Doxycycline Prophylaxis for Skin and Soft Tissue Infections in Naval Special Warfare Trainees, United States1

In 2015, several severe cases of skin and soft tissue infection (SSTI) among US Naval Special Warfare trainees prompted the introduction of doxycycline prophylaxis during the highest-risk portion of training, Hell Week. We performed a retrospective analysis of the effect of this intervention on SSTI incidence and resulting hospital admissions during 2013-2020. In total, 3,371 trainees underwent Hell Week training during the study period; 284 SSTIs were diagnosed overall, 29 of which led to hospitalization. After doxycycline prophylaxis was introduced, admission rates for SSTI decreased from 1.37 to 0.64 admissions/100 trainees (p = 0.036). Overall SSTI rates remained stable at 7.42 to 8.86 SSTIs/100 trainees (p = 0.185). Hospitalization rates per diagnosed SSTI decreased from 18.4% to 7.2% (p = 0.009). Average length of hospitalization decreased from 9.01 days to 4.33 days (p = 0.034). Doxycycline prophylaxis was associated with decreased frequency and severity of hospitalization for SSTIs among this population.

Risk factors for acute mountain sickness in travellers to Cusco, Peru: coca leaves, obesity and sex

BACKGROUND

Acute mountain sickness (AMS) may occur after rapid ascents to altitudes >2500 m. Cusco (3350 m) in Peru is a popular destination for altitude inexperienced travellers. This study aimed at evaluating the incidence and risk factors for AMS among a cohort of foreign Spanish language students in Cusco.

METHODS

We performed a cohort study among young healthy foreign Spanish language students arriving to Cusco between 2012 and 2016. Consenting students answered an enrollment questionnaire on demographics, travel history and intended AMS preventive behaviour within 48 h of arrival. At 4-5 days after enrollment participants answered a second questionnaire about actual preventive behaviour before symptoms and the development of symptoms compatible with AMS during their first 48 h in Cusco. We used the 2018 Lake Louise Scoring System for AMS diagnosis. Participants with headache and a score ≥ 3 were considered to have AMS.

RESULTS

We enrolled 142 language students, the median age was 21 years (interquartile range 20-25) and 57% were female. Participants decreased physical activity (38%), increased fluid intake (34%), drank coca leaf tea (34%), took acetazolamide (16%) and acclimatized at a lower altitude (6%) to prevent AMS. Thirty-nine percent had AMS. In the multivariate analysis, obesity [odds ratio (OR) 14.45 (2.33-89.6)] and female sex [OR 4.32 (1.81-10.28)] were associated with increased risk of AMS. Taking acetazolamide [OR 0.13 (0.03-0.56)] was associated with decreased AMS risk. Consumption of coca leaf tea was not associated with decreased risk of AMS.

CONCLUSIONS

In our cohort, AMS affected two out of five travellers. Obesity and female sex were associated with increased risk. Drinking coca leaf tea for prevention did not decrease the risk of AMS. Acetazolamide prophylaxis was associated with decreased risk of AMS.

TaqMan Array Card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travellers' diarrhoea†

BACKGROUND

We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travellers' diarrhoea (TD)-associated pathogens by using a quantitative Polymerase Chain Reaction (PCR) assay [customized TaqMan® array card (TAC)] in a prospective, observational cohort of travellers.

METHODS

Enrolled travellers documented symptoms on a travel diary and collected an FTA Card during a diarrhoeal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios were used to determine the association between detected pathogens and TD.

RESULTS

Of 2456 travellers, 484 (19.7%) completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1-4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95% CI: 52.5-64.8). Enterotoxigenic Escherichia coli was the most common pathogen in TD cases (26.8%), and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls were 5.4 (95% CI: 3.6-8.1) and 2.0 (95% CI: 1.1-3.7) in 121 matched TD and loose stool cases (P < 0.05). Enteroaggregative E. coli was the most common pathogen detected in asymptomatic controls and loose stool cases. Detection of diarrhoeagenic E. coli, Shigella/enteroinvasive E. coli and Campylobacter spp. was significantly associated with TD.

CONCLUSION

FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.

632. A Randomized, Placebo-Controlled, Double-Blind, Clinical Trial Evaluating Two Dose Regimens of Rifaximin (550mg daily or twice-daily) for Chemoprophylaxis Against Travelers’ Diarrhea Among Deployed U.S. and U.K. Military Personnel (PREVENT TD)

Background

Travelers’ diarrhea (TD) is a leading threat to military readiness. Most trials of rifaximin chemoprophylaxis involve civilians or short-duration travel, whereas military travelers are exposed for longer periods at austere locations and are often physically taxed. We sought to assess efficacy of two regimens among military personnel deployed overseas.

Methods

This was a multi-site, double-blind, placebo-controlled trial of deployed military, randomized to placebo, rifaximin 550 mg daily, or rifaximin 550 mg twice-daily, for up to 42 days (1:1:1; 6 randomizations/block). Diaries were reviewed with subjects on return. Primary endpoint was time to first unformed stool (TFUS) in a TD episode. Other endpoints were assessed by intention to treat (ITT) and subgroups included incidence of any loose stool, meeting criteria for TD, safety, efficacy, adherence and impact to activity endpoints.

Results

343 subjects were included in the ITT population. All UK travelers deployed to a single-site in Kenya; US travelers mostly deployed to various Asia-Pacific locations. Of 73 (21.2%) subjects reporting diarrhea, 42 (57.5%) met TD criteria. Among rifaximin-treated subjects, 15.9% (n=17) reported diarrhea in the twice-daily arm, 20.7% (n=25) in the daily arm, vs. 27.0% (n=31) of placebo recipients; p=.04 and 0.26 respectively. TD was reported by 10.3% (n=11) and 10.7% (n=13) in the daily and twice-daily arms, vs. 15.7% (n=18) among placebo recipients; p=0.24 vs. 0.26 respectively. Among UK personnel, a twice-daily regimen vs. placebo resulted in significantly fewer TD episodes (1.6% vs. 11.9%; p=0.03). Adverse events were similar between groups.

Table 1: Demographics, endpoints, and adverse events (Comparisons are across placebo vs. each dosing regimen. Intent-to-treat [ITT] population defined as subjects enrolled into the study, randomized, travelled and had follow-up. p-values calculated from chi-square or Fisher’s exact test [categorical variables] and Wilcoxon-Mann-Whitney test [continuous variables]. Analyses performed on SAS v9.4. BID: twice-daily)

Conclusion

This is the first trial comparing two high-dose regimens of rifaximin prophylaxis in deployed personnel. Unlike prior reports, neither regimen was associated with an overall significant decrease in TD, potentially due to low overall TD incidence. However, the twice-daily regimen was associated with a numerically lower incidence of diarrheal stool, and in the UK subject group, there was a significant decrease of both TD and diarrheal stool. The impact of variability in regional TD risk, pathogen distribution and adherence in austere deployment environments on efficacy will be reviewed.

Disclosures

All Authors: No reported disclosures

207. Travel Related Risk Behaviors and Antibiotic Use among Older Travelers

Background

Older travelers (≥ 60 years) are a unique risk population for travel related infections and adverse events from antibiotics. We evaluated the differences in travel characteristics, exposures, illnesses and antibiotic use among older travelers and those between 18 – 59 y using a prospective, observational cohort of US Department of Defense (DoD) beneficiaries traveling outside the US for ≤ 6.5 months (TravMil).

Methods

Adult DoD beneficiaries were enrolled pre-travel. Itineraries limited to Western/Northern Europe, Canada, or New Zealand and active duty personnel on military travel were excluded. Demographics, itineraries and prescriptions were abstracted. A post-travel survey collected information on exposures and illnesses (travelers’ diarrhea (TD), influenza-like illness (ILI) or febrile illness). Categorical variables were analyzed using chi-square or Fishers exact test and the Mann-U Whitney test was used for continuous variables.

Results

Of the 1468 travelers, 755 were ≥ 60y and 719 were < 60y. Asia (35%) and South/Central America (28%) were the most common travel regions. Older travelers were more likely to be Caucasian (80% vs. 67%), male (52% vs. 39%) and travel for tourism (84% vs. 51%) (p< 0.05). Younger travelers were more likely engage in risk behaviors (e.g. consume poorly cooked meat or seafood (16% vs 9%) or street vendor food (26% vs 8.6%), wade in fresh water (24% vs. 18%), and non-compliance with malaria prophylaxis (22% vs 12%) (p< 0.05). Older travelers had a lower incidence of TD (18% vs 24%), and a higher proportion of cases with loose stool or mild TD that did not interfere with daily activities (63% vs. 51%) (p< 0.05). Inappropriate antibiotic use for loose stool or mild TD were similar among the two age groups (67% vs 59%). Non-significant trends of lower incidence and mild infections were observed for ILI and febrile illness in older travelers.

Conclusion

Older travelers were less likely to engage in risk behaviors, had a lower TD incidence and reported mild diarrheal symptoms. Inappropriate antibiotic use for loose stool or mild TD was common in both age groups. Enhancing antibiotic stewardship is important for older travelers to prevent potential side effects, drug interactions and antibiotic resistance.

Disclosures

All Authors: No reported disclosures

Fecal Contamination of Drinking Water Was Associated with Diarrheal Pathogen Carriage among Children Younger than 5 Years in Three Peruvian Rural Communities

Drinking water contamination is a frequent problem in developing countries and could be associated with bacterial pathogen carriage in feces. We evaluated the association between the risk of drinking water and bacterial carrier status in children younger than 5 years in a cross-sectional study conducted in 199 households from three Peruvian rural communities. Fecal samples from children were screened for pathogenic Aeromonas, Campylobacter, and Vibrio species, as well as for Enterobacteriaceae, including pathogenic Escherichia coli. The drinking water risk was determined using E. coli as an indicator of contamination. Nineteen (9.5%) children were colonized with pathogens and classified as carriers, all without diarrhea symptoms. Of 199 drinking water samples, 38 (19.1%) were classified as very high risk because of high fecal contamination (> 100 E. coli/100 mL). Shared-use water sources, daily washing of containers, and washing using only water were associated with higher prevalence of bacterial carriage, whereas there was no association between households reporting boiling and chlorination of water and carrier status. The prevalence of carriage in children exposed to very high-risk water was 2.82 (95% CI: 1.21-6.59) times the prevalence of those who consumed less contaminated water, adjusted by the water source and daily washing. Our results suggest that household drinking water plays an important role in the generation of carriers with diarrheal pathogens. Our findings also highlight the importance of interventions to ensure the safety of drinking water. Further studies are needed to validate the observed association and determine its significance with respect to diarrhea in the community.

Validation of the T86I mutation in the gyrA gene as a highly reliable real time PCR target to detect Fluoroquinolone-resistant Campylobacter jejuni

BACKGROUND

Campylobacter jejuni is a leading cause of bacterial diarrhea worldwide, and increasing rates of fluoroquinolone (FQ) resistance in C. jejuni are a major public health concern. The rapid detection and tracking of FQ resistance are critical needs in developing countries, as these antimicrobials are widely used against C. jejuni infections. Detection of point mutations at T86I in the gyrA gene by real-time polymerase chain reaction (RT-PCR) is a rapid detection tool that may improve FQ resistance tracking.

METHODS

C. jejuni isolates obtained from children with diarrhea in Peru were tested by RT-PCR to detect point mutations at T86I in gyrA. Further confirmation was performed by sequencing of the gyrA gene.

RESULTS

We detected point mutations at T86I in the gyrA gene in 100% (141/141) of C. jejuni clinical isolates that were previously confirmed as ciprofloxacin-resistant by E-test. No mutations were detected at T86I in gyrA in any ciprofloxacin-sensitive isolates.

CONCLUSIONS

Detection of T86I mutations in C. jejuni is a rapid, sensitive, and specific method to identify fluoroquinolone resistance in Peru. This detection approach could be broadly employed in epidemiologic surveillance, therefore reducing time and cost in regions with limited resources.

741. TravMil Surveillance of Travel-Related Illness in a Prospective Cohort of US Military Beneficiaries, 2010–2018

Background

Increasing international travel places larger populations at risk for infections outside of their usual exposure. Deployed military personnel have unique risks for such infections. Our cohort’s rates of travelers’ diarrhea and influenza-like illness have been defined, but the rate of travelers with symptoms apart from a clinical syndrome has not. We present a survey of intra-travel symptoms of all travelers and confirmed diagnoses of ill-returned travelers in a cohort of military and civilian travelers.

Methods

TravMil is a prospective, multicenter observational study enrolling US military beneficiaries traveling outside the continental United States from 2010–2018; beneficiaries could also enroll after travel if they presented for a possible travel-related illness. Demographic information, intra-travel symptoms, and confirmed diagnoses were recorded.

Results

2671 travelers embarked on 3050 trips: 63.1% male; median age 38 years (IQR 27, 57); median trip duration 20 days (IQR 13, 46). Common purposes of travel: military deployment (45.9%), vacation (23.7%), and visiting friends/relatives (10.9%). Ninety-seven travelers (3.2%) enrolled post-travel. Top regions of travel: Africa (31.5%), South and Central America/Caribbean (25.5%), and Southeast and North Asia/Oceania (19.4%). During travel, 56.6% experienced gastrointestinal (GI) symptoms, 11.9% respiratory symptoms, and 3.0% fever; of those, 10.3% sought medical care. Eighty returned travelers sought medical care (21 prospective enrollees vs. 59 post-travel enrollees): 5 vs. 17 malaria cases, 3 vs. 16 arbovirus infections, and 6 vs. 14 GI syndromes. All malaria cases in prospective enrollees were in military subjects. Post-travel enrollees accounted for 1 acute human immunodeficiency virus and 3 rickettsial infections.

Conclusion

A majority of our travelers experienced symptoms during travel. Post-travel diagnoses, although uncommon, emphasize needed improvements in the application of known risk mitigation strategies. Our findings can help clinicians optimize their pretravel counseling by focusing education on self-treatment of common travel-related symptoms, prevention of GI, arthropod-borne, and respiratory illness, and emphasizing symptoms that should prompt medical care.

Disclosures

All authors: No reported disclosures.

Extensively drug-resistant (XDR) Pseudomonas aeruginosa identified in Lima, Peru co-expressing a VIM-2 metallo-β-lactamase, OXA-1 β-lactamase and GES-1 extended-spectrum β-lactamase

Introduction

Pseudomonas aeruginosa has the ability to acquire plasmids and other mobile genetic elements that confer resistance to antibiotics. Bacterial genes encoding different β-lactamases (bla), such as metallo-β-lactamases (MBLs) and extended-spectrum β-lactamases (ESBL), can confer resistance to multiple classes of β-lactam antibiotics.

Case presentation

An 83 year old female was admitted in 2012 to the Peruvian Naval Hospital, Centro Médico Naval 'Cirujano Mayor Santiago Távara' (CEMENA), in Lima, Peru. A midstream urine sample was collected and sent to the local CEMENA laboratory for routine urine culture. P. aeruginosa was isolated and initial antibiotic susceptibility testing showed it to be sensitive to imipenem. The clinicians started a course of meropenem, but the patient did not improve. After 5 days, a second urine culture was performed and a P. aeruginosa was isolated again, but this time the strain showed resistance to imipenem. The treatment course was changed to fosfomycin and the patient improved. Phenotypic and molecular laboratory testing to characterize the antibiotic resistance were performed, demonstrating the presence of both MBL and ESBL genes.

Conclusion

To our knowledge, this is the first report of a P. aeruginosa XDR clinical isolate that co-expresses an MBL (VIM-2), OXA-1 beta-lactamase and the ESBL (GES-1) in Peru. It is also the first report of a VIM carbapenemase in Peru.

An Improved Enzyme-Linked Immunoassay for the Detection of Leptospira-Specific Antibodies

Leptospirosis is a neglected zoonotic disease with worldwide endemicity and continues to be a significant public health burden on resource-limited populations. Previously, we produced three highly purified recombinant antigens (rLipL32, rLipL41, and rLigA-Rep) and evaluated their performance of detecting Leptospira-specific antibodies in enzyme-linked immunosorbent assay (ELISA) as compared with the microscopic agglutination test (MAT). The overall sensitivity of this assay approached 90%. Recently, another recombinant antigen (rLigB-Rep) was prepared. We tested each individual antigen and a 1:1:1:1 mixture of these four antigens for the detection of Leptospira-specific antibodies in ELISA. The performance of these recombinant antigens was evaluated with a much larger febrile patient panel (337 MAT-confirmed positive sera and 92 MAT-negative sera from febrile patients). Combining the detection results of immunoglobulin M and immunoglobulin G from these four individual antigens, the overall sensitivity was close to 90% but the specificity was only 66%, based on the MAT reference method. The overall sensitivity and specificity of the four-antigen mixture were 82% and 86%, respectively. The mixture of four antigens also exhibited a broader reactivity with MAT-positive samples of 18 serovars from six major pathogenic Leptospira species. Given the limitations of MAT, the data were further analyzed by Bayesian latent class model, showing that ELISA using a 1:1:1:1 mixture still maintained high sensitivity (79%) and specificity (88%) as compared with the sensitivity (90%) and specificity (83%) of MAT. Therefore, ELISA using a mixture of these four antigens could be a very useful test for seroprevalence studies.

Case-Case Analysis Using 7 Years of Travelers' Diarrhea Surveillance Data: Preventive and Travel Medicine Applications in Cusco, Peru

AbstractIn Cusco, Peru, and South America in general, there is a dearth of travelers' diarrhea (TD) data concerning the clinical features associated with enteropathogen-specific infections and destination-specific risk behaviors. Understanding these factors would allow travel medicine providers to tailor interventions to patients' risk profiles and travel destination. To characterize TD etiology, evaluate region-specific TD risk factors, and examine relationships between preventive recommendations and risk-taking behaviors among medium- to long-term travelers' from high-income countries, we conducted this case-case analysis using 7 years of prospective surveillance data from adult travelers' presenting with TD to a physician in Cusco. At the time of enrollment, participants provided a stool sample and answered survey questions about demographics, risk behaviors, and the clinical features of illness. Stool samples were tested for norovirus (NV), bacteria, and parasites using conventional methods. Data obtained were then analyzed using case-case methods. NV (14%), enterotoxigenic Escherichia coli (11%), and Campylobacter (9%), notably ciprofloxacin-resistant Campylobacter, were the most frequently identified pathogens among adults with TD. Coinfection with multiple enteropathogens occurred in 5% of cases. NV caused severe disease relative to other TD-associated pathogens identified, confining over 90% of infected individuals to bed. Destination-specific risk factors include consumption of the local beverage "chicha," which was associated with Cryptosporidium infection. Preventive interventions, such as vaccines, directed against these pathogens could significantly reduce the burden of TD.

"Improved" But Not Necessarily Safe: An Assessment of Fecal Contamination of Household Drinking Water in Rural Peru

The indicator used to measure progress toward the Millennium Development Goal (MDG) for water is access to an improved water supply. However, improved supplies are frequently fecally contaminated in developing countries. We examined factors associated with Escherichia coli contamination of improved water supplies in rural Pisco province, Peru. A random sample of 207 households with at least one child less than 5 years old was surveyed, and water samples from the source and storage container were tested for E. coli contamination. Although over 90% of households used an improved water source, 47% of source and 43% of stored water samples were contaminated with E. coli. Pouring or using a spigot to obtain water from the storage container instead of dipping a hand or object was associated with decreased risk of contamination of stored water (adjusted prevalence ratio [aPR] = 0.58, 95% confidence interval [CI] = 0.42, 0.80). Container cleanliness (aPR = 0.67, 95% CI = 0.45, 1.00) and correct handwashing technique (aPR = 0.62, 95% CI = 0.42, 0.90) were also associated with decreased contamination risk. These findings highlighted the limitations of improved water supplies as an indicator of safe water access. To ensure water safety in the home, household water treatment and improved hygiene, water handling, and storage practices should be promoted.

Epidemiology and Genetic Characterization of Noroviruses among Adults in an Endemic Setting, Peruvian Amazon Basin, 2004-2011

Background

Successful vaccination strategies against norovirus will require understanding the burden of disease and relevant genotypes in populations. However, few data are available from cohort studies of adults living in low- and middle-income countries (LMIC).

Materials and Methods

We conducted a nested case-control study within a Peruvian military cohort to characterize the burden of norovirus infection, predominant genotypes, and associated symptoms from 2004 through 2011. Randomly selected case and control stools were tested for norovirus, bacteria, and parasites. The odds ratio of the association between norovirus infection and diarrhea was estimated using multiple logistic regression and co-infection adjusted attributable fractions were calculated.

Results

Of the 3,818 cohort study participants, 624 developed diarrhea. Overall and norovirus-associated diarrhea incidence rates were 42.3 and 6.0 per 100 person-years, respectively. The most prevalent norovirus genogroup was GII (72.5%, 29/40), which was associated with diarrhea (AOR 3.4, 95% CI: 1.3–8.7, P = 0.012). The co-infection adjusted GII attributable fraction was 6.4%.

Discussion

Norovirus was a frequent cause of diarrhea in an adult population followed longitudinally in an LMIC setting. Vaccine strategies should consider targeting adults in endemic settings and special populations that could serve as community transmission sources.

Virulence factors and mechanisms of antimicrobial resistance in Shigella strains from periurban areas of Lima (Peru)

The study was aimed to describe the serotype, mechanisms of antimicrobial resistance, and virulence determinants in Shigella spp. isolated from Peruvian children. Eighty three Shigella spp. were serogrouped and serotyped being established the antibiotic susceptibility. The presence of 12 virulence factors (VF) and integrase 1 and 2, along with commonly found antibiotic resistance genes was established by PCR. S. flexneri was the most relevant serogroup (55 isolates, 66%), with serotype 2a most frequently detected (27 of 55, 49%), followed by S. boydii and S. sonnei at 12 isolates each (14%) and S. dysenteriae (four isolates, 5%). Fifty isolates (60%) were multi-drug resistant (MDR) including 100% of S. sonnei and 64% of S. flexneri. Resistance levels were high to trimethoprim-sulfamethoxazole (86%), tetracycline (74%), ampicillin (67%), and chloramphenicol (65%). Six isolates showed decreased azithromycin susceptibility. No isolate was resistant to nalidixic acid, ciprofloxacin, nitrofurantoin, or ceftriaxone. The most frequent resistance genes were sul2 (95%), tet(B) (92%), cat (80%), dfrA1 (47%), blaOXA-1like (40%), with intl1 and intl2 detected in 51 and 52% of the isolates, respectively. Thirty-one different VF profiles were observed, being the ipaH (100%), sen (77%), virA and icsA (75%) genes the most frequently found. Differences in the prevalence of VF were observed between species with S. flexneri isolates, particularly serotype 2a, possessing high numbers of VF. In conclusion, this study highlights the high heterogeneity of Shigella VF and resistance genes, and prevalence of MDR organisms within this geographic region.

Detection of Leptospira-specific antibodies using a recombinant antigen-based enzyme-linked immunosorbent assay

We produced three highly purified recombinant antigens rLipL32, rLipL41, and rLigA-Rep (leptospiral immunoglobulin-like A repeat region) for the detection of Leptospira-specific antibodies in an enzyme-linked immunosorbent assay (ELISA). The performance of these recombinant antigens was evaluated using 121 human sera. Among them, 63 sera were microscopic agglutination test (MAT)-confirmed positive sera from febrile patients in Peru, 22 sera were indigenous MAT-negative febrile patient sera, and 36 sera were from patients with other febrile diseases from Southeast Asia, where leptospirosis is also endemic. Combining the results of immunoglobulin M (IgM) and IgG detection from these three antigens, the overall sensitivity is close to 90% based on the MAT. These results suggest that an ELISA using multiple recombinant antigens may be used as an alternative method for the detection of Leptospira-specific antibodies.

Outbreak of Group A beta hemolytic Streptococcus pharyngitis in a Peruvian military facility, April 2012

Group A Streptococcus (GAS), or Streptococcus pyogenes, is a common cause of acute pharyngitis as well as other diseases. Closed populations such as those living on military bases, nursing homes, and prisons are particularly vulnerable to GAS outbreaks due to crowding that facilitates person-to-person transmission. This report details a large outbreak of GAS pharyngitis at a Peruvian military training facility near Lima, Peru, in April 2012. Initial findings showed 145 cases. However, as the investigation continued it was revealed that some trainees may have concealed their illness to avoid real or perceived negative consequences of seeking medical care. A subsequent anonymous survey of all trainees revealed at least 383 cases of pharyngitis among the facility's 1,549 trainees and an attack rate of 34 percent among the 1,137 respondents. The epidemic curve revealed a pattern consistent with routine person-to-person transmission, although a point-source initiating event could not be excluded. Laboratory results showed GAS emm type 80.1 to be the culprit pathogen, an organism not commonly implicated in outbreaks of GAS in the Americas. Barious unique and illustrative features of outbreak investigation in military facilities and populations are discussed.

The U.S. military's Neisseria gonorrhoeae resistance surveillance initiatives in selected populations of five countries

Multi-drug resistant Neisseria gonorrhoeae (GC) threatens the successful treatment of gonorrhea. This report presents preliminary findings with regard to the prevalence of laboratory-confirmed GC and the extent of drug-resistance among sample populations in five countries. Between October 2010 and January 2013, 1,694 subjects (54% male; 45% female; 1% unknown) were enrolled and screened for the presence of laboratory-confirmed GC in the United States, Djibouti, Ghana, Kenya, and Peru. Overall, 108 (6%) of enrolled subjects tested positive for GC. Antimicrobial susceptibility testing results were available for 66 GC isolates. Resistance to at least three antibiotics was observed at each overseas site. All isolates tested in Ghana (n=6) were resistant to ciprofloxacin, penicillin, and tetracycline. In Djibouti, preliminary results suggested resistance to penicillin, tetracycline, ciprofloxacin, cefepime, and ceftriaxone. The small sample size and missing data prevent comparative analysis and limit the generalizability of these preliminary findings.

Streptococcus equi subsp. zooepidemicus meningitis in Peru

A 59-year-old man with a history of fever, unsteadiness, hemiparesis, motor aphasia and consciousness disturbance was hospitalized for Streptococcus equi subsp. zooepidemicus meningitis. He denied contact with farm animals, but had a practice of consuming unpasteurized goats' cheese from an uncertain source.

The frequency of autoimmune N-methyl-D-aspartate receptor encephalitis surpasses that of individual viral etiologies in young individuals enrolled in the California Encephalitis Project

BACKGROUND

In 2007, the California Encephalitis Project (CEP), which was established to study the epidemiology of encephalitis, began identifying cases of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. Increasing numbers of anti-NMDAR encephalitis cases have been identified at the CEP, and this form rivals commonly known viral etiologies as a causal agent. We report here the relative frequency and differences among encephalitides caused by anti-NMDAR and viral etiologies within the CEP experience.

METHODS

Demographic, frequency, and clinical data from patients with anti-NMDAR encephalitis are compared with those with viral encephalitic agents: enterovirus, herpes simplex virus type 1 (HSV-1), varicella-zoster virus (VZV), and West Nile virus (WNV). All examined cases presented to the CEP between September 2007 and February 2011 and are limited to individuals aged ≤30 years because of the predominance of anti-NMDAR encephalitis in this group. The diagnostic costs incurred in a single case are also included.

RESULTS

Anti-NMDAR encephalitis was identified >4 times as frequently as HSV-1, WNV, or VZV and was the leading entity identified in our cohort. We found that 65% of anti-NMDAR encephalitis occurred in patients aged ≤18 years. This disorder demonstrated a predilection, which was not observed with viral etiologies, for females (P < .01). Seizures, language dysfunction, psychosis, and electroencephalographic abnormalities were significantly more frequent in patients with anti-NMDAR encephalitis (P < .05), and autonomic instability occurred exclusively in this group.

DISCUSSION

Anti-NMDAR encephalitis rivals viral etiologies as a cause of encephalitis within the CEP cohort. This entity deserves a prominent place on the encephalitic differential diagnosis to avoid unnecessary diagnostic and treatment costs, and to permit a more timely treatment.

Echoencephalographic findings of Apert syndrome

Although Apert syndrome has been characterized in the prenatal period and clinically described in the literature, postnatal echoencephalographic findings have not been reported. We present a case of Apert syndrome that shows bilateral periventricular cysts, unusual posterior downward curving of the lateral ventricles without evidence of hydrocephalus, along with a decreased anterior-posterior diameter of the cranial vault. Given that Apert syndrome, characterized by acrocephalosyndactyly, can give rise to numerous CNS abnormalities, echoencephalography could be used to further characterize Apert syndrome in the postnatal period.

Who benefits from tricyclic antidepressants: a survey

To determine what patients are likely to benefit from treatment with a tricyclic antidepressant, the authors surveyed American researchers, teachers of psychiatry, general psychiatric practitioners, and foreign researchers. Areas of agreement were appreciable and can serve as an index of accepted community practice and as guidelines for teaching. Responses indicated that patients most likely to benefit from a tricyclic antidepressant are those with primary depression; early morning awakening; motor retardation; loss of appetite; weight loss; prior positive response to a tricyclic antidepressant; loss of interest in work or hobbies; sad, blue, or depressed feelings; improved mood in evening; and loss of interest in sex. Amitriptyline was preferred for agitated depressions, and imipramine was preferred for retarded depressions.

A survey of psychiatrists' practices related to the use of tricyclic antidepressants

Four groups of psychiatrists were surveyed about their clinical practices in relation to the use of tricyclic antidepressants to determine if there is any unanimity about procedures. The four groups were U.S. experts in the pharmacotherapy of depression, faculty who taught the pharmacotherapy of depression in accredited departments of psychiatry, general psychiatrists in Virginia who treated depressions with drugs, and non-U.S. experts. The authors report on practices related to dosage buildup, side effects, concurrent medical conditions, blood level information, and maintenance on tricyclics. They found moderate to high consensus on most issues; exceptions were treatment of a patient with chronic hypertension and maintenance dosage and duration.

A survey of consultation-liaison psychiatry program characteristics and functions

A survey of medical school affiliated consultation-liaison psychiatry programs has provided useful information on several aspects of current C-L program activity, including: (a) patients seen and treatments provided; (b) C-L training; (c) program structure (and fiscal operations); and (d) subjective appraisal by program directors. Data on patients, diagnostic categories, and treatments support the findings of similar, previous studies. Training and research appear to be continuing at past levels rather than increasing. Limited information on fiscal operations and program structure preclude adequate assessment of their strengths and vulnerabilities. Recording of better data and the development of more aggressive management techniques are proposed as appropriate foci of attention for C-L program leaders.