Cryptococcus neoformans primarily affects immunocompromised individuals and the central nervous system (CNS) is the most common site of dissemination. Entrapped temporal horn syndrome (ETH) remains a rare CNS manifestation and has not previously been described in solid organ transplant recipients. Here, we present a case of ETH in a 55-year-old woman with history of renal transplant and prior treated Cryptococcal meningitis.

Meningitis and encephalitis are potentially life-threatening diseases with a wide array of infectious, postinfectious, and noninfectious causes. Diagnostic testing is central to determining the underlying etiology, treatment, and prognosis, but many patients remain undiagnosed due to suboptimal testing and lack of tests for all pathogens. In this article, we summarize the epidemiology, barriers to diagnosis, and current best tests for meningitis and encephalitis in developed countries. We end with a brief discussion of new test methods, such as multiplex panel-based tests and metagenomic sequencing, which are likely to alter diagnostic strategies for these conditions in the near future.

Liver disease causes relative compromise of the host immune system through multiple overlapping mechanisms and is an established risk factor for invasive fungal diseases including candidiasis and cryptococcosis. This immunologic derangement also leads to rapid progression of disease with resultant increases in morbidity and mortality. We describe severe coccidioidomycosis cases in the setting of liver dysfunction. Collaborative multi-center epidemiologic studies should be performed to determine the incidence of severe coccidioidomycosis in patients with concurrent liver disease.

Clonorchis sinensis, a trematode prevalent in East Asia, causes hepatobiliary infection. Exposure typically occurs through ingestion of raw or undercooked fish containing the encysted larval form of the parasite. Extrahepatobiliary disease has not commonly been described. In this case report, we describe an unusual case of C. sinensis infection associated with eosinophilic pneumonia. A middle-aged man from China presented with subacute cough and was found to have a bilateral diffuse eosinophilic pneumonia with associated peripheral eosinophilia. Stool microscopy revealed C. sinensis eggs, and the patient improved after treatment with prednisone and praziquantel. Pulmonary clonorchiasis should be considered in patients with eosinophilic pneumonia from areas highly endemic for this pathogen.

Background

The 2019 novel coronavirus infectious disease (COVID-19) pandemic resulted in a surge of assays aimed at detecting severe acute respiratory syndrome (SARS) - coronavirus (CoV) - 2 infection and prior exposure. Although both molecular and antigen testing have clearly defined uses, the utility of serology remains uncertain and is presently not recommended for assessing immunity.

Methods

We conducted a pragmatic, observational study evaluating four commercially available emergency use authorized laboratory-based COVID-19 serology assays (Assays A-D). Remnant samples from hospitalized, and non-hospitalized SARS-CoV-2 PCR positive patients, as well as vaccinated and unvaccinated individuals were collected and tested. Positive percent agreement (PPA) and negative percent agreement (NPA) were calculated. Antibody concentrations were compared across the platforms and populations.

Results

A total of 588 remnant samples derived from 500 patients were tested. PPA at 5-12 weeks post-PCR positive results for Assays A-D was 98.3, 97.4, 99.2, and 95.8% respectively. NPA was 100% across all platforms. Mean antibody concentrations at 2-4 weeks post-PCR positive result were significantly higher in hospitalized versus non-hospitalized patients, respectively, for Assay A (131.8 [101.7] vs. 95.6 [100.3] AU/mL, P < 0.001), B (61.7 [62.4] vs. 38.1 [40.5] AU/mL, P < 0.001), and C (157.6 [105.3] vs. 133.3 [100.7] AU/mL, P < 0.001). For individuals receiving two vaccine doses mean antibody concentrations were respectively 169.6 (104.4), 27.3 (50.8), 189.6 (120.9), 21.19 (13.1) AU/mL for Assays A-D.

Conclusions

Overall, PPA and NPA differed across the four assays. Assays A and C produced higher PPA and NPA and detected larger concentrations of antibodies following vaccination.

Abstract

Background

Skin and soft-tissue infections (SSTI) account for 2.4 million annual U.S. emergency department (ED) visits. A majority of physicians give empiric antibiotic treatment that is non-compliant with guidelines, leading to potential patient harm and fueling the emergence of antibiotic resistance. The ED is a deserving focus of antimicrobial stewardship yet interventions have not been well studied in this setting.

Methods

Quasi-experimental study of a multifaceted antimicrobial stewardship intervention at an academic ED in a setting of high prevalence of clindamycin resistance among S. aureus. Our intervention included educational presentations by a physician champion, implementation of an electronic order set based on 2014 IDSA guidelines, dissemination of an ED specific S. aureus wound isolate antibiogram, monthly departmental peer-comparisons, and bimonthly, confidential, individual audit and feedback. Visits with ICD-10 codes for cutaneous abscess or other SSTI for patients discharged to home from the ED for consented providers were included for analysis. Primary endpoint of antibiotic selection and treatment duration was assessed during the pre-intervention and intervention periods using contingency tables for categorical outcome and a linear regression model for clustered survey data for comparing mean durations.

Results

Seventy-four consented providers’ data were included, accounting for 310 patient visits over the baseline (Oct 15-Mar 16) and 315 visits over the intervention period (Oct 16-Mar 17). Mean antibiotic duration decreased from 9.5 to 6.5 days, a difference (95% CI adjusted for provider cluster effects) of -3.0 (-0.6, -5.3) days. Among patients discharged with a diagnosis of abscess, the use of >2 antibiotics declined from 12% (15/125) in the baseline to 4% (4/110) in the intervention period. The relative frequency of clindamycin use decreased from 59% to 23%. Among patients discharged with a diagnosis of cellulitis, cephalexin use increased from 22% to 42%, with clindamycin use declining from 58% to 28%.

Conclusion

Our ED specific antibiotic stewardship program successfully reduced antibiotic duration and improved guideline adherence in discharged patients with SSTI. Similar implementation strategies should be assessed in a wider variety of settings.

Disclosures

All authors: No reported disclosures.

Objectives

To provide a descriptive analysis for species identification of culture and Gram stain results from ultrasound transducers and multiuse ultrasound transmission gel bottle tips in active clinical use and to compare bacterial cultures from ultrasound transducers before and after aseptic cleansing.

Methods

A prospective blinded descriptive analytic study of 18 distinct clinical care sites within a single primary clinical institution was conducted. Before and after a disinfectant towel cleanse, transducers were pressed against tryptic soy agar contact plates. Plates were deidentified and submitted for blind incubation, Gram staining, and species identification with microsequencing. Results were classified as clinically relevant (CR) or non-clinically relevant. In total, 188 samples were analyzed: 80 from ultrasound transducers before and cleansing, 13 from multiuse gel bottle tips before and after cleansing, and 2 precleansing samples from the data collector's pen and badge.

Results

Fifty-nine precleansing samples (73.8%) grew cultures with CR bacteria, and 21 samples (26.3%) did not. Staphylococcus simulans represented 31.0% of all positive culture samples. Thirteen postcleansing samples (16.3%) grew cultures with CR bacteria, equating to a 78.0% reduction of CR bacterial growth (likelihood ratio, 57.10; P < .001).

Conclusions

Ultrasound transducers have a notable CR bacterial burden and may serve as potential infective vectors. Aseptic cleansing effectively eliminates most of the bacterial load from ultrasound transducers, but some bacteria persist, presenting a risk of nosocomial infection with ultrasound-guided interventions. These findings support American Institute of Ultrasound in Medicine 2018 guidelines intended to ensure an appropriate level of transducer preparation based on the examination type while emphasizing rational infection control measures to minimize the risk of potential patient harm.

Background

High rates of asymptomatic infections with COVID-19 have been reported.

Objective

We aimed to describe an asymptomatic COVID-19 testing protocol in a pediatric emergency department (ED).

Methods

This was a retrospective cohort study of pediatric patients (younger than 18 years) who were tested for COVID-19 via the asymptomatic testing protocol at a single urban pediatric ED between May 2020 and January 2021. This included all pediatric patients undergoing admission, urgent procedures, and psychiatric facility placement. The primary outcome was the percentage of positive COVID-19 tests. COVID-19 testing was performed via real-time polymerase chain reaction RNA assay testing. County-level COVID-19 data were used to estimate local daily COVID-19 cases/100,000 individuals (from all ages). Data were described with simple descriptive statistics.

Results

There were 1459 children tested for COVID-19 under the asymptomatic protocol. Mean ± standard deviation age was 8.2 ± 5.8 years. Two tests were inconclusive and 29 (2.0%; 95% confidence interval [CI] 1.3-2.8%) were positive. Of the 29 positive cases, 14 (48%; 95% CI 29-67%) had abnormal vital signs or signs and symptoms of COVID-19, on retrospective review. A total of 15 truly asymptomatic infections were identified. On the days that asymptomatic cases were identified, the lowest average daily community rate was 7.67 cases/100,000 individuals.

Conclusions

Asymptomatic COVID-19 positivity rates in the pediatric ED were low when the average daily community rate was fewer than 7.5 cases/100,000 individuals. In the current pandemic, ED clinicians should assess for signs and symptoms of COVID-19, even when children present to the ED with unrelated chief symptoms.

We estimate the environmental and public health benefits that may be realized if solar energy cost reductions continue until solar power is competitive across the U.S. without subsidies. Specifically, we model, from 2015 to 2050, solar power–induced reductions to greenhouse gas (GHG) emissions, air pollutant emissions, and water usage. To find the incremental benefits of new solar deployment, we compare the difference between two scenarios, one where solar costs have fallen such that solar supplies 14% of the nation's electricity by 2030 and 27% by 2050, and a baseline scenario in which no solar is added after 2014. We monetize benefits, where credible methods exist to do so. We find that under these scenarios, solar power reduces GHG and air pollutants by ∼10%, from 2015 to 2050, providing a discounted present value of $56–$789 billion (central value of ∼$250 billion, equivalent to ∼2 ¢/kWh-solar) in climate benefits and $77–$298 billion (central value of $167 billion, or ∼1.4 ¢/kWh-solar) in air quality and public health benefits. The ranges reflect uncertainty within the literature about the marginal impact of emissions of GHG and air pollutants. Solar power is also found to reduce water withdrawals and consumption by 4% and 9%, respectively, including in many drought-prone states.