Prognosis of prosthetic valve infective endocarditis due to Streptococcus spp., a retrospective multi-site study to assess the impact of antibiotic treatment duration.

PURPOSE: The duration of antibiotic treatment for prosthetic valve endocarditis caused by Streptococcus spp. is largely based on clinical observations and expert opinion rather than empirical studies. Here we assess the impact of a shorter antibiotic duration. OBJECTIVES: To assess the impact of antibiotic treatment duration for streptococcal prosthetic valve endocarditis on 12-month mortality as well as subsequent morbidity resulting in additional cardiac surgical interventions, and rates of relapse and reinfection. METHODS: This retrospective multisite (N= 3) study examines two decades of data on patients with streptococcal prosthetic valve endocarditis receiving either 4 or 6 weeks of antibiotics. Overall mortality, relapse, and reinfection rates were also assessed for the entire available follow-up period. RESULTS: The sample includes 121 patients (median age 72 years, IQR [53; 81]). The majority (74%, 89/121) received a ß-lactam antibiotic combined with aminoglycoside in 74% (89/121, median bi-therapy 5 days [1; 14]). Twenty-eight patients underwent surgery guided by ESC-guidelines (23%). The 12-month mortality rate was not significantly affected by antibiotic duration (4/40, 10% in the 4-week group vs 3/81, 3.7% in the 6-week group, p=0.34) or aminoglycoside usage (p=0.1). Similarly, there were no significant differences between the 2 treatment groups for secondary surgical procedures (7/40 vs 21/81, p=0.42), relapse or reinfection (1/40 vs 2/81 and 2/40 vs 5/81 respectively). CONCLUSIONS: Our study found no increased adverse outcomes associated with a 4-week antibiotic duration compared to the recommended 6-week regimen. Further randomized trials are needed to ascertain the optimal duration of treatment for streptococcal endocarditis.

Prevotella bivia Septic Arthritis in an Immunocompetent Adult: A Case Report and Review of Literature.

Septic arthritis is a medical emergency that requires prompt diagnosis to prevent long-term intra-articular complications. Prevotella bivia is an anaerobic gram-negative rod which has been infrequently reported to cause septic arthritis. We present a 49-year-old female that presented with spontaneous left knee pain and swelling without history of insult to the knee. She was initially misdiagnosed with patellar tendinitis and gout but later underwent joint aspiration due to worsening symptoms, which demonstrated 60 800/µL nucleated cells with a polymorphonuclear burden consistent with septic arthritis. Arthroscopy with irrigation and drainage was subsequently performed, and the patient was started on empiric antibiotics while awaiting cultures. Cultures grew Prevotella bivia, and antibiotics were deescalated to ertapenem alone followed by oral metronidazole. Prevotella species as a source of septic arthritis is rare, and its occurrence in a patient without known insult to the knee is even more uncommon. It is essential that it is recognized to treat appropriately and prevent long-term loss of function in the joint.

Blastomyces dermatitidis Septic Arthritis in a Renal Transplant Patient.

Blastomycosis is a rare endemic fungal infection caused by the dimorphic fungus Blastomyces dermatitidis. It is more likely to occur in persons living in areas of the United States and Canada, which border the Ohio and Mississippi River Valleys and the Great Lakes region. Most infections are localized to the lungs, often presenting as acute or chronic pneumonia. Occasionally, patients progress to develop disseminated disease and extrapulmonary infections. Blastomycosis tends to be misdiagnosed initially at clinical evaluation as it is rare and may resemble other common conditions. We present a case of a 78-year-old immunosuppressed renal transplant patient who was suspected of having gout but eventually was diagnosed with an unusual presentation of septic arthritis of the ankle secondary to blastomycosis.

Effectiveness of the vacuum assisted aspiration AngioVac system in the removal of intravascular masses.

BACKGROUND: Invasive procedures used to manage intravascular masses such as vegetation from endocarditis, deep vein thrombosis, and septic emboli are associated with high rates of complications and mortality, especially in patients with several pre-existing comorbidities. A minimally invasive technique that has become more popular in recent years is the AngioVac procedure. This single-centered, retrospective study focuses on patient presenting comorbidities and indications for the procedure as well as postprocedural outcomes. METHODS: A total of 33 patients who underwent an AngioVac procedure at Sanford Health between March 2014 and October 2019 was reviewed. Data were collected on pre-existing comorbidities, indication of procedure, length of stay, and postoperative outcomes. RESULTS: We evaluated a total of 33 patients who underwent an AngioVac procedure for removal of intravascular mass. The most common indications for the procedure were endocarditis (24/33, 73%); intracardiac mass (5/33, 15%); and deep vein thrombosis or pulmonary embolism (2/33, 6%). Post-procedural blood transfusion was required in nearly half (15/33, 45%). Almost all patients (31/33, 94%) required intraoperative vasopressor use. Nearly all patients (32/33, 97%) were directed to the intensive care unit following the procedure with an average length of stay of 8 days (interquartile range: 3-13). Most common complications seen after the procedure were shock requiring vasopressors, (13/33, 39%), pleural effusion (9/33, 27%), and sepsis (4/33, 12%). Procedural success in this single-centered experience was 85% (28/33), which was defined as size reduction of the initial vegetation by >50% in the absence of severe intraoperative complications and absence of need for further valvular surgical intervention. CONCLUSION: For surgically high-risk patients, the AngioVac procedure may offer a less invasive option in the management of right sided endocarditis requiring vegetation debulking, intravascular thrombi or cardiac masses.

Tuberculosis treatment outcomes among precarious patients in France.

OBJECTIVES: Patients lost to follow-up and treatment failure in tuberculosis disease (TB) are major public health issues. In the absence of appropriate treatment, approximately 70 % of smear-positive patients will die within 10 years of disease progression. This study, conducted in the French region with the highest incidence, aimed to assess tuberculosis treatment outcomes and its determinants. PATIENTS AND METHODS: A prospective, multicenter cohort study (CO1TB) of adults and children treated for TB was conducted in four hospitals in the North of Paris. Treatment outcome at 1 year and associated socioeconomic and clinical factors were studied by multivariate logistic regression. RESULTS: Among 145 TB cases included from May 2018 to January 2020, patients were mainly born abroad and most lived in difficult socioeconomic conditions. During treatment, 25/145 (17 %) patients experienced adverse effects, which were not significantly associated with discontinuation of treatment (p = 0.99). At 1 year, 114 (78 %) had completed treatments, 26 (19 %) were lost to follow-up, three (2.1 %) were still being treated and two (1.4 %) had died. In the multivariate analysis, a history of TB was significantly associated with unfavorable treatment outcome (aOR = 5.3, 95 %CI (1.5;18.6) and a trend towards significance (p < 0.2) was observed among patients aged under 24 years (aOR = 2.9, 95 %-CI 0.95;8.5). CONCLUSION: In this precarious population, socioeconomic conditions were not found to be associated with unfavorable treatment outcome, whereas history of tuberculosis and young age played a role. Increased monitoring is thus required for these patients.

Clinical and Financial Impact of Rapid Antimicrobial Susceptibility Testing in Blood Cultures.

The rapid identification of pathogens that cause bloodstream infections plays a vital role in the modern clinical microbiology laboratory. Despite demonstrating a significant reduction in turnaround time and a significant effect on clinical decisions, most methods do not provide complete antimicrobial susceptibility testing (AST) information. We employed rapid identification (ID) and AST using the Accelerate PhenoTest on positive blood cultures containing Gram-negative bacilli. The length of stay (LOS) significantly decreased from an average of 12.1 days prior to implementation to 6.6 days post-implementation (p = 0.02), representing potential total savings of USD 666,208.00. All-cause mortality did not differ significantly, 27 (19%) versus 18 (12%), p = 0.11. We also observed an associated decrease in the use of broad-spectrum antimicrobials, including meropenem and quinolones. The implementation of a rapid ID and AST method, along with a well-established antimicrobial stewardship program, has the potential to decrease LOS, broad-spectrum antibiotic use, and costs to the healthcare system, with no observable impact on mortality.

Rhabdomyolysis Secondary to COVID-19 Vaccination.

Rhabdomyolysis has been described as a complication of coronavirus disease 2019 (COVID-19) infection, but few cases of rhabdomyolysis associated with COVID-19 vaccination have been reported. We described a case of an 80-year-old male who developed rhabdomyolysis two days after receiving his second dose of the Moderna COVID-19 vaccine. He presented with severe weakness, myalgias, and an initial creatinine kinase (CK) of 6,546 IU/L that improved with intravenous fluids. Common causes of rhabdomyolysis were excluded including statin use, strenuous exercise, and trauma. With the increasing immunization efforts against COVID-19, physicians should consider the possibility of rhabdomyolysis when a patient presents with neuromuscular complaints following vaccination.

A Rare Case of Spontaneous Splenic Rupture Secondary to Tularemia Following a Cat Bite.

Spontaneous splenic rupture is a rare but potentially life-threatening condition. More common infectious causes include infectious mononucleosis, cytomegalovirus (CMV), human immunodeficiency virus (HIV), and malaria. We present a case of a 42-year-old male who was admitted with persistent fevers, myalgia, and a recent ulcerative lesion on the base of his left thumb after a cat bite. He developed abdominal and back pains, left axillary lymphadenopathy, and near syncope. Abdominal computed tomography (CT) scan showed splenomegaly with subcapsular splenic rupture and large hematoma requiring emergent splenic embolization. Infectious work-up revealed tularemia as a cause which was successfully treated with oral doxycycline. Though not a common cat zoonoses, tularemia should be considered in a patient with splenomegaly or spontaneous splenic rupture in the setting of cat bite.

Maggot Wound Therapy Associated with Wohlfahrtiimonas chitiniclastica Blood Infection.

Maggot therapy is the intentional application of live, disinfected fly larvae to wounds for debridement and wound care. Although some studies suggest possible beneficial applications for wound healing, subsequent infection is a potential risk of treatment. We present a case of a 70-year-old male with chronic left temporal wound from squamous cell carcinoma treated with maggot therapy complicated by bacteremia with Wohlfahrtiimonas chitiniclastica (W. chitiniclastica). This case illustrates the risk for W. chitiniclastica infection associated with maggots used in medical wound therapy of chronic wounds.

Fatal Case of Liver and Brain Abscesses Due to Fusobacterium nucleatum.

Fusobacterium nucleatum is an anaerobic gram-negative organism regarded as an oral commensal. We present a case of a 63-year-old male presenting with weakness, encephalopathy and right upper quadrant palpable mass found to have F. nucleatum liver abscess with innumerable intracranial abscesses. F. nucleatum is a rare cause of concomitant liver and brain abscesses associated with odontogenic infection with potentially fatal outcomes.

Chronic Infectious Complications of Recreational Urethral Sounding With Retained Foreign Body.

The practice of recreational urethral sounding involves insertion of foreign body in the urethra usually for sexual gratification. We present a case of a 62-year-old male with longstanding recurrent urinary tract infections complicated with Staphylococcus epidermidis bacteremia, discitis, and osteomyelitis at T12-L1 vertebral level associated with left psoas abscess secondary to a retained foreign body inserted into his urethra and urinary bladder. He had extraction of foreign body, cystoscopy, and open cystolithotripsy. He received long-term antibiotics and back surgery resulting in residual chronic back pain. This case illustrates important chronic infectious complications associated with the high-risk sexual practice of urethral sounding.

Sickle cell retinopathy and other chronic complications of sickle cell anemia: A clinical study of 84 Sub-Saharan African cases (Cameroon).

OBJECTIVE: Sickle retinopathy is a severe complication of sickle cell disease than can lead to blindness. We aim to describe the epidemiology of sickle retinopathy in homozygous sickle cell (SS) African patients and to analyze its association with non-ophthalmologic disease complications of sickle cell anemia. METHODS: We conducted a nested study within the CADRE cohort in Cameroon. Eighty-four consecutive SS outpatients, aged 10 years and older, with no visual symptoms, underwent an ophthalmologic examination. Mean age was 23±10 years. Clinical and biological features were compared between patients with and without sickle retinopathy. We compared the prevalence of the clinical complications and main biological characteristics in patients with and without sickle retinopathy using a univariate logistic regression. The same analysis was used to compare the patients with non-proliferative sickle retinopathy to those with proliferative sickle retinopathy. Statistical analyses were done using the R software (version 3.1.2). RESULTS: Fifty-two patients (62%) displayed sickle retinopathy, among them 23 (27%) had a non-proliferative sickle retinopathy, and 29 (35%) had proliferative sickle retinopathy. Patients with proliferative sickle cell retinopathy had a mean age of 28±11 years. Sickle retinopathy was associated with higher hemoglobin level (P=0.047) and fewer leg ulcers (P=0.018). Proliferative SR was associated with increasing age (P=0.008) and male sex (P=0.025) independently of the hemoglobin level. CONCLUSIONS: Sickle retinopathy is particularly frequent in sub-Saharan sickle cell SS patients, which advocates for early systematic screening.

Acquisition of Clostridium difficile Colonization and Infection After Transfer From a Veterans Affairs Hospital to an Affiliated Long-Term Care Facility.

BACKGROUND Clostridium difficile infection (CDI) and asymptomatic carriage of toxigenic C. difficile are common in long-term care facilities (LTCFs). However, whether C. difficile is frequently acquired in the LTCF versus during acute-care admissions remains unknown. OBJECTIVE To test the hypothesis that LTCF residents often acquire C. difficile colonization and infection in the LTCF DESIGN This 5-month cohort study was conducted to determine the incidence of acquisition of C. difficile colonization and infection in asymptomatic patients transferred from a Veterans Affairs hospital to an affiliated LTCF. METHODS Rectal swabs were cultured for toxigenic C. difficile at the time of transfer to the LTCF and weekly for up to 6 weeks. We calculated the proportion of LTCF-onset CDI cases within 1 month of transfer that occurred in residents colonized on admission versus those with new acquisition in the LTCF. RESULTS Of 110 patients transferred to the LTCF, 12 (11%) were asymptomatically colonized with toxigenic C. difficile upon admission, and 4 of these 12 patients (33%) developed CDI within 1 month, including 3 recurrent and 1 initial CDI episode. Of 82 patients with negative cultures on transfer and at least 1 follow-up culture, 22 (27%) acquired toxigenic C. difficile colonization, and 4 developed CDI within 1 month, including 1 recurrent and 3 initial CDI episodes. CONCLUSION LTCF residents frequently acquired colonization with toxigenic C. difficile after transfer from the hospital, and 3 of 4 initial CDI cases with onset within 1 month of transfer occurred in residents who acquired colonization in the LTCF. Infect Control Hosp Epidemiol 2017;38:1070-1076.

A Comparison of Molecular Typing Methods Applied to Enterobacter cloacae complex: hsp60 Sequencing, Rep-PCR, and MLST.

Molecular typing using repetitive sequenced-based PCR (rep-PCR) and hsp60 sequencing were applied to a collection of diverse Enterobacter cloacae complex isolates. To determine the most practical method for reference laboratories, we analyzed 71 E. cloacae complex isolates from sporadic and outbreak occurrences originating from 4 geographic areas. While rep-PCR was more discriminating, hsp60 sequencing provided a broader and a more objective geographical tracking method similar to multilocus sequence typing (MLST). In addition, we suggest that MLST may have higher discriminative power compared to hsp60 sequencing, although rep-PCR remains the most discriminative method for local outbreak investigations. In addition, rep-PCR can be an effective and inexpensive method for local outbreak investigation.

Utility of a single nasal polymerase chain reaction assay in predicting absence of skin and environmental contamination in hospitalized patients with past methicillin-resistant Staphylococcus aureus.

We evaluated hospitalized patients with a history of methicillin-resistant Staphylococcus aureus (MRSA) for persistent colonization and need for contact precautions. Up to 3 daily cultures of nares, skin, and any present wounds were compared with a single nasal polymerase chain reaction (PCR) assay. Most patients (76.2%) were no longer colonized with MRSA. A single PCR assay was sufficient to exclude persistent colonization and environmental contamination and remove the contact precautions.

Appropriateness of empiric therapy in patients with suspected Clostridium difficile infection.

OBJECTIVE: The objective of this study was to test the hypothesis that many patients with suspected Clostridium difficile infection (CDI) receive inappropriate empiric therapy and/or receive continued therapy despite negative test results. METHODS: We performed a 3 month prospective cohort study at the Cleveland Veteran Affairs Medical Center to assess the appropriateness of empiric CDI therapy for all patients with stool samples submitted for CDI testing. Empiric therapy for CDI was considered appropriate if patients with suspected CDI had findings suggestive of severe or complicated illness. RESULTS: Of 251 patients tested for CDI, 53 (21%) received empiric treatment, including 45 (85%) treated with metronidazole and 8 (15%) treated with vancomycin. Of the 53 empirical therapy regimens, only 20 (38%) were deemed appropriate based on criteria for severe or severe, complicated CDI and 39 (74%) had negative laboratory testing for CDI. Twenty-one of 39 (54%) patients with negative testing were continued on therapy for three or more days despite the negative results. The key limitations of the study are the fact that it was conducted in a single institution and had a small sample size. CONCLUSION: In our facility, empiric treatment for CDI was common and more than half of empirical treatment was deemed inappropriate because patients did not meet criteria for severe CDI. Because CDI therapy may be associated with adverse effects, there is a need for interventions to improve the appropriateness of empiric CDI treatment.

Beyond the Hawthorne effect: reduction of Clostridium difficile environmental contamination through active intervention to improve cleaning practices.

Education and passive observation resulted in a significant improvement in housekeeper disinfection of nontoxigenic Clostridium difficile spores artificially inoculated onto surfaces in C. difficile infection rooms. A further significant reduction occurred with direct supervision and real-time feedback, suggesting that optimal disinfection is achieved by working closely with housekeepers.

Diagnostic assessment of different environmental cleaning monitoring methods.

In a simultaneous assessment of 250 environmental surfaces after terminal cleaning using aerobic cultures as a gold standard, both fluorescent marker and an adenosine triphosphate bioluminescence assay system demonstrated better diagnosticity compared with subjective visual inspection. These results support the use of these environmental monitoring systems in the health care setting.