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

Actinomyces Israelii – A Rare Cause of Bacterial Peritonitis

Background: Actinomyces, a filamentous, gram-positive, facultative anaerobic bacterium, is part of the commensal flora of the oral cavity, gastrointestinal tract and the female genital tract. Actinomyces have low virulence potential and cause opportunistic infection associated with injury to the mucosal barrier, such as that occurring from surgery, trauma, peritoneal dialysis catheter, viscus perforation or intrauterine devices. Infections associated with actinomyces are often reported by imaging studies as masses, pseudotumors or abscesses. Fistulas and sinus tract formation are not uncommon. Primary peritonitis with actinomyces is very rare. We report a case of Actinomyces peritonitis in an elderly gentleman with a history of pancreatic cancer. Case Report: An 88 year-old man with history of adenocarcinoma of the pancreatic head diagnosed 15 months ago, malignant biliary stricture with common bile duct stent on palliative chemotherapy, presents to the emergency department with 1-2 weeks of worsening abdominal pain, anorexia and malaise. The patient was afebrile, tachycardic and hypotensive. Initial labs include elevated WBC, AKI, LFT and lactic acidosis. Abdominal imaging showed cirrhotic liver, cholecystitis and increasing ascites with peritoneal enhancement. Empiric Ceftriaxone and Metronidazole were initiated. A cholecystostomy tube was placed by interventional radiology. Bile fluid culture was positive for Klebsiella pneumoniae and streptococcus species. Paracentesis was performed and fluid analysis showed 43,000 WBC with \u3e 95% neutrophils. The patient progressed to septic shock following the procedures and broad spectrum antibiotics with vancomycin and pipercillin-tazobactam were initiated. Five days later, ascetic fluid culture revealed Actinomyces israelii. The patient was started on Ampicillin-Sulbactam with plan for six months of antibiotic therapy. The patient was discharged in stable condition with scheduled follow up with infectious diseases. Conclusion: Peritonitis due to Actinomyces is very rare, and should remain in the differential diagnosis especially in cases of peritonitis not responding to typical empiric antibiotics therapy for primary peritonitis. Primary pelvic-abdominal peritonitis without abscess formation is very rare yet possible. The therapy of choice for actinomycosis is high-dose penicillin for 2-4 weeks, followed by 2-6 months of oral antibiotics to prevent recurrence.https://scholarlycommons.henryford.com/merf2019caserpt/1121/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

Trends in Legionnaires\u27 Disease-Associated Hospitalizations, United States, 2006-2010

Background: Legionella pneumophila is a waterborne cause of both healthcare-associated and community-acquired pneumonia. Legionella pneumophila serogroup 1 is responsible for 80% of infections. There is currently limited published disease burden data on Legionnaires\u27 disease-associated hospitalization in the United States. Methods: In this study, we estimated the annual incidence of Legionnaires\u27 disease-associated hospitalizations in United States and identified demographic, temporal, and regional characteristics of individuals hospitalized for Legionnaires\u27 disease. A retrospective study was conducted using the National Hospital Discharge Survey (NHDS) data from 2006 to 2010. The NHDS is a nationally representative US survey, which includes estimates of inpatient stays in short-stay hospitals in the United States, excluding federal, military, and Veterans Administration hospitals. All discharges assigned with the Legionnaires\u27 disease International Classification of Diseases 9th Clinical Modification discharge diagnostic code (482.84) were included in this study. Results: We observed the annual incidence and number of Legionnaires\u27 disease-associated hospitalizations (per 100 000 population) in the United States by year, age, sex, race, and region. Over a 5-year period, 14 574 individuals experienced Legionnaires\u27 disease-associated hospitalizations in the United States The annual population-adjusted incidence (per 100 000 population) of Legionnaires\u27 disease-associated hospitalizations was 5.37 (95% confidence interval [CI], 5.12-5.64) in 2006, 7.06 (95% CI, 6.80-7.40) in 2007, 8.77 (95% CI, 8.44-9.11) in 2008, 17.07 (95% CI, 16.62-17.54) in 2009, and 9.66 (95% CI, 9.32-10.01) in 2010. A summer peak of Legionnaires\u27 disease-associated hospitalizations occurred from June through September in 2006, 2007, 2008, and 2010. Conclusions: Legionnaires\u27 disease-associated hospitalizations significantly increased over the 5-year study period. The increasing disease burden of Legionnaires\u27 disease suggests that large segments of the US population are at risk for exposure to this waterborne pathogen

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

Molecular typing, pathogenicity factor genes and antimicrobial susceptibility of vancomycin resistant enterococci in Belgrade, Serbia

In this study the distribution of species and antimicrobial resistance among vancomycin resistant enterococci (VRE) recovered from clinical specimens obtained from five hospitals in Belgrade was analyzed. Strains were further characterized by pulsed-field gel electrophoresis (PFGE). Polymerase chain reaction (PCR) was used to investigate the presence of vanA and vanB genes and pathogenicity factor genes. Identification of 194 VRE isolates revealed 154 Enterococcus faecium, 21 Enterococcus faecalis, 10 Enterococcus raffinosus and 9 Enterococcus gallinarum. This study revealed existence of 8 major clones of VRE. PCR determined vanA gene to be present in all of the VRE studied. Esp and hyl genes were present in 29.22% and 27.92% of E. faecium, respectively, and in 76.19% and 0 of E. faecalis, respectively. Esp and hyl genes were not found more frequently in members of predominant clones of E. faecium than in single isolates; nor was their presence connected to invasiveness

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