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Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United States, March-August 2020 [Case Report]

Morris, Sapna Bamrah; Schwartz, Noah G; Patel, Pragna; Abbo, Lilian; Beauchamps, Laura; Balan, Shuba; Lee, Ellen H; Paneth-Pollak, Rachel; Geevarughese, Anita; Lash, Maura K; Dorsinville, Marie S; Ballen, Vennus; Eiras, Daniel P; Newton-Cheh, Christopher; Smith, Emer; Robinson, Sara; Stogsdill, Patricia; Lim, Sarah; Fox, Sharon E; Richardson, Gillian; Hand, Julie; Oliver, Nora T; Kofman, Aaron; Bryant, Bobbi; Ende, Zachary; Datta, Deblina; Belay, Ermias; Godfred-Cato, Shana
During the course of the coronavirus disease 2019 (COVID-19) pandemic, reports of a new multisystem inflammatory syndrome in children (MIS-C) have been increasing in Europe and the United States (1-3). Clinical features in children have varied but predominantly include shock, cardiac dysfunction, abdominal pain, and elevated inflammatory markers, including C-reactive protein (CRP), ferritin, D-dimer, and interleukin-6 (1). Since June 2020, several case reports have described a similar syndrome in adults; this review describes in detail nine patients reported to CDC, seven from published case reports, and summarizes the findings in 11 patients described in three case series in peer-reviewed journals (4-6). These 27 patients had cardiovascular, gastrointestinal, dermatologic, and neurologic symptoms without severe respiratory illness and concurrently received positive test results for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) or antibody assays indicating recent infection. Reports of these patients highlight the recognition of an illness referred to here as multisystem inflammatory syndrome in adults (MIS-A), the heterogeneity of clinical signs and symptoms, and the role for antibody testing in identifying similar cases among adults. Clinicians and health departments should consider MIS-A in adults with compatible signs and symptoms. These patients might not have positive SARS-CoV-2 PCR or antigen test results, and antibody testing might be needed to confirm previous SARS-CoV-2 infection. Because of the temporal association between MIS-A and SARS-CoV-2 infections, interventions that prevent COVID-19 might prevent MIS-A. Further research is needed to understand the pathogenesis and long-term effects of this newly described condition.
PMID: 33031361
ISSN: 1545-861x
CID: 4627142

Case Report: Mucosal Leishmaniasis in New York City

Murray, Henry W; Eiras, Daniel P; Kirkman, Laura A; Chai, Raymond L; Caplivski, Daniel
The six previously reported civilian cases of mucosal leishmaniasis (ML) diagnosed in the United States have all represented imported New World ML. We describe two new patients with ML diagnosed in New York City-a Syrian immigrant with a nasal mass (Leishmania tropica), the first report of Old World ML in the United States, and an American ecologist who worked in Bolivia and had been treated for cutaneous infection 23 years before developing lesions (L. (Viannia) braziliensis) initially of the uvula, soft palate, and posterior pharynx and subsequently the larynx.
PMID: 32228792
ISSN: 1476-1645
CID: 4370102

The Special Pathogens Research Network: Enabling Research Readiness

Kraft, Colleen S; Kortepeter, Mark G; Gordon, Bruce; Sauer, Lauren M; Shenoy, Erica S; Eiras, Daniel P; Larson, LuAnn; Garland, Jennifer A; Mehta, Aneesh K; Barrett, Kevin; Price, Connie S; Croyle, Caroline; West, Lauren R; Noren, Brooke; Kline, Susan; Arguinchona, Christa; Arguinchona, Henry; Grein, Jonathan D; Connally, Chad; McLellan, Susan; Risi, George F; Uyeki, Timothy M; Davey, Richard T; Schweinle, Jo Ellen; Schwedhelm, Michelle M; Harvey, Melissa; Hunt, Richard C; Kratochvil, Christopher J
The 2013-2016 epidemic of Ebola virus disease (EVD) that originated in West Africa underscored many of the challenges to conducting clinical research during an ongoing infectious disease epidemic, both in the most affected countries of Guinea, Liberia, and Sierra Leone, as well as in the United States and Europe, where a total of 27 patients with EVD received care in biocontainment units. The Special Pathogens Research Network (SPRN) was established in the United States in November 2016 to provide an organizational structure to leverage the expertise of the 10 Regional Ebola and Other Special Pathogen Treatment Centers (RESPTCs); it was intended to develop and support infrastructure to improve readiness to conduct clinical research in the United States. The network enables the rapid activation and coordination of clinical research in the event of an epidemic and facilitates opportunities for multicenter research when the RESPTCs are actively caring for patients requiring a biocontainment unit. Here we provide an overview of opportunities identified in the clinical research infrastructure during the West Africa EVD epidemic and the SPRN activities to meet the ongoing challenges in the context of Ebola virus and other special pathogens.
PMID: 30779607
ISSN: 2326-5108
CID: 3686002

Nephrotoxicity Associated with Intravenous Polymyxin B Once versus Twice Daily Dosing Regimen

Okoduwa, Adeola; Ahmed, Nabeela; Guo, Yi; Scipione, Marco R; Papadopoulos, John; Eiras, Daniel P; Dubrovskaya, Yanina
Nephrotoxicity is a known adverse effect of polymyxin B (PMB). Animal data suggests that once daily dosing may reduce the rate and delay the onset of acute kidney injury (AKI).In a multicenter, retrospective study, we evaluated adult patients with a creatinine clearance (CrCl) ≥30 mL/min who received ≥48h of PMB therapy. The primary endpoint was the difference in rate of AKI comparing once and twice daily PMB dosing. Secondary endpoints included time to AKI and recovery of renal function.Of 273 eligible patients, 100 from each group were matched based on propensity scores. In the matched groups, nephrotoxicity, defined according to RIFLE criteria, was more frequent with once versus twice daily dosing (47% vs. 17% P=0.0005). After adjusting for residual differences by multivariate conditional logistic regression, once daily dosing was more likely to result in nephrotoxicity (adjusted odds ratio 2.5, 95% CI 1.413-4.541, P=0.002). Among 64 patients who developed AKI, the median onset was similar between groups (7 days with once vs. 6 days with twice daily dosing, P=0.095). Of 37 patients who had their serum creatinine evaluated subsequently, 29/37 (78%) had recovery of renal function. No patient required renal replacement therapy.Our findings suggest that AKI is significantly more common with PMB once daily as compared to twice daily dosing with no difference in time to AKI. Prospective randomized study is warranted to validate these results.
PMCID:6105789
PMID: 29844039
ISSN: 1098-6596
CID: 3136892

Knowledge, Attitudes, and Practices Regarding Antimicrobial Use and Stewardship Among Prescribers at Acute-Care Hospitals

Salsgiver, Elizabeth; Bernstein, Daniel; Simon, Matthew S; Eiras, Daniel P; Greendyke, William; Kubin, Christine J; Mehta, Monica; Nelson, Brian; Loo, Angela; Ramos, Liz G; Jia, Haomiao; Saiman, Lisa; Furuya, E Yoko; Calfee, David P
OBJECTIVE To assess antimicrobial prescriber knowledge, attitudes, and practices (KAP) regarding antimicrobial stewardship (AS) and associated barriers to optimal prescribing. DESIGN Cross-sectional survey. SETTING Online survey. PARTICIPANTS A convenience sample of 2,900 US antimicrobial prescribers at 5 acute-care hospitals within a hospital network. INTERVENTION The following characteristics were assessed with an anonymous, online survey in February 2015: attitudes and practices related to antimicrobial resistance, AS programs, and institutional AS resources; antimicrobial prescribing and AS knowledge; and practices and confidence related to antimicrobial prescribing. RESULTS In total, 402 respondents completed the survey. Knowledge gaps were identified through case-based questions. Some respondents sometimes selected overly broad therapy for the susceptibilities given (29%) and some "usually" or "always" preferred using the most broad-spectrum empiric antimicrobials possible (32%). Nearly all (99%) reported reviewing antimicrobial appropriateness at 48-72 hours, but only 55% reported "always" doing so. Furthermore, 45% of respondents felt that they had not received adequate training regarding antimicrobial prescribing. Some respondents lacked confidence selecting empiric therapy using antibiograms (30%), interpreting susceptibility results (24%), de-escalating therapy (18%), and determining duration of therapy (31%). Postprescription review and feedback (PPRF) was the most commonly cited AS intervention (79%) with potential to improve patient care. CONCLUSIONS Barriers to appropriate antimicrobial selection and de-escalation of antimicrobial therapy were identified among front-line prescribers in acute-care hospitals. Prescribers desired more AS-related education and identified PPRF as the most helpful AS intervention to improve patient care. Educational interventions should be preceded by and tailored to local assessment of educational needs. Infect Control Hosp Epidemiol 2018;39:316-322.
PMID: 29402339
ISSN: 1559-6834
CID: 2989552

Understanding Barriers to Optimal Cleaning and Disinfection in Hospitals: A Knowledge, Attitudes, and Practices Survey of Environmental Services Workers

Bernstein, Daniel A; Salsgiver, Elizabeth; Simon, Matthew S; Greendyke, William; Eiras, Daniel P; Ito, Masahiro; Caruso, Dean A; Woodward, Timothy M; Perriel, Odette T; Saiman, Lisa; Furuya, E Yoko; Calfee, David P
In this study, we used an online survey to assess knowledge, attitudes, and practices related to environmental cleaning and other infection prevention strategies among environmental services workers (ESWs) at 5 hospitals. Our findings suggest that ESWs could benefit from additional education and feedback as well as new strategies to address workflow challenges. Infect Control Hosp Epidemiol 2016;1492-1495.
PMID: 27619896
ISSN: 1559-6834
CID: 2378772

Nephrotoxicity associated with intravenous (IV) polymyxin B (PMB) once versus twice daily dosing

Ahmed, Nabeela; Scipione, Marco R; Papadopoulos, John; Eiras, Daniel; Dubrovskaya, Yanina
ORIGINAL:0014897
ISSN: 2328-8957
CID: 4722512

Combination Regimens for Treatment of Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infections

Gomez-Simmonds, A; Nelson, B; Eiras, D P; Loo, A; Jenkins, S G; Whittier, S; Calfee, D P; Satlin, M J; Kubin, C J; Furuya, E Y
Previous studies reported decreased mortality in patients with carbapenemase-producing Klebsiella pneumoniae bloodstream infections (BSIs) treated with combination therapy but included carbapenem-susceptible and -intermediate isolates, as per revised CLSI breakpoints. Here, we assessed outcomes in patients with BSIs caused by phenotypically carbapenem-resistant K. pneumoniae (CRKP) according to the number of in vitro active agents received and whether an extended-spectrum beta-lactam (BL) antibiotic, including meropenem, or an extended-spectrum cephalosporin was administered. We retrospectively reviewed CRKP BSIs at two New York City hospitals from 2006 to 2013, where all isolates had meropenem or imipenem MICs of >/=4 mug/ml. Univariate and multivariable models were created to identify factors associated with mortality. Of 141 CRKP BSI episodes, 23% were treated with a single active agent (SAA), 26% were treated with an SAA plus BL, 28% were treated with multiple active agents (MAA), and 23% were treated with MAA plus BL. Ninety percent of isolates had meropenem MICs of >/=16 mug/ml. Thirty-day mortality was 33% overall and did not significantly differ across the four treatment groups in a multivariable model (P = 0.4); mortality was significantly associated with a Pitt bacteremia score of >/=4 (odds ratio [OR], 7.7; 95% confidence interval [CI], 3.2 to 18.1; P = 0.1), and immunosuppression was protective (OR, 0.4; 95% CI, 0.2 to 1.0; P = 0.04). Individual treatment characteristics were also not significantly associated with outcome, including use of SAAs versus MAA (26% versus 38%, P = 0.1) or BL versus no BL (26% versus 39%, P = 0.1). In summary, in patients with CRKP BSIs caused by isolates with high carbapenem MICs, the role of combination therapy remains unclear, highlighting the need for prospective studies to identify optimal treatment regimens.
PMCID:4879408
PMID: 27044555
ISSN: 1098-6596
CID: 2151832

CHLAMYDIA PROCTOCOLITIS MASQUERADING AS AN ULCERATIVE COLITIS FLARE [Meeting Abstract]

Wu, Patrick B; Ortigoza, Mila; Eiras, Daniel
ISI:000392201602134
ISSN: 1525-1497
CID: 2481902

Clinical outcomes associated with polymyxin B dose in patients with bloodstream infections due to carbapenem-resistant Gram-negative rods

Nelson, Brian C; Eiras, Daniel P; Gomez-Simmonds, Angela; Loo, Angela S; Satlin, Michael J; Jenkins, Stephen G; Whittier, Susan; Calfee, David P; Furuya, E Yoko; Kubin, Christine J
There is significant variation in the use of polymyxin B (PMB), and optimal dosing has not been defined. The purpose of this retrospective study was to evaluate the relationship between PMB dose and clinical outcomes. We included patients with bloodstream infections (BSIs) due to carbapenem-resistant Gram-negative rods who received >/=48 h of intravenous PMB. The objective was to evaluate the association between PMB dose and 30-day mortality, clinical cure at day 7, and development of acute kidney injury (AKI). A total of 151 BSIs were included. The overall 30-day mortality was 37.8% (54 of 151), and the median PMB dosage was 1.3 mg/kg (of total body weight)/day. Receipt of PMB dosages of <1.3 mg/kg/day was significantly associated with 30-day mortality (46.5% versus 26.3%; P = 0.02), and this association persisted in multivariable analysis (odds ratio [OR] = 1.58; 95% confidence interval [CI] = 1.05 to 1.81; P = 0.04). Eighty-two percent of patients who received PMB dosages of <1.3 mg/kg/day had baseline renal impairment. Clinical cure at day 7 was not significantly different between dosing groups. AKI was more common in patients receiving PMB dosages of >/=250 mg/day (66.7% versus 32.0%; P = 0.03), and this association persisted in multivariable analysis (OR = 4.32; 95% CI = 1.15 to 16.25; P = 0.03). PMB dosages of <1.3 mg/kg/day were administered primarily to patients with renal impairment, and this dosing was independently associated with 30-day mortality. However, dosages of >/=250 mg/day were independently associated with AKI. These data support the use of PMB without dose reduction in the setting of renal impairment.
PMCID:4604419
PMID: 26324272
ISSN: 1098-6596
CID: 2036482