Background:After diagnosis, a substantial number of people with HIV disease fall out of care. Effective interventions are needed for this priority population.Methods:The “Peers Keep It Real” study aimed to help adults who were disengaged from HIV treatment. Peers, lay individuals living with HIV, facilitated intervention sessions. Participants were randomized to immediately receive the peer-facilitated intervention or were wait-listed.Results:Considerable attrition occurred in the control group. Pre-/postanalyses showed that among participants (n = 23) who received the intervention, 65% had viral load suppression and 100% remained in care at 12 months postintervention. Impact on viral load was significant (P = .0326), suggesting that peers are effective change agents who positively impacted outcomes for individuals struggling with adherence to HIV treatment.Conclusion:Future endeavors should consider providing all individuals from this priority population with an active peer intervention from the onset to enhance retention and adherence.

A Brucella isolate was identified from purulent material collected during a hip surgery. Two previous blood cultures from the same patient yielded Ochrobactrum anthropi. After rRNA sequencing, all the isolates were identified as Brucella species and subsequently serotyped as Brucella suis. Misidentification of Brucella species remains a problem with bacterial identification systems. CASE REPORTA 62-year-old female presented to the emergency department with left hip pain and was unable to bear weight on that hip. The day before presentation she had fallen while standing up from a sitting position. On presentation the patient was febrile (38.7°C) with a low white blood cell count of 4,300 cells/l. One set of blood cultures was obtained, but no antibiotics were given.The patient was admitted to the hospital for surgery to stabilize the impacted fracture with a pin. She continued to have a high temperature, and a second set of blood cultures was collected. The first blood culture became positive after 3 days of incubation, with a short, Gram-negative bacillus in the aerobic bottle only. This bacterium was identified as Ochrobactrum anthropi by the RapID NF Plus system (Remel, Lenexa, KS). The second blood culture remained negative after 7 days of incubation. Antibiotics were administered to the patient, and she was released from the hospital after a successful surgery that stabilized the femoral neck fracture. The patient was given 2 weeks of antibiotics as an outpatient.One month later, the patient was readmitted for severe abdominal pain. Despite the absence of subjective fever, chills, or sweats, her temperature was 38.6°C. Her white blood cell count was 3,100 cells/ml with 66% neutrophils. Two sets of blood cultures were obtained, and antibiotics were started. The fever resolved after 2 days. Four days after blood cultures were collected, a short, Gram-negative bacillus was detected in a single aerobic bottle and was also identified as Ochrobactrum anthropi by the RapID NF Plus system. Three other sets of blood cultures remained negative.Seven months later, the patient was again admitted to the hospital for a permanent repair of the femoral neck fracture.During surgery, purulent material was collected from inflammatory tissue around the screws and within the hip socket. Fluid analysis revealed chronic inflammation with 44,000 white blood cells/l. The Gram stain showed few neutrophils with no organisms. The bacterial culture was positive, with growth of small colonies on the sheep blood agar plate after 3 days of incubation. The Gram stain of the colonies was initially reported as corynebacterium-like bacteria with Gram-variable properties.The organism was not identified by the Vitek2 Gram-positive identification (GPI) card, and after review it was evaluated with the Vitek2 Gram-negative identification (GNI) card. The Vitek2 GNI card identified the isolate as Brucella melitensis with a 97% probability. After this identification, the two earlier blood culture isolates were reevaluated. The isolates that were ident...

Background Histoplasmosis is an endemic fungal disease with diverse clinical presentations. Histoplasmosis-associated hemophagocytic lymphohistiocytosis (HLH) is a rare disorder with limited data regarding treatment and outcome. We described the clinical features, treatment, and outcomes of five patients in our institution with histoplasmosis-associated HLH. This review also summarizes the current literature about presentation, treatment, and outcome of this infection-related HLH entity. Methods We searched the electronic medical records for patients with histoplasmosis-associated HLH at our institution from 1/1/2006 to 9/30/2017. Diagnosis of HLH was confirmed by chart review using the HLH-04 criteria. We also searched the current literature for case reports and case series. Results Five cases of histoplasmosis-associated HLH were included from our institution. All five patients were diagnosed after 2010. The literature review yielded 60 additional cases of histoplasmosis-associated HLH. The most common underlying condition was HIV in 61% of cases. The majority of histoplasmosis patients (81%) were treated with amphotericin B formulations. Documented specific treatments for HLH were as follows: nine patients received steroids only, six patients received intravenous immunoglobulin (IVIG) only, three patients received dexamethasone and etoposide, two patients received etoposide, dexamethasone, and cyclosporine, two patients received steroids and IVIG, and one patient received Anakinra and IVIG. The inpatient case fatality rate was 31% with most of the deaths occurring within two weeks of hospital admission. Conclusions Histoplasmosis-associated HLH among adults is an uncommon but serious complication with high associated mortality. Early antifungal therapy with a lipid formulation amphotericin B is critical. The initiation of immunosuppressive therapy with regimens like HLH-04 in this disease entity should be individualized.

Background: The association between vancomycin trough (VT) and acute kidney injury (AKI) at the recommended doses remains controversial. Methods: The authors conducted a retrospective, observational cohort study of 500 adult patients who received vancomycin for ≥72 h. Data collected included 2 main predictors: average VT (including only VTs before the occurrence of AKI), first VT and other possible risk factors for AKI. The baseline characteristics/variables between patients with AKI and patients with no AKI were compared. Logistic regression models were used to develop multivariate models. The authors divided the patients into 4 subgroups: (1) VT <10, (2) 10 ≤ VT < 15, (3) 15 ≤ VT < 20 and (4) VT ≥20 µg/ml. All subgroups were compared to subgroup 2 (reference group). Results: AKI occurred in 12.85% of patients while on vancomycin. The incidence of AKI in subgroups 1-4 was 8.02, 13.61, 13.70 and 31.82%, respectively, using the first VT, that is significantly higher in subgroup 4. Using average VT, AKI incidence was 5, 10.38, 19.01 and 25.58%, respectively, that is significantly higher in subgroups 3 and 4. On multivariate logistic regression, average VT, first VT, average VT >15, first VT >15, methicillin-resistant Staphylococcus aureus infection and morbid obesity were significantly associated with increased incidence of AKI. Conclusion: Clinicians should be careful when aiming for a VT >15 μg/ml as this is associated with increased incidence of AKI.