Mansoor Mehmood

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

Staphylococcus Lugdunensis Gluteal Abscess in a Patient with End Stage Renal Disease on Hemodialysis

25.7 compared with

Bacteremic skin and soft tissue infection caused by Prevotella loescheii

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.

A 45-year-old Male with Cough, Shortness of Breath and Constitutional Symptoms

A 57-year-old end stage renal disease patient on hemodialysis (HD) presented with sepsis secondary to right buttock abscess and overlying cellulitis. She was started on broad-spectrum antibiotic therapy and underwent incision and drainage with marked improvement. Her cultures grew methicillin-resistant Staphylococcus lugdunensis. This bacterium is more virulent than other coagulase negative staphylococci and has been implicated in causing a variety of serious infections but it has been underreported as a cause of skin infections in HD patients and possible other patient populations.

Right-sided Pleuritic Chest Pain in a 36-year-old Male.

BackgroundAnaerobes are a major component of gut flora. They play an important role in the pathogenesis of infections resulting from breaches in mucus membranes. Because of the difficulties in cultivating and identifying it, their role continues to be undermined. The purpose of this paper is to report a case of Prevotella loescheii bacteremic skin and soft tissue infection and review the literature.Case presentationA 42-year-old Caucasian man was admitted for an elective bariatric surgery. A lengthy intensive care unit stay and buttocks decubitus ulcers complicated his post-operative course. After being transferred to a long-term care facility, the decubitus ulcer became secondarily infected with multiple bacteria including P. loescheii; an anaerobe that grew in blood and wound cultures. The patient was treated successfully with aggressive surgical debridement, antibiotics and subsequent wound care.ConclusionP. loescheii colonizes the gut and plays an important role in periodontal infections. In rare occasions and under suitable circumstances, it can infect skin and soft tissues as well as joints. Given the difficulties in isolating anaerobes in the microbiology lab, considering this bacterium alongside other anaerobes in infections of devitalized tissue is indicated even if cultures were reported negative.

The yield of stool testing in hospital-onset diarrhea: Has evidence changed practice?

A 45-year-old painter was admitted with a five day-history of a dry cough, headache, shortness of breath, and fever. His complaints started 10 days after he finished the remodeling of an old house. His physical exam was non-focal, and he had no rashes or lymphadenopathy. His blood tests showed white blood cell count of 12.7 × 109/μL and his kidney and liver function tests were within normal limits. Lumbar puncture results and human immunodeficiency virus infection (HIV) test were negative. His chest X-ray showed bilateral interstitial opacities. Lung computed tomography scans showed bilateral parenchymal micronodules. The patient’s blood and bronchoalveolar lavage cultures were negative. He was diagnosed with atypical community-acquired pneumonia (CAP) and discharged on a course of azithromycin. The patient was lost to follow-up until he presented to our hospital four months later with constitutional symptoms. He reported night sweats and fever, poor appetite, dry cough, and shortness of breath. Follow-up chest imaging showed an increase in the size of the pulmonary nodules [Figure 1a and 1b]. He underwent video-assisted thoracoscopy with a lung biopsy. Biopsy staining is shown in Figure 2 and 3. Figures 1 Computed tomography scans of two sections of the patient’s chest showing bilateral pulmonary nodules of variable size. Figure 2 Hematoxylin and eosin stained section of the lung shows two well-defined granulomas with central necrosis, magnification = 40 ×. Figure 3 Gomori methanamine silver stain shows small budding yeast consistent with histoplasma. The yeast clustering indicates the intracellular location within macrophages, magnification = 400 ×.

A 19-year-old woman with pleuritic chest pain

A 36-year-old male was admitted with right-sided pleuritic chest pain that had lasted five days. There was no fever or chills, but he reported shortness of breath and long-standing coughing and wheezing. The cough was intermittently productive of brown sputum. The patient was diagnosed with bronchial asthma 10 years prior. He was managed by a pulmonologist until he lost his job and insurance three years before his presentation to the hospital. In those three years he continued to treat himself with 20 to 60mg prednisone daily to control his coughing and wheezing. His medical history was otherwise unremarkable. He was married with two healthy sons, and he had no history of smoking. On examination, the patient was thin and in mild respiratory distress. Vital signs were as follows: temperature 37.6oC, heart rate 104beats/min (regular), blood pressure 127/76mmHg, respiratory rate 28breaths/min, and oxygen saturation 94% while on 2L/min of oxygen via a nasal cannula. Significant physical examination findings included the following: right-sided pleural rub and shallow inspirations, regular heart sounds without murmurs or gallop, and no lymphadenopathy or rash. Pertinent laboratory findings included the following: white blood cells count 12,200/μL (79% neutrophils and 15% lymphocytes), hemoglobin level 11.8g/dL, platelet count 276,000/μL, and human immunodeficiency virus (HIV) test was negative. Liver enzymes, kidney function tests, and coagulation studies were within normal limits. Chest X-ray (CXR) on admission and computed tomography (CT) scan are shown in Figures 1 and 2. Figure 1 Chest X-ray on admission of a 36-year-old male with right-sided pleuritic chest pain. Figure 2 Computed tomography scan cross-section on admission. The patient underwent CT guided biopsy and histopathology [Figures 3 and 4]. Figure 3 Hematoxylin and eosin stained lung biopsy, magnification=200×. Figure 4 Gomori methenamine silver stained lung biopsy, magnification=200×.

Leg pain following Staphylococcus aureus bacteraemia.

Abstract Introduction: Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown. Methods: A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization. Results: 132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort’s mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01. Conclusion: Despite improvements in stool samples’ testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians’ embracement of the ‘3-day rule’ continues to be poor.

A 29-year-old man with hospital-acquired cavitary pneumonia

Case presentation A 19-year-old woman with a medical history significant for poorly controlled diabetes mellitus (DM) (hemoglobin A1C 11.2%) presented with a 12-day history of right-sided pleuritic chest pain. One month earlier, she had developed sudden-onset fever, dry cough and shortness of breath. At the time, she did not have any gastrointestinal symptoms including epigastric pain, heartburn, vomiting or retching. She denied sick contacts and had no preceding symptoms of an upper respiratory tract infection. She was seen at a local emergency department and was released home on a 10-day course of oral doxycycline (100 mg every 12 h) to treat a community-acquired pneumonia (CAP). After an initial two-week improvement, her complaints relapsed, with fevers, dry cough, poor appetite and the above-described chest pain. The patient did not smoke and she denied alcohol abuse or illicit drug use. On presentation to the hospital, she was febrile (temperature 38.2°C), her oxygen saturation was 86% on room air and she was thin. She was awake and oriented but in obvious pain. She had no jugular venous distention. Her heart sounds were regular without murmurs or gallops. The lung examination revealed reduced air entry over the right lung base with bronchial breath sounds and egophony. The abdomen was soft without tenderness or distension and she had no evidence of subcutaneous emphysema or lymphadenopathy. There were no lower limb edema and no joint swelling or deformities. The laboratory tests revealed a white blood cell count of 26.0×109/L and a hemoglobin level of 119 g/L. Blood chemistry showed normal kidney and liver function. Tests for HIV and pregnancy were negative. Chest imaging included a chest x-ray and a contrasted chest computed tomography scan (Figures 1 and 2). The patient was admitted to hospital with severe sepsis due to CAP complicated by an empyema and was started on intravenous broad-spectrum antibiotics, vancomycin (15 mg/kg every 12 h) and piperacillin/tazobactam (3.375 g every 6 h). She underwent computed tomography-guided drainage 48 h afterwards. An interventional radiologist performed the procedure under strict sterile techniques. Cytopathology (Figure 3) and cultures were ordered on the drained fluid. What is your diagnosis?

A 71-year-old woman with recurrent falls and confusion

### Presentation A 47-year-old Indian immigrant with a medical history significant for diabetes presented with severe sepsis due to complicated methicillin susceptible Staphylococcus aureus (MSSA) bacteraemia. His transoesophageal echocardiogram was negative. His condition improved markedly on intravenous nafcillin and his follow-up blood cultures were negative. In spite of the above, he continued to complain of throbbing pain in different muscle groups in his lower limbs (LL). Physical examination showed tender and swollen thighs and left calf. Overlying skin was normal. CT of the LL in the second week of illness was negative but a follow-up …