Case Report: Candida dubliniensis as a Cause of Chronic Meningitis.

Background: Candida dubliniensis is closely related to Candida albicans and rarely isolated in clinical specimens. C. dubliniensis is increasingly recognized as a pathogen in immunocompromised hosts. We present the third known case of Candida dubliniensis meningitis in a young immunocompetent host. Case Presentation: A 27-year-old female with a history of intravenous heroin use and chronic hepatitis C presented with a 10-month history of headaches and progressive bilateral vision loss. On physical examination, visual acuity was 20/20 in her right eye and grade II papilledema was noted. Examination of her left eye revealed complete loss of vision and grade IV papilledema. An MRI with and without contrast revealed increased leptomeningeal enhancement involving the posterior fossa and spinal cord. After multiple lumbar punctures, cerebrospinal fluid fungal cultures grew Candida dubliniensis. The patient was successfully treated with a combination of liposomal amphotericin and fluconazole for 6 weeks with complete resolution of her CNS symptoms, with the exception of irreversible vision loss. Conclusion: We report a case of chronic meningitis due to Candida dubliniensis in an immunocompetent woman with hepatitis C and a history of intravenous heroin use. Additional studies are needed to confirm risk factors for Candida dubliniensis colonization, which likely predisposes individuals to invasive candidiasis.

Why do clinicians order inappropriate Clostridium difficile testing? An exploratory study.

BACKGROUND: The drivers behind Clostridium difficile testing are not well understood. METHODS: C difficile testing orders were reviewed. An algorithm that sequentially considered the presence of diarrhea, leukocytosis, fever, and laxative use was created. Tests deemed potentially inappropriate were discussed with the ordering team. RESULTS: Of 128 orders reviewed, 62% (n = 79) were appropriate. Patients whose testing was deemed inappropriate had longer lengths of stay. Diarrhea and laxative use were common and similarly distributed in those appropriately or inappropriately tested. The most commonly cited reason for ordering an inappropriate test was the reporting of diarrhea to the clinician by the patient or nursing that was not documented in the electronic health record. The next most common reason was clinician perception of risk. Demographics, laxative use, fever, leukocytosis, and diarrhea were similarly distributed between patients testing positive or negative by C difficile polymerase chain reaction. DISCUSSION: The discriminating value of diarrhea or laxative use in assessing for C difficile infection is poor. Multiple streams of information add to the complexities of decision making around C difficile testing. Inconsistent definitions of diarrhea likely contribute to this complexity. Clinician-perceived risk to the patient, partially driven by length of stay, may be a large driver of testing practices. CONCLUSIONS: Without understanding the knowledge, attitudes, and values that underlie clinician behavior, interventions targeting ordering practices may not succeed.