Seafood-Associated Outbreak of ctx-Negative Vibrio mimicus Causing Cholera-Like Illness, Florida, USA.

Vibrio mimicus caused a seafood-associated outbreak in Florida, USA, in which 4 of 6 case-patients were hospitalized; 1 required intensive care for severe diarrhea. Strains were ctx-negative but carried genes for other virulence determinants (hemolysin, proteases, and types I-IV and VI secretion systems). Cholera toxin-negative bacterial strains can cause cholera-like disease.

Clinical and Microbiologic Outcomes in Patients with Monomicrobial Stenotrophomonas maltophilia Infections.

Stenotrophomonas maltophilia is an opportunistic pathogen observed in nosocomial infections. Due to biofilm production and resistance to numerous antimicrobials, eradication is difficult. This study evaluated outcomes for monomicrobial S. maltophilia infections. Seventy-six patients were included, with 45 patients on trimethoprim-sulfamethoxazole and 31 patients on levofloxacin. Overall clinical cure, microbiological eradication, and 28-day mortality were observed in 79%, 82%, and 14% of patients, respectively. The use of trimethoprim-sulfamethoxazole or levofloxacin resulted in high cure rates; however, a trend toward resistance selection with levofloxacin was identified.

Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test.

OBJECTIVE: Recent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery. METHODS: This is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery. RESULTS: There were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002). CONCLUSION: Shorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates. LEVEL OF EVIDENCE: Level 2b.

Efficacy of Messenger RNA-1273 Against Severe Acute Respiratory Syndrome Coronavirus 2 Acquisition in Young Adults From March to December 2021.

Background: The efficacy of messenger RNA (mRNA)-1273 against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is not well defined, particularly among young adults. Methods: Adults aged 18-29 years with no known history of SARS-CoV-2 infection or prior vaccination for coronavirus disease 2019 (COVID-19) were recruited from 44 US sites from 24 March to 13 September 2021 and randomized 1:1 to immediate vaccination (receipt of 2 doses of mRNA-1273 vaccine at months 0 and 1) or the standard of care (receipt of COVID-19 vaccine). Randomized participants were followed up for SARS-CoV-2 infection measured by nasal swab testing and symptomatic COVID-19 measured by nasal swab testing plus symptom assessment and assessed for the primary efficacy outcome. A vaccine-declined observational group was also recruited from 16 June to 8 November 2021 and followed up for SARS-CoV-2 infection as specified for the randomized participants. Results: The study enrolled 1149 in the randomized arms and 311 in the vaccine-declined group and collected >122 000 nasal swab samples. Based on randomized participants, the efficacy of 2 doses of mRNA-1273 vaccine against SARS-CoV-2 infection was 52.6% (95% confidence interval, -14.1% to 80.3%), with the majority of infections due to the Delta variant. Vaccine efficacy against symptomatic COVID-19 was 71.0% (95% confidence interval, -9.5% to 92.3%). Precision was limited owing to curtailed study enrollment and off-study vaccination censoring. The incidence of SARS-CoV-2 infection in the vaccine-declined group was 1.8 times higher than in the standard-of-care group. Conclusions: mRNA-1273 vaccination reduced the incidence of SARS-CoV-2 infection from March to September 2021, but vaccination was only one factor influencing risk. Clinical Trials Registration: NCT04811664.

Development of a Prediction Model for Antibiotic-Resistant Urinary Tract Infections Using Integrated Electronic Health Records from Multiple Clinics in North-Central Florida.

INTRODUCTION: Urinary tract infections (UTIs) are common infections for which initial antibiotic treatment decisions are empirically based, often without antibiotic susceptibility testing to evaluate resistance, increasing the risk of inappropriate therapy. We hypothesized that models based on electronic health records (EHR) could assist in the identification of patients at higher risk for antibiotic-resistant UTIs and help guide the selection of antimicrobials in hospital and clinic settings. METHODS: EHR from multiple centers in North-Central Florida, including patient demographics, previous diagnoses, prescriptions, and antibiotic susceptibility tests, were obtained for 9990 patients diagnosed with a UTI during 2011-2019. Decision trees, boosted logistic regression (BLR), and random forest models were developed to predict resistance to common antibiotics used for UTI management [sulfamethoxazole-trimethoprim (SXT), nitrofurantoin (NIT), ciprofloxacin (CIP)] and multidrug resistance (MDR). RESULTS: There were 6307 (63.1%) individuals with a UTI caused by a resistant microorganism. Overall, the population was majority female, white, non-Hispanic, and older aged (mean = 60.7 years). The BLR models yielded the highest discriminative ability, as measured by the out-of-bag area under the receiver-operating curve (AUROC), for the resistance outcomes [AUROC = 0.58 (SXT), 0.62 (NIT), 0.64 (CIP), and 0.66 (MDR)]. Variables in the best performing model were sex, history of UTIs, catheterization, renal disease, dementia, hemiplegia/paraplegia, and hypertension. CONCLUSIONS: The discriminative ability of the prediction models was moderate. Nonetheless, these models based solely on EHR demonstrate utility for the identification of patients at higher risk for resistant infections. These models, in turn, may help guide clinical decision-making on the ordering of urine cultures and decisions regarding empiric therapy for these patients.

Efficacy of Losartan in Hospitalized Patients With COVID-19-Induced Lung Injury: A Randomized Clinical Trial.

Importance: SARS-CoV-2 viral entry may disrupt angiotensin II (AII) homeostasis, contributing to COVID-19 induced lung injury. AII type 1 receptor blockade mitigates lung injury in preclinical models, although data in humans with COVID-19 remain mixed. Objective: To test the efficacy of losartan to reduce lung injury in hospitalized patients with COVID-19. Design, Setting, and Participants: This blinded, placebo-controlled randomized clinical trial was conducted in 13 hospitals in the United States from April 2020 to February 2021. Hospitalized patients with COVID-19 and a respiratory sequential organ failure assessment score of at least 1 and not already using a renin-angiotensin-aldosterone system (RAAS) inhibitor were eligible for participation. Data were analyzed from April 19 to August 24, 2021. Interventions: Losartan 50 mg orally twice daily vs equivalent placebo for 10 days or until hospital discharge. Main Outcomes and Measures: The primary outcome was the imputed arterial partial pressure of oxygen to fraction of inspired oxygen (Pao2:Fio2) ratio at 7 days. Secondary outcomes included ordinal COVID-19 severity; days without supplemental o2, ventilation, or vasopressors; and mortality. Losartan pharmacokinetics and RAAS components (AII, angiotensin-[1-7] and angiotensin-converting enzymes 1 and 2)] were measured in a subgroup of participants. Results: A total of 205 participants (mean [SD] age, 55.2 [15.7] years; 123 [60.0%] men) were randomized, with 101 participants assigned to losartan and 104 participants assigned to placebo. Compared with placebo, losartan did not significantly affect Pao2:Fio2 ratio at 7 days (difference, -24.8 [95%, -55.6 to 6.1]; P = .12). Compared with placebo, losartan did not improve any secondary clinical outcomes and led to fewer vasopressor-free days than placebo (median [IQR], 9.4 [9.1-9.8] vasopressor-free days vs 8.7 [8.2-9.3] vasopressor-free days). Conclusions and Relevance: This randomized clinical trial found that initiation of orally administered losartan to hospitalized patients with COVID-19 and acute lung injury did not improve Pao2:Fio2 ratio at 7 days. These data may have implications for ongoing clinical trials. Trial Registration: ClinicalTrials.gov Identifier: NCT04312009.

Draft Genome Sequence of a Burkholderia cepacia Complex Strain Isolated from a Human Intra-abdominal Abscess.

Burkholderia cepacia complex (Bcc) bacteria are opportunistic pathogens with high transmissibility and mortality. Here, we report the draft genome sequence of a Bcc strain isolated from a deep abscess culture in an immunocompetent patient with no relevant prior medical history.

Dissemination mechanisms of NDM genes in hospitalized patients.

BACKGROUND: NDM-producing Enterobacteriaceae are a major clinical concern worldwide. We characterized NDM-positive pathogens isolated from patients and assessed the dissemination patterns of the bla NDM genes in a hospital setting. METHODS: Eleven NDM-positive Enterobacteriaceae (three Enterobacter hormaechei, six Klebsiella pneumoniae and two Escherichia coli) were isolated from nine patients over a 1 year period. Antimicrobial susceptibility was assessed by MICs. A combination of short- and long-read WGS was used for genome analysis. Clinical treatment history of patients was linked with genetic features of individual isolates to investigate the dissemination patterns of the bla NDM genes and NDM-positive strains. RESULTS: bla NDM in clonal K. pneumoniae were transmitted between two patients. In other instances, an identical IncC plasmid encoding NDM-1 was transmitted between E. coli and K. pneumoniae isolated from the same patient, and an IncX3 plasmid, carrying bla NDM-1 or bla NDM-5, was harboured in non-clonal E. hormaechei. Varying patterns of IS elements were identified as a critical transmission mechanism in association with bla NDM genes. CONCLUSIONS: Multiple transmission patterns were identified in hospitalized patients, including dissemination of clonal bacterial strains carrying resistance genes and horizontal transfer of resistance genes among divergent bacterial strains. Controlling spread of NDM is complex: while attention to standard infection control practices is critically important, this needs to be matched by aggressive efforts to limit unnecessary antimicrobial use, to minimize the selection for and risk of transfer of 'high mobility' resistance genes among Enterobacteriaceae.

Severe COVID-19 After Recent Heart Transplantation Complicated by Allograft Dysfunction.

A 50-year-old male presented with atrial flutter 25 days after heart and kidney transplantation. Rejection was excluded, but he developed severe COVID-19 infection with cardiac allograft dysfunction. Despite continued corticosteroid and tacrolimus therapy, he remained aviremic. Respiratory and myocardial functions recovered after a week of mechanical ventilation. The cardiomyopathy was stress induced. (Level of Difficulty: Advanced.).

Application of an objective structured clinical examination to evaluate and monitor intern's proficiency of hand hygiene and personal protective equipment use in the United States.

PURPOSE: To determine if an objective structured clinical examination (OSCE) could be used to evaluate and monitor hand hygiene and personal protective equipment (PPE) proficiency for medical interns in the United States. METHODS: Interns in July 2015 (N=123, Cohort 1) without OSCE-based contact precaution evaluation and teaching were evaluated early 2016 by OSCE for hand hygiene and PPE proficiency. They performed poorly. Therefore, the new interns entering July 2016 (N=151, Cohort 2) were immediately tested in the same OSCE station as Cohort 1 and provided feedback and teaching. Cohort 2 was then retested in the OSCE station early 2017. The Mann Whitney U test was used to compare Cohort 1 vs. Cohort 2 performances on checklist items. Cohort 2 performance differences at the beginning and end of the intern year were compared using McNemar's X2 test for paired nominal data. RESULTS: Checklist items were scored, summed and reported as percent correct. In Cohort 2, the mean percent correct was higher in posttest than pretest, 92% vs. 77% )(P <0 .0001). The passing rate (100% correct) was significantly higher, 55% vs. 16%. Comparing Cohort 1 and Cohort 2 at the end of intern year, the mean percent correct was higher for Cohort 2 compared to Cohort 1, 95% vs 90% (P < 0.0001). 55% of the Cohort 2 passed (a perfect score) compared to 24% in Cohort 1 (P < 0.0001). CONCLUSION: An OSCE can be utilized to evaluate and monitor hand hygiene and PPE proficiency for interns in the United States.

Peripheral T-cell lymphoma mimicking classic Hodgkin's lymphoma in a patient presenting with fevers of unknown origin.

A 52-year-old man presented to our hospital for further workup of fever of unknown origin after an extensive workup at an outside hospital had failed to reveal a diagnosis. At the outside hospital, he underwent excisional biopsy of the left supraclavicular lymph node, which showed non-necrotising granulomatous changes, and a bone marrow biopsy which showed a normocellular marrow. He was discharged without a diagnosis with recommendations to present to a tertiary hospital. During his admission, his hospital course was complicated by new direct hyperbilirubinaemia and eosinophilia, prompting liver and skin biopsies which showed CD30+ and CD3+ cells. He subsequently underwent left axillary lymph node biopsy, which was reported as 'classic Hodgkin's lymphoma'. With worsening lab values and T cells noted on liver and skin biopsies, excisional lymph node biopsy was sent to the National Institute of Health, where it was confirmed patient had peripheral T cell lymphoma.