Treatment of MDR urinary tract infections with oral fosfomycin: a retrospective analysis.

OBJECTIVES: Limited options for treating MDR organisms have led clinicians to turn to older antimicrobial agents that may display activity against such infections. One such agent is fosfomycin, an oral drug with activity against a variety of Gram-positive and -negative bacteria, but only approved for use in the USA for urinary tract infection (UTI) due to Escherichia coli and Enterococcus faecalis. The purpose of this study was to assess the efficacy of fosfomycin treatment of MDR UTI and identify predictors of outcome. PATIENTS AND METHODS: A retrospective review was performed of patients treated for MDR UTI at a large quaternary medical centre between 1 January 2010 and 30 September 2014. Sixty patients received 69 courses of fosfomycin in the inpatient or outpatient setting for UTIs due to Enterobacteriaceae, Pseudomonas aeruginosa or VRE. RESULTS: In the 58 patients for whom follow-up data were available, the treatment success rate (no persistent or recurrent infection) was 55%. Chronic kidney disease was associated with persistent infection (OR = 3.56, 95% CI = 1.02-12.40, P = 0.04). No other factors, including comorbidities, infecting organism, fosfomycin MIC or number of doses of fosfomycin received, were associated with recurrent infection or treatment failure. CONCLUSIONS: This study supports the use of fosfomycin as an oral option for treating MDR UTIs. Additional studies are required to assess the optimal dosing and utility of combination therapy to decrease the incidence of treatment failure.

The Burden of Arboviral Infections in the Military Health System 2012-2019.

Arboviral infections, including dengue (DNV), chikungunya (CHIKV), and Zika (ZIKV), impact both travelers and native populations of endemic regions. We sought to assess the disease burden of arboviral infections in the Military Health System, the validity of arboviral diagnostic codes, and the role of pretravel counseling on insect avoidance precautions. We searched for diagnostic codes consistent with arboviral infection and grouped them into DNV, CHIKV, ZIKV, Japanese encephalitis virus (JEV), and Other. Demographic data were evaluated. A subset of charts in each category were reviewed for diagnostic validity and travel characteristics. In all, 10,547 unique subjects carried 17,135 arboviral diagnostic codes, including 1,606 subjects (15.2%) coded for DNV, 230 (2.2%) for ZIKV, 65 (0.6%) for CHIKV, and 4,317 (40.9%) for JEV. A chart review was performed on 807 outpatient charts, yielding outpatient diagnostic code positive predictive values of 60.5% (DNV), 15.3% (ZIKV), and 64.5% (CHIKV); there were no valid cases of JEV. Dengue represented the greatest burden of arboviral infections with 2.2 cases per 100,000 military healthcare enrollees over the 2012-2019 fiscal years. More than 80% of subjects with arboviral infection did not have documented pretravel counseling. Arboviral infections represent a significant disease burden in young travelers to endemic regions. After adjustment for diagnostic validity, DNV represented the greatest burden. Diagnostic codes for ZIKV and JEV overestimate the burden of these diseases. Low rates of pretravel visits represent an opportunity for increased emphasis on insect exposure precautions.

Developing Military Doctors: An Institutional Approach to Medical Force Readiness in Graduate Medical Education.

Military physicians are required to not only meet civilian accreditation standards upon completion of their Graduate Medical Education (GME) training programs but also be proficient in the military-unique aspects of their field, including medical care in austere environments and management of combat casualties. They must also be familiar with the administrative and leadership aspects of military medicine, which are often absent from the training curriculum. The San Antonio Uniformed Services Health Education Consortium Military Readiness Committee, by incorporating questions of military relevance into each GME program's mandatory Annual Program Evaluation, identified curricular gaps upon which military readiness training objectives and opportunities were developed. These activities included a lecture series on the sustainment of medical and military readiness, an interactive procedural skills training event, trainee involvement in operational pre-deployment exercises, and the development of an elective operational rotation in Honduras. The Military Readiness Committee provides a model for other military GME institutions to develop training goals and opportunities to strengthen the preparedness of their trainees for military service.

Sporotrichosis in a U.S. Army Basic Trainee.

Lymphocutaneous sporotrichosis is a mycotic disease caused by traumatic inoculation of the dimorphic fungus Sporothrix schenckii, found ubiquitously in decaying vegetation. The potential for outbreaks, difficulty with timely diagnosis, as well as the prolonged treatment course and recovery from surgical intervention can have a substantial impact on the medical readiness of service members. Treatment with the antifungal therapy of choice, itraconazole, requires close patient monitoring for the duration of treatment for clinical response, drug tolerance, as well as therapeutic drug levels. We present a case of a U.S. Army enlistee with sporotrichosis contracted during basic training, highlighting the impact of delayed diagnosis and prolonged treatment course and recovery on medical readiness.

Late-onset ulnar neuritis following treatment of lepromatous leprosy infection.

Neuritis is a frequent complication of Myocobacteria leprae infection and treatment due to the variety of mechanisms through which it can occur. Not only can mycobacterial invasion into peripheral nerves directly cause damage and inflammation, but immune-mediated inflammatory episodes (termed leprosy reactions) can also manifest as neuritis at any point during infection. Treatment of leprosy reactions with thalidomide can also lead to neuritis due to an adverse drug effect. Neuritis can emerge years after initial diagnosis and treatment, although it is most frequently found at time of diagnosis or early into the treatment course. Treatment of neuritis is dependent on high-dose corticosteroid therapy as well as therapy for suspected underlying etiology. Here, we present a case of ulnar neuritis presenting in a patient with lepromatous leprosy four years after treatment of initial infection, with subsequent improvement after corticosteroid burst while maintained on thalidomide therapy.