Episodes Of Infection Research Articles

Multisystem inflammatory syndrome in adult with features of Kawasaki disease

AbstractWe present a case of a 21‐year‐old woman with fever (>38.0°C) for 5 days, mucocutaneous lesions and refractory hypotension requiring dual inotropic support. The only significant past medical history was an episode of COVID infection 4 months before admission. She was diagnosed to have multisystem inflammatory syndrome in adult (MIS‐A)—a relatively new entity which occurs as a severe complication in patients post‐COVID‐19 infection. This condition can present remarkably similarly to Kawasaki disease. Although the paediatric counterpart of MIS‐A typically occurs within 2–6 weeks post COVID‐19 infection, MIS‐A may occur up to 4 months post‐COVID‐19 infection. We wish to raise awareness of this rare entity, their similarities with Kawasaki disease and the importance of early initiation of intravenous immunoglobulin and high‐dose aspirin.

P-65 A case of relapse of Graves ophthalmopathy due to an ophthalmic herpes zoster infection in a thyroidectomized patient with multiple comorbidities

Abstract Introduction Graves ophthalmopathy usually occurs in patients with hyperthyroidism or a history of Graves disease, but it can appear in euthyroid patients or patients with chronic thyroiditis also. It is a possible cause of sight-threatening eye disease. Its incidence is 16 for women and 3 cases for men, per 100 000 population but more severe in men, and it's higher among smokers. In mild forms, treatment can be local, but in severe cases and recurrences, systemic glucocorticoids are compulsory, with or without immunosuppressive drugs, surgery or radiotherapy. in recurrences. Clinical Case We present the case of a 76-year-old male, former smoker, diagnosed with Graves disease in 2017. He was treated with anti-thyroid treatment and in 2018 he was thyroidectomized. He also developed a progressive Graves ophthalmopathy from April to July 2017 with a reduced visual acuity for both eyes, conjunctival erythema, palpebral edema and erythema. He received methyl-prednisolone (MP) pulse therapy 6×125 mg weekly with favorable outcome. In 2019, he underwent a recession of internal rectus and inferior rectus for both eyes to correct a divergent strabism and his eye-sight improved. He presents now for an aggravation of the ophthalmopathy after an episode of a herpes zoster infection affecting the ophthalmic branch of the trigeminal nerve. He also suffers from heart failure NYHA III, permanent atrial fibrillation, large aortic stenosis, asymptomatic hyperuricemia, secondary pulmonary hypertension and chronic kidney disease stage IIIb. His medical history revealed hypercholesterolemia, hyperuricemia, heart failure, insufficient status of vitamin D3 and confirmed the chronic kidney disease stage IIIb; normal thyroid function but with high anti TSH receptor antibodies (TRAb=18.37 U/L). Given the age and the comorbidities but also the high activity of the Graves disease and the orbital CT that revealinged a great hypertrophy of the ocular muscles, our ophthalmologist suggested methyl-prednisolone pulse therapy in a standard regimen, but our cardiologist contradicted it because of the heart conditions. As the patient's left eye sight was only 2% and for the right one 20%, we decided to adapt the doses of the pulse therapy and closely monitor the patient. The first dose was 125mg MP, after that 7 doses of 250mg MP weekly was followed by 3 doses of 125mg MP weekly. After a total of 2250 mg MP at a 3 months follow-up, the patients’ eyesight improved to 60% on the left eye and 75% on the right eye and a lower level of TRAb=5.59 UI/L. Conclusion Even in patients with comorbidities where corticosteroid therapy may be detrimental, there is a possibility to adapt the doses in a safe way and with a continuous clinical monitoring so that the patients’ eyesight can be saved, therefore increasing the quality of life.

Infectious complications following major heart surgery from the day of the surgery to hospital discharge

BackgroundAt some point in their lives, many people will require major heart surgery (MHS). Patients are generally older adults with various risk factors for infection. However, the incidence of infection after MHS is poorly known, as reported infection data are frequently biased due to different factors like the surgical procedure, postoperative timing, and infectious syndromes or etiologic agents, among others. In addition, most patient data are retrospectively obtained.Purpose and methodsData were prospectively collected regarding the incidence of all nosocomial infections produced from the time of surgery to hospital discharge in a cohort of 800 adults consecutively undergoing a MHS procedure.ResultsDuring postoperative hospitalization, 124 of the 800 participants developed one or more infections (15.5%): during their ICU stay in 68 patients (54.8%), during their stay on the general ward post ICU in 50 (40.3%), and during their stay in both wards in 6 (4.8%). The most common infections were pneumonia (related or not to mechanical ventilation), surgical site and bloodstream. As etiological agents, 193 pathogens were isolated: mostly Gram-negative bacilli (54.4%), followed by Gram-positive bacteria (30%), viruses (4.6%) and fungi (1.5%). In our cohort, all-cause mortality was recorded in 33 participants (4.1%) and 9 infection-related deaths (1.1%) were produced. Among subjects who developed infections, overall mortality was 13.7% and in those who did not, this was only 2.3%.ConclusionInfection following MHS remains frequent and severe. Our data suggest that hospital-acquired infection studies should consider episodes of infection in all populations during their entire hospital stay and not only those related to specific clinical syndromes or acquired while the patient is in intensive care.

X-Linked Lymphoproliferative Syndrome: A Spectrum of Clinical and Immunological Profile and Novel Pathogenic Variants from Chandigarh, India

Introduction: X-linked lymphoproliferative syndrome (XLP) is a rare primary immune deficiency. Two types of XLP have been described: XLP-1 and XLP-2. Methods: We found 7 patients with XLP (3 had XLP-1 and 4 had XLP-2) after reviewing the data from Pediatric Immunodeficiency Clinic from 1997 to 2021. Results: Mean age at diagnosis was 3.8 years, and mean delay in diagnosis was 2.6 years. Five patients had recurrent episodes of infections. Four patients developed at least one episode of hemophagocytic lymphohistiocytosis (HLH) (2 with XLP-1 and 2 with XLP-2). Of these, 2 had recurrent HLH (both with XLP-2). Epstein-Barr virus (EBV) infection was detected in 2 (1 with XLP-1 and 1 with XLP-2). Both these patients had HLH. One child with XLP-2 had inflammatory bowel disease. Hypogammaglobulinemia was seen in 3 (2 with XLP-1 and 1 with XLP-2). Genetic analysis showed previously reported variants in 5, while 2 had novel variants (one in exon 7 of XIAP gene [c.1370dup p.Asn457Lysfs Ter16] and other had splice site variant in intron 1 of SH2D1A gene [c.138-2_138-1insG]). Episodes of HLH were managed with intravenous immunoglobulin (IVIg), methylprednisolone, oral prednisolone, cyclosporine, and rituximab. Inflammatory bowel disease was managed using oral prednisolone and azathioprine. One patient underwent haploidentical hematopoietic stem cell transplantation. One child with XLP-2 and WAS died because of fulminant pneumonia. Discussion/Conclusions: XLP should be considered as a strong possibility in any patient with features of HLH, repeated infections with hypogammaglobulinemia, persistent EBV infection, and early-onset IBD.

Outbreak of group B Streptococcus in a neonatal care unit confirmed by whole-genome sequencing.

Clusters of group B Streptococcus (GBS) infections in neonatal intensive care units (NICU) are poorly documented. We aimed to assess GBS cross-transmission during an outbreak of GBS sepsis. The study was carried out between October and November 2021 in a French University Hospital. Neonatal intensive care unit (NICU) patients with GBS sepsis were included. Clinical data were retrieved from electronic patient records. Group B Streptococcus isolates were characterized at the molecular level using capsular genotyping and whole-genome sequencing (WGS). The outbreak of GBS sepsis affected three very preterm neonates with a gestational age of less than 26 weeks, including one recurrent male index case aged 26 days, and two female secondary cases aged 5 and 17 days. The microbiological investigation identified a GBS isolate of capsular type III and Sequence Type 17 as responsible for the four infectious episodes. Whole-genome sequencing confirmed the identity between the isolates. The outbreak and the results of the microbiological investigations led to an immediate reinforcement of hygiene measures. Clustered cases of GBS infections in NICU and horizontal transmission of the hypervirulent GBS Sequence Type 17 are likely underestimated. Prospective investigation of all nosocomial cases using WGS should contribute to improving vigilance regarding GBS cross-transmission and infection prevention.

Chronogram: an R package for data curation and analysis of infection and vaccination cohort studies.

Observational cohort studies that track vaccine and infection responses offer real-world data to inform pandemic policy. Translating biological hypotheses, such as whether different patterns of accumulated antigenic exposures confer differing antibody responses, into analysis code can be onerous, particularly when source data is dis-aggregated. The R package chronogram introduces the class chronogram, where metadata is seamlessly aggregated with sparse infection episode, clinical and laboratory data. Each experimental modality is added sequentially, allowing the incorporation of new data, such as specialized time-consuming research assays, or their downstream analyses. Source data can be any rectangular data format, including database tables (such as structured query language databases). This supports annotations that aggregate data types/sources, for example, combining symptoms, molecular testing, and sequencing of one or more infectious episodes in a pathogen-agnostic manner. Chronogram arranges observational data to allow the translation of biological hypotheses into their corresponding code via a shared vocabulary. Chronogram is implemented R and available under an MIT licence at: https://www.github.com/FrancisCrickInstitute/chronogram; a user manual is available at: https://franciscrickinstitute.github.io/chronogram/.

Bacterial Vaginosis and Vulvovaginal Candidiasis Pathophysiologic Interrelationship.

Among the infectious causes of vulvovaginal symptoms, bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC) dominate. Apart from infrequent mixed infections, both are considered independent and caused by unrelated pathogenic mechanisms. Clinical experience, however, is strongly suggestive that in some populations these infections are linked with recurrent BV (RBV) serving as the dominant etiopathogenic trigger for development of recurrent VVC (RVVC) with profound clinical and therapeutic consequences. The biologic basis for this critical interrelationship is discussed and suggests that as a consequence of BV dysbiosis, and not necessarily because of antibiotics prescribed, immune defenses are compromised, neutralizing vaginal yeast tolerance. The consequent BV-induced vaginal proinflammatory environment predisposes to mixed infection or consecutive episodes of post-treatment VVC. Recurrent BV and repeated antimicrobial drug exposure also predispose to acquired fluconazole resistance in C. albicans isolates, contributing to refractory vulvovaginal candidiasis.

Utility of the Interferon-Gamma Enzyme-Linked Immunosorbent Spot Assay to Predict Risk of Cytomegalovirus Infection in Kidney Transplant Recipients.

Non-specific interferon-gamma (IFN-γ) enzyme-linked immunosorbent (ELISpot) responses after solid organ transplant (SOT) and their relationship with cytomegalovirus (CMV) reactivation have hardly been investigated. Adult kidney transplant (KT) recipients underwent measurement of IFN-γ-producing T cells using the ELISpot assay before and 1 month after transplantation. Data for CMV infection episodes were collected. Risk factors for post-transplant CMV infection, based on IFN-γ responses, were analyzed using a Cox proportional hazards model. A total of 93 KT recipients were enrolled in the study and 84 evaluable participants remained at 1 month post KT. Thirty-three (39%) recipients developed subsequent CMV infection within 6 months post-transplant. At 1-month post-transplant, IFN-γ-producing T cells with <250 spot-forming units (SFUs)/2.5 × 105 peripheral blood mononuclear cells (PBMCs) were significantly associated with CMV infection (HR 3.1, 95% CI 1.4-7.1, p = 0.007). On multivariable analysis, posttransplant IFN-γ-producing T cells with <250 SFUs/2.5 × 105 PBMCs remained independently associated with CMV infection (HR 3.1, 95% CI 1.2-7.8, p = 0.019). Conclusions: KT recipients with low IFN-γ-producing T cells measured by the ELISpot assay are more likely to develop CMV infection after transplantation. Therefore, measurement of nonspecific cell-mediated immunity ELISpot responses could potentially stratify recipients at risk of CMV infection (Thai Clinical Trials Registry, TCTR20210216004).

Infections in children and adolescents with Acute Leukemia

The incidence and spectrum of infections in pediatric leukemia patients vary depending on the type of leukemia. AML, which involves intensive chemotherapeutic regimes, leads to profound and prolonged neutropenia, making children more susceptible to infection. The intensity of chemotherapy, the duration of neutropenia, and antimicrobial prophylaxis implementation all affect the risk of life-threatening infections. In AML studies have shown that during intensive treatment, children experience more than one episode of infection, with majority being bacteremias. Viridans group Streptococci comprises around 20% of all isolates. Infection related deaths range from 5.4% to 7.3% during chemotherapy being more frequent on intensive phase. Invasive fungal infections (IFI) were highly associated with mortality specially caused by Aspergillus spp. In ALL induction and consolidation phases posing a higher risk for infections due to severe neutropenia. Infection related mortality in ALL is 2–4%, and infections are the main cause of treatment related deaths. IFI are significant concern with risk factors including age and treatment intensity. High risk include older children, delayed response during early induction therapy and corticosteroid administration. In summary, while survival rates for childhood leukemia have improved, the risk of infections, particularly bacterial and fungal infections, remains a significant concern, especially during intensive treatment phases. Ongoing research is needed to better understand and manage these infections in pediatric leukemia patients

Immunological characterization of an Italian PANDAS cohort.

This cross-sectional study aimed to contribute to the definition of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) pathophysiology. An extensive immunological assessment has been conducted to investigate both immune defects, potentially leading to recurrent Group A β-hemolytic Streptococcus (GABHS) infections, and immune dysregulation responsible for a systemic inflammatory state. Twenty-six PANDAS patients with relapsing-remitting course of disease and 11 controls with recurrent pharyngotonsillitis were enrolled. Each subject underwent a detailed phenotypic and immunological assessment including cytokine profile. A possible correlation of immunological parameters with clinical-anamnestic data was analyzed. No inborn errors of immunity were detected in either group, using first level immunological assessments. However, a trend toward higher TNF-alpha and IL-17 levels, and lower C3 levels, was detected in the PANDAS patients compared to the control group. Maternal autoimmune diseases were described in 53.3% of PANDAS patients and neuropsychiatric symptoms other than OCD and tics were detected in 76.9% patients. ASO titer did not differ significantly between the two groups. A possible correlation between enduring inflammation (elevated serum TNF-α and IL-17) and the persistence of neuropsychiatric symptoms in PANDAS patients beyond infectious episodes needs to be addressed. Further studies with larger cohorts would be pivotal to better define the role of TNF-α and IL-17 in PANDAS pathophysiology.

P06 The effect of ciprofloxacin prophylaxis during haematopoietic cell transplantation on infection episodes, exposure to treatment antimicrobials and antimicrobial resistance: a single-centre retrospective cohort study

Abstract Background Fluroquinolone prophylaxis during haematopoietic cell transplantation (HCT) remains contentious. Objectives To determine the effectiveness of ciprofloxacin prophylaxis across different HCT indications and its association with exposure to treatment antimicrobials and antimicrobial resistance. Methods All admission episodes for HCT (N=400) in a tertiary centre between January 2020 and December 2022 were studied. Allogeneic haematopoietic cell transplantation (allo-HCT) recipients received prophylaxis with ciprofloxacin during chemotherapy-induced neutropenia, while autologous haematopoietic cell transplantation (auto-HCT) recipients did not. Results Allo-HCT was performed for 43.3% (173/400) of patients, auto-HCT for 56.7% (227/400). Allo-HCT was associated with an average of 1.01 fewer infection episodes per 100 admission days (95% CI 0.62–1.40, P&amp;lt;0.001) compared with auto-HCT. In allo-HCT, the total exposure to all antimicrobials was higher (+24.8 days of therapy [DOT]/100 admission days, P&amp;lt;0.001), as was exposure to ciprofloxacin (+40.5 DOT/100 admission days, P&amp;lt;0.001). In contrast, exposure to meropenem (−4.5 DOT/100 admission days, P=0.02), piperacillin/tazobactam (−5.2 DOT/100 admission days, P&amp;lt;0.001), aminoglycosides (−4.5 DOT/100 admission days, P&amp;lt;0.001), glycopeptides (−6.4 DOT/100 admission days, P&amp;lt;0.001), was reduced. Enterobacteriaceae isolated during allo-HCT were more resistant to ciprofloxacin (65.5%, 19/29 versus 6.1%, 2/33, P&amp;lt;0.001), ceftriaxone (65.5%, 19/29 versus 9.1%, 3/33, P&amp;lt;0.001), and other antimicrobial classes. Vancomycin-resistant enterococci were more common in allo-HCT recipients (11%, 19/173 versus 0.9%, 2/227, P&amp;lt;0.001). Inpatient mortality during allo- and auto-HCT was 9.8% (17/173) and 0.4% (1/227) respectively (P&amp;lt;0.001). An invasive bacterial infection was documented in 31.3% (125/400) of cases. Allo-HCT patients were more likely to have an invasive Gram-positive bacterial infection (23.1% versus 12.8%, P=0.01), while a difference was not observed for invasive Gram-negative bacterial infections (19.7% versus 18.5%, P=0.77). Among auto-HSCT recipients, patients with germ cell tumours had the highest probability (P for trend 0.03) of recording an invasive bacterial infection (12/23, 52.2%, 95% CI 31.3–74) compared with other indication for auto-HCT. Conclusions Ciprofloxacin prophylaxis in allo-HCT was associated with fewer infection episodes and reduced exposure to treatment antimicrobials. Mortality in auto-HCT remained low. A significant burden of antimicrobial resistance was detected in allo-HCT recipients. HCT recipients due to germ cell tumours, not receiving ciprofloxacin prophylaxis, recorded the highest incidence of invasive bacterial infections and represent a possible target group for this intervention.

Economic burden of infectious diseases and its equity implications in Indian households: Estimates from a nationally representative household survey (2017–18)

Infectious diseases remain one of the major causes of health and economic burden for Indian households. Furthermore, the magnitude of economic losses on account of infectious disease episodes varies widely across rich and poor households. The primary objective of this research is to estimate the equity impact of infectious disease episodes on out-of-pocket expenditure (OOPE) and wage losses among Indian households. We analysed the Social Consumption: Health (SCH) data from the 75th round (2017–18) of India's National Sample Survey (NSSO). The sample included approximately 113,823 households and 555,352 individuals through a multistage stratified sampling process. We report i) the prevalence of infectious disease and healthcare utilisation rate by levels of care; ii) medical and non-medical OOPE per episode; iii) OOPE and wage loss as a share of households' monthly non-medical consumption expenditure (non-medical MPCE) across wealth quintiles. We adopted a microeconomic cost of illness approach to estimate the OOPE on infectious disease episodes for outpatient care and hospitalization. We also estimated potential wage losses due to a reduction in effective labour supply at the household level because of infectious disease using a production function approach. The overall prevalence of infectious diseases and hospitalization rate were 31 and 9 per thousand persons, respectively. Per capita medical OOPE was more in higher wealth quintiles for outpatient care and hospitalization. However, OOPE as a share of non-medical MPCE was higher in the poorest 20% households (outpatient: 14%; hospitalization: 153%) in comparison to the richest 20% households (outpatient: 5.5%; hospitalization: 96%). Similarly, the wage losses as a share of non-medical MPCE were higher among the poorest 20% households (outpatient: 21%; hospitalization:38%) in comparison to the richest 20% households (outpatient: 15%; hospitalization:11%). Furthermore, the proportion of households reporting the sale of assets and borrowing to finance hospitalization was higher in the poorest (24%) compared to the richest (12.5%). To our knowledge, this is the first paper which contributes to developing an understanding of the equity impact of infectious disease on households in India. We recommend improved targeting and coverage of publicly funded health insurance schemes among socially disadvantaged populations.

Diffusion-weighted MRI in the identification of renal parenchymal involvement in children with a first episode of febrile urinary tract infection.

This study aims to assess the diagnostic accuracy of diffusion-weighted Magnetic Resonance Imaging (DW-MRI) and determine the inter-reader agreement between two expert radiologists in detecting pyelonephritic foci during the initial episode of febrile urinary tract infection (fUTI) in children aged 0-5 years. Also, we aim to establish the correlation between clinical data and DW-MRI findings. Children aged 0-5 years presenting with their first episode of fUTI were included in the study and underwent DW-MRI and Ultrasound (US) examinations within 72 h of admission. Inter-observer agreement between the two expert radiologists in assessing DW-MRI scans was evaluated using Cohen's kappa statistic. Clinical and laboratory data were subjected to statistical analysis. 84 children (40 male, 44 female) with a mean age of 7.3 (SD 6.2) months were enrolled. DW-MRI detected pyelonephritis in 78 out of 84 cases (92.9%), with multiple foci observed in 73 out of 78 cases (93.6%). There was a "substantial" level of agreement between the two expert radiologists (κ = 0.725; observed agreement 95.2%). Renal US revealed pyelonephritis in 36 out of 78 cases (46.2%). White blood cell (WBC) count (p = 0.04) and lymphocyte count (p = 0.01) were significantly higher in patients with positive DW-MRI. Although not statistically significant, patients with positive DW-MRI had higher mean values of C-Reactive Protein, Procalcitonin, and neutrophil WBC count (7.72 mg/dl, 4.25 ng/dl, and 9,271 /μl, respectively). DW-MRI exhibited excellent diagnostic performance in detecting pyelonephritic foci, with substantial inter-reader agreement among expert radiologists, indicating the reliability of the technique. However, a weak correlation was observed between laboratory parameters and DW-MRI results, potentially because of the low rate of negative DW-MRI findings.

What is the annual risk of infection in congenital midline neck cysts in children? Thyroglossal duct cysts versus dermoid cysts

IntroductionMidline neck lumps in children are mostly found to be thyroglossal duct cysts or dermoid cysts. Thyroglossal duct cysts often have an associated sinus tract which may connect all the way to the foramen caecum on the tongue, while dermoids have no such connection. This study aims to estimate the annual infection risk for midline neck cysts based on our patient series, and to see if this differs between thyroglossal duct cysts and dermoid cysts. MethodsAll children seen at the Royal Hospital for Children, Glasgow who underwent surgical excision of a midline neck cyst between 1st January 2017 and 31st December 2021 were identified. In those whose cyst had been infected prior to surgical excision, the age at which the first episode of infection occurred was recorded and used to calculate a survival curve. ResultsWe identified 53 children (29 male, 24 female) aged 1–16 years (median 4) at the time of surgical excision. There were 26 thyroglossal and 24 dermoid cysts, plus 2 with indeterminate histology and 1 lymph node. Of the 24 dermoids, 4 suffered infection prior to surgery (17%), and 2 of these recurred after surgery (8%). Of the 26 thyroglossal cysts, 16 suffered infection prior to surgery (62%) and 5 of these recurred (19%). 78% of thyroglossal and dermoid cysts had at least 1 episode of infection by age 10 years. DiscussionIn a child with a congenital midline neck cyst that has never been infected, deferring surgery for a year comes with a 7.8% risk that the cyst will get infected.

Microbiology and Antimicrobial Resistance Profile of Infectious Peritonitis: A Cohort Study with 10-year Follow-up

Abstract Objectives: Peritoneal dialysis (PD) is a feasible option for patients with renal failure, but infectious peritonitis has long been a common complication in PD. The purpose of the current study was to provide epidemiological data about the rate, microbiology profile, and antimicrobial susceptibility pattern of infectious peritonitis in adult PD patients in Saudi Arabia. Materials and Methods: A descriptive study was performed. Demographics and diagnostic data of adult PD patients between 2009 and 2019 were collected. The infectious peritonitis episodes were explained per patient and the microbiology profile along with antimicrobial susceptibility testing results were analyzed. Results: One hundred renal failure adult patients underwent PD during 2009–2019, with 55.0% were female. Ninety-three infectious peritonitis episodes were identified in 52 patients and the overall peritonitis rate was 0.56 episodes per patient-year. Gram-positive bacteria were more responsible (61.3%) for infectious peritonitis than Gram-negative bacteria (37.6%) and expressed more antimicrobial resistance patterns. Coagulase-negative Staphylococci were the most frequently isolated Gram-positive bacteria from the PD fluid culture (27.9%). Acinetobacter baumannii, followed by Pseudomonas luteola, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most common Gram-negative bacteria identified at 6.5%, 5.4%, 5.4%, and 5.4%, respectively, with susceptibility patterns detected against most of the antimicrobials tested. Conclusions: The overall rate of infectious peritonitis was 0.56 episodes per patient-year, which is higher than the reported target published by the International Society for PD. More intense training programs and establishment of a national infectious peritonitis registry are recommended to minimize infection risk and improve patients’ quality of life.

A search for bacteria identified from cerebrospinal fluid shunt infections in previous surgical events.

Shunt infections are a common complication when treating hydrocephalus by cerebrospinal fluid (CSF) shunt placement. The source of infecting pathogens is not well understood. One hypothesis, which we explored here, is that microorganisms persist chronically in the host long before a symptomatic infection occurs and may be detectable in surgical events preceding infection. A cohort of 13 patients was selected, for which CSF samples were available from an infection episode and from a previous surgery event, which was either an initial shunt placement or a revision. Microbiota were analyzed both directly from CSF and from isolates cultured from CSF on aerobic and anaerobic media. The detection and identification of bacteria was done with high throughput DNA sequencing methods and mass spectrometry. The presence of bacteria was confirmed in 4 infection samples, of which 2 were after initial placement and 2 after revision surgery. Taxonomic identification was consistent with clinical microbiology laboratory results. Bacteria were not detected in any of the CSF samples collected at the time of the previous surgical events. While our findings do not provide direct evidence for long-term persistence of pathogens, they suggest the need for consideration of additional source material, such as biofilm and environmental swabs, and/or the use of more sensitive and specific analytical methods.

The impact of hospital-specific guidelines on carbapenem use and patient outcomes in a setting for high endemicity with multidrug-resistant gram-negative bacilli

Abstract Objective: This study aims to assess the impact of hospital-specific guidelines on the optimal utilization of carbapenems and to examine their effects on patient outcomes. Design: Quasi-experimental study. Setting: Tertiary care hospital in Turkey where infectious diseases (IDs) consultation and antibiotic approval are mandatory for carbapenem use. Participants: All inpatients ≥18 years of age who received a carbapenem for at least 24 hours during the study periods were enrolled. Intervention: Hospital-specific treatment guidelines were introduced in April 2019. The control group was the year 2018, when there were no guidelines (pre-GP). The year 2020 was analyzed as the intervention period (post-GP). Results: A total of 678 patients were analyzed, 326 in the pre-GP period and 352 in the post-GP period. Following guideline implementation, there was a significant increase in appropriate carbapenem use (49.1% in pre-GP vs 71.9% in post-GP, P &lt; .001). The duration of carbapenem use decreased significantly (P = .019). However, there was no significant change in the incidence of new infection episodes within the subsequent 30 days (27.6% in pre-GP vs 28.3% in post-GP), or in the length of hospitalization [median (25%–75%) = 28 (16–46) in pre-GP, 28 (15–47.5) in post-GP, P = .678]. Mortality rates were similar at day 7 post-GP (1.7%) compared to pre-GP (0.03%) (P = .125). Conclusions: The implementation of guidelines increased the appropriate utilization of carbapenems, without resulting in extended hospital stays or recurrent episodes. Despite an increased number of patients admitted to the ICU during the latter period, infection-related mortality rates remained comparable.

Two young adults presenting with breathlessness and recurrent chest infection: a major miss!!!

Dyspnea is of multi-factorial etiology, and in young adults, obstructive airway disease is the commonest cause. We are reporting two cases of young adults who presented with breathlessness and recurrent episodes of respiratory tract infections since childhood associated with poor physical development. They were referred to our hospital for an evaluation of suspected lung collapse. The evaluation revealed it to be an unusual case of right lung hypoplasia presenting in the second decade, and which was not associated with any other systemic anomaly in the first case, while the second case was diagnosed as a case of left pulmonary aplasia with right tracheal bronchus and double SVC drainage. The treating physicians should have a high clinical suspicion about developmental pulmonary disorders while treating young patients with recurrent episodes of pneumonia.

Effects of COVID-19 Pandemic in Patients with a Previous Phrenic Nerve Transfer for a Traumatic Brachial Plexus Palsy.

Background With the advent of the coronavirus disease 2019 (COVID-19) pandemic, some doubts have been raised regarding the potential respiratory problems that patients who previously underwent a phrenic nerve transfer could have. Objectives To analyze the effects of the coronavirus infection on two populations, one from Argentina and another from Taiwan. Specific objectives were: (1) to identify the rate of COVID in patients with a history of phrenic nerve transfer for treatment of palsy; (2) to identify the overall symptom profile; (3) to compare Argentinian versus Taiwanese populations; and (4) to determine if any phrenic nerve transfer patients are at particular risk of more severe COVID. Methods A telephonic survey that included data regarding the number of episodes of acute COVID-19 infection, the symptoms it caused, the presence or absence of potential or life-threatening complications, and the status of COVID-19 vaccination were studied. Intergroup comparisons were conducted using the nonparametric Mann-Whitney U test, with categorical variables conducted using either the Pearson χ2 analysis or the Fisher's exact test, as appropriate. Results A total of 77 patients completed the survey, 40 from Taiwan and 37 from Argentina. Fifty-five (71.4%) developed a diagnosis of COVID. However, among these, only four had any level of dyspnea reported (4/55 = 7.3%), all mild. There were also no admissions to hospital or an intensive care unit, no intubations, and no deaths. All 55 patients isolated themselves at home. Conclusions It can be concluded that an acute COVID-19 infection was very well tolerated in our patients. (Level of evidence 3b, case reports).

Determination of COVID-19 Late Disorders as Possible Long-COVID and/or Vaccination Consequences.

In this era in which the vast majority of the global population have developed COVID-19 infection and/or got vaccinated against it, identification of the late disorders as the vaccines' side effect or long-COVID manifestation seems essential. This study included the vaccinated individuals of 4 different vaccine regimens including inactivated virus-based, subunit protein, and adenovirus-based vaccines in a follow-up schedule 6-month post the booster shot. All the documented vaccine adverse events were thoroughly assessed considering the cases' medical history by Adverse Events Committee of Pasteur Institute of Iran. Totally 329 individuals who got 3 doses of vaccination were followed 6 months after the booster shots among whom 41 (12.4%) cases with the mean age of 40.9 ± 10.48 years had a type of disorder. Gynecological and osteoarticular involvements were the most common recorded disorders of which 73.1% were possibly linked to vaccination outcomes and the rest were affected by both long-COVID-19 and vaccination. Notably, the average time of symptoms persistence was 155 ± 10.4 days. This study has the advantage of long-term follow-up which presents various forms of late events in each episode of COVID-19 infection and vaccination. About 26.8% of people with persistent complications suffered from both long-COVOD/ vaccination in whom the differentiation between the vaccine side effect and long-COVID manifestation was quite challenging. Long-term follow-up studies in large population seems essential to outline the role of long-COVID and vaccination regarding persistent complications.