Background. The occurrence of community-associated infections due to extended-spectrum β-lactamase (ESBL)-producing Escherichia coli has been recognized as a major clinical problem in Europe and other regions. Methods. We conducted a prospective observational study to examine the occurrence of community-associated infections due to ESBL-producing E. coli at centers in the United States. Five academic and community hospitals and their affiliated clinics participated in this study in 2009 and 2010. Sites of acquisition of the organisms (community-associated or healthcare-associated), risk factors, and clinical outcome were investigated. Screening for the global epidemic sequence type (ST) 131 and determination of the ESBL types was conducted by polymerase chain reaction and sequencing. Results. Of the 291 patients infected or colonized with ESBL-producing E. coli as outpatients or within 48 hours of hospitalization, 107 (36.8%) had community-associated infection (81.5% of which represented urinary tract infection), while the remainder had healthcare-associated infection. Independent risk factors for healthcare-associated infection over community-associated infection were the presence of cardiovascular disease, chronic renal failure, dementia, solid organ malignancy, and hospitalization within the previous 12 months. Of the community-associated infections, 54.2% were caused by the globally epidemic ST131 strain, and 91.3% of the isolates produced CTX-M-type ESBL. Conclusions. A substantial portion of community-onset, ESBL-producing E. coli infections now occur among patients without discernible healthcare-associated risk factors in the United States. This epidemiologic shift has implications for the empiric management of community-associated infection when involvement of E. coli is suspected.

As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

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We investigated the clinical and microbiologic features of 300 cases of cephalosporin-resistant Escherichia coli producing extended-spectrum ␤-lactamase (ESBL) or plasmid-mediated AmpC ␤-lactamase (pAmpC) at three medical centers in the United States. Solid-organ malignancy, connective tissue disease, and a recent history of surgery were more common among pAmpCproducing cases (n ‫؍‬ 49), whereas urinary catheter at enrollment, diabetes, and hospitalization in the past year were more common among ESBL-producing cases (n ‫؍‬ 233). .7%), followed by SHV-and TEM-type ESBLs (6.3 and 1.3%, respectively). Seven cases (2.3%) had KPC-type ␤-lactamase. Ertapenem, imipenem, meropenem, doripenem, piperacillin-tazobactam, amikacin, nitrofurantoin, and tigecycline were highly active, with greater than 90% of the isolates being susceptible. Cefepime was less active, with only 74.2% being susceptible due to the predominance of CTX-M-15. These findings have implications in the selection of appropriate empirical therapy when infection due to cephalosporin-resistant E. coli is suspected. C ephalosporin-resistant Escherichia coli producing extendedspectrum ␤-lactamase (ESBL) or plasmid-mediated AmpC ␤-lactamase (pAmpC) commonly occurs in health care settings as well as in the community (7, 11). The rising incidence of these organisms, coupled with their spread into nursing homes and the community, has implications for the empirical management of patients presenting with infections in which E. coli is suspected as the causative pathogen.CTX-M-type ESBLs are replacing the conventional TEM-and SHV-type ESBLs in E. coli worldwide (11, 13). While the United States initially appeared to be spared from this epidemic (1), it has subsequently been shown in surveillance and single-center studies that CTX-M-type ESBLs are becoming common in U.S. hospitals as well (8,9,12,17). In Pittsburgh, more than 70% of ESBLproducing E. coli strains isolated between 2007 and 2008 were found to produce CTX-M-type ESBLs (15).Infections due to pAmpC-producing E. coli are likely common but underrecognized due to the lack of standardized detection methods (16). The most commonly observed pAmpC in E. coli is the CMY type (7). In addition to penicillins, cephalosporins, and aztreonam, pAmpC-producing E. coli is often resistant to ␤-lactam-␤-lactamase inhibitor combinations as well.Given the paucity of clinical and microbiologic data regarding cephalosporin-resistant E. coli from the United States, we conducted this multicenter study to determine the risk factors for acquisition and predictors of clinical outcome associated with these organisms. In addition, we elucidated the epidemiology of the relevant ␤-lactamases and their correlation with antimicrobial susceptibility. MATERIALS AND METHODSPatients. Three medical centers participated in this study: the University of Pittsburgh Medical Center (Pittsburgh, PA), Henry Ford Hospital (Detroit, MI), and the University of Texas Health Science Center at San Antonio (San Antonio, TX). Ethical approval was obtained fro...

IntroductionToxoplasma gondii is an obligate intracellular protozoan that infects up to one-third of the world's population. Although this case is not the first of its kind, it is clinically important since it will help doctors keep a broad differential diagnosis in mind when attending to similar patients.Case presentationWe present the case of a 20-year-old man of Middle Eastern heritage presenting with only generalized lymphadenopathy who was diagnosed with acute toxoplasmosis.ConclusionThis case illustrates the important fact that toxoplasmosis can present with just simple lymphadenopathy, and thus can be confused with other infections such as Epstein-Barr virus and other mononucleosis-like illnesses such as cytomegalovirus, HIV with acute retroviral syndrome, cat scratch disease, leishmaniasis and syphilis. This case underlines why appropriate testing should be performed in confusing cases, and helps increase the knowledge about the diagnosis of this disease.