Anjali N. Kunz

Two cases of Lactobacillus bacteremia during probiotic treatment of short gut syndrome.

Lactobacillus, a gram-positive bacillus, is a constituent of the indigenous flora of the colon. Often used as a probiotic agent, it appears to help prevent both intestinal colonization by pathogenic organisms and bacterial overgrowth syndrome. Lactobacillus organisms in the intestine are thought to produce acetic acid, lactic acid, and hydrogen peroxide and to promote the secretion of antimicrobial substances. The production of short chain fatty acids and the resultant low luminal pH of the colon also appear to inhibit growth of bacterial pathogens (1). Lactobacillus may also compete with pathogenic organisms for mucosal surface receptors and may decrease the incidence of antibiotic-associated diarrhea and Clostridium difficile colitis (2). Although Lactobacillus generally is not considered a pathogen, it can cause disease in compromised hosts, including bacterial endocarditis, pleuropulmonary infections, gastrointestinal abscesses, urinary tract infection, conjunctivitis, dental caries, and endometritis (3). Lactobacillus bacteremia, presumably secondary to bacterial translocation from the gastrointestinal tract, has been reported in a patient with severe intestinal inflammation caused by ulcerative colitis (4). There are no published reports of bacteremia or sepsis secondary to Lactobacillus given as a probiotic agent. We report two cases of Lactobacillus GG sepsis occurring during the therapeutic use of this organism.

Emerging Resistant Gram-Negative Aerobic Bacilli in Hospital-Acquired Infections

The increasing emergence of serious multidrug-resistant (MDR) Gram-negative infections has led to a new health-care crisis. These infections predominately include MDR Pseudomonas aeruginosa, extended-spectrum beta-lactamase-producing Enterobacteriaceae and MDR Acinetobacter baumannii. These organisms are present in a variety of clinical settings, but there is a distinct paucity of antibiotics to effectively treat these infections. The increasing use of broad-spectrum antibiotics and lack of good stewardship have contributed to the increase in these MDR organisms. This review focuses on the main MDR Gram-negative infections contributing to the current crisis in health care, their mechanisms of resistance and various treatment options for empiric therapy.

Impact of fluoroquinolone resistance mutations on gonococcal fitness and in vivo selection for compensatory mutations.

BACKGROUND Quinolone-resistant Neisseria gonorrhoeae (QRNG) arise from mutations in gyrA (intermediate resistance) or gyrA and parC (resistance). Here we tested the consequence of commonly isolated gyrA(91/95) and parC86 mutations on gonococcal fitness. METHODS Mutant gyrA(91/95) and parC86 alleles were introduced into wild-type gonococci or an isogenic mutant that is resistant to macrolides due to an mtrR(-79) mutation. Wild-type and mutant bacteria were compared for growth in vitro and in competitive murine infection. RESULTS In vitro growth was reduced with increasing numbers of mutations. Interestingly, the gyrA(91/95) mutation conferred an in vivo fitness benefit to wild-type and mtrR(-79) mutant gonococci. The gyrA(91/95), parC86 mutant, in contrast, showed a slight fitness defect in vivo, and the gyrA(91/95), parC86, mtrR(-79) mutant was markedly less fit relative to the parent strains. A ciprofloxacin-resistant (Cip(R)) mutant was selected during infection with the gyrA(91/95), parC86, mtrR(-79) mutant in which the mtrR(-79) mutation was repaired and the gyrA(91) mutation was altered. This in vivo-selected mutant grew as well as the wild-type strain in vitro. CONCLUSIONS gyrA(91/95) mutations may contribute to the spread of QRNG. Further acquisition of a parC86 mutation abrogates this fitness advantage; however, compensatory mutations can occur that restore in vivo fitness and maintain Cip(R).

The Role of Adenovirus in Respiratory Tract Infections

Adenovirus plays a significant role in respiratory tract disease in pediatric and adult patients. It has been linked to outbreaks and epidemics in various patient populations, resulting in considerable morbidity and mortality. In this article, we discuss the epidemiology, pathogenesis, respiratory tract illnesses and complications, and roles of potential treatment options. The role of the past oral adenovirus vaccine and the military implications of its withdrawal from routine use in military recruits is discussed as well.

Lactobacillus Sepsis Associated With Probiotic Therapy

better practices associated with a reduced risk of severe ROP.3 Manzoni and colleagues raise the interesting question of how much weight should be given to data from population-based studies versus local-institution audit when discussing risks of preterm birth with parents. In many cases, the database from individual units will simply be too small to allow unbiased analysis, a factor that has been a key motivation for the growth of neonatal networks.4,5 Manzoni and colleagues reported their data by birth weight groups. As we noted in our report, significantly growth-restricted infants will be overrepresented in such groupings, and different associations may be apparent when analysis is undertaken by gestational age bands.6,7 Looking at the example of vaginal versus operative delivery cited by Manzoni et al, caesarian section (CS) with no labor showed a protective effect for severe ROP on unadjusted analysis in our data set, but it did not retain significance on multivariate analysis.1 In fact, when the effect of method of birth was adjusted for gestation alone, the effect disappeared, giving an odds ratio for CS with no labor of 1.13 (95% confidence interval: 0.76, 1.67). An additional problem with the analysis presented by Manzoni and colleagues is that they seem to be concluding an effect of mode of birth in 1 subgroup and not the other based on an inappropriate analysis. As many authors have noted, the appropriate test for performing subgroup analysis is a test of statistical interaction; it is not valid to draw this conclusion based on the fact that the P value is significant in 1 subgroup but not the other.8 However, in this example, even if a unit in the Australia and New Zealand Neonatal Network did have sufficient local institutional data to show a valid protective association with CS, although it would be reasonable to convey that information, it would also be appropriate to emphasize that overall, in Australia and New Zealand, there was no such association. We agree with Manzoni and colleagues that it is important for units to collect their own data and continually review their practices. Our study is aimed at informing and enhancing such a process for all regional neonatal units in both Australia and New Zealand. We would encourage units elsewhere to contribute data to an appropriate network.

Disseminated Cutaneous Varicella Zoster Virus Infections During Infliximab Therapy for Crohn’s Disease: Case Report of Two Pediatric Patients at One Institution

Infliximab is a monoclonal antibody against tumor necrosis factor-a (TNF-a) that has been approved for the treatment of rheumatoid arthritis and Crohn’s disease. It is used in steroid-sparing regimens for patients who have had an inadequate response to conventional therapy. There are a number of studies that have shown an increased risk of infections with bacteria, fungi, mycobacterium, and more recently, chronic viral infections in patients receiving TNF-a antagonists. We report 2 cases of pediatric patients on infliximab therapy for Crohn’s disease who presented with disseminated cutaneous varicella zoster and primary varicella infections. Despite prompt and appropriate antiviral therapy both patients continued to manifest clinical findings of varicella zoster virus (VZV) infection and ultimately required hospitalization.

Mosquito Exposure and Chikungunya and Dengue Infection among Travelers during the Chikungunya Outbreak in the Americas

AbstractTravelers are at risk for arbovirus infection. We prospectively enrolled 267 Department of Defense beneficiaries traveling to chikungunya-outbreak regions in the Americas between December 2013 and May 2015 and assessed travel characteristics and serologic exposure to chikungunya virus (CHIKV) and dengue virus (DENV). Ten ill-returning travelers were also assessed retrospectively. Self-reported mosquito exposure was common (64% of 198 evaluable travelers saw mosquitoes; 53% of 201 reported ≥ 1 bite). Increased exposure was associated with active-duty travelers (odds ratio [OR] = 2.6 [1.3-5.4] for seeing mosquitoes) or travelers visiting friends and relatives (VFR) (OR = 3.5 [1.0-10.0] for high-intensity bite exposure). Arbovirus infection was defined as seroconversion on plaque reduction neutralization testing (PRNT) of pre- and posttravel sera. For ill subjects enrolled posttravel, infection was defined by a positive convalescent PRNT and/or a positive reverse transcription polymerase chain reaction for CHIKV or DENV. We identified seven cases of arbovirus infection: four with CHIKV, five with DENV, and two with both. The composite attack rate for CHIKV and DENV infection was 3.7% of 108 evaluable, immunologically naïve, prospectively assessed travelers; there was serologic and/or polymerase chain reaction evidence of arbovirus infection in three of four evaluable (three of 10 total) ill-returning travelers. We identified both symptomatic and asymptomatic cases. Military purpose of travel and VFR travel accounted for five of seven cases. Pretravel counseling is important and should target higher risk groups. Given a shared vector between CHIKV, DENV, and Zika virus (ZIKV), this study can also help guide counseling for travelers to ZIKV-outbreak regions.

Clinically Relevant Antibiotic Resistance Mechanisms Can Enhance the In Vivo Fitness of Neisseria gonorrhoeae

In 2007 the Centers for Disease Control and Prevention placed Neisseria gonorrhoeae on the infamous “Super Bugs” list to highlight the high prevalence of strains resistant to relatively inexpensive antibiotics, such as penicillin, tetracycline and fluoroquinolones, previously used in therapy to treat gonorrhea (Shafer et al., 2010). This event was significant because the gonococcus, a strict human pathogen, causes > 95 million infections worldwide each year and since the mid-1940s mankind has relied on effective antibiotic therapy to treat infections and stop local spread of disease. Today, such therapy is threatened by antibiotic resistance. Specifically, the third generation cephalosporins, especially ceftriaxone, may be losing their effectiveness since some (albeit still rare) isolates in the Far East, most recently Japan, and Europe have displayed clinical resistance to currently used levels of ceftriaxone, and treatment failures have been reported (Ohnishi et al., 2011; Unemo et al., 2010). Concern has been raised that the spectrum of resistance expressed by some gonococcal strains may make standard antibiotic treatment for gonorrhea ineffective in the not too distant future (Dionne-Odom et al., 2011). Without new, effective antibiotics or novel combination therapies of existing antibiotics, the reproductive health of the world’s sexually active population may be placed at risk due to such antibiotic resistant gonococci.

Epidemiologic, Clinical, and Virologic Characteristics of Respiratory Syncytial Virus Infection among Otherwise Healthy Adults

www.PosterPresentations.com Epidemiologic, clinical, and virologic characteristics of Respiratory Syncytial Virus infection among otherwise healthy adults Anjali Kunz, MD3, Levi Strube, MD3, Christina Schofield, MD3, Tahaniyat N. Lalani MD4,9, Patrick J. Danaher MD5, Michael Rajnik MD6, Leslie Malone MS MB(ASCP)CM8, Elena Grigorenko PhD8, Donald Stalons PhD8, Deepika Mor MS2,9, Michelande Ridore, MS2,9, Wei-Ju Chen, PhD2,9, John C. Arnold MD1, Eugene Millar, PhD2,9, Mary P. Fairchok, MD2,3,9