Objective: Transmission of SARS-CoV-2 has significant implications for hospital infection prevention and control, discharge management, and public health. We reviewed available literature to reach an evidenced-based consensus on the expected duration of viral shedding. Design: We queried four scholarly repositories/search engines for studies reporting SARS-CoV-2 viral shedding dynamics by PCR and/or culture available through September 8, 2020. We calculated the pooled median duration of viral RNA shedding from respiratory and fecal sources. Results: Seventy-seven studies on SARS-CoV-2 were included. All studies reported PCR-based testing and 12 also included viral culture data. The overall pooled median duration of RNA shedding from respiratory sources was 18.4 days (95% CI: 15.5 days - 21.3 days; I2=98.87%, p<0.01) among 28 studies. When stratified by disease severity, the pooled median duration of viral RNA shedding from respiratory sources was 19.8 days (95% CI: 16.2 days – 23.5 days; I2=96.42%, p<0.01) among severely ill patients and 17.2 days (95% CI: 14.0 days - 20.5 days; I2=95.64%, p<0.01) in mild/moderate illness. Viral RNA was detected up to 92 days after symptom onset. Viable virus was isolated by culture from -6 days to 20 days relative to symptom onset. Conclusions: SARS-COV-2 RNA shedding can be prolonged, yet high heterogeneity exists. Detection of viral RNA may not correlate with infectivity since available viral culture data suggests shorter durations of shedding of viable virus. Additional data is needed to determine the duration of shedding of viable virus and the implications for risk of transmission.

Background Isavuconazole (ISA) is an attractive candidate for primary mold-active prophylaxis in high-risk patients with hematologic malignancies or hematopoietic cell transplant (HCT) recipients. However, data supporting the use of ISA for primary prophylaxis in these patients are lacking. Methods We conducted a retrospective review of breakthrough invasive fungal infections (bIFIs) among adult hematologic malignancy patients and HCT recipients who received ≥7 days of ISA primary prophylaxis between 1 September 2016 and 30 September 2018. The incidence of bIFIs in patients receiving ISA was compared to those receiving posaconazole (POS) and voriconazole (VOR) during the same time period. Results One hundred forty-five patients received 197 courses of ISA prophylaxis. Twelve bIFIs (Aspergillus fumigatus [5], Aspergillus species [2], Mucorales [2], Fusarium species [2], and Candida glabrata [1]) occurred, representing 8.3% of patients and 6.1% of courses, after a median duration of 14 days of ISA prophylaxis. All bIFIs occurred during periods of neutropenia. Seven patients (58.3%) died within 42 days of onset of bIFI. In addition, bIFIs complicated 10.2% of ISA, 4.1% of POS, and 1.1% of VOR courses among patients with de novo or relapsed/refractory acute myeloid leukemia during the study period, with invasive pulmonary aspergillosis (IPA) complicating 6.8% of ISA, 1.3% of POS, and zero VOR courses. Conclusions Although ISA has been approved for treatment of invasive Aspergillus and mucormycosis, we observed an increased rate of bIFI, notably IPA, using ISA for primary prophylaxis. These results support the need for further study to determine the role of ISA as primary prophylaxis.

Respiratory virus infections (RVIs) are increasingly recognized as a cause of significant morbidity and mortality in recipients of hematologic stem cell transplant (HCT) and patients with hematologic malignancy (HM). 1,2 With now widespread use of molecular diagnostics, the epidemiology and spectrum of clinical disease of these infections can be better characterized. Apart from influenza, the currently available antivirals are limited in efficacy and/or associated with potential for toxicity, thus emphasizing the importance of prevention strategies. This article provides a review of the epidemiology, clinical characteristics, management, and prevention of RVIs in HCT recipients and HM patients.No disclosures. KEYWORDS Respiratory virus infection Hematopoietic stem cell transplant RSV Influenza Parainfluenza Human metapneumovirus Rhinovirus Coronavirus KEY POINTSThe morbidity and associated complications of respiratory virus infections are greater in hematopoietic stem cell transplant recipients and patients with hematologic malignancy than in immunocompetent individuals, with severity of illness related to the degree of immunosuppression. Molecular microbiologic testing is the gold standard for diagnosis, allowing differentiation of what are largely overlapping clinical syndromes. Most of the respiratory viruses, apart from influenza and in some circumstances respiratory syncytial virus and adenovirus, are managed supportively. Prevention is key and should focus on vaccination for influenza, avoidance of ill contacts, and compliance with principles of infection control.Infect Dis Clin N Am 33 (2019) 523-544 a Studies are a combination of PCR and traditional laboratory methods (eg, culture, direct fluorescent antibody, and enzyme immunoassay). b PCR-based studies. c Includes all-cause and attributable mortality with variable timeframe to death. d One mortality in a coinfected patient attributed to enterovirus/rhinovirus infection.

A 72-year-old Japanese male with a history of colorectal cancer with metastases to the liver and peritoneum presented to the emergency department with fever and abdominal pain and was subsequently found to have Gram-negative bacteremia. The patient had undergone numerous chemotherapy treatment courses since his diagnosis 18 months prior as well as a central hepatectomy with hepaticojejunostomy. One year after the resection, he developed recurrent ascending cholangitis from a biliary stricture with an associated bile leak, necessitating the placement of a biliary stent and percutaneous drain. Despite drain placement, he presented to the hospital several times with Gram-negative bacteremia, most frequently growing either Escherichia coli or Klebsiella pneumoniae. Prior to transfer of his care to our institution 1 month prior, he had been placed on rotating prophylactic antibiotics, including amoxicillin-clavulanic acid, ciprofloxacin, and trimethoprim-sulfamethoxazole. Vital signs on admission revealed a fever of 103.0°F, heart rate of 100 bpm, and a blood pressure of 96/64 mm Hg. On exam he was cachectic, lethargic, and diaphoretic. His respiratory exam was notable for rales in the left lower base, and he had rightupper-quadrant abdominal pain with deep palpation but did not have rebound tenderness. His biliary drain contained scant amounts of dark green bilious fluid, and the rest of his exam was unremarkable. The initial complete metabolic panel (CMP) revealed an elevated alkaline phosphatase of 763 U/liter, which was above his baseline of 200 to 300 U/liter. His white blood cell (WBC) count was 6.99 ϫ 10 3 cells/mm 3. A paracentesis was performed which was inconsistent with spontaneous bacterial peritonitis, noting only 11/mm 3 neutrophils. A computed tomography (CT) scan of his abdomen and pelvis with contrast revealed that the percutaneous biliary drain terminated in the hepaticojejunostomy and that the intrahepatic bile duct remained undrained, raising concern for possible obstruction. Two sets of bioMérieux BacT/Alert FN Anaerobic Plus and FA Aerobic Plus blood cultures were obtained. One of the two sets grew Gram-negative bacilli that could not be identified by our lab's Verigene Gram-negative blood culture panel. The sample was next tested using a Biofire Filmarray blood culture identification panel, which returned K. pneumoniae. The blood cultures were sent to our reference lab, Kaiser Permanente Northwest Regional Laboratory, which identified the pathogen as K. pneumoniae using a Vitek mass spectrometry matrix-assisted laser desorption/ionization time of flight (MALDI-TOF MS) instrument with version 2.0 software. An adonitol fermentation test was also performed on a Vitek 2 instrument running version 7.01 software, which was negative. These discordant results suggested that this could be a Klebsiella species other than K. pneumoniae. Our institution's probe for K. pneumoniae used with the Verigene panel does not cross-react with Klebsiella variicola and therefore returned the result "no molecular ID det...

Introduction Noroviral infection can lead to chronic diarrhea in solid organ transplant (SOT) recipients with significant morbidity and mortality. Existing literature has described a wide spectrum of illness and has not come to a consensus on the optimal management of this condition. Methods We undertook a retrospective review of all adult SOT recipients between 1/1/2018 and 12/31/2020 who were diagnosed with their first episode of noroviral diarrhea (NVD). Demographic, clinical interventions, and outcomes within 6 months of diagnosis were recorded. Patients’ outcomes were classified as either resolved, improved or persistent at 6 months. Results Seventy‐nine SOT recipients were included. Thirty‐eight patients (48%) had chronic diarrhea at baseline (CDB). Thirty‐two patients (40%) received nitazoxanide, 28 patients (35%) had their immunosuppression adjusted and seven patients (9%) received intravenous immunoglobulin. Diarrhea improved or resolved in 68 patients (85%). Improvement or resolution of diarrhea was observed in 98% of those who did not have history of chronic diarrhea versus 74% in those who did (p = .002). NVD improved in all 12 patients who had mycophenolate discontinued, although this was not statistically significant (p = .131). Conclusion CDB was associated with worse outcomes regardless of intervention. A low threshold to test for NVD in SOT recipients with chronic diarrhea is prudent to prevent delayed diagnosis.