Investigating Detroit Water Shutoffs and Hepatitis A

Introduction: Hepatitis A (HAV) is a self-limiting viral liver disease that can manifest as abdominal pain, anorexia, nausea, fatigue, and jaundice with elevated serum aminotransferase levels. Despite an efficacious vaccine, there has been an outbreak across the country, including metropolitan Detroit. Recent cases in Michigan have presented with severe life-threatening manifestations. Already, 905 cases of hepatitis A have been reported in Michigan in the months of September and October 2018, of which 726 have resulted in hospitalization (80.2%) and 28 deaths. The historical notion of transmission fecal-orally via food is now more complex, as higher risk populations include those using drugs and those experiencing homelessness. This study evaluated risk factors for hepatitis A in an epidemic setting in urban Detroit including potential association with Detroit mandated water shutoff. Methods: Patients who received care at Henry Ford Health System between August 2016 and December 2017 with positive hepatitis A diagnoses were selected if their electronic medical record (EMR) indicated their home addresses within Detroit city proper. Patients were contacted via telephone numbers listed in the EMR and asked for voluntary phone interview participation. Patients were asked a standardized set of questions. This study was approved by the Henry Ford Hospital Institutional Review Board. Results: Sixty-six Detroit patients with Hepatitis A were reviewed. Twenty-two were available for contact and agreed to phone interview. Thirteen of the 22 were male (59.1%). Average age was 49, ranging from 21 to 81 years of age. Three (13.6%) had a history of intravenous drug use; two (9.1%) were food handlers; and four (14.2%) were homeless. Three patients (13.6%) were discovered deceased upon phone interview with a family member and fourteen (63.6%) were hospitalized, according to hospital records. Of note, four patients (14.2%) had their water shut off. Conclusion: Recent data from the CDC demonstrates a new trend of hepatitis A infections among persons reporting injection or non-injection drug use or homelessness. This study evaluated risk factors for hepatitis A in an epidemic setting in urban Detroit including potential association with Detroit-mandated water shutoffs. It is worth investigating the importance of water shutoffs and homelessness among hepatitis A outbreaks, as those who are homeless often lack access to clean water. This public health crisis continues despite a HAV vaccine being readily available and efficacious, warranting further investigation as to the source.https://scholarlycommons.henryford.com/merf2019clinres/1062/thumbnail.jp

Increasing Incidence of MDROs: An Emerging Global Concern

Introduction: With massive efflux of civilians from violence-stricken countries, the high rates of colonization with multidrug-resistant organisms (MDROs) amongst the refugees is an emerging global concern. Our report describes two Middle Eastern patients who suffered severe traumatic injuries in their home countries, subsequently developing chronic wounds. Upon arrival to the United States, the patients sought treatment in our institution for wound infection with MDRO. Materials and methods: Clinical data was collected from the patients’ charts. Identification and susceptibility testing were performed as part of routine identification/susceptibility test in the clinical microbiology laboratory. MICs performed by manual microbroth dilution according to Clinical and Laboratory Standards Institute (CLSI) guidelines.Time kill curves used to determine in vitro synergy of Pseudomonas aeruginosa isolate in various antibiotic combinations (½ x MIC meropenem plus ½ x MIC colistin, ½ x MIC meropenum plus ½ x MIC colistin plus ½ x MIC rifampin and ½ x MIC meropenem plus ½ x MIC ceftazidime/avibactam). Mueller Hinton II broth was used. Samples were serially diluted at 0, 4 and 24 hours and plated on TSA II agar. Time kill curves were constructed, plotting colony counts over time, with synergy being defined as ≥2-log10 decrease in CFU/ml between the combination and its most active constituent after 24h, the number of surviving organisms in the presence of combination must be ≥2 log10 CFU/ml below the starting inoculum. Results: Patient 1 came from Syria, and patient 2 from Yemen. Both patients’ wound infections were healthcare-associated, with underlying chronic osteomyelitis. Both had multiple risk factors for MDRO, including multiple prior surgeries and antibiotic courses. Patient 1 culture grew CRE Klebsiella and MDR Morganella, and later ESBL Escherichia coli. Patient 2 culture grew Pseudomonas aeruginosa sensitive only to colistin. Patient 1 was treated with ertapenem. Patient 2 received rifampin+meropenen+colistin, the only antibiotic combination demonstrating synergistic killing. Both patients required prolonged therapy, and on follow up were doing well. Conclusions: Colonization with MDRO amongst Middle Eastern immigrants is an alarming phenomenon.In vitro experiments with available antibacterial agents may assist in the choice of therapy for MDRO strains when conventional options are exhausted.https://scholarlycommons.henryford.com/merf2019basicsci/1001/thumbnail.jp

Ceftaroline fosamil monotherapy for methicillin-resistant Staphylococcus aureus bacteremia: a comparative clinical outcomes study

OBJECTIVES: Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; however, its use has been subject to scrutiny due to failure in severe infections. Ceftaroline fosamil (CPT-F) is approved for MRSA acute bacterial skin and skin structure infections, but not for bloodstream infections. The clinical outcomes of treatment with CPT-F in patients with MRSA bacteremia were evaluated. METHODS: Patients diagnosed with MRSA bacteremia at Henry Ford Hospital in Detroit, Michigan, USA, involving isolates with a vancomycin minimum inhibitory concentration ≥1.0mg/l and susceptible in vitro to CPT-F, were systematically reviewed retrospectively. Ceftaroline fosamil-treated patients were matched with at least two vancomycin- and/or one daptomycin-treated control patient based on age-patients age 65 years or greater or less than 65 years of age. Outcomes evaluated included the duration of hospitalization, duration of therapy, adverse events, relapse, hospital readmission, and death. RESULTS: Thirty consecutive cases of MRSA bacteremia treated with CPT-F during the period May 2011 to June 2013 were identified; these patients were matched to 56 MRSA bacteremia patients treated with vancomycin and 46 MRSA bacteremia patients treated with daptomycin. The primary source of MRSA bacteremia in the cohort treated with CPT-F was endocarditis (n=7, 23%), skin/wound (n=9, 30%), and bone/joint (n=8, 27%). The MRSA bacteremia in those treated with CPT-F was community-acquired in 43% of cases, healthcare-associated in 43%, and hospital-acquired in 13%. The mean length of hospital stay for these patients was 22 days. The overall 30-day mortality rate was 13% (n=4) in CPT-F patients versus 24% (n=11) in daptomycin patients and 11% (n=6) in vancomycin patients (p=0.188). CONCLUSIONS: CPT-F demonstrated comparable clinical outcomes in MRSA bacteremia patients compared with the other agents, especially as salvage therapy

Assessment of invitrosynergy of daptomycin or vancomycin plus ceftaroline for daptomycin non-susceptible Staphylococcus aureus

The combination of vancomycin or daptomycin plus ceftaroline has showed synergistic results in vitro. This study aimed to investigate in vitro synergy of vancomycin or daptomycin plus ceftaroline for seven patients with daptomycin non-susceptible Staphylococcus aureus (SA) bacteremia Thirteen isolates from seven patients were evaluated: two methicillin-susceptible and five methicillin-resistant SA infections. All patients were treated with daptomycin and became non-susceptible (minimum inhibitory concentration (MIC) \u3e1 μg/mL) with therapy or had resistant strains initially. Time kill experiments were completed with 0.25 × MIC, 0.5 × MIC, and 0.75 × MIC concentrations. No synergy was seen at 0.25 × MIC. Synergy was observed for 4 isolates with vancomycin plus ceftaroline and with daptomycin plus ceftaroline for 2 isolates at 0.5 × MIC. These results are in accordance with literature that supports synergistic combinations of daptomycin or vancomycin with ceftaroline for SA bacteremia. Daptomycin non-susceptible SA bacteremia presents a treatment challenge

Comparison of Mortality and Therapy in Community Acquired Pneumonia

Background: Community associated pneumonia (CAP) is one the most common causes of hospital admissions, exceeding more than one million per year in the United States, contributing to 3.4% of inpatient mortality. Our objective was to compare 30-day mortality using therapies recommended for treatment of CAP. Methods: A multicenter retrospective analysis from four different hospitals was assessed from 2008 to 2013. The data was obtained from electronic medical records which included more than 70,000 patients. CAP patients were identified using discharge diagnostic codes during the years 2008-2013, as well as receiving therapy with ceftriaxone and azithromycin or a respiratory fluoroquinolone. Demographic data, antibiotic therapy, and Charlson comorbidity score was obtained to compare the study groups. Results: A total of 21,800 patients met the inclusion criteria for CAP. 1,740 patients were excluded as they received both beta-lactams and fluoroquinolones. The study included 20,600 patients. 11,201 patients (55.84%) received ceftriaxone with azithromycin, and 8,859 (44.16%) received fluoroquinolone therapy. The mortality rate for patients who received fluoroquinolone therapy was lower compared to the patients who received ceftriaxone plus azithromycin (3.56% vs 6.71%, p-value \u3c0.001). Conclusion: Our study showed statistically significant lower 30-day mortality using fluoroquinolone therapy compared to ceftriaxone plus azithromycin for treatment of CAP. Prospective blinded randomized control trials would be needed to support this evidence

Comparative study of virulence factor genes, β-hemolysis and biofilm production in invasive and colonizing enterococci

Objectives: In humans, enterococci are among the most important opportunistic pathogens. This study aims to compare invasive isolates obtained from blood cultures of patients with sepsis and endocarditis with colonizing isolates obtained from healthy donors’ stool samples. Methods: A case-by-case assessment was conducted on invasive infection cases to determine whether enterococci were involved in their pathogenesis. They were tested for the presence of virulence factor genes, β-hemolysis on agars supplemented with human and sheep blood, and biofilm forming capacity. Results: Three species of enterococci were identified among invasive isolates: Enterococcus faecalis, Enterococcus faecium, and Enterococcus durans. All endocarditis isolates were biofilm producers. Genes esp, gelE, asa1, ace, hyl, cylB, and cylA were present in 7 (41.2%), 11 (64.7%), 11 (64.7%), 13 (76.5%), 0, 3 (17.6%), and 1 (5.9%) invasive isolate, but none of them could be linked to a particular infection (sepsis or endocarditis). Colonizing isolates proved to have had more virulence factor genes, but the differences were not statistically significant. Members of that group produced a greater amount of biofilm when the ace gene was absent (p = 0.047). The production of β-hemolysis by noninvasive strains was detected more frequently when agar was supplemented with human blood (p = 0.021). In general, the presence of either cyl gene on that specific agar was in direct connection with the production of β-hemolysis: cylA (p = 0.047) or cylB (p = 0.020). Conclusion: We have been unable to establish any correlation between invasive isolates and any virulence gene carriage and biofilm formation. β-hemolysis was produced significantly more often by colonizing strains when agar had been supplemented with human blood

The impact of obesity and timely antiviral administration on severe influenza outcomes among hospitalized adults

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141541/1/jmv24946.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141541/2/jmv24946_am.pd

Reduced production of bacterial membrane vesicles predicts mortality in ST45/USA600 methicillin-resistant Staphylococcus aureus bacteremia

Immune biomarkers can stratify mortality risk in staphylococcal bacteremia. Microbial biomarkers may provide more consistent signals during early infection. We demonstrate that in ST45/USA600 bacteremia, bacterial membrane vesicle production in vitro predicts clinical mortality (773 vs. 116 RFU, survivors vs. decedents, p \u3c 0.0001). Using a threshold of 301 relative fluorescence units (RFU), the sensitivity and specificity of the membrane vesicles to predict mortality are 78% and 90%, respectively. This platform is facile, scalable and can be integrated into clinical microbiology lab workflows

Successful treatment of Candida parapsilosis and Pseudomonas aeruginosa infection using medical and surgical management in an injecting drug user with mitral and aortic valve endocarditis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Polymicrobial endocarditis is a well-recognized problem in intravenous drug users and it accounts for 1 to 3% of endocarditis cases overall and up to 9% in other series. The most common combinations of organisms include <it>Staphylococcus aureus</it> and <it>Streptococcus pneumoniae</it> followed by <it>Staphylococcus aureus</it> and <it>Pseudomonas aeruginosa</it>. <it>Candida parapsilosis</it> endocarditis carries a mortality rate of 45%, and each infection with <it>Candida</it> or <it>Pseudomonas</it> endocarditis per se carries a very high mortality rate approaching 85% and 80%, respectively. The combination of <it>P. aeruginosa</it> and <it>C. parapsilosis</it> has never been encountered and there have been no earlier reports of the combination of <it>C. parapsilosis</it> and <it>P. aeruginosa</it> in adult intravenous drug users as a cause of endocarditis.</p> <p>Case presentation</p> <p>We present a 49-year-old man with bivalvular endocarditis with <it>P. aeruginosa</it> and <it>C. parapsilosis</it>. He had a prior bivalvular replacement in 2005 that became infected with the above microorganisms and he was treated with intravenous antibiotics. Because of ongoing intravenous drug use, a second valve replacement was denied. A few days later, the patient presented with septic shock secondary to <it>P. aeruginosa</it> and <it>C. parapsilosis</it> recurrent endocarditis. The infection was cured with a second bivalvular replacement and extended therapy with antibiotics and antifungals.</p> <p>Conclusion</p> <p>This is the first time a patient has presented with <it>P. aeruginosa</it> and <it>C. parapsilosis endocarditis</it>. Relapsing polymicrobial endocarditis can be cured with medical and surgical therapy.</p