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Prompt and accurate detection of SARS-CoV-2, the virus that causes COVID-19, has been important during public health responses for containing the spread of COVID-19, including in hospital settings (1-3). In vitro diagnostic nucleic acid amplification tests (NAAT), such as real-time reverse transcription-polymerase chain reaction (RT-PCR) can be expensive, have relatively long turnaround times, and require experienced laboratory personnel.* Antigen detection tests can be rapidly and more easily performed and are less expensive. The performance† of antigen detection tests, compared with that of NAATs, is an area of interest for the rapid diagnosis of SARS-CoV-2 infection. The Quidel Sofia 2 SARS Antigen Fluorescent Immunoassay (FIA) (Quidel Corporation) received Food and Drug Administration Emergency Use Authorization for use in symptomatic patients within 5 days of symptom onset (4). The reported test positive percentage agreement§ between this test and an RT-PCR test result is 96.7% (95% confidence interval [CI] = 83.3%-99.4%), and the negative percentage agreement is 100.0% (95% CI = 97.9%-100.0%) in symptomatic patients.¶ However, performance in asymptomatic persons in a university setting has shown lower sensitivity (5); assessment of performance in a clinical setting is ongoing. Data collected during June 30-August 31, 2020, were analyzed to compare antigen test performance with that of RT-PCR in a hospital setting. Among 1,732 paired samples from asymptomatic patients, the antigen test sensitivity was 60.5%, and specificity was 99.5% when compared with RT-PCR. Among 307 symptomatic persons, sensitivity and specificity were 72.1% and 98.7%, respectively. Health care providers must remain aware of the lower sensitivity of this test among asymptomatic and symptomatic persons and consider confirmatory NAAT testing in high-prevalence settings because a false-negative result might lead to failures in infection control and prevention practices and cause delays in diagnosis, isolation, and treatment.

Pregnant women at public medical centers in Porto Alegre, Brazil, were recruited for a study on screening and treatment of sexually transmitted infections (STIs). STIs were detected in 79 (23%) of 350 pregnant women and were found to be associated with infant low birth weight (adjusted odds ratio 5.8; 95% confidence interval 1.9-18).

Almost 1 in 4 women being seen for prenatal care in our clinics in Porto Alegre Brazil were diagnosed with a sexually transmitted infection. Among women who tested positive, 59% did not have any symptoms. Supplemental digital content is available in the text., Background Porto Alegre, Brazil, has the highest rates of congenital syphilis and HIV in the country. Other treatable sexually transmitted infections (STIs) are associated with poor pregnancy and neonatal outcomes, but are only diagnosed by syndromic algorithms. Methods Between September 2018 and November 2019, we offered all pregnant women clinic-based STI testing for HIV antibody and treponemal antibody (via lateral flow assay rapid tests provided by the Brazilian Government) and for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis (via polymerase chain reaction–based testing provided by Gene Xpert, Sunnyvale, CA) in 10 public prenatal health clinics in Porto Alegre. Participating women answered a brief survey via audio computer-assisted survey instrument regarding demographics, partnerships, and sexual behaviors. All infected individuals received appropriate treatment and referrals. Results Of 400 pregnant women recruited, 94 (24%) were diagnosed with an STI, including 2% with HIV, 11% with syphilis, 9% with chlamydia, 1% with gonorrhea, 5% with trichomoniasis, and 3% with more than 1 STI. In our multivariate analysis, younger age (adjusted odds ratio [AOR], 1.1; 95% confidence interval [CI], 1–1.2), being non-White (AOR, 1.8; 95% CI, 1.1–3.1), having less education (AOR, 2; 95% CI, 1.2–3.4), and having a relationship

Sexually transmitted infections (STIs) can adversely affect a woman's pregnancy and the health of the developing fetus. The source of these infections may be the male sexual partner who remains under-diagnosed and un-treated due to a combination of lack of symptoms, decreased access to health care, and poor health-seeking behaviors. From September 2018 to November 2019, we offered a cohort of pregnant women (gestational age range: 4.6-41 weeks) clinic-based STI testing for HIV and syphilis (via lateral flow assay rapid tests) and for Neisseria (N.) gonorrhoeae, Chlamydia (C.) trachomatis, and Trichomonas (T.) vaginalis (via PCR-based testing) at Santa Casa Hospital and 10 affiliated prenatal clinics in Porto Alegre, Brazil. 400 women between the ages of 18 and 46years (mean age: 27years) enrolled and 24% were diagnosed with an STI. Each woman enrolled agreed to invite their male partners to clinic for the same panel of STI testing, and 255 men (64%) between the ages of 18 and 64years (mean age: 29years) attended clinic and all accepted full intervention. In these male partners, 40 (16%) were diagnosed with an STI including 22 (8.7%) testing positive for C. trachomatis, 15 (6%) for treponemal antibody (syphilis), 7 (2.8%) for T. vaginalis, 3 (1.2%) for N. gonorrhoeae, and 1 (0.4%) for HIV antibody. In our multivariate analysis, having symptoms of an STI (AOR 4.5, 95% CI 1.3-15.2) and arguing about jealousy (AOR 3.1, 95% CI 1.2-8.2) remained significantly associated with male diagnosis of an STI. Sexually transmitted infections are common in sexual partners of pregnant women in Brazil and should be addressed to prevent reinfection of pregnant women.

This brief report presents transmission rates from a prospective study of 15 households with pediatric index cases of severe acute respiratory coronavirus-2 in Los Angeles County from December 2020 to February 2021. Our findings support ongoing evidence that transmission from pediatric index cases to household contacts is frequent but can be mitigated with practicing well-documented control measures at home, including isolation, masking and good hand hygiene.

Mucormycosis is a rare fungal infection that typically affects severely immunocompromised individuals, often resulting in significant morbidity and mortality. Although early and aggressive intervention is necessary to prevent poor outcomes, diagnosis of this infection remains difficult. We report the first case, to our knowledge, of invasive gastrointestinal mucormycosis initially identified by next-generation sequencing of cfDNA from the blood, and discuss the various benefits and challenges which come with new molecular diagnostic techniques.

Curable sexually transmitted infections in pregnant women may cause poor maternal and newborn outcomes worldwide. Syndromic management is practiced in many settings yet fails to identify most infections. Etiologic screening has promise, but further effectiveness and cost-effectiveness studies are needed. Supplemental digital content is available in the text., Background Sexually transmitted infections (STI), such as chlamydial, gonorrheal, and trichomonal infections, are prevalent in pregnant women in many countries and are widely reported to be associated with increased risk of poor maternal and neonatal outcomes. Syndromic STI management is frequently used in pregnant women in low- and middle-income countries, yet its low specificity and sensitivity lead to both overtreatment and undertreatment. Etiologic screening for chlamydial, gonorrheal, and/or trichomonal infection in all pregnant women combined with targeted treatment might be an effective intervention. However, the evidence base is insufficient to support the development of global recommendations. We aimed to describe key considerations and knowledge gaps regarding chlamydial, gonorrheal, and trichomonal screening during pregnancy to inform future research needed for developing guidelines for low- and middle-income countries. Methods We conducted a narrative review based on PubMed and clinical trials registry searches through January 20, 2020, guidelines review, and expert opinion. We summarized our findings using the frameworks adopted by the World Health Organization for guideline development. Results Adverse maternal-child health outcomes of potential interest are wide-ranging and variably defined. No completed randomized controlled trials on etiologic screening and targeted treatment were identified. Evidence from observational studies was limited, and trials of presumptive STI treatment have shown mixed results. Subgroups that might benefit from specific recommendations were identified. Evidence on harms was limited. Cost-effectiveness was influenced by STI prevalence and availability of testing infrastructure and high-accuracy/low-cost tests. Preliminary data suggested high patient acceptability. Discussion Preliminary data on harms, acceptability, and feasibility and the availability of emerging test technologies suggest that etiologic STI screening deserves further evaluation as a potential tool to improve maternal and neonatal health outcomes worldwide.

Hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients are at increased risk for Clostridioides difficile infection (CDI). We conducted a multicenter retrospective study to describe the incidence of CDI in children transplanted between January 2010 and June 2013. Nested case-control substudies, matched 1:1 by transplant type, institution, patient age, and time of year (quartile) of transplant, identified CDI risk factors. Cohorts included 1496 HCT and 1090 SOT recipients. Among HCT recipients, 355 CDI episodes were diagnosed in 265 recipients (18.2%). Nested case-control study identified prior history of CDI (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.7), proton pump inhibitors (PPIs; OR 2.1, 95% CI 1.3-3.4), and exposure to third- (OR 2.4, 95% CI 1.4-4.2) or fourth-generation (OR 2.1, 95% CI 1.2-3.7) cephalosporins as risk factors. Notably, fluoroquinolone exposure appeared protective (OR 0.6, 95% CI 0.3-0.9). Ninety-two episodes of CDI were diagnosed among 79 SOT recipients (7.3%), and exposure to PPIs (OR 2.4, 95% CI 1.1-5.4) and third-generation cephalosporin therapy (OR 3.9, 95% CI 1.4-10.5) were identified as risk factors. Strategies to decrease PPI use and changes in the class of prophylactic antibiotics may impact CDI incidence and warrant further study.

Male partner involvement in prenatal care has been shown to improve outcomes for the entire family in low- and middle income countries. In Brazil, partners of pregnant women are encouraged to attend prenatal care for HIV testing. From November 2016 to July 2017, male partners of women delivering at Hospital Conceiçao were interviewed using computer-assisted telephone interviews regarding individual, relationship and system-wide facilitators and barriers to attending prenatal care. Of 403 men interviewed, 202 attended prenatal care and 201 did not. Individual factors that predicted prenatal care attendance included over-estimating the risk of mother to child transmission (AOR 2.13, 95% CI: 1.35–3.4), and endorsing that HIV-infected individuals can live satisfying lives (AOR 7.24, 95% CI: 1.9–47.5). Partnership factors associated with attendance included invitation by partner (AOR 5.6, 95% CI: 2.4–15.6). Systemic factors negatively associated with prenatal care attendance included a history of not being able to afford medical care (AOR 0.3, 95% CI: 0.15–0.6) and identifying work as a barrier to prenatal care attendance (AOR 0.19 95% CI: 0.11–0.31). Partners should be actively invited to prenatal care during flexible flexible hours. Once involved, almost all would accept HIV and sexually transmitted infection (STI) testing to protect partners and unborn infants during this vulnerable period.

A 48-hour-old male infant born at 38+3/7 weeks’ gestation is transported from home via ambulance to the emergency department (ED) for poor feeding, lethargy, duskiness, and rhythmic twitching of lower extremities. The mother received prenatal care from a midwife. The pregnancy was complicated by a maternal genital herpes outbreak in the first trimester. The mother was given valacyclovir for viral suppression and no herpetic lesions are noted at delivery. Clear artificial rupture of membranes is performed by the midwife 5 hours before delivery and the infant is born via vaginal delivery into a water birthing tub with a disposable liner. Apgar scores are 7, 8, and 9 at 1, 5, and 10 minutes. The umbilical cord is not cut based on the parents’ request for umbilical nonseverance. The placenta is washed and dried, wrapped in muslin, and left attached to the infant until the midwife cuts the cord with sterilized scissors before transfer to the ED. Postnatal history is remarkable for poor feeding. The infant has difficulty latching on and receives supplemental formula as well as donor unpasteurized breast milk from a lactation consultant. On the morning of admission, the infant has perioral cyanosis and is unresponsive. In the ED, he is cyanotic with shallow respirations and is found to be hypothermic (rectal temperature of 95.3°F [35.2°C]), and hypoglycemic (peripheral blood glucose level of 15 mg/dL [0.83 mmol/L]) with multifocal clonic seizures. He is tachycardic, with a …

HIV-exposed uninfected (HEU) infants are a growing population with potentially poor health outcomes. We evaluated morbidity and mortality in HEU formula-fed infants enrolled in the NICHD HPTN 040/PACTG 1043 trial.Infectious morbidity, mortality and undernutrition were evaluated within a cohort of 1000 HEU infants enrolled between April 2004 and April 2010 in Brazil (n = 766) and South Africa (n = 234) as part of the NICHD/HPTN 040 trial of 3 different antiretroviral regimens to decrease intrapartum HIV vertical transmission.Twenty-three percent of infants had at least 1 infectious serious adverse effect. Infants born to mothers with12 years of education [adjusted odds ratio (AOR), 2.6; 95% confidence interval [CI], 1.2-5.9), with maternal viral load of1,000,000 copies/mL at delivery (AOR, 9.9; 95% CI, 1.6-63.1) were more likely to have infectious serious adverse effects. At 6 months, the infant mortality rate per 1000 live births overall was 22 ± 2.6, 9.1 ± 1.8 in Brazil and 64.1 ± 3 in South Africa. Undernutrition and stunting peaked at 1 month of age with 18% having a weight-for-age Z score ≤-2, and 22% with height for Z score ≤-2. The likelihood of infant mortality was greater among infants born in South Africa compared with Brazil (AOR, 6.2; 95% CI, 2.5-15.8), high maternal viral load (AOR, 1.7; 95% CI, 1.01-2.9) and birth weight-for-age Z score ≤-2 (AOR, 5.2; 95% CI, 1.8-14.8).There were high rates of undernutrition, stunting and infectious serious adverse effect in this study's formula-fed HEU population. Suppressing maternal HIV viral load during the peripartum period may be a modifiable risk factor to decrease infant mortality.

Author(s): Winter, Kathleen; Zipprich, Jennifer; Harriman, Kathleen; Murray, Erin L; Gornbein, Jeffrey; Hammer, Sandra Jo; Yeganeh, Nava; Adachi, Kristina; Cherry, James D | Abstract: BackgroundIn the current era, most pertussis deaths occur in infants l3 months of age. Leukocytosis with lymphocytosis and pneumonia are commonly observed among cases of severe pertussis.MethodsRisk factors associated with fatal pertussis were identified by comparing fatal pertussis cases among patients l120 days of age occurring from 1 January 1998 through 26 December 2014, matched by age (l120 days), county of residence, and closest symptom onset date with 1-4 nonfatal hospitalized cases. California Department of Public Health surveillance data were reviewed to identify cases; demographics, clinical presentation, and course were abstracted from corresponding birth and medical records. Logistic regression and classification tree analyses were used to examine the risk of fatal pertussis with respect to identified factors.ResultsFifty-three fatal infant pertussis cases were identified and compared with 183 nonfatal hospitalized pertussis cases. Fatal cases had significantly lower birth weight, younger gestational age, younger age at time of cough onset, and higher peak white blood cell (WBC) and lymphocyte counts. Fatal cases were less likely to have received macrolide antibiotics and more likely to have received steroids or nitric oxide and to develop pulmonary hypertension, seizures, encephalitis, and pneumonia. Additionally, exchange transfusion, extracorporeal membrane oxygenation, and intubation occurred significantly more frequently among fatal cases. In multivariate analyses, peak WBC count, birth weight, intubation, and receipt of nitric oxide were predictors of death.ConclusionsEarly recognition of pertussis in young infants and treatment with appropriate antibiotic therapy are important in preventing death. Several risk factors are strongly associated with fatal pertussis in infants.

Background Untreated syphilis during pregnancy is associated with spontaneous abortion, stillbirth, prematurity and infant mortality. Syphilis may facilitate HIV transmission, which is especially concerning in low- and middle-income countries where both diseases are common. Methods We performed an analysis of data available from NICHD/HPTN 040 (P1043), a study focused on the prevention of intrapartum HIV transmission to 1684 infants born to 1664 untreated HIV-infected women. This analysis evaluates risk factors and outcomes associated with a syphilis diagnosis in this cohort of HIV-infected women and their infants. Results Approximately, 10% of women (n=171) enrolled had serological evidence of syphilis without adequate treatment documented and 1.4% infants (n=24) were dually HIV and syphilis infected. Multivariate logistic analysis showed that compared with HIV-infected women, co-infected women were significantly more likely to self-identify as non-white (adjusted odds ratio [AOR] 2.5, 95% CI: 1.5-4.2), to consume alcohol during pregnancy (AOR 1.5, 95% CI: 1.1-2.1) and to transmit HIV to their infants (AOR 2.1, 95% CI: 1.3-3.4), with 88% of HIV infections being acquired in utero. As compared with HIV-infected or HIV-exposed infants, co-infected infants were significantly more likely to be born to mothers with venereal disease research laboratory titers≥1:16 (AOR 3, 95% CI: 1.1-8.2) and higher viral loads (AOR 1.5, 95% CI: 1.1-1.9). Of 6 newborns with symptomatic syphilis, 2 expired shortly after birth, and 2 were HIV-infected. Conclusion Syphilis continues to be a common co-infection in HIV-infected women and can facilitate in utero transmission of HIV to infants. Most infants are asymptomatic at birth, but those with symptoms have high mortality rates.

A 37-6/7-week-gestation male infant born via vaginal delivery is transferred to our institution on day 13 after birth for acute liver failure (ALF). The pregnancy was complicated by poor prenatal care, maternal depression triggered by partner infidelity, and upper respiratory symptoms 3 weeks before delivery. Maternal temperature of 39.4°C was noted 6 days before delivery, which was accompanied by a diagnosis of pyelonephritis and Trichomonas vaginitis. Prenatal laboratory values were negative, and no history of genital lesions was found. Labor was induced because of preeclampsia, with artificial rupture of membranes occurring 1 hour before delivery. The infant was discharged home on day 2 but was described as a “quiet” infant who rarely awoke to feed. On day 7, the patient had an isolated fever, with a temperature of 38.3°C that self-resolved and did not receive medical attention. On day 11, the infant exhibited a high-pitched cry and subsequently became apneic and floppy. He was admitted to an outside hospital, where he was noted to be hypothermic, with a temperature of 33.6°C; he had apnea requiring intubation and hypotension requiring dopamine. Workup revealed multiorgan failure, including ALF and renal dysfunction with disseminated intravascular coagulation. Laboratory findings were notable for an aspartate aminotransferase of 10,648 U/L (177.8 μkat/L), alanine aminotransferase of 2,196 U/L (36.7 μkat/L), international normalized ratio of 9.4, fibrinogen of less than 60 mg/dL (1.7 μmol/L), and platelets of 60 × 103/μL (60 × 109/L). Treatment …

BACKGROUND: The presence of antiretroviral drug-associated resistance mutations (DRMs) may be particularly problematic in human immunodeficiency virus (HIV)–infected pregnant women as it can lead to mother-to-child transmission (MTCT) of resistant HIV strains. This study evaluated the prevalence and the effect of antiretroviral DRMs in previously untreated mother-infant pairs. METHODS: A case-control design of 1:4 (1 transmitter to 4 nontransmitters) was utilized to evaluate DRMs as a predictor of HIV MTCT in specimens obtained from mother-infant pairs. ViroSeq HIV-1 genotyping was performed on mother-infant specimens to assess for clinically relevant DRMs. RESULTS: One hundred forty infants acquired HIV infection; of these, 123 mother-infant pairs (88%) had specimens successfully amplified using ViroSeq and assessed for drug resistance genotyping. Additionally, 483 of 560 (86%) women who did not transmit HIV to infants also had samples evaluated for DRMs. Sixty-three of 606 (10%) women had clinically relevant DRMs; 12 (2%) had DRMs against >1 drug class. Among 123 HIV-infected infants, 13 (11%) had clinically relevant DRMs, with 3 (2%) harboring DRMs against >1 drug class. In univariate and multivariate analyses, DRMs in mothers were not associated with increased HIV MTCT (adjusted odds ratio, 0.8 [95% confidence interval, .4–1.5]). Presence of DRMs in transmitting mothers was strongly associated with DRM presence in their infants (P < .001). CONCLUSIONS: Preexisting DRMs were common in untreated HIV-infected pregnant women, but did not increase the risk of HIV MTCT. However, if women with DRMs are not virologically suppressed, they may transmit resistant mutations, thus complicating infant management.

Background Providing HIV voluntary counseling and testing (VCT) to men who attend their partner's prenatal care is an intervention with potential to reduce HIV transmission to women and infants during the vulnerable period of pregnancy. Little is known about the acceptability of this intervention in global settings outside of Africa. Methods We conducted in-depth qualitative interviews to evaluate potential barriers and facilitators to prenatal care attendance for HIV VCT with 20 men who did and 15 men who did not attend prenatal care with their partners at Hospital Conceicao in Porto Alegre, Brazil. Men were recruited at the labor and delivery unit at Hospital Conceicao via a scripted invitation while visiting their newborn infant. Interviews lasted from 35-55 minutes and were conducted in Portuguese by a local resident trained extensively in qualitative methods. All interviews were transcribed verbatim, translated, and then analyzed using Atlast.ti software. An analysis of themes was then conducted using direct quotes and statements. We applied and adapted the AIDS Risk Reduction Theoretical Model and HIV Testing Decisions Model to the qualitative data to identify themes in the 35 interviews. Results If offered HIV testing during prenatal care, all men in both groups stated they would accept this intervention. Yet, individual, relationship and systemic factors were identified that affect these Brazilian men's decision to attend prenatal care, informing our final conceptual model. The men interviewed had a general understanding of the value of HIV prevention of mother to child transmission. They also described open and communicative relationships with their significant others and displayed a high level of enthusiasm towards optimizing the health of their expanding family. The major barriers to attending prenatal care included perceived stigma against HIV infected individuals, men's lack of involvement in planning of the pregnancy as well as inconvenient scheduling of prenatal care, due to conflicting work schedules. Conclusions Brazilian men displayed high levels of HIV-related knowledge as well as open communication about HIV testing; especially when compared to findings from African studies. Future efforts should reorient prenatal care towards providing care to the entire family with a clear focus on protecting the infant from preventable diseases. Formally inviting men to prenatal care and providing them an acceptable medical excuse from work may enhance male involvement.

1. Kristina Adachi, MD* 2. Colin L. Robinson, MD, MPH* 3. Nava Yeganeh, MD, MPH* 1. *Department of Pediatrics, David Geffen School of Medicine, UCLA, Los Angeles, CA. A 15-year-old previously healthy boy presents with 9 days of left ankle pain and 4 days of fever. He had sustained an ankle inversion injury from basketball and 4 days later was diagnosed with an ankle sprain. Six days after the initial injury, he again went to the emergency department with increasing ankle pain and low-grade fevers but was discharged following normal findings on radiographic evaluation. After 3 days of increasing ankle pain, swelling, redness, and fevers, he is admitted to our facility. On admission, he is noted to be febrile (38.3°C [100.9°F]) with tachycardia (heart rate 135 beats/min). Physical examination of his left lateral malleolus reveals a 3 × 3-cm area of necrotic-appearing skin and a 7 ×7-cm area of fluctuance with spontaneous, clear drainage (Figure). The erythema, warmth, swelling, and tenderness extend from his lateral malleolus to his mid-tibia. Figure. Erythematous, bullous, and necrotic-appearing skin over the left lateral malleolus. Laboratory studies demonstrate leukocytosis with a white blood cell count of 22,000 cells/μL (22 × 109/L) with 89% neutrophils and elevated inflammatory markers with an erythrocyte sedimentation rate (ESR) of greater than 100 mm/hr and C-reactive protein (CRP) of 24.4 mg/dL (2323.9 nmol/L). Magnetic resonance imaging demonstrates a diffuse abnormal distal tibial marrow …

Pregnant women have a significantly higher risk of HIV acquisition during gestation than their non-pregnant counterparts due to behavioral and biological factors. Acute seroconversion during gestation results in increased HIV mother-to-child transmission rates and has been identified as a major public health challenge. In order to address potential HIV seroconversion in our pregnant patients, we conducted a prospective cohort study to evaluate the acceptability of offering HIV testing to sexual partners of HIV-negative pregnant women receiving antenatal care at two hospitals in Porto Alegre, Brazil. Over a 14-month study period, HIV-negative pregnant women at two hospital-based clinic sites were encouraged to bring their stable sexual partner for HIV voluntary counseling and testing during prenatal care. Women were re-interviewed following delivery to measure success of the intervention. Of the 1223 HIV-negative pregnant women enrolled in the study, 663 (54%) of their male sexual partners received HIV testing during antenatal care and 4 (0.6%) were diagnosed with HIV infection. A total of 645 women were interviewed at the time of delivery, with 620 (97%) confirming that HIV testing was suggested to their partner. The most common reason provided by women as to why partners did not come for testing was work (69%) and lack of perceived risk (14%). Independent predictors of successful partner testing included being white (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.18-2.12), married (OR 1.78, 95% CI 1.08-2.94), having an older age of sexual debut (OR 0.94, 95% CI 0.9-0.98), and being recruited at Hospital Conceiçao (OR 2.1, 95% CI 1.52-2.88). We conclude that HIV partner testing during prenatal care is acceptable, rendering this intervention attractive to public health programs targeting prevention of sexually transmitted infections.

SummaryAudio computer-assisted survey instrument (ACASI) has been shown to decrease under-reporting of socially undesirable behaviours, but has not been evaluated in pregnant women at risk of HIV acquisition in Brazil. We assigned HIV-negative pregnant women receiving routine antenatal care at in Porto Alegre, Brazil and their partners to receive a survey regarding high-risk sexual behaviours and drug use via ACASI ( n = 372) or face-to-face (FTF) ( n = 283) interviews. Logistic regression showed that compared with FTF, pregnant women interviewed via ACASI were significantly more likely to self-report themselves as single (14% versus 6%), having >5 sexual partners (35% versus 29%), having oral sex (42% versus 35%), using intravenous drugs (5% versus 0), smoking cigarettes (23% versus 16%), drinking alcohol (13% versus 8%) and using condoms during pregnancy (32% versus 17%). Therefore, ACASI may be a useful method in assessing risk behaviours in pregnant women, especially in relation to drug and alcohol use.

Plague is a disease caused by Yersinia pestis. Septicemic and pneumonic plague have a high mortality rate if untreated. Here we describe the challenges of accurately diagnosing a nonfatal pediatric case of septicemic plague with involvement of multiple organs; to our knowledge, the first documented case of multifocal plague osteomyelitis.

1. Nurul I. Hariadi, MD* 2. Nava Yeganeh, MD† 3. Jennifer Dien Bard, PhD‡ 4. Natascha Ching, MD§ 1. *Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, MI. 2. †Department of Pediatrics, Division of Pediatric Infectious Diseases, UCLA Medical Center, Los Angeles, CA. 3. ‡Department of Pathology and Molecular Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada. 4. §Pediatric Infectious Diseases, ‘Specially For Children, Dell Children's Medical Center of Central Texas, Austin, TX. A previously healthy 5-year old boy passes white ribbonlike objects in a bowel movement that are removed in multiple segments (Fig. 1). The specimens are sent to the microbiology laboratory, and the patient is seen in the pediatric infectious diseases clinic. Before the episode, he had normal appetite with no abdominal pain, diarrhea, constipation, flatulence, cough, or any other constitutional symptoms. He complains of intermittent periumbilical pain after the episode but has no other symptoms. Figure 1. Multiple white ribbonlike segments measuring approximately to 3 to 10 in. Further questioning of the patient and family reveals sophisticated and adventurous eating habits. He has been eating raw fish for 1 year before presentation, including salmon and tuna sushi and sashimi. He eats rare beef and lamb and tries delicacies such as cooked crickets, ants, and scorpions. He has three cats with fleas and feeds Koi fish in a pond but has no contact with other animals. During recent travel to Sierra, California, he swam in a cave pond but did not drink its water. He also visited Kauai, Hawaii, 2 months ago but did not consume sushi, sashimi, or Hawaiian delicacies of raw fish there. Findings on his physical examination are normal, his weight is at the 25th percentile, and his height is between the 10th and 25th percentiles. Complete blood cell count reveals no evidence of anemia. The white blood cell count is 9.6×103/μL (9.6×109/L) with a normal differential count, hemoglobin is 13.0 g/dL (130 g/L), hematocrit is 38.2% (0.38), and platelet count is 258×103/μL (258×109/L). Mean corpuscular volume is 84.1 …

Background Male partner involvement in sub-Saharan Africa has been investigated and shown to improve outcomes for the entire family. However, little research is available in other regions. In Porto Alegre, Brazil, partners of pregnant women are encouraged to attend prenatal care for HIV voluntary counseling and testing (VCT) to decrease acute HIV serconversion during pregnancy. Uptake of this intervention has been sub-optimal. Methods From November 2016 to July 2017, 202 men who attended prenatal care at Hospital Conceicao and 201 men who did not attend prenatal care were interviewed using computer-assisted telephone interviews regarding individual, relationship and system-wide facilitators and barriers to attending prenatal care. Multivariate regression was performed to identify factors associated with male involvement in prenatal care. Results Of 403 men interviewed, 91% stated they had been invited to prenatal care, 94% of men stated they would accept HIV testing if offered, but only 50% attended. Men identified making their partner happy as the most important facilitator for prenatal care attendance, and having to miss work as the most significant barrier. Frequency of commonly identified barriers and facilities are indicated by Figure 1. Individual factors that predicted prenatal care attendance included over-estimating the risk of mother-to-child transmission (AOR 2.1 95% CI 1.3–3.3), and endorsing that HIV-infected individuals can live satisfying lives (AOR 7.8, 95% CI 2.1–50.8). Partnership factors associated with attendance included being invited by partner (AOR 5.6, 95% CI 2.4–15.6), whereas admitting jealous behavior was negatively associated with attendance (AOR 0.82 95% CI 0.7–0.97). Systemic factors negatively associated with prenatal care attendance included a history of not affording medical care (AOR 0.28, 95% CI 0.15–0.55) and identifying work as a barrier (AOR 0.19 95% CI 0.11–0.31). Conclusion Involvement of male partners during pregnancy may be enhanced by providing free care during flexible hours. Partners should be actively invited to prenatal care as once involved, almost all would accept HIV VCT and other interventions to protect partners and infants from HIV and other sexually transmitted diseases during this vulnerable period. Disclosures All authors: No reported disclosures.

A 23-month-old girl with relapsed acute myeloid leukemia (AML) was admitted in partial remission for matched-unrelated donor umbilical cord stem cell transplantation. She received intense pretransplant conditioning with cytarabine (on day 11 pretransplant [here referred to as day −11] to day −6

Background Detection of antiretroviral (ARV) resistance in HIV-infected individuals is not uncommon and may be particularly problematic in HIV-infected pregnant women as it can lead to infant infection with resistant strains. To better evaluate the effect of drug resistance mutations (DRMs) on HIV mother-to-child transmission (MTCT), we determined the prevalence of DRMs in a subset of mother–infant pairs enrolled in a multi-center trial of infant prophylaxis among women not receiving ARVs during the current pregnancy. Methods A case–control design of 1:4 (1 transmitter to 4 nontransmitters) was utilized to evaluate ARV resistance as a predictor of HIV MTCT in specimens obtained from mother–infant pairs. Secondary objectives included identification of potential risk factors associated with the presence of DRMs. Viroseq HIV-1 Genotyping System was performed on mother–infant specimens to assess for mutations that might result in a substantial reduction in drug susceptibility and clinical outcome, as determined by the Stanford HIV Drug Resistance Database. Results One hundred and forty infants were infected. Of these, 123 HIV infected mother–infant pairs and 483 of 560 women who did not transmit HIV had amplifiable HIV nucleic acid enabling ARV resistance testing. A wide variety of DRMs were detected (Figure 1). Sixty (10%) of 606 women had clinically relevant DRMs; 12 (2%) had DRMs against more than 1 ARV class. Among 123 HIV− infected infants, 13 (11%) had clinically relevant DRMs with 3 (2%) harboring DRMs against more than 1 ARV class. Of 13 infants with DRMs, 10 (77%) were infected in utero. In univariate and multivariate analyses, DRMs in mothers were not associated with increased risk of HIV MTCT (AOR 0.79, 95% CI 0.38–1.5). Log HIV viral load was the only predictor of MTCT (OR 1.4, 95% CI 1.2−1.6). The presence of DRMs in mothers who transmitted was strongly associated with the presence of DRMs in infants (P Conclusion In infected pregnant women without ARV exposure during their current gestation, the presence of pre-existing DRMs with a wide diversity was noted. DRMs do not increase the risk of HIV MTCT. However, if women with DRMs are not virologically suppressed they are likely to transmit resistant mutations even without selective ARV pressure, thus complicating treatment options. Disclosures All authors: No reported disclosures.

We report the first pediatric case of enteric fever caused by Salmonella enterica serotypes Typhi and Paratyphi A. Mixed infections are infrequently reported, potentially because detection of two different Salmonella serotypes in blood cultures is technically challenging. We suggest laboratory strategies to aid in the recognition of mixed infections.

In order to understand antiretroviral resistance during pregnancy and its impact on HIV vertical transmission, we performed a cross-sectional analysis of 231 HIV-infected pregnant women who fulfilled Brazilian guidelines for antiretroviral testing and had antiretroviral genotypic testing performed between April 2010 and October 2012. At entry into prenatal care, the mean CD4 cell count for this cohort of patients was 406 cells/mm3 (95% CI: 373–438 cells/mm3), while the mean HIV RNA was 24,394 copies/ml (95% CI: 18,275–30,513 copies/ml). Thirty-six women (16%) had detectable antiretroviral-resistant mutations. By 34 weeks gestation, 75% had achieved HIV RNA 3 was eight times that of subjects with CD4 cell counts >500 CD4 cells/mm3 (95% CI 1.5–42.73). Six infants were HIV infected, four born to mothers with detectable viraemia at 34 weeks and two born to mothers who were lost to follow up. Antiretroviral resistance is common in prenatal care but did not increase vertical transmission if viral load was appropriately suppressed. Genotyping should be considered in Brazil in order to assist initiation of appropriate combination antiretroviral therapy during pregnancy to suppress viral load to avoid vertical transmission.

BACKGROUND: Women in Brazil are routinely tested for HIV-1 during pregnancy with rapid testing repeated during labor in some settings. Partner testing is not routinely offered. The peripartum period provides opportunity for HIV testing of couples. METHODS: A cross-sectional study was conducted in a large public hospital in southern Brazil. HIV rapid testing was offered to all pregnant women in labor. Male partners of women who consented to partner inclusion were offered testing. Within HIV-serodiscordant couples HIV-negative individuals were evaluated for the delta-32 base-pair CCR5 deletion allele. RESULTS: From February to September 2009 2888 women delivered with 1729 eligible women approached for study participation; 1648 (95%) HIV-negative women consented to partner testing and 66% of partners accepted testing. Seven HIV-infected men (0.6%) with no prior diagnosis were identified. Testing strategies uncovered 7 additional serodiscordant couples 4 HIV-infected women diagnosed at delivery and 3 HIV-infected men who had not disclosed their status to their partners for a total serodiscordance rate of 1.3% in 1101 couples. No cases of acute maternal or infant infection were noted. No delta-32 base-pair deletions were identified in 14 HIV-negative partners in serodiscordant relationships. Parameters associated with increased acceptance of partner testing included higher income (P = 0.003) education (P < 0.0001) stable relationships of longer duration (P = 0.001) and female support of partner testing (P < 0.0001). CONCLUSIONS: Testing of couples at the time of labor and delivery is a feasible public health strategy in areas of moderate-to-high HIV prevalence which can potentially prevent acute infections in men women and infants.

Recent studies suggest that acquisition of HIV-1 infection during pregnancy and breastfeeding is associated with a high risk of HIV mother-to-child transmission. This study evaluates risk factors associated with HIV acquisition during pregnancy in women delivering at a large metropolitan medical facility located in the south of Brazil. From February to August 2009, our group conducted a cross-sectional study assessing women’s risk for HIV acquisition by administering an oral survey to peripartum women. Of 2465 participants, 42% (n=1046) knew that partner had been tested for HIV. During pregnancy, 82% (n=2022) of participants never used condoms; yet 97% (n=2399) practiced vaginal sex. Multivariate logistic regression analysis showed that patients with more years of education, in a relationship for more than 1 year, and who knew their own HIV status were more likely to know their partners' HIV status (P<0.05). Those who were in relationship for more than 1 year and were married/living together were more likely to be comfortable discussing HIV testing with partners (P<0.05). In conclusion, women in Brazil are at risk of HIV-infection during pregnancy as they remain sexually active, often do not know their sexual partner’s HIV status, and have minimal condom use.

Answer: Methylobacterium fujisawaense. The organism was identified as Methylobacterium fujisawaense. The pink-pigmented nonfermenters (PPNFs) include Asaia, Azospirillum, Methylobacterium, and Roseomonas species. Roseomonas colonies are typically larger than those of Methylobacterium, and Gram