 days less of therapeutic use days compared to the BR group, p<0.001. Patienta had similar admission rates to the hospital in both groups. However, when patients were admitted to the hospital in the first year after treatment, those who received (90)Y-IT spent an average of 1.5 days less in the hospital compared to the BR group, p=0.046. The overall use of growth factors was 40% less in the (90)Y-IT group as compared to the BR group, p<0.001. The therapeutic cost of induction of (90)Y-IT was 54% less than that of 6 cycles of BR. Transformation to a high grade of lymphoma was seen in 4 patients in the BR group and 2 patients in the (90)Y-IT group. There was only one case of myelodysplastic syndrome in the BR group and none in the (90)Y-IT group. Conclusion Radio-immunoconjugate therapy with (90)Y-IT is a very convenient and cost-effective treatment for low-grade UFL and UMZL. This is especially important amidst the COVID-19 pandemic as it requires less contact with the health system with decreased number of therapeutic days, clinic visits, use of growth factors and number of hospitalization days. The cost of the therapeutic agents and heir administration was also significantly lower for the (90)Y-IT which could help reducing the burden on the health system. (Figure Presented).

Manufacturing Processes of SER-109, a Purified Investigational Microbiome Therapeutic, Reduce Risk of Transmission of Emerging and Undetected Infections in Donor Stool

Background. Fecal microbiota transplantation (FMT) is vulnerable to emerging pathogens due to reliance on donor screening for risk mitigation. These concerns were highlighted by dual FDA safety alerts regarding FMT transmission of bacterial pathogens, which were recognized in hindsight only after hospitalizations and deaths. The FDA also warned of potential risk of SARS-CoV-2 transmission, leading to quarantine of FMT in March 2020, two months after COVID-19 was reported on US soil. Conversely, our development program for SER-109, an oral investigational microbiome therapeutic, was prospectively designed to inactivate organisms of concern, while purifying the hardy Firmicutes spores. We evaluated whether the manufacturing processes for SER-109 inactivate model organisms, including a coronavirus with gastrointestinal tropism, and a representative Gram-negative bacterium. Methods. Model organisms were selected based on biologic suitability, detectability, and laboratory safety. Porcine Epidemic Diarrhea Virus (PEDV, a coronavirus) was selected to model SARS-CoV-2. Quantitation used a Vero cell tissue culture infectious dose (TCID50) assay. For E. coli, a rifampicin-tolerant Salmonella enterica was selected and quantified with MacConkey lactose agar plus rifampicin. Spiking experiments into representative fecal suspensions were completed to measure inactivation of model organisms. Log-reduction factors (LRF) were calculated based on the drop in organism titer during inactivation. Hold controls in non-ethanolic test matrices were used to confirm specificity of the ethanol inactivation. Results. In 70% v/v ethanol, PEDV was inactivated by more than 4.2 log10 (to limit of detection, LOD) within 4 minutes (Fig1). In 50% v/v ethanol, S. enterica was inactivated by more than 6.5 log10 (to LOD) within 30 seconds (Fig2). Average of three experiments with error bars represent 95% CI. Also shown is the maximum achievable inactivation based on the limit of detection (LOD). Conclusion. These experiments demonstrate substantial inactivation of the model organisms and support the potential benefit of SER-109 manufacturing process to mitigate risks of undetected or emerging pathogens for which reliable screening is limited. Ethanol exposure leads to a purified investigational product of beneficial Firmicutes spores while affording a safety net beyond donor screening alone.

Utility of hydrogen peroxide disinfection in decreasing pathogens in a critical care environment

INTRODUCTION: Environmental surfaces impact pathogen transmission and thus hospital acquired infections. This underscores the need for high-level disinfection, especially considering the vulnerability of critical care patients and the risks posed by multi-drug resistant organisms (MDRO). Enhanced cleaning practices employed by hospitals for environmental disinfection are not all equal. For this investigation, a hydrogen peroxide disinfection system was chosen due to its EPA approval against SARS-CoV-2 and its sporicidal efficacy. This study sought to evaluate the efficacy/ feasibility of a hybrid form of hydrogen peroxide (HHP fogging) compared to current disinfection practices (standard cleaning and enhanced UV-light cleaning) in a critical care setting. METHODS: From Dec '20-Jun '21 data were collected in 17 critical care patient rooms post-discharge. Samples were collected to evaluate HHP fogging versus standard and enhanced cleaning. Sampling followed each intervention: post-EVS standard cleaning, post-enhanced cleaning with UV-light, and post HHP fogging following standard/enhanced practices. Five preset high touch patient room locations were swabbed for aerobic colony counts (ACC) and enumerated for MDRO presence: toilet, phone, bed rail, touchscreen, sink countertop. Measurements included quantitative and qualitative counts (ACC, adenosine triphosphate (ATP) swabs -measured in relative light units,RLU), hydrogen peroxide chemical indicators, and bacterial spore biological indicators(BIs, Geobacillus stearothermophilus). RESULTS: No difference was seen between standard cleaning and enhanced cleaning with UV light (mean ACC 7.16 and 6.35, respectively;p=0.186). HHP fogging reduced present ACC levels by 98% beyond current EVS post-discharge cleaning practices (mean ACC 0.137, p< 0.0001). MRSA instances were observed after standard and enhanced cleaning with UV light (mean ACC 0.178), no MRSA was detected after HHP fogging. ATP results showed an average 88% reduction post HHP fogging (mean RLU: post cleaning=9012, post HHP fogging=1109;p=0.014) and BIs confirmed a 6-log bacterial spore efficacy. CONCLUSION: HHP fogging resulted in successful elimination of MDROs and reduction in aerobic colony counts versus standard and UV-light cleaning. Deployment of HHP fogging is feasible and safe in a critical care setting.