Validation of a Retrospective Computing Model for Mortality Risk in the Intensive Care Unit.

OBJECTIVE: To compare the predictive performance of Epic Systems Corporation's proprietary intensive care unit (ICU) mortality risk model (IMRM) with that of the Acute Physiology and Chronic Health Evaluation (APACHE) IV score. METHODS: This is a retrospective cohort study of patients treated from January 1, 2008, through January 1, 2018. This single-center study was performed at Mayo Clinic (Rochester, MN), a tertiary care teaching and referral center. The primary outcome was death in the ICU. Discrimination of each risk model for hospital mortality was assessed by comparing area under the receiver operating characteristic curve (AUROC). RESULTS: The cohort mostly comprised older patients (median age, 64 years) and men (56.7%). The mortality rate of the cohort was 3.5% (2251 of 63,775 patients). The AUROC for mortality prediction was 89.7% (95% CI, 89.5% to 89.9%) for the IMRM, which was significantly greater than the AUROC of 88.2% (95% CI, 87.9% to 88.4%) for APACHE IV (P<.001). CONCLUSION: The IMRM was superior to the commonly used APACHE IV score and may be easily integrated into electronic health records at any hospital using Epic software.

Disseminated Cryptococcus neoformans infection in a left ventricular assist device recipient.

A 51-year-old man with a medical history of coronary artery disease and dyslipidaemia presented with acute myocardial infarction resulting in cardiogenic shock, necessitating intra-aortic balloon pump placement and extracorporeal membrane oxygenation (ECMO). His hospital course was complicated by several infectious complications including ECMO circuit Pseudomonas aeruginosa bloodstream infection and presumed infected right atrial thrombus. He subsequently underwent urgent left ventricular assist device placement and had a prolonged hospital stay. On day 100 of admission, he developed acute hypoxic respiratory distress with new pulmonary infiltrates. Sputum cultures grew Cryptococcus neoformans Blood culture also grew C. neoformans after 96 hours of incubation and cryptococcal serum antigen was elevated at 1:20. Cerebrospinal fluid studies from a lumbar puncture were normal. He was treated with 2 weeks of combination antifungal therapy followed by life-long fluconazole suppression.

Clinical Presentation, Management, and Outcomes of Cardiovascular Implantable Electronic Device Infections Due to Gram-Negative Versus Gram-Positive Bacteria.

OBJECTIVE: To describe and compare the clinical presentation, management, and outcomes of cardiovascular implantable electronic device (CIED) infections due to gram-negative bacteria (GNB) and CIED infections due to gram-positive bacteria (GPB). PATIENTS AND METHODS: We retrospectively reviewed all CIED infection cases at Mayo Clinic from January 1, 1992, through December 31, 2015. Cases were classified based on positive microbiology data from extracted devices or blood cultures. RESULTS: Of the 623 CIED infections during the study period, 31 (5.0%) were caused by GNB and 323 (51.8%) by GPB. Patients in the GNB group were more likely to present with local inflammatory findings at the pocket site (90.3% vs 72.4%; P=.03). All patients with bacteremia due to GNB had concomitant pocket infection compared with those with GPB (100% vs 33.9%; P=.002). After extraction, 41.9% of patients in the GNB group were managed with oral antibiotics vs 2.4% in the GPB group (P<.001). There were no statistically significant differences in infection relapse/recurrence or 1-year survival rates between the 2 groups. CONCLUSION: Compared with CIED infections caused by GPB, those due to GNB are more likely to present with pocket infection. Device-related GNB bacteremia almost always originates from the generator pocket. After extraction, oral antibiotic drug therapy may be a reasonable option in select cases of pocket infections due to GNB. No difference in outcomes was observed between the 2 groups.

Pre-travel counseling for immunocompromised travelers: A 12-year single-center retrospective review.

BACKGROUND: Immunocompromised travelers (ICTs) are medically complex and challenging for travel medicine providers. Our study hypothesizes that ICTs have high-risk travel itineraries and do not have adequate immunity against vaccine-preventable infections. METHODS: This retrospective review of 321 ICTs from 2004 to 2015 included patients with solid organ transplant (SOT, n = 134), connective tissue disease (CTD, n = 121), inflammatory bowel disease (IBD, n = 46), and human immunodeficiency virus (HIV, n = 20). Variables included immunosuppressive medications, hepatitis A and B vaccination and serology, gamma-globulin use, and antimalarial and antidiarrheal prophylaxis. Chi-square analysis was used for categorical variables and Kruskal-Wallis for continuous variables. RESULTS: Malaria-endemic regions accounted for 38.9% (125/321) of travel destinations. High-risk activities were planned by 37.4% (120/321) of travelers. A significant proportion of HIV patients [70.0% (14/20)] visited friends and relatives, whereas other ICTs traveled for tourism. Hepatitis A and B vaccination rates were 77.3% (248/321) and 72.3% (232/321). Post-vaccination hepatitis A and B serologic testing were completed by 66.1% (41/62) and 61.1% (11/18) of travelers, respectively. CONCLUSION: ICTs demonstrate differences in travel patterns and risk. Serologic testing was uncommon, and vaccination rates were low. Providers should screen ICTs early for upcoming travel plans and advise vaccine completion prior to departure.

Impact of pre-travel consultation on clinical management and outcomes of travelers' diarrhea: a retrospective cohort study.

BACKGROUND: International travelers are at high risk of acquiring travelers' diarrhea. Pre-travel consultation has been associated with lower rates of malaria, hepatitis, and human immunodeficiency virus (HIV) infections. The objective was to study the impact of pre-travel consultation on clinical management and outcomes of travelers' diarrhea. METHODS: This retrospective cohort study analyzed 1160 patients diagnosed with travelers' diarrhea at Mayo Clinic Rochester, MN from 1994 to 2017. Variables included high-risk activities, post-travel care utilization, antimicrobial prescriptions, hospitalizations, and complications. Travelers were divided into those who sought (n = 256) and did not seek (n = 904) pre-travel consultation. The two groups were compared using the Wilcoxon test for continuous variables and chi-square test for categorical variables. Multivariate logistic regression was used to adjust for differences in traveler characteristics. RESULTS: More pre-travel consultation recipients were young Caucasians who had more post-travel infectious disease (ID) consultation [OR 3.1 (95% CI 1.9-5.3)], more stool sampling [OR 1.6 (95% CI 1.1-2.4)], and more antimicrobial prescriptions [OR 1.6 (95% CI 1.1-2.5)] for travelers' diarrhea compared to the non-pre-travel consultation group. The pre-travel consultation group had shorter hospital stays (mean 1.8 days for pre-travel versus 3.3 days for non-pre-travel consultation group, p = 0.006) and reduced gastroenterology consultation rates [OR 0.4 (95% CI 0.2-0.9)]. 23 patients with positive stool cultures had Campylobacter susceptibilities performed; 65% (15/23) demonstrated intermediate susceptibility or resistance to ciprofloxacin. CONCLUSION: Pre-travel consultation was associated with higher rates of stool testing and antimicrobial prescriptions. The high rate of quinolone-resistant Campylobacter in our small sample suggests the need for judicious antimicrobial utilization. The pre-travel consultation group did have a shorter duration of hospitalization and reduced need for gastroenterology consultation for prolonged or severe symptoms, which are positive outcomes that reflect reduced morbidity of travelers' diarrhea.

Diabetes Mellitus Management Among Patients with Limited English Proficiency: A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with limited English proficiency (LEP) and type 2 diabetes mellitus (T2DM) have several health disparities, including suboptimal patient-provider interactions, poorer glycemic control, and T2DM complications. Understanding existing interventions for improving T2DM outcomes in this population is critical for reducing disparities. METHODS: We performed a systematic review of randomized controlled trials (RCTs) and observational studies examining the effectiveness of interventions in improving T2DM outcomes among patients with LEP in North America. Quality was assessed using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for non-RCT studies. Meta-analysis was conducted using the random-effects model. RESULTS: Fifty-four studies, 39 of which reported sufficient data for meta-analysis of glycemic control, were included. The interventions were associated with a statistically significant reduction in hemoglobin A1c (HbA1c) (weighted difference in means, -0.84% [95% CI, -0.97 to -0.71]) that was, however, very heterogeneous across studies (I2 = 95.9%). Heterogeneity was explained by study design (lower efficacy in RCTs than non-RCTs) and by intervention length and delivery mode (greater reduction in interventions lasting <6 months or delivered face-to-face); P < 0.05 for all three covariates. The interventions were also associated in most studies with improvement in knowledge, self-efficacy in diabetes management, quality of life, blood pressure, and low-density lipoprotein cholesterol. DISCUSSION: Multiple types of interventions are available for T2DM management in patients with LEP. Multicomponent interventions delivered face-to-face seem most effective for glycemic control. More research is needed to better understand other aspects of multicomponent interventions that are critical for improving important outcomes among patients with T2DM and LEP.

Impacts of a care process model and inpatient electrophysiology service on cardiovascular implantable electronic device infections: a preliminary evaluation.

PURPOSE: Cardiovascular implantable electronic device infection (CIEDI) rates are rising. To improve outcomes, our institution developed an online care process model (CPM) and a specialized inpatient heart rhythm service (HRS). METHODS: This retrospective review compared hospital length of stay (LOS), mortality, and times to subspecialty consultation and procedures before and after CPM and HRS availability. RESULTS: CPM use was associated with shortened time to surgical consultation (median 2 days post-CPM vs. 3 days pre-CPM, p = 0.0152), pocket closure (median 4 vs. 5 days, p < 0.0001), and days to new CIED implant (median 7 vs. 8 days, p = 0.0126). Post-HRS patients were more likely to have a surgical consultation (OR 7.01, 95% CI 1.56-31.5, p = 0.011) and shortened time to pocket closure (coefficient - 2.21 days, 95% CI - 3.33 to - 1.09, p < 0.001), compared to pre-HRS. CONCLUSIONS: The CPM and HRS were associated with favorable outcomes, but further integration of CPM features into hospital workflow is needed.

Incidence and Effects of Seasonality on Nonpurulent Lower Extremity Cellulitis After the Emergence of Community-Acquired Methicillin-Resistant Staphylococcus aureus.

Nonpurulent lower extremity cellulitis (NLEC) is a common clinical diagnosis, with ß-hemolytic streptococci and Staphylococcus aureus considered to be the most frequent causes. In 1999, the US Public Health Service alerted clinicians to the presence of community-acquired methicillin-resistant S aureus (CA-MRSA) infections in 4 children in the upper Midwest. Since then, it has become a well-recognized cause of skin and soft-tissue infections, in particular, skin abscess. A previous population-based study of NLEC in Olmsted County, Minnesota, reported an unadjusted incidence rate of 199 per 100,000 person-years in 1999, but it is unknown whether CA-MRSA subsequently has affected NLEC incidence. We, therefore, sought to determine the population-based incidence of NLEC since the emergence of CA-MRSA. Age- and sex-adjusted incidence (per 100,000 persons) of NLEC was 176.6 (95% CI, 151.5-201.7). Incidence differed significantly between sexes with age-adjusted sex-specific rates of 133.3 (95% CI, 104.1-162.5) and 225.8 (95% CI, 183.5-268.0) in females and males, respectively. Seasonal incidence differed, with rates of 224.6 (95% CI, 180.9-268.4) in warmer months (May-September) compared with 142.3 (95% CI, 112.8-171.9) in colder months (January-April and October-December). Despite emergence and nationwide spread of CA-MRSA since 1999 in the United States, the incidence of NLEC in Olmsted County was lower in 2013 than in 1999, particularly in females. This suggests that CA-MRSA is not a significant cause of NLEC and that NLEC cases are seasonally distributed. These findings may be important in formulation of empirical therapy for NLEC and in patient education because many patients with NLEC are prone to recurrent bouts of this infection.

Outcomes in Patients With Cardiovascular Implantable Electronic Device Infection Managed With Chronic Antibiotic Suppression.

BACKGROUND.: Most cardiovascular implantable electronic device (CIED) recipients are elderly, have multiple comorbid conditions, and are at increased risk of CIED infection (CIEDI). Current guidelines recommend complete device removal in patients with CIEDI to prevent relapse and mortality. However, comorbidities or other factors may preclude device removal, thus prompting a nonsurgical approach that includes chronic antibiotic suppression (CAS). There are limited data on outcomes of patients receiving CAS for CIEDI. METHODS.: We retrospectively screened 660 CIEDI cases from 2005 to 2015 using electronic health records and a CIEDI institutional database and identified 48 patients prescribed CAS. Primary outcomes were infection relapse and survival. RESULTS.: The median age was 78 years, and 73% (35/48) were male. The median Charlson comorbidity index was 4. Common pathogens were coagulase-negative staphylococci (21%, 10/48) and methicillin-sensitive Staphylococcus aureus (19%, 9/48). At 1 month after hospitalization, 25% (12/48) of patients had died, of whom only 1 initiated CAS; 67% (8/12) of these had staphylococcal infections. Of the 37 patients who initiated CAS, the most common antimicrobials were trimethoprim-sulfamethoxazole, penicillin, and amoxicillin (22%, 8/37 each). Estimated median overall survival was 1.43 years (95% confidence interval, 0.27-2.14), with 18% (6/33 survivors) developing relapse within 1 year. Of the 6 patients who relapsed, 2 (33%) subsequently underwent CIED extraction. CONCLUSION.: CAS is reasonable in select patients who are not candidates for complete device removal for attempted cure of CIEDI. Nevertheless, 1-month mortality in our sample of CAS-eligible patients was high and reflective of high rates of comorbid conditions.

Mycobacterium iranicum septic arthritis and tenosynovitis.

Mycobacterium iranicum is a newly reported nontuberculous mycobacterial (NTM) species that has been previously isolated in twelve patients. Our report presents the thirteenth known case of M. iranicum, which caused septic arthritis of the right third proximal interphalangeal joint and associated tenosynovitis in a 39-year-old female following a rose thorn injury.

Efficacy of Antitoxin Therapy in Treating Patients With Foodborne Botulism: A Systematic Review and Meta-analysis of Cases, 1923-2016.

Background: Botulism is a rare, potentially severe illness, often fatal if not appropriately treated. Data on treatment are sparse. We systematically evaluated the literature on botulinum antitoxin and other treatments. Methods: We conducted a systematic literature review of published articles in PubMed via Medline, Web of Science, Embase, Ovid, and Cumulative Index to Nursing and Allied Health Literature, and included all studies that reported on the clinical course and treatment for foodborne botulism. Articles were reviewed by 2 independent reviewers and independently abstracted for treatment type and toxin exposure. We conducted a meta-analysis on the effect of timing of antitoxin administration, antitoxin type, and toxin exposure type. Results: We identified 235 articles that met the inclusion criteria, published between 1923 and 2016. Study quality was variable. Few (27%) case series reported sufficient data for inclusion in meta-analysis. Reduced mortality was associated with any antitoxin treatment (odds ratio [OR], 0.16; 95% confidence interval [CI], .09-.30) and antitoxin treatment within 48 hours of illness onset (OR, 0.12; 95% CI, .03-.41). Data did not allow assessment of critical care impact, including ventilator support, on survival. Therapeutic agents other than antitoxin offered no clear benefit. Patient characteristics did not predict poor outcomes. We did not identify an interval beyond which antitoxin was not beneficial. Conclusions: Published studies on botulism treatment are relatively sparse and of low quality. Timely administration of antitoxin reduces mortality; despite appropriate treatment with antitoxin, some patients suffer respiratory failure. Prompt antitoxin administration and meticulous intensive care are essential for optimal outcome.

Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study.

BACKGROUND: Universal human immunodeficiency virus (HIV) screening remains low in many clinical practices despite published guidelines recommending screening for all patients between ages 13-65. Electronic clinical decision support tools have improved screening rates for many chronic diseases. We designed a quality improvement project to improve the rate of universal HIV screening of adult patients in a Midwest primary care practice using a clinical decision support tool. METHODS: We conducted this quality improvement project in Rochester, Minnesota from January 1, 2014 to December 31, 2014. Baseline primary care practice HIV screening data were acquired from January 1, 2014 to April 30, 2014. We surveyed providers and educated them about current CDC recommended screening guidelines. We then added an HIV screening alert to an existing electronic clinical decision support tool and post-intervention HIV screening rates were obtained from May 1, 2014 to December 31, 2014. The primary quality outcome being assessed was change in universal HIV screening rates. RESULTS: Twelve thousand five hundred ninety-six unique patients were eligible for HIV screening in 2014; 327 were screened for HIV. 6,070 and 6,526 patients were seen before and after the intervention, respectively. 1.80 % of eligible patients and 3.34 % of eligible patients were screened prior to and after the intervention, respectively (difference of -1.54 % [-2.1 %, -0.99 %], p < 0.0001); OR 1.89 (1.50, 2.38). Prior to the intervention, African Americans were more likely to have been screened for HIV (OR 3.86 (2.22, 6.71; p < 0.001) than Whites, but this effect decreased significantly after the intervention (OR 1.90 (1.12, 3.21; p = 0.03). CONCLUSIONS: These data showed that an electronic alert almost doubled the rates of universal HIV screening by primary care providers in a Midwestern practice and reduced racial disparities, but there is still substantial room for improvement in universal screening practices. Opportunities for universal HIV screening remain abundant, as many providers either do not understand the importance of screening average risk patients or do not remember to discuss it. Alerts to remind providers of current guidelines and help identify screening opportunities can be helpful.

Poststernotomy Osteomyelitis Presenting with Severe Sepsis and Rhabdomyolysis.

A 39-year-old male, who recently underwent a composite valve graft of the aortic root and ascending aorta for bicuspid aortic valve and aortic root aneurysm, was hospitalized for severe sepsis, rhabdomyolysis (creatine kinase 29000 U/L), and severe liver dysfunction (AST > 7000 U/L, ALT 4228 U/L, and INR > 10). Cardiac magnetic resonance imaging (MRI) findings were consistent with sternal osteomyelitis with a 1.5 cm abscess at the inferior sternotomy margin, which was contiguous with pericardial thickening. Aspiration and culture of this abscess did not yield any organisms, so he was treated with vancomycin and cefepime empirically for 4 weeks. Because this patient was improving clinically on antibiotics and did not show external signs of wound infection, there was no compelling indication for sternectomy. This patient's unusual presentation with osteomyelitis and rhabdomyolysis has never been reported and is crucial for clinicians to recognize in order to prevent delays in diagnosis.

Is Abnormal Urine Protein/Osmolality Ratio Associated with Abnormal Renal Function in Patients Receiving Tenofovir Disoproxil Fumarate?

BACKGROUND: Risk factors for and optimal surveillance of renal dysfunction in patients on tenofovir disoproxil fumarate (TDF) remain unclear. We investigated whether a urine protein-osmolality (P/O) ratio would be associated with renal dysfunction in HIV-infected persons on TDF. METHODS: This retrospective, single-center study investigated the relationship between parameters of renal function (estimated glomerular filtration rate (eGFR) and P/O-ratio) and risk factors for development of kidney dysfunction. Subjects were HIV-infected adults receiving TDF with at least one urinalysis and serum creatinine performed between 2010 and 2013. Regression analyses were used to analyze risk factors associated with abnormal P/O-ratio and abnormal eGFR during TDF therapy. RESULTS: Patients were predominately male (81%); (65%) were Caucasian. Mean age was 45.1(±11.8) years; median [IQR] TDF duration was 3.3 years. [1.5-7.6]. Median CD4+ T cell count and HIV viral load were 451 cells/µL [267.5-721.5] and 62 copies/mL [0-40,150], respectively. Abnormal P/O-ratio was not associated with low eGFR. 68% of subjects had an abnormal P/O-ratio and 9% had low eGFR. Duration of TDF use, age, diabetes and hypertension were associated with renal dysfunction in this study. After adjustment for age, subjects on TDF > 5 years had almost a four-fold increased likelihood of having an abnormal P/O-ratio than subjects on TDF for < 1yr (OR 3.9; 95% CI 1.2-14.0; p = 0.024). CONCLUSION: Abnormal P/O-ratio is common in HIV-infected patients on TDF but was not significantly associated with low eGFR, suggesting that abnormal P/O-ratio may be a very early biomarker of decreased renal function in HIV infected patients.

High Rates of Diabetes Mellitus, Pre-diabetes and Obesity Among Somali Immigrants and Refugees in Minnesota: A Retrospective Chart Review.

We examined the prevalence of cardiovascular risk factors among Somali refugees at a midwestern hospital in the U.S. This was a retrospective cohort study of 1007 adult Somali patients and an age and frequency-matched cohort of non-Somali patients actively empanelled to a large, academic primary care practice network in the Midwest United States between January 1, 2011 and December 31, 2012. Cardiovascular risk factors were obtained by chart review and compared between the two cohorts using a Chi squared test. Median age was 35 years (Q1, Q3; 27, 50). The prevalence of diabetes was significantly higher among Somali versus non-Somali patients (12.1 vs 5.3 %; p = 0.0001), as was prediabetes (21.3 vs 17.2 %; p < 0.02) and obesity (34.6 vs 32.1 %; p = 0.047). After adjusting for age, sex, body mass index, education and employment, among the Somali patients, the odds ratio (95 % confidence interval) for diabetes was 2.78 (1.76-4.40) and 1.57 (1.16-2.13) for pre-diabetes. There was a significantly higher prevalence of diabetes, pre-diabetes and obesity among Somali patients compared with non-Somali patients. Further research into the specific causes of these disparities and development of targeted effective and sustainable interventions to address them is needed.

Mycobacterium avium intracellulare complex causing olecranon bursitis and prosthetic joint infection in an immunocompromised host.

CASE: A 73-year-old immunocompromised male presented with recurrent left elbow swelling due to Mycobacterium avium intracellulare complex (MAC) olecranon bursitis. 3 years after completing MAC treatment, he underwent right total knee arthroplasty (TKA). 1 year later, he developed TKA pain and swelling and was diagnosed with MAC prosthetic joint infection (PJI). He underwent TKA resection, reimplantation, and 12 months of anti-MAC therapy. This patient is the seventh case report of MAC olecranon bursitis and the third case report of MAC PJI. He is the only report of both MAC olecranon bursitis and PJI occurring in the same patient. INFORMED CONSENT: This patient was informed and agreed to the publication of this material.

Fever and Cardiac Arrest in a Patient With a Left Ventricular Assist Device.

A 68-year-old avid deer hunter with ischemic cardiomyopathy underwent left ventricular assist device (LVAD) implantation for destination therapy two years ago. He was living an active lifestyle, tracking deer and fishing in a Midwestern forest in November. His wife removed an engorged tick on his thorax. A few days later, he experienced fever, confusion, and ataxia and was hospitalized with septic shock and ventricular fibrillation. The LVAD site had no signs of trauma, drainage, warmth, or tenderness. A peripheral blood smear revealed intraleukocytic anaplasma microcolony inclusions. After completing 14 days of doxycycline, he recovered. Typical non-device-associated infections in LVAD recipients include pneumonia, urinary tract infection, or Clostridium difficile colitis. Human granulocytic anaplasmosis (HGA) is a very atypical non-LVAD infection, and the incidence of tickborne illnesses in LVAD recipients is unknown.