Maria Teresa Seville

Treatment of Refractory Coccidioidomycosis With Voriconazole or Posaconazole

BACKGROUND Coccidioidomycosis is a fungal infection of the desert southwestern United States. It may be self-limited or may require antifungal therapy. Currently used triazoles (eg, fluconazole and itraconazole) have largely supplanted amphotericin B, which is fraught with adverse effects. Limited case reports and small open-label trials show that voriconazole and posaconazole benefit patients with coccidioidomycosis refractory to first-line agents. METHODS We conducted a retrospective review of patients prescribed voriconazole or posaconazole for coccidioidomycosis at our institution between 1 January 2006 and 1 August 2010. Outcomes were assessed with both a retrospectively applied Mycosis Study Group score (ie, a composite score for symptoms, serology, and radiographic findings) and the documented impressions of treating medical practitioners. RESULTS Twenty-one patients who received voriconazole and 16 who received posaconazole met study criteria. After a median duration of 6 months of voriconazole treatment, 14 of 21 patients (67%) were improved in overall status, 5 were unchanged, and 2 were unresponsive to voriconazole. After a median of 17 months of posaconazole treatment, 12 of 16 patients (75%) showed improvement, 1 was unchanged, and 3 were unresponsive due to medication intolerance or relapsed infection. CONCLUSIONS Voriconazole and posaconazole are reasonable but not infallible options for salvage treatment of refractory coccidioidomycosis. Prospective comparative trials are required to provide further insights into their efficacy and utility.

Predictive Value of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Swab PCR Assay for MRSA Pneumonia

ABSTRACT Pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA) is associated with poor outcomes and frequently merits empirical antibiotic consideration despite its relatively low incidence. Nasal colonization with MRSA is associated with clinical MRSA infection and can be reliably detected using the nasal swab PCR assay. In this study, we evaluated the performance of the nasal swab MRSA PCR in predicting MRSA pneumonia. A retrospective cohort study was performed in a tertiary care center from January 2009 to July 2011. All patients with confirmed pneumonia who had both a nasal swab MRSA PCR test and a bacterial culture within predefined time intervals were included in the study. These data were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value for clinically confirmed MRSA pneumonia. Four hundred thirty-five patients met inclusion criteria. The majority of cases were classified as either health care-associated (HCAP) (54.7%) or community-acquired (CAP) (34%) pneumonia. MRSA nasal PCR was positive in 62 (14.3%) cases. MRSA pneumonia was confirmed by culture in 25 (5.7%) cases. The MRSA PCR assay demonstrated 88.0% sensitivity and 90.1% specificity, with a positive predictive value of 35.4% and a negative predictive value of 99.2%. In patients with pneumonia, the MRSA PCR nasal swab has a poor positive predictive value but an excellent negative predictive value for MRSA pneumonia in populations with low MRSA pneumonia incidence. In cases of culture-negative pneumonia where initial empirical antibiotics include an MRSA-active agent, a negative MRSA PCR swab can be reasonably used to guide antibiotic de-escalation.

Reactivation of coccidioidomycosis despite antifungal prophylaxis in solid organ transplant recipients.

Background. Coccidioidomycosis is an airborne infection caused by the fungus Coccidioides, which is endemic to the southwestern United States. Cell-mediated immunity is required for the control of this infection, and some patients such as organ transplant recipients, who lack such immunity, have a high risk of severe, disseminated, or relapsed infection with high mortality. Previously latent coccidioidal infection can reactivate after transplantation. Antifungal prophylaxis has substantially decreased the risk of reactivated coccidioidomycosis after transplantation in these patients. Methods. We conducted a retrospective review of all patients with coccidioidomycosis who underwent solid organ transplantation at our center to identify factors for recrudescent coccidioidomycosis (despite antifungal prophylaxis) after transplantation. Results. Between June 1999 and June 2009, 100 patients with previous coccidioidomycosis underwent solid organ transplantation at our institution. Ninety-four (94%) received anticoccidioidal prophylaxis after transplantation. The six patients who did not receive such prophylaxis did not experience reactivated coccidioidomycosis. Five patients who received anticoccidioidal prophylaxis experienced reactivated infection. All five patients survived with further antifungal treatment. Among patients who experienced recrudescent infection despite antifungal prophylaxis, African American race was an identified risk factor. Pretransplant dissemination may be a risk factor for reactivated coccidioidomycosis, but this finding was not statistically significant. Whether nonadherence to prophylaxis played a small or large role is uncertain. Conclusions. Antifungal prophylaxis effectively suppressed recrudescent coccidioidomycosis after solid organ transplantation for the large majority of patients with a history of coccidioidomycosis before transplantation. Strict lifelong adherence to antifungal prophylaxis is imperative.

Characteristics of Patients with Mild to Moderate Primary Pulmonary Coccidioidomycosis

Convalescence is prolonged, regardless of whether the patient receives treatment.

Thymidine Auxotrophic Staphylococcus aureus Small-Colony Variant Endocarditis and Left Ventricular Assist Device Infection

ABSTRACT We describe a thymidine-dependent small-colony variant of Staphylococcus aureus associated with left ventricular assist device infection and prosthetic valve and pacemaker endocarditis.

Standardizing Central Line Safety: Lessons Learned for Physician Leaders

A comprehensive central venous catheter (CVC) safety program reduces mechanical and infectious complications and requires an integrated multidisciplinary effort. A multistate health care system implemented a discovery and diffusion project addressing CVC insertion, maintenance, and removal. Process and outcome measures were collected before and after the intervention. The project was completed in 12 months. It was associated with statistically significant improvement in 6 process measures and reduction in the rate of ICU central line-associated bloodstream infection (from 1.16 to 0.80 infections/1000 catheter days; incidence rate ratio = 0.69; 95% confidence interval = 0.51, 0.93). A comprehensive CVC standardization project increased compliance with several established best practices, was associated with improved outcomes, produced a refined definition of discovery and diffusion project components, and identified several discrete leadership principles that can be applied to future clinical improvement initiatives.

The impact of early and brief corticosteroids on the clinical course of primary pulmonary coccidioidomycosis.

OBJECTIVE Primary pulmonary coccidioidomycosis can often be associated with hypersensitivity symptoms treatable with a short course of palliative corticosteroids. Long-term use of corticosteroids is a known risk factor for severe or disseminated infection but the effects of short-term use are not known. METHODS A retrospective review was conducted of immunocompetent patients with acute pulmonary coccidioidomycosis who received systemic corticosteroids for relief of coccidioidal-related symptoms. Age- and sex-matched controls were also reviewed. Predetermined end-points were assessed. RESULTS Seventy-four patients met inclusion criteria for the corticosteroid-treated group, and 74 controls were identified. Cumulative corticosteroid (prednisone-equivalent) doses were 10 mg → 3,600 mg (mean = 206 mg; median = 120 mg). Corticosteroids were prescribed most commonly for rash 43/74 [58%] or asthma/wheezing/cough 30/74 [41%]. Coccidioidal-related hospitalization occurred in 19 patients in the corticosteroid group vs. 22 in the control group (P = .58). Coccidioidal-related symptoms resolved within a mean of 19 weeks (median = 8 weeks [range = 2-208 weeks]) vs. 32.3 weeks (median = 8 weeks [range = 1-1040 weeks]) in the corticosteroid and control groups (P = .38). Relapse of symptoms occurred in 12% of both groups (P > .99). Extrapulmonary dissemination occurred in 3% vs. 4.0% (P > .99) in the corticosteroid and control groups, respectively. CONCLUSION This study found no adverse effects of short-term corticosteroid therapy for early symptomatic treatment in acute pulmonary coccidioidomycosis.

2009 H1N1 influenza in hospitalized transplant recipients

Background. The 2009 H1N1 influenza virus was first identified in April 2009 and rapidly evolved into a pandemic. There are limited reports of 2009 H1N1 influenza in transplant recipients. We report on our experience with hospitalized transplant recipients with 2009 H1N1 influenza virus. Methods. Ongoing review of hospitalized 2009 H1N1 influenza cases identified six patients who had received transplants. Clinical characteristics and outcomes were abstracted from the medical record. Results. Between April 27 and November 30, 2009, 29 patients with influenza A virus were admitted to the Mayo Clinic Hospital. Six of the 29 patients were transplant recipients; 4 were confirmed to have 2009 H1N1 influenza virus. Most patients presented with an acute febrile respiratory illness. Duration of antiviral treatment was 5 to 7 days except for one patient who was treated for 11 days until withdrawal of care. Prolonged viral shedding was not noted, and the patients recovered promptly except for a patient with recalcitrant multiple myeloma who died because of the disease. Conclusion. 2009 H1N1 influenza disease in this cohort of hospitalized transplant recipients was relatively mild. The majority of the patients improved promptly, and prolonged viral shedding was not noted.

Coccidioidal Tenosynovitis of the Hand and Wrist: Report of 9 Cases and Review of the Literature

BACKGROUND Tenosynovitis is an uncommon manifestation of disseminated infection with Coccidioides fungal species. Most experts treat this infection with combined surgical debridement and antifungal medication. The aim of our study was to examine the outcomes of patients with coccidioidal tenosynovitis of the hand and wrist. METHODS We retrospectively searched for the records of patients with coccidioidal tenosynovitis of the hand and wrist at our institution. between 1987 and 2013. We also conducted a review of the literature from 1950 to 2014 to identify additional cases. RESULTS We identified 9 cases of coccidioidal tenosynovitis of the hand and wrist at our institution, along with 5 other cases found in a review of the literature. The relapse rate was high overall (50%) and was higher after discontinuation of antifungal therapy (71%) in both immunocompromised and immunocompetent patients. Results of serologic testing were not predictive of relapse. CONCLUSIONS A treatment strategy for coccidioidal tenosynovitis should focus on long-term administration of antifungal agents.

Is it actionable? An Evaluation of the Rapid PCR-Based Blood Culture Identification Panel on the Management of Gram-Positive and Gram-Negative Blood Stream Infection

Background There is growing interest in the use of rapid blood culture identification (BCID) panels in antimicrobial stewardship programs (ASP). While many studies have looked at its clinical and economic utility, its comparative utility in gram-positive and gram-negative blood stream infections (BSI) have not been as well characterized. Methods The study was a quasi-experimental retrospective study at the Mayo Clinic in Phoenix, Arizona. All adult patients with positive blood cultures before BCID implementation (June 2015 to December 2015) and after BCID implementation (June 2016 to December 2016) were included. The outcomes of interest included: time to first appropriate antibiotic escalation, time to first appropriate antibiotic de-escalation, time to organism identification, LOS, infectious disease consultation, discharge disposition, and in-hospital mortality. Results In total, 203 patients were included in this study. There was a significant difference in the time to organism identification between pre- and post-BCID cohorts (27.1h vs. 3.3h, p<0.0001). BCID did not significantly reduce the time to first appropriate antimicrobial escalation or de-escalation for either GP-BSIs or GN-BSIs. Providers were more likely to escalate antimicrobial therapy in GP-BSIs after gram stain and more likely to de-escalate therapy in GN-BSIs after susceptibilities. While there were no significant differences in changes in antimicrobial therapy after organism identification by BCID, over a quarter of providers (28.1%) made changes after organism identification. Conclusions While BCID significantly reduced the time to identification for both GP-BSIs and GN-BSIs, BCID did not reduce the time to first appropriate antimicrobial escalation and de-escalation.