Eva Steel

Implementation of a multidisciplinary infectious diseases team in a tertiary hospital within an Antimicrobial Stewardship Program

Abstract Background: In January 2011, as part of an antimicrobial stewardship program the Antimicrobial Management Team (AMT) at the Ghent University Hospital initiated a multidisciplinary Infectious Diseases Team (MIT) consisting of infectious diseases physicians, clinical microbiologists, and clinical pharmacists. The aim of this study is to describe the type and acceptance rate of recommendations provided by the MIT. Method: Prospective, observational study in a tertiary care, university teaching hospital with 1062 beds in non-consecutive hospitalized adult patients, excluding intensive care units and paediatrics. Results: The MIT communicated 432 recommendations in 87 days observed. Of the 293 patients for whom a recommendation was made, the median age was 57 years (range: 16–91 years) and 169 (57·7%) were male. Skin or soft tissue infections (14%), respiratory tract infections (13%), infections without known focus (11%), abdominal infections (11%), and bone infections (8%) were most common. Recommendations were made to perform additional clinical investigation(s) [N = 137 (27%)], to adjust the dose of an antimicrobial drug [N = 42 (8%)], to stop an antimicrobial drug [N = 104 (21%)], to switch from a parenteral to an oral drug [N = 39 (8%)] or to initiate an antimicrobial drug [N = 178 (36%)], with an acceptance rate of 73·0%, 83·3%, 81·7%, 76·9%, and 84·0%, respectively. Conclusions: The MIT formulated about five recommendations a day primarily focusing on pharmacotherapy, but also on clinical investigations. In both fields, a high acceptance rate was observed.

Early recognition of malignant lactic acidosis in clinical practice: report on 6 patients with haematological malignancies

Abstract Background: Malignant lactic acidosis is a potentially overlooked but life-threatening complication in patients with haematological malignancies. The aim of this study is to describe the features of six patients with malignant lactic acidosis and to discuss how its initial presentation can be differentiated from that of severe sepsis. Methods: We prospectively collected data of all consecutive patients with haematological malignancies, admitted to the Ghent University Hospital Intensive Care Unit (ICU) between 2000 and 2007. Results: Of 372 patients with haematological malignancies admitted to the ICU for life- threatening complications, 58 presented with lactic acid levels ≥ 5 mmol/L. Six were diagnosed with malignant lactic acidosis. All patients with malignant lactic acidosis had high-grade lymphoblastic malignancies and were referred with a tentative diagnosis of severe sepsis or septic shock; lactic acid levels exceeded 9.45 mmol/L and lactate dehydrogenase (LDH) levels were at least 1785 U/L. Two patients had hypoglycaemia. All had a pronounced polypnea. In all patients hepatic malignant involvement was suspected. Two of the six patients survived their episode thanks to the early recognition of malignant lactic acidosis and the prompt administration of chemotherapy. One patient was still alive 6 months after initiating chemotherapy. Conclusion: Malignant lactic acidosis is a rare and often rapidly fatal metabolic complication if not promptly recognized and treated. An elevated lactic acid concentration, in disproportion with the level of tissue hypoxia, together with high serum LDH are cornerstones in the diagnosis. In contrast to septic shock patients, pronounced polypnea (Kussmaul’s breathing pattern) rather than the haemodynamic instability is prominent.

Cutaneous mucormycosis as result of insulin administration in an AML patient: Case report and review of the literature.

We present a case of cutaneous mucormycosis in a patient with several important risk factors precipitating disease, namely underlying acute myeloid leukaemia and poorly controlled secondary diabetes. Inoculation was most likely caused by repeated minor trauma (insulin injection) at the site of infection. Treatment consisted of surgical debridement and liposomal Amphotericin B (LAmB) during 71 days. Posaconazole had already been initiated prior to infection as primary antifungal prophylaxis but was discontinued during follow-up as susceptibility testing later revealed resistance to posaconazole. Additional treatment with caspofungin and G-CSF was associated because of poor initial result to treatment. Caspofungin was later continued as monotherapy when LAmB had to be interrupted because of renal toxicity. Treatment was completed after closure of the surgical site. The patient was successfully treated and remains infection free for one year after initial diagnosis.

Aggressive extensive cardiac mass in an HIV-1-infected patient : should we go for comfort therapy?

Cardiac masses are rare, the differential diagnosis includes infections with vegetations or abscesses, neoplasms, thrombi, and structural abnormalities. A pathology specimen is essential in therapeutic strategy planning for a cardiac mass, also if the primary imaging findings look dramatic at the start. Even in an inoperable setting, a life-saving therapy might be available. We report a case of a 49-year-old man, known with HIV-1, who was several times admitted with pericarditis. Now he was hospitalized with progressive lower limb edema, atrial fibrillation and detection of a giant cardiac mass in left and right atrium with infiltration of surrounding tissues. Given the extent and invasiveness of the mass, he was inoperable. Biopsy specimen was obtained and staging was performed by PET-CT scan. The diagnosis of stage IV Burkitt lymphoma with predominant extranodal cardiac involvement was withheld wherefore promptly aggressive therapy was started according to the GMALL B-NHL86 protocol. The therapy was downgraded to R-CHOP due to tolerance problems. He achieved a complete remission and during follow-up no relapse was detected.

Effect of iron overload on the pituitary gland and associated imaging findings

Dyserythropoetic anemia type IV is a congenital form of aberrant normoor megaloblastic erythropoesis, resulting in hemolysis and secondary hemochromatosis. Commonly affected organs are endocrine organs such as the pancreas, and also the spleen and liver. In the brain, structures lying outside the blood–brain barrier like the choroid plexus, pituitary and pineal gland are prone to elevated iron levels. We report the case of a patient with pituitary iron overload. A 35-year-old male with known congenital dyserythropoetic anemia type IV, secondary hypogonadotropic hypogonadism and atrial fibrillation, complaints of fatigue, diminished strength and progressive muscle cramps. Medical history shows that the patient underwent a splenectomy and regularly requires transfusions. Biochemical analysis showed decreased pituitary function (testosterone 28 ng/dl, no free testosterone, LH 0.5 U/l, FSH 1.1 U/l, SHBG 5.9 lg/dl) as well as elevated serum iron, iron saturation and ferritine levels, and prior abdominal magnetic resonance imaging (MRI) showed iron accumulation in the liver and pancreas. Additional brain imaging revealed a marked compensatory thickening of the calvarium due to the dyserythropoetic anemia. The pituitary stalk appeared enlarged, but more striking was the profound low signal intensity of the anterior lobe on T1 and T2 with lack of normal contrast enhancement (Fig. 1a, b). The normal hyperintense signal of the posterior lobe was preserved on the T1 weighted sequence. The pituitary gland, lying in the sella turcica, is a threelobed major endocrine organ lying outside of the brain. Connected to the hypothalamus by the pituitary stalk, this gland is responsible for hormone secretions regulating metabolism, growth, osmolality, thyroid function etc. Especially the anterior lobe is prone to the toxic effects from iron overload [1]. Like in our patient, the progressive and toxic deposition of iron products is believed to damage