JAMMI最新文献

Background: Infections in sterile body sites are serious despite their low incidence. Accurate diagnosis is crucial for effective antimicrobial management. This study assessed the diagnostic yield of multiplex polymerase chain reaction (PCR) in identifying bacterial pathogens in sterile site specimens other than blood and cerebrospinal fluid.

Methods: Bacterial pathogen PCR panels were independently developed and validated by the laboratories at the Hamilton Regional Laboratory Medicine Program (HRLMP) in Canada and Sidra Medicine in Qatar. Retrospective culture and PCR data for the periods of July 2022 to November 2023 and September 2021 to February 2023 were extracted from the laboratory information systems of HRLMP and Sidra Medicine, respectively. The diagnostic yield of PCR between different groups was compared using the McNemar test or chi-square test.

Results: Validation studies showed 100% sensitivity for PCR assays in both laboratories, with varying specificity due to the detection of additional pathogens by PCR. Combining post-implementation data from both laboratories, 38.7% of 512 specimens were PCR-positive for target organisms, compared to 6.1% by culture. While the diagnostic yield of PCR was significantly higher than that of culture in both adult and paediatric populations (p < .001), HRLMP data indicated a significantly higher diagnostic yield of PCR in the paediatric population compared to adults (64.7% versus 17.4%; p < .001). The most commonly PCR-detected pathogens were Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus, with pleural fluid being the most frequently positive specimen type.

Conclusion: This study supports using PCR alongside culture to enhance pathogen detection and improve the management of sterile site infections, particularly in paediatric patients.

Introduction: Refractory or resistant cytomegalovirus (CMV) infection and disease pose a significant challenge in immunocompromised patients, including solid organ transplant (SOT) and allogeneic hematopoietic cell transplant (allo-HCT) recipients. This study aimed to evaluate letermovir as a treatment for patients with CMV infection or disease.

Methods: We performed an open-label, phase II non-randomized clinical trial. Adult and paediatric (≥12 years of age) patients who had undergone an SOT or allo-HCT and who required antiviral treatment for refractory or resistant CMV or who had CMV with concurrent organ dysfunction were eligible. Patients received letermovir treatment daily for up to 12 weeks with an optional additional 12 weeks of therapy for secondary prophylaxis if clinically indicated. The primary objectives were to evaluate the safety and efficacy of letermovir treatment based upon virological and clinical responses.

Results: Ten patients were enrolled in the study, and seven patients completed the study treatment and follow-up period. The overall virological response (defined as a complete virological response at the end of the study period) rate was 60% in the study population. The study drug was well tolerated, as only two patients experienced study drug-related toxicity and only one grade 3 toxicity (elevated ALT) was observed. Letermovir was not associated with acute kidney injury, hepatotoxicity, cardiac arrhythmias, or bone marrow suppression.

Conclusion: In this limited sample, letermovir for CMV treatment was safe and well tolerated. Further research is needed to determine if letermovir can be used for the treatment of refractory or resistant CMV infection or disease.

Background: Canada aims to end the HIV epidemic as a public health threat by 2030. However, the provinces Alberta, Saskatchewan, and Manitoba reported 564 new HIV diagnoses in 2021 and over 600 in 2022. This study describes changes in HIV epidemiology in these three provinces compared to the rest of Canada between 1985 and 2022.

Methods: This was an ecological study that used data from publicly available HIV reports published by the Governments of Manitoba, Saskatchewan, Alberta, and Canada from the first reported HIV diagnoses to the latest available information. Variables of interest included number of HIV diagnoses per year (new, introduced), advanced HIV disease, proportion of diagnoses by sex (female/male), ethnicity, age, self-reported HIV mode of transmission, and mortality. We report the HIV incidence, advanced HIV disease, and mortality over time by province, and by sex, ethnicity, age, and mode of HIV transmission when data are available.

Results: Canadian HIV incidence decreased over time, while new HIV diagnoses in Manitoba and Saskatchewan increased to the highest ever recorded. In Saskatchewan and Manitoba, the male-to-female ratio is 1:1, while in Alberta and Canada, it is 2:1. Indigenous people have been overrepresented in Saskatchewan and Manitoba diagnoses since 2006 and 2016, respectively. The most common modes of HIV transmission are injection drug use and heterosexual sex in Saskatchewan and Manitoba for several years, while "out-of-country" is the most common category in Alberta. The advanced HIV disease and mortality statistics have decreased over time in Canada and the three provinces.

Conclusion: HIV incidence in Canada has slowly decreased; however, Manitoba and Saskatchewan have shown unprecedented increases in HIV incidence. The current epidemiology requires immediate public health action from local, provincial, and federal governments, considering that Alberta, Saskatchewan, and Manitoba contribute to about 40% of all new HIV diagnoses in Canada.

Background: A growing number of people living with HIV (PLWH) are developing an indication for hematopoietic stem cell transplantation (HSCT). While overlapping immunosuppression and medication interactions make this a complicated situation, the risk is mitigable, and PLWH should have similar access to HSCT as the general population. There are currently no guidelines available for the management of HSCT in PLWH, and through this document we hope to provide initial guidance.

Methods: We performed a non-systematic review of published English-language literature regarding medication and opportunistic infection risk management in both PLWH and HSCT recipients, as well as local, national, and international guidelines. We then generated recommendations for PLWH undergoing HSCT that went through multiple rounds of review with the authors and expert peers.

Results: Patients living with well-controlled HIV are expected to have similar outcomes with HSCT as people without HIV. Focus should be on minimizing interruptions in antiretroviral therapy, avoiding drug-drug interactions (minimized with integrase strand transfer inhibitors), and managing overlapping toxicities. Opportunistic infections common in both advanced HIV and in HSCT include Pneumocystis pneumonia, toxoplasmosis, herpes simplex virus, varicella zoster virus, and cytomegalovirus, with nontuberculous mycobacteria and cryptococcosis being somewhat more common in advanced HIV. Assuming a patient has well-controlled HIV, most of the opportunistic infection risk is due to transplant-related immunosuppression, and we provide specific prophylactic recommendations.

Conclusions: PLWH should have similar access to HSCT as people without HIV, and we offer this document as guidance to support hematology/oncology providers.

Starting in the early 2000s, the rate of infectious syphilis in Canada began rising. Since the mid-2010s, the rate among females, particularly females in their reproductive years, has increased rapidly. Coincident with this shift, congenital syphilis has re-emerged in Canada in recent years. Infectious and congenital syphilis disproportionately impact communities affected by social and structural determinants of health, including homelessness and inadequate or inaccessible health care services. These realities underscore the importance of emerging strategies, including rapid diagnostic tests that can be deployed at the point of care, as tools to help reverse these trends. Increased access to testing is one of the pillars of the Pan-Canadian Framework for Action on Sexually Transmitted and Blood-Borne Infections (STBBI) and the Government of Canada's STBBI Action Plan 2024-2030. The National Microbiology Laboratory Branch of the Public Health Agency of Canada has worked towards introducing rapid diagnostic tests including point-of-care tests (POCTs) for STBBI testing. With Health Canada's first approval of a syphilis POCT (bioLytical's INSTI MULTIPLEX HIV-1/2 Syphilis Ab Test) in 2023, it is timely to reflect on important implementation considerations for this and other syphilis POCTs in Canada. In this article, we aim to review antibody-detecting syphilis POCTs that are commercially available, their performance in recent Canadian field studies, and key contextual considerations for Canada in implementing POCTs for syphilis.

Background: Little has been written about the role of COVID assessment centres set up during the COVID-19 pandemic.

Methods: This descriptive study reviewed and compared COVID cases presenting to the Mount Sinai Hospital COVID assessment centre and emergency departments over a 4-month period at the start of the pandemic in 2020.

Results: Of 185 COVID-positive presentations, 115 (62.2%) were assessed in the COVID assessment centre and 70 (37.8%) in the emergency department. Patients seen in the COVID assessment centre tended to be younger (mean age 33.5 years) than in the emergency department (mean age 51.8 years, P < .001), had fewer comorbidities (P ≤ .05 for hypertension, congestive heart failure, diabetes, and cancer), and were less likely to have shortness of breath, fever, or focal lung findings (P < .01 for all). Chest imaging was ordered for 57.1% of emergency department cases versus 0% for COVID assessment centre cases (P < .001). Overall, 21 out of 69 (30.4%) COVID-positive cases were admitted from the emergency department, while all COVID assessment centre cases were discharged home.

Conclusions: The Mount Sinai COVID assessment centre assessed the majority of COVID cases early on in the pandemic at this site. While these were milder COVID infections, this decreased the overall number of COVID infections that might otherwise have needed to be seen in the emergency department.

Background: The location of onset of bloodstream infections (BSIs) associated with intensive care unit (ICU) admission may influence their clinical and epidemiological characteristics.

Methods: A multicentre, retrospective cohort study was conducted in Queensland, Australia, and BSIs associated with ICU admission were identified and classified as community-onset, hospital-onset, or ICU-onset if first isolated within, after 48 hours but within 48 hours of ICU admission, or after 48 hours following ICU admission, respectively.

Results: We included 3,540 episodes of ICU-associated BSI, with 1,693 classified as community-onset, 663 hospital-onset, and 1,184 ICU-onset. Compared with hospital-onset BSIs, patients with ICU-onset BSIs were younger, had fewer comorbidities, had lower APACHE II scores, and were more likely male. Patients with ICU-onset BSI were more likely to be surgical admissions and have a primary cardiovascular or neurological diagnosis. The distribution of infective agents varied significantly among community-, hospital-, and ICU-onset BSI groups. The all-cause 30-day case-fatality rates for first-episode community-onset, hospital-onset, and ICU-onset BSIs were 17.1%, 21.7%, and 23.5%, respectively (p < 0.001).

Conclusion: With different epidemiological features and causal pathogens, ICU-onset BSI represents a distinct BSI group arising in hospitalized patients.

Background: Blastomycosis is a disease caused by infection with thermally dimorphic fungi belonging to the genus Blastomyces. Central nervous system (CNS) involvement occurs in an estimated 1% to 10% of patients with blastomycosis, and treatment requires at least 12 months of antifungal therapy.

Methods: We describe a 32-year-old male who presented with recurrent blastomycosis involving the CNS.

Results: The patient was initially diagnosed with pulmonary blastomycosis with possible involvement of the CNS approximately 1 year prior to his current presentation. At that time, he was treated with amphotericin B deoxycholate and then subsequently transitioned to oral voriconazole. On discharge he only filled his voriconazole prescription for 8 weeks out of a planned year-long treatment course, due to an inability to afford it. He subsequently re-presented with symptoms of headache, nausea, and ataxia, and was found to have a right-sided cerebellar abscess. The abscess was drained and Blastomyces sp was isolated on culture. Following surgery, the patient was once again started on voriconazole after completing a course of liposomal amphotericin B. Social work was engaged early on during this admission. Fortunately, the patient's financial situation had improved and medication cost was no longer a barrier. When seen in follow-up, he remained on oral therapy and was doing well.

Conclusions: A case of recurrent blastomycosis with involvement of the CNS is presented, where treatment failure occurred due to an inability of the patient to afford the required medication. Medication cost should always be considered and discussed with a patient when developing a treatment plan.

Eight provinces and territories are currently experiencing syphilis outbreaks in Canada, with the national rate of infectious syphilis increasing significantly from 5.1 per 100,000 population in 2011 to 36.1 per 100,000 population in 2022. Neurosyphilis refers to infection of the central nervous system by Treponema pallidum, which may occur at any stage. It is to be expected that along with the syphilis outbreak, a concomitant rise in neurosyphilis cases will occur. It is important to note that Canadian national surveillance data on neurosyphilis is not currently published as it is inconsistently reported and often lumped in with secondary and tertiary syphilis rates. Future surveillance efforts must focus on properly identifying these cases to quantify the scope of the problem. This article summarizes Canadian Public Health Laboratory Network guidelines for neurosyphilis diagnosis.