Coccidioidomycosis Seroincidence and Risk among Military Personnel, Naval Air Station Lemoore, San Joaquin Valley, California, USA1.

We conducted a retrospective cohort study that tested 2,000 US military personnel for Coccidioides antibodies in a disease-endemic region. The overall incidence of seroconversion was 0.5 cases/100 person-years; 12.5% of persons who seroconverted had illnesses requiring medical care. No significant association was found between demographic characteristics and seroconversion or disease.

Staphylococcus intermedius Brain Abscess as a Complication of Pulmonary Arteriovenous Malformation in a Patient With Hereditary Hemorrhagic Telangiectasia.

Staphylococcus intermedius is a rare cause of human infections ranging from skin and soft tissue infections to bacteremia. It is particularly known for its association with exposure to dogs. We report an unusual case of a 73-year-old female with a brain abscess caused by S intermedius who was recently diagnosed with hereditary hemorrhagic telangiectasia and a pulmonary arteriovenous malformation. The patient underwent debridement of the brain abscess followed by a 6-week course of vancomycin and rifampin, after which she made a near complete recovery. This is the first case of a brain abscess in an adult due to S intermedius in the published literature, and we provide a comprehensive review of the literature of all human infections caused by this pathogen and summarize its clinical manifestations, treatment recommendations, and outcomes.

Case Series and Review of the Literature of Mycobacterium chelonae Infections of the Lower Extremities.

Mycobacterium chelonae infections involving the lower extremities are rare clinical entities that present a diagnostic challenge given its diverse clinical presentations ranging from superficial (e.g., cellulitis, painful vesicular lesions) to deep (e.g., tenosynovitis) infections. We present 1 cases of M chelonae infections of the feet diagnosed 6 to 12 months after initial symptoms representing the difficulty of diagnosing this condition. Both cases were successfully managed with aggressive surgical debridement and long durations of antibiotic therapy with long-term care. A comprehensive review of the literature of M chelonae infections of the lower extremities was performed to provide summary data on the presenting symptoms, examination findings, predisposing conditions, and management approaches of this rare, but emerging clinical entity. Our cases and comprehensive review serve to raise awareness of atypical mycobacterial infections, including M chelonae, and advocate for the early consideration of mycobacterial cultures in the diagnostic workup of chronic lower extremity infections especially in the setting of poor initial response to standard antibacterial therapies.

The impact of changing reflexive to clinician-ordered Clostridioides difficile polymerase chain reaction (PCR) testing for indeterminate cases: Cost savings without associated adverse events.

OBJECTIVE: To evaluate changing Clostridioides difficile infection (CDI) testing among inpatients with indeterminate enzyme immunoassay (EIA) results (antigen+/toxin-) from reflexive polymerase chain reaction (PCR) testing to clinician-ordered PCR testing. DESIGN: Multicenter, before-and-after, quasi-experimental study. SETTING: Four large urban tertiary-care hospitals. METHODS: We evaluated two 6-month periods before and after an intervention. The primary study outcome was the change in the number of CDI diagnoses between periods. Secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings. RESULTS: In total, 500 EIA-indeterminate C. difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 in the preintervention period versus 94 patients in the postintervention period (48% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281; 1 not performed due to an inhibitor) in the preintervention period versus 66% (144 of 219) in the postintervention period (34% reduction; P < .01). We observed no differences between study periods in 30-day all-cause (P = .96), GI-related (P = .93), or C. difficile (P = .47) readmissions, nor in 30-day C. difficile infections (P > .99). No patient without a PCR test in the postintervention period and not treated was later diagnosed with CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient. CONCLUSIONS: Applying diagnostic stewardship to C. difficile PCR testing in the inpatient setting led to significant reductions in both testing and cases. Changing the C. difficile PCR testing algorithm for EIA-indeterminate cases from reflexive to clinician-required ordering resulted in valuable cost savings without associated adverse events.

Purulent infectious myositis (formerly tropical pyomyositis).

Purulent infectious myositis (PIM), formerly known as tropical pyomyositis, is a pyogenic infection of skeletal muscles. Staphylococcus aureus, a normal human skin inhabitant, is the main pathogen involved, but multiple other microorganisms have been implicated. Although usually a progressive febrile disease with pain in the affected muscle(s), severe, life-threatening forms have been described, especially in immunosuppressed patients and children. PIM may elude early diagnosis given the lack of overlying skin changes. Hence, high index of suspicion followed by imaging modalities (ultrasonography when superficial and computed tomography or magnetic resonance imaging with contrast when deep) help confirm the diagnosis. Treatment requires combination of percutaneous or open surgical drainage along with antimicrobial therapy guided by culture results. The rising incidence of cases due to methicillin-resistant Staphylococcus aureus (MRSA) strains, makes the inclusion of vancomycin be recommended. This paper reviews PIM highlighting its global distribution, causative agents, predisposing factors, management, and potential complications.

Ceftaroline-Associated Neutropenia: Case Series and Literature Review of Incidence, Risk Factors, and Outcomes.

Ceftaroline is increasingly prescribed for "off-label" indications involving longer durations and higher doses. There have been postmarketing case reports of neutropenia among patients who have received extended durations of ceftaroline, but limited published data currently exist on its incidence and risk factors. We review a total of 37 published cases of ceftaroline-associated neutropenia including cases (n = 4) identified in our health care system. The median time from ceftaroline initiation to development of neutropenia (range) was 25 (8-125) days, with a median duration of neutropenia (range) of 4 (1-16) days. Agranulocytosis (absolute neutrophil count [ANC] nadir < 100 cells/mm3) developed in 49% of cases (n = 18), and there was an ANC nadir of 0 in 27% (n = 10). The overall incidence of neutropenia among cases receiving ceftaroline for ≥7-14 days (range) was 12% (7%-18% per individual study), higher than for comparator antibiotics in the literature. Risk factors for ceftaroline-associated neutropenia varied among studies and remain poorly defined.

Posttraumatic Stress Disorder and Neurocognitive Impairment in a U.S. Military Cohort of Persons Living with HIV.

Objective: Neurocognitive impairment (NCI) is a well-known complication of human immunodeficiency virus (HIV) infection and may be influenced by a number of psychological factors. We examined the relationship between NCI and mental health disorders, including posttraumatic stress disorder (PTSD), in a cohort of 189 active-duty and retired U.S. military men living with HIV. Methods: Participants completed selected modules of the Composite International Diagnostic Interview (CIDI) to ascertain the presence of PTSD, major depressive disorder, and other mental health diagnoses. We also obtained demographic data, including history of head trauma, via personal interview. NCI was assessed with a comprehensive battery of standardized neuropsychological tests. Results: The median age of study subjects was 36 years (interquartile range [IQR] 28 to 43) and median total years of education was 14 (IQR 12 to 16). NCI was diagnosed in 19% of subjects. Individuals with and without a history of PTSD were similar with respect to most HIV-related characteristics; however, the former were significantly more likely to have a prior acquired immunodeficiency syndrome (AIDS) diagnosis. In multivariate analysis, lifetime history of PTSD was independently associated with NCI (odds ration [OR] = 6.12; 95% confidence interval [CI] = 1.85, 20.27), while a history of head of trauma was negatively associated (OR = 0.37 95% CI = 0.15,0.92). Conclusions: Our findings demonstrate that PTSD is an important predictor of NCI in this U.S. military cohort. HIV-infected individuals with cognitive difficulties should be screened for mental health disorders, including PTSD, and prospective studies of the longitudinal relationship between PTSD and NCI, as well as the impact of PTSD treatment on future NCI, are warranted.

Capnocytophaga canimorsus Meningitis: Diagnosis Using Polymerase Chain Reaction Testing and Systematic Review of the Literature.

INTRODUCTION: Capnocytophaga canimorsus infections are associated with dog bites, especially in asplenic or immunocompromised patients, and typically manifest as sepsis and/or bacteremia. Meningitis has been rarely described, and its diagnosis may be delayed due to poor or slow growth using traditional culture techniques. We provide our experience using polymerase chain reaction (PCR) to establish the diagnosis and perform a comprehensive review of C. canimorsus meningitis cases to provide summary data on the clinical manifestations, diagnosis, and outcomes of this unusual infection. METHODS: A systematic review of the peer-reviewed English literature (PubMed, Embase, Ovid Medline) from January 1966 to March 2018 was conducted to identify cases of C. canimorsus meningitis. Data collected included demographics, risk factors, cerebrospinal fluid (CSF) findings, PCR results, treatments, and outcomes. Descriptive statistics are presented as numbers (percentages) and medians (ranges). RESULTS: A total of 37 patients were reviewed with a median age of 63 years (12 days to 83 years) with a male predominance (76%). A relatively low proportion had an immunocompromised state (16% splenectomy and 5% steroid use); the most common risk factor was alcoholism (19%). Fifty-nine percent reported a dog bite (all within ≤ 14 days prior to presentation), while 22% reported a non-bite dog exposure, 3% reported cat bite, and 3% reported both dog and cat exposures; 11% reported no animal contact. CSF parameters included a median white count of 1024 cells/mm3, 81% had neutrophilic predominance, median protein of 190 mg/dl, and median glucose CSF/serum ratio 0.23. In 54% of cases, blood cultures were positive for C. canimorsus (median, 4 days) and 70% had positive CSF cultures (median, 5 days). PCR established the diagnosis in eight (22%) cases. Antibiotic therapy was given for a median of 15 days (range, 7 to 42 days). Prognosis was overall favorable with only one (3%) death reported and adverse neurologic and/or physical sequelae in 19% of the survivors. CONCLUSION: C. canimorsus meningitis is a rare but increasingly important clinical entity occurring in patients of all ages, typically after dog exposure. While classically considered an infection among immunocompromised patients, most cases have occurred in previously healthy, immunocompetent persons. Diagnosis may be rapidly established by PCR, and this test should be considered in culture-negative cases with associated exposures. Outcome was generally favorable after a median antibiotic duration of 15 days.

25-hydroxyvitamin D, influenza vaccine response and healthcare encounters among a young adult population.

BACKGROUND: Influenza causes significant morbidity and mortality; the pandemic in 2009-2010 was a reminder of the potential for novel strains and antigenic changes. Studies have shown that vitamin D deficiency may be associated with poor vaccine immunogenicity, therefore we sought to determine if there was a correlation between 25-hydroxyvitamin D [25(OH)D] and influenza vaccine response. METHODS: A retrospective observational study was conducted among young, healthy military members to evaluate the association between total 25(OH)D levels with post influenza vaccination antibody titers and healthcare encounters during the 2009-10 influenza season. Univariate analyses were performed to evaluate whether 25(OH)D levels are associated with baseline characteristics and post-vaccination antibody responses. Multivariable logistic regression models were utilized to determine the associations between antibody responses and 25(OH)D levels adjusting for possible confounders. RESULTS: A total of 437 subjects were studied. Most participants were young adults (91% were 18-39 years of age), 50% were male, and 56% resided in the southern U.S. Overall, 152 (34.8%) were vitamin D deficient, 167 (38.2%) insufficient, and 118 (27.0%) with normal 25(OH)D levels. There were no demographic differences by 25(OH)D category. Only 224 (51.3%) demonstrated a seroprotective anti-influenza post-vaccination titer, which did not vary by categorical 25(OH)D levels [vitamin D deficient vs. normal: OR 1.10 (0.68-1.78) and insufficient vs. normal: OR 1.25 (0.78-2.01)] or continuous vitamin D levels [OR 0.98 (0.84-1.15)]. There were also no associations with increased influenza like illnesses, respiratory diagnoses and healthcare encounters between the vitamin D groups. CONCLUSION: Vitamin D insufficiency and deficiency were highly prevalent despite evaluating a young, healthy adult population. There were no significant associations between 25(OH)D levels and post-vaccination antibody titers to influenza vaccine. Further studies are required to discover strategies to improve vaccine efficacy as well as to determine the role of 25(OH)D in vaccine immunity.

Emergence of multi-drug resistant organisms (MDROs) causing Fournier's gangrene.

BACKGROUND: Fournier's gangrene is an uncommon but often devastating infection. There are few contemporary data on the risk factors and evolving microbiologic trends including drug-resistant organisms implicated in these life-threatening infections. METHODS: A retrospective study of Fournier's gangrene from 2006 to 2015 at a large academic hospital was conducted. Cases were identified using ICD codes (ICD-9: 608.83, V13.89; ICD-10: N49.3, Z87.438), and a review of medical, radiographic, and pathology records was performed to confirm each case. Data collected included socio-demographics, medical conditions, bacterial pathogens and their resistance patterns, treatments, and outcome. Descriptive and univariate statistics were performed. RESULTS: A total of 59 cases were evaluated with an overall incidence of 31.8 cases per 100,000 admissions which remained stable over the study period. Mean age was 56 years (range 18-91), 71% were male, and 44% white. Risk factors included overweight/obesity (61%), diabetes (44%, with a mean A1c of 9.6%), immunocompromised state (34%), and illicit use (20%). A causative organism was identified in all except 2 cases; 12 patients (21%) had a multidrug-resistant organism (MDRO) with MRSA being the most common pathogen (n = 8, 14% of all cases), followed by ESBL E. coli (n = 3) and MDRO Acinetobacter (n = 1). MRSA was the sole pathogen isolated in five (63%) of the eight cases involving this organism. Among those with an aerobic Gram-negative rod (GNR) isolated, 32% were fluoroquinolone-resistant. Overall, 30% of cases had a poor outcome (15% died and an additional 15% had loss of an organ/body part). Those with an MDRO were more likely to experience a poor outcome (42% vs. 28%), although this was not statistically significant (p = 0.48); of note, most (83%) MDRO cases were initially treated with an antibiotic that the organism was susceptible. CONCLUSIONS: This report highlights the emergence of MDROs as an important cause of Fournier's gangrene including MRSA and drug-resistant GNRs. Antibiotics should be chosen with broad-spectrum, anti-MDRO activity given the high morbidity and mortality associated with these infections.

Autoantibodies to Granulocyte-Macrophage Colony-Stimulating Factor Associated With Severe and Unusual Manifestations of Cryptococcus gattii Infections.

Cryptococcus gattii infections, especially including those with severe clinical manifestations, may be related to underlying host immunologic factors. We present 2 cases with autoantibodies to granulocyte-macrophage colony-stimulating factor (GM-CSF), a key cytokine in macrophage function. Immunologic evaluation for anti-GM-CSF antibodies may be important to inform management and counseling.

Evaluation of T and B memory cell responses elicited by the pandemic H1N1 vaccine in HIV-infected and HIV-uninfected individuals.

BACKGROUND: This study was to compare B and T memory cells elicited by a single dose monovalent 2009 influenza A (H1N1) vaccine (strain A/California/7/2009 H1N1) in HIV+ and HIV- groups, and to analyze the impact of the prior seasonal vaccines to the immunogenicity of this vaccine. METHODS: Blood samples were collected before vaccination (day 0) and at days 28 and 180. Participants were categorized into HIV-/LAIV, HIV-/TIV and HIV+/TIV subgroups according to the trivalent live-attenuated or inactivated (LAIV or TIV) seasonal influenza vaccines they received previously. The IgG+ memory B cells (BMem) and IFNγ+ T cells were measured against antigens including the H1N1 vaccine, the hemagglutinin (HA) and neuraminidase (NA) proteins or peptide pools of the pandemic and the seasonal H1N1 strains, respectively. RESULTS: Overall BMem responses increased significantly at day 28 but returned to baseline by day 180 in all three subgroups. The average frequency of the H1N1-specific BMem at day 28 for the HIV-/LAIV, HIV-/TIV and HIV+/TIV groups was 2.14%, 1.26% and 1.67%, respectively, and the average fold change was 14.39, 3.81 and 3.93, respectively. The differences of BMem between HIV-/LAIV and the two TIV subgroups were significant. For the IFNγ response, the overall spot counts ranged widely between 0 and 958/106 PBMCs. The group average spot counts to H1N1 vaccine was 89, 102, and 30 at day 28 for HIV-/LAIV, HIV-/TIV and HIV+/TIV subgroups, respectively. The average increase of IFNγ response at day 28 vs day 0 in all three subgroups did not reach 2-fold. CONCLUSION: Participants with a prior LAIV seasonal vaccine, as compared to a TIV seasonal vaccine, responded significantly better to the monovalent H1N1 vaccine. Excluding LAIV participants, no difference was seen between the HIV+ and HIV- subject groups in terms of BMem. The BMem response declined at 6months.

Vaccinations for the HIV-Infected Adult: A Review of the Current Recommendations, Part I.

Vaccination is a critical component for ensuring the health of those living with the human immunodeficiency virus (HIV) by protection against vaccine-preventable diseases. Since HIV-infected persons may have reduced immune responses and shorter durations of protection post-vaccination, HIV-specific guidelines have been published by global and national advisory organizations to address these potential concerns. This article provides a comprehensive review of the current guidelines and evidence-based data for vaccinating HIV-infected adults, including guidance on modified vaccine dosing and testing strategies, as well as safety considerations, to enhance protection among this vulnerable population. In the current article, part I of the two-part series, inactivated vaccines with broad indications as well as vaccines for specific risk and age groups will be discussed.

Vaccinations for the HIV-Infected Adult: A Review of the Current Recommendations, Part II.

Vaccination is a critical component for ensuring the ongoing health HIV-infected adults. Since this group may have reduced immune responses and shorter durations of protection post-vaccination, HIV-specific guidelines have been published. This review article provides a comprehensive discussion of the current guidelines and evidence-based data for vaccinating HIV-infected adults, including data on dosing schedules, immunogenicity studies, and safety. In the current paper, part II of the review, live vaccines, as well as vaccines for travelers and specific occupational groups, will be discussed.

Spinal Epidural Abscess: A Series of 101 Cases.

BACKGROUND: Spinal epidural abscesses are uncommon but potentially devastating infections that often elude early diagnosis. An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time. METHODS: A retrospective study of spinal epidural abscesses from 2004 to 2014 at a large academic hospital was conducted. Cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) code 324.1, and a review of medical and radiographic records was performed to confirm each case. Data collected included sociodemographics, medical history, suspected route of infection, treatments, and outcome. RESULTS: The incidence was 5.1 cases for each 10,000 admissions, with no significant changes during the study period. The route of infection was identified in 52% of cases, with bacteremia as the most common (26%), followed by recent surgery/procedure (21%) and spinal injection (6%). An identifiable underlying risk factor was present in 84% of cases, most commonly diabetes and intravenous drug use. A causative organism was identified in 84% of cases, most commonly Staphylococcus aureus; methicillin-resistant isolates accounted for 25% of S. aureus cases. All cases received intravenous antibiotic therapy, and 73% underwent a drainage procedure. Fifteen percent had an adverse outcome (8% paralysis and 7% death). CONCLUSIONS: The incidence of spinal epidural abscesses may be increasing, with the present study demonstrating a ≥5-fold higher rate compared with historical data. Although the outcome in most cases was favorable, spinal epidural abscesses continue to cause substantial morbidity and mortality and should remain a "not to be missed diagnosis."

Risk Factors Associated With Suicide Completions Among US Enlisted Marines.

US enlisted Marines have experienced a substantial increase in suicide rates. We sought to identify risk factors for suicide completions among male Marines who entered basic training in San Diego, California, between June 2001 and October 2010. Suicides that occurred during active-duty military service were counted from June 1, 2001, through June 30, 2012. A total of 108,930 male Marines (66,286 deployers and 42,644 never deployed) were followed for 467,857 person-years of active-duty service time. Of the 790 deaths, 123 (15.6%) were suicides. In the final multivariate hazard model, preservice characteristics of not being a high-school graduate (hazard ratio (HR) = 2.17, 95% confidence interval (CI): 1.28, 3.68) and being a smoker at the time of enlistment (HR = 1.91, 95% CI: 1.32, 2.76) were significantly associated with a higher risk for suicide completion. Diagnosed with traumatic brain injury (HR = 4.09, 95% CI: 2.08, 8.05), diagnosed with depression (HR = 2.36, 95% CI: 1.22, 4.58), and received relationship counseling (HR = 3.71, 95% CI: 1.44, 9.54) during military service were significant risks for suicide death. Deployment alone was not significantly associated with a risk for suicide death (HR = 0.53, 95% CI: 0.26, 1.05).

A 10-Year Retrospective Review of Nephrolithiasis in the Navy and Navy Pilots.

PURPOSE: Little is known about the incidence of nephrolithiasis in the United States Navy. Navy pilots must be kidney stone-free and are often referred for treatment of small asymptomatic stones. The primary objectives of this study were to determine the incidence of nephrolithiasis and computerized tomography, proportion undergoing treatment and incidence of stone related mishaps in Navy pilots compared with other Navy personnel. MATERIALS AND METHODS: We retrospectively studied the records of all Navy service members from 2002 to 2011 for nephrolithiasis based on ICD-9 stone codes to determine the mentioned rates. We also reviewed NSC (Naval Safety Center) data for a history of accidents associated with nephrolithiasis. Rates of disease were calculated using person-years of followup and inferential statistics were done using univariable and multivariable analyses. RESULTS: We evaluated 667,840 Navy personnel with a total of 3,238,331 person-years of followup. The annual incidence of nephrolithiasis was 240/100,000 person-years with a 5-year recurrence rate of 35.3%. On multivariable analysis pilots had nephrolithiasis incidence and treatment rates similar to those of the overall Navy population. Women had a higher incidence of nephrolithiasis compared with men (OR 1.17, p <0.0001). The rate of computerized tomography was lower in pilots than in the rest of the Navy (39 vs 66/10,000 person-years, p <0.0001). No recorded accidents were associated with kidney stones. CONCLUSIONS: Navy pilots had a similar incidence of nephrolithiasis and were no more likely to undergo a surgical procedure. Given that no accidents were associated with nephrolithiasis, this study suggests reconsidering current military policies necessitating pilots to be completely stone-free.

Risk Factors Associated with Miscarriage and Impaired Fecundity among United States Servicewomen during the Recent Conflicts in Iraq and Afghanistan.

BACKGROUND: Research on the reproductive health of U.S. servicewomen deployed in support of the recent operations in Iraq and Afghanistan is sparse. The objective of this study was to evaluate whether military experiences, including combat deployment, deployment length, and life stressors during the recent conflicts, were associated with increased odds for miscarriage or impaired fecundity among U.S. servicewomen. METHODS: We used data from the Millennium Cohort Study, a large longitudinal military study that began in 2001 and includes military personnel from all service branches, including active duty and Reserve/National Guard personnel. Participants for this study included women aged 18 to 45 years who had completed two questionnaires (2004-2006 and 2007-2008). Separate multivariable logistic regression models were performed to estimate the odds of reporting miscarriage and impaired fecundity by military experiences that adjusted for covariates. Subanalyses were conducted using International Classification of Diseases, Ninth Revision, Clinical Modification codes found in the Military Health System Data Repository for both outcomes among servicewomen on active duty. RESULTS: Overall, 31% and 11% of military servicewomen reported miscarriage and impaired fecundity, respectively, during the approximate 3-year follow-up period. After adjusting for demographic, behavioral, and military characteristics, deployment experiences and life stressors were not associated with miscarriage or perceived impaired fecundity. Subanalyses using medical record data confirmed these results. CONCLUSIONS: Overall, these results suggest that military deployments do not increase risk for miscarriage and impaired fecundity among U.S. servicewomen. However, because the point estimates for many of the exposures were elevated, more research is needed to better understand the potential risks associated with environmental exposures and specific types of combat exposures.