Comparative Outcomes of Candida auris Bloodstream Infections: A Multicenter Retrospective Case-Control Study.

BACKGROUND: This study was performed to compare clinical characteristics and outcomes between patients with bloodstream infections (BSIs) caused by Candida auris and those with BSIs caused by other Candida spp. METHODS: A multicenter retrospective case-control study was performed at 3 hospitals in Brooklyn, New York, between 2016 and 2020. The analysis included patients ≥18 years of age who had a positive blood culture for any Candida spp. and were treated empirically with an echinocandin. The primary outcome was the 30-day mortality rate. Secondary outcomes were 14-day clinical failure, 90-day mortality rate, 60-day microbiologic recurrence, and in-hospital mortality rate. RESULTS: A total of 196 patients were included in the final analysis, including 83 patients with candidemia caused by C. auris. After inverse propensity adjustment, C. auris BSI was not associated with increased 30-day (adjusted odds ratio, 1.014 [95% confidence interval, .563-1.828]); P = .96) or 90-day (0.863 [.478-1.558]; P = .62) mortality rates. A higher risk for microbiologic recurrence within 60 days of completion of antifungal therapy was observed in patients with C. auris candidemia (adjusted odds ratio, 4.461 [95% confidence interval, 1.033-19.263]; P = .045). CONCLUSIONS: C. auris BSIs are not associated with a higher mortality risk than BSIs caused by other Candida spp. The rate of microbiologic recurrence was higher in the C. auris group.

Diagnosing Common Deadly Infections in the Era of COVID-19: A Case Report.

The COVID-19 pandemic has challenged clinicians to recognize COVID-19 as one of the diagnostic explanation for common presentations, including fever, cough, and shortness of breath. Latent tuberculosis is responsible for 80% of active tuberculosis cases in the United States, and presentation can vary from asymptomatic to disseminated disease. This potential diagnosis should be thoroughly investigated in foreign-born patients in US hospitals, regardless of travel history and presenting symptoms. We report a patient diagnosed with postpartum disseminated tuberculosis with hematogenous spread to the fetus.

Subacute Aspergillosis "Fungal Balls" Complicating COVID-19.

Severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2), commonly known as COVID-19 (coronavirus disease-2019), began in the Wuhan District of Hubei Province, China. It is regarded as one of the worst pandemics, which has consumed both human lives and the world economy. COVID-19 infection mainly affects the lungs triggering severe hypoxemic respiratory failure, also providing a nidus for superimposed bacterial and fungal infections. We report the case of a 73-year-old male who presented with progressive dyspnea; diagnosed with SARS-CoV-2-related severe acute respiratory distress syndrome and complicated with lung cavitations growing Aspergillus sp. COVID-19, to our knowledge, has rarely been associated with subacute invasive pulmonary aspergillosis with aspergillomas. Subacute invasive pulmonary aspergillosis as a superimposed infection in patients with SARS-CoV-2 is a rare entity. By reporting this case, we would like to make the readers aware of this association.

Tuberculosis-immune reconstitution inflammatory syndrome in HIV-infected patient: A case report.

We describe a case of immune reconstitution inflammatory syndrome (IRIS) secondary to reactivation of Mycobacterium tuberculosis in an HIV-infected patient with a high CD4+ cell count, who presented with a generalized seizure 6 weeks after starting antiretroviral therapy (ART). In our patient, the inflammatory response resulted in radiological features of neurological, pulmonary, and lymph node (LN) tuberculosis- (TB) IRIS, without the typical symptoms. Diagnosis was confirmed by LN biopsy and acid-fast bacilli (AFB) culture of LN and sputum. Treatment with isoniazid, rifabutin, ethambutol, and pyrazinamide was started in addition to continuation of ART. To our knowledge, we describe the first case of an atypical clinical presentation of an unmasking reaction of disseminated TB-IRIS in an HIV infected patient without acquired immune deficiency syndrome (AIDS), with restoring immunity during ART. Clinical and radiological predictors of TB-IRIS in co-infected patients starting ART are therefore essential in anticipating complications and facilitating expeditious management and prompt therapy.

Case report on pulmonary disease due to coinfection of Mycobacterium tuberculosis and Mycobacterium abscessus: Difficulty in diagnosis.

Mycobacterium abscessus, which is ubiquitous environmental organism, is more likely to cause pulmonary infection in the presence underlying lung disease and immunosuppression. We report a case of pulmonary disease due to coinfection of Mycobacterium tuberculosis (MTB) and Mycobacterium abscessus (M. abscessus) in an immunocompetent patient without underlying lung disease. Healthcare professionals should be aware of co-infection with MTB and M. abscessus, and treatment should be based on clinical suspicion and/or epidemiological circumstances.

Staphylococcus lugdunensis endocarditis with destruction of the ventricular septum and multiple native valves.

Staphylococcus lugdunensis (S. lugdunensis) is a coagulase negative staphylococcus (CoNS) that can cause destructive infective endocarditis. S. lugdunensis, unlike other CoNS, should be considered to be a pathogen. We report the first case of S. lugdunensis endocarditis causing ventricular septal defect and destruction of the aortic and mitral valves. A 53-year-old male with morbid obesity and COPD presented with intermittent fever and progressive shortness of breath for 2 weeks. Chest examination showed bilateral basal crepitations, and a grade 2 systolic murmur along the right sternal border. The leukocyte count was 26,000 cells/µl with 89% neutrophils. He was treated with intravenous vancomycin and ceftriaxone. Blood cultures grew Staphylococcus lugdunensis. Transthoracic echocardiogram, which was limited by body habitus, showed no definite valvular vegetations. Repeat transthoracic echocardiogram performed one week later revealed a large aortic valve vegetation Vancomycin was switched to daptomycin on day 4 because of difficulty achieving therapeutic levels of vancomycin and the development of renal insufficiency. Open heart surgery on day 10 revealed aortic valve and mitral valve vegetations with destruction, left ventricular outflow tract (LVOT) septal abscess and ventricular septal defect (VSD). Bio-prosthetic aortic and mitral valve replacement, LVOT and VSD repair were done. Intraoperative cultures grew Staphylococcus lugdunensis. The patient was discharged home with daptomycin to complete 6 weeks of treatment. S. lugdunensis can cause rapidly progressive endocarditis with valve and septal destruction. Early diagnosis and therapy are essential, with consideration of valve replacement.

Rise and fall of KPC-producing Klebsiella pneumoniae in New York City.

OBJECTIVES: The study objective was to examine the epidemiological trends of KPC-producing Klebsiella pneumoniae in New York City medical centres. PATIENTS AND METHODS: Single patient isolates of K. pneumoniae were collected from nine medical centres in New York City during a 3 month period from 2013 to 2014. Isolates were tested for the presence of blaKPC. Results were compared with similar surveillance studies conducted in 2006 and 2009. Infection control data, including utilization of medical devices, were analysed at a subset of hospitals. RESULTS: There was a progressive decline in the percentage of K. pneumoniae harbouring blaKPC from 2006 to 2013-14. For the nine hospitals that participated in all three surveillance studies, the percentages of isolates with blaKPC fell from 36% in 2006 to 25% in 2009 to 13% in 2013-14. Seven of the nine hospitals had marked declines in isolates with blaKPC, while two hospitals continued to struggle with this pathogen. These two hospitals were smaller and had longer lengths of patient stay. Device utilization rates were obtained from two hospitals that successfully controlled the spread of KPC-producing K. pneumoniae; both had ∼20%-25% reduction in the usage of urinary catheters. Changes in antibiotic usage at one hospital could not explain the decline in these pathogens. CONCLUSIONS: Over the past decade there has been a steady decline in KPC-producing K. pneumoniae in most New York City hospitals. The reason for the decline is probably multifactorial, involving a reduction in device (catheter) utilization and possibly an improvement in infection control practices.

Does Alkaline Colonic pH Predispose to Clostridium difficile Infection?

OBJECTIVES: Clostridium difficile caused nearly 500,000 infections and was associated with approximately 29,000 deaths in 2011, according to data from the Centers for Disease Control and Prevention. C. difficile is a bacterium that causes diarrhea and, often, severe illness in healthcare facilities, as well as the community. Our objective was to determine whether alkaline colonic pH predisposes to colonization and infection with C. difficile. METHODS: A total of 228 patients with diarrhea and/or abdominal pain, leukocytosis, and fever were included. Stool pH was measured, and C. difficile antigen and toxin in stool were detected. RESULTS: Of 228 patients, 30 (13.2%) tested positive for C. difficile (antigen+/toxin+) and 171 (75%) were C. difficile negative (antigen-/toxin-). Of 171 patients who tested negative, 93 (54.4%) had stool pH >7.0 and 78 (45.6%) had pH ≤7.0. Among the 30 patients who tested positive, 26 (86.7%) had stool pH >7.0 (P = 0.002). Among the 27 colonized patients (antigen+/toxin-), 12 (44.4%) had stool pH >7.0 (P = 0.34). For all patients with stool pH ≤7.0, 96% tested negative for C. difficile infection (P = 0.002). CONCLUSIONS: A strong association between C. difficile infection and alkaline stool pH was found.

Artesunate-related fever and delayed hemolysis in a returning traveler.

Malaria is a serious and sometimes fatal disease caused by an intraerythrocytic parasite, and is commonly seen in developing countries. Approximately 1500 cases of malaria are diagnosed in the United States each year, mostly in travelers and immigrants returning from endemic areas [1]. There are many different regimens used to treat malaria, some of which are not approved in the USA. The side effects of these medications may not be familiar to physicians in the USA. We report a case of a returning traveler from Nigeria presenting with fever and hemolytic anemia caused by a delayed response to artesunate given 3 weeks earlier while in Nigeria. To our knowledge, there are few cases reported in the United States of hemolytic anemia secondary to artesunate therapy [2].

Streptococcus agalactiae endogenous endophthalmitis.

Streptococcus agalactiae (SA) is a Group B Streptococcus, which is a common pathogen implicated in neonatal and geriatric sepsis. Endogenous bacterial endophthalmitis (EBE) is a condition that results from haematogenous seeding of the globe, during transient or persistent bacteremia. We document a case of a non-septic geriatric patient, who developed EBE after a transient bacteraemia with SA.

Endocapsular cellulomonas as a cause of persistent postoperative endophthalmitis.

Sequestration of bacteria within the capsular fornices after cataract extraction with intraocular lens implantation can cause both acute and chronic inflammation. A case of persistent postoperative endophthalmitis caused by capsular sequestration of Cellulomonas is described. The patient underwent uncomplicated cataract extraction with intraocular lens implantation and subsequently developed acute postoperative endophthalmitis. Inflammation persisted despite several vitreous taps and the injection of intravitreal antibiotics. Definitive treatment required pars plana vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal and parenteral antibiotics. In patients with postoperative endophthalmitis, one must consider atypical organisms as the source and should consider explantation of the intraocular lens with capsular bag removal.

Parenteral polymyxin B use in patients with multidrug-resistant gram-negative bacteremia and urinary tract infections: a retrospective case series.

BACKGROUND: Parenteral polymyxin use declined after the 1960s, due to safety concerns. An increase in multidrug-resistant (MDR) gram-negative infections and a shortage of new agents have prompted increased use of parenteral polymyxin. OBJECTIVE: To describe our clinical experience with parenteral polymyxin B for MDR gram-negative bacteremia and urinary tract infection (UTI). METHODS: Paper pharmacy records were used to identify patients aged 18 years or older, presence of MDR gram-negative bacteremia or UTI, and use of parenteral polymyxin B for at least 48 hours. Electronic and paper patient records were then retrospectively reviewed. Polymyxin B susceptibility was evaluated using the Kirby-Bauer method. MDR isolates were defined as resistant to at least 3 antimicrobial classes, excluding polymyxin B. Microbiologic clearance was defined by 1 repeat urine or 2 repeat blood cultures that were sterile or growing different organisms. Secondary outcomes included hospital mortality and nephrotoxicity, defined as an increase in serum creatinine of 0.5 mg/dL or more, or a 50% reduction in creatinine clearance. RESULTS: Seventeen infections in 16 patients were treated with polymyxin B (1 pt. had 2 infections that were analyzed separately). Microbiologic clearance occurred in 14 of 16 (88%) cases of MDR gram-negative bacteremia or UTI in which repeat cultures were done. Ten of 16 patients died (all-cause mortality 63%). Five patients required hemodialysis prior to polymyxin B use. Six (55%) of the remaining 11 patients with baseline renal insufficiency developed nephrotoxicity, and none of them required hemodialysis. The mean +/- SD number of days from the initiation of therapy to the onset of nephrotoxicity was 7.5 +/- 2.3 (range 4-10) days. Three (50%) of 6 patients with nephrotoxicity died. CONCLUSIONS: Our data suggest that polymyxin B may be effective for MDR gram-negative infections in patients with limited therapeutic options, but precautions should be taken to avoid toxicity.

Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has rarely been reported in the hospital setting. We report an outbreak of 7 cases of skin and soft tissue infections due to a strain of CA-MRSA. All patients were admitted to the labor and delivery, nursery, or maternity units during a 3-week period. Genetic fingerprinting showed that the outbreak strain was closely related to the USA 400 strain that includes the midwestern strain MW2. All isolates contained the staphylococcal chromosome cassette mec type IV. Genes for Panton-Valentine leukocidin and staphylococcal enterotoxin K were detected in all isolates, and most contained other enterotoxin genes. Testing of nearly 2,000 MRSA isolates collected during citywide surveillance studies from 1999 to 2003 showed that approximate, equals 1% were genetically related to MW2. CA-MRSA strain MW2 has been present in this region at least since 1999. This study documents the spread of this strain among healthy newborns at 1 hospital.