Maroun Sfeir

Prevalence of Staphylococcus aureus methicillin-sensitive and methicillin-resistant nasal and pharyngeal colonization in outpatients in Lebanon

BACKGROUND There is an increasing concern about methicillin-resistant Staphylococcus aureus (MRSA) infections in the community. This study aimed to evaluate the rate of S aureus nasopharyngeal colonization in outpatients as the primary endpoint, and also to study the impact of several possible risk factors, including recent hospitalization, recent surgical procedures, and antibiotic intake. METHODS A total of 1,526 consecutive outpatients underwent surveillance cultures after completing a questionnaire. Isolated S aureus strains were tested for antibiotic susceptibility. The Pearson χ(2) test was used for statistical analysis. The differences were considered to be statistically significant at a P value <.05. RESULTS Out of the 1,526 outpatients tested, 133 (8.7%) carried S aureus in the nose and/or throat. Only 2 of those cases were MRSA, and both were isolated from the nose. One hundred thirty-one patients had methicillin-sensitive S aureus, 13 with simultaneous carriage in the nose and throat. Among the risk factors, a relative working in health care, presence of an intravascular device, recent dental procedure, and health club use were significantly associated with an increased risk of S aureus colonization, with P values of .00, .02, .04, and .00, respectively, calculated by the χ(2) test. CONCLUSIONS The prevalence of MRSA is still low in our study population within the Lebanese community. The only significant risk factors playing a role in increasing the carriage of S aureus were related to health care exposure.

Carbapenem-Resistant Acinetobacter baumannii : Concomitant Contamination of Air and Environmental Surfaces

OBJECTIVE To concomitantly determine the differential degrees of air and environmental contamination by Acinetobacter baumannii based on anatomic source of colonization and type of ICU layout (single-occupancy vs open layout). DESIGN Longitudinal prospective surveillance study of air and environmental surfaces in patient rooms. SETTING A 1,500-bed public teaching hospital in Miami, Florida. PATIENTS Consecutive A. baumannii-colonized patients admitted to our ICUs between October 2013 and February 2014. METHODS Air and environmental surfaces of the rooms of A. baumannii-colonized patients were sampled daily for up to 10 days. Pulsed-field gel electrophoresis (PFGE) was used to type and match the matching air, environmental, and clinical A. baumannii isolates. RESULTS A total of 25 A. baumannii-colonized patients were identified during the study period; 17 were colonized in the respiratory tract and 8 were colonized in the rectum. In rooms with rectally colonized patients, 38.3% of air samples were positive for A. baumannii; in rooms of patients with respiratory colonization, 13.1% of air samples were positive (P=.0001). In rooms with rectally colonized patients, 15.5% of environmental samples were positive for A. baumannii; in rooms of patients with respiratory colonization, 9.5% of environmental samples were positive (P=.02). The rates of air contamination in the open-layout and single-occupancy ICUs were 17.9% and 21.8%, respectively (P=.5). Environmental surfaces were positive in 9.5% of instances in open-layout ICUs versus 13.4% in single-occupancy ICUs (P=.09). CONCLUSIONS Air and environmental surface contaminations were significantly greater among rectally colonized patients; however, ICU layout did not influence the rate of contamination. Infect Control Hosp Epidemiol 2016;37:777-781.

Scabies and Bedbugs in Hospital Outbreaks

Scabies and bedbugs are two emerging ectoparasitic infections reported in crowded areas, including hospitals. Skin involvement is the main presenting initial manifestation for both infections, and the diagnosis is yet challenging for both. Topical permethrin is considered the first-line therapy for scabies except for crusted scabies which is mainly treated with oral ivermectin. To the contrary, treatment of bedbugs is mainly symptomatic. Avoiding close contact, early diagnosis and treatment of infected persons as well as decontamination of the involved environment play an essential role in controlling outbreaks in healthcare settings.

Salmonella typhi sternal wound infection

Samonella typhi usually causes gastrointestinal infections. Few reports in the literature described skin and soft tissue infections related to Salmonella species, especially in immunocompetent patients. Our case exhibited sternal abscess growing Salmonella typhi.

Mycobacterium abscessus complex infections: A retrospective cohort study

Abstract Background Infections caused by Mycobacterium abscessus group strains are usually resistant to multiple antimicrobials and challenging to treat worldwide. We describe the risk factors, treatment, and clinical outcomes of patients in 2 large academic medical centers in the United States. Methods A retrospective cohort study of hospitalized adults with a positive culture for M. abscessus in Miami, Florida (January 1, 2011, to December 31, 2014). Demographics, comorbidities, the source of infection, antimicrobial susceptibilities, and clinical outcomes were analyzed. Early treatment failure was defined as death and/or infection relapse characterized either by persistent positive culture for M. abscessus within 12 weeks of treatment initiation and/or lack of radiographic improvement. Results One hundred eight patients were analyzed. The mean age was 50.81 ± 21.03 years, 57 (52.8%) were females, and 41 (38%) Hispanics. Eleven (10.2%) had end-stage renal disease, 34 (31.5%) were on immunosuppressive therapy, and 40% had chronic lung disease. Fifty-nine organisms (54.6%) were isolated in respiratory sources, 21 (19.4%) in blood, 10 (9.2%) skin and soft tissue, and 9 (8.3%) intra-abdominal. Antimicrobial susceptibility reports were available for 64 (59.3%) of the patients. Most of the isolates were susceptible to clarithromycin, amikacin, and tigecycline (93.8%, 93.8%, and 89.1%, respectively). None of the isolates were susceptible to trimethoprim/sulfamethoxazole, and only 1 (1.6%) was susceptible to ciprofloxacin. Thirty-six (33.3%) patients early failed treatment; of those, 17 (15.7%) died while hospitalized. On multivariate analysis, risk factors significantly associated with early treatment failure were disseminated infection (odds ratio [OR], 11.79; 95% confidence interval [CI], 1.53–81.69; P = .04), acute kidney injury (OR, 6.55; 95% CI, 2.4–31.25; P = .018), organ transplantation (OR, 2.37; 95% CI, 2.7–23.1; P = .005), immunosuppressive therapy (OR, 2.81; 95% CI, 1.6–21.4; P = .002), intravenous amikacin treatment (OR, 4.1; 95% CI, 0.9–21; P = .04), clarithromycin resistance (OR,79.5; 95% CI, 6.2–3717.1, P < .001), and presence of prosthetic device (OR, 5.43; 95% CI, 1.57–18.81; P = .008). Receiving macrolide treatment was found to be protective against early treatment failure (OR, 0.13; 95% CI, 0.002–1.8; P = .04). Conclusions Our cohort of 108 M. abscessus complex isolates in Miami, Florida, showed an in-hospital mortality of 15.7%. Most infections were respiratory. Clarithromycin and amikacin were the most likely agents to be susceptible in vitro. Resistance to fluoroquinolone and trimethoprim/sulfamethoxazole was highly common. Macrolide resistance, immunosuppression, and renal disease were significantly associated with early treatment failure.

Cerebellitis associated with influenza A(H1N1)pdm09, United States, 2013.

To the Editor: Central nervous system (CNS) manifestations of influenza are uncommon, especially in adults (1,2), and influenza-associated cerebellitis is exceedingly rare: 8 cases have been reported (3–7; Technical Appendix). We describe a case of cerebellitis caused by influenza A(H1N1)pdm09 in an adult woman.

Spontaneous Massive Splenic Infarction in the Setting of Renal Transplant and Septic Shock: A Case Report and Review of the Literature

Massive splenic infarction (MSI) is a rare phenomenon that results from compromised blood flow to more than half of the spleen. Causes of MSI include hematological disorders, coagulopathies, infection, and embolization, and, rarely, MSI is spontaneous. The mainstay of treatment is splenectomy. We report the case of a 50-year-old man with a history of renal transplant who presented with diffuse abdominal pain and rapidly developed septic shock. A computed tomographic study (CT scan) of the abdomen demonstrated MSI. The surgical team was consulted for splenectomy but conservative management was maintained and immune function preserved. The patients clinical condition was resolved over a three-week period. This report demonstrates successful nonoperative management of a spontaneous MSI most likely secondary to hypoperfusion and a hypercoagulable state from both septic shock and renal transplant.

An unusual case of hematuria.

A 66-year-old woman presented with acute onset of painless gross hematuria and generalized fatigue of 10 days’ duration. The patient was asymptomatic until she started to notice blood in her urine, not associated with dysuria or dribbling. Shortly afterward, she developed oliguria, and swelling of both legs, associated with mild exertional dyspnea, diffuse body aches, and fatigue without subjective fevers or chills. She had no oral or nasal ulcers, alopecia, photosensitivity, joint pain, joint swelling or redness, or symptoms of Raynaud’s phenomenon. She had mild exertional shortness of breath, but without chest pain or cough. She denied abdominal pain or any change in her bowel habits. Beside the gross hematuria, she denied any other urinary symptom. She denied weight loss, recent travels, or sick contacts. On evaluation in the emergency department, she was afebrile but hypertensive (blood pressure 188/98 mm Hg), which was a new symptom for her. She had periorbital edema as well as bilateral lower extremity pitting edema to the knees. Laboratory evaluation in the emergency room showed normocytic anemia, blood urea nitrogen of 44 mg/dl (normal range 7–18), and a creatinine level of 3.8 mg/dl (normal range 0.6–1.2). Her estimated creatinine clearance was 11.9 ml/minute/1.73 m (normal range 80–125) with a fractional excretion of sodium of 2.5%. Her creatinine was checked 3 weeks prior to admission during a routine checkup and found to be elevated at 1.4 mg/dl. She had a potassium level of 5.5 mEq/liter (normal range 3.5–5.1), a phosphorus level of 6.1 mg/dl (normal range 2.8–4.1), and a total calcium level of 8.2 mg/dl (normal range 8.4–10.2). Her urine analysis at presentation revealed 3 proteins, 3 blood, gross red blood cells (RBCs), 1–3 white blood cells, and trace leukocyte esterase. A chest radiograph performed on admission showed cardiomegaly with mild congestion. Kidney ultrasound did not show any hydronephrosis, kidney mass, or evidence of nephrolithiasis. She was admitted to the general medical floor with a diagnosis of acute kidney injury and nephrotic syndrome.

Raw milk intake: beware of emerging brucellosis

Brucellosis is a challenging zoonosis to diagnose and treat. The recent outbreaks of Brucella abortus RB51 in several states in the United States, including New Jersey and Texas, due to raw milk consumption has raised the concern of drug-resistant Brucella spp. This commentary highlights the importance of being on the lookout for this emerging infection.

Echinocandin Resistant Candida tropicalis Bloodstream Infections

Abstract Background The aim of this study is to describe the clinical manifestations, molecular mechanisms, and treatment outcomes of patients with echinocandin-resistant Candida tropicalis (C. tropicalis) bloodstream infections (BSI). Methods A PubMed search was conducted using the search terms related to C. tropicalis BSI and echinocandin resistance. Two previously unreported cases from our institution diagnosed with C. tropicalisBSI that developed resistance to echinocandins were also included. Demographics, comorbidities, treatment, clinical outcomes, and molecular mechanisms were analyzed. Results Seven patients with echinocandin-resistant C. tropicalis BSI were identified, including 5 previously reported cases and two from our institution. Median age was 58.7 ± 20.4 years; 3 (43%) patients were males. Three (43%) had acute myelogenous leukemia, 3 (43%) had acute lymphoblastic leukemia, and 1 (14%) had urothelial cancer. All patients were immunocompromised having received chemotherapy in the last six months and 3 (43%) were hematopoietic stem cell transplant recipients. Five (71%) had breakthrough of echinocandin resistance while receiving an echinocandin; one (14%) received caspofungin in the past 3 months and only one (14%) had no reported echinocandin exposure in the past 3 months. DNA sequencing of the FKS1 gene for mutations known to confer echinocandin resistance was performed in 4 cases, including our two index cases. Homozygous T-to-C mutations in two alleles of FKS1gene was detected in 2 cases, and a heterozygous mutation was detected in the other 2 cases, which resulted in a deduced serine-to-proline amino acid change at position 654 (S654P). Six patients (86%) survived after being treated with an antifungal agent other than an echinocandin. Treatment was changed to liposomal amphotericin B in two cases, and one each to voriconazole, fluconazole, voriconazole plus liposomal amphotericin B, and caspofungin plus voriconazole. The one patient who died received intravenous voriconazole. Conclusion Echinocandin resistance emerged in neutropenic patients with C. tropicalis fungemia through a characteristic mutational hot-spot amino acid change in the target FKS1 gene. Although alternative antifungal agents may be successfully used as salvage therapy, the outcome may still be fatal. Disclosures D. Perlin, Pfizer: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Astrellas: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Merck: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Cidara: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Synexis: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. F2G: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Myconostica: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Amplyx: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. Matinas: Research support, honoraria and/or consulting fees and/or has served on advisory board, Research support, honoraria and/or consulting fees and/or has served on advisory board. GAFFI: Scientific Advisor, Advisor. Bill and Melinda Gates Foundation: Scientific Advisor, Advisor