Infectious Disease Physicians Research Articles

GPT-based chatbot tools are still unreliable in the management of prosthetic joint infections.

Artificial intelligence chatbot tools responses might discern patterns and correlations that may elude human observation, leading to more accurate and timely interventions. However, their reliability to answer healthcare-related questions is still debated. This study aimed to assess the performance of the three versions of GPT-based chatbots about prosthetic joint infections (PJI). Thirty questions concerning the diagnosis and treatment of hip and knee PJIs, stratified by a priori established difficulty, were generated by a team of experts, and administered to ChatGPT 3.5, BingChat, and ChatGPT 4.0. Responses were rated by three orthopedic surgeons and two infectious diseases physicians using a five-point Likert-like scale with numerical values to quantify the quality of responses. Inter-rater reliability was assessed by interclass correlation statistics. Responses averaged "good-to-very good" for all chatbots examined, both in diagnosis and treatment, with no significant differences according to the difficulty of the questions. However, BingChat ratings were significantly lower in the treatment setting (p = 0.025), particularly in terms of accuracy (p = 0.02) and completeness (p = 0.004). Agreement in ratings among examiners appeared to be very poor. On average, the quality of responses is rated positively by experts, but with ratings that frequently may vary widely. This currently suggests that AI chatbot tools are still unreliable in the management of PJI.

Quantitative analysis of the impact of infectious disease physicians on patients in the emergency department fast-track parenteral antibiotics program

IntroductionThe outpatient parenteral antibiotic therapy (OPAT) program of Vancouver General Hospital (VGH) was supervised by emergency physicians (EPs) until 2017 when infectious disease (ID) physicians began assisting in management. We designed a retrospective study to determine whether ID involvement led to improved outcomes.MethodsThis study analyzes the impact of ID involvement by comparing the mean days patients spent on OPAT with ID involvement versus EPs alone through a retrospective chart review. Secondary research objectives were to compare patient care decisions, e.g., antibiotic choice, tests ordered, and final diagnosis.ResultsThere was no difference between the mean number of days on OPAT between physician types. Compared to historic patterns, patients seen in OPAT after increased ID consultation spent an average of 0.5 fewer days in the program. However, when grouped by the first day of ID assessment, the average total days in OPAT was closely aligned with the day of first ID assessment, implying that ID frequently discharged patients close to initial assessment. Patients seen by ID were less likely to return within one month of discharge compared to those not seen by ID. Secondary findings include ID physicians prescribing a greater range of antibiotics, providing more varied final diagnoses, prescribing antibiotics less frequently, as well as ordering more cultures, diagnostic imaging and specialist consults.DiscussionThe findings of this study support the hypothesis that ID involvement in OPAT programs leads to changes in care that may have beneficial outcomes for patients and the healthcare system.

ICU care through NGS – Based identification of infectious agents: A comparative study

BackgroundSepsis claims 1 in 5 lives annually as per global statistics. Sepsis incidence in recent studies represents at least 35 % of all ICU admissions and has a high mortality rate, especially in the presence of co-existing morbidities. The challenge has been to accurately diagnose the causative organism, considering factors such as possible polymicrobial infections, commensals and environmental contaminants. Legacy techniques such as culture, automated culture systems or even newer species-specific PCR or film array these challenges difficult to overcome. The Bactfast® and Fungifast® assays along with the integrated workflow is based on next generation sequencing and have the ability to demarcate infecting pathogen from contamination and commensal. The unique ability to pinpoint the exact pathogen, considering the commensal and contamination in a variety of samples, with an extremely high sensitivity could lead it to be a tool of diagnostic choice for non-resolving ICU sepsis due to its comprehensive coverage and speed. The aim of this study was to evaluate the use of Bactfast® and Fungifast® as a last mile diagnostic tool in a ICU setting. MethodThis study was carried out considering access to four intensive care units (ICU). Legacy testing, mostly done on culture, was conducted at the various integrated microbiology facilities of the hospitals where the ICUs were located, in Chennai, India. NABL accredited laboratory Micro Genomics (India) Pvt Ltd, was established as the central processing facility for next generation sequencing to run the Bactfast® and Fungifast® assay. Co-relation of results for 490 samples was done retrospectively by a multi-disciplinary team of consultants which comprised of microbiologists, and infectious disease physicians. ResultThe diagnostic workflow established with the Bactfast® assay provided a sensitivity of 94.1 % and specificity of 86.6 %. Identification of pathogens in Bactfast® was better when compared to the data published in 2017, as reflected by positive co-relation with clinical confirmation. Although the Fungifast® specificity was high, at 99.4 %, only 12 samples were positive on fungal culture out of 490 samples. Therefore, it was concluded a further study for fungi based on multiple technologies with more true positive samples is required to evaluate the test. ConclusionBactfast® can identify pathogens in a sample without any bias. Its introduction as diagnostic modality in life threatening ICU sepsis could reduce mortality and morbidity. Although the initial results of Fungifast® are encouraging a further research is required for more information on test sensitivity.

Joel Breman: infectious diseases physician who investigated the first outbreak of Ebola

Joel Breman: infectious diseases physician who investigated the first outbreak of Ebola

Part 1: Current Concepts in Radiologic Imaging and Intervention in Acute Cholecystitis.

Acute calculous cholecystitis and acute acalculous cholecystitis are encountered commonly among critically ill, often elderly, patients. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, infectious disease physicians, gastroenterologists, and endoscopists able to contribute to patient care. In this article intended predominantly for intensivists, we will review the imaging findings and radiologic treatment of critically ill patients with acute calculous cholecystitis and acute acalculous cholecystitis.

Part 2: Current Concepts in Radiologic Imaging & Intervention in Acute Biliary Tract Diseases.

Acute cholangitis is encountered commonly in critically ill, often elderly, patients. The most common causes of cholangitis include choledocholithiasis, biliary strictures, and infection from previous endoscopic, percutaneous, or surgical intervention of the biliary tract. Rare causes of acute cholangitis in the United States include sclerosing cholangitis and recurrent pyogenic cholangitis, the latter predominantly occurring in immigrants of Asian descent. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, gastroenterologists, endoscopists, and infectious disease physicians typically involved in the care of these patients. In this paper intended for intensivists predominantly, we will review the imaging findings and radiologic interventional management of critically ill patients with acute cholangitis, primary and secondary sclerosing cholangitis, and recurrent pyogenic cholangitis.

Do HIV Care Outcomes Differ by Provider Type?

We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce. United States. We analyzed data from Center for Disease Control and Prevention's Medical Monitoring Project collected during June, 2019-May, 2021 from 6323 adults receiving HIV medical care. Provider types include infectious disease physicians only (ID physicians), non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus nurse practitioners and/or physician assistants (mixed providers). We measured patient characteristics, social determinants of health, and clinical outcomes, including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust. Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and social determinants of health associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different; however, higher percentages of patients of non-ID physicians, nurse practitioners, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had sexually transmitted infection testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively). Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, nurse practitioners, and mixed providers were more likely to be retained in care and have recommended sexually transmitted infection testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.

Evaluation of hospital-onset bacteraemia and fungaemia in the USA as a potential healthcare quality measure: a cross-sectional study

BackgroundHospital-onset bacteraemia and fungaemia (HOB) is being explored as a surveillance and quality metric. The objectives of the current study were to determine sources and preventability of HOB in hospitalised...

Unmet Needs for Ancillary Services by Provider Type Among People With Diagnosed Human Immunodeficiency Virus.

Unmet needs for ancillary services are substantial among people with human immunodeficiency virus (PWH), and provider type could influence the prevalence of unmet needs for these services. Data from a national probability sample of PWH were analyzed from the Centers for Disease Control and Prevention's Medical Monitoring Project. We analyzed 2019 data on people who had ≥1 encounter with a human immunodeficiency virus (HIV) care provider (N = 3413) and their care facilities. We assessed the proportion of needs that were unmet for individual ancillary services, overall and by HIV care provider type, including infectious disease (ID) physicians, non-ID physicians, nurse practitioners, and physician assistants. We calculated prevalence differences (PDs) with predicted marginal means to assess differences between groups. An estimated 98.2% of patients reported ≥1 need for an ancillary service, and of those 46% had ≥1 unmet need. Compared with patients of ID physicians, needs for many ancillary services were higher among patients of other provider types. However, even after adjustment, patients of non-ID physicians had lower unmet needs for dental care (adjusted PD, -5.6 [95% confidence interval {CI}, -9.9 to -1.3]), and patients of nurse practitioners had lower unmet needs for HIV case management services (adjusted PD, -5.4 [95% CI, -9.4 to -1.4]), compared with patients of ID physicians. Although needs were greater among patients of providers other than ID physicians, many of these needs may be met by existing support systems at HIV care facilities. However, additional resources may be needed to address unmet needs for dental care and HIV case management among patients of ID physicians.

Management of the Drug-Drug Interactions Between Valproic Acid and Dolutegravir-A Case Study.

Preliminary evidence shows that concomitant administration of valproic acid can reduce the exposure to dolutegravir with limited clinical impacts. Here, we describe a male living with HIV who experienced a drastic reduction in dolutegravir trough concentrations a few weeks after starting valproic acid treatment as identified by therapeutic drug monitoring. Concomitantly, pharmacists recommended a supplementation of magnesium to improve insomnia. A 62-year-old man with HIV on antiretroviral therapy with dolutegravir and lamivudine recently added valproic acid to clonazepam and sertraline to treat severe sleep disturbances. An 84% reduction in dolutegravir trough concentrations was observed compared with the previous outpatient visit (418 versus 2714 ng/mL), with values close to the minimum effective drug concentration (300 ng/mL). Considering this, we strongly discourage the use of magnesium. We are confident that our findings can contribute to a better understanding of the clinical problems that infectious disease physicians encounter in their daily management of people with HIV and how therapeutic drug monitoring may add value in this context. This case also highlights the importance of multidisciplinary services for the optimal management of polypharmacy in people with HIV.

Notes from the Field: Potential Outbreak of Extrapulmonary Mycobacterium abscessus subspecies massiliense Infections from Stem Cell Treatment Clinics in Mexico - Arizona and Colorado, 2022.

Mycobacterium abscessus is an intrinsically drug-resistant, rapidly growing, nontuberculous mycobacterium; extrapulmonary infections have been reported in association with medical tourism (1). During November-December 2022, two Colorado hospitals (hospitals A and B) treated patient A, a Colorado woman aged 30-39 years, for M. abscessus meningitis. In October 2022, she had received intrathecal donor embryonic stem cell injections in Baja California, Mexico to treat multiple sclerosis and subsequently experienced headaches and fevers, consistent with meningitis. Her cerebrospinal fluid revealed neutrophilic pleocytosis and grew M. abscessus in culture at hospital A. Hospital A's physicians consulted hospital B's infectious diseases (ID) physicians to co-manage this patient (2).

The effectiveness of intervention in hepatitis C patients and improvement in their referral rate

Background To investigate the effectiveness of the intervention with critical value management and push short messaging service (SMS), and to determine improvement in the referral rate of patients with positive hepatitis C antibody (anti-HCV). Methods No intervention was done for patients with positive anti-HCV screening results from 1 January 2015 to 31 October 2021. Patients with positive anti-HCV results at our hospital from 1 November 2021 to 31 July 2022 were informed vide critical value management and push SMS. For inpatients, a competent physician was requested to liaise with the infectious disease physician for consultation, and patients seen in the OPD (outpatient department) were asked to visit the liver disease clinic. The Chi-square correlation test, one-sided two-ratio test and linear regression were used to test the relationship between intervention and referral rate. Results A total of 638,308 cases were tested for anti-hepatitis C virus (HCV) in our hospital and 5983 of them were positive. 51.8% of the referred patients were aged 18–59 years and 10.8% were aged ≥75 years. The result of Chi-square correlation test between intervention and referral was p = .0000, p < .05. One-sided two-ratio test was performed for statistics of pre-intervention referral rate (p1) and post-intervention referral rate (p2). Normal approximation and Fisher’s exact test for the results obtained were 0.000, p < .05, and the alternative hypothesis p1 − p 2 < 0 was accepted. The linear regression equation was referral = 0.1396 × intervention + 0.3743, and the result model p = 8.79e − 09, p < .05. The model was significant, and the coefficient of intervention was 0.1396. Conclusions The interventions of critical value management and push SMS were correlated with the referral rate of patients with positive anti-HCV.

Static Versus Articulating Spacer: Does Infectious Pathogen Type Affect Treatment Success?

Treatment with a static or an articulating antibiotic-containing spacer is a common strategy for treating periprosthetic joint infection (PJI), yet many patients have persistent infections after spacer treatment. Although previous studies have compared the efficacy of a static and articulating spacer for treating PJI, few studies have assessed infection control from the time of spacer implantation, or they defined treatment failure as including reinfection, reoperation, or chronic suppressive therapy. Additionally, few studies have examined whether there is an interaction between spacer and pathogen type with respect to treatment success. (1) Is there a difference in failure-free survival (defined as no reoperation, reinfection, or suppressive antibiotic therapy) between static and articulating spacers after spacer implantation for PJI? (2) Did the relationship between spacer type and failure-free survival differ by pathogen type (staphylococcal versus nonstaphylococcal and difficult-to-treat [including methicillin-resistant Staphylococcus aureus, methicillin-susceptible S. aureus, Corynebacterium, Mycobacterium, Enterococcus spp, and other gram-negative bacterium] versus not-difficult-to-treat organisms)? Between January 2014 and January 2022, a convenience sample of 277 patients was identified as having knee PJIs treated with an articulating (75% [208 of 277]) or static (25% [69 of 277]) antibiotic spacer and potentially eligible for this study. During that time, providers at our institution generally used spacers for later-presenting or chronic infections. Spacer choice was determined by surgeon preference, with static spacers used more often in instances of higher bone loss and poor soft tissue coverage. Thirty-one patients (8 static and 23 articulating spacers) were considered lost to follow-up or had incomplete datasets and were excluded from the analysis, resulting in a final analysis cohort of 246 patients: 25% (61 of 246) received a static spacer and 75% (185 of 246) received an articulating spacer. The mean ± standard deviation age of patients was 66 ± 9.9 years, BMI was 33.3 ± 6.9 kg/m2, and Elixhauser score was 18.1 ± 16.9. Demographic and clinical characteristics were similar between the two groups. Pathogen type was collected and categorized as staphylococcal versus nonstaphylococcal, and difficult-to-treat (including methicillin-resistant Staphylococcus aureus, methicillin-susceptible S. aureus, Corynebacterium, Mycobacterium, Enterococcus spp, and other gram-negative bacterium) versus not-difficult-to-treat, as defined by an infectious disease physician. Other variables we collected included sex, age, American Society of Anesthesiologists classification, BMI, and Elixhauser score. The primary outcome of interest was failure-free survival, which was a composite time-to-event outcome, with failure defined as reoperation, reinfection, death owing to infection, or chronic antibiotic use at a minimum of 1 year after the completion of the patient's Stage 1 postoperative antibiotic course, whichever came first. Reinfection was determined by the treating physicians in accordance with the Musculoskeletal Infection Society guidelines and included an evaluation of infectious laboratory values, cultures, and clinical signs of infection. We compared static and articulating spacers using a Cox proportional hazards model, with spacer type as the primary predictor variable. We compared staphylococcal versus nonstaphylococcal and difficult-to-treat versus not-difficult-to-treat infections by running additional models with interaction terms between spacer type and pathogen type. No difference was observed in the cause-specific hazard ratio for static versus articulating (reference) spacers (HR 1.45 [95% confidence interval 0.94 to 2.22]; p = 0.09), after adjusting for covariates. Additionally, no difference in the association between spacer type and failure-free survival was found between pathogen types or treatment difficulty after evaluating interactions (staphylococcal HR 0.37 [95% CI 0.15 to 0.91], nonstaphylococcal HR 0.79 [95% CI 0.49 to 1.28]; p value for interaction = 0.14; difficult-to-treat HR 0.37 [95% CI 0.14 to 0.99], not-difficult-to-treat HR 0.75 [95% CI 0.47 to 1.20]; p value for interaction = 0.20). The lack of a difference in failure-free survival and insufficient evidence of a difference in the association between spacer type and treatment failure by pathogen type suggests that infectious organism may not be an important consideration in the decision about spacer treatment type. Further studies should aim to elucidate which patient factors are the most influential in surgeon decision-making when choosing a spacer type in patients with PJI of the knee.Level of Evidence Level III, therapeutic study.

Knowledge and perceptions of infectious disease physicians about epidemiology, causes, diagnosis, treatment and prevention of Q fever in the Republic of Kazakhstan: results of online survey

&lt;b&gt;Background:&lt;/b&gt; Q fever is a significant zoonotic infectious illness triggered by the pathogen known as &lt;i&gt;Coxiella burnetii&lt;/i&gt;, whichcauses severe symptoms when inhaled through the respiratory tract. Serious acute Q fever may cause complications as pneumonia, hepatitis or myocarditis, and some patients may develop chronic Q fever due to incomplete treatment and the topical resistance of &lt;i&gt;C.burnetii&lt;/i&gt;. This often requires surgical intervention and anti-infective treatment up to several years, seriously endangering the health of the patients and resulting in the increase of economic burdens. Poor awareness of clinicians about the disease can be one of the reasons for delay intreatment. In view of the above, a survey has been carried out to collect information on the approach of modern Kazakhstani doctorsto the problem of Q fever.&lt;br /&gt; &lt;b&gt;Methods&lt;b&gt;:&amp;nbsp;&lt;/b&gt;&lt;/b&gt;The electronic survey was conducted among infectious disease physicians from different cities of Kazakhstan, based on convenient sampling through social network platforms. Data were collected anonymously between November 14, 2022 and December 14, 2022 among infectious disease doctors. The data collection form consisted of 24 questions including demographic information, general questions about epidemiology, causes, diagnosis, treatment and prevention of Q fever. Duplicate entries were avoided and standard guidelines for reporting Internet surveys were followed.&lt;br /&gt; &lt;b&gt;Results:&amp;nbsp;&lt;/b&gt;The majority of the respondents (91.7%) considered themselves to have knowledge of information, however 80.2% of physicians showed satisfactory level of knowledge. Westudied the relationship between the proficiency level and various socio-demographic features of the respondents.&amp;nbsp; A statistically significant difference was found in relation of work experience and age (&lt;sup&gt;*&lt;/sup&gt;&lt;i&gt;P&lt;/i&gt;&amp;lt;0.05). When comparing the level of knowledge in terms of age categories, it was found that age groups 50-55 years, above 55 yearsshowed significantly more "good" results than other age groups. There were no statistically significant differences in the knowledge level of the participants according to the level of education, gender, place of residence and type of institution (&lt;i&gt;P&lt;/i&gt;&amp;gt; 0.05). According to the domains explored, the weakest knowledge was on routes of transmission (39, 32.2%), risk factors of the disease (24, 19.8%), materials used for diagnosis (33, 27.3%), prevention (53, 43.8%), outcomes and complications (33, 27.3%) of Q fever. While there werehigh indicators on the knowledge of sources of infection (87, 71.9%), about the vector (63, 52.1%) and seasonality of the disease (79, 65.3%), symptoms (63, 52.1%), differential diagnosis (73, 60.3%), diagnostic methods (91, 75.2%) and treatment (93, 76.9%).&lt;br /&gt; &lt;b&gt;Conclusions:&lt;/b&gt; According to the results of the study, the level of experience of infectious disease physicians about Q fever can be assessed as satisfactory. However, the study revealed gaps, especially among young specialists, in the awareness about transmission, risk factors, diagnosis, prevention, outcomes and complications of the disease. &lt;b&gt;We also found that the level of registration of its’ diagnosis is low due to the lack of diagnostic testing systems and poor knowledge about the disease in Kazakhstan. As a consequence, we consider it advisable to enhance the level of knowledge about Q fever among young specialists by including comprehensive information in training programs, seminars, conferences in the field of infectiology, epidemiology and public health, as well as expanding diagnostic opportunities in Kazakhstan.&lt;/b&gt;

Mapping Proximity to Infectious Disease Physicians Across the United States.

Enduring shortages of infectious disease physicians across the United States continue despite efforts to mitigate the problem. The recent fellowship match results underscore the difficulty in rectifying that shortage. Our report sheds light on the current geographic distribution of US infectious disease physicians and highlights the challenges faced by rural communities.

COVID-19 Impact on Infectious Disease Training and Residents’ Satisfaction in the Republic of Croatia

Background: The COVID-19 pandemic has caused significant changes in healthcare. Infectious disease (ID) physicians were among the most affected, yet comparisons are scarce on training implementation and the levels of residents’ satisfaction between the pre-pandemic and the pandemic era. Methods: We conducted a nationwide cross-sectional survey among Croatian ID residents between May and July 2021. The survey included 34 Likert-scale and multiple-choice questions pertaining to training rotation interruptions, educational opportunities, work hours, symptoms of burnout and overall satisfaction. Results: The survey was completed by 52 (67.5%) ID trainees in Croatia. The curriculum-defined rotations were not met in real life before the pandemic (56.8%), and 63.5% of participants reported working exclusively with COVID-19 patients more than a year into the pandemic. The pre-pandemic educational opportunities included regular lectures for 61.4%, extra-curricular training for 59.1%, congress and symposia attendances for 52.3% and peer lectures for 27.3%. As many as 11.4% had never had a meeting with their mentor, while 59.1% only met in passing. Overtime work affected 90.9% of residents before and 96.1% during the pandemic. All burnout symptoms have increased from the pre-pandemic to the pandemic era. Overall satisfaction with specialty training has dropped from an average of 3.1 (SD 0.9) before the pandemic to 1.9 (SD 0.9) during the pandemic. Conclusions: Our survey among Croatian ID residents indicated problems with educational opportunities and disruption of the planned training rotations before the pandemic. These problems were aggravated during the pandemic, thus causing a plunge in resident satisfaction levels. A closer monitoring of adherence to the training curriculum is mandated, as well as improvements in mentorship programs and burnout detection and reduction activities.

COVID-19 Impact on Infectious Disease Training and Residents’ Satisfaction in the Republic of Croatia

Background: The COVID-19 pandemic has caused significant changes in healthcare. Infectious disease (ID) physicians were among the most affected, yet comparisons are scarce on training implementation and the levels of residents’ satisfaction between the pre-pandemic and the pandemic era. Methods: We conducted a nationwide cross-sectional survey among Croatian ID residents between May and July 2021. The survey included 34 Likert-scale and multiple-choice questions pertaining to training rotation interruptions, educational opportunities, work hours, symptoms of burnout and overall satisfaction. Results: The survey was completed by 52 (67.5%) ID trainees in Croatia. The curriculum-defined rotations were not met in real life before the pandemic (56.8%), and 63.5% of participants reported working exclusively with COVID-19 patients more than a year into the pandemic. The pre-pandemic educational opportunities included regular lectures for 61.4%, extra-curricular training for 59.1%, congress and symposia attendances for 52.3% and peer lectures for 27.3%. As many as 11.4% had never had a meeting with their mentor, while 59.1% only met in passing. Overtime work affected 90.9% of residents before and 96.1% during the pandemic. All burnout symptoms have increased from the pre-pandemic to the pandemic era. Overall satisfaction with specialty training has dropped from an average of 3.1 (SD 0.9) before the pandemic to 1.9 (SD 0.9) during the pandemic. Conclusions: Our survey among Croatian ID residents indicated problems with educational opportunities and disruption of the planned training rotations before the pandemic. These problems were aggravated during the pandemic, thus causing a plunge in resident satisfaction levels. A closer monitoring of adherence to the training curriculum is mandated, as well as improvements in mentorship programs and burnout detection and reduction activities.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice. To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment. This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024. Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship. The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

Clinical Problem Solving: Management Conundrums in Tuberculous Meningitis

Tuberculosis involving the central nervous system is a treacherous disease. Resistant TB, vasculitis, raised intracranial pressure, and paradoxical response add to the problems faced by the patient. Adverse effects of drugs, interactions, and uncertainties in management mean that a multidisciplinary approach involving infectious diseases physician, neurologist, and microbiologist is needed for optimal management.

When the Trojan horse is unable to reach inside the city: investigation of the mechanism of resistance behind the first reported cefiderocol-resistant E. coli in Canada.

Gram-negative metallo-β-lactamase-producing bacteria can be extremely problematic, especially when found to be extensively drug-resistant (XDR). Cefiderocol is a novel antimicrobial that has been shown to overcome most carbapenemases, with very rare resistance reported to date. Within our institution, two multidrug-resistant and one XDR strains were isolated from a patient who recently emigrated from India. Each isolate underwent whole-genome sequencing to resolve plasmids and determine phylogenetics, strain typing, and mechanisms of resistance. The XDR E. coli was ST167, harbored NDM-5, cirA and PBP3 mutations, consistent with cefiderocol resistance. Our study suggests that the NDM region is required in conjunction with cirA and PBP3 mutations. It is not clear why; however, our study did determine a potential novel iron-transport region unique to the cefiderocol-resistant isolate. This is the first characterized cefiderocol-resistant E.coli reported from Canada. Health centers should be on alert for this clone.IMPORTANCEThe development of cefiderocol, a novel siderophore cephalosporin, has provided additional options to the treatment of extensively drug-resistant (XDR) Gram-negative bacteria. Resistance to cefiderocol is poorly understood and only recently described. Here, we describe a case of a patient with recent travel to India harboring three Escherichia coli isolates, one resistant and two susceptible to cefiderocol. Two isolates are highly similar genetically, allowing the mechanism of resistance to be described more closely. The importance of this manuscript contributes both globally to the understanding of cefiderocol resistance in E. coli as well as nationally as this is the first resistant case reported in Canada. This is especially concerning as cefiderocol is not currently approved in Canada. The implications of reporting emerging resistance to new antimicrobials for XDR Gram negatives are impactful to infectious disease specialists, clinical microbiologists, physicians, and public health.