Candida auris inpatient screening in collaboration with the public health department.

Candida auris is a multidrug-resistant fungal pathogen that is associated with nosocomial outbreaks in patients with extensive health care exposure and treatment outside the United States. The Ohio Department of Health recommends C auris screening in high-risk patients. However, this can be operationally difficult for many health care facilities. This report describes a C auris and carbapenem-resistant Enterobacterales inpatient screening program done in collaboration with state public health.

Outbreak of postpartum group a Streptococcus infections on a labor and delivery unit.

A healthcare-associated group A Streptococcus outbreak involving six patients, four healthcare workers, and one household contact occurred in the labor and delivery unit of an academic medical center. Isolates were highly related by whole genome sequencing. Infection prevention measures, healthcare worker screening, and chemoprophylaxis of those colonized halted further transmission.

Describing the monthly variability of hospital-onset Clostridioides difficile during early coronavirus disease 2019 (COVID-19) using electronic health record data.

OBJECTIVE: To assess the relative risk of hospital-onset Clostridioides difficile (HO-CDI) during each month of the early coronavirus disease 2019 (COVID-19) pandemic and to compare it with historical expectation based on patient characteristics. DESIGN: This study used a retrospective cohort design. We collected secondary data from the institution's electronic health record (EHR). SETTING: The Ohio State University Wexner Medical Center, Ohio, a large tertiary healthcare system in the Midwest. PATIENTS OR PARTICIPANTS: All adult patients admitted to the inpatient setting between January 2018 and May 2021 were eligible for the study. Prisoners, children, individuals presenting with Clostridioides difficile on admission, and patients with <4 days of inpatient stay were excluded from the study. RESULTS: After controlling for patient characteristics, the observed numbers of HO-CDI cases were not significantly different than expected. However, during 3 months of the pandemic period, the observed numbers of cases were significantly different from what would be expected based on patient characteristics. Of these 3 months, 2 months had more cases than expected and 1 month had fewer. CONCLUSIONS: Variations in HO-CDI incidence seemed to trend with COVID-19 incidence but were not fully explained by our case mix. Other factors contributing to the variability in HO-CDI incidence beyond listed patient characteristics need to be explored.

Experiential learning and mentorship as the foundation of clinical epidemiology training during infectious diseases fellowship: Response to "Training infectious diseases fellows for a new era of hospital epidemiology".

A specific, clinical-epidemiology, month-long rotation for all infectious disease fellows as well as a 1-year subspecialty track provides education in clinical epidemiology during infectious disease fellowship training. We describe the educational process created at our institution to provide this training.

Early Administration of Remdesivir and Intensive Care Unit Admission in Hospitalized Pregnant Individuals With Coronavirus Disease 2019 (COVID-19).

Remdesivir has been shown to shorten the time to recovery in hospitalized patients with coronavirus disease 2019 (COVID-19). Data on its use in pregnancy are limited. In this single-center retrospective cohort study, our objective was to determine whether early remdesivir use in pregnant individuals is associated with decreased risk of admission to the intensive care unit (ICU). Forty-one pregnant patients were included in this study, and outcomes were compared between those who received remdesivir less than 7 days (early group) and 7 or more days (late group) from onset of patient-reported symptoms. Early remdesivir administration was associated with improved clinical outcomes, including lower rates of ICU admission, decreased length of hospitalization, and decreased progression to critical disease in pregnant individuals hospitalized with COVID-19.

Clinical Outcomes of Daptomycin Versus Anti-Staphylococcal Beta-Lactams in Definitive Treatment of Methicillin-susceptible Staphylococcus aureus Bloodstream Infections.

OBJECTIVES: Staphylococcus aureus (S. aureus) is the leading cause of bacteraemia and infective endocarditis worldwide. The preferred management of patients with methicillin-susceptible S. aureus (MSSA) bacteraemia includes definitive therapy with intravenous anti-staphylococcal beta-lactam (ASBL) antibiotics. Daptomycin (DAP) has been targeted as a viable substitute for beta-lactam allergic or intolerant patients. METHODS: This single-center retrospective cohort study assessed clinical outcomes of DAP compared with ASBL antibiotics [nafcillin (NAF) or cefazolin (CFZ)] for the treatment of MSSA bacteraemia in patients hospitalised from 01 November 2011 to 31 October 2018. The primary outcome was a composite of the following: clinical failure, MSSA recurrence and MSSA persistence or inpatient infection-related mortality. Secondary outcomes included duration of MSSA bacteraemia, infection-related length of stay, infection-related 90-day readmission, 30-day all-cause mortality, and adverse events necessitating a change in therapy. RESULTS: Of 89 patients with MSSA bacteraemia who were included: 29 received DAP, 30 received NAF and 30 received CFZ. There was no difference in the composite primary outcome in patients treated with DAP compared with ASBL (10% vs. 5%, P = 0.39). The DAP cohort had a longer hospital length of stay compared with the ASBL group (20 days vs. 11.5 days, P = 0.0007). No differences were detected between other secondary outcomes. CONCLUSION: This study suggests that DAP may serve as a comparable alternative to ASBLs for treatment of MSSA bacteraemia, as no differences in clinical outcomes were identified. Larger studies are needed to confirm these findings.

Blastomycosis infection of the knee treated with staged total knee arthroplasty.

Blastomycosis is a rare fungal disease that can cause intraarticular infection and joint destruction requiring surgical reconstruction. We describe a patient who presented with destruction of the knee joint of unknown etiology. The patient was initially treated with debridement and spacer placement followed by antifungal therapy after cultures grew blastomycosis. Following adequate treatment of the infection, the patient was taken back to the operating room for reconstruction with a total knee arthroplasty. The patient had a successful outcome with no evidence of infection at two years following surgery. To our knowledge, this case report represents the first documented case in which a blastomycotic infection of a native knee was successfully treated with a two-stage total knee arthroplasty.

An Infectious Diseases Physician-Led Antimicrobial Stewardship Program at a Small Community Hospital Associated With Improved Susceptibility Patterns and Cost-Savings After the First Year.

The importance of antimicrobial stewardship is increasingly recognized, yet data from community hospitals are limited. Despite an initially low acceptance rate, an Infectious Diseases physician-led program at a 70-bed rural hospital was associated with a 42% decrease in anti-infective expenditures and susceptibility improvement in Pseudomonas aeruginosa over 3 years.

Legionella pneumophila utilizes a single-player disulfide-bond oxidoreductase system to manage disulfide bond formation and isomerization.

Legionella pneumophila uses a single homodimeric disulfide bond (DSB) oxidoreductase DsbA2 to catalyze extracytoplasmic protein folding and to correct DSB errors through protein-disulfide isomerase (PDI) activity. In Escherichia coli, these functions are separated to avoid futile cycling. In L. pneumophila, DsbA2 is maintained as a mixture of disulfides (S-S) and free thiols (SH), but when expressed in E. coli, only the SH form is observed. We provide evidence to suggest that structural differences in DsbB oxidases (LpDsbB1 and LpDsbB2) and DsbD reductases (LpDsbD1 and LpDsbD2) (compared with E. coli) permit bifunctional activities without creating a futile cycle. LpdsbB1 and LpdsbB2 partially complemented an EcdsbB mutant while neither LpdsbD1 nor LpdsbD2 complemented an EcdsbD mutant unless DsbA2 was also expressed. When the dsb genes of E. coli were replaced with those of L. pneumophila, motility was restored and DsbA2 was present as a mixture of redox forms. A dominant-negative approach to interfere with DsbA2 function in L. pneumophila determined that DSB oxidase activity was necessary for intracellular multiplication and assembly/function of the Dot/Icm Type IVb secretion system. Our studies show that a single-player system may escape the futile cycle trap by limiting transfer of reducing equivalents from LpDsbDs to DsbA2.

Successful treatment of osseous blastomycosis without pulmonary or disseminated disease and review of the literature.

Blastomycosis commonly occurs following inhalation of Blastomyces dermatitidis conidia causing a pulmonary infection and can disseminate to extrapulmonary sites. Osseous involvement primarily results from hematogenous spread, but in rare cases, direct inoculation can occur. We describe a case of osseous blastomycosis without pulmonary or disseminated disease successfully treated with posaconazole.

Quantification of the adenylate cyclase toxin of Bordetella pertussis in vitro and during respiratory infection.

Whooping cough results from infection of the respiratory tract with Bordetella pertussis, and the secreted adenylate cyclase toxin (ACT) is essential for the bacterium to establish infection. Despite extensive study of the mechanism of ACT cytotoxicity and its effects over a range of concentrations in vitro, ACT has not been observed or quantified in vivo, and thus the concentration of ACT at the site of infection is unknown. The recently developed baboon model of infection mimics the prolonged cough and transmissibility of pertussis, and we hypothesized that measurement of ACT in nasopharyngeal washes (NPW) from baboons, combined with human and in vitro data, would provide an estimate of the ACT concentration in the airway during infection. NPW contained up to ≈ 10(8) CFU/ml B. pertussis and 1 to 5 ng/ml ACT at the peak of infection. Nasal aspirate specimens from two human infants with pertussis contained bacterial concentrations similar to those in the baboons, with 12 to 20 ng/ml ACT. When ≈ 10(8) CFU/ml of a laboratory strain of B. pertussis was cultured in vitro, ACT production was detected in 60 min and reached a plateau of ≈ 60 ng/ml in 6 h. Furthermore, when bacteria were brought into close proximity to target cells by centrifugation, intoxication was increased 4-fold. Collectively, these data suggest that at the bacterium-target cell interface during infection of the respiratory tract, the concentration of ACT can exceed 100 ng/ml, providing a reference point for future studies of ACT and pertussis pathogenesis.

Disulfide bond oxidoreductase DsbA2 of Legionella pneumophila exhibits protein disulfide isomerase activity.

The extracytoplasmic assembly of the Dot/Icm type IVb secretion system (T4SS) of Legionella pneumophila is dependent on correct disulfide bond (DSB) formation catalyzed by a novel and essential disulfide bond oxidoreductase DsbA2 and not by DsbA1, a second nonessential DSB oxidoreductase. DsbA2, which is widely distributed in the microbial world, is phylogenetically distinct from the canonical DsbA oxidase and the DsbC protein disulfide isomerase (PDI)/reductase of Escherichia coli. Here we show that the extended N-terminal amino acid sequence of DsbA2 (relative to DsbA proteins) contains a highly conserved 27-amino-acid dimerization domain enabling the protein to form a homodimer. Complementation tests with E. coli mutants established that L. pneumophila dsbA1, but not the dsbA2 strain, restored motility to a dsbA mutant. In a protein-folding PDI detector assay, the dsbA2 strain, but not the dsbA1 strain, complemented a dsbC mutant of E. coli. Deletion of the dimerization domain sequences from DsbA2 produced the monomer (DsbA2N), which no longer exhibited PDI activity but complemented the E. coli dsbA mutant. PDI activity was demonstrated in vitro for DsbA2 but not DsbA1 in a nitrocefin-based mutant TEM ß-lactamase folding assay. In an insulin reduction assay, DsbA2N activity was intermediate between those of DsbA2 and DsbA1. In L. pneumophila, DsbA2 was maintained as a mixture of thiol and disulfide forms, while in E. coli, DsbA2 was present as the reduced thiol. Our studies suggest that DsbA2 is a naturally occurring bifunctional disulfide bond oxidoreductase that may be uniquely suited to the majority of intracellular bacterial pathogens expressing T4SSs as well as in many slow-growing soil and aquatic bacteria.

Infection of nonphagocytic host cells by legionella.

Legionella pneumophila is an intracellular pathogen of free-living protozoa that can also infect alveolar macrophages, L929 fibroblast cells, and HeLa cells. Infection of nonphagocytic cells by L. pneumophila can be used to study invasion mechanisms, compare infectivity of different strains and identify factors important for virulence. Virulent strains of L. pneumophila exposed to monolayers of L929 cells are able to invade and form virus-like plaques, which can be enumerated as a measure of infectivity. Invasiveness of HeLa cells can also be used to evaluate relative infectivity and to study mechanisms of invasion and to track the development of cyst-like forms. The detailed methods of both the L929 plaque assay and HeLa cell invasion assay are described.

Community-associated and healthcare-associated methicillin-resistant Staphylococcus aureus virulence toward Caenorhabditis elegans compared.

Community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged as major human pathogens. CA-MRSA virulence appears to be distinct from healthcare-associated (HA) MRSA with several factors [α-hemolysin (Hla), Panton-Valentine leukocidin (PVL), α-type phenol soluble modulins (PSMα) and SCCmec IV] postulated to enhance virulence or fitness. Using the Caenorhabditis elegans infection model, we compared the virulence of clinical and laboratory isolates of CA-MRSA and HA-MRSA and explored the contribution of CA-MRSA associated virulence factors to nematode killing. All CA-MRSA strains were highly pathogenic to nematodes, while HA-MRSA strains demonstrated variable nematode killing. Nematode killing by isogenic mutants of hla or the loci for PVL, PSMα, PSMß, PSMδ or SCCmec IV was not different than the parental strains. These results demonstrate that CA-MRSA is highly virulent, shows some strains of HA-MRSA are equally virulent toward nematodes and suggests CA-MRSA virulence in C. elegans is not linked to a single virulence factor.

Tricarboxylic acid cycle-dependent synthesis of Staphylococcus aureus Type 5 and 8 capsular polysaccharides.

Staphylococcus aureus capsule synthesis requires the precursor N-acetyl-glucosamine; however, capsule is synthesized during post-exponential growth when the availability of N-acetyl-glucosamine is limited. Capsule biosynthesis also requires aerobic respiration, leading us to hypothesize that capsule synthesis requires tricarboxylic acid cycle intermediates. Consistent with this hypothesis, S. aureus tricarboxylic acid cycle mutants fail to make capsule.

Caenorhabditis is a metazoan host for Legionella.

We investigated whether nematodes contribute to the persistence, differentiation and amplification of Legionella species in soil, an emerging source for Legionnaires' disease. Here we show that Legionella spp. colonize the intestinal tracts of Caenorhabditis nematodes leading to worm death. Susceptibility to Legionella is influenced by innate immune responses governed by the p38 mitogen-activated protein kinase and insulin/insulin growth factor-1 receptor signalling pathways. We also show that L. pneumophila colonizes the intestinal tract of nematodes cultivated in soil. To distinguish between transient infection and persistence, plate-fed and soil-extracted nematodes-fed fluorescent strains of L. pneumophila were analysed. Bacteria replicated within the nematode intestinal tract, did not invade surrounding tissue, and were excreted as differentiated forms that were transmitted to offspring. Interestingly, the ultrastructural features of the differentiated bacterial forms were similar to cyst-like forms observed within protozoa, amoeba and mammalian cell lines. While intestinal colonization of L. pneumophila dotA and icmT mutant strains did not alter the survival rate of nematodes in comparison to wild-type strains, nematodes colonized with the dot/icm mutant strains exhibited significantly increased levels of germline apoptosis. Taken together, these studies show that nematodes may serve as natural hosts for these organisms and thereby contribute to their dissemination in the environment and suggest that the remarkable ability of L. pneumophila to subvert host cell signalling and evade mammalian immune responses evolved through the natural selection associated with cycling between protozoan and metazoan hosts.