Amoxicillin and penicillin G dosing in pediatric community-acquired pneumococcal pneumonia in the era of conjugate pneumococcal vaccines.

BACKGROUND: Parenteral penicillin G (PENG) and oral amoxicillin (AMOX) are recommended as treatment for pediatric community-acquired pneumonia (CAP). With recent epidemiologic penicillin susceptibility data for Streptococcus pneumoniae, the most common etiology of CAP, the objective of this study was to evaluate optimal dosing regimens of PENG and AMOX based on population pharmacokinetics linked to current susceptibility data. METHODS: Using NONMEM v7.3, Monte Carlo simulations (N = 10,000) were conducted for AMOX 15 mg/kg/dose PO every 8 h (standard-dose), AMOX 45 mg/kg/dose PO every 12 h (high-dose), and PENG 62,500 units/kg/day IV every 6 h using six virtual subjects with ages spanning 3 months to 15 years old. The probability of target attainment (PTA) was determined for both serum and epithelial lining fluid (ELF) to achieve free drug concentrations above the minimum inhibitory concentration (%fT>MIC) across the population of pneumococci for 30%-50% of the dosing interval. RESULTS: In 2018, all 21 (100%) pneumococcal isolates were susceptible to both PENG and AMOX based on Clinical and Laboratory Standards Institute (CLSI; MIC at 2 mg/L) breakpoints, and 15 of 21 (71%) were susceptible based on EUCAST (MIC at 0.5 mg/L) breakpoints. As compared to CLSI, EUCAST breakpoints consistently achieved higher PTA for all antibiotic regimens. At 50% fT>MIC in the serum at the susceptible MICs, standard-dose AMOX achieved >4% PTA (CLSI) and >86% PTA (EUCAST); high-dose AMOX achieved >73% PTA (CLSI) and >99% PTA (EUCAST); and PENG achieved 0% PTA (using CLSI) and 100% PTA (using EUCAST). Standard-dose AMOX, high-dose AMOX, and PENG achieved >71%, >93%, and 100% PTA, respectively, in the serum at 30%-50% fT>MIC when each patient was stochastically linked to an MIC based on the frequency distribution of national susceptibility data. The PTA was consistently lower in ELF as compared with serum for all regimens. CONCLUSION: Based on the recent rates of resistance, antibiotic doses evaluated provide appropriate exposure for pediatric CAP based on the serum and ELF data associated with predicted clinical and microbiologic success for pneumococcus. High-dose AMOX may still be required to treat pediatric CAP, especially if using CLSI breakpoints. Ongoing surveillance for resistance is essential.

Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula.

Background: We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods: Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012-2017 by surgical approach using the NSQIP database. Results: We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012-2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46, P=0.02) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min, P < 0.01). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%, P=0.77) but a decrease in conversion rate (8.1% vs. 13.8%, P < 0.01) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min, P < 0.01) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%, P=0.14) and between laparoscopic and robotic approaches (2.8% vs. 3.8%, P=0.99). Conclusions: We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.

A Case of Iatrogenic Splenic Injury Following Routine Colonoscopy With Possible Influence of Unique Anatomy Due to Severe Scoliosis.

Iatrogenic splenic injury is a rare complication of all abdominal surgeries. Despite the procedure's overall safety, colonoscopy is now the procedure most frequently associated with iatrogenic splenic injury. A 58-year-old male with a past medical history of hypertension, lung cancer in remission, colon polyps, and severe scoliosis presented for grade three splenic laceration two days following a routine colonoscopy. He had no recent history of injury or other inciting events that could have led to traumatic injury. Non-operative management included splenic artery embolization and transfusion of one unit of packed red blood cells, after which he improved in the hospital and was discharged home in stable condition. This case postulates the possible influence of his severe scoliosis, and thus altered abdominal viscera anatomy, on his iatrogenic splenic injury, as well as the potential importance of investigating scoliosis as a risk factor for difficult colonoscopy or even iatrogenic splenic injury during colonoscopy.

Resuscitative Thoracotomy for Multiple Gunshot Wounds With Cardiac Tamponade Despite Pericardial Window.

This report reviews the indications and complications of resuscitative thoracotomy in the trauma patient as seen with the clinical course of a 19-year-old male who experienced postoperative pericardial tamponade after a bilateral resuscitative thoracotomy with pericardiotomy. This patient presented to the hospital in critical condition with 31 gunshot wounds (GSWs) distributed over the chest, abdomen, and extremities. After undergoing an initially successful resuscitative thoracotomy, the patient continued to bleed into his chest at a greater rate than the chest tubes were able to adequately evacuate. Despite the presence of a large pericardial window, clotted blood led to cardiac tamponade. Subsequent bedside reopening of thoracotomy under conscious sedation (ketamine, fentanyl, and midazolam) was required to evacuate the clots and stabilize the patient. This case provides the opportunity to discuss several interesting points for managing the traumatized patient, including indications for resuscitative thoracotomy, use of conscious sedation for bedside major surgery, and complications of clamshell thoracotomy, and ethics of resource allocation.

Right Paraduodenal Hernia.

Clinical suspicion is necessary to prevent possible complications and mortality from paraduodenal hernias, a rare cause of small bowel obstruction.

Breast cancer worry among women awaiting mammography: is it unfounded? Does prior counseling help?

The purpose of this study was to explore the prevalence of breast cancer anxiety and risk counseling in women undergoing mammography, and the association with known risk factors for cancer. Women awaiting mammography were surveyed regarding anxiety, prior breast cancer risk counseling, demographic and risk factors. Anxiety was assessed via 7-point Likert-type scale (LS). Risk was defined by Gail model or prior breast cancer. Data were analyzed by nonparametric methods; significance determined at alpha = 0.05. Of 227 women surveyed, 54 were classified "higher risk". Counseling prevalence was similar (52%) for all ethnic groups, but higher (72%, P<0.001) for "higher risk" women. On average, women awaiting screening/diagnostic mammography were somewhat worried (median LS = 4). Worry was significantly higher (P<0.05) in "higher risk" women (LS = 5), and in women living outside Honolulu (LS = 6). Counseling by primary care physicians (PCP) did not correlate with lower worry scores. It was concluded that most women awaiting mammography are not unduly anxious. Additionally, the findings showed a correlation between a woman's concern about developing cancer with known risk factors and rural residence.