Open Forum Infectious Diseases最新文献

Background: We aimed to identify and evaluate clinical subphenotypes in a cohort of patients with methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) and to assess their association with all-cause 90-day mortality.

Methods: This post hoc analysis of the MRSA-GEIRAS-SEIMC study was conducted across 15 Spanish hospitals. MRSAB in adult patients from 2019 to 2022 were included. Clinical subphenotypes were identified using a combination of principal component analysis and latent class analysis based on age, sex, comorbidities, SOFA score, creatinine levels, metastatic foci, source, and acquisition. The 90-day mortality associated with each subphenotype was estimated using the Kaplan-Meier method. Cox regression was performed to assess the risk of death.

Results: A total of 419 MRSAB were included. Four distinct subphenotypes were identified: S1 was associated with younger age, community acquisition, and unknown or skin and soft-tissue infection source; S2 was associated with older age, female sex, high burden of comorbidities, and healthcare-related acquisition; S3 was linked to a catheter source and nosocomial acquisition; and S4 was predominantly associated with the presence of heart valve prostheses, and metastatic foci. Significant differences in all-cause 90-day mortality were observed across subphenotypes: 20.0% in S1, 47.4% in S2, 26.2% in S3, and 35.1% in S4 (P < .01). Cox regression indicated an increased 90-day mortality risk in S2 (HR, 2.98; 95% CI, 1.59-5.56) and S4 (HR, 1.99; 95% CI, 1.16-3.42) compared with S1.

Conclusions: We identified 4 distinct clinical subphenotypes of MRSAB associated with prognostic outcomes. Further investigation is needed to implement them into clinical practice.

Background: Despite classification as the most common endemic mycosis in the United States, few data exist supporting the optimal care of patients with histoplasmosis, making diagnosis and treatment challenging. This study aimed to describe patients with histoplasmosis across a Michigan health system.

Methods: A retrospective, multicenter cohort study of patients diagnosed with histoplasmosis between January 2020 and April 2023. The primary objective was to describe patients diagnosed with histoplasmosis, methods of diagnosis, and treatment they received. Patient outcomes, including mortality with treatment, and 6-month relapse of disease, were also evaluated.

Results: A total of 88 patients were included in the study, and most received care from an infectious diseases provider (86.4%). Tissue histopathology was the most common diagnostic method (59%). Treatment was initiated in 58 patients (66%); 17 (29.3) had disseminated disease. Five (8.6%) patients died within 6 months. Itraconazole was the agent most prescribed for definitive therapy (81%) followed by posaconazole (17%). Median treatment duration was 24 weeks. Adverse events occurred in more than one quarter of patients receiving triazoles. Loading doses were absent in 35% of itraconazole prescriptions; therapeutic drug monitoring was absent in 19.2%. No patients experienced a relapse of disease within 6 months of therapy completion.

Conclusions: In a cohort of patients with histoplasmosis from Michigan, variation in diagnostic testing and treatment was observed. Most patients were diagnosed by positive tissue histopathology and itraconazole was the most frequently prescribed antifungal followed by posaconazole. Opportunities for more sensitive diagnostic testing and improved antifungal dose optimization and monitoring were identified.

Background: Since September 2022, an ongoing increase in gonorrhea positivity rates and diagnoses among young women visiting sexual health centers was observed in the Netherlands. To gain more insight into possible drivers of this increase, this study aimed to investigate the molecular diversity, clustering, and transmission of Neisseria gonorrhoeae related to the gonorrhea increase in the Netherlands.

Methods: Between January 2022 and March 2023, viable and stored N gonorrhoeae isolates from vaginal swab samples from 273 women <25 years of age were included from 4 sexual health centers in the Netherlands. All isolates were subjected to whole genome sequencing. The molecular diversity was investigated by analyzing (core genome) multilocus sequence types (STs) over time and by patient characteristics.

Results: The prevalence of ST7359 and ST7822 increased from <5% in the beginning of 2022 to ∼23% in 2023 and ST9363 from 6% to 14%. ST7359 and ST9363 were associated with hosts with university-level education and Dutch ethnicity. ST7359 and ST7822 also included large clusters of genetically related isolates (<6-gene difference). No indication for reduced antimicrobial susceptibility to ceftriaxone was found in any ST.

Conclusions: The N gonorrhoeae surge among young women is not caused by a single strain. The prevalence of STs shifted over time, and certain STs were associated with distinct populations and showed clustering of genetically related isolates. These findings suggest rapid clonal expansion of several circulating STs. This may be indicative of increased transmission within specific sexual networks.

Infectious diseases telehealth (IDt) management of outpatient parenteral antimicrobial therapy (OPAT) across 18 small community hospitals was associated with similar rates of OPAT failure, lower rates of clinical failure and mortality, and higher likelihood of inpatient source control procedure compared to OPAT managed by other services. IDt program expansion might further improve care.

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.