Archive for January 12, 2017

IDSA GUIDELINES – Diagnosis of Tuberculosis in Adults and Children

Clinical Infectious Diseases January 15, 2017 V.64 N.2 P.111-115

David M. Lewinsohn, Michael K. Leonard, Philip A. LoBue, David L. Cohn, Charles L. Daley, Ed Desmond, Joseph Keane, Deborah A. Lewinsohn, Ann M. Loeffler, Gerald H. Mazurek, Richard J. O’Brien, Madhukar Pai, Luca Richeldi, Max Salfinger, Thomas M. Shinnick, Timothy R. Sterling, David M. Warshauer, and Gail L. Woods

1 Oregon Health & Science University, Portland, Oregon,

2 Emory University School of Medicine and

3 Centers for Disease Control and Prevention, Atlanta, Georgia,

4 Denver Public Health Department, Denver, Colorado,

5 National Jewish Health and the University of Colorado Denver, and

6 California Department of Public Health, Richmond;

7 St James’s Hospital, Dublin, Ireland;

8 Francis J. Curry International TB Center, San Francisco, California;

9 Foundation for Innovative New Diagnostics, Geneva, Switzerland;

10 McGill University and McGill International TB Centre, Montreal, Canada;

11 University of Southampton, United Kingdom;

12 National Jewish Health, Denver, Colorado,

13 Vanderbilt University School of Medicine, Vanderbilt Institute for Global Health, Nashville, Tennessee,

14 Wisconsin State Laboratory of Hygiene, Madison, and

15 University of Arkansas for Medical Sciences, Little Rock


Individuals infected with Mycobacterium tuberculosis (Mtb) may develop symptoms and signs of disease (tuberculosis disease) or may have no clinical evidence of disease (latent tuberculosis infection [LTBI]). Tuberculosis disease is a leading cause of infectious disease morbidity and mortality worldwide, yet many questions related to its diagnosis remain.


A task force supported by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America searched, selected, and synthesized relevant evidence. The evidence was then used as the basis for recommendations about the diagnosis of tuberculosis disease and LTBI in adults and children. The recommendations were formulated, written, and graded using the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach.


Twenty-three evidence-based recommendations about diagnostic testing for latent tuberculosis infection, pulmonary tuberculosis, and extrapulmonary tuberculosis are provided. Six of the recommendations are strong, whereas the remaining 17 are conditional.


These guidelines are not intended to impose a standard of care. They provide the basis for rational decisions in the diagnosis of tuberculosis in the context of the existing evidence. No guidelines can take into account all of the often compelling unique individual clinical circumstances.



January 12, 2017 at 6:21 pm

Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses

Clinical Infectious Diseases January 15, 2017 V.64 N.2 P.134-140

Shawn R. Lockhart, Kizee A. Etienne, Snigdha Vallabhaneni, Joveria Farooqi, Anuradha Chowdhary, Nelesh P. Govender, Arnaldo Lopes Colombo, Belinda Calvo, Christina A. Cuomo, Christopher A. Desjardins, Elizabeth L. Berkow, Mariana Castanheira, Rindidzani E. Magobo, Kauser Jabeen, Rana J. Asghar, Jacques F. Meis, Brendan Jackson, Tom Chiller, and Anastasia P. Litvintseva

1 Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia;

2 Broad Institute, MIT and Harvard, Cambridge, Massachusetts;

3 JMI Laboratories, North Liberty, Iowa;

4 Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, and

5 Centers for Disease Control and Prevention Field Epidemiology and Laboratory Training Program, Islamabad, Pakistan;

6 Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, India;

7 National Institute for Communicable Diseases–Centre for Opportunistic, Tropical and Hospital Infections, a Division of the National Health Laboratory Service, Johannesburg, South Africa;

8 Division of Infectious Diseases, Federal University of São Paulo–UNIFESP, Brazil;

9 Department of Infectious Diseases, School of Medicine, Universidad del Zulia, Maracaibo, Venezuela;

10 Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, and

11 Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands


Candida auris, a multidrug-resistant yeast that causes invasive infections, was first described in 2009 in Japan and has since been reported from several countries.


To understand the global emergence and epidemiology of C. auris, we obtained isolates from 54 patients with C. auris infection from Pakistan, India, South Africa, and Venezuela during 2012–2015 and the type specimen from Japan. Patient information was available for 41 of the isolates. We conducted antifungal susceptibility testing and whole-genome sequencing (WGS).


Available clinical information revealed that 41% of patients had diabetes mellitus, 51% had undergone recent surgery, 73% had a central venous catheter, and 41% were receiving systemic antifungal therapy when C. auris was isolated. The median time from admission to infection was 19 days (interquartile range, 9–36 days), 61% of patients had bloodstream infection, and 59% died. Using stringent break points, 93% of isolates were resistant to fluconazole, 35% to amphotericin B, and 7% to echinocandins; 41% were resistant to 2 antifungal classes and 4% were resistant to 3 classes. WGS demonstrated that isolates were grouped into unique clades by geographic region. Clades were separated by thousands of single-nucleotide polymorphisms, but within each clade isolates were clonal. Different mutations in ERG11 were associated with azole resistance in each geographic clade.


C. auris is an emerging healthcare-associated pathogen associated with high mortality. Treatment options are limited, due to antifungal resistance. WGS analysis suggests nearly simultaneous, and recent, independent emergence of different clonal populations on 3 continents. Risk factors and transmission mechanisms need to be elucidated to guide control measures.


January 12, 2017 at 6:19 pm

Editorial – Emergence of Candida auris  An International Call to Arms

Clinical Infectious Diseases January 15, 2017 V.64 N.2 P.141-143

Cornelius J. Clancy and M. Hong Nguyen

1 Department of Medicine, University of Pittsburgh,

2 VA Pittsburgh Healthcare System, and

3 University of Pittsburgh Medical Center, Pennsylvania

On June 24, 2016, the Centers for Disease Control and Prevention (CDC) issued an extraordinary alert, advising US healthcare facilities “to be on the lookout for Candida auris in patients” [1]. The alert noted that C. auris infections had been identified in several countries since 2009. Although cases have not been described in the United States, CDC reported that a C. auris isolate from 2013 was detected during ongoing surveillance. Within a week, Public Health England (PHE) announced that C. auris was recovered from healthcare facilities in that country, and 1 hospital has been managing an outbreak involving more than 40 patients in an intensive care unit (ICU) since April 2015 [2]. The outbreak persisted despite regular patient screening, environmental decontamination, ward closure, and other enhanced infection control interventions [2]. In this issue of Clinical Infectious Diseases, Lockhart and colleagues describe the study that prompted the CDC alert [3].

Reports of C. auris infections have been published from Japan, South Korea, India, South Africa, Kuwait, and Venezuela, describing 45 patients with candidemia and 26 patients with other invasive diseases or colonization [4–11]. The earliest case to date was identified in retrospect by DNA sequencing of a Korean bloodstream isolate from 1996 [6]. These studies established salient features of C. auris invasive infections. Candida auris is typically misidentified by commercial API-20C or Vitek-2 systems (Table 1). Infections often occur as part of nosocomial outbreaks. Patients range from neonates to the elderly and have well-recognized risk factors for invasive candidiasis. A large majority of isolates are fluconazole resistant, and amphotericin B and echinocandin resistance rates are approximately 30%–40% and approximately 5%–10%, respectively…


January 12, 2017 at 6:16 pm

Visceral leishmaniasis in immunocompromised diagnostic and therapeutic approach and evaluation of the recently released IDSA guidelines.

Infez Med. 2016 Dec 1;24(4):265-271.

Pagliano P, Ascione T, Di Flumeri G, Boccia G, De Caro F.

Visceral Leishmaniasis (VL) is a chronic infectious disease endemic in tropical and sub-tropical areas including the Mediterranean basin, caused by a group of protozoan parasites of the genus Leishmania and transmitted by phlebotomine sandflies.

Typically, VL is classified as a zoonotic infection when Leishmania infantum is the causative agent and as an anthroponotic one when L. donovani is the causative agent. Immunocompromised patients, in particular HIV positive, are considered at risk of VL.

They may present atypical signs and poor response to the treatment due to a compromission of T-helper and regulatory cells activity. Also pregnancy can be considered a condition predisposing to Leishmania reactivation and to the changes in immune response, due to a switch toward a Th2 response reported in this condition of the life.

Laboratory diagnosis is based on microscopy for parasites detection on bone-marrow or spleen aspirates. Value of serology remains high in term of sensibility, but a positive test has to be confirmed by microscopy or molecular tests.

Hypergammaglobulinemia and pancytopenia are the main alteration identified by blood examination. Treatment is based on use of liposomal amphotericin B (L-AmB) whose administration is associated to lower incidence of side effects, in respect to antimonials and other formulations of AmB. Use of Miltefosine needs further investigation when L. infantum is the causative agent. Relapses to treatment are observed in coinfected HIV patients. They can benefit of a second cycle, but cumulative efficacy of the treatment can be low.


January 12, 2017 at 9:02 am


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