Clinical Focus

  • Infectious Disease

Academic Appointments

Administrative Appointments

  • Director, Hospital Epidemiology/Infection Prevention & Control Fellowship, Stanford University (2021 - Present)
  • Medical Director, Infection Prevention and Control Program, Stanford Healthcare (2021 - Present)
  • Hospital Epidemiologist, University of Iowa (2017 - 2021)

Honors & Awards

  • Chair Diversity Award, Stanford Medicine (2022)
  • Integrated Plan Star Award, Stanford Medicine (2021)
  • Merit Award, Iowa Medical Society (2021)
  • 40 under 40, Corridor Business Journal, Iowa (2020)
  • Excellence in the Workplace Award, University of Iowa Physicians (2020)
  • Young Investigator Award, Conference on Retroviruses and Opportunistic Infections (CROI) (2015)
  • VECD Fogarty Global Health Fellow, Fogarty Center, National Institutes of Health (2014)
  • Travel Award, IDSA Annual Meeting, IDWeek (2012)
  • Honorable Mention, Thomas N. James Award for Excellence in Research, Trainee, Department of Medicine, The University of Alabama at Birmingham (2012)
  • TIME-R AWARD, Department of Medicine, The University of Alabama at Birmingham (2010)

Boards, Advisory Committees, Professional Organizations

  • Chair, Public Health Taskforce. Society for Healthcare Epidemiology of America (2023 - Present)
  • Member, Healthcare-associated Infection Advisory Committee. California Department of Public Health (2022 - Present)
  • Co-chair, Mpox Clinical Advisory Leadership Council, Stanford Healthcare (2022 - 2022)
  • Member, Editorial Board, Antimicrobial Stewardship and Healthcare Epidemiology journal (2021 - Present)
  • Member, COVID Clinical Oversight Resource Team, Stanford Healthcare (2021 - 2023)
  • Member, Publications Committee, Society for Healthcare Epidemiology of America (2020 - 2023)
  • Member, Infectious Disease Advisory Council to the Iowa Department of Public Health (2020 - 2021)
  • Member, Governor's, Economic Recovery Advisory Board, Public Health and Healthcare Workgroup, Iowa (2020 - 2020)
  • Reviewer, Special Emphasis Panel. Modelling Infectious Diseases in Healthcare Network. CDC (2020 - 2020)
  • Reviewer, Consejo Nacional de Ciencia, Tecnologia e Innovacion Tecnologica. Peru (2020 - 2020)
  • Member, Healthcare Associated Infection & Antibiotic Resistance Advisory Group, Iowa Department of Public Health (2019 - 2021)

Professional Education

  • Epidemic Intelligence Service, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention (2017)
  • Fellowship: Emory University Infectious Diseases Fellowship (2015) GA
  • Board Certification: American Board of Internal Medicine, Infectious Disease (2014)
  • Residency: University of Alabama at Birmingham (2012) AL
  • Medical Education: Universidad Nacional De San Marcos (2007) Peru

Graduate and Fellowship Programs

All Publications

  • Low infectivity among asymptomatic patients with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) admission test at a tertiary care center, 2020-2022. Infection control and hospital epidemiology Tayyar, R., Kiener, M. A., Liang, J. W., Contreras, G., Rodriguez-Nava, G., Zimmet, A. N., Contag, C. A., Srinivasan, K., McIntyre, K., Subramanian, A., Shepard, J., Tompkins, L. S., Pinsky, B. A., Salinas, J. L. 2023: 1-3


    We used a strand-specific RT-qPCR to evaluate viral replication as a surrogate for infectiousness among 242 asymptomatic inpatients with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) admission test. Only 21 patients (9%) had detectable SARS-CoV-2 minus-strand RNA. Because most patients were found to be noninfectious, our findings support the suspension of asymptomatic admission testing.

    View details for DOI 10.1017/ice.2023.210

    View details for PubMedID 37746805

  • Diagnostic Stewardship: A Systematic Review and Meta-analysis of Blood Collection Diversion Devices Used to Reduce Blood Culture Contamination and Improve the Accuracy of Diagnosis in Clinical Settings. Open forum infectious diseases Callado, G. Y., Lin, V., Thottacherry, E., Marins, T. A., Martino, M. D., Salinas, J. L., Marra, A. R. 2023; 10 (9): ofad433


    Blood culture contamination may lead to misdiagnosis, overutilization of antibiotics, and prolonged length of stay. Blood specimen diversion devices can reduce contamination rates during blood culture collection procedures. We performed a systematic literature review and meta-analysis evaluating the influence of blood specimen diversion devices in blood culture contamination rates.We searched Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science, from database inception to 1 March 2023, for studies evaluating the impact of a diversion device on blood culture contamination. Blood culture contamination was a positive blood culture with microorganisms not representative of true bacteremia, but rather introduced during collection or processing the blood sample. Random-effects models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test.Of 1768 screened studies, 12 met inclusion criteria for this systematic literature review. Of them, 9 studies were included in the meta-analysis. Studies were substantially heterogeneous, but stratified analyses considering only high-quality studies revealed that venipuncture using a diversion device was associated with a significant reduction in blood culture contamination in comparison to the standard procedure of collection (pooled odds ratio [OR], 0.26 [95% confidence interval {CI}, .13-.54]; I2 = 19%). Furthermore, the stratified analysis showed that the adoption of a diversion device did not reduce the detection of true infection (pooled OR, 0.85 [95% CI, .65-1.11]; I2 = 0%).Blood culture diversion devices was associated with decreased contamination rates and could improve quality of care, reduce costs, and avoid unnecessary antibiotic use.

    View details for DOI 10.1093/ofid/ofad433

    View details for PubMedID 37674630

    View details for PubMedCentralID PMC10478151

  • Hospitalization risk among patients with Mpox infection-a propensity score matched analysis. Therapeutic advances in infectious disease Henao-Martínez, A. F., Orkin, C. M., Titanji, B. K., Rodriguez-Morales, A. J., Salinas, J. L., Franco-Paredes, C., Tuells, J., Chastain, D. B. 2023; 10: 20499361231196683


    Monkeypox (Mpox) is a reemerging, neglected viral disease. By May 2023, worldwide Mpox cases surpassed 87,000. Predictive factors for hospitalization with Mpox are lacking.We aim to compare clinical characteristics and outcomes in hospitalized and nonhospitalized patients with Mpox infection.A multicenter retrospective case-control cohort of patients with Mpox infection.We performed a propensity score match analysis from a global health network (TrinetX). We compare clinical characteristics and outcomes between hospitalized and nonhospitalized patients with Mpox.Of 1477 patients, 6% were hospitalized, 52% required an ED visit, and 29% received treatment at urgent care. After propensity score matching, 80 patients remained in each group. Hospitalizations were more common among Black persons (51% versus 33%, p = 0.01), people with HIV (50% versus 20%, p < 0.0001), and those with proctitis (44% versus 12.5%, p < 0.001).Independent predictive factors of hospitalization in our cohort for Mpox included people who are Black with a diagnosis of HIV, severe proctitis, pain requiring opioids, and elevated lactate dehydrogenase. Greater recognition of factors associated with increased risk of Mpox severity and hospitalization is paramount.

    View details for DOI 10.1177/20499361231196683

    View details for PubMedID 37663111

    View details for PubMedCentralID PMC10469242

  • A review of extended coronavirus disease 2019 (COVID-19) isolation duration among inpatients in a tertiary-care hospital-Iowa, 2020-2022. Infection control and hospital epidemiology Abosi, O. J., Trannel, A., Schwartzhoff, P., Ackman, M., Zilles, B., Marra, A. R., Dains, A., Naito, T., Salinas, J. L., Diekema, D. J., Hanna, B., Murphy, J. P., Wellington, M., Brust, K., Kobayashi, T. 2023: 1-4


    Of the 2,668 patients admitted with coronavirus disease 2019 (COVID-19), 4% underwent prolonged isolation for >20 days. Reasons for extended isolation were inconsistent with Centers for Disease Control and Prevention (CDC) guidelines in 25% of these patients and were questionable in 54% due to an ongoing critically ill condition at day 20 without CDC-defined immunocompromised status.

    View details for DOI 10.1017/ice.2023.154

    View details for PubMedID 37528757

  • Use of a severe acute respiratory coronavirus virus 2 (SARS-CoV-2) strand-specific assay to evaluate for prolonged viral replication >20 days from illness onset. Infection control and hospital epidemiology Ferguson, J. D., Tayyar, R., Contreras, G., Kiener, M., Zimmet, A. N., Contag, C. A., Rodriguez Nava, G., Tompkins, L. S., Shepard, J., Rosenthal, A., Subramanian, A. K., Pinsky, B. A., Salinas, J. L. 2023: 1-3


    Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) real-time reverse-transcription polymerase chain reaction (rRT-PCR) strand-specific assay can be used to identify active SARS-CoV-2 viral replication. We describe the characteristics of 337 hospitalized patients with at least 1 minus-strand SARS-CoV-2 assay performed >20 days after illness onset. This test is a novel tool to identify high-risk hospitalized patients with prolonged SARS-CoV-2 replication.

    View details for DOI 10.1017/ice.2023.105

    View details for PubMedID 37381726

  • Longer-term effectiveness of a heterologous coronavirus disease 2019 (COVID-19) vaccine booster in healthcare workers in Brazil. Antimicrobial stewardship & healthcare epidemiology : ASHE Marra, A. R., Miraglia, J. L., Malheiro, D. T., Guozhang, Y., Teich, V. D., Victor, E. d., Pinho, J. R., Cypriano, A., Vieira, L. W., Polonio, M., Ornelas, R. H., de Oliveira, S. M., Borges, F. A., Oler, S. C., Ricardo, V. C., Maezato, A. M., Callado, G. Y., Schettino, G. d., de Oliveira, K. G., Santana, R. A., Malta, F. d., Amgarten, D., Boechat, A. L., Kobayashi, T., Salinas, J. L., Edmond, M. B., Rizzo, L. V. 2023; 3 (1): e104


    To compare the long-term vaccine effectiveness between those receiving viral vector [Oxford-AstraZeneca (ChAdOx1)] or inactivated viral (CoronaVac) primary series (2 doses) and those who received an mRNA booster (Pfizer/BioNTech) (the third dose) among healthcare workers (HCWs).We conducted a retrospective cohort study among HCWs (aged ≥18 years) in Brazil from January 2021 to July 2022. To assess the variation in the effectiveness of booster dose over time, we estimated the effectiveness rate by taking the log risk ratio as a function of time.Of 14,532 HCWs, coronavirus disease 2019 (COVID-19) was confirmed in 56.3% of HCWs receiving 2 doses of CoronaVac vaccine versus 23.2% of HCWs receiving 2 doses of CoronaVac vaccine with mRNA booster (P < .001), and 37.1% of HCWs receiving 2 doses of ChAdOx1 vaccine versus 22.7% among HCWs receiving 2 doses of ChAdOx1 vaccine with mRNA booster (P < .001). The highest vaccine effectiveness with mRNA booster was observed 30 days after vaccination: 91% for the CoronaVac vaccine group and 97% for the ChAdOx1 vaccine group. Vacine effectiveness declined to 55% and 67%, respectively, at 180 days. Of 430 samples screened for mutations, 49.5% were SARS-CoV-2 delta variants and 34.2% were SARS-CoV-2 omicron variants.Heterologous COVID-19 vaccines were effective for up to 180 days in preventing COVID-19 in the SARS-CoV-2 delta and omicron variant eras, which suggests the need for a second booster.

    View details for DOI 10.1017/ash.2023.173

    View details for PubMedID 37396193

    View details for PubMedCentralID PMC10311693

  • Photo Quiz: A 50-Year Old Man with Fever and Headache. Journal of clinical microbiology Zimmet, A. N., Mah, J. K., Budvytiene, I., Banaei, N., Salinas, J. L. 2023; 61 (6): e0172522

    View details for DOI 10.1128/jcm.01725-22

    View details for PubMedID 37338227

  • Answer to June 2023 Photo Quiz. Journal of clinical microbiology Zimmet, A. N., Mah, J. K., Budvytiene, I., Banaei, N., Salinas, J. 2023; 61 (6): e0175422

    View details for DOI 10.1128/jcm.01754-22

    View details for PubMedID 37338230

  • Reconsidering the routine use of contact precautions in preventing the transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in healthcare settings. Infection control and hospital epidemiology Rodriguez-Nava, G., Diekema, D. J., Salinas, J. L. 2023: 1-2

    View details for DOI 10.1017/ice.2023.91

    View details for PubMedID 37138546

  • Retrospective Screening of Clinical Samples for Monkeypox Virus DNA, California, USA, 2022. Emerging infectious diseases Contag, C. A., Lu, J., Renfro, Z. T., Karan, A., Salinas, J. L., Khan, M., Solis, D., Sahoo, M. K., Yamamoto, F., Pinsky, B. A. 2023; 29 (4): 848-850


    We retrospectively screened oropharyngeal and rectal swab samples originally collected in California, USA, for Chlamydia trachomatis and Neisseria gonorrhoeae testing for the presence of monkeypox virus DNA. Among 206 patients screened, 17 (8%) had samples with detectable viral DNA. Monkeypox virus testing from mucosal sites should be considered for at-risk patients.

    View details for DOI 10.3201/eid2904.221576

    View details for PubMedID 36918374

    View details for PubMedCentralID PMC10045697

  • A deep-learning algorithm to classify skin lesions from mpox virus infection. Nature medicine Thieme, A. H., Zheng, Y., Machiraju, G., Sadee, C., Mittermaier, M., Gertler, M., Salinas, J. L., Srinivasan, K., Gyawali, P., Carrillo-Perez, F., Capodici, A., Uhlig, M., Habenicht, D., Loser, A., Kohler, M., Schuessler, M., Kaul, D., Gollrad, J., Ma, J., Lippert, C., Billick, K., Bogoch, I., Hernandez-Boussard, T., Geldsetzer, P., Gevaert, O. 2023


    Undetected infection and delayed isolation of infected individuals are key factors driving the monkeypox virus (now termed mpox virus or MPXV) outbreak. To enable earlier detection of MPXV infection, we developed an image-based deep convolutional neural network (named MPXV-CNN) for the identification of the characteristic skin lesions caused by MPXV. We assembled a dataset of 139,198 skin lesion images, split into training/validation and testing cohorts, comprising non-MPXV images (n=138,522) from eight dermatological repositories and MPXV images (n=676) from the scientific literature, news articles, social media and a prospective cohort of the Stanford University Medical Center (n=63 images from 12 patients, all male). In the validation and testing cohorts, the sensitivity of the MPXV-CNN was 0.83 and 0.91, the specificity was 0.965 and 0.898 and the area under the curve was 0.967 and 0.966, respectively. In the prospective cohort, the sensitivity was 0.89. The classification performance of the MPXV-CNN was robust across various skin tones and body regions. To facilitate the usage of the algorithm, we developed a web-based app by which the MPXV-CNN can be accessed for patient guidance. The capability of the MPXV-CNN for identifying MPXV lesions has the potential to aid in MPXV outbreak mitigation.

    View details for DOI 10.1038/s41591-023-02225-7

    View details for PubMedID 36864252

  • Case Report: Monkeypox - Not Just a Rash. The American journal of tropical medicine and hygiene Contag, C. A., Karan, A., Studemeister, L., Bansil, R., Fong, I., Srinivasan, K., Salinas, J. L., Narasimhan, S., Cooper, J. D., Sahni, H. 2023


    Mpox (formally monkeypox) is an Orthopoxvirus associated with both zoonotic and person-to-person spread. Human mpox classically presents with rash and systemic symptoms. Although sporadic outbreaks of mpox have occurred worldwide, the 2022 outbreak is the first of pandemic significance. Thousands of geographically dispersed cases were reported beginning in May 2022. The clinical presentations and outcomes of mpox infection have varied greatly based on viral clade. Further guidance is needed for clinicians to diagnose and treat this emerging infection. We present five clinical vignettes of confirmed cases diagnosed in June and July 2022 in northern California to demonstrate the range of mpox disease, including myocarditis, pharyngitis, epididymitis, and proctitis. We note a significant overlap with HIV infection and a high rate of concurrent sexually transmitted infection. Given the heterogenous presentations of mpox disease, clinicians should maintain a high degree of suspicion in patients with oropharyngeal or genital lesions, proctitis, or new rash.

    View details for DOI 10.4269/ajtmh.22-0626

    View details for PubMedID 36716741

  • Human Monkeypox without Viral Prodrome or Sexual Exposure, California, USA, 2022. Emerging infectious diseases Karan, A., Styczynski, A. R., Huang, C., Sahoo, M. K., Srinivasan, K., Pinsky, B. A., Salinas, J. L. 2022; 28 (10)


    We report human monkeypox in a man who returned to the United States from the United Kingdom and reported no sexual contact. He had vesicular and pustular skin lesions but no anogenital involvement. The potential modes of transmission may have implications for the risk of spread and for epidemic control.

    View details for DOI 10.3201/eid2810.221191

    View details for PubMedID 35971952

  • Pediatric surgical site infections in 287 hospitals in the United States, 2015-2018. Infection control and hospital epidemiology Mathew, R., Salinas, J. L., Hsu, H. E., Jin, R., Rhee, C., Lee, G. M. 2022: 1-3


    Among 287 US hospitals reporting data between 2015 and 2018, annual pediatric surgical site infection (SSI) rates ranged from 0% for gallbladder to 10.4% for colon surgeries. Colon, spinal fusion, and small-bowel SSI rates did not decrease with greater surgical volumes in contrast to appendix and ventricular-shunt SSI rates.

    View details for DOI 10.1017/ice.2022.154

    View details for PubMedID 35801814

  • Lack of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission from a healthcare worker to a cohort of immunosuppressed patients during the SARS-CoV-2 omicron variant surge, California, 2022. Infection control and hospital epidemiology Karan, A., Ferguson, J., Salinas, J. L. 2022: 1-2

    View details for DOI 10.1017/ice.2022.175

    View details for PubMedID 35794737

  • Corowa-kun: A messenger app chatbot delivers COVID-19 vaccine information, Japan 2021. Vaccine Kobayashi, T., Nishina, Y., Tomoi, H., Harada, K., Tanaka, K., Matsumoto, E., Horimukai, K., Ishihara, J., Sasaki, S., Inaba, K., Seguchi, K., Takahashi, H., Salinas, J. L., Yamada, Y. 2022


    BACKGROUND: There is a long history in Japan of public concerns about vaccine adverse events. Few studies have assessed how mobile messenger apps affect COVID-19 vaccine hesitancy.METHODS: Corowa-kun, a free chatbot, was created on February 6, 2021 in LINE, the most popular messenger app in Japan. Corowa-kun provides instant, automated answers to 70 frequently asked COVID-19 vaccine questions. A cross-sectional survey with 21 questions was performed within Corowa-kun during April 5-12, 2021.RESULTS: A total of 59,676 persons used Corowa-kun during February-April 2021. Of them, 10,192 users (17%) participated in the survey. Median age was 55years (range 16-97), and most were female (74%). COVID-19 vaccine hesitancy reported by survey respondents decreased from 41% to 20% after using Corowa-kun. Of the 20% who remained hesitant, 16% (1,675) were unsure, and 4% (364) did not intend to be vaccinated. Factors associated with vaccine hesitancy were: age 16-34 (odds ratio [OR]=3.7; 95% confidential interval [CI]: 3.0-4.6, compared to age≥65), female sex (OR=2.4; Cl: 2.1-2.8), and history of a previous vaccine side-effect (OR=2.5; Cl: 2.2-2.9). Being a physician (OR=0.2; Cl: 0.1-0.4) and having received a flu vaccine the prior season (OR=0.4; Cl: 0.3-0.4) were protective.CONCLUSIONS: A substantial number of people used the chabot in a short period. Mobile messenger apps could be leveraged to provide accurate vaccine information and to investigate vaccine intention and risk factors for vaccine hesitancy.

    View details for DOI 10.1016/j.vaccine.2022.06.007

    View details for PubMedID 35750541

  • Coronavirus Disease-2019 (COVID-19) among Non-physician Healthcare Personnel by Work Location at a Tertiary Care Center, Iowa, 2020-2021. Infection control and hospital epidemiology Kobayashi, T., Heinemann, J., Trannel, A., Marra, A. R., Alsuhaibani, M., Etienne, W., Sheeler, L. L., Abosi, O., Holley, S., Kukla, M. B., Dains, A., Jenn, K. E., Meacham, H., Hanna, B., Ford, B., Brust, K., Wellington, M., Hartley, P. G., Diekema, D. J., Salinas, J. L. 2022: 1-11


    We describe COVID-19 cases among non-physician healthcare personnel (HCP) by work location. The proportion of HCP with COVID-19 was highest in the emergency department and lowest among those working remotely. COVID-19 and non-COVID-19 units had similar proportions of HCP with COVID-19 (13%). Cases decreased across all work locations following COVID-19 vaccination.

    View details for DOI 10.1017/ice.2022.148

    View details for PubMedID 35652600

  • Effectiveness of heterologous COVID-19 vaccine booster dosing in Brazilian healthcare workers, 2021. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Marra, A. R., Miraglia, J. L., Malheiros, D. T., Guozhang, Y., Teich, V. D., da Silva Victor, E., Pinho, J. R., Cypriano, A., Vieira, L. W., Polonio, M., Ornelas, R. H., de Oliveira, S. M., Borges Junior, F. A., Oler, S. C., de Paula Pinto Schettino, G., de Oliveira, K. G., Santana, R. A., de Mello Malta, F., Amgarten, D., Boechat, A. L., Trecenti, N. M., Kobayashi, T., Salinas, J. L., Edmond, M. B., Rizzo, L. V. 2022


    Little is currently known about vaccine effectiveness (VE) for either two doses of Oxford-AstraZeneca (ChAdOx1) viral vector vaccine or CoronaVac inactivated viral vaccine followed by a third dose of mRNA vaccine (Pfizer/BioNTech) among healthcare workers (HCWs).We conducted a retrospective cohort study among HCWs (aged ≥18 years) working in a private healthcare system in Brazil from January to December 2021. VE was defined as 1-IRR (incidence rate ratio), with IRR determined using Poisson models with the occurrence of laboratory-confirmed COVID-19 infection as the outcome, adjusting for age, sex, and job type. We compared those receiving viral vector or inactivated viral primary series (two doses) to those who received an mRNA booster.A total of 11,427 HCWs met the inclusion criteria. COVID-19 was confirmed in 31.5% of HCWs receiving two doses of CoronaVac vaccine vs. 0.9% of HCWs receiving two doses of CoronaVac vaccine with mRNA booster (p < 0.001), and 9.8% of HCWs receiving two doses of ChAdOx1 vaccine vs. 1% among HCWs receiving two doses of ChAdOx1 vaccine with mRNA booster (p < 0.001). In the adjusted analyses, the estimated VE was 92.0% for two CoronaVac vaccines plus mRNA booster, and 60.2% for two ChAdOx1 vaccines plus mRNA booster, when compared to those with no mRNA booster. Of 246 samples screened for mutations, 191 (77.6%) were Delta variants.While two doses of ChAdOx1 or CoronaVac vaccines prevent COVID-19, the addition of a Pfizer/BioNTech booster provided significantly more protection.

    View details for DOI 10.1093/cid/ciac430

    View details for PubMedID 35639918

  • Blood culture practices in patients with a central line at an academic medical center-Iowa, 2020. Antimicrobial stewardship & healthcare epidemiology : ASHE Kovoor, E., Kobayashi, T., Sheeler, L. L., Trannel, A., Etienne, W., Abosi, O., Holley, S., Dains, A., Jenn, K. E., Meacham, H., Hanna, B., Marra, A. R., Parsons, M., Ford, B., Wellington, M., Diekema, D. J., Salinas, J. L. 2022; 2 (1): e64


    We analyzed blood-culture practices to characterize the utilization of the Infectious Diseases Society of America (IDSA) recommendations related to catheter-related bloodstream infection (CRBSI) blood cultures. Most patients with a central line had only peripheral blood cultures. Increasing the utilization of CRBSI guidelines may improve clinical care, but may also affect other quality metrics.

    View details for DOI 10.1017/ash.2022.45

    View details for PubMedID 36483395

    View details for PubMedCentralID PMC9726581

  • We should allow family presence for hospitalized patients in isolation for COVID-19. Infection control and hospital epidemiology Salinas, J. L. 2022: 1-5

    View details for DOI 10.1017/ice.2022.95

    View details for PubMedID 35373726

  • Effectiveness of two COVID-19 vaccines (viral vector and inactivated viral vaccine) against SARS-CoV-2 infection in a cohort of healthcare workers. Infection control and hospital epidemiology Marra, A. R., Miraglia, J. L., Malheiros, D. T., Guozhang, Y., Teich, V. D., da Silva Victor, E., Pinho, J. R., Cypriano, A., Vieira, L. W., Polonio, M., Ornelas, R. H., de Oliveira, S. M., Borges Junior, F. A., Shibata, A. R., Schettino, G. d., de Oliveira, K. G., Ferraz Santana, R. A., de Mello Malta, F., Amgarten, D., Boechat, A. L., Trecenti, N. M., Kobayashi, T., Salinas, J. L., Edmond, M. B., Rizzo, L. V. 2022: 1-20


    OBJECTIVES: We aimed to investigate real-world vaccine effectiveness (VE) for Oxford-AstraZeneca (ChAdOx1) and CoronaVac against laboratory-confirmed COVID-19 infection among healthcare workers (HCWs).METHODS: We conducted a retrospective cohort study among HCWs (aged ≥18 years) working in a private healthcare system in Brazil between January 1, 2021 and August 3, 2021. To assess VE, we calculated VE=1-RR (rate ratio), with RR determined by adjusting Poisson models with the occurrence of COVID-19 infection as the outcome, and the vaccination status as the main exploratory variable. We used the logarithmic link function and simple models adjusting for sex, age and job types.RESULTS: 13,813 HCWs met the inclusion criteria for this analysis. 6,385 (46.2%) received the CoronaVacvaccine, 5,916 (42.8%) received the ChAdOx1 vaccine, and 1,512 (11.0%) were not vaccinated. Overall, COVID-19 infection cases happened in 6% of unvaccinated HCWs, 3% of HCWs receiving two doses of CoronaVacvaccine, and 0.7% of HCWs receiving two doses of ChAdOx1 vaccine (p-value< 0.001). In the adjusted analyses, the estimated VE was 51.3% for CoronaVac, and 88.1% for ChAdOx1 vaccine. Both vaccines reduced the number of hospitalizations, the length of hospital stay, and the need of mechanical ventilation. Nineteen SARSCoV-2 samples from nineteen HCWs were screened for mutations of interest. Eighteen out of nineteen of those samples were Gamma SARS-CoV-2 variant.CONCLUSIONS: While both COVID-19 vaccines (viral vector and inactivated virus) can significantly prevent COVID-19 infection among HCWs, CoronaVac was much less effective. The COVID-19 vaccines were also effective even against a dominant Gamma variant.

    View details for DOI 10.1017/ice.2022.50

    View details for PubMedID 35351217

  • Risk factors, management, and outcomes of Acanthamoeba keratitis: A retrospective analysis of 110 cases. American journal of ophthalmology case reports Scruggs, B. A., Quist, T. S., Zimmerman, M. B., Salinas, J. L., Greiner, M. A. 2022; 25: 101372


    Purpose: To evaluate the risk factors, medical and surgical management, and visual outcomes of patients affected by Acanthamoeba keratitis (AK) over a 16-year period.Observations: Records were reviewed retrospectively for all AK patients treated at University of Iowa between 2002 and 2017. Main outcomes measured were risk factors, time to diagnosis, coinfection types, initial and final visual acuities, and treatment outcomes, with failure of medical therapy defined as need for therapeutic keratoplasty (TK). Effects of steroid use on these outcomes were determined. Among all AK cases occurring during the study period (N=110), the median age of the AK cohort was 31 years (range 8-80 years), and 49.1% were men. Contact lens wear was the primary risk factor for AK (95/100, 86.4%), and the median time to diagnosis was 0.70 (0.23-1.23) months. Forty-four AK patients (40%) failed medical therapy. Vision outcomes were better for AK patients with successful medical therapy compared to those requiring TK (LogMAR 0.00 v. 0.30; p<0.0001). Corticosteroid use was associated with increased time to diagnosis (1.00 v. 0.50 months; p=0.002), decreased final vision (LogMAR 0.10 v. 0.00; p<0.05) and increased need for TK (40/77 v. 4/33; p<0.001).Conclusions and importance: Acanthamoeba keratitis cases have increased over the past two decades at our institution. In this large retrospective study, AK was commonly misdiagnosed with delayed diagnosis and high rates of failed medical therapy. Corticosteroid use before AK diagnosis led to poorer outcomes. Our findings underscore the need for ophthalmologists to suspect Acanthamoeba in the setting of contact lens-associated keratitis before topical steroids are initiated.

    View details for DOI 10.1016/j.ajoc.2022.101372

    View details for PubMedID 35198803

  • Development and evaluation of a structured guide to assess the preventability of hospital-onset bacteremia and fungemia. Infection control and hospital epidemiology Schrank, G. M., Sick-Samuels, A., Bleasdale, S. C., Jacob, J. T., Dantes, R., Gokhale, R. H., Mayer, J., Mehrotra, P., Mehta, S. A., Mena Lora, A. J., Ray, S. M., Rhee, C., Salinas, J. L., Seo, S. K., Shane, A. L., Nadimpalli, G., Milstone, A. M., Robinson, G., Brown, C. H., Harris, A. D., Leekha, S., CDC Prevention Epicenters Program 1800: 1-7


    OBJECTIVE: To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.DESIGN: HOB preventability rating guide was compared against a reference standard expert panel.PARTICIPANTS: A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.METHODS: The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the kappa (kappa) statistic.RESULTS: Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (kappa, 0.76; 95% confidence interval [CI], 0.64-0.88]) and 87% (kappa, 0.79; 95% CI, 0.65-0.94) for the 52 scenarios with expert consensus.CONCLUSIONS: Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.

    View details for DOI 10.1017/ice.2021.528

    View details for PubMedID 35086601

  • Short-term effectiveness of COVID-19 vaccines in immunocompromised patients: a systematic literature review and meta-analysis. The Journal of infection MarraMS, A. R., Kobayashi, T., Suzuki, H., Alsuhaibani, M., Tofaneto, B. M., Bariani, L. M., Auler, M. d., Salinas, J. L., Edmond, M. B., Doll, M., Kutner, J. M., Pinho, J. R., Rizzo, L. V., Miraglia, J. L., Schweizer, M. L. 2022


    We aimed to assess the short-term effectiveness of COVID-19 vaccines among immunocompromised patients to prevent laboratory-confirmed symptomatic COVID-19 infection.Systematic review and meta-analysis. We calculated the pooled diagnostic odds ratio [DOR] (95% CI) for COVID-19 infection between immunocompromised patients and healthy people or those with stable chronic medical conditions. VE was estimated as 100% x (1-DOR). We also investigated the rates of developing anti-SARS-CoV-2 spike protein IgG between the 2 groups.Twenty studies evaluating COVID-19 vaccine response, and four studies evaluating VE were included in the meta-analysis. The pooled DOR for symptomatic COVID-19 infection in immunocompromised patients was 0.296 (95% CI: 0.108-0.811) with an estimated VE of 70.4% (95% CI: 18.9%- 89.2%). When stratified by diagnosis, IgG antibody levels were much higher in the control group compared to immunocompromised patients with solid organ transplant (pOR 232.3; 95% Cl: 66.98-806.03), malignant diseases (pOR 42.0, 95% Cl: 11.68-151.03), and inflammatory rheumatic diseases (pOR 19.06; 95% Cl: 5.00-72.62).We found COVID-19 mRNA vaccines were effective against symptomatic COVID-19 among the immunocompromised patients but had lower VE compared to the controls. Further research is needed to understand the discordance between antibody production and protection against symptomatic COVID-19 infection.

    View details for DOI 10.1016/j.jinf.2021.12.035

    View details for PubMedID 34982962

  • Association between job role and coronavirus disease 2019 (COVID-19) among healthcare personnel, Iowa, 2021. Antimicrobial stewardship & healthcare epidemiology : ASHE Kobayashi, T., Trannel, A., Heinemann, J., Marra, A. R., Etienne, W., Abosi, O. J., Holley, S., Dains, A., Jenn, K. E., Meacham, H., Schuessler, B. A., Wendt, L., Ten Eyck, P., Hanna, B., Salinas, J. L., Hartley, P. G., Ford, B., Wellington, M., Brust, K. B., Diekema, D. J. 2022; 2 (1): e188


    We describe the association between job roles and coronavirus disease 2019 (COVID-19) among healthcare personnel. A wide range of hazard ratios were observed across job roles. Medical assistants had higher hazard ratios than nurses, while attending physicians, food service workers, laboratory technicians, pharmacists, residents and fellows, and temporary workers had lower hazard ratios.

    View details for DOI 10.1017/ash.2022.349

    View details for PubMedID 36505945

  • The effectiveness of coronavirus disease 2019 (COVID-19) vaccine in the prevention of post-COVID-19 conditions: A systematic literature review and meta-analysis. Antimicrobial stewardship & healthcare epidemiology : ASHE Marra, A. R., Kobayashi, T., Suzuki, H., Alsuhaibani, M., Hasegawa, S., Tholany, J., Perencevich, E., Maezato, A. M., Ricardo, V. C., Salinas, J. L., Edmond, M. B., Rizzo, L. V. 2022; 2 (1): e192


    Background: Although multiple studies have revealed that coronavirus disease 2019 (COVID-19) vaccines can reduce COVID-19-related outcomes, little is known about their impact on post-COVID-19 conditions. We performed a systematic literature review and meta-analysis on the effectiveness of COVID-19 vaccination against post-COVID-19 conditions (ie, long COVID).Methods: We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 1, 2019, to April 27, 2022, for studies evaluating COVID-19 vaccine effectiveness against post-COVID-19 conditions among individuals who received at least 1 dose of Pfizer/BioNTech, Moderna, AstraZeneca, or Janssen vaccine. A post-COVID-19 condition was defined as any symptom that was present 3 or more weeks after having COVID-19. Editorials, commentaries, reviews, study protocols, and studies in the pediatric population were excluded. We calculated the pooled diagnostic odds ratios (DORs) for post-COVID-19 conditions between vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% * (1 - DOR).Results: In total, 10 studies with 1,600,830 individuals evaluated the effect of vaccination on post-COVID-19 conditions, of which 6 studies were included in the meta-analysis. The pooled DOR for post-COVID-19 conditions among individuals vaccinated with at least 1 dose was 0.708 (95% confidence interval (CI), 0.692-0.725) with an estimated vaccine effectiveness of 29.2% (95% CI, 27.5%-30.8%). The vaccine effectiveness was 35.3% (95% CI, 32.3%-38.1%) among those who received the COVID-19 vaccine before having COVID-19, and 27.4% (95% CI, 25.4%-29.3%) among those who received it after having COVID-19.Conclusions: COVID-19 vaccination both before and after having COVID-19 significantly decreased post-COVID-19 conditions for the circulating variants during the study period although vaccine effectiveness was low.

    View details for DOI 10.1017/ash.2022.336

    View details for PubMedID 36505947

  • The long-term effectiveness of coronavirus disease 2019 (COVID-19) vaccines: A systematic literature review and meta-analysis. Antimicrobial stewardship & healthcare epidemiology : ASHE Marra, A. R., Kobayashi, T., Suzuki, H., Alsuhaibani, M., Schweizer, M. L., Diekema, D. J., Tofaneto, B. M., Bariani, L. M., Auler, M. d., Salinas, J. L., Edmond, M. B., Pinho, J. R., Rizzo, L. V. 2022; 2 (1): e22


    Background: Although multiple studies revealed high vaccine effectiveness of coronavirus disease 2019 (COVID-19) vaccines within 3 months after the completion of vaccines, long-term vaccine effectiveness has not been well established, especially after the delta (delta) variant became prominent. We performed a systematic literature review and meta-analysis of long-term vaccine effectiveness.Methods: We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 2019 to November 15, 2021, for studies evaluating the long-term vaccine effectiveness against laboratory-confirmed COVID-19 or COVID-19 hospitalization among individuals who received 2 doses of Pfizer/BioNTech, Moderna, or AstraZeneca vaccines, or 1 dose of the Janssen vaccine. Long-term was defined as >5 months after the last dose. We calculated the pooled diagnostic odds ratio (DOR) with 95% confidence interval for COVID-19 between vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% * (1 - DOR).Results: In total, 16 studies including 17,939,172 individuals evaluated long-term vaccine effectiveness and were included in the meta-analysis. The pooled DOR for COVID-19 was 0.158 (95% CI: 0.157-0.160) with an estimated vaccine effectiveness of 84.2% (95% CI, 84.0- 84.3%). Estimated vaccine effectiveness against COVID-19 hospitalization was 88.7% (95% CI, 55.8%-97.1%). Vaccine effectiveness against COVID-19 during the delta variant period was 61.2% (95% CI, 59.0%-63.3%).Conclusions: COVID-19 vaccines are effective in preventing COVID-19 and COVID-19 hospitalization across a long-term period for the circulating variants during the study period. More observational studies are needed to evaluate the vaccine effectiveness of third dose of a COVID-19 vaccine, the vaccine effectiveness of mixing COVID-19 vaccines, COVID-19 breakthrough infection, and vaccine effectiveness against newly emerging variants.

    View details for DOI 10.1017/ash.2021.261

    View details for PubMedID 36310810

  • Clinical Decision Support Systems to Reduce Unnecessary Clostridoides difficile Testing Across Multiple Hospitals. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Rock, C., Abosi, O., Bleasdale, S., Colligan, E., Diekema, D. J., Dullabh, P., Gurses, A. P., Heaney-Huls, K., Jacob, J. T., Kandiah, S., Lama, S., Leekha, S., Mayer, J., Mena Lora, A. J., Morgan, D. J., Osei, P., Pau, S., Salinas, J. L., Spivak, E., Wenzler, E., Cosgrove, S. E. 2022


    Inappropriate C. difficile testing has adverse consequences for the patient, hospital, and public health. Computerized Clinical Decision Supports (CCDS) in the Electronic Health Record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into the healthcare providers' (HCP) workflow, are not well understood.Nine academic and 6 community U.S. hospitals participated in this 2-year cohort study. CCDS (hard- or soft-stop) triggered when duplicate C. difficile test order attempted, or if laxatives were recently received. The primary outcome was the difference in testing rates pre- and post-CCDS interventions, using incident rate ratios (IRR) and mixed effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary- and sub-nodes.In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing IRR reduction was 33% (95% CI, 30-36%), and 23% (95% CI 21-25%), respectively. Two hospitals implemented a non-EMR based human intervention with IRR reduction of 21% (95% CI 15-28%). HCPs reported generally favorable experiences, and highlighted time efficiencies such as inclusion of the patients most recent laxative administration on the CCDS. Organizational factors including hierarchical cultures, and communication between HCPs caring for the same patient, impact CCDS acceptance and integration.CCDS reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow, and when displayed relevant patient specific information needed for decision-making.

    View details for DOI 10.1093/cid/ciac074

    View details for PubMedID 35100620

  • Impact of COVID-19 on an infection prevention and control program, Iowa 2020-2021. American journal of infection control Alsuhaibani, M., Kobayashi, T., McPherson, C., Holley, S., Marra, A. R., Trannel, A., Dains, A., Abosi, O. J., Jenn, K. E., Meacham, H., Sheeler, L., Etienne, W., Kukla, M. E., Wellington, M., Edmond, M. B., Diekema, D. J., Salinas, J. L. 1800


    BACKGROUND: The COVID-19 pandemic has affected infection prevention and control (IPC) programs worldwide. We evaluated the impact of COVID-19 on the University of Iowa Hospitals & Clinics IPC program by measuring the volume of calls to the program, changes in healthcare-associated infection rates, and team member perceptions.METHODS: We retrieved the IPC call log and healthcare-associated infection trends for 2018-2020. We defined 2 periods: pre-COVID-19 (2018-2019) and COVID-19 (January-December 2020). We also conducted one-on-one interviews and focus group interviews with members of the IPC program and describe changes in their working conditions during the COVID-19 period.RESULTS: A total of 6,564 calls were recorded during 2018-2020. The pre-COVID-19 period had a median of 71 calls and/or month (range: 50-119). During the COVID-19 period, the median call volume increased to 368/month (range: 149-829), and most calls were related to isolation precautions (50%). During the COVID-19 period, the central line-associated bloodstream infection incidence increased significantly. Infection preventionists reported that the ambiguity and conflicting guidance during the pandemic were major challenges.CONCLUSIONS: Our IPC program experienced a 500% increase in consultation requests. Planning for future bio-emergencies should include creative strategies to increase response capacity within IPC programs.

    View details for DOI 10.1016/j.ajic.2021.11.015

    View details for PubMedID 35000801

  • The short-term effectiveness of coronavirus disease 2019 (COVID-19) vaccines among healthcare workers: a systematic literature review and meta-analysis. Antimicrobial stewardship & healthcare epidemiology : ASHE Marra, A. R., Kobayashi, T., Suzuki, H., Alsuhaibani, M., Tofaneto, B. M., Bariani, L. M., de Amorim Auler, M., Salinas, J. L., Edmond, M. B., Pinho, J. R., Rizzo, L. V., Schweizer, M. L. 2021; 1 (1): e33


    Healthcare workers (HCWs) are at risk of COVID-19 due to high levels of SARS-CoV-2 exposure. Thus, effective vaccines are needed. We performed a systematic literature review and meta-analysis on COVID-19 short-term vaccine effectiveness among HCWs.We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 2019 to June 11, 2021, for studies evaluating vaccine effectiveness against symptomatic COVID-19 among HCWs. To meta-analyze the extracted data, we calculated the pooled diagnostic odds ratio (DOR) for COVID-19 between vaccinated and unvaccinated HCWs. Vaccine effectiveness was estimated as 100% × (1 - DOR). We also performed a stratified analysis for vaccine effectiveness by vaccination status: 1 dose and 2 doses of the vaccine.We included 13 studies, including 173,742 HCWs evaluated for vaccine effectiveness in the meta-analysis. The vast majority (99.9%) of HCWs were vaccinated with the Pfizer/BioNTech COVID-19 mRNA vaccine. The pooled DOR for symptomatic COVID-19 among vaccinated HCWs was 0.072 (95% confidence interval [CI], 0.028-0.184) with an estimated vaccine effectiveness of 92.8% (95% CI, 81.6%-97.2%). In stratified analyses, the estimated vaccine effectiveness against symptomatic COVID-19 among HCWs who had received 1 dose of vaccine was 82.1% (95% CI, 46.1%-94.1%) and the vaccine effectiveness among HCWs who had received 2 doses was 93.5% (95% CI, 82.5%-97.6%).The COVID-19 mRNA vaccines are highly effective against symptomatic COVID-19, even with 1 dose. More observational studies are needed to evaluate the vaccine effectiveness of other COVID-19 vaccines, COVID-19 breakthrough after vaccination, and vaccine efficacy against new variants.

    View details for DOI 10.1017/ash.2021.195

    View details for PubMedID 36168453

    View details for PubMedCentralID PMC9495770

  • Stable Clostridioides difficile Infection Rates After the Discontinuation of Ultraviolet Light for Terminal Disinfection at a Tertiary Care Center, Iowa 2019-2020. American journal of infection control Abosi, O. J., Kobayashi, T., Holley, S., Kukla, M. E., Dains, A., Alsuhaibani, M., Marra, A. R., Jenn, K. E., Meacham, H., Sheeler, L. L., Etienne, W., Trannel, A., Garringer, J., Millard, W., Diekema, D. J., Edmond, M. B., Wellington, M., Salinas, J. L. 2021


    We compared the incidence of Clostridioides difficile infection before and after the discontinuation of Ultraviolet light used in addition to bleach in terminal disinfection of hospital rooms. We found no difference in C. difficile infection rates but found a decreased turn over time. The benefit of Ultraviolet light may be diminished in hospitals with a high thoroughness of manual cleaning.

    View details for DOI 10.1016/j.ajic.2021.08.005

    View details for PubMedID 34400244

  • COVID-19 Incidence After Exposures in Shared Patient Rooms, Tertiary Care Center, Iowa, July 2020-May 2021. Infection control and hospital epidemiology Trannel, A., Kobayashi, T., Dains, A., Abosi, O. J., Jenn, K. E., Meacham, H., Sheeler, L. L., Etienne, W., Kukla, M. E., Alsuhaibani, M., Holley, S., Strandberg, K., Marra, A. R., Kritzman, J., Ford, B., Wellington, M., Diekema, D. J., Salinas, J. L. 2021: 1-13


    The incidence of COVID-19 exposures in shared patient rooms was low at our institution: 1.8/1,000 shared room patient-days. However, the secondary attack rate (21.6%) was comparable to that reported in household exposures. Lengthier exposures were associated with COVID-19 conversion. Hospitals should implement measures to decrease shared room exposures.

    View details for DOI 10.1017/ice.2021.313

    View details for PubMedID 34250882

  • Suspected COVID-19 Reinfections at a Tertiary Care Center, Iowa, 2020. Open forum infectious diseases Kobayashi, T., Ortiz, M. E., Imborek, K. L., Alsuhaibani, M., Holley, S. A., Trannel, A., Marra, A. R., Etienne, W., Jenn, K. E., Abosi, O. J., Meacham, H., Sheeler, L. L., Dains, A., Kukla, M. E., McCray, P. B., Perlman, S., Ford, B., Diekema, D. J., Wellington, M., Salinas, J. L., Pezzulo, A. A. 2021; 8 (7): ofab188

    View details for DOI 10.1093/ofid/ofab188

    View details for PubMedID 34322564

  • Molecular epidemiology of large coronavirus disease 2019 (COVID-19) clusters before and after the implementation of routine serial testing at an academic medical center in Iowa, 2020. Infection control and hospital epidemiology Ortiz, M. E., Kobayashi, T., Imborek, K., Alsuhaibani, M., Holley, S., Trannel, A., Marra, A. R., Etienne, W., Jenn, K. E., Abosi, O. J., Meacham, H., Sheeler, L., Dains, A., Kukla, M. E., McCray, P. B., Perlman, S., Ford, B., Diekema, D. J., Wellington, M., Pezzulo, A. A., Salinas, J. L. 2021: 1-3

    View details for DOI 10.1017/ice.2021.301

    View details for PubMedID 34229775

  • COVID-19 Admission Screening, and Assessment of Infectiousness at an Academic Medical Center, Iowa 2020. Infection control and hospital epidemiology Alsuhaibani, M., Kobayashi, T., Trannel, A., Holley, S., Abosi, O. J., Jenn, K. E., Meacham, H., Sheeler, L., Etienne, W., Dains, A., Kukla, M. E., Ward, E., Ford, B., Edmond, M. B., Wellington, M., Diekema, D. J., Salinas, J. L. 2021: 1-19


    OBJECTIVE: Patients admitted to the hospital may unknowingly carry SARS-CoV-2 and hospitals have implemented SARS-CoV-2 admission screening. However, because SARS-CoV-2 RT-PCR may remain positive for months after infection, positive results may represent active or past infection. We determined the prevalence and infectiousness of patients who were admitted for reasons unrelated to COVID-19 but tested positive on admission screening.METHODS: We conducted an observational study at the University of Iowa Hospitals & Clinics from July 7 to October 25, 2020. All patients admitted without suspicion of COVID-19 infection were included and medical records of those with a positive admission screening test were reviewed. Infectiousness was determined using patient history, PCR cycle threshold (Ct) value, and serology.RESULTS: A total of 5,913 patients were screened and admitted for reasons unrelated to COVID-19. Of these, 101 had positive admission RT-PCR results. Thirty-six patient were excluded because they had respiratory signs/symptoms on admission on chart review. Sixty-five patients (1.1%) did not have respiratory symptoms. A total of 55 patients had Ct values available and were included in this analysis. The median age was 56 years, and (51%) were male. Our assessment revealed that 23 patients (42%) were likely infectious. The median duration of in-hospital isolation was five days for those likely infectious and two days for those deemed non-infectious.CONCLUSIONS: COVID-19 infection was infrequent among patients admitted for reasons unrelated to COVID-19. An assessment of the likelihood of infectiousness using clinical history, RT-PCR Ct values, and serology may help discontinue isolation and conserve resources.

    View details for DOI 10.1017/ice.2021.294

    View details for PubMedID 34169812

  • Immediate preoperative hyperglycemia correlates with complications in non-cardiac surgical cases. Journal of clinical anesthesia Dougherty, S. M., Schommer, J., Salinas, J. L., Zilles, B., Belding-Schmitt, M., Rogers, W. K., Shibli-Rahhal, A., O'Neill, B. T. 2021; 74: 110375


    STUDY OBJECTIVE: Assess for a relationship between immediate preoperative glucose concentrations and postoperative complications.DESIGN: Retrospective cohort study.SETTING: Single large, tertiary care academic medical center.PATIENTS: A five-year registry of all patients at our hospital who had a glucose concentration (plasma, serum, or venous/capillary/arterial whole blood) measured up to 6h prior to a non-emergent surgery.INTERVENTIONS: The glucose registry was cross-referenced with a database from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We applied an outcomes review to the subset of patients for whom we had data from both registries (n=1774).MEASUREMENTS: Preoperative glucose concentration in the full population as well as the subgroups of patients with or without diabetes were correlated with adverse postsurgical outcomes using 1) univariable analysis and 2) full multivariable analysis correcting for 27 clinical factors available from the ACS NSQIP database. Logistic regression analysis was performed using glucose level either as a continuous variable or as a categorical variable according to the following classifications: mild (≥140mg/dL; ≥7.8mmol/L), moderate (≥180mg/dL; ≥10mmol/L), or severe (≥250 mg/dL; ≥13.9mmol/L) hyperglycemia. A third analysis was performed correcting for 7 clinically important factors (age, BMI, predicted duration of procedure, sex, CKD stage, hypoalbuminemia, and diabetic status) identified by anesthesiologists and surgeons as immediately available and important for decision making.MAIN RESULTS: Univariable analysis of all patients and the subgroups of patients without diabetes or with diabetes showed that immediate preoperative mild or moderate hyperglycemia correlates with postoperative complications. Statistical significance was lost in most groups using full multivariable analysis, but not when correcting for the 7 factors available immediately preoperatively. However, for all patients with diabetes, moderate hyperglycemia (≥180mg/dL; ≥10mmol/L) continued to significantly correlate with complications even in the full multivariable analysis [odds ratio (OR) 1.79; 95% Confidence Intervals (CI) 1.10, 2.92], and with readmission/reoperation within 30days [OR 1.93; 95% CI 1.18, 3.13].CONCLUSIONS: Preoperative hyperglycemia within 6h of surgery is a marker of adverse postoperative outcomes. Among patients with diabetes in our study, a preoperative glucose level≥180mg/dL (≥10mmol/L) independently correlates with risk of postoperative complications and readmission/reoperation. These results should encourage future work to determine whether addressing immediate preoperative hyperglycemia can improve complication rates, or simply serves as a marker of higher risk.

    View details for DOI 10.1016/j.jclinane.2021.110375

    View details for PubMedID 34147016

  • Palliative care consultation in patients with Staphylococcus aureus bacteremia PALLIATIVE MEDICINE Kobayashi, T., Salinas, J. L., Ten Eyck, P., Chen, B., Ando, T., Inagaki, K., Alsuhaibani, M., Auwaerter, P. G., Molano, I., Diekema, D. J. 2021; 35 (4): 785-792


    Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with Staphylococcus aureus bacteremia remains unclear despite its high mortality.To examine the frequency of palliative care consultation and factors associated with palliative care consult in Staphylococcus aureus bacteremia patients in the United States.A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality.All inpatients with a discharge diagnosis of Staphylococcus aureus bacteremia (ICD-9-CM codes; 038.11 and 038.12).Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult.A total of 111,320 Staphylococcus aureus bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant Staphylococcus aureus bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult (p < 0.001).Palliative care consultation was infrequent during the management of Staphylococcus aureus bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in Staphylococcus aureus bacteremia. Selecting patients who may benefit the most should be explored.

    View details for DOI 10.1177/0269216321999574

    View details for Web of Science ID 000634468700001

    View details for PubMedID 33757367

  • Insertion site inflammation was associated with central-line-associated bloodstream infections at a tertiary-care center, 2015-2018 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Kobayashi, T., Clore, G. S., Kukla, M. E., Alzunitan, M., Kritzman, J., Abosi, O., Puig-Asensio, M., Marra, A. R., Diekema, D. J., Edmond, M. B., Salinas, J. L. 2021; 42 (3): 348-350


    There are currently no guidelines for central-line insertion site evaluation. Our study revealed an association between insertion site inflammation (ISI) and the development of central-line-associated bloodstream infections (CLABSIs). Automated surveillance for ISI is feasible and could help prevent CLABSI.

    View details for DOI 10.1017/ice.2020.445

    View details for Web of Science ID 000626909300019

    View details for PubMedID 33032671

  • The short-term effectiveness of coronavirus disease 2019 (COVID-19) vaccines among healthcare workers: a systematic literature review and meta-analysis Antimicrobial Stewardship & Healthcare Epidemiology Marra, A. R., Kobayashi, T., Suzuki, H., Alsuhaibani, M., Tofaneto, B., Bariani, L., Auler, M., Salinas, J. L., Edmond, M. B., Pinho, J., Rizzo, L., Schweizer, M. 2021; 1 (1): e33

    View details for DOI 10.1017/ash.2021.195

  • Bat intrusions at a tertiary care center in Iowa, 2018-2020. Infection control and hospital epidemiology Alsuhaibani, M. A., Dains, A., Kobayashi, T., Sheeler, L. L., Trannel, A., Holley, S., Marra, A. R., Abosi, O. J., Jenn, K. E., Meacham, H., Etienne, W., Kukla, M. E., Millard, B., Wellington, M., Diekema, D. J., Salinas, J. L. 2021: 1-3


    We described the epidemiology of bat intrusions into a hospital and subsequent management of exposures during 2018-2020. Most intrusions occurred in older buildings during the summer and fall months. Hospitals need bat intrusion surveillance systems and protocols for bat handling, exposure management, and intrusion mitigation.

    View details for DOI 10.1017/ice.2021.355

    View details for PubMedID 34396947

  • Occupational tuberculosis exposures and conversion rates can guide deimplementation of annual tuberculosis skin test screening INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Kobayashi, T., Meacham, H., Alsuhaibani, M., Holley, S., Marra, A. R., Edmond, M. B., Diekema, D. J., Hartley, P. G., Salinas, J. L. 2021; 42 (1): 123-124

    View details for DOI 10.1017/ice.2020.205

    View details for Web of Science ID 000603967200030

    View details for PubMedID 32484119

  • Assessment of room quality of manual cleaning and turnaround times with and without ultraviolet light at an academic medical center INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Abosi, O. J., Kobayashi, T., Holley, S., Kukla, M. E., Dains, A., Izakovic, T., Jenn, K. E., Meacham, H., Rogers, G. H., Garringer, J., Millard, W., Diekema, D. J., Edmond, M. B., Wellington, M., Salinas, J. L. 2021; 42 (1): 107-108

    View details for DOI 10.1017/ice.2020.1246

    View details for Web of Science ID 000603967200020

    View details for PubMedID 33118887

  • Asymptomatic Pre-Operative COVID-19 Screening for Essential and Elective Surgeries: Early Results of Universal Screening at a Midwestern Academic Medical Center. The Iowa orthopaedic journal Hendrickson, N. R., Kesler, K., DeMik, D. E., Glass, N. A., Watson, M. K., Ford, B. A., Salinas, J. L., Pugely, A. J. 2021; 41 (1): 33-38


    Background: During the novel Coronavirus 2019 (COVID-19) worldwide pandemic, viral testing has largely focused on patients presenting with fever and respiratory symptoms. Although Centers for Disease Control has reported 1,551,095 cases in the United States as of May 21, 2020, asymptomatic infection rates remain unknown within the U.S., especially in geographically disparate regions.Methods: On April 7, 2020 our hospital established universal SARS-CoV-2 screening using RT-PCR RNA detection from nasopharyngeal swabs from asymptomatic patients prior to essential and elective surgeries. This study included 1,997 asymptomatic patients undergoing surgical procedures and 1,797 admitted for medical management at a Midwestern academic hospital between April 7, 2020 and May 21, 2020.Results: As of May 21, asymptomatic testing for SARS-CoV-2 infection had been completed for 1,997 surgical patients and 1,797 non-surgical patients. Initial testing was positive in 26 patients, with an additional four positive tests occurring during repeat testing when greater than 48 hours had elapsed since initial testing. Overall asymptomatic infection rate was 0.79%. Asymptomatic infection rate was significantly lower in surgical patients (0.35% vs. 1.28%, p=0.001). Surgical patients tended to be older than non-surgical patients, although this was not statistically significant (51, IQR 27-65 vsx 46, IQR 28-64, p=0.057). Orthopedic surgery patients were significantly younger than those from other surgical services (42 vs. 53 yrs, p<0.001), however orthopedic and non-orthopedic surgical patients had similar asymptomatic infection rates (0.70% vs. 0.25%, p=0.173).Conclusion: Among asymptomatic patients tested at a Midwestern academic medical center, 0.79% were infected with SARS-CoV-2 virus. These findings will help guide screening protocols at medical centers while providing essential and elective procedures during the COVID-19 pandemic. While the asymptomatic infection rate was low, this data substantiates the threat of asymptomatic infections and potential for community viral spread. These results may not be generalizable to large urban population centers or areas with high concentrations of COVID-19, each region must use available data to evaluate the risk-benefit ratio of universal testing vs universal contact precautions.Level of Evidence: IV.

    View details for PubMedID 34552401

  • Reduction in abdominal hysterectomy surgical site infection rates after the addition of anaerobic antimicrobial prophylaxis INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Kobayashi, T., Jenn, K. E., Bowdler, N., Malloy, R., Holley, S., Izakovic, T., Kukla, M. E., Abosi, O., Dains, A., Meacham, H., Diekema, D. J., Edmond, M. B., Salinas, J. L. 2020; 41 (12): 1469-1471

    View details for DOI 10.1017/ice.2020.386

    View details for Web of Science ID 000595580600023

    View details for PubMedID 32856576

  • Administrative coding methods impact surgical site infection rates INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Alsuhaibani, M. A., Alzunitan, M. A., Jenn, K. E., Edmond, M. B., Dains, A. M., Holley, S. A., Kukla, M. E., Abosi, O. J., Meacham, H. M., Diekema, D. J., Salinas, J. L. 2020; 41 (12): 1461-1463


    We performed a retrospective analysis of the impact of using the International Classification of Diseases, Tenth Revision procedure coding system (ICD-10) or current procedural terminology (CPT) codes to calculate surgical site infection (SSI) rates. Denominators and SSI rates vary depending on the coding method used. The coding method used may influence interhospital performance comparisons.

    View details for DOI 10.1017/ice.2020.340

    View details for Web of Science ID 000595580600019

    View details for PubMedID 32772952

  • A 28-Year-Old Pregnant Woman With a Lung Abscess and Complicated Pleural Effusion CHEST Llanos, O., Lee, S., Salinas, J. L., Sanchez, R. 2020; 158 (5): E233-E236


    A 28-year-old woman G1P0 at 22 weeks of gestation and with no significant medical history presented to the ED complaining of worsening dyspnea and right-sided pleuritic chest pain. Symptoms started 2 weeks before presentation, with minimal productive cough and dyspnea on exertion. One week after the initial symptoms, the patient started noticing right-sided chest and shoulder pain along with subjective fevers and night sweats. She denied hemoptysis, weight loss, abdominal pain, diarrhea, nausea, vomiting, arthralgia, or rash. Her pregnancy had so far been uncomplicated. The patient did not use tobacco, alcohol, or recreational drugs. She worked at a daycare center but denied any particular sick contacts. She moved to the United States 7 years ago from Sudan and denied any recent travel.

    View details for DOI 10.1016/j.chest.2020.07.008

    View details for Web of Science ID 000609614300005

    View details for PubMedID 33160543

  • COVID-19 Serial Testing among Hospitalized Patients in a Midwest Tertiary Medical Center, July-September 2020. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Kobayashi, T., Trannel, A., Holley, S. A., Alsuhaibani, M., Abosi, O. J., Jenn, K. E., Meacham, H., Sheeler, L. L., Etienne, W., Dains, A., Casado, F., Kukla, M. E., Ward, E., Ford, B., Edmond, M. B., Wellington, M., Diekema, D. J., Salinas, J. L. 2020


    We implemented serial COVID-19 testing for inpatients with a negative test on admission. The conversion rate (negative to positive) on repeat testing was one percent. We identified patients during their incubation period and hospital-onset cases, rapidly isolated them, and potentially reduced exposures. Serial testing and infectiousness determination were resource intensive.

    View details for DOI 10.1093/cid/ciaa1630

    View details for PubMedID 33103196

  • Impact of UV-Light Use on the Quality of Manual Cleaning and Room Turnover Times at a Large Tertiary-Care Hospital, 2019 Abosi, O., Holley, S., Kukla, M., Dains, A., Izakovic, T., Jenn, K., Meacham, H., Rogers, G., Millard, B., Diekema, D., Edmond, M., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S266-S267
  • Modest Clostridiodes difficile infection prediction using machine learning models in a tertiary care hospital DIAGNOSTIC MICROBIOLOGY AND INFECTIOUS DISEASE Marra, A. R., Alzunitan, M., Abosi, O., Edmond, M. B., Street, W., Cromwell, J. W., Salinas, J. L. 2020; 98 (2): 115104


    Previous studies have shown promising results of machine learning (ML) models for predicting health outcomes. We develop and test ML models for predicting Clostridioides difficile infection (CDI) in hospitalized patients. This is a retrospective cohort study conducted during 2015-2017. All inpatients tested for C. difficile were included. CDI was defined as having a positive glutamate dehydrogenase and toxin results. We restricted analyses to the first record of C. difficile testing per patient. Of 3514 patients tested, 136 (4%) had CDI. Age and antibiotic use within 90 days before C. difficile testing were associated with CDI (P < 0.01). We tested 10 ML methods with and without resampling. Logistic regression, random forest and naïve Bayes models yielded the highest AUC ROC performance: 0.6. Predicting CDI was difficult in our cohort of patients tested for CDI. Multiple ML models yielded only modest results in a real-world population of hospitalized patients tested for CDI.

    View details for DOI 10.1016/j.diagmicrobio.2020.115104

    View details for Web of Science ID 000569800800004

    View details for PubMedID 32650284

  • Predicting Community-Onset Candidemia in an Academic Medical Center Using Machine Learning AlZunitan, M., Marra, A., Edmond, M., Street, N., Cromwell, J., Diekema, D., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S355
  • Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center Sheeler, L., Kukla, M., Abosi, O., Meacham, H., Holley, S., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S84
  • Administrative Coding Methods Impact Surgical Site Infection Rates Alsuhaibani, M., Alzunitan, M., Jenn, K., Diekema, D., Edmond, M., Kukla, M., Holley, S., Meacham, H., Abosi, O., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S111-S112
  • Development and Evaluation of a Structured Tool to Assess the Preventability of Hospital-Onset Bacteremia and Fungemia Schrank, G., Sick-Samuels, A., Bleasdale, S., Jacob, J., Dantes, R., Gokhale, R., Mayer, J., Mehrotra, P., Mehta, S., Lora, A., Ray, S., Rhee, C., Salinas, J., Seo, S., Shane, A., Nadimpalli, G., Milstone, A., Robinson, G., Brown, C., Harris, A., Leekha, S. CAMBRIDGE UNIV PRESS. 2020: S31-S32
  • Infection Prevention Time Required for Construction and Design at a Large Tertiary-Care Hospital, 2019 Dains, A., Edmond, M., Diekema, D., Holley, S., Abosi, O., Meacham, H., Kukla, M., Jenn, K., Kuse, A., Miller, R., Leiden, L., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S69-S70
  • Tuberculosis Exposure and Conversion Rates Can Guide Deimplementation of Annual Tuberculosis Screening Meacham, H., Kobayashi, T., Alsuhaibani, M., Holley, S., Edmond, M., Diekema, D., Dains, A., Abosi, O., Kukla, M., Jenn, K., Hartely, P., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S419
  • Impact of an Enhanced Prevention Bundle on Central-Line-Associated Bloodstream Infection Incidence in Adult Oncology Units Kukla, M., Hunger, S., Bullard, T., Van Scoyoc, K., Hovda-Davis, M., Silverman, M., Petrulavich, K., Young, L., Wicks, B., Lyckholm, L., Diekema, D., Edmond, M., Salinas, J., Holley, S., Abosi, O., Dains, A., Jenn, K., Meacham, H. CAMBRIDGE UNIV PRESS. 2020: S256-S258
  • Reduction in Abdominal Hysterectomy Surgical Site Infection Rates After the Addition of Anaerobic Antimicrobial Prophylaxis Jenn, K., Bowdler, N., Malloy, R., Holley, S., Izakovic, T., Kukla, M., Abosi, O., Dains, A., Meacham, H., Diekema, D., Edmond, M., Salinas, J. CAMBRIDGE UNIV PRESS. 2020: S47
  • Impact of Infectious Disease Consultation in Patients With Candidemia: A Retrospective Study, Systematic Literature Review, and Meta-analysis OPEN FORUM INFECTIOUS DISEASES Kobayashi, T., Marra, A. R., Schweizer, M. L., Ten Eyck, P., Wu, C., Alzunitan, M., Salinas, J. L., Siegel, M., Farmakiotis, D., Auwaerter, P. G., Healy, H. S., Diekema, D. J. 2020; 7 (9): ofaa270


    Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from Staphylococcus aureus bacteremia, little is known about the impact of IDC in candidemia.We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched 5 databases through February 2020 and performed a meta-analysis of the impact of IDC on the mortality of patients with candidemia.A total of 151 patients met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%; P = .002; 23% vs 50%; P = .0022, respectively). A systematic literature review returned 216 reports, of which 13 studies including the present report fulfilled the inclusion criteria. Among the 13 studies with a total of 3582 patients, IDC was performed in 50% of patients. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% vs 47.6%), with a pooled relative risk of 0.41 (95% CI, 0.35-0.49). Ophthalmology referral, echocardiogram, and central line removal were performed more frequently among patients receiving IDC.This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with significantly lower mortality and should be considered in all patients with candidemia.

    View details for DOI 10.1093/ofid/ofaa270

    View details for Web of Science ID 000593127000001

    View details for PubMedID 32904995

    View details for PubMedCentralID PMC7462368

  • A primer on data visualization in infection prevention and antimicrobial stewardship INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Salinas, J. L., Kritzman, J., Kobayashi, T., Edmond, M. B., Ince, D., Diekema, D. J. 2020; 41 (8): 948-957


    Data visualization refers to the techniques used to communicate information by encoding it as visual objects (eg, points, lines, or bars) contained in graphics. The recent acceleration in informatics technology has made it possible to obtain and process large amounts of data. Although data visualization can provide insights from large datasets, it can also help simplify messaging, making information more accessible for healthcare stakeholders. The field of data visualization is constantly evolving, and new techniques are frequently being created. However, evidence regarding the best way to visualize data in the fields of infection prevention and antimicrobial stewardship is limited. We provide an overview of data visualization theory and history, as well as recommendations for creating graphs for infection prevention and antimicrobial stewardship.

    View details for DOI 10.1017/ice.2020.142

    View details for Web of Science ID 000553062300013

    View details for PubMedID 32389138

  • Disseminated pulmonary histoplasmosis in immunocompetent patients: a common epidemiological exposure BMJ CASE REPORTS Klein, M., Khan, M., Salinas, J. L., Sanchez, R. 2019; 12 (3)


    We describe the initial presentation, diagnostic work-up and treatment of three adult immunocompetent men who presented within a short time frame of each other to an academic medical centre with acute respiratory distress syndrome. Their presentation was found to be secondary to a large inoculum of histoplasmosis from remodelling a building with bat droppings infestation. We discuss the pathophysiology of histoplasmosis and highlight the importance of exposure history in patients with acute respiratory failure and why patients with the occupational risk of exposure to fungal inoculum should wear protective respirator gear.

    View details for DOI 10.1136/bcr-2018-227994

    View details for Web of Science ID 000661378700099

    View details for PubMedID 30898964

    View details for PubMedCentralID PMC6453286

  • Acanthamoeba Keratitis Cases-Iowa, 2002-2017 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Scruggs, B. A., Quist, T. S., Salinas, J. L., Greiner, M. A. 2019; 68 (19): 448-449

    View details for DOI 10.15585/mmwr.mm6819a6

    View details for Web of Science ID 000469511400006

    View details for PubMedID 31095535

    View details for PubMedCentralID PMC6522078

  • Long-Term Outcomes of Guillain-Barre Syndrome Associated with Zika Virus Infection Walteros, D., Soares, J., Styczynski, A., Abrams, J., Galindo, J., Acosta-Reyes, J., Bravo, E., Arteta, Z., Solano, A., Prieto, F., Gonzales, M., Lechuga, E., Salinas, J., Belay, E., Schonberger, L., Damon, I., Ospina, M., Sejvar, J. LIPPINCOTT WILLIAMS & WILKINS. 2019
  • Plasmodium vivax Parasite Load Is Associated With Histopathology in Saimiri boliviensis With Findings Comparable to P vivax Pathogenesis in Humans OPEN FORUM INFECTIOUS DISEASES Peterson, M. S., Joyner, C. J., Cordy, R. J., Salinas, J. L., Machiah, D., Lapp, S. A., Meyer, E. S., Gumber, S., Galinski, M. R., MaHPIC Consortium 2019; 6 (3): ofz021


    Plasmodium vivax can cause severe malaria with multisystem organ dysfunction and death. Clinical reports suggest that parasite accumulation in tissues may contribute to pathogenesis and disease severity, but direct evidence is scarce.We present quantitative parasitological and histopathological analyses of tissue sections from a cohort of naive, mostly splenectomized Saimiri boliviensis infected with P vivax to define the relationship of tissue parasite load and histopathology.The lung, liver, and kidney showed the most tissue injury, with pathological presentations similar to observations reported from autopsies. Parasite loads correlated with the degree of histopathologic changes in the lung and liver tissues. In contrast, kidney damage was not associated directly with parasite load but with the presence of hemozoin, an inflammatory parasite byproduct.This analysis supports the use of the S boliviensis infection model for performing detailed histopathological studies to better understand and potentially design interventions to treat serious clinical manifestations caused by P vivax.

    View details for DOI 10.1093/ofid/ofz021

    View details for Web of Science ID 000465327200006

    View details for PubMedID 30937329

    View details for PubMedCentralID PMC6436601

  • Impact of expanded influenza post-exposure prophylaxis on healthcare worker absenteeism at a tertiary care center during the 2017-2018 season INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Puig-Asensio, M., Douglas, M., Holley, S., Kukla, M. E., Abosi, O., Mascardo, L., Carmody, B., Gent, C., Diekema, D. J., Hartley, P., Edmond, M. B., Salinas, J. L. 2019; 40 (2): 260-261

    View details for DOI 10.1017/ice.2018.317

    View details for Web of Science ID 000458501900031

    View details for PubMedID 30522537

  • Long-term outcomes of Guillain-Barré syndrome possibly associated with Zika virus infection. PloS one Walteros, D. M., Soares, J. n., Styczynski, A. R., Abrams, J. Y., Galindo-Buitrago, J. I., Acosta-Reyes, J. n., Bravo-Ribero, E. n., Arteta, Z. E., Solano-Sanchez, A. n., Prieto, F. E., Gonzalez-Duarte, M. n., Navarro-Lechuga, E. n., Salinas, J. L., Belay, E. D., Schonberger, L. B., Damon, I. K., Ospina, M. L., Sejvar, J. J. 2019; 14 (8): e0220049


    This prospective cohort investigation analyzed the long-term functional and neurologic outcomes of patients with Zika virus-associated Guillain-Barré syndrome (GBS) in Barranquilla, Colombia.Thirty-four Zika virus-associated GBS cases were assessed a median of 17 months following acute GBS illness. We assessed demographics, results of Overall Disability Sum Scores (ODSS), Hughes Disability Score (HDS), Zung Depression Scale (ZDS), and Health Related Quality of Life (HRQL) questionnaires; and compared outcomes indices with a normative sample of neighborhood-selected control subjects in Barranquilla without GBS.Median age at time of acute neurologic onset was 49 years (range, 10-80); 17 (50%) were male. No deaths occurred. At long-term follow-up, 25 (73%) patients had a HDS 0-1, indicating complete / near complete recovery. Among the group, HDS (mean 1.4, range 0-4), ODSS (mean 1.9, range 0-9) and ZDS score (mean 34.4, range 20-56) indicated mild / moderate ongoing disability. Adjusting for age and sex, Zika virus-associated GBS cases were similar to a population comparison group (n = 368) in Barranquilla without GBS in terms of prevalence of physical or mental health complaints, though GBS patients were more likely to have an ODSS of ≥ 1 (OR 8.8, 95% CI 3.2-24.5) and to suffer from moderate / moderate-severe depression (OR 3.89, 95% CI 1.23-11.17) than the comparison group.Long-term outcomes of Zika virus-associated GBS are consistent with those associated with other antecedent antigenic stimuli in terms of mortality and ongoing long-term morbidity, as published in the literature. Persons with Zika virus-associated GBS more frequently reported disability and depression after approximately one year compared with those without GBS.

    View details for DOI 10.1371/journal.pone.0220049

    View details for PubMedID 31369576

  • Metabolome-wide association study of peripheral parasitemia in Plasmodium vivax malaria INTERNATIONAL JOURNAL OF MEDICAL MICROBIOLOGY Gardinassi, L., Cordy, R., Lacerda, M. G., Salinas, J. L., Monteiro, W. M., Melo, G. C., Siqueira, A. M., Val, F. F., ViLinh Tran, Jones, D. P., Galinski, M. R., Li, S. 2017; 307 (8): 533-541


    Plasmodium vivax is one of the leading causes of malaria worldwide. Infections with this parasite cause diverse clinical manifestations, and recent studies revealed that infections with P. vivax can result in severe and fatal disease. Despite these facts, biological traits of the host response and parasite metabolism during P. vivax malaria are still largely underexplored. Parasitemia is clearly related to progression and severity of malaria caused by P. falciparum, however the effects of parasitemia during infections with P. vivax are not well understood.We conducted an exploratory study using a high-resolution metabolomics platform that uncovered significant associations between parasitemia levels and plasma metabolites from 150 patients with P. vivax malaria. Most plasma metabolites were inversely associated with higher levels of parasitemia. Top predicted metabolites are implicated into pathways of heme and lipid metabolism, which include biliverdin, bilirubin, palmitoylcarnitine, stearoylcarnitine, phosphocholine, glycerophosphocholine, oleic acid and omega-carboxy-trinor-leukotriene B4.The abundance of several plasma metabolites varies according to the levels of parasitemia in patients with P. vivax malaria. Moreover, our data suggest that the host response and/or parasite survival might be affected by metabolites involved in the degradation of heme and metabolism of several lipids. Importantly, these data highlight metabolic pathways that may serve as targets for the development of new antimalarial compounds.

    View details for DOI 10.1016/j.ijmm.2017.09.002

    View details for Web of Science ID 000419083000012

    View details for PubMedID 28927849

    View details for PubMedCentralID PMC5698147

  • Factors Associated With All-Cause Mortality Among Patients With Multidrug-Resistant Tuberculosis-United States, 1993-2013. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Salinas, J. L., Armstrong, L. R., Silk, B. J., Haddad, M. B., Cegielski, J. P. 2017; 65 (11): 1924-1926


    We assessed characteristics associated with all-cause mortality among US patients with multidrug-resistant tuberculosis. Mortality decreased from 31% during 1993-2002 to 11% during 2003-2013. Directly observed therapy coverage increased from 74% to 95% and was protective against all-cause mortality after accounting for demographics, clinical characteristics, human immunodeficiency virus status, and period of treatment.

    View details for DOI 10.1093/cid/cix667

    View details for PubMedID 29020169

  • Plasma metabolomics reveals membrane lipids, aspartate/asparagine and nucleotide metabolism pathway differences associated with chloroquine resistance in Plasmodium vivax malaria PLOS ONE Uppal, K., Salinas, J. L., Monteiro, W. M., Val, F., Cordy, R. J., Liu, K., Melo, G. C., Siqueira, A. M., Magalhaes, B., Galinski, M. R., Lacerda, M. G., Jones, D. P. 2017; 12 (8): e0182819


    Chloroquine (CQ) is the main anti-schizontocidal drug used in the treatment of uncomplicated malaria caused by Plasmodium vivax. Chloroquine resistant P. vivax (PvCR) malaria in the Western Pacific region, Asia and in the Americas indicates a need for biomarkers of resistance to improve therapy and enhance understanding of the mechanisms associated with PvCR. In this study, we compared plasma metabolic profiles of P. vivax malaria patients with PvCR and chloroquine sensitive parasites before treatment to identify potential molecular markers of chloroquine resistance.An untargeted high-resolution metabolomics analysis was performed on plasma samples collected in a malaria clinic in Manaus, Brazil. Male and female patients with Plasmodium vivax were included (n = 46); samples were collected before CQ treatment and followed for 28 days to determine PvCR, defined as the recurrence of parasitemia with detectable plasma concentrations of CQ ≥100 ng/dL. Differentially expressed metabolic features between CQ-Resistant (CQ-R) and CQ-Sensitive (CQ-S) patients were identified using partial least squares discriminant analysis and linear regression after adjusting for covariates and multiple testing correction. Pathway enrichment analysis was performed using Mummichog.Linear regression and PLS-DA methods yielded 69 discriminatory features between CQ-R and CQ-S groups, with 10-fold cross-validation classification accuracy of 89.6% using a SVM classifier. Pathway enrichment analysis showed significant enrichment (p<0.05) of glycerophospholipid metabolism, glycosphingolipid metabolism, aspartate and asparagine metabolism, purine and pyrimidine metabolism, and xenobiotics metabolism. Glycerophosphocholines levels were significantly lower in the CQ-R group as compared to CQ-S patients and also to independent control samples.The results show differences in lipid, amino acids, and nucleotide metabolism pathways in the plasma of CQ-R versus CQ-S patients prior to antimalarial treatment. Metabolomics phenotyping of P. vivax samples from patients with well-defined clinical CQ-resistance is promising for the development of new tools to understand the biological process and to identify potential biomarkers of PvCR.

    View details for DOI 10.1371/journal.pone.0182819

    View details for Web of Science ID 000407672200041

    View details for PubMedID 28813452

    View details for PubMedCentralID PMC5559093

  • Increased rates of Guillain-Barré syndrome associated with Zika virus outbreak in the Salvador metropolitan area, Brazil. PLoS neglected tropical diseases Styczynski, A. R., Malta, J. M., Krow-Lucal, E. R., Percio, J., Nóbrega, M. E., Vargas, A., Lanzieri, T. M., Leite, P. L., Staples, J. E., Fischer, M. X., Powers, A. M., Chang, G. J., Burns, P. L., Borland, E. M., Ledermann, J. P., Mossel, E. C., Schonberger, L. B., Belay, E. B., Salinas, J. L., Badaro, R. D., Sejvar, J. J., Coelho, G. E. 2017; 11 (8): e0005869


    In mid-2015, Salvador, Brazil, reported an outbreak of Guillain-Barré syndrome (GBS), coinciding with the introduction and spread of Zika virus (ZIKV). We found that GBS incidence during April-July 2015 among those ≥12 years of age was 5.6 cases/100,000 population/year and increased markedly with increasing age to 14.7 among those ≥60 years of age. We conducted interviews with 41 case-patients and 85 neighborhood controls and found no differences in demographics or exposures prior to GBS-symptom onset. A higher proportion of case-patients (83%) compared to controls (21%) reported an antecedent illness (OR 18.1, CI 6.9-47.5), most commonly characterized by rash, headache, fever, and myalgias, within a median of 8 days prior to GBS onset. Our investigation confirmed an outbreak of GBS, particularly in older adults, that was strongly associated with Zika-like illness and geo-temporally associated with ZIKV transmission, suggesting that ZIKV may result in severe neurologic complications.

    View details for DOI 10.1371/journal.pntd.0005869

    View details for PubMedID 28854206

    View details for PubMedCentralID PMC5595339

  • Tuberculosis Among Incarcerated Hispanic Persons in the United States, 1993-2014. Journal of immigrant and minority health Mindra, G., Wortham, J. M., Haddad, M. B., Salinas, J. L., Powell, K. M., Armstrong, L. R. 2017; 19 (4): 982-986


    We examined the National tuberculosis surveillance system to describe Hispanic persons who were incarcerated at time of tuberculosis (TB) diagnosis and to compare their characteristics with those of non-Hispanic incarcerated TB patients. After declines between 1993 and 2002, the annual proportion of Hispanic TB patients who were incarcerated grew from 4.9% in 2003 to 8.4% in 2014. During 2003-2014, 19% of incarcerated US-born TB patients were Hispanic, and 86% of the foreign-born were Hispanic. Most incarcerated TB patients were in local jails, but about a third of all foreign-born Hispanics were in the facility category that includes Immigration and Customs Enforcement detention centers. Foreign birth and recent U.S. arrival characterized many Hispanic persons receiving a TB diagnosis while incarcerated. Hispanic patients had twice the odds of being in federal prisons. Systematic efforts to identify TB infection and disease might lead to early diagnoses and prevention of future cases.

    View details for DOI 10.1007/s10903-016-0534-8

    View details for PubMedID 27900592

  • Zika virus disease-associated Guillain-Barré syndrome-Barranquilla, Colombia 2015-2016. Journal of the neurological sciences Salinas, J. L., Walteros, D. M., Styczynski, A. n., Garzón, F. n., Quijada, H. n., Bravo, E. n., Chaparro, P. n., Madero, J. n., Acosta-Reyes, J. n., Ledermann, J. n., Arteta, Z. n., Borland, E. n., Burns, P. n., Gonzalez, M. n., Powers, A. M., Mercado, M. n., Solano, A. n., Sejvar, J. J., Ospina, M. L. 2017; 381: 272–77


    An outbreak of Guillain-Barré syndrome (GBS), a disorder characterized by acute, symmetric limb weakness with decreased or absent deep-tendon reflexes, was reported in Barranquilla, Colombia, after the introduction of Zika virus in 2015. We reviewed clinical data for GBS cases in Barranquilla and performed a case-control investigation to assess the association of suspect and probable Zika virus disease with GBS.We used the Brighton Collaboration Criteria to confirm reported GBS patients in Barranquilla during October 2015-April 2016. In April 2016, two neighborhood and age range-matched controls were selected for each confirmed GBS case-patient. We obtained demographics and antecedent symptoms in the 2-month period before GBS onset for case-patients and the same period for controls. Sera were collected for Zika virus antibody testing. Suspected Zika virus disease was defined as a history of rash and ≥2 other Zika-related symptoms (fever, arthralgia, myalgia, or conjunctivitis). Probable Zika virus disease was defined as suspected Zika virus disease with laboratory evidence of a recent Zika virus or flavivirus infection. Conditional logistic regression adjusted for sex and race/ethnicity was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).We confirmed 47 GBS cases. Incidence increased with age (10-fold higher in those ≥60years versus those <20years). We interviewed 40 case-patients and 79 controls. There was no significant difference in laboratory evidence of recent Zika virus or flavivirus infection between case-patients and controls (OR: 2.2; 95% CI: 0.9-5.1). GBS was associated with having suspected (OR: 3.0, 95% CI: 1.1-8.6) or probable Zika virus disease (OR: 4.6, CI: 1.1-19.0).Older individuals and those with suspected and probable Zika virus disease had higher odds of developing GBS.We confirmed a Guillain-Barré syndrome (GBS) outbreak in Barranquilla, Colombia, during October 2015-April 2016. A case-control investigation using neighborhood controls showed an association of suspected and probable Zika virus disease with GBS.

    View details for PubMedID 28991697

  • Respiratory Complications of Plasmodium vivax Malaria: Systematic Review and Meta-Analysis AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Val, F., Machado, K., Barbosa, L., Salinas, J., Siqueira, A., Costa Alecrim, M., del Portillo, H., Bassat, Q., Monteiro, W., Guimaraes Lacerda, M. 2017; 97 (3): 733-743


    Malaria, a major global public health problem, is mainly caused by Plasmodium falciparum and Plasmodium vivax, and is responsible for nearly half a million deaths annually. Although P. vivax malaria was not believed to cause severe disease, recent robust studies have proved otherwise. However, the clinical spectrum and pathogenesis of severe vivax malaria and, especially, its respiratory complications remain poorly understood. A systematic search for articles reporting respiratory complications associated with vivax malaria was performed in Lilacs, Cochrane, Scielo, Web of Science, and Medline databases irrespective of publication date. Prevalence of acute respiratory distress syndrome (ARDS) and associated mortality among vivax patients were calculated from cross-sectional and longitudinal studies, whereas factors associated with mortality were calculated from data pooled from case reports and series of cases. A total of 101 studies were included (49 cross-sectional or longitudinal and 52 case reports or series of cases). Prevalence of ARDS was 2.8% and 2.2% in children and adults, respectively, with nearly 50% mortality. Moreover, female sex (P = 0.013), having any comorbidity (P = 0.036), lower body temperature (P = 0.032), lower hemoglobin (P = 0.043), and oxygen saturation (P = 0.053) values were significantly associated with mortality. Plasmodium vivax malaria respiratory complications included ARDS and were associated with high mortality. Demographics and clinical characteristics upon presentation to hospital were associated with mortality among patients with respiratory complications in vivax malaria. This study reaffirms the evidence of severe and fatal complications of P. vivax malaria and its associated respiratory complications.

    View details for DOI 10.4269/ajtmh.17-0131

    View details for Web of Science ID 000423202900023

    View details for PubMedID 28722625

    View details for PubMedCentralID PMC5590608

  • Baseline, Time-Updated, and Cumulative HIV Care Metrics for Predicting Acute Myocardial Infarction and All-Cause Mortality CLINICAL INFECTIOUS DISEASES Salinas, J. L., Rentsch, C., Marconi, V. C., Tate, J., Budoff, M., Butt, A. A., Freiberg, M. S., Gibert, C. L., Goetz, M., Leaf, D., Rodriguez-Barradas, M. C., Justice, A. C., Rimland, D. 2016; 63 (11): 1423-1430


     After adjustment for cardiovascular risk factors and despite higher mortality, those with human immunodeficiency virus (HIV+) have a greater risk of acute myocardial infarction (AMI) than uninfected individuals. We included HIV+ individuals who started combination antiretroviral therapy (cART) in the Veterans Aging Cohort Study (VACS) from 1996 to 2012. We fit multivariable proportional hazards models for baseline, time-updated and cumulative measures of HIV-1 RNA, CD4 counts, and the VACS Index. We used the trapezoidal rule to build the following cumulative measures: viremia copy-years, CD4-years, and VACS Index score-years, captured 180 days after cART initiation until AMI, death, last clinic visit, or 30 September 2012. The primary outcomes were incident AMI (Medicaid, Medicare, and Veterans Affairs International Classification of Diseases-9 codes) and death. A total of 8168 HIV+ individuals (53 861 person-years) were analyzed with 196 incident AMIs and 1710 deaths. Controlling for known cardiovascular risk factors, 6 of the 9 metrics predicted AMI and all metrics predicted mortality. Time-updated VACS Index had the lowest Akaike information criterion among all models for both outcomes. A time-updated VACS Index score of 55+ was associated with a hazard ratio (HR) of 3.31 (95% confidence interval [CI], 2.11-5.20) for AMI and a HR of 31.77 (95% CI, 26.17-38.57) for mortality. Time-updated VACS Index provided better AMI and mortality prediction than CD4 count and HIV-1 RNA, suggesting that current health determines risk more accurately than prior history and that risk assessment can be improved by biomarkers of organ injury.

    View details for DOI 10.1093/cid/ciw564

    View details for Web of Science ID 000392713900005

    View details for PubMedID 27539575

    View details for PubMedCentralID PMC5106607

  • Zika Virus Infection Associated With Severe Thrombocytopenia. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Sharp, T. M., Muñoz-Jordán, J., Perez-Padilla, J., Bello-Pagán, M. I., Rivera, A., Pastula, D. M., Salinas, J. L., Martínez Mendez, J. H., Méndez, M., Powers, A. M., Waterman, S., Rivera-García, B. 2016; 63 (9): 1198-1201


    We report two patients that developed severe thrombocytopenia after Zika virus (ZIKV) infection. The first patient had 1000 platelets/μL and died after multiple hemorrhages. The second patient had 2000 platelets/μL, had melena and ecchymoses, and recovered after receiving intravenous immunoglobulin. ZIKV may be associated with immune-mediated severe thrombocytopenia.

    View details for DOI 10.1093/cid/ciw476

    View details for PubMedID 27418575

    View details for PubMedCentralID PMC5176332

  • Guillain-Barre Syndrome During Ongoing Zika Virus Transmission - Puerto Rico, January 1-July 31, 2016 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Dirlikov, E., Major, C. G., Mayshack, M., Medina, N., Matos, D., Ryff, K. R., Torres-Aponte, J., Alkis, R., Munoz-Jordan, J., Colon-Sanchez, C., Salinas, J. L., Pastula, D. M., Garcia, M., Segarra, M., Malave, G., Thomas, D. L., Rodriguez-Vega, G. M., Luciano, C. A., Sejvar, J., Sharp, T. M., Rivera-Garcia, B. 2016; 65 (34): 910-914


    Guillain-Barré syndrome (GBS) is a postinfectious autoimmune disorder characterized by bilateral flaccid limb weakness attributable to peripheral nerve damage (1). Increased GBS incidence has been reported in countries with local transmission of Zika virus, a flavivirus transmitted primarily by certain Aedes species mosquitoes (2). In Puerto Rico, three arthropod-borne viruses (arboviruses) are currently circulating: Zika, dengue, and chikungunya. The first locally acquired Zika virus infection in Puerto Rico was reported in December 2015 (3). In February 2016, the Puerto Rico Department of Health (PRDH), with assistance from CDC, implemented the GBS Passive Surveillance System (GBPSS) to identify new cases of suspected GBS (4). Fifty-six suspected cases of GBS with onset of neurologic signs during January 1-July 31, 2016, were identified. Thirty-four (61%) patients had evidence of Zika virus or flavivirus infection; the median age of these patients was 55 years (range = 21-88 years), and 20 (59%) patients were female. These 34 patients were residents of seven of eight PRDH public health regions. All 34 patients were hospitalized and treated with intravenous immunoglobulin G (IVIg), the standard treatment for GBS; 21 (62%) required intensive care unit admission, including 12 (35%) who required endotracheal intubation and mechanical ventilation. One patient died of septic shock after treatment for GBS. Additionally, 26 cases of neurologic conditions other than GBS were reported through GBPSS, including seven (27%) in patients with evidence of Zika virus or flavivirus infection. Residents of and travelers to Puerto Rico and countries with active Zika virus transmission should follow recommendations for prevention of Zika virus infections.* Persons with signs or symptoms consistent with GBS should promptly seek medical attention. Health care providers in areas with ongoing local transmission seeing patients with neurologic illnesses should consider GBS and report suspected cases to public health authorities.

    View details for DOI 10.15585/mmwr.mm6534e1

    View details for Web of Science ID 000382902700006

    View details for PubMedID 27584942

  • Cardiovascular changes in patients with non-severe Plasmodium vivax malaria IJC HEART & VASCULATURE Alencar-Filho, A., Bemfica Barbosa Ferreira, J., Salinas, J., Fabbri, C., Monteiro, W., Siqueira, A., Okoshi, K., Guimaraes Lacerda, M., Okoshi, M. 2016; 11: 12-16


    Cardiovascular system involvement in patients with Plasmodium vivax malaria has been poorly addressed. The aim of this study was to evaluate cardiac structures and function, and serum markers of cardiovascular injury in patients with the non-severe form of vivax malaria in Manaus, Amazonas State, Brazil.We prospectively evaluated 26 patients with vivax malaria in an outpatient referral hospital and compared results with a control group of 25 gender- and age-matched healthy individuals. Patients underwent clinical evaluation, laboratory tests, and transthoracic echocardiography at first evaluation (day zero, D0) and seven days (D7) after malaria diagnosis. At D0 echocardiography showed higher left ventricular (LV) systolic diameter (28.8 ± 2.82 vs 30.9 ± 4.03 mm; p = 0.037) and LV diastolic volume (82.4 ± 12.3 vs 93.8 ± 25.9 ml; p = 0.05), and lower LV ejection fraction (Teicholz method: 73.2 ± 6.59 vs 68.4 ± 4.87%; p = 0.004) in patients compared to controls. Right ventricle (RV) fractional area change (54.7 ± 5.11 vs 50.5 ± 6.71%; p = 0.014) was lower, and RV myocardial performance index (0.21 ± 0.07 vs 0.33 ± 0.19; p = 0.007), and pulmonary vascular resistance (1.13 ± 0.25 vs 1.32 ± 0.26 Woods unit; p = 0.012) were higher in patients than controls. Patients presented higher serum levels of unconjugated bilirubin (0.24 ± 0.15 vs 1.30 ± 0.89 mg/dL; p < 0.001), soluble vascular cell adhesion molecule-1 (sVCAM-1; 453 ± 143 vs 1983 ± 880 ng/mL; p < 0.001), N-terminal prohormone brain natriuretic peptide (0.59 ± 0.86 vs 1.08 ± 0.81 pg/mL; p = 0.045), and troponin T (861 ± 338 vs 1037 ± 264 pg/mL; p = 0.045), and lower levels of plasma nitrite (13.42 ± 8.15 vs 8.98 ± 3.97 μM; p = 0.016) than controls. Most alterations had reversed by D7.Patients with non-severe Plasmodium vivax malaria present subclinical reversible cardiovascular changes.

    View details for DOI 10.1016/j.ijcha.2016.03.004

    View details for Web of Science ID 000399038600003

    View details for PubMedID 28616519

    View details for PubMedCentralID PMC5441355

  • Low Health System Performance, Indigenous Status and Antivenom Underdosage Correlate with Spider Envenoming Severity in the Remote Brazilian Amazon PLOS ONE Sampaio, V., Gomes, A., Silva, I., Sachett, J., Lima Ferreira, L., Oliveira, S., Sabido, M., Chalkidis, H., Vale Barbosa Guerra, M., Salinas, J., Wen, F., Guimaraes Lacerda, M., Monteiro, W. 2016; 11 (5): e0156386


    A better knowledge of the burden and risk factors associated with severity due to spider bites would lead to improved management with a reduction of sequelae usually seen for this neglected health problem, and would ensure proper use of antivenoms in remote localities in the Brazilian Amazon. The aim of this study was to analyze the profile of spider bites reported in the state of Amazonas in the Western Brazilian Amazon, and to investigate potential risk factors associated with severity of envenomation.We used a case-control study in order to identify factors associated with spider bite severity in the Western Brazilian Amazon from 2007 to 2014. Patients evolving to any severity criteria were considered cases and those with non-severe bites were included in the control group. All variables were retrieved from the official Brazilian reporting systems. Socioeconomical and environmental components were also included in a multivariable analysis in order to identify ecological determinants of incidence and severity. A total of 1,181 spider bites were recorded, resulting in an incidence of 4 cases per 100,000 person/year. Most of the spider bites occurred in males (65.8%). Bites mostly occurred in rural areas (59.5%). The most affected age group was between 16 and 45 years old (50.9%). A proportion of 39.7% of the bites were related to work activities. Antivenom was prescribed to 39% of the patients. Envenomings recorded from urban areas [Odds ratio (OR) = 0.40 (95%CI = 0.30-0.71; p<0.001)] and living in a municipality with a mean health system performance index (MHSPI >median [OR = 0.64 (95%CI = 0.39-0.75; p<0.001)] were independently associated with decreased risk of severity. Work related accidents [OR = 2.09 (95%CI = 1.49-2.94; p<0.001)], Indigenous status [OR = 2.15 (95%CI = 1.19-3.86; p = 0.011)] and living in a municipality located >300 km away from the state capital Manaus [OR = 1.90 (95%CI = 1.28-2.40; p<0.001)] were independently associated with a risk of severity. Living in a municipality located >300 km away from the state capital Manaus [OR = 1.53 (95%CI = 1.15-2.02; p = 0.003)] and living in a municipality with a MHSPI 300 km away from the state capital Manaus could be contributing factors to higher severity of spider envenomings in this area, as well as to antivenom underdosage.

    View details for DOI 10.1371/journal.pone.0156386

    View details for Web of Science ID 000376882500129

    View details for PubMedID 27227455

    View details for PubMedCentralID PMC4881914

  • Micronutrient Deficiencies and Plasmodium vivax Malaria among Children in the Brazilian Amazon PLOS ONE Benzecry, S., Alexandre, M., Vitor-Silva, S., Salinas, J., de Melo, G., Marinho, H., Paes, A., de Siqueira, A., Monteiro, W., Guimaraes Lacerda, M., Leite, H. 2016; 11 (3): e0151019


    There is a growing body of evidence linking micronutrient deficiencies and malaria incidence arising mostly from P. falciparum endemic areas. We assessed the impact of micronutrient deficiencies on malaria incidence and vice versa in the Brazilian state of Amazonas.We evaluated children <10 years old living in rural communities in the state of Amazonas, Brazil, from May 2010 to May 2011. All children were assessed for sociodemographic, anthropometric and laboratory parameters, including vitamin A, beta-carotene, zinc and iron serum levels at the beginning of the study (May 2010) and one year later (May 2011). Children were followed in between using passive surveillance for detection of symptomatic malaria. Those living in the study area at the completion of the observation period were reassessed for micronutrient levels. Univariate Cox-proportional Hazards models were used to assess whether micronutrient deficiencies had an impact on time to first P. vivax malaria episode. We included 95 children median age 4.8 years (interquartile range [IQR]: 2.3-6.6), mostly males (60.0%) and with high maternal illiteracy (72.6%). Vitamin A deficiencies were found in 36% of children, beta-carotene deficiency in 63%, zinc deficiency in 61% and iron deficiency in 51%. Most children (80%) had at least one intestinal parasite. During follow-up, 16 cases of vivax malaria were diagnosed amongst 13 individuals. Micronutrient deficiencies were not associated with increased malaria incidence: vitamin A deficiency [Hazard ratio (HR): 1.51; P-value: 0.45]; beta-carotene [HR: 0.47; P-value: 0.19]; zinc [HR: 1.41; P-value: 0.57] and iron [HR: 2.31; P-value: 0.16]). Upon reevaluation, children with al least one episode of malaria did not present significant changes in micronutrient levels.Micronutrient serum levels were not associated with a higher malaria incidence nor the malaria episode influenced micronutrient levels. Future studies targeting larger populations to assess micronutrients levels in P. vivax endemic areas are warranted in order to validate these results.

    View details for DOI 10.1371/journal.pone.0151019

    View details for Web of Science ID 000371993000091

    View details for PubMedID 26963624

    View details for PubMedCentralID PMC4786135

  • Case Report: Complex Type 2 Reactions in Three Patients with Hansen's Disease from a Southern United States Clinic AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Leon, K. E., Salinas, J. L., McDonald, R. W., Sheth, A. N., Fairley, J. K. 2015; 93 (5): 1082-1086


    In non-endemic countries, leprosy, or Hansen's disease (HD), remains rare and is often underrecognized. Consequently, the literature is currently lacking in clinical descriptions of leprosy complications in the United States. Immune-mediated inflammatory states known as reactions are common complications of HD. Type 1 reactions are typical of borderline cases and occur in 30% of patients and present as swelling and inflammation of existing skin lesions, neuritis, and nerve dysfunction. Type 2 reactions are systemic events that occur at the lepromatous end of the disease spectrum, and typical symptoms include fever, arthralgias, neuritis, and classic painful erythematous skin nodules known as erythema nodosum leprosum. We report three patients with lepromatous leprosy seen at a U.S. HD clinic with complicated type 2 reactions. The differences in presentations and clinical courses highlight the complexity of the disease and the need for increased awareness of unique manifestations of lepromatous leprosy in non-endemic areas.

    View details for DOI 10.4269/ajtmh.15-0052

    View details for Web of Science ID 000364437500035

    View details for PubMedID 26304919

    View details for PubMedCentralID PMC4703255

  • Disseminated emm Type 12 Group A Streptococcus and Review of Invasive Disease AMERICAN JOURNAL OF THE MEDICAL SCIENCES Heeke, A. L., Blumberg, H. M., Perry, J. M., Weiss, D. S., Crispell, E. K., Satola, S. W., Salinas, J. L. 2015; 350 (5): 429-431


    The authors present a case of invasive group A Streptococcus (GAS) in a previously healthy 63-year-old male complicated by trans-esophageal echocardiogram negative endocarditis, septic arthritis, and multiple cerebral septic emboli. Despite antibiotics and drainage of his largest brain abscess, the patient expired. This case highlights the potential mortality from invasive GAS disease. Included is a review of current literature regarding invasive GAS that addresses its presentation, prevalence, virulence and treatment.

    View details for DOI 10.1097/MAJ.0000000000000400

    View details for Web of Science ID 000364325600020

    View details for PubMedID 25723882

  • METABOLOMIC ANALYSIS OF PLASMODIUM VIVAX CHLOROQUINE RESISTANCE Salinas, J. L., Uppal, K., Val, F. F., Monteiro, W. M., Melo, G. C., Siqueira, A. M., Magalhaes, B., Jones, D. P., Styczynski, M. P., Galinski, M. R., Lacerda, M. V. AMER SOC TROP MED & HYGIENE. 2015: 452-453
  • METABOLOMICS OF PLASMODIUM VIVAX RELATED ANEMIA FROM THE BRAZILIAN AMAZON Salinas, J. L., Uppal, K., Val, F. F., Monteiro, W. M., Melo, G. C., Magalhaes, B., Siqueira, A. M., Jones, D. P., Styczynski, M. P., Galinski, M. R., Lacerda, M. V. AMER SOC TROP MED & HYGIENE. 2015: 190
  • Association between anthropometry-based nutritional status and malaria: a systematic review of observational studies MALARIA JOURNAL Ferreira, E., Alexandre, M. A., Salinas, J. L., de Siqueira, A. M., Benzecry, S. G., de Lacerda, M. G., Monteiro, W. M. 2015; 14: 346


    Multiple studies in various parts of the world have analysed the association of nutritional status on malaria using anthropometric measures, but results differ due to the heterogeneity of the study population, species of the parasite, and other factors involved in the host and parasite relationship. The aim of this study was to perform a systematic review on the inter-relationship of nutritional status based on anthropometry and malarial infection.Two independent reviewers accessed the MEDLINE and LILACS databases using the same search terms related to malaria and anthropometry. Prospective studies associating anthropometry and malaria (incidence or severity) were selected. References from the included studies and reviews were used to increase the review sensitivity. Data were extracted using a standardized form and the quality of the prospective studies was assessed. Selected articles were grouped based on exposures and outcomes.The search identified a total of 1688 studies: 1629 from MEDLINE and 59 from LILACS. A total of 23 met the inclusion criteria. Five additional studies were detected by reading the references of the 23 included studies and reviews, totaling 28 studies included. The mean sample size was 662.1 people, ranging from 57 to 5620. The mean follow-up was 365.8 days, ranging from 14 days to 1 year and 9 months, and nine studies did not report the follow-up period. Prospective studies assessing the relationship between malaria and malnutrition were mostly carried out in Africa. Of the 20 studies with malarial outcomes, fifteen had high and five had average quality, with an average score of 80.5 %. Most anthropometric parameters had no association with malaria incidence (47/52; 90.4 %) or parasite density (20/25; 80 %). However, the impact of malnutrition was noted in malaria mortality and severity (7/17; 41.2 %). Regarding the effects of malaria on malnutrition, malaria was associated with very few anthropometric parameters (8/39; 20.6 %).This systematic review found that most of the evidence associating malaria and malnutrition comes from P. falciparum endemic areas, with a significant heterogeneity in studies' design. Apparently malnutrition has not a great impact on malaria morbidity, but could have a negative impact on malaria mortality and severity. Most studies show no association between malaria and subsequent malnutrition in P. falciparum areas. In Plasmodium vivax endemic areas, malaria was associated with malnutrition in children. A discussion among experts in the field is needed to standardize future studies to increase external validity and accuracy.

    View details for DOI 10.1186/s12936-015-0870-5

    View details for Web of Science ID 000361358800002

    View details for PubMedID 26377094

    View details for PubMedCentralID PMC4574180

  • Older Age and Time to Medical Assistance Are Associated with Severity and Mortality of Snakebites in the Brazilian Amazon: A Case-Control Study PLOS ONE Feitosa, E. L., Sampaio, V. S., Salinas, J. L., Queiroz, A. M., da Silva, I., Gomes, A. A., Sachett, J., Siqueira, A. M., Ferreira, L. L., dos Santos, M., Lacerda, M., Monteiro, W. 2015; 10 (7): e0132237


    The Amazon region reports the highest incidence of snakebite envenomings in Brazil. We aimed to describe the epidemiology of snakebites in the state of Amazonas and to investigate factors associated with disease severity and lethality. We used a nested case-control study, in order to identify factors associated with snakebite severity and mortality using official Brazilian reporting systems, from 2007 to 2012. Patients evolving to severity or death were considered cases and those with non-severe bites were included in the control group. During the study period, 9,191 snakebites were recorded, resulting in an incidence rate of 52.8 cases per 100,000 person/years. Snakebites mostly occurred in males (79.0%) and in rural areas (70.2%). The most affected age group was between 16 and 45 years old (54.6%). Fifty five percent of the snakebites were related to work activities. Age ≤15 years [OR=1.26 (95% CI=1.03-1.52); (p=0.018)], age ≥65 years [OR=1.53 (95% CI=1.09-2.13); (p=0.012)], work related bites [OR=1.39 (95% CI=1.17-1.63); (p<0.001)] and time to medical assistance >6 hours [OR=1.73 (95% CI=1.45-2.07); (p<0.001)] were independently associated with the risk of severity. Age ≥65 years [OR=3.19 (95% CI=1.40-7.25); (p=0.006)] and time to medical assistance >6 hours [OR=2.01 (95% CI=1.15-3.50); (p=0.013)] were independently associated with the risk of death. Snakebites represent an occupational health problem for rural populations in the Brazilian Amazon with a wide distribution. These results highlight the need for public health strategies aiming to reduce occupational injuries. Most cases of severe disease occurred in the extremes of age, in those with delays in medical attention and those caused by Micrurus bites. These features of victims of snakebite demand adequate management according to well-defined protocols, including prompt referral to tertiary centres when necessary, as well as an effective response from surveillance systems and policy makers for these vulnerable groups.

    View details for DOI 10.1371/journal.pone.0132237

    View details for Web of Science ID 000358193100031

    View details for PubMedID 26168155

    View details for PubMedCentralID PMC4500501

  • Neisseria sicca Endocarditis Presenting as Multiple Embolic Brain Infarcts OPEN FORUM INFECTIOUS DISEASES Kirlew, C., Wilmot, K., Salinas, J. L. 2015; 2 (3): ofv105


    A 58 year old male presented with a 14 day history of progressive forgetfulness and aggressiveness. He had a history of human immunodeficiency virus infection, ischemic cardiomyopathy, and a myxomatous mitral valve (status post Saint Jude's mitral valve replacement 8 years before presentation). International normalized ratio was supra-therapeatutic on admission. A non-contrast computed tomography of the brain indicated multiple infarcts with hemorrhagic conversion. The source was later found to be a rare case of Neisseria sicca endocarditis.

    View details for DOI 10.1093/ofid/ofv105

    View details for Web of Science ID 000365786500021

    View details for PubMedID 26284256

    View details for PubMedCentralID PMC4536332

  • Metabolomics in the fight against malaria MEMORIAS DO INSTITUTO OSWALDO CRUZ Salinas, J. L., Kissinger, J. C., Jones, D. P., Galinski, M. R. 2014; 109 (5): 589-U204


    Metabolomics uses high-resolution mass spectrometry to provide a chemical fingerprint of thousands of metabolites present in cells, tissues or body fluids. Such metabolic phenotyping has been successfully used to study various biologic processes and disease states. High-resolution metabolomics can shed new light on the intricacies of host-parasite interactions in each stage of the Plasmodium life cycle and the downstream ramifications on the host's metabolism, pathogenesis and disease. Such data can become integrated with other large datasets generated using top-down systems biology approaches and be utilised by computational biologists to develop and enhance models of malaria pathogenesis relevant for identifying new drug targets or intervention strategies. Here, we focus on the promise of metabolomics to complement systems biology approaches in the quest for novel interventions in the fight against malaria. We introduce the Malaria Host-Pathogen Interaction Center (MaHPIC), a new systems biology research coalition. A primary goal of the MaHPIC is to generate systems biology datasets relating to human and non-human primate (NHP) malaria parasites and their hosts making these openly available from an online relational database. Metabolomic data from NHP infections and clinical malaria infections from around the world will comprise a unique global resource.

    View details for DOI 10.1590/0074-0276140043

    View details for Web of Science ID 000343603800011

    View details for PubMedID 25185001

    View details for PubMedCentralID PMC4156452

  • Medication Possession Ratio Predicts Antiretroviral Regimens Persistence in Peru PLOS ONE Salinas, J. L., Alave, J. L., Westfall, A. O., Paz, J., Moran, F., Carbajal-Gonzalez, D., Callacondo, D., Avalos, O., Rodriguez, M., Gotuzzo, E., Echevarria, J., Willig, J. H. 2013; 8 (10): e76323


    In developing nations, the use of operational parameters (OPs) in the prediction of clinical care represents a missed opportunity to enhance the care process. We modeled the impact of multiple measurements of antiretroviral treatment (ART) adherence on antiretroviral treatment outcomes in Peru.Retrospective cohort study including ART naïve, non-pregnant, adults initiating therapy at Hospital Nacional Cayetano Heredia, Lima-Peru (2006-2010). Three OPs were defined: 1) Medication possession ratio (MPR): days with antiretrovirals dispensed/days on first-line therapy; 2) Laboratory monitory constancy (LMC): proportion of 6 months intervals with ≥1 viral load or CD4 reported; 3) Clinic visit constancy (CVC): proportion of 6 months intervals with ≥1 clinic visit. Three multi-variable Cox proportional hazard (PH) models (one per OP) were fit for (1) time of first-line ART persistence and (2) time to second-line virologic failure. All models were adjusted for socio-demographic, clinical and laboratory variables.856 patients were included in first-line persistence analyses, median age was 35.6 years [29.4-42.9] and most were male (624; 73%). In multivariable PH models, MPR (per 10% increase HR=0.66; 95%CI=0.61-0.71) and LMC (per 10% increase 0.83; 0.71-0.96) were associated with prolonged time on first-line therapies. Among 79 individuals included in time to second-line virologic failure analyses, MPR was the only OP independently associated with prolonged time to second-line virologic failure (per 10% increase 0.88; 0.77-0.99).The capture and utilization of program level parameters such as MPR can provide valuable insight into patient-level treatment outcomes.

    View details for DOI 10.1371/journal.pone.0076323

    View details for Web of Science ID 000325427100058

    View details for PubMedID 24098475

    View details for PubMedCentralID PMC3788135

  • Underutilization of Aspirin for Primary Prevention of Cardiovascular Disease Among HIV-Infected Patients CLINICAL INFECTIOUS DISEASES Burkholder, G. A., Tamhane, A. R., Salinas, J. L., Mugavero, M. J., Raper, J. L., Westfall, A. O., Saag, M. S., Willig, J. H. 2012; 55 (11): 1550-1557


    Individuals infected with human immunodeficiency virus (HIV) are at increased risk for cardiovascular disease (CVD) events compared with uninfected persons. However, little is known about HIV provider practices regarding aspirin (ASA) for primary prevention of CVD.A cross-sectional study was conducted among patients attending the University of Alabama at Birmingham 1917 HIV Clinic during 2010 to determine the proportion receiving ASA for primary prevention of CVD and identify factors associated with ASA prescription. Ten-year risk for CVD events was calculated for men aged 45-79 and women aged 55-79. The 2009 US Preventive Services Task Force (USPSTF) guidelines were used to determine those qualifying for primary CVD prevention.Among 397 patients who qualified to receive ASA (mean age, 52.2 years, 94% male, 36% African American), only 66 (17%) were prescribed ASA. In multivariable logistic regression analysis, diabetes mellitus (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.28-5.27), hyperlipidemia (OR, 3.42; 95% CI, 1.55-7.56), and current smoking (OR, 1.87; 95% CI, 1.03-3.41) were significantly associated with ASA prescription. Odds of ASA prescription more than doubled for each additional CVD-related comorbidity present among hypertension, diabetes, hyperlipidemia, and smoking (OR, 2.13, 95% CI, 1.51-2.99).In this HIV-infected cohort, fewer than 1 in 5 patients in need received ASA for primary CVD prevention. Escalating likelihood of ASA prescription with increasing CVD-related comorbidity count suggests that providers may be influenced more by co-occurrence of these diagnoses than by USPSTF guidelines. In the absence of HIV-specific guidelines, interventions to improve HIV provider awareness of and adherence to existing general population guidelines on CVD risk reduction are needed.

    View details for DOI 10.1093/cid/cis752

    View details for Web of Science ID 000310966200023

    View details for PubMedID 22942209

    View details for PubMedCentralID PMC3491860

  • Long-Term Albendazole Effectiveness for Hepatic Cystic Echinococcosis AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Salinas, J., Vildozola Gonzales, H., Astuvilca, J., Arce-Villavicencio, Y., Carbajal-Gonzalez, D., Talledo, L., Willig, J. H. 2011; 85 (6): 1075-1079


    Little is known about the long-term effectiveness of albendazole in the medical therapy of non-complicated hepatic cystic echinococcosis (HCE) in resource-constrained settings. We performed a retrospective review of patients starting albendazole for HCE in Lima, Peru from January 1997 to December 2007. Patients successfully recontacted underwent chart abstraction and clinical and ultrasonographic reevaluation. Descriptive statistics were used to delineate patient characteristics and treatment effectiveness at the conclusion of albendazole and after reevaluation. Patients (N = 27) were primarily female, mean age was 51. Initial treatment success at albendazole conclusion was 26% (N = 7) per patient and 37.5% (N = 24) per cyst. After 3.8 ± 2.5 years, albendazole success was 34% (N = 9) per patient and 40% (N = 24) per cyst. We found a gap in the effectiveness of albendazole HCE therapy compared with the efficacy reported in clinical trials. This underscores the need for further investigation into alternate therapeutic strategies for this neglected disease.

    View details for DOI 10.4269/ajtmh.2011.11-0382

    View details for Web of Science ID 000297781000021

    View details for PubMedID 22144447

    View details for PubMedCentralID PMC3225155

  • No olvidemos el higado graso no alcoholico en pacientes con infeccion por VIH. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru Salinas, J. L., Vildozola Gonzales, H., Ticona, E. 2009; 29 (2): 191-2

    View details for PubMedID 19609336

  • Historia natural de la infeccion cronica por el virus hepatitis B. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru Vildozola Gonzales, H., Salinas, J. L. 2009; 29 (2): 147-57


    UNLABELLED: In the last years notable steps have been done towards the understanding of the biology of Hepatitis B Virus (HBV), its natural history and immunopathogenesis, while succesful universal vaccination programs were implemented around the world and important advances in antiviral therapeuthics occurred. Nevertheless, HBV infection remains a public health problem with nearly 350 million carriers worlwide. The natural history of chronic hepatitis B and the spectrum of its clinical forms are complex and variable.We review the natural history of chronic HBV infection describing the early replicative phase and late or non-replicative (inactive carrier) in those patients who adquired the infection during adulthood and the immune tolerant phase, immune clearance and non-replicative in those who acquired the infection in the perinatal period. Emphasis is made in the course of HBeAg negative chronic hepatitis and occult hepatitis B. The complexity of the natural history of hepatitis B depends on viral features, hepatocyte behavior and patient immune response. The intrinsic and extrinsic HBV factors associated with the progression to cirrhosis and hepatocellular carcinoma are also reviewed.KEYWORDS: Hepatitis B, Natural history, liver cirrhosis, hepatocellular carcinoma.

    View details for PubMedID 19609330

  • Blastocystis Infection in Patients with Chronic Renal Disease BRAZILIAN JOURNAL OF INFECTIOUS DISEASES Salinas, J. 2009; 13 (1): 1
  • Publicacion duplicada: Un caso peruano. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru Salinas, J. L., Mayta-Tristan, P. 2008; 28 (4): 390-392

    View details for PubMedID 19156185

  • Infeccion por Blastocystis. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru Salinas, J. L., Vildozola Gonzales, H. 2007; 27 (3): 264-74


    Blastocystis sp. is an anaerobic unicellular micro-organism belonging to the kingdom Chromista, frequently found in the digestive tracts of humans and animals, the pathogenic role of which continues being controversial for human beings. Its genetic classification, which shows nine sub-types, some of which seem to have a role in cases with gastrointestinal symptomathology, opens a new field for research. In this article, an extensive revision is carried out which includes the historic development of the parasite, its taxonomy, epidemiology, morphology, vital cycle, as well as biochemical, cytochemical and genetic aspects, the pathogenic role in contrast with different variables which include the sub-types, quantity, response to the treatment and association with other pathogens. Finally, the clinical and therapeutic aspects are also reviewed.

    View details for PubMedID 17934541