Primary splenic abscess in an adult female patient: a case report.

BACKGROUND: Primary splenic abscess is rare and typically presents in patients who are immunocompromised. We present a case of a 47-year-old apparently immunocompetent female patient who was diagnosed with primary splenic abscess from a Salmonella Typhimurium infection following emergency laparotomy. CASE PRESENTATION: A 47-year-old female patient presented with subjective fever and severe epigastric and left flank pain. She was treated empirically with intravenous piperacillin/tazobactam and gentamicin and was resuscitated with intravenous crystalloid infusion. A radiological diagnosis of splenic infarct secondary to splenic artery aneurysm superimposed with splenic abscess was presumed, however at emergency laparotomy, primary splenic abscess was identified. This abscess had eroded the left hemidiaphragm and had ruptured the splenic capsule leading to intra-abdominal pus in the pelvis which on culture grew Salmonella Typhimurium. A splenectomy and primary repair of the left hemidiaphragm were performed, with postoperative pancreatitis diagnosed following the procedure. After intensive care treatment, this patient made a full recovery. CONCLUSION: This case of primary splenic abscess was treated successfully with a combination of surgery (i.e.: splenectomy and surgical drainage), prolonged antimicrobial therapy, and intensive care in the perioperative period.

Whole genome sequencing of increased number of azithromycin-resistant Shigella flexneri 1b isolates in Ontario.

Azithromycin (AZM) resistance among Shigella is a major public health concern. Here, we investigated the epidemiology of Shigella flexneri serotype 1b recovered during 2016-2018 in Ontario, to describe the prevalence and spread of AZM resistance. We found that 72.3% (47/65) of cases were AZM-resistant (AZMR), of which 95.7% (45/47) were among males (P < 0.001). Whole-genome based phylogenetic analysis showed three major clusters, and 56.9% of isolates grouped within a single closely-related cluster (0-10 ∆SNP). A single AZMR clonal population was persistent over 3 years and involved 67.9% (36/53) of all male cases, and none reported international travel. In 2018, a different AZMR cluster appeared among adult males not reporting travel. A proportion of isolates (10.7%) with reduced susceptibility to ciprofloxacin (CIP) due to S83L mutation in gyrA were AZM susceptible, and 71.4% reported international travel. Resistance to AZM was due to the acquisition of mph gene-bearing incFII plasmids having > 95% nucleotide similarity to pKSR100. Plasmid-borne resistance limiting treatment options to AZM, ceftriaxone (CRO) and CIP was noted in a single isolate. We characterized AZMR isolates circulating locally among males and found that genomic analysis can support targeted prevention and mitigation strategies against antimicrobial-resistance.

Indwelling central venous catheter infection with Chryseobacterium shandongense - successful eradication in a 5-year-old with cystic fibrosis.

Introduction: Chryseobacterium shandongense is a Gram-negative Flavobacterium bacillus with intrinsic multidrug-resistant properties. Case Presentation: Herein, we present the first case report of human C. shandongense infection, relating to an implantable portal and catheter (port-a-cath) central line in a 5-year-old female with cystic fibrosis. The infection was identified using a Bruker MALDI-TOF Biotyper with BDAL (v12) of blood, which was cultured due to pyrexia and rigour following port-a-cath access. This report details the effective eradication of C. shandongense infection from the port-a-cath device using initial empirical gentamicin followed by targeted ciprofloxacin locks and systemic antibiotics. Conclusion: We demonstrated successful eradication of C. shandongense from a port-a-cath device, including the minimum inhibitory concentrations (MICs) required in this case. The result was eradication of central access infection, preventing progression to bacteraemia/septicaemia and preserving central access in a child with cystic fibrosis and established respiratory disease.

A Prolonged Outbreak of Human Adenovirus A31 (HAdV-A31) Infection on a Pediatric Hematopoietic Stem Cell Transplantation Ward with Whole Genome Sequencing Evidence of International Linkages.

A surge in hematopoietic stem cell transplantation (HSCT) human adenovirus A31 (HAdV-A31) infections was initially observed in late 2014/2015 at SickKids (SK) Hospital, Toronto, Canada. In response, enhanced laboratory monitoring for all adenovirus infections was conducted. Positive samples underwent genotyping, viral culture, and, in selected cases, whole-genome sequencing (WGS). HAdV-A31 specimens/DNA obtained from four international pediatric HSCT centers also underwent WGS. During the SK outbreak period (27 October 2014 to 31 October 2018), 17/20 HAdV-A31 isolates formed a distinct clade with 0 to 8 mutations between the closest neighbors. Surveillance before and after the outbreak detected six additional HAdV-A31 HSCT cases; three of the four sequenced cases clustered within the outbreak clade. Two SK outbreak isolates were identical to sequences from two patients in an outbreak in England. Three SK non-outbreak sequences also had high sequence similarity to strains from three international centers. Environmental PCR testing of the HSCT ward showed significant adenovirus contamination. Despite intense infection control efforts, we observed re-occurrence of infection with the outbreak strain. Severe but nonfatal infection was observed more commonly with HAdV-A31 compared to other genotypes, except HAdV-C1. Our findings strongly implicate nosocomial spread of HAdV-A31 over 10 years on a HSCT unit and demonstrate the value of WGS in defining and mapping the outbreak. Close linkages among strains in different countries suggest international dissemination, though the mechanism is undetermined. This large, extended outbreak emphasizes the pre-eminent role of HAdV-A31 in causing intractable pediatric HSCT outbreaks of severe illness worldwide.

Outcomes of implementation of the FilmArray meningoencephalitis panel in a tertiary hospital between 2017 and 2020.

BACKGROUND: Acute meningoencephalitis is encountered commonly in the acute hospital setting and is associated with significant morbidity and mortality, in addition to significant healthcare costs. Multiplex PCR panels now allow syndromic testing for central nervous system infection. The BioFire® FilmArray® Meningoencephalitis (ME) allows testing of 14 target pathogens using only 0.2mls of cerebrospinal fluid (CSF). We conducted a retrospective observational study to assess the performance of the assay and secondarily to observe the clinical utility of negative results by comparing clinical outcomes of aseptic meningitis to bacterial and viral meningoencephalitis. METHODS: Data for CSF samples tested using the FilmArray ME panel from October 2017 to October 2020 were analysed. Detection of bacterial and viral targets was analysed. Admission to critical care area, 90-day readmission rates, average length of stay and 30-day and 90-day mortality were analysed for three groups with following diagnoses: bacterial meningitis, viral meningoencephalitis, or aseptic meningitis. RESULTS: From October 2017 to October 2020, 1926 CSF samples were received in the Clinical Microbiology laboratory. Of those, 543 CSF samples from 512 individual patients were tested using the FilmArray ME panel. Twenty-one bacterial targets and 56 viral targets were detected during the study period. For viral targets, the cumulative specificity was 98.9% (95% confidence interval: 93.1-99.9) when compared to the reference laboratory methods. The outcomes for 30- and 90-day mortality of the aseptic meningitis group were non-inferior relative to the viral meningoencephalitis and bacterial meningitis group. Patients with bacterial meningitis had a longer average length of stay. Aseptic meningitis was associated with a higher 90-day readmission rate than the other 2 groups, but without statistical significance. CONCLUSION: In our hands, implementation of the FilmArray ME panel was relatively straightforward. We experienced a transition in our workflow processes that enabled streamlining of CSF diagnostics and the safe removal of Gram staining in those samples being tested by this molecular assay. Coupled to this improvement, there was a positive clinical impact on patient care due to rapid turnaround time to results.

Effect of Pseudomonas colonisation on lower limb venous ulcer healing: a systematic review.

OBJECTIVE: Pseudomonas aeruginosa is a Gram-negative bacillus that commonly colonises lower limb venous ulcers. Its effects on venous ulcer healing are widely debated. It produces exotoxins and elastase, as well as forming biofilms in hard-to-heal wounds. It is postulated that these virulence factors lead to slower healing times in patients with lower limb venous ulcers colonised with Pseudomonas. This review aimed to summarise the available evidence pertaining to this topic. METHOD: A systematic review was performed in August 2019, where the Pubmed, Cochrane and Embase databases were searched for relevant literature according to PRISMA guidelines. Retrospective and prospective studies examining the effect of Pseudomonas colonisation on any measure of ulcer healing were included. RESULTS: Some 282 articles were screened, of which seven studies including 491 patients were ultimately included for analysis. Of these, no study demonstrated a significant association between Pseudomonas colonisation and delayed healing of venous ulcers. In five of the seven studies, the effect of Pseudomonas aeruginosa on initial ulcer size at presentation was recorded. CONCLUSION: All the studies demonstrated an association between ulcer size and the presence of Pseudomonas aeruginosa. While Pseudomonas aeruginosa may colonise larger ulcers or those with a worse prognosis, no evidence was found to support the hypothesis that this colonisation had a negative impact on lower limb venous ulcer healing.

Tinea capitis with multiple isolates: The interaction of nature, animal and child.

Tinea capitis is an infection of the scalp and hair commonly seen in the pediatric population. Detection of multiple dermatophytes is unusual, and true mixed infections have been rarely reported. Herein, we describe an 8-year-old girl with tinea capitis revealing three different dermatophyte isolates that highlight the clinical challenge posed by this phenomenon.

Evaluation of digital dispense-assisted broth microdilution antimicrobial susceptibility testing for Pseudomonas aeruginosa isolates.

Antimicrobial susceptibility testing (AST) is essential for detecting resistance in Pseudomonas aeruginosa and other bacterial pathogens. Here we evaluated the performance of broth microdilution (BMD) panels created using a semi-automated liquid handler, the D300e Digital Dispenser (Tecan Group Ltd., CH) that relies on inkjet printing technology. Microtitre panels (96-well) containing nine twofold dilutions of 12 antimicrobials from five classes (ß-lactams, ß-lactam/ß-lactamase inhibitors, aminoglycosides, fluoroquinolones, polymyxins) were prepared in parallel using the D300e Digital Dispenser and standard methods described by CLSI/ISO. To assess performance, panels were challenged with three well characterized quality control organisms and 100 clinical P. aeruginosa isolates. Traditional agreement and error measures were used for evaluation. Essential (EA) and categorical (CA) agreements were 92.7% and 98.0% respectively for P. aeruginosa isolates with evaluable on-scale results. The majority of minor errors that fell outside acceptable EA parameters (≥ ± 1 dilution, 1.9%) were seen with aztreonam (5%) and ceftazidime (4%), however all antimicrobials displayed acceptable performance in this situation. Differences in MIC were often log2 dilution lower for D300e dispensed panels. Major and very major errors were noted for aztreonam (2.6%) and cefepime (1.7%) respectively. The variable performance of D300e panels suggests that further testing is required to confirm their diagnostic utility for P. aeruginosa.

Pseudomonas aeruginosa Strain-sharing in Early Infection Among Children With Cystic Fibrosis.

BACKGROUND: We previously identified Pseudomonas aeruginosa isolates with characteristics typical of chronic infection in some early infections in children with cystic fibrosis (CF), suggesting that these isolates may have been acquired from other patients. Our objective was to define the extent of P. aeruginosa strain-sharing in early CF infections and its impact on antibiotic eradication treatment failure rates. METHODS: We performed whole genome sequencing on isolates from early pediatric CF pulmonary infections and from the following comparator groups in the same hospital: chronic CF infection, sink drains, sterile site infections, and asymptomatic carriage. Univariate logistic regression was used to assess factors associated with treatment failure. RESULTS: In this retrospective, observational study, 1029 isolates were sequenced. The CF clones strain B and clone C were present. In 70 CF patients with early infections, 14 shared strains infected 29 (41%) patients over 5 years; 16% (n = 14) of infections had mixed strains. In the 70 children, approximately one-third of shared-strain infections were likely due to patient-to-patient transmission. Mixed-strain infections were associated with strain-sharing (odds ratio, 8.50; 95% confidence interval, 2.2-33.4; P = .002). Strain-sharing was not associated with antibiotic eradication treatment failure; however, nosocomial strain transmission was associated with establishment of chronic infection in a CF sibling pair. CONCLUSIONS: Although early P. aeruginosa CF infection is thought to reflect acquisition of diverse strains from community reservoirs, we identified frequent early CF strain-sharing that was associated with the presence of mixed strains and instances of possible patient-to-patient transmission.

Identification and characterization of invasive multi-drug-resistant (MDR) Bacteroides genomospecies in Canada.

We identified and characterized a genome of the multi-drug-resistant Bacteroides genomospecies recovered from an invasive specimen from a hospitalized patient in Canada. The strain was resistant to penicillin, pipercillin-tazobactam, meropenem, clindaymycin and metronidazole. The strain harboured a plasmid containing the nimE gene, which has been shown to be associated with metronidazole resistance. The study highlights the importance of being vigilant in suspecting antimicrobial drug resistance when a patient is not improving on therapy.

Dual RNA-Seq characterization of host and pathogen gene expression in liver cells infected with Crimean-Congo Hemorrhagic Fever Virus.

Crimean-Congo hemorrhagic fever virus (CCHFV) is a tick-borne virus that can cause a hemorrhagic fever in humans, with a case fatality rate of up to 40%. Cases of CCHFV have been reported in Africa, Asia, and southern Europe; and recently, due to the expanding range of its vector, autochthonous cases have been reported in Spain. Although it was discovered over 70 years ago, our understanding of the pathogenesis of this virus remains limited. We used RNA-Seq in two human liver cell lines (HepG2 and Huh7) infected with CCHFV (strain IbAr10200), to examine kinetic changes in host expression and viral replication simultaneously at 1 and 3 days post infection. Through this, numerous host pathways were identified that were modulated by the virus including: antiviral response and endothelial cell leakage. Notably, the genes encoding DDX60, a cytosolic component of the RIG-I signalling pathway and OAS2 were both shown to be dysregulated. Interestingly, PTPRR was induced in Huh7 cells but not HepG2 cells. This has been associated with the TLR9 signalling cascade, and polymorphisms in TLR9 have been associated with poor outcomes in patients. Additionally, we performed whole-genome sequencing on CCHFV to assess viral diversity over time, and its relationship to the host response. As a result, we have demonstrated that through next-generation mRNA deep-sequencing it is possible to not only examine mRNA gene expression, but also to examine viral quasispecies and typing of the infecting strain. This demonstrates a proof-of-principle that CCHFV specimens can be analyzed to identify both the virus and host biomarkers that may have implications for prognosis.

Whole-Genome Sequencing of Mycobacterium tilburgii Strain MEPHI.

Mycobacterium tilburgii is a fastidious mycobacterium which has previously been reported to cause severe disseminated infections. Genome sequencing of the M. tilburgii MEPHI clinical isolate yielded 3.14 Mb, with 66.3% GC content, and confirmed phylogenetic placement within the Mycobacterium simiae complex.

'Start smart': using front-line ownership to improve the quality of empiric antibiotic prescribing in a paediatric hospital.

Infection is the most frequent indication for non-scheduled admission to paediatric hospitals, leading to high levels of empiric antibiotic prescribing. Antibiotic prescribing in line with local guidelines, improves patient outcomes, reduces adverse drug events and helps to reduce the emergence of antimicrobial resistance. We undertook an improvement project at Temple Street Children's University Hospital targeting documentation of indication and compliance with empiric antibiotic prescribing guidelines among medical admissions via the emergency department (ED). Results of weekly audits of empiric antibiotic prescribing were fed back to prescribers. Front-line ownership techniques were used to empower prescribers to generate ideas for change, such as regular discussion of antibiotic prescribing issues at weekly clinical meetings, antibiotic 'spot quiz', updates to prescribing guidelines, improved access and promotion of a prescribing app, laminated guideline summary cards, and reminders and guideline summaries at a point of prescribing in ED. Documentation of indication and guideline compliance increased from a median of 30% in December 2014 to 100% in March 2015, and was sustained at 100% to September 2016, then 90% to December 2017. The intervention was associated with improvements in non-targeted indicators of prescribing quality, an overall reduction in antimicrobial consumption in the hospital, and a €105 000 reduction in annual antimicrobial acquisition costs. We found that a simple, paper-based, data collection system was effective, provided opportunities for a point-of-care interaction with prescribers, and facilitated weekly data feedback. We also found that using a pre-existing weekly clinical meeting to foster prescriber ownership of the data, allowing prescribers to identify possible tests of change, and exploiting the competitive nature of doctors, led to a rapid and sustained improvement in prescribing quality. Awareness of local prescribing processes and culture are essential to delivering improvements in antimicrobial stewardship.

Antimicrobial Susceptibility of Clinical and Environmental Mycobacterium chimaera Isolates.

Mycobacterium chimaera is a slow-growing nontuberculous Mycobacterium species belonging to the Mycobacterium avium complex (MAC). It has been identified globally as the cause of a large outbreak of cardiovascular infections following open heart surgery, but it can also cause respiratory infections in individuals with underlying structural pulmonary disease. Invasive M. chimaera infections are associated with poor clinical responses, and the optimal antibiotic treatment regimen for these infections is not known. In this study, the drug susceptibility profiles of clinical and environmental M. chimaera isolates for antimicrobial agents that are commonly considered for treatment of MAC infections were determined. All M. chimaera isolates were susceptible to clarithromycin, with a median MIC of 2 µg/ml, while 98% (85/87 isolates) were susceptible to amikacin. Twenty-five percent of isolates (22/87 isolates) had intermediate susceptibility and 52% (46/87 isolates) were resistant to moxifloxacin. Similarly, 39% of isolates (34/87 isolates) had intermediate susceptibility and 39% (34/87 isolates) were resistant to linezolid. MIC breakpoints derived from the literature were used to determine resistance to rifampin (16/87 isolates [18%]), ethambutol (10/87 isolates [11%]), rifabutin (2/87 isolates [2%]), and streptomycin (1/87 isolates [1%]). In conclusion, our results showed that clarithromycin, amikacin, rifabutin, and streptomycin had the best activity against M. chimaera isolates, while susceptibility rates were lower for rifampin and ethambutol. In contrast, there was a high prevalence of isolates that were not susceptible to moxifloxacin or linezolid. While factors in addition to antibiotic susceptibility may determine the outcomes of treatment of M. chimaera infections, our results should inform the selection of antimicrobials as part of the overall therapeutic strategy.

Application of whole genome sequencing to query a potential outbreak of Elizabethkingia anophelis in Ontario, Canada.

Bioinformatic analysis of whole genome sequence (WGS) data is emerging as a tool to provide powerful insights for clinical microbiology. We used WGS data to investigate the genetic diversity of clinical isolates of the bacterial pathogen Elizabethkingia anophelis to query the existence of a single-strain outbreak in Ontario, Canada. The Public Health Ontario Laboratory (PHOL) provides reference identification of clinical isolates of bacteria for Ontario and prior to 2016 had not identified E. anophelis . In the wake of the Wisconsin outbreak of 2015-2016 for which a source was never elucidated, the identification of E. anophelis from clinical specimens from five Ontario patients gave reason to question the presence of an outbreak. Genomic comparisons based on core genome multi-locus sequence typing conclusively refuted the existence of an outbreak, since the 5 Ontario isolates were genetically dissimilar, representing at least 3 distinct sub-lineages scattered among a set of 39 previously characterized isolates. Further interrogation of the genomic data revealed multiple antimicrobial resistance genes. Retrospective reidentification via rpoB sequence analysis of 22 clinical isolates of Elizabethkingia spp. collected by PHOL from 2010 to 2018 demonstrated that E. anophelis was isolated from clinical specimens as early as 2010. The uptick in E. anophelis in Ontario was not due to an outbreak or increased incidence of the pathogen, but rather enhanced laboratory identification techniques and improved sequence databases. This study demonstrates the usefulness of WGS analysis as a public health tool to quickly rule out the existence of clonally related case clusters of bacterial pathogens indicative of single-strain outbreaks.

Early detection using qPCR of Pseudomonas aeruginosa infection in children with cystic fibrosis undergoing eradication treatment.

BACKGROUND: Infection with Pseudomonas aeruginosa (Pa) with a chronic phenotype is associated with antibiotic eradication therapy (AET) failure. Our objective was to determine whether higher levels of Pa (detected using qPCR) prior to culture positivity were associated with AET failure in pediatric CF patients. METHODS: Pa-specific qPCR was performed on stored sputa prior to culture positivity in pediatric CF patients with new-onset culture-positive Pa infections undergoing AET with a 28-day course of tobramycin-inhaled solution (TIS). DNA concentrations were compared in patients in whom AET was successful (Eradicated) to those with persistently positive sputum cultures (Persistent). RESULTS: Forty-seven patients were included. AET was successful in 32 cases (68%), but failed in 15 cases (32%). Median sputum Pa-specific DNA concentration preceding the positive sputum culture was 2.2 × 10-6 µg/mL in Eradicated cases compared to 3 × 10-5 µg/mL in Persistent cases (p = 0.14). There was no significant difference in DNA concentration in the last sputum sample prior to culture positivity, nor in maximal DNA values. There was also no difference in sputum Pa DNA concentrations in patients who had a mucoid (compared to non-mucoid) Pa infection. CONCLUSIONS: Pediatric CF patients with new-onset Pa infections have detectable Pa-specific DNA in the year preceding a positive culture, however, there is no significant difference in Pa DNA concentrations between patients in whom AET is successful compared to those in whom it fails. Therefore, early molecular detection of Pa may not lead to improved eradication success rates.

Outbreaks of extended spectrum beta-lactamase-producing Enterobacteriaceae in neonatal intensive care units: a systematic review.

OBJECTIVE: To establish the number of outbreaks of extended spectrum beta-lactamase (ESBL) producing organisms in neonatal intensive care units (NICUs), to determine causes, mortality rates, proportions of infants colonised and infected and the interventions that terminated outbreaks. METHODS: A systematic review of the literature in English, Spanish and French was undertaken with searches in four databases. The review conformed to the PRISMA guidelines, and the data extraction was modelled on the ORION criteria for studies of nosocomial infection. RESULTS: 75 studies fulfilled the inclusion criteria. There were 1185 cases of colonisation, 860 infections and 139 deaths. The median outbreak duration was 6.2 months (IQR 2.0-7.5 months). Klebsiella pneumoniae was the most frequently implicated pathogen. Understaffing was the most frequent risk factor for outbreaks. The most commonly identified source was admission of an ESBL-colonised infant with subsequent horizontal dissemination. The main interventions described were improved infection-control procedures and screening of staff and the environment. 26 studies were included in the quantitative analysis. Random effects meta-analysis indicated high mortality rates in infants who developed infection (31%, 95% CI 20% to 43%). CONCLUSION: ESBL outbreaks in NICUs are associated with significant mortality and prolonged disruption. Understaffing is a major risk factor, but is infrequently addressed by interventions. Poor infection-control procedures are frequently implicated as contributing to ESBL spread. Better reporting of outbreaks may help clarify the role for routine ESBL screening in NICUs.

Pregnancy Outcomes of Mothers with Detectable CMV-Specific IgM Antibodies: A Three-Year Review in a Large Irish Tertiary Referral Maternity Hospital.

A retrospective audit was performed for all obstetric patients who had positive CMV IgM results between January 2012 and December 2014 in the Rotunda Hospital, Ireland. In total, 622 CMV IgM positive tests were performed on samples from 572 patients. Thirty-seven patients had a positive CMV IgM result (5.9%) on the Architect system as part of the initial screening. Three patients were excluded as they were not obstetric patients. Of the 34 pregnant women with CMV IgM positive results on initial screening, 16 (47%) had CMV IgM positivity confirmed on the second platform (VIDAS) and 18 (53%) did not. In the 16 patients with confirmed positive CMV IgM results, four (25%) had acute infection, two (12.5%) had infection of uncertain timing, and ten (62.5%) had infection more than three months prior to sampling as determined by the CMV IgG avidity index. Two of the four neonates of women with low avidity IgG had CMV DNA detected in urine. Both these cases had severe neurological damage and the indication for testing their mothers was because the biparietal diameter (BPD) was less than the 5th centile at the routine 20-week gestation anomaly scan.

Challenges in the management of Neisseria gonorrhoeae keratitis.

We describe the presentation and subsequent management of a case of keratitis caused by Neisseria gonorrhoeae. A thirty-nine year old gentleman presented with a purulent ocular discharge. Corneal melt with corneal perforation occurred. Neisseria gonorrhoeae was cultured. Systemic and topical antibiotics were given. Deep lamellar keratoplasty was performed for corneal perforation. At three months post treatment no recurrence of infection was noted. The possibility of Neisseria gonorrhoeaea keratitis should always be considered in patients with a purulent ocular discharge even if the case history is not immediately suggestive of the same. Severe gonococcal keratitis may be unilateral. Deep lamellar keratoplasty can be considered as a therapeutic option in patients with severe gonococcal keratitis.