Search

Answer: Intestinal spirochetosis. The condition was diagnosed as intestinal spirochetosis (IS). Histopathology of the colonic mucosa showed hematoxylin and eosin (H&E) and Warthin-Starry stains that were characteristic of intestinal spirochetosis. Intestinal spirochetosis is an uncommon disease in

A 47-year-old Caucasian male with an 11-year history of human immunodeficiency virus (HIV) presented with new-onset hematochezia (blood in stool), constipation, and rectal pain with defecation for 1 month. He denied any abdominal pain, diarrhea, fever, rash, weight loss, recent travel, new

Background: Infection is the most frequent complication after severe burns and remains the predominant cause of death. Burn patients may require multiple courses of antibiotics, lengthy hospitalizations, and invasive procedures that place burn patients at especially high risk for infections with multi-drug-resistant organisms (MDROs). Methods: The published literature on MDROs in burn patients was reviewed to develop a strategy for managing these infections. Results: Within a burn unit meticulous infection prevention and control measures and effective antimicrobial stewardship can limit MDRO propagation and decrease the antibiotic pressure driving the selection of MDROs from less resistant strains. Several new antimicrobial agents have been developed offering potential therapeutic options, but familiarity with their benefits and limitations is required for safe utilization. Successful management of MDRO burn infections is supported by a multifactorial approach. Novel non-antibiotic therapeutics may help combat MDRO infections and outbreaks. Conclusions: Multi-drug-resistant organisms are being identified with increasing frequency in burn patients. Effective sensitivity testing is essential to identify MDROs and to direct appropriate antibiotic choices for patient treatment.

Background Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort. Methods An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest. Result The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02). Conclusions Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

Background C. difficile infection (CDI) is the leading hospital associated (HA) infection in an era of antibiotic overuse and highly-sensitive PCR-based diagnostics. PCR does not differentiate CDI versus colonization making over-reporting a concern. HA-CDI can impact hospital reimbursement, lead to unnecessary treatment, increase costs and length of stay. Our aim was to implement an intervention to target inappropriate C. difficile (CD) testing. Methods Two-tiered testing is not utilized at our facility. After provider education on guidelines for appropriate CD testing, prompts were introduced into the electronic medical record (EMR) for CD test orders. At order input, providers are prompted to answer “yes” or “no” to two questions; 1) receipt of stool softeners within the preceding 48 hours and 2) criteria of 3 loose stools within 24 hours. The test order was completed regardless of the responses to the prompted questions. Six-month post-intervention data was compared to the same timeframe during the year prior. Results A total of 334 and 236 tests were ordered in the pre- and post-intervention periods respectively. Accounting for inpatient bed days, the incidence reduction rate (IRR) was 0.75 (CI 0.63–0.89, p < 0.001) corresponding to an estimated hospital cost-savings of $12,250 based on testing costs alone. The majority of CD tests were ordered by IM providers, who also demonstrated the greatest reduction in tests ordered post-intervention. Patient characteristics were analyzed in the pre- and post-intervention periods finding significantly less positive CD tests ordered for patients with recurrent C. difficileduring the post-intervention period (2 vs 7, p = 0.04). Patients who were transferred from another institution had significantly more positive CD tests in the post-intervention period (19 vs 7, p = 0.02). Conclusion In conclusion, the results demonstrate that implementing a systems-based EMR initiative led to a 25% reduction in CD testing with a cost-savings of $12,250 not accounting for potential associated cost savings. This project suggests that even without restricting order access, educational prompts integrated in the EMR can have meaningful impact on stewardship endeavors to help reduce inappropriate CD testing. Sustained effect would be an area to explore. Disclosures All Authors: No reported disclosures

Rapidly growing nontuberculous mycobacteria (RGNTM) have yet to be described in combat-related injuries. This study investigates the epidemiology, clinical findings, treatment, and outcomes of RGNTM infections among combat casualties wounded in Afghanistan from 2010 to 2012.Patients with RGNTM were identified from the Department of Defense Trauma Registry through the Trauma Infectious Disease Outcomes Study. Trauma history, surgical management, and clinical data were collected. Six isolates from patients requiring antimycobacterial therapy were sequenced.Seventeen cases were identified. Six cases, predominantly associated with Mycobacterium abscessus, required aggressive debridement and a median of 180 days of multidrug antimycobacterial therapy that included clofazimine. M. abscessus isolates expressed the erythromycin resistance methylase (erm(41)) gene for inducible macrolide resistance, yet there were no clinical treatment failures when macrolides were utilized in combination therapy. No clonal similarity between M. abscessus isolates was found. Eleven cases had positive wound cultures, but did not require antimycobacterial therapy. The median duration of time of injury to first detection of a RGNTM was 57 days.This represents the first report of RGNTM infections in war-wounded patients. RGNTM should be recognized as potential pathogens in grossly infected combat wounds. Surgical debridement and multidrug antimycobacterial therapy, when clinically indicated, was associated with satisfactory clinical outcomes.

Introduction Nationally, the number of internal medicine physicians practicing in primary care has decreased amidst increasing interest in hospitalist medicine. Current priorities in the Military Health System include access to primary care and retention of trained personnel. Recently, we have conducted a study of military internal medicine residents' decision to enter infectious disease. As part of our larger effort, we saw an opportunity to characterize factors impacting decision making of internal medicine residents' desire to apply for subspecialty training and to extend active duty service obligations. Materials and Methods Questions were developed after discussion with various military graduate medical education and internal medicine leaders, underwent external review, and were added to a larger question set. The survey link was distributed electronically to all U.S. military affiliated residencies' graduating internal medicine residents in December 2016-January 2017. Data were analyzed by decision to apply to fellowship and decision to extend military obligation using Fisher's exact test or Pearon's chi-square test. Results Sixty-eight residents from 10 of 11 military residency programs responded, for a response rate of 51%. The majority (62%) applied to fellowship to start after residency completion. Reasons cited for applying to fellowship included wanting to become a specialist as soon as possible (74%), wishing to avoid being a general internist (57%), and because they are unable to practice as a hospitalist in the military (52%). Fellowship applicants were more likely to plan to extend their military obligation than non-applicants, as did those with longer duration of military commitments. No other factors, including Uniformed Services University attendance or participation in undergraduate military experiences, were found to impact plan to extend active duty service commitment. Conclusion The majority of graduating internal medicine residents apply for fellowship and report a desire to avoid being a general internist. Prospective fellows anticipate extending their active duty commitment, as do those with longer commitments.

Treatment options for cutaneous leishmaniasis in the United States are problematic because the available products are either investigational, toxic, and/or of questionable effectiveness. A retrospective review of patients receiving liposomal amphotericin B through the Walter Reed Army Medical Center for the treatment of cutaneous leishmaniasis during 2007-2009 was conducted. Twenty patients who acquired disease in five countries and with five different strains of Leishmania were treated, of whom 19 received a full course of treatment. Sixteen (84%) of 19 experienced a cure with the initial treatment regimen. Three patients did not fully heal after an initial treatment course, but were cured with additional dosing. Acute infusion-related reactions occurred in 25% and mild renal toxicity occurred in 45% of patients. Although the optimum dosing regimen is undefined and the cost and toxicity may limit widespread use, liposomal amphotericin B is a viable treatment alternative for cutaneous leishmaniasis.

Although antimicrobial therapy of leptospirosis has been studied in a few randomized controlled clinical studies, those studies were limited to specific regions of the world and few have characterized infecting strains. A broth microdilution technique for the assessment of antibiotic susceptibility has been developed at Brooke Army Medical Center. In the present study, we assessed the susceptibilities of 13 Leptospira isolates (including recent clinical isolates) from Egypt, Thailand, Nicaragua, and Hawaii to 13 antimicrobial agents. Ampicillin, cefepime, azithromycin, and clarithromycin were found to have MICs below the lower limit of detection (0.016 μg/ml). Cefotaxime, ceftriaxone, imipenem-cilastatin, penicillin G, moxifloxacin, ciprofloxacin, and levofloxacin had MIC 90 s between 0.030 and 0.125 μg/ml. Doxycycline and tetracycline had the highest MIC 90 s: 2 and 4 μg/ml, respectively. Doxycycline and tetracycline were noted to have slightly higher MICs against isolates from Egypt than against strains from Thailand or Hawaii; otherwise, the susceptibility patterns were similar. There appears to be possible variability in susceptibility to some antimicrobial agents among strains, suggesting that more extensive testing to look for geographic variability should be pursued.

Background Burn patients constitute approximately 5% of casualties injured in support of US military operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]). Since the onset of these conflicts, there have been numerous casualties infected with multidrug-resistant bacteria. It is currently unclear if bacteremia with these multidrug-resistant organisms in OIF/OEF burn casualties is associated with increased mortality. Study Design We performed a retrospective cohort study of all patients admitted to the US Army Institute of Surgical Research burn center from January 2003 to May 2006 to evaluate bacteremia in our burn-patient population. Results One hundred twenty-nine of 1,258 patients admitted to the burn center became bacteremic during their hospitalization. Of these, 92 had bacteremia with the top four pathogens in our burn center, ie, Pseudomonas aeruginosa , Klebsiella pneumoniae , Acinetobacter calcoaceticus-baumannii complex, and Staphylococcus aureus . Presence of any bacteremia was associated with mortality and increased ventilator days. Bacteremia with K pneumoniae was associated with a statistically increased mortality and a prolonged ventilator course relative to all other pathogens. Conclusions Casualties of OIF/OEF with burn injuries did not have different outcomes than patients whose burns were not associated with military operations. Bacteremia, especially with a multidrug-resistant organism, causes increased mortality in burn patients. Of all the pathogens causing bacteremia, K pneumonia appears to have the greatest impact on mortality.

Disseminated phaeohyphomycosis is an uncommon infection affecting immunocompetent and immunocompromised individuals in which response to older antifungal agents has been variable. We compared the effect of six days of therapy with caspofungin, posaconazole, and amphotericin B in parallel studies of survival and fungal burden in an immunocompromised mouse model of Exophiala infection. Mice immunocompromised with cyclophosphamide were treated for 6 days starting one day after initiation of infection. Treatment regimens included amphotericin B, caspofungin, and posaconazole. In the survival studies, experimental animals were observed for 14 days. In the fungal burden tests the experimental animals were sacrificed 7 days after infection and brain and kidney burden determined. Treatment with any agent decreased mortality (P0.05), with 40%, 30%, and 80% observed survival of the animals treated with amphotericin B, caspofungin, and posaconazole, respectively. Amphotericin B and posaconazole treatment resulted in a decrease in fungal burden compared to untreated controls (P0.05). No reduction in fungal burden was noted in the caspofungin group. All three antifungals evaluated improved survival of immunocompromised mice in this otherwise fatal disseminated phaeohyphomycosis. Amphotericin B and posaconazole reduced fungal burden. Posaconazole and caspofungin appear to have potential for use in treatment of this rare infection.

Objectives Azithromycin is not associated with significant adverse effects or restricted usage in certain populations unlike standard antileptospirosis agents. In this study, the utility of short courses of azithromycin in treating or preventing leptospirosis was investigated in a lethal hamster model. Methods All hamsters were infected intraperitoneally with 10(5) leptospires. In experiment one, animals received 5 mg/kg of doxycycline or 10 mg/kg of azithromycin via intraperitoneal injection beginning on the second day after infection and continuing once daily for 1, 2, 3 or 5 days. In experiment two, animals received 1 or 2 day courses of azithromycin initiated 2 or 4 days following infection, or 4 days prior to infection. Results All untreated control animals died between the sixth and ninth day following infection. In experiment one, survival rates in the doxycycline groups were 0, 50, 80 and 100% for those animals treated for 1, 2, 3 and 5 days, respectively. Except for the 1 day treatment group (which had an 80% survival), there was 100% survival in all azithromycin-treated groups. In experiment two, all animals treated after infection survived until study completion. No animals survived with 1 day of therapy started 4 days prior to infection while only 20% survived if they received 2 days. Conclusions These results suggest short-course therapy with azithromycin, even started well after infection, is efficacious in preventing mortality from acute leptospirosis.

Nocardiosis is an opportunistic infection that generally occurs in immunocompromised patients, especially in those with phagocyte defects that are induced by systemic corticosteroids or seen in chronic granulomatous disease [1]. However, there remain some patients with nocardiosis for whom no defect has been found. Nocardia's proclivity for central nervous system involvement has been long appreciated [2], although the mechanisms underlying this remain obscure. Anticytokine autoantibodies are an emerging cause of adult-onset immunodeficiency [3]. Neutralizing anti–interferon gamma (IFN-γ) autoantibodies have been identified in the context of severe disseminated opportunistic infections [4]; anti–interleukin (IL) 17A, anti–IL-17F, and anti–IL-22 autoantibodies in association with and chronic mucocutaneous candidiasis [5, 6]; anti–IL-6 autoantibodies in the setting of staphylococcal skin infections [7]; and recently, anti–granulocyte macrophage colony-stimulating factor (GM-CSF) autoantibodies in association with Cryptococcus gattii meningitis [8]. Anti–GM-CSF autoantibodies were first recognized as etiologic in most cases of pulmonary alveolar proteinosis (PAP), a rare lung disorder characterized by the accumulation of proteinaceous material within the alveoli [9] due to defective GM-CSF–dependent surfactant clearance by pulmonary macrophages [10]. It is now appreciated that these autoantibodies may also contribute to infection susceptibility in the absence of PAP [8, 11]. Abrogation of GM-CSF signaling, either by gene knockout in mice or neutralizing autoantibodies, impacts other phagocytic activities [12, 13] and increases susceptibility to infection with opportunists typically controlled by phagocytes, such as Nocardia species, Histoplasma, and Cryptococcus [9, 14–16]. These observations implicate a direct role for GM-CSF in host defense against these opportunists. The recognition of anti–GM-CSF autoantibodies in previously healthy patients with cryptococcal meningitis [8] prompted us to evaluate the plasma of healthy, human immunodeficiency virus (HIV)-uninfected and otherwise immunocompetent adults with disseminated/extrapulmonary nocardiosis.

Broth microdilution was used to determine the MICs of AR-709 and comparator antimicrobial agents for 224 invasive multidrug-resistant isolates of Streptococcus pneumoniae . AR-709 was highly active, with a MIC 50 of 0.25 μg/ml, a MIC 90 of 0.5 μg/ml, and a range of ≤0.008 μg/ml to 1 μg/ml.

A 21-year-old African-American male suffered multiple injuries from an improvised explosive device while deployed in Afghanistan. His trauma resulted in severe soft tissue injuries involving the posterior upper arms and left shoulder, as well as the left flank, which communicates with the abdominal cavity. A splenectomy was required due to the splenic lacerations that he received. During his hospital course, the complication of polymicrobial wound infection occurred, which required repeated debridements with wound vacuum (WV) placement and broad spectrum antibiotic coverage. Ten days after his injury, he developed coagulopathy with persistently bloody WV output that required multiple transfusions of packed red blood cells, platelets, and cryoprecipitate. The patient had no known prior medical problems, and there was no report of unusual exposures to pathogens during his 8 months of deployment. On examination, the patient was febrile, hypotensive, tachycardic, intubated, and sedated. Two weeks after his injury and during surgical intervention for wound debridement and wound hemostasis, his surgeon noted several yellow, soft, slightly raised, pustular lesions on the surface of his liver, 1 of which was biopsied. The patient also developed pustular skin lesions on his forehead, right axilla, and right thorax, 1 of which was also biopsied (Figure 1). His laboratory test results during this episode were as follows: white blood cell count 20.6 × 10(3)/μL with 23% bands; hemoglobin 11.5 g/dL; hematocrit 22.2%; platelet count 47 × 10 (3)/μL; prothrombin time 17 seconds; partial thromboplastin time 33 seconds; international normalized ratio 1.3; aspartate aminotransferase 873 U/L; alanine aminotransferase 470 U/L; total bilirubin 7.1 mg/dL, and direct bilirubin 6.9 mg/dL. His liver biopsy showed multifocal coagulative necrosis without zonation. His skin biopsy was diagnostic (Figure 2). What is your diagnosis?