A comprehensive approach to ending an outbreak of rare blaOXA-72 gene-positive carbapenem-resistant Acinetobacter baumannii at a Community Hospital, Kansas City, MO, 2018

We identified a cluster of extensively drug-resistant, carbapenemase gene-positive, carbapenem-resistant Acinetobacter baumannii (CP-CRAB) at a teaching hospital in Kansas City. Extensively drug-resistant CRAB was identified from eight patients and 3% of environmental cultures. We used patient cohorting and targeted environmental disinfection to stop transmission. After implementation of these measures, no additional cases were identified.

Treatment and Prevention of Histoplasmosis in Adults Living with HIV

Histoplasmosis causes life-threatening disseminated infection in adult patients living with untreated HIV. Although disease incidence has declined dramatically in countries with access to antiretroviral therapy, histoplasmosis remains prevalent in many resource-limited regions. A high index of suspicion for histoplasmosis should be maintained in the setting of a febrile multisystem illness in severely immunosuppressed patients, particularly in persons with hemophagocytic lymphohistiocytosis. Preferred treatment regimens for initial therapy include liposomal amphotericin B for severe disease, or itraconazole for mild to moderate disease. Subsequently, itraconazole maintenance therapy should be administered for at least one year and then discontinued if CD4 count increases to ≥150 cells/µL. Antiretroviral therapy, which improves outcome when administered together with an antifungal agent, should be instituted immediately, as the risk of triggering Immune Reconstitution Syndrome is low. The major risk factor for relapsed infection is nonadherence. Itraconazole prophylaxis reduces risk for histoplasmosis in patients with CD4 counts <100/µL but is not associated with survival benefit and is primarily reserved for use in outbreaks. Although most patients with histoplasmosis have not had recognized high-risk exposures, avoidance of contact with bird or bat guano or inhalation of aerosolized soil in endemic regions may reduce risk. Adherence to effective antiretroviral therapy is the most important strategy for reducing the incidence of life-threatening histoplasmosis.

2458. A comprehensive approach to ending an outbreak of rare OXA-72 producing carbapenem-resistant Acinetobacter baumannii at a Community Hospital, Kansas City, MO, 2018

Background

In 2018, an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) containing a rare β-lactamase (OXA-72) was detected at Research Medical Center, a 511 bed community hospital in Kansas City, MO. We describe a coordinated effort among hospital infection control personnel and public health to control the outbreak.

Methods

We defined a case as isolation of OXA-72-producing CRAB from any clinical culture collected from a hospitalized patient during 2018. We assessed infection control practices, including adherence to transmission-based precautions and hand hygiene, environmental cleaning and patient transfers. After patients with CRAB were discharged, terminal cleaning was performed using bleach and environmental cultures were collected; rooms were closed to new patients until CRAB was not isolated. Whole-genome sequencing and bioinformatics analyses were performed.

Results

From January through October, CRAB was isolated from clinical cultures among 20 patients; 6 OXA-72-positive cases were identified during June and July. We found practices for cleaning and disinfection of shared medical equipment were not clearly delineated among nursing and environmental services staff and we ensured responsibilities were well defined. W restricted all patients with CRAB to certain medical units in order to limit the spread. In total, 248 environmental cultures were collected; 151 (61%) from inside patient rooms and 97 (39%) from shared medical equipment or surfaces outside patient rooms. Overall, Acintobacter baumannii was isolated from 39 (16%) environmental cultures (21 from inside rooms and 18 from outside rooms); 5 isolates were confirmed to contain OXA-72. Using WGS, we compared 6 clinical and 5 environmental OXA-72 CRAB isolates; all were determined to be genetically related (0–6 single nucleotide polymorphisms, 88.4% core genome) (figure). No additional cases were identified after these interventions.

Conclusion

We identified widespread CRAB environmental contamination, illustrating the challenges of eradicating CRAB from the hospital environment. We developed a comprehensive approach focusing on infection control, environmental cleaning and culturing, and patient movement to stop the outbreak.

Disclosures

All authors: No reported disclosures.

The Jonas Hypertension Program: An Academic-Community Partnership to Address Hypertension in Four Dominican Bateyes

INTRODUCTION

Adults living in bateyes (i.e., sugarcane plantation villages) in the Dominican Republic have minimal access to health care services. Hypertension (HTN) is a serious and often unrecognized health problem among batey residents. The Jonas Batey Hypertension Program was built on existing social networks to address the detection and treatment of HTN.

METHODS

An ongoing community-based participatory research endeavor involves a partnership among three organizations and collaboration with promotoras who engage their batey communities in a mobile HTN screening and treatment program. Adults are screened and, if indicated, are treated with antihypertensive medications. Data collection includes project documentation, participant observation, demographic data, blood pressure (BP) measurements, and pill counts.

RESULTS

To date, 243 adults have received HTN treatment in four batey communities. A within-group, as-treated, repeated-measures, pre-/postanalysis showed that among participants who had been receiving antihypertensive treatment for 12 months ( n = 70), there was a significant decrease in BP ( p < .005).

CONCLUSION

Results of an interim data analysis indicate that the program model has been implemented successfully and is making a positive impact on BP control. Evaluation is ongoing with regard to the long-term HTN-related health outcomes of batey residents. Ensuring program sustainability is an important consideration for the future.

Histoplasmosis complicating tumor necrosis factor-α blocker therapy: a retrospective analysis of 98 cases

BACKGROUND

Histoplasmosis may complicate tumor necrosis factor (TNF)-α blocker therapy. Published case series provide limited guidance on disease management. We sought to determine the need for long-term antifungal therapy and the safety of resuming TNF-α blocker therapy after successful treatment of histoplasmosis.

METHODS

We conducted a multicenter retrospective review of 98 patients diagnosed with histoplasmosis between January 2000 and June 2011. Multivariate logistic regression was used to evaluate risk factors for severe disease.

RESULTS

The most commonly used biologic agent was infliximab (67.3%). Concomitant corticosteroid use (odds ratio [OR], 3.94 [95% confidence interval {CI}, 1.06-14.60]) and higher urine Histoplasma antigen levels (OR, 1.14 [95% CI, 1.03-1.25]) were found to be independent predictors of severe disease. Forty-six (47.4%) patients were initially treated with an amphotericin B formulation for a median duration of 2 weeks. Azole treatment was given for a median of 12 months. TNF-α blocker therapy was initially discontinued in 95 of 98 (96.9%) patients and later resumed in 25 of 74 (33.8%) patients at a median of 12 months (range, 1-69 months). The recurrence rate was 3.2% at a median follow-up period of 32 months. Of the 3 patients with recurrence, 2 had restarted TNF-α blocker therapy, 1 of whom died. Mortality rate was 3.2%.

CONCLUSIONS

In this study, disease outcomes were generally favorable. Discontinuation of antifungal treatment after clinical response and an appropriate duration of therapy, probably at least 12 months, appears safe if pharmacologic immunosuppression has been held. Resumption of TNF-α blocker therapy also appears safe, assuming that the initial antifungal therapy was administered for 12 months.

Postexposure prophylaxis for common infectious diseases

Postexposure prophylaxis (PEP) is effective in preventing illness after potential or documented exposure to a variety of microbial pathogens and in reducing the risk of secondary spread of infection. Guidelines have been published by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices for proper use of PEP for bloodborne pathogens, for microorganisms transmitted by either airborne or droplet spread or through direct contact, and for infections acquired after traumatic injuries. Depending on the type of exposure, different forms of PEP are available, including vaccines, immune globulins, antibiotics, and antiviral medications. Physicians should assess a patient's potential need for PEP based on several factors, including the type of exposure, the timing and severity of illness in the source patient, the exposed person's susceptibility to infectious diseases of concern, and the relative risks and benefits of the PEP regimen in an individual situation. Immunity to certain infectious diseases can be ensured with prior infection or vaccination, and by serologic testing in patients with a negative or uncertain history. PEP should be given to persons exposed to index cases of pertussis and invasive meningococcal infection regardless of immunization history, and should be given following rabies and tetanus exposure regardless of the length of delay. In general, PEP should be given as soon as possible following a high-risk exposure. Persons exposed to bloodborne pathogens should have baseline testing for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus antibodies, and follow-up testing at six weeks, three months, and six months postexposure.

Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level

REMARKABLE ADVANCES IN THE TREATMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HAVE BEEN BLUNTED BY WIDESPREAD SUBOPTIMAL ADHERENCE (IE, NONADHERENCE), WHICH HAS EMERGED AS A MAJOR BARRIER TO ACHIEVING THE PRIMARY GOAL OF ANTIRETROVIRAL (ARV) THERAPY: suppression of HIV viral load. Nonsuppressed HIV viral load is associated with drug resistance, increased morbidity and mortality, and a higher risk of person-to-person HIV transmission. For HIV-infected individuals who are failing HIV treatment due to nonadherence, becoming adherent is a life-saving behavior change. However, overcoming nonadherence is one of the most daunting challenges in the successful management of HIV disease. The purpose of this paper is to provide clinicians with a better understanding of nonadherence to ARV treatment and to review the various factors that have been associated with either adherence or nonadherence. Strategies are presented that may help the nonadherent individual become ready to take HIV medications as prescribed.

Development and efficacy of an intervention to enhance readiness for adherence among adults who had previously failed HIV treatment

This paper outlines the development and initial testing of the READY intervention that was designed to enhance readiness for adherence among adults with a history of nonadherence to HIV treatment. Participants in this study were adults (n = 28) who ranged in age from 24 to 57: most were male (75%) and African American (64%). Participants had failed an average of four prior HIV treatment regimens due to nonadherence and were beginning a new regimen of protease inhibitor (PI)-based antiretroviral medications. The study was conducted from 2003 to 2006, prior to the standard use of boosted PI regimens. Results indicated that 50% of participants became adherent and had suppressed viral loads to less than 50 copies per milliliter at the 3-month postintervention follow-up time point. Of those who became adherent, 79% remained adherent at the 12-month postintervention follow-up time point. Implementation of the intervention was found to be feasible in a real-world setting and participants reported that they liked the intervention. A 6-session length of the intervention was found to have the same impact on adherence outcomes as a 12-session length. No differences were found in outcomes with regard to the intervention's start time: before or at the same time the new antiretroviral regimen was initiated. These results suggest that the READY intervention may have merit and that the 6-session length may be more acceptable. However, a larger controlled study is indicated to examine intervention efficacy further.

Interlaboratory discrepancy of antigenuria results in 2 patients with AIDS and histoplasmosis

Histoplasma polysaccharide antigen testing is used routinely to diagnose histoplasmosis. At least 3 antigen tests are commercially available. Controversy exists about the relative accuracy of these tests. We report 2 patients with AIDS and culture-confirmed Histoplasma capsulatum meningitis from whom discrepant Histoplasma polysaccharide antigen results were obtained from different laboratories and discuss the potential clinical implications of these results.

Clinical Practice Guidelines for the Management of Patients with Histoplasmosis: 2007 Update by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with histoplasmosis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 30:688–95). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. Since 2000, several new antifungal agents have become available, and clinical trials and case series have increased our understanding of the management of histoplasmosis. Advances in immunosuppressive treatment for inflammatory disorders have created new questions about the approach to prevention and treatment of histoplasmosis. New information, based on publications from the period 1999–2006, are incorporated into this guideline document. In addition, the panel added recommendations for management of histoplasmosis in children for those aspects that differ from aspects in adults.

Gastrointestinal histoplasmosis in the acquired immunodeficiency syndrome: report of 18 cases and literature review

No large case series of gastrointestinal histoplasmosis (GIH) in patients with AIDS has been published. We report 18 cases and review 34 published cases in the medical literature. We did a retrospective chart review from patients seen in our medical practices between 1989 and 2004. Most of our patients were men who had sex with men and who were not receiving highly active antiretroviral therapy. Median CD4 count was 34/muL. The most common presenting symptoms were diarrhea, fever, abdominal pain, and weight loss. The most commonly involved site was the colon or cecum. Biopsies revealed visible Histoplasma capsulatum organisms in 89%. Cultures from any site were positive in 76.9%. Four patients died from GIH. Gastrointestinal histoplasmosis occurs in severely immunocompromised patients with AIDS not receiving highly active antiretroviral therapy. Typical manifestations include diarrhea, fever, abdominal pain, and weight loss. Diagnosis is confirmed by blood or gastrointestinal tissue culture. Improvements in antiretroviral and antifungal therapies appear to have reduced the incidence of GIH and may improve the prognosis of this disease.

Viral infections in the elderly. The challenges of managing herpes zoster, influenza, and RSV

Viral diseases are an important cause of morbidity and mortality in elderly patients, whether they live in the community or in long-term care facilities. Management of viral infections in older adults is complicated by factors that include the infrequency or absence of common signs and symptoms of infection and adverse drug reactions. In this article, Drs Bader and McKinsey discuss the clinical features and treatment of herpes zoster and the respiratory diseases caused by influenza and respiratory syncytial virus (RSV).

Successful adherence after multiple HIV treatment failures

BACKGROUND

Non-adherence to human immunodeficiency virus (HIV) medications often results in irreparable drug resistance and poor outcomes. Hence, care providers generally think that treatment of HIV disease should be delayed until a person is 'ready' to adhere. However, little research has focused on understanding the process that results in readiness for successful adherence.

AIM

The aim of this phenomenological study was to describe and understand the experience and decision-making processes of people who became adherent to their HIV medication regimens after previously failing treatment because of non-adherence.

METHOD

A Husserlian phenomenological approach was taken, and in-depth interviews were analysed using Giorgi's method of phenomenological description and analysis.

FINDINGS

Thirteen HIV-positive men and women who had previously failed two or more treatment regimens because of non-adherence were purposefully selected from two infectious diseases clinics in the Midwest region of the United States. They had achieved and sustained adherence to their HIV medications for 1 year or longer without formal intervention. All participants experienced a 'trigger' event preceding the process that led to the ability to incorporate lifestyle and health behaviour changes necessary for successful adherence. Factors associated with the process leading to adherence were: changing attitudes towards HIV medication, finding the right health care provider, creating the right support system, getting control of life and having goals.

CONCLUSIONS

This study demonstrated that HIV-positive individuals who had been non-adherent and had been viewed as 'difficult to treat' nonetheless successfully adhered to treatment once they became 'ready'. Findings from this study implicate that readiness may be a necessary component for successful adherence, particularly in HIV-positive individuals who have previously failed treatment. Understanding the relationship between the phenomenon of readiness and subsequent HIV treatment adherence has implications for clinical decision-making and for development of interventions that enhance adherence and prevent HIV drug resistance.

Assessment of Readiness for Adherence by HIV-Positive Males Who Had Previously Failed Treatment

The purpose of this prospective pilot study was to examine the relationship between the level of readiness for health behavior change and adherence by HIV-positive males (n = 19) who had previously failed treatment due to nonadherence. Participants completed the Index of Readiness (IR), an instrument measuring readiness to initiate health behavior change, prior to beginning new antiretroviral medications. After 6 months, participants were divided into two mutually exclusive groups: those who reached and sustained viral suppression and those who did not. Participants who experienced and sustained viral suppression had statistically significantly higher scores on the Identification of Barriers/Creating Strategies subscale of the IR compared to participants who did not reach viral suppression. Results from this preliminary study indicate that readiness may be a key component in successful adherence and that the IR may be a useful tool in assessing readiness for adherence to antiretroviral medications.

Hydroxyurea in combination with didanosine and stavudine in antiretroviral-experienced HIV-infected subjects with a review of the literature

The safety and efficacy of hydroxyurea with didanosine in combination with stavudine in nucleoside reverse-transcriptase inhibitor (NRTI)-experienced patients was investigated. Entry criteria included HIV-1 infected, NRTI-experienced adults, with CD4(+) counts 50-550 cells/mm(3) and viral loads >or=12,500 copies/mL. Subjects were treated with didanosine 200 mg twice a day (BID), stavudine 40 mg BID, and hydroxyurea 1000 mg daily for 16 weeks. Thirty-one HIV-1 subjects with mean bDNA viral load 1x10(5) log(10) copies/mL and mean CD4(+) T-cell counts of 231 cells/mm(3) were enrolled. A 1.3 log(10) decrease in mean viral load was seen at 12 weeks of therapy. Prior didanosine use resulted in a more rapid response to therapy compared with prior zidovudine use. Side effects consisting of neutropenia, pancreatitis, and peripheral neuropathy occurred in four subjects and resolved upon withdrawal of therapy. This non-randomized study in subjects with a mean CD4(+) T-cell count of 230 cells/mm(3) demonstrates the antiviral activity of hydroxyurea+didanosine and stavudine. Toxicities related to therapy need to be followed closely. The results support the need for a randomized, prospective study to determine the safety and efficacy of hydroxyurea plus didanosine in antiretroviral-experienced patients with CD4(+) cell counts below 300 cells/mm(3).

DNA fingerprinting of serial Candida albicans isolates obtained during itraconazole prophylaxis in patients with AIDS

During a randomized double-blind placebo-controlled study testing the efficacy of itraconazole for prophylaxis of systemic and mucosal fungal infections in patients with acquired immune deficiency syndrome, 298 patients were enrolled with 295 evaluable. Of those, 46 patients were considered prophylaxis failures because of recurrent oral or esophageal candidiasis. Oropharyngeal fungal cultures were taken at the time of suspected thrush or Candida esophagitis, but not at baseline. All of the Candida spp. isolates were cultured on CHROMagar Candida medium then identified using API 20 AUX strips. Antifungal susceptibility testing was performed following the National Committee for Clinical Laboratory Standards M-27A guidelines. Sequential isolates were genotyped using randomly amplified polymorphic DNA. Polymerase chain reaction fingerprints were generated using two repetitive sequence primers, (GGA)7 and (GACA)4. The study group consisted of 23 patients, nine from the itraconazole arm and 14 from the placebo arm, who were prophylaxis failures and had more than two C. albicans isolates. Five of 23 had isolates showing a > or =4-fold reduction in susceptibility; four of these patients were in the itraconazole prophylaxis arm and one was in the placebo arm. Three of the five had yeast isolations showing changes in banding patterns over time. Such changes may indicate genetic changes in the same strain that could be linked to acquired resistance to itraconazole, or acquisition of a new strain, or emergence of a previously minor component of the original population.

Does long-term itraconazole prophylaxis result in in vitro azole resistance in mucosal Candida albicans isolates from persons with advanced human immunodeficiency virus infection? The National Institute of Allergy and Infectious Diseases Mycoses study group

The effects of prolonged itraconazole exposure on the susceptibility of Candida albicans isolates to itraconazole and fluconazole have not been well characterized. A recent placebo-controlled study of long-term itraconazole antifungal prophylaxis in persons with advanced human immunodeficiency virus infection afforded the opportunity to address this question. Mucosal Candida sp. isolates were obtained from subjects who developed oropharyngeal or esophageal candidiasis, and in vitro susceptibilities of the last isolate obtained at removal from the study as a prophylaxis failure were compared in itraconazole and placebo recipients. More subjects in the placebo group (74 of 146 [51%]) than in the itraconazole group (51 of 149 [34%]) developed mucosal candidiasis (P = 0.004). A total of 112 isolates were recovered from 56 of the 74 (76%) subjects with mucosal candidiasis assigned to the placebo group, compared to 97 isolates from 45 of the 51 (88%) subjects in the itraconazole group. C. albicans accounted for 98% of isolates in the placebo group and 89% of isolates in the itraconazole group. The itraconazole MIC at which 50% of the isolates tested were inhibited (MIC(50)) for last-episode isolates from the itraconazole group was 0.125 microg/ml compared to 0.015 microg/ml for the placebo group subjects, P = 0.0001. The MIC(50) of fluconazole for the last isolates from the itraconazole group was 1.5 microg/ml compared to 0.5 microg/ml for the placebo subjects (P = 0.005). A lower proportion of isolates recovered from subjects on itraconazole therapy were classified as susceptible to itraconazole (63%) compared to isolates from the placebo group (96%) (P = 0.001). Similarly, a lower proportion of C. albicans isolates from subjects on itraconazole therapy were susceptible to fluconazole (78%) compared to isolates from the placebo group (96%) (P = 0.01). Also, the proportion of isolates that were not fully susceptible to itraconazole or fluconazole was greater in patients assigned to the itraconazole group than the placebo group (itraconazole susceptibility, 37 and 4%, respectively (P = 0.001); fluconazole susceptibility, 23 and 4%, respectively (P = 0.01). In conclusion, long-term itraconazole prophylaxis in patients with AIDS is associated with reduction in susceptibility to itraconazole and cross-resistance to fluconazole.

Prospective multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group

Although fungal urinary tract infections are an increasing nosocomial problem, the significance of funguria is still not clear. This multicenter prospective surveillance study of 861 patients was undertaken to define the epidemiology, management, and outcomes of funguria. Diabetes mellitus was present in 39% of patients, urinary tract abnormalities in 37.7%, and malignancy in 22.2%; only 10.9% had no underlying illnesses. Concomitant nonfungal infections were present in 85%, 90% had received antimicrobial agents, and 83.2% had urinary tract drainage devices. Candida albicans was found in 51.8% of patients and Candida glabrata in 15.6%. Microbiological and clinical outcomes were documented for 530 (61.6%) of the 861 patients. No specific therapy for funguria was given to 155 patients, and the yeast cleared from the urine of 117 (75.5%) of them. Of the 116 patients who had a catheter removed as the only treatment, the funguria cleared in 41 (35.3%). Antifungal therapy was given to 259 patients, eradicating funguria in 130 (50.2%). The rate of eradication with fluconazole was 45.5%, and with amphotericin B bladder irrigation it was 54.4%. Only 7 patients (1.3%) had documented candidemia. The mortality rate was 19.8%, reflecting the multiple serious underlying illnesses found in these patients with funguria.

Meningococcal pneumonia: characterization and review of cases seen over the past 25 years

Fifty-eight cases of meningococcal pneumonia were included in this review. Fifty cases previously described in the literature from 1974 through 1998 and 8 new cases were included in this series. The median age of patients was 57.5 years, and pleuritic chest pain was described in 21 (53.9%) of 39 cases. Blood cultures were positive in 42 (79.3%) of 53 cases for which results were mentioned. Despite the presence of bacteremia, patients did not develop the syndrome of meningococcemia with its associated complications. Serogroup Y meningococci were most commonly recovered and accounted for 44.2% of identified isolates. Therapy has dramatically changed over the past 25 years; prior to 1991, penicillin antibiotics were most often used. Since 1991, 12 (80%) of 15 patients received cephalosporin antibiotics. Only 5 (8.62%) of 58 patients died. Secondary cases of meningococcal infections following exposure to patients with meningococcal pneumonia were noted in 2 instances.

Itraconazole prophylaxis for fungal infections in patients with advanced human immunodeficiency virus infection: randomized, placebo-controlled, double-blind study. National Institute of Allergy and Infectious Diseases Mycoses Study Group

In a prospective, randomized, double-blind trial, 149 patients with advanced human immunodeficiency virus (HIV) infection were randomized to receive itraconazole capsules (200 mg daily) and 146 to receive a matched placebo. Both groups were monitored for evidence of fungal infections. Baseline characteristics of the two groups were similar. Failure of prophylaxis occurred in 29 (19%) of the itraconazole recipients and 42 (29%) of the placebo recipients (P = .004; log-rank test). There were 6 invasive fungal infections in the itraconazole group (4, histoplasmosis; 1, cryptococcosis; 1, aspergillosis) and 19 in the placebo group (10, histoplasmosis; 8, cryptococcosis; 1, aspergillosis) (P = .0007; log-rank test). Itraconazole significantly delayed time to onset of histoplasmosis (P = .03; log-rank test) and cryptococcosis (P = .0005; log-rank test). Prophylaxis failure due to recurrent or refractory mucosal candidiasis occurred with similar frequency in the two groups (itraconazole, 15%; placebo, 16%). A survival benefit was not demonstrated. Itraconazole generally was well tolerated. Primary prophylaxis with itraconazole capsules prevents histoplasmosis and cryptococcosis in patients with HIV infection.

Histoplasmosis in AIDS: advances in management

Histoplasmosis is one of the most common opportunistic infections in HIV-infected patients who reside in endemic areas, and "imported infections" also occur elsewhere. A recent decline in the incidence of histoplasmosis appears to correlate with advances in antiretroviral therapy. Histoplasmosis occurs due to either dissemination of newly acquired infection or reactivation of latent foci of infection. Major risk factors include a CD4 count < or = 150/microL, positive complement fixation serology for the Histoplasma capsulatum mycelial antigen, and a history of exposure to chicken coops; in addition, suboptimal antiretroviral therapy seems likely to be a risk factor. Although there are a variety of clinical manifestations, most patients present with a several-week history of fever, chills, weakness, and weight loss. Diagnosis is based on positive cultures of blood, bone marrow, or other sites; detection of antigen in serum or urine; or characteristic histopathologic findings in biopsy specimens. Induction therapy consists of amphotericin B for acutely ill patients or itraconazole for patients with mild to moderately severe disease. Subsequent lifelong maintenance therapy with itraconazole is recommended. In patients with CD4 counts of < or = 150/microL, itraconazole is effective primary prophylaxis.

Prospective study of histoplasmosis in patients infected with human immunodeficiency virus: incidence, risk factors, and pathophysiology

Histoplasmosis is a common opportunistic infection in patients with human immunodeficiency virus (HIV) infection who reside in areas where Histoplasma capsulatum is endemic. We undertook a prospective study of a cohort of 304 HIV-Infected patients in Kansas City from October 1990 through March 1993 to define the incidence-specific risk factors, and pathophysiology of histoplasmosis. The annual incidence of histoplasmosis was 4.7%; 74% of the patients with histoplasmosis were symptomatic (all of whom had disseminated disease). A history of exposure to chicken coops, a positive baseline serology for complement-fixing antibodies to Histoplasma mycelium antigen, and a baseline CD4+ lymphocyte count of < 150/microL were associated with an increased risk for histoplasmosis. Histoplasmin reactivity and the presence of pulmonary calcifications were not useful markers for patients at high risk. Symptomatic infection occurred in 9.9% of patients with evidence of prior exposure to H. capsulatum, in 4.0% of patients without documented prior exposure, and in 3.0% of patients who were anergic; these findings suggest that the pathophysiology of histoplasmosis in patients with AIDS involves reactivation of latent infection in some cases and dissemination of exogenously acquired infection in other cases.

Fluconazole therapy for histoplasmosis. The National Institute of Allergy and Infectious Diseases Mycoses Study Group

We assessed the efficacy of oral fluconazole (200-800 mg daily) in the treatment of non-life-threatening acute pulmonary histoplasmosis, chronic pulmonary histoplasmosis, or disseminated histoplasmosis in patients without human immunodeficiency virus infection. Of 27 evaluable patients, two had progressive acute pulmonary histoplasmosis, 11 had chronic pulmonary histoplasmosis, and 14 had disseminated histoplasmosis. Median durations of treatment in each of the three groups were 6 months, 7 months, and 11 months, respectively. Nineteen patients were treated with 400 mg of fluconazole daily (two of these patients received 800 mg daily for a portion of their treatment courses), seven were treated with 200 mg daily, and one was treated with 800 mg daily. Treatment was successful in 17 (63%) of 27 cases. Both of the patients with acute pulmonary infection responded to therapy, as did five (46%) of 11 patients with chronic pulmonary infection and 10 (71%) of 14 patients with disseminated infection. No substantial toxicity was observed. We conclude that fluconazole therapy for histoplasmosis is only moderately effective and should be reserved for patients who cannot take itraconazole.

The effect of a portable HEPA-filtered body exhaust system on airborne microbial contamination in a conventional operating room

OBJECTIVE

To study the effect of a portable HEPA-filtered air exhaust system (Stackhouse Freedom Surgical Helmet System) on airborne microbial contamination in a modern conventional operating room.

DESIGN AND SETTING

Microbial air sampling was done with a two-stage Anderson sampler at the wound site during 46 total joint replacements. All operations were performed by the same surgeon in the same operating room at a large community hospital.

RESULTS

In 18 cases done without air exhaust hoods, the number of bacterial and fungal colony-forming units (CFU) ranged from 0.6 to 11.7 (mean, 3.6). Air sampling during 28 operations with the operating team in air exhaust hoods revealed a mean of 3.6 CFU (range, 0 to 11.4). Bacterial CFU averaged 3.4 without hoods and 3.2 with exhaust hoods. Coagulase-negative staphylococci were the most common isolates (48% of isolates with hood, 55% without hood). No infections occurred.

CONCLUSION

We concluded that these air exhaust hoods did not lower airborne microbial contamination detectable with this air sampling method, as compared to standard head cover and mask, in a modern conventional operating room.

A prospective study of 2,092 "curbside" questions asked of two infectious disease consultants in private practice in the midwest

We prospectively studied 2,092 consecutive informal (or "curbside") consultations (CCs) posed of two infectious disease (ID) consultants in private practice in different cities. The frequency of CCs was similar for the two physicians: 31 and 30 per month. The majority of CCs (69%) were initiated by staff physicians, of whom 47% were engaged in primary care. The average duration of CCs was 5.1 minutes overall and increased significantly from 3 minutes in 1990 to 7 minutes in 1994 for one consultant (P < .0001). Overall, 52% of questions asked by staff physicians were considered inappropriate (on the basis of their complexity); this rate increased from 40% in 1990 to 53% in 1994 for one physician (P = .005). Although a variety of subject matters were represented, questions concerning treatment of specific infections were the most common. We conclude that the demand for community-based ID physicians' informal advice remains significant. Any need-assessment for the practice of these specialists in the community should take into account their often unrecognized direct and indirect contribution to the care of many patients they never formally see.

Treatment of lymphocutaneous and visceral sporotrichosis with fluconazole

Thirty patients with documented sporotrichosis were treated with 200-800 mg of fluconazole daily. Fourteen patients had lymphocutaneous infection; only five (36%) of these patients had any underlying illnesses. Sixteen patients had osteoarticular or visceral sporotrichosis; 12 (75%) of these patients had underlying diseases, mostly alcoholism, diabetes mellitus, and chronic obstructive pulmonary disease. Eleven of the 30 patients had relapsed after prior antifungal therapy. Most patients were treated with 400 mg of fluconazole; however, four received 200 mg of fluconazole daily for the entire course, and four received 800 mg of fluconazole daily for a portion of their therapy or for the entire course of therapy. Fluconazole therapy cured 10 (71%) of 14 patients with lymphocutaneous sporotrichosis. However, only five (31%) of 16 patients with osteoarticular or visceral sporotrichosis responded to therapy; the conditions of two of these five patients improved only, and there was no documented cure of their infections. With the exception of alopecia in five patients, toxic effects were minimal. Fluconazole is only modestly effective for treatment of sporotrichosis and should be considered second-line therapy for the occasional patient who is unable to take itraconazole.

Alopecia associated with fluconazole therapy

OBJECTIVE

To describe the association between fluconazole and reversible alopecia.

DESIGN

A retrospective survey of 1) patients enrolled in NIAID Mycoses Study Group (MSG) protocols involving the long-term use of fluconazole for treatment of endemic mycoses and 2) patients treated with fluconazole outside of a protocol setting but by the MSG investigators who were MSG members.

SETTING

26 MSG sites in the United States.

PATIENTS

33 patients with various deep and superficial mycoses who developed alopecia while receiving fluconazole.

RESULTS

11 of 26 investigators reported a total of 33 patients with substantial alopecia related to fluconazole therapy. Underlying mycoses included blastomycosis, sporotrichosis, histoplasmosis, cryptococcosis, coccidioidomycosis, and mucosal candidiasis. In separate MSG studies, 17 of 136 (12.5%) and 8 of 40 (20%) patients had substantial reversible alopecia associated with fluconazole therapy. Eight patients who were not in the protocol had similar adverse effects. Twenty-nine of 33 patients (88%) received at least 400 mg of fluconazole daily for a mean of 7.1 months. Alopecia developed a median of 3 months after initiation of fluconazole therapy and involved the scalp in all patients. Other sites were involved in about one third of patients. Three patients required wigs because of extensive hair loss. Alopecia resolved within 6 months of discontinuation of fluconazole therapy or reduction of the daily dose by at least 50%.

CONCLUSIONS

Alopecia appears to be a common adverse event associated with higher-dose (400 mg/d) fluconazole given for 2 months or longer. This effect may be severe but is reversed by discontinuing fluconazole therapy or substantially reducing the daily dose.

Mycobacterium kansasii among patients infected with human immunodeficiency virus in Kansas City. Kansas City AIDS Research Consortium

Previous reports of infection due to Mycobacterium kansasii among patients infected with human immunodeficiency virus (HIV) have conflicted with regard to the significance of the isolate; the clinical, radiographic, and laboratory features of the disease; and the response to therapy. To clarify the spectrum of M. kansasii infection in this population, we conducted a retrospective study of 35 patients. Twenty-eight of these patients were believed to have disease due to M. kansasii, while the remaining seven patients were probably colonized with the organism. All but two patients presented with advanced HIV infection; the median CD4 cell count was 12/microL. Most patients with pulmonary disease presented with fever, cough, and dyspnea, but only eight of these 22 patients had radiographic findings of either pulmonary cavitation or predominantly upper-lobe disease. Ten patients had M. kansasii isolated from blood or bone marrow. The majority of patients with pulmonary or disseminated disease responded to therapy. However, 11 patients died either before mycobacterial infection was diagnosed or early in the course of treatment, and two had a relapse of infection during therapy.

Histoplasmosis in Missouri: historical review and current clinical concepts

Histoplasmosis is particularly common in Missouri, and many important clinical observations about the disease were made in this state in the 1950s and 1960s. When the AIDS epidemic spread to Missouri in the mid-1980s, histoplasmosis became recognized as a common and important opportunistic infection among Missourians with AIDS. Clinicians must maintain a high level of suspicion for histoplasmosis in any HIV-infected patient who presents with unexplained fever, particularly if the patient has evidence of hepatosplenomegaly, generalized lymphadenopathy, pancytopenia, abnormal liver function tests, or bilateral pulmonary infiltrates. The diagnosis of histoplasmosis can be established rapidly by observation of organisms on peripheral blood smear or bone marrow biopsy specimens or by Histoplasma Polysaccharide Antigen testing. The diagnosis can be confirmed by blood cultures in most cases. Histoplasmosis in AIDS is invariably fatal if not treated. Treatment consists of two phases: initial induction therapy and subsequent lifelong maintenance therapy. Amphotericin B and itraconazole are extremely effective for induction and maintenance therapy; fluconazole appears to be effective maintenance therapy. Strategies for the prevention of histoplasmosis in high risk patients are being evaluated currently.

Recurrent massive pleural effusion due to pleural, pericardial, and epicardial fibrosis in histoplasmosis

Acute histoplasmosis is generally a benign, self-limited pulmonary infection. Although Histoplasma capsulatum pneumonitis is common, pleural effusions associated with histoplasmosis are quite rare, and massive pleural effusions have not been reported. There have been several reports of pericardial fibrosis secondary to histoplasmosis, but epicardial fibrosis has not been described. We report a biopsy-proven case of histoplasmosis initially associated with recurrent massive pleural effusions and excessive pleural fibrosis causing a trapped lung. The patient later developed constrictive pericarditis. Despite pericardiectomy, severe cor pulmonale occurred, and the patient died. Necropsy demonstrated fibrosis of the epicardium.

Detection of the source of recurrent Staphylococcus aureus bacteremia by ultrafast computerized tomography

A patient with spina bifida secondary to an Arnold-Chiari deformity experienced seven episodes of sustained bacteremia due to Staphylococcus aureus over 2 years. Despite an extensive diagnostic evaluation the source of the recurrent bacteremia remained obscure. The patient's mother eventually recalled that a procedure for replacement of a ventriculoatrial shunt performed 16 years earlier had been complicated by retention of a shunt fragment in the bloodstream. Standard radiographic techniques failed to identify an intravascular foreign body; however, ultrafast computerized tomography of the heart demonstrated a density in the right atrium. Atriotomy was performed and a plastic catheter fragment was excised. Bacteremia has not recurred during a follow-up period of 24 months. Patients with recurrent unexplained bacteremia should be evaluated carefully for the presence of occult intravascular catheter fragments that may be retained after surgical procedures or intravascular instrumentation. Ultrafast computed tomographic scanning of the heart is a useful technique for detecting intracardiac catheter fragments.

Colonic histoplasmosis in acquired immunodeficiency syndrome. Report of two cases

Colonic histoplasmosis is a rare entity. There have been four previous reported cases within the population of patients with human immunodeficiency virus (HIV) infection. Because of the increasing incidence of HIV infection within regions where histoplasmosis is endemic, this condition may become more common. Gastrointestinal histoplasmosis has protean clinical manifestations, and symptoms are often nonspecific. Any patient with HIV infection who has unexplained GI symptoms should undergo evaluation for possible histoplasmosis. Aggressive long-term amphotericin B therapy has been effective in HIV patients with histoplasmosis. Resection or diversion of symptomatic colonic strictures caused by histoplasmosis may be necessary in addition to medical therapy.

Histoplasmosis in patients with acquired immunodeficiency syndrome. Hematologic and bone marrow manifestations

In areas where Histoplasma capsulatum infections are endemic in the United States, there is an increasing frequency of progressive disseminated histoplasmosis (PDH) as an opportunistic infection in patients with acquired immune deficiency syndrome (AIDS). The bone marrow and peripheral blood (PB) specimens in 13 patients with AIDS and PDH were reviewed. Anemia, leukopenia, and thrombocytopenia were found in 12, 10, and 7 patients, respectively. Circulating organisms were detected in the blood smears or buffy coat preparations from five patients and were associated with PB nRBCs and severe absolute monocytopenia. Morphologically, the marrow specimens showed one of four patterns: (1) no morphologic evidence of infection (two patients, one with a positive marrow culture); (2) discrete granulomas (two patients, both with positive marrow cultures); (3) lymphohistiocytic aggregates (six patients, four with positive marrow cultures); and (4) diffuse macrophage infiltrates (three patients, all with positive marrow cultures). Morphologic examination of the bone marrow combined with cultures is useful in diagnosing disseminated histoplasmosis in patients with AIDS. However, the morphologic findings in the bone marrow may be different in patients with AIDS compared with non-AIDS patients, and seemingly nondiagnostic morphologic features must be approached with a high degree of suspicion in diagnosing infections with H. capsulatum in this population.

Immune complex glomerulonephritis associated with Staphylococcus aureus bacteremia: response to corticosteroid therapy

Immune complex glomerulonephritis developed in a patient with high-grade Staphylococcus aureus bacteremia. Renal function declined steadily despite treatment with a prolonged course of bactericidal antimicrobial agents and apparent cure of the staphylococcal infection. Following initiation of corticosteroid therapy, renal function improved dramatically. Judicious use of corticosteroids should be considered in patients with persistent renal dysfunction secondary to infection-associated immune complex glomerulonephritis.

Long-term amphotericin B therapy for disseminated histoplasmosis in patients with the acquired immunodeficiency syndrome (AIDS)

STUDY OBJECTIVE

To assess the efficacy and toxicity of long-term maintenance amphotericin B therapy in preventing relapses after treatment in patients with the acquired immunodeficiency syndrome (AIDS) and disseminated histoplasmosis.

DESIGN

Open, nonrandomized pilot study.

SETTING

Three private, university-affiliated community hospitals.

PATIENTS

We studied 22 consecutive patients with disseminated histoplasmosis and human immunodeficiency virus (HIV) infection. Sixteen patients completed the study, 5 patients died before completing the initial intensive phase of treatment, and 1 patient received a different treatment regimen.

INTERVENTIONS

Seven patients were treated with an initial intensive course of 1000 mg of amphotericin B, followed by weekly infusions of 50 to 80 mg until a cumulative dose of 2000 mg was attained; biweekly infusions of 50 to 80 mg were then continued indefinitely. Nine patients received an initial amphotericin B course of 2000 mg followed by weekly infusions of 80 mg.

MEASUREMENTS AND MAIN RESULTS

Of the 7 patients in the 1000-mg intensive regimen group, 6 patients have survived without clinical or laboratory evidence of a histoplasmosis relapse, and 1 died of unrelated causes. Of the 9 patients in the 2000-mg intensive regimen group, 7 patients have survived, 1 patient died of a histoplasmosis relapse, and 1 patient died of other causes. Thus, 13 of 14 patients (93%) who did not die of other causes remained relapse-free. The median follow-up period was 14 months (range, 2 to 23 months). No apparent differences in outcome were observed between patients treated with weekly maintenance regimens and those treated with biweekly maintenance regimens. Sixty-three percent of patients developed intravascular device-related complications.

CONCLUSIONS

Long-term, intermittent maintenance amphotericin B therapy in HIV-infected patients with disseminated histoplasmosis is well tolerated and is highly effective in suppressing relapses after treatment.