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.

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.

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.

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.

Methicillin-resistant Staphylococcus aureus infection in a college football team: risk factors outside the locker room and playing field.

We investigated a cluster of methicillin-resistant Staphylococcus aureus infections in college football players. Risk factors included a history of recurrent skin infections and contact with the skin lesions of persons outside college. The infections were controlled through treatment of carriers with topical mupirocin, chlorhexidine body washes, and enhancement of personal hygiene practices. Varsity and professional teams need to consider similar preventive measures.

Challenges for management of the diabetic foot in Africa: doing more with less.

Diabetes mellitus reached epidemic proportions in much of the less-developed world over a decade ago. In Africa, incidence and prevalence rates of diabetes are increasing and foot complications are rising in parallel. The predominant risk factor for foot complications is underlying peripheral neuropathy, although there is a body of evidence that confirm the increasing role of peripheral vascular disease. Gangrene and infections are two of the more serious sequelae of diabetic foot ulcer disease that cause long-standing disability, loss of income, amputation or death. Unfortunately, diabetes imposes a heavy burden on the health services in many African countries, where resources are already scarce or cut back. Reasons for poor outcomes of foot complications in various less-developed countries include the following: lack of awareness of foot care issues among patients and health care providers alike; very few professionals with an interest in the diabetic foot or trained to provide specialist treatment; non existent podiatry services; long distances for patients to travel to the clinic; delays among patients in seeking timely medical care, or among untrained health care providers in referring patients with serious complications for specialist opinion; lack of the concept of a team approach; absence of training programs for health care professionals; and finally lack of surveillance activities. There are ways of improving diabetic foot disease outcomes that do not require an exorbitant outlay of financial resources. These include implementation of sustainable training programmes for health care professionals, focusing on the management of the complicated diabetic foot and educational programmes that include dissemination of information to other health care professionals and patients; sustenance of working environments that inculcate commitment by individual physicians and nurses through self growth; rational optimal use of existing microbiology facilities and prescribing through epidemiologically directed empiricism, where appropriate; and using sentinel hospitals for surveillance activities. Allied with the golden rules of prevention (i.e. maintenance of glycaemic control to prevent peripheral neuropathy, regular feet inspection, making an effort not to walk barefooted or cut foot callosities with razors or knives at home and avoidance of delays in presenting to hospital at the earliest onset of a foot lesion), reductions in the occurrence of adverse events associated with the diabetic foot is feasible in less-developed settings.

Blood culture contamination in Tanzania, Malawi, and the United States: a microbiological tale of three cities.

We conducted retrospective, comparative analyses of contamination rates for cultures of blood obtained in the emergency rooms of Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania; Lilongwe Central Hospital (LCH) in central Malawi; and the Duke University Medical Center (DUMC) in the United States. None of the emergency room patients had indwelling intravascular devices at the time that the blood samples for cultures were obtained. In addition, we reviewed the contamination rates for a cohort of patients already hospitalized in the DUMC inpatient medical service, most of whom had indwelling intravascular devices. The bloodstream infection rates among the patients at MNH (n=513) and LCH (n=486) were similar (approximately 28%); the contamination rates at the two hospitals were 1.3% (7/513) and 0.8% (4/486), respectively. Of 54 microorganisms isolated from cultures of blood collected in the DUMC emergency room, 26 (48%) were identified as skin contaminants. Cultures of blood collected in the DUMC emergency room were significantly more likely to yield growth of contaminants than the cultures of blood collected in the emergency rooms at MNH and LCH combined (26/332 versus 11/1,003; P<0.0001) or collected in the DUMC inpatient medical service (26/332 versus 7/283; P<0.01). For the MNH and LCH blood cultures, lower contamination rates were observed when skin was disinfected with isopropyl alcohol plus tincture of iodine rather than isopropyl alcohol plus povidone-iodine. In conclusion, blood culture contamination was minimized in sub-Saharan African hospitals with substantially limited resources through scrupulous attention to aseptic skin cleansing and improved venipuncture techniques. Application of these principles when blood samples for culture are obtained in U.S. hospital emergency rooms should help mitigate blood culture contamination rates and the unnecessary microbiology workup of skin contaminants.

Pyrogenic reactions in hemodialysis patients, Hanoi, Vietnam.

Of 33,111 patients admitted to a large hospital in Vietnam from November 2000 through July 2001, a total of 303 were undergoing hemodialysis and had pyrogenic reactions (ie, fever and/or rigors). Ten case patients (3.3%) had documented bacteremia; pathogens were largely waterborne microorganisms. Pyrogenic reactions in case patients might have occurred because of suboptimal water quality or inadequate dialyzer reprocessing procedures.