Infectious Disease Practitioners Research Articles

New US DHHS Guidelines for Feeding of HIV Exposed Infants: Uptake, Practice Variability and Concerns

Abstract Background Approximately 5000 infants are born to mothers living with HIV annually in the US. In the past, the Center for Disease Control (CDC), American Academy of Pediatrics (AAP), and US Department of Health and Human Services (DHHS) have recommended that people living with HIV (PWH) not breast/chest feed their infants. Recent changes published in January 2023 in the “Section on Infant Feeding for Individuals Living with HIV” in the US DHHS HIV Guidelines, now include that individuals with HIV who are on antiretroviral therapy (ART) with a sustained undetectable viral load (VL) and who choose to breastfeed should be supported in this decision. We evaluated the uptake of these guidelines, and practice variability across providers who care for such mothers and infants. Methods We surveyed Pediatric Infectious Diseases Society members who practice clinically in the US, via an internal email list serve. The ten-question survey assessed uptake of the updated DHHS guidelines and respondents’ clinical practice in three key areas that are subject to interpretation in the guidelines: VL control, mixed feeding, and ART prophylaxis. We used descriptive statistics to examine guideline uptake and variability in practice. We used inductive qualitative thematic analysis to identify themes in open-ended survey responses. Results Of 915 individuals who opened the survey, 165 responded and 129 were included in the final analysis. Respondents represented 86 US clinical centers. Uptake varied: 14 respondents (10.8%) were unaware of the new guidelines, 103 (79.8%) had implemented or were planning to implement the new guidelines, and 12 (9.3%) were not planning to implement the guidelines. The table summarizes variability in pre-delivery VL suppression and mixed feeding criteria used by 117 respondents who are either planning/already implementing guidelines or who are unaware of guidelines. Areas of concern revealed by thematic analysis included insufficient data to support guidelines and lack of specific criteria for implementation. Conclusion We identified substantial heterogeneity in provider uptake and comfort with new breastfeeding guidelines among US pediatric infectious diseases practitioners, and variability in assessment of safety to breastfeed. Further research is essential to explore patient preferences, define necessary follow-up, and address provider concerns regarding insufficient data to support guidelines and lack of specific criteria for implementation.

Waning Interest in Infectious Diseases Among Trainees: Is Medicine Pulling the Goalie?

Relatively low salaries in infectious diseases (ID) compared to other medical specialties, in a world where cost of living is skyrocketing, are an easy explanation for unmet needs of ID training programs to fill their positions. However, the interest in ID falling short of expectations may reflect that some features of the ID specialty are counter to select pervasive tendencies of modern culture, including (1) slow uptake of innovation into daily routines of ID practitioners, (2) the emphasis of clinical mastery of ID practitioners in an environment of medical corporatization and increased focus on revenue generation, and (3) the fact that ID practice takes societal interests into consideration (eg, prevention of antibiotic resistance) in a world dominated by rights of individuals, frequently at the expense of the common good. This article reflects on these possibilities to determine what steps can be taken to resurrect interest in our specialty.

At the Intersection of Critical Care and Infectious Diseases: The Year in Review.

Severe infection represents a leading reason for admission to the intensive care unit (ICU) while nosocomial infection can arise as a complication of care in the ICU. The mortality and morbidity of such infections are substantial. These processes also put economic strain on the healthcare system. Additionally, the continued spread of antimicrobial resistance has made it more challenging both to prevent and treat severe infection. Until recently, there were few well-done trials addressing infection among the critically ill. However, over the last year, six important randomized studies have dealt with a range of topics at the intersection of infectious diseases and critical care. Our goal is to review these reports in order to clarify their major findings, significance, strengths, weaknesses, and clinical applications. Specifically, we explore and discuss six trials conducted in the areas of (1) prevention, (2) the present use of standard antimicrobials, and (3) novel adjunctive and antibiotic treatments. Through highlighting these trials, we hope to help clinicians apply their important findings in an evidence-based fashion at the bedside. It is through the application of key evidence that both infectious disease practitioners and intensivists can improve patient outcomes.

Oral Complications related to tropical infectious Diseases: an introduction and analysis of survey data

BackgroundsThe non-indigenous tropical infectious diseases that occur in the non-tropics arise from personnel communication between locals and visitors. Many of these infectious diseases involve oral complications. It is very important for practitioners to manage such cases based on a clear understanding of the association between tropical infectious diseases and oral health. In this study, we summarize the oral complications related to tropical infectious diseases and investigate the understanding of infectious disease practitioners in relation to the association between these conditions. In addition, we provide supportive advice to facilitate the oral management of tropical infectious diseases.MethodsFirst, we investigate the oral complications related to tropical infectious diseases by performing an appropriate literature search. Then, we analyzed the understanding of 207 Chinese practitioners specializing in infectious diseases in relation to the association between these two conditions by applying a bespoke online questionnaire.ResultsAnalysis revealed that the Chinese practitioners had very poor attitudes and knowledge relating to the association between tropical infectious diseases and oral health. Different backgrounds had no significant impact on the understanding of Chinese practitioners with regards to the association between tropical infectious diseases and oral health.ConclusionMany oral complications are related to tropical infectious diseases. The understanding of Chinese practitioners with regards to the association between infectious disease and oral health was very inadequate. It is essential to promote publicity and education relating to infectious tropical diseases and oral health.

SG-APSIC1061: First-response infection prevention and control during COVID-19 outbreaks in residential aged-care facilities

Objectives: COVID-19 has highlighted the importance of the hierarchy of controls and early implementation of transmission-based precautions during outbreaks in residential aged-care facilities (RACFs). The RACF outreach team is a service provided by the Sydney Local Health District (SLHD) that provides RACFs with expert clinical care and advice, along with outbreak management and infection control and prevention education. Methods: The RACF outreach team developed 2 unique IPC management tools designed to assist RACFs during the COVID-19 pandemic: (1) the comprehensive initial review and (2) first-responder assessment tool designed to assist the team in identifying high-risk issues during afterhours shifts. The tool reviews 5 key components in outbreak management: screening, PPE usage, resident care, communication and signage, and infection control and prevention. The outreach team provides an IPC report of the comprehensive initial review, which provides site-specific advice regarding zoning, cohorting, implementation of donning and doffing stations, safe staffing and workflows, ventilation, personal protective equipment (PPE) use, and PPE safety. The recommendations supplied in the SLHD IPC report are provided to facilities and are implemented at the facility level. These reviews are followed up in meetings of the outbreak management team conducted virtually via Zoom videoconferencing. These meetings include an RACF senior manager and a representative from the local PHU, the outreach service, the Australian Commonwealth, the Aged Care Commission, an SLHD executive manager, and an infectious diseases practitioner. Results: Since the outbreak of the SARS-CoV-2 ο (omicron) variant began in Sydney, Australia, in November 2021, 58 facilities with >2,500 residents have been reviewed, and 57 of these facilities had a COVID-19 outbreak at some point during the pandemic. Conclusions: The RACFs in SLHD continue to report death rates <5% among all SARS-COV-2–positive residents.

Awareness of the epidemiological investigation tasks of the nurse in charge of COVID-19 epidemiological investigations

Purpose: This qualitative study was to understand the awareness of epidemiological investigation tasks for nurses who were in charge of coronavirus disease 2019 (COVID-19) epidemiological investigations.Methods: Before data collection, written consent was obtained from 13 participants, and the data were then collected from September 1 to December 31, 2021. Individual interviews were conducted and recorded by video interview using Zoom, and data were transcribed verbatim. Four themes were derived by using the qualitative thematic analysis method.Results: The participants perceived that epidemiological investigations were burdensome but that the field work was important, and that expertise and collaboration were required. The participants started work without preparation due to the explosive increase in the number of confirmed COVID-19 cases, and they recognized work conflicts, unstable employment, and exhaustion as obstacles to their work performance. On the other hand, the participants took pride in contributing to the national epidemiological investigation and control and felt a sense of responsibility as nursing professionals. Finally, participants mentioned that the training of infectious disease practitioner was important for work improvement.Conclusion: Further research is needed on the development of standardized manuals for the training of nursing personnel as infectious disease specialists through the job analysis of epidemiological investigators.

A case of reactivation of chronic Epstein-Barr viral infection, complicated by hepatitis, in a teenager with COVID-19

The article presents a clinical case of reactivation of chronic Epstein-Barr viral (EBV) infection complicated by the development of hepatitis in a 15-year-old teenager with COVID-19, which is of interest to infectious disease practitioners, pediatricians and other specialists in terms of the clinical course and differential diagnosis of these two viral diseases.It is shown that the reactivation of EBV against the background of the current new coronavirus infection COVID-19, accompanied by an increase in the level of aminotransferases in the blood, leads to a more severe course and prolonged stay of the patient in the hospital, as well as the appointment of additional drug therapy with subsequent rehabilitation measures.

Syndromic Approach: The Febrile Stroke

Infectious disease practitioners are often tasked with evaluating fever in the setting of acute stroke. Although fever is often considered a host response to acute ischemia, underlying infections are identified in approximately one-fourth of cases. Physicians should be vigilant in evaluating for infectious triggers of stroke, as well as potential infectious consequences of ischemia and direct infectious invasion of the central nervous system leading to stroke.

Healthcare practitioner experiences and willingness to prescribe pre-exposure prophylaxis in the US.

Less than 10 percent of the more than one million people vulnerable to HIV are using pre-exposure prophylaxis (PrEP). Practitioners are critical to ensuring the delivery of PrEP across care settings. In this study, we target a group of prescribers focused on providing HIV care and seeking up-to-date information about HIV. We assessed their experiences prescribing PrEP, whether these experiences differed by clinical specialty, and examined associations between willingness to prescribe PrEP as a "best first step" and different hypothetical prescribing scenarios. Between March and May 2015, we circulated a paper survey to 954 participants ((652 of whom met our inclusion criteria of being independent prescribers and 519 of those (80%) responded to the survey)) at continuing medical education advanced-level HIV courses in five locations across the US on practitioner practices and preferences of PrEP. We employed multivariable logistic regression analysis for binary and collapsed ordinal outcomes. Among this highly motivated group of practitioners, only 54% reported ever prescribing PrEP. Internal medicine practitioners were 1.6 times more likely than infectious disease practitioners to have prescribed PrEP (95% CI: 0.99-2.60, p = .0524) and age, years of training, and sex were significantly associated with prescribing experience. Based on clinical vignettes describing different hypothetical prescribing scenarios, practitioners who viewed PrEP as the first clinical step for persons who inject drugs (PWID) were twice as likely to have also considered PrEP as the first clinical option for safer conception, and vice-a-versa (95% CI: 1.4-3.2, p < .001). Practitioners considering PrEP as the first preventive option for MSM were nearly six times as likely to also consider PrEP as the first clinical step for PWID, and vice-a-versa (95% CI: 2.28-13.56, p = .0002). Our findings indicate that even among a subset of HIV-focused practitioners, PrEP prescribing is not routine. This group of practitioners could be an optimal group to engage individuals that could most benefit from PrEP.

Aplicación de la secuenciación masiva y la bioinformática al diagnóstico microbiológico clínico

Massive parallel sequencing (High-Throughput Sequencing [HTS]) allows to read millions or billions of DNA sequences or fragments (reads) in parallel and is revolutionizing microbiology research, moving from laboratory methods to computed-assisted analyses, with the compelling use of Bioinformatics. The time and cost reduction in studies on the microbiota, microbiome and metagenome, allows to rapidly progress in diagnosis, taxonomy, epidemiology, comparative genomics, virulence, discovery of genes or variants of interest and the association of microorganisms with traditionally considered non-microbial diseases. In this review, the terminology, the sequencing technologies and their applications are described for microbial analysis using open-source bioinformatics software, analysis pipelines, databases and web platforms that allow a user-friendly bioinformatics approach affordable by the clinical microbiologist and infectious disease practitioners.

1091. An Ethnographic Approach to Interrogating Antimicrobial Stewardship at US Teaching Hospitals

BackgroundHospital antimicrobial stewardship programs (ASPs) deploy variably evidence-based interventions aimed at improving antimicrobial use and reducing antimicrobial resistance. Little is known about how ASPs are perceived by hospital clinicians or how such data might inform ASP improvement. We conducted an ethnographic study of hospital ASPs and infectious diseases (ID), surgical intensive care unit (SICU) and medical intensive care unit (MICU) practitioners to identify how ASPs are understood and integrated into everyday practice by hospital staff.MethodsA medical anthropologist performed direct observation of patient care and semi-structured interviews with ID (N = 29), SICU (N = 10), and MICU (N = 19) practitioners at two affiliated teaching hospitals in Chicago, IL, between July 2017 and September 2018, accruing >576 hours of direct observations and 48 hours of semi-structured interview data. Data collection and analysis centered on explicating the understandings and interpretations of ASPs present in diverse practice groups. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software.ResultsUnderstandings and interpretations of ASPs varied greatly between the practice groups. ID practitioners commonly focused on “changing prescribing behavior” and “restricting inappropriate usage,” while MICU and SICU practitioners more often emphasized “following guidelines” and maintaining clinical “balance.” Additionally, direct observation data demonstrate that MICU and SICU practitioners are bounded by social and institutional determinants of antimicrobial prescribing (Table 1) that affect the pursuit of “appropriate antimicrobial use.”ConclusionEthnographic interrogation found that practice groups understand and integrate ASPs differently according to everyday encounters with the social and institutional determinants of antimicrobial prescribing. ASP effectiveness might be enhanced by adopting a more mindful approach to accounting for and addressing the distinct understandings and interpretations of ASPs among diverse practice groups operating within the same institution. Disclosures All authors: No reported disclosures.

Laboratory Diagnosis of HIV in the Outpatient Setting: One Hospital’s Perspective

Abstract Traditional methods for the diagnosis of human immunodeficiency virus types 1 and 2 (HIV-1, HIV-2) involve initial screening by an immunoassay followed by a specific method Western blot. However, Western blot is not sensitive compared to third-generation immunoassay, which detects both IgG and IgM antibodies against viral envelope proteins causing false-positive results. In addition, neither initial screening nor confirmatory Western blot is capable of detecting acute infection earlier in the disease process, when the virus is more adaptable and highly infectious. To detect both acute and established infection, Abbott Architect platform introduced a new fourth-generation antigen/antibody initial screening assay in 2013. Also, to reduce false-negative results from Western blot, an alternate method Bio-Rad multisport immunoassay was recommended by the Centers for Disease Control and Prevention (CDC) that has higher sensitivity and can differentiate HIV-1 and HIV-2 infections. In 2014, the CDC released updated recommendations for the laboratory diagnosis of HIV. The CDC diagnostic algorithm recommends an initial combination immunoassay that detects HIV-1 and HIV-2 antibodies, followed by supplemental testing with an immunoassay that differentiates HIV-1 and HIV-2 antibodies. Specimens reactive on the initial antigen/antibody immunoassay but nonreactive or indeterminate on the differentiation immunoassay should be followed by nucleic acid testing (NAT) for resolution of this discrepancy. The objective of our study was to review the effect of this updated testing algorithm on HIV testing results in the outpatient setting at Banner University Medical Center–Tucson in Tucson, Arizona. Our study utilized laboratory information system queries to retroactively review all outpatient HIV laboratory testing results obtained from 2013 to 2017. A total of 17,397 HIV-1/2 antigen/antibody immunoassays were performed during this time period. Of the initial antigen/antibody immunoassays, 1.1% were reactive (n = 183). Of these reactive tests, 85% were collected from individuals with established HIV infections (n = 155). HIV-1/HIV-2 antibody differentiation assays were performed on 175 patients, with 86% reactive (n = 150), 2.3% indeterminate (n = 4), and 12% nonreactive (n = 21). Acute HIV-1 infections (antigen/antibody immunoassay reactive, antibody differentiation immunoassay nonreactive or indeterminate, and NAT positive) accounted for 2.7% of patients with reactive initial antigen/antibody immunoassays and 0.03% of all patients screened for HIV infection with the initial antigen/antibody immunoassay (n = 5). Viral loads in the patients with acute HIV-1 infection ranged from 173,000 to &gt;10,000,000 copies/mL. No HIV-2 infections were identified in our patient population. Given that the previous CDC testing algorithm for HIV-1 failed to identify acute HIV-1 infections, our data, which confirm the ability of the current CDC algorithm to detect HIV-1 infections, represent important information for infectious disease practitioners, public health officials, and laboratory directors.

Knowledge, attitude, and practice of health care workers towards antibiotic resistance and antimicrobial stewardship programmes: A cross-sectional study.

Antibiotic development was a major breakthrough in defeating infections; however, their vast use has led to antimicrobial resistance (AMR) causing mortality, morbidity, and financial burden worldwide. Considering the limited introduction of newer antimicrobials to overcome resistance patterns, sufficient knowledge of their use can help manage this issue. Antimicrobial stewardship programmes (ASPs) with the mainstay of education can be a good resolution. The aim of this study was to seek aspects in which knowledge regarding antibiotics is lacking at our institutions. This cross-sectional study performed in Shiraz, South of Iran, was designed as a knowledge, attitude, and practice (KAP) study. A self-administered questionnaire consisting of 15 questions was designed and handed out to health care workers including infectious disease practitioners, surgeons, internal medicine specialists and residents, general practitioners, medical students, and microbiology lab technicians and PhD graduates. Difference in response to questions was evaluated between the practitioner and nonpractitioner groups. Completed questionnaires were collected (n = 126). According to the results, most participants (88.1%) agreed on establishment of local guidelines. Majority (94.4%) also believed that education regarding antibiotics can help reduce AMR. Good patient care was not believed to be impaired by limiting use of antibiotics (72.2%). A significant difference in the practitioner and nonpractitioner groups' practice score was observed. In our study, knowledge deficit was observed in some aspects of AMR. We can conclude that more practice and education are needed in ASP for the better performance in reducing resistant patterns.

Defining the Role of Novel β-Lactam Agents That Target Carbapenem-Resistant Gram-Negative Organisms.

With the current carbapenem-resistant organism crisis, conventional approaches to optimizing pharmacokinetic-pharmacodynamic parameters are frequently inadequate, and traditional salvage agents (eg, colistin, tigecycline, etc) confer high toxicity and/or have low efficacy. However, several β-lactam agents with activity against carbapenem-resistant organisms were approved recently by the US Food and Drug Administration, and more are anticipated to be approved in the near future. The primary goal of this review is to assist infectious disease practitioners with preferentially selecting 1 agent over another when treating patients infected with a carbapenem-resistant organism. However, resistance to some of these antibiotics has already developed. Antibiotic stewardship programs can ensure that they are reserved for situations in which other options are lacking and are paramount for the survival of these agents.

The future of careers in pediatric infectious diseases: a call to action

The purpose of this review is to describe some current challenges facing the field of pediatric infectious diseases and discuss strategies for enhancing recognition of the value of infectious disease services and for recruiting new talent to the field. Pediatric infectious disease programs are currently filling approximately half of their fellowship positions, and salaries are among the lowest in medical subspecialties. Research-intensive careers in pediatric infectious diseases are threatened by low the National Institutes of Health paylines for career development awards. Despite this, there are new opportunities in pediatric infectious diseases in growing areas, such as transplant infectious diseases and antimicrobial stewardship. Pediatric infectious disease practitioners are concerned that infectious disease services are often undervalued by the healthcare system. Some of the contributions made by this cognitive specialty to overall patient outcomes are difficult to quantify and are not fully reimbursed. Strategies to enhance value and program support are needed, including sharing individual success stories and collecting data from programs nationally to generate some standards for support of pediatric infectious disease programs in areas, such as antimicrobial stewardship, transplant infectious diseases, and infection prevention. Recruitment of top talent to the field can be enhanced by a number of initiatives that can be implemented at the local level with encouragement and leadership from the pediatric infectious diseases society.

A Pilot Study to Evaluate Appropriateness of Empirical Antibiotic Use in Intensive Care Unit of King Saud Medical City, Riyadh, Saudi Arabia

Background: Antibiotics are commonly administered therapies in ICU. There has been a concern over antibiotic misuse recently. ICU is both a victim and a contributor to the ongoing antibiotic misuse problem and a cause of emerging resistance among the pathogens commonly acquired in intensive care units. Because of high mortality associated with sepsis, it is a great challenge for intensive care physicians to select appropriate antibiotic sometimes without any culture and sensitivity. Similarly the time to deescalate also remains a tough call. Selection of appropriate antibiotics empirically has always been a topic of debate among Intensive Care and Infectious Disease practitioners. Objective: The aim of our pilot study was not only to assess the appropriateness of use of antibiotics in our ICU but to help us guide to design a bigger study and structure a stewardship program for ICU; also to assess the differences among prescription of ICU and Infectious Disease Consultants. Method: A prospective observational study in King Saud Medical City ICU following antibiotics started and stopped from 6th November 2014 to 23rd November 2014. Study included 23 adult patients admitted with different etiologies. All 23 patients’ records were shared with two alien referees (one was infectious diseases and other was ICU consultant) from other hospital. Prescribers were blinded to the fact that data was being collected for auditing and the referees were blinded to prescribers and to each other’s. Results: Total 46 antibiotics were used. 40 among them were started on empirically, 6 were culture based. 31 antibiotics were stopped by ICU. 28 among these 31 antibiotics were empirical. Most of included patients responded to combination or monotherapy. Piperacillin-Tazobactam was the most commonly prescribed antibiotic. No major difference was noted among the choice of intensive care or infectious disease consultant. Conclusion: Empirical antibiotics are vital for patients admitted in ICU. We need to follow hospital's anti-biogram and stewardship programs with prompt de-escalation wherever appropriate.

3rd World Bronchiectasis Conference.

The 3rd World Bronchiectasis Conference was held at Georgetown University in Washington, D.C., on July 12-14, 2018. The meeting brought together the expertise of the U.S. Bronchiectasis Research Registry and the European Bronchiectasis Registry principal investigators, as well as experts from Canada, Asia, Australia and New Zealand. This program benefited the entire health care team who care for patients with bronchiectasis and nontuberculous mycobacterial lung infections (NTM) including pulmonologists, infectious disease physicians, pharmacists, nurses and respiratory care practitioners. This gathering of the international community of participants highlighted an authentic world bronchiectasis conference as an extension of the previous 2 World Bronchiectasis Conferences in Milan, Italy in 2017 and Hannover, Germany in 2016. The burgeoning amount of research interest, much needed development of clinical trials, and support of international collaborative work attests to progress made in the past several years awakening the new age of research and clinical work involving bronchiectasis and nontuberculous mycobacterial lung disease. With nearly 300 attendees, the conference was a focused, cutting-edge gathering of the world’s experts on bronchiectasis and NTM. Original work spanning basic science to clinical investigations were featured during the conference presentations as well as abstracts included in this publication. Highlights included recent advances in research on disease mechanisms in bronchiectasis, including new understandings on the role of inflammation, infection and the microbiome. Clinical topics included sessions on the diagnosis and treatment of bronchiectasis and NTM infections, including small group, case-based presentations specifically aimed at understanding the role of airway clearance, anti-inflammatory treatments and antibiotics. On Saturday morning, July 14th, the program focused on the management of patients with NTM lung infections. This session was well attended by pulmonologists and infectious disease practitioners who treat patients with these challenging infections. Saturday afternoon offered a halfday workshop solely focused on patients, with educational presentations featuring ways to manage their condition and learn more about bronchiectasis and NTM infections. Much appreciation is given collectively to the large number of patients, staff, clinicians, researchers, and industry partners involved in making this conference possible. Without the generous time, effort, and support provided, progress towards advancing the science and actively addressing the current gap in knowledge would not be possible. As a result of the 3rd World Bronchiectasis Conference we can look forward optimistically to the opportunities at hand for continuing this international enthusiasm and scientific inquiry, and, most importantly, positively impacting the lives of patients with bronchiectasis and NTM lung disease. NOTE: The following abstracts have NOT been copyedited but are presented here in their original format, as presented by the authors at the 3rd World Bronchiectasis Conference July 12-14, 2018.

The Microbial Self: Sensation and Sympoiesis

The Microbial SelfSensation and Sympoiesis Kyla Schuller (bio) The idea that we people are really walking assemblages,beings who have integrated various other kinds oforganisms—that each of us is a sort of loosecommittee—opens up … many challenging speculations.When "the committee" gets sick, is simply a single animalgetting sick, or is illness more a rearrangement of the members? —Lynn Margulis and Dorion Sagan, Acquiring Genomes, 19 Consider the spirochete. A long, narrow, tightly coiled bacterium featuring internal flagella bundled together in sheaths, the spirochete propels itself forward through continuous rotation. Spirochetes, in other words, are adept tiny drills, far too small to be detected by standard microscopy. They penetrate tissues of the human body that bacteria typically cannot enter and that pursuant immune leukocytes have difficulty reaching: mammalian and avian brain, bone, cartilage, and gelatinous connective tissue. They also bore through individual cell walls. Thus, once spirochetes have drilled into the body, they often remain. Emergent microbiology research suggests that spirochete infections are likely relations for the long haul, with ramifications still largely unknown. Some spirochetes have long-term symbiotic relationships with the bodies they dwell within, with effects both beneficial and disastrous. Several, such as Treponema pallidum and Borrelia burgdorferi, are notorious for their capacity to cross the mammalian blood-brain barrier, a homeostasis-ensuring endothelial layer lining blood and lymphatic vessels that protects the brain and also prevents [End Page 51] the passage of most medication into brain tissue. These bacteria result in syphilis and Lyme disease, respectively, both devastating, multisystemic illnesses. The latter is embroiled in a heated controversy: Do the ongoing, often-disabling sensory, affective, cognitive, and muscular-skeletal symptoms experienced by hundreds of thousands of Lyme patients for months and years—even after the recommended twenty-eight days of antibiotic therapy—reflect chronic infection, as patients, activists, and their Lyme-literate physicians insist? Or are these symptoms signs of a lingering postinfection inflammatory syndrome that fails to respond to further antibiotic treatment, as most infectious disease practitioners and researchers, and authorities including the Centers for Disease Control and Prevention (CDC) and Infectious Disease Society of America (IDSA), advise?1 Tens of thousands of patients are caught in these Lyme wars, a debate that enables health insurance companies to deny coverage to even the most debilitated patients beyond the recommended short courses of treatment.2 Yet the very terms of this controversy, which hinge on competing explanations of ongoing infection or noninfectious inflammatory response, are themselves stuck within an increasingly obsolete biomedical model that positions spirochetes and other so-called harmful bacteria as pathogenic intruders into the inviolate well body. The debate as typically construed in a clinical setting concerns the temporality of infection rather than the validity of the conventional infection model to which both sides ascribe. It is this biomedical model, in which the body is positioned as a discrete milieu that must be defended against external pathogens, that spirochetes most clearly destabilize.3 The individual human body is entangled in spirals with spirochetes, unfolding and enfolding in dynamic relation with the bacteria in ways that challenge conventional notions of infection, disease, and health. The late microbiologist Lynn Margulis and her lab insisted that existing research demonstrates the "irreversible integration of spirochetes at behavioral, metabolic, gene product and genetic levels into animal tissue," integration that impacts species change over time.4 Margulis's lab provocatively asks if spirochete illness is "better described as an obligate and ancient symbiosis where the bionts (spirochetes and humans) are integrated at the behavioral, metabolic and genetic level rather than a new viral [or bacterial] infection?"5 For Eva Hayward, [End Page 52] infection discourse is itself a key player in the fiction of the human subject, a discourse that paradoxically "exposes the symptom that our body has never been our own."6 The rise of the Human Microbiome Project and related investigations suggests that medical research is slowly inching toward a perspective increasingly insisted on by environmental humanities scholars and embraced by publics at large—that we live our lives fully imbricated with our environments, including microbial life-forms, which not only are interdependent with us but, more fundamentally, do not preexist as...

Can a collaborative subspecialty antimicrobial stewardship intervention have lasting effects?

We previously demonstrated the benefit of direct, daily collaboration between infectious disease (ID) and critical care practitioners (CCP) on guideline adherence and antibiotic use in the medical intensive care unit (MICU). In this post-intervention review, we sought to establish whether the effect on antibiotic use and guideline adherence was sustainable. A retrospective review of 87 patients, admitted to the 24-bed MICU, was done 3 (n=45) and 6months (n=42) after the intervention. Data included demographics, severity indicators, admitting pathology, infectious diagnosis, clinical outcomes [mechanical ventilation days (MVD) and MICU length of stay (LOS), antibiotic days of therapy (DOT), in-hospital mortality], and antibiotic appropriateness based on current guidelines. In the 3-month (3-PI) and 6-month post-intervention (6-PI), there were no significant differences in the APACHE II score, MVD, LOS, DOT, or total antibiotic use at 3 (p=0.59) and 6-PI (p=0.87). There was no change in the mean use of extended-spectrum penicillins, cephalosporin, and carbapenems. While there were significant differences in vancomycin usage at 3-PI [3.1 DOT vs. 4.3 DOT (p=0.007)], this finding was not seen after 6 months [3.1 DOT vs. 3.4 DOT (p=0.08)]. When compared to the intervention period, the inappropriateness of antibiotic use at 3 (p=1.00) and 6-PI (p=0.30) did not change significantly. There were no significant differences in either total antibiotic use or inappropriate antibiotic use at the 6-PI time period. Continuous, daily, direct collaboration between ID and CCP, once implemented, can have lasting effects even at 6months after the interaction has been discontinued.

Evaluation of the Virulence Features and Antibiotic Resistance Patterns of Pathogenic Pseudomonas aeruginosa Strains Isolated from Hospitalized Patients in Gonabad, Iran

Background: Pseudomonas aeruginosa is a ubiquitous microorganism, which is present in diverse environmental niches and is seldom a member of normal human microbiota community. P. aeruginosa is an increasingly problematic drug-resistant bacterium in today’s world. In fact, we are now faced with growing clones of pandrug-resistant P. aeruginosa in hospital settings. Objectives: The aim of the present study was to examine the antibiotic resistance patterns and presence of nan1 and int1 virulence genes (encoding neuraminidase and class 1 integrons, respectively) in clinical P. aeruginosa isolates and to analyze the measured values with regard to hospital wards, specimens, and antibiotic resistance of the strains. Methods: In this cross sectional study, strains recovered consecutively from different samples of hospitalized patients between 2014 and 2016 in Gonabad, Iran, were tested. Culture of specimens was performed on common bacteriological culture media. The isolates were recognized as P. aeroginosa, based on morphological and biochemical tests. The isolates, identified as presumptive P. aeruginosa, were further confirmed by species-specific polymerase chain reaction (PCR) to detect exoA gene. All the isolates were tested for their antimicrobial susceptibility patterns, using the standard guidelines issued by the clinical and laboratory standards institute (CLSI). Genes encoding the virulence factors (nan1 and int1) were investigated by PCR using specific primers. Results: Overall, 95 P. aeruginosa isolates were studied during the study period. The isolates were recovered from 30 (31.6%) males and 65 (68.4%) females. In total, 34 (35.5%) infected patients were in the age group of 30 - 44 years. There were 24 (25.3%) patients hospitalized in the intensive care unit (ICU). A total of 31 (32.6%) strains were isolated from the blood. Colistin was the most effective antibiotic against the isolates, and ticarcillin was the least effective antimicrobial agent. Based on the findings, 21.1% of the P. aeroginosa strains were resistant to the quinolone class of antimicrobial agents. Also, ceftazidime resistance was detected in the isolates (10.5%). Based on the results, 5.26% of the tested isolates were co-resistant to ceftazidime, amikacin, and piperacillin/tazobactam. Among 95 P. aeroginosa isolates on which PCR assay was performed, 44.2% had the nan1 gene. Conclusions: Selection of the most effective anti-Pseudomonal drug (including in vitro test and report) is a decision best made by each clinical microbiology laboratory in consultation with the infectious diseases practitioners and pharmacologists, as well as therapeutic and hospital infection control committees. The guidelines for each bacterium include antibiotics of confirmed effectiveness, which show acceptable results in antibiotic susceptibility tests