Potential benefit of combination antifungal therapy in Aspergillus endocarditis.

Aspergillus endocarditis (AE) is a rare condition with a mortality rate greater than 60%. While it is generally accepted that both antifungal therapy and surgery are necessary for survival, the optimal antifungal regimen is unclear. A 62-year-old man was diagnosed with AE of a prosthetic aortic valve, complicated by cerebral emboli. He underwent debridement of the aortic valve abscess and valve replacement, and was managed with a combination of liposomal amphotericin B and voriconazole for 7 weeks followed by long-term suppressive azole therapy. He remained well at follow-up 18 months later. Data from a review of case reports published between 1950 and 2010 revealed greater survival rates in patients managed with two or more antifungals as opposed to single agent therapy. We provide an updated literature review with similar findings, suggesting that dual agent antifungal therapy should be considered in patients with AE.

Sporotrichosis (Sporothrix schenckii infection) in the New South Wales mid-north coast, 2000-2010.

OBJECTIVE: To determine the geographical, epidemiological and clinical features of sporotrichosis (a cutaneous fungal infection caused by Sporothrix schenckii) in the New South Wales mid-north coast. DESIGN AND SETTING: We undertook a retrospective case review of S. schenckii infections that occurred during the period 2000-2010. Microbiology laboratory staff and medical practitioners in the NSW mid-north coast were contacted to identify cases through database searches and clinical data collection. RESULTS: Thirty-one cases of S. schenckii infection were identified. Twenty-one occurred in males, the mean age of patients was 59 years, and all cases with data available involved cutaneous disease affecting the limbs (multiple lesions in 18 of 20 cases). Despite an impression of temporal clustering (eight cases in 1 year), this was not statistically significant (P = 0.3). Most cases occurred in months with higher rainfall (13 of 14 cases with data available). Inoculating events included injuries in gardens, in bushland and on farms, and possible bites. Symptom duration before correct diagnosis ranged from 4 to 30 weeks (median, 8 weeks; data available for 15 cases), unnecessary antibacterial therapy was common (13 of 19 cases with data available), and morbidity occurred in the form of recurrence (three cases) and mild itraconazole-induced hepatotoxicity (two cases). In all cases with recorded treatment details, the patients received itraconazole, and the median duration of itraconazole treatment was 24 weeks. CONCLUSIONS: These data highlight that health providers on the NSW mid-north coast should consider sporotrichosis when patients present with characteristic lesions after an inoculating injury sustained from or contaminated by decaying vegetation. The risk may be higher in older people and in wetter months. Fungal culture to confirm the diagnosis needs to be specifically requested. In contrast to outbreaks reported from other states, the epidemiological pattern in NSW appears most consistent with sporadic occurrence in an endemic setting.

Community-associated methicillin-resistant Staphylococcus aureus endocarditis 'down under': case series and literature review.

Infective endocarditis is a common complication of Staphylococcus aureus bacteraemia, but literature reports of community-associated methicillin-resistant S. aureus (CA-MRSA) endocarditis are relatively uncommon and mostly comprise intravenous drug users (IVDUs) with the USA300 strain. We report 5 cases of CA-MRSA endocarditis in previously healthy young Australian adults, 4 in IVDUs. Morbidity was high with frequent septic emboli; 3 patients required cardiac surgery and 1 patient died. Typing revealed the 2 most common Australian strains, the Panton-Valentine leukocidin (PVL)-positive ST93 (Queensland) strain and the PVL-negative ST1 (WA-MRSA-1) strain.

Communication loads on clinical staff in the emergency department.

OBJECTIVE: To measure communication loads on clinical staff in an acute clinical setting, and to describe the pattern of informal and formal communication events, Australia. DESIGN: Observational study. SETTING: Two emergency departments, one rural and one urban, in New South Wales hospitals, between June and July 1999. PARTICIPANTS: Twelve clinical staff members, comprising six nurses and six doctors. MAIN OUTCOME MEASURES: Time involved in communication; number of communication events, interruptions, and overlapping communications; choice of communication channel; purpose of communication. RESULTS: 35 hours and 13 minutes were observed, and 1286 distinct communication events were identified, representing 36.5 events per person per hour (95% CI, 34.5-38.5). A third of communication events (30.6%) were classified as interruptions, giving a rate of 11.15 interruptions per hour for all subjects; 10% of communication time involved two or more concurrent conversations; and 12.7% of all events involved formal information sources such as patients' medical records. Face-to-face conversation accounted for 82%. While medical staff asked for information slightly less frequently than nursing staff (25.4% v 30.9%), they received information much less frequently (6.6% v 16.2%). CONCLUSION: Our results support the need for communication training in emergency departments and other similar workplaces. The combination of interruptions and multiple concurrent tasks may produce clinical errors by disrupting memory processes. About 90% of the information transactions observed involved interpersonal exchanges rather than interaction with formal information sources. This may put a low upper limit on the potential for improving information processes by introducing electronic medical records.