We report two immigrants from Cuba seen in a US travel clinic with a confirmed diagnosis of cutaneous leishmaniasis in whom we also suspected malaria co-infection. Both individuals likely acquired leishmaniasis in the Darien Gap region of Panama during their migratory path to the United States. As part of their clinical workup to rule out malaria, a rapid malaria antigen testing for P. falciparum was obtained and reported positive in both patients, However, both a qualitative reverse transcription-polymerase chain reaction (RT-PCR) for Plasmodium falciparum in blood and repeated thick-and-thin smear direct microscopy were negative in both, deeming the rapid malaria test as a false-positive. Thus, confirmation of malaria in travelers requires thick-and-thin film microscopy. Clinicians should be aware of the growing recognition of the possibility of false-positive malaria rapid diagnostic tests in those with some forms of leishmaniasis.

Retention in HIV pre-exposure prophylaxis (PrEP) care and adherence to PrEP have been suboptimal in some populations, despite evidence that high adherence dramatically enhances PrEP efficacy. A comprehensive PrEP Clinic with a retention specialist and clinical pharmacist could impact patient's retention and adherence in PrEP care. A retrospective electronic medical record review of patients attending an academic PrEP Clinic was conducted between June 2018 and June 2019 (at least one visit attended for PrEP was required). Retention was defined as a medical or laboratory visit every 3 months ±30 days, as recommended by CDC guidelines, but was analyzed using the number of visits and time between visits via multivariate regression analyses. PrEP adherence was calculated using a Medication-Possession Ratio (MPR) and compared between patient characteristics using Kruskal-Wallis tests. One hundred twenty-two patients were identified by chart review, 96 had sufficient data for follow-up and were included in at least one analysis. The population was primarily cisgender men who have sex with men and over half were African American or Hispanic. Overall, patient retention was 43%. The retention analysis demonstrated that individuals who self-identified as gay were more likely to be retained than those who identified as heterosexual (53% vs. 18%, hazard ratio = 1.75, 95% confidence interval = [1.01-3.03], p = .045). Although not statistically significant, African Americans and cisgender women were less likely to be retained in care. The adherence analysis identified higher median MPRs among patients not reporting previous incarceration (80% vs. 35%, p < .01). Although not statistically significant, there was lower adherence among youth 18-24 (11% vs. 54% MPR >80, p = .058). Despite comprehensive PrEP clinical care, heterosexual individuals were less likely to be retained in PrEP care than those who self-identified as gay and previously incarcerated individuals were less likely to be adherent to PrEP.

Background Bartonella quintana is an important cause of infection amongst people experiencing homelessness that is underdiagnosed due to its nonspecific clinical manifestations. We reviewed cases identified in the Denver metropolitan area in 2016-2021. Methods The electronic medical records from 2 large academic medical centers in Colorado were reviewed for demographic, clinical, and laboratory features of patients with B. quintana infection confirmed by blood culture, serologies, and/or molecular testing from July 2016 to December 2021. Results Fourteen patients with B. quintana infection were identified. The mean age was 49.5 years (SD 12.7 years) and 92.9% of patients were male. Twelve patients had history of homelessness (85.7%) and 11 were experiencing homelessness at the time of diagnosis (78.6%). Most frequent comorbidities included substance use (78.6%), of which 42.9% had alcohol use disorder. The average time to blood culture positivity was 12.1 days (SD 6.2 days). Three patients with bacteremia had negative B. quintana IgG, and 6 of 14 (42.8%) patients had evidence of endocarditis on echocardiography. Conclusions B. quintana is an underrecognized cause of serious infection in individuals experiencing homelessness. Serologic and microbiologic testing, including prolonged culture incubation, should be considered in at-risk patients due to ongoing transmission in homeless populations.

Background: Streptococcus pyogenes, or Group A Streptococcus (GAS), causes acute pharyngitis and necrotizing fasciitis. Seasonal variations in GAS infections are not robustly characterized. We assessed seasonal variations and risk factors of GAS pharyngitis and ICD-10-diagnosed necrotizing fasciitis. Methods: From the period 2010-2019, we conducted a case-control study using laboratory-confirmed cases of GAS pharyngitis and a descriptive observational study of necrotizing fasciitis using IDD-10 codes. Data were collected from TriNetX, a federated research network. We extracted seasonal (quarterly) incidence rates. We used an autoregressive integrated moving average (ARIMA) model to assess seasonal variations. Demographic characteristics and 1-month outcomes were compared among adults with or without GAS pharyngitis. Results: We identified 224,471 adults with GAS pharyngitis (test-positive) and 546,142 adults without it (test-negative). GAS pharyngitis adults were younger (25.3 versus 30.2 years of age, p <0.0001), more likely to be Hispanic individuals (10% versus 8%, p <0.0001) and slightly more likely to be Black or African American individuals (14% versus 13%, p< 0.0001). Propensity score matching found that adults with test-positive cases of GAS pharyngitis had a higher risk of acute rheumatic fever while having no significant differences in risk of intensive care unit admission and mortality compared with test-negative cases. GAS pharyngitis average incidence peaked in the winter while dipping in the summer (0.32 versus 0.18 and 4.07 versus 1.78 per 1000 adults and pediatric patients, respectively). Necrotizing fasciitis diagnoses were highest during summer (0.032 per 1000 adults). There was a significant ARIMA seasonal variation in the time series analysis for adult and pediatric GAS pharyngitis (p<0.0001 and p= 0.014, respectively). Necrotizing fasciitis diagnosis was not associated with seasonal variation (p= 0.861). Conclusion: Peaks in GAS pharyngitis occur in the winter months. IDD code-based necrotizing fasciitis did not show a quarterly seasonal variation.

Background: Streptococcus pyogenes , or Group A Streptococcus (GAS), causes acute pharyngitis and necrotizing fasciitis. Seasonal variations in GAS infections are not robustly characterized. We assessed seasonal variations and risk factors of GAS pharyngitis and ICD-10-diagnosed necrotizing fasciitis. Methods: From the period 2010–2019, we conducted a case–control study using laboratory-confirmed cases of GAS pharyngitis and a descriptive observational study of necrotizing fasciitis using ICD-10 codes. Data were collected from TriNetX, a federated research network. We extracted seasonal (quarterly) incidence rates. We used an autoregressive integrated moving average (ARIMA) model to assess seasonal variations. Demographic characteristics and 1-month outcomes were compared among adults with or without GAS pharyngitis. Results: We identified 224,471 adults with GAS pharyngitis (test-positive) and 546,142 adults without it (test-negative). GAS pharyngitis adults were younger (25.3 versus 30.2 years of age, p < 0.0001), more likely to be Hispanic individuals (10% versus 8%, p < 0.0001) and slightly more likely to be Black or African American individuals (14% versus 13%, p < 0.0001). Propensity score matching found that adults with test-positive cases of GAS pharyngitis had a higher risk of acute rheumatic fever while having no significant differences in risk of intensive care unit admission and mortality compared with test-negative cases. GAS pharyngitis average incidence peaked in the winter while dipping in the summer (0.32 versus 0.18 and 4.07 versus 1.78 per 1000 adults and pediatric patients, respectively). Necrotizing fasciitis diagnoses were highest during summer (0.032 per 1000 adults). There was a significant ARIMA seasonal variation in the time series analysis for adult and pediatric GAS pharyngitis ( p < 0.0001 and p = 0.014, respectively). Necrotizing fasciitis diagnosis was not associated with seasonal variation ( p = 0.861). Conclusion: Peaks in GAS pharyngitis occur in the winter months. ICD code–based necrotizing fasciitis did not show a quarterly seasonal variation.

Multidrug-resistant (MDR) bacteria pose a grave concern to global health, which is perpetuated by a lack of new treatments and countermeasure platforms to combat outbreaks or antibiotic resistance. To address this, we have developed a Facile Accelerated Specific Therapeutic (FAST) platform that can develop effective peptide nucleic acid (PNA) therapies against MDR bacteria within a week. Our FAST platform uses a bioinformatics toolbox to design sequence-specific PNAs targeting non-traditional pathways/genes of bacteria, then performs in-situ synthesis, validation, and efficacy testing of selected PNAs. As a proof of concept, these PNAs were tested against five MDR clinical isolates: carbapenem-resistant Escherichia coli , extended-spectrum beta-lactamase Klebsiella pneumoniae , New Delhi Metallo-beta-lactamase-1 carrying Klebsiella pneumoniae , and MDR Salmonella enterica . PNAs showed significant growth inhibition for 82% of treatments, with nearly 18% of treatments leading to greater than 97% decrease. Further, these PNAs are capable of potentiating antibiotic activity in the clinical isolates despite presence of cognate resistance genes. Finally, the FAST platform offers a novel delivery approach to overcome limited transport of PNAs into mammalian cells by repurposing the bacterial Type III secretion system in conjunction with a kill switch that is effective at eliminating 99.6% of an intracellular Salmonella infection in human epithelial cells.

We present a case of Cryptococcus neoformans pericarditis in a cardiac transplant recipient. This article reviews the diagnosis, treatment, and complications of cryptococcosis specifically in transplant patients. While pericarditis is a rare manifestation of Cryptococcus infection, this case highlights that cryptococcosis should be considered in the differential diagnosis for solid organ transplant and immunocompromised patients presenting with pericardial effusions.

BACKGROUND: Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees. AIM: To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP. SETTING: A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse. PARTICIPANTS: Thirty-four internal medicine residents completed the course between November 2017 and May 2018. PROGRAM DESCRIPTION: The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic. PROGRAM EVALUATION AND RESULTS: The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n=19), additional post-surveys on the online modules (n=22), and interviews (n=9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p<0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients. DISCUSSION: An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ.

Colorado has had rising rates of gonorrhea and syphilis. Guidelines for those diagnosed with sexually transmitted infectious (STIs) stipulate that patients should receive screening for other STIs, including syphilis and HIV. We aimed to study how often patients received guideline-based evaluation and hypothesized that providers adequately treat STIs but fail to provide comprehensive screening. We retrospectively reviewed 868 patients diagnosed with chlamydia, gonorrhea, and trichomonas within the University of Colorado Health System. We defined “comprehensive screening” as testing for both syphilis and HIV and “re-screening” as testing again for the originally detected pathogen. Statistical analysis was performed with chi-square analysis. Eight hundred one (92.2%) of 868 patients received treatment, 98.3% of which was guideline-based. At time of diagnosis, 16 (3.0%) of 550 patients seen in the emergency department, urgent care, or obstetrical triage received comprehensive screening compared with 183 (57.5%) of 318 patients seen in clinics. Comprehensive screening at diagnosis was more common in infectious disease (ID, 84.2%) and obstetrics (OB, 70.8%) clinics than in gynecology (GYN, 29.1%), family medicine (FM, 45.2%), or internal medicine (IM, 41.3%) clinics (P < 0.01). 62 (43.1%) of 144 patients without prior comprehensive screening received screening at time of follow-up, more commonly in ID (68.4%) and OB (57.1%) clinics than in FM (24.1%) and GYN (22.9%) clinics (P < 0.01). Two hundred (84.7%) of 236 patients seen in follow-up received re-screening. Only 96 patients (11.1%) received extra-genital testing at any point; of these 93 (96.9%) were men and 79 (82.2%) were tested in ID clinic. Guideline-based treatment and re-screening were routinely performed for those diagnosed with STIs. However, rates of comprehensive screening were below standard of care. Additionally, extra-genital testing was not routinely performed in any setting outside of ID clinic. Providers in ID and OB clinics, where screening is either routine or protocolized, were more likely to perform comprehensive screening. Protocolization of STI screening within the University of Colorado Health System may improve guideline adherence and improve identification of comorbid STIs in high-risk populations. All authors: No reported disclosures.

Detection of bacteremia directly from blood may improve time to clinical diagnosis and initiation of appropriate antibiotic therapy for hospitalized patients. Administration of empiric antibiotic therapy, whether prior to standard of care (SOC) or research study blood collection, adds to challenges in bacterial recovery. Strategies to improve detection were explored in this pilot study to inform future clinical trial design (CTD) on Enterobacteriaceae (ENT) detection directly from blood. One of the objectives was to assess effects of prior antibiotic administration on novel assay performance. Confirmed ENT bacteremic (Protocol A (P-A), n = 26), and suspected bacteremic (Protocol B (P-B), n = 25) participants were enrolled into one of two IRB approved protocols after obtaining informed consent. Fresh whole blood (20 mL) was collected within 12 hours of SOC blood culture positivity (P-A) or 20 hours of SOC blood culture collection (P-B), and divided: 10 mL inoculated into a lytic media collection vessel (P-A and B); and 10 mL into a BD BACTEC™ Bottle (P-A) as a control, or an Isolator™ lysis centrifugation tube (P-B) for quantification. For collection vessels, a 3-hour amplification step in lytic growth medium followed by cleanup and concentration steps was employed. Processed samples were tested using an investigational assay for universal bacterial detection on the Accelerate Pheno™ system. Results were analyzed manually and with proprietary software. Descriptive statistics were performed to inform future CTD. Empiric antibiotic therapy was initiated prior to blood collection in 89% (P-A) and 36% (P-B) of participants. Improved detection sensitivity was achieved in P-B over P-A, when a study sample was obtained prior to empiric antibiotic therapy initiation (Table 1). Prior antibiotic administration and low bacterial load in clinical samples affects ability to detect ENT directly from blood. Multiple factors are critical to address in future CTD to increase sensitivity of detecting ENT directly from blood including: (1) Targeting study samples prior to antibiotic therapy initiation and (2) Using enzymatic methods to neutralize antibiotics present in the blood. M. Fuchs, Accelerate Diagnostics, Inc.: Employee, Salary. S. Kim, Accelerate Diagnostics, Inc.: Employee, Salary. S. Metzger, NIH: Grant Investigator, Grant recipient. Accelerate Diagnostics, Inc.: Employee, Salary.

We report here the draft genome sequences of two clinically isolated Acinetobacter baumannii strains. These samples were obtained from patients at the University of Colorado Hospital in 2007 and 2013 and encode an estimated 20 and 13 resistance genes, respectively.

A 39-year-old female patient from Myanmar with a medical history significant for migraines presented at 22 weeks of pregnancy with evidence of anemia. Her physical examination and vital signs were unremarkable. Her initial hemoglobin level was 11.4 g/dL with a hematocrit of 35.2%. Her immigration screening test revealed positive result for immunoglobulin G antibodies for Strongyloides. Microcytosis was observed and studies were consistent with iron deficiency. The ova and parasites (O&P) examination showed positive result for Trichuris trichiura. Blood smears showed negative result for blood parasites. Based on World Health Organization recommendations to avoid mebendazole and ivermectin during pregnancy, therapy for both the infections in the absence of significant symptoms was deferred until after delivery. The patient was placed on iron supplementation. Her anemia remained stable. Screening for other infections (hepatitis B virus, human immunodeficiency virus, hepatitis C virus and tuberculosis) showed negative results. After delivery, she then received a course of ivermectin 200 mcg/kg daily for 2 consecutive days for both strongyloidiasis and trichuriasis. After 2 months, her hemoglobin improved to 11.9 g/dL. A follow-up O&P, 4 months after initial treatment, revealed an ovum (Figure). Diagnosis of hookworm infection was made. The O&P examination revealed a characteristic hookworm ovum of an approximate size of 50 × 35 µm.

The rise of multidrug-resistant (MDR) bacteria is a growing concern to global health and is exacerbated by the lack of new antibiotics. To treat already pervasive MDR infections, new classes of antibiotics or antibiotic adjuvants are needed. Reactive oxygen species (ROS) have been shown to play a role during antibacterial action; however, it is not yet understood whether ROS contribute directly to or are an outcome of bacterial lethality caused by antibiotics. We show that a light-activated nanoparticle, designed to produce tunable flux of specific ROS, superoxide, potentiates the activity of antibiotics in clinical MDR isolates of Escherichia coli, Salmonella enterica, and Klebsiella pneumoniae. Despite the high degree of antibiotic resistance in these isolates, we observed a synergistic interaction between both bactericidal and bacteriostatic antibiotics with varied mechanisms of action and our superoxide-producing nanoparticles in more than 75% of combinations. As a result of this potentiation, the effective antibiotic concentration of the clinical isolates was reduced up to 1000-fold below their respective sensitive/resistant breakpoint. Further, superoxide-generating nanoparticles in combination with ciprofloxacin reduced bacterial load in epithelial cells infected with S. enterica serovar Typhimurium and increased Caenorhabditis elegans survival upon infection with S. enterica serovar Enteriditis, compared to antibiotic alone. This demonstration highlights the ability to engineer superoxide generation to potentiate antibiotic activity and combat highly drug-resistant bacterial pathogens.

Light-activated quantum dots can selectively kill multidrug-resistant bacteria by altering the cellular redox environment.

We report here the draft genome sequence of a multidrug-resistant Enterococcus faecalis strain, isolated from a patient at the University of Colorado Hospital. The genome assembly is 3,040,186 bp in length with 37.6% GCcontent. This isolate encodes eleven resistance genes, including those for glycopeptide, aminoglycoside, macrolide-lincosamide-streptogramin, and tetracycline resistance.

Introduction: Staphylococcus intermedius group (SIG) comprises coagulase-positive staphylococci isolated from veterinary wounds, with anecdotal association of this pathogen and disease in humans. To date, 28 human cases have been described in the literature. Here, we described four cases of human infection caused by SIG members and, through a literature review, identified potential common characteristics and risk factors for this infection. Case presentations: Cases were obtained via electronic query of existing microbiology records for S. intermedius isolates at three teaching hospitals in Denver, CO, USA, between 2003 and 2008. Four cases were identified. Three cases were soft tissue and/or bone infection and one case was a urinary tract infection. Conclusion: Staphylococcus intermedius infections in humans are rarely identified. Dog ownership as well as diabetes or other causes of immunosuppression may place patients at higher risk. Misidentifying SIG infections could lead to delays in treatment as well as undertreatment of this zoonosis.

A previously fit and well 24 year old US born white man presented for evaluation of abdominal pain. He had felt tired for the past two days and had been experiencing headaches, subjective fevers, and diffuse abdominal pain. Despite this he had maintained a good appetite and his normal diet, which included eating sushi at least once a week. His symptoms improved greatly after he noted a tape-like object in his stool. He had travelled to California, …