Fournier gangrene (FG) is a necrotizing soft tissue infection (NSTI) of the perineum. Recent retrospective studies from quaternary centers suggest improved outcomes and a potentially less aggressive clinical course for FG than non-perineal NSTIs. However, comprehensive nationwide data remain limited. This retrospective cohort study analyzed the National Inpatient Sample (2016–2020) to compare outcomes between FG and non-perineal NSTIs. Adult patients undergoing surgical debridement with a diagnosis of FG or NSTI were identified using ICD-10 codes. Outcomes included in-hospital mortality, length of stay (LOS), hospital costs, and home discharge rates. Multivariable regression analyses adjusted for patient demographics, comorbidities, and hospital characteristics. A total of 5,007 FG and 24,782 non-perineal NSTI patients were identified. Crude in-hospital mortality rates were 5.8% for FG and 5.4% for non-perineal NSTIs, with stable trends observed over five years. After adjustment, no significant difference in mortality was observed (adjusted odds ratio [aOR]: 1.04; 95% CI: 0.90–1.20). However, FG was associated with longer LOS (adjusted mean difference: 1.99 days; 95% CI: 1.53–2.46) and higher hospital costs ($37,809 higher; 95% CI: $29,540–$46,077). Home discharge rates were similar between groups (aOR: 0.97; 95% CI: 0.89–1.05). Despite similar mortality rates, FG hospitalizations were associated with increased LOS and higher costs compared to non-perineal NSTIs. These findings suggest potential nationwide disparities in FG care quality, particularly outside specialized referral centers. Further research is needed to understand if standardized care pathways tailored to FG may optimize management and reduce resource utilization. All Authors: No reported disclosures

Staphylococcus aureus bacteremia (SAB) remains a leading cause of bloodstream infection in both community and healthcare settings, with reported mortality rates ranging from 10% to 30%. This study aimed to characterize the frequency, predictors, and clinical impact of palliative care consultation (PCC) in hospitalized patients with SAB.Figure 1.Distribution of Palliative Care Consults in hospitalized Staphylococcus aureus bacteremia patientsFigure 2.Distribution of Staphylococcus aureus bacteremia patients during hospitalization We conducted a retrospective cohort study of adult and pediatric inpatients with SAB, defined by ≥1 positive blood culture for S. aureus, between January 1, 2016, and December 31, 2018. Baseline characteristics were compared between patients who did and did not receive PCC using chi-square, Fisher’s exact, and Wilcoxon rank-sum tests. Temporal trends, predictors of PCC, and associated outcomes were assessed using multivariable regression models. Survival was analyzed using Kaplan-Meier methods. Among 479 patients with SAB, 89 (18.6%) received PCC. Although PCC use increased over time, the trend was not statistically significant. Goals-of-care (GoC) discussions were the most common indication. Independent predictors of PCC included older age (adjusted odds ratio [aOR], 1.03 per year; 95% CI, 1.02–1.05; P< 0.001) and prolonged bacteremia (aOR, 1.10 per day; 95% CI, 1.00–1.21; P=0.042). Female sex (aOR, 0.54; 95% CI, 0.29–0.97; P=0.043) and musculoskeletal/soft tissue source of infection (aOR, 0.35; 95% CI, 0.14–0.83; P=0.021) were associated with lower odds of PCC. PCC was associated with shorter antibiotic duration (aOR, 0.58; 95% CI, 0.55–0.61; P< 0.001), increased GoC documentation (aOR, 1369.48; 95% CI, 257.29–25,917.74; P< 0.001), and higher rates of transition to comfort care (aOR, 42.40; 95% CI, 19.96–98.50; P< 0.001) and hospice (aOR, 164.34; 95% CI, 26.55–360.32; P< 0.001). Median time from consultation to discharge was 4 days (IQR, 1–10), and was shorter among those who died in-hospital (2 vs. 8 days; P< 0.0001). PCC was infrequently utilized among patients with SAB but strongly associated with care transitions and antimicrobial stewardship outcomes. A substantial proportion of patients died without PCC involvement. These findings highlight the need for earlier integration of palliative care in the management of SAB to support patient-centered care. Paul G. Auwaerter, MD, Capricor: Board Member|Capricor: Stocks/Bonds (Public Company)|Johnson and Johnson: Stocks/Bonds (Public Company)|Pfizer: Grant/Research Support|Shionogi: Advisor/Consultant

Background: Following the COVID-19 pandemic, the University of Kentucky (UKY) experienced elevated rates of methicillin-resistant Staphylococcus aureus (MRSA). To drive rapid improvement, an MRSA escalation program was developed incorporating targeted contact precautions for units not meeting decolonization thresholds, enhanced MRSA surveillance testing, and data-driven reports to support unit leadership. Methods: The UKY Infection Prevention and Control Program (IPAC) implemented a data-driven MRSA escalation strategy. At baseline, all patients in intensive care units, patients with indwelling lines or tubes, and patients testing positive for MRSA were expected to undergo daily chlorhexidine bathing and intranasal povidone iodine decolonization. Upon review, gaps were identified in decolonization performance and screening of at-risk populations. The intervention addressed these gaps by including electronic health record (EHR)–prompted MRSA screening for at-risk patients, development of aggregate decolonization compliance dashboards, and real-time performance dashboards for unit supervisors. A monthly decolonization performance threshold of 70 percent was established. Units with persistent compliance below 70 percent were placed on contact precautions with an “MRSA Escalation” designation in the EHR. IPAC met with identified units to provide toolkits and education on dashboard utilization and integration of MRSA metrics into routine huddles and sprints. In March 2025, intranasal decolonization was transitioned from povidone iodine to mupirocin. Monthly hospital-onset MRSA bacteremia counts, chlorhexidine bathing compliance, and nasal decolonization compliance from July 2023 through December 2025 were analyzed using simple linear regression with time in months as the independent variable. Results: Multidisciplinary education was conducted across nursing, physician, and leadership groups from August 2023 through January 2024, with program go-live in February 2024. Chlorhexidine bathing compliance increased significantly over time, with an average improvement of 0.39 percentage points per month (95% CI 0.24–0.55, p < 0.001, R² = 0.48, Figure 1). Nasal decolonization compliance also increased significantly, with an average improvement of 0.30 percentage points per month (95% CI 0.16–0.44, p < 0.001, R² = 0.40). Hospital-onset MRSA bacteremia demonstrated a significant downward trend (slope –0.089 cases per month, p = 0.012, R² = 0.20), corresponding to an average reduction of approximately one case every 11 months. Quarterly SIR decreased from 1.10 in Q3 2023 to 0.54 in Q4 2025. Conclusions: Implementation of an MRSA escalation program incorporating decolonization performance thresholds, targeted contact precautions, enhanced education, real-time data reporting, and transition to mupirocin for nasal decolonization was associated with significant improvements in decolonization compliance and a sustained reduction in hospital-onset MRSA bacteremia.

Background:Despite trial data supporting oral stepdown therapy for infective endocarditis (IE), its use remains limited, especially in North America. We evaluated outcomes of patients with IE managed by a multidisciplinary team and treated with either intravenous (IV) or partial oral antibiotics. Methods:This was a single-center retrospective study of patients with definite IE identified from an institutional registry between 7 September 2021 and 1 March 2025. Clinical and outcomes data were analyzed using multivariable logistic regression. Results:Of 236 patients, 143 received IV therapy alone and 93 were transitioned to partial oral therapy. Baseline characteristics were similar, though valve surgery was more frequent in the oral group (40.9% vs 28.0%; P = .04). There were no significant differences in 90-day relapsed infection (0.7% vs 2.2%; P = .32), 90-day all-cause mortality (2.8% vs 6.5%; P = .17), or the composite of both outcomes (3.5% vs 8.6%; P = .09). There was no difference in relapsed infection or all-cause mortality at 90 days for patients with methicillin-resistant Staphylococcus aureus transitioned to oral therapy. In multivariable analysis, oral therapy was not associated with increased 90-day mortality (odds ratio [OR], 1.72 [95% confidence interval {CI} .41-7.24]; P = .46). Independent predictors of mortality included older age (OR, 1.06 per year [95% CI, 1.00-1.13]; P < .001), acute heart failure (OR, 18.61), and discharge before medically advised (OR, 8.60). Conclusions:In selected patients managed by a multidisciplinary team, partial oral therapy for IE appears to be safe and effective, with outcomes comparable to exclusive IV treatment, consistent with European guidelines.

Background:Fournier gangrene (FG) is a necrotizing soft tissue infection (NSTI) of the perineum. Recent retrospective studies from quaternary centers suggest improved outcomes and a potentially less aggressive clinical course for FG than non-perineal NSTIs. However, comprehensive nationwide data remain limited. Methods:This retrospective cohort study analyzed the National Inpatient Sample (2016-2020) to compare outcomes between FG and non-perineal NSTIs. Adult patients undergoing surgical debridement with a diagnosis of FG or NSTI were identified using ICD-10 codes. Outcomes included in-hospital mortality, length of stay (LOS), hospital costs, and home discharge rates. Multivariable regression analyses adjusted for patient demographics, comorbidities, and hospital characteristics. Results:A total of 5,007 FG and 24,782 non-perineal NSTI patients were identified. Crude in-hospital mortality rates were 5.8% for FG and 5.4% for non-perineal NSTIs, with stable trends observed over five years. After adjustment, no significant difference in mortality was observed (adjusted odds ratio [aOR]: 1.04; 95% CI: 0.90-1.20). However, FG was associated with longer LOS (adjusted mean difference: 1.99 days; 95% CI: 1.53-2.46) and higher hospital costs ($37,809 higher; 95% CI: $29,540-$46,077). Home discharge rates were similar between groups (aOR: 0.97; 95% CI: 0.89-1.05). Discussion:Despite similar mortality rates, FG hospitalizations were associated with increased LOS and higher costs compared to non-perineal NSTIs. These findings may suggest potential nationwide disparities in FG care quality, particularly outside specialized referral centers. Further research is needed to understand if standardized care pathways tailored to FG may optimize management and reduce resource utilization.

Background: Approximately half of all fevers in intensive care units (ICUs) are attributed to noninfectious causes. Despite this, most providers routinely culture urine from patients with indwelling urinary catheters who develop a new fever, which can lead to overdiagnosis and unnecessary antibiotic use. This study evaluated the impact of transitioning from a urinalysis (UA) with reflex to culture order to a stand-alone UA with microscopy in the Surgical and Neurosciences Intensive Care Unit (SNICU) on the frequency of urine cultures ordered and Catheter-Associated Urinary Tract Infections (CAUTIs). Methods: This quasi-experimental before-and-after study was conducted at the University of Iowa between July 2022 and August 2024 and included all SNICU patients. In August 2023, SNICU staff were educated to send a UA with microscopy, review results with the care team, and then decide whether a reflex to culture was warranted. This initiative was collaboratively developed by SNICU leadership and the hospital epidemiology team. Data on the frequency of urine cultures and CAUTI rates per 1,000 catheter days were compared before and after implementation using a P chart in QI Macros. Results: During the pre-intervention period, SNICU ordered approximately 66 urine cultures per 1,000 patient days, with a CAUTI rate of 1.55 per 1,000 catheter days (Figure 1a and 1b). While all data points remained within control limits, red data points between November 2022 and January 2023 indicated possible special cause variation; after further investigation, the specific cause was not identified and data points returned to normal cause variation. Following implementation, the frequency of urine cultures decreased to approximately 32 per 1,000 patient days, and the CAUTI rate dropped to 0.47 per 1,000 catheter days. The intervention also resulted in greater process stability, as evidenced by a narrower range between the upper control limit (48.97) and lower control limit (15.36). These improvements demonstrated the effectiveness of transitioning to a deliberate, decision-making process based on UA with microscopy. Conclusion: Transitioning from reflex urine culture orders to a stand-alone UA with microscopy, combined with provider decision-making and leadership engagement, significantly reduced the frequency of urine cultures and CAUTI rates in the SNICU. By requiring a deliberate review of UA results before ordering cultures, this intervention successfully optimized diagnostic stewardship. The pilot program will be integrated into the electronic medical record and expanded to other units.

BACKGROUND:Diagnosing pediatric infectious diseases is challenging due to nonspecific presentations, small sample volumes, and the limited sensitivity of conventional microbiological tests (CMTs). Metagenomic next-generation sequencing (mNGS) enables broad, hypothesis-free pathogen detection, but its diagnostic performance in children remains insufficiently characterized. This study evaluates the diagnostic accuracy of mNGS in pediatric infectious diseases and compares its performance with CMTs. METHODS:This systematic review and meta-analysis was registered in PROSPERO (CRD42024542444). Searches were performed using multiple databases through August 2024. Eligible studies evaluated mNGS and CMTs in pediatric patients (≤21 years) with suspected infectious diseases and compared their respective results with clinical diagnosis. Pooled sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated using a bivariate random-effects model. RESULTS:Thirty-three studies (n = 4,165) met inclusion criteria, and nine were eligible for meta-analysis. Pooled sensitivity and specificity of mNGS versus clinical diagnosis were 0.84 (95% CI: 0.82-0.86) and 0.71 (95% CI: 0.66-0.75), respectively, compared with 0.40 (95% CI: 0.37-0.43) and 0.82 (95% CI: 0.78-0.86) for CMTs. The pooled DOR favored mNGS (18.6 vs. 5.4). Respiratory infections were most frequently investigated, followed by bloodstream and mixed infections. Over two-thirds of studies reported changes in antimicrobial management following mNGS results. CONCLUSIONS:mNGS demonstrates superior sensitivity and diagnostic accuracy compared with CMTs, enabling comprehensive pathogen detection, including rare and co-infecting organisms, and informing targeted antimicrobial therapy. Despite limitations related to cost, complex interpretation, and methodological standardization, mNGS represents a promising complement to conventional diagnostics in pediatric infectious disease management.

Background: Candida auris is an emerging multidrug-resistant fungus recognized as a global health threat. Despite increasing rates of colonization, no standardized protocol exists in the United States for C. auris screening upon admission. In February 2023, the University of Kentucky Healthcare (UKHC) implemented a targeted C. auris screening system for select high-risk patients. Methods: This retrospective observational study was conducted at UKHC, a 1,086-bed academic medical center, using data from patients aged ≥18 years screened for C. auris between July 1, 2021, and June 30, 2024. Prior to February 2023, C. auris screening occurred only during outbreak investigations. Post-implementation, screening was expanded to include ICU admissions, patients from external facilities with wounds or tracheostomies, and patients with a history of carbapenem-resistant organism infection. Axillary and groin swabs were tested via polymerase chain reaction (PCR). Cases were classified as community-onset (CO) Results: Of 13,642 C. auris tests performed, 70 positive cases were identified: 13 cases (6 CO, 7 HO) pre-implementation and 57 cases (31 CO, 26 HO) post-implementation (Figure 1). The mean age was 60.24 years, and males comprised 57.75%. The monthly positivity rate post-implementation ranged from 0% to 2.18% (with a mean of 0.96%). Among the 70 cases, 10 (14.29%) were classified as clinical infections, and 60 (85.71%) as colonization. The primary indications for C. auris screening included ICU admission (42.86%), point prevalence surveys (17.14%), and admission from external facilities with wounds (5.72%). No significant differences were observed between clinical and colonized cases by age, gender, race, or most other comorbidities. However, clinical cases were more likely to have diabetes (90% vs. 48.33%, p=0.0143) and medical device usage, including tracheostomy (80% vs. 45.00%, p=0.0404), gastrostomy tubes (90% vs. 53.33%, p=0.0293), central lines (60% vs. 41.67%, p=0.2799), and urinary catheters (60% vs. 46.67%, p=0.4348). Among ten clinical cases, seven patients received antifungal treatment. Three patients did not receive any treatment since C. auris was not considered clinically significant. 30-day mortality was higher among clinical cases compared to colonized cases; however, the difference was not statistically significant (30% vs. 25%, p=0.7377). Conclusions: The implementation of a targeted C. auris screening program at UKHC has provided critical insights into epidemiologic trends, patient demographics, and risk factors. Understanding these factors is essential for optimizing infection prevention strategies, refining screening protocols, and informing public health efforts to mitigate the spread of C. auris in healthcare settings.

Background:Artificial intelligence (AI) has the potential to enhance clinical decision-making, including in infectious diseases. By improving antimicrobial resistance prediction and optimizing antibiotic prescriptions, these technologies may support treatment strategies and address critical gaps in healthcare. This study evaluates the effectiveness of AI in guiding appropriate antibiotic prescriptions for infectious diseases through a systematic literature review. Methods:We conducted a systematic review of studies evaluating AI (machine learning or large language models) used for guidance on prescribing appropriate antibiotics in infectious disease cases. Searches were performed in PubMed, CINAHL, Embase, Scopus, Web of Science, and Google Scholar for articles published up to October 25, 2024. Inclusion criteria focused on studies assessing the performance of AI in clinical practice, with outcomes related to antimicrobial management and decision-making. Results:Seventeen studies used machine learning as part of clinical decision support systems (CDSS). They improved prediction of antimicrobial resistance and optimized antimicrobial use. Six studies focused on large language models to guide antimicrobial therapy; they had higher prescribing error rates, patient safety risks, and needed precise prompts to ensure accurate responses. Conclusions:AI, particularly machine learning integrated into CDSS, holds promise in enhancing clinical decision-making and improving antimicrobial management. However, large language models currently lack the reliability required for complex clinical applications. The indispensable role of infectious disease specialists remains critical for ensuring accurate, personalized, and safe treatment strategies. Rigorous validation and regular updates are essential before the successful integration of AI into clinical practice.

Abstract Background Staphylococcus aureus is a common cause of both community-acquired and nosocomial bacteremia in children. Multiple studies evaluating the role of infectious disease consultation (IDC) in adult patients with Staphylococcus aureus bacteremia (SAB) have shown a protective effect of IDC on mortality and recurrence rates. However, there is limited data available regarding the impact of IDC on outcomes of SAB in the pediatric population. Literature Search on the Impact of Infectious Disease Consultation in Pediatric Patients with Staphylococcus aureus Bacteremia Methods This systematic literature review and meta-analysis were performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A search strategy to identify publications about SAB and IDC in children was developed in collaboration with a health sciences librarian. The primary outcomes were all-cause mortality and SAB recurrence rates. Crude or unadjusted numbers were used for the pooled odds ratios (ORs) as adjusted ORs were not available in all articles. Meta-analysis of outcomes of Staphylococcus aureus Bacteremia in pediatric patients Results Among 972 articles screened, 8 studies were included in the systematic review, of which, 2 were retrospective cohort studies, 2 were prospective cross-sectional studies, and 4 were quasi-experimental studies. The quality of 6 studies was considered good ( >18 of 28 possible points) per the Downs and Black quality tool while two studies were considered fair (15 – 18 points). Five of 8 studies directly evaluated the impact of IDC on outcomes in pediatric SAB and included in the meta-analysis. Pooled results showed IDC was associated with significantly lower mortality in pediatric SAB with low heterogeneity (pooled OR = 0.44, 95% confidence interval [CI]: 0.20−0.97, I2 = 0%). IDC was associated with lower recurrence rates, however this was not statistically significant with moderate heterogeneity (pooled OR = 0.24, 95% CI: 0.04 to 1.34, I2 = 56%). Funnel Plot of Mortality and Recurrence in Pediatric Patients with Staphylococcus aureus Bacteremia Conclusion Our study suggests that IDC significantly improves the mortality of pediatric patients with SAB. Given there have been only five papers evaluating the same topic, with most being retrospective studies at a single center, a multicenter prospective study will be required. Our study provides a strong argument in favor of policies such as “automatic” IDC for children with SAB. Disclosures All Authors: No reported disclosures

Scrub typhus is a tick-borne disease caused by the intracellular organism Orientia tsutsugamushi. It typically presents with the cardinal "triad" of fever, rash, and eschar, along with other nonspecific symptoms. We report a case of scrub typhus in a 74-year-old man who did not exhibit the typical rash. He presented to the emergency room with a one-week history of generalized symptoms, including fever, throat pain, and myalgia, and was admitted due to suspected cholangitis based on elevated liver enzymes. However, computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) ruled out this diagnosis. A transient rash developed after the initiation of antibiotics, considered to be a drug reaction. Further laboratory workup showed mildly positive results for cytomegalovirus (CMV)-IgM, and subsequent tests revealed an elevation of atypical lymphocytes, leading to a misdiagnosis of acute CMV infection. During a subsequent physical examination, an initially overlooked eschar was identified on his medial malleolus. Serology tests showed highly elevated Orientia tsutsugamushi IgM and IgG levels and treatment with tetracycline led to full recovery. Paired serology after two weeks showed no elevation in CMV antibodies, and the initial positive CMV-IgM result was considered insignificant. Scrub typhus can manifest with a wide range of symptoms, underscoring the importance of a thorough physical examination and maintaining clinical suspicion, especially in febrile patients in endemic areas.

Background: Prosthetic valve endocarditis (PVE) is a serious complication of valve replacement associated with significant morbidity and mortality. However, outcomes for medical vs surgical strategies remain incompletely characterized. Methods: We conducted a retrospective cohort study of adult patients with PVE, defined by modified Duke criteria, evaluated by a multidisciplinary endocarditis team at a tertiary-care centre between September 2021 and February 2024. Demographic, clinical, management, and outcome data were collected. Logistic regression analyses were performed to identify factors associated with in-hospital mortality. Results: Among 67 patients with PVE, 58.2% (n = 39) were managed medically, and 41.8% (n = 28) underwent surgical intervention during the index hospitalization. Baseline characteristics and comorbidities were similar across groups. The in-hospital mortality incidence was 7.7% in the medical cohort and 10.7% in the surgical cohort, and the incidence of 90-day mortality was 30.8% and 21.4%, respectively. Surgical patients had a longer median length of stay (28 days vs 15 days). Readmission and reinfection rates were comparable. Acute renal failure was the only independent predictor of in-hospital mortality on multivariable analysis (odds ratio, 9.61; 95% confidence interval, 1.19-77.67; P = 0.04). Medical management was not independently associated with increased in-hospital mortality (odds ratio, 0.97; 95% confidence interval, 0.14-6.68; P = 0.97). Conclusions: In this cohort of patients with PVE, individualized treatment guided by a multidisciplinary team was associated with favourable short-term outcomes. Medical therapy may be a safe alternative in selected patients without surgical indications. Early identification of acute renal dysfunction may assist in prognostication and inform management decisions.

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections (HAIs), often resulting in prolonged hospital stays, increased healthcare costs, and additional clinical interventions. The COVID-19 pandemic introduced new challenges to infection prevention, with global reports indicating increased rates of certain HAIs, such as ventilator-associated pneumonia and bloodstream infections, due to healthcare strain and the intensified use of invasive devices. However, trends in CAUTI rates during the pandemic varied across healthcare settings. Methods: This retrospective study was conducted at the University of Iowa Health Care Medical Center, an 866-bed academic hospital, from 2018 to 2023. Manual chart reviews of CAUTI cases reported to the National Healthcare Safety Network (NHSN) were performed to collect data on patient demographics, medical histories, catheter usage, and infection prevention practices. CAUTI incidence was analyzed over time and compared with monthly COVID-19 admission rates. Results: A total of 226 CAUTI cases were identified during the study period. The average CAUTI rate per 1,000 catheter line-days declined from 1.23 in 2019 to 0.85 in 2020, but increased to 1.28 in 2021, coinciding with COVID-19 surges (Figure 1). The median patient age was 61 years, with females accounting for 56% of cases. Foley catheters were already in place upon admission in 24% of cases. Non-intensive care unit (ICU) inpatient settings accounted for 24% of catheter placements, while ICUs accounted for 18%. Additionally, 16% of cases originated from the operating room, and 7% from the emergency department. Neurologic disease was the most common admission diagnosis (27%), followed by cardiovascular disease (13%) and Hematologic/Oncologic disease (13%). Twenty six percent of cases were incontinent of urine and 24% of stool. Comorbidities included immunocompromised status (20%) and diabetes (36%). The primary indication for Foley catheter use was monitoring intake and output (42%). Of the 226 cases, 61% of patients were clinically considered to have a UTI. In-hospital mortality was 22%. Conclusion: The findings from this study provide insights into factors contributing to CAUTI at our institution. Fluctuations in CAUTI incidence, particularly during the COVID-19 pandemic, underscore the need for robust infection prevention strategies. The finding that only 61% of cases required treatment suggests urine cultures were often obtained inappropriately or positive results were not used in selected situations. This highlights an opportunity for diagnostic stewardship to improve urine culture practices. Addressing identified risk factors and enhancing catheter management are critical to reducing CAUTI incidence and improving patient outcomes.

Background:Extrapulmonary tuberculosis (EPTB) accounts for 15-20 % of TB, but necrotic retroperitoneal lymphadenopathy is exceptionally rare, particularly in immunocompetent hosts. Case presentation:A 32-year-old immunocompetent man from Peru presented with two weeks of severe abdominal pain and intermittent fever. CT revealed conglomerate necrotic retroperitoneal lymph nodes encasing the pancreatic head and major vessels. Image-guided biopsy showed necrotizing granulomas; acid-fast bacilli smear and GeneXpert MTB/RIF confirmed Mycobacterium tuberculosis. Chest CT demonstrated additional necrotic mediastinal nodes without parenchymal disease. Standard therapy (2HRZE/4HR) was initiated; due to partial radiologic response at six months, isoniazid-rifampicin was extended to complete ten months, achieving full clinical and imaging resolution. Literature review:A structured search identified seven additional immunocompetent adults with necrotic retroperitoneal lymphadenopathy. Abdominal pain predominated; CT consistently showed multiple necrotic nodes. Final diagnoses were tuberculosis (3/7), high-grade B-cell lymphoma (2/7), Kikuchi-Fujimoto disease (1/7), and metastatic esophageal carcinoma (1/7). All cases required tissue confirmation. Conclusions:Necrotic retroperitoneal lymphadenopathy is an uncommon manifestation of TB that can mimic malignancy. In patients from TB-endemic settings, TB should remain high in the differential when CT demonstrates necrotic retroperitoneal nodes. Early image-guided biopsy with mycobacterial testing is decisive. Drug-susceptible disease generally responds to standard six-month therapy, although extended treatment may be warranted for delayed radiologic response.

Identifying those most susceptible to COVID-19 reinfection and understanding the associated characteristics is essential for developing effective prevention and control strategies. We aimed to evaluate the influence of social determinants, regional disparities, and variant evolution on COVID-19 reinfection rates. We conducted a retrospective cohort study in São Paulo, Brazil, involving laboratory-confirmed COVID-19 patients. Reinfection was defined as a subsequent positive COVID-19 test at least 90 days after the previous confirmed infection. We assessed socioeconomic indicators, demographic factors, and spatial correlations. Reinfection rates were analyzed across different variants and subvariants. Among 73 741 patients, 5626 (7.6%) experienced reinfections, with most (95.0%) having 1 reinfection. Reinfection rates increased significantly during the Omicron period, particularly with subvariants BA.1, BA.2/BA.4, BA.5, and XBB/XBB.1.5/XBB.1.16. The highest rates were seen in patients initially infected during the BA.2/BA.4 and BA.5 periods, who were later reinfected by XBB subvariants. Socioeconomic indicators, including lower Human Development Index, higher proportions of informal settlements, and lower employment rates, were significantly associated with higher reinfection rates. Geospatial analysis showed significant clustering of reinfections in areas with higher social vulnerability. COVID-19 reinfection rates were heavily influenced by socioeconomic disparities and variant-specific factors. Regions with lower Human Development Index and worse socioeconomic conditions experienced higher reinfection rates. These findings highlight the need for targeted public health interventions focused on vulnerable populations, particularly in areas with greater social inequality. As new variants continue to emerge, ongoing surveillance and adaptive public health strategies will be critical to reducing reinfections.

Background:We aimed to assess the accuracy, clinical efficacy, and limitations of metagenomic next-generation sequencing (mNGS) for diagnosing infectious meningoencephalitis. Methods:We performed a systematic literature review and meta-analysis of studies that evaluated the performance of mNGS to determine the cause of infectious meningoencephalitis. We explored PubMed, Cumulative Index to Nursing and Allied Health, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Web of Science up to 12 November 2024. To perform a meta-analysis, we calculated the pooled diagnostic odds ratio (DOR) for mNGS and for conventional microbiological tests (CMTs) compared to the clinical diagnosis. Results:Thirty-four studies met the inclusion criteria, with mNGS-positive rates ranging from 43.5% to 93.5% for infectious meningoencephalitis. The meta-analysis included 23 studies with 1660 patients. The pooled sensitivity was 0.70 (95% confidence interval [CI], .67-.72), and its specificity was 0.93 (95% CI, .92-.94). The DOR for mNGS was 26.7 (95% CI, 10.4-68.8), compared to 12.2 (95% CI, 3.2-47.0) for CMTs. For tuberculosis meningoencephalitis, mNGS demonstrated a pooled sensitivity of 0.67 (95% CI, .61-.72) and specificity of 0.97 (95% CI, .95-.99), with a DOR of 43.5 (95% CI, 7.4-256.6). Conclusions:Our review indicates that mNGS can be a valuable diagnostic tool for infectious meningoencephalitis, offering high sensitivity and specificity. mNGS's superior DOR compared to that of CMTs highlights its potential for more accurate diagnoses and targeted interventions. Further research is needed to optimize which patients and at what point in the diagnostic process mNGS should be used.

BACKGROUND:Central venous catheters (CVCs) pose a risk of infection through fluid infusion, medication administration, and blood draws. We conducted a scoping review evaluating the risk of accessing a CVC and aiming to identify strategies for limiting CVC usage to decrease the incidence of central line-associated bloodstream infections (CLABSIs) in hospital settings. METHODS:This review adheres to the methodological framework proposed by Arksey and O'Malley and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Searches were conducted in the CINAHL, EMBASE, PubMed, and Scopus databases, focusing on publications from the past decade. RESULTS:Six studies met inclusion criteria. Three interventions were identified: (1) establishing standardized CVC sampling times, (2) utilizing phlebotomists to perform peripheral blood cultures, and (3) avoiding the use of CVCs for both blood cultures and routine blood draws. CONCLUSIONS:Increased frequency of CVC access is associated with a higher risk of CLABSI. Interventions to reduce CVC access for blood draws can effectively lower CLABSI rates. Identifying and implementing strategies such as use of phlebotomy teams and standardized sampling protocols may help guide hospital policies and improve patient safety outcomes. Future research should focus on prospective evaluation of these approaches.

Introduction:Field hospitals, following the Fangcang Shelter Hospital model, were critical during the global COVID-19 pandemic to alleviate the strain on overwhelmed healthcare systems. Despite their widespread adoption, concerns persist regarding their efficacy and cost-effectiveness. This study aimed to assess the impact of the Pacaembu Field Hospital in São Paulo, Brazil during the COVID-19 pandemic, specifically focusing on lives saved and the associated public health costs. Methods:This retrospective cohort study was conducted April 6 to June 29. The 200-bed field hospital, a collaboration between Sociedade Beneficente Israelita Brasileira Albert Einstein and the São Paulo City Hall, São Paulo Municipal Health Departament, operated at Pacaembu Stadium and admitted. Adult patients with mild to moderate COVID-19. Electronic health records provided comprehensive data on demographics, clinical outcomes, and resource utilization. The mortality rate among field hospital patients was compared to that of two groups: I-confirmed COVID-19 cases in São Paulo, and II-severe acute respiratory syndrome patients with COVID-19 in São Paulo. Results:A total of 152,928 COVID-19 cases were confirmed in São Paulo, with 20,603 patients hospitalized for ARDS and 1,499 patients admitted to the Pacaembu Field Hospital for mild to moderate disease. The median age of Pacaembu patients was 57 years (IQR 46-67), with 43.8% aged 60 or older. Lung disease was the most common comorbidity, affecting 31.0% of cases. The median length of stay was 4.2 days, and 14.2% of patients required intensive care, with 7.9% needing mechanical ventilation. The hospital had a survival rate of 99.8%. The cost per year of life saved, adjusted for gender, was R$44,243.02 (US$8,208.35). In the most favorable scenario, approximately 200 lives were saved, with a cost of R$5,640.92 (US$1,046.55) per life saved for both genders. In the least favorable scenario, around 50 lives were saved, with a cost of R$36,863.48 (US$6,839.24) per life saved for both genders, all within cost-effectiveness thresholds. Conclusion:The Pacaembu Field Hospital played a crucial role in saving lives during the initial COVID-19 wave, highlighting the importance of ongoing evaluation and resource optimization in field hospital strategies for an effective pandemic response.

We report a rare case of invasive Klebsiella pneumoniae infection in a previously healthy 52-year-old Japanese man who presented with extensor tenosynovitis associated with subcutaneous abscess of the right hand, in the setting of concomitant liver and prostatic abscesses. Cultures from blood, liver abscess aspirate, synovial fluid and aspirate from the subcutaneous tissue of the hand all grew K. pneumoniae. Although genomic biomarker testing was not available, a positive string test along with the characteristic clinical presentation suggested a hypervirulent phenotype. Surgical debridement of the hand and targeted antimicrobial therapy led to clinical improvement. This case underscores the importance of considering hematogenous dissemination in cases of tenosynovitis without a history of trauma and highlights the protean manifestations of hypervirulent K. pneumoniae.