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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 10/13/2022
Medscape CME Activity
Ehrlichiosis and Anaplasmosis among Transfusion and Transplant Recipients in the United States [PDF - 1.10 MB - 8 pages]
S. J. Mowla et al.

Ehrlichiosis and anaplasmosis are emerging tickborne diseases that can also be transmitted through blood transfusions or organ transplants. Since 2000, ehrlichiosis and anaplasmosis cases in the United States have increased substantially, resulting in potential risk to transplant and transfusion recipients. We reviewed ehrlichiosis and anaplasmosis cases among blood transfusion and solid organ transplant recipients in the United States from peer-reviewed literature and Centers for Disease Control and Prevention investigations. We identified 132 cases during 1997–2020, 12 transfusion-associated cases and 120 cases in transplant recipients; 8 cases were donor-derived, and in 13 cases illness occurred <1 year after transplant. Disease in the remaining 99 cases occurred ≥1 year after transplant, suggesting donor-derived disease was unlikely. Severe illness or death were reported among 15 transfusion and transplant recipients. Clinicians should be alert for these possible infections among transfusion and transplant recipients to prevent severe complications or death by quickly treating them.

EID Mowla SJ, Drexler NA, Cherry CC, Annambholta PD, Kracalik IT, Basavaraju SV. Ehrlichiosis and Anaplasmosis among Transfusion and Transplant Recipients in the United States. Emerg Infect Dis. 2021;27(11):2768-2775. https://doi.org/10.3201/eid2711.211127
AMA Mowla SJ, Drexler NA, Cherry CC, et al. Ehrlichiosis and Anaplasmosis among Transfusion and Transplant Recipients in the United States. Emerging Infectious Diseases. 2021;27(11):2768-2775. doi:10.3201/eid2711.211127.
APA Mowla, S. J., Drexler, N. A., Cherry, C. C., Annambholta, P. D., Kracalik, I. T., & Basavaraju, S. V. (2021). Ehrlichiosis and Anaplasmosis among Transfusion and Transplant Recipients in the United States. Emerging Infectious Diseases, 27(11), 2768-2775. https://doi.org/10.3201/eid2711.211127.

Expires 9/20/2022
Medscape CME Activity
Relapsing Fever Infection Manifesting as Aseptic Meningitis, Texas, USA [PDF - 2.81 MB - 5 pages]
L. Ellis et al.

Tickborne relapsing fever spirochetes are an overlooked cause of disease around the globe. We report a case of tickborne relapsing fever in a patient in Texas, USA, who had a single febrile episode and gastrointestinal and neurologic symptoms. Immunoblot analysis using recombinant Borrelia immunogenic protein A implicated Borrelia turicatae as the causative agent.

EID Ellis L, Curtis MW, Gunter SM, Lopez JE. Relapsing Fever Infection Manifesting as Aseptic Meningitis, Texas, USA. Emerg Infect Dis. 2021;27(10):2681-2685. https://doi.org/10.3201/eid2710.210189
AMA Ellis L, Curtis MW, Gunter SM, et al. Relapsing Fever Infection Manifesting as Aseptic Meningitis, Texas, USA. Emerging Infectious Diseases. 2021;27(10):2681-2685. doi:10.3201/eid2710.210189.
APA Ellis, L., Curtis, M. W., Gunter, S. M., & Lopez, J. E. (2021). Relapsing Fever Infection Manifesting as Aseptic Meningitis, Texas, USA. Emerging Infectious Diseases, 27(10), 2681-2685. https://doi.org/10.3201/eid2710.210189.

Expires 9/17/2022
Medscape CME Activity
Recurrence of Human Babesiosis Caused by Reinfection [PDF - 721 KB - 4 pages]
J. Ho et al.

Babesiosis developed in a 62-year-old immunocompetent physician, who had an uneventful recovery after receiving atovaquone and azithromycin. Three years later, babesiosis developed again, and he was again successfully given treatment. Clinical and laboratory evidence were highly supportive of Babesia reinfection. Healthcare professionals should be aware that reinfection might occur in babesiosis.

EID Ho J, Carey E, Carey DE, Krause PJ. Recurrence of Human Babesiosis Caused by Reinfection. Emerg Infect Dis. 2021;27(10):2658-2661. https://doi.org/10.3201/eid2710.211240
AMA Ho J, Carey E, Carey DE, et al. Recurrence of Human Babesiosis Caused by Reinfection. Emerging Infectious Diseases. 2021;27(10):2658-2661. doi:10.3201/eid2710.211240.
APA Ho, J., Carey, E., Carey, D. E., & Krause, P. J. (2021). Recurrence of Human Babesiosis Caused by Reinfection. Emerging Infectious Diseases, 27(10), 2658-2661. https://doi.org/10.3201/eid2710.211240.

Expires 9/15/2022
Medscape CME Activity
Population-Based Study of Bloodstream Infection Incidence and Mortality Rates, Finland, 2004–2018 [PDF - 2.78 MB - 10 pages]
K. Kontula et al.

We evaluated the incidence, outcomes, and causative agents of bloodstream infections (BSI) in Finland during 2004–2018 by using data from the national registries. We identified a total of 173,715 BSIs; annual incidence increased from 150 to 309 cases/100,000 population. BSI incidence rose most sharply among persons >80 years of age. The 1-month case-fatality rate decreased from 13.0% to 12.6%, but the 1-month all-cause mortality rate rose from 20 to 39 deaths/100,000 population. BSIs caused by Escherichia coli increased from 26% to 30% of all BSIs. BSIs caused by multidrug-resistant microbes rose from 0.4% to 2.8%, mostly caused by extended-spectrum β-lactamase-producing E. coli. We observed an increase in community-acquired BSIs, from 67% to 78%. The proportion of patients with severe underlying conditions rose from 14% to 23%. Additional public health and healthcare prevention efforts are needed to curb the increasing trend in community-acquired BSIs and antimicrobial drug–resistant E. coli.

EID Kontula K, Skogberg K, Ollgren J, Järvinen A, Lyytikäinen O. Population-Based Study of Bloodstream Infection Incidence and Mortality Rates, Finland, 2004–2018. Emerg Infect Dis. 2021;27(10):2560-2569. https://doi.org/10.3201/eid2710.204826
AMA Kontula K, Skogberg K, Ollgren J, et al. Population-Based Study of Bloodstream Infection Incidence and Mortality Rates, Finland, 2004–2018. Emerging Infectious Diseases. 2021;27(10):2560-2569. doi:10.3201/eid2710.204826.
APA Kontula, K., Skogberg, K., Ollgren, J., Järvinen, A., & Lyytikäinen, O. (2021). Population-Based Study of Bloodstream Infection Incidence and Mortality Rates, Finland, 2004–2018. Emerging Infectious Diseases, 27(10), 2560-2569. https://doi.org/10.3201/eid2710.204826.

Expires 8/16/2022
Medscape CME Activity
Maternal Carriage in Late-Onset Group B Streptococcus Disease, Italy [PDF - 1.04 MB - 9 pages]
A. Berardi et al.

We retrospectively investigated mother-to-infant transmission of group B Streptococcus (GBS) in 98 cases of late-onset disease reported during 2007–2018 by a network in Italy. Mothers with full assessment of vaginal/rectal carriage tested at prenatal screening and at time of late onset (ATLO) were included. Thirty-three mothers (33.7%) were never GBS colonized; 65 (66.3%) were vaginal/rectal colonized, of which 36 (36.7%) were persistently colonized. Mothers with vaginal/rectal colonization ATLO had high rates of GBS bacteriuria (33.9%) and positive breast milk culture (27.5%). GBS strains from mother–infant pairs were serotype III and possessed the surface protein antigen Rib. All but 1 strain belonged to clonal complex 17. GBS strains from 4 mother–infant pairs were indistinguishable through pulsed-field gel electrophoresis. At least two thirds of late-onset cases are transmitted from mothers, who often have vaginal/rectal carriage, positive breast milk culture, or GBS bacteriuria, which suggests heavy maternal colonization.

EID Berardi A, Spada C, Creti R, Auriti C, Gambini L, Rizzo V, et al. Maternal Carriage in Late-Onset Group B Streptococcus Disease, Italy. Emerg Infect Dis. 2021;27(9):2279-2287. https://doi.org/10.3201/eid2709.210049
AMA Berardi A, Spada C, Creti R, et al. Maternal Carriage in Late-Onset Group B Streptococcus Disease, Italy. Emerging Infectious Diseases. 2021;27(9):2279-2287. doi:10.3201/eid2709.210049.
APA Berardi, A., Spada, C., Creti, R., Auriti, C., Gambini, L., Rizzo, V....Lugli, L. (2021). Maternal Carriage in Late-Onset Group B Streptococcus Disease, Italy. Emerging Infectious Diseases, 27(9), 2279-2287. https://doi.org/10.3201/eid2709.210049.

Expires 7/21/2022
Medscape CME Activity
Four Human Cases of Eastern Equine Encephalitis in Connecticut, USA, during a Larger Regional Outbreak, 2019 [PDF - 3.33 MB - 10 pages]
S. C. Brown et al.

During 3 weeks in 2019, 4 human cases of Eastern equine encephalitis (EEE) were diagnosed at a single hospital in Connecticut, USA. The cases coincided with notable shifts in vector–host infection patterns in the northeastern United States and signified a striking change in EEE incidence. All 4 cases were geographically clustered, rapidly progressive, and neurologically devastating. Diagnostic tests conducted by a national commercial reference laboratory revealed initial granulocytic cerebrospinal fluid pleocytosis and false-negative antibody results. EEE virus infection was diagnosed only after patient samples were retested by the arbovirus laboratory of the Centers for Disease Control and Prevention in Fort Collins, Colorado, USA. The crucial diagnostic challenges, clinical findings, and epidemiologic patterns revealed in this outbreak can inform future public health and clinical practice.

EID Brown SC, Cormier J, Tuan J, Lier AJ, McGuone D, Armstrong PM, et al. Four Human Cases of Eastern Equine Encephalitis in Connecticut, USA, during a Larger Regional Outbreak, 2019. Emerg Infect Dis. 2021;27(8):2042-2051. https://doi.org/10.3201/eid2708.203730
AMA Brown SC, Cormier J, Tuan J, et al. Four Human Cases of Eastern Equine Encephalitis in Connecticut, USA, during a Larger Regional Outbreak, 2019. Emerging Infectious Diseases. 2021;27(8):2042-2051. doi:10.3201/eid2708.203730.
APA Brown, S. C., Cormier, J., Tuan, J., Lier, A. J., McGuone, D., Armstrong, P. M....Gobeske, K. T. (2021). Four Human Cases of Eastern Equine Encephalitis in Connecticut, USA, during a Larger Regional Outbreak, 2019. Emerging Infectious Diseases, 27(8), 2042-2051. https://doi.org/10.3201/eid2708.203730.

Expires 7/14/2022
Medscape CME Activity
Fungemia and Other Fungal Infections Associated with Use of Saccharomyces boulardii Probiotic Supplements [PDF - 848 KB - 7 pages]
J. Rannikko et al.

Because of widespread use of probiotics, their safety must be guaranteed. We assessed use of Saccharomyces boulardii probiotic yeast from medical records for patients who had Saccharomyces fungemia or other clinical Saccharomyces culture findings. We evaluated all Saccharomyces sp. findings at 5 university hospitals in Finland during 2009–2018. We found 46 patients who had Saccharomyces fungemia; at least 20 (43%) were using S. boulardii probiotic. Compared with a control group that had bacteremia or candidemia, the odds ratio for use of an S. boulardii probiotic was 14 (95% CI 4–44). Of 1,153 nonblood culture findings, the history for 125 patients was checked; at least 24 (19%) were using the probiotic (odds ratio 10, 95% CI 3–32). This study adds to published fungemia cases linked to use of S. boulardii probiotic and sheds light on the scale of nonblood Saccharomyces culture findings that are also linked to use of this probiotic.

EID Rannikko J, Holmberg V, Karppelin M, Arvola P, Huttunen R, Mattila E, et al. Fungemia and Other Fungal Infections Associated with Use of Saccharomyces boulardii Probiotic Supplements. Emerg Infect Dis. 2021;27(8):2043-2051. https://doi.org/10.3201/eid2708.210018
AMA Rannikko J, Holmberg V, Karppelin M, et al. Fungemia and Other Fungal Infections Associated with Use of Saccharomyces boulardii Probiotic Supplements. Emerging Infectious Diseases. 2021;27(8):2043-2051. doi:10.3201/eid2708.210018.
APA Rannikko, J., Holmberg, V., Karppelin, M., Arvola, P., Huttunen, R., Mattila, E....Hohenthal, U. (2021). Fungemia and Other Fungal Infections Associated with Use of Saccharomyces boulardii Probiotic Supplements. Emerging Infectious Diseases, 27(8), 2043-2051. https://doi.org/10.3201/eid2708.210018.

Expires 6/18/2022
Medscape CME Activity
Non–C. difficile Clostridioides Bacteremia in Intensive Care Patients, France [PDF - 1.42 MB - 10 pages]
G. Morel et al.

Usually responsible for soft tissue infections, Clostridioides species can also cause bacteremia, life-threatening infections often requiring intensive care unit (ICU) admission. We conducted a multicenter retrospective study to investigate Clostridioides bacteremia in ICUs to describe the clinical and biologic characteristics and outcomes in critically ill patients. We identified 135 patients with Clostridioides bacteremia, which occurred almost exclusively (96%) in patients with underlying conditions. Septic shock and digestive symptoms were the hallmarks of Clostridioides bacteremia in the ICU. We identified 16 different species of Clostridioides, among which C. perfringens accounted for 31% of cases. Despite the high sensitivity of Clostridioides to common antimicrobial drugs, mortality rates were high: 52% for ICU patients and 71% overall at 3 months. In multivariate analysis, the most important factor associated with increased risk for death was the presence of hemolysis. Clostridioides bacteremia often leads to multiple organ failures, which have high mortality rates.

EID Morel G, Mulier G, Ghrenassia E, Abdel Nabey M, Tandjaoui Y, Kouatchet A, et al. Non–C. difficile Clostridioides Bacteremia in Intensive Care Patients, France. Emerg Infect Dis. 2021;27(7):1840-1849. https://doi.org/10.3201/eid2707.203471
AMA Morel G, Mulier G, Ghrenassia E, et al. Non–C. difficile Clostridioides Bacteremia in Intensive Care Patients, France. Emerging Infectious Diseases. 2021;27(7):1840-1849. doi:10.3201/eid2707.203471.
APA Morel, G., Mulier, G., Ghrenassia, E., Abdel Nabey, M., Tandjaoui, Y., Kouatchet, A....Zafrani, L. (2021). Non–C. difficile Clostridioides Bacteremia in Intensive Care Patients, France. Emerging Infectious Diseases, 27(7), 1840-1849. https://doi.org/10.3201/eid2707.203471.

Expires 5/23/2022
Medscape CME Activity
Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018 [PDF - 1.54 MB - 6 pages]
W. He et al.

During 2013–2018, antimicrobial drugs were prescribed for 6.8% of cases of acute gastroenteritis encountered in general practice in Australia, including 35.7% of Salmonella infections and 54.1% of Campylobacter infections. During that time, prescriptions for acute gastroenteritis decreased by 2.0%. Managing infectious gastroenteritis in general practice will require greater antimicrobial stewardship.

EID He W, Kirk MD, Hall J, Liu B. Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018. Emerg Infect Dis. 2021;27(5):1462-1467. https://doi.org/10.3201/eid2705.203692
AMA He W, Kirk MD, Hall J, et al. Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018. Emerging Infectious Diseases. 2021;27(5):1462-1467. doi:10.3201/eid2705.203692.
APA He, W., Kirk, M. D., Hall, J., & Liu, B. (2021). Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018. Emerging Infectious Diseases, 27(5), 1462-1467. https://doi.org/10.3201/eid2705.203692.

Expires 5/22/2022
Medscape CME Activity
Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy [PDF - 2.70 MB - 11 pages]
M. Rossi et al.

Klebsiella pneumoniae carbapenemase–producing K. pneumoniae (KPC-Kp) has been endemic in Italy since 2013. In a multicenter cohort study, we investigated various aspects of KPC-Kp among patients, including 15-day mortality rates and delays in adequate therapy. Most (77%) KPC-Kp strains were sequence type (ST) ST512 or ST307. During 2017, KPC-Kp prevalence was 3.26 cases/1,000 hospitalized patients. Cumulative incidence of KPC-Kp acquired >48 hours after hospital admission was 0.68% but varied widely between centers. Among patients with mild infections and noninfected colonized patients, 15-day mortality rates were comparable, but rates were much higher among patients with severe infections. Delays of >4 days in receiving adequate therapy more frequently occurred among patients with mild infections than those with severe infections, and delays were less common for patients with known previous KPC-Kp colonization. Italy urgently needs a concerted surveillance system to control the spread of KPC-Kp.

EID Rossi M, Chatenoud L, Gona F, Sala I, Nattino G, D'Antonio A, et al. Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy. Emerg Infect Dis. 2021;27(5):1416-1426. https://doi.org/10.3201/eid2705.203662
AMA Rossi M, Chatenoud L, Gona F, et al. Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy. Emerging Infectious Diseases. 2021;27(5):1416-1426. doi:10.3201/eid2705.203662.
APA Rossi, M., Chatenoud, L., Gona, F., Sala, I., Nattino, G., D'Antonio, A....Gori, A. (2021). Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy. Emerging Infectious Diseases, 27(5), 1416-1426. https://doi.org/10.3201/eid2705.203662.

Expires 5/19/2022
Medscape CME Activity
HIV Infection as Risk Factor for Death among Hospitalized Persons with Candidemia, South Africa, 2012–2017 [PDF - 1.02 MB - 9 pages]
N. P. Govender et al.

We determined the effect of HIV infection on deaths among persons >18 months of age with culture-confirmed candidemia at 29 sentinel hospitals in South Africa during 2012–2017. Of 1,040 case-patients with documented HIV status and in-hospital survival data, 426 (41%) were HIV-seropositive. The in-hospital case-fatality rate was 54% (228/426) for HIV-seropositive participants and 37% (230/614) for HIV-seronegative participants (crude odds ratio [OR] 1.92, 95% CI 1.50–2.47; p<0.001). After adjusting for relevant confounders (n = 907), mortality rates were 1.89 (95% CI 1.38–2.60) times higher among HIV-seropositive participants than HIV-seronegative participants (p<0.001). Compared with HIV-seronegative persons, the stratum-specific adjusted mortality OR was higher among HIV-seropositive persons not managed in intensive care units (OR 2.27, 95% CI 1.47–3.52; p<0.001) than among persons who were (OR 1.56, 95% CI 1.00–2.43; p = 0.05). Outcomes among HIV-seropositive persons with candidemia might be improved with intensive care.

EID Govender NP, Todd J, Nel J, Mer M, Karstaedt A, Cohen C. HIV Infection as Risk Factor for Death among Hospitalized Persons with Candidemia, South Africa, 2012–2017. Emerg Infect Dis. 2021;27(6):1607-1615. https://doi.org/10.3201/eid2706.210128
AMA Govender NP, Todd J, Nel J, et al. HIV Infection as Risk Factor for Death among Hospitalized Persons with Candidemia, South Africa, 2012–2017. Emerging Infectious Diseases. 2021;27(6):1607-1615. doi:10.3201/eid2706.210128.
APA Govender, N. P., Todd, J., Nel, J., Mer, M., Karstaedt, A., & Cohen, C. (2021). HIV Infection as Risk Factor for Death among Hospitalized Persons with Candidemia, South Africa, 2012–2017. Emerging Infectious Diseases, 27(6), 1607-1615. https://doi.org/10.3201/eid2706.210128.

Expires 5/18/2022
Medscape CME Activity
Neurologic Disease after Yellow Fever Vaccination, São Paulo, Brazil, 2017–2018 [PDF - 1.40 MB - 11 pages]
A. Ribeiro et al.

Yellow fever (YF) vaccine can cause neurologic complications. We examined YF vaccine–associated neurologic disease reported from 3 tertiary referral centers in São Paulo, Brazil, during 2017–2018 and compared the performance of criteria established by the Yellow Fever Vaccine Working Group/Centers for Disease Control and Prevention and the Brighton Collaboration. Among 50 patients who met inclusion criteria, 32 had meningoencephalitis (14 with reactive YF IgM in cerebrospinal fluid), 2 died, and 1 may have transmitted infection to an infant through breast milk. Of 7 cases of autoimmune neurologic disease after YF vaccination, 2 were acute disseminated encephalomyelitis, 2 myelitis, and 3 Guillain-Barré syndrome. Neurologic disease can follow fractional vaccine doses, and novel potential vaccine-associated syndromes include autoimmune encephalitis, opsoclonus-myoclonus-ataxia syndrome, optic neuritis, and ataxia. Although the Brighton Collaboration criteria lack direct vaccine causal assessment, they are more inclusive than the Centers for Disease Control and Prevention criteria.

EID Ribeiro A, Guedes B, Sulleiman J, de Oliveira F, de Souza I, Nogueira J, et al. Neurologic Disease after Yellow Fever Vaccination, São Paulo, Brazil, 2017–2018. Emerg Infect Dis. 2021;27(6):1577-1587. https://doi.org/10.3201/eid2706.204170
AMA Ribeiro A, Guedes B, Sulleiman J, et al. Neurologic Disease after Yellow Fever Vaccination, São Paulo, Brazil, 2017–2018. Emerging Infectious Diseases. 2021;27(6):1577-1587. doi:10.3201/eid2706.204170.
APA Ribeiro, A., Guedes, B., Sulleiman, J., de Oliveira, F., de Souza, I., Nogueira, J....de Oliveira, A. (2021). Neurologic Disease after Yellow Fever Vaccination, São Paulo, Brazil, 2017–2018. Emerging Infectious Diseases, 27(6), 1577-1587. https://doi.org/10.3201/eid2706.204170.

Expires 5/12/2022
Medscape CME Activity
Rocky Mountain Spotted Fever in a Large Metropolitan Center, Mexico–United States Border, 2009–2019 [PDF - 1.68 MB - 10 pages]
O. E. Zazueta et al.

Epidemic levels of Rocky Mountain spotted fe­­­ver (RMSF) have persisted in Mexicali, Mexico, since the initial outbreak was first reported in December 2008. We compared clinical and epidemiologic data of cases in Mexicali during 2009–2019 between patients with an IgG titer reactive with Rickettsia rickettsii bacteria by indirect immunofluorescence antibody (IFA) assay and those who demonstrated DNA of R. rickettsii in a whole blood sample when tested by PCR. We identified 4,290 patients with clinical and epidemiologic features compatible with RMSF; of these, 9.74% tested positive by IFA and 8.41% by PCR. Overall, 140 patients died (11-year case-fatality rate 17.97%). Substantial differences in the frequency of commonly recognized clinical characteristics of RMSF were identified between PCR-positive and IFA-positive cases. The Mexicali epidemic is unique in its size and urban centralization. Cases confirmed by PCR most accurately reflect the clinical profile of RMSF.

EID Zazueta OE, Armstrong PA, Márquez-Elguea A, Hernández Milán N, Peterson AE, Ovalle-Marroquín DF, et al. Rocky Mountain Spotted Fever in a Large Metropolitan Center, Mexico–United States Border, 2009–2019. Emerg Infect Dis. 2021;27(6):1567-1576. https://doi.org/10.3201/eid2706.191662
AMA Zazueta OE, Armstrong PA, Márquez-Elguea A, et al. Rocky Mountain Spotted Fever in a Large Metropolitan Center, Mexico–United States Border, 2009–2019. Emerging Infectious Diseases. 2021;27(6):1567-1576. doi:10.3201/eid2706.191662.
APA Zazueta, O. E., Armstrong, P. A., Márquez-Elguea, A., Hernández Milán, N., Peterson, A. E., Ovalle-Marroquín, D. F....Paddock, C. D. (2021). Rocky Mountain Spotted Fever in a Large Metropolitan Center, Mexico–United States Border, 2009–2019. Emerging Infectious Diseases, 27(6), 1567-1576. https://doi.org/10.3201/eid2706.191662.

Expires 3/19/2022
Medscape CME Activity
Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019 [PDF - 1.14 MB - 8 pages]
E. M. Rabold et al.

Unsafe injection practices and injection drug use have been linked to multiple HIV outbreaks in Pakistan since 2003; however, few studies have systematically analyzed the causes of these outbreaks. We conducted a systematic review of published English-language literature indexed in bibliographic databases and search engines and a focused gray literature review to collate and analyze all reported HIV outbreaks in Pakistan during 2000–2019. Of 774 unique publications reviewed, we identified 25 eligible publications describing 7 outbreaks. More than half occurred during 2016–2019. The primary sources of transmission were iatrogenic transmission, affecting children, persons with chronic medical conditions, and the general population (4 outbreaks); injection drug use (2 outbreaks); and a combination of both (1 outbreak). In the absence of robust HIV testing and surveillance in Pakistan, timely and detailed outbreak reporting is important to understand the epidemiology of HIV in the country.

EID Rabold EM, Ali H, Fernandez D, Knuth M, Schenkel K, Asghar R, et al. Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerg Infect Dis. 2021;27(4):1039-1047. https://doi.org/10.3201/eid2704.204205
AMA Rabold EM, Ali H, Fernandez D, et al. Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerging Infectious Diseases. 2021;27(4):1039-1047. doi:10.3201/eid2704.204205.
APA Rabold, E. M., Ali, H., Fernandez, D., Knuth, M., Schenkel, K., Asghar, R....Morgan, O. (2021). Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerging Infectious Diseases, 27(4), 1039-1047. https://doi.org/10.3201/eid2704.204205.

Expires 3/18/2022
Medscape CME Activity
Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018 [PDF - 1.18 MB - 9 pages]
M. Markowicz et al.

The aim of this prospective study was to assess the risk for tickborne infections after a tick bite. A total of 489 persons bitten by 1,295 ticks were assessed for occurrence of infections with Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Rickettsia spp., Babesia spp., Candidatus Neoehrlichia mikurensis, and relapsing fever borreliae. B. burgdorferi s.l. infection was found in 25 (5.1%) participants, of whom 15 had erythema migrans. Eleven (2.3%) participants were positive by PCR for Candidatus N. mikurensis. One asymptomatic participant infected with B. miyamotoi was identified. Full engorgement of the tick (odds ratio 9.52) and confirmation of B. burgdorferi s.l. in the tick by PCR (odds ratio 4.39) increased the risk for infection. Rickettsia helvetica was highly abundant in ticks but not pathogenic to humans. Knowledge about the outcome of tick bites is crucial because infections with emerging pathogens might be underestimated because of limited laboratory facilities.

EID Markowicz M, Schötta A, Höss D, Kundi M, Schray C, Stockinger H, et al. Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018. Emerg Infect Dis. 2021;27(4):1048-1056. https://doi.org/10.3201/eid2704.203366
AMA Markowicz M, Schötta A, Höss D, et al. Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018. Emerging Infectious Diseases. 2021;27(4):1048-1056. doi:10.3201/eid2704.203366.
APA Markowicz, M., Schötta, A., Höss, D., Kundi, M., Schray, C., Stockinger, H....Stanek, G. (2021). Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018. Emerging Infectious Diseases, 27(4), 1048-1056. https://doi.org/10.3201/eid2704.203366.

Expires 3/17/2022
Medscape CME Activity
Blastomycosis Surveillance in 5 States, United States, 1987–2018 [PDF - 1.79 MB - 8 pages]
K. Benedict et al.

Blastomycosis is caused by inhalation of Blastomyces spp. fungi. Limited data are available on the incidence and geographic range of blastomycosis in the United States. To better characterize its epidemiologic features, we analyzed combined surveillance data from the 5 states in which blastomycosis is reportable: Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin. Surveillance identified 4,441 cases during 1987–2018, a mean of 192 cases per year. The mean annual incidence was <1 case/100,000 population in most areas but >20 cases/100,000 population in some northern counties of Wisconsin. Median patient age was 46 years, 2,892 (65%) patients were male, 1,662 (57%) were hospitalized, and 278 (8%) died. The median time from symptom onset to diagnosis was 33 days. The severity of illness and diagnostic delays suggest that surveillance underestimates the true number of cases. More in-depth surveillance in additional states could elucidate blastomycosis incidence and inform efforts to increase awareness.

EID Benedict K, Gibbons-Burgener S, Kocharian A, Ireland M, Rothfeldt L, Christophe N, et al. Blastomycosis Surveillance in 5 States, United States, 1987–2018. Emerg Infect Dis. 2021;27(4):999-1006. https://doi.org/10.3201/eid2704.204078
AMA Benedict K, Gibbons-Burgener S, Kocharian A, et al. Blastomycosis Surveillance in 5 States, United States, 1987–2018. Emerging Infectious Diseases. 2021;27(4):999-1006. doi:10.3201/eid2704.204078.
APA Benedict, K., Gibbons-Burgener, S., Kocharian, A., Ireland, M., Rothfeldt, L., Christophe, N....Jackson, B. R. (2021). Blastomycosis Surveillance in 5 States, United States, 1987–2018. Emerging Infectious Diseases, 27(4), 999-1006. https://doi.org/10.3201/eid2704.204078.

Expires 2/22/2022
Medscape CME Activity
Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan [PDF - 698 KB - 8 pages]
A. A. Malik et al.

In Karachi, Pakistan, a South Asian megacity with a high prevalence of tuberculosis (TB) and low HIV prevalence, we assessed the effectiveness of fluoroquinolone-based preventive therapy for drug-resistant (DR) TB exposure. During February 2016–March 2017, high-risk household contacts of DR TB patients began a 6-month course of preventive therapy with a fluoroquinolone-based, 2-drug regimen. We assessed effectiveness in this cohort by comparing the rate and risk for TB disease over 2 years to the rates and risks reported in the literature. Of 172 participants, TB occurred in 2 persons over 336 person-years of observation. TB disease incidence rate observed in the cohort was 6.0/1,000 person-years. The incidence rate ratio ranged from 0.29 (95% CI 0.04–1.3) to 0.50 (95% CI 0.06–2.8), with a pooled estimate of 0.35 (95% CI 0.14–0.87). Overall, fluoroquinolone-based preventive therapy for DR TB exposure reduced risk for TB disease by 65%.

EID Malik AA, Gandhi NR, Lash TL, Cranmer LM, Omer SB, Ahmed JF, et al. Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerg Infect Dis. 2021;27(3):805-812. https://doi.org/10.3201/eid2703.203916
AMA Malik AA, Gandhi NR, Lash TL, et al. Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerging Infectious Diseases. 2021;27(3):805-812. doi:10.3201/eid2703.203916.
APA Malik, A. A., Gandhi, N. R., Lash, T. L., Cranmer, L. M., Omer, S. B., Ahmed, J. F....Becerra, M. C. (2021). Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerging Infectious Diseases, 27(3), 805-812. https://doi.org/10.3201/eid2703.203916.

Expires 2/19/2022
Medscape CME Activity
Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018 [PDF - 730 KB - 10 pages]
E. Won et al.

We investigated the clinical outcomes and molecular mechanisms of fluconazole-resistant (FR) Candida glabrata bloodstream infections. Among 1,158 isolates collected during multicenter studies in South Korea during 2008–2018, 5.7% were FR. For 64 patients with FR bloodstream infection isolates, the 30-day mortality rate was 60.9% and the 90-day mortality rate 78.2%; these rates were significantly higher than in patients with fluconazole-susceptible dose-dependent isolates (30-day mortality rate 36.4%, 90-day mortality rate 43.8%; p<0.05). For patients with FR isolates, appropriate antifungal therapy was the only independent protective factor associated with 30-day (hazard ratio 0.304) and 90-day (hazard ratio 0.310) mortality. Sequencing of pleiotropic drug-resistance transcription factor revealed that 1–2 additional Pdr1p amino acid substitutions (except genotype-specific Pdr1p amino acid substitutions) occurred in 98.5% of FR isolates but in only 0.9% of fluconazole-susceptible dose-dependent isolates. These results highlight the high mortality rate of patients infected with FR C. glabrata BSI isolates harboring Pdr1p mutations.

EID Won E, Choi MJ, Kim M, Yong D, Lee W, Uh Y, et al. Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018. Emerg Infect Dis. 2021;27(3):779-788. https://doi.org/10.3201/eid2703.203482
AMA Won E, Choi MJ, Kim M, et al. Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018. Emerging Infectious Diseases. 2021;27(3):779-788. doi:10.3201/eid2703.203482.
APA Won, E., Choi, M. J., Kim, M., Yong, D., Lee, W., Uh, Y....Shin, J. (2021). Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018. Emerging Infectious Diseases, 27(3), 779-788. https://doi.org/10.3201/eid2703.203482.

Expires 1/22/2022
Medscape CME Activity
Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018 [PDF - 1.48 MB - 13 pages]
V. Joste et al.

We retrospectively analyzed epidemiologic, clinical, and biologic characteristics of 368 Plasmodium ovale wallikeri and 309 P. ovale curtisi infections treated in France during January 2013–December 2018. P. ovale wallikeri infections displayed deeper thrombocytopenia and shorter latency periods. Despite similar clinical manifestations, P. ovale wallikeri–infected patients were more frequently treated with artemisinin-based combination therapy. Although the difference was not statistically significant, P. ovale wallikeri–infected patients were 5 times more frequently hospitalized in intensive care or intermediate care and had a higher proportion of severe thrombocytopenia than P. ovale curtisi–infected patients. Rapid diagnostic tests that detect aldolase were more efficient than those detecting Plasmodium lactate dehydrogenase. Sequence analysis of the potra gene from 90 P. ovale isolates reveals an insufficient polymorphism for relapse typing.

EID Joste V, Bailly J, Hubert V, Pauc C, Gendrot M, Guillochon E, et al. Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018. Emerg Infect Dis. 2021;27(2):372-384. https://doi.org/10.3201/eid2702.202143
AMA Joste V, Bailly J, Hubert V, et al. Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018. Emerging Infectious Diseases. 2021;27(2):372-384. doi:10.3201/eid2702.202143.
APA Joste, V., Bailly, J., Hubert, V., Pauc, C., Gendrot, M., Guillochon, E....Houzé, S. (2021). Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018. Emerging Infectious Diseases, 27(2), 372-384. https://doi.org/10.3201/eid2702.202143.

Expires 1/21/2022
Medscape CME Activity
Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018 [PDF - 2.56 MB - 12 pages]
A. Benavides-Lara et al.

After Zika virus (ZIKV) infection in Costa Rica was confirmed in January 2016, the national surveillance system was enhanced to monitor associated birth defects. To characterize the ZIKV outbreak among live-born infants during March 2016–March 2018, we conducted a descriptive analysis. Prevalence of ZIKV-associated birth defects was 15.3 cases/100,000 live births. Among 22 infants with ZIKV-associated birth defects, 11 were designated as confirmed (positive for ZIKV) and 11 were designated as probable cases (negative for ZIKV or not tested, but mother was expsed to ZIKV during pregnancy). A total of 91% had microcephaly (head circumference >2 SDs below mean for age and sex), 64% severe microcephaly (head circumference >3 SDs below mean for age and sex), 95% neurodevelopmental abnormalities, 82% brain anomalies, 41% eye abnormalities, and 9% hearing loss. Monitoring children for >1 year can increase identification of ZIKV-associated abnormalities in addition to microcephaly.

EID Benavides-Lara A, la Paz Barboza-Arguello Md, González-Elizondo M, Hernández-deMezerville M, Brenes-Chacón H, Ramírez-Rojas M, et al. Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018. Emerg Infect Dis. 2021;27(2):360-371. https://doi.org/10.3201/eid2702.202047
AMA Benavides-Lara A, la Paz Barboza-Arguello Md, González-Elizondo M, et al. Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018. Emerging Infectious Diseases. 2021;27(2):360-371. doi:10.3201/eid2702.202047.
APA Benavides-Lara, A., la Paz Barboza-Arguello, M. d., González-Elizondo, M., Hernández-deMezerville, M., Brenes-Chacón, H., Ramírez-Rojas, M....Soriano-Fallas, A. (2021). Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018. Emerging Infectious Diseases, 27(2), 360-371. https://doi.org/10.3201/eid2702.202047.

Expires 12/23/2021
Medscape CME Activity
Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015 [PDF - 565 KB - 10 pages]
E. Pérez-Nadales et al.

Invasive fusariosis (IF) is associated with severe neutropenia in patients with concurrent hematologic conditions. We conducted a retrospective observational study to characterize the epidemiology of IF in 18 Spanish hospitals during 2000–2015. In that time, the frequency of IF in nonneutropenic patients increased from 0.08 cases per 100,000 admissions in 2000–2009 to 0.22 cases per 100,000 admissions in 2010–2015. Nonneutropenic IF patients often had nonhematologic conditions, such as chronic cardiac or lung disease, rheumatoid arthritis, history of solid organ transplantation, or localized fusariosis. The 90-day death rate among nonneutropenic patients (28.6%) and patients with resolved neutropenia (38.1%) was similar. However, the death rate among patients with persistent neutropenia (91.3%) was significantly higher. We used a multivariate Cox regression analysis to characterize risk factors for death: persistent neutropenia was the only risk factor for death, regardless of antifungal therapy.

EID Pérez-Nadales E, Alastruey-Izquierdo A, Linares-Sicilia M, Soto-Debrán J, Abdala E, García-Rodríguez J, et al. Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015. Emerg Infect Dis. 2021;27(1):24-36. https://doi.org/10.3201/eid2701.190782
AMA Pérez-Nadales E, Alastruey-Izquierdo A, Linares-Sicilia M, et al. Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015. Emerging Infectious Diseases. 2021;27(1):24-36. doi:10.3201/eid2701.190782.
APA Pérez-Nadales, E., Alastruey-Izquierdo, A., Linares-Sicilia, M., Soto-Debrán, J., Abdala, E., García-Rodríguez, J....Nucci, M. (2021). Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015. Emerging Infectious Diseases, 27(1), 24-36. https://doi.org/10.3201/eid2701.190782.

Expires 12/22/2021
Medscape CME Activity
Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018 [PDF - 1.75 MB - 11 pages]
J. Bennett et al.

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000–2018 and RHD mortality rates during 2000–2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0–14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9–27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9–3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2–5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3–14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1–13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.

EID Bennett J, Zhang J, Leung W, Jack S, Oliver J, Webb R, et al. Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018. Emerg Infect Dis. 2021;27(1):36-46. https://doi.org/10.3201/eid2701.191791
AMA Bennett J, Zhang J, Leung W, et al. Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018. Emerging Infectious Diseases. 2021;27(1):36-46. doi:10.3201/eid2701.191791.
APA Bennett, J., Zhang, J., Leung, W., Jack, S., Oliver, J., Webb, R....Baker, M. G. (2021). Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018. Emerging Infectious Diseases, 27(1), 36-46. https://doi.org/10.3201/eid2701.191791.

Expires 11/20/2021
Medscape CME Activity
Tuberculosis among Children and Adolescents at HIV Treatment Centers in Sub-Saharan Africa [PDF - 2.14 MB - 11 pages]
A. M. Mandalakas et al.

HIV-infected children and adolescents are at increased risk for tuberculosis (TB). Antiretroviral therapy (ART) reduces TB risk in HIV-infected adults, but its effectiveness in HIV-infected children and adolescents is unknown. We analyzed data from 7 integrated pediatric HIV/TB centers in 6 countries in sub-Saharan Africa. We used a Bayesian mixed-effect model to assess association between ART and TB prevalence and used adaptive lasso regression to analyze risk factors for adverse TB outcomes. The study period encompassed 57,525 patient-years and 1,160 TB cases (2,017 cases/100,000 patient-years). Every 10% increase in ART uptake resulted in a 2.33% reduction in TB prevalence. Favorable TB outcomes were associated with increased time in care and early ART initiation, whereas severe immunosuppression was associated with death. These findings support integrated HIV/TB services for HIV-infected children and adults and demonstrate the association of ART uptake with decreased TB incidence in high HIV/TB settings.


Expires 11/19/2021
Medscape CME Activity
Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil [PDF - 2.48 MB - 11 pages]
C. Brandão-de-Resende et al.

In 2015, an outbreak of presumed waterborne toxoplasmosis occurred in Gouveia, Brazil. We conducted a 3-year prospective study on a cohort of 52 patients from this outbreak, collected clinical and multimodal imaging findings, and determined risk factors for ocular involvement. At baseline examination, 12 (23%) patients had retinochoroiditis; 4 patients had bilateral and 2 had macular lesions. Multimodal imaging revealed 2 distinct retinochoroiditis patterns: necrotizing focal retinochoroiditis and punctate retinochoroiditis. Older age, worse visual acuity, self-reported recent reduction of visual acuity, and presence of floaters were associated with retinochoroiditis. Among patients, persons >40 years of age had 5 times the risk for ocular involvement. Five patients had recurrences during follow-up, a rate of 22% per person-year. Recurrences were associated with binocular involvement. Two patients had late ocular involvement that occurred >34 months after initial diagnosis. Patients with acquired toxoplasmosis should have long-term ophthalmic follow-up, regardless of initial ocular involvement.

EID Brandão-de-Resende C, Santos H, Rojas Lagos A, Lara C, Arruda J, Marino A, et al. Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil. Emerg Infect Dis. 2020;26(12):2922-2932. https://doi.org/10.3201/eid2612.200227
AMA Brandão-de-Resende C, Santos H, Rojas Lagos A, et al. Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil. Emerging Infectious Diseases. 2020;26(12):2922-2932. doi:10.3201/eid2612.200227.
APA Brandão-de-Resende, C., Santos, H., Rojas Lagos, A., Lara, C., Arruda, J., Marino, A....Vasconcelos-Santos, D. (2020). Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil. Emerging Infectious Diseases, 26(12), 2922-2932. https://doi.org/10.3201/eid2612.200227.

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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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