Neurovascular Complications of Iatrogenic Fusarium solani Meningitis.

A multinational outbreak of nosocomial fusarium meningitis occurred among immunocompetent patients who had undergone surgery with epidural anesthesia in Mexico. The pathogen involved had a high predilection for the brain stem and vertebrobasilar arterial system and was associated with high mortality from vessel injury. Effective treatment options remain limited; in vitro susceptibility testing of the organism suggested that it is resistant to all currently approved antifungal medications in the United States. To highlight the severe complications associated with fusarium infection acquired in this manner, we report data, clinical courses, and outcomes from 13 patients in the outbreak who presented with symptoms after a median delay of 39 days.

Screening donors for COVID-19 convalescent plasma.

BACKGROUND: Convalescent plasma is used as a treatment for COVID-19. Only limited data describe the efforts to recruit COVID-19 convalescent plasma (CCP) donors. We describe our experience engaging persons recovered from COVID-19 to donate CCP. STUDY DESIGN AND METHODS: We performed a retrospective analysis of the CCP recruitment for an 11-hospital health system in Houston, Texas. We sought CCP donations from: a) "volunteers" responding to advertisements in social media, press releases, and websites and b) "referred" individuals directed to the program or identified from hospitalization records. We determined the proportions of donor candidates who passed initial telephone health screening, who qualified after diagnostic testing, who presented to the regional CCP donation center, and who completed CCP donation. RESULTS: There were 900 CCP donor candidates, including 363 volunteers and 537 referred donors. Of 360 contacted volunteers, 186 (5.7%) were excluded by interview; 133 were referred for additional diagnostic screening, 97 completed donor antibody and antigen testing, and 87 were qualified for CCP donation, resulting in 35 CCP donations (9.7% of initial telephone contacts). Among 533 referred donors, 448 (84.1%) were excluded by interview, 71 were referred for additional screening, 48 completed donor antibody and antigen testing, and 40 were qualified for CCP donation, resulting in one CCP donation (0.2% of initial telephone contacts). CONCLUSION: In this community, screening of a high number of candidates yielded a limited number of CCP donations. These observations have important implications for CCP donor recruitment and community pandemic planning.

Simultaneous Infection with Enterobacteriaceae and Pseudomonas aeruginosa Harboring Multiple Carbapenemases in a Returning Traveler Colonized with Candida auris.

We report our clinical experience treating a critically ill patient with polymicrobial infections due to multidrug-resistant Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa in a 56-year-old woman who received health care in India and was also colonized by Candida auris A precision medicine approach using whole-genome sequencing revealed a multiplicity of mobile elements associated with NDM-1, NDM-5, and OXA-181 and, supplemented with susceptibility testing, guided the selection of rational antimicrobial therapy.

Long-Term Compassionate Use of Cefiderocol To Treat Chronic Osteomyelitis Caused by Extensively Drug-Resistant Pseudomonas aeruginosa and Extended-Spectrum-ß-Lactamase-Producing Klebsiella pneumoniae in a Pediatric Patient.

We report a 15 year-old Nigerian adolescent male with chronic osteomyelitis caused by an extensively drug-resistant (XDR) Pseudomonas aeruginosa strain of sequence type 773 (ST773) carrying blaNDM-1 and an extended spectrum ß-lactamase (ESBL)-producing Klebsiella pneumoniae strain. The patient developed neurological side effects in the form of circumoral paresthesia with polymyxin B and asymptomatic elevation of transaminases with aztreonam (used in combination with ceftazidime-avibactam). Cefiderocol treatment for 14 weeks plus bone implantation resulted in apparent cure and avoided amputation.

In Vitro Evaluation of BacT/Alert FA Blood Culture Bottles and T2Candida Assay for Detection of Candida in the Presence of Antifungals.

The T2Candida assay is a novel, non-culture-based assay for the diagnosis of candidemia directly from whole blood. The impact of antifungals on the performance of the T2Candida assay and blood culture bottles has not been well described. In this study, the performance of the T2Candida assay was compared to that of blood culture in detecting Candida spp. in spiked blood cultures with or without the presence of antifungals. Clinical bloodstream isolates of Candida spp. were inoculated into human whole blood at low (1 to 5 cells/ml) and high (10 to 50 cells/ml) concentrations with or without the presence of caspofungin and fluconazole. Time to detection (TTD) was assessed for prepared samples using BacT/Alert FA aerobic blood culture bottles or the T2Candida assay. In the absence of antifungals, T2Candida assay sensitivity was comparable to that of blood culture at both the low inoculum and the high inoculum (95% versus 97.5% and 100% versus 100%, respectively) and the assay had an average TTD that was significantly shorter (5.1 h versus 27.2 to 30 h, respectively). Neither caspofungin nor fluconazole was observed to impact the sensitivity or TTD of the T2Candida assay, while fluconazole reduced the overall blood culture sensitivity by 7.5% to 12.5% (at the low inoculum and high inoculum, respectively) and significantly increased the TTD of Candida albicans, C. tropicalis, and C. parapsilosis by 14.8 to 67 h. Neither caspofungin nor fluconazole impacted the performance of the T2Candida assay in vitro, and the assay may be useful for the diagnosis of candidemia in patients receiving antifungal therapy.

Multicenter Evaluation of Ceftolozane/Tazobactam for Serious Infections Caused by Carbapenem-Resistant Pseudomonas aeruginosa.

A multicenter, retrospective study of patients infected with carbapenem-resistant Pseudomonas aeruginosa who were treated with ceftolozane/tazobactam was performed. Among 35 patients, pneumonia was the most common indication and treatment was successful in 26 (74%). Treatment failure was observed in all cases where isolates demonstrated ceftolozane-tazobactam minimum inhibitory concentrations ≥8 µg/mL.

Ceftaroline-Resistant, Daptomycin-Tolerant, and Heterogeneous Vancomycin-Intermediate Methicillin-Resistant Staphylococcus aureus Causing Infective Endocarditis.

We report a case of infective endocarditis (IE) caused by ceftaroline-resistant, daptomycin-tolerant, and heterogeneous vancomycin-intermediate methicillin-resistant S. aureus (MRSA). Resistance to ceftaroline emerged in the absence of drug exposure, and the E447K substitution in the active site of PBP2a previously associated with ceftaroline resistance was identified. Additionally, we present evidence of patient-to-patient transmission of the strain within the same unit. This case illustrates the difficulties in treating MRSA IE in the setting of a multidrug-resistant phenotype.

Carbapenem-resistant Lactobacillus intra-abdominal infection in a renal transplant recipient with a history of probiotic consumption.

BACKGROUND: Lactobacillus sp. is a low virulence bacterium, which rarely causes infection in immunocompetent individuals and usually is considered a contaminant. Normally this organism is susceptible to ß-lactam antibiotics, yet resistant strains have been reported. CASE PRESENTATION AND DISCUSSION: Here, we report a case of a 60-year-old renal transplant recipient who developed an intra-abdominal abscess which grew a carbapenem-resistant Lactobacillus casei. This is significant since it is the first report of a clinical isolate of Lactobacillus sp. that demonstrated both microbiological and clinical resistance to carbapenem use. Moreover, the probiotic supplement that the patient had taken also grew a similar organism raising the concern of probiotic associated infection in immunocompromised individual.

Evaluation of vancomycin susceptibility testing for methicillin-resistant Staphylococcus aureus: comparison of Etest and three automated testing methods.

We evaluated the ability of four commercial MIC testing systems (MicroScan, Vitek 2, Phoenix, and Etest) to detect vancomycin MIC values of ≤1 to ≥2 in 200 methicillin-resistant Staphylococcus aureus (MRSA) strains compared to the Clinical and Laboratory Standards Institute broth microdilution (BMD) reference methods. Compared to the BMD method, absolute agreement (0 ± dilution) was highest for the Phoenix system (66.2%) and the MicroScan turbidity method (61.8%), followed by the Vitek 2 system (54.3%). The Etest produced MIC values 1 to 2 dilutions higher than those produced by the BMD method (36.7% agreement). Of interest, the MicroScan system (prompt method) was more likely to overcall an MIC value of 1 mg/liter (74.1%), whereas the Phoenix (76%) and Vitek 2 (20%) systems had a tendency to undercall an MIC of 2 mg/liter. The ability to correctly identify vancomycin MIC values of 1 and 2 has clinical implications and requires further evaluation.

Clinical Epidemiology and Antimicrobial Resistance Patterns of Infections Due to Salmonella Species in Children, Houston, TX. 2016-2021: A Retrospective Study.

BACKGROUND: Salmonellosis continues to be a major public health issue and high rates of infection are reported among young children. The contemporary clinical epidemiology of pediatric Salmonella spp. infections in the US is not well characterized. METHODS: We performed a retrospective observational study in a large hospital network in Houston, TX. We included all patients 18 years or younger identified as having a positive culture for Salmonella spp. from any body site during the years 2016-2021. The patient's medical record was accessed and detailed demographic, clinical and microbiologic information were collected. RESULTS: We identified a total of 110 pediatric patients with Salmonella spp. infections between 2016 and 2021. The highest frequency (69%) of infections was observed among children 0-5 years old. Bloody diarrhea was most frequently reported for children 0-1 years old. Although the highest number of salmonellosis was among infants smaller than 1 year, the percentage of bacteremia in this age group was the lowest (15%). Serotype Infantis was the most common (21%) and was less likely to cause Salmonella bacteremia. Among the Salmonella spp. isolates that had antimicrobial susceptibility performed 5 showed resistance to one or more antibiotics including 1 extensively drug-resistant S . ser. Typhi originating from Pakistan. CONCLUSION: Our findings suggest distinct clinical characteristics of Salmonella infections in the pediatric population. Consistent identification of isolates to the sub-species level along with serotyping seems critical to identify emerging lineages with increased virulence. Special consideration should be given to empiric treatment for patients who have recently returned from the Indian subcontinent.

Evolving landscape of carbapenem-resistant Pseudomonas aeruginosa at a single centre in the USA.

Objectives: The increased identification of carbapenem-resistant Pseudomonas aeruginosa (CR-PA) is an ongoing concern. However, information on the evolving antimicrobial resistance profile and molecular epidemiology of CR-PA over time is scarce. Thus, we conducted a cross-sectional analysis to investigate the phenotypic and genotypic characteristics of CR-PA recovered over different time periods, focusing on the isolates exhibiting a ceftolozane/tazobactam resistance phenotype. Methods: A total of 169 CR-PA isolated from clinical specimens at a single centre in Houston, TX, USA were studied. Among them, 61 isolates collected between 1999 and 2005 were defined as historical strains, and 108 collected between 2017 and 2018 were defined as contemporary strains. Antimicrobial susceptibilities against selected ß-lactams was determined. WGS data were used for the identification of antimicrobial resistance determinants and phylogenetic analysis. Results: Non-susceptibility to ceftolozane/tazobactam and ceftazidime/avibactam increased from 2% (1/59) to 17% (18/108) and from 7% (4/59) to 17% (18/108) from the historical to the contemporary collection, respectively. Carbapenemase genes, which were not identified in the historical collection, were harboured by 4.6% (5/108) of the contemporary strains, and the prevalence of ESBL genes also increased from 3.3% (2/61) to 16% (17/108). Genes encoding acquired ß-lactamases were largely confined to the high-risk clones. Among ceftolozane/tazobactam-resistant isolates, non-susceptibility to ceftazidime/avibactam, imipenem/relebactam and cefiderocol was observed in 94% (15/16), 56% (9/16) and 12.5% (2/16), respectively. Resistance to ceftolozane/tazobactam and imipenem/relebactam was primarily associated with the presence of exogenous ß-lactamases. Conclusions: Acquisition of exogenous carbapenemases and ESBLs may be a worrisome trend in P. aeruginosa.

Correlation between mutations in liaFSR of Enterococcus faecium and MIC of daptomycin: revisiting daptomycin breakpoints.

Mutations in liaFSR, a three-component regulatory system controlling cell-envelope stress response, were recently linked with the emergence of daptomycin (DAP) resistance in enterococci. Our previous work showed that a liaF mutation increased the DAP MIC of a vancomycin-resistant Enterococcus faecalis strain from 1 to 3 µg/ml (the DAP breakpoint is 4 µg/ml), suggesting that mutations in the liaFSR system could be a pivotal initial event in the development of DAP resistance. With the hypothesis that clinical enterococcal isolates with DAP MICs between 3 and 4 µg/ml might harbor mutations in liaFSR, we studied 38 Enterococcus faecium bloodstream isolates, of which 8 had DAP MICs between 3 and 4 µg/ml by Etest in Mueller-Hinton agar. Interestingly, 6 of these 8 isolates had predicted amino acid changes in the LiaFSR system. Moreover, we previously showed that among 6 DAP-resistant E. faecium isolates (MICs of >4 µg/ml), 5 had mutations in liaFSR. In contrast, none of 16 E. faecium isolates with a DAP MIC of ≤2 µg/ml harbored mutations in this system (P < 0.0001). All but one isolate with liaFSR changes exhibited DAP MICs of ≥16 µg/ml by Etest using brain heart infusion agar (BHIA), a medium that better supports enterococcal growth. Our findings provide a strong association between DAP MICs within the upper susceptibility range and mutations in the liaFSR system. Concomitant susceptibility testing on BHIA may be useful for identifying these E. faecium first-step mutants. Our results also suggest that the current DAP breakpoint for E. faecium may need to be reevaluated.

Native valve endocarditis caused by Corynebacterium striatum with heterogeneous high-level daptomycin resistance: collateral damage from daptomycin therapy?

We describe a patient who developed Corynebacterium striatum native valve endocarditis after receiving two 6-week courses of daptomycin for the treatment of methicillin-resistant Staphylococcus aureus bacteremia and osteomyelitis. The organism exhibited in vitro heteroresistance to daptomycin, with two subpopulations showing daptomycin susceptibility (MIC of ≤ 0.094 µg/ml) and high-level resistance to daptomycin (MIC of ≥ 256 µg/ml). The selection of daptomycin-resistant Gram-positive skin flora with the potential of causing invasive disease may be a concern during prolonged courses of daptomycin.

Cutaneous phaeohyphomycosis caused by Paraconiothyrium cyclothyrioides.

Paraconiothyrium cyclothyrioides is a recently described coelomycetous fungal species. We present a case in a renal transplant patient with chronic skin lesions of the lower extremities caused by P. cyclothyrioides. Treatment with posaconazole led to complete resolution of the lesions. P. cyclothyrioides should be considered an opportunistic human pathogen in immunocompromised patients.

Determination of vancomycin and daptomycin MICs by different testing methods for methicillin-resistant Staphylococcus aureus.

Vancomycin and daptomycin MICs from 161 isolates of methicillin-resistant Staphylococcus aureus (MRSA) were compared using commercial and in-house broth microdilution, Etest, and common automated methods. Vancomycin Etest MICs were higher than those of other methods, whereas the MICs for daptomycin testing were comparable. Vancomycin MICs vary depending on the testing methodology.

Predictors of relapse of methicillin-resistant Staphylococcus aureus bacteremia after treatment with vancomycin.

The risk factors for relapse of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia after vancomycin treatment are unknown. Diversilab typing was used to classify recurrent bacteremia as relapse or reinfection. Bacteremia for >7 days and staphylococcal cassette chromosome mec element (SCCmec) type II were independently associated with relapse of MRSA bacteremia after vancomycin treatment.

Active surveillance culturing impacts methicillin-resistant Staphylococcus aureus acquisition in a pediatric intensive care unit.

OBJECTIVE: To determine whether active surveillance culturing for methicillin-resistant Staphylococcus aureus (MRSA) decreases nosocomial MRSA acquisition in the pediatric intensive care unit. DESIGN: Before and after observational study. SETTING: A tertiary care, 20-bed, pediatric intensive care unit. PATIENTS: All patients admitted to the pediatric intensive care unit. INTERVENTIONS: Anterior nares cultures for MRSA were obtained on admission and weekly in the pediatric intensive care unit from January 2007 to December 2009 as part of a hospital quality improvement project. MEASUREMENTS AND MAIN RESULTS: MRSA admission prevalence and nosocomial incidence density were determined retrospectively for 2006 and prospectively for 2007-2009. Nosocomial MRSA incidence density during the intervention period was determined monthly and analyzed by trend analysis by using a general linear model. The correlation of active surveillance culturing compliance with nosocomial acquisition of MRSA was analyzed. Possible confounding by healthcare worker hand hygiene compliance observed during the intervention period was also analyzed by multivariate linear regression analysis. The yearly MRSA incidence density significantly decreased from 2006 to 2009 (6.88 per 1,000 patient days to 1.45 per 1,000 patient days, p < .001) and from 2007 to 2009 (7.32 per 1,000 patient days to 1.45 per 1,000 patient days, p < .001). Trend analysis demonstrated a significant decline in MRSA acquisition over time following the introduction of active surveillance culturing (p < .001). Surveillance culturing was significantly associated with the decline in MRSA acquisition observed in the pediatric intensive care unit by multivariate regression analysis when controlling for hand hygiene (p = .01). CONCLUSIONS: Active surveillance culturing resulted in significantly decreased nosocomial acquisition of MRSA in a pediatric intensive care unit setting. Admission and weekly active surveillance culturing appears to be an effective tool to decrease the spread of MRSA in the pediatric intensive care unit, independent of improvement in hand hygiene compliance. The impact on hospital-acquired MRSA infections and the cost benefit of active surveillance culturing require further study.

Recognizing a MIS-Chievous Cause of Acute Viral Gastroenteritis.

Historically, children evaluated for vomiting and diarrhea secondary to viral enteritis have symptoms lasting 2-4 days and respond to supportive care, including oral rehydration and anti-emetics if required. Recently, within a 14-day timespan, we encountered three children with severe diarrhea who rapidly became dehydrated and went into hypotensive shock. Although SARS-CoV-2 molecular tests were negative by nasopharyngeal swab, all were later found to have MIS-C. This small case series underscores features reported in previous larger studies and emphasizes the rapid clinical evolution of this condition. We highlight the importance of early recognition of cardinal laboratory findings characteristic of MIS-C (i.e., lymphopenia, markedly elevated acute phase reactants, and hypoalbuminemia). We also show serologic evidence that the pathophysiological mechanism of SARS-CoV-2 related diarrhea may differ from other causes of dehydrating vomiting and diarrhea, with no serologic evidence of villus cell injury.

Successful implementation of the CDC recommendations during the care of 2 patients with Candida auris in in-patient rehabilitation and intensive care settings.

Candida auris presents a unique challenge to practitioners and infection control teams worldwide because of its virulence, alarming resistance profile, environmental fitness, and risk of nosocomial transmission. We describe 2 cases of Candida auris infection managed with the CDC recommendations with no evidence of in-hospital transmission.