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Medscape CME Activity

Medscape, LLC is pleased to provide online continuing medical education (CME) for selected journal articles, allowing clinicians the opportunity to earn CME credit. In support of improving patient care, these activities have been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CME credit is available for one year after publication.

Active CME Articles


Expires 5/19/2020
Medscape CME Activity
Epidemiologic and Clinical Features of Lassa Fever Outbreak in Nigeria, January 1–May 6, 2018 [PDF - 1.90 MB - 9 pages]
E. A. Ilori et al.

Lassa fever (LF) is endemic to Nigeria, where the disease causes substantial rates of illness and death. In this article, we report an analysis of the epidemiologic and clinical aspects of the LF outbreak that occurred in Nigeria during January 1–May 6, 2018. A total of 1,893 cases were reported; 423 were laboratory-confirmed cases, among which 106 deaths were recorded (case-fatality rate 25.1%). Among all confirmed cases, 37 occurred in healthcare workers. The secondary attack rate among 5,001 contacts was 0.56%. Most (80.6%) confirmed cases were reported from 3 states (Edo, Ondo, and Ebonyi). Fatal outcomes were significantly associated with being elderly; no administration of ribavirin; and the presence of a cough, hemorrhaging, and unconsciousness. The findings in this study should lead to further LF research and provide guidance to those preparing to respond to future outbreaks.

EID Ilori EA, Furuse Y, Ipadeola OB, Dan-Nwafor CC, Abubakar A, Womi-Eteng OE, et al. Epidemiologic and Clinical Features of Lassa Fever Outbreak in Nigeria, January 1–May 6, 2018. Emerg Infect Dis. 2019;25(6):1066-1074. https://dx.doi.org/10.3201/eid2506.181035
AMA Ilori EA, Furuse Y, Ipadeola OB, et al. Epidemiologic and Clinical Features of Lassa Fever Outbreak in Nigeria, January 1–May 6, 2018. Emerging Infectious Diseases. 2019;25(6):1066-1074. doi:10.3201/eid2506.181035.
APA Ilori, E. A., Furuse, Y., Ipadeola, O. B., Dan-Nwafor, C. C., Abubakar, A., Womi-Eteng, O. E....Ihekweazu, C. (2019). Epidemiologic and Clinical Features of Lassa Fever Outbreak in Nigeria, January 1–May 6, 2018. Emerging Infectious Diseases, 25(6), 1066-1074. https://dx.doi.org/10.3201/eid2506.181035.

Expires 5/17/2020
Medscape CME Activity
Nontuberculous Mycobacterial Musculoskeletal Infection Cases from a Tertiary Referral Center, Colorado, USA [PDF - 578 KB - 7 pages]
N. Goldstein et al.

Nontuberculous mycobacteria represent an uncommon but important cause of infection of the musculoskeletal system. Such infections require aggressive medical and surgical treatment, and cases are often complicated by delayed diagnosis. We retrospectively reviewed all 14 nonspinal cases of nontuberculous mycobacterial musculoskeletal infections treated over 6 years by orthopedic surgeons at a university-affiliated tertiary referral center. All patients required multiple antimicrobial agents along with aggressive surgical treatment; 13 of 14 patients ultimately achieved cure. Four patients required amputation to control the infection. Half these patients were immunosuppressed by medications or other medical illness when they sought care at the referral center. Six cases involved joint prostheses; all ultimately required hardware removal and placement of an antimicrobial spacer for eradication of infection. Our findings highlight the importance of vigilance for nontuberculous mycobacterial musculoskeletal infection, particularly in patients who are immunosuppressed or have a history of musculoskeletal surgery.

EID Goldstein N, St. Clair J, Kasperbauer SH, Daley CL, Lindeque B. Nontuberculous Mycobacterial Musculoskeletal Infection Cases from a Tertiary Referral Center, Colorado, USA. Emerg Infect Dis. 2019;25(6):1075-1083. https://dx.doi.org/10.3201/eid2506.181041
AMA Goldstein N, St. Clair J, Kasperbauer SH, et al. Nontuberculous Mycobacterial Musculoskeletal Infection Cases from a Tertiary Referral Center, Colorado, USA. Emerging Infectious Diseases. 2019;25(6):1075-1083. doi:10.3201/eid2506.181041.
APA Goldstein, N., St. Clair, J., Kasperbauer, S. H., Daley, C. L., & Lindeque, B. (2019). Nontuberculous Mycobacterial Musculoskeletal Infection Cases from a Tertiary Referral Center, Colorado, USA. Emerging Infectious Diseases, 25(6), 1075-1083. https://dx.doi.org/10.3201/eid2506.181041.

Expires 4/17/2020
Medscape CME Activity
Novel Sequence Type in Bacillus cereus Strains Associated with Nosocomial Infections and Bacteremia, Japan [PDF - 2.53 MB - 8 pages]
R. Akamatsu et al.

Bacillus cereus is associated with foodborne illnesses characterized by vomiting and diarrhea. Although some B. cereus strains that cause severe extraintestinal infections and nosocomial infections are recognized as serious public health threats in healthcare settings, the genetic backgrounds of B. cereus strains causing such infections remain unknown. By conducting pulsed-field gel electrophoresis and multilocus sequence typing, we found that a novel sequence type (ST), newly registered as ST1420, was the dominant ST isolated from the cases of nosocomial infections that occurred in 3 locations in Japan in 2006, 2013, and 2016. Phylogenetic analysis showed that ST1420 strains belonged to the Cereus III lineage, which is much closer to the Anthracis lineage than to other Cereus lineages. Our results suggest that ST1420 is a prevalent ST in B. cereus strains that have caused recent nosocomial infections in Japan.

EID Akamatsu R, Suzuki M, Okinaka K, Sasahara T, Yamane K, Suzuki S, et al. Novel Sequence Type in Bacillus cereus Strains Associated with Nosocomial Infections and Bacteremia, Japan. Emerg Infect Dis. 2019;25(5):883-890. https://dx.doi.org/10.3201/eid2505.171890
AMA Akamatsu R, Suzuki M, Okinaka K, et al. Novel Sequence Type in Bacillus cereus Strains Associated with Nosocomial Infections and Bacteremia, Japan. Emerging Infectious Diseases. 2019;25(5):883-890. doi:10.3201/eid2505.171890.
APA Akamatsu, R., Suzuki, M., Okinaka, K., Sasahara, T., Yamane, K., Suzuki, S....Higashi, H. (2019). Novel Sequence Type in Bacillus cereus Strains Associated with Nosocomial Infections and Bacteremia, Japan. Emerging Infectious Diseases, 25(5), 883-890. https://dx.doi.org/10.3201/eid2505.171890.

Expires 4/12/2020
Medscape CME Activity
Age-Dependent Increase in Incidence of Staphylococcus aureus Bacteremia, Denmark, 2008–2015 [PDF - 1.04 MB - 8 pages]
L. Thorlacius-Ussing et al.

Staphylococcus aureus bacteremia (SAB) is a major cause of illness and death worldwide. We analyzed temporal trends of SAB incidence and death in Denmark during 2008–2015. SAB incidence increased 48%, from 20.76 to 30.37 per 100,000 person-years, during this period (p<0.001). The largest change in incidence was observed for persons >80 years of age: a 90% increase in the SAB rate (p<0.001). After adjusting for demographic changes, annual rates increased 4.0% (95% CI 3.0–5.0) for persons <80 years of age, 8.4% (95% CI 7.0–11.0) for persons 80–89 years of age, and 13.0% (95% CI 9.0–17.5) for persons >90 years of age. The 30-day case-fatality rate remained stable at 24%; crude population death rates increased by 53% during 2008–2015 (p<0.001). Specific causes and mechanisms for this rapid increase in SAB incidence among the elderly population remain to be clarified.

EID Thorlacius-Ussing L, Sandholdt H, Larsen A, Petersen A, Benfield T. Age-Dependent Increase in Incidence of Staphylococcus aureus Bacteremia, Denmark, 2008–2015. Emerg Infect Dis. 2019;25(5):875-882. https://dx.doi.org/10.3201/eid2505.181733
AMA Thorlacius-Ussing L, Sandholdt H, Larsen A, et al. Age-Dependent Increase in Incidence of Staphylococcus aureus Bacteremia, Denmark, 2008–2015. Emerging Infectious Diseases. 2019;25(5):875-882. doi:10.3201/eid2505.181733.
APA Thorlacius-Ussing, L., Sandholdt, H., Larsen, A., Petersen, A., & Benfield, T. (2019). Age-Dependent Increase in Incidence of Staphylococcus aureus Bacteremia, Denmark, 2008–2015. Emerging Infectious Diseases, 25(5), 875-882. https://dx.doi.org/10.3201/eid2505.181733.

Expires 3/18/2020
Medscape CME Activity
Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015–2017 [PDF - 994 KB - 5 pages]
N. Trung et al.

Rickettsioses are endemic to Vietnam; however, only a limited number of clinical studies have been performed on these vectorborne bacteria. We conducted a prospective hospital-based study at 2 national referral hospitals in Hanoi to describe the clinical characteristics of scrub typhus and murine typhus in northern Vietnam and to assess the diagnostic applicability of quantitative real-time PCR assays to diagnose rickettsial diseases. We enrolled 302 patients with acute undifferentiated fever and clinically suspected rickettsiosis during March 2015–March 2017. We used a standardized case report form to collect clinical information and laboratory results at the time of admission and during treatment. We confirmed scrub typhus in 103 (34.1%) patients and murine typhus in 12 (3.3%) patients. These results highlight the need for increased emphasis on training for healthcare providers for earlier recognition, prevention, and treatment of rickettsial diseases in Vietnam.

EID Trung N, Hoi L, Dien V, Huong D, Hoa T, Lien V, et al. Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015–2017. Emerg Infect Dis. 2019;25(4):633-641. https://dx.doi.org/10.3201/eid2504.180691
AMA Trung N, Hoi L, Dien V, et al. Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015–2017. Emerging Infectious Diseases. 2019;25(4):633-641. doi:10.3201/eid2504.180691.
APA Trung, N., Hoi, L., Dien, V., Huong, D., Hoa, T., Lien, V....Van Kinh, N. (2019). Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015–2017. Emerging Infectious Diseases, 25(4), 633-641. https://dx.doi.org/10.3201/eid2504.180691.

Expires 2/19/2020
Medscape CME Activity
Bacillus Calmette-Guérin Cases Reported to the National Tuberculosis Surveillance System, United States, 2004–2015 [PDF - 1.01 MB - 6 pages]
Z. Wansaula et al.

Mycobacterium bovis bacillus Calmette-Guérin (BCG) is used as a vaccine to protect against disseminated tuberculosis (TB) and as a treatment for bladder cancer. We describe characteristics of US TB patients reported to the National Tuberculosis Surveillance System (NTSS) whose disease was attributed to BCG. We identified 118 BCG cases and 91,065 TB cases reported to NTSS during 2004–2015. Most patients with BCG were US-born (86%), older (median age 75 years), and non-Hispanic white (81%). Only 17% of BCG cases had pulmonary involvement, in contrast with 84% of TB cases. Epidemiologic features of BCG cases differed from TB cases. Clinicians can use clinical history to discern probable BCG cases from TB cases, enabling optimal clinical management. Public health agencies can use this information to quickly identify probable BCG cases to avoid inappropriately reporting BCG cases to NTSS or expending resources on unnecessary public health interventions.

EID Wansaula Z, Wortham JM, Mindra G, Haddad MB, Salinas JL, Ashkin D, et al. Bacillus Calmette-Guérin Cases Reported to the National Tuberculosis Surveillance System, United States, 2004–2015. Emerg Infect Dis. 2019;25(3):451-456. https://dx.doi.org/10.3201/eid2503.180686
AMA Wansaula Z, Wortham JM, Mindra G, et al. Bacillus Calmette-Guérin Cases Reported to the National Tuberculosis Surveillance System, United States, 2004–2015. Emerging Infectious Diseases. 2019;25(3):451-456. doi:10.3201/eid2503.180686.
APA Wansaula, Z., Wortham, J. M., Mindra, G., Haddad, M. B., Salinas, J. L., Ashkin, D....Langer, A. J. (2019). Bacillus Calmette-Guérin Cases Reported to the National Tuberculosis Surveillance System, United States, 2004–2015. Emerging Infectious Diseases, 25(3), 451-456. https://dx.doi.org/10.3201/eid2503.180686.

Expires 2/19/2020
Medscape CME Activity
Treatment Outcomes in Global Systematic Review and Patient Meta-Analysis of Children with Extensively Drug-Resistant Tuberculosis [PDF - 965 KB - 10 pages]
M. Osman et al.

Extensively drug-resistant tuberculosis (XDR TB) has extremely poor treatment outcomes in adults. Limited data are available for children. We report on clinical manifestations, treatment, and outcomes for 37 children (<15 years of age) with bacteriologically confirmed XDR TB in 11 countries. These patients were managed during 1999–2013. For the 37 children, median age was 11 years, 32 (87%) had pulmonary TB, and 29 had a recorded HIV status; 7 (24%) were infected with HIV. Median treatment duration was 7.0 months for the intensive phase and 12.2 months for the continuation phase. Thirty (81%) children had favorable treatment outcomes. Four (11%) died, 1 (3%) failed treatment, and 2 (5%) did not complete treatment. We found a high proportion of favorable treatment outcomes among children, with mortality rates markedly lower than for adults. Regimens and duration of treatment varied considerably. Evaluation of new regimens in children is required.

EID Osman M, Harausz EP, Garcia-Prats AJ, Schaaf H, Moore BK, Hicks RM, et al. Treatment Outcomes in Global Systematic Review and Patient Meta-Analysis of Children with Extensively Drug-Resistant Tuberculosis. Emerg Infect Dis. 2019;25(3):441-450. https://dx.doi.org/10.3201/eid2503.180852
AMA Osman M, Harausz EP, Garcia-Prats AJ, et al. Treatment Outcomes in Global Systematic Review and Patient Meta-Analysis of Children with Extensively Drug-Resistant Tuberculosis. Emerging Infectious Diseases. 2019;25(3):441-450. doi:10.3201/eid2503.180852.
APA Osman, M., Harausz, E. P., Garcia-Prats, A. J., Schaaf, H., Moore, B. K., Hicks, R. M....Hesseling, A. C. (2019). Treatment Outcomes in Global Systematic Review and Patient Meta-Analysis of Children with Extensively Drug-Resistant Tuberculosis. Emerging Infectious Diseases, 25(3), 441-450. https://dx.doi.org/10.3201/eid2503.180852.

Expires 1/17/2020
Medscape CME Activity
Acute and Delayed Deaths after West Nile Virus Infection, Texas, USA, 2002–2012 [PDF - 1.21 MB - 9 pages]
D. Philpott et al.

Infection with West Nile virus (WNV) has a well-characterized acute disease process. However, long-term consequences are less understood. We searched death records for 4,142 residents of Texas, USA, infected with WNV during 2002–2012 and identified 557 (13%) deaths. We analyzed all-cause and cause-specific deaths after WNV infection by calculating standardized mortality ratios and using statewide mortality data. Acute-phase deaths (<90 days after symptom onset) occurred in 289 (7%) of case-patients; of those deaths, 289 (92%) were cases of West Nile neuroinvasive disease (WNND). Convalescent-phase deaths (>90 days after symptom onset) occurred in 268 (7%) of the remaining 3,853 case-patients; 210 (78%) of these deaths occurred in patients with WNND. Convalescent-phase WNND case-patients showed excess deaths from infectious and renal causes; case-patients <60 years of age had increased risk for all-cause death, specifically from renal, infectious, digestive, and circulatory causes. We provide population-level evidence of increased risk for death after WNV infection resulting in WNND.

EID Philpott D, Nolan MS, Evert N, Mayes B, Hesalroad D, Fonken E, et al. Acute and Delayed Deaths after West Nile Virus Infection, Texas, USA, 2002–2012. Emerg Infect Dis. 2019;25(2):256-264. https://dx.doi.org/10.3201/eid2502.181250
AMA Philpott D, Nolan MS, Evert N, et al. Acute and Delayed Deaths after West Nile Virus Infection, Texas, USA, 2002–2012. Emerging Infectious Diseases. 2019;25(2):256-264. doi:10.3201/eid2502.181250.
APA Philpott, D., Nolan, M. S., Evert, N., Mayes, B., Hesalroad, D., Fonken, E....Murray, K. O. (2019). Acute and Delayed Deaths after West Nile Virus Infection, Texas, USA, 2002–2012. Emerging Infectious Diseases, 25(2), 256-264. https://dx.doi.org/10.3201/eid2502.181250.

Expires 1/17/2020
Medscape CME Activity
Human Pasteurellosis Health Risk for Elderly Persons Living with Companion Animals [PDF - 1.33 MB - 7 pages]
S. Körmöndi et al.
EID Körmöndi S, Terhes G, Pál Z, Varga E, Harmati M, Buzás K, et al. Human Pasteurellosis Health Risk for Elderly Persons Living with Companion Animals. Emerg Infect Dis. 2019;25(2):229-235. https://dx.doi.org/10.3201/eid2502.180641
AMA Körmöndi S, Terhes G, Pál Z, et al. Human Pasteurellosis Health Risk for Elderly Persons Living with Companion Animals. Emerging Infectious Diseases. 2019;25(2):229-235. doi:10.3201/eid2502.180641.
APA Körmöndi, S., Terhes, G., Pál, Z., Varga, E., Harmati, M., Buzás, K....Urbán, E. (2019). Human Pasteurellosis Health Risk for Elderly Persons Living with Companion Animals. Emerging Infectious Diseases, 25(2), 229-235. https://dx.doi.org/10.3201/eid2502.180641.

Expires 1/17/2020
Medscape CME Activity
Zika Virus Epidemic in Pregnant Women, Dominican Republic, 2016–2017 [PDF - 2.59 MB - 9 pages]
F. Peña et al.

Zika virus infection during pregnancy may result in birth defects and pregnancy complications. We describe the Zika virus outbreak in pregnant women in the Dominican Republic during 2016–2017. We conducted multinomial logistic regression to identify factors associated with fetal losses and preterm birth. The Ministry of Health identified 1,282 pregnant women with suspected Zika virus infection, a substantial proportion during their first trimester. Fetal loss was reported for ≈10% of the reported pregnancies, and 3 cases of fetal microcephaly were reported. Women infected during the first trimester were more likely to have early fetal loss (adjusted odds ratio 5.9, 95% CI 3.5–10.0). Experiencing fever during infection was associated with increased odds of premature birth (adjusted odds ratio 1.65, 95% CI 1.03–2.65). There was widespread morbidity during the epidemic. Our findings strengthen the evidence for a broad range of adverse pregnancy outcomes resulting from Zika virus infection.

EID Peña F, Pimentel R, Khosla S, Mehta SD, Brito MO. Zika Virus Epidemic in Pregnant Women, Dominican Republic, 2016–2017. Emerg Infect Dis. 2019;25(2):247-255. https://dx.doi.org/10.3201/eid2502.181054
AMA Peña F, Pimentel R, Khosla S, et al. Zika Virus Epidemic in Pregnant Women, Dominican Republic, 2016–2017. Emerging Infectious Diseases. 2019;25(2):247-255. doi:10.3201/eid2502.181054.
APA Peña, F., Pimentel, R., Khosla, S., Mehta, S. D., & Brito, M. O. (2019). Zika Virus Epidemic in Pregnant Women, Dominican Republic, 2016–2017. Emerging Infectious Diseases, 25(2), 247-255. https://dx.doi.org/10.3201/eid2502.181054.

Expires 12/13/2019
Medscape CME Activity
Enterovirus A71 Infection and Neurologic Disease, Madrid, Spain, 2016 [PDF - 1.02 MB - 8 pages]
C. Taravilla et al.

We conducted an observational study from January 2016 through January 2017 of patients admitted to a reference pediatric hospital in Madrid, Spain, for neurologic symptoms and enterovirus infection. Among the 30 patients, the most common signs and symptoms were fever, lethargy, myoclonic jerks, and ataxia. Real-time PCR detected enterovirus in the cerebrospinal fluid of 8 patients, nasopharyngeal aspirate in 17, and anal swab samples of 5. The enterovirus was genotyped for 25 of 30 patients; enterovirus A71 was the most common serotype (21/25) and the only serotype detected in patients with brainstem encephalitis or encephalomyelitis. Treatment was intravenous immunoglobulins for 21 patients and corticosteroids for 17. Admission to the pediatric intensive care unit was required for 14 patients. All patients survived. At admission, among patients with the most severe disease, leukocytes were elevated. For children with brainstem encephalitis or encephalomyelitis, clinicians should look for enterovirus and not limit testing to cerebrospinal fluid.

EID Taravilla C, Pérez-Sebastián I, Salido A, Serrano C, Extremera V, Rodríguez A, et al. Enterovirus A71 Infection and Neurologic Disease, Madrid, Spain, 2016. Emerg Infect Dis. 2019;25(1):25-32. https://dx.doi.org/10.3201/eid2501.181089
AMA Taravilla C, Pérez-Sebastián I, Salido A, et al. Enterovirus A71 Infection and Neurologic Disease, Madrid, Spain, 2016. Emerging Infectious Diseases. 2019;25(1):25-32. doi:10.3201/eid2501.181089.
APA Taravilla, C., Pérez-Sebastián, I., Salido, A., Serrano, C., Extremera, V., Rodríguez, A....González, A. (2019). Enterovirus A71 Infection and Neurologic Disease, Madrid, Spain, 2016. Emerging Infectious Diseases, 25(1), 25-32. https://dx.doi.org/10.3201/eid2501.181089.

Expires 12/12/2019
Medscape CME Activity
Prescription of Antibacterial Drugs for HIV-Exposed, Uninfected Infants, Malawi, 2004–2010
A. C. Ewing et al.

Antimicrobial drug resistance is a serious health hazard driven by overuse. Administration of antimicrobial drugs to HIV-exposed, uninfected infants, a population that is growing and at high risk for infection, is poorly studied. We therefore analyzed factors associated with antibacterial drug administration to HIV-exposed, uninfected infants during their first year of life. Our study population was 2,152 HIV-exposed, uninfected infants enrolled in the Breastfeeding, Antiretrovirals and Nutrition study in Lilongwe, Malawi, during 2004–2010. All infants were breastfed through 28 weeks of age. Antibacterial drugs were prescribed frequently (to 80% of infants), and most (67%) of the 5,329 prescriptions were for respiratory indications. Most commonly prescribed were penicillins (43%) and sulfonamides (23%). Factors associated with lower hazard for antibacterial drug prescription included receipt of cotrimoxazole preventive therapy, receipt of antiretroviral drugs, and increased age. Thus, cotrimoxazole preventive therapy may lead to fewer prescriptions for antibacterial drugs for these infants.

EID Ewing AC, Davis NL, Kayira D, Hosseinipour MC, van der Horst C, Jamieson DJ, et al. Prescription of Antibacterial Drugs for HIV-Exposed, Uninfected Infants, Malawi, 2004–2010. Emerg Infect Dis. 2019;25(1):103-112. https://dx.doi.org/10.3201/eid2501.180782
AMA Ewing AC, Davis NL, Kayira D, et al. Prescription of Antibacterial Drugs for HIV-Exposed, Uninfected Infants, Malawi, 2004–2010. Emerging Infectious Diseases. 2019;25(1):103-112. doi:10.3201/eid2501.180782.
APA Ewing, A. C., Davis, N. L., Kayira, D., Hosseinipour, M. C., van der Horst, C., Jamieson, D. J....Kourtis, A. P. (2019). Prescription of Antibacterial Drugs for HIV-Exposed, Uninfected Infants, Malawi, 2004–2010. Emerging Infectious Diseases, 25(1), 103-112. https://dx.doi.org/10.3201/eid2501.180782.

Expires 11/14/2019
Medscape CME Activity
Reemergence of St. Louis Encephalitis Virus in the Americas [PDF - 1.71 MB - 8 pages]
A. Diaz et al.

We summarize and analyze historical and current data regarding the reemergence of St. Louis encephalitis virus (SLEV; genus Flavivirus) in the Americas. Historically, SLEV caused encephalitis outbreaks in the United States; however, it was not considered a public health concern in the rest of the Americas. After the introduction of West Nile virus in 1999, activity of SLEV decreased considerably in the United States. During 2014–2015, SLEV caused a human outbreak in Arizona and caused isolated human cases in California in 2016 and 2017. Phylogenetic analyses indicate that the emerging SLEV in the western United States is related to the epidemic strains isolated during a human encephalitis outbreak in Córdoba, Argentina, in 2005. Ecoepidemiologic studies suggest that the emergence of SLEV in Argentina was caused by the introduction of a more pathogenic strain and increasing populations of the eared dove (amplifying host).

EID Diaz A, Coffey LL, Burkett-Cadena N, Day JF. Reemergence of St. Louis Encephalitis Virus in the Americas. Emerg Infect Dis. 2018;24(12):2150-2157. https://dx.doi.org/10.3201/eid2412.180372
AMA Diaz A, Coffey LL, Burkett-Cadena N, et al. Reemergence of St. Louis Encephalitis Virus in the Americas. Emerging Infectious Diseases. 2018;24(12):2150-2157. doi:10.3201/eid2412.180372.
APA Diaz, A., Coffey, L. L., Burkett-Cadena, N., & Day, J. F. (2018). Reemergence of St. Louis Encephalitis Virus in the Americas. Emerging Infectious Diseases, 24(12), 2150-2157. https://dx.doi.org/10.3201/eid2412.180372.

Expires 11/14/2019
Medscape CME Activity
Substance Use and Adherence to HIV Preexposure Prophylaxis for Men Who Have Sex with Men [PDF - 1.35 MB - 11 pages]
M. Hoenigl et al.

The effectiveness of oral HIV preexposure prophylaxis (PrEP) strongly depends on maintaining adherence. We investigated the association between substance use and PrEP adherence, as well as incident sexually transmitted infections (STIs) in a high-risk cohort of 394 participants (391 men who have sex with men and 3 transgender women) who were enrolled in a PrEP demonstration project. We assessed baseline and ongoing substance use over a 48-week period for stimulants and nonstimulant substances and for each substance separately. We measured PrEP adherence by using dried blood spots to obtain levels of tenofovir diphosphate. No differences in these levels were found between substance users and nonsubstance users. Baseline stimulant use was strongly associated (odds ratio 3.4; p<0.001) with incident STIs during the study. Thus, PrEP adherence was not decreased by substance use. Because substance users had increased rates of STIs, indicating higher-risk behavior, they might be excellent candidates for PrEP.

EID Hoenigl M, Jain S, Moore D, Collins D, Sun X, Anderson PL, et al. Substance Use and Adherence to HIV Preexposure Prophylaxis for Men Who Have Sex with Men. Emerg Infect Dis. 2018;24(12):2292-2302. https://dx.doi.org/10.3201/eid2412.180400
AMA Hoenigl M, Jain S, Moore D, et al. Substance Use and Adherence to HIV Preexposure Prophylaxis for Men Who Have Sex with Men. Emerging Infectious Diseases. 2018;24(12):2292-2302. doi:10.3201/eid2412.180400.
APA Hoenigl, M., Jain, S., Moore, D., Collins, D., Sun, X., Anderson, P. L....Morris, S. (2018). Substance Use and Adherence to HIV Preexposure Prophylaxis for Men Who Have Sex with Men. Emerging Infectious Diseases, 24(12), 2292-2302. https://dx.doi.org/10.3201/eid2412.180400.

Expires 10/16/2019
Medscape CME Activity
Cryptococcus gattii Complex Infections in HIV-Infected Patients, Southeastern United States [PDF - 553 KB - 5 pages]
K. T. Bruner et al.

Cryptococcus gattii traditionally infects immunocompetent hosts and causes devastating pulmonary or central nervous system disease. However, this infection rarely occurs in patients infected with HIV. We report 3 cases of HIV-associated C. gattii complex infections in the southeastern United States. Detection of C. gattii in HIV-infected patients in this region warrants increased awareness of this threat to ensure appropriate diagnosis and treatment to optimize patient outcomes.

EID Bruner KT, Franco-Paredes C, Henao-Martínez AF, Steele GM, Chastain DB. Cryptococcus gattii Complex Infections in HIV-Infected Patients, Southeastern United States. Emerg Infect Dis. 2018;24(11):1998-2002. https://dx.doi.org/10.3201/eid2411.180787
AMA Bruner KT, Franco-Paredes C, Henao-Martínez AF, et al. Cryptococcus gattii Complex Infections in HIV-Infected Patients, Southeastern United States. Emerging Infectious Diseases. 2018;24(11):1998-2002. doi:10.3201/eid2411.180787.
APA Bruner, K. T., Franco-Paredes, C., Henao-Martínez, A. F., Steele, G. M., & Chastain, D. B. (2018). Cryptococcus gattii Complex Infections in HIV-Infected Patients, Southeastern United States. Emerging Infectious Diseases, 24(11), 1998-2002. https://dx.doi.org/10.3201/eid2411.180787.

Expires 10/15/2019
Medscape CME Activity
Rickettsia typhi as Cause of Fatal Encephalitic Typhus in Hospitalized Patients, Hamburg, Germany, 1940–1944 [PDF - 3.69 MB - 6 pages]
J. Rauch et al.

We evaluated formalin-fixed paraffin-embedded tissue specimens from 7 patients who died with encephalitic typhus in Hamburg, Germany, during World War II. The archived specimens included only central nervous system tissues >70 years old that had been stored at room temperature. We demonstrated successful detection of Rickettsia typhi DNA by a nested qPCR specific to prsA in 2 patients. These results indicate that R. typhi infections contributed to typhus outbreaks during World War II. Immunohistochemical analyses of brain tissue specimens of R. typhi DNA–positive and –negative specimens showed perivascular B-cell accumulation. Around blood vessels, nodular cell accumulations consisted of CD4-positive and CD8-positive T cells and CD68-positive microglia and macrophages; neutrophils were found rarely. These findings are similar to those of previously reported R. prowazekii tissue specimen testing. Because R. typhi and R. prowazekii infections can be clinically and histopathologically similar, molecular analyses should be performed to distinguish the 2 pathogens.

EID Rauch J, Muntau B, Eggert P, Tappe D. Rickettsia typhi as Cause of Fatal Encephalitic Typhus in Hospitalized Patients, Hamburg, Germany, 1940–1944. Emerg Infect Dis. 2018;24(11):1982-1987. https://dx.doi.org/10.3201/eid2411.171373
AMA Rauch J, Muntau B, Eggert P, et al. Rickettsia typhi as Cause of Fatal Encephalitic Typhus in Hospitalized Patients, Hamburg, Germany, 1940–1944. Emerging Infectious Diseases. 2018;24(11):1982-1987. doi:10.3201/eid2411.171373.
APA Rauch, J., Muntau, B., Eggert, P., & Tappe, D. (2018). Rickettsia typhi as Cause of Fatal Encephalitic Typhus in Hospitalized Patients, Hamburg, Germany, 1940–1944. Emerging Infectious Diseases, 24(11), 1982-1987. https://dx.doi.org/10.3201/eid2411.171373.

Expires 9/14/2019
Medscape CME Activity
Human Pegivirus in Patients with Encephalitis of Unclear Etiology, Poland [PDF - 3.00 MB - 10 pages]
I. Bukowska-Ośko et al.

Human pegivirus (HPgV), previously called hepatitis G virus or GB virus C, is a lymphotropic virus with undefined pathology. Because many viruses from the family Flaviviridae, to which HPgV belongs, are neurotropic, we studied whether HPgV could infect the central nervous system. We tested serum and cerebrospinal fluid samples from 96 patients with a diagnosis of encephalitis for a variety of pathogens by molecular methods and serology; we also tested for autoantibodies against neuronal antigens. We found HPgV in serum and cerebrospinal fluid from 3 patients who had encephalitis of unclear origin; that is, all the markers that had been tested were negative. Single-strand confirmation polymorphism and next-generation sequencing analysis revealed differences between the serum and cerebrospinal fluid–derived viral sequences, which is compatible with the presence of a separate HPgV compartment in the central nervous system. It is unclear whether HPgV was directly responsible for encephalitis in these patients.

EID Bukowska-Ośko I, Perlejewski K, Pawełczyk A, Rydzanicz M, Pollak A, Popiel M, et al. Human Pegivirus in Patients with Encephalitis of Unclear Etiology, Poland. Emerg Infect Dis. 2018;24(10):1785-1794. https://dx.doi.org/10.3201/eid2410.180161
AMA Bukowska-Ośko I, Perlejewski K, Pawełczyk A, et al. Human Pegivirus in Patients with Encephalitis of Unclear Etiology, Poland. Emerging Infectious Diseases. 2018;24(10):1785-1794. doi:10.3201/eid2410.180161.
APA Bukowska-Ośko, I., Perlejewski, K., Pawełczyk, A., Rydzanicz, M., Pollak, A., Popiel, M....Laskus, T. (2018). Human Pegivirus in Patients with Encephalitis of Unclear Etiology, Poland. Emerging Infectious Diseases, 24(10), 1785-1794. https://dx.doi.org/10.3201/eid2410.180161.

Expires 9/13/2019
Medscape CME Activity
Influenza Transmission Dynamics in Urban Households, Managua, Nicaragua, 2012–2014 [PDF - 686 KB - 7 pages]
A. Gordon et al.

During August 2012–November 2014, we conducted a case ascertainment study to investigate household transmission of influenza virus in Managua, Nicaragua. We collected up to 5 respiratory swab samples from each of 536 household contacts of 133 influenza virus–infected persons and assessed for evidence of influenza virus transmission. The overall risk for influenza virus infection of household contacts was 15.7% (95% CI 12.7%–19.0%). Oseltamivir treatment of index patients did not appear to reduce household transmission. The mean serial interval for within-household transmission was 3.1 (95% CI 1.6–8.4) days. We found the transmissibility of influenza B virus to be higher than that of influenza A virus among children. Compared with households with <4 household contacts, those with >4 household contacts appeared to have a reduced risk for infection. Further research is needed to model household influenza virus transmission and design interventions for these settings.

EID Gordon A, Tsang TK, Cowling BJ, Kuan G, Ojeda S, Sanchez N, et al. Influenza Transmission Dynamics in Urban Households, Managua, Nicaragua, 2012–2014. Emerg Infect Dis. 2018;24(10):1882-1888. https://dx.doi.org/10.3201/eid2410.161258
AMA Gordon A, Tsang TK, Cowling BJ, et al. Influenza Transmission Dynamics in Urban Households, Managua, Nicaragua, 2012–2014. Emerging Infectious Diseases. 2018;24(10):1882-1888. doi:10.3201/eid2410.161258.
APA Gordon, A., Tsang, T. K., Cowling, B. J., Kuan, G., Ojeda, S., Sanchez, N....Harris, E. (2018). Influenza Transmission Dynamics in Urban Households, Managua, Nicaragua, 2012–2014. Emerging Infectious Diseases, 24(10), 1882-1888. https://dx.doi.org/10.3201/eid2410.161258.

Expires 8/16/2019
Medscape CME Activity
National Surveillance for Clostridioides difficile Infection, Sweden, 2009–2016 [PDF - 2.86 MB - 9 pages]
K. Rizzardi et al.

We report results from a national surveillance program for Clostridioides difficile infection (CDI) in Sweden, where CDI incidence decreased by 22% and the proportion of multidrug-resistant isolates decreased by 80% during 2012–2016. Variation in incidence between counties also diminished during this period, which might be attributable to implementation of nucleic acid amplification testing as the primary diagnostic tool for most laboratories. In contrast to other studies, our study did not indicate increased CDI incidence attributable the introduction of nucleic acid amplification testing. Our results also suggest that successful implementation of hygiene measures is the major cause of the observed incidence decrease. Despite substantial reductions in CDI incidence and prevalence of multidrug-resistant isolates, Sweden still has one of the highest CDI incidence levels in Europe. This finding is unexpected and warrants further investigation, given that Sweden has among the lowest levels of antimicrobial drug use.

EID Rizzardi K, Norén T, Aspevall O, Mäkitalo B, Toepfer M, Johansson Å, et al. National Surveillance for Clostridioides difficile Infection, Sweden, 2009–2016. Emerg Infect Dis. 2018;24(9):1617-1625. https://dx.doi.org/10.3201/eid2409.171658
AMA Rizzardi K, Norén T, Aspevall O, et al. National Surveillance for Clostridioides difficile Infection, Sweden, 2009–2016. Emerging Infectious Diseases. 2018;24(9):1617-1625. doi:10.3201/eid2409.171658.
APA Rizzardi, K., Norén, T., Aspevall, O., Mäkitalo, B., Toepfer, M., Johansson, Å....Åkerlund, T. (2018). National Surveillance for Clostridioides difficile Infection, Sweden, 2009–2016. Emerging Infectious Diseases, 24(9), 1617-1625. https://dx.doi.org/10.3201/eid2409.171658.

Expires 7/13/2019
Medscape CME Activity
Epidemiology of Diphyllobothrium nihonkaiense Diphyllobothriasis, Japan, 2001–2016 [PDF - 1.15 MB - 7 pages]
H. Ikuno et al.

We report 958 cases of cestodiasis occurring in Japan during 2001–2016. The predominant pathogen was Diphyllobothrium nihonkaiense tapeworm (n = 825), which caused 86.1% of all cases. The other cestode species involved were Taenia spp. (10.3%), Diplogonoporus balaenopterae (3.3%), and Spirometra spp. (0.2%). We estimated D. nihonkaiense diphyllobothriasis incidence as 52 cases/year. We observed a predominance of cases during March–July, coinciding with the cherry salmon and immature chum salmon fishing season, but cases were present year-round, suggesting that other fish could be involved in transmission to humans. Because of increased salmon trade, increased tourism in Japan, and lack of awareness of the risks associated with eating raw fish, cases of D. nihonkaiense diphyllobothriasis are expected to rise. Therefore, information regarding these concerning parasitic infections and warnings of the potential risks associated with these infections must be disseminated to consumers, food producers, restaurant owners, physicians, and travelers.

EID Ikuno H, Akao S, Yamasaki H. Epidemiology of Diphyllobothrium nihonkaiense Diphyllobothriasis, Japan, 2001–2016. Emerg Infect Dis. 2018;24(8):1428-1434. https://dx.doi.org/10.3201/eid2408.171454
AMA Ikuno H, Akao S, Yamasaki H. Epidemiology of Diphyllobothrium nihonkaiense Diphyllobothriasis, Japan, 2001–2016. Emerging Infectious Diseases. 2018;24(8):1428-1434. doi:10.3201/eid2408.171454.
APA Ikuno, H., Akao, S., & Yamasaki, H. (2018). Epidemiology of Diphyllobothrium nihonkaiense Diphyllobothriasis, Japan, 2001–2016. Emerging Infectious Diseases, 24(8), 1428-1434. https://dx.doi.org/10.3201/eid2408.171454.

Expires 7/11/2019
Medscape CME Activity
Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome [PDF - 891 KB - 6 pages]
N. S. Rajapakse et al.

Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system. We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.

EID Rajapakse NS, Ellsworth K, Liesman RM, Ho M, Henry N, Theel ES, et al. Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome. Emerg Infect Dis. 2018;24(8):1422-1427. https://dx.doi.org/10.3201/eid2408.180057
AMA Rajapakse NS, Ellsworth K, Liesman RM, et al. Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome. Emerging Infectious Diseases. 2018;24(8):1422-1427. doi:10.3201/eid2408.180057.
APA Rajapakse, N. S., Ellsworth, K., Liesman, R. M., Ho, M., Henry, N., Theel, E. S....Meneses, J. (2018). Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome. Emerging Infectious Diseases, 24(8), 1422-1427. https://dx.doi.org/10.3201/eid2408.180057.

Expires 7/11/2019
Medscape CME Activity
Ancylostoma ceylanicum Hookworm in Myanmar Refugees, Thailand, 2012–2015 [PDF - 1.27 MB - 10 pages]
E. M. O’Connell et al.

During 2012–2015, US-bound refugees living in Myanmar–Thailand border camps (n = 1,839) were surveyed for hookworm infection and treatment response by using quantitative PCR. Samples were collected at 3 time points: after each of 2 treatments with albendazole and after resettlement in the United States. Baseline prevalence of Necator americanus hookworm was 25.4%, Ancylostoma duodenale 0%, and Ancylostoma ceylanicum (a zoonosis) 5.4%. Compared with N. americanus prevalence, A. ceylanicum hookworm prevalence peaked in younger age groups, and blood eosinophil concentrations during A. ceylanicum infection were higher than those for N. americanus infection. Female sex was associated with a lower risk for either hookworm infection. Cure rates after 1 dose of albendazole were greater for A. ceylanicum (93.3%) than N. americanus (65.9%) hookworm (p<0.001). Lower N. americanus hookworm cure rates were unrelated to β-tubulin single-nucleotide polymorphisms at codons 200 or 167. A. ceylanicum hookworm infection might be more common in humans than previously recognized.

EID O’Connell EM, Mitchell T, Papaiakovou M, Pilotte N, Lee D, Weinberg M, et al. Ancylostoma ceylanicum Hookworm in Myanmar Refugees, Thailand, 2012–2015. Emerg Infect Dis. 2018;24(8):1472-1481. https://dx.doi.org/10.3201/eid2408.180280
AMA O’Connell EM, Mitchell T, Papaiakovou M, et al. Ancylostoma ceylanicum Hookworm in Myanmar Refugees, Thailand, 2012–2015. Emerging Infectious Diseases. 2018;24(8):1472-1481. doi:10.3201/eid2408.180280.
APA O’Connell, E. M., Mitchell, T., Papaiakovou, M., Pilotte, N., Lee, D., Weinberg, M....Nutman, T. B. (2018). Ancylostoma ceylanicum Hookworm in Myanmar Refugees, Thailand, 2012–2015. Emerging Infectious Diseases, 24(8), 1472-1481. https://dx.doi.org/10.3201/eid2408.180280.

Expires 6/15/2019
Medscape CME Activity
Epidemiology and Geographic Distribution of Blastomycosis, Histoplasmosis, and Coccidioidomycosis, Ontario, Canada, 1990–2015 [PDF - 1.95 MB - 10 pages]
E. M. Brown et al.

Endemic mycoses represent a growing public health challenge in North America. We describe the epidemiology of 1,392 microbiology laboratory–confirmed cases of blastomycosis, histoplasmosis, and coccidioidomycosis in Ontario during 1990–2015. Blastomycosis was the most common infection (1,092 cases; incidence of 0.41 cases/100,000 population), followed by histoplasmosis (211 cases) and coccidioidomycosis (89 cases). Incidence of blastomycosis increased from 1995 to 2001 and has remained elevated, especially in the northwest region, incorporating several localized hotspots where disease incidence (10.9 cases/100,000 population) is 12.6 times greater than in any other region of the province. This retrospective study substantially increases the number of known endemic fungal infections reported in Canada, confirms Ontario as an important region of endemicity for blastomycosis and histoplasmosis, and provides an epidemiologic baseline for future disease surveillance. Clinicians should include blastomycosis and histoplasmosis in the differential diagnosis of antibiotic-refractory pneumonia in patients traveling to or residing in Ontario.

EID Brown EM, McTaggart LR, Dunn D, Pszczolko E, Tsui K, Morris SK, et al. Epidemiology and Geographic Distribution of Blastomycosis, Histoplasmosis, and Coccidioidomycosis, Ontario, Canada, 1990–2015. Emerg Infect Dis. 2018;24(7):1257-1266. https://dx.doi.org/10.3201/eid2407.172063
AMA Brown EM, McTaggart LR, Dunn D, et al. Epidemiology and Geographic Distribution of Blastomycosis, Histoplasmosis, and Coccidioidomycosis, Ontario, Canada, 1990–2015. Emerging Infectious Diseases. 2018;24(7):1257-1266. doi:10.3201/eid2407.172063.
APA Brown, E. M., McTaggart, L. R., Dunn, D., Pszczolko, E., Tsui, K., Morris, S. K....Richardson, S. E. (2018). Epidemiology and Geographic Distribution of Blastomycosis, Histoplasmosis, and Coccidioidomycosis, Ontario, Canada, 1990–2015. Emerging Infectious Diseases, 24(7), 1257-1266. https://dx.doi.org/10.3201/eid2407.172063.

Expires 6/14/2019
Medscape CME Activity
Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016 [PDF - 1.30 MB - 9 pages]
E. van Schalkwyk et al.

Candidemia is a major cause of healthcare-associated infections. We describe a large outbreak of Candida krusei bloodstream infections among infants in Gauteng Province, South Africa, during a 4-month period; a series of candidemia and bacteremia outbreaks in the neonatal unit followed. We detected cases by using enhanced laboratory surveillance and audited hospital wards by environmental sampling and epidemiologic studies. During July–October 2014, among 589 patients, 48 unique cases of C. krusei candidemia occurred (8.2% incidence). Risk factors for candidemia on multivariable analyses were necrotizing enterocolitis, birthweight <1,500 g, receipt of parenteral nutrition, and receipt of blood transfusion. Despite initial interventions, outbreaks of bloodstream infection caused by C. krusei, rarer fungal species, and bacterial pathogens continued in the neonatal unit through July 29, 2016. Multiple factors contributed to these outbreaks; the most functional response is to fortify infection prevention and control.

EID van Schalkwyk E, Iyaloo S, Naicker SD, Maphanga TG, Mpembe RS, Zulu TG, et al. Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016. Emerg Infect Dis. 2018;24(7):1204-1212. https://dx.doi.org/10.3201/eid2407.171087
AMA van Schalkwyk E, Iyaloo S, Naicker SD, et al. Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016. Emerging Infectious Diseases. 2018;24(7):1204-1212. doi:10.3201/eid2407.171087.
APA van Schalkwyk, E., Iyaloo, S., Naicker, S. D., Maphanga, T. G., Mpembe, R. S., Zulu, T. G....Govender, N. P. (2018). Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016. Emerging Infectious Diseases, 24(7), 1204-1212. https://dx.doi.org/10.3201/eid2407.171087.

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The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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