Improving wound swab collection in paediatric patients: a quality improvement project.

Microbiology sample swabs may be unsuccessful or rejected for a variety of reasons. Typically, errors occur in the preanalytical phase of sample collection. Errors with collection, handling and transport can lead to the need to repeat specimen collection. Unsuccessful specimens contribute to delays in diagnosis, increased patient stress and increased healthcare costs. An audit of sample swabs from London Health Sciences Centre Children's Hospital from August through October 2021 yielded complete success rates of 100% for ear and eye culture swabs, 98.1% for methicillin-resistant Staphylococcus aureus swabs and 88.9% for wound swabs. This project aimed to improve wound swab success to 95% on the paediatric inpatient and paediatric emergency departments by May 2022.Stakeholders from paediatric clinical services including physicians, nurses and the laboratory medicine team at our centre were engaged to guide quality improvement interventions to improve specimen success rate. Based on feedback, we implemented visual aids to our electronic laboratory test information guide. Additionally, visual reminders of correct sample collection equipment were placed in high traffic areas for nursing staff.After the interventions were implemented, a three-month follow-up showed that wound swab success rate rose to 95.3%. This study achieved its aim of improving wound swab success rate to 95%. It adds to the growing pool of evidence that preanalytical phase intervention such as visual aids can increase swab success rates, in healthcare settings.

Increasing SARS-CoV-2 testing capacity through specimen pooling: An acute care center experience.

Innovation in laboratory testing algorithms to address seemingly uncontrollable global supply chain shortages in plastics and other consumables during emergencies such as the current COVID-19 pandemic have been urgently needed. We report our experience with specimen pooling on SARS-CoV-2 testing in an acute care hospital microbiology laboratory during a high testing demand period that exceeded available processing capacity. A fully automated four-in-one pooling algorithm was designed and validated. Correlation and agreement were calculated. A custom Microsoft Excel tool was designed for use by the technologists to aid interpretation, verification and result entry. Cost-per-test impact for pooling was measured in reference to the consumable cost and was denoted as the percentage reduction of cost versus the baseline cost-per-test of testing specimens individually. Validation showed a strong correlation between the signals observed when testing specimens individually versus those that were pooled. Average crossing point difference was 1.352 cycles (95% confidence interval of -0.235 and 2.940). Overall agreement observed between individually and pooled tested specimens was 96.8%. Stratified agreement showed an expected decreased performance of pooling for weakly positive specimens dropping below 60% after a crossing point of 35. Post-implementation data showed the consumable cost-savings achieved through this algorithm was 85.5% after 8 months, creating both testing and resource capacity. Pooling is an effective method to be used for SARS-CoV-2 testing during the current pandemic to address resource shortages and provide quick turnaround times for high test volumes without compromising performance.

Performance of MassARRAY system for the detection of SARS-CoV-2 compared to real-time PCR.

Background: Early identification of COVID-19 (coronavirus disease of 2019) by diagnostic tests played an important role in the isolation of infectious patients and management of this pandemic. Various methodologies and diagnostic platforms are available. The current "gold standard" for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) diagnosis is real-time reverse transcriptase-polymerase chain reaction (RT-PCR). To overcome the limitations posed by the short supply experienced early during the pandemic and to increase our capacity, we assessed the performance of the MassARRAY System (Agena Bioscience). Methods: MassARRAY System (Agena Bioscience) combines RT-PCR (reverse transcription-polymerase chain reaction) with high-throughput mass spectrometry processing. We compared the MassARRAY performance to a research-use-only E-gene/EAV (Equine Arteritis Virus) assay and RNA Virus Master PCR. Discordant results were tested with a laboratory-developed assay using the Corman et al. E-gene primers and probes. Results: 186 patient specimens were analyzed using the MassARRAY SARS-CoV-2 Panel. The performance characteristics were as follows: the positive agreement was 85.71%, 95% CI (78.12 - 91.45), and the negative agreement was 96.67%, 95% CI (88.47 - 99.59). 19/186 (10.2%) results were found to be discordant and assessed by a different assay with the exception of 1, where the sample was not available for repeat testing. 14 out of 18 agreed with the MassARRAY after testing with the secondary assay. The overall performance after discordance testing was as follows: the positive agreement was 97.3%, 95% CI (90.58 - 99.67), and the negative agreement was 97.14%, 95% CI (91.88 - 99.41). Conclusion: Our study demonstrates that the MassARRAY System is an accurate and sensitive method for SARS-CoV-2 detection. Following the discordant agreement with an alternate RT-PCR test, the performance was found to have sensitivity, specificity, and accuracy exceeding 97%, making it a viable diagnostic tool. It can be used as an alternative method during periods when real-time RT-PCR reagent supply chains are disrupted.

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018.

BACKGROUND: Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals. METHODS: Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd). RESULTS: Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd). CONCLUSIONS: This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.

Yokenella regensburgei infection in an immunocompetent individual after trauma following a fall from a personal conveyance.

Background: Yokenella regensburgei infections have been documented in several immunocompromised individuals with numerous associated risk factors including soft tissue infections, organ transplants, and metabolic disorders. Our report presents a rare case of Y. regensburgei infection in an immunocompetent individual. Methods: In September 2020, a 38-year-old man who was otherwise healthy fell from a personal conveyance causing a puncture of his elbow. Two months later, he was admitted to the hospital with a chronic draining wound on his left arm with no fever (36.7°C) and stable vital signs. The patient underwent white blood cell (WBC) imaging, and single-photon emission computed tomography (SPECT/CT) to rule out osteomyelitis. Incision and drainage were performed, and the collected fluid was sent to a microbiology lab for culture diagnosis. Subsequently, matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) analysis and antimicrobial susceptibility testing were performed. Results: A WBC image and SPECT/CT test showed an increase in WBC uptake and activity in the subcutaneous tissue of the left arm. The culture diagnosis identified the isolate as Y. regensburgei and the patient received 2 weeks of sulfamethoxazole 800 mg and trimethoprim 160 mg orally twice daily based on the results of the antimicrobial susceptibility testing. He demonstrated clinical improvements shown through wound healing and reduced pain. Conclusion: This report supports the potential of Y. regensburgei to act as an opportunistic pathogen even in hosts with no prior underlying diseases or conditions.

Historique: Les infections à Yokenella regensburgei, qui ont été diagnostiquées chez plusieurs personnes immunodéprimées, sont associées à des facteurs de risque, y compris des infections des tissus mous, des transplantations d'organes et des troubles métaboliques. Le présent rapport expose un rare cas d'infection à Y. regensburgei chez une personne immunocompétente. Méthodologie: En septembre 2020, un homme de 38 ans en bonne santé a subi une blessure ponctiforme sur le coude gauche à cause d'une chute en vélo de montagne. Deux mois plus tard, il a été hospitalisé en raison d'une plaie purulente chronique sur le bras gauche. Il ne faisait pas de fièvre (36,7°C), et ses signes vitaux étaient stables. Il a été soumis à une scintigraphie aux globules blancs et une tomographie par émission monophotonique pour écarter la possibilité d'ostéomyélite. Après une incision et un drainage, le liquide recueilli a été envoyé à un laboratoire de microbiologie pour poser un diagnostic par culture. Une analyse de la spectrométrie de masse à temps de vol selon la technique de désorption-ionisation laser assistée par matrice (MALDI-TOF) et un test de susceptibilité antimicrobienne ont ensuite été exécutés. Résultats: La scintigraphie aux globules blancs et la tomographie par émission monophotonique ont révélé une augmentation de la numération et de l'activité des globules blancs dans les tissus sous-cutanés du bras gauche. La culture a identifié que l'isolat était l'Y. regensburgei, et le patient a reçu un traitement de 800 mg de sulfaméthoxazole et de 160 mg de triméthoprime par voie orale deux fois par jour pendant deux semaines, en fonction du test de susceptibilité antimicrobienne. Son état clinique s'est amélioré, car sa plaie a guéri et sa douleur a diminué. Conclusion: Le présent rapport appuie la possibilité que l'infection à Y. regensburgei agisse comme agent pathogène opportuniste, même chez des hôtes sans maladie ou affection sous-jacente.

Comamonas kerstersii Bacteremia of Unknown Origin.

Comamonas kerstersii (C. kerstersii) is a Gram-negative bacillus abundant in the environment and rarely implicated in human disease. Previously considered nonpathogenic, its scarcity in literature may be partly due to the unreliability of past phenotypic tests used for its identification. In recent years, the development of matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) has enabled fast and accurate laboratory identification of C. kerstersii. Since the first report of human infection in 2013, several others have emerged, with most cases involving peritoneal infection. Here, we present a rare case of C. kerstersii bacteremia in an 82-year-old male patient. With no clear predisposing conditions, the source of his infection is unclear. We accompany this report with a review of C. kerstersii bacteremia cases found in the literature.

Validation of the Cepheid Xpert® Xpress SARS-CoV-2 using upper and lower respiratory tract specimens.

This study validated the performance of the reverse transcriptase-polymerase chain reaction (rRT-PCR) based Cepheid Xpert® Xpress SARS-CoV-2 assay against the TIB MOLBIOL E-gene/EAV, a standard laboratory rRT-PCR SARS-CoV-2 assay. Upper and lower respiratory tract samples (nasopharyngeal and nasal swabs, bronchoalveolar lavage, and tracheal aspirate) were obtained from patients suspected to have contracted COVID-19. Results from the Xpert® Xpress and standard rRT-PCR assays were compared for positive and negative agreement and analyzed for precision, reproducibility, 95% confidence intervals, and coefficients of variation. The Xpert® Xpress assay demonstrated 100% agreement with the standard lab rRT-PCR for both upper and lower respiratory tract samples. Both the Xpert® Xpress and lab rRT-CPR identified weakly positive (Ct values 35-39) sample replicates with 100% reproducibility and showed 100% precision in identifying triplicates of upper respiratory tract samples. The single-cartridge Xpert® Xpress system has a short turnaround time and can be employed to improve patient management and hospital bed allocation. Further verification of the system is required before implementation and consideration must be paid to its higher cost and impracticality for high-throughput use.

Renal Infarcts-A Perplexing Case in the Middle of the COVID-19 Pandemic.

Renal infarction is a rare finding in children. Associations between SARS-CoV-2 infections and thromboembolic events including renal infarcts have been described in adults. Although a similar association in children has not yet been described with this pandemic, the pediatric literature is still evolving with the recognition of new manifestations including the post-infectious Multisystem Inflammatory Syndrome in Children (MIS-C). We report the rare event of multiple renal infarcts in a 6-year-old boy manifesting several features of MIS-C 9 weeks following a self-limiting febrile illness characteristic of COVID-19. An underlying Factor V Leiden mutation was identified in this child but felt to be insufficient on its own to explain his clinical presentation. As SARS-CoV-2 testing was delayed, the failure to identify viral RNA or antibodies may not exclude the virus' potential role in precipitating the infarct in this host. Given that renal infarcts have been described in adult patients with COVID-19, reporting this perplexing case where SARS-CoV-2 may have played a role, may help identify this potential complication.

Antimicrobial use among adult inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program: 2009 to 2016.

BACKGROUND: Antimicrobial resistance is a growing threat to the world's ability to prevent and treat infections. Links between quantitative antibiotic use and the emergence of bacterial resistance are well documented. This study presents benchmark antimicrobial use (AMU) rates for inpatient adult populations in acute-care hospitals across Canada. METHODS: In this retrospective surveillance study, acute-care adult hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) submitted annual AMU data on all systemic antimicrobials from 2009 to 2016. Information specific to intensive care units (ICUs) and non-ICU wards were available for 2014-2016. Data were analyzed using defined daily doses (DDD) per 1000 patient days (DDD/1000pd). RESULTS: Between 2009 and 2016, 16-18 CNISP adult hospitals participated each year and provided their AMU data (22 hospitals participated in ≥1 year of surveillance; 11 in all years). From 2009 to 2016, there was a significant reduction in use (12%) (from 654 to 573 DDD/1000pd, p = 0.03). Fluoroquinolones accounted for the majority of this decrease (47% reduction in combined oral and intravenous use, from 129 to 68 DDD/1000pd, p < 0.002). The top five antimicrobials used in 2016 were cefazolin (78 DDD/1000pd), piperacillin-tazobactam (53 DDD/1000pd), ceftriaxone (49 DDD/1000pd), vancomycin (combined oral and intravenous use was 44 DDD/1000pd; 7% of vancomycin use was oral), and ciprofloxacin (combined oral and intravenous use: 42 DDD/1000pd). Among the top 10 antimicrobials used in 2016, ciprofloxacin and metronidazole use decreased significantly between 2009 and 2016 by 46% (p = 0.002) and 26% (p = 0.002) respectively. Ceftriaxone (85% increase, p = 0.0008) and oral amoxicillin-clavulanate (140% increase, p < 0.0001) use increased significantly but contributed only a small component (8.6 and 5.0%, respectively) of overall use. CONCLUSIONS: This study represents the largest collection of dispensed antimicrobial use data among inpatients in Canada to date. Between 2009 and 2016, there was a significant 12% decrease in AMU, driven primarily by a 47% decrease in fluoroquinolone use. Modest absolute increases in parenteral ceftriaxone and oral amoxicillin-clavulanate use were noted but contributed a small amount of total AMU. Ongoing national surveillance is crucial for establishing benchmarks and antimicrobial stewardship guidelines.

Correction: A controlled-release oral opioid supports S. aureus survival in injection drug preparation equipment and may increase bacteremia and endocarditis risk.

[This corrects the article DOI: 10.1371/journal.pone.0219777.].

The Antibacterial and Anti-inflammatory Activity of Chicken Cathelicidin-2 combined with Exogenous Surfactant for the Treatment of Cystic Fibrosis-Associated Pathogens.

Cystic fibrosis (CF) is characterized by recurrent airway infections with antibiotic-resistant bacteria and chronic inflammation. Chicken cathelicin-2 (CATH-2) has been shown to exhibit antimicrobial activity against antibiotic-resistant bacteria and to reduce inflammation. In addition, exogenous pulmonary surfactant has been suggested to enhance pulmonary drug delivery. It was hypothesized that CATH-2 when combined with an exogenous surfactant delivery vehicle, bovine lipid extract surfactant (BLES), would exhibit antimicrobial activity against CF-derived bacteria and downregulate inflammation. Twelve strains of CF-pathogens were exposed to BLES+CATH-2 in vitro and killing curves were obtained to determine bactericidal activity. Secondly, heat-killed bacteria were administered in vivo to elicit a pro-inflammatory response with either a co-administration or delayed administration of BLES+CATH-2 to assess the antimicrobial-independent, anti-inflammatory properties of BLES+CATH-2. CATH-2 alone exhibited potent antimicrobial activity against all clinical strains of antibiotic-resistant bacteria, while BLES+CATH-2 demonstrated a reduction, but significant antimicrobial activity against bacterial isolates. Furthermore, BLES+CATH-2 reduced inflammation in vivo when either co-administered with killed bacteria or after delayed administration. The use of a host-defense peptide combined with an exogenous surfactant compound, BLES+CATH-2, is shown to exhibit antimicrobial activity against antibiotic-resistant CF bacterial isolates and reduce inflammation.

Candida glabrata Esophagitis: Are We Seeing the Emergence of a New Azole-Resistant Pathogen?

Background. Candida glabrata (C. glabrata) has become a recognized pathogen in fungal esophagitis. A proportion of these isolates are azole-resistant which may have treatment implications. Variability in the prevalence of this organism exists in the limited data available. Objective. To determine the incidence of C. glabrata esophagitis in a North American hospital setting and to highlight factors that may predispose patients to this condition. Methods. Patient charts were collected from January 1, 2009 to July 30, 2011. Any charts of patients identified as having esophagitis with a positive fungal culture were reviewed for the species of Candida and the presence of factors that would predispose them to esophageal candidiasis. Results. The prevalence of Candida esophagitis based on culture was 2.2% (37 subjects). C. glabrata was the 2nd most prevalent pathogen identified (24.3% or 9 subjects). Of the C. glabrata cohort, all patients had at least one factor predisposing them to candidiasis. Conclusion. C. glabrata esophagitis makes up a large portion of the candidal esophagitis seen in hospital. C. glabrata infections were associated with at least one risk factor for candidal infection. Given its resistance to azole-based therapy, this may have treatment implications for how candidal esophagitis is approached by the clinician.

Determination of real-time polymerase chain reaction uncertainty of measurement using replicate analysis and a graphical user interface with Fieller's theorem.

BACKGROUND: Disease monitoring of viruses using real-time polymerase chain reaction (PCR) requires knowledge of the precision of the test to determine what constitutes a significant change. Calculation of quantitative PCR confidence limits requires bivariate statistical methods. OBJECTIVE: To develop a simple-to-use graphical user interface to determine the uncertainty of measurement (UOM) of BK virus, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) real-time PCR assays. METHODS: Thirty positive clinical samples for each of the three viral assays were repeated once. A graphical user interface was developed using a spreadsheet (Excel, Microsoft Corporation, USA) to enable data entry and calculation of the UOM (according to Fieller's theorem) and PCR efficiency. RESULTS: The confidence limits for the BK virus, CMV and EBV tests were ∼0.5 log, 0.5 log to 1.0 log, and 0.5 log to 1.0 log, respectively. The efficiencies of these assays, in the same order were 105%, 119% and 90%. The confidence limits remained stable over the linear range of all three tests. DISCUSSION: A >5 fold (0.7 log) and a >3-fold (0.5 log) change in viral load were significant for CMV and EBV when the results were ≤1000 copies/mL and >1000 copies/mL, respectively. A >3-fold (0.5 log) change in viral load was significant for BK virus over its entire linear range. PCR efficiency was ideal for BK virus and EBV but not CMV. Standardized international reference materials and shared reporting of UOM among laboratories are required for the development of treatment guidelines for BK virus, CMV and EBV in the context of changes in viral load.

HISTORIQUE: Pour surveiller les virus au moyen de la réaction en chaîne de la polymérase (PCR) en temps réel, il faut connaître la précision du test pour déterminer ce qui constitue un changement important. Il faut des méthodes statistiques bivariées pour calculer les limites de confiance de la PCR quantitative. OBJECTIF: Élaborer une interface utilisateur graphique facile à utiliser pour déterminer l'incertitude des mesures (IDM) du virus BK, du cytomégalovirus (CMV) et du virus d'Epstein-Barr (VEB) par PCR en temps réel. MÉTHODOLOGIE: Trente échantillons cliniques positifs de cha-cune des analyses virales ont été répétés une fois. Une interface utilisateur graphique a été élaborée au moyen d'un chiffrier (Excel, Microsoft Corporation, États-Unis) pour saisir les données et calculer l'IDM (selon le théorème de Fieller) et l'efficacité de la PCR. RÉSULTATS: Les limites de confiance des tests du virus BK, du CMV et du VEB étaient de ∼0,5 log, 0,5 log à 1,0 log, et 0,5 log à 1,0 log, respectivement. L'efficacité de ces analyses était de 105 %, de 119 % et de 90 %, respectivement. Les limites de confiance sont demeurées stables pendant la trajectoire linéaire de ces trois tests. EXPOSÉ: Un changement de la charge virale plus de cinq fois plus élevé (0,7 log) et plus de trois fois plus élevé (0,5 log) était important pour le CMV et le VEB lorsque les résultats étaient d'un maximum de 1 000 copies/mL et de plus de 1 000 copies/mL, respectivement. Un changement de la charge virale plus de trois fois élevé (0,5 log) était important pour toute la trajectoire linéaire du virus BK. La PCR avait une efficacité idéale pour le virus BK et le VEB, mais pas pour le CMV. Il faudra élaborer des normes de référence internationales standardisées et partager les signalements d'IDM entre laboratoires pour préparer des directives thérapeutiques relatives au virus BK, au CMV et au VEB dans le contexte des changements de la charge virale.

Risk factors for mortality among patients with Staphylococcus aureus bacteremia: a single-centre retrospective cohort study.

INTRODUCTION: Staphylococcus aureus bacteremia is associated with significant morbidity and mortality. Given the paucity of recent Canadian data, we estimated the mortality rate associated with S. aureus bacteremia in a tertiary care hospital and identified risk factors associated with mortality. METHODS: We retrospectively reviewed the records of adults with S. aureus bacteremia admitted to a tertiary care centre in southwestern Ontario between 2008 and 2012. Cox regression analysis was used to evaluate associations between predictor variables and all-cause, in-hospital, and 90-day postdischarge mortality. RESULTS: Of the 925 patients involved in the study, 196 (21.2%) died in hospital and 62 (6.7%) died within 90 days after discharge. Risk factors associated with in-hospital and all-cause mortality included age, sepsis (adjusted hazard ratio [adjusted HR] 1.49, 95% confidence interval [CI] 1.08-2.06, p = 0.02), admission to the intensive care unit (adjusted HR 3.78, 95% CI 2.85-5.02, p < 0.0001), hepatic failure (adjusted HR 3.36, 95% CI 1.91-5.90, p < 0.0001) and metastatic cancer (adjusted HR 2.58, 95% CI 1.77-3.75, p < 0.0001). Methicillin resistance, hepatic failure, cerebrovascular disease, chronic obstructive pulmonary disease and metastatic cancer were associated with postdischarge mortality. INTERPRETATION: The all-cause mortality rate in our cohort was 27.9%. Identification of predictors of mortality may guide empiric therapy and provide prognostic clarity for patients with S. aureus bacteremia.

Fournier's gangrene of the penis caused by Streptococcus dysgalactiae subspecies equisimilis: case report and incidence study in a tertiary-care hospital.

BACKGROUND: Fournier's gangrene is a rare necrotizing soft tissue infection of the scrotum and penis. We report, to our knowledge, the first case of Fournier's gangrene caused by Streptococcus dysgalactiae subsp. equisimilis (SDSE), a strain of pyogenic ß-hemolytic streptococci that is increasingly being recognized as an important human pathogen. CASE PRESENTATION: We describe a healthy 59 year-old Caucasian male who presented to the emergency department with Fournier's gangrene of the penis and scrotum, with extension to the anterior abdominal wall. He underwent urgent surgical debridement of his scrotum, penis, and anterior abdomen. Swabs from the scrotum grew Gram-positive cocci, which were initially identified as Streptococcus anginosus group by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). However, polymerase chain reaction (PCR) amplification and sequencing of the 16S rRNA gene identified the isolate as Streptococcus dysgalatiae subspecies equisimilis (SDSE). The incidences of invasive S. anginosus group and SDSE infections at the London Health Sciences Centre, a tertiary-care institution in southwestern Ontario, were determined between August 1, 2011 and August 31, 2012, revealing a slightly lower rate of SDSE (3.2 cases per 100,000 population) than other studies. CONCLUSIONS: This case highlights a unique disease manifestation of the emerging human pathogen Streptococcus dysgalatiae subspecies equisimilis that has not been previously reported. This case also underscores the limitations of MALDI-TOF MS in differentiating between closely-related streptococcal species which may have different pathogenic profiles.