Arif R. Sarwari

Impact of a Multimodal Antimicrobial Stewardship Program on Pseudomonas aeruginosa Susceptibility and Antimicrobial Use in the Intensive Care Unit Setting

Objective. To study the impact of our multimodal antibiotic stewardship program on Pseudomonas aeruginosa susceptibility and antibiotic use in the intensive care unit (ICU) setting. Methods. Our stewardship program employed the key tenants of published antimicrobial stewardship guidelines. These included prospective audits with intervention and feedback, formulary restriction with preauthorization, educational conferences, guidelines for use, antimicrobial cycling, and de-escalation of therapy. ICU antibiotic use was measured and expressed as defined daily doses (DDD) per 1,000 patient-days. Results. Certain temporal relationships between antibiotic use and ICU resistance patterns appeared to be affected by our antibiotic stewardship program. In particular, the ICU use of intravenous ciprofloxacin and ceftazidime declined from 148 and 62.5 DDD/1,000 patient-days to 40.0 and 24.5, respectively, during 2004 to 2007. An increase in the use of these agents and resistance to these agents was witnessed during 2008–2010. Despite variability in antibiotic usage from the stewardship efforts, we were overall unable to show statistical relationships with P. aeruginosa resistance rate. Conclusion. Antibiotic resistance in the ICU setting is complex. Multimodal stewardship efforts attempt to prevent resistance, but such programs clearly have their limits.

A matched-control evaluation of an antifungal bundle in the intensive care unit at a university teaching hospital

Background Antimicrobial use bundles are becoming a common means of implementing antimicrobial stewardship initiatives in the hospital setting. Although the utility of these bundles has been described for many disease states, their adoption for antifungal therapy management is largely unknown. Objective Our objective was to assess the utility of an antifungal bundle protocol in limiting excessive use of echinocandins in the intensive-care inpatient setting. Methods In this matched-control evaluation, pre-protocol control patients were matched with each prospective patient in a 2:1 ratio using five demographic and clinical characteristics. The impact of the antifungal bundle protocol on caspofungin days of therapy, drug costs, and adherence to bundle criteria was assessed. Results A significant reduction in median days of caspofungin therapy (4.00 vs. 2.00 days, p = 0.001) was found in the bundle group. Most of this reduction in use was realized in the medical ICU (p = 0.002) as opposed to the surgical ICU (p = 0.188). Conclusions Use of an antifungal bundle approach appears to facilitate a reduction in caspofungin use in the ICU without adversely affecting patient outcomes. Further trials are needed to assess the utility of such bundles in providing antimicrobial stewardship for antifungal drug use.

THE PHARMACOLOGIC CONSEQUENCES OF FEVER

Despite its potential importance to the management of patients with febrile illnesses, the effect of fever on pharmacokinetics and pharmacodynamics has received little attention in the clinical literature. This article considers literature published in this potentially important area.

Pneumococcal purpura fulminans successfully treated with activated protein C.

Evidence suggests that sepsis is a systemic inflammatory condition complicated by dysequilibrium in coagulation and fibrinolytic homeostasis, with a shift in the balance towards increased coagulation over fibrinolysis. Protein C is a natural anticoagulant consumed and inactivated during sepsis. We present the case of a 33-year-old female, postsplenectomy, with pneumococcal sepsis and purpura fulminans, successfully treated with activated protein C.

Multiple Subcutaneous Mycetomas caused by Pseudallescheria boydii: Response to therapy with oral potassium iodide solution

We describe the case of a sixteen-year-old male who presented with multiple subcutaneous mycetomas proven on culture to be secondary to Pseudallescheria boydi., The lesions responded completely to oral potassium iodide solution. To our knowledge this has never been reported in humans.

North American blastomycosis of the eyelid

A 26-year-old diabetic man presented with a papillomatous eyelid lesion. Histopathology was consistent with Blastomyces dermatitidis. A 1-year course of itraconazole led to resolution in this case. Although skin is the most common extrapulmonary site of blastomycosis, eyelid involvement is rare. Prompt diagnosis and treatment improve morbidity and mortality.

Clinical outcomes following hospital-wide implementation of prolonged-infusion cefepime and ceftazidime

Prolonged infusion (3–4 h) of -lactam antibiotics may optiise the pharmacodynamic properties of these time-dependent gents [1]. Whilst clinical outcome data exist for some -lactam ntibiotics, limited data are available for cefepime and ceftazidime 2,3]. Our academic medical centre recently selected prolonged nfusion (PI) as the preferred infusion method for ceftazidime nd cefepime administration based on previously published pharacokinetic and pharmacodynamic data [4]. We conducted a uasi-experimental study to determine whether there was a clincal advantage or disadvantage to PI compared with standard nfusion (SI) in treating infections caused by Gram-negative orgaisms. Medication records at our academic medical centre for adult atients receiving ≥3 days of cefepime or ceftazidime from 1 anuary 2010 to 31 March 2013 were retrospectively searched. atients receiving either drug prior to 1 January 2012 received SI ver 30 min; after this date, all regimens were administered with a oading dose given over 30 min followed by PI over 180 min. Clinical utcomes were compared between the pre-intervention (SI) and ost-intervention (PI) groups. Only patients with a proven Gramegative organism identified in blood or respiratory cultures were ncluded in the study. The primary outcome was in-hospital morality. Secondary outcomes included clinical cure at 7 days as well as ospital and intensive care unit (ICU) length of stay. This study was ranted exempt status by the institutional review board of West irginia University Healthcare. A total of 2868 patients received cefepime or ceftazidime durng the study period, with 329 (11.5%) of these patients having culture meeting the inclusion criteria. Following other excluions, 108 patients were included in the final analysis. Overall, aseline characteristics were similar between the SI and PI groups, ith the exception that isolation of Pseudomonas aeruginosa was ore frequent in the PI group (40.6% vs. 63.6%; P = 0.03). Primary nd secondary outcomes were similar between groups (Table 1) ith the exception of longer ICU length of stay in the PI group P = 0.003). There was a non-statistically significant trend in inospital mortality favouring PI when limiting the analysis to atients admitted to the ICU [hazard ratio (HR) = 0.44, 95% confience interval (CI) 0.12–1.60] or those infected with P. aeruginosa HR = 0.38, 95% CI 0.10–1.46). Isolation of a resistant pathogen was he only variable independently predictive of in-hospital mortality adjusted HR = 4.04, 95% CI 1.03–15.85). After controlling for resisant pathogens, receipt of PI continued to be associated with longer CU length of stay (P = 0.03).

A Patient with a Painless Neck Swelling

A 26-year-old man who was otherwise healthy developed a painless swelling on the right side of the neck. During the 4 weeks after onset, the swelling increased rapidly in size, and a second smaller swelling developed on its superior aspect. The patient had no comorbid conditions and no constitutional symptoms. He denied a history of any preceding viral illness or head or neck trauma, and he had no history of international travel. He had never experienced any neck swelling in the past. On physical examination, there was a fluctuant, erythema-tous, nontender swelling along the anterior border of the right sternocleidomastoid muscle that was 4 cm ϫ 4 cm in area. No warmth of the overlying skin was present. A smaller swelling, 1 cmϫ 1 cm in area, was present on the superior aspect of the initial lesion (figure 1). The findings of a systemic examination were unremarkable. Fine-needle aspiration was performed. Pathological examination of the aspirate showed dense inflam-matory exudate with epithelioid cells consistent with granu-loma. The results of Gram staining were negative, and kinyon staining of the specimen did not reveal acid-fast bacilli. Bacterial , fungal, and mycobacterial cultures showed no growth. A CT scan of the neck was performed and is shown in figure 2. What is your diagnosis?

Adherence to HIV Treatment and Care at a Rural Appalachian HIV Clinic

&NA; Persons living with HIV (PLWH) in rural areas face different barriers to care and treatment adherence compared to persons in urban areas. Our project identified strategies used by a rural HIV clinic with high rates of viral suppression, as evidenced by data abstraction from medical records from January 2010 through December 2014, including 411 patients ages 18 years or older. As HIV viral load is used as a marker for adherence and impacts health outcomes and transmission, it is an important assay. The national goal is for 80% of PLWH to be virologically suppressed by the end of 2020. This clinic exceeded the goal in 2014 with observed rates of 80% to 90% suppression. Eleven national guidelines for HIV care have been adopted by this clinic, along with five additional evidence‐based interventions. Nurses played a critical role in all of these methods, and our intent was to report success‐related factors.

Pyomyositis of the chest wall presenting with empyema thoracis

DISCUSSION Splenic rupture after videothoracoscopic lung procedures is a very rare event. In the only case previously described in the literature, an emergency splenectomy was required after a splenic injury occurred during video-assisted pulmonary resection of a nonmalignant tumor. The suggested cause of injury was a transdiaphragmatic blunt trauma with intact diaphragm. In our case we did not detect any direct evidence of a laceration of the diaphragm at the end of the videothoracoscopic procedure, and the ensuing radiographic examinations also yielded negative results. Transdiaphragmatic blunt trauma to the spleen was clearly caused by the positioning of one of the thoracoscopic ports (the lowest was inserted in the ninth intercostal space posteriorly) or by the insertion of the mechanical suture device (we have used the lowest one for the stapler), which can be troublesome if the pulmonary lesions are in close proximity to the chest wall.