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regarding identification of MIS-C and its distinction from other pediatric conditions, a review of available literature comparing MIS-C phenotype with that of pediatric COVID-19 and other hyperinflammatory syndromes, and retrospective application of different criteria to data from MIS-C cases previously reported to CDC.

We describe 2116 multisystem inflammatory syndrome in children (MIS-C) cases reported to the Centers for Disease Control and Prevention during Delta and Omicron circulation from July 2021 through January 2022. Half of MIS-C patients were aged 5–11 years, 52% received intensive care unit–level care, and 1.1% died. Only 3.0% of eligible patients were fully vaccinated prior to MIS-C onset.

Pellagra is caused by niacin (vitamin B3) deficiency and patients with pellagra present with a characteristic rash. Isoniazid disrupts intracellular niacin synthesis and might induce niacin deficiency. In 2017, Malawi scaled up continuous isoniazid preventive treatment (IPT) for tuberculosis prevention among people living with HIV. In addition, an under-diversified diet based on subsistence maize, as is commonly the case in Malawi, is a risk factor for pellagra. We aimed to investigate whether large-scale isoniazid exposure in Malawi contributed to the cumulative risk for pellagra in a nutritionally vulnerable population.We did a matched case-control study to evaluate the association between daily, continuous isoniazid exposure and pellagra. We matched sequentially enrolled patients with pellagra each with four control participants by sex and age from referral dermatology centres in three IPT scale-up districts in Malawi (Lilongwe, Blantyre, and Zomba) to evaluate isoniazid as a risk for pellagra using multivariable conditional logistic regression. We established a community clinic referral system surrounding the dermatology clinic in each district to enhance case-finding and included all patients with pellagra, regardless of referral status. The primary outcome was dermatologist-diagnosed pellagra. We calculated the interval between isoniazid initiation and rash onset and assessed 30-day clinical outcomes after multi-B vitamin treatment containing 300 mg nicotinamide daily.Between Feb 5 and Aug 9, 2019, we enrolled 197 patients with pellagra and 781 matched controls. Isoniazid exposure was associated with an increased risk of pellagra (adjusted odds ratio 42·6 [95% CI 13·3-136·6]). Significant covariates included HIV infection, referral status, food insecurity, underweight, excess alcohol consumption, and, among women, lactation. The median time from isoniazid initiation to rash onset was shorter during the season of food scarcity (5 months [IQR 3-7]) compared with the harvest season (9 months [8-11]; hazard ratio 7·2 [95% CI 3·2-16·2], log-rank p0·0001). Those with isoniazid-associated pellagra who discontinued isoniazid and adhered to multi-B vitamin treatment showed 30-day clinical improvement.Continuous IPT scale-up and the annual period of food scarcity both increased the risk of pellagra in Malawi. Use of shorter rifamycin-based regimens for tuberculosis prevention and food fortification in populations with undernutrition might reduce this risk. Niacin-containing multi-B vitamin co-administration with isoniazid as pellagra prevention is worth exploring further.This study was supported by the President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention under project 7173.

Background Multisystem inflammatory syndrome in adults (MIS-A) is a severe condition temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods In this retrospective cohort study, we applied the US Centers for Disease Control and Prevention (CDC) case definition to identify diagnosed and undiagnosed MIS-A cases among adults discharged during April 2020–January 2021 from 4 Atlanta, Georgia hospitals affiliated with a single medical center. Non–MIS-A coronavirus disease 2019 (COVID-19) hospitalizations were identified using International Classification of Diseases, Tenth Revision, Clinical Modification encounter code U07.1. We calculated the ratio of MIS-A to COVID-19 hospitalizations, compared demographic characteristics of the 2 cohorts, and described clinical characteristics of MIS-A patients. Results We identified 11 MIS-A cases, none of which were diagnosed by the treatment team, and 5755 COVID-19 hospitalizations (ratio 1:523). Compared with patients with COVID-19, patients with MIS-A were more likely to be younger than 50 years (72.7% vs 26.1%, P < .01) and to be non-Hispanic Black (81.8% vs 50.0%, P = .04). Ten patients with MIS-A (90.9%) had at least 1 underlying medical condition. Two MIS-A patients (18.2%) had a previous episode of laboratory-confirmed COVID-19, occurring 37 and 55 days prior to admission. All MIS-A patients developed left ventricular systolic dysfunction. None had documented mucocutaneous involvement. All required intensive care, all received systemic corticosteroids, 8 (72.7%) required mechanical ventilation, 2 (18.2%) required mechanical cardiovascular circulatory support, and none received intravenous immunoglobulin. Two (18.2%) died or were discharged to hospice. Conclusions MIS-A is a severe but likely underrecognized complication of SARS-CoV-2 infection. Improved recognition of MIS-A is needed to quantify its burden and identify populations at highest risk.

In mid-December 2021, the B.1.1.529 (Omicron) variant of SARS-CoV-2, the virus that causes COVID-19, surpassed the B.1.617.2 (Delta) variant as the predominant strain in California.

Ongoing symptoms might follow acute COVID-19. Using electronic health information, we compared pre‒ and post‒COVID-19 diagnostic codes to identify symptoms that had higher encounter incidence in the post‒COVID-19 period as sequelae. This method can be used for hypothesis generation and ongoing monitoring of sequelae of COVID-19 and future emerging diseases.

Background CDC began collecting COVID-19 vaccination status of persons with MIS-C as part of national surveillance in May, 2021. We describe and compare MIS-C in fully vaccinated persons with MIS-C in persons with partial or no vaccination reported. Methods We identified COVID-19 vaccine age-eligible persons meeting the CDC MIS-C case definition reported by health departments as of March 28, 2022 and divided them into 3 groups for this analysis: 1) fully vaccinated (receipt of a 2-dose mRNA primary vaccine series with MIS-C onset ≥28 days after vaccine dose 2 to account for the delay between infection and MIS-C), 2) partially vaccinated (MIS-C onset after dose 1 or < 28 days from dose 2 or receipt of Janssen [Johnson & Johnson] vaccine and 3) no vaccination reported. We compared characteristics between the groups. Results Of 7,880 MIS-C cases reported, 1,085 were vaccine eligible: 45 were fully vaccinated, 64 partially vaccinated, and 976 had no vaccine reported. Demographic characteristics were similar, although the Northeast had the lowest percentage of persons with vaccination not reported (Table). Though not statistically significant, fully vaccinated persons less frequently had severe cardiac involvement (67% vs 74%), shock (33% vs 44%), severe hematologic involvement (47% vs 54%), and mucocutaneous involvement (53% vs 63%) compared with those with no vaccine reported (Table). Forty-four percent of those fully vaccinated required ICU-level care vs 59% with no vaccine reported (p=0.053). Nineteen (2%) of those without vaccine reported died; no fully or partially vaccinated persons died. Table.Demographic and clinical characteristics of individuals with MIS-C with COVID-19 vaccine not reported compared to partially and fully vaccinated individuals Conclusion Persons who acquire SARS-CoV-2 infection after being fully vaccinated can develop MIS-C, with similar clinical characteristics to those with no vaccination reported. A lower but not statistically significant percentage of fully vaccinated persons required ICU-level care compared with those without vaccination, and there were no deaths in the fully vaccinated group. These data do not account for trends in MIS-C over time, including the influence of circulating SARS-CoV-2 variants on MIS-C clinical manifestations. We will continue to evaluate these comparisons as the sample size of reported MIS-C cases increases. Disclosures All Authors: No reported disclosures.

Background In 1995, the United States was the first country to introduce universal childhood varicella vaccination. High vaccine coverage was attained among young children, ≥ 90% since 2007. In 2007, the policy was changed from 1-dose to a 2-dose program. We describe the impact of 25 years of the U.S. varicella vaccination program on varicella disease nationally. Methods We reviewed published data and analyzed overall and age-specific trends for rates from the pre-vaccine period (1990–1994) through 2019 for varicella incidence using National Notifiable Diseases Surveillance System data, hospitalizations using National Inpatient Sample data, and deaths using National Center for Health Statistics data. We present trends in persons aged < 50 years, which captures most varicella burden and avoids misclassified herpes zoster in older people. Outbreak (≥ 5 varicella cases epidemiologically linked) characteristics were assessed for 1995–2019 and were informed by published data and analysis of surveillance data reported to CDC. Results Within the 10 years of the 1-dose program, varicella incidence, hospitalization, and mortality rates declined dramatically (71%–90%) vs. pre-vaccine. However, limited transmission continued in school settings which informed the change to a 2-dose policy. By 2019, declines reached > 97% for incidence and 94% and 97% for hospitalizations and deaths, respectively. The greatest decline occurred among persons aged < 20 years, born during the varicella vaccination program, with 99%, 97%, and > 99% reduction in incidence, hospitalizations, and deaths, respectively. The 2-dose program further reduced the number, size, and duration of outbreaks vs. the 1-dose program; over the entire program, the proportion of outbreaks with < 10 cases increased from 28% to 73%. Conclusion The varicella vaccination program significantly reduced varicella morbidity and mortality in the U.S. Twenty-five years into the program, pediatric varicella hospitalization has become a rare event and varicella deaths in persons aged < 20 years are practically eliminated in the U.S. Annually, > 3.8 million cases, 10,500 hospitalizations, and 100 deaths from varicella are now prevented in the United States due to the varicella vaccination program. Disclosures All Authors: No reported disclosures.

To describe the impact of the US varicella vaccination program on severe varicella outcomes, we analyzed varicella hospitalizations using the National Inpatient Sample 1993–2019 and varicella deaths using the National Center for Health Statistics data 1990–2019. Over 25 years of vaccination program (1995–2019), varicella hospitalizations, and deaths declined 94% and 97%, respectively, among persons aged 99%, respectively) was among persons aged 10 500 varicella hospitalizations and 100 varicella deaths are now prevented annually in the United States as a direct result of vaccination and reduction in varicella-zoster virus circulation.

ObjectiveU.S. healthcare utilization declined during the COVID-19 pandemic, potentially leading to spurious drops in disease incidence recorded in administrative healthcare datasets used for public health surveillance. We used time series modeling to characterize the magnitude and duration of the COVID-19 pandemic’s impact on claims-based monthly incidence of 12 symptomatic conditions among Medicare beneficiaries aged ≥65 years.MethodsTime series of observed monthly incidence of each condition were generated using Medicare claims data from January 2016–May 2021. Incidence time series were decomposed through seasonal and trend decomposition using Loess, resulting in seasonal, trend, and remainder components. We fit a non-linear mixed effects model to remainder time series components and used it to estimate underlying incidence and number of unrecorded cases of each condition during the pandemic period.ResultsObserved incidence of all 12 conditions declined steeply in March 2020 with nadirs in April 2020, generally followed by return to pre-pandemic trends. The relative magnitude of the decrease varied by condition, but month of onset and duration did not. Estimated unrecorded cases during March 2020–May 2021 ranged from 9,543 (95% confidence interval [CI]: 854–15,703) for herpes zoster to 236,244 (95% CI: 188,583–292,369) for cataracts.ConclusionsDue to reduced healthcare utilization during the COVID-19 pandemic, claims-based data underestimate incidence of non-COVID-19 conditions. Time series modeling can be used to quantify this underestimation, facilitating longitudinal analyses of disease incidence pre- and post-pandemic.

Alcohol-based hand sanitizer is a liquid, gel, or foam that contains ethanol or isopropanol used to disinfect hands. Hand hygiene is an important component of the U.S. response to the emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). If soap and water are not readily available, CDC recommends the use of alcohol-based hand sanitizer products that contain at least 60% ethyl alcohol (ethanol) or 70% isopropyl alcohol (isopropanol) in community settings (1); in health care settings, CDC recommendations specify that alcohol-based hand sanitizer products should contain 60%-95% alcohol (≥60% ethanol or ≥70% isopropanol) (2). According to the Food and Drug Administration (FDA), which regulates alcohol-based hand sanitizers as an over-the-counter drug, methanol (methyl alcohol) is not an acceptable ingredient. Cases of ethanol toxicity following ingestion of alcohol-based hand sanitizer products have been reported in persons with alcohol use disorder (3,4). On June 30, 2020, CDC received notification from public health partners in Arizona and New Mexico of cases of methanol poisoning associated with ingestion of alcohol-based hand sanitizers. The case reports followed an FDA consumer alert issued on June 19, 2020, warning about specific hand sanitizers that contain methanol. Whereas early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. If left untreated methanol poisoning can be fatal (5). Survivors of methanol poisoning might have permanent visual impairment, including complete vision loss; data suggest that vision loss results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve (6). CDC and state partners established a case definition of alcohol-based hand sanitizer-associated methanol poisoning and reviewed 62 poison center call records from May 1 through June 30, 2020, to characterize reported cases. Medical records were reviewed to abstract details missing from poison center call records. During this period, 15 adult patients met the case definition, including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Persons should never ingest alcohol-based hand sanitizer, avoid use of specific imported products found to contain methanol, and continue to monitor FDA guidance (7). Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.

Tuberculosis (TB) is the leading cause of death among persons living with human immunodeficiency virus (HIV) infection. In 2018, an estimated 251,000 persons living with HIV infection died from TB, accounting for one third of all HIV-related deaths and one sixth of all TB deaths (1). TB preventive treatment (TPT) is recommended by the World Health Organization (WHO) for persons living with HIV infection without active TB disease (i.e., adults with a negative clinical symptom screen for cough, fever, night sweats, or weight loss; and children with a negative clinical screen for cough, fever, contact with a person with TB, or poor weight gain) and either without* a tuberculin skin test result or with a known positive result (2). TPT decreases morbidity and mortality among persons living with HIV infection, independent of antiretroviral therapy (ART) (3); however, in 2017, fewer than 1 million of the estimated 21.3 million ART patients started TPT worldwide. Most patients receiving TPT were treated with 6 months of daily isoniazid (1,4). This report summarizes data on TB symptom screening and TPT initiation and completion among ART patients in 16 countries supported by the U.S. President's Emergency Plan for AIDS† Relief (PEPFAR) during April 1, 2017-March 31, 2019. During this period, these 16 countries accounted for approximately 90% of PEPFAR-supported ART patients. During April 1, 2017-September 30, 2018, TB symptom screening increased from 54% to 84%. Overall, nearly 2 million ART patients initiated TPT, and 60% completed treatment during October 1, 2017-March 31, 2019. Although TPT initiations increased substantially, completion among those who initiated TPT increased only from 55% to 66%. In addition to continuing gains in initiation, improving retention after initiation and identifying barriers to TPT completion are important to increase TPT scale-up and reduce global TB mortality.

Multisystem inflammatory syndrome in adults (MIS-A) is a hyperinflammatory illness related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The characteristics of patients with this syndrome and the frequency with which it occurs among patients hospitalised after SARS-CoV-2 infection are unclear. Using the Centers for Disease Control and Prevention case definition for MIS-A, we created ICD-10-CM code and laboratory criteria to identify potential MIS-A patients in the Premier Healthcare Database Special COVID-19 Release, a database containing patient-level information on hospital discharges across the United States. Modified MIS-A criteria were applied to hospitalisations with discharge from March to December 2020. The proportion of hospitalisations meeting electronic health record criteria for MIS-A and descriptive statistics for patients in the potential MIS-A cohort were calculated. Of 34 515 SARS-CoV-2-related hospitalisations with complete clinical and laboratory data, 53 met modified criteria for MIS-A (0.15%). The median age was 62 years (IQR 52–74). Most patients met the severe cardiac illness criterion through either myocarditis (66.0%) or new-onset heart failure (35.8%). A total of 79.2% of patients required ICU admission, while 43.4% of patients in the cohort died. MIS-A appears to be a rare but severe outcome of SARS-CoV-2 infection. Additional studies are needed to investigate how this syndrome differs from severe coronavirus disease 2019 (COVID-19) in adults.

Background Multisystem inflammatory syndrome in adults (MIS-A) was reported in association with the coronavirus disease 2019 (COVID-19) pandemic. MIS-A was included in the list of adverse events to be monitored as part of the emergency use authorizations issued for COVID-19 vaccines. Methods Reports of MIS-A patients received by the Centers for Disease Control and Prevention (CDC) after COVID-19 vaccines became available were assessed. Data collected on the patients included clinical and demographic characteristics and their vaccine status. The Vaccine Adverse Events Reporting System (VAERS) was also reviewed for possible cases of MIS-A. Results From 14 December 2020 to 30 April 2021, 20 patients who met the case definition for MIS-A were reported to CDC. Their median age was 35 years (range, 21–66 years), and 13 (65%) were male. Overall, 16 (80%) patients had a preceding COVID-19-like illness a median of 26 days (range 11–78 days) before MIS-A onset. All 20 patients had laboratory evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Seven MIS-A patients (35%) received COVID-19 vaccine a median of 10 days (range, 6–45 days) before MIS-A onset; 3 patients received a second dose of COVID-19 vaccine 4, 17, and 22 days before MIS-A onset. Patients with MIS-A predominantly had gastrointestinal and cardiac manifestations and hypotension or shock. Conclusions Although 7 patients were reported to have received COVID-19 vaccine, all had evidence of prior SARS-CoV-2 infection. Given the widespread use of COVID-19 vaccines, the lack of reporting of MIS-A associated with vaccination alone, without evidence of underlying SARS-CoV-2 infection, is reassuring., Seven of 20 MIS-A patients received COVID-19 vaccination before illness onset. All patients had evidence of prior SARS-CoV-2 infection. Given widespread COVID-19 vaccinations in the United States, the lack of reporting of MIS-A associated with vaccination alone is reassuring.

Background Multisystem inflammatory syndrome in children (MIS-C) is a severe hyperinflammatory condition in persons aged Methods We included patients meeting the MIS-C case definition with onset date from 19 February 2020 through 31 July 2021, using CDC’s MIS-C case report form, which collects information on demographics, clinical presentation, and laboratory results. Trends over time across 3 MIS-C pandemic waves were assessed using Cochran-Armitage test for categorical and Jonckheere-Terpstra test for continuous variables. Results Of 4901 reported cases, 4470 met inclusion criteria. Median patient age increased over time (P Conclusions Over the first 3 pandemic waves of MIS-C in the United States, cardiovascular complications and clinical outcomes including length of hospitalization, receipt of ECMO, and death decreased over time. These data serve as a baseline for monitoring future trends associated with SARS-CoV-2 B.1.617.2 (Delta) or other variants and increased COVID-19 vaccination among children.

Recent mumps outbreaks among highly vaccinated populations, including college students, have called into question the vaccine effectiveness (VE) of routine two-dose measles, mumps, and rubella (MMR2) immunization. We aimed to estimate the VE required for a novel vaccination strategy (e.g., MMR booster dose, novel vaccine) to prevent large mumps outbreaks on college campuses. Using mumps college outbreak data reported to the U.S. Centers for Disease Control and Prevention during 2016-2017, we estimated current MMR2 VE using the screening method and implemented a compartmental model of mumps transmission. We performed 2000 outbreak simulations, following introduction of an infectious person to a population of 10,000, over ranges of MMR2 vaccine coverage (VC) and VE (30.0-99.0%). We compared the impact of varying VC and VE on mumps and mumps orchitis case counts and determined VE thresholds that ensured 5.0% and 2.0% of the outbreak simulations exceeded 20 and 100 mumps cases. Median estimated MMR2 VE in reported mumps outbreaks was 60.5% and median reported MMR2 VC was 97.5%. Simulated mumps case count was more sensitive to changes in VE than in VC. The opposite was true for simulated mumps orchitis case count, though orchitis case count was small (mean10 cases across simulations for VE near 60.5% and VC near 97.5%). At 97.5% VC, 73.1% and 78.2% VE were required for 5.0% and 2.0% of outbreaks, respectively, to exceed 100 mumps cases. Maintaining 97.5% VC, 82.4% and 85.9% VE were required for 5.0% and 2.0% of outbreaks, respectively, to exceed 20 cases. We conclude that maintaining current levels of MMR2 VC, a novel vaccination strategy aimed at reducing mumps transmission must achieve at least 73.1-85.9% VE among young adults to prevent large mumps outbreaks on college campuses.

Background The Ministry of Health Zambia recommends tuberculosis preventive treatment (TPT) with 6 months daily isoniazid for all people living with human immunodeficiency virus (HIV) after ruling out active tuberculosis disease. We sought to estimate the percentage of people living with HIV who progress through each stage of the tuberculosis case-finding and prevention cascade in two provinces with the highest tuberculosis burden in Zambia. Methods In this cross-sectional survey, we used a two-stage cluster sampling method. We sampled 12 healthcare facilities with probability proportional to size. Patient volume determined facility cluster size. During October 2018, from each facility we systematically sampled medical records of adults and children living with HIV. Our primary outcome of interest was TPT initiation rate among eligible people living with HIV, weighted for complex survey design. The Rao-Scott adjusted chi-square test was used to test for differences in TPT initiation rate and other indicators from the tuberculosis prevention cascade by age group and province of residence. Additionally, we conducted semi-structured interviews with healthcare workers at each facility to assess TPT knowledge and identify challenges to its implementation. Results We sampled 482 records of people living with HIV (including 128 children living with HIV). Excluding two people diagnosed with tuberculosis disease before enrollment in HIV care, 93.4% underwent tuberculosis symptom screening. Of those, 4.7% were diagnosed with tuberculosis disease and 95.3% were TPT-eligible, of whom 24.7% initiated TPT. TPT initiation was lower among eligible children (7.7%) compared with adults (25.2%, p = 0.03) and Copperbelt residents (3.1%) compared with Lusaka residents (35.8%, p Conclusions TPT uptake among people living with HIV in Zambia is challenged by inconsistent tuberculosis screening, lack of TPT training for healthcare workers, and supply chain inefficiencies. Addressing these barriers may increase TPT initiations and improve outcomes among people living with HIV.

Idiopathic intussusception is a common cause of bowel obstruction in infants, presenting as refractory abdominal pain or mass, vomiting, lethargy, and currant jelly stool. Coronavirus disease 2019 is not well characterized in children, especially infants, but symptoms in children have included nausea, vomiting, diarrhea, and abdominal pain. From January to July 2020, intussusception was reported in 5 infants 4-10 months of age who had laboratory-confirmed SARS-CoV-2 infection. All 5 infants presented with currant jelly stool and at least 1 other abdominal symptom, and none presented with respiratory symptoms. Four infants recovered but the fifth infant progressed to a critical illness and death. While an association between SARS-CoV-2 infection and intussusception has not been established, infants with symptoms consistent with intussusception may warrant testing for viral pathogens, including SARS-CoV-2, especially if presenting to healthcare with a history of SARS-CoV-2 exposure or with signs and symptoms of COVID-19. More investigation is needed to determine whether intussusception is part of the clinical spectrum of COVID-19 in infants or a coincidental finding among infants with SARS-CoV-2 infection.

An increasing number of emerging tick-borne diseases has been reported in the United States since the 1970s. Using metagenomic next generation sequencing, we detected nucleic acid sequences from 2 novel viruses in the family Bunyaviridae and an emerging human rickettsial pathogen, Rickettsia philipii, in a population of the Pacific Coast tick, Dermacentor occidentalis in Mendocino County sampled annually from 2011 to 2014. A total of 250 adults of this human-biting, generalist tick were collected from contiguous chaparral and grassland habitats, and RNA from each individually extracted tick was deep sequenced to an average depth of 7.3 million reads. We detected a Francisella endosymbiont in 174 ticks (70%), and Rickettsia spp. in 19 ticks (8%); Rickettsia-infected ticks contained R. rhipicephali (16 of 250, 6.4%) or R. philipii (3 of 250,1.2%), the agent of eschar-associated febrile illness in humans. The genomes of 2 novel bunyaviruses (>99% complete) in the genera Nairovirus and Phlebovirus were also identified and found to be present in 20–91% of ticks, depending on the year of collection. The high prevalence of these bunyaviruses in sampled Dermacentor ticks suggests that they may be viral endosymbionts, although further studies are needed to determine whether they are infectious for vertebrate hosts, especially humans, and their potential role in tick ecology.

Background European trials using procalcitonin (PCT)-guided antibiotic therapy for patients with lower respiratory tract infections (LRTI) have resulted in significant reductions in antibiotic use without increasing adverse outcomes. Few prospective studies have examined PCT-guided antibiotic therapy for LRTI in the United States. Our objective was to examine whether an PCT algorithm compared with standard practice would reduce antibiotic exposure in patients with LRTI [pneumonia and acute exacerbations of chronic obstructive pulmonary disease (AECOPD)] in an American urban academic hospital. Methods From April 17, 2017 until November 1, 2017, consecutive patients admitted to a medicine service were enrolled in the PCT intervention if they were receiving antibiotics for LRTI and gave consent. Providers were encouraged to discontinue antibiotics using a PCT algorithm with predefined cutoffs. Serum PCT was measured in the hospital laboratory once daily. Results and recommendations were communicated to providers by study team and in the medical record. Control patients were selected by reviewing charts for patients admitted to a medicine service for LRTI from December 1, 2016 to April 16, 2017. The primary endpoint was median antibiotic duration. Overall adverse outcomes at 30 days comprised death, transfer to an intensive care unit, antibiotic side effects, Clostridium difficile infection, disease- specific complications, and new antibiotic prescription for LRTI after discharge. Results 174 patients were enrolled in the intervention group and 200 patients in the control group. Intervention group providers complied with the PCT algorithm in 75% of encounters. The rate of overall adverse outcomes was similar in PCT and control groups (21.8% vs. 23.5%; difference, –0.02; 95% CI, –0.10 to 0.07). PCT-guided therapy reduced the median antibiotic duration for pneumonia from 7 days to 6 (P = 0.05), and AECOPD from 4 days to 3 (P = 0.01). Noncompliance with the PCT algorithm resulted in 260 excess antibiotic days in 44 patients. Conclusion In our center, 75% adherence to a PCT-guided algorithm safely reduced the duration of antibiotics for treating LRTI. Incentivizing providers to comply with PCT-guided algorithms could lead to further reductions in antibiotic use. Disclosures J. Townsend, BRAHMS: Grant Investigator, Research grant.

Rapidly growing mycobacteria are rarely found in central nervous system infections. We describe a case of polymicrobial infection in a brain abscess including two rapidly growing Mycobacterium species, M. immunogenum and M. llatzerense . The Mycobacterium isolates were distinguishable by molecular methods, and whole-genome sequencing showed