Utilization of deceased donors during a pandemic: argument against using SARS-CoV-2-positive donors.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly become an unprecedented pandemic that has impacted society, disrupted hospital functions, strained health care resources, and impacted the lives of transplant professionals. Despite this, organ failure and the need for transplant continues throughout the United States. Considering the perpetual scarcity of deceased donor organs, Kates et al present a viewpoint that advocates for the utilization of coronavirus disease 2019 (COVID-19)-positive donors in selected cases. We present a review of the current literature that details the potential negative consequences of COVID-19-positive donors. The factors we consider include (1) the risk of blood transmission of SARS-CoV-2, (2) involvement of donor organs, (3) lack of effective therapies, (4) exposure of health care and recovery teams, (5) disease transmission and propagation, and (6) hospital resource utilization. While we acknowledge that transplant fulfills the mission of saving lives, it is imperative to consider the consequences not only to our recipients but also to the community and to health care workers, particularly in the absence of effective preventative or curative therapies. For these reasons, we believe the evidence and risks show that COVID-19 infection should continue to remain a contraindication for donation, as has been the initial response of donation and transplant societies.

Risk factors for recurrent percutaneous nephrostomy catheter-related infections.

PURPOSE: Percutaneous nephrostomy (PCN) catheters are mainly indicated for urinary tract obstructions. Unfortunately, the rate for infection and recurrence remains elevated. Our objective was to identify the risk factors leading to recurrent PCN-related infections (PCNI) in cancer patients. METHODS: We retrospectively reviewed 571 patients who underwent initial PCN catheter placement at our institution. Of these, we identified patients with a definite PCNI and catheter exchange, with a minimum 30-day follow-up. We defined PCNI as presence of a urine culture positive for bacteria (≥ 104 CFU/mL) plus symptoms of urinary tract infection. A PCNI was considered recurrent if the same organism was isolated. Antibiotics were considered concordant if they were active against all identified organisms. RESULTS: A total of 81 patients (14%) developed an initial PCNI. Of 47 patients with 30-day follow-up, 10 patients (21%) were identified as having a recurrent PCNI. In terms of demographic characteristics, clinical manifestations, and microbiological data, there was no statistically significant difference between the recurrent and non-recurrent groups. However, in multivariate logistic regression analysis, two factors were independently associated with a decrease in recurrent PCNI: concordant antibiotic use (OR 0.04; p = 0.008) and PCN catheter exchange within 4 days of infection (OR 0.1; p = 0.048). CONCLUSIONS: To decrease the high rate of recurrent infections, associated costs, and potential delay in further chemotherapy, we recommend that once antimicrobial susceptibility test results are available and the patient is known to be receiving concordant antimicrobials, clinicians proceed with immediate PCN catheter exchange, ideally within the first 4 days of the infection.

A "Cat"-astrophic Case of Bartonella henselae infective endocarditis followed by cardiac transplantation salvage therapy.

To our knowledge, no cases of Bartonella henselae endocarditis leading to subsequent heart transplantation salvage therapy have been published. We present a case of a 29-year-old man with cat-inflicted B henselae endocarditis and concurrent worsening heart failure, who then underwent successful heart transplantation 50 days following diagnosis. Treatment and monitoring strategies used in this patient are discussed. Furthermore, we review literature related to heart transplantation salvage therapy for endocarditis due to other intracellular pathogens.

Long term outcomes of patients transplanted for hepatocellular carcinoma with human immunodeficiency virus infection.

BACKGROUND: We aimed to study outcomes in HIV + patients with HCC in the US following Liver Transplantation (LT) using the UNOS dataset. METHODS: The database was queried from 2003 to 2016 for patients undergoing LT with HCC, HIV+, and HCC/HIV+. RESULTS: Out of 17,397 LT performed for HCC during the study period, 113 were transplanted for HCC with HIV infection (91 isolated livers). Patients transplanted for HCC/HIV+ were younger (55.54 ± 5.89 vs 58.80 ± 7.37, p < 0.001), had lower total bilirubin (1.20 vs 1.60, p = 0.042) significantly lower BMI (25.35 ± 4.43 vs 28.39 ± 5.17, p < 0.001) and were more likely to be co-infected with HBV (25.3% vs 8.2% p < 0.001) than those transplanted for HCC alone. HCC/HIV + patients were found to have a 3.8 fold increased risk of peri-operative mortality at 90 days after matching. HCC/HIV + recipients had 54% decreased long-term survival within the HCC cohort. Our initial analysis of overall graft and patient survival found significant differences between HCC/HIV and HCC/HIV + recipients. However, these variances were lost after case-matching. Recurrence and disease free survival were similar in HCC alone vs HCC/HIV + recipients. CONCLUSIONS: Our analysis suggests that excellent outcomes can be achieved in selected patients with HCC/HIV+.

Biomarkers of Sepsis and Bloodstream Infections: The Role of Procalcitonin and Proadrenomedullin With Emphasis in Patients With Cancer.

Sepsis and bloodstream infections remain a leading cause of death in immunocompromised patients with cancer. The management of these serious infections consist of empiric use of antimicrobial agents which are often overused. Procalcitonin and proadrenomedullin are biomarkers that have been extensively evaluated in the general populations but with little emphasis in the population immunocompromised patients with cancer, where they may have promising roles in the management of febrile patients. In this review, we summarize the available evidence of the potential role of these available biomarkers in guiding antimicrobial therapy to optimize the use of resources in the general patient population. Special emphasis is given to the role of these 2 biomarkers in the immunocompromised and critically ill patients with cancer, highlighting the distinctive utility of each.

CMV sinusitis, an overlooked diagnosis, a predisposing condition or is it a bystander? A Case report and review of the literature.

The disease entity of cytomegalovirus (CMV) sinusitis has been uncommonly described in the literature, although other end organ debilitating diseases are frequently encountered in people with advanced Human immunodeficiency virus (HIV) infection. We herein present a case of CMV sinusitis in an patient with acquired immunodeficiency syndrome (AIDS) diagnosed by the detection of intranuclear viral inclusions and positive CMV immunostains. The patient responded to surgical debridement and targeted medical therapy. A consideration should be made to this rarely described form of CMV disease. There is heterogeneity in how the diagnosis was made in the reported cases in the reviewed literature. Unlike our patient, not all the patients had cytopathological evidence of the disease. Furthermore, some of the patients improved with surgical therapy alone raising the question of the true clinical significance of the recovery of CMV viral particles without cytopathic evidence in their corresponding diagnostic workup. On another note, the recovery of CMV in samples of patients with chronic antibiotic-resistant sinusitis may suggest a pathogenic role and necessitates adequate therapeutic interventions.

Disseminated Mucormycosis with Extensive Cardiac Involvement.

Mucormycosis is an opportunistic fungal infection. Cardiac involvement is a rare, yet fatal, complication that can occur in disseminated disease. A strong index of suspicion is necessary for prompt treatment, especially in high-risk patients. We present a 62-year-old male patient with a history of diabetes and acute myeloid leukemia; he had pulmonary mucormycosis that was complicated by cardiac involvement as part of disseminated mucormycosis syndrome.

A Rare Case of Herpes Simplex Virus-2 Hepatitis with Negative Serology.

Herpes simplex virus-2 (HSV2) hepatitis represents a rare but serious complication of HSV2 infection that can progress to acute liver failure (ALF). We describe a case of a pregnant teenager who presented with four days of fever, headache, malaise, nausea, and vomiting. She was initially misdiagnosed with sepsis of unclear source and treated with broad-spectrum antibiotics. Empiric acyclovir was started one week into her hospitalization despite negative serologies while awaiting HSV2 PCR leading to complete resolution of symptoms. Given its high mortality and nonspecific presentation, clinicians should consider HSV hepatitis in all patients with acute hepatitis especially in high-risk population.

Bowel Perforation Resulting in Necrotizing Soft-Tissue Infection of the Abdomen, Flank, and Lower Extremities.

BACKGROUND: Fournier's gangrene is a necrotizing soft-tissue infection (NSTI) that often originates from a break in bowel integrity and affects the perineum, anus, or genitalia. Although the pathogenesis is similar, NSTI caused by a break in bowel integrity less commonly presents as infection of other sites. OBJECTIVE: To characterize NSTIs originating from bowel perforation and presenting as infection of the abdominal wall, flank, or thigh but that largely spare the perineum, anus, and genitalia. METHODS: We describe a characteristic case and summarize findings from 67 reported cases. RESULTS: The causes of bowel injury included trauma (29%), perforated appendicitis (23%), perforated diverticulitis (16%), and perforation of a gastrointestinal tract cancer (16%). The symptomatic prodrome is indolent and nondescript. Most patients have polymicrobial infections and require antibiotic therapy combined with serial surgical debridements. Because the presentation differs from that of typical Fournier's gangrene, recognition of NSTI was delayed in the reported cases, and the associated bowel perforation often was overlooked, leading to delayed surgical treatment. As a result, the mortality rate was >33%, far exceeding that of typical Fournier's gangrene. Delays in diagnosis or surgical intervention predict a poor outcome. CONCLUSIONS: An NSTI resulting from bowel perforation can present in an atypical fashion carrying significant morbidity and mortality rates. Delayed diagnosis and treatment of this condition is associated with a poor outcome.

Author Correction: Procalcitonin Guiding Antimicrobial Therapy Duration in Febrile Cancer Patients with Documented Infection or Neutropenia.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Epidemiology of bloodstream infections caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York.

BACKGROUND: In the United States, bloodstream infections (BSIs) are predominated by Staphylococcus aureus. The proportion of community-acquired methicillin-resistant S aureus (MRSA) BSI is on the rise. The goal of this study is to explore the epidemiology of BSI caused by S aureus within Staten Island, New York. METHODS: This is a case-case-control study from April 2012-October 2014. Cases were comprised of patients with BSI secondary to MRSA and methicillin-sensitive S aureus (MSSA). The control group contained patients who were hospitalized during the same time period as cases but did not develop infections during their stay. Two multivariable models compared each group of cases with the uninfected controls. RESULTS: A total of 354 patients were analyzed. Infections were community acquired in 76% of cases. The major source of BSI was skin-related infections (n = 76). The first multivariable model showed that recent central venous catheter placement was an independent infection risk factor (odds ratio [OR] = 80.7; 95% confidence interval [CI], 2.2-3,014.1). In the second model, prior hospital stay >3 days (OR = 4.1; 95% CI, 1.5-5.7) and chronic kidney disease (OR = 3.0; 95% CI, 1.01-9.2) were uniquely associated with MSSA. Persistent bacteremia, recurrence, and other hospital-acquired infections were more likely with MRSA BSI than MSSA BSI. CONCLUSION: Most infections were community acquired. The presence of a central venous catheter constituted a robust independent risk factor for MRSA BSI. Patients with MRSA BSI suffered worse outcomes than those with MSSA BSI.

Exploring Novel Medicare Readmission Risk Variables in Chronic Obstructive Pulmonary Disease Patients at High Risk of Readmission within 30 Days of Hospital Discharge.

RATIONALE: New risk factors for readmission within 30 days of hospital discharge for patients with chronic obstructive pulmonary disease (COPD) need to be identified in view of the lack of efficacy of current interventions for preventing readmission. OBJECTIVES: To identify novel risk predictors for 30-day readmission among COPD index admissions at high risk of readmission. METHODS: For this analysis, we used the fiscal year 2015 hospital-specific Medicare Hospital Readmissions Reduction Program workbook for Staten Island University Hospital (Staten Island, NY). We analyzed 41 variables, each with a risk-variable score. A predicted probability of readmission was calculated for each case by using the risk-variable regression coefficient and a hospital-specific effect. A predicted probability greater than 0.4 was used to identify patients with COPD with a high risk of readmission in both the readmitted and nonreadmitted groups. A percent ratio of the readmission percentage divided by the nonreadmission percentage was generated for each risk variable for patients with a predicted probability of readmission greater than 0.4. A percent ratio greater than 3 was used to identify high-risk variables predictive of readmission. A risk index was defined as the number of high-risk variables present for each index admission. MEASUREMENTS AND MAIN RESULTS: Nine high-risk variables were identified. A risk index greater than 3 for all index admissions identified 54 (22.7%) of 238 readmitted patients versus 41 (6.5%) of 630 nonreadmitted patients (P < 0.0001; positive predictive value, 0.56; specificity, 0.93). A risk index greater than 2 for multiple-admission patients identified 56 (65.1%) of 86 readmitted patients versus 135 (40.7%) of 332 nonreadmitted patients (P < 0.0001; positive predictive value, 0.65; specificity, 0.86). Over 30% of readmitted patients meeting the risk index criteria were discharged to home without organized home care. Sleep apnea, vertebral fractures, and electrolyte and acid-base disorders were newly identified predictors of readmission. CONCLUSIONS: This study developed a risk index based upon the 2015 Hospital Readmissions Reduction Program worksheet for one hospital to explore risk variables predictive of 30-day readmissions for patients with COPD at high risk of readmission (>0.4). Because most currently used interventions lack efficacy in preventing 30-day readmission, interventions based upon the newly identified variables should be validated with larger validation cohorts.