Impact of cytomegalovirus on outcomes in acute severe ulcerative colitis: a retrospective observational study.

Background: Concomitant cytomegalovirus (CMV) is highly prevalent in acute severe ulcerative colitis (ASUC) but data for outcomes of CMV positivity in ASUC and the benefit of antiviral therapy remain unclear. Objectives: We aim to determine the impact of CMV positivity, and antiviral therapy, on outcomes such as colectomy-free survival, length of hospital stay and readmission rate, among hospitalized patients with ASUC. Design: This is a retrospective, multicentre study of patients admitted with ASUC. Methods: CMV positivity was diagnosed from blood CMV DNA and inpatient colonic biopsies. Background demographics and disease characteristics, clinical characteristics and outcomes during admission and long-term outcomes were obtained from electronic medical records and compared according to the presence of CMV and the use of antiviral therapy. Results: CMV was detected in 40 (24%) of 167 ASUC admissions. Previous steroid exposure was the only clinical predictor of CMV positivity on multivariate analysis. Outcomes of greater requirement for rescue therapy (60% versus 33%), longer hospital stay (14.3 versus 9.9 days) and higher readmission rates at 3 and 12 months were associated with CMV positivity. No difference was found in the rate of colectomy or colectomy-free survival. Antiviral therapy was not associated with a lower risk of colectomy but did extend the time to colectomy (126 versus 36 days). Conclusion: CMV positivity was associated with worse outcomes of need for rescue therapy, hospital stay and readmissions. Antiviral therapy was not found to reduce the risk of colectomy but did extend the time to colectomy. Further prospective studies will be required to more clearly determine its benefit in patients with concomitant CMV and ASUC.

Cytomegalovirus reactivation in acute severe ulcerative colitis Cytomegalovirus (CMV) is a highly prevalent virus that may result in concominant reactivation in patients with acute severe ulcerative colitis and potentially worsen their outcomes. Our study aims to determine the impact of presence of CMV in patients with acute severe ulcerate colitis requiring hospitalisation and its association with outcomes including risk of surgical resection of colon, length of hospital stay, readmission rate, as well as effect of outcomes amongst those treated with antivirals for CMV. Our results did not find a significant association between detection of CMV on surgical risk, though outcomes including longer hospital stays, higher readmission rate were found. Antiviral use was not associated with lower risk of surgery but was found to prolong time to surgery. Given that our study was based on retrospective data, further prospective studies will be required to examine the benefit of antiviral use in outcomes for those with concominant CMV and acute severe ulcerative colitis. We conclude from our study that while having concomitant CMV with acute severe uclerative colitis may not necessarily increase risk for surgery, patients may still have worse outcomes in other areas therefore the detection of CMV should be considered a significant and clinically relevant result.

Aggregatibacter actinomycetemcomitans pacemaker lead infection-A case report and literature review.

Aggregatibacter spp. is a rare cause for cardiac device infections. Due to limited data, the management of Aggregatibacter spp. device infections is not clearly defined but should always involve device removal and prolonged intravenous antibiotics.

Ocular streptococcal infections: A clinical and microbiological review.

Streptococcus is a diverse bacterial genus that is part of the ocular surface microbiome implicated in conjunctivitis, keratitis, endophthalmitis, dacryocystitis, and orbital cellulitis that can lead to decreased visual acuity and require surgical intervention. The pathophysiology of S. pneumoniae is well-established and the role of the polysaccharide capsule, pneumolysin, neuraminidases, and zinc metalloproteinases in ocular infections described. Additionally, key virulence factors of the viridans group streptococci such as cytolysins and proteases have been outlined, but there is a paucity of research on the remaining streptococcus species. These virulence factors tend to result in aggressive disease. Clinically, S. pneumoniae is implicated in 2.7-41.2% of bacterial conjunctivitis cases, more predominant in the pediatric population, and is implicated in 1.8-10.7% of bacterial keratitis isolates. Streptococcus bacteria are significantly implicated in acute postoperative, postintravitreal, and bleb-associated endophthalmitis, responsible for 10.3-37.5, 29.4, and 57.1% of cases, respectively. Group A and B streptococcus endogenous endophthalmitis is rare, but has a very poor prognosis. Inappropriate prescription of antibiotics in cases of nonbacterial aetiology has contributed to increasing resistance, and a clinical index is needed to more accurately monitor this. Furthermore, there is an increasing need for prospective, surveillance studies of antimicrobial resistance in ocular pathogens, as well as point-of-care testing using molecular techniques.

Salmonella enterica Serovar Typhi: An Unusual Cause of Infective Endocarditis.

While typhoid fever is a common infection, Salmonella enterica serovar Typhi is a rare cause of endocarditis. We describe the case of a 20-year-old male who was treated for a primary episode of microbiologically-confirmed typhoid fever. He presented six weeks post-discharge with fever and lethargy. S. Typhi was again identified in blood cultures, and echocardiography identified a mitral valve lesion. Our case suggests that a relapse of typhoid should prompt further investigation for a deep-seated infection, including consideration of echocardiographic evaluation to rule out infective endocarditis.

A 12-Year Retrospective Study of Invasive Amoebiasis in Western Sydney: Evidence of Local Acquisition.

In Australia, amoebiasis is thought to occur in travellers, immigrants from endemic areas, and among men who have sex with men. Prevalence of amoebiasis in communities with immigrants from Entamoeba histolytica-endemic countries is unknown. The present study is a retrospective case series analysis of patients with laboratory-confirmed amoebiasis from Western Sydney Local Health District, Australia, between years 2005 and 2016. Forty-nine patients with amoebiasis were identified, resulting in an estimated annual incidence of up to 1.1 cases per 100,000 adults. Many were born in Australia (15/47) and India (12/47). Three patients (3/37) had no history of overseas travel, two others had not travelled to an endemic country, and an additional two had a very remote history of overseas travel; one died of fulminant amoebic colitis. Three patients (3/16) were employed in the food industry and one had a history of colonic irrigation in an Australian 'wellness clinic'. Patients had invasive amoebiasis with either liver abscess (41/48) or colitis (7/48), diagnosed most commonly by serology. Invasive procedures were common, including aspiration of liver abscess (28/41), colonoscopy (11/49), and partial hepatectomy (1/49). Although rare, local acquisition of amoebiasis occurs in Western Sydney and contributes to significant morbidity and hospital admissions.

Seasonal clustering of sinopulmonary mucormycosis in patients with hematologic malignancies at a large comprehensive cancer center.

Background: Invasive Mucorales infections (IMI) lead to significant morbidity and mortality in immunocompromised hosts. The role of season and climatic conditions in case clustering of IMI remain poorly understood. Methods: Following detection of a cluster of sinopulmonary IMIs in patients with hematologic malignancies, we reviewed center-based medical records of all patients with IMIs and other invasive fungal infections (IFIs) between January of 2012 and August of 2015 to assess for case clustering in relation to seasonality. Results: A cluster of 7 patients were identified with sinopulmonary IMIs (Rhizopus microsporus/azygosporus, 6; Rhizomucor pusillus, 1) during a 3 month period between June and August of 2014. All patients died or were discharged to hospice. The cluster was managed with institution of standardized posaconazole prophylaxis to high-risk patients and patient use of N-95 masks when outside of protected areas on the inpatient service. Review of an earlier study period identified 11 patients with IMIs of varying species over the preceding 29 months without evidence of clustering. There were 9 total IMIs in the later study period (12 month post-initial cluster) with 5 additional cases in the summer months, again suggesting seasonal clustering. Extensive environmental sampling did not reveal a source of mold. Using local climatological data abstracted from National Centers for Environmental Information the clusters appeared to be associated with high temperatures and low precipitation. Conclusions: Sinopulmonary Mucorales clusters at our center had a seasonal variation which appeared to be related to temperature and precipitation. Given the significant mortality associated with IMIs, local climatic conditions may need to be considered when considering center specific fungal prevention and prophylaxis strategies for high-risk patients.

Legionnaires' disease in transplant recipients: A 15-year retrospective study in a tertiary referral center.

Legionnaires' disease (LD) can be fatal among high-risk transplant recipients. To understand the epidemiology of LD, we reviewed 15-year longitudinal data from a center in Seattle, Washington that cares for both solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients. We identified all laboratory-confirmed LD and extracted data on species, diagnostic modalities, clinical presentation, management, and outcomes from medical records. Among 32 patients with LD, transplant recipients made up the majority of diagnoses (22, 69%; SOT 10, HCT 12). Approximately 0.8% of transplant recipients who underwent Legionella-specific testing were positive. Non-pneumophila Legionella species (LNLP), which are not detected by urinary antigen test, accounted for half the cases, led by Legionella micdadei (32%). The severity and outcome between Legionella pneumophila and LNLP infections were similar (attributed mortality, 36% vs 27%); all LNLP deaths occurred in transplant recipients with L. micdadei. The clinical and radiological features mimicked other opportunistic pathogens; 32% (n=7) were not on empiric treatment at the time of diagnosis. These data add to the emerging literature describing the importance of LD and highlight the need for both routine Legionella testing on transplant recipients with pulmonary findings and empiric Legionella-active antibiotic therapy.

Legionellosis in Transplantation.

Legionella species are emerging opportunistic pathogens in hematopoietic stem cell and solid organ transplant recipients, associated with significant morbidity and mortality. The clinical and radiological features of Legionella infections can mimic other opportunistic pathogens in these profoundly immunocompromised patients. Diagnosis in transplant patients is challenging as non-pneumophila Legionella infections, for which these patients are at risk, cannot be identified using the urinary antigen test. Changes in management of transplant recipients and changes in Legionella epidemiology suggest that the number of transplant patients potentially exposed to Legionella spp. may be on the rise. Yet, evidence-based, transplant-specific guidelines for managing and preventing Legionella infections are not currently available. In this article, we review the epidemiology, clinical features, diagnostic challenges, treatment options, and preventive strategies of Legionella infections in these high-risk patient populations.

Rapid Detection of Vancomycin-Intermediate Staphylococcus aureus by Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry.

Vancomycin is the standard of care for the treatment of invasive methicillin-resistantStaphylococcus aureus(MRSA) infections. Infections with vancomycin-nonsusceptible MRSA, including vancomycin-intermediateS. aureus(VISA) and heterogeneous VISA (hVISA), are clinically challenging and are associated with poor patient outcomes. The identification of VISA in the clinical laboratory depends on standard susceptibility testing, which takes at least 24 h to complete after isolate subculture, whereas hVISA is not routinely detected in clinical labs. We therefore sought to determine whether VISA and hVISA can be differentiated from vancomycin-susceptibleS. aureus(VSSA) using the spectra produced by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Strains of MRSA were characterized for vancomycin susceptibility phenotype by broth microdilution and modified population analysis. We tested 21 VISA, 21 hVISA, and 38 VSSA isolates by MALDI-TOF MS. Susceptibility phenotypes were separated by using a support vector machine (SVM) machine learning algorithm. The resulting model was validated by leave-one-out cross validation. Models were developed and validated by using spectral profiles generated under various subculture conditions, as well as with and without hVISA strains. Using SVM, we correctly identified 100% of the VISA and 97% of the VSSA isolates with an overall classification accuracy of 98%. Addition of hVISA to the model resulted in 76% hVISA identification, 100% VISA identification, and 89% VSSA identification, for an overall classification accuracy of 89%. We conclude that VISA/hVISA and VSSA isolates are separable by MALDI-TOF MS with SVM analysis.

Epidemiology of invasive group A Streptococcus infections in Sydney, Australia.

There is concern of global resurgence of invasive group A Streptococcus (iGAS) infections. We compared the clinical and molecular epidemiology of patients admitted with iGAS over two time periods, 2008 and 2010, in Western Sydney, Australia. The annual incidence was 19 cases per 100,000 admissions in 2008, compared to 33 per 100,000 in 2010. An increasing proportion of patients died (0% versus 13%), had an APACHE II score ≥30 (0% versus 19%), and had no known risk-factors (12% versus 25%). A potential skin source was identified as a trigger in fewer cases in 2010 (36% versus 11%). In total, there were 27 different emm types and 11 different emm clusters. There were some new emm types/clusters in 2010 that were not present in 2008. However, the study was not adequately powered to detect statistically significant differences in the distribution of emm types (p = 0.06) and emm clusters (p = 0.16) between the two years. There were also no clear associations between emm types/clusters and severity and clinical manifestations of iGAS infections. Although the proposed 30-valent M protein vaccine encompasses only 47% of our isolates, it will likely provide coverage for at least 71% of iGAS infections due to cross-opsonisation.

Thermomyces lanuginosus infective endocarditis: Case report and a review of endocarditis due to uncommon moulds.

We describe a case of Thermomyces lanuginosus endocarditis, the first reported in a living patient, and review the literature to delineate the clinical characteristics, investigations and management of endocarditis due to such rare but emerging mould pathogens.

Sporotrichosis (Sporothrix schenckii infection) in the New South Wales mid-north coast, 2000-2010.

OBJECTIVE: To determine the geographical, epidemiological and clinical features of sporotrichosis (a cutaneous fungal infection caused by Sporothrix schenckii) in the New South Wales mid-north coast. DESIGN AND SETTING: We undertook a retrospective case review of S. schenckii infections that occurred during the period 2000-2010. Microbiology laboratory staff and medical practitioners in the NSW mid-north coast were contacted to identify cases through database searches and clinical data collection. RESULTS: Thirty-one cases of S. schenckii infection were identified. Twenty-one occurred in males, the mean age of patients was 59 years, and all cases with data available involved cutaneous disease affecting the limbs (multiple lesions in 18 of 20 cases). Despite an impression of temporal clustering (eight cases in 1 year), this was not statistically significant (P = 0.3). Most cases occurred in months with higher rainfall (13 of 14 cases with data available). Inoculating events included injuries in gardens, in bushland and on farms, and possible bites. Symptom duration before correct diagnosis ranged from 4 to 30 weeks (median, 8 weeks; data available for 15 cases), unnecessary antibacterial therapy was common (13 of 19 cases with data available), and morbidity occurred in the form of recurrence (three cases) and mild itraconazole-induced hepatotoxicity (two cases). In all cases with recorded treatment details, the patients received itraconazole, and the median duration of itraconazole treatment was 24 weeks. CONCLUSIONS: These data highlight that health providers on the NSW mid-north coast should consider sporotrichosis when patients present with characteristic lesions after an inoculating injury sustained from or contaminated by decaying vegetation. The risk may be higher in older people and in wetter months. Fungal culture to confirm the diagnosis needs to be specifically requested. In contrast to outbreaks reported from other states, the epidemiological pattern in NSW appears most consistent with sporadic occurrence in an endemic setting.