BACKGROUND Heart transplant (HT) recipients are at risk for invasive fungal disease (IFD), a morbid and potentially fatal complication. METHODS We performed a retrospective cohort study to evaluate the incidence and risk factors for IFD in HT recipients from 1995 to 2012 at a single center. IFD cases were classified as proven or probable IFD according to current consensus definitions of the European Organization for Research and Treatment of Cancer/Mycoses Study Group. We calculated IFD incidence rates and used Cox proportional hazards models to determine IFD risk factors. RESULTS Three hundred sixty patients underwent HT during the study period. The most common indications were dilated (39%) and ischemic (37%) cardiomyopathy. There were 23 (6.4%) cases of proven (21) or probable (2) IFD, for a cumulative incidence rate of 1.23 per 100 person-years (95% CI 0.78 to 1.84). Candida (11) and Aspergillus (5) were the most common etiologic fungi. Thirteen cases (56%) occurred within 3 months of HT, with a 3-month incidence of 3.8% (95% CI 2.2 to 6.4). Delayed chest closure (HR 3.3, 95% CI 1.4 to 7.6, p = 0.01) and the addition of OKT3, anti-thymocyte globulin or daclizumab to standard corticosteroid induction therapy (HR 2.7, 95% CI 1.1 to 6.2, p = 0.02) were independently associated with an increased risk of IFD. CONCLUSIONS IFD incidence was greatest within the first 3 months post-HT, largely reflecting early surgical-site and nosocomial Candida and Aspergillus infections. Patients receiving additional induction immunosuppression or delayed chest closure were at increased risk for IFD. Peri-transplant anti-fungal prophylaxis should be considered in this subset of HT recipients.

cWe report a patient with relapsed acute myelogenous leukemia after allogeneic stem cell transplantation who developed disseminated mucormycosis due to Rhizomucor pusillus/R. miehei involving lung, brain, and skin. After failing posaconazole and being intolerant to amphotericin, he was treated effectively with isavuconazole for over 6 months despite ongoing treatment for relapsed leukemia. CASE REPORTA 59-year-old male construction worker, with a history of coronary artery disease, was diagnosed with myelodysplastic syndrome (MDS) and underwent reduced-intensity HLAmatched related allogeneic hematopoietic stem cell transplantation (HSCT) in October 2008. In July 2009 (9 months later), a bone marrow biopsy specimen demonstrated MDS relapse and progression to acute myelogenous leukemia (AML), which persisted despite tapering of immunosuppression and donor-lymphocyte infusion.In August 2009, he presented to the emergency room with left upper quadrant and shoulder pain, diaphoresis, and fevers. A chest X-ray demonstrated a left lower lobe infiltrate. He was admitted to the hospital and started on ceftazidime for suspected bacterial pneumonia. His leukocyte count was 36,000/l with 14% blasts and an absolute neutrophil count of 11,500/l. The patient underwent bronchoalveolar lavage, but no bacteria or fungi grew in culture. Serum galactomannan and (1¡3)-␤-D-glucan results were also negative. He was started on hydroxyurea and reinduction chemotherapy with cytarabine and daunorubicin after bone marrow biopsy confirmed progressive AML.His hospital course was complicated by neutropenia, mucositis, persistent fevers, and pain and redness at his central venous catheter site. The catheter was removed and empirical treatment with vancomycin and micafungin was initiated a week after admission.Ten days after admission, a chest computed tomography (CT) scan revealed a left-sided pleural effusion, scattered areas of nodular consolidation with adjacent ground glass in the right lower lobe, and bilateral ground-glass abnormalities. The patient developed altered mental status and facial droop 18 days after admission. A head CT was normal. A subsequent brain magnetic resonance imaging (MRI) procedure demonstrated multiple foci of restricted diffusion compatible with acute ischemia or embolic events.The patient developed violaceus nodular plaques on his face, scalp, posterior neck, and middle and upper back 2 weeks after admission. A skin biopsy was performed and revealed hyphal forms suggestive of mucormycosis within and outside dermal vessels on hematoxylin-eosin stain. Skin biopsy cultures were negative. Three weeks after admission, treatment with liposomal amphotericin (LAmB) (5 mg/kg of body weight) once daily was started. Improvement was noted, with a decrease in the size of the skin lesions and partial improvement in mental status.The patient received treatment with LAmB for 4 weeks. The infecting species was identified as Rhizomucor pusillus/R. miehei by DNA sequencing performed on formalin-fixed, paraffin-embedded skin biopsy...

PURPOSE Patients with cancer are at increased risk for unfavorable outcomes from COVID-19. Knowledge about the outcome determinants of severe acute respiratory syndrome coronavirus 2 infection in this population is essential for risk stratification and definition of appropriate management. Our objective was to evaluate prognostic factors for all-cause mortality in patients diagnosed with both cancer and COVID-19. METHODS All consecutive patients with cancer hospitalized at our institution with COVID-19 were included. Electronic medical records were reviewed for clinical and laboratory characteristics potentially associated with outcomes. RESULTS Five hundred seventy-six consecutive patients with cancer and COVID-19 were included in the present study. An overall in-hospital mortality rate of 49.3% was demonstrated. Clinical factors associated with increased risk of death because of COVID-19 were age over 65 years, Eastern Cooperative Oncology Group performance status > 0 zero, best supportive care, primary lung cancer, and the presence of lung metastases. Laboratory findings associated with a higher risk of unfavorable outcomes were neutrophilia, lymphopenia, and elevated levels of D-dimer, creatinine, C-reactive protein, or AST. CONCLUSION A high mortality rate in patients with cancer who were diagnosed with COVID-19 was demonstrated in the present study, emphasizing the need for close surveillance in this group of patients, especially in those with unfavorable prognostic characteristics.

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OBJECTIVE To reduce transmission of carbapenem-resistant Enterobacteriaceae (CRE) in an intensive care unit with interventions based on simulations by a developed mathematical model. DESIGN Before-after trial with a 44-week baseline period and 24-week intervention period. SETTING Medical intensive care unit of a tertiary care teaching hospital. PARTICIPANTS All patients admitted to the unit. METHODS We developed a model of transmission of CRE in an intensive care unit and measured all necessary parameters for the model input. Goals of compliance with hand hygiene and with isolation precautions were established on the basis of the simulations and an intervention was focused on reaching those metrics as goals. Weekly auditing and giving feedback were conducted. RESULTS The goals for compliance with hand hygiene and contact precautions were reached on the third week of the intervention period. During the baseline period, the calculated R0 was 11; the median prevalence of patients colonized by CRE in the unit was 33%, and 3 times it exceeded 50%. In the intervention period, the median prevalence of colonized CRE patients went to 21%, with a median weekly Rn of 0.42 (range, 0-2.1). CONCLUSIONS The simulations helped establish and achieve specific goals to control the high prevalence rates of CRE and reduce CRE transmission within the unit. The model was able to predict the observed outcomes. To our knowledge, this is the first study in infection control to measure most variables of a model in real life and to apply the model as a decision support tool for intervention. Infect Control Hosp Epidemiol 2016;1-8.