Patients Follow-up for Spinal Epidural Abscess as a Critical Treatment Plan Consideration.

INTRODUCTION:  Spinal epidural abscess (SEA) is a rare process with significant risk for morbidity and mortality. Treatment includes an extended course of antibiotics with or without surgery depending on the clinical presentation. Both non-operative and surgically treated patients require close follow-up to ensure the resolution of the infection without recurrence and/or progression of neurologic deficits. No previous study has looked specifically at follow-up in the SEA population, but the review of the literature does show evidence of varying degrees of difficulty with follow-up for this patient population. METHODS:  This retrospective review looked at follow-up for 147 patients with SEA at a single institution from 2012 to 2021. Statistical analyses were performed to assess differences between groups of surgical versus non-surgical patients and those with adequate versus inadequate follow-up. RESULTS: Sixty-two of 147 (42.2%) patients had inadequate follow-up (less than 90 days) with their surgical team, and 112 of 147 (76.2%) patients had inadequate follow-up (less than 90 days) with infectious disease (ID). The primary statistically significant difference between patients with adequate versus inadequate follow-up was found to be surgical status with those treated surgically more likely to have adequate follow-up than those treated non-operatively. CONCLUSION: Improved follow-up in surgical patients should be considered as a factor when deciding on surgical versus non-operative treatment in the SEA patient population. Extra efforts coordinating follow-up care should be made for SEA patients.

Prevention of Neisseria gonorrhoeae With Meningococcal B Vaccine: A Matched Cohort Study in Southern California.

BACKGROUND: Neisseria gonorrhoeae is acquiring increasing resistance to available oral antibiotics, and current screening and treatment approaches have not decreased gonorrhea incidence. Although a gonorrhea-specific vaccine does not exist, N. gonorrhoeae shares much of its genome with Neisseria meningitidis, notably critical antigenic determinants including outer membrane vesicles (OMV). Prior observational studies have suggested that OMV-based meningococcal serogroup B vaccines confer protection against gonorrhea. METHODS: We conducted a matched cohort study from 2016 to 2020 to examine the association of OMV-containing recombinant meningococcal serogroup B vaccine (4CMenB) with gonorrhea infection among teens and young adults at Kaiser Permanente Southern California. Recipients of 4CMenB were matched in a ratio of 1:4 to recipients of non-OMV-containing polysaccharide-conjugate vaccine targeting serotypes A, C, W, and Y (MenACWY) who had not received 4CMenB and were followed for incident gonorrhea. We used Cox proportional hazards regression to compare gonorrhea rates among recipients of 4CMenB vs MenACWY, adjusting for potential confounders. We conducted the same analysis with chlamydia as a negative control outcome. RESULTS: The study included 6641 recipients of 4CMenB matched to 26 471 recipients of MenACWY. During follow-up, gonorrhea incidence rates per 1000 person-years (95% confidence intervals [CIs]) were 2.0 (1.3-2.8) for recipients of 4CMenB and 5.2 (4.6-5.8) for recipients of MenACWY. In adjusted analyses, gonorrhea rates were 46% lower among recipients of 4CMenB vs MenACWY (hazard ratio [HR], 0.54; 95% CI, .34-.86), but chlamydia rates were similar between vaccine groups (HR, 0.98; 95% CI, .82-1.17). CONCLUSIONS: These results suggest cross-protection of 4CMenB against gonorrhea, supporting the potential for vaccination strategies to prevent gonorrhea.

Convalescent Plasma for COVID-19: A Single Center Prospective Experience with Serial Antibody Measurements and Review of the Literature.

Background: High-titer convalescent plasma given early for COVID-19 may decrease progression into a severe infection. Here, we reported a study of serial antibody measurements in patients who received CP at our center and performed a systematic review of randomized trials on CP. Methods: Our center participated in the Mayo Clinic Expanded Access Program for COVID-19 Convalescent Plasma. Patients diagnosed with COVID-19 by nasopharyngeal polymerase chain reaction at our center between April and August 2020 were included in the study if staffing was available for specimen collection. Through a colloidal gold immunochromatography assay, these patients' IgM and IgG antibody responses were measured at baseline (Day 0) and after transfusion (Day 1, 2, etc.). Donor CP antibody levels were measured as well. Results: 110 serum specimens were obtained from 21 COVID-19 patients, 16 of whom received CP. The median time from developing symptoms to receiving CP was 11 days (range 4−21). In 9 of 14 (64%) cases where both recipient and donor CP antibody levels were tested, donor COVID-19 IgG was lower than that of the recipient. Higher donor antibody levels compared with the recipient (R = 0.71, p < 0.01) and low patient IgG before CP transfusion (p = 0.0108) correlated with increasing patient IgG levels from baseline to Day 1. Among all patients, an increased COVID-19 IgG in the short-term and longitudinally was positively correlated with improved clinical outcomes (ρ = 0.69, p = 0.003 and ρ = 0.58, p < 0.006, respectively). Conclusions: In a real-world setting where donor CP was not screened for the presence of antibodies, CP in donors might have less COVID-19 IgG than in recipients. An increase in patient antibody levels in the short term and longitudinally was associated with improved clinical outcomes.

Capnocytophaga tricuspid valve endocarditis: a case report and literature review.

Capnocytophaga canimorsus is a Gram-negative zoonotic pathogen capable of causing serious infection following dog or cat bite. Infections often manifest as sepsis, fatal septic shock, gangrene, bacteraemia, meningitis and endocarditis. Here we report a case of C. canimorsus bacteraemia complicated by tricuspid valve infective endocarditis and septic pulmonary emboli.

Elective inpatient video-EEG monitoring during the COVID-19 pandemic.

To evaluate the safety and feasibility of admission for elective video-EEG monitoring during the SARS-CoV-2 pandemic. We performed a retrospective review of elective inpatient epilepsy monitoring unit admissions at our institution from May 3rd, 2020 to August 12th, 2020. All patients were screened by telephone for symptoms concerning infection or recent diagnosis of SARS-CoV-2 or excess medical risk prior to admission. Patients deemed eligible for admission underwent testing via a nasopharyngeal swab for SARS-CoV-2 within three days of admission, and were directed to self-quarantine between testing and admission. The community seven-day case rate for SARS-CoV-2 (new cases per 100,000 population) ranged from 2.8 to 28.9 during the study period in our region. A total of 95 patients (63 adults and 32 children) were admitted. One adult patient developed mild SARS-CoV-2 infection and one adult patient tested positive for asymptomatic SARS-CoV-2 infection. These findings illustrate that inpatient epilepsy monitoring can be safely performed in carefully selected patients when appropriate processes are in place, even in the setting of the SARS-CoV-2 pandemic. There is a risk of nosocomial spread, and the potential benefits of admission should be balanced against the risks of infection.

Adding a Physical Therapist to the Health Care Team in an HIV Clinic Increases Physical Therapy Referrals and Reduces Opioid Prescriptions Provided for Chronic Musculoskeletal Pain in Patients Living With HIV.

BACKGROUND: Musculoskeletal (MSK) pain is common in people living with HIV (PLWH). Health care providers sometimes prescribe opioids to control pain, which may lead to opioid misuse. An interdisciplinary approach that includes physical therapy has been successful in managing MSK pain in various health care settings. Therefore, we sought to find the impact of recruiting a physical therapist (PT) on the number of opioid prescriptions and physical therapy referrals made by physicians in training to manage MSK pain in PLWH. METHODS: We performed a retrospective chart review of patients seen by Internal Medicine physicians in training in an HIV clinic in Detroit before (2017) and after (2018) recruiting a PT to the health care team and collected demographic and clinical data. We also surveyed the trainees to assess how the PT addition influenced their learning. Institutional review board waiver was obtained. RESULTS: Results showed that of all PLWH seen at the clinic, 28/249 (11%) and 37/178 (21%) had chronic MSK pain in the 2017 and 2018 data sets, respectively. In 2017, all 28 patients with MSK pain were prescribed opioids. This decreased in 2018 after the PT addition (10/37 patients; P < .0001). The number of physical therapy referrals significantly increased after the PT addition (2017: 5/28 patients; 2018: 17/37 patients; P = .03). Trainees felt that the PT helped improve their examination skills and develop a treatment plan for patients. CONCLUSIONS: The addition of a PT encouraged physicians in training to utilize nonopioid management of MSK pain in PLWH and enhanced their learning experience, as perceived by the trainees.

Lumbar and sacral brucellosis due to queso fresco ingestion.

Brucellosis is rare in the USA, with 100-200 cases reported annually. In this case we illustrate the complex management of spinal brucellosis. A 22-year-old male presented with 3 months of low back pain. Imaging revealed osteomyelitis/diskitis of L5/S1 and abscesses involving the pre-vertebral, epidural and pelvic recesses. Initial biopsies were inconclusive, but the patient later endorsed eating unpasteurized cheese (queso fresco) from Mexico; therefore, Brucella serology was sent and was positive. Despite aggressive antibiotic therapy there was disease progression. The patient underwent debridement of the involved vertebrae and drainage. Multiple cultures failed to grow the organisms, but Brucella polymerase chain reaction was positive. A month later he underwent a second vertebral debridement as well as placement of tobramycin impregnated beads in the vertebral space. He has since recovered. Surgery should be considered if there is a poor response to medical management and patients may need repeated debridement.

Alopecia After Switch to Tenofovir Alafenamide in 6 African American Women.

No cases of tenofovir alafenamide (TAF)-induced alopecia have been reported in the literature. We describe 6 cases of hair loss in African American female patients after switching to TAF and aim to raise awareness about this potential adverse effect of TAF, which could predominate in certain patient populations.

Cutaneous geotrichosis due to Geotrichum candidum in a burn patient.

Geotrichum candidum is a saprophytic yeast known to colonize the human skin, respiratory tract and gastrointestinal tract. It can cause local or disseminated disease (geotrichosis), mainly in the immunocompromised host. Trauma, indwelling catheter use, prolonged broad-spectrum antibiotic treatment and critical illness have also been implicated as risk factors. Here we report the first case, to our knowledge, of cutaneous G. candidum infection in a burn patient. The isolate had a high amphotericin B minimum inhibitory concentration (MIC) and the patient experienced concomitant Candida orthopsilosis fungaemia, and so was treated with a combination of voriconazole and micafungin. This case highlights the importance of source control, rapid identification of G. candidum infection and MIC determination to guide antifungal therapy, which typically consists of amphotericin B with or without flucytosine or voriconazole alone. Clinicians should be aware of geotrichosis as a clinical entity in burn patients as well as in the immunocompromised. Antifungal resistance and breakthrough disease are an ongoing concern due to the increasing number of immunocompromised at-risk patients and the use of routine mould prophylaxis.

Gemella morbillorum Cryptogenic Brain Abscess: A Case Report and Literature Review.

A case of cryptogenic brain abscess caused by Gemella morbillorum is reported in a 28-year-old immunocompetent man who presented with seizures and hemiparesis. The patient underwent successful stereotactic drainage of the abscess with complete resolution of symptoms and radiographic evidence of resolution. We report the significant pathogenic potential of a normal commensal rarely identified in neurologic infections.

Clinical and Microbiological Aspects of ß-Lactam Resistance in Staphylococcus lugdunensis.

Antimicrobial susceptibility results from broth microdilution MIC testing of 993 Staphylococcus lugdunensis isolates recovered from patients at a tertiary care medical center from 2008 to 2015 were reviewed. Ninety-two oxacillin-susceptible isolates were selected to assess the accuracy of penicillin MIC testing, the penicillin disk diffusion test, and three ß-lactamase tests, including the cefoxitin-induced nitrocefin test, penicillin cloverleaf assay, and penicillin disk zone edge test. The results of all phenotypic tests were compared to the results of blaZ PCR. The medical records of 62 patients from whom S. lugdunensis was isolated, including 31 penicillin-susceptible and 31 penicillin-resistant strains, were retrospectively reviewed to evaluate the clinical significance of S. lugdunensis isolation, the antimicrobial agents prescribed, if any, and the clinical outcome. MIC testing revealed that 517/993 (52.1%) isolates were susceptible to penicillin and 946/993 (95.3%) were susceptible to oxacillin. The induced nitrocefin test was 100% sensitive and specific for the detection of ß-lactamase compared to the blaZ PCR results, whereas the penicillin disk zone edge and cloverleaf tests showed sensitivities of 100% but specificities of only 9.1% and 89.1%, respectively. The penicillin MIC test had 100% categorical agreement with blaZ PCR, while penicillin disk diffusion yielded one major error. Only 3/31 patients with penicillin-susceptible isolates were treated with a penicillin family antimicrobial. The majority of cases were treated with other ß-lactams, trimethoprim-sulfamethoxazole, or vancomycin. These data indicate that nearly all isolates of S. lugdunensis are susceptible to narrow-spectrum antimicrobial agents. Clinical laboratories in areas with resistance levels similar to those described here can help promote the use of these agents versus vancomycin by effectively designing their antimicrobial susceptibility reports to convey this message.

Feasibility and Acceptability of Cryptococcal Antigen Screening and Prevalence of Cryptocococcemia in Patients Attending a Resource-Limited HIV/AIDS Clinic in Malawi.

BACKGROUND: The World Health Organization (WHO) recommends screening patients living with AIDS to detect and treat early cryptococcal infection. METHODS: The authors evaluated a cryptococcal antigen (CrAg) screening and treatment program at an HIV/AIDS clinic in Malawi. Eligible patients were of age >18 years, had a CD4 count <100 cells/µL or WHO clinical HIV/AIDS stage III or IV. RESULTS: Of 552 patients who presented for care, 113 were eligible, and all (100%) agreed to CrAg screening. Of them, 2 (1.8%; 95% confidence interval [CI]: 0-4.2%) patients were CrAg positive. Among those with CD4 count <100 cells/µL or WHO stage IV, the CrAg prevalence was 3.5% (95% CI: 0-8.4%) and 5.0% (95% CI: 0-15%), respectively. CONCLUSION: A CrAg screening program was acceptable to new patients in a Malawian HIV/AIDS clinic. The CrAg prevalence for patients with CD4 count < 100 cells/µL and WHO stage IV was consistent with cost-effectiveness estimates. CrAg screening and treatment programs for patients living with AIDS should be expanded.

Meningitis in HIV-positive patients in sub-Saharan Africa: a review.

INTRODUCTION: Meningitis is one of the leading causes of death among patients living with HIV in sub-Saharan Africa. There is no widespread tracking of the incidence rates of causative agents among patients living with HIV, yet the aetiologies of meningitis are different than those of the general population. METHODS: We reviewed the scientific literature published in PubMed to determine the incidence rates of meningitis among hospitalized people living with HIV in sub-Saharan Africa and report our findings from seven studies across sub-Saharan Africa. RESULTS: We found high rates of cryptococcal meningitis (19-68%). Tuberculous meningitis was lower (1-36%), although some centres included possible cases as "other" meningitis; therefore, this may not be a true representation of the total cases. Pyogenic meningitis ranged from 6 to 30% and "other" meningitis ranged from 7 to 28% of all reported cases of meningitis. Mortality rates ranged from 25 to 68%. This review describes the most common aetiologies and provides practical diagnostic, treatment and prevention considerations as they apply to the individual living with HIV in sub-Saharan Africa. CONCLUSIONS: Diagnosis is often limited, and wider availability of accurate and low-cost laboratory diagnostics is desperately needed for prompt diagnosis and initiation of appropriate treatment. Wider acceptance and adoption of available preventative modalities can decrease the incidence of potentially fatal central nervous system infections in African patients living with HIV.

Impact of cefepime therapy on mortality among patients with bloodstream infections caused by extended-spectrum-ß-lactamase-producing Klebsiella pneumoniae and Escherichia coli.

Extended-spectrum-ß-lactamase (ESBL)-producing pathogens are associated with extensive morbidity and mortality and rising health care costs. Scant data exist on the impact of antimicrobial therapy on clinical outcomes in patients with ESBL bloodstream infections (BSI), and no large studies have examined the impact of cefepime therapy. A retrospective 3-year study was performed at the Detroit Medical Center on adult patients with BSI due to ESBL-producing Klebsiella pneumoniae or Escherichia coli. Data were collected from the medical records of study patients at five hospitals between January 2005 and December 2007. Multivariate analysis was performed using logistic regression. One hundred forty-five patients with BSI due to ESBL-producing pathogens, including K. pneumoniae (83%) and E. coli (16.5%), were studied. The mean age of the patients was 66 years. Fifty-one percent of the patients were female, and 79.3% were African-American. Fifty-three patients (37%) died in the hospital, and 92 survived to discharge. In bivariate analysis, the variables associated with mortality (P < 0.05) were presence of a rapidly fatal condition at the time of admission, use of gentamicin as a consolidative therapeutic agent, and presence of one or more of the following prior to culture date: mechanical ventilation, stay in the intensive care unit (ICU), and presence of a central venous catheter. In multivariate analysis, the predictors of in-hospital mortality included stay in the intensive care unit (odds ratio [OR], 2.17; 95% confidence interval [CI], 0.98 to 4.78), presence of a central-line catheter prior to positive culture (OR, 2.33; 95% CI, 0.77 to 7.03), presence of a rapidly fatal condition at the time of admission (OR, 5.13; 95% CI, 2.13 to 12.39), and recent prior hospitalization (OR, 1.92; 95% CI, 0.83 to 4.09). When carbapenems were added as empirical therapy to the predictor model, there was a trend between empirical carbapenem therapy and decreased mortality (OR, 0.61; 95% CI, 0.26 to 1.50). When added to the model, receipt of empirical cefepime alone (n = 43) was associated with increased mortality, although this association did not reach statistical significance (OR, 1.66; 95% CI, 0.71 to 3.87). The median length of hospital stay was shorter for patients receiving empirical cefepime than for those receiving empirical or consolidated carbapenem therapy. In multivariate analysis, empirical therapy with cefepime for BSI due to an ESBL-producing pathogen was associated with a trend toward an increased mortality risk and empirical carbapenem therapy was associated with a trend toward decreased mortality risk.