Faisal A Khasawneh

Safety and feasibility of antibiotic de-escalation in bacteremic pneumonia

Background Antibiotic de-escalation is a potential strategy advocated to conserve the effectiveness of broad-spectrum antibiotics. The aim of this study was to examine the safety and feasibility of antibiotic de-escalation in patients admitted with bacteremic pneumonia. Methods A retrospective chart review was done for patients with bacteremic pneumonia admitted to Northwest Texas Hospital in Amarillo, TX, USA, during 2008. Antibiotic de-escalation was defined as changing the empiric antibiotic regimen to a culture-directed single agent with a narrower spectrum than the original regimen. Results Sixty-eight patients were admitted with bacteremic pneumonia. Eight patients were not eligible for de-escalation. Among the 60 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 27 cases (45.0%). Discharge to a long-term care facility predicted failure to de-escalate antibiotics, while an infectious diseases consultation was significantly associated with antibiotic de-escalation. The average daily cost of antibacterial therapy in the de-escalation group was

Guidewire-Related Complications during Central Venous Catheter Placement: A Case Report and Review of the Literature

25.7 compared with

Linezolid-induced black hairy tongue: a case report

61.6 in the group where de-escalation was not implemented. The difference in mean length of hospital stay and mortality between the two groups was not statistically significant. Conclusion Antibiotic de-escalation is a safe management strategy but unfortunately is not widely adopted. Although bacterial resistance poses a significant threat and is rising, antimicrobial de-escalation has emerged as a potential intervention that can conserve the effectiveness of broad-spectrum antibiotics without compromising the patient’s outcome. This practice is becoming important in the face of slow development of new anti-infective agents.

Pyogenic liver abscess and the emergence of Klebsiella as an etiology: a retrospective study

Seldingers technique is widely used to place central venous and arterial catheters and is generally considered safe. The technique does have multiple potential risks. Guidewire-related complications are rare but potentially serious. We describe a case of a lost guidewire during central venous catheter insertion followed by a review of the literature of this topic. Measures which can be taken to prevent such complications are explained in detail as well as recommended steps to remedy errors should they occur.

The prevalence and reliability of self-reported penicillin allergy in a community hospital

IntroductionLinezolid-induced black hairy tongue has been rarely reported. The purpose of this paper is to report a case of linezolid-induced black hairy tongue and review the literature.Case presentationA 56-year-old Caucasian man was admitted with community-acquired pneumonia that failed to respond to levofloxacin 750mg daily. He was started on linezolid and meropenem and was subsequently discharged home on oral linezolid 600mg every 12 hours and intravenous ertapenem 1g daily. On a follow-up clinic visit, day 14 of linezolid therapy, he complained of dysgeusia and his tongue examination was consistent with black hairy tongue. After he finished his antibiotic course, his complaints resolved with regular tongue brushing.ConclusionBlack hairy tongue is characterized by abnormal hypertrophy and elongation of filiform papillae. Five reported cases of linezolid-induced black hairy tongue were identified in a MEDLINE search (from January 2000 to June 2012). The Naranjo Probability Scale revealed a probable adverse drug reaction of linezolid-induced black hairy tongue. Potential contributing factors included other antibiotics, drug–drug interaction and poor oral hygiene. Health care professionals should be aware of the possibility of linezolid-induced black hairy tongue. Thorough history for other possible contributing factors should be obtained. Patients on linezolid should be counseled to perform good oral hygiene.

Mucormycosis in two community hospitals and the role of infectious disease consultation: a case series.

Objectives Pyogenic liver abscess (PLA) is a significant, though uncommon, cause of morbidity in the United States. Recently, Klebsiella has emerged as an important cause of PLA. We analyzed the clinical course, microbiology, and treatment outcomes of patients discharged with PLA. In addition, we sought to examine the incidence of and risk factors for Klebsiella liver abscess (KLA). Methods We reviewed the charts of patients who discharged with PLA from two teaching hospitals in West Texas between January 1, 2007 and December 31, 2011. Results We identified 49 cases of PLA. Abscess cultures were positive in 23 (48%) patients. The mean age of the cohort was 56 years (range: 20–83 years). Sixty percent were male. The most frequent conditions associated with PLA were intra-abdominal infections (ten cases; 20%), diabetes mellitus (nine cases; 18%) and malignancy (nine cases; 18%). Klebsiella was the most commonly isolated species from the abscess cultures (seven cases; 30% of all positive abscess cultures). We used univariate and logistic regression analyses to identify the risk factors for KLA. Controlling for age, only malignancy was identified in our cohort as a risk factor for a Klebsiella liver abscess. The overall mortality was 2%. Conclusion Klebsiella is emerging as an important cause of liver abscesses. Malignancy may be an important risk factor for Klebsiella liver abscess.

Focused Transthoracic Echocardiography

Background Penicillin (PCN) accounts for most cases of antibiotic allergies. Reported PCN allergy deprives the patient from this class of antibiotics and creates hesitancy in using other beta-lactam antibiotics. The aim of this study is to report the prevalence of self-reported PCN allergy among adult patients admitted to the hospital and to examine the probable validity of these reports. Methods A questionnaire was conducted among 192 patients with self-reported PCN allergy who were admitted to a community hospital between July 25, 2011 and January 25, 2012. Patients admitted with an infection and treated with a beta-lactam were also followed until hospital discharge. Results The mean age of patients at the time of their self-reported allergic reaction was 20.3 years. The most common allergic symptoms reported in decreasing order of frequency were itchy rash, angioedema, and urticaria. Based on analysis of the questionnaires, 121 patients (63.0%) had probable PCN allergy, 54 (28.1%) had possible PCN allergy, and 17 (8.9%) were unlikely to have a PCN allergy. Fifty-one participants (26.6%) had self-reported subsequent exposure to PCN in their life. This subsequent exposure was well tolerated in 86.3% of the participants. Fifty participants (25.9%) had self-reported subsequent exposure to a first generation cephalosporin and it was well tolerated in 78.4% of them. Conclusion Taking a detailed history from patients with self-reported PCN allergy can help to distinguish a true PCN allergy from a false positive report of allergy and hence allow clinicians to use this important class of antibiotics when truly indicated.

Cardiovascular Complications of HIV-Associated Immune Dysfunction

Background Mucorales are ubiquitous filamentous fungi that can cause a devastating, invasive infection. This order has become an increasingly important pathogen during the last two decades, due to the dramatic increase in patients with predisposing factors. The aim of this retrospective study was to report the clinical characteristics, therapeutic options, and outcomes of patients diagnosed with mucormycosis in community hospitals in Amarillo, Texas, and to reflect on the role of infectious disease (ID) physicians in managing this potentially life-threatening problem. Patients and methods This was a retrospective chart review of patients hospitalized with mucormycosis in two community hospitals in Amarillo between January 1, 2001 and December 31, 2011. Results Ten patients were diagnosed with mucormycosis during the study period, with a mean age of 58.8 years. There were five cases of pulmonary infection, two cases of cutaneous infection, two cases of rhinocerebral infection, and one case of gastrointestinal infection. Poorly controlled diabetes was the most common risk factor, identified in six patients, followed by hematological malignancy, immunosuppression, and trauma. ID physicians were consulted in all cases, albeit late in some cases. Nine patients received antifungal therapy, and five patients received surgical debridement. Lipid formulations of amphotericin B were prescribed for eight patients, used alone in two cases, and combined with caspofungin and posaconazole in one and five cases, respectively. One patient was treated with posaconazole alone. Eight patients were discharged from the hospital alive. The mortality rate at 6-month follow-up was 40%. Conclusion Mucormycosis is an emerging fungal infection that continues to carry significant morbidity and mortality. At-risk patient populations are on the rise, and include those with poorly controlled diabetes mellitus. Early diagnosis, in consultation with an ID physician, and an aggressive combined approach with surgical debridement and combined antifungal therapy is pivotal in improving patients’ outcomes.

The Effect of a Nurse-Led Multidisciplinary Team on Ventilator-Associated Pneumonia Rates

Abstract Caring for critically ill patients requires rapid and accurate diagnosis followed by prompt interventions. The physical examination remains an important part of the assessment of such patients, but it has been shown to have a low sensitivity and specificity in judging left ventricular function and intravascular volume. Invasive hemodynamic monitoring has similarly been shown to have significant limitations and has failed to demonstrate a mortality benefit in several recent studies. In some studies, it has been shown to be harmful. Focused transthoracic echocardiography (TTE) has emerged as a noninvasive and portable imaging technique that is capable of providing rapid and accurate information about the heart at the bedside. It can be used to complement the physical examination and result in marked improvement in diagnostic accuracy. Focused TTE can be used as a screening and monitoring tool. Studies have shown that clinicians can be trained to determine left ventricular function, detect pericardial effusions, predict intravenous fluid responsiveness, and identify important valvular defects in a relatively short period. This article describes the indications for focused TTE, provides evidence that clinicians can be rapidly taught the technique, reviews how the focused studies affect management, and discusses the advantages and limitations of this tool.

Progressive disseminated histoplasmosis presenting with cachexia and hypercalcemia

Prolonged survival in HIV infection is accompanied by an increased frequency of non-HIV-related comorbidities. It is suggested that cardiovascular diseases (CVD) occur earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed which can be categorized into traditional and nontraditional risk factors. Immune dysfunction is a nontraditional risk factor that contributes significantly to cardiovascular pathology. Markers of inflammation are elevated in HIV-infected patients, and elevations in markers such as high-sensitivity C-reactive protein, D-dimer, and interleukin-6 (IL-6) have been associated with increased risk for cardiovascular disease. However, the data currently suggest the most practical advice is to start antiretroviral therapy early and to manage traditional risk factors for CVD aggressively. A better understanding of the mechanisms of CVD in this population and further efforts to modify chronic inflammation remain an important research area.