Correcting a Deficiency: Furthering Our Knowledge of Nutritionally Variant Streptococci No abstract available

Infectious Complications of Mucositis in Postchemotherapy Neutropenic Cancer Patients: Three Case Reports and a Review of the Literature Mucositis is a common, painful, and potentially dangerous adverse effect of many chemotherapy regimens. The mucosal barrier can be compromised from oncologic therapies resulting in high levels of exposure to organisms. These are often normal flora that become opportunistic pathogens, especially in these patients who already have compromised cellular immunity from neutropenia and humoral immunity from cytotoxic agents. The combination of a hampered immune system along with breakdown of the mucosa can lead to severe infections and lead to complications that undermine patient outcomes. The most common types of infections that are seen in neutropenic patients are bacterial, followed by viral, and then fungal. This case series will outline 3 vignettes of patients who developed mucositis secondary to chemotherapy-induced neutropenia and will review the most common infections seen in this delicate patient population plus empiric treatment strategies. For this review, a literature search was made using Google Scholar Database. Key words searched included bacterial, fungal, viral, mucositis, and leukemia. Articles published between 1983 and 2018 were selected.

Role of Inflammatory Markers in Diagnosing Diabetic Foot Infection: A Meta-Analysis Background Inflammatory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) are frequently ordered in suspected cases of diabetic foot infection (DFI). We did a meta-analysis to compare diagnostic performance of these inflammatory markers for detecting DFI. Materials and Methods The meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used bivariate random-effects regression model to pool the sensitivity and specificity of the targeted biomarkers. Results A comprehensive literature search identified 73 studies. Twelve studies met our inclusion criteria. The number of studies reporting data on each individual biomarker was as follows: 11 for ESR, 7 for CRP, and 5 for PCT. For Infectious Diseases Society of America grade I versus grade II, we calculated pooled sensitivity and specificity for ESR to be 0.86 and 0.82, positive likelihood ratio (LR+) of 4.7, negative likelihood ratio (LR−) of 0.17, and area under receiver operating characteristic curve (AUROC) of 0.91. Pooled sensitivity and specificity for CRP were found to be 0.54 and 0.91, LR+ of 6.2, LR− of 0.50, and AUROC of 0.80. Pooled sensitivity and specificity for PCT were 0.72 and 0.96, LR+ of 18.4, LR− of 0.29, and AUROC of 0.84. For Infectious Diseases Society of America grade II versus grade III, we calculated pooled sensitivity and specificity for ESR to be 0.81 and 0.80, LR+ of 4.0, LR− of 0.24, and AUROC of 0.84. Conclusions Erythrocyte sedimentation rate has the highest AUROC of 0.91 followed by PCT (0.84) and CRP (0.80) to diagnose DFI. For osteomyelitis, ESR has a diagnostic accuracy of 0.84. Erythrocyte sedimentation rate could be beneficial in ruling out infection in persons who have low suspicion of disease (lowest −LR). For those who have high suspicion of disease, PCT could be helpful in ruling in infection (highest +LR). All inflammatory markers need standardization of threshold levels for detecting infection.

Acute Bacterial Parotitis in Adult Hematologic Malignancy: Two Case Reports and Literature Review Acute bacterial parotitis (ABP) is an uncommon condition in immunosuppressed adult cancer patients. Here, we report 2 cases of parotitis in immunocompromised patients; one with a diagnosis of extranodal marginal zone B-cell lymphoma and the other with acute myeloid lymphoma. Both patients were treated with antibiotics and local management with resolution of their parotitis. Per review of literature, this is the first article describing ABP in patients with bone marrow transplantation and hematologic malignancies. Moreover, this is also the first article reporting ABP due to Stenotrophomonas maltophilia, an opportunistic gram-negative rod bacterium.

Nutritionally Variant Streptococcal Bacteremia in the 21st Century: Report of 26 Episodes for a 12-Year Period (2006–2017) at a Large Community Teaching Hospital and Review of the Literature We report the results of a 12-year retrospective study of nutritionally variant streptococcal (NVS) bacteremia in a 510-bed, a large medical school-affiliated teaching hospital. Twenty-six episodes of NVS bacteremia were identified in this institutional review board—approved study of all positive blood cultures for NVS from January 1, 2006, to December 31, 2017. Most patients with NVS bacteremia were 50 years and older. Detection of bacteremia in the microbiology laboratory took from 2 to 11 days of incubation with an average of 4.65 days. Endocarditis was the most common source of bacteremia (7 patients), followed by primary bacteremia, skin and soft tissue infections, bone and joint infections, and device-associated infections. The mortality of patients in the study was 15% despite all but 1 patient who died receiving appropriate antimicrobial therapy immediately upon hospital admission. Nutritionally variant streptococcal bacteremia is uncommon, is frequently associated with infective endocarditis, is often detected late in the hospital course because of delayed growth of NVS organisms in blood culture media, and had a 15% mortality rate.

Impact of Rapid mecA Polymerase Chain Reaction Rapid Diagnostic Testing for Staphylococcus aureus in a Pediatric Setting Background Rapid mecA testing, in combination with antimicrobial stewardship intervention, has improved outcomes in adults with Staphylococcus aureus (SA) bacteremia. In pediatric patients, data comparing rapid molecular testing to conventional susceptibility testing for methicillin resistance in SA are limited, and benefits have been observed only in combination with a coordinated real-time antimicrobial stewardship response. The objective of this study was to determine the impact of rapid mecA detection on time to optimal therapy in patients at a pediatric institution without a specific antimicrobial stewardship intervention. Methods This was a retrospective cohort study at a freestanding children’s hospital including patients with a blood culture positive for SA. Outcomes before and after the implementation of rapid mecA detection via use of GeneXpert MRSA/SA BC (Cepheid, Sunnyvale, CA) were compared. The primary outcome was time to optimal therapy, which was defined as vancomycin alone for methicillin-resistant SA or nafcillin, oxacillin, or cefazolin alone for methicillin-susceptible SA. Results One hundred one patients were included, with 61 patients in the preimplementation period receiving conventional susceptibility testing only and 40 patients in the postimplementation period receiving rapid molecular mecA testing. The median (interquartile range) time (hours) to optimal therapy from culture collection was decreased from 61.5 (47.8–68.1) preimplementation to 42.5 (21.9–56.6; P = 0.003) postimplementation. Conclusions Despite lack of a protocol for response to molecular mecA test results, time to optimal therapy and vancomycin use were significantly decreased. Future studies are needed to assess the impact on infection-related outcomes and antibiotic adverse effects.

Predictive Factors Associated With In-Hospital Mortality for Patients Across the Sepsis Spectrum Introduction Sepsis poses a large burden for hospitals across the world owing to its high resource utilization and poor patient outcomes. This project aimed to assess and quantify the importance of sepsis-specific predictors for in-hospital mortality. Several studies have identified comorbidities and clinical laboratory variables associated with mortality among the severe sepsis population, but few have combined the 2 in making a model specific for all sepsis patients. Methods We used clinical and laboratory variables seen at the time of first lactic acid measurement and patient characteristics upon admission to develop a logistic regression model to predict mortality in a sepsis population at 2 area hospitals in Omaha, Nebraska. Results Overall, sepsis-related mortality was 12.9%. Advanced age, a higher number of comorbidities, and leucopenia were positively associated with mortality, whereas preexisting diabetes was negatively associated with mortality. Each 1 mmol/L difference in lactic acid levels was positively associated with 1.38 times higher adjusted odds (95% confidence interval, 1.30–1.48) of mortality after adjustment for other covariates. For every 1% decrease in hematocrit, the adjusted odds of mortality were 1.04 times higher (95% confidence interval, 1.02–1.06). Conclusions We identified a number of sepsis mortality predictors. The negative association between preexisting diabetes mellitus and sepsis mortality requires further investigation.

Microbiological Spectrum of Infection-Related Febrile Episodes in Adult Patients With Hematologic Malignancies: A Prospective Cohort From a Tertiary Center in Iran Background In recent years, antimicrobial resistance and the limited number of new antimicrobials under development have profoundly complicated treatment options especially in patients with hematologic malignancies that are treated with sequential courses of antimicrobial therapy. These issues emphasize on the importance of surveillance studies to monitor antimicrobial resistance and implement the antimicrobial stewardship strategies in health care centers. Methods The study was a prospective cohort with the aim of evaluating the microbiological spectrum of infection-related febrile episodes in adult patients with hematologic malignancies who admitted in a 1000-bed teaching hospital affiliated to Mashhad University of Medical Sciences, Iran. Results One hundred eight infection-related febrile episodes were identified in 108 individuals with hematologic malignancies of whom 18.5% had bacteremia. The most commonly isolated pathogens were coagulase-negative staphylococci (40%), followed by Escherichia coli (25%), and Klebsiella spp (10%), respectively. Carbapenems and glycopeptides were prescribed in the empirical regimen of 96.4% and 61.2% of patients. Although more than 67% of them needed to be deescalated at the second key time of antimicrobial therapy, it was performed only in 9%. Conclusions Our study highlighted the high rates of prescription of broad-spectrum antimicrobials in the empirical regimen of patients and a poor adherence to appropriate deescalation strategies after the second key time point of antimicrobial therapy among physicians in charge of patients with hematologic malignancies. It also emphasizes the importance of developing infrastructure for implementation and adherence to antimicrobial stewardship strategies in hematologic malignancy wards in developing countries such as Iran.

Outcomes of Extended Infusion Cefepime in Pediatric Patients Background Extended infusions of cefepime optimize pharmacokinetic and pharmacodynamic parameters and improve clinical outcomes in adults with gram-negative infections, but there are no similar studies in children. The objective of this study was to compare clinical outcomes in children receiving extended and traditional infusion cefepime. Methods This was a retrospective cohort study of patients aged 31 days to 17 years receiving extended or traditional infusion cefepime for at least 48 hours for a susceptible gram-negative bacteremia at a tertiary care children's hospital. The primary outcome was a composite clinical outcome comprised of infection-related mortality within 14 days of antibiotic initiation, bacteremic relapse within 30 days of culture clearance, and treatment failure. Results Sixty-seven patients were included; 21 (31.3%) received extended infusion, and 46 (68.7%) received traditional infusion. Extended infusion patients were older and larger than traditional infusion patients with a median (interquartile range) age of 7 (0.8–11.5) years versus 0.5 (0.2–2) years (P = 0.05) and weight of 23.7 (8.2–44.2) kg versus 6.2 (2.4–13.1) kg (P < 0.05). The most common pathogens within the extended infusion group were Enterobacter cloacae (23.8%) and Klebsiella oxytoca (23.8%), whereas Escherichia coli was the most common within the traditional infusion group (28.2%). There was no difference in minimum inhibitory concentrations, as the most common minimum inhibitory concentrations were less than or equal to 1 μg/mL in both extended (95.2%) and traditional infusion (87.0%) (P = nonsignificant). The primary outcome occurred in 2 extended (9.5%) and 3 traditional infusion patients (6.5%) (P = nonsignificant). Conclusions Clinical outcomes were similar with extended and traditional infusion cefepime in this cohort of children with susceptible gram-negative bacteremia.

Clostridium septicum Triad: Infected Aortic Aneurysm, Empyema, and Colon Cancer Infected aortic aneurysm is a rare occurrence accounting for 2.6% of described aneurysms. Staphylococcus species and Salmonella species are the most frequently isolated microbes, with Clostridium septicum being decidedly less commonly detected. It is well documented that C. septicum bacteremia in the presence of an infected aneurysm is strongly associated with gastrointestinal cancer, particularly colorectal adenocarcinoma. Although blood cultures were repeatedly negative, a left pleural effusion culture grew C. septicum. The patient was treated with an endovascular prosthesis and prolonged antibiotic therapy including lifelong suppression. Serial abdominal computed tomographic scans with contrast displayed an enlarging appendiceal lesion that was described as a mucocele. Surgical histopathology revealed an invasive moderately differentiated adenocarcinoma. This case highlights both the association of C. septicum with malignancy and the utility of pleural effusion culture in the presence of culture-negative infected aortic aneurysm.