Open Forum Infectious Diseases最新文献

Background: Tuberculosis preventive treatment (TPT) is crucial for reducing tuberculosis (TB) incidence and related mortality among people with human immunodeficiency virus (HIV); however, its implementation in Georgia faces challenges. In this study, we aimed to explore the TPT care cascade among people with HIV (PWH) in Georgia.

Methods: Using a mixed-methods approach, we assessed TPT uptake, adherence, and impact on TB development within the 2019-2020 cohort of newly diagnosed PWH across 4 major HIV service providers in Georgia. With qualitative analysis under the Consolidated Framework for Implementation Research, we identified barriers and facilitators to its implementation.

Results: Among 1165 PWH, only 11.8% initiated TPT with isoniazid. Thirty-two developed active TB (incidence rate, 10/1000 person-years [95% confidence interval, 9.6-10.4]), none of whom received TPT. Only 43% of 137 PWH on TPT adhered for 3-6 months; 29 (21.1%) completed the full course. The study revealed poor TPT service coordination, worsened by major data limitations. Interviews identified several barriers to effective TPT implementation, summarized into 3 broad categories: the need for TPT service integration into HIV care, the potential development of an integrated electronic data system, and training gaps.

Conclusions: Our study revealed low TPT coverage among Georgian PWH and significant data gaps. Findings underscore the need to reevaluate the TPT care cascade, emphasizing improved record-keeping and reporting practices through an integrated electronic system. Enhancing access by integrating TPT into HIV care, reducing stigma through streamlined referrals, and strengthening healthcare worker training are critical to increasing TPT uptake and ultimately reducing TB morbidity and mortality among PWH in Georgia.

Background: Adults aged ≥65 years are at high risk of harm from antibiotic misuse due to misdiagnosis of asymptomatic bacteriuria (ASB) as urinary tract infection (UTI). Alongside strategies to improve prescribing, patients should be informed and empowered to discuss the harms/benefits of antibiotic treatment. We tested whether a patient-focused educational leaflet improved reported willingness to avoid antibiotics when not clinically necessary.

Methods: In an online randomized controlled survey experiment, US adult respondents aged ≥65 years read a scenario of themselves as an asymptomatic patient with a positive urine test before a nonurologic surgical procedure. They were assigned to 1 of 4 conditions, which varied by educational leaflet provision and surgeons' treatment recommendation for antibiotics. The primary outcome was respondents' comfort with not taking antibiotics for ASB. Secondary outcomes were reported misperceptions of ASB as UTI and knowledge.

Results: Of the 504 respondents (completion = 89%), the mean age was 72, 64.5% identified as male, 53.4% identified as Non-Hispanic White, and 35.7% reported prior antibiotic prescriptions for UTI. In response to the vignette, respondents shown the leaflet were more comfortable not taking antibiotics (P < .001), were less likely to misperceive ASB as a UTI (P < .001), and displayed greater knowledge (P < .001). Respondents told that the surgeon recommends antibiotics were less comfortable not taking antibiotics (P = .013) and more likely to misperceive ASB as UTI (P < .001).

Conclusions: In an online randomized controlled survey experiment, a patient-centered educational leaflet decreased reported desires to take antibiotics for ASB and improved knowledge among US adults age ≥65 years. Patient-focused education may prepare patients to engage in antibiotic treatment decisions.

Background: Antimicrobial stewardship programs (ASPs) aim to optimize antimicrobial use through coordinated interventions that improve patient outcomes and reduce adverse events. While guidance exists from organizations including the Centers for Disease Control and Prevention and the Infectious Diseases Society of America, recommendations on effort allocation, working hours, and initiatives remain unclear.

Methods: This cross-sectional survey assessed the institutional structure, effort allocation, initiatives, and on-call participation of adult ASPs in the United States from September to October 2024. The survey was distributed via email to several ASP-related listservs. Respondents indicating on-call participation were also inquired about working hours, initiatives performed, participants, and compensation.

Results: Of 69 responses, most were from academic medical centers (59%) or community hospitals (35%), with 65% covering >500 beds. ASPs were often system-wide (78%) and primarily funded by their respective departments of pharmacy (87%). Common initiatives performed by all ASPs include answering ASP/infectious diseases questions, therapy de-escalation, and prospective audit and feedback. Twenty-four (69%) respondents indicated having an on-call model, with said programs reporting higher median inpatient full-time equivalents (FTEs) for physicians (0.5 vs 0.25) and pharmacists (2.9 vs 1.45) than those without. Commonly performed after-hours initiatives include preauthorization and answering microbiology inquiries. On-call coverage was generally performed during weekend daytimes and holidays, most often by pharmacists.

Conclusions: This survey highlights differences in structure, effort allocation, and initiatives of ASPs based on on-call participation. Institutions participating in on-call reported higher FTE assignments for physicians and pharmacists and were more likely to perform time-sensitive initiatives.

Background: Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is a chronic, HPV-driven condition marked by recurrent airway papillomas. This study aimed to determine the prevalence and incidence of JoRRP and to identify clinical predictors of aggressive JoRRP.

Methods: We conducted a retrospective analysis of JoRRP patients treated at Inkosi Albert Luthuli Central Hospital from 2012 to mid-2023. Demographics, patient HIV status, exposure to maternal HIV, frequency of surgical interventions, and extralaryngeal involvement were recorded.

Results: The cohort of 277 patients had a median diagnosis age of 4 years. The incidence of JoRRP was 3.82 per 100 000 live births (95% CI, 2.86-5.01), and prevalence was 4.17 per 100 000 population (95% CI, 3.47-4.97). Half of the study cohort met the criteria for aggressive disease (AD) (139; 50%). Children diagnosed at ≤2 years of age had higher odds of AD than older children, 3-5 years (OR: 0.43, 95% CI: 0.24-0.78) and >5 years (OR: 0.30, 95% CI: 0.16-0.54); both P < .001. Additionally, exposure to maternal HIV was significantly associated with pulmonary involvement (P = .03).

Conclusions: Early age at diagnosis and exposure to maternal HIV are potential predictors of aggressive JoRRP in high HIV-prevalence settings. These findings underscore the importance of integrated maternal-child healthcare, and robust public health interventions, such as expanded HPV vaccination and enhanced HIV prevention strategies, to reduce the clinical burden of JoRRP.

Background: Monocyte activation contributes to the pathogenesis of inflammation-driven comorbidities in people with HIV (PWH). We investigated the impact of tuberculin skin test (TST)/interferon-γ release assay (IGRA) status and tuberculosis preventive therapy (TPT) on monocyte activation in PWH.

Methods: We analyzed peripheral blood mononuclear cells from participants from the A5279/BRIEF-TB trial, which compared 1 month of rifapentine/isoniazid (1HP) versus 9 months of isoniazid (9H) as TPT in PWH. All included participants were on suppressive antiretroviral therapy and had available TST or IGRA results at study entry. Samples collected at week 0 (pre-TPT) and week 48 (post-TPT) were analyzed. Monocyte subset and activation markers were measured using multiparameter flow cytometry. Proinflammatory cytokines (IL-6 and TNF-α) were assessed after 6-hour lipopolysaccharide (LPS) stimulation. Linear regression models were used for primary comparisons of monocyte markers by TST/IGRA status, adjusted for age, sex, country, and CD4 count.

Results: In adjusted models, compared with TST/IGRA-negative participants (n = 27), TST/IGRA-positive participants (n = 30) had ∼2-fold relative increases in the median fluorescence intensity of CD64 (unstimulated) and CCR2 (post-LPS) on total monocytes and across monocyte subsets, pre- and post-TPT. Among TST/IGRA-positive participants, 1HP was associated with decreased fold changes over time for the percentage of CCR2+ monocytes and blunted IL-6/TNF-α responses compared with 9H.

Conclusions: PWH with a positive TST or IGRA exhibited signals of monocyte activation pre- and post-TPT. TPT with 1HP led to blunted proinflammatory monocyte changes compared with 9H.

Background: Outpatient parenteral antimicrobial therapy (OPAT) coordination is challenging in multidrug-resistant organism (MDRO)-infected patients. The study purpose was to describe barriers and medication costs associated with OPAT utilizing therapies for MDRO.

Methods: This was an institutional review board-approved, retrospective cohort of hospitalized, MDRO-infected adults medically stable for discharge (MSDC) with an intended OPAT for cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam, eravacycline, meropenem/vaborbactam, or tigecycline from 1 January 2017 through 31 March 2025. Cohorts included patients who received an intended or modified OPAT regimen, defined as transition to alternative intravenous (IV)/oral therapy, in-hospital completion of IV therapy, or in-hospital death. Secondary outcomes included post-MSDC medication costs, length of stay (LOS), and oral-switch therapy opportunities.

Results: One hundred-twenty patients were included; 29% received a modified OPAT regimen. β-lactams were the most intended OPAT regimen (67%). Patients with a modified OPAT regimen had higher median (interquartile range [IQR]) medication costs ($4828 [$1209-$18 066] vs $1975 [$494-$4872], P < .001), more frequently experienced discharge delays ≥1 day (89% vs 66%, P = .011) and discharge referral disposition changes (40% vs 16%, P = .006), and had a prolonged median (IQR) LOS (20 [14-46] vs 13 [7-27] days, P  = .023), compared to those who received an intended OPAT regimen. Oral-switch therapy opportunities were identified in 40% of patients. After adjusting for Medicaid, referral disposition changes (adjusted odds ratio [aOR], 3.46 [95% confidence interval {CI}, 1.21-9.89) and initial β-lactam therapy (aOR, 4.08 [95% CI, 1.55-10.79]) were associated with an increased odds of receiving a modified OPAT regimen.

Conclusions: Modified OPAT regimens are common and associated with increased costs, prolonged LOS, and discharge delays in MDRO-infected patients. These findings support the use of oral-switch therapy and improved care coordination.

[This corrects the article DOI: 10.1093/ofid/ofaf630.].

Background: Point-of-care (POC) polymerase chain reaction (PCR) tests for sexually transmitted infections (STIs) represent a potential paradigm shift for emergency department (ED) management of patients with suspected STIs, given there are now Food and Drug Administration-cleared POC tests that permit definite rapid diagnosis and result-driven care.

Methods: A quasi-experimental real-world implementation study was conducted in an urban ED, comparing two approaches for female STI testing for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV): (1) central laboratory testing (August-November 2022) with batched nucleic acid amplification testing (CT/NG) and wet prep for TV; (2) POC PCR Testing Integration (ED POC) (January-April 2023) in an ED POC laboratory for all three STIs. We compared proportions of appropriate treatment and ED length of stay (LOS) between the two testing modalities using chi-square test and log-transformed multivariable linear regression, respectively.

Results: Of 627 patients, 340 received central laboratory testing and 287 received ED POC; ED POC resulted in a significant decrease in LOS by 76 minutes or 9.3% (95% confidence interval [CI], -16.3% to -1.7%; P = .017). ED POC also significantly lowered overtreatment rates for CT (n = 595) and NG (n = 607) by 73% (95% CI, 44-87; P < .001) and 63% (95% CI, 28-81; P = .002), respectively. ED POC testing was associated with 67% lower rate of undertreatment (95% CI, -19% to 91%; P = .093) for any CT/NG/TV-positive (n = 78), but not statistically significant due to relatively small number of undertreated cases .

Discussion: Compared to traditional STI testing, POC PCR testing significantly shortened ED LOS, allowed for organism-specific targeted treatment, and reduced overtreatment of CT and NG infections.

Fungal pathogens and the infections they cause are notoriously understudied and underrepresented in public health surveillance programs. Recent initiatives, such as that of the Joint Programming Initiative on Anti-Microbial Resistance (JPIAMR), recognize these gaps and have supported the development of a fungal surveillance resistance network. The International Fungal Network for One-Health Resistance Surveillance: Antifungal Resistance (INFORM-AFR) network sought to enhance understanding of existing surveillance programs, with the ultimate goal of developing standardized fungal surveillance strategies that enable international comparisons. A survey was conducted involving mycology reference centers or public health institutes (n = 15) from 12 countries, each responsible for nationwide or regional surveillance programs on fungal infections or pathogens. The ongoing programs were heterogenous, not only in terms of the epidemiological focus of surveillance (pathogen vs disease based), but also in relation to the mycological procedures used (identification and antifungal susceptibility testing methods). Funding dedicated to surveillance was variable and often lacked long-term stability, resulting in suboptimal surveillance data in many centers and limiting the generation of accurate and consistent knowledge. With the expanding number of fungal disease cases and increasing reports of antifungal resistance, we strongly advocate for improved integration of fungal infections into nationwide health surveillance programs as well as international standardization.