Meeting the Consultation Surge: A Nationwide Survey of Consult Volume and Mitigation Strategies in Infectious Diseases Fellowship Programs.

High patient volume in fellowship programs can affect learning, wellness, and patient outcomes. Training programs must find ways to mitigate high consultation volume to protect the learning environment. This survey describes average new consults and average censuses for infectious diseases training programs and strategies implemented to mitigate high volume.

High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for Infectious Diseases Training Programs.

The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area.

Sequential dosing of convalescent COVID-19 plasma with significant temporal clinical improvements in a persistently SARS-COV-2 positive patient.

The current global pandemic, SARS-CoV-2 infection, is still extending across the world affecting millions of lives to the date. While new successful vaccines are available with promising outcomes to minimize the spread and to reduce the severity of the disease, optimal therapeutic options still remain elusive. COVID-19 convalescent plasma (CCP) is an investigational treatment option which studies suggesting signals of efficacy and favorable outcomes only for patients treated very early in course of the disease. Benefits of the use of CCP later in the disease remain highly debated and therefore are not common practice. We hereby report a case of severe SARS-CoV-2 infection in a young male patient with prolonged COVID-19 positivity who received repeat doses of CCP treatments later in the disease with temporal clinical improvement. This patient's case highlights the need of further studies evaluating efficacy of repeated dosing of CCP. This also suggests a potential of successful use of CCP later in the disease in selected COVID-19 patients.

OXA-23 and OXA-40 producing carbapenem-resistant Acinetobacter baumannii in Central Illinois.

We reviewed susceptibility of 840 A. baumannii complex isolates at two academic medical centers and explored their mechanism of carbapenem resistance. Carbapenem resistance rates among A. baumannii increased from <5% before 2005 to 55% in 2011 and declined thereafter. We subjected 86 isolates for further antibiotic susceptibility testing using E-test, screened for MBL and carbapenemase production, and performed PCR for blaOXA genes. Statistical analyses included correlation of resistance genes with susceptibility. Sixty-one isolates were non-susceptible to carbapenems (MIC >2 µg/mL). Phenotypic screening showed carbapenemase production in 50 isolates, but none was positive for MBL. Among carbapenem non-susceptible isolates, the CHDL (group D carbapenemase) encoding genes blaOXA-23 (52%) and blaOXA-40 (28%) were the most frequent genes. In conclusion, carbapenem resistance rates in A. baumannii peaked in 2011 and have since declined in our region. Carbapenem resistance among A. baumannii was primarily associated with production of acquired CHDLs including OXA-23 and OXA-40.

Diagnostic Microbiology from the Beginning to the Future: Regional Antibiograms as Public Health Tools to Slow Down Antibiotic Resistance.

Infectious diseases is the only area of medicine where we can isolate the cause and study it in the laboratory under conditions similar to human body. Once isolated, we are able to determine the most optimal drug to treat it. Unfortunately, it is also the only specialty where after making truly wondrous strides we find ourselves at the crossroads of a public health crisis in the form of ongoing antibiotic resistance. Among the factors responsible for the current status, is the suboptimal utilization of the diagnostic microbiology laboratory. In this review authors provide a short historical perspective of diagnostic microbiology. The focus of discussion is the generation and utilization of cumulative antibiograms at the institutional and regional levels and discuss the pitfalls in large national databases with respect to the day-to-day patient care. This public health tool to slow down antibiotic resistance happens to be low-tech and inexpensive.

Empyema Necessitans in the Setting of Methicillin-Susceptible Staphylococcus aureus Causing Pneumonia and Bacteremia.

Empyema necessitans (EN) is a rare phenomenon that refers to an insidious extension of the empyema through parietal pleura and subsequent dissection into subcutaneous tissue of the chest wall. A 29-year-old man presented to the hospital with fever and chills a few days after an inadvertent needle stick while injecting heroin. His left forearm was warm with an area of fluctuance. He underwent incision and drainage of the left forearm abscess with fluid submitted for Gram stain and culture. His condition rapidly deteriorated due to sepsis, and he required transfer to the intensive care unit. A new 4 × 3 cm area over the left pectoralis muscle had become increasingly indurated, fluctuant, and erythematous. CT of the chest demonstrated extensive cavitary lung lesions and a large loculated left-sided pleural effusion with extension through the chest wall. TEE revealed a 3 cm complex lesion on the superior septal leaflet of the tricuspid valve. The patient underwent incision and drainage of the pectoralis major EN with placement of a drain. Blood and sputum cultures grew methicillin-susceptible Staphylococcus aureus (MSSA) at which time antibiotic therapy was tailored to oxacillin. Our case highlights a rare occurrence of EN due to MSSA in a patient with intravenous drug use (IDU) and underscores the importance of prompt diagnosis and treatment.

Immunotherapies in infectious diseases.

The development of an infection involves interplay between the host's immune system and the virulence of the infecting microorganism. The traditional treatment of an infection involves antimicrobial chemotherapy to kill the organism. The use of immunotherapies in infections includes treatment options that modulate the immune response and can lead to control of infections. These therapies are expected to become more important therapeutic options with the increase in infections due to multidrug-resistant organisms and the increasing number of immunocompromised patients.

Antibacterial properties of additives used in injection immunotherapy.

BACKGROUND: Previous studies have reviewed the safety of preparing and administering allergy injection immunotherapy in a physician's office, and showed no evidence of infectious complications. The current study examines the antimicrobial properties of the common additives used in preparation of multidose immunotherapy vials. METHODS: Vials were prepared with varying concentrations of glycerin (0-25%), phenol (0-0.4%) and combinations of glycerin with phenol. A standard inoculum of Staphylococcus aureus was introduced in each vial and incubated. Optical densities were measured and colony counts were performed at 24 and 48 hours. Follow-up broth microdilution assays were performed using varying inocula of bacteria and the highest concentrations of additives to determine the number of bacteria for which these solutions were bacteriostatic and/or bactericidal. Optical densities were measured and colony counts were performed as in the vial assays. RESULTS: All vials with varying dilutions of glycerin, phenol, and their combination showed bacterial growth with the standard inoculum of Staphylococcus aureus. Visible turbidity and optical density were inversely related to additive concentration. Follow-up microdilution assays with differing concentrations of bacteria demonstrated bactericidal activity with inocula of 1 × 10(3) colony forming units (CFU) of Staphylococcus aureus at clinically used concentrations of glycerin and phenol. CONCLUSION: Higher concentrations of additives show better inhibition of bacterial growth. Solutions containing glycerin showed superior bactericidal activity than those containing only phenol. At concentrations of additives used in preparing allergy immunotherapy vials, antibacterial effects were observed with inoculation of 1 × 10(3) CFU or less of Staphylococcus aureus.

Mycobacteria and biological response modifiers: two sides of the relationship.

With increasing use of biological response modifiers (BRMs) for various systemic inflammatory diseases there is a need to be vigilant about complications with the use of these therapies. It is important to have appropriate screening for the infections in patients requiring BRMs. However, many studies have reported benefits of certain BRMs in the treatment of infections such as tuberculosis as adjuncts. Continued research and technical advances in immunogenetics helps understand complex mechanisms in the usage of the BRMs. This article summarizes the different aspects of the relationship between mycobacterial infections and the use of various BRMs for inflammatory conditions.

Characterization of macrophage activation states in patients with cystic fibrosis.

BACKGROUND: Chronic airway inflammation characterizes patients with cystic fibrosis (CF). The role of alternative macrophage activation in this disease course is unknown. OBJECTIVE: We evaluated markers of alternative and classical macrophage activation in the lungs of patients with CF and evaluated these characteristics in the context of Pseudomonas aeruginosa (PA) infection, immunomodulatory drug therapy and pulmonary function. METHODS: Bronchoalveolar lavage or spontaneously expectorated sputum samples were collected from 48 CF patients. Clinical data were related to macrophage surface expression of mannose receptor (MR) (up-regulated in alternatively activated macrophages) and TLR4 (up-regulated in classically activated macrophages). Also, the activity of the alternatively activated macrophage effector molecule arginase was compared among patient groups, and pro- and anti-inflammatory cytokines produced by alternatively and classically activated macrophages were measured. RESULTS: There were significant differences between PA-infected and -uninfected patients in several clinical measurements. PA-infected patients exhibited increased use of azithromycin, up-regulation of MR on CD11b+ cells and increased arginase activity in their lung samples, and had a strong inverse relationship between MR and arginase activity to FEV(1). Upon further analysis, PA-infected patients who were treated with azithromycin had the highest arginase activity and the highest number of macrophages that were MR+TLR4-, and both of these markers were inversely related to the FEV(1). CONCLUSIONS: Our findings suggest an increase in both MR and arginase expression as pulmonary function declines in PA-infected patients with CF. These markers of an alternatively activated macrophage phenotype give cause for future study to define the function of macrophage activation states in the CF lung.

Azithromycin alters macrophage phenotype.

OBJECTIVES: To investigate the in vitro effects of azithromycin on macrophage phenotype. Utilizing a mouse macrophage cell line (J774), we examined the effect of azithromycin on the properties that define classical macrophage activation (M1) and alternative macrophage activation (M2). METHODS: J774 cells were cultured in the presence of azithromycin and stimulated with classical activation [interferon-gamma (IFNgamma)] and alternative activation [interleukin (IL)-4 and IL-13] cytokines along with lipopolysaccharide (LPS). Macrophages were analysed for inflammatory cytokine production, surface receptor expression, inducible nitric oxide synthase (iNOS) protein expression and arginase activity. RESULTS: Azithromycin altered the overall macrophage phenotype. Azithromycin-treated J774 macrophages demonstrated a significantly reduced production of the pro-inflammatory cytokines IL-12 and IL-6, increased production of the anti-inflammatory cytokine IL-10 and decreased the ratio of IL-12 to IL-10 by 60%. Receptor expression indicative of the M2 phenotype (mannose receptor and CD23) was increased, and receptor expression typically up-regulated in M1 cells (CCR7) was inhibited. The presence of azithromycin increased arginase (M2 effector molecule) activity 10-fold in cells stimulated with IFNgamma and LPS, and iNOS protein (M1 effector molecule) concentrations were attenuated by the drug. CONCLUSIONS: These data provide evidence that azithromycin affects the inflammatory process at the level of the macrophage and shifts macrophage polarization towards the alternatively activated phenotype. This recently defined M2 phenotype has been described in conditions in which pulmonary inflammation and fibrosis are major determinants of clinical outcome, but the concept of antibiotics altering macrophage phenotype has not yet been critically evaluated.