Mazen S. Bader

Intramuscular Methotrexate-Induced Aseptic Meningitis

Objective: To report a case of aseptic meningitis induced by intramuscularly administered methotrexate in a patient with rheumatoid arthritis. Case Summary: A 62-year-old male presented on 3 separate occasions with symptoms consistent with aseptic meningitis: 2 required hospitalization and 1 was noted during a subsequent ambulatory care visit. Prior to the first episode the methotrexate dose ranged between 17.5 mg and 20 mg given once weekly over 5 years, 11 months. One month before the patients first admission, the dose was increased to 22,5 mg. Symptoms on presentation included headache, neck stiffness, and fever. Cerebrospinal fluid testing indicated pleocytosis and low glucose level. Methotrexate was discontinued but was restarted 2 weeks after hospital discharge at the same dose and resulted in a second hospitalization for aseptic meningitis. Upon discharge from the second hospitalization, methotrexate was withheld. After a 2 month withdrawal period and rechallenge, the symptoms returned within 3 days. The drug was then discontinued. Discussion: Methotrexate-induced aseptic meningitis has been reported in the literature; however, in those cases, the effect occurred only when methotrexate was given via the intrathecal route. We Identified 7 relevant articles via a search of MEDLINE, International Pharmaceutical Abstracts, and EMBASE (1970–August 3, 2007): 3 were review articles, 2 were case series, and 2 were case reports. All of the series and reports involved patients with leukemia. The available literature suggests that aseptic meningitis is associated with long-term use of methotrexate or recent dose escalation. A definitive mechanism for methotrexate-induced aseptic meningitis is not known. The Naranjo probability scale indicates a probable relationship between the development of the condition and the methotrexate use in our patient. Conclusions: Aseptic meningitis has been previously associated with intrathecal use of methotrexate. Our report describes the first case of aseptic meningitis that occurred in a patient being treated with intramuscular methotrexate

Herpes Zoster: Diagnostic, Therapeutic, and Preventive Approaches

Abstract Herpes zoster (Hz), which generally presents as a localized, painful cutaneous eruption, is a common clinical problem, particularly among adults ≥ 50 years of age and immunocompromised patients. The diagnosis of Hz is mainly made clinically, except in patients with atypical manifestations or certain complications, such as central nervous system involvement, in which laboratory virologic testing is required. In addition to having a higher mortality rate, immunocompromised individuals have atypical and severe clinical findings and are at greater risk for complications and recurrence of Hz. Treatment of Hz includes the use of antiviral agents, analgesics for control of acute zoster pain, good skin care for healing, and prevention of secondary bacterial infection. Antiviral agents, preferably valacyclovir or famciclovir, should be started within 72 hours of onset to reduce the severity of the infection, the duration of the eruptive phase, and the intensity of acute pain. Herpes zoster has been associated with several complications, of which post-herpetic neuralgia (PHN) is the most common and debilitating. Varicella-zoster virus vaccine and early treatment with either famciclovir or valacyclovir are the only measures proven to prevent PHN. The options for treating PHN include topical agents, such as lidocaine patches, and systemic agents, such as the anticonvulsants gabapentin and pre-gabalin. Measures for preventing Hz include infection control through routine hand hygiene and appropriate use of isolation precautions and personal protective equipment; immunoglobulins, such as the varicella-zoster virus immunoglobulin and vaccine; and antiviral agents. The zoster vaccine has been shown to be effective in reducing the incidence of Hz and PHN. The vaccine is recommended for all individuals aged ≥ 60 years who have no contraindications, including individuals who report a previous episode of Hz.

Staphylococcus aureus Bacteremia in Community-Dwelling Older Adults: Hyperglycemia, Mortality, and Discharge Destination

BackgroundStaphylococcus aureus bacteremia (SAB) is associated with a significant morbidity and mortality. The aim of this study is to assess the impact of the degree of hyperglycemia on inhospital mortality and discharge destination in community-dwelling older adults with SAB. MethodsA retrospective cohort study of 100 community-dwelling older adults with SAB was carried out at 2 hospitals. A stepwise logistic regression analysis was performed for both inhospital mortality and discharge destination. ResultsDuring the follow-up period from admission till discharge, 23 (23%) patients died. Ten (14.3%) of 70 patients with 7 days post-SAB mean blood glucose less than 170 mg/dL died while 13 (43.3%) of 30 patients with 7 days post-SAB mean blood glucose of 170 mg/dL or greater died (P = 0.004). Multivariate analysis identified 3 independent determinants of death; Simplified Acute Physiology Score (SAPS) score at onset of SAB greater than 45 (odds ratio [OR], 9.4; 95% confidence interval [95% CI], 2.4–37.3; P = 0.002), 7 days post-SAB mean blood glucose of 170 mg/dL or greater (OR, 6.7; 95% CI, 1.8–24.5; P = 0.004), and altered mental status at the onset of SAB (OR, 3.9; 95% CI, 1.1–14.3; P = 0.04). Thirty (39%) of the survived patients were discharged to long-term care facility or inpatient rehabilitation unit. Older adults with blood glucose level of 170 mg/dL or greater in the first 7 days post-SAB (OR, 4.1; P = 0.02) and hospital stay longer than 10 days (OR, 5.2; P = 0.01) were more likely to be discharged to a long-term care facility or inpatient rehabilitation unit. ConclusionsHyperglycemia is associated with increased inhospital mortality and discharge to destination other than home in older adults with SAB.

Management of Hospitalized Patients with Diabetic Foot Infections

Abstract Diabetic foot infections (DFIs), which present with a variety of clinical manifestations, are commonly encountered by clinicians. They are associated with a high morbidity, a high amputation rate, a high mortality, and increased health care costs. An effective management of DFIs requires a multidisciplinary approach with a strong collaboration among all involved health care providers as well as patient involvement. Diagnosing DFIs appropriately requires consideration of the clinical symptoms and signs of infection in addition to supplementary laboratory testing such as inflammatory markers and imaging studies. The comprehensive patient assessment should include the predisposing risk factors for infection; the type, severity, and extent of the infection; and the assessment of neurologic and vascular status, comorbid conditions, and psychosocial factors. The comprehensive management of DFIs include not only effective antibiotic therapy but also surgical debridement, pressure offloading, wound care and moisture, maintaining good vascular perfusion, control of edema and pain, correction of metabolic abnormalities such as hyperglycemia, and addressing psychosocial and nutritional issues. Discharge planning that addresses full medical and social needs along with suitable follow-up, patient education and counseling, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient management of hospitalized patients with DFIs.

Management of Diabetic Foot Infections with Appropriate Use of Antimicrobial Therapy

Up to 25% of patients with diabetes will develop a foot ulcer during their lifetime with a 50-70% recurrence rate over the ensuing 5 year. Additionally more than 50% of patients with a diabetic foot ulcer (DFU) develop a diabetic foot infection (DFI). DFI remains a challenge to manage because of coexisting immunopathy. Antibiotic therapy is the main stay of treatment for patients with deep and surrounding tissue infection. A multidisciplinary approach is required with the focus on the comprehensive patient assessment, vascular assessment with revascularization, proper offloading devices and use of appropriate antimicrobials. Wound care professionals have a unique position to lessen the inappropriate use of antimicrobials.

Postexposure management of healthcare personnel to infectious diseases

Abstract Healthcare personnel (HCP) are at risk of exposure to various pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. Management of HCP exposed to infectious agents can be disruptive to patient care, time-consuming, and costly. Exposure of HCP to an infectious source should be considered an urgent medical concern to ensure timely management and administration of postexposure prophylaxis, if available and indicated. Infection control and occupational health departments should be notified for management of exposed HCP, identification of all contacts of the index case, and application of immediate infection control measures for the index case and exposed HCP, if indicated. This article reviews the main principles of postexposure management of HCP to infectious diseases, in general, and to certain common infections, in particular, categorized by their route of transmission, in addition to primary prevention of these infections.

Risk factors of cellulitis treatment failure with once-daily intravenous cefazolin plus oral probenecid.

Objectives Once-daily intravenous cefazolin with probenecid is used commonly to treat cellulitis. The primary objective of this study was to determine the risk factors of treatment failure with this regimen. Methods This was a retrospective cohort study of adult outpatients with cellulitis who were initially treated with once-daily intravenous cefazolin plus probenecid. Treatment failure is defined as inadequate improvement that necessitates either hospital admission or a change in antibiotic therapy to a different intravenous regimen. A stepwise logistic regression analysis was performed to determine the risk factors for regimen failure. Results From January 2003 to December 2008, 159 patients with cellulitis were initially treated with once daily intravenous cefazolin plus probenecid. Thirty-five (22%) patients had treatment failure. The treatment for 53% (9/17) of the patients with a history of chronic venous disease (CVD) failed, whereas the treatment for 18% (26/142) of patients without CVD failed (P = 0.001). Multivariate analysis identified the presence of CVD as the only risk factor associated with treatment failure (odds ratio 4.4, 95% confidence interval 1.5–13; P = .007). Conclusions Patients with cellulitis and CVD who are being treated with once-daily intravenous cefazolin plus probenecid should be monitored closely for treatment failure.

Postexposure management of infectious diseases

Anyone exposed to an infectious disease—whether a healthcare provider, patient, or contact of a patient—should be evaluated promptly and the source of the infection identified. A systematic response entails postexposure prophylactic therapy if available and indicated, infection control measures to prevent further transmission, counseling and educating those involved, and assessing those who may require work restriction or modification. People who have been exposed to an infectious disease should be evaluated promptly and systematically.

Community-Acquired Pneumonia in Elderly Patients With Diabetes Mellitus: Outcomes and Time to First Dose of Appropriate Antibiotic Therapy

BackgroundBoth diabetes mellitus (DM) and community-acquired pneumonia (CAP) are prevalent in elderly and are associated with significant morbidity and mortality. The primary objective of this subgroup analysis was to determine risk factors of the inhospital mortality, complication rate, and prolonged length of hospital stay (LOS) of CAP in elderly diabetic patients hospitalized with CAP. MethodsA retrospective cohort study of 157 elderly diabetic patients hospitalized with CAP at 2 tertiary teaching hospitals was carried out. Multivariate logistic and cox regression analyses were used to assess risk factors associated with inhospital mortality, complications, and LOS. ResultsDuring the follow-up period from admission till discharge, 30 (19.1%) patients died and 66 (42%) had complications. Seventeen (56.67%) of the patients who died received their first dose of appropriate antibiotic for CAP longer than 8 hours since triage, whereas 26 (20.47%) of survived patients received their first dose longer than 8 hours of triage at emergency department (ED) (P = <0.0001). Thirteen of 114 (11.4%) patients who received their first appropriate antibiotics in 8 hours or less since triage at ED died, whereas 17 of 43 (39.5%) patients who received their first appropriate antibiotics longer than 8 hours since triage died (P = <0.0001). In the multivariate analysis, time to first dose of appropriate antibiotic therapy longer than 8 hours since triage was associated with increased inhospital mortality (odds ratio, 5.94; 95% confidence interval [95% CI], 2.02–17.43; P = 0.001), complications (odds ratio, 2.90; 95% CI, 1.24–6.79; P = 0.01), and prolonged LOS of CAP (hazard ratio, 0.36; 95% CI, 0.20–0.65; P = 0.001). ConclusionsTime to first dose of appropriate antibiotic therapy longer than 8 hours since triage at ED might be associated with increased morbidity and mortality of CAP in elderly patients with diabetes mellitus.