Nocardia farcinica: No Farce Bacteremia

Nocardia species are gram-positive, aerobic, partially acid-fast organisms with a beaded branching growth pattern. This species is commonly found in soil, dust, decomposing vegetation, salt and fresh water. Nocardia species are opportunistic bacteria, acquired either through inhalation of airborne spores or direct skin inoculation. The typical patient population includes cases of neoplasms, solid organ and hematopoietic stem cell transplant on immunosuppression, HIV infection, and long-term steroid use. Of all the nocardiosis cases, 22-39% of patients are immunocompetent. Although rare, Nocardia bacteremia, in conjunction with disseminated disease, has a 50% mortality rate. The usual clinical tableau consists of severe pulmonary disease, a frequent mimicker of lung tumors and tuberculosis, and central nervous system infections, such as brain abscess or meningitis. Here we present a case of Nocardia bacteremia with systemic nocardiosis in an HIV/AIDS patient. The patient is a 48 year-old African American male with a history of untreated HIV due to lack of insurance. He presented to the ED with worsening cough, shortness of breath, generalized weakness and fatigue over the past two months along with a left axillary abscess. The patient was in septic shock on arrival with hypotension, tachycardia, leukocytosis and blood cultures positive for Nocardia farcinica. An X-ray of the chest revealed a left lower lobe pneumonia with positive sputum cultures for the same species. The axillary abscess was excised with cultures returning positive for Nocarida farcinica as well. In addition, the infection also manifested with skin lesions and bilateral ring enhancing brain lesions on MRI. The patient was started on Vancomycin, Cefepime, Bactrim and Azithromycin upon arrival. After cultures returned, he was switched to IV Amikacin, Bactrim and Meropenem for a duration of one-year total.The most common Nocardia spp. responsible for infections in humans are N. asteroides (80-90%) followed by N.brasiliens, N. farcinica and N. nova. Nocardiosis usually affects the lungs, followed by the central nervous system, with skin, soft tissue and pleura, less commonly involved. Nocardia farcinica is known to be multi-drug resistant and more prone to dissemination. AIDS patients with a CD4 count /uL and those not on HAART or Bactrim for PCP prophylaxis are at a higher risk for dissemination. Diagnosing these patients can be cumbersome due to the length of time it takes for Nocardia to grow in blood cultures: median incubation time is four days. The median total duration of treatment is 75 days with sulfonamide-based antibiotics, such as Bactrim, followed by carbapenems.https://scholarlycommons.henryford.com/merf2020caserpt/1082/thumbnail.jp

Efficacy of Convalescent Plasma and Short Course of Corticosteroids in Patients with COVID-19

This study reported the efficacy of short course corticosteroids and convalescent plasma (CP) transfusion in treating five patients with severe COVID-19 disease. Five adults (mean age: 70 ± 9 years) with laboratory-confirmed COVID-19 and severe hypoxemia (PaO2/FiO2 [P/F]\u3c100) requiring invasive mechanical ventilation received 5-days methylprednisolone (40 mg intravenously every 12 hours) and subsequent CP transfusion (250-400 ml). Compared with the baseline, P/F ratios increased by 46% and by 28% after short course corticosteroids and CP transfusion. Four patients survived. Short course corticosteroids and CP transfusion may improve hypoxemia in patients with severe COVID-19 disease

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

Project #37: Management Guidelines for Patients with COVID-19: Rapid Cycle Improvement

Project’s purpose is to rapidly devise, continually improve, educate, and implement a live and changing COVID-19 management guideline based upon emerging best available evidence. This project also aims to optimize the care of patients with COVID-19 and improve patient outcomes.https://scholarlycommons.henryford.com/qualityexpo2022/1004/thumbnail.jp

Expect the Unexpected: A Rare Case of Pseudomonas aeruginosa Endocarditis

Infective endocarditis (IE) caused by Pseudomonas aeruginosa is extremely uncommon. Reported cases have usually been associated with intravenous drug use, prosthetic heart valves, and/or implanted cardiac devices. Traditionally, successful treatment has necessitated a combination of antimicrobial(s) and valve replacement. Yet, P. aeruginosa IE remains difficult to manage, especially in cases where valve replacement may not be an immediate option. We present such a case of P. aeruginosa IE, highlighting that medical management with 2 antipseudomonal synergistic agents may be an alternative to surgery in particularly complicated cases

Can the One Health Approach Save Us from the Emergence and Reemergence of Infectious Pathogens in the Era of Climate Change: Implications for Antimicrobial Resistance?

Climate change has become a controversial topic in today’s media despite decades of warnings from climate scientists and has influenced human health significantly with the increasing prevalence of infectious pathogens and contribution to antimicrobial resistance. Elevated temperatures lead to rising sea and carbon dioxide levels, changing environments and interactions between humans and other species. These changes have led to the emergence and reemergence of infectious pathogens that have already developed significant antimicrobial resistance. Although these new infectious pathogens are alarming, we can still reduce the burden of infectious diseases in the era of climate change if we focus on One Health strategies. This approach aims at the simultaneous protection of humans, animals and environment from climate change and antimicrobial impacts. Once these relationships are better understood, these models can be created, but the support of our legislative and health system partnerships are critical to helping with strengthening education and awareness

Expect the Unexpected: A Rare Case of Pseudomonas aerguinosa Endocarditis

Infective endocarditis (IE) caused by Pseudomonas aeruginosa is extremely uncommon. Reported cases have usually been associated with intravenous drug use, prosthetic heart valves, and/or implanted cardiac devices. Traditionally, successful treatment has necessitated a combination of antimicrobial(s) and valve replacement. Yet, P. aeruginosa IE remains difficult to manage, especially in cases where valve replacement may not be an immediate option. We present such a case of P. aeruginosa IE, highlighting that medical management with 2 antipseudomonal synergistic agents may be an alternative to surgery in particularly complicated cases

Expect the Unexpected! A Rare Case of Nocardia Bacteremia

Background: Nocardia species are partially acid fast, aerobic, gram-positive, branching filamentous bacteria that are found ubiquitously in the soil, decaying vegetable matter and aquatic environments. The Nocardia species most commonly associated with infections in humans are caused by asteroides (80-90%) followed by brasiliensis, farcinica and nova1. Nocardia spp. can cause serious pulmonary infections which are associated with frequent metastatic brain abscesses. Nocardia bacteremia is rarely reported and usually only seen in immunocompromised patients. We present a case of a central line associated Nocardia bloodstream infection in an immunocompetent patient. Case presentation: 53 year old Caucasian male with a history of a chronic small bowel stricture leading to oral intolerance and total parenteral nutrition (TPN) dependence initially presented with an intraabdominal abscess. The patient was immediately taken to the operative room for a laparotomy. Cultures from the operative room grew Enterococcus spp. and Salmonella spp. Patient was started on daptomycin, ceftriaxone and metronidazole to treat the infection. Blood cultures were also obtained and reported as Nocardia nova. CT chest and head and transesophageal echocardiogram did not reveal any evidence of disseminated Nocardiosis. The patient was then started on trimethoprim-sulfamethoxazole with plans to treat for three months followed by suppression therapy. The bacteremia source was thought to be from a 400 day old PICC due to the patient’s TPN dependence, which was removed. Conclusion: Nocardia infections in humans are uncommon, with a reported incidence in the United States of 500 to 1,000 new cases per year. Nocardia bacteremia is a rare event as a literature review from 1998 found only 36 cases of Nocardia bacteremia worldwide from the last 52 years3. Our patient had positive blood cultures with no evidence of disseminated Nocardiosis. Although, Nocardia species infections are mostly found in immunocompromised hosts, our patient’s long term PICC likely was the etiology for his bacteremia. This case illustrates the importance of monitoring central venous catheters as it can lead to central line-associated bloodstream opportunistic infections.https://scholarlycommons.henryford.com/merf2019caserpt/1033/thumbnail.jp

Atypical presentation of progressive disseminated histoplasmosis in a patient recently diagnosed with AIDS

Opportunistic infections, including progressive disseminated histoplasmosis (PDH), may have variable and surprising presentations in patients with AIDS. This can be either a primary infection or reactivation of a latent infection. Latent infections may occur due to being unmasked by the immune reconstitution inflammatory syndrome after the initiation of combined antiretroviral therapy. PDH can be difficult to diagnose in patients with AIDS due to its variable presentation and many overlapping symptoms with other opportunistic infections. Serum and urine antigen testing are highly sensitive and typically used as the initial diagnostic test to workup suspected PDH. However, negative antigen and antibody tests do not rule out Histoplasmosis capsulatum infection and suspicion should remain high for PDH in the right clinical context. A definitive diagnosis may require biopsy-proven narrow-based budding yeast. We present an interesting patient with AIDS who presented with worsening cognitive decline and was ultimately diagnosed with PDH based on biopsy histopathology in the setting of negative antigen and antibody testing