Faculty Bibliography

Chronic kidney disease (CKD) is a potentially progressive disease that culminates in end-stage renal disease (ESRD) and has substantial morbidity. ESRD patients on hemodialysis (HD) are at high risk of hepatitis B (HBV) infection given prolonged vascular access, and person-to-person transmission via contaminated machines and personnel hands. Once patients have reached ESRD, they often fail to have adequate antibody response to HBV vaccination; whereas patients with CKD stage 4-5 NOT on HD have a higher antibody response. In a study of 68 patients, Fraser et al. found that after a 4-dose series, the seroprotection rate in adult pre-HD patients with serum creatinine levels of <=4 mg/dL was 86%, compared with 37% in patients with serum creatinine levels > 4 mg/dL, of whom 88% were on HD. Data was mined from the electronic medical record of all patients with CKD 4 and 5 seen in the Renal clinic at the Manhattan Campus of the VA NY Harbor Health Care System in July 2019 and their HBV immunity status confirmed by chart review. Barriers to vaccinating were identified through interviews with physician and patients. Several barriers were identified such as lack of housestaff education leading to not understanding the importance of checking HBV labs; delay in obtaining labs/or results, vaccination myths and inadequate follow-up. Countermeasures were developed for these barriers. We created and implemented a protocol for testing for HBV immunity and for immunization as appropriate. We are educating our fellows and ancillary staff. We also created a patient education flyer to increase CKD patients' awareness of HBV that would indirectly increase compliance with testing and adherence to the immunization schedule. Data collection for Sept-Oct 2019 prior to implementing the protocol, after only increased physician awareness, showed a decline in the percent of CKD 4-5 patients with insufficient or unknown immunity from 97.8% to 80%. The project is ongoing, and we are expecting that the results will be more robust as patient and staff education are emphasized; and patients complete their individualized vaccination schedules as appropriate.
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Pneumococci remain the most common etiology of community-acquired pneumonia in adults, with significant attendant mortality in the elderly. With the recognition of increasing rates of drug-resistant Streptococcus pneumoniae in recent years, efforts to prevent disease through vaccination have gained greater impetus. The 23-valent pneumococcal vaccine is used widely in the United States and provides effective protection against bacteremic pneumococcal disease, particularly in the immunocompetent host. The 7-valent pneumococcal conjugate vaccine, licensed in the United States in 2000, has had a dramatic impact on pneumococcal disease in the pediatric population, and its use in children has had effects on incidence rates in nonimmunized adults as well. Future directions include efforts to improve vaccination coverage in targeted populations and the development of more immunogenic and efficacious vaccines for high-risk groups

The emergence of Streptococcus pneumoniae isolates resistant to not only penicillin, but to other antipneumococcal agents as well, has major public health implications. Drug-resistant S. pneumoniae are distributed worldwide, and resistance has become increasingly prevalent in the United States within the past decade. The relevance of resistance, particularly to the beta-lactams, to treatment outcome has been subject to debate. Pneumonia due to intermediate-level-resistant penicillin-resistant isolates of S. pneumoniae appears to be adequately treated by beta-lactam agents. Interpretation of resistance reports, which may be based on achievable cerebrospinal fluid levels of drug, may depend on the clinical setting, and efforts are underway to adjust breakpoints so that reports are more easily applicable to clinical practice. Infectious Diseases Society of America and American Thoracic Society guidelines, as well as others, for community-acquired pneumonia have addressed the impact of drug-resistant S. pneumoniae on antimicrobial selection

The increasing number of solid organ transplant (SOT) recipients have high rates of pulmonary infections due to bacterial, fungal, and viral pathogens. These patients have unique sets of factors predisposing to infection. Lung and heart-lung transplants are associated with particularly high infection rates. The prominence of cytomegalovirus (CMV) as a pathogen in all subsets of SOT patients has led to new strategies for prophylaxis, detection, and treatment of CMV pneumonitis. Progress is similarly being made in managing fungal and bacterial infections. Advances in liver, kidney, heart, and lung transplantation are being discussed, with further attention to specific pathogens (ie, CMV, Aspergillus, Pneumocystis carinii, and Mycobacterium tuberculosis)

Fungi, both endemic and opportunistic, continue to be recognized as increasingly frequent pulmonary pathogens. Better appreciation of their epidemiology and clinical course, as well as clarification of the roles of the newer triazoles and lipid formulations of amphotericin B in treatment, have occurred within the past few years. Both endemic and opportunistic fungal pulmonary pathogens are reviewed, with emphasis on recent therapeutic advances

Non-opportunistic bacterial infections are an important cause of morbidity and mortality for HIV-infected adults and children. Factors associated with increased risk of these include altered B- and T-cell function; altered phagocytic cell function; skin and mucous membrane defects; and use of indwelling vascular catheters, antibiotics, or cytotoxic agents. The pathogens encountered most frequently are S. aureus, S. pneumoniae, H. influenzae, Salmonella sp., and Pseudomonas aeruginosa. Less commonly encountered organisms include Rhodococcus equi, Listeria monocytogenes, Shigella sp., and Nocardia asteroides, Strategies for prevention as well as diagnosis and treatment of these are discussed

Tuberculous infections of the breast are considered rare in the developed world. We describe a case of mammary tuberculosis in a woman who was not initially known to be seropositive for the human immunodeficiency virus (HIV) and who was thought to have a pyogenic breast abscess. This uncommon presentation of extrapulmonary tuberculosis as an AIDS-defining condition highlights the necessity for performing mycobacterial smears and cultures in such cases when patients are at risk for HIV infection