Clinicopathologic conference: Bloodstream infection in an allogeneic hamatopoietic cell transplant: Thinking beyond the usual.

This case involves a 53-year-old female with concurrent acute myeloid leukemia (AML) and multiple myeloma. She underwent cytarabine and daunorubicin (7+3) induction chemotherapy followed by cytarabine (HiDAC) consolidation, with an early AML relapse requiring azacitidine and venetoclax therapy. She achieved complete remission and incomplete count recovery. Following fludarabine, melphalan, and thymoglobulin induction chemotherapy, she underwent an allogeneic stem cell transplant with failure to engraft, requiring autologous stem cell rescue, buffy coat, and granulocyte transfusions, eventually presenting with a diffuse skin rash consistent with Steven-Johnson syndrome and toxic epidermal necrolysis, persistent neutropenic fevers and positive blood cultures.

Identification and antimicrobial susceptibility of referred Nocardia isolates in Victoria, Australia 2009-2019.

Introduction. Nocardia is an opportunistic pathogen that can cause significant morbidity and mortality, particularly in the immunocompromised host. Antimicrobial susceptibility profiles vary across Nocardia spp. and vary within Australia as well as worldwide. Knowledge of local susceptibility patterns is important in informing appropriate empiric antimicrobial therapy.Gap Statement. This is the largest study to date in Australia that correlates antimicrobial susceptibility profiles with molecular identification of Nocardia species. It is the first study that examines isolates from multiple institutions across the state of Victoria, Australia.Aim. To investigate the species distribution and antibiotic susceptibility of Nocardia spp. isolates referred to the Mycobacterial Reference Laboratory (MRL) in Victoria, Australia from 2009 to 2019.Methodology. We conducted a retrospective review of Nocardia spp. isolates which were identified using molecular sequencing. Antimicrobial susceptibility testing was performed using standardized broth microdilution method with Sensititre RAPMYCO1 plates. Species distribution and antibiotic susceptibility profiles were analysed.Results. In total, 414 Nocardia isolates were identified to 27 species levels, the majority originating from the respiratory tract (n=336, 81.2 %). N. nova (n=147, 35.5 %) was the most frequently isolated, followed by N. cyriacigeorgica (n=75, 18.1 %). Species distribution varied by isolate source, with N. farcinica and N. paucivorans found more commonly from sterile sites. Linezolid and amikacin had the highest proportion of susceptible isolates (100 and 99% respectively), while low susceptibility rates were detected for ceftriaxone (59 %) and imipenem (41 %). Susceptibility to trimethoprim sulfamethoxazole varied by species (0-100 %).Conclusion. This is the largest study to date in Australia of Nocardia species distribution and antimicrobial susceptibility patterns. N. farcinica and N. paucivorans were more likely to be isolated from sterile sites, while N. brasiliensis and N. otitidiscvarium were more likely to be isolated from skin and soft tissue. First line therapeutic antimicrobial recommendations by local guidelines were not necessarily reflective of the in vitro susceptibility of Nocardia isolates in this study, with high susceptibility detected for linezolid and amikacin, but poor susceptibility demonstrated for ceftriaxone and imipenem. Profiles for trimethoprim-sulfamethoxazole varied across different Nocardia species, warranting ongoing susceptibility testing for targeted clinical use.

Assessing patient understanding of their antimicrobial treatment: How are we doing and how might we improve?

BACKGROUND: The Antimicrobial Stewardship Clinical Care Standard states that patients should receive certain information about their antimicrobial therapy. How well the patient communication recommendations of the standard are followed in clinical practice is not well established. The aim of this pilot quality improvement study was to assess current practices around communication with hospitalised patients about their antimicrobial therapy, to determine compliance with current recommendations, and develop and implement quality improvement actions focused on patient communication for antimicrobial stewardship in Australia. METHODS: Adult inpatients receiving one or more antimicrobials for greater than 72 h were recruited. A survey was conducted to assess rates of compliance with requirements to inform patients about the indication, duration and potential side effects of current antimicrobial therapy; modes of delivery of information; and rates of patient satisfaction with the information provided. A paper-based survey was conducted on the general medical, infectious diseases, geriatric evaluation and management, and rehabilitation wards in a 500-bed tertiary Australian hospital. A sample size of 50 was determined as adequate for a baseline analysis of patient communication practices and the development of quality improvement resources and actions. Responses to categorical questions were analysed quantitatively, with additional feedback from patients was collated and analysed qualitatively. RESULTS: A total of 54 patients were surveyed. A majority (83%) of patients had been informed that they were taking antimicrobials, and, of these, 96% said they knew the indication, 18% were informed of potential side effects, and 36% knew the duration. Only 22% were informed of the review plan and 27% knew if antimicrobials would be continued on discharge. Written information was given to 11% of patients. Over half (62%) of patients either wanted more information or had concerns about their antimicrobial therapy. Patients reported difficulty in obtaining information. Fifty-eight percent of patients received antimicrobial information from doctors, 13% from nurses and 12% from pharmacists. CONCLUSIONS: This study identified gaps in communication with patients regarding in-hospital antimicrobial therapy, and highlighted the need for development and delivery of local quality improvement activities to address this gap.

A Case of Surreptitious Glargine Overdose Confirmed by Insulin Pharmacokinetic Time Curves.

CASE: A 49-year-old man presented with recurrent altered conscious state suggestive of encephalitis. This was followed by an episode of severe hypoglycemia requiring protracted intravenous glucose administration. Comparing the pharmacokinetic time curves of serum insulin levels on two insulin immunoassays with different insulin analog cross-reactivity allowed the likely diagnosis of surreptitious glargine overdose to be made rapidly. DISCUSSION: The differing insulin analog cross-reactivity of serum insulin immunoassays, in this case the Abbott ARCHITECT and Roche Elecsys, allows the presence of insulin analog to be detected. Through comparison of time curves the characteristic signature of the specific causative insulin analog can be identified. This information confirms surreptitious insulin overdose in a timely manner, therefore avoiding the expensive and time-consuming investigations required to exclude alternate causes of severe hypoglycemia.