Bacteremia and polyarticular septic arthritis secondary to Moraxella bovis in a pregnant patient with HIV who injects drugs.

CASE PRESENTATION: We report a rare case of Moraxella bovis bacteremia and polyarticular septic arthritis in a 37-year-old pregnant woman with HIV who injects drugs. Two sets of blood cultures obtained 5 hours apart were positive for gram-negative bacilli, and purulent fluid was present intra-operatively from both her left knee and her right third MCP joints. DIAGNOSIS: Organism identification using ligation sequencing confirmed both her blood culture and synovial tissue isolates as M. bovis. Her infection was initially treated with third-generation cephalosporins and later changed to moxifloxacin because of a drug reaction; although she defervesced clinically with improvement in her C-reactive protein levels, she died most likely as a result of a non-traumatic fat embolism after an elective cesarean delivery. DISCUSSION: In contrast to Moraxella catarrhalis, other Moraxella species are rarely associated with disease in human hosts. M. bovis is classically associated with infectious bovine keratoconjunctivitis in cattle; interestingly, our patient denied significant animal exposure. To the authors' knowledge, this is the first case describing infection secondary to M. bovis in an adult host.

PRÉSENTATION DU CAS: Les auteurs rendent compte d'un rare cas de bactériémie à Moraxella bovis et d'arthrite septique polyarticulaire chez une femme enceinte de 37 ans atteinte du VIH qui s'injectait des médicaments. Deux séries d'hémocultures obtenues à cinq heures d'intervalle étaient positives aux bacilles Gram négatif, et du liquide purulent a été observé dans le genou gauche et la troisième articulation métacarpophalangienne pendant la période peropératoire. DIAGNOSTIC: La détection des organismes au moyen du séquençage par ligature a confirmé que les isolats des hémocultures et des tissus synoviaux contenaient du M. bovis. L'infection a d'abord été soignée au moyen de céphalosporines de troisième génération, qui ont ensuite été remplacées par de la moxifloxacine en raison d'une réaction au médicament. Même si elle a présenté une défervescence sur le plan clinique et que les taux de protéine C-réactive se sont améliorés, la patiente est décédée, probablement à cause d'une embolie graisseuse d'origine non traumatique après une césarienne non urgente. DISCUSSION: Contrairement au Moraxella catarrhalis, les autres espèces de Moraxella sont rarement associées à des maladies chez les hôtes humains. Le M. bovis est normalement relié à une kératoconjonctivite bovine infectieuse chez le bétail. Fait intéressant, la patiente a nié une exposition importante à des animaux. À la connaissance des auteurs, il s'agit de la première description d'une infection secondaire au M. bovis chez un hôte adulte.

Disseminated Native Tricuspid Valve Infective Endocarditis and Vertebral Osteomyelitis Secondary to Veillonella dispar in a Patient Who Injects Drugs.

We present the case of a 50-year-old man presenting with fever, back pain, persistent bacteremia with Veillonella dispar, echocardiographic evidence of a tricuspid valve vegetation increasing in size, and magnetic resonance imaging suggesting new vertebral osteomyelitis. He was successfully treated with intravenous ceftriaxone for six weeks. Deep-seated infections secondary to Veillonella species are rare, but cases of endocarditis, osteomyelitis, and meningitis have been reported in the literature. Given Veillonella species are normal human commensals present in the oropharyngeal flora, we suspect our patient developed native tricuspid valve endocarditis and vertebral osteomyelitis as a complication of either poor dentition or contaminated injection drug use paraphernalia and subsequent hematogenous seeding.

The 2018 Global Point Prevalence Survey of antimicrobial consumption and resistance in 47 Canadian hospitals: a cross-sectional survey.

BACKGROUND: Patient-level surveillance of antimicrobial use (AMU) in Canadian hospitals empowers the reduction of inappropriate AMU and was piloted in 2017 among 14 hospitals in Canada. We aimed to describe AMU on the basis of patient-level data in Canadian hospitals in 2018 in terms of antimicrobial prescribing prevalence and proportions, antimicrobial indications, and agent selection in medical, surgical and intensive care wards. METHODS: Canadian adult, pediatric and neonatal hospitals were invited to participate in the standardized web-based cross-sectional Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) conducted in 2018. An identified site administrator assigned all wards admitting inpatients to specific surveyors. A physician, pharmacist or nurse with infectious disease training performed the survey. The primary outcomes were point prevalence rates for AMU over the study period regarding prescriptions, indications and agent selection in medical, surgical and intensive care wards. The secondary outcomes were AMU for resistant organisms and practice appropriateness evaluated on the basis of quality indicators. Antimicrobial consumption is presented in terms of prevalence and proportions. RESULTS: Forty-seven of 118 (39.8%) hospitals participated in the survey; 9 hospitals were primary care centres, 15 were secondary care centres and 23 were tertiary or specialized care centres. Of 13 272 patients included, 33.5% (n = 4447) received a total of 6525 antimicrobials. Overall, 74.1% (4832/6525) of antimicrobials were for therapeutic use, 12.6% (n = 825) were for medical prophylaxis, 8.9% (n = 578) were for surgical prophylaxis, 2.2% (n = 143) were for other use and 2.3% (n = 147) were for unidentified reasons. A diagnosis or indication was documented in the patient's file at the initiation for 87.3% (n = 5699) of antimicrobials; 62.9% (n = 4106) of antimicrobials had a stop or review date; and 72.0% (n = 4697) of prescriptions were guided by local guidelines. INTERPRETATION: Overall, three-quarters of AMU was for therapeutic use across participating hospitals. Canadian hospitals should be further incentivized to create and adapt local guidelines on the basis of recent antimicrobial resistance data.

A case of multifocal cutaneous alternariosis in a patient with hairy cell leukemia.

We present a case of multifocal cutaneous alternariosis in a 69-year-old man with hairy cell leukemia. The patient presented with painful, violaceous nodules of the lower extremities and left forearm. His physical examination was otherwise normal. Biopsy specimens were submitted first for histopathological examination, followed by microbiological testing. Histopathology showed epidermal hyperplasia, intraepidermal abscess formation, and intracellular and extracellular fungal elements. Subsequent microbiological investigations, including fungal culture and polymerase chain reaction (PCR), isolated Alternaria alternata. The patient was treated for cutaneous alternariosis with itraconazole for 12 weeks and demonstrated significant improvement of the lesions. This case highlights the role of dual histopathological and microbiological laboratory investigation in suspected opportunistic cutaneous mycoses.

Les chercheurs présentent un cas d'alternariose cutanée multifocale chez un homme de 69 ans atteint d'une leucémie à tricholeucocytes. Le patient a consulté à cause de nodules violacés et douloureux sur les extrémités inférieures et l'avant-bras gauche. Son examen physique était autrement normal. Des biopsies ont été d'abord soumises en vue d'un examen histopathologique, puis de tests microbiologiques. L'histopathologie a révélé une hyperplasie épidermique, la formation d'abcès épidermiques et des éléments fongiques intracellulaires et extracellulaires. Les explorations microbiologiques subséquentes, y compris les cultures fongiques et l'amplification en chaîne par polymérase, ont isolé l'Alternaria alternata. Le patient a reçu un traitement de 12 semaines à l'itraconazole pour vaincre une alternariose cutanée, et ses lésions ont considérablement diminué. Ce cas souligne l'intérêt de conjuguer l'exploration histopathologique à l'exploration microbiologique dans les cas présumés de mycose opportuniste.

Attitudes and Perceptions amongst Critical Care Physicians towards Handshake Antimicrobial Stewardship Rounds.

Rationale In an era of antimicrobial resistance, antimicrobial stewardship programs are tasked with reducing inappropriate use of antimicrobials in community and hospital settings. Intensive care units are unique, high-stakes environments where high usage of broad-spectrum antimicrobials is often seen. Handshake stewardship has emerged as an effective mode of prospective audit and feedback to help optimize antimicrobial usage, emphasizing an in-person approach to providing feedback. Objectives Six months following the implementation of handshake stewardship rounds in our intensive care unit, we performed a cross-sectional survey of critical care physicians to assess their attitudes and perceptions towards handshake stewardship rounds and preferred mode of delivery of antimicrobial stewardship prospective audit and feedback strategies. Methods A web-based survey was distributed to 22 critical care physicians working in our hospital and responses were collected over a two-week period. Measurements and Main Results Most critical care physicians believe that handshake stewardship rounds improve the quality of patient care (85.7%) and few believe that handshake stewardship rounds are an ineffective use of their time (14.3%). The majority of critical care physicians believe formal, scheduled rounds with face-to-face verbal interaction are very useful compared to providing written suggestions in the absence of face-to-face interaction (71.4% vs 0%). Conclusions Based upon our survey results, handshake stewardship is valued amongst the majority of critical care physicians. Antimicrobial stewardship prospective audit and feedback strategies emphasizing face-to-face interaction are favored amongst critical care physicians.

Successful Treatment of Legionnaires' Disease with Tigecycline in an Immunocompromised Man with a Legion of Antibiotic Allergies.

Legionella species are Gram-negative bacilli that are relatively rare causes of community-acquired pneumonia but can be associated with significant morbidity and mortality if unrecognized or improperly treated. Limited data exist regarding the use of tigecycline, a third generation glycylcycline, in the treatment of Legionnaires' disease. We present an immunocompromised patient with Legionnaires' disease and allergies to both fluoroquinolones and macrolides, which are first-line treatment options for Legionnaires' disease. He was successfully treated using tigecycline, a third generation glycylcycline, indicating that tigecycline may serve as a safe and effective alternative therapeuticl option for treatment of Legionnaires' disease.