Escherichia coli Meningitis in a 72-year-old Woman.

Spontaneous community-acquired meningitis caused by E. coli is rare in the adult population. It is associated with a high risk of morbidity and mortality. We describe a case of a 72-year-old woman who presented with altered mental status and neck stiffness and was found to have E. coli meningitis. Urine cultures grew E. coli, representing a likely source. The E. coli strain was identified as sequence type 73 (E. coli ST73). Her symptoms and laboratory values improved following antibiotic initiation, and she was discharged from the hospital to a rehabilitation facility.

Improvise, Adapt & Overcome: Successful Surgery-Sparing Prosthetic Hip Infection Antibiotic Suppression During COVID-19 Crisis.

CASE: A 79-year-old active male presented during the first COVID-19 pandemic surgery moratorium with late Staphylococcus lugdunensis periprosthetic total hip arthroplasty infection. Due to the unprecedented circumstances, novel treatment of IV and oral antibiotic suppression was trialed without preceding surgical intervention. At latest follow-up, the patient has two-year revision-free survival with normalization of inflammatory markers and MRI findings, and resolution of clinical symptoms. CONCLUSION: We report a novel surgery-sparing treatment for periprosthetic hip infection. Judicious caution should be used in the application of similar therapies, as host and organism characteristics likely contributed substantially to the success of this case.

Brucella Species Staining as Gram-Positive Rod and Gram-Positive Cocci in Chains.

Two cases of Brucellosis were identified at a hospital in Rhode Island. In both cases, the organisms were isolated from the blood cultures. The bacteria did not appear as the classical textbook description of Brucella spp. as short, Gram-negative rods; instead, Gram-positive rods and Gram-positive cocci in chains were observed. Due to the atypical Gram stain morphology, Brucella spp. were not initially considered as a possible pathogen. Antimicrobial prophylaxes were offered to the technologists who were exposed to the organisms.

Validation and performance comparison of three SARS-CoV-2 antibody assays.

Serology testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is increasingly being used during the current pandemic of coronavirus disease 2019 (COVID-19), although its clinical and epidemiologic utilities are still debatable. Characterizing these assays provides scientific basis to best use them. The current study assessed one chemiluminescent assay (Abbott COVID-2 IgG) and two lateral flow assays (STANDARD Q [SQ] IgM/IgG Duo and Wondfo total antibody test) using 113 blood samples from 71 PCR-confirmed COVID-19 hospitalized patients, 119 samples with potential cross-reactions, and 1068 negative controls including 942 pre-pandemic samples. SARS-CoV-2 IgM antibodies became detectable 3-4 days post-symptom onset using SQ IgM test and IgG antibodies were first detected 5-6 days post-onset using SQ IgG. Abbott IgG and Wondfo Total were able to detect antibodies 7 to 8 days post-onset. After 14 days post-symptom onset, the SQ IgG, Abbott IgG and Wondfo Total tests were able to detect antibodies from 100% of the PCR-confirmed patients in this series; 87.5% sensitivity for SQ IgM. Overall agreement was 88.5% between SQ IgM/IgG and Wondfo Total and 94.6% between SQ IgG and Abbott IgG. No cross-reaction due to recent sera with three of the endemic coronaviruses was observed. Viral hepatitis and autoimmune samples were the main source of limited cross-reactions. The specificities were 100% for SQ IgG and Wondfo Total, 99.62% for Abbott IgG, and 98.87% for SQ IgM. These findings demonstrated high sensitivity and specificity of appropriately validated SARS-CoV-2 serologic assays with implications for clinical use and epidemiological seroprevalence studies.

COVID-19 in a Patient Presenting with Syncope and a Normal Chest X-ray.

SARS-CoV-2 is a novel virus that has now affected hundreds of thousands of individuals across the world. Amidst this global pandemic, maintaining a high index of suspicion, rapid testing capacity, and infection control measures are required to curtail the virus' rapid spread. While fever and respiratory symptoms have been commonly used to identify COVID-19 suspects, we present an elderly female who arrived to the hospital after a syncopal episode. She was afebrile with a normal chest X-ray and there was no suspicion of COVID-19. She then developed a fever and tested positive for COVID-19. Our unique case underscores the increasing diversity of COVID-19 presentations and potential for initial mis- diagnosis and delay in implementing proper precautions.

Co-infection with SARS-CoV-2 and Human Metapneumovirus.

The novel coronavirus (now called SARS-CoV-2) initially discovered in Wuhan, China, has now become a global pandemic. We describe a patient presenting to an Emergency Department in Rhode Island on March 12, 2020 with cough and shortness of breath after a trip to Jamaica. The patient underwent nasopharyngeal swab for a respiratory pathogen panel as well as SARS-CoV-2 RT-PCR. When the respiratory pathogen panel was positive for human metapneumovirus, the patient was treated and discharged. SARS-CoV-2 RT-PCR came back positive 24 hours later. Although respiratory viral co-infection is thought to be relatively uncommon in adults, this case reflects that SARS-CoV-2 testing algorithms that exclude patients who test positive for routine viral pathogens may miss SARS-CoV-2 co-infected patients.

MRSA Prevalence in Preoperative S. aureus Nasal Culture Isolates is Significantly Different From a Traditional Hospital-wide Antibiogram.

Hospital antibiograms, because they are typically derived from samples obtained from hospitalized patients, may overestimate the prevalence of methicillin resistance in S. aureus in individuals presenting to the hospital for surgery. Because hospital antibiograms are commonly used to justify empiric perioperative prophylactic antibiotic selection prior to surgery, this may lead to unnecessary treatment with broad-spectrum antibiotics such as vancomycin. In a single-institution study, we observed that in our hospital antibiogram the proportion of S. aureus that are methicillin-resistant (MRSA) was significantly higher (45%) than isolates in preoperative nasal cultures obtained at the same hospital in outpatients prior to their lower extremity joint replacement surgery (13%): mean difference 0.32, [95% CI 0.25, 0.39], p <0.0001. These data suggest that hospital antibiograms may overstate the true prevalence of MRSA in those at risk for MRSA surgical site infections who present from the outpatient setting.

Safety and Nosocomial Clostridioides difficile Infections.

The rate of nosocomial C. difficile in the state of Rhode Island is among the highest in the country. Multiple factors impact the occurrence of nosocomial C. difficile. Improvement in a single factor may not lead to a decrease in the rate. We report the results of a multidisciplinary team that implemented multiple interventions, which led to a 42% reduction of nosocomial C. difficile at The Miriam Hospital.

Antibiotics and Nosocomial Clostridioides difficile, a Retrospective Chart Review.

C. difficile is a complication of antibiotic therapy. Certain antibiotics are associated with a higher rate of developing C. difficile. The charts of 54 patients with nosocomial C. difficile were reviewed and very few had received a high-risk antibiotic. Seven (13%) of 54 patients had not received any antibiotics in the hospital prior to the positive stool test for C. difficile. Moreover, 6 of the 7 had no documentation of receiving an antibiotic in the 56 days prior to admission suggesting that they might be colonized with C. difficile.

Rate of Clostridioides difficile Culture Positivity Among Hospitalized Patients.

The rate of nosocomial C. difficile in Rhode Island is among the highest in the country. Colonization with C. difficile is uncommon but can lead to falsely identifying a patient as having C. difficile infection. Additionally, unrecognized C. difficile colonization may act as a reservoir in the hospital. During a 19-day period, rectal swabs obtained for routine VRE surveillance were cultured for C. difficile. Overall, 51 (7.9%) of 649 patients had C. difficile by culture. The majority (n=36, 71%) of patients from whom a rectal swab grew C. difficile did not have a sample sent to the clinical laboratory. Hence, at least 5.5% of the 649 patients were colonized. One patient was classified as having hospital-acquired C. difficile since the clinical specimen was sent to the clinical laboratory on hospital day 4. This patient was culture positive on admission and hence misclassified as having hospital- acquired C. difficile.

Infection Control and Antimicrobial Stewardship.

Infection Control measures can reduce the transmission of bacteria in the hospital. Reduction in the use of antibiotics via Antimicrobial Stewardship programs can reduce antibiotic resistance. The combination of Infection Control measures and Antimicrobial Stewardship can lead to a greater reduction in antibiotic resistant bacteria.

Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature.

In the United States, sexually transmitted diseases due to Chlamydia trachomatis and Neisseria gonorrhoeae continue to be a major public health burden. Screening of extragenital sites including the oropharynx and rectum is an emerging practice based on recent studies highlighting the prevalence of infection at these sites. We reviewed studies reporting the prevalence of extragenital infections in women, men who have sex with men (MSM), and men who have sex only with women (MSW), including distribution by anatomical site. Among women, prevalence was found to be 0.6-35.8% for rectal gonorrhea (median reported prevalence 1.9%), 0-29.6% for pharyngeal gonorrhea (median 2.1%), 2.0-77.3% for rectal chlamydia (median 8.7%), and 0.2-3.2% for pharyngeal chlamydia (median 1.7%). Among MSM, prevalence was found to be 0.2-24.0% for rectal gonorrhea (median 5.9%), 0.5-16.5% for pharyngeal gonorrhea (median 4.6%), 2.1-23.0% for rectal chlamydia (median 8.9%), and 0-3.6% for pharyngeal chlamydia (median 1.7%). Among MSW, the prevalence was found to be 0-5.7% for rectal gonorrhea (median 3.4%), 0.4-15.5% for pharyngeal gonorrhea (median 2.2%), 0-11.8% for rectal chlamydia (median 7.7%), and 0-22.0% for pharyngeal chlamydia (median 1.6%). Extragenital infections are often asymptomatic and found in the absence of reported risk behaviors, such as receptive anal and oral intercourse. We discuss current clinical recommendations and future directions for research.

Candida and cardiovascular implantable electronic devices: a case of lead and native aortic valve endocarditis and literature review.

Use of cardiovascular implantable electronic devices (CIED), including permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD), has increased dramatically over the past two decades. Most CIED infections are caused by staphylococci. Fungal causes are rare and their prognosis is poor. To our knowledge, there has not been a previously reported case of multifocal Candida endocarditis involving both a native left-sided heart valve and a CIED lead. Here, we report the case of a 70-year-old patient who presented with nausea, vomiting, and generalised fatigue, and was found to have Candida glabrata endocarditis involving both a native aortic valve and right atrial ICD lead. We review the literature and summarise four additional cases of CIED-associated Candida endocarditis published from 2009 to 2014, updating a previously published review of cases prior to 2009. We additionally review treatment guidelines and discuss management of CIED-associated Candida endocarditis.

Hidden epidemic of macrolide-resistant pneumococci.

Community-acquired respiratory tract infections (RTIs) account for a substantial proportion of outpatient antimicrobial drug prescriptions worldwide. Concern over the emergence of multidrug resistance in pneumococci has largely been focused on penicillin-resistant Streptococcus pneumoniae. Macrolide antimicrobial drugs have been widely used to empirically treat community-acquired RTIs because of their efficacy in treating both common and atypical respiratory pathogens, including S. pneumoniae. However, increased macrolide use has been associated with a global increase in pneumococcal resistance, which is leading to concern over the continued clinical efficacy of the macrolides to treat community-acquired RTIs. We provide an overview of macrolide-resistant S. pneumoniae and assess the impact of this resistance on the empiric treatment of community-acquired RTIs.

Telithromycin: a ketolide antibiotic for treatment of respiratory tract infections.

Telithromycin, a recently approved ketolide antibiotic derived from 14-membered macrolides, is active against erythromycin-resistant pneumococci. Telithromycin has enhanced activity in vitro because it binds not only to domain V of ribosomal RNA (like macrolides do) but also to domain II. However, it is not active against streptococci and staphylococci with constitutive macrolide, lincosamide, and streptogramin B resistance. Telithromycin, available in an oral formulation, is approved by the US Food and Drug Administration for use in adults for treatment of (1) community-acquired pneumonia due to Streptococcus pneumoniae (including multidrug-resistant isolates), Haemophilus influenzae, Moraxella catarrhalis, Chlamydia pneumoniae, or Mycoplasma pneumoniae; (2) acute exacerbation of chronic bronchitis due to S. pneumoniae, H. influenzae, or M. catarrhalis; or (3) acute bacterial sinusitis due to S. pneumoniae, H. influenzae, M. catarrhalis, or methicillin- and erythromycin-susceptible Streptococcus aureus. It is not approved for treatment of tonsillitis, pharyngitis, or severe pneumococcal pneumonia. Unique visual adverse effects occurred in 0.27%-2.1% of patients receiving telithromycin therapy. Its enhanced activity against some common respiratory pathogens makes it a valuable addition to the available macrolides.

Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia.

Empiric antimicrobial prescribing for community-acquired pneumonia remains a challenge, despite the availability of treatment guidelines. A number of key differences exist between North American and European guidelines, mainly in the outpatient setting. The North American approach is to use initial antimicrobial therapy, which provides coverage for Streptococcus pneumoniae plus atypical pathogens. Europeans tend to focus on providing pneumococcal coverage with less emphasis on covering for an atypical pathogen. Ambulatory patients without comorbidity are more likely to receive macrolide therapy in North America, whereas in Europe these patients would probably receive a beta-lactam agent. Major issues that are fundamental to this difference include the importance of providing therapy for atypical pathogens and the clinical significance of macrolide-resistant S pneumoniae. Prospective data are required to evaluate which of these two approaches offers clinical superiority.

What Is the Clinical Impact of Macrolide Resistance?

Respiratory tract infections are treated empirically. Treatment is based on the likely pathogens and their antibiotic susceptibility. The most common respiratory tract pathogen is Streptococcus pneumoniae. In the United States, approximately 25% to 30% of S. pneumoniae are resistant to erythromycin and other macrolides. There are two mechanisms of resistance: ribosomal methylation that causes high-level resistance, and an efflux pump that causes low-level resistance. Macrolides are ineffective in animal models that use pneumococcal isolates with the methylase- or efflux-mediated resistance mechanisms. There are many case reports that describe clinical failure and isolation of a macrolide-resistant pneumococcus while a patient receives macrolide treatment. Two recent studies that included macrolide-susceptible and macrolide-resistant pneumococci showed that breakthrough bacteremia in patients receiving macrolide treatment occurred only with macrolide-resistant isolates. Study of bacteremic disease ensures the pathogenic role of the pneumococcus; however, it underestimates the true clinical impact of macrolide resistance.