Extrapulmonary Nontuberculous Mycobacterial Disease Surveillance - Oregon, 2014-2016

Therapeutic developments for tuberculosis and nontuberculous mycobacterial lung disease

Tuberculosis (TB) drug discovery and development has undergone nothing short of a revolution over the past 20 years. Successful public-private partnerships and sustained funding have delivered a much-improved understanding of mycobacterial disease biology and pharmacology and a healthy pipeline that can tolerate inevitable attrition. Preclinical and clinical development has evolved from decade-old concepts to adaptive designs that permit rapid evaluation of regimens that might greatly shorten treatment duration over the next decade. But the past 20 years also saw the rise of a fatal and difficult-to-cure lung disease caused by nontuberculous mycobacteria (NTM), for which the drug development pipeline is nearly empty. Here, we discuss the similarities and differences between TB and NTM lung diseases, compare the preclinical and clinical advances, and identify major knowledge gaps and areas of cross-fertilization. We argue that applying paradigms and networks that have proved successful for TB, from basic research to clinical trials, will help to populate the pipeline and accelerate curative regimen development for NTM disease.

Surveillance of Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2015-2020

Problem/Condition

Public health agencies in U.S. states, territories, and freely associated states investigate and voluntarily report waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS). This report summarizes NORS drinking water outbreak epidemiologic, laboratory, and environmental data, including data for both public and private drinking water systems. The report presents outbreak-contributing factors (i.e., practices and factors that lead to outbreaks) and, for the first time, categorizes outbreaks as biofilm pathogen or enteric illness associated.

Period Covered

2015-2020.

Description of System

CDC launched NORS in 2009 as a web-based platform into which public health departments voluntarily enter outbreak information. Through NORS, CDC collects reports of enteric disease outbreaks caused by bacterial, viral, parasitic, chemical, toxin, and unknown agents as well as foodborne and waterborne outbreaks of nonenteric disease. Data provided by NORS users, when known, for drinking water outbreaks include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated type of water system (e.g., community or individual or private); 4) the setting of exposure (e.g., hospital or health care facility; hotel, motel, lodge, or inn; or private residence); and 5) relevant epidemiologic and environmental data needed to describe the outbreak and characterize contributing factors.

Results

During 2015-2020, public health officials from 28 states voluntarily reported 214 outbreaks associated with drinking water and 454 contributing factor types. The reported etiologies included 187 (87%) biofilm associated, 24 (11%) enteric illness associated, two (1%) unknown, and one (<1%) chemical or toxin. A total of 172 (80%) outbreaks were linked to water from public water systems, 22 (10%) to unknown water systems, 17 (8%) to individual or private systems, and two (0.9%) to other systems; one (0.5%) system type was not reported. Drinking water-associated outbreaks resulted in at least 2,140 cases of illness, 563 hospitalizations (26% of cases), and 88 deaths (4% of cases). Individual or private water systems were implicated in 944 (43%) cases, 52 (9%) hospitalizations, and 14 (16%) deaths.Enteric illness-associated pathogens were implicated in 1,299 (61%) of all illnesses, and 10 (2%) hospitalizations. No deaths were reported. Among these illnesses, three pathogens (norovirus, Shigella, and Campylobacter) or multiple etiologies including these pathogens resulted in 1,225 (94%) cases. The drinking water source was identified most often (n = 34; 7%) as the contributing factor in enteric disease outbreaks. When water source (e.g., groundwater) was known (n = 14), wells were identified in 13 (93%) of enteric disease outbreaks.Most biofilm-related outbreak reports implicated Legionella (n = 184; 98%); two nontuberculous mycobacteria (NTM) (1%) and one Pseudomonas (0.5%) outbreaks comprised the remaining. Legionella-associated outbreaks generally increased over the study period (14 in 2015, 31 in 2016, 30 in 2017, 34 in 2018, 33 in 2019, and 18 in 2020). The Legionella-associated outbreaks resulted in 786 (37%) of all illnesses, 544 (97%) hospitalizations, and 86 (98%) of all deaths. Legionella also was the outbreak etiology in 160 (92%) public water system outbreaks. Outbreak reports cited the premise or point of use location most frequently as the contributing factor for Legionella and other biofilm-associated pathogen outbreaks (n = 287; 63%). Legionella was reported to NORS in 2015 and 2019 as the cause of three outbreaks in private residences (2).

Interpretation

The observed range of biofilm and enteric drinking water pathogen contributing factors illustrate the complexity of drinking water-related disease prevention and the need for water source-to-tap prevention strategies. Legionella-associated outbreaks have increased in number over time and were the leading cause of reported drinking water outbreaks, including hospitalizations and deaths. Enteric illness outbreaks primarily linked to wells represented approximately half the cases during this reporting period. This report enhances CDC efforts to estimate the U.S. illness and health care cost impacts of waterborne disease, which revealed that biofilm-related pathogens, NTM, and Legionella have emerged as the predominant causes of hospitalizations and deaths from waterborne- and drinking water-associated disease.

Public Health Action

Public health departments, regulators, and drinking water partners can use these findings to identify emerging waterborne disease threats, guide outbreak response and prevention programs, and support drinking water regulatory efforts.

Extrapulmonary nontuberculous mycobacterial infections: a guide for the general physician

Non-tuberculous mycobacteria (NTM) infections predominantly present as pulmonary disease. Although relatively rare, 20-30 % originate from extrapulmonary sites resulting in a wide range of clinical syndromes. Immunocompromised individuals are particularly susceptible. Clinical manifestations include skin and soft-tissue infections, lymphadenitis, musculoskeletal infections and disseminated disease. Diagnosing extrapulmonary NTM is challenging, and management is complex, often involving multiple radiological and microbiological investigations, long courses of combination antibiotic regimens and may require adjuvant surgical interventions. We highlight both the importance of involving NTM experts at an early stage and the role of a multidisciplinary approach in the diagnosis and management of these infections.

Nontuberculous Mycobacterial Pulmonary Disease in the Immunocompromised Host

The immunocompromised host is at an increased risk for pulmonary and extrapulmonary NTM infections. Where data are available in these specific populations, increased mortality is observed with NTM disease. Prior to starting therapy for NTM disease, providers should ensure diagnostic criteria are met as treatment is long and often associated with significant side effects and toxicities. Treatment should involve 2 to 4 agents and be guided by cultures and antimicrobial susceptibilities. Drug interactions are important to consider, especially in those with HIV or transplant recipients. Whenever possible, immunosuppression should be reduced or changed.

Global Epidemiology of Nontuberculous Mycobacterial Pulmonary Disease: A Review

Nontuberculous mycobacterial (NTM) isolation and pulmonary disease (NTM-PD) have continued to increase in most regions of the world, driven mainly by Mycobacterium avium. Single-center studies also support increasing trends as well as a persistent burden of undiagnosed NTM among persons suspected of having tuberculosis (TB), in countries with moderate-to-high TB prevalence. Cumulative exposure to water and soil presents an increased risk to susceptible hosts, and trace metals in water supply are recently recognized risk factors. Establishing standard case definitions for subnational and national surveillance systems with mandatory notification of NTM-PD are needed to allow comparisons within and across countries and regions.

Clinical characteristics of extrapulmonary nontuberculous mycobacteria infections in comparison with pulmonary infections: A single-center, retrospective study in Japan

INTRODUCTION

The prevalence of nontuberculous mycobacteria (NTM) infections is increasing worldwide. Although NTM can affect extrapulmonary organs, studies on the clinical characteristics of extrapulmonary NTM are rare.

METHODS

We retrospectively analyzed patients who were newly diagnosed with NTM infections at Hiroshima University Hospital between 2001 and 2021 to investigate species distribution, infected sites, and risk factors of extrapulmonary NTM compared to pulmonary NTM.

RESULTS

Of the 261 NTM infections, 9.6% and 90.4% had extrapulmonary and pulmonary NTM, respectively. The mean ages of patients with extrapulmonary and pulmonary NTM were 53.4 and 69.3 years, 64.0% and 42.8% were male, 36.0% and 9.3% received corticosteroids, 20.0% and 0% had acquired immune deficiency syndrome (AIDS), and 56.0% and 16.1% had any immunosuppressive conditions, respectively. Younger age, corticosteroid use, and AIDS were associated with extrapulmonary NTM. In pulmonary NTM, Mycobacterium avium complex (MAC) accounted for 86.4% of NTM species, followed by M. abscessus complex (4.2%), whereas in extrapulmonary NTM, M. abscessus complex, MAC, M. chelonae, and M. fortuitum accounted for 36.0%, 28.0%, 12.0%, and 8.0%, respectively. Compared to pulmonary NTM, extrapulmonary NTM were significantly more likely to be rapid-growing mycobacteria (RGM) (56.0% vs. 5.5%). The most common sites of infection were the skin and soft tissues (44.0%), followed by the blood (20.0%), tenosynovium, and lymph nodes (12.0%).

CONCLUSION

Younger age and immunosuppressive conditions are associated with extrapulmonary NTM, with a higher prevalence of RGM in extrapulmonary NTM than in pulmonary NTM. These results provide a better understanding of extrapulmonary NTM.

Epidemiology of Pulmonary and Extrapulmonary Nontuberculous Mycobacteria Infections at 4 US Emerging Infections Program Sites: A 6-Month Pilot

BACKGROUND

Nontuberculous mycobacteria (NTM) cause pulmonary (PNTM) and extrapulmonary (ENTM) disease. Infections are difficult to diagnose and treat, and exposures occur in healthcare and community settings. In the United States, NTM epidemiology has been described largely through analyses of microbiology data from health departments, electronic health records, and administrative data. We describe findings from a multisite pilot of active, laboratory- and population-based NTM surveillance.

METHODS

The Centers for Disease Control and Prevention's Emerging Infections Program conducted NTM surveillance at 4 sites (Colorado, 5 counties; Minnesota, 2 counties; New York, 2 counties; and Oregon, 3 counties [PNTM] and statewide [ENTM]) from 1 October 2019 through 31 March 2020. PNTM cases were defined using published microbiologic criteria. ENTM cases required NTM isolation from a nonpulmonary specimen, excluding stool and rectal swabs. Patient data were collected via medical record review.

RESULTS

Overall, 299 NTM cases were reported (PNTM: 231, 77%); Mycobacterium avium complex was the most common species group. Annualized prevalence was 7.5/100 000 population (PNTM: 6.1/100 000; ENTM: 1.4/100 000). Most patients had signs or symptoms in the 14 days before positive specimen collection (ENTM: 62, 91.2%; PNTM: 201, 87.0%). Of PNTM cases, 145 (62.8%) were female and 168 (72.7%) had underlying chronic lung disease. Among ENTM cases, 29 (42.6%) were female, 21 (30.9%) did not have documented underlying conditions, and 26 (38.2%) had infection at the site of a medical device or procedure.

CONCLUSIONS

Active, population-based NTM surveillance will provide data for monitoring the burden of disease and characterize affected populations to inform interventions.

Estimating Waterborne Infectious Disease Burden by Exposure Route, United States, 2014

More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases.

Toto, we're not in Kansas anymore: First reported case of M. persicum septic arthritis

In this report, we describe a case of septic arthritis caused by the newly described Mycobacterium persicum (formerly Mycobacterium kansasii complex). The patient's only significant exposure was home gardening. To our knowledge, this represents the first documented case of M. persicum infection in the United States and first septic arthritis.

A Rare Case of Osteomyelitis of an Ankle Caused by Mycobacterium chelonae

Mycobacterium chelonae, a rapidly growing nontuberculous mycobacterium, is usually described as a causative agent of soft tissue infections (postsurgical, posttraumatic, posttransplantation, postinjection, catheter infection, etc.), but only rarely as a cause of osteomyelitis. The authors describe a case report of a 72-year-old man with osteomyelitis of the talus. Initially, the infection was assessed as a soft tissue infection, without any osteolytic changes on the X-ray. After cultivation with subsequent targeted molecular typing of the rpoB gene, M. chelonae was identified from the affected tissue. The bone involvement was subsequently detected on MRI and confirmed histologically with findings of the granulomatous tissue and acid-fast bacilli. The patient was initially treated intravenously with a combination of tigecycline, amikacin, and moxifloxacin for 4 weeks, after which the oral combination of doxycycline and moxifloxacin continued. Identification of the infecting pathogen using molecular typing thus helped to establish the correct diagnosis and represents a rarely described case of osteomyelitis caused by M. chelonae.

Clinical characteristics of nontuberculous mycobacterial disease in people living with HIV/AIDS in South Korea: A multi-center, retrospective study

With the introduction of combination antiretroviral therapy (cART), the prevalence of human immunodeficiency virus (HIV)-associated nontuberculous mycobacteria (NTM) disease has declined. However, NTM diseases still occur in people living with HIV/acquired immunodeficiency syndrome (AIDS) (PLWHA). We analysed the clinical and microbiological features of NTM diseases in PLWHA in South Korea. PLWHA who were diagnosed with NTM diseases between January 2000 and March 2021 were retrospectively enrolled from five different hospitals in South Korea. Data on baseline demographics, HIV status, CD4+ T cell counts, viral load, past and current cART regimens, isolated NTM species, results of antimicrobial susceptibility tests, treatment regimens, and outcomes were collected by reviewing medical records. A total of 34 cases of NTM in PLWHA were included. Pulmonary and extrapulmonary NTM diseases accounted for 58.8% (n = 20) and 41.2% (n = 14), respectively. The lymph node was the most common site of extrapulmonary NTM disease (64.3%). The age at the time of NTM disease diagnosis was younger in the extrapulmonary NTM group than in the pulmonary NTM group (37.0 vs. 49.0 years). Mean CD4+ T cell counts at the time of NTM disease diagnosis was 186.6 cells/μL (range: 1–1394). Nine patients (26.5%) had fully suppressed viral loads at the time of NTM disease diagnosis. Mycobacterium avium complex (MAC) was the most common species found, followed by M. intracellulare and M. kansasii. MAC isolates were all susceptible to clarithromycin, but the rates of non-susceptibility to moxifloxacin, linezolid, ethambutol, and rifampin were 75%, 37.5%, 12.5%, and 12.5%, respectively. The average duration of treatment was 17 months and the mortality rate was 8.8%. NTM diseases may occur in PLWHA, even with completely suppressed viral loads. The identified clinical features of NTM diseases are essential for its clinical management in South Korea.

A case of mediastinal abscess and infected aortic aneurysm caused by dissemination of Mycobacterium abscessus subsp. massiliense pulmonary disease

An 81-year-old man was admitted to our hospital because of fever and malaise that had persisted for 3 months. The patient had undergone two aortic valve replacements, 10 and 5 years previously, because of aortic valve regurgitation and infectious endocarditis. He also had had asymptomatic Mycobacterium abscessus complex (MABC) pulmonary disease for the two previous years. Contrast-enhanced computed tomography showed a mediastinal abscess and an ascending aortic aneurysm. Mycobacterium abscessus subsp. massiliense was cultured from his blood, suggesting the aortic aneurysm was secondary to infection of an implanted device. After enlargement over only a few days, a leakage of contrast medium to the mediastinal abscess was found on computed tomography. The patient was diagnosed with rupture of an infectious aortic aneurysm, and emergency aortic replacement and drainage of the mediastinal abscess were successful. The patient was treated with several antibiotics, including meropenem, amikacin, and clarithromycin, and his general condition improved. Cultures from both the mediastinal abscess and a pericardial patch that was placed at the time of surgery 5 years previously revealed MABC. In our case, the infected aortic aneurysm most likely resulted from MABC pulmonary disease rather than from previous intraoperative contamination. This route of infection is rare. Physicians should be aware of the possibility of dissemination and subsequent infection of implants related to MABC pulmonary disease.

In vitro study of the effect of ALA-PDT on Mycobacterium abscessus and its antibiotic susceptibility

BACKGROUND

The skin infection caused by Mycobacterium abscessus (M. abscessus) is extremely difficult to treat in clinical practice. PDT (photodynamic therapy) is a promising antibacterial treatment. We evaluated the effect of photodynamic therapy using 5-aminolevulinic acid (ALA) as a photosensitizer on M. abscessus and its antibiotic resistance in this study.

METHODS

M. abscessus and biofilm were treated with different concentrations of ALA and then irradiated with LED light (635 nm, 80 J/cm²), while there were ALA-only group, light-only group, and negative control group. The effects were observed by colony counting, crystal violet staining, confocal laser scanning microscope (CLSM), and scanning electron microscope (SEM). The changes of drug susceptibility of M. abscessus at sublethal doses were detected by micro-broth dilution method, and the possible mechanism was explored by fluorometer and real-time fluorescence quantitative Polymerase Chain Reaction (RT-qPCR).

RESULTS

ALA-PDT showed a significant killing effect on M. abscessus at ALA concentrations greater than 50 μg/ml and the effect increased with increasing photosensitizer concentrations. ALA-PDT also showed a notable scavenging effect on M. abscessus biofilm, which was also enhanced with increasing ALA concentrations. At sublethal doses, the susceptibility of M. abscessus to antibiotics was increased, and ALA-PDT greatly increased the cell wall permeability of M. abscessus and decreased the mRNA expression of drug resistance genes whiB7 and erm (41), as well as efflux pump genes MAB_1409c and MAB_3142c at the transcriptional level.

CONCLUSIONS

ALA-PDT has a significant killing effect on M. abscessus and can increase its antibiotic susceptibility.

Non-tuberculous Mycobacterial Infection of the Musculoskeletal System Detected at Two Tertiary Medical Centres in Henan, China, 2016-2020

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal system is rare but poses a grave threat to public health. These infections yield non-specific symptoms that remain undetected until the development of the later stages of the disease. In this study, we performed a retrospective review of 25 cases of musculoskeletal NTM infection at two tertiary medical centres over a 5-year period to determine the clinical features and improve the current clinical diagnosis and treatment. The most common mycobacterial species detected were Mycobacterium fortuitum in eleven patients, Mycobacterium abscessus in eight patients, Mycobacterium houstonense in three patients, Mycobacterium avium in two patients, and Mycobacterium smegmatis in one patient. The sites of infection included the limbs and joints, most commonly the knee (ten patients) and foot (six patients). The median duration from the onset of symptoms to diagnosis was 2.5 months (0.8-13.5 months). Deep sinus tracts extending to the surgical site were observed in 60% of the patients (15/25), and granulomatous inflammation and granulomatous inflammation with necrosis occurred in 60% of the patients (15/25). All patients underwent surgical treatment for infection control, and all patients, except one, received antimycobacterial therapy based on drug sensitivity assays. The median duration of the antimicrobial chemotherapy was 5 months (range: 3-20 months). At the final follow-up, 24 patients presented with absence of recurrence and one patient succumbed owing to heart failure after debridement. Our findings highlight the importance of vigilance and improvements in the diagnostic methods for musculoskeletal NTM infection. Aggressive surgical treatment and antimycobacterial drug treatment can help achieve satisfactory results.

The epidemiology, demographics, and comorbidities of pulmonary and extra-pulmonary non-tuberculous mycobacterial infections at a large central Florida Academic Hospital

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Non-tuberculous mycoabcteria (NTM) cases have been increasing in the state of Florida, especially in the central portion of the state, where the population has been steadily increasing.

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Our analysis suggests that in our Mycobacterium abscessus complex was the most prevalent NTM seen in our patients, with Mycobacterium avium Complex being a distant second.

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Our GIS mapping of these local NTM cases describes where the patients lived relative to the organism which they grew.

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Furthermore, for the NTM isolates that we obtained data, we demonstrate the actual variability of antibiotic susceptibility, and with a few isolates, this was observed over time.

Rationale

In the United States, non-tuberculous mycobacterium (NTM) infections are considered an important cause of morbidity and mortality, especially in people with progressive lung disease. The state of Florida has an extremely high incidence and prevalence of NTM disease which is likely a rapidly emerging infection in the state due to environmental and demographic factors.

Objectives

Adjemian et al. [1] To determine the burden of NTM disease of patients admitted to a large Central Florida academic center, Falkinham [2] to identify the most common risk factors associated with developing NTM disease in this area, and Sfeir et al. [4] to categorize antimicrobial susceptibilities and genetic resistance markers.

Methods

We conducted a retrospective case review from January 1, 2011 to December 31, 2017 in a large university-associated metropolitan hospital in west-central Florida. NTM infections were identified using TheraDoc® during the study period with the inclusion criteria of any inpatient admission, culture confirmed NTM at any site, and age ≥ 12 years. Demographic variables (including residential zip code) and comorbidity data (including solid organ transplant status, HIV status and subsequent testing results, intrinsic pulmonary disease, and cancer diagnosis of any site) were collected for each patient. Microbiologic data collected included NTM species/subspecies, anatomic location of specimen collection, antimicrobial susceptibility including minimum inhibitory concentration (MIC). All collected data were analyzed within Stata/IC14.2. Geospatial relationships between zip codes, diagnosis type, and co-morbidities were computed using Arc GIS Pro.

Results

Our results demonstrated that a substantial number of our inpatient cases with NTM were of the M. abscessus group, and with M. avium complex and M. fortuitum also representing the pathogen in numerous cases. Novel findings included compilation of the first hospital wide comprehensive NTM resistance plot to our knowledge. Our results did show a concordance with previous data with expected predominance of NTM inpatient cases in Caucasian males with pre-existing pulmonary disease, though additional work could be done with isolates within the transplant and immunosuppressed populations.

Conclusions

Our data set demonstrates the most common species/subspecies of NTM infections and their associated conditions seen at our central Florida hospital, and includes an antimicrobial sensitivity analysis in toto. This could be insight into the possible prevalence of NTM in the area, and provides the foundation for future studies on both the acquisition and prevention for NTM infections in central Florida.

Mycobacterium porcinum Skin and Soft Tissue Infections After Vaccinations - Indiana, Kentucky, and Ohio, September 2018-February 2019

During December 2018-February 2019, a multistate investigation identified 101 patients with vaccination-associated adverse events among an estimated 940 persons in Kentucky, Indiana, and Ohio who had received influenza; hepatitis A; pneumococcal; or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines at the workplace during September 11-November 28, 2018. These vaccines had been administered by staff members of a third-party health care company contracted by 24 businesses. Company A provided multiple vaccine types during workplace vaccination events across 54 locations in these adjoining states. Injection-site wound isolates from patients yielded Mycobacterium porcinum, a nontuberculous mycobacteria (NTM) species in the Mycobacterium fortuitum group; subtyping using pulsed-field gel electrophoresis of all 28 available isolates identified two closely related clusters. Site visits to company A and interviews with staff members identified inadequate hand hygiene, improper vaccine storage and handling, lack of appropriate medical record documentation, and lack of reporting to the Vaccine Adverse Event Reporting System (VAERS). Vaccination-associated adverse events can be prevented by training health care workers responsible for handling or administering vaccines in safe vaccine handling, administration, and storage practices, timely reporting of any suspected vaccination-associated adverse events to VAERS, and notifying public health authorities of any adverse event clusters.

Extrapulmonary Nontuberculous Mycobacteria Infections in Hospitalized Patients, United States, 2009-2014

Nontuberculous mycobacteria (NTM) cause pulmonary and extrapulmonary infections in susceptible persons. To characterize the epidemiology of skin and soft tissue (SST) and disseminated extrapulmonary infections caused by NTM in the United States, we used a large electronic health record database to examine clinical, demographic, and laboratory data for hospitalized patients with NTM isolated from extrapulmonary sources during 2009–2014. Using all unique inpatients as the denominator, we estimated prevalence and summarized cases by key characteristics. Of 9,196,147 inpatients, 831 had confirmed extrapulmonary NTM. The 6-year prevalence was 11 cases/100,000 inpatients; source-specific prevalence was 4.4 SST infections/100,000 inpatients and 3.7 disseminated infections/100,000 inpatients. NTM species varied across geographic region; rapidly growing NTM were most prevalent in southern states. Infection with Mycobacterium avium complex was more common among patients with concurrent HIV and fungal infection, a relevant finding because treatment is more effective for M. avium complex than for other NTM infections.

Coinfection by Talaromyces marneffei and Mycobacterium abscessus in a human immunodeficiency virus-negative patient with anti-interferon-γ autoantibody: a case report

Patients with anti-interferon (IFN)-γ autoantibodies have weakened immune defenses against intracellular pathogens. Because of its low incidence and non-specific symptoms, diagnosis of anti-IFN-γ autoantibody syndrome is difficult to establish during the early stages of infection. Here, we report a patient with high titers of serum anti-IFN-γ autoantibodies suffering from opportunistic infections. The patient presented with intermittent fever for 2 weeks. During his first hospitalization, he was diagnosed with Talaromyces marneffei pulmonary infection and successfully treated with antifungal therapy. However, multiple cervical lymph nodes subsequently became progressively enlarged. Mycobacterium abscessus infection was confirmed by positive cervical lymph node tissue cultures. High-titer serum anti-IFN-γ antibodies were also detected. Following anti-M. abscessus therapy, both his symptoms and lymph node lymphadenitis gradually improved. Anti-IFN-γ autoantibody syndrome should be considered in adult patients with severe opportunistic coinfections in the absence of other known risk factors.

Profiles of Extrapulmonary Nontuberculous Mycobacteria Infections and Predictors for Species: A Multicenter Retrospective Study

Extrapulmonary nontuberculous mycobacteria (NTM) infections contribute to morbidity and mortality worldwide. However, studies about extrapulmonary NTM infections have been limited. Therefore, we aim to describe the diversity of extrapulmonary NTM infections and identify predictors for species. Information regarding diversity of NTM isolates, antimicrobial susceptibility testing, treatment regimens, and outcomes were collected from four tertiary care centers in South Korea. Comparisons were made between patients with rapidly growing mycobacteria (RGM) and slowly growing mycobacteria (SGM) infections. A total of 117 patients (46 males vs. 71 females) were included. Skin and soft tissue infections (SSTIs) predominated (34.2%), followed by bone and joint infections (28.2%). In SSTIs, RGM species were predominantly identified (26/28, 92.9%), whereas SGM species were mainly identified in bone and joint infections (18/26, 69.2%), and the difference of isolated sites was verified by a post hoc test (p < 0.001). Multivariable regression analysis revealed that male sex (vs. female sex; OR 5.30, CI 1.35–24.26, p = 0.020) and bone and joint infections (vs. SSTIs; OR 18.10, CI 3.28–157.07, p = 0.002) were predictors of SGM infections, whereas the opposite was observed for RGM infections. Bone and joint infections and male sex were predictors for SGM infections, whereas SSTIs and female sex were predictors for RGM infections.

Characteristics of clinical extrapulmonary nontuberculous mycobacteria isolates in Minnesota, 2013-2017

Approximately 80 species of nontuberculous mycobacteria (NTM) that cause disease are found environmentally and in animal reservoirs. Typically, pulmonary NTM infections are sporadic; extrapulmonary NTM (ENTM) infections are commonly outbreak associated. Recent sources of ENTM outbreaks in Minnesota include contaminated heater-cooler units used during cardiac surgery and contaminated hormone injections. We examined patient demographics and characteristics of ENTM isolates characterized by four Minnesota reference laboratories during 2013-2017 to assess potential value of systematic laboratory-based ENTM surveillance in Minnesota. Laboratories characterized 490 ENTM isolates, representing an estimated burden of 1.8/100,000 people/year in Minnesota. Thirty-one species or complexes were identified; most common were M. avium complex (31%), M. chelonae (22%), M. fortuitum (11%), and M. abscessus (4%). Most common specimen collection sites included skin and soft tissue (38%), blood (15%), neck lymph node or tissue (12%), sinus (8%), joint or bone (5%), device or implant (4%), and eye (3%). Median age of patients was 55 years (range: 2-98 years); 18% were from patients aged <18 years, 20% aged 18-44 years, 28% aged 45-64 years and 34% aged >65 years. Sex was documented for 238 (49%) patients; 127 (53%) were males. County information was available for 313 patients (64%); approximately half (49%) resided in metropolitan Minneapolis-Saint Paul. Laboratory data can be used for ENTM surveillance in Minnesota. Implementing laboratory-based surveillance can detect ENTM cases, provide a mechanism for obtaining clinical and epidemiological information, and enable earlier identification of potential health care transmission or community clusters.

Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017

OBJECTIVE

Water exposures in healthcare settings and during healthcare delivery can place patients at risk for infection with water-related organisms and can potentially lead to outbreaks. We aimed to describe Centers for Disease Control and Prevention (CDC) consultations involving water-related organisms leading to healthcare-associated infections (HAIs).

DESIGN

Retrospective observational study.

METHODS

We reviewed internal CDC records from January 1, 2014, through December 31, 2017, using water-related terms and organisms, excluding Legionella, to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare. We determined plausible exposure pathways and routes of transmission when possible.

RESULTS

Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, that involved the investigation of potential water-related HAIs or infection control lapses with the potential for water-related HAIs. Nontuberculous mycobacteria were involved in the greatest number of investigations (n = 40, 29.9%). Most frequently, investigations involved medical products (n = 48, 35.8%), and most of these products were medical devices (n = 40, 83.3%). We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices.

CONCLUSIONS

Water-related investigations represent a substantial proportion of CDC HAI consultations and likely represent only a fraction of all water-related HAI investigations and outbreaks occurring in US healthcare facilities. Water-related HAI investigations should consider all potential pathways of water exposure. Finally, healthcare facilities should develop and implement water management programs to limit the growth and spread of water-related organisms.

Nontuberculous mycobacterial infections of the lower extremities: A 15-year experience

Objectives

Nontuberculous mycobacterial infection (NTMI), which is increasing in prevalence, is challenging to diagnose and manage despite the availability of capable laboratories because of subtle and nonspecific clinical findings and nonstandardized treatment guidelines. We aimed to present our experience with lower-extremity NTMI and to compare clinical characteristics and treatment outcomes between immunocompetent and immunocompromised patients.

Methods

To determine clinical presentations and outcomes, we reviewed electronic health records of all patients with lower-extremity NTMI treated and followed up at our institution from January 2002 through December 2017.

Results

Twenty-four patients were included in this study. Mean (SD) age was 58 (19) years. Eighteen patients (75%) were men; 13 (54%) were immunocompetent; and 9 (37%) had bone and joint involvement. No significant differences existed between immunocompetent and immunocompromised patients, except immunocompetent patients had significantly more infections at the hip, thigh, and toe. Bone and joint infection required significantly longer treatment time than skin and soft-tissue infection.

Conclusions

Regardless of immune status, patients with lower-extremity NTMI had similar characteristics, treatments, and outcomes. However, immunosuppression can be a major risk factor in the development of disseminated NTMI and associated complications. Acid-fast bacilli culture is strongly recommended for evaluation of delayed or nonhealing lesions. Aggressive medical and surgical management can be associated with good clinical outcomes.