Inadequate empiric antimicrobial therapy and mortality in geriatric patients with bloodstream infection: A target for antimicrobial stewardship.

BACKGROUND: Bloodstream infections are responsible for a large proportion of deaths among geriatric patients. Japan is a rapidly aging society; however, little is known about the epidemiology of bloodstream infections in geriatric patients in Japanese institutions. METHODS: We conducted a retrospective cohort study of patients aged ≥65 years old with a bloodstream infection in a Japanese tertiary care hospital in 2013. We defined inadequate empiric antimicrobial therapy as either antimicrobial treatment that was ineffective against subsequently isolated organisms or treatment initiated after notification of a positive culture. Predictors of inadequate antimicrobial therapy and 30-day mortality among geriatric patients with bloodstream infections were evaluated. RESULTS: We identified 275 patients with a bloodstream infection, of which 42.2% of cases (116/275) were healthcare-associated, hospital-onset. The most common source of bloodstream infection was hepatobiliary (28.0%). Inadequate empiric antimicrobial therapy occurred in 29.8% of the patients. Factors associated with inadequate empiric therapy included a history of surgery prior to bloodstream infection during index hospitalization (adjusted odds ratio [aOR] 3.27; 95% confidence interval [CI] 1.18-9.12). In 275 patients, 38 (13.8%) died within 30 days after the first positive blood culture. Predictors of 30-day mortality was Pitt bacteremia score >6 (aOR 9.80; 95% CI 4.72-20.36). CONCLUSION: Inadequate empiric antimicrobial therapy occurred in approximately one-third of episodes of bloodstream infection in geriatric patients. Severity at the time of bloodstream infection was likely to have contributed to mortality. The initiation of adequate empiric antimicrobial therapy may have important implications for antimicrobial stewardship even in the elderly population.

Cervical Stenosis After Hysteroscopic Surgery for Cesarean Scar Disorder.

Cesarean scar disorder (CSDi) is a newly recognized cause of secondary infertility. Laparoscopic or hysteroscopic surgery is generally chosen for the surgical treatment of CSDi, depending on the residual myometrial thickness of the cesarean scar. Previously, hysteroscopic transcervical resection for CSDi (TCR-CSDi) has been reported to be a safe procedure, with no cases of postoperative cervical stenosis. Herein, we report a novel case of cervical stenosis after circumferential hysteroscopic TCR-CSDi of an extensive CSDi lesion. Notably, although no cervical stenosis was observed upon postoperative hysteroscopy one month postoperatively, cervical stenosis developed four months after the surgery; therefore, it is important to avoid circumferential resection and cauterization in patients with CSDi, even when abnormal blood vessels are present. Additionally, it is advisable to check for delayed cervical stenosis at least three weeks before embryo transfer in patients who have undergone TCR-CSDi.

Effect of Uterine Weight on the Surgical Outcomes of Robot-Assisted Hysterectomy in Benign Indications.

Background Uterine weight is an important factor in determining the complexity of a hysterectomy. Although greater uterine weight increases operative time and blood loss in open or laparoscopic surgery, it remains uncertain whether this applies to robot-assisted hysterectomy. This study aimed to investigate the effect of uterine weight on the surgical outcomes of robot-assisted hysterectomy. Methods We conducted a retrospective cohort study involving 872 patients who underwent robot-assisted hysterectomies at our institution between January 2019 and June 2022. Of these, 724 cases were analyzed and classified into four groups based on uterine weight: <250 g (377 patients), 250-500 g (253 patients), 500-750 g (69 patients), and ≥750 g (25 patients). We performed univariate analysis with the following endpoints: operation time, blood loss, postoperative hospital stay, complication rate, conversion to laparotomy rate, and blood transfusion rate. Results Operating time and blood loss increased significantly with greater uterine weight in the four groups (both p-values <0.01), but postoperative hospital stay and complication rate did not increase (p = 0.448, p = 0.679, respectively). None of the patients underwent conversion to laparotomy or blood transfusion. Conclusion Although the operating time for robot-assisted hysterectomy and blood loss increased with greater uterine weight, the complications and length of postoperative hospital stay were similar between groups. Robot-assisted hysterectomy is safe in cases of much uterine weight.

A Cross-Sectional Study on Whether Comprehensively Gathering Information From Medical Records Is Useful for the Collection of Operational Characteristics.

This study tests whether comprehensively gathering information from medical records is useful for developing clinical decision support systems using Bayes' theorem. Using a single-center cross-sectional study, we retrospectively extracted medical records of 270 patients aged ≥16 years who visited the emergency room at the Tokyo Metropolitan Tama Medical Center with a chief complaint of experiencing headaches. The medical records of cases were analyzed in this study. We manually extracted diagnoses, unique keywords, and annotated keywords, classifying them as either positive or negative. Cross tables were created, and the proportion of combinations for which the likelihood ratios could be calculated was evaluated. Probability functions for the appearance of new unique keywords were modeled, and theoretical values were calculated. We extracted 623 unique keywords, 26 diagnoses, and 6,904 annotated keywords. Likelihood ratios could be calculated only for 276 combinations (1.70%), of which 24 (0.15%) exhibited significant differences. The power function+constant was the best fit for new unique keywords. The increase in the number of combinations after increasing the number of cases indicated that while it is theoretically possible to comprehensively gather information from medical records in this way, doing so presents difficulties related to human costs. It also does not necessarily solve the fundamental issues with medical informatics or with developing clinical decision support systems. Therefore, we recommend using methods other than comprehensive information gathering with Bayes' theorem as the classifier to develop such systems.

Trousseau's syndrome associated with an ovarian borderline tumour.

A 71-year-old woman was admitted to our hospital because of sudden onset of weakness on the left side of her body. Her medical history was unremarkable, and on physical examination, hemiparesis and hyperreflexia on the left side were found. MRI of the brain showed multiple areas of restricted diffusion in both parietal lobes and in the cerebellum, consistent with embolic shower. Magnetic resonance angiography showed no abnormal findings. A contrast-enhanced CT scan revealed multiple pulmonary emboli. Abdominal MRI showed a 135 mm left ovarian tumour composed of a solid and a cystic component with liquid level formation. After a total hysterectomy and bilateral adnexectomy, the histopathology confirmed a seromucinous borderline tumour. Therefore, the patient was diagnosed with Trousseau's syndrome associated with an ovarian seromucinous borderline tumour. To our knowledge, this is the first report mentioning a borderline ovarian tumour detected as Trousseau's syndrome.

Atypical Ramsay Hunt syndrome (zoster sine herpete) with otitis media.

A 21-year-old man presented with an acute onset of bilateral throbbing headache, left ear pain, tinnitus, and fever. There was no skin rash on his face. Otoscopy revealed hyperemia and exudate over the left tympanic membrane. The swab culture of the exudate grew methicillin-sensitive Staphylococcus aureus, and the patient was diagnosed as acute otitis media. Hearing loss and ipsilateral facial paralysis developed on hospital day 4. Despite the absence of typical bullous lesions, serology testing and polymerase chain reaction of the otic exudate for varicella-zoster virus were positive. The patient was finally diagnosed as zoster sine herpete.