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A multicenter, case-control study was conducted to assess risk factors and patient outcomes from bacteremia due to Enterobacteriaceae producing extended-spectrum β-lactamases (ESBL) and Klebsiella pneumoniae carbapenemases (KPCs). One hundred five and 20 patients with bacteremia due to ESBL and KPC-producing organisms were matched to controls that had bacteremia with non-ESBL/KPC-producing organisms, respectively. Independent risk factors for ESBL production included admission from a nursing home (odds ratio [OR], 4.64; 95% confidence interval [CI], 2.64–8.16), chronic renal failure (OR, 2.09; 95% CI, 1.11–3.92), the presence of a gastrostomy tube (OR, 3.36; 95% CI, 1.38–8.18), length of hospital stay before infection (OR, 1.02; 95% CI, 1.01–1.03), transplant recipients (OR, 2.48; 95% CI, 1.24–4.95) and receipt of antibiotics with Gram-negative activity in the preceding 30 days (OR, 1.76; 95% CI, 1.00–3.08). 28-day crude mortality rates for patients infected with ESBL or KPC-producing organisms and controls were 29.1% (34/117) and 19.5% (53/272), respectively (OR 1.70; 95% CI 1.04–2.80). On multivariate analysis, inadequate empiric therapy (OR, 2.26; 95% CI, 1.18–4.34), onset of bacteremia while in ICU (OR, 2.74; 95% CI, 1.47–5.11), Apache II score (OR, 1.17; 95% CI, 1.12–1.23), and malignancy (OR, 2.66; 95% CI, 1.31–5.41) were independent risk factors for mortality. CTX-M was the most common ESBL type in E. coli, whereas SHV predominated in Klebsiella spp. and Enterobacter spp.

Although Legionnaires' disease occurs more commonly in patients with some degree of immunosuppression (diabetes, chronic lung disease, end stage renal disease, cancer, etc.), it has been infrequently described in patients infected with human immunodeficiency virus (HIV) and AIDS. Some studies suggest that pneumonia caused by Legionella tends to present with more severe clinical features and complications in the HIV-infected population. The use of antibiotic prophylaxis or the association of severe pneumonia with other pathogens may account for under diagnosis of the disease. We diagnosed five cases of Legionella pneumonia in patients with HIV infection at our institution during a 1-year period. The cases seen ranged in severity, regardless of the CD4(+) counts of the patients. Based on our observations, it seems impossible to discern whether HIV infection is an additional risk factor for Legionnaires' disease. We describe those five cases and review the available literature.

SUMMARYThe majority of infections caused by R. equi occur in hosts with some degree of cell-mediated immunodeficiency. Immunocompetent individuals are infrequently affected and usually present with localized disease. Infections of the skin or related structures are uncommon and are usually related to environmental contamination. The microbiology laboratory plays a key role in the identification of the organism since it may be mistaken for common skin flora. We describe a 31 year-old woman without medical problems who presented nine weeks after breast reduction with right breast cellulitis and purulent drainage from the surgical wound. She underwent incision and drainage, and cultures of the wound yielded Rhodococcus equi. The patient completed six weeks of antimicrobial therapy with moxifloxacin and rifampin with complete resolution.

INTRODUCTION: Cryptococcus neoformans and Coccidioides immitis are important opportunistic mycoses. C. neoformans is widely found in soil and bird droppings while C. immitis is endemic to the southwestern US. These infections behave more aggressively in immunocompromised hosts and may present as pulmonary nodules mimicking malignancy. We present a case of a pulmonary nodule revealing coinfection with both mycoses. CASE PRESENTATION:A 47-year-old male was brought to the ED due to erratic behavior. He was hemodynamically stable, but had choreoathetoid movements, lip smacking and garbled speech. He had a history of polysubstance abuse, baseline chorea of unknown etiology, and HIV not on ART. He was on vacation from California. Initial chemistries were normal. UDS was positive for amphetamines and methamphetamines. CT brain showed global cerebral atrophy. RPR was positive. Due to concern for CNS infection, LP was performed. Opening pressure and CSF studies were normal. MRI revealed global and caudate atrophy concerning for neurodegenerative disease. On hospital day 2, the patient was febrile to 102.7 degrees F with associated nonproductive cough. CXR revealed pneumonic consolidation in the LLL and a well-defined RLL nodule. Broad spectrum antibiotics were initiated. Chest CT confirmed a pleural based mass measuring 2.4x2.2 cm concerning for malignancy. CT guided lung biopsy revealed benign pulmonary parenchyma with extensive necrosis. GMS stain was positive for two morphologically distinct fungal species consistent with C. immitis and C. neoformans coinfection. Oral fluconazole was initiated with improvement in his clinical condition. His chorea and speech improved throughout his hospitalization. Underlying Huntington's disease exacerbated by amphetamine use was suspected.DISCUSSION: Pulmonary cryptococcosis is rare, representing 20% of pulmonary fungal infections. In immunocompetent hosts, it may present as a consolidation, reticulonodular process, or lung mass that mimics cancer. In those with altered immune function, it may establish latent infection through persistence within granulomas or may cause disseminated disease, such as meningitis. Similarly, C. immitis usually causes a severe pneumonia and may cause disseminated disease in immunocompromised patients. In non-immunocompromised patients, coccidiomycosis presents similarly to bacterial CAP with cough, fever and a consolidation on CXR (75%). However, thoracic manifestations are variable and include nodules, cavities, and peribronchial thickening. Pulmonary nodules caused by both fungal species may be positive on FDG-PET imaging, further mimicking malignancy. CONCLUSIONS: Our literature review returned no prior reports of pulmonary coinfection C. neoformans and C. immitis. We postulate that such a coinfection occurred due impaired host immune function and geographic prevalence of both organisms.