Patient: Male, 61Final Diagnosis: Strongyloides stercolaris-associated diarrheaSymptoms: Diarrhea • epigastric pain • nausea • weight lossMedication: IvermectinClinical Procedure: Colonic biopsiesSpecialty: Infectious DiseasesObjective:Rare diseaseBackground:Strongyloides stercoralis infection is endemic in subtropical and tropical regions but is reported rather sporadically in temperate countries. In the USA, the highest rates of infection are from the southeastern states, predominantly among immigrants. There is paucity of case reports on S. stercoralis infection among HIV-infected patients who were born and raised in the USA.Case Report:A 61-year-old male with known HIV infection (CD4 count: 235 cells/uL, undetectable HIV RNA, on antiretroviral therapy) presented with a 3-month history of diarrhea. He was initially diagnosed to have diarrhea secondary to norovirus and later with Escherichia coli. He was treated with levofloxacin but the diarrhea persisted. Stool PCR, Clostridium difficile enzyme-linked immunoassay, cryptosporidium and giardia antigen, cyclospora and isospora smear, and fecal microscopy were all negative. Peripheral blood eosinophil count was 1,000 eosinophils/mcL. Colonic biopsies revealed fragments of S. stercoralis larvae within the crypts. The patient was treated with ivermectin with improvement of symptoms. Social history revealed that he was born and raised in the northeastern USA. He was a daily methamphetamine user and engaged in anal sex with men. He denied travel to endemic areas, except for a visit to Japan more than 30 years ago.Conclusions:Our case highlights that S. stercoralis may be an underdiagnosed/under-reported cause of chronic diarrhea among HIV-infected patients. What makes this case peculiar is that the patient was born and raised in the continental USA, absence of recent travel to endemic areas, and relatively high CD4 counts. Parasitic infections, such as S. stercoralis, should be considered among HIV-infected patients with persistent diarrhea and eosinophilia regardless of ethnicity or recent travel history.

with ceftriaxone 1 g every 24 h for 7 days and discharged with improvement of abdominal pain and return to baseline mental status.Raoultella planticola is increasingly recognized as a clinically relevant pathogen, implicated in bacteremia, soft tissue, urinary and gastrointestinal tract-related infections [2]. To our knowledge, we present the first documented case of UTI from R. planticola in a female. The first two cases of R. planticola isolated from the urinary tract were from males. The first case of cystitis from R. planticola was reported by Olson et al. in 2013 and was isolated from an 89-year-old male [3]. A case of acute prostatitis from R. planticola was published by Koukoulaki in 2014 from a 67-year-old man with end-stage renal disease [4]. Both strains isolated by Olson and Koukoulaki were sensitive to carbapenems.In the article of Xu et al.[1], patients with underlying malignancy appear to be at greater risk for CRRP. Of note, all six CRRP cases had pneumonia and/or bacteremia. So far, all reported cases of R. planticola isolated from the urine (Olson, Koukoulaki, and current report) were carbapenem sensitive. Review of medical records showed that our patient has not recently received a carbapenem; however, she had recurrent UTI, including an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae isolate that was treated with ertapenem 3 years prior to the current UTI with R. planticola. She was also treated 6 months ago with ceftriaxone for E. coli UTI that was susceptible to cephalosporins, nitrofurantoin, trimethoprim-sulfamethoxazole, and carbapenems. It is interesting that despite multiple risk factors (recurrent UTI, older age, hydronephrosis, and residence in a nursing home), we isolated R. planticola susceptible to carbapenems, cephalosporins, aztreonam, piperacillin-sulbactam, quinolones, and tigecycline. More intriguingly, the patient reported by Koukoulaki with acute To the Editor, In the recent article by Xu et al., the emergence of carbapenem-resistant Raoultella planticola (CRRP) was highlighted [1]. They listed previously reported R. planticola cases, including one case of cystitis. In Bridgeport Hospital, a private not-for-profit acute care hospital in Connecticut, we have recently encountered a case of urinary tract infection (UTI) from R. planticola.A 92-year-old female with dementia and recurrent UTI was brought to the emergency department from a nursing home for chest pain, non-bloody diarrhea, vague abdominal pain, and loss of appetite. Vital signs were stable and the patient was afebrile. Blood WBC count was within normal range. Urinalysis from straight catheterization revealed a large leukocyte count (>100/hpf), RBC of 4-8/hpf, and a moderate number of bacteria. Nitrite test was negative. Urine culture grew >100,000 cfu/ml of R. planticola resistant to ampicillin but sensitive to other antimicrobials, including carbapenems (Table 1). The organism was identified using Vitek 2 (BioMerieux, Lenexa, KS) with very good identification (Bionumber 6627735777575052). Renal ult...

Ceftazidime-avibactam and ceftolozane-tazobactam are new antimicrobials with activity against multidrug-resistant Pseudomonas aeruginosa. We present the first case of persistent P. aeruginosa bacteremia with in vitro resistance to these novel antimicrobials. A 68-year-old man with newly diagnosed follicular lymphoma was admitted to the medical intensive care unit for sepsis and right lower extremity cellulitis. The patient was placed empirically on vancomycin and piperacillin-tazobactam. Blood cultures from Day 1 of hospitalization grew P. aeruginosa susceptible to piperacillin-tazobactam and cefepime identified using VITEK 2 (Biomerieux, Lenexa, KS). Repeat blood cultures from Day 5 grew P. aeruginosa resistant to all cephalosporins, as well as to meropenem by Day 10. Susceptibility testing performed by measuring minimum inhibitory concentration by E-test (Biomerieux, Lenexa, KS) revealed that blood cultures from Day 10 were resistant to ceftazidime-avibactam and ceftolozane-tazobactam. The Verigene Blood Culture-Gram-Negative (BC-GN) microarray-based assay (Nanosphere, Inc., Northbrook, IL) was used to investigate underlying resistance mechanism in the P. aeruginosa isolate but CTX-M, KPC, NDM, VIM, IMP, and OXA gene were not detected. This case report highlights the well-documented phenomenon of antimicrobial resistance development in P. aeruginosa even during the course of appropriate antibiotic therapy. In the era of increasing multidrug-resistant organisms, routine susceptibility testing of P. aeruginosa to ceftazidime-avibactam and ceftolozane-tazobactam is warranted. Emerging resistance mechanisms to these novel antibiotics need to be further investigated.

Highlights Many factors confer increased risk of recurrent endocarditis. Often many of these factors co-exist in the same host. There is always the risk of residual infected endocardial tissue despite repeated debridement. The traditional 4–6 week parenteral course in endocarditis accounts for bacterial tolerance and antimicrobial resistance. The decision on antimicrobial therapy and duration are supported by evidence but should be individualized.

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Patient: Male, 71Final Diagnosis: Pulmonary nocardiosisSymptoms: Cough • dyspnea • feverMedication: CarfillzomibClinical Procedure: BronchoscopySpecialty: Infectious DiseasesObjective:Rare co-existance of disease or pathologyBackground:The use of proteasome inhibitors like Bortezomib to treat multiple myeloma has been associated with increased rates of opportunistic infections, including Nocardia, especially when lymphopenia is present. The prevalence or association of such infections with newer agents like Carfilzomib is not known.Case Report:A 71-year-old man with multiple myeloma presented with a 6-week history of respiratory symptoms and cyclic fevers. He was undergoing chemotherapy with Carfilzomib. Work-up revealed severe lymphopenia and a CT chest showed multiple lung nodules and a mass-like consolidation. He underwent a bronchoscopy, and respiratory cultures grew Nocardia species. He responded well to intravenous antibiotics with resolution of symptoms and CT findings.Conclusions:With the introduction of newer agents like Carfilzomib for the treatment of multiple myeloma, clinicians must maintain a high degree of suspicion for opportunistic infections to achieve early diagnosis and treatment.

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OBJECTIVE: To identify an indicator of appropriate antibiotic use for bacteremia that is scientifically sound, that is noncontroversial, and that can be broadly applied as an index of the quality of care. DESIGN: Retrospective review of consecutive cases of significant documented bacteremias. SETTING: Suburban tertiary-care hospital. RESULTS: Two hundred ninety-one of 300 (97%) patients received appropriate antibiotics within 48 hours after the final antibiotic sensitivity report was placed on the hospital chart. Therapy was not appropriate in 6 patients with methicillin-resistant Staphylococcus aureus and in 3 patients with enterococcal bacteremia.