Acute and Chronic Prostatitis.

Prostatitis is a common clinical syndrome classified into four categories: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Bacterial prostatitis (acute and chronic) is primarily diagnosed with history and microbiologic studies, although physical examination can be helpful to localize infection within the genitourinary system. Bacterial prostatitis is treated with antibiotics; the span of treatment is guided by the duration of symptoms and presence of complications. Chronic prostatitis/chronic pelvic pain syndrome is the most common form of prostatitis and is a diagnosis of exclusion with no standardized treatments. Asymptomatic prostatitis does not require treatment and is usually diagnosed incidentally during the workup for other urologic presentations.

Management of Pyogenic Liver Abscesses: Contemporary Strategies and Challenges.

Pyogenic liver abscesses (PLAs) are a suppurative infection of the hepatic parenchyma responsible for significant morbidity and mortality. PLAs are categorized into a variety of mechanisms: (1) via the portal vein, (2) through the biliary tract, (3) via the hepatic artery, (4) from trauma, (5) contiguously via direct extension, and (6) cryptogenically. The pathogenesis of PLA, which informs treatment, can often be discerned based on host factors, clinical presentation, and causative microorganisms. The Streptococcus anginosus group, hypervirulent Klebsiella pneumoniae , and multidrug-resistant gram-negative pathogens have emerged as microbiologically challenging organisms to treat. The identification of hypervirulent K. pneumoniae should prompt for assessment for metastatic spread and consideration of prolonged antimicrobial treatment. Abdominal imaging is indispensable in characterizing PLAs and facilitating source control interventions. Source control remains the most critical aspect of PLA management, followed by antimicrobial therapy. Empiric antibiotics for PLAs are informed by the suspected etiology of PLA formation. Duration of antimicrobial therapy is individualized and dependent on multiple components, including the success of achieving source control, host factors, mechanism of PLA development, and the illness course of the individual-factoring in clinical, biochemical, and radiographic parameters.

Incidence, susceptibility and outcomes of candidemia in adults living in Calgary, Alberta, Canada (2010-2018).

BACKGROUND: Candidemia is increasing in frequency and is associated with high mortality. We sought to determine the burden of illness, the population it affects and its resistance profile in our region. METHODS: The Calgary Zone (CZ) provides all care for residents of Calgary and surrounding communities (~ 1.69 million) via five tertiary hospitals each served by a common single laboratory for acute care microbiology. All adult patients in the CZ with at least one Candida spp.-positive blood culture between January 1, 2010, and December 31, 2018, were identified using microbiological data from Calgary Lab Services, the laboratory that processes > 95% of all blood culture samples in the CZ, were reviewed for the study. RESULTS: The overall annual incidence of candidemia among individuals living in the CZ was 3.8 per 100,000 persons (Median age 61 years (IQR 48-72) and 221/455 (47.4%) were female). C. albicans was the most common species (50.6%), followed by C. glabrata, (24.0%). No other species accounted for more than 7% of cases. Overall mortality at 30, 90, and 365 days was 32.2, 40.1, and 48.1% respectively. Mortality rate did not differ by Candida species. Of individuals who developed candidemia, more than 50% died within the next year. No new resistance pattern has emerged in the most common Candida species in Calgary, Alberta. CONCLUSIONS: In Calgary, Alberta, the incidence of candidemia has not increased in the last decade. C. albicans was the most common species and it remains susceptible to fluconazole.

Forgoing transesophageal echocardiogram in selected patients with complicated Staphylococcus aureus bacteremia.

Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18 years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7 days, IQR 23.4-48.6 vs. 43.8 days, IQR 33.3-49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.

Epidemiology and risk factors for pyogenic liver abscess in the Calgary Health Zone revisited: a population-based study.

BACKGROUND: Pyogenic liver abscess (PLA), although uncommon in North America, is associated with significant morbidity and mortality. We sought to re-examine the epidemiology, risk factors, and outcomes of PLA in a large, diverse Canadian health zone. METHODS: All Calgary Health Zone (CHZ) residents aged ≥20 with PLA between 2015 and 2017 were identified. Incidence and mortality rates were calculated using census data. Risk factors for PLA were identified using a multivariate analysis. Data was compared to 1999-2003 data, also collected in the CHZ. RESULTS: There were 136 patients diagnosed with PLA between 2015 and 2017. Incidence rate during this period increased significantly relative to 1999-2003 (3.7 vs 2.3 cases/100,000 population, p < 0.01), however, mortality rates remained similar. The microbiological composition of PLA did not change over this 15-year time period but the number of antimicrobial resistant isolates did increase (8% vs 1%, p = 0.04). The greatest risk factors for PLA relative to general populations included current malignancy, liver-transplant, end-stage renal disease, and cirrhosis. Thirty-day mortality was 7.4% and independent risk factors included polymicrobial bacteremia, absence of abscess drainage, congestive-heart failure, a history of liver disease, and admission bilirubin. CONCLUSIONS: Pyogenic liver abscess is a health concern with rising incidence rate. The increasing prevalence of comorbidities in our population and factors that are associated with risk of PLA suggests this will continue to be an emerging diagnosis of concern. Increasing prevalence of antibiotic resistant organisms compounding unclear optimal treatment regimens is an issue that requires urgent study.

Epidemiology and Outcome Determinants of Staphylococcus aureus Bacteremia Revisited: A Population-Based Study.

PURPOSE: Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to re-define the burden, epidemiology and mortality-associated risk factors of SAB in a large Canadian health region. METHODS: Residents (> 18 years) experiencing SAB from 2012 to 2014 were assessed. Incidence rates were calculated using civic census results. Factors associated with 30-day mortality were determined through multivariate logistic regression. Incidence and risk factors for SAB were compared to 2000-2006 data. RESULTS: 780 residents experienced 840 episodes of SAB (MRSA; 20%). Incidence rates increased from 23.5 to 32.0 cases/100,000 from 2012 to 2014; [IRR 1.15 (95% CI 1.07-1.23); p < 0.001]. Compared to a decade ago, incidence of SAB has increased [IRR 1.28 (95% CI 1.21-1.36); p < 0.001] despite minimal change in nosocomial SAB. MRSA proportion did not change through the study (p = 0.3), but did increase relative to a decade ago (20.0% vs 11.0%, p < 0.001). Thirty-day mortality rates were 30.6% and 21.3% for MRSA and MSSA, respectively (p = 0.01), similar to rates from 2000 to 2006. Several clinical, demographic, and biochemical factors were independently associated with SAB mortality. CONCLUSIONS: SAB is common within our population resulting in significant mortality. Incidence rates of SAB are increasing in our health region; however, 30-day mortality rates remain stable.

Severe facial necrosis in a type 1 diabetic patient secondary to mucormycosis masquerading as an internal maxillary artery occlusion: a case report.

BACKGROUND: Mucormycosis is a group of rare but life threatening angioinvasive infections caused by fungi of the order Mucorales that often occurs in immunocompromised patients and individuals with poorly controlled diabetes. Rhinocerebral mucormycosis can mimic sinusitis but can rapidly progress to deeper disease and cause facial necrosis. Facial vascular thrombosis is a rare complication of mucormycosis and can confound diagnosis of the disease. CASE PRESENTATION: We report the case of a 25-year-old female with poorly controlled type 1 diabetes mellitus who initially presented with symptoms of sinusitis but rapidly progressed with signs of left-sided facial necrosis due to occlusion of the left internal maxillary artery. Early surgical debridement did not yield a microbiological diagnosis. Deeper surgical debridements ultimately revealed angioinvasive fungal disease consistent with mucormycosis. The patient recovered after repeated surgical intervention and aggressive parenteral antifungal therapy. CONCLUSION: This case illustrates an atypical complication of mucormycosis, and emphasizes that a high index of suspicion in vulnerable patient populations aids in the diagnosis of this life-threatening infection.

Long-term clinical outcomes of 'Prairie Epidemic Strain' Pseudomonas aeruginosa infection in adults with cystic fibrosis.

RATIONALE: Epidemic Pseudomonas aeruginosa (PA) plays an important role in cystic fibrosis (CF) lung disease. A novel strain, the 'Prairie Epidemic Strain' (PES), has been identified in up to 30% of patients in Prairie-based Canadian CF centres. OBJECTIVE: To determine the incidence, prevalence and long-term clinical impact of PES infection. METHODS: A cohort of adults with CF was followed from 1980 to 2014 where bacteria isolated from clinical encounters were prospectively collected. Strain typing was performed using pulse-field gel electrophoresis and multilocus sequence typing. Patients were divided into one of four cohorts: no PA, transient PA, chronic PA with unique strains and chronic PES. Proportional Cox hazard and linear mixed models were used to assess for CF-associated respiratory death or transplantation, and rates of %FEV1 and body mass index (BMI) decline. RESULTS: 274 patients (51.7% male) were analysed: 44--no PA, 29--transient PA, 137--unique PA, 64--PES. A total of 92 patients (33.6%) died or underwent lung transplantation (2423.0 patient-years). PES infection was associated with greater risk of respiratory death or lung transplant compared with the no PA group (aHR, 3.94 (95% CI 1.18 to 13.1); p=0.03) and unique PA group (aHR, 1.75 (95% CI 1.05 to 2.92) p=0.03). Rate of lung function decline (%FEV1 predicted) was greatest in the PES group (1.73%/year (95% CI 1.63% to 1.82%); p<0.001). BMI improved over time but at an attenuated rate in the PES group (p=0.001). CONCLUSIONS: Infection with PES was associated with increased patient morbidity through three decades and manifested in an increased risk of respiratory death and/or lung transplantation.

Reduction in Pseudomonas aeruginosa sputum density during a cystic fibrosis pulmonary exacerbation does not predict clinical response.

BACKGROUND: Pulmonary exacerbations (PEx) are critical events in cystic fibrosis (CF), responsible for reduced quality of life and permanent loss of lung function. Approximately 1/4 of PEx are associated with failure to recover lung function and/or resolve symptoms. Developing tools to optimize PEx treatment is of paramount importance. METHODS: We retrospectively audited all adults infected with Pseudomonas aeruginosa, experiencing PEx necessitating parenteral antibiotic therapy from 2006-2012 from our center. Quantitative analysis of sputum at admission, twice-weekly during hospitalization, and end of therapy were compared to baseline (most recent healthy) and follow-up (after PEx) samples. Change in P. aeruginosa burden from baseline was assessed for any and all morphotypes (ALL), as well as mucoid (MUC) and non-mucoid (NON) isolates specifically. PEx were identified as failures if >90% of baseline pulmonary function was not recovered. RESULTS: Forty-six patients meeting the above inclusion and exclusion criteria experienced 144 PEx during this time (median 3, IQR 2-6). Patients were treated for a median 14 days (IQR 13-16). No increase in ALL, MUC or NON were detected at PEx, nor was there an association between change in sputum density and magnitude of lung function decline. PEx failures were observed in 30% of events. Reductions of at least 1-log and 2 log P. aeruginosa sputum density was observed in 57% and 46% (ALL), 73% and 55% (MUC) and 58% and 46% (NON) of PEx, respectively. Factors associated with greater reduction of P. aeruginosa sputum density included choice of ß-lactam antibiotic, antibiotics with in vitro predicted activity and treatment duration. PEx associated with reductions in P. aeruginosa sputum density were not associated with a reduced risk of PEx failure. CONCLUSIONS: Enhanced killing of P. aeruginosa during PEx does not predict improved clinical outcomes. Studies accounting for the polymicrobial nature of CF respiratory disease and the heterogeneity of P. aeruginosa causing chronic infection may enable the identification of a more appropriate pathogen(s) based biomarker of PEx outcomes.

Ten Clinical Pearls in Microbiology: How Effective Collaboration Optimizes Patient Care.

Medical microbiology laboratories play an essential role in patient care-appertaining to infectious diseases diagnostics and treatment, infection prevention, and antimicrobial stewardship. Collaboration between clinicians and the microbiology laboratory can promote and enhance the safety, quality, and efficiency of patient care. We review practical, evidence-informed core concepts to explicate how effective partnership between clinicians and the microbiology laboratory improves patient outcomes.

An unusual case of Brodie's abscess in the humerus of an adult female.

Brodie's abscess is a manifestation of subacute to chronic osteomyelitis, characterized as intraosseous abscess formation, usually on the metaphysis of the long tubular bones in the lower extremities of male pediatric patients. Clinically, Brodie's abscess presents with atraumatic bone pain of an insidious onset, with absence of systemic findings. Delay in diagnosis is common, as diagnostic imaging, followed by biopsy for culture and histologic examination are generally required to secure a diagnosis of Brodie's abscess. Treatment of Brodie's abscess is non-standardized, and usually consists of surgical debridement and antibacterial therapy. Despite the variability in therapeutic approaches, outcomes of Brodie's abscess treated with surgery and antibiotics are favourable. Herein we report a case of a delayed diagnosis of Brodie's abscess in the upper extremity of an adult female. While she improved with treatment of Brodie's abscess, the case serves to remind clinicians to consider this entity in adult individuals who present with atraumatic bone pain.

Polymerase chain reaction negative cryptococcal meningitis.

A 61-year-old male with subacute headache was found to have cryptococcal meningitis despite a negative BioFire FilmArray meningitis/encephalitis panel. This case underscores the importance of liberal cryptococcal antigen testing, and that a negative FilmArray panel is inadequate in excluding cryptococcal meningitis, particularly in a HIV-negative host.

The Golden Grapes of Wrath - Staphylococcus aureus Bacteremia: A Clinical Review.

Staphylococcus aureus bacteremia is common and associated with fatality rates approximating 25%. We provide a brief overview of S. aureus bacteremia from a clinical and microbiological lens and review the relevant evidence and literature gaps in its management. Using a case-based approach, evidence and clinical judgement are meshed to highlight and justify the 5 core interventions that ought to be performed for all cases of S. aureus bacteremia: 1) appropriate anti-staphylococcal therapy, 2) screening echocardiography, 3) assessment for metastatic phenomena and source control, 4) decision on duration of antimicrobial therapy, and 5) Infectious Diseases consultation.

Ten common misconceptions about antibiotic use in the hospital.

Antimicrobials are one of the most administered medications in hospitals. Thoughtful and rational antibiotic prescribing by clinicians are important in reducing the adverse effects to both the host that takes the antibiotic and also the individuals in the host's community. Principles informing antibiotic prescribing in the hospital are commonly rooted in misconceptions. We review 10 common myths associated with antibacterial usage in hospitalized patients and share contemporary evidence in hopes of enhancing evidence-informed practice in this patient care setting.

How I manage bacterial prostatitis.

BACKGROUND: Bacterial prostatitis is a highly prevalent infection responsible for significant morbidity among men. The diagnosis and treatment for bacterial prostatitis remains complicated. The difficulty in diagnosis is in part owing to the paucity of high-quality evidence that guides a clinician's interpretation of patients' history, physical examination, and laboratory findings. Treatment is challenging because of the few antimicrobials capable of prostate penetration, growing antimicrobial resistance limiting effective treatment options, and the high risk of recurrence. OBJECTIVES: We aimed to provide a useful resource for clinicians in effectively diagnosing and managing acute bacterial prostatitis (ABP) and chronic bacterial prostatitis (CBP). SOURCES: A PubMed literature search on prostatitis was performed with no restrictions on publication date. CONTENT: The epidemiology, pathophysiology, diagnosis, and treatment for ABP and CBP are explored using a clinical vignette as relevant context. IMPLICATIONS: Bacterial prostatitis can be diagnosed through a focused history and microbiological investigations. The Meares-Stamey 4-glass test or modified 2-glass test can help confirm the diagnosis if uncertainty exists. Typical uropathogens are common contributors to bacterial prostatitis but there is growing interest in exploring the role atypical and traditional non-pathogenic organisms may have. Fluoroquinolones remain first-line therapy, followed by trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline if the pathogen is susceptible. Fosfomycin has emerged as a repurposed and useful agent because of the increasing incidence of multidrug-resistant pathogens. Selection of appropriate antimicrobial regimens can be challenging and is dependent on the host, chronicity of symptoms, uropathogens' susceptibilities, antimicrobials' side effect profile, and the presence of prostatic abscesses or calcifications. ABP can typically be treated similar to other complicated urinary tract infections. However, CBP requires prolonged therapy, with a minimum of 4 weeks and up to 12 weeks of therapy.

Recurrent amebic liver abscesses despite metronidazole treatment: A rare case report.

Amebic liver abscesses should be considered in adult males with a liver abscess and a history of travel to endemic areas. Effective treatment includes metronidazole, followed by paromomycin.

Principles of empiric antimicrobial usage and dosing: Lessons learned.

A lack of clinical response to empiric antimicrobials behooves the clinician to reflect further on diagnostic considerations. When prescribing antibiotics, determining the correct dose, most optimal route of administration, and considering the pharmacokinetic properties of the drug with respect to clinical and patient factors are crucial.