c CASE On his 23rd day of life (DOL), a baby boy was transferred to our medical center from a community emergency department for treatment and management of presumed neonatal sepsis and meningitis.He was born full term via normal spontaneous vaginal delivery. His mother was primigravida with no medical complications during her pregnancy. Her prenatal lab results were negative for group B streptococci (GBS) at 36 weeks of gestation, and testing for HIV, syphilis, gonorrhea, chlamydia, and hepatitis B and C was negative. She reported no history of herpes simplex virus (HSV) infection, and no genital lesions were noted on examination. She did not recall having any fever or influenza-like symptoms at any point during her pregnancy. The baby emerged vigorous, was discharged after 2 days in the hospital, was exclusively breastfed, and regained his birth weight by DOL 14.One day prior to his admission on DOL 22, the patient developed a tactile fever, decreased feeding, and fussiness. He was taken to his outpatient pediatrician, who noted an afebrile, well-appearing baby. The baby was given acetaminophen and discharged from the clinic. Over the subsequent night, the patient became fussier and again had tactile fevers. His mother then took him to an emergency department, where he was found to be irritable, tachycardic, and febrile to 39.2°C. No other abnormal examination findings were identified.Blood and cerebrospinal fluid (CSF; obtained by lumbar puncture [LP]) were collected prior to administration of antimicrobials and submitted for culture and laboratory studies (Table 1). His initial CSF was significant for a pleocytosis, as well as abnormally elevated protein (143 mg/dl) and low glucose (16 mg/dl), highly suggestive of bacterial meningitis. The patient was empirically started on intravenous ampicillin (300 mg/kg/day, 4 divided doses), gentamicin (7.5 mg/kg/day, 3 divided doses), and acyclovir (60 mg/kg/day, 3 divided doses) and transferred to our medical center. Upon arrival, he was fussy but afebrile. As the Gram stain was negative for a causative organism, his gentamicin was exchanged for cefotaxime (300 mg/kg/day, 4 divided doses) for more complete empirical Gram-negative coverage and he was continued on ampicillin for empirical treatment of GBS and Listeria, as well as on acyclovir for HSV. Magnetic resonance imaging with contrast of his brain was performed on DOL 24, and mild enhancement of the leptomeninges was noted without any other findings such as abscess or infarction.Blood cultures and CSF cultures remained negative at the community medical center, and an HSV CSF PCR assay was also negative. Repeat blood cultures and CSF were collected on DOL 25. One aerobic blood culture bottle (BD Bactec Peds Plus/F) was collected and incubated in the Bactec automated blood culture system (Becton Dickinson, Franklin Lakes, NJ, USA), and no growth was detected after 5 days. Gram staining of the CSF revealed many white blood cells and no organisms. The specimen was inoculated onto 5% sheep blood agar (blood agar plate...

Answer: c. Listeria species are intrinsically resistant to several classes of antibiotics, including broad-spectrum cephalosporins, first-generation quinolones, fosfomycin, and monobactams. Recognizing the intrinsic resistance to broad-spectrum cephalosporins is clinically important, as they are commonly employed to empirically treat sepsis and meningitis of unknown etiology. The mechanism associated with cephalosporin resistance in Listeria spp. is complex and is thought to be secondary to unique penicillin binding protein 3 in the cytoplasmic membrane, which is the primary target for other beta-lactams but does not bind well to cephalosporins. TAKE-HOME POINTS• The constellation of low glucose in the CSF, high protein, and pleocytosis is highly suggestive of bacterial meningitis, even in the absence of a positive culture, and warrants empirical treatment.• L. monocytogenes is a Gram-positive, rod-shaped bacterium that is a rare but recognized cause of bacterial meningitis, particularly in neonates and the immunocompromised. It can be particularly challenging to isolate by culture.• New molecular technologies are available that can rapidly and accurately detect a broad spectrum of pathogens directly in CSF specimens and can be particularly useful in providing definitive etiology when organisms are uncultivable because of a fastidious nature or exposure to antimicrobials prior to lumbar puncture. These novel technologies can be used to augment traditional culture and other techniques for the diagnosis of infections of the central nervous system.

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Background Respiratory syncytial virus (RSV) infection causes substantial morbidity and mortality in children and adults. Socioeconomic status (SES) is known to influence many health outcomes, but there have been few studies of the relationship between RSV-associated illness and SES, particularly in adults. Understanding this association is important in order to identify and address disparities and to prioritize resources for prevention. Methods Adults hospitalized with a laboratory-confirmed RSV infection were identified through population-based surveillance at multiple sites in the U.S. The incidence of RSV-associated hospitalizations was calculated by census-tract (CT) poverty and crowding, adjusted for age. Log binomial regression was used to evaluate the association between Intensive Care Unit (ICU) admission or death and CT poverty and crowding. Results Among the 1713 cases, RSV-associated hospitalization correlated with increased CT level poverty and crowding. The incidence rate of RSV-associated hospitalization was 2.58 (CI 2.23, 2.98) times higher in CTs with the highest as compared to the lowest percentages of individuals living below the poverty level (≥ 20 and < 5%, respectively). The incidence rate of RSV-associated hospitalization was 1.52 (CI 1.33, 1.73) times higher in CTs with the highest as compared to the lowest levels of crowding (≥5 and < 1% of households with > 1 occupant/room, respectively). Neither CT level poverty nor crowding had a correlation with ICU admission or death. Conclusions Poverty and crowding at CT level were associated with increased incidence of RSV-associated hospitalization, but not with more severe RSV disease. Efforts to reduce the incidence of RSV disease should consider SES.

Context: Alameda County, California, is a high tuberculosis (TB) burden county that reported a TB incidence rate of 8.1 per 100 000 during 2017. It is the only high TB burden California county that does not have a public health-funded TB clinic. Objective: To describe TB public health expenditures and clinical and social complexities of TB case-patients. Design, Setting, and Participants: Public health surveillance of confirmed and possible TB case-patients reported to Alameda County Public Health Department during July 1, 2017, to December 31, 2017. Social complexity status was categorized for all case-patients using surveillance data; clinical complexity status, either by surveillance definition or by the Charlson Comorbidity Index (CCI), was categorized only for confirmed TB case-patients. Main Outcome Measures: Total public health and per patient expenditures were stratified by insurance status. Cohen's kappa assessed concordance between clinical complexity definitions. All comparisons were conducted using Fisher's exact or Kruskal-Wallis tests. Results: Of 81 case-patients reported, 68 (84%) had confirmed TB, 29 (36%) were socially complex, and 15 (19%) were uninsured. Total public health expenditures were $487 194, and 18% of expenditures were in nonlabor domains, 57% of which were for TB treatment, diagnostics, and insurance, with insured patients also incurring such expenditures. Median per patient expenditures were significantly higher for uninsured and government-insured patients than for privately insured patients ($7007 and $5045 vs $3704; P = .03). Among confirmed TB case-patients, 72% were clinically complex by surveillance definition and 53% by the CCI; concordance between definitions was poor (κ = 0.25; 95% confidence interval, 0.03-0.46). Conclusions: Total public health expenditures approached $500 000. Most case-patients were clinically complex, and about 20% were uninsured. While expenditures were higher for uninsured case-patients, insured case-patients still incurred TB treatment, diagnostic, and insurance-related expenditures. State and local health departments may be able to use our expenditure estimates by insurance status and description of clinically complex TB case-patients to inform efforts to allocate and secure adequate funding.