Prevalence of Urogenital Mycoplasma genitalium Infection at 2 US Army Medical Facilities.

BACKGROUND: Sexually transmitted infections (STIs) have a high incidence in the US Armed Forces and can adversely impact service members' ability to perform their duties. Better knowledge of Mycoplasma genitalium (MG) epidemiology in the military is needed to understand the potential impact of this emerging pathogen on force readiness. METHODS: We conducted cross-sectional analyses of data from US Army service members and other Military Health System beneficiaries participating in a trial of an STI/HIV behavioral intervention at Fort Liberty, NC, and Joint Base Lewis-McChord, WA. At enrollment, participants completed questionnaires and provided biological specimens for nucleic acid amplification testing for MG, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG). We used principal component analysis and robust Poisson regression to examine associations between participant characteristics and prevalent urogenital MG. RESULTS: Among 432 participants enrolled between November 2020 and February 2023, 43 had MG (prevalence, 10.0%), of whom 13 had coinfection with another bacterial STI (all 13 were positive for CT, with 1 also positive for NG). The prevalence of MG was significantly higher among female (13.5%) versus male (7.6%; P = 0.048) participants and non-Hispanic Black (14.9%) versus non-Hispanic White participants (6.6%; P = 0.045). Single relationship status and increased number of recent sexual partners were correlated, and their component was associated with higher MG prevalence (adjusted prevalence ratio, 2.11; 95% confidence interval, 1.29-3.48). CONCLUSIONS: The high prevalence of urogenital MG among Military Health System beneficiaries highlights the importance of understanding the potential clinical sequelae of MG and conducting additional epidemiologic research in military settings.

Leading a New Team: Critical Lessons Learned.

Leading medical teams as a new attending physician can be a challenging task. This case highlights the important role of leaders in fostering a positive learning environment, developing interpersonal relationships, and establishing clear expectations with regular feedback to improve team function to deliver effective health care.

Evaluation of Self-Collection as a Method of Extragenital STI Screening.

INTRODUCTION: The goal of this study is to improve overall screening, detection, and treatment of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) at our institution. MATERIALS AND METHODS: An observational study with two phases was conducted at a U.S. Army Medical Center. Previously collected samples from January 2014 through December 2015 were compared to prospectively collected data from March 2016 through December 2017. All data were collected from a convenience sample of active duty, HIV-positive men who have sex with men. Concordance between provider-collected and self-collected extragenital screening (EGS) samples was evaluated. RESULTS: The rate of detection using EGS was higher than previously found using urogenital screening alone. Our prospective analysis revealed that expanding screening to include extragenital sites increased rates of detection of GC and CT. Our rates of GC detection at the pharynx and rectum, and CT detection at the rectum, were higher than those reported in the literature for men who have sex with men. Rates of CT infection at the pharynx were comparable with those reported in the literature. Detection of GC at the pharynx was exactly concordant between self-collected and provider-collected samples. Concordance of GC and CT detection at the rectum was very good. The kappa coefficient for detection of CT at the pharynx was zero, which corresponded to 44 out of 45 concordant observations. CONCLUSIONS: Prior to implementation of EGS at our institution, we missed the opportunity to detect a substantial number of GC/CT infections with urogenital screening alone. Our results suggest that self-collection is a reliable method of EGS as compared to provider collection of samples.

Case report of penile Rhizopus arrhizus infection in an unexpected patient.

There are few reports of penile mucormycosis and even fewer in the absence of overt immune suppression. An eighty year old male with diabetes presents with penile mass. The pathology and culture demonstrated Rhizopus arrhizus. He was treated with surgery and liposomal amphotericin B. His therapy was stopped after pathology demonstrated clear surgical margins. His good outcome provides evidence that stopping antifungal therapy after achieving clear surgical margins is acceptable in patients without ongoing immunosuppression.

Transfusion-transmitted malaria not preventable by current blood donor screening guidelines: a case report.

BACKGROUND: Transfusion-transmitted malaria (TTM) is a well-known, though rare, entity in the United States with only 100 cases previously reported. With no Food and Drug Administration-approved screening tests of donated blood for malaria in the United States, prevention relies solely on deferral of the highest-risk donors. We present a case of TTM not preventable by these guidelines. CASE REPORT: A 76-year-old male presented with fever, hypotension, tachycardia, and a urinalysis consistent with a urinary tract infection. He was admitted to the intensive care unit and initiated on broad-spectrum antibiotics. On Hospital Day 2, he was incidentally found to have intraerythrocytic parasites on a peripheral smear, identified as Plasmodium malariae by polymerase chain reaction and was treated successfully with atovaquone-proguanil. The patient had no recent foreign travel or exposure to malaria but had received 15 units of blood products in the past 6 years. Index samples from the 10 most recent units were obtained, with one testing positive for P. malariae via serology. The donor was a 20-year-old male who immigrated to the United States from Liberia at the age of 5 with no subsequent travel or exposure to malaria. DISCUSSION: A review of current literature demonstrated that 71% of TTM cases occur from imperfect application of the current deferral guidelines. In this case, however, 15 years had elapsed between the donor's immigration and the transmission of the disease, placing him well outside any current deferral period. As such, the case demonstrates the need for continued development of highly sensitive and cost-effective laboratory screening for high-risk donors.

Staphylococcus aureus colonization of healthy military service members in the United States and Afghanistan.

BACKGROUND: Staphylococcus aureus [methicillin-resistant and methicillin-susceptible (MRSA/MSSA)] is a leading cause of infections in military personnel, but there are limited data regarding baseline colonization of individuals while deployed. We conducted a pilot study to screen non-deployed and deployed healthy military service members for MRSA/MSSA colonization at various anatomic sites and assessed isolates for molecular differences. METHODS: Colonization point-prevalence of 101 military personnel in the US and 100 in Afghanistan was determined by swabbing 7 anatomic sites. US-based individuals had received no antibiotics within 30 days, and Afghanistan-deployed personnel were taking doxycycline for malaria prophylaxis. Isolates underwent identification and testing for antimicrobial resistance, virulence factors, and pulsed-field type (PFT). RESULTS: 4 individuals in the US (4 isolates- 3 oropharynx, 1 perirectal) and 4 in Afghanistan (6 isolates- 2 oropharynx, 2 nare, 1 hand, 1 foot) were colonized with MRSA. Among US-based personnel, 3 had USA300 (1 PVL+) and 1 USA700. Among Afghanistan-based personnel, 1 had USA300 (PVL+), 1 USA800 and 2 USA1000. MSSA was present in 40 (71 isolates-25 oropharynx, 15 nare) of the US-based and 32 (65 isolates- 16 oropharynx, 24 nare) of the Afghanistan-based individuals. 56 (79%) US and 41(63%) Afghanistan-based individuals had MSSA isolates recovered from extra-nare sites. The most common MSSA PFTs were USA200 (9 isolates) in the US and USA800 (7 isolates) in Afghanistan. MRSA/MSSA isolates were susceptible to doxycycline in all but 3 personnel (1 US, 2 Afghanistan; all were MSSA isolates that carried tetM). CONCLUSION: MRSA and MSSA colonization of military personnel was not associated with deployment status or doxycycline exposure. Higher S. aureus oropharynx colonization rates were observed and may warrant changes in decolonization practices.

Detection of methicillin-resistant and methicillin-susceptible Staphylococcus aureus colonization of healthy military personnel by traditional culture, PCR, and mass spectrometry.

BACKGROUND: Methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) Staphylococcus aureus colonization is associated with increased rates of infection. Rapid and reliable detection methods are needed to identify colonization of nares and extra-nare sites, particularly given recent reports of oropharynx-only colonization. Detection methods for MRSA/MSSA colonization include culture, PCR, and novel methods such as PCR/electrospray ionization time-of-flight mass spectrometry (ESI-TOF-MS). METHODS: We evaluated 101 healthy military members for S. aureus colonization in the nares, oropharynx, axilla, and groin, using CHROMagar S. aureus medium and Xpert SA Nasal Complete PCR for MRSA/MSSA detection. The same subjects were screened in the nares, oropharynx, and groin using PCR/ESI-TOF-MS. RESULTS: By culture, 3 subjects were MRSA-colonized (all oropharynx) and 34 subjects were MSSA-colonized (all 4 sites). PCR detected oropharyngeal MRSA in 2 subjects, which correlated with culture findings. By PCR, 47 subjects were MSSA-colonized (all 4 sites); however, 43 axillary samples were invalid, 39 of which were associated with deodorant/anti-perspirant use (93%, p < 0.01). By PCR/ESI-TOF-MS, 4 subjects were MRSA-colonized, 2 in the nares and 2 in the oropharynx; however, neither of these correlated with positive MRSA cultures. Twenty-eight subjects had MSSA by PCR/ESI-TOF-MS, and 41 were found to have possible MRSA (S. aureus with mecA and coagulase-negative Staphylococcus (CoNS)). CONCLUSION: The overall 3% MRSA colonization rate is consistent with historical reports, but the oropharynx-only colonization supports more recent findings. In addition, the use of deodorant/anti-perspirant invalidated axillary PCR samples, limiting its utility. Defining MRSA positivity by PCR/ESI-TOF-MS is complicated by co-colonization of S. aureus with CoNS, which can also carry mecA.

Multidrug-resistant gram-negative bacteria colonization of healthy US military personnel in the US and Afghanistan.

BACKGROUND: The US military has seen steady increases in multidrug-resistant (MDR) gram-negative bacteria (GNB) infections in casualties from Iraq and Afghanistan. This study evaluates the prevalence of MDR GNB colonization in US military personnel. METHODS: GNB colonization surveillance of healthy, asymptomatic military personnel (101 in the US and 100 in Afghanistan) was performed by swabbing 7 anatomical sites. US-based personnel had received no antibiotics within 30 days of specimen collection, and Afghanistan-based personnel were receiving doxycycline for malaria chemoprophylaxis at time of specimen collection. Isolates underwent genotypic and phenotypic characterization. RESULTS: The only colonizing MDR GNB recovered in both populations was Escherichia coli (p=0.01), which was seen in 2% of US-based personnel (all perirectal) and 11% of Afghanistan-based personnel (10 perirectal, 1 foot+groin). Individuals with higher off-base exposures in Afghanistan did not show a difference in overall GNB colonization or MDR E. coli colonization, compared with those with limited off-base exposures. CONCLUSION: Healthy US- and Afghanistan-based military personnel have community onset-MDR E. coli colonization, with Afghanistan-based personnel showing a 5.5-fold higher prevalence. The association of doxycycline prophylaxis or other exposures with antimicrobial resistance and increased rates of MDR E. coli colonization needs further evaluation.

Variations of CHROMagar Acinetobacter to detect imipenem-resistant Acinetobacter baumannii-calcoaceticus complex.

BACKGROUND: Acinetobacter baumannii-calcoaceticus complex (ABC) isolates are often multidrug-resistant, including to carbapenems. Chromogenic media can facilitate the rapid detection of Gram-negative bacteria, often with the addition of supplements to a base chromogenic medium to detect resistance. We examined various combinations of available media to detect imipenem resistance among 107 ABC clinical isolates. METHODS: CHROMagar Orientation, CHROMagar KPC, and CHROMagar Acinetobacter, by itself, with Acinetobacter supplement, with KPC supplement, or CHROMagar Acinetobacter with increasing concentrations (1, 2.5, and 5 ml/l) of a new CR102 supplement, were examined. RESULTS: Sensitivity for the detection of isolates was high (> 98%) for all formulations. Specificity was high for CHROMagar Acinetobacter with 2.5 ml/l and 5 ml/l of the CR102 supplement, at 95.3% and 97.7%, respectively, with positive predictive values of 97% and 98.5%. Negative predictive values of these 2 formulations were 100%. CONCLUSIONS: CHROMagar Acinetobacter with the addition of the CR102 supplement at 2.5 ml/l and 5ml/l is highly sensitive and specific for the detection of imipenem-resistant ABC, and may be useful for the rapid detection of imipenem-resistant ABC in clinical samples.

Invasive Apophysomyces variabilis infection in a burn patient.

Apophysomyces variabilis is an emerging fungal pathogen that can cause significant infections in immunocompetent patients. We report a case of A. variabilis invasive wound infection in a 21-year-old male after a self-inflicted burn injury.

Pythium aphanidermatum infection following combat trauma.

Pythium aphanidermatum is a fungus-like plant pathogen which has never been reported as a cause of human infection. We report a case of P. aphanidermatum invasive wound infection in a 21-year-old male injured during combat operations in Afghanistan.

Carbapenem susceptibility testing errors using three automated systems, disk diffusion, Etest, and broth microdilution and carbapenem resistance genes in isolates of Acinetobacter baumannii-calcoaceticus complex.

The Acinetobacter baumannii-calcoaceticus complex (ABC) is associated with increasing carbapenem resistance, necessitating accurate resistance testing to maximize therapeutic options. We determined the accuracy of carbapenem antimicrobial susceptibility tests for ABC isolates and surveyed them for genetic determinants of carbapenem resistance. A total of 107 single-patient ABC isolates from blood and wound infections from 2006 to 2008 were evaluated. MICs of imipenem, meropenem, and doripenem determined by broth microdilution (BMD) were compared to results obtained by disk diffusion, Etest, and automated methods (the MicroScan, Phoenix, and Vitek 2 systems). Discordant results were categorized as very major errors (VME), major errors (ME), and minor errors (mE). DNA sequences encoding OXA beta-lactamase enzymes (bla(OXA-23-like), bla(OXA-24-like), bla(OXA-58-like), and bla(OXA-51-like)) and metallo-ß-lactamases (MBLs) (IMP, VIM, and SIM1) were identified by PCR, as was the KPC2 carbapenemase gene. Imipenem was more active than meropenem and doripenem. The percentage of susceptibility was 37.4% for imipenem, 35.5% for meropenem, and 3.7% for doripenem. Manual methods were more accurate than automated methods. bla(OXA-23-like) and bla(OXA-24-like) were the primary resistance genes found. bla(OXA-58-like), MBLs, and KPC2 were not present. Both automated testing and manual testing for susceptibility to doripenem were very inaccurate, with VME rates ranging between 2.8 and 30.8%. International variability in carbapenem breakpoints and the absence of CLSI breakpoints for doripenem present a challenge in susceptibility testing.

Central nervous system infections in patients with severe burns.

BACKGROUND: Central nervous system (CNS) infections develop in 3-9% of neurosurgical ICU patients and 0.4-2% of all patients hospitalized with head trauma. CNS infection incidence in burn patients is unknown and this study sets out to identify the incidence and risk factors associated with CNS infections. METHODS: A retrospective electronic chart review was performed from 1 July 2003 to 30 June 2008 evaluating inpatient medical records along with cerebrospinal fluid (CSF) microbiological results for the presence of CNS infection. The presence of facial and head injuries and burns, along with intracranial interventions were reviewed for association with CNS infections. RESULTS: There were 1964 admissions with 2 patients (0.1%) found to have CNS infection; 1 each with MRSA and Acinetobacter baumannii. Both patients had facial burns and trauma to their head that required intracranial surgery. Of note, both patients had bacteremia with the same microorganisms isolated from their CSF and both survived. Of all patients, 29% had head or neck trauma and burns; 0.35% of those had a CNS infection. Scalp harvest for grafts or debridement of burned scalp was performed on 125 patients of which 9 had an invasive surgical procedure that involved penetration of the skull. The 2 infected patients were from these 9 intracranial surgical patients revealing a 22% infection rate. CONCLUSION: The incidence of CNS infections in patients with severe burns is extremely low at 0.1%. This rate was low even with head and face burns with trauma unless the patient underwent an intracranial procedure.

Community-associated methicillin-resistant Staphylococcus aureus mediastinitis.

Community-associated methicillin (meticillin)-resistant Staphylococcus aureus (CA-MRSA) continues to emerge as a cause of serious infections, chiefly of the skin and soft tissues. We present the first documented case of CA-MRSA mediastinitis in an adult. Blood and mediastinal isolates were characterized as CA-MRSA by pulsed-field gel electrophoresis and susceptibility testing.

Use of a high-flow oxygen delivery system in a critically ill patient with dementia.

We used a high-flow nasal cannula with a patient who required a high fraction of inspired oxygen but could not tolerate a nasal or facial mask. We saw a 92-year-old woman with delirium and dementia in the intensive care unit for multi-lobar pneumonia with severe hypoxemia. Attempts to oxygenate the patient failed because she was unable to tolerate various facial and nasal masks. We then tried a high-flow nasal cannula (Vapotherm 2000i), which she tolerated well, and she had marked improvement in gas exchange and quality of life. The patient had severe health-care-associated pneumonia, accompanied by delirium and hypoxemia. It became apparent that the patient's death was imminent, and the goal of therapy was palliative. She had previously clearly expressed a desire not to undergo intubation and mechanical ventilation. In a situation where the patient was agitated and unable to tolerate a mask, the high-flow cannula reduced her agitation and improved her dyspnea, oxygenation, tolerance of oxygen therapy, and comfort at the end of life. Oxygen via high-flow cannula may enhance quality of life by reducing hypoxemia in patients who are unable to tolerate a mask but need a high oxygen concentration.