Prevalence and factors associated with inappropriate continuation of stress ulcer prophylaxis at discharge.

Stress ulcer prophylaxis is started in the critical care unit to decrease the risk of upper gastrointestinal ulcers in critically ill persons and to decrease mortality caused by stress ulcer complications. Unfortunately, the drugs are often continued after recovery through discharge, paving the way for unnecessary polypharmacy. STUDY DESIGN: We conducted a retrospective cross-sectional study including patients admitted to the adult critical care unit and started on the stress ulcer prophylaxis with a proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) with an aim to determine the prevalence of inappropriate continuation at discharge and associated factors. RESULT: 3200 people were initiated on stress ulcer prophylaxis, and the medication was continued in 1666 patients upon discharge. Indication for long-term use was not found in 744 of 1666, with a 44% prevalence of inappropriate continuation. A statistically significant association was found with the following risk factors: discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on a mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of stress ulcer prophylaxis drug used (H2 blocker vs PPI, p<0.001). CONCLUSION: The prevalence of inappropriate continuation was found to be higher than prior studies. Given the risk of unnecessary medication intake and the associated healthcare cost, a web-based quality improvement initiative is being considered.

Methotrexate-Induced Lymphoproliferative Disorder Complicating Into Spontaneous Tumor Lysis Syndrome and Disseminated Intravascular Coagulation.

Lymphoproliferative disorder (LPD) is a severe adverse outcome of methotrexate (MTX) administration in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). The immunosuppression caused is attributed to pathogenesis. Hence, discontinuation is the treatment. Reports on spontaneous tumor lysis with cessation of MTX are rare. We report a case of a female in her 50s with methotrexate-associated lymphoproliferative disease (MTX-LPD) following treatment for rheumatoid arthritis. Methotrexate was discontinued immediately. She presented two months later with severe disseminated intravascular coagulation (DIC) and spontaneous tumor lysis syndrome (STLS). Although tumor lysis syndrome responded well to rasburicase therapy, DIC was a challenge. MTX-LPD has various complications and highly variable presentation. RA/SLE patients receiving MTX should be regularly monitored, and MTX should be immediately stopped in suspicion of MTX-LPD. Although many patients respond to MTX cessation, some patients head to remission and relapse. At the same time, some worsen with complications such as DIC and tumor lysis syndrome, as described above. This case reiterates the need for regular monitoring following MTX therapy cessation for early identification and treatment of these complications to improve prognosis.

Infectious complications after second allogeneic hematopoietic cell transplant in adult patients with hematological malignancies.

We conducted a retrospective review of the infectious complications and outcomes over a 2-year follow-up period of adult patients who received a second allogeneic hematopoietic cell transplant (2nd allo-HCT) during a five-year period at two cancer centers in Michigan. Sixty patients, of whom 44 (73%) had acute leukemia or myelodysplastic syndrome, were studied. The majority (n = 37,62%) received a 2nd allo-HCT because of relapsed leukemia. Infection episodes after the 2nd allo-HCT totaled 112. Bacteria were identified in 76 episodes, the majority of which occurred pre-engraftment. The most common infecting organisms were Enterococcus species and Clostridioides difficile. Viral infections, predominantly cytomegalovirus, accounted for 59 infection episodes and occurred mostly in pre-engraftment and early post-engraftment periods. There were 16 proven/probable fungal infections, of which 9 were invasive aspergillosis or candidiasis. Mortality was 45% (n = 27) at one year and 65% (n = 39) at 2 years after transplant, and 16 deaths (41%) were due to infection. Of those 16 infection deaths, 8 were bacterial, 4 fungal, 2 both bacterial and fungal, and 2 viral. Failure to engraft neutrophils or platelets was significantly associated with decreased survival, p < 0.0001 and p < 0.001, respectively. Infections are common after a 2nd allo-HCT and are associated with a high mortality rate.

Persistent viremia in an immunocompetent patient with inherited chromosomally integrated HHV-6B.

Human herpesvirus-6 (HHV-6), the virus which causes roseola, has traditionally been associated with benign and self-limited childhood illness. However, HHV-6 establishes lifelong latency and can reactivate in immunocompromised adult patients. In about 1% of cases, it integrates into the human genome as inherited chromosomally integrated HHV-6 (iciHHV-6). We report the case of a 70-year-old man presenting with altered mental status and agitation. His infectious workup revealed a cerebrospinal fluid sample positive for HHV-6 with virus detectable in the blood as well. He was subsequently treated with ganciclovir. HHV-6 viremia (DNAemia) persisted, and the antiviral medications were switched to foscarnet under the assumption of treatment failure due to drug resistance. After several admissions to the hospital for the same complaint, and after noticing that DNAemia persisted despite adequate treatment for HHV-6, infectious disease specialists ordered testing for chromosomally integrated virus. Test results confirmed the presence of iciHHV-6, explaining his consistently elevated serum viral load. Primary HHV-6 infection in adults causes a transient increase in viral load with resolution and clearance after a few weeks while iciHHV-6 is characterized by persistent detection of viral DNA at a high copy number. Individuals with iciHHV-6 can develop HHV-6 disease and are at increased risk for active viral replication when treated with immunosuppressive medications, but only mRNA testing, which is not widely available can differentiate between latent and active infection. This makes the decision to treat challenging in this patient population. When faced with a positive HHV-6 DNA result in the setting of equivocal symptoms, clinicians should consider the possibility of chromosomally integrated virus rather than drug-resistant virus in order to reduce exposure to potentially toxic antiviral medications.

When Zoonotic Organisms Cross Over-Trueperella pyogenes Endocarditis Presenting as a Septic Embolic Stroke.

Infective endocarditis (IE) remains a significant cause of morbidity and mortality worldwide, with numerous pathogens as culprits. We present a case of IE that evolved to a septic embolic stroke caused by an extremely rare bacteria Trueperella (T.) pyogenes that primarily infects non-humans. In contrast to most cases occurring outside the United States (US), this is the second case of T. pyogenes-associated endocarditis and the first to present as a stroke in the US. T. pyogenes has undergone numerous taxonomic revisions over the years since first being reported and characterized as Bacillus pyogenes in the 1800s. T. pyogenes is a zoonotic infection, and despite advancements in chemotaxonomic detection methods, Trueperella is often misidentified and under-diagnosed. Although epidemiological data is scarce, T. pyogenes infections have the propensity to cause endocarditis, and we aim to summarize all isolated reports of T. pyogenes infections that have been reported in the literature thus far.

Infectious Complications After Umbilical Cord Blood Transplantation for Hematological Malignancy.

BACKGROUND: Umbilical cord blood transplant (UCBT) is used for patients who do not have a matched donor, but engraftment often takes longer than with a standard allogeneic transplant, likely increasing the risk for infection. We characterized specific infections and outcomes in adults undergoing UCBT at our 2 centers. METHODS: All adults who underwent UCBT between January 1, 2006 and December 31, 2015 were included. Infectious episodes from 6 months before to 2 years after UCBT were reviewed. RESULTS: Fifty-seven patients underwent UCBT; 47 had neutrophil engraftment. A total of 179 infectious episodes occurred in 55 patients, 73 (41%) within 30 days post-UCBT. Viruses caused 85 (47%) infections. Cytomegalovirus caused 32 infectious episodes and was most common from day 30 to 100. Human herpesvirus 6 occurred in 28 episodes, was most common within 30 days, and caused 1 death. Bacteria were responsible for 82 (46%) infections, most commonly bacteremias due to Staphylococcus spp, Enterococcus spp, and Enterobacteriaceae. Of 11 invasive fungal infections, 9 were aspergillosis, 4 of which were fatal. Overall mortality was 56% in the first year. Thirteen deaths were from infection; 11 occurred in the first 100 days and 7 in the first 30 days post-UCBT. Of 10 patients who never engrafted, 9 died, 6 from infection, within 100 days post-UCBT. CONCLUSIONS: Infectious complications were common after UCBT, especially in the first 30 days. Deaths from viral infections were fewer than expected. Delayed engraftment and nonengraftment continue to convey increased risk for fatal bacterial and fungal infections post-UCBT.

Cutaneous geotrichosis due to Geotrichum candidum in a burn patient.

Geotrichum candidum is a saprophytic yeast known to colonize the human skin, respiratory tract and gastrointestinal tract. It can cause local or disseminated disease (geotrichosis), mainly in the immunocompromised host. Trauma, indwelling catheter use, prolonged broad-spectrum antibiotic treatment and critical illness have also been implicated as risk factors. Here we report the first case, to our knowledge, of cutaneous G. candidum infection in a burn patient. The isolate had a high amphotericin B minimum inhibitory concentration (MIC) and the patient experienced concomitant Candida orthopsilosis fungaemia, and so was treated with a combination of voriconazole and micafungin. This case highlights the importance of source control, rapid identification of G. candidum infection and MIC determination to guide antifungal therapy, which typically consists of amphotericin B with or without flucytosine or voriconazole alone. Clinicians should be aware of geotrichosis as a clinical entity in burn patients as well as in the immunocompromised. Antifungal resistance and breakthrough disease are an ongoing concern due to the increasing number of immunocompromised at-risk patients and the use of routine mould prophylaxis.

A Rare Case of Mediastinal Bronchogenic Cyst Infected by Salmonella enteritidis.

Bronchogenic cysts are rare congenital malformations which arise from abnormal budding of the primitive tracheobronchial tube and can localize to either the mediastinum or lung parenchyma. They remain clinically silent in most adults unless they become infected or are large enough to compress adjacent structures. Infections involving bronchogenic cysts are often polymicrobial. Gram-positive, Gram-negative, and mycobacterial infections have been reported, though frequently a pathogen is not identified. We present the case of a 46-year-old female with known history of bronchogenic cyst who presented with suspected postobstructive pneumonia. She underwent cyst excision with culture positive for Salmonella enteritidis, an extremely rare finding on review of the literature. The patient recovered following a three-week course of antibiotics for extraintestinal salmonellosis.