William M. Janda's research while affiliated with Cook County Health and Hospitals System and other places

Dioctophyma renale (D. renale), or giant kidney worms are the largest nematodes that infect mammals. Approximately 20 cases of human infection have been reported. We present a case of a 71-year-old man with a recent history of unintentional weight loss and painle haematuria, passing elongated erythematous tissue via his urethra. CT revealed a left renal mass with pulmonary nodules and hepatic lesions. On microscopy the erythematous tissue passed was identified as D. renale. On subsequent renal biopsy, pathology was consistent with renal cell carcinoma. This is the first reported case of concomitant D. renale infection and renal cell carcinoma, and the second reported case of D. renale infection of the left kidney alone.

Over the last several decades, Neisseria gonorrhoeae has sequentially developed resistance to the agents recommended by the CDC and the Public Health Service for the treatment of gonorrhea. During the 1970s and through the 1990s, penicillin, tetracyclines, and the fluoroquinolones were recommended and subsequently removed as the therapy of choice for gonorrhea, leaving intramuscular ceftriaxone and the oral cephalosporin cefixime as the sole agents recommended for treatment of gonorrhea in 2010. In the late 1990s, treatment failures following oral cefixime therapy were recognized in Japan and the Far East, and subsequently, cefixime treatment failures were reported from the United Kingdom, Europe, and the United States. Gonococcal isolates from these cases showed diminished susceptibility to both cefixime and ceftriaxone, and molecular studies have shown that N. gonorrhoeae isolates with elevated cephalosporin MICs have genetic alterations primarily in the chromosomal penA gene, which encodes penicillin-binding protein 2. The altered proteins bind cephalosporins less efficiently, and isolates phenotypically demonstrate diminished cephalosporin susceptibility and elevated cefixime and ceftriaxone MICs. The penA alleles in these strains have a “mosaic” composition, as they contain nucleic acid sequences that were acquired from commensal Neisseria species. The strains also have genetic alterations in several other chromosomal loci that contribute to incremental cephalosporin resistance. With the utility of extended-spectrum cephalosporins for gonorrhea treatment being threatened, older agents (e.g., gentamicin and ertapenem) and newly developed antimicrobials (e.g., solithromycin) are now being evaluated as possible treatment options. The CDC has issued guidelines for the public health response to the emergence of cephalosporin-resistant N. gonorrhoeae. This plan includes improvements in gonococcal surveillance, identification by clinicians of “probable” and “suspected” treatment failures, the re-establishment of culture-based testing, and the timely performance of antimicrobial susceptibility testing on isolates obtained from treatment failures. Potential problems central to implementation of the response plan are also addressed.

In the second part of this two-part series on an update on the streptococci, new species and emergent human pathogens in the “viridans streptococci” and the “miscellaneous streptococci” groups are discussed. Among the “miscellaneous streptococci,” the most important organism in human infectious diseases is Streptococcus suis. This organism is primarily an agent of disease in swine and other animals and has now emerged as a significant human pathogen, causing bacteremia and meningitis, particularly among populations in Asia and the Far East. While S. suis capsular serotype 2 is the most frequently isolated agent, infections caused by other serotypes are increasingly being reported. In addition, disease caused by S. suis is now being described more frequently in North America in individuals with significant occupational exposure to swine. Among the viridans streptococci, several new species in the mitis-sanguinis group have been described as human pathogens, including Streptococcus pseudopneumoniae, Streptococcus oligofermentans, and Streptococcus tigurinus. Other newly reported viridans group species either comprise part of the human oral microbiome or have been isolated from animals. This article presents information on these bacterial agents, including characteristics for the recognition and identification of the more important clinical isolates in these streptococcal groups.

In this first part of a two-part update on the streptococci, new and emerging pathogens in the “pyogenic cocci group” and the “Streptococcus bovis group” are addressed. Among the pyogenic cocci, several new species have been described, and some of these are becoming relevant agents of human disease. Streptococcus porcinus and Streptococcus pseudoporcinus are β-hemolytic streptococci that are found in swine and humans, respectively. S. pseudoporcinus has been isolated primarily from the female genital tract and may play a role in genitourinary tract infections, wound infections, and adverse pregnancy outcomes. Streptococcus iniae, Streptococcus hongkongensis, and Streptococcus ictaluri are fish pathogens, and S. iniae, in particular, has been isolated from several human infections in persons who handle raw seafood or experience penetrating injuries from fish spines or crab pincers. Streptococcus gallolyticus subspecies (i.e., the former “S. bovis group”) are well-recognized causes of bacteremia, meningitis, and endocarditis. S. gallolyticus subsp. gallolyticus is known to be associated with colon cancer, and current studies suggest that other S. gallolyticus subspecies (particularly S. gallolyticus subsp. pasteurianus) may also be associated with meningitis and other digestive tract malignancies. In this review, current research on S. gallolyticus subspecies and proposed mechanisms for their involvement in the pathogenesis of colonic carcinoma are also briefly addressed.

The HACEK group of bacteria—Haemophilus parainfluenzae, Aggregatibacter species (Aggregatibacter aphrophilus, Aggregatibacter actinomycetemcomitans, and Aggregatibacter segnis), Cardiobacterium species (Cardiobacterium hominis and Cardiobacterium valvarum), Eikenella corrodens, and Kingella species—are fastidious gram-negative bacilli that are found in the human upper respiratory and genitourinary tracts. The HACEK bacteria are particularly associated with bacteremia and endocarditis, along with a variety of other infectious processes. This article describes the taxonomic status of the HACEK group, the types of infections and clinical specimens that may yield such organisms on culture, the phenotypic characteristics that are useful for species identification, and the susceptibility of these organisms to antimicrobial agents used for the treatment of HACEK group infections. Part I of this article will addresses the clinical significance of the HACEK group and specifically addresses Haemophilus, Aggregatibacter, and Cardiobacterium.

Characterizing pathogens responsible for recreational waterborne gastrointestinal illness is important in estimating risk and developing management strategies to prevent infection. Although water recreation is associated with sporadic cases of gastrointestinal illness, pathogens responsible for such illness are not well characterized. A prospective cohort study was conducted enrolling non-water recreators (such as cyclists and joggers) and two groups of limited-contact waters recreators (such as boaters and kayakers): those on an effluent-dominated urban waterway and those on general use waters. Stool samples were collected from participants who developed gastrointestinal symptoms during a three-week follow-up period. Samples were analyzed for bacterial, viral, and protozoan pathogens. Logistic regression models were used to identify associations between water recreation and the presence of pathogens in stool samples. Among 10,998 participants without gastrointestinal symptoms at baseline, 2,429 (22.1%) developed at least one symptom during 21 days of follow-up. Of those, 740 (30.5%) provided at least one stool sample, of which 76 (10.3%) were positive for a pathogen. Rotavirus, found primarily among adults, accounted for 53 of the 76 (70%) infections. Among participants with symptoms, pathogen presence was not associated with water recreation or the extent of water exposure. The range of pathogens that could be identified and sample size limitations may have contributed to this lack of association. We did not find specific pathogens or groups of pathogens associated with recreational waterborne gastrointestinal illness. Although pathogens responsible for outbreaks of waterborne gastrointestinal illness have been described, microbes that cause sporadic cases remain poorly defined.

A retrospective matched case-control study of hospitalized patients with vancomycin-resistant Enterococcus (VRE) infection with reduced susceptibility to linezolid was performed in order to identify risk factors for this infection and describe patient outcomes. Forty-eight linezolid nonsusceptible VRE cases were identified between January 1, 2000, and September 30, 2008, and compared to 96 controls with linezolid-susceptible VRE, matched based on culture date and anatomic site of infection. Demographic, clinical and microbiological data were collected. On univariable analysis, risk factors for reduced linezolid susceptibility included allogeneic hematopoietic stem cell transplant and/or solid organ transplant (odds ratio [OR]: 2.63; 95% confidence interval [CI]: 1.13-6.15; P = 0.025), receipt of immunosuppressive medications (OR: 2.39; 95% CI: 1.08-5.29; P = 0.032) including corticosteroids (OR: 2.40; 95% CI: 1.03-5.58; P = 0.042) and noncorticosteroid immunosuppressives (OR: 2.31; 95% CI: 1.00-5.30; P = 0.049), and receipt of linezolid within 1 year prior to infection (OR: 34.50, 95% CI: 4.60-259.02; P < 0.001). On multivariable analysis, only receipt of linezolid within 1 year remained an independent risk factor for reduced linezolid susceptibility (OR: 31.84; 95% CI: 4.20-241.39; P < 0.001), although most patients with VRE with reduced linezolid susceptibility had not received linezolid in the year prior. Reduced linezolid susceptibility did not impact patient outcomes including clinical or microbiological cure, hospital length of stay, or all-cause mortality.

We sought to determine the impact of timing of appropriate antifungal therapy, as assessed by susceptibility results, on patient survival. Patients ≥16 years of age with first episodes of candidaemia during 2001-09 were included. Clinical data were collected retrospectively, including time to appropriate antifungal therapy and patient survival. The study population included 446 patients [243 (54%) female, mean age 53 years] with candidaemia, 380 (85%) of whom had antifungal susceptibility data. Candida albicans was the most common pathogen (221, 50%) followed by Candida glabrata (99, 22%), Candida parapsilosis (59, 13%), Candida tropicalis (48, 11%) and Candida krusei (6, 1%). Appropriate antifungal therapy consisted of fluconazole (177, 40%), an echinocandin (125, 28%), amphotericin B (41, 9%) and voriconazole (6, 1%); 97 (22%) failed to receive appropriate antifungal therapy. The 30 day mortality was 34% (151/446) and there was no clear relationship between time from positive culture to receipt of appropriate antifungal therapy and 30 day survival. On multivariable Cox regression, increased APACHE II score [hazard ratio (HR) 1.11, 95% CI 1.09-1.13, P<0.001], cirrhosis (HR 2.15, 95% CI 1.48-3.13, P<0.001) and HIV infection (HR 2.03, 95% CI 1.11-3.72, P=0.02) were independent predictors of mortality. A secondary analysis requiring patients in the early treatment group to have received ≥24 h of effective antifungal therapy did show a significant mortality benefit to receiving antifungal treatment within 72 h of a positive blood culture being drawn (30 day mortality for early treatment: 27% versus 40%, P=0.004; HR for mortality with delayed treatment on multivariable analysis: 1.41, 95% CI 1.01-1.98, P=0.045). Candida bloodstream infection is associated with high mortality, despite timely receipt of appropriate antifungal therapy.

Since 1981, when the family Pasteurellaceae was established, this group of organisms has undergone a significant revision. This article describes the taxonomic status of the family Pasteurellaceae, especially the members of the genera Pasteurella and Actinobacillus.