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With rates of ECMO utilization on the rise, prevention of nosocomial infections is of paramount importance. Candida auris, an emerging highly pathogenic multidrug resistant fungus, is of particular concern as it is associated with persistent colonization of environmental surfaces, inability to be recognized by many diagnostic platforms, inconsistent laboratory susceptibility results, and high mortality rates. We describe a case of C. aurisin a VV-ECMO patient successfully managed with a combination of anidulafungin, amphotericin B, and flucytosine.

Background Rivaroxaban is a first-line option for the management of venous thromboembolism (VTE). However, limited data are available regarding its effectiveness in morbidly obese patients.Objective To evaluate rates of thrombosis and bleeding in morbidly obese patients receiving rivaroxaban or warfarin for VTE.Methods A multicenter, retrospective cohort study was conducted to compare rates of bleeding and thrombosis in patients receiving rivaroxaban versus warfarin for acute VTE. Patients were included if they were older than 18 years and had a body mass index (BMI) greater than 40 kg/m2or weight greater than 120 kg. The primary effectiveness outcome was hazard of VTE recurrence; the primary safety outcome was hazard of major bleeding. Patients were followed for up to 12 months.Results A total of 1281 patients were identified for acute VTE and were included in this study with 487 patients receiving rivaroxaban and 785 receiving warfarin. The average cohort age was 57.6 ± 14.6 years, and the average weight was 136.4 ± 27.2 kg. After controlling for confounding factors, the use of rivaroxaban was not associated with an increased hazard of VTE events when compared with warfarin (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.42-1.08, P= 0.12) or major bleeding (HR = 1.29, 95% CI: 0.66-2.30, P= 0.52).Conclusion and Relevance No difference was observed in obese patients with weight >120 kg or BMI >40 kg/m2receiving rivaroxaban or warfarin for VTE treatment in hazard of VTE or major bleeding. Either agent may be considered an appropriate treatment option in this population.

Background: Carbapenem-resistant (Car-R) Pseudomonas aeruginosais an urgent threat. These isolates may remain susceptible to traditional noncarbapenem antipseudomonal β-lactams, but it is unclear if carbapenem resistance impacts the effectiveness of these agents.Objective: The purpose of this study was to compare clinical outcomes in Car-R and cephalosporin-susceptible (Ceph-S) P. aeruginosapneumonia treated with cefepime versus other susceptible agents.Methods: This retrospective cohort study evaluated patients diagnosed with hospital-acquired or ventilator-associated pneumonia who had a respiratory isolate of Car-R Ceph-S P. aeruginosa. Patients were excluded if they had polymicrobial respiratory cultures, other concomitant infections, empyema, death within 3 days of index culture, or received less than 3 days of susceptible therapy. Patients treated with cefepime were compared to other susceptible therapies. The primary endpoint was 30-day in-hospital mortality.Results: Eighty-seven patients were included: cefepime, n = 61; other susceptible therapies, n = 26. There were no differences in 30-day in-hospital mortality between cefepime and other susceptible therapies (19.6% vs. 19.2%, pvalue = 0.719). In addition, there were no differences between clinical cure rates (cefepime 65.6% vs. other therapies 72 %, p value = 0.47). In multivariate logistic regression, treatment with cefepime (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.11-2.52) was not independently associated with 30-day in-hospital mortality.Conclusion and Relevance: For the treatment of Car-R Ceph-S P. aeruginosapneumonia, cefepime showed similar rates of 30-day in-hospital mortality and clinical outcomes when compared to other susceptible therapies. Cefepime may be utilized to conserve novel β-lactam and β-lactamase inhibitors.

Problem drinking that predates enlistment into military service may contribute to the overall burden of alcohol misuse in the Armed Forces; however, evidence bearing on this issue is limited. This study examines prevalence and correlates of alcohol misuse among new U.S.Army soldiers. Cross‐sectional survey data were collected from soldiers reporting for basic combat training. The survey retrospectively assessed lifetime alcohol consumption and substance abuse/dependence, enabling estimation of the prevalence of lifetime binge drinking and heavy drinking in a sample of 30,583 soldiers and of probable alcohol use disorder (AUD) among 26,754 soldiers with no/minimal lifetime use of other drugs. Co‐occurrence of mental disorders and other adverse outcomes with binge drinking, heavy drinking, and AUDwas examined. Discrete‐time survival analysis, with person‐year the unit of analysis and a logistic link function, was used to estimate associations of AUDwith subsequent onset of mental disorders and vice versa. Weighted prevalence of lifetime binge drinking was 27.2% (SE= 0.4) among males and 18.9% (SE= 0.7) among females; respective estimates for heavy drinking were 13.9% (SE= 0.3) and 9.4% (SE= 0.4). Among soldiers with no/minimal drug use, 9.5% (SE= 0.2) of males and 7.2% (SE= 0.5) of females had lifetime AUD. Relative to no alcohol misuse, binge drinking, heavy drinking, and AUDwere associated with increased odds of all mental disorders and other adverse outcomes under consideration (adjusted odds ratios [AORs] = 1.5 to 4.6; ps < 0.001). Prior mental disorders and suicidal ideation were associated with onset of AUD(AORs = 2.3 to 2.8; ps< 0.001), and prior AUDwas associated with onset of mental disorders and suicidal ideation (AORs = 2.0 to 3.2, ps < 0.005). Strong bidirectional associations between alcohol misuse and mental disorders were observed in a cohort of soldiers beginning Army service. Conjoint recognition of alcohol misuse and mental disorders upon enlistment may provide opportunities for risk mitigation early in a soldier's career. Weighted prevalence of lifetime post‐traumatic stress disorder, suicidal behavior, major depressive disorder, and panic disorder by categories of alcohol misuse among new soldiers in a sample of the US Army, assessed during basic training. Standard errors range from 0.1 to 1.5%. All four co‐occurring conditions were more prevalent among soldiers with lifetime binge drinking, lifetime heavy drinking, lifetime probable alcohol use disorder (AUD) and past‐year probable AUD than among soldiers with no lifetime alcohol misuse (all p's < 0.001).

High levels of alcohol use and alcohol-related problems are associated with suicidal behaviors (i.e., seriously considering and/or attempting suicide) in military and civilian populations. Examination of reasons for drinking alcohol may identify subgroups of soldiers who may either be at risk for suicidal behaviors or resilient to suicidality.

Reasons for alcohol consumption are often conceptualized as deriving from internal and external sources and positive and negative reinforcement. The revised Drinking Motives Questionnaire (DMQ–R) was developed to classify reasons or motives for alcohol use which are associated with different drinking patterns. The factor structure of a subset of DMQ–R items was examined using exploratory factor analysis on a U.S. Army sample, to assess whether the DMQ–R subscales represent drinking motives typically identified by military service members. This study used the Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, which sampled 10,400 Army soldiers. A total of 4,475 responses were included in the analysis, which corresponded with a weighted sample of 391,185 soldiers. Principal-axis factor analysis with promax rotation identified two factors representing pleasure-seeking/enjoyment and avoiding rejection/“fitting in.” These factors may be useful in investigating relationships between drinking motives and alcohol use patterns within the U.S. Army population.