Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment.

PURPOSE OF REVIEW: The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF). RECENT FINDINGS: NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery. SUMMARY: Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.

Mucormycosis: A 14-Year Retrospective Study from a Tertiary Care Center in Lebanon.

Mucormycosis (MCM) is a serious invasive fungal disease (IFD) that is associated with high mortality, particularly in immunocompromised patients. A global surge in MCM cases was reported with the COVID-19 pandemic. We analyzed all recorded cases of MCM at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, over 14 years. We aimed to identify the incidence, seasonal variation, clinical characteristics of the patients, and predictors of mortality. We conducted a retrospective chart review between 1 January 2008 and 1 January 2023. All patients with proven or probable MCM were included in the study. Proven or probable MCM was defined by positive histopathology and/or positive cultures. A total of 43 patients were identified as having MCM. Their median age was 53 years, and the majority were males (58.1%). Most of the cases were diagnosed in the autumn season. In total, 67.4% of the patients had hematological malignancies (HMs), and 34.9% had uncontrolled diabetes mellitus (DM). The most common site of involvement was rhino-orbital-cerebral MCM (ROCM) (74%). The annual cases of MCM per 100,000 patient days increased markedly during the years of the COVID-19 pandemic (from 0 to 4.4 cases/100,000 patient days to 7.5 cases/100,000 during 2020 and 2021). Liposomal amphotericin (Ampho) B was used as a first-line agent in most of the patients (86%). The median duration of total in-hospital antifungal therapy was 21 days and 51.2% of the patients received step-down therapy with azoles. Surgical debridement and isolated ROCM were significantly associated with survival (p-value: 0.02 and <0.001, respectively). All-cause mortality was 46.7%, with chronic renal disease being significantly associated with mortality (p-value < 0.05). The incidence of MCM has been increasing at our institution, particularly since the COVID-19 pandemic. Early diagnosis, treatment, and surgical debridement improve patient outcomes and overall survival.

Salmonella typhimurium necrotizing fasciitis: a case report.

BACKGROUND: Necrotizing fasciitis is an aggressive disease that causes necrosis in the muscular fascia and subcutaneous tissues. The infection spreads rapidly along the fascia and perifascial planes, followed by extension of the infection to nearby soft tissues and muscles. Necrotizing fasciitis can be attributed to different pathogens, namely Staphylococcus aureus, group A streptococci, and Clostridium perfringes. Only a few cases of skin and soft tissue infections from Salmonella species have been reported to date. Herein we report a case of Salmonella non-typhi necrotizing fasciitis, an exceedingly rare entity. This case report may serve as a potential management plan in similar cases in light of the scarcity of evidence. CASE PRESENTATION: A 20-year-old Caucasian male patient with congenital cardiac anomaly presented with diarrhea and unilateral lower extremity cellulitis causing septic shock. Cultures from blood and the bullae associated with the lower extremity cellulitis grew Salmonella typhimurium. Surgical debridement was performed. Intraoperative tissue cultures were positive for Salmonella typhimurium, and surgical pathology confirmed the diagnosis of necrotizing fasciitis. After a total of 6 weeks of appropriate antimicrobial therapy, another surgical debridement was executed for poor wound healing. New intraoperative cultures grew Fusarium species, and the patient received voriconazole with an adequate response. Immunologic studies showed humoral and cellular immunodeficiency. CONCLUSION: It is important to maintain a high index of suspicion for rare entities that can cause skin and soft tissue infections, such as Salmonella non-typhi, in particular in immunosuppressed patients where a delay in diagnosis and management may have significant morbidity and mortality.

Management of cytomegalovirus infection in allogeneic hematopoietic stem cell transplants.

Cytomegalovirus (CMV) is a common infection encountered in immunocompromised patients. It is associated with high morbidity and mortality, particularly in patients undergoing allogeneic (allo-) haematopoietic stem cell transplantation (HSCT). This review presents the most recent management strategies for CMV infection in allo-HSCT recipients. Pre-emptive treatment (PET) consists of frequent monitoring of CMV polymerase chain reaction (PCR) after HSCT; this has been the standard of care for prevention of CMV for many years, given the potential drug toxicity associated with the traditional drugs used as prophylaxis. However, letermovir, recently approved as a chemoprophylactic agent for prevention of CMV, has shown great efficacy in randomized clinical trials and real-world data. Treatment of CMV disease is becoming increasingly difficult, and must take into account the patient's risk profile and the potential for CMV drug resistance. Different treatment strategies exist for refractory and resistant CMV disease. Maribavir is a new drug that showed promising results in the treatment of refractory and resistant CMV disease. Other alternative treatments, such as cellular adoptive immunotherapy, artesunate and leflunomide, may play an adjunctive role in the treatment of challenging cases; however, further investigation is warranted.

Infective Endocarditis after Transcatheter Aortic Valve Replacement: Challenges in the Diagnosis and Management.

Although initially conceived for high-risk patients who are ineligible for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) is now recommended in a wider spectrum of indications, including among young patients. However, similar to SAVR, TAVR is also associated with a risk of infectious complications, namely, prosthetic valve endocarditis (PVE). As the number of performed TAVR procedures increases, and despite the low incidence of PVE post-TAVR, clinicians should be familiar with its associated risk factors and clinical presentation. Whereas the diagnosis of native valve endocarditis can be achieved straightforwardly by applying the modified Duke criteria, the diagnosis of PVE is more challenging given its atypical symptoms, the lower sensitivity of the criteria involved, and the low diagnostic yield of conventional echocardiography. Delay in proper management can be associated with increased morbidity and mortality. Therefore, clinicians should have a high index of suspicion and initiate proper work-up according to the severity of the illness, the underlying host, and the local epidemiology of the causative organisms. The most common causative pathogens are Gram-positive bacteria such as Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp., and Streptococcus spp. (particularly the viridans group), while less-likely causative pathogens include Gram-negative and fungal pathogens. The high prevalence of antimicrobial resistance complicates the choice of therapy. There remain controversies regarding the optimal management strategies including indications for surgical interventions. Surgical assessment is recommended early in the course of illness and surgical intervention should be considered in selected patients. As in other PVE, the duration of therapy depends on the isolated pathogen, the host, and the clinical response. Since TAVR is a relatively new procedure, the outcome of TAVR-PVE is yet to be fully understood.

Community-acquired skin and soft-tissue infections in people who inject drugs.

PURPOSE OF REVIEW: The aim of this review is to discuss the latest evidence of the epidemiology, microbiology, risk factors, diagnosis and management of community-acquired skin and soft tissue infections (SSTIs) in people who inject drug (PWID). RECENT FINDINGS: SSTIs are common complications in PWID and a major cause of morbidity and mortality. Infections can range from uncomplicated cellulitis, to abscesses, deep tissue necrosis and necrotizing fasciitis. They are predominantly caused by Gram-positive pathogens in particular Staphylococcus aureus and Streptococcus species; however, toxin-producing organisms such as Clostridium botulism or Clostridium tetani should be considered. The pathogenesis of SSTI in the setting of intravenous drug use (IDU) is different from non-IDU related SSTI, and management often requires surgical interventions in addition to adjunctive antibiotics. Harm reduction strategies and education about safe practices should be implemented to prevent morbidity and mortality as well as healthcare burden of SSTI in PWID. SUMMARY: Prompt diagnosis and proper medical and surgical management of SSTI will improve outcomes in PWID.

The Ten Most Common Questions on Cytomegalovirus Infection in Hematopoietic Stem Cell Transplant Patients.

With the rising number of patients undergoing hematopoietic stem cell transplantation (HSCT), clinicians are more likely to encounter infectious complications in immunocompromised hosts, particularly cytomegalovirus (CMV) infection. Besides the high mortality of CMV end-organ disease, patients with detectable CMV viremia may have worse outcomes and decreased survival even in the absence of end-organ disease. In view of the implications on morbidity and mortality, clinicians should maintain a high index of suspicion and initiate antiviral drugs promptly when CMV infection is confirmed. High-risk patients should be identified in order to provide optimal management. Additionally, novel antiviral agents with a good safety profile and minor adverse events are now available for prophylaxis in high-risk patients and for treatment of resistant or refractory CMV infection. The following review provides concise, yet comprehensive, guidance on the burden and risk factors of CMV in this population, as well as an update on the latest evidence for the management of CMV infection.

Correction: Human monkeypox: A review of the literature.

[This corrects the article DOI: 10.1371/journal.ppat.1010768.].

Human monkeypox: A review of the literature.

Monkeypox (MPX) has recently made international headlines for the rapid and simultaneous progression of the disease across the world. This review aims at summarizing the literature available as well as describing the evolution of the disease as it pertains to the cases today along with potential treatments and infection control strategies. To date, more than 76 countries have reported cases in more than 12,261 people. Before this, MPX was a rare zoonotic disease confined to endemic areas in Western and Central Africa with sporadic outbreaks namely in the United States, associated with the import of wild animals from Ghana. However, during the current outbreak, human-to-human transmission has become the primary mode of transmission, raising concerns for unaccounted community spread. Most of these patients did not travel to the endemic areas of Africa, suggesting possible previously underdetected community transmission. Observations from emergent cases have reported that the manifestations of the disease were sometimes atypical from what has been previously described. Young men who have sex with men seem to be the population most vulnerable to infection. Though the disease is currently perceived to be mild in its clinical course, questions that remain unclear and warrant further investigation include potential of humans harboring a genital reservoir of the virus and the possibility of airborne transmission, which has implications for infection control and health of the community at large.

Duration of antibiotic therapy in Gram-negative infections with a particular focus on multidrug-resistant pathogens.

PURPOSE OF REVIEW: Antimicrobial overuse is a major health problem that contributes to antimicrobial resistance (AMR). Infections with Gram-negative bacilli (GNB) and multidrug-resistant organisms (MDRs) are associated with high morbidity and mortality, particularly in patients with underlying medical conditions. RECENT FINDINGS: Although many recent studies have been published about the novel antibiotics in treating infections including those due to MDR-GNB, the optimal duration of treatment (DOT) remains inconclusive. Recent observation has supported that short antibiotic therapy (SAT) decreases AMR and adverse effects. This narrative review provides an overview of the most recent published studies on the duration of therapy in the treatment of GNB infections, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), intra-abdominal infections (IAIs), bloodstream infections (BSIs) and urinary tract infections (UTIs), with a particular focus on MDR-GNB. SUMMARY: Studies showed different outcomes when comparing SAT to long antimicrobial therapy (LAT). No generalization can be made on all sites of infections and different GNBs. Further studies are needed to address the optimal DOT in MDR-GNB, as this group is underrepresented in recent studies.

COVID-19 and C. auris: A Case-Control Study from a Tertiary Care Center in Lebanon.

Many healthcare centers around the world have reported the surge of Candida auris (C. auris) outbreaks during the COVID-19 pandemic, especially among intensive care unit (ICU) patients. This is a retrospective study conducted at the American University of Beirut Medical Center (AUBMC) between 1 October 2020 and 15 June 2021, to identify risk factors for acquiring C. auris in patients with severe COVID-19 infection and to evaluate the impact of C. auris on mortality in patients admitted to the ICU during that period. Twenty-four non-COVID-19 (COV−) patients were admitted to ICUs at AUBMC during that period and acquired C. auris (C. auris+/COV−). Thirty-two patients admitted with severe COVID-19 (COV+) acquired C. auris (C. auris+/COV+), and 130 patients had severe COVID-19 without C. auris (C. auris−/COV+). Bivariable analysis between the groups of (C. auris+/COV+) and (C. auris−/COV+) showed that higher quick sequential organ failure assessment (qSOFA) score (p < 0.001), prolonged length of stay (LOS) (p = 0.02), and the presence of a urinary catheter (p = 0.015) or of a central venous catheter (CVC) (p = 0.01) were associated with positive culture for C. auris in patients with severe COVID-19. The multivariable analysis showed that prolonged LOS (p = 0.008) and a high qSOFA score (p < 0.001) were the only risk factors independently associated with positive culture for C. auris. Increased LOS (p = 0.02), high "Candida score" (p = 0.01), and septic shock (p < 0.001) were associated with increased mortality within 30 days of positive culture for C. auris. Antifungal therapy for at least 7 days (p = 0.03) appeared to decrease mortality within 30 days of positive culture for C. auris. Only septic shock was associated with increased mortality in patients with C. auris (p = 0.006) in the multivariable analysis. C. auris is an emerging pathogen that constitutes a threat to the healthcare sector.

First Candida auris Outbreak during a COVID-19 Pandemic in a Tertiary-Care Center in Lebanon.

Candida auris is an emerging fungal pathogen considered as a global health threat. Recently there has been growing concern regarding drug resistance, difficulty in identification, as well as problems with eradication. Although outbreaks have been reported throughout the globe including from several Arab countries, there were no previous reports from Lebanon. We herein report the first cases of C. auris infection from the American University of Beirut Medical Center, a tertiary care center in Lebanon describing the clinical features of the affected patients in addition to the infection control investigation and applied interventions to control the outbreak. Fourteen patients with C. auris infection/colonization identified using MALDI-TOF and VITEK 2- Compact system were reported over a period of 13 weeks. Patients were admitted to four separate critical care units. All of them came through the emergency room and had comorbid conditions. Half of the patients were infected with COVID-19 prior to isolation of the C. auris. C. auris was isolated from blood (two isolates), urine (three isolates), respiratory tract (10 isolates) and skin (one isolate). All the patients had received broad spectrum antibiotics prior to isolation of C. auris. Six patients received antifungal treatment, while the remaining eight patients were considered colonized. Environmental cultures were taken from all four units and failed to isolate the organism from any cultured surfaces. A series of interventions were initiated by the Infection Prevention and Control team to contain the outbreak. Rapid detection and reporting of cases are essential to prevent further hospital transmission. A national standardized infection control registry needs to be established to identify widespread colonization.

Effect of Vitamin D Deficiency on Voice.

PURPOSE: The purpose of this article was to investigate the relationship between low level of vitamin D, phonatory symptoms, and acoustic findings. METHOD: A total of 38 subjects presenting to the endocrinology clinic were enrolled in 2 groups: 19 with vitamin D deficiency who were not on treatment, and 19 with normal vitamin D level who were on treatment. Demographic data included age, gender, and history of smoking. All patients were asked about the presence or absence of dysphonia, degree of phonatory effort, and vocal fatigue. Acoustic analysis and perceptual evaluation using the grade, roughness, breathiness, asthenia, and strain scale were performed on all subjects. RESULTS: The mean age of the total group was 47.29 ± 13.52 years. The difference in the mean and frequency of phonatory effort, vocal fatigue, and dysphonia, and in the mean of the acoustic variables, perceptual parameters, and the score of the Voice Handicap Index-10 was not statistically significant between patients with low vitamin D levels compared with controls. CONCLUSION: The results of this study revealed no significant difference in the prevalence of phonatory symptoms in patients with vitamin D deficiency compared with patients with no vitamin D deficiency. A larger study is needed to substantiate the difference in the prevalence of phonatory systems between the 2 groups.