PEERA HEMARAJATA, M.D., PH.D., D(ABMM)

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Lit Review Mar #1

March 15, 2018

Disclaimer: this compilation of synopses have been collected from multiple sources, including Mark Crislip's Puscast, Journal Watch Infectious Diseases, Medscape Infectious Diseases, CDC MMWR, AMA Morning Rounds, ProMED Mail, Journal of Clinical Microbiology, Antimicrobial Agents and Chemotherapy, Clinical Infectious Diseases, and more. I chose these articles based on their relevance to clinical microbiology and would be of interest to my fellows, and some other pieces that I found amusing to read. All credit goes to these original contributors. I'm just a messenger :).

 

Leading Photo by Suzanne Tucker on Unsplash

Trichinellosis Outbreak Linked to Consumption of Privately Raised Raw Boar Meat — California, 2017

https://www.cdc.gov/mmwr/volumes/67/wr/mm6708a3.htm?s_cid=mm6708a3_e

  • Not bear meat this time!

  • Initial patient and at least three family members  evaluated for fever, myalgia, abdominal pain, diarrhea, and vomiting after attending a celebration where several pork dishes were served, including larb, a traditional Laotian raw pork dish (LARB DOESN’T HAVE TO BE RAW – I’ve never had a raw pork larb EVER)

  • lameda County Public Health Department (ACPHD) identified 29 individuals who attended the party and 7 more that consumed dishes brought home

  • Source of meat: domesticated wild boar raised and slaughtered on a private family farm

  • Tested for IgG: identified 10 confirmed and 2 probably cases (not lab confirmed)

  • Most got pretty sick (sepsis, AKI, GI bleeding) requiring ICU admission

  • Identified T. spiralis using touch prep slides confirmed by PCR and sequencing of ITS1-2 region

  • Owners of farm reported that small animals (chicks, etc) occasionally got into the pen and eaten by the pigs

  • Educated owners on meat processing (freezing for 30 days and cooking to internal temperature of 160°F (71.1°C))

  • Some patients said they would never eat raw meat again

  • One patient said he would continue to eat raw meat but from animals that he hunts, believing that raw meat confers strength

Increase in Hospital Admissions for Severe Influenza A/B among Travelers on Cruise Ships to Alaska, 2015

https://wwwnc.cdc.gov/eid/article/24/3/17-1378_article

  • Case report of lab-confirmed cluster of influenza (n=25) requiring hospital admission associated with cruise ships to Alaska during summer of 2015, admitted in an acute care center in Vancouver, mostly H3N2

    • 7 tested positive on ship and started oseltamivir

    • 1 tested negative on ship and did not receive treatment, although should have regardless of test results

  • Response due to surge in cases compared to same time in previous years

  • Only 4 people had been vaccinated

  • CDC recommendation on influenza on cruise ships

    • Crew and passengers should be vaccinated

    • Postpone travel when ill

    • Comply with respiratory etiquette and isolation

    • Initiate antiviral treatment in cases of confirmed or suspected influenza in ILI patients with severe manifestations or risk factors for severe disease

Interim Estimates of 2017–18 Seasonal Influenza Vaccine Effectiveness — United States, February 2018

https://www.cdc.gov/mmwr/volumes/67/wr/mm6706a2.htm

  • This year's flu vaccine effectiveness was 36% overall, 25% against H3N2, 67% against (H1N1)pdm09, and 42% against influenza B. Not that bad at all!

Invasive pulmonary aspergillosis and influenza co-infection in immunocompetent hosts: case reports and review of the literature

https://www.ncbi.nlm.nih.gov/pubmed/29454654

  • Report of 2 fatal cases of IPA in patients with flu A and flu B

  • Both relatively immunocompetent (one has poorly-controlled DM)

  • Positive for flu at admission, then developed respiratory failure and multi-organ failure afterwards

  • One had positive galactomannan, one didn’t

  • Autopsy confirmed IPA

  • Moral of the story: don’t ignore Aspergillus in severe flu patients

High Prevalence of Multidrug-Resistant Mycoplasma genitalium in Human Immunodeficiency Virus-Infected Men Who Have Sex With Men in Alabama

https://academic.oup.com/cid/article-pdf/66/5/796/23879834/cix853.pdf

  • Cause of up to 20% of nongonococcal urethritis, detected in 12% of MSM with proctitis

  • No FDA approved test

  • CDC recommendation: AZT as first line, MOX as second line

  • Looked at 157 HIV-infected MSMs over 2 years

    • Prevalence of M. genitalium infection was 17.2% (27 of 157)

      • 10.8% urogenital

      • 6.4% rectal

  • SO MUCH RESISTANCE – determined by Sanger sequencing

    • 74.1% of all isolates (27) had mutations conferring macrolide resistance

      • 80% of rectal samples and 70.6% of urogenital

    • 29.6% had at least one typical parC fluoroquinolone-resistance mutation

      • 40% of rectal samples and 26.7% of urogenital

    • 24% had both

Delftia tsuruhatensis, an Emergent Opportunistic Healthcare-Associated Pathogen

https://wwwnc.cdc.gov/eid/article/24/3/16-0939_article

  • Another non-fermenter (SO MANY OF THEM) first isolated from sludge in Japan in 2003

  • Case report from France in ex 36 weeker with congenital cardiac anomaly requiring surgery, post-op complications included ARF, VAP

  • Bronch secretion grew this GNR and IDed by MALDI (Bruker) confirmed with 16S

  • AST using non-Enterobacteriaceae BPs and treated with CAZ, repeat culture negative

    • Review non-fermenter AST: NO DISK DIFFUSION BPs – BMD only

      • Non-Enterobacteriaceae for

        • Pseudomonas spp. (not P. aeruginosa)

        • Other nonfastidious, glucose-nonfermenting, GNRs except

          • Those with own BPs in M100: P. aeruginosa, Acinetobacter spp., B. cepacia, B. mallei, B. pseudomallei, and S. maltophilia

          • Those with BPs in M45: B. mallei, B. pseudomallei, Aeromonas spp., Vibrio spp.

  • VAP again a month later, this time MALDI mis-IDed as D. acidovorans, 16S confirmed correct ID (same bug as last time)

  • Treated with IPM, AMK, TOB but pt expired anyway

  • Reviewed records at institution: identified 11 patients, isolated from BCB, resp, urine

    • Most have underlying, including CVC, post-transplant, etc

    • All healthcare-associated

Invasive Infections Caused by Nannizziopsis spp. Molds in Immunocompromised Patients

https://wwwnc.cdc.gov/eid/article/24/3/17-0772_article

  • Phylum Ascomycota. previously reported as extremely rare cause of cerebral and disseminated infections

  • Case report from France again but different hospital

    • 2 cases of cerebral abscesses in immunocompromised patients (leukemia and HIV)

    • One case positive BCB, another direct ITS PCR and sequencing positive in CSF followed by positive culture from cerebral biopsy

    • Seemed to have low MICs for most antifungals

    • One case passed away before positive BCB, the other got treated and improved

    • Both had recently spent time in Africa

High Cryptococcal Antigen Titers in Blood Are Predictive of Subclinical Cryptococcal Meningitis Among Human Immunodeficiency Virus-Infected Patients

  • Generally, it is believed that positive CrAg in blood is strongly predictive of subsequent cryptococcal meningitis in HIV patients with CD4<100

    • People have been using “screen-and-treat” approach before starting ART in pt with  CD4 <100: tested forCrAg in blood

      • If positive in absence of meningitis: treat pre-emptively with fluc and maintained pending immune reconstitution with ART

      • Not super well supported, and many studies reported high mortality in these patients despite treatment

      • Possibility that asymptomatic or minimally symptomatic patients (a little bit of headache) with positive CrAg in blood could be having concurrent meningitis and there is no data for concurrent yet

    • Looked at over 505 HIV patients with CD4<100 and positive for CrAG in blood

      • 50% no headache or confusion at all

      • 34% headache only

      • 15% confused only – excluded

    • Who actually had evidence of meningitis? Only LP would be able to tell, so among people who had LP done:

      • Asymp group: 34% had meningeal infection

      • Headache only: 90% had meningeal infection

    • What about CrAg positivity and titer in blood for these patients?

      • Among cases that had blood available for testing, blood CrAg titers significantly associated with concurrent meningeal infection in both groups

      • Best cutoff: blood CrAg titer >160, with sensitivity of 88.2% and specificity 82.1%

  • Not a whole lot of patients, but useful data: maybe people with positive CrAg in absence of symptoms should be treated more aggressively since they could already be having meningeal infection

Coccidioidomycosis Outbreaks, United States and Worldwide, 1940–2015

https://wwwnc.cdc.gov/eid/article/24/3/17-0623_article

  • Look at 47 outbreaks (>2 human coccidioidomycosis cases linked to a common source) all over the world involving >1400 patients

  • Most associated with environmental exposure (earthquakes – 1994 Northridge earthquake was part of this, dust storms)

  • >1/3 of cases occurred in area not know to be endemic for cocci

  • >1/2 occupational exposure (military, construction, archeology, labs)

  • Should increase awareness regardless of endemicity

Evidence for Previously Unidentified Sexual Transmission of Protozoan Parasites

https://wwwnc.cdc.gov/eid/article/24/3/17-1838_article

  • Parasites could reach seminal fluid from bloodstream to male genital tract or by directly infecting reproductive organ

  • Lit review: 5 parasite species with demonstrated presence in seminal fluid (doesn’t necessarily shown to transmit)

    • Entamoeba hystolytica: testicles, epididymis, and seminal fluid. Can cause damage and infertility, evidence of transmission

    • Schistosoma haematobium: migrate from bladder, no evidence of transmission

    • Trichomonas vaginalis: most common nonviral STI in the world and on the rise, associated with decreased sperm quality

    • Trypanosoma cruzi: found in chronically infected men, experimental mouse model demonstrated infection through intravaginal infusion of semen from infected humans

    • Toxoplasma gondii: also reported to affect sperm quality, experimental sheep model demonstrated infection after vaginal infusion of vegetative cysts

Protection of the Human Gut Microbiome From Antibiotics

https://academic.oup.com/jid/article/217/4/628/4653556

  • Free (not absorbed) antibiotics in lumen of intestine believed to have a negative effect on intestinal microbiome

  • A small study in 44 healthy volunteers to look at the effect of a new product (DAV132 – based on absorbent activated charcoal) on free fecal concentration of MXF after oral administration

  • Reduced free drug concentration by 99% while no effect on serum level

  • Metagenomic sequencing demonstrated preservation of composition of microbiota

The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk

https://academic.oup.com/cid/article/66/3/329/4372047

  • Fact: >90% of reported PEN allergy is not real

  • Looked at >8000 patients undergoing surgical procedures

  • Patients that reported PEN allergy had OR of developing surgical site infection of 1.5 compared to control

    • Associated with less administration of CFZ and more of second-line peri-op antibiotics including CLI, VAN, GEN

  • Significance of a more thorough evaluation of reported PEN allergy – pt missing out on getting effective prophylaxis

FDA OKs First Tests to Detect Tickborne Parasite in Whole Blood and Plasma

https://www.medscape.com/viewarticle/893546

  • Babesia: most frequently reported transfusion-transmitted parasitic infection, although still pretty uncommon

  • First screening tests for antibodies (using Arrayed Fluorescent Immunoassay (AFIA)) to Babesia microti in human plasma samples and B microti DNA (using NAAT) in human whole blood samples

  • Should reduce risk of transmission through blood transfusion

Pediatricians Should Know More About Lassa Virus

https://www.medscape.com/viewarticle/893469

  • CDC said clinicians should be able to recognize potential infection among children (mostly <10 yo) newly arrived in the Un