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Handel is a pediatric infectious diseases physician at Stony Brook Children's Hospitaland at Stony Brook’s Regional Tick-Borne Disease Center in Hampton Bays, NY.

Andrew Handel, MD, discusses prevention, how to remove ticks, and the burden of Lyme disease in certain populations. 

‘Tis the Season: Addressing Tick-Borne Illnesses

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

Logan Brock, PharmD, presents UF Health Shands data at MAD-ID 2025 showing limited diagnostic yield from routine fungal cultures and delayed results compared to standard methods.

A retrospective analysis from UF Health Shands Hospital questions the clinical value of routinely ordering fungal blood cultures alongside standard blood cultures during initial sepsis evaluations. The findings, presented by Logan Brock, PharmD, at MAD-ID 2025, show that fungal blood cultures rarely provide additional diagnostic information and take longer to yield results.

The single-center study reviewed 2,073 adult inpatient encounters from January 1, 2023, to December 31, 2024, in which fungal and standard blood cultures were collected within 24 hours of each other. Of those, 96.9% showed no growth in either type of culture. Among the 64 pairs that did show growth, only 8 (12.5%) fungal cultures were positive when standard cultures were negative. Conversely, 30 (46.9%) standard cultures identified fungal pathogens that fungal cultures missed. Both cultures were positive in 26 (40.6%) cases. 

 species accounted for 93.8% of all fungal isolates.

Median time-to-positivity was significantly longer for fungal cultures (48 hours; IQR: 41–93) than for standard cultures (33 hours; IQR: 28–43; 

 < 0.001). All-cause in-hospital and 30-day mortality rates were 17.4% and 16.4%, respectively.

“Paired fungal blood cultures infrequently identified fungal pathogens not detected by standard blood cultures and had a longer time-to-positivity,” the authors concluded.

Logan Brock, a PGY-2 infectious diseases pharmacy resident at UF Health Shands, said the study originated from concerns raised by an ICU pharmacist, “One of our ICU pharmacists reached out to us because she was seeing an increase in fungal blood cultures being ordered at our hospital. So, us and the ID stewardship department did a little digging with her, and we confirmed that there were actually a lot of fungal blood cultures being ordered. Anecdotally, we weren’t seeing a lot of fungal growth from these fungal blood cultures. Even in the cases where they did grow, the standard blood cultures were also growing the fungus. So, we wanted to take a closer look at our hospital’s fungal blood culture ordering and see if they’re providing any utility—or perhaps not.”

While no formal restrictions have been implemented yet, Brock says discussions are underway, “Full disclosure—at my hospital, we haven’t decided how we’re going to restrict fungal blood cultures based on the results of this study. There are a lot of key stakeholders that will have to get engaged—ID physicians, ICU doctors who are ordering the fungal blood cultures.”

He noted that one possible model could mirror how the hospital managed anaerobic blood culture bottles during a supply shortage, “Some ideas we’ve been talking about are doing something similar to what we did with our anaerobic blood culture bottles during the shortage… so that any people or teams who wanted to order anaerobic bottles had to request them from the micro lab—and usually had to show that they had some indication for them, like intra-abdominal infections… I can see doing something similar for fungal blood cultures.”

Despite the low yield overall, Brock emphasized that fungal blood cultures may still be valuable in select high-risk patients. He shared one case in which they led to a meaningful therapeutic adjustment.

“Yeah, so there was actually one case in particular where fungal blood cultures provided a really big benefit, I would say. This was a 73-year-old patient who came in septic. He had a bowel perforation, so he was started on fungal coverage. Predictably and appropriately, standard blood cultures were drawn, fungal blood cultures were drawn, and the standard blood cultures grew a couple of bacteria—

“The fungal blood culture did actually grow a 

 ended up being 32, which is susceptible dose-dependent. It is susceptible, but it’s right at the breakpoint for susceptible—so it’s a very high MIC.

“Based on those results, we switched him from fluconazole to our echinocandin at our hospital, micafungin, which I think was a much better therapy. Their white count came down, they improved, and I think without using fungal blood cultures there, we might not have known they had a fungal infection at all.” The findings support targeted, rather than routine, use of fungal blood cultures, especially in patients without clear risk factors for invasive fungal disease

Brock L, DeSear K, Engeleit A, Gurram P, Vuong L. Under the Microscope: The (Over)Utilization of Fungal Blood Cultures. Abstract 46 OR FRS. MAD-ID Meeting. May 28–31, 2025. Orlando, FL.

Logan Brock, PharmD, presents data at MAD-ID, showing limited diagnostic yield from routine fungal cultures and delayed results compared with standard methods.

Conferences

Rethinking Fungal Blood Cultures in Sepsis Workups

VOWST Shows Consistent Safety Profile for rCDI Patients with Comorbidities

At the 2025 MAD-ID meeting, Dianne Nguyen, MD, head of medical affairs for the pharmaceutical division at Nestlé Health Science, presented new data demonstrating the consistent safety profile of VOWST™ (fecal microbiota spores, live–brpk) in adults with recurrent 

 infection (rCDI), including those with significant comorbid conditions.

The findings come from an integrated analysis of two Phase 3 trials: the randomized, double-blind, placebo-controlled ECOSPOR III study (n=182) and the open-label, single-arm ECOSPOR IV study (n=263). In both trials, VOWST was administered orally as four capsules daily for three consecutive days following the completion of antibacterial treatment.

“This integrated analysis helps us better understand the product's safety and how it looks in this particularly more vulnerable patient population,” Nguyen said.

Among the 349 participants who received VOWST, 51% (n=178) had comorbid conditions such as renal impairment/failure, diabetes, cardiac disease, or were immunocompromised/immunosuppressed (IC/IS). Despite these underlying conditions, safety findings remained favorable.

In patients with renal impairment/failure, TEAEs occurred in 80%, serious TEAEs in 35%, and adverse events of special interest (TEAESIs) in 26%.

Those with diabetes experienced TEAEs at 70%, serious TEAEs at 20%, and TEAESIs at 9%.

Among those with cardiac disease, respective rates were 75%, 27%, and 12%.

The IC/IS subgroup showed rates of 77%, 20%, and 14%.

By comparison, placebo-treated participants in ECOSPOR III experienced even higher rates in several categories, for example, 100% of renal impairment patients reported TEAEs and 57% had serious TEAEs.

“First of all, patients with comorbidities—especially those with multiple—are more likely to experience treatment-emergent adverse events regardless of whether they received active treatment or placebo,” Nguyen explained. “That’s not surprising. But what we observed is that among those who did receive VOWST, the safety profile was consistent regardless of comorbidity status. That’s very encouraging.”

Importantly, no serious adverse events were attributed to VOWST, and no patients discontinued the study due to treatment-related side effects. TEAEs leading to death were infrequent across all subgroups and in the overall integrated population.

Looking ahead, Nguyen noted that while no formal controlled trials are planned in these high-risk groups, real-world studies are already underway. “We’re doing some work right now looking at clinical experience in these patient populations,” she said. “That’s going to give us more information about groups who may have been underrepresented in our clinical trials.”

She added that broader awareness of VOWST’s tolerability could support its use in routine care, “I’m looking forward to getting more information out there to really better describe how this particular product looks in terms of its effectiveness in a routine clinical setting.”

Sims M, Stevens R, Nguyen D, Pullman J, Berenson C. Safety of fecal microbiota spores, live-brpk (formerly SER-109) in participants with recurrent 

 infection and comorbidities: an integrated analysis of Phase 3 trials. Abstract 108 E. MAD-ID Meeting. May 28–31, 2025. Orlando, FL.

At MAD-ID, Dianne Nguyen, MD, shares Phase 3 data showing consistent tolerability of the microbiome therapy across high-risk patient populations

Vowst Maintains Consistent Safety Profile in rCDI Patients With Comorbidities

Part 1 of 4: Understanding how infectious diseases may trigger or worsen psychiatric disorders through genetics, immune response, and environmental factors.

Exploring the Hidden Link Between Infection and Mental Illness: An Introduction with Dr. Robert C Bransfield

For half a century, psychiatrist Robert C Bransfield, MD, has practiced psychiatry in New Jersey, dedicating his career to one of the field’s most challenging areas: treatment-resistant psychiatric illness. Over time, his curiosity and clinical observation led him to a striking and often underrecognized contributor to mental illness, infectious disease.

“In doing that,” says Bransfield, “many cases, particularly here in New Jersey, they had an infectious disease component, and when we looked at that infectious disease component, it helped us to get more effective treatment for people who would otherwise be treatment resistant.”

Bransfield has long been fascinated by the complex etiology of mental illness. “I've always been interested in what exactly causes mental illness. That's always been a mystery,” he reflects. “And if you look at it historically, there were old beliefs of demon possession. It was your mother's fault, low serotonin, you had bad genes. And in reality, it's a very complicated formula of what causes it.”

He challenges the notion that mental illness arises spontaneously. “Some people feel that it just comes from nowheres, which doesn't make sense. Everything's caused by something. Nothing's caused by nothing,” he asserts.

While genetics have played a central role in modern psychiatry’s understanding of mental illness, Bransfield urges caution. “Developmental genes alone don't make sense. There's only about half a dozen clear mental illness genes. But in reality, there's susceptibility genes.”

These susceptibility genes, he explains, can be activated by environmental triggers—one of the most compelling being infection. “The environmental trigger can be many things, but infection does come up a lot, and we found 60 different infectious diseases that are associated with different mental illnesses when we did a literature search.”

From an evolutionary standpoint, the prevalence of mental illness remains paradoxical. “If the brain is perfected so well with evolution, why is there so much mental illness?” he asks. His working theory: “You have susceptibility genes that are triggered by certain environmental conditions and that can cause mental illness, either congenitally or early development or fairly recently, and there's often an immune mediator.”

Bransfield emphasizes the importance of mapping disease progression in psychiatric disorders. “If you understand the susceptibility, the early stages, the later stages—think of it like a row of dominoes. And if you intervene at any one of those dominoes, that could prevent disease progression.”

He continues, “Once the disease occurs, then you can look at what perpetuates it, which may be different than what caused it. So it's like a vicious cycle. You're trying to break that, knowing there's many contributors, many deterrents, and sometimes acute triggers.”

The link between infection and mental illness isn't new. “Syphilis drew attention to it. Noguchi, he wrote about that. So that was clear infection in the brain. But then once we had penicillin, there was kind of a shifting away from that.”

He recalls the work of Dr. Henry Cotton in New Jersey’s Trenton State Hospital, who hypothesized infection's role in psychiatric illness and employed a now-infamous method of removing infected organs. “That went over the top, even though there may be some basis to that. It was a radical treatment approach.”

Later, the slow virus theory of the 1960s, along with work from the Stanley Lab at Johns Hopkins, brought renewed attention to infectious contributors—particularly 

. “We would meet in Germany every two years, in Gunzburg, and we would look at the psychoimmunology—the neuropsychoimmunology—which is the intermediate link. You have the infection, then it affects the immune system, and then the immune system contributes to a lot of symptoms.”

In recent decades, tick-borne diseases have emerged as a significant contributor to neuropsychiatric symptoms—especially in New Jersey. “A lot of people have tick-borne disease, and you see a lot of mental illness associated with tick-borne diseases. That happens a lot, often many years after initial infection.”

 as a key pathogen. “The most frequent infection can be Borrelia. Different kinds of Borrelia—it could be relapsing fever Borrelia, it could be Lyme Borrelia. There's a lot of different types of Borrelia.”

, often in tandem with other infections. “Bartonella—think of it almost like with HIV or COVID or Lyme. You see it, one organism. It's a complex, interactive infection, and there may be one organism that may be immunosuppressant, and then that activates other infections that might otherwise be latent.”

Such coinfections complicate diagnosis and treatment. “It's a very complicated formula, it seems, how these infections interact with each other, and we're still trying to understand how that works. It's not a simple postulate, where you get one organism and one clear manifestation.”

Indeed, two patients with the same infection may present very differently. “Many different people can have the same infection, have many different manifestations of it, depending on their vulnerabilities or genetic vulnerabilities.”

Among the various psychiatric outcomes, depression stands out. “The most common manifestation is really depression—depression particularly with tick-borne disease. With Lyme disease, there have been about 10 different studies on depression.”

But depression is only the tip of the iceberg. “Then there are other, less common manifestations that you see. You can see a broad range of psychiatric illnesses, cognitive impairments, neurological, and general medical impairments.”

Stay tuned for Part 2-4, where we’ll dive deeper into the specific infectious agents linked to mental illness and explore how they interact with the immune system to influence psychiatric symptoms. This series will shed light on new perspectives in understanding and treating complex psychiatric conditions. 

Robert Bransfield introduces his understanding of how infectious diseases may trigger or worsen psychiatric disorders through genetics, immune response, and environmental factors.

Rethinking Mental Illness: The Overlooked Impact of Infection

At MAD-ID 2025, Kimberly Leuthner, PharmD, FIDSA, highlights need for larger prospective studies amid limited current evidence.

A retrospective single-center chart review presented at MAD-ID 2025 by Kimberly Leuthner, PharmD, FIDSA, evaluated the use of trimethoprim/sulfamethoxazole (TMP/SMX) versus minocycline for the treatment of 

 pneumonia and found no difference in clinical outcomes between the two antibiotics.

The study, conducted at Sunrise Hospital and University Medical Center of Southern Nevada, included adult patients with respiratory cultures growing only 

. To qualify, patients had to have radiographic evidence of pneumonia and at least three clinical criteria such as purulent sputum, worsening respiratory status, temperature abnormalities, leukocytosis/leukopenia, or more than 15% immature neutrophils. Eligible patients received either TMP/SMX or minocycline within 48 hours of positive culture for a minimum of 72 hours. Patients were excluded if treated with other antibiotics active against 

 or if treatment began before cultures were obtained.

 respiratory cultures, 39 (35%) were excluded for receiving no treatment targeting 

. An additional 62 (55.9%) were excluded primarily because they were not treated with either study drug (27/62, 43.5%) or lacked radiographic evidence of pneumonia (16/62, 25.8%). Ten patients met all inclusion criteria and were enrolled, three treated with TMP/SMX and seven with minocycline. Baseline characteristics were similar between groups.

The primary outcome measured was improvement in at least two clinical signs within 72 hours of treatment initiation. This was observed in one patient (33%) receiving TMP/SMX and three patients (43%) receiving minocycline, with no statistically significant difference (P = 1). Secondary outcomes including clinical response at the end of therapy, 30-day all-cause mortality, and microbiologic eradication showed no differences between groups. Overall, the clinical success rate was low in both treatment arms.

Leuthner explained the motivation behind evaluating minocycline as an alternative therapy. "We’ve been a fan of using minocycline for 

 for the last probably 15 years or so. Unfortunately, our population seems to have a high number of patients that are allergic to Bactrim, and so we had to find some alternative options in those patients. We have done some previous research looking at whether or not this would be a reasonable option. Unfortunately, studies are extremely limited, so we wanted to see what we could do about getting more literature out there to show the use of minocycline."

Regarding the small sample size, Leuthner noted, "We realized that our inclusion criteria was going to result in a very small population, mostly due to the fact we applied prospective criteria to a retrospective study. But we were trying to ensure that we focused on 

 specifically, since that’s the population that really has not been studied. I don’t think that there is going to be a huge clinical impact with this, but hopefully it’s going to be the starting point for people to discuss whether or not monotherapy is still a reasonable option, since our patients did do reasonably well with either drug, versus whether more prospective randomized trials need to be done, which may be a bit complicated."

She also discussed the challenges of strict diagnostic and treatment criteria in retrospective studies: "So unfortunately, retrospective data is retrospective data. You’re stuck with what the doctors document and the information that’s available. That limited our application so much because if the doctors didn’t write it, we did not make the assumption it was there. And so it limited the number that we use. But what we’re hoping for is that people will see that this is a possibility of using the newer criteria for prospective studies and potentially develop discussions between multiple collaborations to try and set up a prospective study. This is not a very common organism at all, and so to get the data that we truly need is going to require collaboration from multiple places."

Leuthner K, Jinings T. Trimethoprim/Sulfamethoxazole vs Minocycline for 

. Abstract 99 OR. MAD-ID Meeting. May 28–31, 2025. Orlando, FL.

At MAD-ID 2025, Kimberly Leuthner, PharmD, FIDSA, highlights the need for larger prospective studies amid limited current evidence.


Trimethoprim/Sulfamethoxazole and Minocycline Show Comparable Outcomes in Stenotrophomonas maltophilia Pneumonia

After the leaders of the NIH, FDA, and HHS made an announcement stating that both pregnant women and children were going to be taken off the COVID-19 immunization schedule, they decided to offer a new designation for the latter group making it a shared decision between providers and patients

CDC Changes Course Again on COVID-19 Vaccine Policy

Last week, the leaders of the National Institutes of Health, Health and Human Services, and FDA, announced the removal of the COVID-19 vaccine from the CDC immunization schedule for pregnant women and healthy children in a video social media post.

"I couldn't be more pleased to announce that, as of today, the COVID-19 vaccine for healthy children and healthy pregnant women has been removed from the CDC recommended immunization schedule," Kennedy said in the video.

However, since that post, and during the same week, the federal government has yet again changed its stance on the vaccine and healthy children. In fact, on the CDC's Child and Adolescent Immunization Schedule by Age, the COVID-19 vaccines will be available to the pediatric population under what is called 

This addresses children who ages 6 months through 17 years, and who are not moderately or severely immunocompromised. It says the following: "Shared clinical decision-making vaccinations are individually based and informed by a decision process between the health care provider and the patient or parent/guardian. Where the parent presents with a desire for their child to be vaccinated, children 6 months and older may receive COVID-19 vaccination, informed by the clinical judgment of a healthcare provider and personal preference and circumstances," the CDC says on the website.

The way the federal health agencies are operating is very different from the past, offers William Schaffner, MD, professor of Medicine in the Division of Infectious Diseases at the Vanderbilt University School of Medicine.

"So the Food and Drug Administration regarding COVID vaccines has become very assertive in indicating which populations ought to be vaccinated going forward this fall. Well, that to the minds of many of us, has the FDA getting into the CDC territory. You know, the FDA looks at the effectiveness of the vaccine and its safety and then licenses it, and traditionally, then that vaccine has been left to the CDC advisory committee to make recommendations as to which populations ought to receive the vaccine. But here, just recently, the FDA seems to be, if you will, poaching on CDC territory,” Schaffner said. “People are uncertain,” Schaffner said. “The mechanism that I've described, first the FDA and then the CDC, has stood in good stead for over 60 years. In the minds of many people, it ain't broke. Why do we have to fix it?”

With this changing guidance, it can leave the general public and clinicians confused about who is eligible for the vaccines. Additionally, there is no updated guidance for pregnant women since the announcement was made that this population was ineligible for COVID-19 vaccines.

In terms of these ongoing, shifting vaccine policies, Schaffner says we will have to wait and see.

“I think the vaccine community is looking forward to, shall we say, how these new policies actually are implemented. They're a little bit different than in the past, and changes always raise questions. There's that old saying, the devil is in the details. And so as these new policies come forward and are implemented, everybody will be looking at them very, very carefully,” he said.

After the leaders of the NIH, FDA, and HHS made an announcement stating that both pregnant women and children were going to be taken off the COVID-19 immunization schedule, they decided to offer a new designation for the latter group, making it a shared decision between providers and patients.

Andrew Handel, MD, FAAP

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