Percutaneous mechanical aspiration in patients with right-sided infective endocarditis: An analysis of the national inpatient sample database-2016-2020.

BACKGROUND: Given the challenges of conventional therapies in managing right-sided infective endocarditis (RSIE), percutaneous mechanical aspiration (PMA) of vegetations has emerged as a novel treatment option. Data on trends, characteristics, and outcomes of PMA, however, have largely been limited to case reports and case series. AIMS: The aim of the current investigation was to provide a descriptive analysis of PMA in the United States and to profile the frequency of PMA with a temporal analysis and the patient cohort. METHODS: The International Classification of Diseases, 10th Revision codes were used to identify patients with RSIE in the national (nationwide) inpatient sample (NIS) database between 2016 and 2020. The clinical characteristics and temporal trends of RSIE hospitalizations in patients who underwent PMA was profiled. RESULTS: An estimated 117,955 RSIE-related hospital admissions in the United States over the 5-year study period were estimated and 1675 of them included PMA. Remarkably, the rate of PMA for RSIE increased 4.7-fold from 2016 (0.56%) to 2020 (2.62%). Patients identified with RSIE who had undergone PMA were young (medial age 36.5 years) and had few comorbid conditions (median Charlson Comorbidity Index, 0.6). Of note, 36.1% of patients had a history of hepatitis C infection, while only 9.9% of patients had a cardiovascular implantable electronic device. Staphylococcus aureus was the predominant (61.8%) pathogen. Concomitant transvenous lead extraction and cardiac valve surgery during the PMA hospitalization were performed in 18.2% and 8.4% of admissions, respectively. The median hospital stay was 19.0 days, with 6.0% in-hospital mortality. CONCLUSIONS: The marked increase in the number of PMA procedures in the United States suggests that this novel treatment option has been embraced as a useful tool in select cases of RSIE. More work is needed to better define indications for the procedure and its efficacy and safety.

Blood Stream Infections in COVID-19 Patients From a Tertiary Care Center in Lebanon: Causative Pathogens and Rates of Multi-Drug Resistant Organisms.

Objective: To report the microbiological profile of the pathogens implicated in blood stream infections (BSI) in hospitalized coronavirus disease 2019 (COVID-19) patients and to examine the risk factors associated with multidrug-resistant organisms (MDROs) causing BSI. Patients and Methods: Between March 2020 and September 2021, 1647 patients were hospitalized with COVID-19 at the American University of Beirut. From 85 patients, 299 positive blood cultures were reported to the Infection Control and Prevention Program. The BSI was defined as 1 positive blood culture for bacterial or fungal pathogens. The following organisms were considered MDROs: methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp, carbapenem-resistant Enterobacterales spp., carbapenem-resistant Pseudomonas aeruginosa, MDR Acinetobacter baumannii only susceptible to colistin or tigecycline, and Candida auris. Results: We identified 99 true positive BSI events. Gram-negative bacteria accounted for 38.4 %, followed by Gram-positive bacteria (37.4%), and fungi (24.2%). The most isolated species were Candida spp. (23%), 3 of which were C. auris, followed by Enterobacterales spp. (13%), Enterococcus spp. (12%), S. aureus (9%), P. aeruginosa (9%), and A. baumannii (3%). The MDROs represented 26% of the events. The overall mortality rate was 78%. The time to acquisition of BSI in patients with MDROs was significantly longer compared with that of non-MDROs (20.2 days vs 11.2 days). And there was a significantly shorter time from acquisition of BSI to mortality between MDROs and non-MDROs (1.5 vs 8.3 days). Conclusion: Rigorous infection prevention and control measures and antimicrobial stewardship are important to prevent antimicrobial resistance progression, especially in low-resource settings.

Bacterial respiratory infections in patients with COVID-19: A retrospective study from a tertiary care center in Lebanon.

BACKGROUND: Despite multiple reports of increased incidence of bacterial respiratory tract infections following COVID-19 globally, the microbiology is not yet fully elucidated. In this study, we describe the microbiology of bacterial infections and the prevalence of multidrug resistant organisms (MDROs) in hospitalized COVID-19 patients with community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP) which includes both non-ventilated hospital acquired pneumonia (NVHAP) and ventilator-associated pneumonia (VAP). To our knowledge, this is the first study that compares the microbiology of VAP and NVHAP in COVID-19 patients. METHODS: This is a longitudinal retrospective cohort study conducted at the American University of Beirut Medical Center (AUBMC), a tertiary-care centre in Lebanon. Adult patients with confirmed COVID-19 and concurrent bacterial respiratory infections with an identifiable causative organism who were hospitalized between March 2020 and September 2021 were included. Bacterial isolates identified in hospital-acquired pneumonia (HAP) were divided into 3 groups based on the time of acquisition of pneumonia after admission: hospital day 3-14, 15-28 and 29-42. RESULTS: Out of 1674 patients admitted with COVID-19, 159 (9.5%) developed one or more respiratory infections with an identifiable causative organism. Overall, Gram-negative bacteria were predominant (84%) and Stenotrophomonas maltophilia was the most common pathogen, particularly in HAP. Among 231 obtained isolates, 59 (26%) were MDROs, seen in higher proportion in HAP, especially among patients with prolonged hospital stay (> 4 weeks). Non-fermenter Gram-negative bacilli (NFGNB) (OR = 3.52, p-value<0.001), particularly S. maltophilia (OR = 3.24, p-value = 0.02), were significantly more implicated in VAP compared to NVHAP. CONCLUSIONS: NFGNB particularly S. maltophilia were significantly associated with COVID-19 VAP. A high rate of bacterial resistance (25%), especially among Gram-negative bacteria, was found which may compromise patients' outcomes and has important implications in guiding therapeutic decisions in COVID-19 patients who acquire bacterial respiratory infections.

Bloodstream Infection Due to Coagulase-Negative Staphylococci: Impact of Species on Prevalence of Infective Endocarditis.

(1) Background: Coagulase-negative staphylococci (CoNS) are an important group of organisms that can cause bloodstream infection (BSI) and infective endocarditis (IE). The prevalence of IE in patients with BSI due to different CoNS species, however, has received limited attention; (2) Methods: A retrospective study of adults with monomicrobial CoNS BSI who had undergone echocardiography and a risk factor analysis was done to determine the most common CoNS species that cause definite IE; (3) Results: 247 patients with CoNS BSI were included in the investigation; 49 (19.8%) had definite IE, 124 (50.2%) possible IE, and 74 (30.0%) BSI only. The latter two entities were grouped in one category for further analysis. The most common species in CoNS BSI was Staphylococcus epidermidis (79.4%) and most patients (83.2%) had possible IE/BSI only. 59.1% of patients with BSI due to S. lugdunensis had definite IE. The majority of CoNS were healthcare-associated/nosocomial bacteremia. Multivariable analysis demonstrated that valve disease (p = 0.002) and a foreign cardiovascular material (p < 0.001) were risk factors associated with definite IE. Patients with S. lugdunensis BSI had an 8-fold higher risk of definite IE than did those with S. epidermidis BSI and nearly a 13-fold higher risk than did patients with BSI due to other species of CoNS (p = 0.002); (4) Conclusions: The prevalence of definite IE in patients with BSI due to different CoNS species was significant. CoNS bacteremia, particularly with S. lugdunensis, confers a significant risk of IE, particularly in patients with a valve disease or intravascular foreign body material and should not be immediately dismissed as a contaminant.

Advances in contraception: vaginal contraceptive rings.

The vaginal contraceptive ring is very effective and user dependent. In this article, we will discuss the different types of vaginal contraceptive rings, namely, the etonogestrel/ethinyl estradiol (ENG/EE) ring (NuvaRing, Merck, Rahway, NJ, USA) and the segesterone acetate (SA)/EE (Annovera, Mayne Pharma, Raleigh, NC, USA) ring. The details of dosing and administration, indications, advantages, disadvantages, and cost-effectiveness are presented. This literature review was conducted using PubMed and Google Scholar. The search terms included 'vaginal contraceptive ring', 'etonogestrel/ethinyl estradiol ring', and 'segesterone acetate/ethinyl estradiol ring'. The search was then sorted by year from 2000 until present, and the most recent articles were reviewed. The purpose of this article is to provide a comprehensive reference on the two vaginal contraceptive rings widely used in the United States for clinicians to guide management. Both vaginal contraceptive rings are combination of hormonal contraceptives that suppress ovulation and create physiologic conditions unfavorable for pregnancy. The ENG/EE ring is designed to be replaced monthly, while the SA/EE ring is a single device used over the course of 1 year. Common side effects of both devices include headaches, nausea, vomiting, and vaginitis. Serious adverse reactions can occur with the vaginal contraceptive rings including venous thromboembolism, psychiatric events, and hypersensitivity. Both devices are contraindicated in patients at high risk for arterial or venous thrombotic events, patients with a history of breast cancer or other estrogen/progesterone cancers, and patients with severe liver disease. Overall, the vaginal contraceptive ring is well tolerated and liked by patients. Patients should be well counseled on known severe adverse reactions. The vaginal contraceptive ring is more expensive than other forms of contraception and this should be an important point of discussion with patients.

The battle against fungi: lessons in antifungal stewardship from COVID 19 times

The COVID-19 pandemic has highlighted the detrimental effect of secondary pathogens in patients with a primary viral insult. In addition to superinfections with bacterial pathogens, invasive fungal infections were increasingly reported. The diagnosis of pulmonary fungal infections has always been challenging; however, it became even more problematic in the setting of COVID-19, particularly regarding the interpretation of radiological findings and mycology test results in patients with these infections. Moreover, prolonged hospitalization in ICU, coupled with underlying host factors. such as preexisting immunosuppression, use of immunomodulatory agents, and pulmonary compromise, caused additional vulnerability to fungal infections in this patient population. In addition, the heavy workload, redeployment of untrained staff, and inconsistent supply of gloves, gowns, and masks during the COVID-19 outbreak made it harder for healthcare workers to strictly adhere to preventive measures for infection control. Taken together, these factors favored patient-to-patient spread of fungal infections, such as those caused by Candida auris, or environment-to-patient transmission, including nosocomial aspergillosis. As fungal infections were associated with increased morbidity and mortality, empirical treatment was overly used and abused in COVID-19-infected patients, potentially contributing to increased resistance in fungal pathogens. The aim of this paper was to focus on essential elements of antifungal stewardship in COVID-19 for three fungal infections, COVID-19-associated candidemia (CAC), -pulmonary aspergillosis (CAPA), and -mucormycosis (CAM).

Management of cytomegalovirus infection in allogeneic hematopoietic stem cell transplants.

Cytomegalovirus (CMV) is a common infection encountered in immunocompromised patients. It is associated with high morbidity and mortality, particularly in patients undergoing allogeneic (allo-) haematopoietic stem cell transplantation (HSCT). This review presents the most recent management strategies for CMV infection in allo-HSCT recipients. Pre-emptive treatment (PET) consists of frequent monitoring of CMV polymerase chain reaction (PCR) after HSCT; this has been the standard of care for prevention of CMV for many years, given the potential drug toxicity associated with the traditional drugs used as prophylaxis. However, letermovir, recently approved as a chemoprophylactic agent for prevention of CMV, has shown great efficacy in randomized clinical trials and real-world data. Treatment of CMV disease is becoming increasingly difficult, and must take into account the patient's risk profile and the potential for CMV drug resistance. Different treatment strategies exist for refractory and resistant CMV disease. Maribavir is a new drug that showed promising results in the treatment of refractory and resistant CMV disease. Other alternative treatments, such as cellular adoptive immunotherapy, artesunate and leflunomide, may play an adjunctive role in the treatment of challenging cases; however, further investigation is warranted.

Diagnostic stewardship in infectious diseases: a continuum of antimicrobial stewardship in the fight against antimicrobial resistance.

Antimicrobial resistance (AMR) has been exacerbated by the inappropriate use of diagnostics, leading to excessive prescription of antimicrobials, and is an imminent threat to global health. Diagnostic stewardship (DS) is an auxiliary to antimicrobial stewardship (AMS) and comprises ordering the right tests, for the right patient, at the right time. It also promotes the judicious use of rapid and novel molecular diagnostic tools to enable the initiation of proper antibiotic therapy, while avoiding excessive use of broad-spectrum antibiotics. Proper interpretation of test results is crucial to avoid overdiagnosis and excessive healthcare costs. Although many rapid diagnostic tools have been developed with a high diagnostic yield, they are often limited by accessibility, cost, and lack of knowledge regarding their use. Careful consideration of clinical signs and symptoms with knowledge of the local epidemiology are essential for DS. This enables appropriate interpretation of microbiological results. Multidisciplinary teams that include well trained professionals should cooperate to promote DS. Challenges and barriers to the implementation of DS are mostly caused by scarcity of resources and lack of trained personnel and, most importantly, lack of knowledge. The lack of resources is often due to absence of awareness of the impact that good medical microbiology diagnostic facilities and expertise can have on the proper use of antibiotics.

High fever in myelin oligodendrocyte glycoprotein-associated disorder (MOGAD): A diagnostic challenge.

The phenotypic spectrum of myelin oligodendrocyte glycoprotein (MOG)-IgG associated disorders (MOGAD) has broadened in the past few years, and atypical phenotypes are increasingly recognized. Febrile meningoencephalitis has rarely been reported as a feature of MOGAD and represents a diagnostic challenge. We report the case of 24-year-old women with high-grade fever, meningoencephalomyelitis, and persistently positive MOG-IgG, for whom an extensive infectious work-up was negative and who responded to high-dose intravenous methylprednisolone. The full clinical spectrum of MOGAD is yet to be completely elucidated. In patients presenting with febrile meningoencephalitis, MOG-IgG testing should be considered particularly if infectious work-up is negative.

The Ten Most Common Questions on Cytomegalovirus Infection in Hematopoietic Stem Cell Transplant Patients.

With the rising number of patients undergoing hematopoietic stem cell transplantation (HSCT), clinicians are more likely to encounter infectious complications in immunocompromised hosts, particularly cytomegalovirus (CMV) infection. Besides the high mortality of CMV end-organ disease, patients with detectable CMV viremia may have worse outcomes and decreased survival even in the absence of end-organ disease. In view of the implications on morbidity and mortality, clinicians should maintain a high index of suspicion and initiate antiviral drugs promptly when CMV infection is confirmed. High-risk patients should be identified in order to provide optimal management. Additionally, novel antiviral agents with a good safety profile and minor adverse events are now available for prophylaxis in high-risk patients and for treatment of resistant or refractory CMV infection. The following review provides concise, yet comprehensive, guidance on the burden and risk factors of CMV in this population, as well as an update on the latest evidence for the management of CMV infection.

Utility of Metagenomic Next-Generation Sequencing in Infective Endocarditis: A Systematic Review.

Blood cultures have been the gold standard for identifying pathogens in infective endocarditis (IE). Blood culture-negative endocarditis (BCNE), however, occurs in 40% or more of IE cases with the bulk of them due to recent antibiotic exposure prior to obtaining blood cultures. Increasingly, molecular techniques are being used for pathogen identification in cases of BCNE and more recently has included metagenomic next-generation sequencing (mNGS). We therefore performed a literature search on August 31, 2022, that assessed the mNGS in IE and 13 publications were identified and included in a systematic review. Eight (61.5%) of them focused only on IE with mNGS performed on cardiac valve tissue in four studies, plasma in three studies and cardiac implantable electronic devices (CIED) in one study. Gram-positive cocci, including Staphylococcus aureus (n = 31, 8.9%), coagulase-negative staphylococci (n = 61, 17.6%), streptococci (n = 130, 37.5%), and Enterococcus faecalis (n = 23, 6.6%) were the predominant organisms identified by mNGS. Subsequent investigations are needed to further define the utility of mNGS in BCNE and its impact on patient outcomes. Despite some pitfalls, mNGS seems to be of value in pathogen identification in IE cases, particularly in those with BCNE. This study was registered and on the Open Science Framework platform.

Correction: Human monkeypox: A review of the literature.

[This corrects the article DOI: 10.1371/journal.ppat.1010768.].

Challenges of coronavirus disease 2019 (COVID-19) in Lebanon in the midst of the economic collapse.

Lebanon, one of the smallest countries in the Middle East, has held for decades a reputation for being the premier medical hub for patients from the Arab world as well as neighboring countries and for offering world-class treatment and advanced medical services. However, this once world-renowned healthcare sector is now facing a risk of imminent collapse as overlapping crises have struck the country since October 2019. In this article, we describe the concomitant political, economic, and financial challenges that Lebanon is facing, which have strained the national healthcare system and have undermined its ability to respond to the coronavirus disease 2019 (COVID-19) pandemic. We present an overview of the political instability, the Lebanese revolution with countrywide protests, as well as the devaluation of the Lebanese currency representing one of the worst economic meltdowns since the 19th century. We describe the unprecedented energy crisis the country is facing and the disastrous consequences of the Beirut port explosion of August 2020. We review the efforts and measures taken by different stakeholders to contain the COVID-19 pandemic amid the multifaceted challenges and the large exodus of healthcare personnel.

Cladophialophora bantiana brain abscess and concurrent pulmonary cryptococcus neoformans infection in a patient twenty years after renal transplantation.

Recipients of solid organ transplants are at risk for a variety of infections due to their immunocompromised status. The types of infections are often correlated to the timing from their transplant. After about six to twelve months, transplant recipients remain at risk for typical community acquired pathogens, late viral infections, and fungal infections including atypical molds such as Cladophialophora bantiana. C. bantiana is a dematiaceous fungus that has a predilection for infecting the brain and is the most common cause of cerebral phaeohyphomycosis - a term used to describe infections caused by molds that produce dark cell walls. Patients with cerebral abscesses due to C. bantiana infections have an estimated mortality of about 70%. Improved outcomes have been seen in patients who receive both surgical and antifungal therapy. While there are no clear guidelines on antifungal therapy, most cases have been treated with combination amphotericin B, a triazole (itraconazole, voriconazole, or posaconazole) with flucytosine sometimes in conjunction as well. This case describes a patient with C. bantiana brain abscess and concurrent Cryptococcus neoformans pulmonary infection that occurred twenty years after his kidney transplantation. He was treated successfully with two craniotomies for cerebral abscess debridement and liposomal amphotericin B followed by planned lifelong voriconazole.

Antimicrobial Treatment of Pseudomonas aeruginosa Severe Sepsis.

Pseudomonas aeruginosa is a pathogen often encountered in a healthcare setting. It has consistently ranked among the most frequent pathogens seen in nosocomial infections, particularly bloodstream and respiratory tract infections. Aside from having intrinsic resistance to many antibiotics, it rapidly acquires resistance to novel agents. Given the high mortality of pseudomonal infections generally, and pseudomonal sepsis particularly, and with the rise of resistant strains, treatment can be very challenging for the clinician. In this paper, we will review the latest evidence for the optimal treatment of P. aeruginosa sepsis caused by susceptible as well as multidrug-resistant strains including the difficult to treat pathogens. We will also discuss the mode of drug infusion, indications for combination therapy, along with the proper dosing and duration of treatment for various conditions with a brief discussion of the use of non-antimicrobial agents.

Human monkeypox: A review of the literature.

Monkeypox (MPX) has recently made international headlines for the rapid and simultaneous progression of the disease across the world. This review aims at summarizing the literature available as well as describing the evolution of the disease as it pertains to the cases today along with potential treatments and infection control strategies. To date, more than 76 countries have reported cases in more than 12,261 people. Before this, MPX was a rare zoonotic disease confined to endemic areas in Western and Central Africa with sporadic outbreaks namely in the United States, associated with the import of wild animals from Ghana. However, during the current outbreak, human-to-human transmission has become the primary mode of transmission, raising concerns for unaccounted community spread. Most of these patients did not travel to the endemic areas of Africa, suggesting possible previously underdetected community transmission. Observations from emergent cases have reported that the manifestations of the disease were sometimes atypical from what has been previously described. Young men who have sex with men seem to be the population most vulnerable to infection. Though the disease is currently perceived to be mild in its clinical course, questions that remain unclear and warrant further investigation include potential of humans harboring a genital reservoir of the virus and the possibility of airborne transmission, which has implications for infection control and health of the community at large.

SARS-CoV-2 genome variations and evolution patterns in Egypt: a multi-center study.

A serious global public health emergency emerged late November 2019 in Wuhan City, China, by a new highly pathogenic virus, SARS-CoV-2. The virus evolution spread has been tracked by three developing databases: GISAID, Nextstrain and PANGO to understand its circulating variants. In this study, 110 diagnosed positive COVID-19 patient's samples, were collected from Kasr Al-Aini Hospital and the Children Cancer Hospital Egypt 57357 between May 2020 and January 2021, with clinical severity ranging from mild to severe. The viral genomes were sequenced by next generation sequencing, and phylogenetic analysis was performed to understand viral transmission dynamics. According to Nextstrain clades, most of our sequenced samples belonged to clades 20A and 20D, which in addition to clade 20B were present from the beginning of sample collection in May 2020. Clades 19A and 19B, on the other hand, appeared in the mid and late 2020 respectively, followed by the disappearance of clade 20B at the end of 2020. We identified a relatively high prevalence of the D614G spike protein variant and novel patterns of mutations associated together and with different clades. We also identified four mutations, spike H49Y, ORF3a H78Y, ORF8 E64stop and nucleocapsid E378V, associated with higher disease severity. Altogether, our study contributes genetic, phylogenetic, and clinical correlation data about the spread of the SARS-CoV-2 pandemic in Egypt.