Lactobacillus rhamnosus endocarditis associated with dental procedure in a patient with Marfan's variant and prior aortic root replacement.

A man in his 60s with a medical history of Marfan's variant with remote valve sparing aortic root replacement presented for evaluation of subacute fevers, chills and night sweats. He had no significant preceding history other than a dental cleaning performed with antibiotic prophylaxis. Blood cultures grew Lactobacillus rhamnosus which was susceptible to penicillin and linezolid but resistant to meropenem and vancomycin. A transthoracic echocardiogram showed an aortic leaflet vegetation with chronic moderate aortic regurgitation but no reduction in his ejection fraction. He was discharged home and treated with gentamicin and penicillin G, initially with adequate response. However, he was subsequently readmitted for persistent fevers, chills, weight loss and dizziness, found to have multiple acute strokes secondary to septic thromboemboli. He underwent definitive aortic valve replacement with excised tissue confirming infective endocarditis.

Comparison between Perianal Swab and Stool Specimens for Detecting Colonization with Extended-Spectrum Beta-Lactamase-Producing and Fluoroquinolone-Resistant Enterobacterales.

Stool specimens are frequently used to detect gastrointestinal tract colonization with antimicrobial-resistant enteric bacteria, but they cannot be rapidly collected. Perianal swab specimens can be collected more quickly and efficiently, but data evaluating their suitability as a specimen type for this purpose are sparse. We performed selective culture for extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E) and fluoroquinolone-resistant Enterobacterales (FQRE) using paired perianal swab and stool specimens that were collected within 1 day of each other from hematopoietic cell transplant recipients and patients with acute leukemia. Nineteen (7.6%) of 251 stool specimens yielded ESBL-E and 64 (26%) of 246 stool specimens yielded FQRE. The positive percent agreement of perianal swab specimens compared to stool specimens was 95% (18/19; 95% confidence interval [CI], 74% to 100%) for detecting ESBL-E and 95% (61/64; 95% CI, 87% to 99%) for detecting FQRE. The concordance between specimen types was 98% (95% CI, 97% to 100%). Perianal swabs are a reliable specimen type for surveillance of the gastrointestinal tract for ESBL-E and FQRE.

Comparing mortality in patients with carbapenemase-producing carbapenem resistant Enterobacterales and non-carbapenemase-producing carbapenem resistant Enterobacterales bacteremia.

Carbapenem-resistant Enterobacterales (CRE) are classified as either carbapenemase-producing CRE (CP-CRE) or non-carbapenemase-producing CRE (non-CP-CRE) based on their mechanism of carbapenem resistance. Few studies have compared outcomes associated with each type of infection. We attempted to determine if either CRE subset is associated with increased mortality. We performed a retrospective observational study to collect demographic, clinical and outcomes data to compare patients with CP-CRE and non-CP-CRE bacteremia. Of 146 cases analyzed, 88/146 (60%) were CP-CRE and 58/146 (40%) were non-CP-CRE. Patients with CP-CRE bacteremia were less likely to receive active empiric or targeted antibiotic therapy. Non-CP-CRE bacteremia was associated with a 2.4 times higher hazard of death at 30 days after bacteremia onset compared to CP-CRE (HR, 2.4; 95% CI, 1.2, 4.6). Patients with non-CP-CRE bacteremia had a higher hazard of death at 30 days after bacteremia onset compared to those with CP-CRE bacteremia.

Linking plasmid-based beta-lactamases to their bacterial hosts using single-cell fusion PCR.

The horizonal transfer of plasmid-encoded genes allows bacteria to adapt to constantly shifting environmental pressures, bestowing functional advantages to their bacterial hosts such as antibiotic resistance, metal resistance, virulence factors, and polysaccharide utilization. However, common molecular methods such as short- and long-read sequencing of microbiomes cannot associate extrachromosomal plasmids with the genome of the host bacterium. Alternative methods to link plasmids to host bacteria are either laborious, expensive, or prone to contamination. Here we present the One-step Isolation and Lysis PCR (OIL-PCR) method, which molecularly links plasmid-encoded genes with the bacterial 16S rRNA gene via fusion PCR performed within an emulsion. After validating this method, we apply it to identify the bacterial hosts of three clinically relevant beta-lactamases within the gut microbiomes of neutropenic patients, as they are particularly vulnerable multidrug-resistant infections. We successfully detect the known association of a multi-drug resistant plasmid with Klebsiella pneumoniae, as well as the novel associations of two low-abundance genera, Romboutsia and Agathobacter. Further investigation with OIL-PCR confirmed that our detection of Romboutsia is due to its physical association with Klebsiella as opposed to directly harboring the beta-lactamase genes. Here we put forth a robust, accessible, and high-throughput platform for sensitively surveying the bacterial hosts of mobile genes, as well as detecting physical bacterial associations such as those occurring within biofilms and complex microbial communities.

Colonization With Fluoroquinolone-Resistant Enterobacterales Decreases the Effectiveness of Fluoroquinolone Prophylaxis in Hematopoietic Cell Transplant Recipients.

BACKGROUND: Levofloxacin prophylaxis is recommended to prevent gram-negative bloodstream infections (BSIs) in patients with prolonged chemotherapy-induced neutropenia. However, increasing fluoroquinolone resistance may decrease the effectiveness of this approach. METHODS: We assessed the prevalence of colonization with fluoroquinolone-resistant Enterobacterales (FQRE) among patients admitted for hematopoietic cell transplantation (HCT) from November 2016 to August 2019 and compared the risk of gram-negative BSI between FQRE-colonized and noncolonized patients. All patients received levofloxacin prophylaxis during neutropenia. Stool samples were collected upon admission for HCT and weekly thereafter until recovery from neutropenia, and underwent selective culture for FQRE. All isolates were identified and underwent antimicrobial susceptibility testing by broth microdilution. FQRE isolates also underwent whole-genome sequencing. RESULTS: Fifty-four of 234 (23%) patients were colonized with FQRE prior to HCT, including 30 of 119 (25%) allogeneic and 24 of 115 (21%) autologous HCT recipients. Recent antibacterial use was associated with FQRE colonization (P = .048). Ninety-one percent of colonizing FQRE isolates were Escherichia coli and 29% produced extended-spectrum ß-lactamases. Seventeen (31%) FQRE-colonized patients developed gram-negative BSI despite levofloxacin prophylaxis, compared to only 2 of 180 (1.1%) patients who were not colonized with FQRE on admission (P < .001). Of the 17 gram-negative BSIs in FQRE-colonized patients, 15 (88%) were caused by FQRE isolates that were genetically identical to the colonizing strain. CONCLUSIONS: Nearly one-third of HCT recipients with pretransplant FQRE colonization developed gram-negative BSI while receiving levofloxacin prophylaxis, and infections were typically caused by their colonizing strains. In contrast, levofloxacin prophylaxis was highly effective in patients not initially colonized with FQRE.

Description and preliminary evaluation of a diabetes technology simulation course.

BACKGROUND: We aim to provide data on a diabetes technology simulation course (DTSC) that instructs internal medicine residents in the use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring system (CGMS) devices. METHODS: The DTSC was implemented during calendar year 2012 and conducted in the institution's simulation center. It consisted of a set of prerequisites, a practicum, and completion of a web-based inpatient CSII-ordering simulation. DTSC participants included only those residents in the outpatient endocrinology rotation. Questionnaires were used to determine whether course objectives were met and to assess the satisfaction of residents with the course. Questionnaires were also administered before and after the endocrine rotation to gauge improvement in familiarity with CSII and CGMS technologies. RESULTS: During the first year, 12 of 12 residents in the outpatient endocrinology rotation completed the DTSC. Residents reported that the course objectives were fully met. The mean satisfaction score with the course ranged from 4.0 to 4.9 (maximum, 5), with most variables rated above 4.5. Self-reported familiarity with the operation of CSII and CGMS devices increased significantly in the postrotation survey compared with that on the prerotation survey (both p < .01). CONCLUSIONS: In this pilot program, simulation-based education increased the perceived familiarity of residents with CSII and CGMS technologies. In light of these preliminary findings, the course will continue to be offered, with further data accrual. Future work will involve piloting the DTSC approach among other types of providers, such as residents in other specialties or inpatient nursing staff.

Improving hypertension control in diabetes: a multisite quality improvement project that applies a 3-step care bundle to a chronic disease care model for diabetes with hypertension.

Hypertension in diabetes patients leads to significant morbidity and mortality. Nonetheless blood pressure (BP) control in patients with diabetes remains disappointing. The authors applied a care bundle to decrease the proportion of patients with BP exceeding 130/80. Teams from 4 sites in 3 states (Minnesota, Florida, and Arizona) developed a bundle consisting of a standardized BP process, an order set, and a patient goal. Baseline data were collected in the first 12 weeks, followed by 6 weeks of implementing changes. The final 16 weeks represented the intervention. There was a statistically significant decrease in the proportion of patients with uncontrolled BP in 3 of 4 sites (P < .0001 in all 3 sites demonstrating improvement). There was a statistically significant improvement in the satisfaction survey (P = .0011). Implementing an evidence-based care bundle for hypertension in diabetes mellitus can improve BP outcomes.

Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period.

Case reports indicate that diabetes patients receiving outpatient insulin pump therapy have been allowed to continue treatment during surgical procedures. Although allowed during surgery, there is actually little information in the medical literature on how to manage patients receiving insulin pump therapy during a planned surgical procedure. A multidisciplinary work group reviewed current information regarding the use of insulin pumps in the perioperative period. Although the work group identified safety issues specific to surgical scenarios, it believed that with the use of standardized guidelines and a checklist, continuation of insulin pump therapy during the perioperative period is feasible. A sample set of protocols have been developed and are summarized. A policy outlining clear procedures should be established at the institutional level to guide physicians and other staff if the devices are to be employed during the perioperative period. Additional clinical experience with the technology in surgical scenarios is needed, and consensus should be developed for insulin pump use in the perioperative phases of care.

Diabetes in the desert: what do patients know about the heat?

BACKGROUND: This study aims to identify self-management strategies used by patients with diabetes in hot weather, examine knowledge of safe temperatures and exposure times, and evaluate comprehension of weather data. METHODS: Patients attending an endocrinology clinic in southwestern United States were surveyed. RESULTS: One hundred fifty-two surveys completed from November 30 to December 31, 2009 were analyzed. Mean patient age was 64 years; diabetes duration e analyzed 15 years; 51% were women 83% had type 2 diabetes, 58% were non Hispanic white, and 77% were on insulin injections. Mean hemoglobin A1c was 7.9%; 38% had hemoglobin A1c values of 8.0% or higher. Patients used an array of personal protective measures during hot weather, and 71% limited heat exposure to less than one hour. Respondents typically took steps to protect their diabetes medication and supplies, but 37% chose to leave medications and supplies at home. Although 73% of respondents had received information regarding the effect of heat on insulin, only 39% had received information about the effect of heat on oral medications, 41% on glucose meters, and 38% on glucose test strips. The temperature at which patients took protective measures varied. Only 55% knew the definition of the heat index. CONCLUSION: Most survey participants took measures to protect themselves from the heat, although gaps in knowledge were evident. Many patients had suboptimal glycemic control, placing them potentially at risk for dehydration during the hottest months. Increased public awareness of this topic is needed, and diabetes education programs should include information about the heat where appropriate.

Inpatient to outpatient transfer of diabetes care: planing for an effective hospital discharge.

OBJECTIVE: To review data on diabetes discharge planning, provide a definition of an effective diabetes discharge, and summarize one institution's diabetes discharge planning processes in a teaching hospital. METHODS: We performed a MEDLINE search of the English-language literature published between January 1998 and December 2007 for articles related to the inpatient to outpatient transition of diabetes care. Regulatory guidelines about discharge planning were reviewed. We also analyzed our institution's procedures regarding hospital discharge. RESULTS: We define an effective diabetes discharge as one where the patient has received the necessary skills training and been provided with a clear and understandable postdischarge plan for diabetes care that has been clearly documented and is accessible by the patient's outpatient health care team. Diabetes is one of the most common conditions managed in the hospital, yet how to transition a patient with diabetes to the outpatient setting is understudied, and the outcome of patients with diabetes after discharge is unknown. Strategies that can be used to ensure an effective diabetes discharge are early identification of patients in need of education, implementation of a clinical pathway, and clear instructions about medications and follow-up appointments at the time of discharge. CONCLUSIONS: Effective transfer of care from the inpatient to the outpatient setting remains a priority in the United States. Studies are needed to better define how best to ensure that patients with diabetes are successfully transitioned to ambulatory care.

Temporal and geographic patterns of hypoglycemia among hospitalized patients with diabetes mellitus.

BACKGROUND: Hypoglycemia is often cited as a barrier to achieving inpatient glycemic targets. We sought to characterize hypoglycemic events in our institution by work-shift cycle and by specific treatment area. METHODS: Capillary (bedside) and blood (laboratory) glucose values of <70 mg/dl for patients with either a known diagnosis of diabetes or with evidence of hyperglycemia were abstracted from our laboratory database for hospitalizations between October 1, 2007, and February 3, 2008. Hypoglycemic events were analyzed by 12 h nursing work-shift cycles (day shift, 07:00 to 18:59; night shift, 19:00 to 06:59) and by the six medical, surgical, and intensive care areas in the hospital (designated areas 1 to 6). RESULTS: We identified 206 individual patients with either diabetes or hyperglycemia (mean age, 67 years; 56% men; 83% white) who had 423 hypoglycemic events. There were 78% more hypoglycemic events during the night shift (n = 271 events in 128 individual patients) than during the day shift (n = 152 events in 96 individual patients). Most of the night-shift hypoglycemic measurements were detected between 04:00 and 04:59 or 06:00 and 06:59. The mean hypoglycemic level was comparable between shifts (p = .79) and across the six inpatient areas. The number of hypoglycemic events per person increased with lengths of hospital stay >5 days. The prevalence of hypoglycemia varied across patient care areas within the hospital, with most (28%) detected in one area of the hospital. CONCLUSION: There are temporal and geographic patterns in the occurrence of hypoglycemia among patients with diabetes or hyperglycemia in our hospital. Further study should focus on the reasons underlying these variations so that specific interventions can address the risk of hypoglycemia during peak times and places.

Development of computer-based training to enhance resident physician management of inpatient diabetes.

BACKGROUND: Treating hyperglycemia promotes better outcomes among inpatients. Knowledge deficits about management of inpatient diabetes are prevalent among resident physicians, which may affect the care of a substantial number of these patients. METHODS: A computer-based training (CBT) curriculum on inpatient diabetes and hyperglycemia was developed and implemented for use by resident physicians and focuses on several aspects of the management of inpatient diabetes and hyperglycemia: (1) review of importance of inpatient glucose control, (2) overview of institution-specific data, (3) triaging and initial admission actions for diabetes or hyperglycemia, (4) overview of pharmacologic management, (5) insulin-dosing calculations and ordering simulations, (6) review of existing policies and procedures, and (7) discharge planning. The curriculum was first provided as a series of lectures, then formatted and placed on the institutional intranet as a CBT program. RESULTS: Residents began using the inpatient CBT in September 2008. By August 2009, a total of 29 residents had participated in CBT: 8 in family medicine, 12 in internal medicine, and 9 in general surgery. Most of the 29 residents confirmed that module content met stated objectives, considered the information valuable to their inpatient practices, and believed that the quality of the online modules met expectations. The majority reported that the modules took just the right amount of time to complete (typically 30 min each). CONCLUSIONS: Improvement in inpatient diabetes care requires continuous educational efforts. The CBT format and curriculum content were well accepted by the resident physicians. Ongoing assessment must determine whether resident practice patterns are influenced by such training.

Diagnosis and treatment of Lyme disease.

Lyme disease is the most common tick-borne disease in the United States. This review details the risk factors, clinical presentation, treatment, and prophylaxis for the disease. Information was obtained from a search of the PubMed and MEDLINE databases (keyword: Lyme disease) for articles published from August 31, 1997, through September 1, 2007. Approximately 20,000 cases of Lyme disease are reported annually. Residents of the coastal Northeast, northwest California, and the Great Lakes region are at highest risk. Children and those spending extended time outdoors in wooded areas are also at increased risk. The disease is transmitted to humans through the bite of the Ixodes tick (Ixodes scapularis and Ixodes pacificus). Typically, the tick must feed for at least 36 hours for transmission of the causative bacterium, Borrelia burgdorferi, to occur. Each of the 3 stages of the disease is associated with specific clinical features: early localized infection, with erythema migrans, fever, malaise, fatigue, headache, myalgias, and arthralgias; early disseminated infection (occurring days to weeks later), with neurologic, musculoskeletal, or cardiovascular symptoms and multiple erythema migrans lesions; and late disseminated infection, with intermittent swelling and pain of 1 or more joints (especially knees). Neurologic manifestations (neuropathy or encephalopathy) may occur. Diagnosis is usually made clinically. Treatment is accomplished with doxycycline or amoxicillin; cefuroxime axetil or erythromycin can be used as an alternative. Late or severe disease requires intravenous ceftriaxone or penicillin G. Single-dose doxycycline (200 mg orally) can be used as prophylaxis in selected patients. Preventive measures should be emphasized to patients to help reduce risk.