Risk Of Recurrent Infection Research Articles

Knowledge, attitudes, and practices status among caregivers of infants and toddlers towards hand, foot and mouth disease: a cross-sectional study

BackgroundHand, foot and mouth disease (HFMD) is a common infectious disease in children, and caregivers’ awareness of the disease is key to reducing its incidence. This study aims to investigate the Knowledge, Attitude, and Practice (KAP) levels of caregivers in Guangzhou regarding HFMD and to analyze the association of their demographic characteristics and family situations.MethodsThis cross-sectional study used face-to-face interviews with caregivers of infants and toddlers to assess their KAP status regarding HFMD through a structured questionnaire. The dependent variables were the scores for KAP, while independent variables included caregivers’ demographic characteristics, household size, etc. Univariate analysis was performed initially to identify potential predictors, and variables with a P-value ≤ 0.10 were included in the multivariate logistic regression model. Adjusted odds ratios and 95% confidence intervals were calculated to determine the strength of associations, with statistical significance set at P ≤ 0.05.ResultsA total of 1,094 survey responses were included. Among the primary caregivers, 655 (59.87%) were mothers, 411 (37.57%) had a college degree or higher, and 298 (27.24%) were homemakers or unemployed. The scores for knowledge, attitude, and behavior were 5.6 ± 1.5 (range 0–8), 18.88 ± 3.44 (range 6–30), and 31.91 ± 4.14 (range 8–40). Caregivers show a relatively low level of concern regarding isolation measures and the risk of recurrent infections. The caregivers identity, age, education level, household size, number of children in childcare, place of residence, and history of illness were significantly associated with KAP levels.ConclusionThe primary caregivers generally exhibit good levels of knowledge and practices regarding HFMD, but the level of attitude is relatively low. Health promotion activities should be strengthened for caregivers who are elderly or have lower education levels, as well as for families with fewer permanent residents or those living in sub-central urban areas.

Staphylococcus aureus bacteraemia, cardiac implantable electronic device, extraction, and the risk of recurrent infection; a retrospective population-based cohort study

Background Patients with cardiac implantable electronic device (CIED) and Staphylococcus aureus bacteraemia (SAB) are at risk of having CIED infection, pocket infection or endocarditis. To avoid treatment failures, guidelines recommend that the CIED should be extracted in all cases of SAB butrecent studies indicate low extraction rates and low risk of relapse. The aim of the study was to describe a Swedish population-based cohort of patients with CIED and SAB, the rate of extraction, and treatment failure measured as recurrent SAB. Methods Patients identified to have SAB in the Karolinska Laboratory database, serving a population of 1.9 million, from January 2015 through December 2019 were matched to the Swedish ICD and Pacemaker Registry. Patients with CIED and SAB were included. Clinical data were collected from medical records. Results A cohort of 274 patients was identified and 38 patients (14%)had the CIED extracted. Factors associated with extraction were lower age, lower Charlson comorbidity index, shorter time since CIED implantation, and non-nosocomial acquisition, but not mortality. No patient was put on lifelong antibiotic treatment. Sixteen patients (6%) had a recurrent SAB within one year, two in patients subjected to extraction (5%) and 14 in patients not subjected to CIED-extraction (6%). Three of the 14 patients were found to have definite endocarditis during the recurrent episode. Conclusions Despite a low extraction rate, there were few recurrences. We suggest that extraction of the CIED might be omitted if pocket infection, changes on the CIED, or definite endocarditis are not detected.

High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution’s experience

Despite 2 stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with two stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. We retrospectively analyzed all two stage revision TEAs performed for infection at a single institution between 2006 and 2020. Data collected included demographics, and treatment course prior to, during and after 2 stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second stage revision. Risk factors for both outcomes were determined. Nineteen patients were included. Seven (37%) patients had either the humeral or ulnar component retained during the 1st stage and ten (53%) had incomplete removal of cement in either the humerus or ulna. Nine (47%) patients had allograft strut used during reimplantation and reconstruction. Nine (47%) patients failed to eradicate the infection after 2 stage revision. Demographic data was similar between the repeat infection and non-repeat infection groups. Six patients (60%) with retained cement failed compared to three patients (33%) with full cement removal (p=0.370). Two patients (29%) with a retained component failed compared to seven patients (58%) with full component removal (p=0.350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to nine with complete component removal (p=0.003). Three (30%) patients with retained cement needed allograft, compared to six (67%) patients who had complete cement removal (p=0.179). Nearly half of the patients failed to eradicate infection after 2 stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Analyzing Treatment Patterns and Clinical Outcomes within the First 24 Hours of Hospitalization in Patients with Sickle Cell Disease and Infection: Evidence from a Retrospective Cohort Study

Introduction: Sickle Cell Disease (SCD) is a deadly, painful set of genetic abnormalities primarily affecting patients of African and Mediterranean descent. Although the hallmark symptom of SCD is pain, it is a multi-system disease that results in an amalgam of severe and life-threatening health consequences including increased susceptibility to bacterial, viral, and fungal infections. Infection remains the leading cause of morbidity and mortality in individuals diagnosed with SCD. We identified no research focused on the treatment patterns of antibiotic utilization in adults with SCD. This dearth of literature specific to SCD is surprising since the first 24 hours of antibiotic treatment in patients with SCD, especially those at risk for recurrent infection could reduce life threatening complications, length of hospital stay, and overall healthcare expenditures. A standardized protocol for treatment of infections in SCD does not exist and the first 24 hours of treatment varies among physicians and institutions. Treatment plans are determined by consensus guidelines, clinical experience and modifying treatment practices that have have shown promise in other diseases. The purpose of this study is to analyze treatment patterns within the first 24 hours of hospitalization in patients with SCD and infection to identify major factors influencing outcomes and clinical management. Methods: We conducted a retrospective cohort study using electronic health records from hospitalizations with a documented infection in North-Central Florida. Encounters from patients with sickle cell disease (SCD) were identified using ICD codes (ICD-9 codes: 282.41, 282.42, 282.61, 282.62, 282.63, 282.64, 282.68, 282.69). Demographics, comorbid conditions, empiric antibiotic use, causative infectious organism, and the presenting infectious syndrome were extracted from EHR for each hospitalization. Outcomes of interest were length of hospitalization and 90-day all-cause mortality. Patients with no listed comorbid conditions at the time of hospital admission were excluded. Patient characteristics and clinical factors between groups were summarized descriptively and compared between SCD encounters. Results: Among approximately 140,000 eligible encounters, 988 (0.71%) encounters were from those with SCD and of those 837 were included in the analysis: Median Age: 47 y/o Sex: Female 583 (69.7%) Male: 254 (30.3%) 209 (0.25%) had an infection fromE. coli and (12.4%) had an infection from staphylococcus aureus. 332 (39.7%) of hospital admissions were secondary to genitourinary infections Vancomycin (28.7) was the most frequently used antibiotic within the first 24 hours of admission More than half (67.4%) of patients had chronic pulmonary disease The median length of stay during our study period was 7 days 12.1% of encounters required intensive care unit hospitalization 90 Day All-Cause Mortality was 5.5% Results: We examined the key comorbid conditions and factors that influence the hospitalization and their outcomes in SCD Future studies are needed to examine the key factors resulting in an increased risk of infection among SCD genotypes and the treatment patterns within the first 24 hours of treatment in patients with SCD and non-SCD to identify major factors influencing differences in outcomes and clinical management. . Machine learning approaches could aid in stratifying patients to direct more intensive interventions towards high-risk groups to improve the health outcomes of patients with SCD

Long-term SARS-CoV-2 neutralizing antibody level prediction using multimodal deep learning: A prospective cohort study on longitudinal data in Wuhan, China.

The ongoing epidemic of SARS-CoV-2 is taking a substantial financial and health toll on people worldwide. Assessing the level and duration of SARS-CoV-2 neutralizing antibody (Nab) would provide key information for government to make sound healthcare policies. Assessed at 3-, 6-, 12-, and 18-month postdischarge, we described the temporal change of IgG levels in 450 individuals with moderate to critical COVID-19 infection. Moreover, a data imputation framework combined with a novel deep learning model was implemented to predict the long-term Nab and IgG levels in these patients. Demographic characteristics, inspection reports, and CT scans during hospitalization were used in this model. Interpretability of the model was further validated with Shapely Additive exPlanation (SHAP) and Gradient-weighted Class Activation Mapping (GradCAM). IgG levels peaked at 3 months and remained stable in 12 months postdischarge, followed by a significant decline in 18 months postdischarge. However, the Nab levels declined from 6 months postdischarge. By training on the cohort of 450 patients, our long-term antibody prediction (LTAP) model could predict long-term IgG levels with relatively high area under the receiver operating characteristic curve (AUC), accuracy, precision, recall, and F1-score, which far exceeds the performance achievable by commonly used models. Several prognostic factors including FDP levels, the percentages of T cells, B cells and natural killer cells, older age, sex, underlying diseases, and so forth, served as important indicators for IgG prediction. Based on these top 15 prognostic factors identified in IgG prediction, a simplified LTAP model for Nab level prediction was established and achieved an AUC of 0.828, which was 8.9% higher than MLP and 6.6% higher than LSTM. The close correlation between IgG and Nab levels making it possible to predict long-term Nab levels based on the factors selected by our LTAP model. Furthermore, our model identified that coagulation disorders and excessive immune response, which indicate disease severity, are closely related to the production of IgG and Nab. This universal model can be used as routine discharge tests to identify virus-infected individuals at risk for recurrent infection and determine the optimal timing of vaccination for general populations.

Design Considerations, Formulation Approaches, and Strategic Advances of Hydrogel Dressings for Chronic Wound Management.

Wound healing is a complex and dynamic physiological process consisting of a series of cellular and molecular events that initiate immediately after a tissue lesion, to reconstruct the skin layer. It is indubitable that patients with chronic wounds, severely infected wounds, or any metabolic disorder of the wound microenvironment always endure severe pain and discomfort that affect their quality of life. It is essential to treat chronic wounds for conserving the physical as well as mental well-being of affected patients and for convalescing to improve their quality of life. For supporting and augmenting the healing process, the selection of pertinent wound dressing is essential. A substantial reduction in healing duration, disability, associated cost, and risk of recurrent infections can be achieved via engineering wound dressings. Hydrogels play a leading role in the path of engineering ideal wound dressings. Hydrogels, comprising water to a large extent, providing a moist environment, being comfortable to patients, and having biocompatible and biodegradable properties, have found their success as suitable wound dressings in the market. The exploitation of hydrogels is increasing perpetually after substantiation of their broader therapeutic actions owing to their resemblance to dermal tissues, their capability to stimulate partial skin regeneration, and their ability to incorporate therapeutic moieties promoting wound healing. This review entails properties of hydrogel supporting wound healing, types of hydrogels, cross-linking mechanisms, design considerations, and formulation strategies of hydrogel engineering. Various categories of hydrogel wound dressing fabricated recently are discussed based on their gel network composition, degradability, and physical and chemical cross-linking mechanisms, which provide an outlook regarding the importance of tailoring the physicochemical properties of hydrogels. The examples of marketed hydrogel wound dressings are also incorporated along with the future perspectives and challenges associated with them.

PET PEEVE: DYSPNEA FROM UNDIAGNOSED PASTEURELLA MULTOCIDA EMPYEMA

PET PEEVE: DYSPNEA FROM UNDIAGNOSED PASTEURELLA MULTOCIDA EMPYEMA

Clinical and epidemiological investigation of a child with asymptomatic COVID-19 infection following reoccurrence

ObjectiveTo investigate the case of a child infected with coronavirus disease 2019 (COVID-19) who had subsequent viral reactivation.MethodsWe retrospectively analyzed the clinical manifestations, epidemiological data, laboratory and imaging examinations, treatment, and follow-up of the child. And then, we searched related literature using PubMed.ResultsThe 9-year-old boy was exposed to COVID-19 in Malawi and tested positive for NAT in Haikou, China. He was asymptomatic and admitted to our hospital. After six negative NATs, he was discharged from the hospital and quarantined in a hotel. His infection was reactivated again after 22 days (interval between first and last positive NATs). The cycle threshold (Ct) values of positive tests were 25 and 31, and the gene sequencing viral loads were very low. The viral strain Kenya/P2601/2020, a variant of the hCoV-19/Wuhan/IVDC-HB-01/2019 genome (GISAID accession IL: EPI_ISL_402119), was found when polymerase chain reaction enrichment was used to sequence the virus. However, people around him tested negative for COVID-19.ConclusionFirst, we confirmed the reactivation of COVID-19 in a child. The risk of recurrent infection with SARS-CoV-2 was low, and the policy of strictly isolating patients carrying long-term viral ribonucleic acid should be reconsidered. The interval positivity was most likely due to incorrect sampling and/or testing methods. SGS and aB testing are recommended for children with viral reactivation. Second, SARS-CoV-2 viral reactivation cannot be ruled out. The possible mechanisms, such as prolonged infection and viral latent reactivation, need further investigation.

Yaws recurrence in children at continued risk of infection.

In yaws-endemic areas, children with Treponema pallidum subsp. pertenue infection may suffer recurrent episodes due to either reinfection or relapse. However, the possibility of infection with other cutaneous ulcer causative agents and difficulties in interpreting standard laboratory results challenges the estimation of yaws recurrence rates. We estimated the rates of yaws recurrences in the Lihir Island (Papua New Guinea) using two approaches: passive surveillance based on a retrospective screening of electronic medical records of cutaneous ulcers diagnosed using serological testing between 2005 and 2016, and active surveillance conducted during a cross-sectional prevalence study which included PCR analyses of ulcers of all suspected cases of yaws. The risk of recurrent infection was assessed based on data from the passive surveillance analysis and using two Cox regression models (crude and multivariate), stratified by year of index episode. Data gathered from the active surveillance was used to characterize the recurrences and no hypothesis testing was performed. The electronic medical records included 6,125 patients (7,889 ulcer episodes) with documented serological results of cutaneous ulcers of which1,486 were diagnosed with yaws. Overall, 1,246/6,125 patients (20.3%) presented more than once with a cutaneous ulcer, and 103/1,486 (6.7%) patients had multiple episodes of yaws. The risk of yaws recurrence significantly increased with age and was higher in patients with ≥3 recurrent episodes. In the active surveillance, we identified 50 individuals with recurrent cutaneous ulcer that had PCR results available for both the index and recurrent episode. Of 12 individuals with T. pallidum in the index ulcer, 8 (66%) had T. pallidum in subsequent assessments, relapse related to macrolide-resistance was identified in two of these cases. Our results confirm the need for active follow-up of yaws patients after treatment, particularly children and individuals with a history of recurrence.

Risk of Instability After Revision Total Knee Arthroplasty for Periprosthetic Joint Infection.

Periprosthetic joint infection (PJI) remains a major source of morbidity after total knee arthroplasty (TKA). The risk of recurrent infection has been more extensively studied than the risk of mechanical failure. We sought to define the incidence of instability after revision TKA for PJI and to compare this incidence with that for revision TKA for instability. We retrospectively reviewed patients treated by 4 arthroplasty surgeons at 1 institution. The primary outcome was a new diagnosis of clinical instability after index revision. We analyzed potential risk factors that may contribute to postoperative instability after PJI, including demographic characteristics, implant alignment, number of previous procedures, level of constraint during index revision, and type of spacer used. Patients were matched 1:1 with patients undergoing revision TKA for instability. Continuous variables were compared with Student's t test for normally distributed variables and Mann-Whitney U test for non-normal variables. Categorical variables were compared with Fisher's exact test. Thirty-seven patients who underwent revision TKA for PJI were identified. Twelve (32.4%) had clinical instability after revision, compared with only 3 (8.1%) in the matched cohort (P=.019). Use of a revision, midlevel constraint device in the PJI cohort did not correlate with a lower risk of instability (P=.445). A greater number of previous surgical procedures increased the likelihood of instability (P=.041). Revision TKA for PJI is associated with a high risk of subsequent instability. Midlevel constrained implants may not be sufficient to prevent instability. A focus on soft tissue tension and a lower threshold for increasing constraint may be prudent in this cohort. [Orthopedics. 2022;45(3):145-150.].

Trends in Infectious Diseases: A Retrospective 5-Year Study

Background: Although hospital admission is frequently due to the exacerbation of chronic diseases, most often it is caused by an underlying infectious process. Patients often have several admissions per year, making them at risk for recurrent infections, increased morbidity, and the emergence of resistant strains of microorganisms. Methods: This is a retrospective, descriptive study of all patients with an infectious disease diagnosis, who were admitted to the medical ward of a tertiary hospital during a 5-year period. Information was collected from electronic medical files regarding gender, age, autonomy, comorbidities, primary diagnosis, in-hospital length of stay, and mortality as well as microbiological data surveillance. Results: A total of 355 patients fulfilled the inclusion criteria. Amongst the sample analysed, the average age was 78.10+12.47 years years. Of the patients, 57.2% (203) were female, with most patients considered as dependent according to Katz score. The average Charlson Comorbidity Index (CCI) score was 6.28+2.74, increasing with age. The main diagnostic categories were respiratory (191 patients: 137 with pneumonia and 49 with acute bronchitis) and urinary tract (138 patients: 69 with pyelonephritis and 66 with cystitis). Urinary tract infections were more frequent in females and in dependent patients. Only 37.8% of infections had a microbiologic isolate: Escherichia coli (28.4%), Pseudomonas aeruginosa (12.7%), and Klebsiella pneumoniae (8.2%). The overall mortality was 6.77%. Conclusions: The frequent in-hospital admission due to infectious diseases makes it imperative to characterise and follow-up on evolution of the disease itself in order to better know the characteristics of community-acquired diseases, establish routes of transmission and outbreak identification, microbiology patterns, and resistance towards further improving empiric therapy.

Trends in Infectious Diseases: A Retrospective 5-year Study

Background: Although hospital admission is frequently due to the exacerbation of chronic diseases, most often it is caused by an underlying infectious process. Patients often have several admissions per year, making them at risk for recurrent infections, increased morbidity, and the emergence of resistant strains of microorganisms. Methods: This is a retrospective, descriptive study of all patients with an infectious disease diagnosis, who were admitted to the medical ward of a tertiary hospital during a 5-year period. Information was collected from electronic medical files regarding gender, age, autonomy, comorbidities, primary diagnosis, in-hospital length of stay, and mortality as well as microbiological data surveillance. Results: A total of 355 patients fulfilled the inclusion criteria. Amongst the sample analysed, the average age was 78.10±12.47 years. Of the patients, 57.2% (203) were female, with most patients considered as dependent according to Katz score. The average Charlson Comorbidity Index (CCI) score was 6.28±2.74, increasing with age. The main diagnostic categories were respiratory (191 patients: 137 with pneumonia and 49 with acute bronchitis) and urinary tract (138 patients: 69 with pyelonephritis and 66 with cystitis). Urinary tract infections were more frequent in females and in dependent patients. Only 37.8% of infections had a microbiologic isolate: Escherichia coli (28.4%), Pseudomonas aeruginosa (12.7%), and Klebsiella pneumoniae (8.2%). The overall mortality was 6.77%. Conclusions: The frequent in-hospital admission due to infectious diseases makes it imperative to characterise and follow-up on evolution of the disease itself in order to better know the characteristics of community-acquired diseases, establish routes of transmission and outbreak identification, microbiology patterns, and resistance towards further improving empiric therapy.

92. Clinical Decision-Making about Chronic Antibiotic Suppression after Prosthetic Joint Infection Treatment: Qualitative Insights for Antibiotic Stewardship

BackgroundPatients who develop prosthetic joint infections (PJI) may be prescribed chronic antibiotic suppression (CAS) ( > 6 months of antibiotics) after initial antibiotic treatment for the PJI. Patients at low risk of recurrent infection may be good targets for antibiotic stewardship. De-implementation of CAS could potentially reduce the emergence of antibiotic resistant organisms and decrease antibiotic-associated adverse events. Our ongoing study aims to characterize clinical decision-making processes about CAS prescribing and identify points for antibiotic stewardship interventions to stop CAS prescribing for patients who will not benefit.MethodsWe conducted semi-structured interviews with 33 physicians and nurses at 8 Veterans Affairs hospitals, chosen for variation in hospital size, complexity, region, and CAS prescribing. Interviewees included orthopedic surgeons, infectious disease (ID) physicians, hospital epidemiologists, nurses, nurse managers, and primary care physicians (PCPs). We conducted inductive, consensus-based thematic analysis on interview transcripts, using the program MAXQDA.ResultsParticipants reported a complex decision-making process that included a range of collaborative approaches with other clinicians and patients. Their risk-benefit calculation for CAS usually included the type of revision surgery performed, the evidence base, the organism, and patient factors. Surgeons and ID physicians, the primary CAS prescribers, collaborated variably and sometimes consulted pharmacists or antibiotic stewards. Participants emphasized the importance of clinician autonomy and buy-in to order to effect practice change based on evidence, rather than top-down policies. They identified other significant time points that occurred before or after the CAS prescribing decision (initial PJI treatment decisions, follow-up appointments) and identified other decision makers about CAS maintenance (e.g., patients, PCPs). (See Figure 1).Figure 1. Decision Points Relevant to Prescribing or Maintenance of Chronic Antibiotic Suppression after PJI. PJI, prosthetic joint infection; ID, Infectious Diseases physician; PCP, primary care physician; IV, intravenous ConclusionInterventions to optimize CAS prescribing should incorporate clinician concerns about prescriber autonomy and a preference for collaborative decision-making as well as understanding the range of decision makers across time.Disclosures Daniel Suh, MS MPH, General Electric (Shareholder)Merck (Shareholder)Moderna (Shareholder)Smile Direct Club (Shareholder) Bruce Alexander, PharmD, Bruce Alexander Consulting (Independent Contractor) Andrew Pugely, MD, MBA, Globus Medical (Research Grant or Support)Medtronic (Consultant)United Healthcare (Consultant) Marin Schweizer, PhD, 3M (Grant/Research Support)PDI (Grant/Research Support)

S1779 Gastrointestinal Amyloidosis: An Unexpected Cause of Diarrhea in an HIV Patient

Introduction: Systemic amyloidosis is a rare multisystem disease caused by the deposition of misfolded protein in various organs, including the gastrointestinal (GI) tract. Amyloidosis occurs in the setting of chronic inflammatory states. The association of acquired immune deficiency syndrome (AIDS) and amyloidosis has been rarely described. We present a case of amyloidosis involving the colon in a patient with uncontrolled human immunodeficiency virus (HIV). Case Description/Methods: A 50-year-old male presented with non-bloody diarrhea of 2 weeks duration. He had a past medical history of Hepatitis C, active IV heroin use, and AIDS. Most recent CD4 count was less than 10 cells/mm3 with an HIV viral load of 36,000 copies/mL. Laboratory workup on admission was significant for severe normocytic anemia, leukopenia, and acute renal failure with proteinuria. An extensive infectious evaluation of the patient’s persistent diarrhea was unremarkable. Computed tomography (CT) scan of the abdomen demonstrated diffuse wall thickening of the sigmoid and descending colon suggestive of colitis. Flexible sigmoidoscopy was performed to further characterize the etiology of colitis. Pale, friable mucosa with scattered telangiectasia was noted on gross examination. Colonic tissue biopsy revealed the presence of extensive perivascular and lamina propria amyloid deposition, which was confirmed by Congo red staining. Apple green birefringence was observed on polarizing microscopy exam. Negative HSV, CMV, AFB, and HHV stains were noted on pathological exam. Subsequent tissue typing was consistent with AA Amyloid secondary to chronic inflammatory state. Discussion: The two most common type of amyloidosis are Amyloid Light chain (AL) amyloidosis and serum Amyloid A (AA) amyloidosis. AL amyloid occurs in the presence of a plasma cell dyscrasia and AA amyloidosis due to ongoing or recurring inflammation from chronic disease. GI involvement has been described in all major systemic amyloid subtypes. The most common GI presentations include GI bleeding, weight loss, diarrhea, and dysmotility. Patients with uncontrolled HIV are at risk for recurrent infections and therefore chronic inflammation. This case highlights the possibility of gastrointestinal AA amyloidosis as an underlying etiology of persistent diarrhea in a patient with AIDS. While amyloidosis secondary to AIDS is rare, it should be considered as part of the broad differential diagnosis of diarrhea in this patient population.Figure 2.: Tissue biopsy showing extensive perivascular and lamina propria amyloid deposition confirmed by Congo red staining.

Daptomycin for the Treatment of Gram-Positive Periprosthetic Hip Infections: Can Daptomycin Prevent the Implant Removal?

IntroductionManagement of periprosthetic hip infections (PHIs) generally consists of implant removal and thorough debridement, accompanied by appropriate antibiotic therapy. Daptomycin (DAP) is a novel antibiotic, which allowed for implant retention in several patients after treating their infected joints. However, there is no consensus about implant retention or removal during the treatment of PHIs. The aim of this study was to examine the effect of DAP and to determine a surgical treatment strategy.MethodsThis study retrospectively evaluated 20 patients between August 2014 and December 2018, divided into implant retention (n=9) and implant removal groups (n=11). Infection control and risk of recurrent infection were evaluated. Infection control was defined as not requiring implant removal after the final treatment.ResultsInfection control rates in implant retention and implant removal groups were 67% and 90%, respectively. All late chronic infections resulted in failure cases within the implant retention group. In the implant retention group, mean preoperative risk scores for successful cases were significantly higher than those for failure cases (p<0.05).ConclusionsPatients with low risk did not require implant removal, suggesting that DAP may be a breakthrough alternative to traditional PHI management.

Sharing of decision-making for infective endocarditis surgery: a narrative review of clinical and ethical implications.

Infective endocarditis (IE) is nowadays one of the most challenging disease in cardiac surgery because of its multifaceted clinical and anatomical presentation. Despite the many clinical and surgical advances achieved in the past 60 years, there is a lack of evidence regarding the ideal strategy. The present review aims to investigate and highlight two main novel concepts for the decision-making of the best substitute. Firstly, the concept of an “endocarditis team”: a coordinated multidisciplinary effort in the diagnostic work-up, especially in conditions of high risk of embolization or clinical deterioration. A good “endocarditis team” has the role to overcome such problem, in order to ensure a prompt and balanced strategy. Secondly, which ethical considerations are required to drive the choice of valvular substitute. The choice of best valve substitute is a relevant issue of debate, not only with operative but also prognostic and accordingly ethical aftermaths. Many different solutions have been developed to substitute the infected valve. Among these: mechanical prosthesis (MP), biological stented prosthesis (BP), sutureless bioprosthesis and cryopreserved homografts (CHs). Patients need to be informed in detail about the technical issues pertaining the use of these valve substitute. We will discuss the evidences regarding the risk of recurrent infections or future potentially severe calcification of aortic homograft valve and wall (in other words, the failure of the homograft) and the difficulties in managing the reoperation.

Joint Initiative Between Infectious Diseases and Podiatry in Outpatient Settings Improves Outcomes and Adherence to Treatment.

A joint infectious disease-podiatry clinic (JIDPC) in which an infectious diseases physician and a podiatrist see patients with diabetic foot infections together once a week was initiated in January 2017. This study was designed to investigate if the JIDPC can improve patient adherence and reduce recurrent infections. A retrospective analysis of patients with diabetic foot infection admitted to Wheeling Hospital from March 2013 to December 2018 was performed. Initially, the patients were followed by infectious diseases and podiatry in their clinics separately (preintervention group). Beginning January 2017, they were followed together at the JIDPC (postintervention group). Recurrent infection, mortality, and loss to follow-up were compared using logistic regression models. Surgeries were performed in 52.5% of preintervention group participants (n = 99) and 81.9% of postintervention group participants (n = 55; P < .001). The preintervention group was more likely to be lost to follow-up (30.3% vs 9.1%; odds ratio [OR], 4.35 [confidence interval (CI), 1.58-11.99]), but the association was attenuated with further adjustment for surgery (OR 3.35 [CI, 1.17-9.62]). The risk of infection recurrence in 6 months was significantly higher in the preintervention group (36.1% vs 20.8%; OR, 2.16 [CI, 0.99-4.71]), but with further adjustment for surgery, this was not significant (P = .067; OR, 2.17 [CI, 0.95-4.94]). Mortality and 90-day readmission were not significantly different. Implementation of JIDPCs may decrease the incidence of recurrent infections among patients with diabetic foot infections.

Safety and Demonstrated Efficacy of Placenta-Derived Cell Therapy PLX-R18 in Subjects with Incomplete Hematopoietic Recovery Following Hematopoietic Cell Transplantation: A Phase I International Multi-Center Study

Introduction: Failure to engraft donor cells is a devastating complication after allogeneic hematopoietic cell transplantation (HCT) while full engraftment remains a challenge in some recipients. Therapeutic approaches, such as recombinant hematopoietic growth factors, salvage only a minority of patients leaving affected patients at risk for recurrent infections and multiple blood products transfusions. PLX-R18 cells have been shown to mitigate bone marrow failure in rodent and non-human primate models. Further, these human placenta-derived mesenchymal-like adherent stromal cells secrete many cytokines after intramuscular (IM) injection that have been shown to stimulate growth and migration of bone marrow cells in vitro, e.g. MCP-1, IL-6, and IL-8. The initial results of the first cohort of this phase I trial were previously reported (ASH 2018 abstract 3379). Methods: Enrollment for this multi-center, open label, dose-escalation, phase I trial (ClinicalTrials.gov: NCT03002519) began in October 2017. Eligibility criteria included patients age ≥18 years who underwent either autologous (auto) or allogeneic (allo) HCT but suffered from incomplete hematopoietic recovery at least 3 months post-transplant, defined as failure to maintain either hemoglobin (Hb) &amp;gt;8g/dL and/or neutrophil count (ANC) &amp;gt;1,000/μL and/or platelet (PLT) count &amp;gt;50,000/μL. Other eligibility criteria included no evidence of underlying malignancy at time of enrollment, no active infection and no evidence of grade 3-4 acute or severe chronic GvHD. Subjects were enrolled into 3 dose-escalating cohorts: low-dose at 1M cells/kg (n=3), intermediate-dose at 2M cells/kg (n=6), and high-dose at 4M cells/kg (n=10). The specified dose of PLX-R18 cells was injected IM in multiple locations and given twice, 1 week apart. Cohorts were recruited sequentially, and progression to the next cohort was based on the safety assessment of its predecessor. Adverse event grading used the NCI CTCAE criteria. As of July 2020, all patients in cohorts 1 and 2 (3 &amp; 6 patients, respectively) and 10 patients in cohort 3 were treated. Data were analyzed using the lmerTest package (ver. 3.1.0) in R (ver. 3.6.1) to produce baseline-adjusted least square means. As study is in progress and data collection ongoing, not all subjects have data on all parameters for all time points. Results: Data on 19 subjects (29-75 yrs) with either allo (n=17) or auto (n=2) HCT are reported herein. Not all patients reached the 9 month time point. Four patients died while on study and 2 withdrew consent within the 1 year follow up period. All deaths and other severe adverse events (SAEs) occurred due to progression of primary disease and were assessed as not related by investigators and sponsor. Most frequent related AEs were injection-site reactions. The table summarizes number of patients who improved from below the critical level, as defined above, at day 0 to above the critical level for a sustained period. Only those patients that were below the critical blood levels at day 0 are shown. To date, the majority of such patients improved to above the critical level after treatment. For example, 9 patients had ANC &amp;lt;1000/μL at day 0. Of the 4 patients for which data currently exists, all improved to ≥1000/μL at 9 months. The plots show changes in Hb, ANC and PLT up to 9 months following treatment. The dashed lines represent respective critical levels. Overall, there was improvement in the 3 parameters, with the greatest improvement observed in patients receiving the predicted optimal dose of 4M cells/kg. In this cohort, Hb levels increased from 9.29±0.5 to 13.19±1.2 (p=0.0019), ANC increased from 1.09±0.6 to 5.13±1.7 (p=0.018) and PLT increased from 45.7±10 to 175.9±28 (p=0.000012). Conclusions: Treatment with PLX-R18 is safe, well-tolerated and clearly effective in some patients. The most frequent AEs were reversible injection site reactions, all without sequelae. An overall improvement was observed in most patients, and among the high-dose cohort clinically impressive improvements in Hb, ANC and PLT were observed. The trial continues to follow up on patients. Upon completion, a large phase II trial, using the optimal dose, is considered for the same indication. Other attractive clinical areas for PLX-R18 therapy include acute radiation syndrome, bone marrow failure, aplastic anemia, myelofibrosis and with HCT as a "pan" cytokine to enhance rapid count recovery in all cells lines. Figure Disclosures Lazarus: Pluristem ltd: Consultancy. McGuirk:Astellas: Research Funding; Bellicum Pharmaceutical: Research Funding; Gamida Cell: Research Funding; Pluristem Ltd: Research Funding; Kite Pharmaceuticals: Consultancy, Honoraria, Research Funding, Speakers Bureau; Allo Vir: Consultancy, Honoraria, Research Funding; Juno Therapeutics: Consultancy, Honoraria, Research Funding; Novartis: Research Funding; Fresenius Biotech: Research Funding. Rowley:AbbVie: Current equity holder in publicly-traded company; FATE Therapeutics: Consultancy. Ofir:Pluristem: Current Employment. Shani:Pluristem ltd: Current Employment. Rowe:Pluristem ltd: Consultancy.

Immune Modulatory Effects of Vitamin D on Viral Infections.

Viral infections have been a cause of mortality for several centuries and continue to endanger the lives of many, specifically of the younger population. Vitamin D has long been recognized as a crucial element to the skeletal system in the human body. Recent evidence has indicated that vitamin D also plays an essential role in the immune response against viral infections and suggested that vitamin D deficiency increases susceptibility to viral infections as well as the risk of recurrent infections. For instance, low serum vitamin D levels were linked to increased occurrence of high burdens viral diseases such as hepatitis, influenza, Covid-19, and AIDS. As immune cells in infected patients are responsive to the ameliorative effects of vitamin D, the beneficial effects of supplementing vitamin D-deficient individuals with an infectious disease may extend beyond the impact on bone and calcium homeostasis. Even though numerous studies have highlighted the effect of vitamin D on the immune cells, vitamin D’s antiviral mechanism has not been fully established. This paper reviews the recent mechanisms by which vitamin D regulates the immune system, both innate and adaptive systems, and reflects on the link between serum vitamin D levels and viral infections.

Revisiting the guidelines and choice the ideal substitute for aortic valve endocarditis.

Aortic valve replacement is the most commonly performed cardiac surgical operation worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the treatment goals. However, no detailed guidelines on prosthesis selection and surgical strategy are available. Management should be guided by a comprehensive evaluation of infection extension and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. We conducted a literature search of the PubMed database, EMBASE and Cochrane Library (through November 2019) for studies reporting to the use of biological substitutes in aortic valve endocarditis (AVE). Studies comparing long-term outcomes in the use of allogenic and autologous with conventional prostheses were investigated. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. In cases of complex IE with the involvement of the root or the aorto-mitral continuity, the use of homografts are recommended, according to surgeon’s and center experience. Homograft use needs to be balanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives. The choice of aortic valves substitute and surgical strategy in IE is multifaceted. Principles guiding the selection of prosthesis and surgical approach rely on the long-term durability and the avoidance of infection relapse. A decisional algorithm considering the extension of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence is provided. A multidisciplinary effort is required to achieve consistent outcomes.