Polymicrobial Prosthetic Valve Endocarditis Due to Neisseria gonorrhoeae and Pseudomonas fluorescens in a Patient With Tetralogy of Fallot: A Case Report.

Disseminated gonococcal infections are rare clinical entities and a few progress to endocarditis. Endocarditis caused by Pseudomonasis even more infrequent, with the few reported cases associated with either intravenous drug use, prosthetic heart valves, or pacemakers. We report a case of a 25-year-old male patient with Tetralogy of Fallot presenting with anasarca and diagnosed with endocarditis due to Neisseria gonorrhoeae and Pseudomonas fluorescens. To our knowledge, this is the first case of tissue-proven infective endocarditis due to P. fluorescens with concomitant N. gonorrhoeae bacteremia. Clinical management of polymicrobial endocarditis in young adults includes obtaining a detailed sexual history, using multiple diagnostic methods to confirm endocarditis, and promptly initiating broad-spectrum antibiotic therapy.

Pasteurella Cerebral Mycotic Aneurysm: A Case Report and Review of the Literature.

Pasteurella species (spp.) are pleomorphic, Gram-negative, facultatively anaerobic bacilli commonly found in the upper respiratory tract and oral cavities of wild and domesticated animals such as dogs and cats. Pasteurella spp. infections in humans are typically caused by animal bites or scratches, or other inadvertent exposure of an open skin lesion to oral secretions of the animal. While skin and soft tissue infections are relatively common, respiratory infections, endocarditis, osteomyelitis, meningitis, and mycotic aneurysms have also been documented. To date, nine cases of mycotic aneurysms caused by Pasteurella spp. have been reported. However, only one of those cases has involved a cerebral mycotic aneurysm, and it had a fatal outcome. This report describes a successfully managed Pasteurella cerebral mycotic aneurysm that had occurred as a complication of underlying mitral valve endocarditis.

Mycobacterium abscessus exit-site infection in peritoneal dialysis patients: should we ever aim to salvage the catheter?

Improvements in the exit-site care for peritoneal dialysis (PD) patients have uncovered a trend for increasing incidence of rapidly growing nontuberculous mycobacterium exit-site infections (ESI). Among these, Mycobacterium abscessus is unique in terms of its high morbidity and treatment failure rates. The international society of PD guidelines encourage PD catheter removal in patients with M. abscessus peritonitis but, do not have evidence-based recommendations for the management of ESIs related to this organism. We report an unusual case in which an asymptomatic end-stage renal disease patient with multiple favorable clinical characteristics, i.e., no apparent immunodeficiency, sensitivity pattern showing possibility of treatment with multiple antibiotics, no evidence of peritonitis, and early clinical response, was treated with a 9-month combination antimicrobial regimen administered orally and intraperitoneally. Despite excellent clinical response with a resolution of the ESI, our patient relapsed quickly, within 30 days of stopping antimicrobial therapy and required PD catheter removal. Our case, taken together with available published case reports, highlights the futility of the conservative approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.

Disseminated Nocardia beijingensis Masquerading as Pulmonary Tuberculosis in a Patient With Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome.

Case of disseminated Nocardia beijingensis, initially diagnosed and treated by health department as tuberculosis, presented with worsening symptoms and new lesions. Adjustment to antinocardial treatment resulted in significant clinical and radiographic improvement. Maintain a high index of suspicion for Nocardia in patients diagnosed with tuberculosis with worsening lesions despite therapy.

Chloroquine and hydroxychloroquine in the context of COVID-19.

Chloroquine and closely related structural analogs, employed initially for the treatment of malaria, are now gaining worldwide attention due to the rapidly spreading pandemic caused by severe acute respiratory syndrome-coronavirus-2, named coronavirus disease (COVID) of 2019 (COVID-19). Although much of this attention has a mechanistic basis, the hard efficacy data for chloroquine/hydroxychloroquine in the management of the clinical syndrome of COVID-19 have been limited thus far. This review aims to present the available in vitro and clinical data for the role of chloroquine/hydroxychloroquine in COVID-19 and attempts to put them into perspective, especially in relation to the different risks/benefits particular to each patient who may require treatment.

Rat bite as a cause of diabetic foot ulcer in sub-Saharan Africa.

There have been relatively few reports of foot ulcers in diabetes resulting from rat bite. The findings were derived from people attending a single specialist service in Dar es Salaam for diabetic foot ulcers (DFUs) between 1 January 1999 and 31 December 2016. Details from people presenting for the first time with an ulcer judged to be caused by rat bite were compared with those with from other causes of foot ulcer. There were 426 first recorded foot ulcer episodes (in 179 people) judged to be caused by rat bite. The affected population was significantly younger (mean 55.9 vs 57.5 years, P = .037) and had a lower body mass index (26.5 vs 27.9, P = .008) than controls with other types of foot ulcer. They also presented significantly sooner (7.8 vs 18.2 days, P < .001) and were more likely to heal (85.8 vs 5.5%, P < .001), even though there was also a trend towards an increased risk of death (9.1% vs 5.3%, P = .032). Rat bite is an uncommon cause of DFU, but is not rare. Although the incidence of ulcer healing is higher than in a general foot ulcer population, the incidence of death is also higher.

Outbreak of Acinetobacter baumannii associated with extrinsic contamination of ultrasound gel in a tertiary centre burn unit.

BACKGROUND: During 2011 and 2012, an increase in occurrence of multidrug-resistant Acinetobacter baumannii infections was recorded in the Shands Hospital Burn Intensive Care Unit (BICU). An epidemic curve together with strain typing was consistent with an intermittent common source outbreak. An investigation was therefore initiated. AIM: To identify risk factors for A. baumannii infection, characterize the source of the pathogen, implement control measures to terminate the outbreak, and institute preventive measures. METHODS: We conducted a retrospective case-control study; reviewed BICU infection control policies, practices and procedures, and patient exposure to healthcare workers (HCWs), and obtained epidemiologically-directed environmental cultures. FINDINGS: Eleven patients met the case definition. On multivariate analysis, case-patients were more likely to have undergone an ultrasound procedure in the BICU (adjusted odds ratio [AOR]: 19.5; confidence interval [CI]: 2.4-435) or have a FlexiSeal™ device (AOR: 11.9, CI:1.3-276). Epidemiologically-directed cultures of the environment, ultrasound equipment, and ultrasound gel from opened containers on the ultrasound trolley and in the Ultrasound Department were negative for the outbreak pathogen. Culture of an open ultrasound gel dispenser stored in the Ultrasound Department yielded an A. baumannii strain with DNA banding patterns identical to the outbreak strain. CONCLUSIONS: Based on data from our epidemiologic, microbiologic, and observational studies, we believe that inadvertent extrinsic contamination of the gel dispenser occurred in the Ultrasound Department. Contaminated gel was then dispensed into multiuse vials of gel stored on the mobile carts. The outbreak was stemmed by instituting changes in practices in the Ultrasound Department, including introduction of single-use ultrasound vials and storage of ultrasound gel.

When is pneumonia not pneumonia: a clinicopathologic study of the utility of lung tissue biopsies in determining the suitability of cadaveric tissue for donation.

Healthcare-associated pneumonia (HCAP) represents a major diagnostic challenge because of the relatively low sensitivity and specificity of clinical criteria, radiological findings, and microbiologic culture results. It is often difficult to distinguish between pneumonia, underlying pulmonary disease, or conditions with pulmonary complications; this is compounded by the often-subjective clinical diagnosis of pneumonia. We conducted this study to determine the utility of post-mortem lung biopsies for diagnosing pneumonia in tissue donors diagnosed with pneumonia prior to death. Subjects were deceased patients who had been hospitalized at death and diagnosed with pneumonia. Post-mortem lung biopsies were obtained from the anatomic portion of the cadaveric lung corresponding to chest radiograph abnormalities. Specimens were fixed, stained with hematoxylin and eosin, and read by a single board-certified pathologist. Histological criteria for acute pneumonia included intense neutrophilic infiltration, fibrinous exudates, cellular debris, necrosis, or bacteria in the interstitium and intra-alveolar spaces. Of 143 subjects with a diagnosis of pneumonia at time of death, 14 (9.8 %) had histological evidence consistent with acute pneumonia. The most common histological diagnoses were emphysema (53 %), interstitial fibrosis (40 %), chronic atelectasis (36 %), acute and chronic passive congestion consistent with underlying cardiomyopathy (25 %), fibro-bullous disease (12 %), and acute bronchitis (11 %). HCAP represents a major diagnostic challenge because of the relatively low sensitivity and specificity of clinical criteria, radiological findings, and microbiologic testing. We found that attending physician-diagnosed pneumonia did not correlate with post-mortem pathological diagnosis. We conclude that histological examination of cadaveric lung tissue biopsies enables ascertainment or rule out of underlying pneumonia and prevents erroneous donor deferrals.

Cronobacter Species Contamination of Powdered Infant Formula and the Implications for Neonatal Health.

Cronobacter is a class of Enterobacteriaceae that cause infections in neonates, especially those born prematurely. Over 90% of these infections have been linked epidemiologically to powdered infant formula (PIF). Contamination of PIF can occur at manufacture, reconstitution, or storage of reconstituted product. Intrinsic properties that enable Cronobacter to cause disease include resistance to heat, ultraviolet radiation, oxygen radicals, stomach acids, and pasteurization; an ability to utilize sialic acid (a nutrition additive to PIF that facilitates the organism's growth and survival), and an exceptional affinity for biofilms in enteral feeding tubes. As part of ongoing endeavors to reduce the incidence of neonatal PIF-associated Cronobacter infections, the World Health Organization and the US Food and Drug Administration have established guidelines for PIF production, preparation for infant feeding, and storage of reconstituted product.

What we don't know may hurt us: urinary drainage system tubing coils and CA-UTIs-A prospective quality study.

Catheter-associated urinary tract infections account for >30% of infections in acute care hospitals. We hypothesized that coiling of/kinks in the indwelling urinary bladder catheter (IUBC) drainage bag tubing would increase the occurrence of infection/bacteriuria. Ninety-one patient events were evaluated over 60 days. All outcome variables trended with greater frequency among those with a coil in the IUBC tubing; only fever (temperature > 38.1°C) correlated significantly between groups (P = .003). If IUBC is unavoidable, strategies such as keeping collection bag below the level of bladder and avoiding any coiling in the drainage system should be employed. Further study of these phenomena is needed.

Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution.

OBJECT: Ventricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated. METHODS: A best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period. RESULTS: At the authors' institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation. CONCLUSIONS: Bundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.

Reducing ventriculostomy-related infections to near zero: the eliminating ventriculostomy infection study.

Implementation of a standard protocol and use of antibiotic-coated ventricular catheters helped reduce EVD-related infections from 9.2% to almost zero at the University of Florida. This project demonstrated the success of creating a task force to identify areas of improvement, implement solutions, and monitor the outcomes.

The effect of increased mobility on morbidity in the neurointensive care unit.

OBJECT: The detrimental effects of immobility on intensive care unit (ICU) patients are well established. Limited studies involving medical ICUs have demonstrated the safety and benefit of mobility protocols. Currently no study has investigated the role of increased mobility in the neurointensive care unit population. This study was a single-institution prospective intervention trial to investigate the effectiveness of increased mobility among neurointensive care unit patients. METHODS: All patients admitted to the neurointensive care unit of a tertiary care center over a 16-month period (April 2010 through July 2011) were evaluated. The study consisted of a 10-month (8025 patient days) preintervention observation period followed by a 6-month (4455 patient days) postintervention period. The intervention was a comprehensive mobility initiative utilizing the Progressive Upright Mobility Protocol (PUMP) Plus. RESULTS: Implementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300% (p < 0.0001). Initiation of this protocol also correlated with a reduction in neurointensive care unit length of stay (LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneumonias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05). Additionally, increased mobility did not lead to increases in adverse events as measured by falls or inadvertent line disconnections. CONCLUSIONS: Among neurointensive care unit patients, increased mobility can be achieved quickly and safely with associated reductions in LOS and hospital-acquired infections using the PUMP Plus program.

The utility of Gram stains and culture in the management of limb ulcers in persons with diabetes.

In Tanzania, limited laboratory services often preclude routine identification of microorganisms that cause infections in persons with diabetes. Thus, we carried out this study to determine the utility of a Gram stain alone versus culture in guiding appropriate antimicrobial therapy. During February 2006 to December 2007 (study period), deep tissue biopsies were obtained from persons with diabetes presenting to the Muhimbili National Hospital (MNH) with infected limb ulcers. Specimens were Gram-stained then cultured for bacteria and fungi. Biopsies were obtained from 128 patients. Of 128 cultures, 118 (92%) yielded bacterial or fungal growth; 59 (50%) of these 118 cultures yielded mixed growth (80% included Gram-negative organisms); 38 (32%) and 20 (17%) yielded Gram-negative and Gram-positive organisms alone, respectively. The predictive value positive of a Gram stain for bacterial growth was 93% (110/118); a Gram-positive stain was 75% (15/20) predictive of growth of Gram-positive organisms whereas a Gram-negative stain was 82% (31/38) predictive of growth of Gram-negative organisms. In regions with limited resources, a Gram stain of an ulcer biopsy that is carefully procured is largely predictive of the type of microorganism causing infection. Gram staining of deep tissue biopsies might have a potential role to play in the management of infected diabetic limb ulcers.

Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success.

OBJECT: To date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate. METHODS: All patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted. RESULTS: The urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r(2) = 0.79, p < 0.0001). CONCLUSIONS: This single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.

Health care-associated infection outbreak investigations by the Centers for Disease Control and Prevention, 1946-2005.

Since 1946, Centers for Disease Control and Prevention (CDC) personnel have investigated outbreaks of infections and adverse events associated with delivery of health care. CDC Epidemic Intelligence Service officers have led onsite investigations of these outbreaks by systematically applying epidemiology, statistics, and laboratory science. During 1946-2005, CDC Epidemic Intelligence Service officers conducted 531 outbreak investigations in facilities across the United States and abroad. Initially, the majority of outbreaks involved gastrointestinal tract infections; however, in later years, bloodstream, respiratory tract, and surgical wound infections predominated. Among pathogens implicated in CDC outbreak investigations, Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, nonfermentative Gram-negative bacteria, or yeasts predominated, but unusual organisms (e.g., the atypical mycobacteria) were often included. Outbreak types varied and often were linked to transfer of colonized patients or health care personnel between facilities (multihospital outbreaks), national distribution of contaminated products, use of invasive medical devices, or variances in practices and procedures in health care environments (e.g., intensive care units, water reservoirs, or hemodialysis units). Through partnerships with health care facilities and local and state health departments, outbreaks were terminated and lives saved. Data from investigations invariably contributed to CDC-generated guidelines for prevention and control of health care-associated infections.

A point-prevalence study on healthcare-associated infections in Vietnam: public health implications.

During 2008, a point-prevalence survey of healthcare-associated infections (HAIs) was conducted in 36 Vietnamese hospitals. Of 7,571 inpatients, 590 (7.8%) had HAIs, including pneumonia (41.9%) and surgical-site infections (27.5%). Device use was a significant risk factor; gram-negative microorganisms predominated. A national reporting system needs to be established for monitoring HAIs and enhancing patient outcomes.

The 'Step by Step' Diabetic Foot Project in Tanzania: a model for improving patient outcomes in less-developed countries.

Foot complications cause substantial morbidity in Tanzania, where 70% of leg amputations occur in diabetic patients. The Step by Step Foot Project was initiated to train healthcare personnel in diabetic foot management, facilitate transfer of knowledge and expertise, and improve patient education. The project comprised a 3-day basic course with an interim period 1-year of for screening, followed by an advanced course and evaluation of activities. Fifteen centres from across Tanzania participated during 2004-2006 and 12 during 2004-2007. Of 11,714 patients screened in 2005, 4335 (37%) had high-risk feet. Of 461 (11%) with ulcers, 45 (9·8%) underwent major amputation. Of 3860 patients screened during 2006-2007, there was a significant increase in the proportion with ulcers and amputations compared with 2005 (P < 0·001), likely a result of enhanced case finding. During 2005-2008, there was a fall in the incidence of foot ulcers in patient referrals to the main tertiary care centre in Dar es Salaam and a parallel fall in amputation among these referrals. In conclusion, the Step by Step Foot Project in Tanzania improved foot ulcer management for persons with diabetes and resulted in permanent, operational foot clinics across the country. This programme is an effective model for improving outcomes in other less-developed countries.

Diabetic foot ulcers and ethnicity in Tanzania: a contrast between African and Asian populations.

To characterise the role of ethnicity in the occurrence of foot ulcer disease in persons with diabetes, we analysed prospectively collected data for persons attending the diabetes clinic at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania. A case was defined as any adult presenting to MNH with an ulcer at or below the ankle joint during July 1998-June 2005. We documented clinical and epidemiologic characteristics, progress, interventions and outcome. Seven hundred and eight persons met the case definition - 570 (80%) ethnic Africans and 138 (20%) Asian Indians. Ethnic Africans were more likely to present with gangrene (P < 0.01); Indians were more likely to be obese (P < 0.001) or have large vessel disease (P < 0.001). For Africans, intrinsic complications (neuro-ischaemia or macrovascular disease) delayed ulcer healing; for Asian Indians, mode of intervention (e.g. sloughectomy or glycaemic control with insulin or oral agents) determined the same outcome. Indigenous ethnic African and Asian Indian populations with diabetes display contrasting foot ulcer epidemiology. Peripheral vascular disease and gangrene are playing a larger role in ulcer pathogenesis and outcomes for both ethnic groups than was previously thought. Preventive efforts and interventions should be tailored to the two ethnic groups to achieve complete ulcer healing.