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Medscape CME Activity

Medscape, LLC is pleased to provide online continuing medical education (CME) for selected journal articles, allowing clinicians the opportunity to earn CME credit. In support of improving patient care, these activities have been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CME credit is available for one year after publication.

Active CME Articles


Expires 4/26/2022
Medscape CME Activity
Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018 [PDF - 1.54 MB - 6 pages]
W. He et al.

During 2013–2018, antimicrobial drugs were prescribed for 6.8% of cases of acute gastroenteritis encountered in general practice in Australia, including 35.7% of Salmonella infections and 54.1% of Campylobacter infections. During that time, prescriptions for acute gastroenteritis decreased by 2.0%. Managing infectious gastroenteritis in general practice will require greater antimicrobial stewardship.

EID He W, Kirk MD, Hall J, Liu B. Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018. Emerg Infect Dis. 2021;27(5):1462-1467. https://doi.org/10.3201/eid2705.203692
AMA He W, Kirk MD, Hall J, et al. Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018. Emerging Infectious Diseases. 2021;27(5):1462-1467. doi:10.3201/eid2705.203692.
APA He, W., Kirk, M. D., Hall, J., & Liu, B. (2021). Prescribing Antimicrobial Drugs for Acute Gastroenteritis, Primary Care, Australia, 2013–2018. Emerging Infectious Diseases, 27(5), 1462-1467. https://doi.org/10.3201/eid2705.203692.

Expires 4/22/2022
Medscape CME Activity
Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy [PDF - 2.70 MB - 11 pages]
M. Rossi et al.

Klebsiella pneumoniae carbapenemase–producing K. pneumoniae (KPC-Kp) has been endemic in Italy since 2013. In a multicenter cohort study, we investigated various aspects of KPC-Kp among patients, including 15-day mortality rates and delays in adequate therapy. Most (77%) KPC-Kp strains were sequence type (ST) ST512 or ST307. During 2017, KPC-Kp prevalence was 3.26 cases/1,000 hospitalized patients. Cumulative incidence of KPC-Kp acquired >48 hours after hospital admission was 0.68% but varied widely between centers. Among patients with mild infections and noninfected colonized patients, 15-day mortality rates were comparable, but rates were much higher among patients with severe infections. Delays of >4 days in receiving adequate therapy more frequently occurred among patients with mild infections than those with severe infections, and delays were less common for patients with known previous KPC-Kp colonization. Italy urgently needs a concerted surveillance system to control the spread of KPC-Kp.

EID Rossi M, Chatenoud L, Gona F, Sala I, Nattino G, D'Antonio A, et al. Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy. Emerg Infect Dis. 2021;27(5):1416-1426. https://doi.org/10.3201/eid2705.203662
AMA Rossi M, Chatenoud L, Gona F, et al. Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy. Emerging Infectious Diseases. 2021;27(5):1416-1426. doi:10.3201/eid2705.203662.
APA Rossi, M., Chatenoud, L., Gona, F., Sala, I., Nattino, G., D'Antonio, A....Gori, A. (2021). Characteristics and Clinical Implications of Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection, Italy. Emerging Infectious Diseases, 27(5), 1416-1426. https://doi.org/10.3201/eid2705.203662.

Expires 3/18/2022
Medscape CME Activity
Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018 [PDF - 1.18 MB - 9 pages]
M. Markowicz et al.

The aim of this prospective study was to assess the risk for tickborne infections after a tick bite. A total of 489 persons bitten by 1,295 ticks were assessed for occurrence of infections with Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Rickettsia spp., Babesia spp., Candidatus Neoehrlichia mikurensis, and relapsing fever borreliae. B. burgdorferi s.l. infection was found in 25 (5.1%) participants, of whom 15 had erythema migrans. Eleven (2.3%) participants were positive by PCR for Candidatus N. mikurensis. One asymptomatic participant infected with B. miyamotoi was identified. Full engorgement of the tick (odds ratio 9.52) and confirmation of B. burgdorferi s.l. in the tick by PCR (odds ratio 4.39) increased the risk for infection. Rickettsia helvetica was highly abundant in ticks but not pathogenic to humans. Knowledge about the outcome of tick bites is crucial because infections with emerging pathogens might be underestimated because of limited laboratory facilities.

EID Markowicz M, Schötta A, Höss D, Kundi M, Schray C, Stockinger H, et al. Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018. Emerg Infect Dis. 2021;27(4):1048-1056. https://doi.org/10.3201/eid2704.203366
AMA Markowicz M, Schötta A, Höss D, et al. Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018. Emerging Infectious Diseases. 2021;27(4):1048-1056. doi:10.3201/eid2704.203366.
APA Markowicz, M., Schötta, A., Höss, D., Kundi, M., Schray, C., Stockinger, H....Stanek, G. (2021). Infections with Tickborne Pathogens after Tick Bite, Austria, 2015–2018. Emerging Infectious Diseases, 27(4), 1048-1056. https://doi.org/10.3201/eid2704.203366.

Expires 3/18/2022
Medscape CME Activity
Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019 [PDF - 1.14 MB - 8 pages]
E. M. Rabold et al.

Unsafe injection practices and injection drug use have been linked to multiple HIV outbreaks in Pakistan since 2003; however, few studies have systematically analyzed the causes of these outbreaks. We conducted a systematic review of published English-language literature indexed in bibliographic databases and search engines and a focused gray literature review to collate and analyze all reported HIV outbreaks in Pakistan during 2000–2019. Of 774 unique publications reviewed, we identified 25 eligible publications describing 7 outbreaks. More than half occurred during 2016–2019. The primary sources of transmission were iatrogenic transmission, affecting children, persons with chronic medical conditions, and the general population (4 outbreaks); injection drug use (2 outbreaks); and a combination of both (1 outbreak). In the absence of robust HIV testing and surveillance in Pakistan, timely and detailed outbreak reporting is important to understand the epidemiology of HIV in the country.

EID Rabold EM, Ali H, Fernandez D, Knuth M, Schenkel K, Asghar R, et al. Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerg Infect Dis. 2021;27(4):1039-1047. https://doi.org/10.3201/eid2704.204205
AMA Rabold EM, Ali H, Fernandez D, et al. Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerging Infectious Diseases. 2021;27(4):1039-1047. doi:10.3201/eid2704.204205.
APA Rabold, E. M., Ali, H., Fernandez, D., Knuth, M., Schenkel, K., Asghar, R....Morgan, O. (2021). Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerging Infectious Diseases, 27(4), 1039-1047. https://doi.org/10.3201/eid2704.204205.

Expires 3/17/2022
Medscape CME Activity
Blastomycosis Surveillance in 5 States, United States, 1987–2018 [PDF - 1.79 MB - 8 pages]
K. Benedict et al.

Blastomycosis is caused by inhalation of Blastomyces spp. fungi. Limited data are available on the incidence and geographic range of blastomycosis in the United States. To better characterize its epidemiologic features, we analyzed combined surveillance data from the 5 states in which blastomycosis is reportable: Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin. Surveillance identified 4,441 cases during 1987–2018, a mean of 192 cases per year. The mean annual incidence was <1 case/100,000 population in most areas but >20 cases/100,000 population in some northern counties of Wisconsin. Median patient age was 46 years, 2,892 (65%) patients were male, 1,662 (57%) were hospitalized, and 278 (8%) died. The median time from symptom onset to diagnosis was 33 days. The severity of illness and diagnostic delays suggest that surveillance underestimates the true number of cases. More in-depth surveillance in additional states could elucidate blastomycosis incidence and inform efforts to increase awareness.

EID Benedict K, Gibbons-Burgener S, Kocharian A, Ireland M, Rothfeldt L, Christophe N, et al. Blastomycosis Surveillance in 5 States, United States, 1987–2018. Emerg Infect Dis. 2021;27(4):999-1006. https://doi.org/10.3201/eid2704.204078
AMA Benedict K, Gibbons-Burgener S, Kocharian A, et al. Blastomycosis Surveillance in 5 States, United States, 1987–2018. Emerging Infectious Diseases. 2021;27(4):999-1006. doi:10.3201/eid2704.204078.
APA Benedict, K., Gibbons-Burgener, S., Kocharian, A., Ireland, M., Rothfeldt, L., Christophe, N....Jackson, B. R. (2021). Blastomycosis Surveillance in 5 States, United States, 1987–2018. Emerging Infectious Diseases, 27(4), 999-1006. https://doi.org/10.3201/eid2704.204078.

Expires 2/19/2022
Medscape CME Activity
Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018 [PDF - 730 KB - 10 pages]
E. Won et al.

We investigated the clinical outcomes and molecular mechanisms of fluconazole-resistant (FR) Candida glabrata bloodstream infections. Among 1,158 isolates collected during multicenter studies in South Korea during 2008–2018, 5.7% were FR. For 64 patients with FR bloodstream infection isolates, the 30-day mortality rate was 60.9% and the 90-day mortality rate 78.2%; these rates were significantly higher than in patients with fluconazole-susceptible dose-dependent isolates (30-day mortality rate 36.4%, 90-day mortality rate 43.8%; p<0.05). For patients with FR isolates, appropriate antifungal therapy was the only independent protective factor associated with 30-day (hazard ratio 0.304) and 90-day (hazard ratio 0.310) mortality. Sequencing of pleiotropic drug-resistance transcription factor revealed that 1–2 additional Pdr1p amino acid substitutions (except genotype-specific Pdr1p amino acid substitutions) occurred in 98.5% of FR isolates but in only 0.9% of fluconazole-susceptible dose-dependent isolates. These results highlight the high mortality rate of patients infected with FR C. glabrata BSI isolates harboring Pdr1p mutations.

EID Won E, Choi MJ, Kim M, Yong D, Lee W, Uh Y, et al. Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018. Emerg Infect Dis. 2021;27(3):779-788. https://doi.org/10.3201/eid2703.203482
AMA Won E, Choi MJ, Kim M, et al. Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018. Emerging Infectious Diseases. 2021;27(3):779-788. doi:10.3201/eid2703.203482.
APA Won, E., Choi, M. J., Kim, M., Yong, D., Lee, W., Uh, Y....Shin, J. (2021). Fluconazole-Resistant Candida glabrata Bloodstream Isolates, South Korea, 2008–2018. Emerging Infectious Diseases, 27(3), 779-788. https://doi.org/10.3201/eid2703.203482.

Expires 2/19/2022
Medscape CME Activity
Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan [PDF - 698 KB - 8 pages]
A. A. Malik et al.

In Karachi, Pakistan, a South Asian megacity with a high prevalence of tuberculosis (TB) and low HIV prevalence, we assessed the effectiveness of fluoroquinolone-based preventive therapy for drug-resistant (DR) TB exposure. During February 2016–March 2017, high-risk household contacts of DR TB patients began a 6-month course of preventive therapy with a fluoroquinolone-based, 2-drug regimen. We assessed effectiveness in this cohort by comparing the rate and risk for TB disease over 2 years to the rates and risks reported in the literature. Of 172 participants, TB occurred in 2 persons over 336 person-years of observation. TB disease incidence rate observed in the cohort was 6.0/1,000 person-years. The incidence rate ratio ranged from 0.29 (95% CI 0.04–1.3) to 0.50 (95% CI 0.06–2.8), with a pooled estimate of 0.35 (95% CI 0.14–0.87). Overall, fluoroquinolone-based preventive therapy for DR TB exposure reduced risk for TB disease by 65%.

EID Malik AA, Gandhi NR, Lash TL, Cranmer LM, Omer SB, Ahmed JF, et al. Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerg Infect Dis. 2021;27(3):805-812. https://doi.org/10.3201/eid2703.203916
AMA Malik AA, Gandhi NR, Lash TL, et al. Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerging Infectious Diseases. 2021;27(3):805-812. doi:10.3201/eid2703.203916.
APA Malik, A. A., Gandhi, N. R., Lash, T. L., Cranmer, L. M., Omer, S. B., Ahmed, J. F....Becerra, M. C. (2021). Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerging Infectious Diseases, 27(3), 805-812. https://doi.org/10.3201/eid2703.203916.

Expires 1/21/2022
Medscape CME Activity
Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018 [PDF - 2.56 MB - 12 pages]
A. Benavides-Lara et al.

After Zika virus (ZIKV) infection in Costa Rica was confirmed in January 2016, the national surveillance system was enhanced to monitor associated birth defects. To characterize the ZIKV outbreak among live-born infants during March 2016–March 2018, we conducted a descriptive analysis. Prevalence of ZIKV-associated birth defects was 15.3 cases/100,000 live births. Among 22 infants with ZIKV-associated birth defects, 11 were designated as confirmed (positive for ZIKV) and 11 were designated as probable cases (negative for ZIKV or not tested, but mother was expsed to ZIKV during pregnancy). A total of 91% had microcephaly (head circumference >2 SDs below mean for age and sex), 64% severe microcephaly (head circumference >3 SDs below mean for age and sex), 95% neurodevelopmental abnormalities, 82% brain anomalies, 41% eye abnormalities, and 9% hearing loss. Monitoring children for >1 year can increase identification of ZIKV-associated abnormalities in addition to microcephaly.

EID Benavides-Lara A, la Paz Barboza-Arguello Md, González-Elizondo M, Hernández-deMezerville M, Brenes-Chacón H, Ramírez-Rojas M, et al. Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018. Emerg Infect Dis. 2021;27(2):360-371. https://doi.org/10.3201/eid2702.202047
AMA Benavides-Lara A, la Paz Barboza-Arguello Md, González-Elizondo M, et al. Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018. Emerging Infectious Diseases. 2021;27(2):360-371. doi:10.3201/eid2702.202047.
APA Benavides-Lara, A., la Paz Barboza-Arguello, M. d., González-Elizondo, M., Hernández-deMezerville, M., Brenes-Chacón, H., Ramírez-Rojas, M....Soriano-Fallas, A. (2021). Zika Virus–Associated Birth Defects, Costa Rica, 2016–2018. Emerging Infectious Diseases, 27(2), 360-371. https://doi.org/10.3201/eid2702.202047.

Expires 1/21/2022
Medscape CME Activity
Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018 [PDF - 1.48 MB - 13 pages]
V. Joste et al.

We retrospectively analyzed epidemiologic, clinical, and biologic characteristics of 368 Plasmodium ovale wallikeri and 309 P. ovale curtisi infections treated in France during January 2013–December 2018. P. ovale wallikeri infections displayed deeper thrombocytopenia and shorter latency periods. Despite similar clinical manifestations, P. ovale wallikeri–infected patients were more frequently treated with artemisinin-based combination therapy. Although the difference was not statistically significant, P. ovale wallikeri–infected patients were 5 times more frequently hospitalized in intensive care or intermediate care and had a higher proportion of severe thrombocytopenia than P. ovale curtisi–infected patients. Rapid diagnostic tests that detect aldolase were more efficient than those detecting Plasmodium lactate dehydrogenase. Sequence analysis of the potra gene from 90 P. ovale isolates reveals an insufficient polymorphism for relapse typing.

EID Joste V, Bailly J, Hubert V, Pauc C, Gendrot M, Guillochon E, et al. Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018. Emerg Infect Dis. 2021;27(2):372-384. https://doi.org/10.3201/eid2702.202143
AMA Joste V, Bailly J, Hubert V, et al. Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018. Emerging Infectious Diseases. 2021;27(2):372-384. doi:10.3201/eid2702.202143.
APA Joste, V., Bailly, J., Hubert, V., Pauc, C., Gendrot, M., Guillochon, E....Houzé, S. (2021). Plasmodium ovale wallikeri and P. ovale curtisi Infections and Diagnostic Approaches to Imported Malaria, France, 2013–2018. Emerging Infectious Diseases, 27(2), 372-384. https://doi.org/10.3201/eid2702.202143.

Expires 12/23/2021
Medscape CME Activity
Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015 [PDF - 565 KB - 10 pages]
E. Pérez-Nadales et al.

Invasive fusariosis (IF) is associated with severe neutropenia in patients with concurrent hematologic conditions. We conducted a retrospective observational study to characterize the epidemiology of IF in 18 Spanish hospitals during 2000–2015. In that time, the frequency of IF in nonneutropenic patients increased from 0.08 cases per 100,000 admissions in 2000–2009 to 0.22 cases per 100,000 admissions in 2010–2015. Nonneutropenic IF patients often had nonhematologic conditions, such as chronic cardiac or lung disease, rheumatoid arthritis, history of solid organ transplantation, or localized fusariosis. The 90-day death rate among nonneutropenic patients (28.6%) and patients with resolved neutropenia (38.1%) was similar. However, the death rate among patients with persistent neutropenia (91.3%) was significantly higher. We used a multivariate Cox regression analysis to characterize risk factors for death: persistent neutropenia was the only risk factor for death, regardless of antifungal therapy.

EID Pérez-Nadales E, Alastruey-Izquierdo A, Linares-Sicilia M, Soto-Debrán J, Abdala E, García-Rodríguez J, et al. Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015. Emerg Infect Dis. 2021;27(1):24-36. https://doi.org/10.3201/eid2701.190782
AMA Pérez-Nadales E, Alastruey-Izquierdo A, Linares-Sicilia M, et al. Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015. Emerging Infectious Diseases. 2021;27(1):24-36. doi:10.3201/eid2701.190782.
APA Pérez-Nadales, E., Alastruey-Izquierdo, A., Linares-Sicilia, M., Soto-Debrán, J., Abdala, E., García-Rodríguez, J....Nucci, M. (2021). Invasive Fusariosis in Nonneutropenic Patients, Spain, 2000–2015. Emerging Infectious Diseases, 27(1), 24-36. https://doi.org/10.3201/eid2701.190782.

Expires 12/22/2021
Medscape CME Activity
Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018 [PDF - 1.75 MB - 11 pages]
J. Bennett et al.

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000–2018 and RHD mortality rates during 2000–2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0–14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9–27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9–3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2–5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3–14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1–13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.

EID Bennett J, Zhang J, Leung W, Jack S, Oliver J, Webb R, et al. Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018. Emerg Infect Dis. 2021;27(1):36-46. https://doi.org/10.3201/eid2701.191791
AMA Bennett J, Zhang J, Leung W, et al. Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018. Emerging Infectious Diseases. 2021;27(1):36-46. doi:10.3201/eid2701.191791.
APA Bennett, J., Zhang, J., Leung, W., Jack, S., Oliver, J., Webb, R....Baker, M. G. (2021). Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000–2018. Emerging Infectious Diseases, 27(1), 36-46. https://doi.org/10.3201/eid2701.191791.

Expires 11/20/2021
Medscape CME Activity
Tuberculosis among Children and Adolescents at HIV Treatment Centers in Sub-Saharan Africa [PDF - 2.14 MB - 11 pages]
A. M. Mandalakas et al.

HIV-infected children and adolescents are at increased risk for tuberculosis (TB). Antiretroviral therapy (ART) reduces TB risk in HIV-infected adults, but its effectiveness in HIV-infected children and adolescents is unknown. We analyzed data from 7 integrated pediatric HIV/TB centers in 6 countries in sub-Saharan Africa. We used a Bayesian mixed-effect model to assess association between ART and TB prevalence and used adaptive lasso regression to analyze risk factors for adverse TB outcomes. The study period encompassed 57,525 patient-years and 1,160 TB cases (2,017 cases/100,000 patient-years). Every 10% increase in ART uptake resulted in a 2.33% reduction in TB prevalence. Favorable TB outcomes were associated with increased time in care and early ART initiation, whereas severe immunosuppression was associated with death. These findings support integrated HIV/TB services for HIV-infected children and adults and demonstrate the association of ART uptake with decreased TB incidence in high HIV/TB settings.


Expires 11/2/2021
Medscape CME Activity
Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil [PDF - 2.48 MB - 11 pages]
C. Brandão-de-Resende et al.

In 2015, an outbreak of presumed waterborne toxoplasmosis occurred in Gouveia, Brazil. We conducted a 3-year prospective study on a cohort of 52 patients from this outbreak, collected clinical and multimodal imaging findings, and determined risk factors for ocular involvement. At baseline examination, 12 (23%) patients had retinochoroiditis; 4 patients had bilateral and 2 had macular lesions. Multimodal imaging revealed 2 distinct retinochoroiditis patterns: necrotizing focal retinochoroiditis and punctate retinochoroiditis. Older age, worse visual acuity, self-reported recent reduction of visual acuity, and presence of floaters were associated with retinochoroiditis. Among patients, persons >40 years of age had 5 times the risk for ocular involvement. Five patients had recurrences during follow-up, a rate of 22% per person-year. Recurrences were associated with binocular involvement. Two patients had late ocular involvement that occurred >34 months after initial diagnosis. Patients with acquired toxoplasmosis should have long-term ophthalmic follow-up, regardless of initial ocular involvement.

EID Brandão-de-Resende C, Santos H, Rojas Lagos A, Lara C, Arruda J, Marino A, et al. Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil. Emerg Infect Dis. 2020;26(12):2922-2932. https://doi.org/10.3201/eid2612.200227
AMA Brandão-de-Resende C, Santos H, Rojas Lagos A, et al. Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil. Emerging Infectious Diseases. 2020;26(12):2922-2932. doi:10.3201/eid2612.200227.
APA Brandão-de-Resende, C., Santos, H., Rojas Lagos, A., Lara, C., Arruda, J., Marino, A....Vasconcelos-Santos, D. (2020). Clinical and Multimodal Imaging Findings and Risk Factors for Ocular Involvement in a Presumed Waterborne Toxoplasmosis Outbreak, Brazil. Emerging Infectious Diseases, 26(12), 2922-2932. https://doi.org/10.3201/eid2612.200227.

Expires 10/14/2021
Medscape CME Activity
Phage-Mediated Immune Evasion and Transmission of Livestock-Associated Methicillin-Resistant Staphylococcus aureus in Humans [PDF - 874 KB - 8 pages]
R. N. Sieber et al.

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) can acquire phage-encoded immune modulators, such as the immune evasion cluster (IEC), which protects bacteria from components of the human innate immune system, and the enzyme TarP, which protects against antibody-mediated immune recognition. We used whole-genome sequencing and epidemiologic investigations to study the effects of IEC- and tarP-harboring phages on household transmission of LA-MRSA in North Denmark Region during 2004–2011. We reviewed information about all patients throughout Denmark who experienced LA-MRSA infection during 2007–2018 to determine whether IEC is associated with increased spread into the general population. Horizontal acquisition of IEC in the human host was associated with increased household transmission of LA-MRSA and spillover into the community and healthcare settings, whereas we found no evidence to suggest that IEC-positive LA-MRSA isolates have become self-sustainable in the general population. By contrast, TarP did not seem to influence household transmission of LA-MRSA.

EID Sieber RN, Urth TR, Petersen A, Møller CH, Price LB, Skov RL, et al. Phage-Mediated Immune Evasion and Transmission of Livestock-Associated Methicillin-Resistant Staphylococcus aureus in Humans. Emerg Infect Dis. 2020;26(11):2578-2585. https://doi.org/10.3201/eid2611.201442
AMA Sieber RN, Urth TR, Petersen A, et al. Phage-Mediated Immune Evasion and Transmission of Livestock-Associated Methicillin-Resistant Staphylococcus aureus in Humans. Emerging Infectious Diseases. 2020;26(11):2578-2585. doi:10.3201/eid2611.201442.
APA Sieber, R. N., Urth, T. R., Petersen, A., Møller, C. H., Price, L. B., Skov, R. L....Larsen, J. (2020). Phage-Mediated Immune Evasion and Transmission of Livestock-Associated Methicillin-Resistant Staphylococcus aureus in Humans. Emerging Infectious Diseases, 26(11), 2578-2585. https://doi.org/10.3201/eid2611.201442.

Expires 9/17/2021
Medscape CME Activity
Healthcare-Associated Legionnaires’ Disease, Europe, 2008−2017 [PDF - 1.77 MB - 10 pages]
J. Beauté et al.

Healthcare-associated Legionnaires’ disease (HCA LD) can cause nosocomial outbreaks with high death rates. We compared community-acquired LD cases with HCA LD cases in Europe during 2008−2017 using data from The European Surveillance System. A total of 29 countries reported 40,411 community-acquired and 4,315 HCA LD cases. Of the HCA LD cases, 2,937 (68.1%) were hospital-acquired and 1,378 (31.9%) were linked to other healthcare facilities. The odds of having HCA LD were higher for women, children and persons <20 years of age, and persons >60 years of age. Out of the cases caused by Legionella pneumophila with a known serotype, community-acquired LD was more likely to be caused by L. pneumophila serogroup 1 (92.3%) than was HCA LD (85.1%). HCA LD patients were more likely to die. HCA LD is associated with specific patient demographics, causative strains, and outcomes. Healthcare facilities should consider these characteristics when designing HCA LD prevention strategies.

EID Beauté J, Plachouras D, Sandin S, Giesecke J, Sparén P. Healthcare-Associated Legionnaires’ Disease, Europe, 2008−2017. Emerg Infect Dis. 2020;26(10):2309-2318. https://doi.org/10.3201/eid2610.181889
AMA Beauté J, Plachouras D, Sandin S, et al. Healthcare-Associated Legionnaires’ Disease, Europe, 2008−2017. Emerging Infectious Diseases. 2020;26(10):2309-2318. doi:10.3201/eid2610.181889.
APA Beauté, J., Plachouras, D., Sandin, S., Giesecke, J., & Sparén, P. (2020). Healthcare-Associated Legionnaires’ Disease, Europe, 2008−2017. Emerging Infectious Diseases, 26(10), 2309-2318. https://doi.org/10.3201/eid2610.181889.

Expires 9/16/2021
Medscape CME Activity
Lessons Learned from a Decade of Investigations of Shiga Toxin–Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada [PDF - 1.41 MB - 10 pages]
K. E. Marshall et al.

Shiga toxin–producing Escherichia coli (STEC) cause substantial and costly illnesses. Leafy greens are the second most common source of foodborne STEC O157 outbreaks. We examined STEC outbreaks linked to leafy greens during 2009–2018 in the United States and Canada. We identified 40 outbreaks, 1,212 illnesses, 77 cases of hemolytic uremic syndrome, and 8 deaths. More outbreaks were linked to romaine lettuce (54%) than to any other type of leafy green. More outbreaks occurred in the fall (45%) and spring (28%) than in other seasons. Barriers in epidemiologic and traceback investigations complicated identification of the ultimate outbreak source. Research on the seasonality of leafy green outbreaks and vulnerability to STEC contamination and bacterial survival dynamics by leafy green type are warranted. Improvements in traceability of leafy greens are also needed. Federal and state health partners, researchers, the leafy green industry, and retailers can work together on interventions to reduce STEC contamination.

EID Marshall KE, Hexemer A, Seelman SL, Fatica MK, Blessington T, Hajmeer M, et al. Lessons Learned from a Decade of Investigations of Shiga Toxin–Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada. Emerg Infect Dis. 2020;26(10):2319-2328. https://doi.org/10.3201/eid2610.191418
AMA Marshall KE, Hexemer A, Seelman SL, et al. Lessons Learned from a Decade of Investigations of Shiga Toxin–Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada. Emerging Infectious Diseases. 2020;26(10):2319-2328. doi:10.3201/eid2610.191418.
APA Marshall, K. E., Hexemer, A., Seelman, S. L., Fatica, M. K., Blessington, T., Hajmeer, M....Gieraltowski, L. (2020). Lessons Learned from a Decade of Investigations of Shiga Toxin–Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada. Emerging Infectious Diseases, 26(10), 2319-2328. https://doi.org/10.3201/eid2610.191418.

Expires 8/18/2021
Medscape CME Activity
Q Fever Osteoarticular Infection in Children [PDF - 1.15 MB - 7 pages]
H. Dabaja-Younis et al.

Q fever osteoarticular infection in children is an underestimated disease. We report 3 cases of Q fever osteomyelitis in children and review all cases reported in the literature through March 2018. A high index of suspicion is encouraged in cases of an unusual manifestation, prolonged course, relapsing symptoms, nonresolving or slowly resolving osteomyelitis, culture-negative osteomyelitis, or bone histopathology demonstrating granulomatous changes. Urban residence or lack of direct exposure to animals does not rule out infection. Diagnosis usually requires use of newer diagnostic modalities. Optimal antimicrobial therapy has not been well established; some case-patients may improve spontaneously or during treatment with a β-lactam. The etiology of treatment failure and relapse is not well understood, and tools for follow-up are lacking. Clinicians should be aware of these infections in children to guide optimal treatment, including choice of antimicrobial drugs, duration of therapy, and methods of monitoring response to treatment..

EID Dabaja-Younis H, Meir M, Ilivizki A, Militianu D, Eidelman M, Kassis I, et al. Q Fever Osteoarticular Infection in Children. Emerg Infect Dis. 2020;26(9):2039-2045. https://doi.org/10.3201/eid2609.191360
AMA Dabaja-Younis H, Meir M, Ilivizki A, et al. Q Fever Osteoarticular Infection in Children. Emerging Infectious Diseases. 2020;26(9):2039-2045. doi:10.3201/eid2609.191360.
APA Dabaja-Younis, H., Meir, M., Ilivizki, A., Militianu, D., Eidelman, M., Kassis, I....Shachor-Meyouhas, Y. (2020). Q Fever Osteoarticular Infection in Children. Emerging Infectious Diseases, 26(9), 2039-2045. https://doi.org/10.3201/eid2609.191360.

Expires 8/14/2021
Medscape CME Activity
Invasive Infections with Nannizziopsis obscura Species Complex in 9 Patients from West Africa, France, 2004–2020 [PDF - 1.59 MB - 9 pages]
D. Garcia-Hermoso et al.

Nine new human invasive infections caused by the keratinophilic fungi Nannizziopsis obscura have been reported in France since 2004. The patients had variable clinical manifestations, had frequent dissemination, were mainly T-cell immunocompromised, and all originated from sub-Saharan West Africa. Before collection of the isolates, the etiologies of these infections were often misidentified, underscoring the extent of microscopic and cultural polymorphisms. All isolates but 1 had low MICs for the 8 antifungal drugs tested. When treated, patients received mainly azole therapy. Two of 7 patients with a known outcome died. We performed multilocus sequence analysis of N. obscura clinical strains and several strains of Nannizziopsis spp. isolated from reptiles. The human strains were clearly differentiated from the animal strains. N. obscura might be endemic to West Africa and responsible for undetected infections, which might become reactivated when immunosuppression occurs. N. obscura infection is probably underestimated because only sequencing enables proper identification.

EID Garcia-Hermoso D, Hamane S, Fekkar A, Jabet A, Denis B, Siguier M, et al. Invasive Infections with Nannizziopsis obscura Species Complex in 9 Patients from West Africa, France, 2004–2020. Emerg Infect Dis. 2020;26(9):2022-2030. https://doi.org/10.3201/eid2609.200276
AMA Garcia-Hermoso D, Hamane S, Fekkar A, et al. Invasive Infections with Nannizziopsis obscura Species Complex in 9 Patients from West Africa, France, 2004–2020. Emerging Infectious Diseases. 2020;26(9):2022-2030. doi:10.3201/eid2609.200276.
APA Garcia-Hermoso, D., Hamane, S., Fekkar, A., Jabet, A., Denis, B., Siguier, M....Bretagne, S. (2020). Invasive Infections with Nannizziopsis obscura Species Complex in 9 Patients from West Africa, France, 2004–2020. Emerging Infectious Diseases, 26(9), 2022-2030. https://doi.org/10.3201/eid2609.200276.

Expires 7/17/2021
Medscape CME Activity
Tuberculosis in Internationally Displaced Children Resettling in Harris County, Texas, USA, 2010–2015 [PDF - 692 KB - 9 pages]
G. S. Lamb et al.

US guidelines have recommended testing children emigrating from high tuberculosis-incidence countries with interferon-gamma release assays (IGRAs) or tuberculin skin tests (TSTs). We describe the Harris County (Texas) Public Health Refugee Health Screening Program’s testing results during 2010–2015 for children <18 years of age: 5,990 were evaluated, and 5,870 (98%) were tested. Overall, 364 (6.2%) children had >1 positive test: 143/1,842 (7.8%) were tested with TST alone, 129/3,730 (3.5%) with IGRA alone, and 92/298 (30.9%) with both TST and IGRA. Region of origin and younger age were associated with positive TST or IGRA results. All children were more likely to have positive results for TST than for IGRA (OR 2.92, 95% CI 2.37–3.59). Discordant test results were common (20%) and most often were TST+/IGRA– (95.0%), likely because of bacillus Calmette-Guérin vaccination. Finding fewer false positives supports the 2018 change in US immigration guidelines that recommends using IGRAs for recently immigrated children.

EID Lamb GS, Cruz AT, Camp EA, Javier M, Montour J, Piper T, et al. Tuberculosis in Internationally Displaced Children Resettling in Harris County, Texas, USA, 2010–2015. Emerg Infect Dis. 2020;26(8):1686-1694. https://doi.org/10.3201/eid2608.190793
AMA Lamb GS, Cruz AT, Camp EA, et al. Tuberculosis in Internationally Displaced Children Resettling in Harris County, Texas, USA, 2010–2015. Emerging Infectious Diseases. 2020;26(8):1686-1694. doi:10.3201/eid2608.190793.
APA Lamb, G. S., Cruz, A. T., Camp, E. A., Javier, M., Montour, J., Piper, T....Starke, J. R. (2020). Tuberculosis in Internationally Displaced Children Resettling in Harris County, Texas, USA, 2010–2015. Emerging Infectious Diseases, 26(8), 1686-1694. https://doi.org/10.3201/eid2608.190793.

Expires 7/15/2021
Medscape CME Activity
Sporadic Creutzfeldt-Jakob Disease among Physicians, Germany, 1993–2018 [PDF - 2.79 MB - 10 pages]
P. Hermann et al.

We investigated sporadic Creutzfeldt-Jakob disease (sCJD) among physicians in Germany by analyzing occupational information of patients with sCJD recorded by the German CJD Surveillance Unit (1993–2005; 1,250 patients, of whom 4 [0.32%] were physicians) and the National Reference Center for Human Spongiform Encephalopathies (2006–2016; 1,491 patients, of whom 13 [0.87%] were physicians). Among the physicians, we did not identify any neurologists, neurosurgeons, psychiatrists, or pathologists. A cumulative sum test showed an increase in reported physicians over time. Data for 2017–2018 indicated an increased rate of physicians among all notified sCJD cases (5/239 [2.1%]) when we used the total population of Germany as control group. Our data suggest the possibility of an increased risk for sCJD among physicians in Germany. However, we can only speculate about the reasons, and larger multinational studies are needed to replicate the finding and to clarify whether this finding is a general or a country-specific phenomenon.

EID Hermann P, Treig J, Unkel S, Goebel S, Bunck T, Jünemann M, et al. Sporadic Creutzfeldt-Jakob Disease among Physicians, Germany, 1993–2018. Emerg Infect Dis. 2020;26(8):1710-1719. https://doi.org/10.3201/eid2608.191159
AMA Hermann P, Treig J, Unkel S, et al. Sporadic Creutzfeldt-Jakob Disease among Physicians, Germany, 1993–2018. Emerging Infectious Diseases. 2020;26(8):1710-1719. doi:10.3201/eid2608.191159.
APA Hermann, P., Treig, J., Unkel, S., Goebel, S., Bunck, T., Jünemann, M....Zerr, I. (2020). Sporadic Creutzfeldt-Jakob Disease among Physicians, Germany, 1993–2018. Emerging Infectious Diseases, 26(8), 1710-1719. https://doi.org/10.3201/eid2608.191159.

Expires 6/18/2021
Medscape CME Activity
Rickettsioses as Major Etiologies of Unrecognized Acute Febrile Illness, Sabah, East Malaysia [PDF - 2.09 MB - 11 pages]
M. J. Grigg et al.

Orientia tsutsugamushi, spotted fever group rickettsioses, and typhus group rickettsioses (TGR) are reemerging causes of acute febrile illness (AFI) in Southeast Asia. To further delineate extent, we enrolled patients >4 weeks of age with nonmalarial AFI in Sabah, Malaysia, during 2013–2015. We confirmed rickettsioses (past or acute, IgG titer >160) in 126/354 (36%) patients. We confirmed acute rickettsioses (paired 4-fold IgG titer rise to >160) in 38/145 (26%) patients: 23 O. tsutsugamushi, 9 spotted fever group, 4 TGR, 1 O. tsutsugamushi/spotted fever group, and 1 O. tsutsugamushi/TGR. PCR results were positive in 11/319 (3%) patients. Confirmed rickettsioses were more common in male adults; agricultural/plantation work and recent forest exposure were risk factors. Dizziness and acute hearing loss but not eschars were reported more often with acute rickettsioses. Only 2 patients were treated with doxycycline. Acute rickettsioses are common (>26%), underrecognized, and untreated etiologies of AFI in East Malaysia; empirical doxycycline treatment should be considered.

EID Grigg MJ, William T, Clemens EG, Patel K, Chandna A, Wilkes CS, et al. Rickettsioses as Major Etiologies of Unrecognized Acute Febrile Illness, Sabah, East Malaysia. Emerg Infect Dis. 2020;26(7):1409-1419. https://doi.org/10.3201/eid2607.191722
AMA Grigg MJ, William T, Clemens EG, et al. Rickettsioses as Major Etiologies of Unrecognized Acute Febrile Illness, Sabah, East Malaysia. Emerging Infectious Diseases. 2020;26(7):1409-1419. doi:10.3201/eid2607.191722.
APA Grigg, M. J., William, T., Clemens, E. G., Patel, K., Chandna, A., Wilkes, C. S....Reller, M. E. (2020). Rickettsioses as Major Etiologies of Unrecognized Acute Febrile Illness, Sabah, East Malaysia. Emerging Infectious Diseases, 26(7), 1409-1419. https://doi.org/10.3201/eid2607.191722.

Expires 6/17/2021
Medscape CME Activity
Atypical Manifestations of Cat-Scratch Disease, United States, 2005–2014 [PDF - 1.37 MB - 9 pages]
C. C. Nawrocki et al.

Atypical manifestations that can be severe and difficult to diagnosis develop in 5%–20% of patients with cat-scratch disease. To clarify the epidemiology of atypical cat-scratch disease in the United States, we analyzed data from the 2005–2014 MarketScan national health insurance claims databases by using the International Classification of Diseases, 9th Revision, Clinical Modification, codes for cat-scratch disease and selected atypical manifestations: retinitis/neuroretinitis, conjunctivitis, neuritis, encephalitis, hepatosplenic disease, osteomyelitis, erythema nodosum, and endocarditis. Atypical cat-scratch disease accounted for 1.5% of all cases, resulting in an average annual incidence of 0.7 cases/100,000 population. Atypical cat-scratch disease was associated with increased risk for hospitalization (risk ratios 8.77, 95% CI 6.56–11.72) and occurred most often in female patients 10–14 years of age. Ocular (48.7%), hepatosplenic (24.6%), and neurologic (13.8%) manifestations were most common among patients. A more comprehensive understanding of atypical cat-scratch disease can improve patient diagnosis and potentially elucidate pathophysiology of the disease.

EID Nawrocki CC, Max RJ, Marzec NS, Nelson CA. Atypical Manifestations of Cat-Scratch Disease, United States, 2005–2014. Emerg Infect Dis. 2020;26(7):1438-1446. https://doi.org/10.3201/eid2607.200034
AMA Nawrocki CC, Max RJ, Marzec NS, et al. Atypical Manifestations of Cat-Scratch Disease, United States, 2005–2014. Emerging Infectious Diseases. 2020;26(7):1438-1446. doi:10.3201/eid2607.200034.
APA Nawrocki, C. C., Max, R. J., Marzec, N. S., & Nelson, C. A. (2020). Atypical Manifestations of Cat-Scratch Disease, United States, 2005–2014. Emerging Infectious Diseases, 26(7), 1438-1446. https://doi.org/10.3201/eid2607.200034.

Expires 5/15/2021
Medscape CME Activity
Statin Use and Influenza Vaccine Effectiveness in Persons ≥ 65 Years of Age, Taiwan [PDF - 1.08 MB - 8 pages]
L. Tsai et al.

Debates on whether statin use reduces the effectiveness of influenza vaccines against critical illness and death among persons >65 years of age continue. We conducted a study of 9,427,392 persons >65 years of age who did and did not receive influenza vaccinations during 12 consecutive influenza seasons, 2000–01 through 2011–12. Using data from Taiwan’s National Health Insurance Research Database, we performed propensity score-matching to compare vaccinated persons with unvaccinated controls. After propensity score-matching, the vaccinated group had lower risks for in-hospital death from influenza and pneumonia and for hospitalization for pneumonia and influenza, circulatory conditions, and critical illnesses compared with the unvaccinated group. We stratified the 2 groups by statin use and analyzed data by interaction analysis and saw no statistically significant difference. We found that influenza vaccine effectively reduced risks for hospitalization and death in persons >65 years of age, regardless of statin use.

EID Tsai L, Chen Y, Shih C, Ou S, Chao P, Lo S. Statin Use and Influenza Vaccine Effectiveness in Persons ≥ 65 Years of Age, Taiwan. Emerg Infect Dis. 2020;26(6):1243-1250. https://doi.org/10.3201/eid2606.190646
AMA Tsai L, Chen Y, Shih C, et al. Statin Use and Influenza Vaccine Effectiveness in Persons ≥ 65 Years of Age, Taiwan. Emerging Infectious Diseases. 2020;26(6):1243-1250. doi:10.3201/eid2606.190646.
APA Tsai, L., Chen, Y., Shih, C., Ou, S., Chao, P., & Lo, S. (2020). Statin Use and Influenza Vaccine Effectiveness in Persons ≥ 65 Years of Age, Taiwan. Emerging Infectious Diseases, 26(6), 1243-1250. https://doi.org/10.3201/eid2606.190646.

Expires 5/14/2021
Medscape CME Activity
Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010–2017 [PDF - 2.48 MB - 7 pages]
A. Cook et al.

Data are limited on the incidence and management of streptococcal toxic shock syndrome (TSS) and nonstreptococcal TSS in children. We aimed to define the clinical patterns of TSS at Nationwide Children’s Hospital in Ohio as they relate to published criteria, diagnostic decisions, and treatment options. Through retrospective chart reviews, we identified 58 patients with TSS (27 streptococcal, 31 nonstreptococcal) during January 2010–September 2017. We observed clinical and laboratory findings that are not part of TSS criteria, such as pyuria in streptococcal TSS (50% of patients) and pulmonary involvement (85%) and coagulopathy (92%) in nonstreptococcal TSS patients. Recommended treatment with clindamycin and intravenous immunoglobulin was delayed in streptococcal TSS patients without rash (3.37 days vs. 0.87 days in patients with rash), leading to prolonged hospitalization and complications. Incorporation of additional TSS signs and symptoms would be helpful in TSS diagnosis and management.

EID Cook A, Janse S, Watson JR, Erdem G. Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010–2017. Emerg Infect Dis. 2020;26(6):1077-1083. https://doi.org/10.3201/eid2606.190783
AMA Cook A, Janse S, Watson JR, et al. Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010–2017. Emerging Infectious Diseases. 2020;26(6):1077-1083. doi:10.3201/eid2606.190783.
APA Cook, A., Janse, S., Watson, J. R., & Erdem, G. (2020). Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010–2017. Emerging Infectious Diseases, 26(6), 1077-1083. https://doi.org/10.3201/eid2606.190783.

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The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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