A single-centre experience rolling out an antibiotic stewardship intervention prior to and during the SARS-CoV-2 pandemic 2019-2022.

Background: Antibiotics are prescribed to nearly one-half of patients with viral respiratory tract infections (RTI) in outpatient settings. This use is ineffective and may cause undue harm and excess cost from unnecessary antibiotic exposure. We implemented a multifaceted intervention to address inappropriate antibiotic prescribing for viral RTI. Here, we discuss the impact over 4 years, before and during the SARS-CoV-2 pandemic. Methods: This observational study describes the implementation and initial impact of a multimodal stewardship intervention on inappropriate antibiotic prescribing for viral RTIs in outpatient care settings at a single centre. We tracked the rate of visits for viral RTI as well as antibiotic prescribing for viral RTIs in urgent care, primary care and the emergency department between January 2018 and March 2022. Data were collected 1 year prior to implementation and 3 years after implementation. The primary outcome - the rate of inappropriate antibiotics prescribed for viral RTIs - was described by calendar year (CY) to review changes after the stewardship intervention. Results: In CY2018, the year prior to implementation of targeted RTI antimicrobial stewardship, the rate of inappropriate RTI antibiotics prescribed was 10% in urgent care, 11% in primary care and 18% in the emergency department (ED). During the first CY of the intervention, rates were 8% in urgent care, 10% in primary care and 16% in the ED. In CY2020, the second year of the intervention, inappropriate RTI antibiotics were prescribed in 5% of urgent care and 3% primary care RTI visits and 15% of ED RTI visits. These rates were similar in CY2021 and the first 3 months of CY2022. Over 30,000 visits for RTIs were seen annually in CY2018 and CY2019. Annual RTI visits dropped to 20,222 in CY2020 and 14,172 in CY2021. Conclusion: Although total visits for non-COVID RTIs decreased by approximately 50% during the first 2 years of the SARS-CoV-2 pandemic, an antimicrobial stewardship intervention was associated with decreases in inappropriate antibiotic prescribing for RTIs. This was maintained throughout 2 years of the pandemic.This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.

Evaluation of Long-pulsed 1064 nm Nd:YAG Laser-assisted Hair Removal vs Multiple Treatment Sessions and Different Hair Types in Indian Patients.

BACKGROUND: LONGER WAVELENGTH LASERS SUCH AS ND: YAG are considered to be the best for darker skin phototypes. OBJECTIVES: The aim of this study was to investigate the safety and efficacy of long-pulsed, 1064 nm Nd:YAG laser-assisted hair removal in relation to multiple treatment sessions and different hair types in Indian patients. METHOD: Fifty-nine adult women with skin phototypes IV and V were treated with a long-pulsed Nd: YAG laser (1064 nm, 10 mm spot size, fluence of 30-50 J/cm(2), pulse duration 15-30 ms). Six consecutive treatment sessions were given at 4-6 week intervals. The modified Ferriman Gallway system of scoring was used to grade the hairs before each treatment session and six weeks after the last therapy. Based on this grading, three main hair types were recognised: thin vellus (Grade 1), intermediate (Grade 2), and terminal hair (Grades 3 and 4). Patients were divided into three groups: achievers who converted to thin vellus hair (Grade I), responders who shifted to a lower grade but were short of reaching grade 1, and failures who did not show any change throughout the six laser sessions. RESULTS: Six weeks after six laser treatment sessions, the achievers totaled 56%, responders 23%, and failures 20% of the patient population. At the end of the 3(rd), 4(th), 5(th), and 6(th) sessions, achievers were 5, 15, 25, and 56% respectively of all the patients (P < 0.001, which was statistically significant). Achievers for terminal hair were 57.5% while it was 53.8% for intermediate hair (P = 0.9, nonsignificant). There were no permanent side effects. There were no failures in the terminal group while nearly 50% of the patients were failures in the intermediate group. CONCLUSION: Six multiple laser treatment sessions with a long-pulsed, 1064 nm Nd: YAG laser with contact cooling were found to be safe and effective for hair reduction in Indian patients with both terminal and intermediate hair. The success rate was found to improve with successive sessions. However, terminal hairs responded better than intermediate hairs.

Anhidrotic ectodermal dysplasia with palmoplantar keratoderma: an unusual presentation.

Anhidrotic ectodermal dysplasia (AED), or Christ-Siemens-Touraine syndrome, was first described in 1848 by Thurnam. It is characterized by a partial or complete absence of sweat glands, hypotrichosis and hypodontia. The mode of inheritance is predominantly X-linked but an autosomal recessive pattern has also been observed.(2) Palmoplantar keratoderma is classically a component of hidrotic ectodermal dysplasia; however, we report herein two brothers who had classical manifestations of AED along with palmoplantar keratoderma.

Pilot trial: Pioglitazone versus placebo in patients with plaque psoriasis (the P6).

BACKGROUND: Disordered differentiation and hyperproliferation of keratinocytes with inflammation are the hallmarks of psoriasis. Ligand activation of peroxisome proliferator receptor-gamma (a class of nuclear receptors) by thiazolidinediones can normalize the histologic features of psoriasis. METHOD: In a 10-week, double-blind, randomized, placebo-controlled, parallel-group study, 70 patients with moderate to severe psoriasis received one of the following treatments: pioglitazone 15 mg, pioglitazone 30 mg or placebo. Efficacy was evaluated by observing the change in the psoriasis area and severity index (PASI) after 10 weeks of treatment. RESULTS: There was a dose-dependent improvement in psoriasis. Median PASI scores at the end of 10 weeks were significantly reduced in the pioglitazone treatment groups as compared to the placebo-treated group. The psoriasis lesions cleared in more than 40% of patients treated with pioglitazone as compared to 12.5% of those with placebo. The percentage reduction in mean PASI scores was 21.6%, 41.1% and 47.5% in the placebo, pioglitazone 15 mg, and 30 mg groups, respectively. No serious adverse events were detected. CONCLUSION: This is the first report from a controlled trial demonstrating that pioglitazone could be considered as an efficacious and safe agent for the treatment of plaque psoriasis. The optimum dose and duration of pioglitazone therapy remain to be determined.

Generalized bullous impetigo in a neonate.

Generalized bullous impetigo is uncommon in healthy and term neonates. It must be differentiated from staphylococcal scalded skin syndrome and other commonly encountered vesiculopustular lesions. We report generalized bullous impetigo in an otherwise healthy neonate.

Epidemiology of childhood psoriasis: a study of 419 patients from northern India.

BACKGROUND: We undertook this study in order to determine the pattern and prevalence of childhood psoriasis in northern India and to highlight the differences and similarities with previous studies. MATERIALS AND METHODS: In this retrospective epidemiologic study, the data from 419 children (less than 14 years of age) with psoriasis registered at the Psoriasis Clinic between January 1990 and December 2002 were included. RESULTS: The 419 children registered at the Psoriasis Clinic constituted 0.3% of the dermatology outpatients and 12.5% of the total psoriasis patients seen over a period of 13 years in the department. There were 219 (52.2%) boys and 200 (47.7%) girls, with a male to female ratio of 1.09 : 1. The age of onset ranged from 4 days to 14 years. The mean age of onset was 8.1 +/- 2.1 years in boys and 9.3 +/- 2.3 years in girls. The peak age of onset in boys was in the 6-10-year age group, whereas the majority of girls showed an onset of psoriasis between the ages of 10 and 14 years. A positive family history was present in only 19 (4.5%) patients. The extensors of the legs were the most common initial site affected [105 (25%) cases], followed by the scalp [87 (20.7%)]. Classical plaque psoriasis was the most frequent clinical presentation [254 (60.6%) patients], followed by plantar psoriasis [54 (12.8%)]. Nail involvement was observed in 130 (31%) cases. All types of nail changes described in psoriasis were seen in these patients. Pitting was the most common nail change, followed by ridging and discoloration. Five children (1.1%) (three girls and two boys) had psoriatic arthropathy. Precipitating factors that brought about the onset of the disease or were associated with exacerbation could be recalled in only 28 (6.6%) patients. Koebnerization was observed in 27.9% of patients. Pruritus was the most frequent symptom, reported by 365 (87.1%) children. Twenty-seven (6.4%) children had other concurrent mucocutaneous diseases (vitiligo, pityriasis alba, alopecia areata, ichthyosis vulgaris, halo nevus, aphthous stomatitis, urticaria, pityriasis versicolor, nummular eczema, salmon patch, and verrucous epidermal nevus). Eighteen children had systemic disorders, including seizures, bronchial asthma, mitral regurgitation, scleroderma, Down's syndrome, high arched palate, cholelithiasis, anterior mongoloid slant, and prognathism; however, these conditions were possibly chance findings only and no correlation with the age of onset or severity of the disease was found. CONCLUSIONS: Our findings differ from those of previous studies in showing a delayed onset, equal sex distribution, less frequent facial involvement, uncommon guttate lesions, more frequent involvement of the soles, and a less frequent history of familial occurrence.

Granuloma multiforme.

CASE 1: A 51-year-old woman presented with skin-colored annular lesions on the upper chest, neck, and dorsa of the hands of 1-year duration. The lesions initially started as small papular lesions, which gradually evolved to form large annular and polycyclic lesions. Initially, the lesions were associated with a burning sensation and pruritus. She had no other systemic complaints. Examination revealed 5-6 annular, polycyclic lesions distributed over the upper chest, neck, and dorsa of both hands, varying in size from 1 to 5 cm. All the lesions had a prominent erythematous to skin-colored, irregular, papular border which was firm in consistency (Figs 1 and 2). Central clearing and minimal atrophy were evident in larger lesions. There was no sensory loss or peripheral nerve thickening. Clinical possibilities entertained were granuloma annulare, granuloma multiforme, and annular sarcoid. Routine investigations, including hemogram, renal and liver functions, blood sugar levels, chest X-ray, and urine examination, were within normal limits. A skin biopsy taken from the edge of a lesion revealed foci of collagen degeneration surrounded by an inflammatory infiltrate composed of many histiocytes and multinucleated giant cells. In addition, there were perivascular and periadnexal lymphocytic aggregates. No acid-fast bacilli (AFB) were detected. These findings were consistent with a diagnosis of granuloma multiforme (Fig. 3). CASE 2: A 47-year-old man presented with annular skin-colored lesions associated with a mild burning sensation of 8 months' duration. On examination, 2-3 annular, arciform lesions were distributed over the upper chest and neck. The lesions ranged in size from 2 to 7 cm in diameter, were irregular in shape, and were rimmed by a well-defined raised papular border. Again, there was no sensory loss or peripheral nerve thickening. Histopathology of the skin from the edge of the lesion showed multiple areas of histiocytic granulomas with focal necrobiosis and prominent multinucleated giant cells, findings consistent with granuloma multiforme.

Variegate porphyria.

Variegate porphyria is a rare, hereditary form of hepatic porphyria characterized by acute systemic symptoms as in acute intermittent porphyria in addition to cutaneous symptoms simulating porphyria cutanea tarda. We describe a 22-year-old female from India who first presented to the emergency department with acute symptoms and was later confirmed to have variegate porphyria.

Subdural hygroma in a patient with Parry-Romberg syndrome.

Parry-Romberg syndrome (PRS) is a poorly understood disorder characterized by progressive hemifacial atrophy. A number of neurologic associations have been reported. We describe a rare association of seizures, PRS, and subdural hygroma. To the best of our knowledge, this association has not been reported in the literature.