The COVID-19 pandemic presented myriad of unprecedented and daunting ethical dilemmas to healthcare workers, patients, their families, and the public health. Here we present a case of a 42-years-old ...Hispanic female with underlying hematological malignancy that developed severe SARS-COV-2 infection amidst the pandemic. This case illustrates some remarkable ethical dilemmas during pandemic times, including the lack of advanced directive planning, the repercussions of restricting family visits, and what ethics in crisis and moral injury entails. Identifying the ethical challenges emerging from the pandemic will assist physicians and other providers in making proper decisions and maintaining the best standard of care.
Abstract
Background
Decubitus ulcers are a costly and challenging problem in the healthcare system, with an estimated 2.5 million pressure ulcers treated annually in the United States at a cost of ...$11 billion. Patients with decubitus ulcers may present with evidence of infection or sepsis, but the source is rarely the ulcer itself. Recent guidelines recommend evaluating patients for curative management before pursuing further testing or empiric antimicrobial treatment. This study aimed to assess the appropriateness of antibiotic usage in patients admitted to the hospital with decubitus ulcers, and to determine the rate of appropriate antibiotic use.
Methods
This study involved a retrospective review of 1678 patients records with decubitus ulcers to assess the appropriate use of antibiotics during their inpatient stay. Appropriateness was determined by one of three criteria. The 1st criteria included patients who met systemic inflammatory response syndrome with suspected infection from osteomyelitis; 2nd criteria included patients who received antibiotics due to another infection (pneumonia, urinary tract infection or bacteremia) and 3rd criteria included use of antibiotics as a bridge therapy to surgical intervention (flap closure or Incision and Drainage). The rate of consultation for infectious disease and plastic surgery was also investigated.
Results
Of the total 1678 patients, the median age was 70 yrs (IQR=21), of that 51 % were males. Based on the criteria for appropriateness, there were a significant difference in gender (p= 0.000) females were more likely to receive inappropriate antibiotics (Table 2). Similarly, the rate of inappropriate use of antibiotics was 15.9% with ID consults as compared with 84.1% who didn’t receive ID consult (p=0.000) as seen in table 1.
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Conclusion
This study contributes to a better understanding of appropriate antibiotic usage in patients with decubitus ulcers. The findings favor the importance of ID consults in the appropriate use of antibiotics. Additionally, there may be some underlying bias with prescribing antibiotics to females compared to males. Thus, the study provides clinicians with tools in order to make evidence-based decisions on the management of these patients, and for healthcare systems to optimize resource allocation
Disclosures
All Authors: No reported disclosures
•Non-tuberculous mycoabcteria (NTM) cases have been increasing in the state of Florida, especially in the central portion of the state, where the population has been steadily increasing.•Our analysis ...suggests that in our Mycobacterium abscessus complex was the most prevalent NTM seen in our patients, with Mycobacterium avium Complex being a distant second.•Our GIS mapping of these local NTM cases describes where the patients lived relative to the organism which they grew.•Furthermore, for the NTM isolates that we obtained data, we demonstrate the actual variability of antibiotic susceptibility, and with a few isolates, this was observed over time.
In the United States, non-tuberculous mycobacterium (NTM) infections are considered an important cause of morbidity and mortality, especially in people with progressive lung disease. The state of Florida has an extremely high incidence and prevalence of NTM disease which is likely a rapidly emerging infection in the state due to environmental and demographic factors.
Adjemian et al. 1 To determine the burden of NTM disease of patients admitted to a large Central Florida academic center, Falkinham 2 to identify the most common risk factors associated with developing NTM disease in this area, and Sfeir et al. 4 to categorize antimicrobial susceptibilities and genetic resistance markers.
We conducted a retrospective case review from January 1, 2011 to December 31, 2017 in a large university-associated metropolitan hospital in west-central Florida. NTM infections were identified using TheraDoc® during the study period with the inclusion criteria of any inpatient admission, culture confirmed NTM at any site, and age ≥ 12 years. Demographic variables (including residential zip code) and comorbidity data (including solid organ transplant status, HIV status and subsequent testing results, intrinsic pulmonary disease, and cancer diagnosis of any site) were collected for each patient. Microbiologic data collected included NTM species/subspecies, anatomic location of specimen collection, antimicrobial susceptibility including minimum inhibitory concentration (MIC). All collected data were analyzed within Stata/IC14.2. Geospatial relationships between zip codes, diagnosis type, and co-morbidities were computed using Arc GIS Pro.
Our results demonstrated that a substantial number of our inpatient cases with NTM were of the M. abscessus group, and with M. avium complex and M. fortuitum also representing the pathogen in numerous cases. Novel findings included compilation of the first hospital wide comprehensive NTM resistance plot to our knowledge. Our results did show a concordance with previous data with expected predominance of NTM inpatient cases in Caucasian males with pre-existing pulmonary disease, though additional work could be done with isolates within the transplant and immunosuppressed populations.
Our data set demonstrates the most common species/subspecies of NTM infections and their associated conditions seen at our central Florida hospital, and includes an antimicrobial sensitivity analysis in toto. This could be insight into the possible prevalence of NTM in the area, and provides the foundation for future studies on both the acquisition and prevention for NTM infections in central Florida.
Abstract
Background
Pneumocystis Pneumonia (PCP) is a respiratory pathogen that has been known to cause severe illness in the immunocompromised patients. The pathogen became well known in the HIV ...epidemic where much of the current standard of practice was first researched. However since the invention of antiretroviral therapy, and advances in cancer therapy the population affected by PCP has shifted to patients with malignancy or a medication induced immunocompromised state. Here we wish to better define the epidemiology and pathogenicity of PCP in the immunocompromised malignancy patients.
Methods
We utilized a retrospective review of 28 consecutive patients from January 1st 2012 to January 1st 2023 that had visited Moffitt Cancer Center with a diagnosis of confirmed or suspected PCP. We collected data on age, underlying malignancy, type of treatment, comorbidities, presenting symptoms, method of diagnosis and computed tomography findings.
Results
Hematologic malignancies comprised 90% of all cases, half of all cases were in patients’ with a type of non-hodgkin’s lymphoma (NHL). The most common malignancy was diffuse large B cell lymphoma 25%, followed by acute myelocytic leukemia treated with stem cell transplant (SCT) 14%, followed by multiple myeloma 11% (Figure 1). The therapy mostly implicated was glucocorticoids in 57% cases, followed by alkylating agents in 32%, and SCT in 25% (Figure 2). The most frequently reported symptoms was dyspnea in 71% of patients, followed by fever 39%, and cough 32%. Diagnosis was made in 21% of patients with serum 1,3-β -D-glucan, 68% were diagnosed following a bronchoalveolar lavage, 11% utilized both (figure 3). of The most common finding on CT was ground glass opacities in 79% of cases. Lymphopenia was present in 79% cases. PCP contributed or was the cause death in 17% cases.
Underlying Malignancy
Underlying Malignancy of those who developed PCP pneumonia, n=28 Diffuse large B Cell Lymphoma DLBCL, Acute Myelocytic Leukemia AML, Chronic Lymphocytic Leukemia CLL, Cutaneous T Cell Lymphoma CTCL, Acute T cell Leukemia/Lymphoma ATLL, Immune Thrombocytopenic Purpura (ITP)
Type of cancer treatment
Cancer Treatment of those who developed PCP pneumonia, multiple different therapies were often used in treatment, n=28
Method of Diagnosis of PCP
Conclusion
Our data shows that patients’ with NHL comprise half of the patients who developed PCP. Consistent with other studies, steroids were the most frequently implicated therapy, however the second most frequent were alkylating agents. Lymphopenia was commonly associated as well. We wish to bring to light that NHL, Alkylating agents, and particularly lymphopenia as risk factors for development of PCP and should prompt early concern of PCP, particularly those with NHL.
Disclosures
All Authors: No reported disclosures
Protection from influenza virus infection is canonically associated with antibodies that neutralize the virus by blocking the interaction between the viral hemagglutinin and host cell receptors. ...However, protection can also be conferred by other mechanisms, including antibody-mediated effector functions. Here, we report the characterization of 22 broadly cross-reactive, nonneutralizing antibodies specific for influenza B virus hemagglutinin. The majority of these antibodies recognized influenza B viruses isolated over the period of 73 years and bind the conserved stalk domain of the hemagglutinin. A proportion of the characterized antibodies protected mice from both morbidity and mortality after challenge with a lethal dose of influenza B virus. Activity in an antibody-dependent cell-mediated cytotoxicity reporter assay correlated strongly with protection, suggesting that Fc-dependent effector function determines protective efficacy. The information regarding mechanism of action and epitope location stemming from our characterization of these antibodies will inform the design of urgently needed vaccines that could induce broad protection against influenza B viruses.
While broadly protective antibodies against the influenza A virus hemagglutinin have been well studied, very limited information is available for antibodies that broadly recognize influenza B viruses. Similarly, the development of a universal or broadly protective influenza B virus vaccine lags behind the development of such a vaccine for influenza A virus. More information about epitope location and mechanism of action of broadly protective influenza B virus antibodies is required to inform vaccine development. In addition, protective antibodies could be a useful tool to treat or prevent influenza B virus infection in pediatric cohorts or in a therapeutic setting in immunocompromised individuals in conjugation with existing treatment avenues.
SARS-CoV-2 lineages have diverged into highly prevalent variants termed “variants of concern” (VOCs). Here, we characterized emerging SARS-CoV-2 spike polymorphisms in vitro and in vivo to understand ...their impact on transmissibility and virus pathogenicity and fitness. We demonstrate that the substitution S:655Y, represented in the gamma and omicron VOCs, enhances viral replication and spike protein cleavage. The S:655Y substitution was transmitted more efficiently than its ancestor S:655H in the hamster infection model and was able to outcompete S:655H in the hamster model and in a human primary airway system. Finally, we analyzed a set of emerging SARS-CoV-2 variants to investigate how different sets of mutations may impact spike processing. All VOCs tested exhibited increased spike cleavage and fusogenic capacity. Taken together, our study demonstrates that the spike mutations present in VOCs that become epidemiologically prevalent in humans are linked to an increase in spike processing and virus transmission.
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•The S:655Y mutation in SARS-CoV-2 enhances spike protein cleavage and fusogenicity•The S:655Y mutation increases transmissibility in vivo•S:655Y was able to outcompete ancestral S:655H in vivo•SARS-CoV-2 VOCs evolve to acquire an increased spike cleavage and fusogenic ability
Escalera et al. show that spike mutation H655Y, which is present in SARS-CoV-2 variants gamma and omicron, enhances spike protein cleavage, cell-cell fusion, and transmission in the hamster model. Additionally, SARS-CoV-2 variants of concern are shown to have independently acquired mutations associated with a gain in spike cleavage and syncytia formation.
Recurrent toxic shock syndrome (TSS) is uncommon. A certain level of clinical suspicion is indicated with a complex sepsis presentation in the postoperative kidney transplant patient. We present a ...case of presumed recurrent postoperative TSS in a living kidney transplant recipient. The patient was a 19-year-old Caucasian female with a 4-year prior single episode of toxin-mediated sepsis and chronic kidney disease (CKD) secondary to autosomal recessive Alport’s syndrome (confirmed via renal biopsy and genetic testing). She received a human leukocyte antigen (HLA) 2A 2B 1DR MM, CMV -D/-R kidney from her 21-year-old friend. The patient received Campath and IV steroid induction after total cold ischemic time of 170 minutes with 40 minutes of revascularization. On postoperative day (POD) 5, she required re-exploration with reimplantation and stenting of the transplanted ureter. The patient subsequently spiked a fever of 101.6° with a generalized rash prompting collection of blood cultures which demonstrated no growth. Infectious Disease was consulted due to persistent fevers despite IV antibiotics. On POD 12, the patient returned to the operating room (OR) for evacuation of hematoma after decline in Hgb to 5.8 and CT confirmed perinephric hematomas. Kidney biopsy showed no rejection and donor specific antibodies (DSAs) were unremarkable. The patient underwent 1 treatment of empiric plasmapheresis for possible non-HLA antibodies followed by initiation of clindamycin. The patient’s condition improved, and she was discharged home with a normal creatinine. Recurrent TSS is rare but should be added to the differential diagnoses of immuno-compromised patients undergoing kidney transplantation with a history of prior toxin-mediated sepsis.
ABSTRACT The fossil remains of Hippohyus (Artiodactyla, Mammalia) from the Late Miocene/Pliocene of Middle and Upper Siwaliks are described. Hippohyus sivalensis is a common suid of late Miocene to ...Pliocene rocks of Tatrot/Hasnot area of Pakistan. The molar resemblance with equids indicates their grazing feeding habits. This species migrated to Potwar land when grasslands became established. It has typical suine characters with hypsodont dentition and complex infolding of enamel surfaces. The described material consists of isolated molars. This discovery will provide a new insight to understand the diversity and geographic distribution of Siwalik Suids.
Abstract
Background
Common Variable Immunodeficiency (CVID) is a primary immunodeficiency disorder which affects B lymphocyte function and differentiation causing decreased levels of Immunoglobulin G ...(IgG), Immunoglobulin A (IgA) and Immunoglobulin M (IgM).1 The objective of this study is to highlight how hypogammaglobulinemia can lead to respiratory infections with microbes that are lesser known in the background of CVID with the help of a two-case series.
Methods
Medical records of two patients with CVID were reviewed who were found to have mycobacterium avium-complex intracellulare and streptococcus agalactiae lung infections respectively.
Results
Decreased IgG in CVID means reduced antibody production, low IgA leads to mucosal inflammation and increased susceptibility to respiratory infections2 and lower IgM memory B-cells causes infections with encapsulated microorganisms.3 Table 1 highlights the various respiratory infections and their etiologies that have been reported with CVID, the most common being encapsulated organisms like Haemophilus influenza, Streptococcus pneumonia, Neisseria meningitidis along with enterovirus. Table 2 demonstrates our findings. In the first case we have reported a patient with mycobacterium avium-complex intracellulare (MAC-I). This could be because of hypogammaglobulinemia, decreased B and T-cell interaction and reduced T-cell signaling caused by CVID.4 Although, mycobacterium tuberculosis, simiae and hominis lung infections and mycobacterium bovis systemic infections have been reported before, MAC-I is relatively rare in CVID.5 In our second case, the patient developed streptococcus agalactiae or Group-B streptococcus (GBS) empyema. Most cases of GBS have been reported in pregnant women and infants. Infections with other encapsulated organisms have been reported in CVID but GBS empyema is less frequent and can happen due to decreased bacteria-specific CD4 cells, microbial translocation and hypogammaglobulinemia.6 .
Table 1. Respiratory Infections reported in CVID along with their etiologies.
Figure 1. CT image of MAC-I infection.
Conclusion
We encountered two unique cases of CVID with rare infectious etiologies. The cases are intended to create an awareness and vigilance regarding CVID induced hypogammaglobulinemia which can cause respiratory infections with lesser known pathogens where antibodies may be important.
Disclosures
All Authors: No reported disclosures
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