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• Yellow fever vaccine seroresponse was >90% regardless of prior LAIV timing. • Female gender was associated with decreased yellow fever vaccine seroresponse. • Decreased yellow fever vaccine seroresponse occurred 7–21 days after LAIV. • Immune interference should be studied with each combination of live vaccines. During routine mass live-attenuated influenza vaccination (LAIV) for military personnel, emergent deployment for Ebola humanitarian assistance (OUA) required mass yellow fever vaccination (YF17D), often < 4-weeks recommended timing post-LAIV—triggering concerns for immune interference. We compared YF17D seroconversion rates in personnel who received YF17D as recommended (vaccinated by guidelines [VBG]) to those who received the vaccine outside the recommended timing following LAIV (not vaccinated by guidelines [NVBG]). OUA deploying personnel who received LAIV simultaneously or before YF17D and had pre- and post-vaccination archived serum were included. VBG was defined as YF17D given concurrently or ≥ 30 days post-LAIV and NVBG as YF17D given 1–29 days post-LAIV. YF17D seroresponse was determined by screening ELISA confirmed with plaque reduction neutralization testing (PRNT) on positive ELISA samples. Exclusion criteria were prior YF17D and pre-vaccination YF17D positive PRNT. Of the 660 personnel included, 507 were VBG and 153 were NVBG. Median age was 25 years for both groups. Men accounted for 84% of those VBG and 79% NVBG (p = 0.194). Seroconversion rates were 97.8% for VBG and 95.4% for NVBG (p = 0.15). Multivariate logistic regression revealed that YF17D on days 7–21 post-LAIV (adjusted odds ratio [aOR] 0.304, p = 0.017; confidence interval [CI] 0.114–0.810) and female sex (aOR 0.330, p = 0.026; CI 0.124–0.879) were associated with decreased seroresponse. In this healthy, young adult military population, there was high seroconversion following YF17D when administered simultaneously and at various time points after LAIV. Slight decreases in seroresponse were seen in women and those receiving YF17D 7–21 days following LAIV. [ABSTRACT FROM AUTHOR]

Abstract: Background: Fungal wound infection is a leading cause of burn wound infections, and diagnosis is often delayed as it conventionally requires culture and histopathology. Fungal screening assays have sped diagnosis of invasive fungal infections in other populations. Few studies have evaluated the performance of fungal screening assays outside of the hematologic malignancy and hematopoietic stem cell transplant populations. Methods: We performed a three year retrospective analysis of all fungal screening assays in burn patients in the ICU between 2008 and 2011. The primary goal was to evaluate the correlation between the two available fungal screening assays, (1→3)-β-d-glucan (BG) and galactomannan (GM) assay, and fungal wound colonization (FWC) and infection (FWI). We also evaluated previously hypothesized causes of false positives and their associations with false positives in the burn population. Results: We identified 53 patients [median 29% total body surface area burned (TBSA), IQR 17–51] with BG or GM serological tests available, of which 15 had a FWI or FWC. FWC/FWI was associated with higher TBSA (p =0.02). BG and GM correlated with TBSA (BG 0.57, p <0.01; GM 0.35, p =0.02), but neither assay was associated with FWI/FWC or species of fungus involved when FWI/FWC was diagnosed. Conclusions: Positive BG and GM fungal screening assays are not associated with FWI/FWC, or with species of fungus when FWC/FWI is present. BG false positives are common and associated with higher TBSA burns. [Copyright &y& Elsevier]

The utility of follow-up blood cultures (FUBC) for gram-negative bloodstream infections (BSIs) are controversial due to low rates of positivity. However, recent studies suggest higher rates of positivity in critically ill patients. The utility of FUBC in gram-negative BSI in patients with severe burn injuries is unknown. Patients ≥ 18 years old admitted to the US Army Institute of Surgical Research Burn Center for combat-related thermal burns from 1/2003–6/2014 with a monomicrobial BSI were included. FUBC were defined as repeat cultures 1–5 days from index BSI. Persistent BSI (pBSI) was defined as isolation of the same organism from initial and FUBC. The primary endpoint was all-cause in-hospital mortality in patients with gram-negative pBSI. Of 126 patients meeting inclusion criteria with BSI, 53 (42%) had pBSI. Compared to patients without persistence, patients with pBSI had more severe burns with median total body surface area (TBSA) burns of 47% ([IQR 34–63] vs. 35.3% [IQR 23.3–56.6], p = 0.02), increased mortality (38 vs. 11%, p = 0.001) compared to those with non-persistent BSI. On multivariate analysis, pBSI was associated with an odds ratio for mortality of 5.3 [95% CI 1.8–15.8, p = 0.003). Amongst gram-negative pathogens, persistence rates were high and associated with increased mortality (41% vs. 11%, p = 0.001) compared to patients without pBSI. In this cohort of military patients with combat-related severe burns, pBSI was more common than in other hospitalized populations and associated with increased mortality. Given this high frequency of persistence in patients with burn injuries and associated mortality, FUBC are an important diagnostic and prognostic study in this population. • Gram-negative bacteremia persistence is common in patients with severe burns. • Persistent gram-negative bacteremia is associated with increased mortality. • Bloodstream infections should be monitored with repeat blood cultures in severe burns. [ABSTRACT FROM AUTHOR]

Introduction: Infections complicating burns generally transition from Gram-positive to Gram-negatives over the first couple weeks, but this depends on multiple factors. The microbiology of infections complicating crude oil (CO) and hydraulic fracturing (FRAC) burns is unknown.Methods: We performed a retrospective study of patients with industrial thermal burns hospitalized >2 days with ≥1 day in the ICU between 4/2011-11/2016. Burns were oil-related (ORB; CO or FRAC) or non-oil related (NORB). Epidemiology and microbiology during the first 15 hospital days was compared.Results: 149 patients were included, with 11 FRAC and 24 CO. CO burns were more severely burned than those with FRAC and NORB (p<0.05). Mortality was 17% and 18% for CO and FRAC burns compared to 3% in NORB (p<0.01). More cultures were obtained from ORB than NORB (p<0.05). ORB were associated with Stenotrophomonas maltophilia and FRAC associated with Serratia marcescens and Candida glabrata. Patients with FRAC, CO and NORB had a median of 13, 3.5, and 4 days to first positive culture respectively (p=0.03).Conclusion: ORB were associated with more severe burns and unique microbiology. FRAC burns had longer to initial positive culture, potentially suggesting our current methodology is inadequate to diagnose infections associated with FRAC. [ABSTRACT FROM AUTHOR]

We present extremity wound microbiology data from 250 combat casualties (2009–2012). Confirmed extremity wound infections (EWIs) were based on clinical and laboratory findings. Suspected EWIs had isolation of organisms from wound cultures with associated signs/symptoms not meeting clinical diagnostic criteria. Colonized wounds had organisms isolated without any infection suspicion. A total of 335 confirmed EWIs (131 monomicrobial and 204 polymicrobial) were assessed. Gram-negative bacteria were predominant (57% and 86% of monomicrobial and polymicrobial infections, respectively). In polymicrobial infections, 61% grew only bacteria, while 30% isolated bacteria and mold. Multidrug resistance was observed in 32% of isolates from first monomicrobial EWIs ±3 days of diagnosis, while it was 44% of isolates from polymicrobial EWIs. Approximately 96% and 52% of the suspected and colonized wounds, respectively, shared ≥1 organism in common with the confirmed EWI on the same patient. Understanding of combat-related EWIs can lead to improvements in combat casualty care. • Sixty-one percent of 335 confirmed extremity wound infections were polymicrobial. • Gram-negative bacteria predominant among combat-related extremity wound infections. • Enterococcus spp. most frequent organism isolated from polymicrobial infections. [ABSTRACT FROM AUTHOR]

Introduction: Surviving the first episode of bacteremia predisposes burn casualties to its recurrence. Herein, we investigate the incidence, mortality, bacteriology, and source of infection of recurrent bacteremia in military burn casualties admitted to the U.S. Army Institute of Surgical Research Burn Center over a 10year period.Methods: Bacteremia was defined as the growth of Gram-positive or Gram-negative organisms in a blood culture that excluded probable skin contaminants. Recurrent bacteremia was defined as a subsequent episode of bacteremia ≥7 days after the first episode. Polymicrobial bacteremia was the presence of more than one pathogen in the same blood culture. Bacteremia was attributed to UTI, pneumonia, or wound sepsis. All other bacteremias were considered non-attributable bloodstream infections. Univariate and multivariate analyses determined factors predictive of clinical outcome.Results: Out of 952 combat-related burn casualties screened, 166 cases were identified; 63% (non-recurrent) and 37% (recurrent) with median time to recurrence of 20 days. Univariate and multivariate analysis showed that the mortality rate was two and nine-fold, respectively, higher with recurrent bacteremia. Univariate analysis found that except for urinary tract infection, large burn size (>20%), 3rd degree burns, increased injuiry severity, perineal burns, and mechanical ventilator days were independent factors predictive of recurrence of bacteremia as well as increased mortality in the recurrent bacteremia cohort. Acinetobacter baumannii complex (63%) was prevalent in the non-recurrent group, while Klebsiella pneumoniae (46% vs. 30%) and Pseudomonas aeruginosa (35% vs. 26%) were prevalent in recurrent bacteremia. Half of the recurrent bacteremia cases were polymicrobial, compared to 9% in non-recurrent bacteremia. Pneumonia was prevalent in non-recurrent bacteremia (38%) and a combination of pneumonia and wound sepsis (29%) in recurrent bacteremia casualties.Conclusions: Recurrent bacteremia increases mortality in military burn casualties. Additional research is needed to address and mitigate the underlying causes, thereby improving survival. [ABSTRACT FROM AUTHOR]

Stenotrophomonas maltophilia is a pathogen with unique resistance patterns. We assessed 70 combat casualties with S. maltophilia clinical isolates to examine its role as a nosocomial pathogen in critically-ill trauma patients. Incidence density was 0.36 S. maltophilia infections per 100 patient-days (95% CI: 0.29–0.44). Patients predominantly had blast trauma (97%) and were critically injured (injury severity score [ISS] >25; 80%). Restricting to patients with ISS >15, 50 patients with S. maltophilia infections were compared to 441 patients with infections attributed to other gram-negative bacilli. Patients with S. maltophilia infections had significantly more operating room visits prior to isolation, traumatic or early surgical amputations, longer hospitalization (median 71 vs 47 days), and higher overall mortality (10% vs 2%; P = 0.01). Initial and serial (≥7 days between initial and subsequent isolation) S. maltophilia isolates had high susceptibility to trimethoprim-sulfamethoxazole and minocycline. Evaluation of newer agents awaiting CLSI breakpoints, including moxifloxacin, showed promising results. [ABSTRACT FROM AUTHOR]