Impact of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) vaccination on the incidence of coronavirus disease 2019 (COVID-19) among healthcare workers at an academic medical center in Vermont.

Infection prevention strategies and vaccination reduce risk of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission to healthcare workers (HCWs). We describe coronavirus disease 2019 (COVID-19) incidence and vaccination rates in a cohort of HCWs at the University of Vermont Medical Center. Before vaccines, the HCW COVID-19 incidence paralleled that of the State of Vermont; after vaccination, incidence fell and remained low.

The Impact of Standardized Infectious Diseases Consultation on Postsplenectomy Care and Outcomes.

Background: Patients who receive splenectomy are at risk for overwhelming postsplenectomy infection (OPSI). Guidelines recommend that adult asplenic patients receive a complement of vaccinations, education on the risks of OPSI, and on-demand antibiotics. However, prior literature suggests that a majority of patients who have had a splenectomy receive incomplete asplenic patient care and thus remain at increased risk. This study assessed the impact of standardized involvement of infectious diseases (ID) providers on asplenic patient care outcomes in patients undergoing splenectomy. Methods: A quasi-experimental study design compared a prospective cohort of patients undergoing splenectomy from August 2017 to June 2021 who received standardized ID involvement in care of the asplenic patient with a historic control cohort of patients undergoing splenectomy at the same institution from January 2010 through July 2017 who did not. There were 11 components of asplenic patient care defined as primary outcomes. Secondary outcomes included the occurrence of OPSI, death, and death from OPSI. Results: Fifty patients were included in the prospective intervention cohort and 128 in the historic control cohort. There were significant improvements in 9 of the 11 primary outcomes in the intervention arm as compared with the historic controls. Survival analysis showed no statistically significant difference in the incidence of OPSI-free survival between the groups (P = .056), though there was a trend toward improvement in the prospective intervention arm. Conclusions: Standardized involvement of an ID provider in the care of patients undergoing splenectomy improves asplenic patient care outcomes. Routine involvement of ID in this setting may be warranted.

Brain abscess with pyogenic ventriculitis.

The authors present the case of a 57-year-old male with a large polymicrobial brain abscess complicated by eruption into the intraventricular space. He was treated with parenteral ampicillin, cefepime, and metronidazole and adjuvant intraventricular vancomycin/gentamicin as well as surgical debridement. The authors discuss the diagnosis, treatment, and prognosis of brain abscesses, with a focus on prior cases with pyogenic ventriculitis and those treated with intraventricular antimicrobials.

What Are We Really Talking About? An Organizing Framework for Types of Consultation and Their Implications for Physician Communication.

Consultation amongst providers is a foundation of modern health care and one of the most frequent means of interdisciplinary communication. Accordingly, clear and efficient communication between providers and across medical specialties during consultation is essential to patient care and a collegial work environment. Traditionally, consultation requests are felt to require a clear question that falls within the purview of the consultant's expertise. However, this narrow constraint is often lacking in the real-world clinical environment and may in fact be detrimental to physician communication and patient care. In this Perspective, the authors propose an organizing framework of seven specific consultation types, which apply broadly across disciplines: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside. The authors describe what factors define each type and the benefits and pitfalls of each. The proposed framework may help providers have more productive, efficient, and collegial conversations about patient care, which may facilitate improved work satisfaction and an enhanced learning environment.

When are Oral Antibiotics a Safe and Effective Choice for Bacterial Bloodstream Infections? An Evidence-Based Narrative Review.

Bacterial bloodstream infections (BSIs) are a major cause of morbidity and mortality in the United States. Traditionally, BSIs have been managed with intravenous antimicrobials. However, whether intravenous antimicrobials are necessary for the entirety of the treatment course in BSIs, especially for uncomplicated episodes, is a more controversial matter. Patients that are clinically stable, without signs of shock, or have been stabilized after an initial septic presentation, may be appropriate candidates for treatment of BSIs with oral antimicrobials. There are risks and costs associated with extended courses of intravenous agents, such as the necessity for long-term intravenous catheters, which entail risks for procedural complications, secondary infections, and thrombosis. Oral antimicrobial therapy for bacterial BSIs offers several potential benefits. When selected appropriately, oral antibiotics offer lower cost, fewer side effects, promote antimicrobial stewardship, and are easier for patients. The decision to use oral versus intravenous antibiotics must consider the characteristics of the pathogen, the patient, and the drug. In this narrative review, the authors highlight areas where oral therapy is a safe and effective choice to treat bloodstream infection, and offer guidance and cautions to clinicians managing patients experiencing BSI.

The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.

BACKGROUND: Curbside consultations are common in clinical practice. The complexity, relative value, and revenue loss associated with curbside consultations are not well defined. METHODS: Curbside consultations performed during a 1-year period were studied. Each curbside consultation was assigned a Current Procedural Terminology (CPT) code on the basis of the inpatient versus outpatient status of the patient, initial versus subsequent care, and clinical complexity. On the basis of the CPT code, the physician work component of the relative value unit (wRVU) was assigned for each curbside consultation. The 2005 Centers for Medicaid and Medicare Services conversion factor of $37.89 per wRVU was used for cost estimates. Comparisons were made with formal consultations performed during the same time period. RESULTS: A total of 1001 curbside consultations were fielded: 66% involved outpatients, and 97% were coded as initial consultations. A total of 78% of curbside consultations were considered complex in nature, being assigned a CPT code of level 4-5, including 84% of the inpatient and 75% of the outpatient curbside consultations. These curbside consultations would have generated 2480 wRVUs. During the same period, formal consultations generated 12,121 wRVUs. Thus, curbside consultations represented 17% (2480/14,601) of the clinical work value of the infectious diseases unit. If the infectious diseases unit had performed these curbside consultations as formal consultations, an additional $93,979 in revenue would have been generated. CONCLUSIONS: Curbside consultations are common and complex. The curbside consultation should be incorporated into measures of infectious diseases providers' productivity and compensation.

The Vermont model for rural HIV care delivery: eleven years of outcome data comparing urban and rural clinics.

CONTEXT: Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. PURPOSE: To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. METHODS: This was a retrospective cohort study. FINDINGS: Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm(3)-350/mm(3) vs 182 cells/mm(3)-379/mm(3)). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]). CONCLUSIONS: This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.

Use of longitudinal surveillance data to assess the effectiveness of infection control in critical care.

A simple method for quantifying nosocomial infection and colonization with multidrug-resistant organisms is described. This method is applied to the intensive care unit of an academic medical center where longitudinal surveillance data have been used to assess the impact of infection control interventions and antibiotic use.

Childhood cryptosporidiosis is associated with a persistent systemic inflammatory response.

Cryptosporidiosis in young children prompts local inflammation in the intestinal tract. We studied a cohort of young children with cryptosporidiosis to determine whether systemic inflammatory responses occur and, if so, to evaluate whether inflammation persists after infection. Cryptosporidiosis was associated with increased levels of interleukin-8 and tumor necrosis factor- alpha systemically, which persisted at 6 months after enrollment. The level of intestinal tumor necrosis factor- alpha was elevated at enrollment, but elevated levels did not persist. Worsening of malnutrition, particularly stunting, was observed after infection. The association of cryptosporidiosis, inflammation, and stunting in children with cryptosporidiosis warrants further evaluation.

Serum mannose-binding lectin deficiency is associated with cryptosporidiosis in young Haitian children.

BACKGROUND: Mannose-binding lectin (MBL) is a component of the innate immune response and binds microbial surfaces through carbohydrate recognition domains. MBL deficiency may contribute to susceptibility to a variety of infectious diseases, particularly in young children. MBL binds to the Cryptosporidium sporozoite and may be important in resistance to cryptosporidiosis. METHODS: We studied the association of serum MBL levels and cryptosporidiosis in a case-control study of young Haitian children with cryptosporidiosis versus children who were control subjects. RESULTS: Ninety-nine children were enrolled, as follows: 49 children with cryptosporidiosis, 41 healthy controls, and 9 children with diarrhea from other causes. Case children were more malnourished than controls, and 49% had persistent or chronic diarrhea. At enrollment, mean serum MBL levels were markedly lower in children with cryptosporidiosis (P = .002), as was the number of children with an MBL deficiency of < or = 70 ng/mL (P = .005). In multivariate analysis, the association of cryptosporidiosis and MBL deficiency persisted (P = .002; adjusted odds ratio, 22.4), as did the association of cryptosporidiosis with general malnutrition. The subset of children with cryptosporidiosis and MBL deficiency were more likely to be male (P = .025). CONCLUSIONS: MBL may be an important component of innate immune protection against Cryptosporidium infection in young children. Additional studies are necessary to determine whether MBL intestinal losses, deficient epithelial expression, and/or genetic polymorphisms in the MBL gene contribute to MBL deficiency in cryptosporidiosis and other enteric infections in young children.

Current immunizations for travel.

PURPOSE OF REVIEW: International travelers may be at risk from a variety of potentially severe and life-threatening infections. Some of these diseases are preventable, and vaccination remains a cornerstone of travel medicine. Vaccines that are important for international travel are reviewed, in a succinct update based on the most recent literature. RECENT FINDINGS: Discussed are vaccines for enteric infections (polio, cholera, hepatitis A, and typhoid), as well as those for hepatitis B, Japanese encephalitis, yellow fever, and meningococcal vaccines. The controversial end to the polio eradication campaign and the recognition of vaccine-derived polioviruses are discussed. New monovalent cholera vaccines, including the live attenuated Peru-15 and CVD 103-HgR and the oral killed whole cell B subunit vaccine are reviewed, as well as a new oral bivalent vaccine that may offer protection against Vibrio cholerae 0139. Advances in typhoid vaccination include promising preclinical and clinical trial results of recombinant ZH9 and CVD 908-htrA vaccines, which, in addition to providing protection against typhoid fever, may be useful vectors for heterologous antigens. A growing recognition of rare adverse reactions to the 17D yellow fever vaccine, especially postvaccinal encephalitis, has led to a reassessment of its risks and benefits. Development of a novel chimeric vaccine may improve the safety and efficacy of the current Japanese encephalitis vaccine. Vaccination for meningococcal disease is characterized by the need for polyvalent, conjugate vaccines as well as a product that affords protection against serotype B. SUMMARY: This travel vaccination review highlights progress in new travel-related vaccine development and updates the reader on issues surrounding licensed products. It will be useful for generalists, infectious disease physicians, and travel medicine specialists.

African trypanosomiasis in two travelers from the United States.

African trypanosomiasis is a rare but well-documented cause of fever in United States travelers returning from areas where it is endemic. We report two recently diagnosed cases that involved tourists who went on safari in Tanzania. Review of these and 29 other published cases indicates that disease in returning United States travelers is nearly always of the East African form, a fulminant illness for which prompt diagnosis is necessary. In the United States, timely and appropriate therapy for this disease has resulted in favorable outcomes for most patients. Chemoprophylaxis for East African trypanosomiasis is not recommended, but travelers visiting areas of endemicity should practice appropriate preventive measures to prevent tsetse fly bites.

Service delivery for patients with HIV in a rural state: the Vermont model.

The incidence of human immunodeficiency virus (HIV) infection is increasing rapidly in rural areas of the United States. Barriers to health-care delivery for this patient population include the complexity of this rapidly changing field, inexperienced rural physicians, long travel distances to receive expert care, lack of psychosocial support systems, and concerns about confidentiality. Models of HIV care for rural areas have not been developed that remove these barriers. We present the philosophy, structure, implementation, and services of a model of care in Vermont that is designed to remove many of these barriers and bring HIV expertise into the rural areas of the state. Three HIV specialty clinics have been developed in regional hospitals throughout the state. The clinic team includes an HIV-trained nurse practitioner and social worker from the hospital, a client consultant from the regional AIDS service organization, and an infectious disease specialist who travels to each of the clinics monthly. Patient care will be centralized in these regionally located clinics. The dispersion of HIV care among numerous and inexperienced rural providers will be obviated. Confidentiality will be emphasized within the hospital environment. The model has the potential to provide a complete continuum of medical care and psychosocial case management, integrate patient care and regional provider education, and increase community awareness. Patients will be able to receive their care in their own community, avoiding long travel distances. This may encourage patients to seek care earlier in their illness. The model may be adaptable to other rural areas of the United States.

Extracellular matrix heparan sulfate modulates endothelial cell susceptibility to Staphylococcus aureus.

The ability of extracellular matrix heparan sulfate to alter the susceptibility of human endothelial cells to S. aureus was investigated. Endothelial cells grown on extracellular matrix synthesized by S. aureus-infected endothelial cells were more susceptible to subsequent staphylococcal infection than endothelial cells grown on the extracellular matrix synthesized by untreated endothelial cells. Endothelial cells were more susceptible to S. aureus infection when 1) grown on heparitinase-treated extracellular matrix that removed heparan sulfate chains, 2) grown on extracellular matrix produced by chlorate-treated endothelial cells that reduced sulfation in the matrix heparan sulfate proteoglycans, 3) grown on heparan sulfate purified from extracellular matrix elaborated by infected endothelial cells, and 4) endothelial cells were chlorate-treated and therefore expressed desulfated cellular heparan sulfate proteoglycans. Extracellular matrix produced by S. aureus-infected endothelial cells contained heparan sulfate proteoglycans with reduced sulfation. The altered extracellular matrix with reduced sulfated heparan sulfate proteoglycans signalled the uninfected endothelial cells to produce under sulfated cellular heparan sulfate proteoglycans that increased S. aureus adherence to the endothelial cells.