Ignatzschineria species have emerged only recently and few cases have been identified worldwide. It has been determined that maggots likely serve as the vector of transmission and the majority of cases described involved cutaneous myiasis. This article presents the first case of an Ignatzschineria species closely related to I. larvae/I. ureclastica causing bacteremia in North America. This isolated Ignatzschineria species is also unique in its broad antimicrobial resistance pattern to carbapenem antimicrobials, an uncommon finding among global Ignatzschineria isolates. Improving the ability to identify Ignatzschineria species is an important step to develop the necessary CLSI breakpoints and treatment guidelines. The paucity of information regarding Ignatzschineria species and the inability to accurately identify these organisms indicate the need for more research and improved identification techniques of this emerging pathogen.

Background In hospitalized people with HIV (PWH) there is an increased risk of mortality from COVID-19 among hospitalized PWH as compared to HIV-negative individuals. Evidence suggests that tocilizumab—a humanized monoclonal interleukin (IL)-6 receptor inhibitor (IL-6ri) antibody—has a modest mortality benefit when combined with corticosteroids in select hospitalized COVID-19 patients who are severely ill. Data on clinical outcomes after tocilizumab use in PWH with severe COVID-19 are lacking. Case presentation We present a multinational case series of 18 PWH with COVID-19 who were treated with IL-6ri’s during the period from April to June 2020. Four patients received tocilizumab, six sarilumab, and eight received an undocumented IL-6ri. Of the 18 patients in the series, 4 (22%) had CD4 counts < 200 cells/mm3; 14 (82%) had a suppressed HIV viral load. Eight patients (44%), all admitted to ICU, were treated for secondary infection; 5 had a confirmed organism. Of the four patients with CD4 counts < 200 cells/mm3, three were treated for secondary infection, with 2 confirmed organisms. Overall outcomes were poor—12 patients (67%) were admitted to the ICU, 11 (61%) required mechanical ventilation, and 7 (39%) died. Conclusions In this case series of hospitalized PWH with COVID-19 and given IL-6ri prior to the common use of corticosteroids, there are reports of secondary or co-infection in severely ill patients. Comprehensive studies in PWH, particularly with CD4 counts < 200 cells, are warranted to assess infectious and other outcomes after IL-6ri use, particularly in the context of co-administered corticosteroids.

BackgroundThe emergence of carbapenem-resistant Klebsiella pneumoniae (CR-Kp) presents significant clinical challenges with our limited antibiotic armamentarium. Infective endocarditis caused by CR-Kp is rare, with few cases reported in the literature. The use of the novel β-lactam/β-lactamase inhibitor combination ceftazidime–avibactam (CAZ-AVI) in this setting has only been described in one 2018 case in Italy. Guidance in how these novel antibiotics should be used becomes more prudent as the prevalence of complicated CR-Kp infections increases.MethodsA 51-year-old male with a past medical history of a gunshot wound to the neck, type 2 diabetes, and osteomyelitis status post right below-the-knee and left toe amputations presented to the emergency department with altered mental status and right upper extremity weakness. The patient’s hospital course was complicated by hemorrhagic stroke, left above-the-knee amputation, and intraoperative cardiac arrest. Subsequently, blood cultures on hospital days 41 and 43 grew CR-Kp and a transthoracic echocardiogram (TTE) showed moderate to severe aortic regurgitation.ResultsAntimicrobial therapy was changed from imipenem-cilastatin and colistin to CAZ-AVI and amikacin. The organism was found to be susceptible to CAZ-AVI and amikacin, intermediate to colistin, and resistant to all carbapenems. A transesophageal echocardiogram (TEE) confirmed the presence of a small mobile vegetation on the aortic valve with perforation and severe regurgitation. CAZ-AVI and amikacin were continued for two weeks, and then switched to CAZ-AVI and ertapenem for an additional four weeks. Follow-up blood cultures on and after day 44 were negative for CR-Kp. A TTE performed after therapy completion no longer demonstrated aortic regurgitation; however, the valves were poorly visualized. The patient then suffered anoxic brain injury after a second cardiac arrest, thought to be unrelated to endocarditis. The patient’s family then decided on hospice care and the patient expired.ConclusionWe report the successful treatment of CR-Kp endocarditis with CAZ-AVI and amikacin for two weeks followed by CAZ-AVI and ertapenem for four weeks. This regimen can be a viable option for patients that present with this rare multidrug-resistant infection.Disclosures All authors: No reported disclosures.