BACKGROUND: Tocilizumab, an IL-6 receptor antagonist, can be used to treat cytokine release syndrome (CRS), with observed improvements in a coronavirus disease 2019 (COVID-19) case series. RESEARCH QUESTION: The goal of this study was to determine if tocilizumab benefits patients hospitalized with COVID-19.

Peritoneal tuberculosis (TB) is one of the most challenging forms of extrapulmonary tuberculosis to diagnose. This challenge can be compounded in low incidence regions, and in patients with cirrhosis in whom the presence of ascites alone may not prompt further investigation. A delay in the diagnosis and treatment of peritoneal tuberculosis may lead to worse clinical outcomes. This case describes a 64-year-old Italian male with decompensated cirrhosis being evaluated for liver transplantation, who developed abdominal pain and a persistent inflammatory ascites with peritoneal thickening despite antibiotic therapy. Peritoneal tuberculosis was suspected, although non-invasive and invasive direct mycobacterial testing remained negative. A constellation of positive QuantiFERON-TB Gold In-Tube test, elevated ascitic adenosine deaminase and dramatic symptomatic and radiographic response to empiric anti-tuberculous therapy confirmed the diagnosis of peritoneal tuberculosis. This paper will review the approach to the diagnosis of peritoneal tuberculosis.

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Background: Vancomycin-resistant Enterococcus (VRE)-colonized liver transplantation (LT) recipients have increased post-LT morbidity, mortality, and higher rates of VRE infections compared with their non-colonized counterparts. Pre-LT screening for VRE colonization and inclusion of daptomycin in the perioperative antibiotic prophylaxis regimen may mitigate this risk. Methods: We performed a retrospective chart review of liver transplant recipients aged ≥ 18 years between 2013 and August 2019 to identify pre-LT VRE-colonized recipients and whether they received daptomycin perioperative prophylaxis (DPP). Demographic and clinical characteristics, including risk factors for VRE infection, were collected. Outcomes measured were VRE-related infection and all-cause mortality within 90 days of LT. Results: Of the 27 VRE-colonized liver transplant recipients within the study period, 25 received DPP. All recipients were admitted to the intensive care unit postoperatively, six (24%) required reoperation, fifteen (60%) required renal replacement therapy, and eight (32%) experienced postoperative hemorrhage within 90 days posttransplant. Two recipients (8%) experienced acute cellular rejection, but no primary graft failure was seen within 90 days. Among those who received DPP, no infections related to VRE or death was seen within 90 days of LT. The two VRE-colonized recipients who did not receive DPP both developed VRE bacteremia in the early post-LT period. Conclusion: Despite having multiple risk factors for post-LT VRE infection, VREcolonized recipients who received DPP did not develop VRE-related infections in the first 90 days post-LT. Our experience demonstrates that pre-LT VRE screening and DPP may be associated with a reduction in VRE infection in the early post-LT period, but this strategy warrants further evaluation in prospective studies. K E Y W O R D S daptomycin, perioperative prophylaxis, vancomycin-resistant Enterococcus

During the COVID-19 pandemic, the antimicrobial stewardship module in our electronic medical record was reconfigured for the management of COVID-19 patients. This change allowed our subspecialist providers to review charts quickly to optimize potential therapy and management during the patient surge.

Human immunodeficiency virus (HIV) infection remains a global pandemic. The primary driver of HIV incidence is sexual transmission between serodifferent individuals. Condoms, when used consistently and correctly, are effective at preventing sexually transmitted HIV infections and are considered an integral component of a comprehensive approach to HIV prevention. However, the demonstrated effectiveness of antiretroviral therapy (ART) to prevent HIV transmission, known as treatment as prevention and of pre-exposure prophylaxis, have raised an intriguing dilemma on the necessity and additive preventive benefit of condom use among individuals in serodifferent relationships utilizing these prevention strategies. Recent published evidence, although of limited follow-up duration, has shown no linked HIV transmissions with condomless sex among serodifferent couples where the infected partner was on ART and virologically suppressed. This paper will review the evidence surrounding HIV transmission risk among serodifferent couples with and without the use of condoms and will highlight factors that increase or attenuate this risk. It will also address the important benefits that condomless sex offers couples. This paper aims to provide a template for providers to have personalized discussions with their patients, particularly those with an HIV-positive sexual partner, around their individual risk of HIV transmission and the role of condom use.

The incubation period of SARS-CoV-2 is rarely greater than 14 days. We report a patient with hypogammaglobulinemia who developed SARS-CoV-2 infection with a confirmed incubation period of at least 21 days. These findings raise concern for a prolonged presymptomatic transmission phase, necessitating a longer quarantine duration in this patient population.

Background Pneumocystis jiroveciii is an opportunistic fungus that causes Pneumocystis pneumonia (PCP) in immunocompromised hosts. Over an 11-month period, we observed a rise in cases of PCP among kidney-transplant recipients (KTR), prompting an outbreak investigation. Methods Clinical and epidemiologic data were collected for KTR diagnosed with PCP between July 2019 and May 2020. Pneumocystis strain typing was performed using restriction fragment length polymorphism analyses and multilocus sequence typing in combination with next-generation sequencing. A transmission map was drawn, and a case-control analysis was performed to determine risk factors associated with PCP. Results Nineteen cases of PCP in KTR were diagnosed at a median of 79 months post-transplantation; eight received monthly belatacept infusions. Baseline characteristics were similar for KTR on belatacept versus other regimens; the number of clinic visits was numerically higher for the belatacept group during the study period (median 7.5 vs 3). Molecular typing of respiratory specimens from nine patients revealed coinfection with up to seven P. jirovecii strains per patient. A transmission map suggested multiple clusters of interhuman transmission. In a case-control univariate analysis, belatacept, lower absolute lymphocyte count, non-White race, and more transplant clinic visits were associated with an increased risk of PCP. In multivariate and prediction power estimate analyses, frequent clinic visits was the strongest risk factor for PCP. Conclusion Increased clinic exposure appeared to facilitate multiple clusters of nosocomial PCP transmission among KTR. Belatacept was a risk factor for PCP, possibly by increasing clinic exposure through the need for frequent visits for monthly infusions.