J. Martin Rodriguez

Detection, Treatment, and Prevention of Clostridium difficile Infection

Clostridium difficile is a gram-positive anaerobic bacillus responsible for approximately 1 of 5 cases of antibiotic-associated diarrhea. C difficile infection (CDI) is defined by at least 3 unformed stools in a 24-hour period and stool, endoscopic, or histopathologic test results that indicate the presence of this bacteria. The history of CDI research can be divided into early (before 2000) and modern eras (after 2000). C difficile was first described in 1935, and the characteristics and causes of CDI as well as therapies were identified during the early era of research. During the modern era, CDI has become a more common, aggressive nosocomial infection. Our understanding of the epidemiology, diagnosis, treatment, and prevention of CDI has increased at a rapid pace. We review features of CDI diagnosis, treatment, and prevention.

Loss of Vancomycin-Resistant Enterococcus Fecal Dominance in an Organ Transplant Patient With Clostridium difficile Colitis After Fecal Microbiota Transplant

We report the use of fecal microbiota transplantation in a single heart-kidney transplant recipient with recurrent Clostridium difficile, vancomycin-resistant Enterococcus (VRE) fecal dominance, and recurrent VRE infections. Fecal microbiota transplantation resulted in the reconstruction of a diverse microbiota with (1) reduced relative abundance of C difficile and VRE and (2) positive clinical outcome.

Identification of donor microbe species that colonize and persist long term in the recipient after fecal transplant for recurrent Clostridium difficile

Fecal microbiota transplantation has been shown to be an effective treatment for patients with recurrent C. difficile colitis. Although fecal microbiota transplantation helps to re-establish a normal gut function in patients, the extent of the repopulation of the recipient microbial community varies. To further understand this variation, it is important to determine the fate of donor microbes in the patients following fecal microbiota transplantation. We have developed a new method that utilizes the unique single nucleotide variants of gut microbes to accurately identify microbes in paired fecal samples from the same individual taken at different times. Using this method, we identified transplant donor microbes in seven recipients 3–6 months after fecal microbiota transplantation; in two of these fecal microbiota transplantation, we were able to identify donor microbes that persist in recipients up to 2 years post-fecal microbiota transplantation. Our study provides new insights into the dynamics of the reconstitution of the gastrointestinal microbe community structure following fecal microbiota transplantation.

Infections associated with adventure travel: A systematic review

Abstract Aim To review infections associated with adventure travel. Methods The PubMed, Embase and Scopus databases were searched combining the words infection with the following keywords: rafting, whitewater, surfing, (surfer* or windsurf*), (caves or caving or spelunking), (triathlon or trekking) or (hiking or adventure race), bicycling, backpacking, (mountain climb* or bouldering), horseback riding, orienteering, trekking, and skiing. Results Adventure travel is becoming much more common among travelers and it is associated with a subset of infectious diseases including: leptospirosis, schistosomiasis, viral hemorrhagic fevers, rickettsial diseases and endemic mycosis. Caving and whitewater rafting places individuals at particular risk of leptospirosis, schistosomiasis and endemic mycosis, while adventure races also place individuals at high risk of a variety of infections including campylobacter, norovirus and leptospirosis. Conclusion Travel practitioners need to be aware of the risks associated with adventure travel and should educate individuals about the risks associated with various activities. Doxycycline prophylaxis should be considered for travelers who are susceptible to leptospirosis due to participation in high-risk sports such as whitewater rafting, caving or adventure races.

Clinical Reasoning for the Infectious Disease Specialist: A Primer to Recognize Cognitive Biases

Infectious disease specialists are frequently consulted for diagnostic and therapeutic advice on challenging cases. When evaluating patients, the infectious disease specialist is well positioned to offer an appropriate diagnostic approach but is also at risk of not recognizing the correct diagnosis for a variety of reasons. We believe it is important to provide infectious disease specialists and trainees with a fundamental understanding of diagnostic errors, clinical reasoning, and cognitive biases. We present 2 cases demonstrating common cognitive biases leading to diagnostic errors, and we reflect on strategies that may aid in their prevention. We hope to provide knowledge and tools that may help prevent diagnostic errors in the future.

Impact of Infectious Disease Consultation on Clinical Management and Mortality in Patients with Candidemia

Candidemia has a high attributable mortality. The objective of this study was to determine the impact of infectious disease consultation on mortality and clinical outcomes in candidemia. Infectious disease consultation was associated with better adherence to guidelines and improved survival, even in patients with high Acute Physiology and Chronic Health Evaluation II scores.

Author Correction: Identification of donor microbe species that colonize and persist long term in the recipient after fecal transplant for recurrent Clostridium difficile

The affiliation details are incorrect in this article. The correct affiliation details are given below: 1Biomedical Informatics, Center for Clinical and Translational Sciences, University of Alabama at Birmingham, Birmingham, AL 35294, USA; 2Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL 35294, USA; 3Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; 4Department of Genetics and Heflin Center for Genomic Science, University of Alabama at Birmingham, Birmingham, AL 35294, USA; 5Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL 35294, USA and 6Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.In addition, this article was originally published without the accompanying supplementary tables. This file is now available in the HTML version of the article; the PDF was correct from the time of publication.

Infectious Disease Consultation Is Associated with Decreased Mortality with Enterococcal Bloodstream Infections

Abstract Background Enterococcal bloodstream infections (EBSI) have been attributed with significant morbidity and mortality. The objective of this study was to determine whether IDC is associated with improved mortality in patients hospitalized with EBSI. Methods This is a cross-sectional study of patients admitted to the University of Alabama Health System between January 1, 2015 and June 30, 2016 who had EBSI. Patients who died within 2 days of hospitalization were excluded. Categorical variables were analyzed with chi-square or Fisher’s exact test and continuous variables were analyzed with a t-test or Wilcoxon rank-sums test when appropriate. A P-value < 0.05 was considered significant. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) for factors associated with 30-day in-hospital mortality. Results A total of 213 patients met the case definition. One hundred and thirty-four (63%) received IDC. Baseline patient demographics and comorbidities were similar in both groups. Patients with IDC were more likely to have repeated blood cultures (99% vs. 72%, P < 0.001), echocardiogram performed (77% vs. 46%, P < 0.001), and interventions for source control (19% vs 6%, P = 0.01). Patients without IDC were more likely to have inappropriate antibiotic treatment or no antibiotics (20% vs. 0%, P < 0.001) as well as inappropriate duration of therapy (54% vs. 10%, P < 0.001). There were no differences in the rates of recurrent bacteremia or readmission within 60 days. Patients who did not receive IDC had higher 30-day in-hospital mortality (27% vs. 13%, P = 0.02). Having an echocardiogram (OR 2.75, 95% CI 1.36–5.55), surgical intervention (OR 3.11, 95% CI 1.07–9.05) and an IV catheter (OR 3.90, 95% CI 1.39–10.88) were associated with increased likelihood of IDC while inappropriate duration of antibiotics was associated with an 87% decreased likelihood of IDC (OR 0.13, 95% CI 0.06–0.29). The strongest association observed with 30-day mortality was inappropriate duration of antibiotics (OR 4.93, 95% CI 1.93–12.61). Conclusion IDC was associated with reduced 30-day in-hospital mortality in patients with EBSI. Although further investigation is warranted, the results of this study suggest that early involvement of ID specialists in EBSI may lead to better outcomes. Disclosures All authors: No reported disclosures.

Does the Zika virus outbreak provide an educational opportunity for STI prevention in the pre-travel setting?

We read with interest the papers published in TMAID on the difficulty of providing STI prevention advice in the pretravel setting [1,2]. The recent Zika epidemic in the Americas has raised concerns among travel clinic patients regarding sexual transmission, health effects, and future childbearing capacity. While the epidemic has had a significant impact on the health and economies of countries in Latin America, it offers a unique opportunity for sexual education, particularly in adolescent travelers. Travel clinics see a wide variety of patients from newborns to retirees. However, each spring, travel clinics across the USA see a bolus of patients traveling to Latin America for educational, work, or mission-oriented trips. These patients vary in age, but are commonly between 12 and 20 years old. From January 2014 to July 2016, the travel clinic at the University of Alabama at Birmingham saw over 500 adolescent travelers. They are typically accompanied by their parents or seen in groups and get standard care as needed including vaccines, antimalarial medication, antidiarrheal medication and educated to use sunscreen and DEET. Unfortunately, limited time is spent educating adolescent travelers regarding safe sex and its importance, not just in preventing Zika transmission, but also other STIs, including HIV. Studies have estimated that up to 20e30% of individuals traveling will have a new sexual encounter during their trip, with only half using barrier protection [3]. We also know that about 45% of high school students are sexually active, with only 57% of those using barrier protection [4]. In addition, alcohol continues to play a major role in the lack of barrier protection in teen sex and is common among young travelers [4,5]. These data suggest that travel clinic practitioners have a unique role in emphasizing the importance of barrier protection to all patients, including adolescents. Travel clinics

A 76-Year-Old Woman with Diaphoresis and Anxiety

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.