Division Of Infectious Diseases Research Articles

Promoting Positive Sexual Health.

AffiliationsRobert A. Pitts is with the Department of Internal Medicine and the Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine and NYC Health and Hospitals/Bellevue, New York, NY. Richard E. Greene is with the Department of Internal Medicine, New York University Grossman School of Medicine and NYC Health and Hospitals/Bellevue.

The Devil Is in the Detail

From the ∗Internal Medicine Residency, Department of Medicine, Summa Health Akron City Hospital, Akron †Department of Internal Medicine, Northeast Ohio Medical University, Rootstown ‡Infectious Disease Division, Department of Medicine, Summa Health Akron City Hospital, Akron §Infectious Disease Section, Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH. Correspondence to: Joseph P. Myers, MD, Summa Health Akron City Hospital Department of Medicine, 55 Arch St, Ste. 1A, Akron, OH 44304. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose.

Mycoplasma Pneumonia in Children and Adolescents.

1. Catherine Krafft, MD* 2. Cynthia Christy, MD†,‡ 1. *Department of Pediatrics and 2. †Division of Pediatric Infectious Diseases, University of Rochester School of Medicine and Dentistry, Rochester, NY 3. ‡Rochester General Hospital, Rochester, NY * Abbreviations: CAP: : community acquired pneumonia EM: : erythema multiforme FDA: : Food and Drug Administration MIRM: : Mycoplasma pneumoniae– induced rash and mucositis PCR: : polymerase chain reaction SJS: : Stevens-Johnson syndrome Mycoplasma pneumoniae is a frequent cause of respiratory infections, including community-acquired pneumonia, in school-age children. However, as the science surrounding the diagnosis of this pathogen improves, our knowledge of its epidemiology, including asymptomatic carriage, and the management of this disease is evolving. After completing this article, readers should be able to: 1. Understand the microbiology and epidemiology of Mycoplasma pneumoniae infection. 2. Describe the variable clinical presentation of M pneumoniae infection and extrapulmonary manifestations. 3. Understand the difficulties associated with diagnosing infection with M pneumoniae and current recommendations for diagnosis. 4. Appropriately treat patients with suspected Mycoplasma infection. A 9-year-old girl presents to her pediatrician with a fever, decreased energy, and a cough for 10 days. She was initially evaluated 4 days ago when she had rhinorrhea, a cough, and decreased energy over the previous week. Her examination at that time was notable only for a mildly erythematous posterior oropharynx and nasal discharge. She was diagnosed as having a viral upper respiratory tract infection, and supportive care measures were recommended. Since that visit, her cough is more persistent and she has developed fevers. On examination her temperature is 100.8°F (38.2°C), heart rate is 100 beats/min, respiratory rate is 40 breaths/min, and oxygen saturation is 90% on room air. She is generally well-appearing. Her physical examination is remarkable for an erythematous posterior oropharynx, nasal discharge, and bilateral diffuse crackles on auscultation of her lungs. What is the next step in diagnosis and management? ### Microbiology Mycoplasma pneumoniae is a tiny, pleomorphic bacteria belonging to the class Mollicutes and is the smallest self-replicating bacteria pathogenic in humans, its only known host. M pneumoniae is unique in having no …

The incidence and clinical effects of Bordetella pertussis in children hospitalized with acute bronchiolitis.

Pertussis is a disease leading to high morbidity and mortality in neonates and infants. Bronchiolitis is the most common cause of hospitalization especially in children < 2 year-old. Although the clinical findings are different in these two diseases, it is sometimes difficult to make this distinction in partially or fully vaccinated children. This study aimed to identify the incidence, clinical and laboratory effects of B. pertussis as a causative agent in hospitalized children with acute bronchiolitis. The study included patients diagnosed with acute bronchiolitis and admitted to the Division of Pediatric Infectious Diseases from January 2012 to December 2015, aged 24 months or younger, evaluated for viruses and bacteria with polymerase chain reaction in respiratory tract secretions. The study included 380 patients hospitalized with acute bronchiolitis. Of these patients, 85.8% were identified to be positive for at least one respiratory pathogen. The most commonly identified pathogens were respiratory syncytial virus (RSV) A/B, rhinovirus, parainfluenza virus, adenovirus, bocavirus and metapneumovirus A/B. B. pertussis was only detected in 5 patients (1.5%). In the patients with B. pertussis identified, coinfection with another virus was observed including rhinovirus (n= 2), influenza A virus (n= 1), coronavirus OC43 (n= 1) and RSV A/B (n= 1). The presence of B. pertussis did not appear to cause any significant clinical or laboratory differences in patients. B. pertussis is a rare pathogen in patients admitted to hospital for acute bronchiolitis. However, in patients who do not respond to standard bronchiolitis treatment, B. pertussis should be considered as a causative agent. Early identification of this pathogen is important in terms of quarantining the patient, administering appropriate antimicrobial treatment, and prophylactic treatment to household and other close contacts.

Evaluation of clinical and laboratory characteristics of childhood tuberculosis.

Aim:Tuberculosis is one of the oldest and most contagious diseases of human history. One- quarter of the world’s population is infected with the tuberculosis bacillus. Childhood tuberculosis does not have a standard clinical and radiologic description. Herein, we aimed to evaluate the clinical, laboratory, and radiologic findings of childhood tuberculosis.Material and Methods:The medical records of 216 patients hospitalized and treated with a diagnosis of TB between January 2015 and July 2019 in the Division of Pediatric Infectious Diseases in our hospital, were examined retrospectively.Results:One hundred twenty-nine (59.7%) of 216 patients who were diagnosed as having TB were female and 87 (40.3%) were male. The age distribution of the patients was 12.3 (range, 0.33–18) years. One hundred sixty-nine patients (78.2%) had pulmonary, 34 (15.7%) had extrapulmonary, 13 had (6%) both pulmonary and extrapulmonary. One hundred forty-three (66.2%) patients had tuberculin skin test positivity. Acid-resistant bacteria were observed in 46 (21.3%) body fluid samples, and culture positivity was observed in 42 (19.4%) samples. The association of pulmonary tuberculosis and extrapulmonary tuberculosis was found with a higher rate in individuals who lived on minimum wage and in patients who had growth and developmental retardation (p=0.001, p<0.001). The hospitalization time was longer in these patients (p=0.027). The hemoglobin and sodium levels were significantly lower in patients who had extrapulmonary tuberculosis (p=0.044, p=0.002).Conclusion:Although the diagnosis of childhood tuberculosis is difficult due to the nonspecific signs and symptoms, it is a preventable and treatable disease.

Editorial introductions

Editorial introductions

Implementation of the University of Louisville COVID-19 Biorepository: Experiences from the Center of Excellence in Infectious Diseases (CERID)

The limited availability of biological samples from patients testing positive for SARS CoV-2 to be available for future research was quickly identified at the onset of the COVID-19 pandemic. In response to this need, a COVID-19 biobank was initiated by the University of Louisville Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases (CERID). The COVID-19 biobank contains waste samples obtained from patients hospitalized with COVID-19 in any of the nine Louisville, Kentucky area hospitals during the timeframe of April 13, 2020 through 09-20-2020. The COVID-19 biobank stores approximately1,623 waste samples with 2,127 aliquots for distribution. All samples are linked to clinical data. The methods described in this paper are intended for use as a guide for other research institutions interested in developing a COVID-19 biobank.

Standardizing Safety Assessment and Reporting for Neonatal Clinical Trials

Standardizing Safety Assessment and Reporting for Neonatal Clinical Trials

Unique Facial and Oral Lesions in a Patient With Human Immunodeficiency Virus

From the ∗College of Medicine †Division of Infectious Diseases, University of Arkansas for Medical Sciences, Little Rock, AR. Correspondence to: Saad O. Atiq, BS, College of Medicine, University of Arkansas for Medical Sciences, 4301 W Markham Street, Slot #550, Little Rock, AR 72211. E-mail: [email protected]. The authors have no conflicts of interest to disclose.

742. The Development, Implementation, and Feasibility of Multidisciplinary Treatment Planning Conference for Individuals with Unstable Substance Use Disorders and Active Infections Requiring Prolonged Antimicrobial Therapy: The OPTIONS-DC Model

BackgroundOutpatient parenteral antimicrobial therapy (OPAT), widely used for serious infections, has high failure rates in people with substances use disorders (SUD)1–2. At our institution, completing therapy in the hospital was previously the best option for high-risk patients; but long hospital stays are often unacceptable to patients and costly. To improve outcomes, our Infectious Diseases division, OPAT program, and Improving Addiction Care Team (IMPACT) developed and implemented a novel multidisciplinary conference (OPTIONS-DC) for inpatients with SUD requiring prolonged antibiotics. This study describes the conference development, tool, and initial experience.MethodsFrom June 2017 to June 2018, diverse stakeholders collaboratively created and implemented a structured conference to discuss treatment options that balance medical efficacy, patient preferences, and feasibility using harm-reduction principles. After 10 months of hospital-wide implementation, we elicited provider feedback and performed a content analysis of OPTIONS-DC notes and patient records to evaluate the impact.ResultsThe goal of conference development was prioritizing patient preferences and engaging multidisciplinary input. One RN facilitates the conference using the tool (Figure 1) to elicit input from the relevant providers. The tool systematically addresses components that may predict treatment success (i.e., working phone) while emphasizing patient preference and harm reduction. The IMPACT social work PICC safety assessment informs risks for IV access. Antibiotic recommendations are not a binary of optimal/suboptimal choices for the infection but options that best fit patient context. The average conference length was 28 minutes (IQR 21). Preliminary data shows good clinical outcomes and savings to inpatient days and cost. Initial feedback suggests the model was positively experienced by medical providers (Figure 2) and supported patient preferences.ConclusionA multidisciplinary patient-centered conference that prioritizes patient preference and uses harm-reduction principles for this high-risk population is practical, effective, and positively experienced by providers. This model may serve as a roadmap for other institutions. Disclosures All authors: No reported disclosures.

2550. A Meeting of the Minds Over Matters of the Heart: Using Interdisciplinary Education to Build Consensus in Managing Cardiac Implantable Electronic Device (CIED) Infections

BackgroundCIED infections carry significant morbidity and mortality. Guidelines differ in management recommendations for CIED infections, which can result in a lack of consensus amongst Infectious Disease (ID) and Cardiology providers caring for these patients. We sought to identify areas of disagreement and consensus in the care of CIED infections amongst ID and Cardiology providers at an academic medical center. We used these data as a needs assessment to develop an interdisciplinary educational intervention focused on standardizing our institutional approach toward CIED infections, to create an internal guideline and to develop a new multidisciplinary team (MDT) for assistance managing complex patients hospitalized with CIED infections.MethodsA pre-intervention survey was delivered to advanced practitioner providers, fellows and faculty of the divisions of Cardiology, Electrophysiology (EP) and ID to assess content knowledge in the diagnosis and management of CIED infections, attitudes toward the formation of a MDT, and perception of the degree of consensus amongst these specialty providers.ResultsThe survey was sent to 206 providers, 40 (19.4%) participated. Only 16/40 (40%) agreed that there was consensus within the ID division in managing patients with CIED infections, and only 8/40 (20%) agreed that there was consensus amongst Cardiology and EP providers. 37/40 (92.5%) agreed that a MDT approach would be beneficial. Some survey responses diverged significantly from guideline recommended management strategies, including only 50% of respondents recommending CIED extraction for devices eroding through the skin. For patients with CIED-related endocarditis, 35% recommended delaying reimplantation of a new CIED until completion of a full course of antibiotics, despite guideline recommendations of significantly shorter delays.ConclusionOur survey revealed a striking lack of consensus amongst ID and Cardiology providers in the appropriate diagnosis and management of CIED infections, along with divergence from guideline recommendations in key areas. An interdisciplinary educational intervention to update provider content knowledge and unify interspecialty approaches could improve collaborative efforts and, ultimately, care of patients with CIED infections.Disclosures All authors: No reported disclosures.

1949. Putting Out Fires: Assessing Burnout within an Infectious Diseases Fellowship at an Academic Medical Center

BackgroundBurnout, “a psychological syndrome of emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA),” is a well-described problem in the medical community. National surveys report 45% of practicing physicians and 60% of residents and fellows are burnt out. A longitudinal study of medical students and residents reported 45% burnout, as well as career choice regret in 14% of trainees. There are little data about burnout in Infectious Diseases (ID) physicians, including fellows. We sought to measure burnout prevalence in an academic ID Division, identify factors that modified the risk of burnout, and assess knowledge and attitudes about fellow and faculty burnout in the division.MethodsThe study population included 33 ID physicians (10 fellows, 23 faculties). Level of burnout was assessed via the Maslach Burnout Inventory (MBI), a validated 22-item tool. An additional survey was distributed as a needs assessment to determine participant understanding of “burnout” and “wellness,” ability to recognize burnout in colleagues, attitudes about the scope of the problem, and specific programmatic and personal factors felt to contribute to burnout.ResultsThe MBI was completed by 10 fellows and 16 faculties (76%). A high score in ≥ 1 domain of burnout was reported in 50% of respondents, and 19% received a high score in both EE and DP. Fellows had moderate to high levels of EE (90%) and DP (70%), though all fellows reported at least a moderate sense of PA.The survey needs assessment was completed by 9 fellows and 17 faculties (79%). In a hypothetical case, 100% and 58% of participants correctly identified elements of DP and EE, respectively. Respondents identified several factors contributing to burnout risk, most commonly being lack of schedule autonomy (100%), increasing patient load (96%), and inability to attend teaching conferences (88%). Fellows felt burnt out when seeing ≥ 4 new consults per day and/or carrying a census of 10–11 patients.ConclusionID fellows at an academic medical center recognize burnout and report levels on par with national data. Fellows and faculty can identify personal and programmatic factors that increase and decrease their risk of burnout. These data can guide programmatic and divisional interventions to improve trainee wellness. Disclosures All Authors: No reported Disclosures.

Impact of combination HIV interventions on HIV incidence in hyperendemic fishing communities in Uganda: a prospective cohort study

Targeting combination HIV interventions to locations and populations with high HIV burden is a global priority, but the impact of these strategies on HIV incidence is unclear. We assessed the impact of combination HIV interventions on HIV incidence in four HIV-hyperendemic communities in Uganda. We did an open population-based cohort study of people aged 15-49 years residing in four fishing communities on Lake Victoria. The communities were surveyed five times to collect self-reported demographic, behavioural, and service-uptake data. Free HIV testing was provided at each interview, with referral to combination HIV intervention services as appropriate. From November, 2011, combination HIV intervention services were rapidly expanded in these geographical areas. We evaluated trends in HIV testing coverage among all participants, circumcision coverage among male participants, antiretroviral therapy (ART) coverage and HIV viral load among HIV-positive participants, and sexual behaviours and HIV incidence among HIV-negative participants. From Nov 4, 2011, to Aug 16, 2017, data were collected from five surveys. Overall, 8942 participants contributed 20 721 person-visits; 4619 (52%) of 8942 participants were male. HIV prevalence was 41% (1598 of 3870) in the 2011-12 baseline survey and declined to 37% (1740 of 4738) at the final survey (p<0·0001). 3222 participants who were HIV-negative at baseline, and who had at least one repeat visit, contributed 9477 person-years of follow-up, and 230 incident HIV infections occurred. From the first survey in 2011-12 to the last survey in 2016-17, HIV testing coverage increased from 68% (2613 of 3870) to 96% (4526 of 4738; p<0·0001); male circumcision coverage increased from 35% (698 of 2011) to 65% (1630 of 2525; p<0·0001); ART coverage increased from 16% (254 of 1598) to 82% (1420 of 1740; p<0·0001); and population HIV viral load suppression in all HIV-positive participants increased from 34% (546 of 1596) to 80% (1383 of 1734; p<0·0001). Risky sexual behaviours did not decrease over this period. HIV incidence decreased from 3·43 per 100 person-years (95% CI 2·45-4·67) in 2011-12 to 1·59 per 100 person-years (95% CI 1·19-2·07) in 2016-17; adjusted incidence rate ratio (IRR) 0·52 (95% CI 0·34-0·79). Declines in HIV incidence were similar among men (adjusted IRR 0·53, 95% CI 0·30-0·93) and women (0·51, 0·27-0·96). The risk of incident HIV infection was lower in circumcised men than in uncircumcised men (0·46, 0·32-0·67). Rapid expansion of combination HIV interventions in HIV-hyperendemic fishing communities is feasible and could have a substantial impact on HIV incidence. However, incidence remains higher than HIV epidemic control targets, and additional efforts will be needed to achieve this global health priority. The National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Cancer Institute, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, Centers for Disease Control and Prevention Uganda, Karolinska Institutet, and the Johns Hopkins University Center for AIDS Research.

Working Toward Broad and Equitable Access to HIV Preexposure Prophylaxis

AffiliationsJulia L. Marcus and Douglas S. Krakower are with the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA. Douglas S. Krakower is also with the Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston.

The Threat of Outbreaks in US Border Patrol Detainment Centers.

Twelve minutes before the arrival of Christmas, medical staff at a county hospital in New Mexico declared an 8-year-old boy dead.1 He had arrived there unresponsive less than 1 hour before, his second visit to the hospital that day. It was the end of a long journey for Felipe Gomez-Alonzo. Early in December 2018, Felipe and his father departed their village in rural Guatemala for the United States.2 On December 18, US Customs and Border Protection apprehended them at the El Paso, Texas, border. During the next 6 days, US Customs and Border Protection detained both Felipe and his father, eventually transferring them to a Border Patrol station in Alamogordo, New Mexico, a city of 30 000 people.1 At 9 am on Christmas Eve, a US Border Patrol processing agent noticed that Felipe was coughing.1 Border Patrol agents transported him and his father to Gerald Champion Regional Medical Center for evaluation of influenza symptoms. Gerald Champion Regional Medical Center is a small county hospital shared by active-duty personnel and residents in Alamogordo. The extent of Felipe’s evaluation at Gerald Champion is unclear. Was an influenza test done? New Mexico had influenza cases since October, and for the previous week, the state department of health had characterized influenza activity as widespread.3 Felipe had a fever of … Address correspondence to Mark A. Travassos, MD, MSc, Division of Infectious Diseases and Tropical Pediatrics, Department of Pediatrics, University of Maryland School of Medicine, 685 W Baltimore St, Room 480, Baltimore, MD 21201. E-mail: mtravass{at}som.umaryland.edu

Separating myths from reality for vaccines causing adverse events following immunization: an interview with Manish Sadarangani.

Dr Manish Sadarangani is Director of the Vaccine Evaluation Center at the BC Children's Hospital Research Institute and an Assistant Professor in the Division of Infectious Diseases, UBC Department of Pediatrics. He completed his undergraduate medical and pediatric training in Cambridge, Oxford and London in the UK. He then completed his DPhil with the Oxford Vaccine Group in the UK, developing novel vaccine candidates for protection against capsular group B meningococcal disease, and completed a fellowship in pediatric infectious diseases in Vancouver in 2013 before returning to Oxford to work as a pediatric infectious diseases physician. His research links clinical trials with basic microbiology, immunology and epidemiology to address clinically relevant problems related to immunization and vaccine-preventable diseases.

Challenges to Pertussis Control.

* Abbreviations: DTaP — : diphtheria-tetanus-acellular pertussis DTwP — : diphtheria, tetanus toxoids, and whole-cell pertussis KPNC — : Kaiser Permanente Northern California In this issue of Pediatrics , the vaccine research group at Kaiser Permanente Northern California (KPNC) contributed another important article outlining the challenges of pertussis control in a highly vaccinated population.1 Nearly one-half million children born between 1999 and 2016 and managed at KPNC from 2006 to 2017 were evaluated. Of those immunized children, all had received only diphtheria-tetanus-acellular pertussis (DTaP) vaccine. In total, 738 polymerase chain reaction–confirmed pertussis cases were diagnosed. Pertussis risk was 13 times higher among unvaccinated and nearly 2 times higher among undervaccinated children when compared with those who were fully vaccinated. However, >80% of the total pertussis cases were seen in children who had received all their recommended DTaP vaccine doses. Pertussis risk increased with increasing time since vaccination, clearly demonstrating waning immunity, which the KPNC group and others had previously reported.2,3 Those individuals who began their medical career after 1997, when DTaP totally replaced the conventional diphtheria, tetanus toxoids, and whole-cell pertussis (DTwP) vaccines, may question why DTaP replaced DTwP in the first place. When I began my academic career at Vanderbilt University School of Medicine in 1980, pertussis disease appeared to be well controlled.4 Rarely would cases present to the medical center, and generally … Address correspondence to Kathryn M. Edwards, MD, Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, 1161 21st Ave South, D-7227 Medical Center North, Nashville, TN 37232. E-mail: kathryn.edwards{at}vumc.org

Effect of Educational Program about Infection Control Precautions for Nurses in Pediatric Hemodialysis Units

Background: Hemodialysis places children at high risk for infection because of patient comorbidities and numerous human, environmental, and procedural factors. The aim of this study was to evaluate the effect of the educational program on the nurse's knowledge and their practices about infection control measures in hemodialysis units. Research design: Pre /post quasi experimental design was used in this study. Sample: A convenient sample of all nurses in hemodialysis units, Setting: the study was conducted in pediatric hemodialysis units at Minia University and Minia General Hospitals. Tools for Data Collection: A structured interview questionnaire sheet in Arabic language was used for the studied nurses as pre/posttest. It composed of the following parts: Part I: Demographic data related to the nurses' age, sex, qualification, years of experience and previous attending courses in infection control. Part II: Nurses, knowledge related to infection control in pediatric hemodialysis unites Part III: An observational checklist that was adopted from Control Diseases Center. (National Center for emerging and zoonotic infectious diseases division of health quality promotion). Results: the finding of the current study revealed that there were statistical significant differences between nurses' knowledge and practices at pre and post- program. There were significance correlations between nurses' knowledge, residence and occupation respectively at pre- program. Conclusion the study concluded that there were statistical significant differences between nurses' knowledge and practices at pre and post- program. Recommendation the study recommended that the developed program should be applied and repeat again every 6 months as well as provision of continuing education programs on regular basis is suggested in order to refresh and update nurse's knowledge.

What Are the Chances?

From the Division of Microbiology and Infectious Diseases, St Mary's Hospital, Montreal, Quebec, Canada. Correspondence to: Joe Dylewski, Division of Microbiology and Infectious Diseases, St Mary's Hospital, 3830 Lacombe, Montreal, Quebec, Canada H3T 1M5. E-mail: [email protected]. The author has no funding or conflicts of interest to disclose.

A Look in the Rear View Mirror

From the Division of Microbiology and Infectious Diseases, St Mary's Hospital, Montreal, Quebec, Canada. Correspondence to: Joe Dylewski, MD, Division of Microbiology and Infectious Diseases, St Mary's Hospital, 3830 Lacombe, Montreal, Quebec, Canada H3T 1M5. E-mail: [email protected]. The author has no funding or conflicts of interest to disclose.