Alyssa R. Letourneau

Pneumonia in the immunocompromised host.

Purpose of review Novel treatment modalities for previously fatal diseases, including newer chemotherapeutic and biologic agents and the expansion of the indications for solid organ and stem cell transplantation, have resulted in prolonged patient survival and a significant increase in the population of immunocompromised hosts (ICHs). Recent findings This review discusses the increasing spectrum of opportunistic infections in the ICH, the general approach for early diagnosis and treatment of pulmonary infections in this population, and the current and novel diagnostic modalities available to establish a rapid and specific microbiologic diagnosis, focusing on recent controversies and advances. Summary Early diagnosis and prompt initiation of effective therapy for infection help reduce morbidity in ICHs. Advances in diagnostic assays using nonculture-based methods, such as nucleic acid amplification, may allow for earlier targeted therapy. Invasive procedures including bronchoscopy and biopsy remain essential and should be vigorously pursued in ICHs given the broad differential diagnosis of possible pulmonary pathogens in this population, and the need to establish a specific diagnosis to allow accurate targeted therapy.

Harnessing claims to improve detection of surgical site infections following hysterectomy and colorectal surgery.

Surgical site infection (SSI) surveillance is performed using a variety of methods with unclear performance characteristics. We used claims data to identify records for review following hysterectomy and colorectal surgery. Claims-enhanced screening identified SSIs missed by routine surveillance and could be used for targeted chart review to improve SSI detection.

Lack of Comprehensive Outbreak Detection in Hospitals

Timely identification of outbreaks of hospital-associated infections is needed to implement control measures and minimize impact. Survey results from 33 hospitals indicated that most hospitals lacked a formal cluster definition and all targeted a very limited group of prespecified pathogens. Standardized, statistically based outbreak detection could greatly improve current practice.

Therapeutic drug monitoring of antitubercular agents for disseminated Mycobacterium tuberculosis during intermittent haemodialysis and continuous venovenous haemofiltration

There is a lack of data regarding therapeutic drug monitoring (TDM) of antitubercular agents in the setting of continuous venovenous haemofiltration (CVVH). We describe TDM results of numerous antitubercular agents in a critically ill patient during CVVH and haemodialysis.

CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 16-2016. A 31-Year-Old Pregnant Woman with Fever.

Dr. Pietro Bortoletto (Obstetrics and Gynecology): A 31-year-old primigravid woman was seen in the labor and delivery unit of this hospital at 35 weeks of gestation because of fever. The patient was pregnant with dichorionic, diamniotic twins, and her gestation was complicated by iron-deficiency anemia and hyperemesis. Approximately 3 weeks before this evaluation, mild pruritus of the palms and soles developed. At 32 weeks 5 days of gestation (16 days before this evaluation), the patient was afebrile, had no visible rash, and reported fetal activity; both fetal hearts were heard on auscultation. Laboratory test results are shown in Table 1. A spot urinalysis revealed trace protein. A diagnosis of cholestasis of pregnancy was made, and ursodiol was administered. Four days later, at 33 weeks 2 days of gestation, the patient reported persistent itching, nausea, and occasional vomiting, along with a new pruritic rash on her abdomen that was thought to be consistent with pruritic urticarial papules and plaques of pregnancy. The results of a biophysical profile that assessed fetal well-being were reassuring. The patient returned home. On the afternoon of the current evaluation, the patient called the obstetrics staff and reported that she had felt “crummy” during the previous week and had noticed decreased fetal activity that day, with a maximum of four movements in 1 hour, despite hydration. She was advised to come to the labor and delivery triage unit for evaluation. On arrival, she reported nausea, decreased appetite, frequent urination (which was unchanged from baseline), subjective fevers, and chills; she did not report bleeding, dysuria, or loss of fluid. She also reported contractions that had occurred during the previous 2 days and had resolved spontaneously. The patient’s medical history included the presence of the sickle cell trait, gastroesophageal reflux disease, and exercise-induced asthma, and she had had dysmenorrhea, a stress fracture of her left tibia, Clostridium difficile infection after clindamycin use, and pancreatitis. Prenatal testing was positive for rubella-specific antibodies and negative for human immunodeficiency virus and hepatitis B virus surface antigen. Her current medications were ursodiol, iron polysaccharide, a prenatal vitamin, doxylamine for sleep, ranitidine, and an albuterol inhaler. She was black and marFrom the Department of Obstetrics and Gynecology, Women and Infants Hospi‐ tal of Rhode Island, and the Department of Obstetrics and Gynecology, the War‐ ren Alpert Medical School of Brown Uni‐ versity — both in Providence (D.J.R.); and the Departments of Radiology (T.W.K.), Obstetrics and Gynecology (L.E.R.), Medi‐ cine (A.R.L.), and Pathology (M.Y.P.), Massachusetts General Hospital, and the Departments of Radiology (T.W.K.), Obstetrics and Gynecology (L.E.R.), Medi‐ cine (A.R.L.), and Pathology (M.Y.P.), Har‐ vard Medical School — both in Boston.

Case 16-2016

Dr. Pietro Bortoletto (Obstetrics and Gynecology): A 31-year-old primigravid woman was seen in the labor and delivery unit of this hospital at 35 weeks of gestation because of fever. The patient was pregnant with dichorionic, diamniotic twins, and her gestation was complicated by iron-deficiency anemia and hyperemesis. Approximately 3 weeks before this evaluation, mild pruritus of the palms and soles developed. At 32 weeks 5 days of gestation (16 days before this evaluation), the patient was afebrile, had no visible rash, and reported fetal activity; both fetal hearts were heard on auscultation. Laboratory test results are shown in Table 1. A spot urinalysis revealed trace protein. A diagnosis of cholestasis of pregnancy was made, and ursodiol was administered. Four days later, at 33 weeks 2 days of gestation, the patient reported persistent itching, nausea, and occasional vomiting, along with a new pruritic rash on her abdomen that was thought to be consistent with pruritic urticarial papules and plaques of pregnancy. The results of a biophysical profile that assessed fetal well-being were reassuring. The patient returned home. On the afternoon of the current evaluation, the patient called the obstetrics staff and reported that she had felt “crummy” during the previous week and had noticed decreased fetal activity that day, with a maximum of four movements in 1 hour, despite hydration. She was advised to come to the labor and delivery triage unit for evaluation. On arrival, she reported nausea, decreased appetite, frequent urination (which was unchanged from baseline), subjective fevers, and chills; she did not report bleeding, dysuria, or loss of fluid. She also reported contractions that had occurred during the previous 2 days and had resolved spontaneously. The patient’s medical history included the presence of the sickle cell trait, gastroesophageal reflux disease, and exercise-induced asthma, and she had had dysmenorrhea, a stress fracture of her left tibia, Clostridium difficile infection after clindamycin use, and pancreatitis. Prenatal testing was positive for rubella-specific antibodies and negative for human immunodeficiency virus and hepatitis B virus surface antigen. Her current medications were ursodiol, iron polysaccharide, a prenatal vitamin, doxylamine for sleep, ranitidine, and an albuterol inhaler. She was black and marFrom the Department of Obstetrics and Gynecology, Women and Infants Hospi‐ tal of Rhode Island, and the Department of Obstetrics and Gynecology, the War‐ ren Alpert Medical School of Brown Uni‐ versity — both in Providence (D.J.R.); and the Departments of Radiology (T.W.K.), Obstetrics and Gynecology (L.E.R.), Medi‐ cine (A.R.L.), and Pathology (M.Y.P.), Massachusetts General Hospital, and the Departments of Radiology (T.W.K.), Obstetrics and Gynecology (L.E.R.), Medi‐ cine (A.R.L.), and Pathology (M.Y.P.), Har‐ vard Medical School — both in Boston.

Antibiotics in Otolaryngology: A Practical Approach

This chapter provides an overview of common antibiotics encountered in otolaryngology with a summary of microbial spectrum of activity, clinical indications, and adverse effects. A clinical approach to choosing antibiotics is outlined. Antibiotic stewardship is highlighted, with an emphasis on the optimal use of antibiotics.

Case 26-2017

A 63-year-old woman with dermatomyositis presented with fever, hypotension, hypoxemia, and pancytopenia. Chest imaging revealed consolidations in the dependent portion of the bilateral lower lobes and bilateral ground-glass opacities. Diagnostic tests were performed.

Case 15-2017 — A 27-Year-Old Woman with Anemia, Thrombocytosis, and Skin Lesions after Travel Abroad

A 27-year-old woman presented with skin lesions that had developed after international travel. Biopsy of a skin lesion revealed granulomatous dermatitis. Fatigue, weakness, and pulselessness developed in the left arm. A diagnosis was made.

Working Together to Define Antibiotic Appropriateness: Point Prevalence Survey in 47 Intensive Care Units from 12 US Hospitals, Partnership for Quality Care, March 2017

Abstract Background A national assessment of antibiotic appropriateness in intensive care units (ICUs) with benchmarking was performed to assist antibiotic stewardship programs (ASPs) identify improvement opportunities. Methods A Centers for Disease Control and Prevention tool was adapted by an expert panel from the Partnership for Quality Care (PQC), a coalition dedicated to high quality care in US hospitals, to validate appropriate antibiotic use measurement via a point prevalence survey on a single day. Data were collected by ASP personnel at each hospital, de-identified and submitted in aggregate to PQC for benchmarking. Hospitals identified reasons for inappropriate antibiotic use by category and antibiotics misused. Results Forty-seven ICUs from 12 PQC hospitals participated: California (2), Florida (2), Massachusetts (3), Minnesota (1), and New York (4). Most hospitals identified as teaching (83%) with 252-1550 bed size (median: 563) and 20–270 licensed ICU beds (median: 70). All hospitals reported a formal ASP. On March 1, 2017, 362 (54%) of 667 patients in participating ICUs were on antibiotics (range: 8-81 patients); 1 patient was not assessed. Of the remaining 361 antibiotic regimens, 112 (31%) were identified as inappropriate from among all 12 hospitals (range: 9-82%) (figure). The table displays inappropriate antibiotic use by ICU type. Reasons for inappropriate use included unnecessarily broad spectrum of activity (29%), duration longer than necessary (21%), and treatment of a non-infectious syndrome (19%). The antibiotic most commonly misused was vancomycin in 7 (58%) hospitals. Conclusion Up to 80% of antibiotic use in some ICUs is inappropriate, underscoring the need for ASP interventions, standardized assessment tools and benchmarking. Strategies should focus on de-escalation of broad-spectrum antibiotics and reducing duration of therapy. Disclosures D. W. Kubiak, Shionogi: Consultant, Consulting fee. Astellas Pharma: Consultant, Consulting fee