Sally Alrabaa

Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment

Klebsiella producing carbapenemase is an emerging pathogen. We report transmission of this organism by contaminated endoscopic instruments. Quick identification of source, staff education, contact precautions, and emphasis on hand and environmental hygiene led to case control and prevention of outbreak.

Survey of physicians' perspectives and knowledge about diagnostic tests for bloodstream infections.

Background Physicians rely on blood culture to diagnose bloodstream infections (BSI) despite its limitations. As new technologies emerge for rapid BSI diagnosis, optimization of their application to patient care requires an understanding of clinicians’ perspectives on BSI diagnosis and how a rapid test would influence medical decisions. Methods We administered a 26-question survey to practitioners in infectious diseases/microbiology, critical care, internal medicine, and hematology/oncology services in USA and Germany about current standards in diagnosing and treating BSI and a hypothetical rapid BSI test. Results Responses from 242 providers had roughly equal representation across specialties. For suspected BSI patients, 78% of practitioners would administer empiric broad spectrum antibiotics although they estimated, on average, that 31% of patients received incorrect antibiotics while awaiting blood culture results. The ability of blood culture to rule in or rule out infection was very/extremely acceptable in 67% and 36%, respectively. Given rapid test results, 60–87% of practitioners would narrow the spectrum of antimicrobial therapy depending on the microorganism detected, with significantly higher percentages when resistance determinants were also tested. Over half of respondents felt a rapid test would be very/extremely influential on clinical practice. Conclusions Limitations of blood culture were perceived as a barrier to patient care. A rapid test to diagnose BSI would impact clinical practice, but the extent of impact may be limited by prevailing attitudes and practices. Opportunities exist for interventions to influence practitioners’ behaviors in BSI management particularly with emergence of newer diagnostic tests.

Fecal microbiota transplantation outcomes in immunocompetent and immunocompromised patients: A single-center experience

Clostridium difficile infection (CDI) is a major infectious disease focus for which fecal microbiota transplantation (FMT) has been used with success in various patient populations.

The HIV Virologic Outcomes of Different Interventions Among Treatment-Experienced Patients With 2 Consecutive Detectable Low-Level Viremia.

Background: Approaches to treatment-experienced HIV-infected patients with persistent low-level viremia are limited by current commercial resistance genotyping assays when the viral load (VL) is <500 copies/mL. The best intervention to achieve virologic suppression in this population is unclear. Methods: This is a case control retrospective chart review study of 149 HIV-infected patients with a VL of 50 to 1000 copies/mL. Patients were in either regimen unchanged group or intervention group (intensification of regimen or switch without guidance from resistance testing). End point was VL < 100 copies/mL. Results: At 6 months post change, 30.8% of patients with intervention versus 36.6% with no intervention achieved a complete virologic suppression. There were no statistically significant differences between these 2 groups (P = .254). The majority of patients without regimen change eventually progressed to complete virologic failure. Conclusion: Patients with persistent low levels of viremia are likely to progress to have virologic failure. This supports the adoption of a more proactive approach to treatment and more sensitive technique to identify drug resistance.

Comparison of Clinical and Radiological Features of Aspergillus, Zygomycosis, and Fusarium Pneumonia in Neutropenic Patients

BackgroundOpportunistic fungal pneumonia in neutropenic patients due to hematologic malignancy or bone marrow transplant continues to rise, and the diagnosis remains challenging. We sought to compare the clinical and early radiological patterns of 3 fungi (Aspergillus, Fusarium, and zygomycosis) in this population to facilitate early diagnosis and improve choice of early empiric therapy before culture results are available. MethodsThis is a retrospective chart review study conducted between January 1999 and June 2010 in neutropenic patients with fungal pneumonia. Clinical and radiological features, duration of neutropenia, underlying illness, culture results, treatment choice, and outcome were recorded for each patient. ResultsTotal of 74 patients with fungal pneumonia met inclusion criteria: 27 had Aspergillus, 25 had Fusarium, and 22 had zygomycosis pneumonia. The following were the findings:Underlying diagnosis: Acute myeloid leukemia was the most common underlying diagnosis in any fungal pneumonia, present in 42 (57%) of the 74 patients.Clinical features: Toe cellulitis was present in 34% of Fusarium pneumonia cases. Blood culture positive for the fungus in 10% of the Fusarium cases. Other clinical features were reported in similar frequencies in all types of fungal pneumonia.Radiological patterns: In 20 (80%) of 25 cases of Fusarium, early lung nodules were multiple (>2) and small with an average diameter less than or equal to 1 cm at initial computed tomography scans (size: minimum 0.1, median 0.8, maximum 2.8 cm). Sixteen (67%) of 24 cases of early nodules caused by Aspergillus and 13 (72%) of 18 cases of early nodules caused by zygomycosis had a bigger size at diagnosis (size: minimum 0.3, median 1.8, maximum 4.3 cm for Aspergillus; and minimum 0.5, median 2.1, maximum 4.5 cm for zygomycosis) (P < 0.0001) and were few in number. Fusarium lung nodules had a scattered (central and peripheral) distribution in 76% of cases. Nodules caused by Aspergillus and zygomycosis were located peripherally, in 75% and 78% of cases respectively.Duration of neutropenia: The median duration of neutropenia was shorter with an average of 18 days (minimum, median, maximum = 1, 10, 60 days, respectively) at the time of invasive Aspergillus diagnosis in contrast to that for Fusarium with an average of 48 days (minimum, median, maximum = 7, 26, 128 days, respectively) and an average of 45 days in cases due to zygomycosis (minimum, median, maximum = 4, 28.5, 105 days, respectively) (P < 0.0001).Initial treatment and outcome: Voriconazole was used empirically initially in 53 (72%) of the 74 patients. Mortality at 3 months for all fungi was 64%, highest for zygomycosis (67%) followed by Aspergillus (63%) and Fusarium (55%). ConclusionsClinical and radiological patterns and duration of neutropenia provide useful clues as to the nature of the fungal pneumonia in neutropenic patients. This can help better guide the choice of the initial empiric antifungal therapy and may help improve patient outcome.

Successful use of subcutaneous ivermectin for the treatment of Strongyloides stercoralis hyperinfection in the setting of small bowel obstruction and paralytic ileus in the immunocompromised population

Severe Strongyloides stercoralis, such as hyperinfection syndrome, carries a high mortality risk. Even with appropriate treatment, patients may experience infectious complications and failure of therapy. Currently, there are no Food and Drug Administration–approved parenteral therapies available for treatment in patients who develop gastrointestinal complications from hyperinfection, including small bowel obstruction. A veterinary form of ivermectin is available as a subcutaneous injection, although current literature in humans is limited. We report on the successful treatment of two surviving immunocompromised patients with S. stercoralis hyperinfection syndrome after prompt recognition and initiation of veterinary subcutaneous ivermectin therapy.

Antibiotic Resistance and Toxin Production of Clostridium difficile Isolates from the Hospitalized Patients in a Large Hospital in Florida

Clostridium difficile is an important cause of nosocomial acquired antibiotic-associated diarrhea causing an estimated 453,000 cases with 29,000 deaths yearly in the U.S. Both antibiotic resistance and toxin expression of C. difficile correlate with the severity of C. difficile infection (CDI). In this report, a total of 139 C. difficile isolates from patients diagnosed with CDI in Tampa General Hospital (Florida) in 2016 were studied for antibiotic resistance profiles of 12 types of antibiotics and toxin production. Antibiotic resistance determined by broth microdilution method showed that strains resistant to multi-antibiotics are common. Six strains (4.32%) showed resistance to six types of antibiotics. Twenty strains (14.39%) showed resistance to five types of antibiotics. Seventeen strains (12.24%) showed resistance to four types of antibiotics. Thirty-nine strains (28.06%) showed resistance to three types of antibiotic. Thirty-four strains (24.46%) showed resistance to two types of antibiotics. While, all isolates were susceptible to metronidazole, and rifaximin, we found that one isolate (0.72%) displayed resistance to vancomycin (MIC ≥ 8 μg/ml), and another one was resistant to fidaxomicin (MIC >1 μg/ml). The percentage of isolates resistant to cefoxitin, ceftriaxone, chloramphenicol, ampicillin, clindamycin, erythromycin, gatifloxacin, and moxifloxacin was 75.54, 10.79, 5.76, 67.63, 82.70, 45.32, 28.06, and 28.78%, respectively. Toxin profiling by PCR showed the isolates include 101 (72.66%) A+B+CDT-strains, 23 (16.55%) A+B+CDT+ strains, 3 (2.16%) A-B+CDT+ strains, 1 (0.72%) A-B+CDT-strains, and 11 (7.91%) A-B-CDT-strains. Toxin production determined by ELISA using supernatants of bacterial culture harvested at 12, 24, 48, and 72 h of post inoculation (hpi) showed that the toxins were mainly produced between 48 and 72 hpi, and toxin B (TcdB) was produced faster than toxin A (TcdA) during the experimental time (72 hpi). In addition, the binary-positive strains were likely to yield more toxins compared to the binary-negative strains. This work contributes to the current understanding of the antibiotic resistance and virulence of C. difficile clinical strains.

Neurosyphilis and HIV Infection

Syphilis and HIV are both diseases of major public health importance globally, affecting tens of millions of people and leading to millions of deaths every year. There is a complex demographic, epidemiologic, and biologic interaction between the HIV virus and Treponema pallidum, the causative agent of syphilis. These interactions lead not only to higher rates of coinfection but also are believed to affect pathogenic mechanisms that result in early central nervous system syphilis among HIV-coinfected patients. Acute syphilitic meningitis and neuro-ophthalmologic syphilitic involvement are also believed to occur at a higher rate and early in the course of syphilis among HIV-coinfected individuals. There needs to be a higher index of suspicion for syphilitic involvement of the CNS among HIV patients especially those with ophthalmological and/or ontological complaints. While there may need to be subtle differences, current recommendations for diagnostic workup for neurosyphilis in HIV-coinfected patients are similar to that of non-HIV patients. Intravenous penicillin remains the treatment of choice for neurosyphilis.

Neuronal Apoptotic Pathways in HIV-Associated Dementia, Alzheimer’s Disease, Parkinson’s Disease, and Huntington’s Disease

Dementia is one of the most devastating healthcare problems in the twenty-first century and involves cognitive impairment with persistent increased dependency and expense of care. Under the panoply of NeuroAIDS, the dementia resulting from human immunodeficiency virus (HIV) infection is termed HIV-associated dementia (HAD). Alzheimer’s disease (AD) is associated with the elderly population over 55 years old, and its prevalence increases with age. Parkinson’s disease (PD) also affects people in old age, and its pathological hallmark involves eosinophilic cytoplasmic inclusions, Lewy bodies. Huntington’s disease (HD) is an autosomal dominant genetic disorder caused by HD gene dysfunction and results in cortical thinning and ventricular enlargement. This chapter reviews the literature on the apoptotic pathways involved in the pathogenesis of these four dementias. Topics include intra-, inter-, and extracellular reactions, biochemical pathway changes, and signaling affecting neurons. Despite clinical differences among the four dementias, related molecular pathways and signaling patterns emerge. Individual-focused, evidence-based, translational healthcare brings this perspective into the twenty-first century.

Pulmonary Infections With Mycobacterium avium-intracellulare in Women With Confirmed or Suspected Malignancy: A Retrospective Observational Study, 1987–2011

BackgroundIn the last 2 decades, there has been an increased interest in infections caused by nontuberculous mycobacteria (NTM). Mycobacterium avium complex is the most common PNTM in the United States. Pulmonary disease caused by MAI is often chronic and occurs particularly in the elderly, in women frequently without underlying lung disease. Although NTM infections are reported in patients with malignancy, few studies investigated the epidemiological, clinical, and radiological characteristics of pulmonary MAI infection in women with cancer. Materials and MethodsWe retrospectively reviewed medical and microbiologic records and radiographic findings of all female patients seen at the Moffitt Cancer Center in Tampa, Florida, with positive lung specimen cultures for MAI from January 1987 to January 2011. Microbiologic records included the cultures of expectorated sputum samples, bronchial wash or lavage, and lung biopsies. Radiographic findings obtained by high-resolution computed tomography permitted a classification of the lung MAI disease in 3 forms: cavitary, nodular bronchiectatic, and nodular form. ResultsA total of 46 patients met the inclusion criteria during a 24-year period. The median age at the time of diagnoses was 68 years. There were some patients who had an underlying cancer, an underlying chronic lung disease, and a comorbid condition. Cough was the most common pulmonary symptom in most of our patients. The most common radiologic finding was consistent with a single nodule. A few of the female patients were definable as Lady Windermere syndrome. Symptomatic improvement was seen in most of the patients with either a monotherapy or a combination therapy. ConclusionsPhysicians need to be aware of the possibility of coexisting pulmonary MAI in elderly women with cancer, principally breast and lung cancer, or chronic lung disease, with a chronic cough and a new nodule on the lung computed tomography scan. Early suspicion can lead to appropriate diagnosis, prompt therapy, and reduction of mortality.