Richard L. Oehler

Bite-related and septic syndromes caused by cats and dogs

Bite infections can contain a mix of anaerobes and aerobes from the patients skin and the animals oral cavity, including species of Pasteurella, Streptococcus, Fusobacterium, and Capnocytophaga. Domestic cat and dog bite wounds can produce substantial morbidity and often require specialised care techniques and specific antibiotic therapy. Bite wounds can be complicated by sepsis. Disseminated infections, particularly those caused by Capnocytophaga canimorsus and Pasteurella multocida, can lead to septic shock, meningitis, endocarditis, and other severe sequelae. An emerging syndrome in veterinary and human medicine is meticillin-resistant Staphylococcus aureus (MRSA) infections shared between pets and human handlers, particularly community-acquired MRSA disease involving the USA300 clone. Skin, soft-tissue, and surgical infections are the most common. MRSA-associated infections in pets are typically acquired from their owners and can potentially cycle between pets and their human acquaintances.

Emerging Therapies in the Treatment of Clostridium Difficile—Associated Disease

Objective: To describe emergent therapies, such as rifaximin, nitazoxanide, intravenous immunoglobulin (IVIG), tinidazole, tolevamer, and the possible use of a vaccine, in Clostridium difficile–associated disease (CDAD), one of the most common causes of diarrhea in hospitalized adults in North America. Data Sources: A literature search was performed using MEDLINE (1996-October 2006), PubMed (1996–October 2006), abstracts from Infectious Diseases Society of America (September 2006) and International Conference on Antimicrobial Agents and Chemotherapy (September 2006), Internet (October 2006), Genzyme product Web site (October 2006), and Romark Laboratories Web site (October 2006) using the terms Clostridium difficile, rifaximin, nitazoxanide, intravenous immunoglobulin, tolevamer, vaccine, and tinidazole. Study Selection and Data Extraction: Data presented in this article were selected based on clinical relevance and power of the studies. In vivo and in vitro studies supporting the use of drugs available for treatment of refractory CDAD were reviewed. Some of the information on new and emerging modalities was also included, although there were limited published data available. Data Synthesis: Clinical trials evaluating the use of nitazoxanide and tolevamer for the treatment of CDAD have been published. Tinidazole use is based on structural similarities to metronidazole; however, clinical trials have not been conducted and the cost of this agent may be a limiting factor. The use of rifaximin and IVIG will require randomized clinical trials to establish their place in therapy. Limited information in the literature suggests that a vaccine may be effective for CDAD prevention. Conclusions: CDAD is a debilitating disease with increasing treatment failure rates and recurrences using standard therapies. Clinicians need to look at other options to expand the available treatment arsenal in addition to placing a greater emphasis on prevention.

Kaposi's sarcoma mimicking cellulitis

Although Kaposis sarcoma is not the most common cause of death in AIDS patients, it is often one of the initial opportunistic illnesses associated with human immunodeficiency virus infection. Extensive plaque formation and edema in the lower extremities may take on the appearance of cellulitis, and in dark-skinned persons, the lesions of the neoplasm may not be noticeable. Treatment is palliative; therapy for local effect is appropriate unless lesions are extensive or systemic involvement is present.

Vancomycin-Resistant and Daptomycin-Resistant Enterococcus faecium Bacteremia and Colonization in Patients With Acute Leukemia With Prolonged Neutropenia

BackgroundVancomycin-resistant Enterococcus faecium (VREF) bacteremia has been reported to be increasing in frequency and is associated with significant morbidity and mortality rates in patients with acute leukemia with prolonged neutropenia and VREF colonization. We report our experience with the prophylactic use of varying doses of daptomycin and other antibiotics active against VREF in this patient population and the development of a cluster of daptomycin-resistant E. faecium bacteremia and colonization cases. MethodsA retrospective chart review was conducted of patients with acute leukemia and prolonged neutropenia with positive microbiological data for VREF bacteremia and/or colonization from July 2009 to June 2010. We collected susceptibility data of the VREF, use and dosage of empiric anti-VREF antibacterial therapy, and the incidence of breakthrough VREF bacteremia among patients with colonization. ResultsBreakthrough VREF bacteremia occurred at the following rates in patients with prolonged neutropenia receiving prophylactic anti-VREF therapy: 14.6% (7/48 patients) receiving daptomycin 6 mg/kg per day, 8.3% (2/24 patients) receiving daptomycin 8 mg/kg per day, 0% (0/13 patients) receiving linezolid, 40% (4/10 patients) receiving tigecycline, and 0% (0/3 patients) receiving dalfopristin-quinupristin. ConclusionsBreakthrough VREF bacteremia was observed despite the use of daptomycin 6 mg/kg per day in patients with neutropenia and colonized VREF. Increasing the dosage of daptomycin to 8 mg/kg per day seemed to reduce this occurrence but breakthroughs were seen in the setting of daptomycin-resistant E. faecium colonization. Linezolid seems to be a promising option to prevent or treat VREF bacteremia in these patients. We recommend close monitoring for VREF colonization including susceptibility data to appropriately select empiric or prophylactic antimicrobial therapy directed against VREF in those patients with prolonged neutropenia.

An Overview of Social Media in the Practice of Infectious Diseases

AbstractThe explosion in the use of social media resources across society has extended to medicine, and perhaps nowhere is it more prevalent than in the field of infectious diseases. Physicians are using blogs to write about infectious diseases, new therapies, and their experiences with them. “Infoepidemiology” promises to quickly uncover future outbreaks without the need to cross oceans or to don a respirator. Infectious disease clinicians are sharing ideas, promoting organizational and philanthropic awareness, and professionally interacting on social networks such as Facebook. YouTube and other media sharing sites have become new resources for remote medical learning and educational collaboration. At the same time, personal and professional users of social media must confront challenging issues such as professionalism, medical confidentiality, peer review, and privacy concerns.

Isolated Pulmonary Cryptococcosis in Hepatic Transplantation: Case Report and Review of the Literature

AbstractDespite advances in the surgical and medical management of liver transplant patients, infections remain a significant cause of transplant-associated morbidity and death. Invasive fungal infections are among the leading causes of infectious complications in solid organ transplant recipients and have a comparatively much higher risk of mortality. Liver transplant recipients with invasive fungal infections have the highest mortality, a finding perhaps attributable to the acuity of their systemic illness as well as their degree of immune system compromise. Cryptococcus neoformans is the third most common fungal infection in this group.In this article, we describe our experience with a 65-year-old patient with type 2 diabetes, ethanol abuse, and hepatitis C/cirrhosis/hepatocellular carcinoma who ultimately received orthotopic (cytomegalovirus [CMV] D+/R−) hepatic transplantation. He developed posttransplant shortness of breath, but workup of this finding was negative, and his immunosuppressive doses were slowly weaned. However, his shortness of breath continued. A computed tomography of the thorax was obtained 6 months after transplantation, and he was found to have multiple bilateral irregular opacities that were suggestive of infection. Cultures were eventually positive for C. neoformans. A CMV polymerase chain reaction also demonstrated evidence of CMV viremia at 7310 copies. Further workup was negative for central nervous system or extrapulmonary disease, and the patient was started on treatment for CMV and pulmonary cryptococcosis with good response.In this article, we review some of the epidemiologic, diagnostic, prognostic, and management issues for cryptococcal disease in solid organ transplant recipients with a focus on hepatic transplantation. We also draw a distinction between C. neoformans and Cryptococcus gattii, a more recently characterized pathogen. Lastly, we discuss the treatment of isolated pulmonary cryptococcosis as well as central nervous system and extrapulmonary disease in this growing patient population.

167Reduction in Contaminated Blood Culture Rates and Associated Costs as an Antimicrobial Stewardship Program Activity

167. Reduction in Contaminated Blood Culture Rates and Associated Costs as an Antimicrobial Stewardship Program Activity John Toney, MD; Narla Fries, CLS, MT(ASCP); Rey Rivera, MD; Stephen Mastorides, MD; Richard Oehler, MD, FACP, FIDSA; Sandra Gompf, MD; Infectious Disease Section, James A. Haley Veterans’Hospital, Tampa, FL; Pathology and Laboratory Medicine Service, James A. Haley Vaterans Hospital, Tampa, FL; Infectious Disease and International Medicine, University of South Florida, Tampa, FL; Division of Infectious Disease and International Medicine, University of South Florida, Tampa, FL; Infectious Disease Section, James A. Haley Veterans Hospital, Tampa, FL

Human Bite Injuries: More Than Meet the Eye

AbstractBite wounds are a common reason for patients to seek medical attention. Proper wound evaluation and appropriate antimicrobial therapies are the cornerstones of managing these wounds, particularly when they are human associated. In this article, we describe the case of a pediatric patient who sustained a facial laceration from a human bite and its complications.