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Costales-Cantrell JK, Chung J, Nomura JH, Ironside KR, Salama PW, Sim JJ. Antibiotic practice patterns with procalcitonin levels in patients with acute lower respiratory tract infection. Am J Manag Care 2022; 28:e35-e41. [PMID: 35139294 DOI: 10.37765/ajmc.2022.88825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Procalcitonin (PCT) testing is FDA approved to guide antibiotic therapy in patients with lower respiratory tract infection (LRTI). However, its utilization and impact on real-world antibiotic prescribing behavior are unknown. We investigated the rate of PCT testing to evaluate an association between initial PCT level and antibiotic prescription patterns for patients with suspected LRTI within a large integrated health system. STUDY DESIGN Retrospective cohort study. METHODS A retrospective cohort study (January 1, 2016, through December 31, 2017) was performed in patients 18 years and older who were hospitalized with LRTI and had a PCT measurement. Antibiotic changes were noted before and 36 hours after initial PCT results. Antibiotic concordance was determined using a PCT cutoff value of 0.25 mcg/L. Concordance was defined as (1) patients received antibiotics after a PCT of at least 0.25 mcg/L resulted or (2) antibiotics were withheld after a PCT less than 0.25 mcg/L resulted. RESULTS PCT testing occurred in 18% of hospitalized patients with LRTI. Among 1606 patients, antibiotic concordance with PCT results was 55%. Among the discordant population, 77% of patients received antibiotics in the setting of a low PCT level compared with 23% who did not receive antibiotics at a high PCT level. There were no statistical differences between LRTI types between patients with PCT-discordant and PCT-concordant care. CONCLUSIONS Within a real-world environment of patients hospitalized with LRTI, PCT testing was low and the PCT levels did not appear to influence antibiotic prescribing behavior. Our findings suggest that clinicians continue to prioritize clinical judgment over initial PCT levels when prescribing antibiotics for suspected LRTIs.
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Affiliation(s)
| | | | | | | | | | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, 4700 Sunset Blvd, Los Angeles, CA 90027.
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Costales-Cantrell JK, Dong EY, Wu BU, Nomura JH. Syphilitic Proctitis Presenting as a Rectal Mass: a Case Report and Review of the Literature. J Gen Intern Med 2021; 36:1098-1101. [PMID: 33469766 PMCID: PMC8042098 DOI: 10.1007/s11606-020-06414-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Jessica K Costales-Cantrell
- Division of Infectious Diseases, University of California Irvine Medical Center, 101 City Drive South, City Tower Suite 400, Orange, CA, 92868, USA.
| | - Elizabeth Y Dong
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Bechien U Wu
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Jim H Nomura
- Division of Infectious Diseases, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Situ BA, Streit SJ, Tran TC, Nomura JH, Bababeygy SR, Rodger DC. Two cases of uveitis associated with severe transaminitis during a Rickettsia typhi outbreak in Los Angeles County. Am J Ophthalmol Case Rep 2020; 19:100813. [PMID: 32715155 PMCID: PMC7374180 DOI: 10.1016/j.ajoc.2020.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 04/07/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose To report the clinical presentation, multimodal imaging, and management of two patients with Rickettsia typhi infection who presented with transaminitis and bilateral uveitis. Observations We report two cases of murine typhus-associated uveitis in the setting of a Rickettsia typhi outbreak in Los Angeles County. In case 1, a 29-year-old Hispanic female presented with scotoma of the right eye and bilateral floaters after 2 weeks of persistent fevers, maculopapular rash, and arthralgia. Clinical examination and optical coherence tomography (OCT) revealed vitreous cell and scattered white spots in both eyes at the level of the inner retina, and a cotton wool spot inferiorly in the left eye. Multiple hyperautofluorescent spots were seen on widefield fundus autofluorescence (FAF). Retinal vascular leakage and optic disc hyperfluorescence were visualized on widefield fluorescein angiography (FA). These findings were concerning for a white dot syndrome (WDS). The patient was started on oral prednisone 30 mg daily. Serologic testing during the convalescent phase returned positive for R. typhi infection and she was started on doxycycline. 3 weeks later, she reported complete resolution of scotoma and significant improvement of bilateral floaters. In the second case, a 42-year-old Hispanic male presented with sudden bilateral increased floaters and blurry vision after 12 days of persistent fever and headache. Clinical examination revealed trace flare with 1+ cell in the anterior chamber, 1+ vitreous cell, and multiple white dots in both eyes at the level of the inner retina. FAF showed scattered hyperautofluorescent spots in both eyes. FA demonstrated late retinal vascular leakage with bilateral hyperfluorescent optic discs. He was started on oral prednisone 40mg, prednisolone acetate 1% drops, and cyclopentolate 1% drops daily. 2 weeks later, serologic titers returned positive for murine typhus and he was started on doxycycline with gradual taper off of steroids. He subsequently had complete resolution of floaters, blurry vision, and the inner retinal white spots. Conclusions and Importance Murine typhus-associated uveitis may present with scotoma and increased floaters in the setting of persistent fevers and transaminitis, with pre- or inner retinal white spots seen on fundus examination. Ophthalmologists may aid in prompt diagnosis and initiation of antibiotic therapy, which can shorten the course of the disease and in turn, reduce the risk of severe complications.
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Affiliation(s)
- Betty A Situ
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA, USA
| | - Susan J Streit
- Kaiser Permanente Los Angeles Medical Center, 4867 W. Sunset Blvd., Los Angeles, CA, USA
| | - Timothy C Tran
- Kaiser Permanente Los Angeles Medical Center, 4867 W. Sunset Blvd., Los Angeles, CA, USA
| | - Jim H Nomura
- Kaiser Permanente Los Angeles Medical Center, 4867 W. Sunset Blvd., Los Angeles, CA, USA
| | - Simon R Bababeygy
- Kaiser Permanente Los Angeles Medical Center, 4867 W. Sunset Blvd., Los Angeles, CA, USA
| | - Damien C Rodger
- Kaiser Permanente Los Angeles Medical Center, 4867 W. Sunset Blvd., Los Angeles, CA, USA
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Park IU, Fakile YF, Chow JM, Gustafson KJ, Jost H, Schapiro JM, Novak-Weekley S, Tran A, Nomura JH, Chen V, Beheshti M, Tsai T, Hoover K, Bolan G. Performance of Treponemal Tests for the Diagnosis of Syphilis. Clin Infect Dis 2020; 68:913-918. [PMID: 29986091 DOI: 10.1093/cid/ciy558] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/07/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Treponemal immunoassays are increasingly used for syphilis screening with the reverse sequence algorithm. There are few data describing performance of treponemal immunoassays compared to traditional treponemal tests in patients with and without syphilis. METHODS We calculated sensitivity and specificity of 7 treponemal assays: (1) ADVIA Centaur (chemiluminescence immunoassay [CIA]); (2) Bioplex 2200 (microbead immunoassay); (3) fluorescent treponemal antibody absorption test (FTA-ABS); (4) INNO-LIA (line immunoassay); (5) LIAISON CIA; (6) Treponema pallidum particle agglutination assay (TPPA); and (7) Trep-Sure (enzyme immunoassay [EIA]), using a reference standard combining clinical diagnosis and serology results. Sera were collected between May 2012-January 2013. Cases were characterized as: (1) current clinical diagnosis of syphilis: primary, secondary, early latent, late latent; (2) prior treated syphilis only; (3) no evidence of current syphilis, no prior history of syphilis, and at least 4 of 7 treponemal tests negative. RESULTS Among 959 participants, 262 had current syphilis, 294 had prior syphilis, and 403 did not have syphilis. FTA-ABS was less sensitive for primary syphilis (78.2%) than the immunoassays or TPPA (94.5%-96.4%) (all P ≤ .01). All immunoassays were 100% sensitive for secondary syphilis, 95.2%-100% sensitive for early latent disease, and 86.8%-98.5% sensitive in late latent disease. TPPA had 100% specificity. CONCLUSIONS Treponemal immunoassays demonstrated excellent sensitivity for secondary, early latent, and seropositive primary syphilis. Sensitivity of FTA-ABS in primary syphilis was poor. Given its high specificity and superior sensitivity, TPPA is preferred to adjudicate discordant results with the reverse sequence algorithm over the FTA-ABS.
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Affiliation(s)
- Ina U Park
- Sexually Transmitted Disease Control Branch, Division of Communicable Disease Control, California Department of Public Health, Richmond.,Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yetunde F Fakile
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joan M Chow
- Sexually Transmitted Disease Control Branch, Division of Communicable Disease Control, California Department of Public Health, Richmond
| | - Kathleen J Gustafson
- Sexually Transmitted Disease Control Branch, Division of Communicable Disease Control, California Department of Public Health, Richmond
| | - Heather Jost
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Susan Novak-Weekley
- Southern California Permanente Medical Group Regional Reference Laboratory, North Hollywood
| | - Anthony Tran
- San Francisco Department of Public Health, California
| | - Jim H Nomura
- Southern California Permanente Medical Group, California
| | - Victor Chen
- Southern California Permanente Medical Group, California
| | - Manie Beheshti
- Southern California Permanente Medical Group, California
| | - Townson Tsai
- Southern California Permanente Medical Group, California
| | - Karen Hoover
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gail Bolan
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Kim JM, Costales JK, Modjtahedi B, Bluestone G, Nomura JH. 1348. Mycobacterium Chimera Infection Following Cardiac Surgery: A Review of a Large Cohort of Cases in the United States. Open Forum Infect Dis 2019. [PMCID: PMC6809341 DOI: 10.1093/ofid/ofz360.1212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Jani M Kim
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | | | - Bobeck Modjtahedi
- Southern California Permanente Medical Group, Baldwin Park, California
| | | | - Jim H Nomura
- Southern California Permanente Medical Group, Baldwin Park, California
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Nomura JH, Tsai T. 240. The Clinical Utility of Molecular Testing in the Diagnosis and Management of Infectious Diseases: Plasma-based Next-Generation Sequencing (PNGS). Open Forum Infect Dis 2019. [PMCID: PMC6810506 DOI: 10.1093/ofid/ofz360.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Molecular diagnostic tests can provide microbiologic results rapidly and with greater sensitivity than traditional methods. However, these tests come with considerable costs, so thoughtful diagnostic stewardship is essential to ensure that resources and outcomes are optimized. We sought to evaluate the impact of PNGS testing on patient management. Methods From February 2017 to January 2019, physicians in our group ordered 164 PNGS tests (Karius, Redwood City CA) on 125 patients. A retrospective chart review was performed to determine the clinical indication and utility of the test. Results The assay failure rate was 4.9% (8/164). Positive (pos) results were noted in 34% (53/156), of which 23 (43.4%) represented false pos results; 28 were true pos (52.8%) but 2 were unnecessary (also had pos blood cultures). The most common reason for testing was to assess for Mycobacterium chimera (Mc) infection, representing 94 of 156 (60.3%) tests. Of the 21 patients with known Mc, only 10/21 had pos initial tests (47.6%); if patients with Mc localized to the sternum were excluded (8 patients), 76.9% with deep organ involvement had pos initial tests. Five patients with deep Mc infection had persistently pos results while on therapy; 4 of these had not had surgery; 1 was 6 months s/p valve replacement for Mc. The next most common indication was to r/o endocarditis in 18/156 (11.5%) and had an impact in 8/18 (44.4%), including 4 patients whose PNGS result identified a likely pathogen in culture negative endocarditis (CNE). Of the 62 tests done for non-Mc patients, 33.9% (21/62) were useful for management decisions. Among patients who eventually had a diagnosis made but had negative PNGS results included patients with Whipple’s (1), CNS infection (2), and fungal infections (5). Conclusion Overall, only 17.9% (28/156) of tests yielded true pos results. The most common reason was to evaluate for Mc infection. PNGS did not detect Mc in patients with proven local disease and was pos in >75% with deep/disseminated disease. However, a negative result did not exclude significant Mc infection. Repeat testing can be considered if clinical suspicion is high but should not be done before standard blood cultures are negative. While more than 60% of the non-Mc tests were not clinically useful, there was modest added utility where infection is high on the differential especially patients with CNE. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Jim H Nomura
- Southern California Permanente Medical Group, Los Angeles, California
| | - Townson Tsai
- Southern California Permanente Medical Group, Los Angeles, California
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Groves JA, Shafi H, Nomura JH, Herron RM, Baez D, Dodd RY, Stramer SL. A probable case of West Nile virus transfusion transmission. Transfusion 2017; 57:850-856. [PMID: 28164314 DOI: 10.1111/trf.14018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/13/2016] [Accepted: 12/18/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transfusion-transmitted West Nile virus (WNV) infection is infrequent as a result of minipool (MP) and individual-donation (ID) nucleic acid testing (NAT) of blood donations. ID-NAT is triggered on the basis of local WNV activity identified by MP-NAT. STUDY DESIGN AND METHODS A 78-year-old male patient who was treated for cardiac disease received 14 blood components from 30 donors in August 2016. He was discharged 7 days after aortic valve replacement and coronary bypass surgery, but was re-admitted on Day 12 with symptoms of viral infection, and eventually was diagnosed with aseptic meningitis. The patent died on Day 51. RESULTS The patient was positive for WNV-immunoglobulin M (IgM) antibodies in his cerebrospinal fluid on Day 14 and was positive for WNV-IgM (on Days 14 and 16) and WNV-IgG antibodies (on Day 16) in his serum. All associated donations were nonreactive by MP-NAT or ID-NAT. However, one MP-NAT was noted to have an elevated (but negative) signal-to-cutoff ratio, and one donor from that MP was subsequently found positive for WNV-IgM and IgG antibodies; the donor was diagnosed with a WNV-like viral syndrome that had an onset 3 to 5 days postdonation. The donor's plasma was transfused 12 days before the patient's onset of WNV-meningoencephalitis. Conversion to ID-NAT was triggered for the region 7 days after the implicated donation, which was associated with the region's first human WNV case. CONCLUSION Despite the possibility of mosquito-borne transmission, this was considered to be a case of transfusion-transmitted WNV infection from an MP-NAT-nonreactive donation collected just before triggering conversion to ID-NAT; a rare event recognized once in 84 million donations.
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Affiliation(s)
- Jamel A Groves
- American Red Cross Scientific Affairs, Gaithersburg, Maryland
| | - Hedyeh Shafi
- Department of Pathology and Laboratory Medicine, Kaiser Permanente
| | - Jim H Nomura
- Southern California Permanente Medical Group, Los Angeles Medical Center, Division of Infectious Diseases, Los Angeles, California
| | - Ross M Herron
- American Red Cross Western Division, Pomona, California
| | - Devin Baez
- American Red Cross Donor Client Support Center, Charlotte, North Carolina
| | - Roger Y Dodd
- American Red Cross Scientific Affairs, Gaithersburg, Maryland
| | - Susan L Stramer
- American Red Cross Scientific Affairs, Gaithersburg, Maryland
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Nomura JH, Eichhorn K, Cao TM, Sahebi F. Cytomegalovirus sinusitis complicated by orbital apex syndrome in an immunocompromised host. Transpl Infect Dis 2016; 18:957-959. [PMID: 27677910 DOI: 10.1111/tid.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/06/2016] [Accepted: 07/14/2016] [Indexed: 11/29/2022]
Abstract
Sinusitis in immunocompromised patients can be caused by a wide variety of pathogens, primarily bacterial and fungal in nature. Tissue invasion can extend into the orbital apex and result in ophthalmoplegia and blindness. We report the first histologically proven case, to our knowledge, caused by cytomegalovirus infection.
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Affiliation(s)
- Jim H Nomura
- Division of Infectious Diseases, Kaiser Permanente Medical Center, Los Angeles, CA, USA
| | - Knut Eichhorn
- Department of Ophthalmology, Kaiser Permanente Medical Center, Los Angeles, CA, USA
| | - Thai M Cao
- Bone Marrow Transplant, Kaiser Permanente Medical Center, Los Angeles, CA, USA
| | - Firoozeh Sahebi
- Bone Marrow Transplant, Kaiser Permanente Medical Center, Los Angeles, CA, USA
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Hechter RC, Jacobsen SJ, Luo Y, Nomura JH, Towner WJ, Tartof SY, Tseng HF. Hepatitis B testing and vaccination among adults with sexually transmitted infections in a large managed care organization. Clin Infect Dis 2014; 58:1739-45. [PMID: 24571863 DOI: 10.1093/cid/ciu103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Data on viral hepatitis B (HBV) testing and vaccination in primary care settings among persons at sexual risk for HBV infection have been sparse. We examined rates and factors associated with HBV serologic testing and vaccination rates in adults infected with sexually transmitted infections. We conducted a retrospective cohort study of adults diagnosed with chlamydia, gonorrhea, or syphilis in Kaiser Permanente Southern California in 2008-2011. The vaccine series initiation was examined in subjects who were tested susceptible. The 90-day hepatitis B surface antigen (HBsAg) testing rate was 28.1% in 15 357 adults. Testing rates increased through the study period. Only 8.8% of patients received both HBsAg and hepatitis B surface antibody tests to determine prior exposure and susceptibility to HBV. Among those who were tested susceptible, 116 (10.6%) subjects initiated the vaccine series. In multivariable logistic regression analysis, the odds of receiving testing was inversely associated with female sex, black race, other/unknown race, or having prespecified chronic comorbidities. In survival analysis, adults aged 25-34 years and ≥55 years were more likely to initiate hepatitis B vaccine series compared with those aged 18-24 years. There are missed opportunities in HBV testing and vaccination in primary care. Implementation of provider decision-making support tools in the electronic medical record system may potentially improve hepatitis B testing and vaccination rates.
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Affiliation(s)
- Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jim H Nomura
- Division of Infectious Disease, Southern California Permanente Medical Group, Los Angeles
| | - William J Towner
- Division of Infectious Disease, Southern California Permanente Medical Group, Los Angeles
| | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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