Mark J. Enzler

Antimicrobial Prophylaxis in Adults

Antimicrobial prophylaxis is commonly used by clinicians for the prevention of numerous infectious diseases, including herpes simplex infection, rheumatic fever, recurrent cellulitis, meningococcal disease, recurrent uncomplicated urinary tract infections in women, spontaneous bacterial peritonitis in patients with cirrhosis, influenza, infective endocarditis, pertussis, and acute necrotizing pancreatitis, as well as infections associated with open fractures, recent prosthetic joint placement, and bite wounds. Perioperative antimicrobial prophylaxis is recommended for various surgical procedures to prevent surgical site infections. Optimal antimicrobial agents for prophylaxis should be bactericidal, nontoxic, inexpensive, and active against the typical pathogens that can cause surgical site infection postoperatively. To maximize its effectiveness, intravenous perioperative prophylaxis should be administered within 30 to 60 minutes before the surgical incision. Antimicrobial prophylaxis should be of short duration to decrease toxicity and antimicrobial resistance and to reduce cost.

Meningeal Coccidioidomycosis Diagnosed by Real-Time Polymerase Chain Reaction Analysis of Cerebrospinal Fluid

We describe two cases of coccidioidal meningitis (CM) diagnosed using real-time polymerase chain reaction (PCR) analysis of cerebrospinal fluid. These cases highlight the promise of PCR as a diagnostic method to assist in the rapid diagnosis of CM.

Evaluation of Impact of Statin Use on Development of CPK Elevation During Daptomycin Therapy

Background: Because both daptomycin and statins may increase creatine phosphokinase (CPK) levels, the manufacturer of daptomycin suggests considering holding statins during daptomycin therapy. Published evidence suggests potential detrimental effects of withdrawing statin therapy. Objectives: The objectives of this study were to determine the impact of concurrent statin therapy on peak CPK values, incidence of CPK elevation in patients receiving daptomycin therapy, and clinical factors associated with increased risk of developing CPK elevation. Methods: This was a single-center, retrospective cohort study of patients ≥18 years of age who received daptomycin for ≥72 hours and had ≥1 follow-up CPK during a 5-year period. A Kaplan-Meier curve was used to evaluate time to CPK elevation. Cox regression analyses were used to compare the risk of developing elevated CPK between 3 study groups: those receiving daptomycin alone, daptomycin with concurrent statin therapy, and statin therapy held while on daptomycin. Results: 498 patients were included in the study—384 received daptomycin alone, 63 received daptomycin concurrent with statin, and 51 with statin held during daptomycin therapy. Cumulative incidence of CPK elevation was 5.1% and 12% at 7 and 14 days. Those on daptomycin and statin concurrent therapy demonstrated an approximately 2-fold risk of CPK elevation compared with those having their statin therapy held, but the overall group effect was not statistically significant (P = .17). Conclusions: Our findings suggest that holding statin during daptomycin therapy may not be necessary, but may indicate need for increased frequency of CPK monitoring when these medications are used concurrently.

Learning from every death

The concepts of peer review and the venerable morbidity and mortality conference are familiar improvement approaches to health care providers. These 2 entities are typically provider or patient centric and are not typically extended within hospitals and health systems as a tool for organizational learning for care process or system failures. Out of a desire to deepen our understanding and accelerate learning about quality and safety opportunities in our hospitals, Mayo Clinic embarked on journey to analyze the stories of all patient deaths. This paper illuminates the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System (Rochester, MN).

Erysipelothrix rhusiopathiae bloodstream infection – A 22‐year experience at Mayo Clinic, Minnesota

Erysipelothrix rhusiopathiae is a facultatively anaerobic Gram‐positive bacillus found mostly in swine, fish and sheep. E. rhusiopathiae classically causes cutaneous eruptions in butchers, fish handlers and veterinarians. Based solely on case reports, 90% of E. rhusiopathiae bloodstream infections (BSI) have been associated with infective endocarditis (IE). To assess the true frequency of IE in E. rhusiopathiae BSI as well as other clinical associations, we performed a retrospective cohort analysis of E. rhusiopathiae BSI at Mayo Clinic. This is a single‐centre, retrospective study conducted between 1/1/1994 and 20/6/2016 at Mayo Clinic in Rochester, MN. Medical records were reviewed for demographics, E. rhusiopathiae BSI, anti‐microbial susceptibilities, incidence of IE, patient comorbidities, intensive care unit (ICU) admission and duration of antibiotics. Five cases of E. rhusiopathiae BSI were identified. Risk factors included animal exposures, immunosuppression, diabetes and kidney disease. All cases involved penicillin‐sensitive strains and high‐grade BSI. Four cases showed no signs of IE on transesophageal echocardiogram. All patients recovered fully with intravenous antibiotics. Our retrospective review illustrates that E. rhusiopathiae can cause invasive BSI in the absence of IE and that the previously reported 90% association between BSI and IE may be overestimated due to reporting bias. E. rhusiopathiae should be suspected in any patient with Gram‐positive bacilli in blood cultures and the aforementioned risk factors. A limitation of our study was the low sample size, and future studies may involve multicentre collaborations and the use of polymerase chain reaction (PCR) or serologic testing to increase the number of diagnoses..

Using Standardized Care Bundles in the Emergency Department to Decrease Mortality in Patients Presenting with Community-Acquired Pneumonia (CAP) and Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

There is significant variability when managing community-acquired pneumonia (CAP) and exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency department among doctors, hospitals, and health systems. This variability could contribute to the variable outcomes related with them. The use of standardized care bundles allows clinical teams to focus their efforts on a small number of measurable strategies aimed at improving specified outcomes. This article will review the importance of clinical care bundles when managing these diseases in the emergency department and its potential to decrease mortality.

Clinical study of an online tool for standardizing hospital care

Abstract:We assessed if use of an online clinical decision support tool improved standardization and quality of care in hospitalized patients with lower extremity cellulitis (LEC). This was a 14-month preintervention and postintervention study of 85 LEC admissions. There was significantly higher usage of the online LEC care process model (CPM) in the postintervention phase (p < .001). There was a trend toward higher rates of appropriate antibiotic regimen in the postintervention group both initially and at discharge (p = .063 for both). A sensitivity analysis of CPM users versus nonusers demonstrated a significantly higher rate of appropriate initial antibiotics prescribed when the CPM was used (p < .001). Use of this online CPM was associated with improved standardization, as demonstrated by increased ordering of an appropriate initial antibiotic regimen for hospitalized patients with LEC.

A Young Man with Pyomyositis and Bullous Disease

Diagnosis: linear IgA bullous dermatosis (LABD). Direct immunofluorescence staining of the skin biopsy specimen obtained from the left thigh, the predominant site of the outbreak of multiple small bullae (figures 1 and 2), revealed the presence of linear IgA deposits along the basement membrane (figure 3) consistent with the diagnosis of LABD related to vancomycin therapy. LABD is an autoimmune subepidermal vesiculobullous disease characterized by IgA deposition in a linear pattern along the basement membrane zone [1]. The disease is mediated by autoantibodies directed against several components of the basement membrane zone [2, 3]. Among antimicrobial drugs, vancomycin is the agent that is most frequently involved in cases of drug-induced LABD. Vancomycin-induced LABD is not dose dependent and has heterogenous presentation, ranging from benign erythema multiforme to toxic epidermal necrolysis [4–6]. The lesions appear 1–15 days after initiation of vancomycin therapy. Spontaneous and complete healing occurs after withdrawal of vancomycin therapy. However, new lesions could still appear up to 2 days after withdrawal of treatment with the drug. The use of steroids and dapsone do not seem to improve the outcome [4]. Rechallenge reproduces the disease with more-rapid and moresevere onset; however, successful rechallenge has been reported [7]. In our patient, vancomycin therapy was switched to daptomycin therapy, and the patient’s bullous rash resolved several days later.

Non-tender recurrent scrotal cellulitis

A 45-year-old man with a medical history of diabetes mellitus, dilated cardiomyopathy and obstructive sleep apnoea was hospitalised with recurrent scrotal cellulitis. He had been hospitalised twice within the past 3 months with scrotal oedema and cellulitis, which were managed with antibiotics and diuretics. The physical exam on the current admission was notable for an erythematous, non-tender, warm, indurated skin of the scrotum with a ‘peau d’orange’ appearance (figure 1A) and umbilicated skin …

A Rare Diagnosis: Recognizing and Managing Fungal Tenosynovitis of the Hand and Upper Extremity

PURPOSE Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period. METHODS A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes. RESULTS There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included Histoplasmacapsulatum (7), Coccidioides posadasii/immitis (2), and Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with Coccidioides infection incurred recurrence. CONCLUSIONS Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.