Disseminated Cryptococcal Disease in Liver Cirrhosis

Introduction: Cryptococcus is an environmental yeast that is typically associated with human immunodeficiency virus (HIV), and transplant recipients. Invasive disease has been described in patients with liver disease, however it is not a common occurrence. We describe a case of disseminated Cryptococcus neoformans infection in a patient with liver cirrhosis. Case presentation: 53-year-old male, with history of Hepatitis C infection, liver cirrhosis, Sjogren’s syndrome, venous thromboembolism (VTE), was admitted to the hospital for worsening debility and weakness. In a recent hospital admission for acute kidney injury (AKI), he was found to have spontaneous bacterial peritonitis secondary to Klebsiella pneumoniae and E. coli, and bacteremia with the latter organism. Patient was treated with IV Ertapenem. On latest admission, patient’s model for end-stage liver disease (MELD)-Na was 25. Physical exam was significant for abdominal distention with mild diffuse tenderness, shifting dullness, positive fluid-wave sign, and bilateral 1+ edema to the knee. Peritoneal fluid was positive for Cryptococcus, and multiple blood cultures (total of 6 different days) were positive for Cryptococcus. Lumbar puncture (LP) showed pleocytosis with monocytes predominance, CSF culture positive for Cryptococcus and a CSF Cryptococcal antigen (CrAg) of 1:2560. Patient was treated with Liposomal Amphotericin B and Flucytosine. Repeated LPs showed persistently elevated opening pressures, requiring ventricular-pleural shunt. He finished a course of 4 weeks of induction therapy, followed by transition to oral Fluconazole for consolidation. Discussion: Cryptococcus neoformans is an encapsulated, ubiquitous, opportunistic yeast. Invasive Cryptococcus disease is a rare but highly morbid infection in patients with liver disease. Peritonitis is common in these patients, especially with high MELD-Na scores. Challenges in diagnosis are due to atypical presentation, mild-moderate fluid pleocytosis, and slow culture turnaround time. Meningitis with Cryptococcus poses a high morbidity condition, especially if complications like elevated intracranial pressure arises. Multiple sites of seeding of Cryptococcus neoformans in an immunocompetent patient is rare. Prompt initiation of adequate therapy and close monitoring of complications are key for improvement in patient’s survival. Treatment is prolonged and challenging.https://scholarlycommons.henryford.com/merf2019caserpt/1036/thumbnail.jp

T2Candida for the Diagnosis and Management of Invasive Candida Infections

Invasive candidiasis is a common healthcare-associated infection with high mortality and is difficult to diagnose due to nonspecific symptoms and limitations of culture based diagnostic methods. T2Candida, based on T2 magnetic resonance technology, is FDA approved for the diagnosis of candidemia and can rapidly detect the five most commonly isolated Candida sp. in approximately 5 h directly from whole blood. We discuss the preclinical and clinical studies of T2Candida for the diagnosis of candidemia and review the current literature on its use in deep-seated candidiasis, its role in patient management and prognosis, clinical utility in unique populations and non-blood specimens, and as an antifungal stewardship tool. Lastly, we summarize the strengths and limitations of this promising nonculture-based diagnostic test

Pilot comparison of the ease of swallowing of single tablet antiretroviral regimens

Daily adherence to lifelong antiretroviral therapy (ART) is required to achieve long term treatment success. However, patient preferences for ART tablet size have not been well studied. Our study assessed factors associated with the ease of swallowing (EoS) and tolerability of two placebo tablets representing and matching B/F/TAF (BPT) and DTG/ABC/3TC (DPT). Fifty ART-naïve patients were randomized into a two-period cross-over study. Likert scale (1-5) questionnaires were administered to assess patient factors influencing the ease of swallowing, adherence, home medications, medication preferences and perceptions. Comparisons were done using Student t-tests and ordinal regression. Participants were 64% female, 61% white, mean age 43 years, and taking a mean (median) of 4(1) pills/day. BPT was reported to be easier than DPT with ease of swallowability 1.76 vs. 2.42 (p \u3c 0.001) (1 = very easy). DPT tablet was correctly perceived as larger than BPT (p \u3c 0.001); with both tablets perceived as smaller than actual size (p \u3c 0.001). EoS of either tablet was positively associated with the EoS of the largest home tablet medication (p = 0.021, p = 0.03). Patient\u27s perceptions of EoS can affect their medication adherence, especially in HIV, and should be considered in treatment regimens

PRIMARY CARE VISITS ARE THE KEY FACTOR IN ENSURING HIGHER VACCINATION RATES IN POST-LIVER TRANSPLANT PATIENTS. A SINGLE CENTER STUDY

Background: Liver transplant recipients are at an increased risk for life threatening vaccine preventable disease. If vaccines are not given pre-transplant, major societal guidelines recommend they are given in the post-transplant period. This retrospective study evaluates vaccination rates in our institution and potential areas for improvement. Methods: A retrospective study of patients transplanted between 1/2015-1/2018 at our institution was performed. Relevant data collected included patient demographics, travel distance to transplant center, primary care provider (PCP) location and PCP and transplant clinic visits. Vaccination status and eligibility for influenza (IV), pneumococcus (PV), Hepatitis-A (HAV) and B (HBV), Tdap and Td vaccines (TdV) were obtained through our electronic medical records and the Michigan Care Improvement Registry. Statistics were calculated using analysis of variance (ANOVA), chi-square, Fisher’s exact test and Wilcoxon Rank Sum Test. Results: 406 patients met our inclusion criteria with 83.0% (336) Caucasians, 10.8% (44 ) African-Americans, 3.7% (15) Hispanics with overall mean age of 59. PCP visitation post-transplant was significantly associated with vaccination of IV (62.9% vs 47.2% p=0.007), HAV (66.7% vs 45.5% p= 0.003), HBV (60.0% vs 50.1% p=0.391), PV (64.6% vs 39.6%

Bridging the gap: An approach to reporting antimicrobial stewardship metrics specific to solid organ transplant recipients

BACKGROUND: This study seeks to describe inpatient antimicrobial use (AU) utilizing the National Healthcare Safety Network-AU (NHSN-AU) framework among solid organ transplant recipients (SOTr) within 12 months after transplant. METHODS: This cross-sectional study included SOTr ≥ 18 years of age who underwent transplantation from January 2015 to December 2016 at a Midwestern US transplant center. Inpatient AU was followed for 12 months post-transplant. Hospital days present up to 12 months post-transplant, AU variables, and Clostridioides difficile infection (CDI) occurrences were analyzed. RESULTS: The cohort of 530 SOTr included 225 kidney (42.5%), 171 liver (32.3%), 45 lung (8.5%), 40 heart (7.5%), 39 multivisceral (7.4%), seven small bowel (1.3%), and three pancreas (0.6%) transplants. Total days of therapy (DOT) were 22 782 among the cohort, with a median of 5 days [interquartile range [IQR], 1-12]. Lung and liver transplants had the most total DOT (6571 vs. 5569 days), while lungs and small bowels had the highest median DOT (13 [IQR, 2-56] vs. 12 [IQR, 2-31]). The facility-wide DOT/1000 days were lowest in pancreas and highest in lung transplants (5.3 vs. 428.1). Small bowel transplants received the most resistant-Gram-positive infection and hospital-onset infection agents for facility-wide DOT/1000 days present. Pancreas and kidney transplants accounted for the most high-risk CDI agents. CDI occurred in 34 patients, with kidney and liver transplants experiencing 13 each. CONCLUSION: This study represents one of the first reports of AU in SOTr utilizing the NHSN-AU framework. More studies are needed for further peer-to-peer comparison of AU in this complex patient population

Clinical characteristics and outcomes of COVID-19 in solid organ transplant recipients: A case-control study

Solid organ transplant recipients (SOTr) with coronavirus disease 2019 (COVID-19) are expected to have poorer outcomes compared to nontransplant patients because of immunosuppression and comorbidities. The clinical characteristics of 47 SOTr (38 kidneys and 9 nonkidney organs) were compared to 100 consecutive hospitalized nontransplant controls. Twelve of 47 SOTr managed as outpatients were subsequently excluded from the outcome analyses to avoid potential selection bias. Chronic kidney disease (89% vs 57% P = .0007), diabetes (66% vs 33% P = .0007), and hypertension (94% vs 72% P = .006) were more common in the 35 hospitalized SOTr compared to controls. Diarrhea (54% vs 17%, P \u3c .0001) was more frequent in SOTr. Primary composite outcome (escalation to intensive care unit, mechanical ventilation, or in-hospital all-cause mortality) was comparable between SOTr and controls (40% vs 48%, odds ratio [OR] 0.72 confidence interval [CI] [0.33-1.58] P = .42), despite more comorbidities in SOTr. Acute kidney injury requiring renal replacement therapy occurred in 20% of SOTr compared to 4% of controls (OR 6 CI [1.64-22] P = .007). Multivariate analysis demonstrated that increasing age and clinical severity were associated with mortality. Transplant status itself was not associated with mortality

Rapid Reorganization of an Academic Infectious Diseases Program During the COVID-19 Pandemic in Detroit: A Novel Unit-Based Group Rounding Model

The surge of coronavirus disease 2019 (COVID-19) hospitalizations at our 877-bed quaternary care hospital in Detroit led to an emergent demand for Infectious Diseases (ID) consultations. The traditional one-on-one consultation model was untenable. Therefore, we rapidly restructured our ID division to provide effective consultative services. We implemented a novel unit-based group rounds model that focused on delivering key updates to teams and providing unit-wide consultations simultaneously to all team members. Effectiveness of the program was studied using Likert-scale survey data. The survey captured data from the first month of the Detroit COVID-19 pandemic. During this period there were approximately 950 patients hospitalized for treatment of COVID-19. The survey of trainees and faculty reported an overall 95% positive response to delivery of information, new knowledge acquisition, and provider confidence in the care of COVID-19 patients. This showed that the unit-based consult model is a sustainable effort to provide care during epidemics