Pericarditis and Sacroiliitis in a World Traveler.

A 65-year-old immunocompromised woman presented with progressive dyspnea and sacroiliac joint pain. Cardiac magnetic resonance showed abnormal right ventricular filling with septal bounce and abnormal pericardial enhancement, suggestive of constrictive pericarditis. Cultures from pericardium following pericardiectomy grew Coccidioides immitis. She was diagnosed with coccidioidomycosis and responded to pericardiectomy and amphotericin. (Level of Difficulty: Intermediate.).

Nocardia beijingensis lung mass in an immunocompetent adult.

A 47-year-old man was referred for ongoing workup of an enlarging lung mass. Extensive workup of the mass had been unrevealing for several months until cultures grew Nocardia beijingensis He was successfully treated with trimethoprim/sulfamethoxazole and then doxycycline with near-complete resolution of the mass on follow-up. This case presents a rare species of N. beijingensis It highlights the importance of considering nocardiosis in immunocompetent adults and the challenge in initiating targeted treatment due to delayed culture results.

Respiratory viruses in transplant recipients: more than just a cold. Clinical syndromes and infection prevention principles.

OBJECTIVES: The aim of this review is to provide updated information on the clinical spectrum, treatment options, and infection prevention strategies for respiratory viral infections (RVIs) in both solid organ (SOT) and hematopoietic stem cell transplant (HSCT) patients. METHODS: The MEDLINE and PubMed databases were searched for literature regarding the aforementioned aspects of RVIs, with focus on respiratory syncytial virus, adenovirus, influenza virus, parainfluenza virus, human metapneumovirus, and rhinovirus. RESULTS: Compared to immunocompetent hosts, SOT and HSCT patients are much more likely to experience a prolonged duration of illness, prolonged shedding, and progression of upper respiratory tract disease to pneumonia when infected with respiratory viruses. Adenovirus and respiratory syncytial virus tend to have the highest mortality and risk for disseminated disease, but all the RVIs are associated with higher morbidity and mortality in these patients than in the general population. These viruses are spread via direct contact and aerosolized droplets, and nosocomial spread has been reported. CONCLUSIONS: RVIs are associated with high morbidity and mortality among SOT and HSCT recipients. Management options are currently limited or lack strong clinical evidence. As community and nosocomial spread has been reported for all reviewed RVIs, strict adherence to infection control measures is key to preventing outbreaks.

The 17th International Congress on Infectious Diseases workshop on developing infection prevention and control resources for low- and middle-income countries.

Hospital-acquired infections (HAIs) are a major concern to healthcare systems around the world. They are associated with significant morbidity and mortality, in addition to increased hospitalization costs. Recent outbreaks, including those caused by the Middle East respiratory syndrome coronavirus and Ebola virus, have highlighted the importance of infection control. Moreover, HAIs, especially those caused by multidrug-resistant Gram-negative rods, have become a top global priority. Although adequate approaches and guidelines have been in existence for many years and have often proven effective in some countries, the implementation of such approaches in low- and middle-income countries (LMICs) is often restricted due to limited resources and underdeveloped infrastructure. While evidence-based infection prevention and control (IPC) principles and practices are universal, studies are needed to evaluate simplified approaches that can be better adapted to LMIC needs, in order to guide IPC in practice. A group of experts from around the world attended a workshop held at the 17th International Congress on Infectious Diseases in Hyderabad, India in March 2016, to discuss the existing IPC practices in LMICs, and how best these can be improved within the local context.

Chlorhexidine: Patient Bathing and Infection Prevention.

Healthcare-associated infections (HAIs) are an important cause of morbidity and mortality in the USA. They are associated with a substantial increase in health care costs each year. Fortunately, many HAIs are preventable, and their eradication is a national priority. Chlorhexidine (CHG) bathing has been used as an infection prevention measure, either alone or bundled with other interventions, with mostly beneficial results. The recent surge in its use as an agent of choice for skin antisepsis has lead to concerns over emerging resistance among microorganisms. Moreover, compliance with CHG-bathing protocols is not routinely monitored. Policies developed to determine the best infection prevention practice must consider that a "one-size-fits-all" strategy may lead to the selection of CHG-tolerant microorganisms, thereby emphasizing the need for more robust guidelines and additional studies on the role of chlorhexidine bathing for the prevention of HAIs.

Fosfomycin: Resurgence of an old companion.

Fosfomycin was discovered over four decades ago, yet has drawn renewed interest as an agent active against a range of multidrug-resistant (MDR) and extensively drug-resistant (XDR) pathogens. Its unique mechanism of action and broad spectrum of activity makes it a promising candidate in the treatment of various MDR/XDR infections. There has been a surge of in vitro data on its activity against MDR/XDR organisms, both when used as a single agent and in combination with other agents. In the United States, fosfomycin is only approved in an oral formulation for the treatment of acute uncomplicated urinary tract infections (UTIs), whereas in some countries both oral and intravenous formulations are available for various indications. Fosfomycin has minimal interactions with other medications and has a relatively favorable safety profile, with diarrhea being the most common adverse reaction. Fosfomycin has low protein binding and is excreted primarily unchanged in the urine. The clinical outcomes of patients treated with fosfomycin are favorable for uncomplicated UTIs, but data are limited for use in other conditions. Fosfomycin maintains activity against most Enterobacteriaceae including Escherichia coli, but plasmid-mediated resistance due to inactivation have appeared in recent years, which has the potential to compromise its use in the future. In this review, we summarize the current knowledge of this resurgent agent and its role in our antimicrobial armamentarium.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective.

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.

Fosfomycin Resistance in Escherichia coli, Pennsylvania, USA.

Fosfomycin resistance in Escherichia coli is rare in the United States. An extended-spectrum ß-lactamase-producing E. coli clinical strain identified in Pennsylvania, USA, showed high-level fosfomycin resistance caused by the fosA3 gene. The IncFII plasmid carrying this gene had a structure similar to those found in China, where fosfomycin resistance is commonly described.

Clinical Appraisal of Fosfomycin in the Era of Antimicrobial Resistance.

Fosfomycin is recommended as one of the first-line agents for treatment of urinary tract infections (UTIs) in the latest guidelines endorsed by the Infectious Diseases Society of America (IDSA) and the European Society for Clinical Microbiology and Infectious Diseases (ESCMID). We evaluated the use of fosfomycin among inpatients at a tertiary care hospital between 2009 and 2013. UTI cases were defined using physician diagnosis and the National Healthcare Safety Network (NHSN) surveillance definitions. The number of patients treated with fosfomycin increased from none in 2009 to 391 in 2013. Among 537 patients who received fosfomycin for any indication during this period, UTI was the most common indication (74%), followed by asymptomatic bacteriuria (10%). All except 19 patients received a single dose of fosfomycin. Escherichia coli was the most common organism involved (52%). For 119 patients with UTIs, after exclusion of those with negative urine culture results, negative urinalysis results, receipt of additional agents, or indeterminate clinical outcomes, the clinical success rate at 48 h was 74.8%. Of 89 patients who met the criteria for NHSN-defined UTIs, 89.9% had successful outcomes. Recurrent infections occurred in 4.3% of cases, and mild adverse events were observed in 2.0%. All 100 randomly selected extended-spectrum ß-lactamase (ESBL)-producing E. coli clinical isolates from this period were susceptible to fosfomycin. In conclusion, the use of fosfomycin has increased substantially since implementation of the updated guidelines at this hospital. Fosfomycin was used mainly for the treatment of physician-diagnosed UTIs, and the clinical outcomes were generally favorable. Fosfomycin maintained activity against E. coli despite the increased use of the agent.

"Stop smoking!" Do we say it enough?

PURPOSE: Patients who continue to smoke after the diagnosis of bronchogenic carcinoma (BC) experience increased rates of morbidity and mortality. Evidence suggests that smokers are more likely to quit if they are counseled by their physicians. However, there may be a prevailing belief among physicians that treating tobacco dependence is futile in this population. The purpose of this study was to investigate whether physicians addressed smoking cessation with patients who were diagnosed with BC. METHODS: A retrospective medical record review of patients who were diagnosed with BC between 2008 and 2010 was conducted at a community medical center using the hospital cancer registry. Demographic information including age, race, sex, stage, and smoking status at the time of diagnosis was collected. Evidence of tobacco cessation counseling was sought through billing codes, physician notes, and orders surrounding the time of diagnosis. RESULTS: A total of 948 patients were diagnosed with lung cancer between 2008 and 2010; 438 were current smokers at diagnosis, and only 36% were counseled on smoking cessation. On average, each patient encountered three different physicians in both the inpatient and outpatient settings. Of note, patients with stage I disease were 1.7× more likely to be counseled than those with stage IV disease (P=.017). CONCLUSION: Despite evidence that smoking cessation is beneficial even after the diagnosis of BC, physicians are not counseling their patients sufficiently. With the implementation of quality improvement programs, we expect smoking cessation counseling for patients with BC will improve.