Changing Landscape of Haemophilus influenzae Meningitis and Implication on Public Health.

Haemophilus influenzae (H. influenzae) has evolved as a prominent pathogen, with nontypeable strains (NTHi) emerging as a leading cause of invasive disease, particularly among the elderly. Since the introduction of Haemophilus influenzae B (Hib) vaccine, invasive infection has shifted from children with Hib to the elderly with NTHi. NTHi affects those primarily with predisposing factors such as an immunocompromised state, CSF leakage, or ENT infections. We present two cases that emphasize the shift of invasive infection, risk factors, and elevated intracranial pressure (ICP) as a complication. Case 1. A 75-year-old female with a sudden onset of weakness and respiratory symptoms deteriorated rapidly. Imaging revealed mastoid effusion and ventriculitis, likely originating from otomastoiditis. Lumber puncture confirmed NTHi. ICU course complicated by elevated ICP prompted repeat lumbar puncture. The patient recovered after 8 days but not near baseline. Case 2. A 50-year-old female with altered mental status, headache, and ear pain exhibited signs of pansinusitis and pseudotumor cerebri. Elevated ICP was evident upon lumbar puncture, and NTHi was isolated in CSF and blood cultures. MRI of the brain showed prominent optic nerve sheaths and transverse sinus arachnoid granulations' concern for underlying pseudotumor cerebri. Repeat lumbar puncture or ventricular drainage was deferred after discussion with neurosurgery. Diabetes was identified as a comorbidity. The patient's condition improved after 14 days of antibiotics and dexamethasone. These cases emphasize the shifting landscape of H. influenzae meningitis, primarily driven by NTHi, especially among the elderly. Although NTHi infections were considered less invasive, recent epidemiology review indicated it as the leading cause of H. influenzae meningitis. With the increasing prevalence of NTHi and its increase in invasive patterns, it is crucial to implement vaccination strategies and develop new vaccines targeting NTHi.

Multicenter Study of Optional In-Person Visits to Residency Programs After Virtual Interviews.

Background Compared to in-person recruitment, virtual interviewing reduces costs and promotes equity. However, many residency applicants believe that visiting programs helps inform their rank decisions. Objective We assessed the feasibility of and stakeholder opinions about optional in-person visits after virtual interviewing and program rank list finalization. Methods Six internal medicine residency programs conducted virtual recruitment in 2022-2023 and finalized their rank lists 4 weeks before the deadline. Applicants were invited for optional in-person visits after program rank list finalization. Interviewed applicants, program directors, and program administrators were given surveys that included 7-17 questions and employed "skip logic," discrete answers (eg, "yes/no/unsure" or multiple choice), and open-ended questions. Survey questions assessed stakeholders' opinions about the value, equity, and potential downsides of this recruitment process. Results Participating programs interviewed an average of 379 applicants (range 205-534) with 39 (10.3% [39 of 379], range 7.9%-12.8% [33 of 420-51 of 397]) applicants completing in-person visits. Of 1808 interviewed applicants, 464 responded to the survey (26%); 88% (407 of 464) believe a similar optional in-person visit should be offered next year, 75% (347 of 464) found this process equitable, but only 56% (258 of 464) trusted programs not to change their rank lists. Nearly all who attended an in-person visit (96.5%, 109 of 113) found it valuable. All program directors liked the optional in-person visit and believe future applicants should be offered similar in-person visits. Conclusions A large majority of participating applicants and program directors believe that in-person visits should be offered after program rank list finalization. The majority of respondents felt this recruitment process was equitable.

Symmetric Ascending Paralysis Secondary to West Nile Virus.

West Nile virus (WNV) is classified as a Flavivirus, belonging to a Japanese encephalitis subgroup often transmitted via mosquitoes. The classic presentation of a WNV infection usually displays high fevers, myalgias, and headache which can progress to neck stiffness, stupor, and coma (Case Rep Infect Dis. 2020;2020:6501658). Our case study presented with a rare manifestation of ascending paralysis, encompassing the feared neuroinvasive disease pattern that is seldom exhibited. This case had an unusual presentation as certain manifestations experienced by our patient closely resembled that of Guillain-Barré syndrome, although others were more indicative of poliomyelitis-like syndrome. Overall, the mainstay of therapy in both conditions is supportive care, although the prognosis varies substantially depending on the underlying diagnosis.

Coronavirus disease 2019 (COVID-19) vaccination preparedness policies in US hospitals.

We surveyed infectious disease specialists about early coronavirus disease 2019 (COVID-19) vaccination preparedness. Almost all responding institutions rated their facility's preparedness plan as either excellent or adequate. Vaccine hesitancy and concern about adverse reactions were the most commonly anticipated barriers to COVID-19 vaccination. Only 60% believed that COVID-19 vaccination should be mandatory.

Adverse Outcomes Associated With Potentially Inappropriate Antibiotic Use in Heart Failure Admissions.

BACKGROUND: Acute decompensated heart failure (ADHF) can be confused with other conditions that cause dyspnea. Patients with ADHF are often simultaneously treated for community-acquired pneumonia (CAP), even when evidence for infection is lacking. We hypothesized that the fluid and sodium content of potentially unnecessary intravenous antibiotic (IVAB) therapy could worsen outcomes of ADHF patients. METHODS: We reviewed 144 ADHF patients at low risk of pneumonia based on diagnostic findings and clinical documentation. The primary end point was length of stay. Secondary outcomes were mortality, readmission rates, amount of diuretic received, and fluid volume and quantity of sodium administered as part of IVAB therapy. RESULTS: Of the 144 admissions reviewed, 88 did not and 56 did receive IVAB. IVAB-treated patients received an average of 1.7 L of additional fluid (230 mL/d) and 9311 mg of additional sodium (1381 mg/d) as a result of IVAB therapy. Length of stay was longer in the IVAB arm (6.6 days) compared with the no-IVAB arm (3.0 days; P < .001). Patients required more furosemide in the IVAB arm (930 mg) compared with the no-IVAB arm (320 mg; P < .001). Patients who received IVAB were also 2.51 times more likely to be readmitted compared with patients who did not receive IVAB (P = .04). CONCLUSIONS: ADHF patients who received IVAB without evidence of infection had longer lengths of stay, required more diuretics, and were more likely to be readmitted compared with ADHF patients not exposed to IVAB. ADHF patients are a promising target of antibiotic stewardship interventions.

Ehlers-Danlos syndrome with infective endocarditis: A case report with literature review.

We report a patient with Ehlers-Danlos syndrome and mitral valve infective endocarditis. The case was complicated due to multiorgan involvement and initially diagnosed as hand-foot-and-mouth disease. The patient was transferred to our hospital with cerebral septic emboli and bilateral lower extremity emboli requiring early surgery. Complications of this syndrome and surgical risks are discussed in this report.

An Assessment of Coliform Bacteria in Water Sources Near Appalachian Trail Shelters Within the Great Smoky Mountains National Park.

OBJECTIVE: Hikers and campers are exposed to risks while in the wilderness. One of these risks is the possibility of contracting an illness, including infectious diarrhea. This project tested for coliform bacteria in water samples taken near popular Appalachian Trail shelters. METHODS: Water was collected from access points within the Great Smoky Mountains National Park. Samples were collected in sterile bottles and inoculated on a commercially available coliform detection kit for quantitative determination of total coliform and Escherichia coli counts. RESULTS: Water samples were taken during summer and fall seasons. During summer, 7 of 10 samples were positive for coliform bacteria and 6 of those 7 for E coli. The most probable number (MPN) of colony-forming units (CFU) for coliform bacteria ranged from 0 to 489 CFU/100 mL, with the MPN for E coli varying from 0 to 123 CFU/100 mL. These data differed from the fall collection, revealing 3 of 7 samples positive for coliform bacteria and 1 of those 3 for E coli. The MPN of CFU for coliform bacteria in fall samples varied from 0 to 119 CFU/100 mL and 0 to 5 to CFU/100 mL for E coli. CONCLUSIONS: Environmental Protection Agency drinking water standards set the standard of 0 CFU/100 mL to be considered safe. This analysis of water samples along the Appalachian Trail emphasizes that the majority of water access points require treatment during the summer season. Coliform burden was not as high through the fall months. These data suggest one infectious disease risk for wilderness travelers.

Adenovirus serotype 14 pneumonia at a basic military training site in the United States, spring 2007: a case series.

Adenovirus, a frequent cause of mild respiratory disease in military trainees, can result in severe manifestations when outbreaks are caused by novel viral strains for which there is little pre-existing immunity. Twenty-five basic military trainees (BMTs) were hospitalized with adenovirus pneumonia from April 1, 2007 through June 21, 2007. Clinical findings for 9 of these patients with PCR-confirmed adenovirus serotype 14 were studied retrospectively. The clinical picture was characterized by cough (88.9%) and sputum production (77.8%). All trainees were febrile. Laboratory results showed 88.9% had normal white blood cell (WBC) counts, 66.7% with high monocytes, and 55.6% with low lymphocytes on differential. All had lobar pneumonia radiographically. One patient required the intensive care unit (ICU) and later expired. In conclusion, among hospitalized patients with the combination of fever, productive cough, normal WBC, a differential showing high monocytes and low lymphocytes in an immunocompetent young adult with lobar pneumonia warrants a high level of suspicion for adenovirus 14 pneumonia.

Case-control study of armadillo contact and Hansen's disease.

Hansen's disease (HD) continues to have worldwide impact despite efforts to eradicate the disease. Although a definitive transmission mode has not been identified, data supports an association between HD and contact with the nine-banded armadillo. We conducted a case-control study of 28 HD patients to determine if there is an association between armadillo exposure and HD. There was no association between HD and place of birth or having hunted, consumed, or had direct or indirect contact with deer, birds, or squirrels. Univariate analysis showed that residence in Mexico (P = 0.001), hunting rabbits (P = 0.04), cleaning rabbits (P < 0.001), and armadillo exposure from hunting (P = 0.005), cleaning (P = 0.004), consuming (P = 0.002) them, or having direct armadillo contact (P = 0.017) were associated with HD. Multivariate analysis showed that eating armadillos (P = 0.039, odds ratio [OR] = 3.65, 95% confidence interval [CI] = 1.07-12.4), cleaning rabbits (P = 0.018, OR = 4.08, 95% CI = 1.27-13.1), and having lived in Mexico (P = 0.006, OR = 24.9, 95% CI = 2.52-245) were associated with HD.

Outcomes of bacteremia in burn patients involved in combat operations overseas.

BACKGROUND: Burn patients constitute approximately 5% of casualties injured in support of US military operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]). Since the onset of these conflicts, there have been numerous casualties infected with multidrug-resistant bacteria. It is currently unclear if bacteremia with these multidrug-resistant organisms in OIF/OEF burn casualties is associated with increased mortality. STUDY DESIGN: We performed a retrospective cohort study of all patients admitted to the US Army Institute of Surgical Research burn center from January 2003 to May 2006 to evaluate bacteremia in our burn-patient population. RESULTS: One hundred twenty-nine of 1,258 patients admitted to the burn center became bacteremic during their hospitalization. Of these, 92 had bacteremia with the top four pathogens in our burn center, ie, Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter calcoaceticus-baumannii complex, and Staphylococcus aureus. Presence of any bacteremia was associated with mortality and increased ventilator days. Bacteremia with K pneumoniae was associated with a statistically increased mortality and a prolonged ventilator course relative to all other pathogens. CONCLUSIONS: Casualties of OIF/OEF with burn injuries did not have different outcomes than patients whose burns were not associated with military operations. Bacteremia, especially with a multidrug-resistant organism, causes increased mortality in burn patients. Of all the pathogens causing bacteremia, K pneumonia appears to have the greatest impact on mortality.

Chest pain in a military recruit.

Lyme borreliosis remains an important and common vector-borne illness in the United States, Europe, and Asia. In the majority of cases, it presents as a localized rash that seldom causes further complications with antibiotic treatment. If left undetected however, various neurologic, cardiovascular, and musculoskeletal manifestations may occur. Reported here is the case of a basic military trainee who first presented with cardiac manifestations of Lyme disease, highlighting this tick-borne illness as a rare, easily forgotten, and treatable cause of complete heart block.

Peripherally inserted central venous catheter-associated thrombosis: retrospective analysis of clinical risk factors in adult patients.

BACKGROUND: Peripherally inserted central catheters (PICC) are common venous access devices. Clinical conditions and therapies that increase the risk of PICC-associated thrombosis have not been studied. METHODS: We performed a retrospective case-control analysis of all adult patients who underwent placement of a PICC at our hospital over a three-year period (n = 1296). Clinical variables examined were indication for PICC placement, active cancer treatment, history of DVT, diabetes mellitus, and use of prophylactic anticoagulation. RESULTS: The overall incidence of PICC-associated DVT was 2% (n = 27). Active cancer therapy was significantly associated with PICC-associated DVT (OR 3.5, 95% CI 1.3-9.8). The use of prophylactic anticoagulation did not reduce this risk. CONCLUSIONS: Patients who suffered a PICC-associated DVT were more likely to be undergoing treatment for cancer. This risk was not lowered by the use of prophylactic anticoagulation. These results suggest a need for prospective studies on effective anticoagulation for patients at high risk for PICC-associated DVT.

Culture-negative surgical site infections.

BACKGROUND: The appearance of postoperative surgical site infection (SSI) in the absence of culturable bacterial pathogens is a common dilemma for the surgeon. METHODS: The literature was searched through references to primary articles, as well as a MEDLINE review, for reports of culture-negative SSIs. RESULTS: Potential causes of culture-negative SSIs include prior antimicrobial therapy; the presence of fastidious or slow-growing microorganisms such as mycobacteria, Mycoplasma spp., and Legionella spp.; infection caused by mundane bacteria that may be dismissed as "contaminants"; factitious infection; and others. CONCLUSIONS: We review the recognized causes of "culture negative" SSIs and discuss the laboratory capabilities that may enhance recognition of many of these pathogens and management options.

History of U.S. military contributions to the study of sexually transmitted diseases.

Sexually transmitted diseases have posed a threat to military service members throughout history. Among these diseases, syphilis, gonorrhea, and human immunodeficiency virus infections have accounted for the most significant morbidity and mortality rates in the U.S. military. In response, military researchers have made significant contributions to the treatment and prevention of these diseases. We review the impact of these diseases through the history of the U.S. Armed Forces and review selected sexually transmitted disease-oriented publications of U.S. military researchers.

Coccidioidomycosis of the male reproductive tract.

Coccidioides immitis infection of the male reproductive tract is a rare entity that can evade diagnosis and pose a dilemma in management. Initially, patients are often evaluated for malignancy or other infections such as tuberculosis. In the past, surgery was the only management option for C. immitis infection of the male reproductive tract, but azole therapy now provides an adjunct or an alternative. We describe two patients who received azole therapy for C. immitis infection of the male reproductive tract. One received fluconazole for prostatic disease, while one received surgery followed by itraconazole for testicular disease. After 12 months of therapy, both remain asymptomatic and have decreased antibody titers against C. immitis.