Central Nervous System Antimicrobial Exposure and Proposed Dosing for Anthrax Meningitis.

BACKGROUND: The high mortality of systemic anthrax is likely a consequence of the severe central nervous system (CNS) inflammation that occurs in anthrax meningitis. Effective treatment of such infections requires, at a minimum, adequate cerebrospinal fluid (CSF) antimicrobial concentrations. METHODS: We reviewed English medical literature and regulatory documents to extract information on serum and CSF exposures for antimicrobials with in vitro activity against Bacillus anthracis. Using CSF pharmacokinetic exposures and in vitro B. anthracis susceptibility data, we employed population pharmacokinetic modeling and Monte Carlo simulations to predict whether a specific antimicrobial dosage would likely achieve effective CSF antimicrobial activity in patients with normal to inflamed meninges (i.e., an intact to markedly disrupted blood brain barrier). RESULTS: Probability of microbiologic success at achievable antimicrobial dosages was high (≥95%) for ciprofloxacin, levofloxacin (500 mg q12 h), meropenem, imipenem/cilastatin, penicillin G, ampicillin, ampicillin/sulbactam, doxycycline, and minocycline; acceptable (90-95%) for piperacillin/tazobactam and levofloxacin (750 mg q24 h); and low (<90%) for vancomycin, amikacin, clindamycin, and linezolid. CONCLUSION: Prompt empiric antimicrobial therapy of patients with suspected or confirmed anthrax meningitis may reduce the high morbidity and mortality. Our data support using several ß-lactam-, fluoroquinolone-, and tetracycline-class antimicrobials as first-line and alternative agents for treatment of patients with anthrax meningitis; all should achieve effective microbiologic exposures. Our data also suggest antimicrobials that should not be relied upon to treat suspected or documented anthrax meningitis. Furthermore, the protein synthesis inhibitors clindamycin and linezolid can decrease toxin production and may be useful components of combination therapy.

External Validation of the 2023 Duke-International Society for Cardiovascular Infectious Diseases Diagnostic Criteria for Infective Endocarditis.

BACKGROUND: The 2023 Duke-International Society of Cardiovascular Infectious Diseases (ISCVID) criteria for infective endocarditis (IE) were introduced to improve classification of IE for research and clinical purposes. External validation studies are required. METHODS: We studied consecutive patients with suspected IE referred to the IE team of Amsterdam University Medical Center (from October 2016 to March 2021). An international expert panel independently reviewed case summaries and assigned a final diagnosis of "IE" or "not IE," which served as the reference standard, to which the "definite" Duke-ISCVID classifications were compared. We also evaluated accuracy when excluding cardiac surgical and pathologic data ("clinical" criteria). Finally, we compared the 2023 Duke-ISCVID with the 2000 modified Duke criteria and the 2015 and 2023 European Society of Cardiology (ESC) criteria. RESULTS: A total of 595 consecutive patients with suspected IE were included: 399 (67%) were adjudicated as having IE; 111 (19%) had prosthetic valve IE, and 48 (8%) had a cardiac implantable electronic device IE. The 2023 Duke-ISCVID criteria were more sensitive than either the modified Duke or 2015 ESC criteria (84.2% vs 74.9% and 80%, respectively; P < .001) without significant loss of specificity. The 2023 Duke-ISCVID criteria were similarly sensitive but more specific than the 2023 ESC criteria (94% vs 82%; P < .001). The same pattern was seen for the clinical criteria (excluding surgical/pathologic results). New modifications in the 2023 Duke-ISCVID criteria related to "major microbiological" and "imaging" criteria had the most impact. CONCLUSIONS: The 2023 Duke-ISCVID criteria represent a significant advance in the diagnostic classification of patients with suspected IE.

CDC Guidelines for the Prevention and Treatment of Anthrax, 2023.

This report updates previous CDC guidelines and recommendations on preferred prevention and treatment regimens regarding naturally occurring anthrax. Also provided are a wide range of alternative regimens to first-line antimicrobial drugs for use if patients have contraindications or intolerances or after a wide-area aerosol release of: Bacillus anthracis spores if resources become limited or a multidrug-resistant B. anthracis strain is used (Hendricks KA, Wright ME, Shadomy SV, et al.; Workgroup on Anthrax Clinical Guidelines. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20:e130687; Meaney-Delman D, Rasmussen SA, Beigi RH, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol 2013;122:885-900; Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014;133:e1411-36). Specifically, this report updates antimicrobial drug and antitoxin use for both postexposure prophylaxis (PEP) and treatment from these previous guidelines best practices and is based on systematic reviews of the literature regarding 1) in vitro antimicrobial drug activity against B. anthracis; 2) in vivo antimicrobial drug efficacy for PEP and treatment; 3) in vivo and human antitoxin efficacy for PEP, treatment, or both; and 4) human survival after antimicrobial drug PEP and treatment of localized anthrax, systemic anthrax, and anthrax meningitis. Changes from previous CDC guidelines and recommendations include an expanded list of alternative antimicrobial drugs to use when first-line antimicrobial drugs are contraindicated or not tolerated or after a bioterrorism event when first-line antimicrobial drugs are depleted or ineffective against a genetically engineered resistant: B. anthracis strain. In addition, these updated guidelines include new recommendations regarding special considerations for the diagnosis and treatment of anthrax meningitis, including comorbid, social, and clinical predictors of anthrax meningitis. The previously published CDC guidelines and recommendations described potentially beneficial critical care measures and clinical assessment tools and procedures for persons with anthrax, which have not changed and are not addressed in this update. In addition, no changes were made to the Advisory Committee on Immunization Practices recommendations for use of anthrax vaccine (Bower WA, Schiffer J, Atmar RL, et al. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices, 2019. MMWR Recomm Rep 2019;68[No. RR-4]:1-14). The updated guidelines in this report can be used by health care providers to prevent and treat anthrax and guide emergency preparedness officials and planners as they develop and update plans for a wide-area aerosol release of B. anthracis.

The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria.

The microbiology, epidemiology, diagnostics, and treatment of infective endocarditis (IE) have changed significantly since the Duke Criteria were published in 1994 and modified in 2000. The International Society for Cardiovascular Infectious Diseases (ISCVID) convened a multidisciplinary Working Group to update the diagnostic criteria for IE. The resulting 2023 Duke-ISCVID IE Criteria propose significant changes, including new microbiology diagnostics (enzyme immunoassay for Bartonella species, polymerase chain reaction, amplicon/metagenomic sequencing, in situ hybridization), imaging (positron emission computed tomography with 18F-fluorodeoxyglucose, cardiac computed tomography), and inclusion of intraoperative inspection as a new Major Clinical Criterion. The list of "typical" microorganisms causing IE was expanded and includes pathogens to be considered as typical only in the presence of intracardiac prostheses. The requirements for timing and separate venipunctures for blood cultures were removed. Last, additional predisposing conditions (transcatheter valve implants, endovascular cardiac implantable electronic devices, prior IE) were clarified. These diagnostic criteria should be updated periodically by making the Duke-ISCVID Criteria available online as a "Living Document."

Safety of Antimicrobials for Postexposure Prophylaxis and Treatment of Anthrax: A Review.

BACKGROUND: Bacillus anthracis, the causative agent for anthrax, poses a potential bioterrorism threat and is capable of causing mass morbidity and mortality. Antimicrobials are the mainstay of postexposure prophylaxis (PEP) and treatment of anthrax. We conducted this safety review of 24 select antimicrobials to identify any new or emerging serious or severe adverse events (AEs) to help inform their risk-benefit evaluation for anthrax. METHODS: Twenty-four antimicrobials were included in this review. Tertiary data sources (e.g. Lactmed, Micromedex, REPROTOX) were reviewed for safety information and summarized to evaluate the known risks of these antimicrobials. PubMed was also searched for published safety information on serious or severe AEs with these antimicrobials; AEs that met inclusion criteria were abstracted and reviewed. RESULTS: A total of 1316 articles were reviewed. No consistent observations or patterns were observed among the abstracted AEs for a given antimicrobial; therefore, the literature review did not reveal evidence of new or emerging AEs that would add to the risk-benefit profiles already known from tertiary data sources. CONCLUSIONS: The reviewed antimicrobials have known and/or potential serious or severe risks that may influence selection when recommending an antimicrobial for PEP or treatment of anthrax. Given the high fatality rate of anthrax, the risk-benefit evaluation favors use of these antimicrobials for anthrax. The potential risks of antimicrobials should not preclude these reviewed antimicrobials from clinical consideration for anthrax but rather guide appropriate antimicrobial selection and prioritization across different patient populations with risk mitigation measures as warranted.

More Specialties, Fewer Problems: Using Collaborative Competency Between Infectious Diseases, Podiatry, and Pathology to Improve the Care of Patients with Diabetic Foot Osteomyelitis.

BACKGROUND: Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking. METHODS: Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses. RESULTS: A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients. CONCLUSIONS: This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.

Association Between Diabetic Foot Infection Wound Culture Positivity and 1-Year Admission for Invasive Infection: A Multicenter Cohort Study.

Inpatients with culture-positive diabetic foot infections are at elevated risk for subsequent invasive infection with the same causative organism. In outpatients with index diabetic foot ulcers, we found that wound culture positivity was independently associated with increased odds of 1-year admission for systemic infection when compared with culture-negative wounds.

A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist.

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

Uncomplicated Staphylococcus aureus Bacteremia Treatment Duration and Outcomes at an Academic Medical Center.

We compared outcomes and clinical characteristics of uncomplicated Staphylococcus aureus bacteremia planned for a 14-day or >14-day course of intravenous antibiotics. Treatment failure was infrequent in both groups (0% and 5%, respectively). Catheter-associated deep vein thrombosis, immunosuppression, and valvular dysfunction were associated with a longer planned duration of therapy.

A PATH TO RESUME AESTHETIC CARE EXECUTIVE SUMMARY OF PROJECT AesCert™ GUIDANCE SUPPLEMENT: PRACTICAL CONSIDERATIONS FOR AESTHETIC MEDICINE PROFESSIONALS SUPPORTING CLINIC PREPAREDNESS IN RESPONSE TO THE SARS-CoV-2 OUTBREAK.

This Project AesCert™ Guidance Supplement ("Guidance Supplement") was developed in partnership with a multi-disciplinary panel of board-certified physician and doctoral experts in the fields of Infectious Disease, Immunology, Public Health Policy, Dermatology, Facial Plastic Surgery and Plastic Surgery. The Guidance Supplement is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-to-work phase of the COVID-19 pandemic, once such activity is permitted by applicable law. Many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated COVID-19 orders and advisories applicable to health care practitioners. The Guidance Supplement is intended to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetic care safely and generally conducting business responsibly in the new world of COVID-19. Aesthetic providers will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the U.S. economy reopens and healthcare systems transition from providing only urgent and other essential treatment to resuming routine care and elective procedures and services. The medical aesthetic specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In a number of areas, this Guidance Supplement exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance Supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. While the Guidance Supplement cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions.

Endocarditis Caused by Highly Penicillin-Resistant Viridans Group Streptococci: Still Room for Vancomycin-Based Regimens.

Optimal treatment options remain unknown for infective endocarditis (IE) caused by penicillin-resistant (PEN-R) viridans group streptococcal (VGS) strains. The aims of this study were to report two cases of highly PEN-R VGS IE, perform a literature review, and evaluate various antibiotic combinations in vitro and in vivo The following combinations were tested by time-kill studies and in the rabbit experimental endocarditis (EE) model: PEN-gentamicin, ceftriaxone-gentamicin, vancomycin-gentamicin, daptomycin-gentamicin, and daptomycin-ampicillin. Case 1 was caused by Streptococcus parasanguinis (PEN MIC, 4 µg/ml) and was treated with vancomycin plus cardiac surgery. Case 2 was caused by Streptococcus mitis (PEN MIC, 8 µg/ml) and was treated with 4 weeks of vancomycin plus gentamicin, followed by 2 weeks of vancomycin alone. Both patients were alive and relapse-free after ≥6 months follow-up. For the in vitro studies, except for daptomycin-ampicillin, all combinations demonstrated both synergy and bactericidal activity against the S. parasanguinis isolate. Only PEN-gentamicin, daptomycin-gentamicin, and daptomycin-ampicillin demonstrated both synergy and bactericidal activity against the S. mitis strain. Both strains developed high-level daptomycin resistance (HLDR) during daptomycin in vitro passage. In the EE studies, PEN alone failed to clear S. mitis from vegetations, while ceftriaxone and vancomycin were significantly more effective (P < 0.001). The combination of gentamicin with PEN or vancomycin increased bacterial eradication compared to that with the respective monotherapies. In summary, two patients with highly PEN-R VGS IE were cured using vancomycin-based therapy. In vivo, regimens of gentamicin plus either ß-lactams or vancomycin were more active than their respective monotherapies. Further clinical studies are needed to confirm the role of vancomycin-based regimens for highly PEN-R VGS IE. The emergence of HLDR among these strains warrants caution in the use of daptomycin therapy for VGS IE.

High Morbidity and Mortality Among Patients With Sentinel Admission for Injection Drug Use-Related Infective Endocarditis.

BACKGROUND: Hospitalizations for individuals with injection drug use-related infective endocarditis (IDU-IE) represent an increasing portion of all patients with endocarditis. This study describes the evolving trends in demographics, clinical characteristics, rates of surgical intervention, and mortality among patients hospitalized with IE, comparing those with and without injection drug use. METHODS: This is a retrospective cohort study of patients admitted between January 1, 2007 to June 30, 2015 at a tertiary care center in Boston, Massachusetts. Endocarditis was defined by International Classification of Diseases, Ninth Revision code and verified by the modified Duke Criteria for IE. The clinical characteristics, microbiology, site of infection, complications of IE, and outcome were all abstracted by chart review. Rates of surgical consultation and surgical intervention within 90 days of admission were obtained, and assessment of surgical risk calculated was by EuroSCORE II (euroscore.org/calc). Subsequent hospitalizations for all causes were also reviewed. RESULTS: Injection drug use-related infective endocarditis occurred in younger patients with lower rates of diabetes, renal dysfunction, and prior cardiothoracic (CT) surgery than those without IDU. Injection drug use-related infective endocarditis was associated with higher rates of complications, CT surgery consultation, and surgery within 90 days for absolute surgical indication. Readmissions for endocarditis occurred in 20% of IDU-IE patients and 9% of those with non-IDU IE. All-cause 1-year mortality rates were similar (IDU-IE 16%, non-IDU IE 13%; P = .58). CONCLUSIONS: Despite younger age, fewer medical comorbidities, and fewer prior cardiac surgeries, all-cause 1-year mortality was similar for patients after sentinel admission for IDU-IE compared with non-IDU IE. Interventions in the acute hospital setting and after discharge are needed to support patients with IDU-IE, focusing on harm reduction and treatment of addiction to reduce the unexpectedly high mortality of this young population.

Methicillin-Resistant Staphylococcus aureus Endocarditis from a Diabetic Foot Ulcer Understanding and Mitigating the Risk.

Diabetic foot infections are a common cause of morbidity and mortality in the United States, and successful treatment often requires an aggressive and prolonged approach. Recent work has elucidated the importance of appropriate therapy for a given severity of diabetic foot infection, and highlighted the ongoing risk such patients have for subsequent invasive life-threatening infection should diabetic foot ulcers fail to heal. The authors describe the case of a man with diabetes who had prolonged, delayed healing of a diabetic foot ulcer. The ulcer subsequently became infected by methicillin-resistant Staphylococcus aureus (MRSA). The infection was treated conservatively with oral therapy and minimal debridement. Several months later, he experienced MRSA bloodstream infection and complicating endocarditis. The case highlights the ongoing risk faced by patients when diabetic foot ulcers do not heal promptly, and emphasizes the need for aggressive therapy to promote rapid healing and eradication of MRSA.

Pretravel Health Preparation of International Travelers: Results From the Boston Area Travel Medicine Network.

OBJECTIVE: To inform future interventions for advising travelers. PATIENTS AND METHODS: We prospectively collected data on travelers seen at the Boston Area Travel Medicine Network, a Boston area research collaboration of 5 travel medicine clinics. Data from 15,440 travelers were collected from March 1, 2008, through July 31, 2010. We compared traveler and trip characteristics and differences in demographic characteristics and travel plans across the 5 clinics, including an analysis of pretravel preparations for certain high-risk destinations. RESULTS: More than half of the 15,440 travelers were female (8730 [56.5]), and 72.4% (10,528 of 14,545) were white; the median age was 34 years, and 29.4% of travelers (3077 of 10,483) were seen less than 2 weeks before their departure date. Substantial variation in racial background, purpose of travel, and destination risk existed across the 5 clinics. For example, the proportion of travelers visiting friends and relatives ranged from 7.6% (184 of 2436) to 39.0% (1029 of 2639) (18.7% [2876 of 15,360] overall), and the percentage of travelers to areas with malaria risk ranged from 23.7% (333 of 1403) to 52.0% (1306 of 2512). Although most clinics were likely to have prescribed certain vaccines for high-risk destinations (eg, yellow fever for Ghana travel), there was wide variability in influenza vaccine use for China travel. CONCLUSION: Substantial differences in clinic populations can occur within a single metropolitan area, highlighting why individual physicians and travel clinics need to understand the specific needs of the travelers they serve in addition to general travel medicine.

Invasive Systemic Infection After Hospital Treatment for Diabetic Foot Ulcer: Risk of Occurrence and Effect on Survival.

BACKGROUND: Diabetic foot ulcers (DFUs) threaten limbs and prompt hospitalization. After hospitalization, remote-site invasive systemic infection related to DFU (DFU-ISI) may occur. The characteristics of DFU-ISIs and their effect on mortality risk have not been defined. METHODS: We conducted a retrospective cohort study of 819 diabetic patients hospitalized for treatment of 1212 unique DFUs during a 9-year period. We defined the index ulcer as that present at the first (index) DFU admission to our hospital. We defined DFU-ISI as a nonfoot infection that occurred after the index hospitalization and was caused by a microorganism concomitantly or previously cultured from the index ulcer. We determined the frequency, risk factors, and mortality risk associated with DFU-ISIs. RESULTS: After 1212 index DFU hospitalizations, 141 patients had 172 DFU-ISIs. Of the initial 141 DFU-ISIs, 64% were bacteremia, 13% deep abscesses, 10% pneumonia, 7% endocarditis, and 6% skeletal infections. Methicillin-resistant Staphylococcus aureus (MRSA) caused 57% of the ISIs. Patients with initial DFU cultures yielding MRSA and protracted open ulcers had a high 24-month cumulative probability of DFU-ISI (31%) and all-cause mortality rate (13%). Analysis with Cox regression modeling showed that complicated ulcer healing (hazard ratio, 3.812; 95% confidence interval, 2.434-5.971) and initial DFU culture yielding MRSA (2.030; 1.452-2.838) predicted DFU-ISIs and that DFU-ISIs were associated with increased mortality risk (1.987; 1.106-3.568). CONCLUSIONS: DFU-ISIs are important late complications of DFUs. Prevention of DFU-ISIs should be studied prospectively. Meanwhile, clinicians should aggressively incorporate treatment to accelerate ulcer healing and address MRSA into the care of diabetic patients with foot ulcers.

Dengue Virus Seroconversion in Travelers to Dengue-Endemic Areas.

We conducted a prospective study to measure dengue virus (DENV) antibody seroconversion in travelers to dengue-endemic areas. Travelers seen in the Boston Area Travel Medicine Network planning to visit dengue-endemic countries for ≥ 2 weeks were enrolled from 2009 to 2010. Pre- and post-travel blood samples and questionnaires were collected. Post-travel sera were tested for anti-DENV IgG by indirect IgG enzyme-linked immunosorbent assay (ELISA) and anti-DENV IgM by capture IgM ELISA. Participants with positive post-travel anti-DENV IgG or IgM were tested for pre-travel anti-DENV IgG and IgM; they were excluded from the seroconversion calculation if either pre-travel anti-DENV IgG or IgM were positive. Paired sera and questionnaires were collected for 62% (589/955) of enrolled travelers. Most participants were 19-64 years of age, female, and white. The most common purposes of travel were tourism and visiting friends and relatives; most trips were to Asia or Africa. Median length of travel was 21 days. DENV antibody seroconversion by either anti-DENV IgM or IgG ELISA was 2.9-6.8%; lower range percent excluded potential false-positive anti-DENV IgG due to receipt of yellow fever or Japanese encephalitis vaccines at enrollment; upper range percent excluded proven false-positive anti-DENV IgM. Eighteen percent of those with seroconversion reported dengue-like symptoms. Seroconversion was documented for travel to Africa as well as countries and regions known to be highly dengue endemic (India, Brazil, southeast Asia). Given widespread risk of dengue, travel medicine counseling should include information on risk of dengue in endemic areas and advice on preventing insect bites and seeking prompt medical attention for febrile illness.