Faculty Bibliography

Background. Urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila is only recommended in patients with severe pneumonia according to the 2019 guidelines from the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA). Unnecessary testing for these organisms may increase antibiotic utilization. This quality improvement project evaluated whether patients who received a Streptococcus pneumoniae or Legionella pneumophila urine antigen met criteria for testing. Methods. We conducted a cohort study of patients who received a urinary antigen test for Streptococcus pneumoniae or Legionella pneumophila within 3 days of admission to the Veterans Affairs Connecticut Healthcare System between September 1, 2018 and September 1, 2021. We determined whether patients had clinically defined pneumonia per National Healthcare Safety Network criteria. Among patients that met criteria for clinically defined pneumonia, the subset with severe pneumonia according to the ATS/IDSA guidelines was identified. We used the ATS/IDSA guidelines to determine whether patients received guideline-concordant choice of therapy. Results. We identified 352 patients who received a urinary antigen test within 3 days of admission. Mean age was 72.6 years, 97% (n=278) were male sex, and 86% (n=301) were White race. Common comorbidities included heart disease (76%, n=268), lung disease (58%, n=203), and diabetes (30%, n=106). Overall, 36% (n=127) of patients met criteria for clinically defined pneumonia, and 7% (n=25) met criteria for severe pneumonia. 9 patients had a positive Streptococcus pneumoniae antigen test and 1 patient had a positive test for Legionella. Among patients with clinically defined pneumonia, 74% (n=75) received guideline-concordant choice of therapy and 74% (n=75) received an antibiotic duration >5 days Diagnostic and Therapeutic Characteristics of Veterans According to Presence of Pneumonia Conclusion. Only 7% of patients who underwent urine antigen testing for Streptococcus pneumoniae or Legionella pneumophila met criteria for testing per ATS/IDSA guidelines, and length of therapy was prolonged in the vast majority of patients. These data support the need for a clinical decision-making tool to reduce unnecessary testing and treatment for pneumonia at our institution. (Table Presented)

Background. With the spread of the SARS-CoV-2 pandemic in 2020 and the attendant global precautions such as masking, travel restrictions and social distancing, the WHO FluNet data indicated a decline in flu rates. The CDC data for the 2020-2021 season showed the same decline in US flu as well as other respiratory viruses. Two hypotheses to explain the observed phenomenon are the impact of non pharmaceutical interventions (NPI) to prevent SARS-CoV-2 infection and suppression of other respiratory viruses by SARS-CoV-2 through a form of resource competition. Methods. We conducted a study using the EPIC Slicer Dicer analytics tool and the Yale Internal Medicine COVID-19 Database to retrieve data from the Yale New Haven Health System (YNHHS). We tabulated the total number of positive and negative tests for SARS-CoV-2 and a panel of respiratory viruses from September 2, 2018 to April 30, 2022 to cover pre- and peri-pandemic periods. These results were divided into three age groups: <=12, 13-59, and >=60. Epidemic curves of each virus with respect to each other, the season, and the introduction of NPIs were constructed to help differentiate between the two hypotheses. Results. Pre-pandemic data from 09/2018 to 02/2020 revealed seasonal spikes in influenza A and B with 254 positive weekly influenza A/B tests from 11/2018 to 02/2019 for a positivity rate of 7.97% and 481 positive weekly tests (10.53% positivity rate [PR]) from November 2019 to February 2020. There were only 0.35 positive weekly influenza A/B tests (0.05% PR) from 11/2020 to 02/2021 with 2018 positive weekly tests (6.45% PR) for SARS-CoV-2 over the same period. From 11/2020 to 02/2021, there were 56 positive weekly influenza A/B tests (1.44% PR) and 4347 positive weekly SARS-CoV-2 tests (10.35% PR). From 07/ 2021 to 11/2021, there was an increased rate of positive RSV tests (82 per week, 15.76% PR) and rhinovirus tests (58 per week, 18.73% PR). There were 803 positive weekly tests (2.53% positivity rate) for SARS-CoV-2 over this same period. Conclusion. Since the start of the SARS-CoV-2 pandemic, the number of positive tests for influenza A/B and seasonal respiratory viruses have not reached prepandemic levels across the YNHHS. However, rates of influenza and other respiratory viruses have increased since the relaxation of NPIs

A young woman in her 20s presented with fever, abdominal pain and malodourous vaginal discharge. She was found to be in septic shock, in the setting of a recent medical abortion with subsequent intrauterine device placement. Her blood cultures grew Fusobacterium necrophorum Despite appropriate antibiotic therapy, the fever failed to defervesce. Subsequent evaluation revealed septic thrombophlebitis of the right gonadal vein and branches of the right iliac vein. She improved with a prolonged course of targeted antimicrobial therapy.

PURPOSE OF REVIEW:Hyperammonemia syndrome is an increasingly recognized and often fatal condition that occurs in immunosuppressed individuals, most commonly lung transplant recipients. Growing evidence suggests hyperammonemia syndrome is associated with systemic infections caused by urease-producing organisms, namely Ureaplasma spp., an organism unable to grow with routine culturing techniques. This review will summarize the epidemiology and clinical manifestations of hyperammonemia syndrome, as well as diagnostic and management strategies once hyperammonemia syndrome is suspected. RECENT FINDINGS:Hyperammonemia syndrome is being described in increasing frequency in the solid organ transplant population. Morbidity and mortality, even with treatment, is high once hyperammonemia syndrome occurs. Surveillance studies indicate the prevalence of lung donor colonization with Ureaplasma spp. is high, suggesting screening and treatment may be of benefit. Antibiotic resistance is common, and rapid diagnostics can facilitate appropriate antimicrobial therapy in the peri-transplant period. SUMMARY:Hyperammonemia syndrome is most commonly seen in lung transplant recipients and has a high mortality rate once it occurs. Screening for Ureaplasma spp. should be considered in all lung transplant donors.