Antibiotic prescribing patterns for adult urinary tract infections within emergency department and urgent care settings.

Urinary tract infections (UTI) are a common reason for emergency department (ED) and urgent care (UC) visits. Fluoroquinolones (FQ) are frequently prescribed for treatment of UTI in the outpatient setting; however, data evaluating prescribing patterns after FDA safety warnings is limited, especially in UC. The study goal was to investigate and compare antimicrobial prescribing for UTIs in a single-site ED and an off-site UC in an urban, academic health system. This retrospective study included patients presenting with a UTI to the ED or UC between January and June 2018. Those 18 years or older with uncomplicated, complicated UTI, or pyelonephritis were included. Exclusion criteria were catheter-related UTI, urinary tract abnormalities, immunocompromised, or hospitalization. Primary outcome was FQ prescribing rate for all UTI in the ED and UC. Secondary outcomes were rates of non-FQ prescribing, re-presentation, bug-drug mismatch, and treatment durations. 184 patients were included. FQ prescribing rate was similar in ED and UC (21.2% vs. 16.3%, p = 0.4). Non-FQs prescribed in ED and UC were nitrofurantoin (20.2% vs 53.6%), beta-lactams (46.1% vs 22.6%), and trimethoprim/sulfamethoxazole (12.5% vs. 5%). A longer than recommended duration was identified in 46.3% UC patients compared to 21.2% ED patients. Thirty-day re-presentation with persistent UTI symptoms occurred more frequently in the ED compared to UC (13.5% vs. 7.5%). Predictors of FQ prescribing on logistic regression were male, recurrent UTI, and malignancy. FQ prescribing rate for UTI treatment was low with no difference between ED and UC. Opportunity exists to improve treatment duration and antimicrobial choice.

Association Between CD4+, Viral Load, and Pulmonary Function in HIV.

PURPOSE: The antiretroviral therapy era has shifted the epidemiology of HIV-associated diseases, increasing the recognition of non-infectious pulmonary complications secondary to HIV. We aimed to determine the association between CD4+, viral load, and pulmonary function in individuals with uncontrolled HIV, and determine how changes in these parameters are associated with pulmonary function longitudinally. METHODS: This is a retrospective observational study of individuals with HIV who underwent pulmonary function testing in an urban medical center between August 1997 and November 2015. RESULTS: Of the 146 participants (mean age 52 ± 10 years), 49% were Hispanic, 56% were men, and 44% were current smokers. CD4+ <200 cells/µl was associated with significant diffusion impairment compared to CD4+ ≥200 cells/µl (DLCO 56 vs. 70%, p = <0.01). VL (viral load) ≥75 copies/ml was associated with significant diffusion impairment compared to VL <75 copies/ml (DLCO 60 vs. 71%, p = <0.01). No difference in FEV1, FEV1/FVC, or TLC was noted between groups. In univariate analysis, CD4+ and VL correlated with DLCO (r = +0.33; p = <0.01; r = -0.26; p = <0.01) and no correlation was noted with FEV1, FEV1/FVC, or TLC. Current smoking and history of AIDS correlated with DLCO (r = -0.20; p = 0.03; r = -0.20; p = 0.04). After adjusting for smoking and other confounders, VL ≥75 copies/ml correlated with a 11.2 (CI 95% [3.03-19.4], p = <0.01) decrease in DLCO. In Spearman's Rank correlation, there was a negative correlation between change in VL and change in DLCO over time (ρ = -0.47; p = <0.01). CONCLUSION: The presence of viremia in individuals with HIV is independently associated with impaired DLCO. Suppression of VL may allow for recovery in diffusing capacity over time, though the degree to which this occurs requires further investigation.

Fulminant ecchymosis as the initial manifestation of antiphospholipid syndrome (APS) triggered by respiratory syncytial virus (RSV) infection: A case report and review of the literature.

We present a unique and informative instance of respiratory syncytial virus (RSV) infection associated with antiphospholipid syndrome (APS), and discuss this case in the context of the literature addressing the immunopathogenesis of APS associated with diverse infections. We describe the case of a 43-year-old man with no significant past medical history who presented with the acute onset of fever, hemoptysis, and extensive bullous, ecchymotic lesions in both lower extremities. Punch biopsy of the lesion demonstrated thrombotic vasculopathy. Further evaluation revealed serum antiphospholipid antibodies as well as a positive RSV PCR in a nasal swab specimen. Clinical manifestations, positive laboratory and pathological findings were strongly suggestive of APS associated with a recent RSV infection. When an infectious etiology is considered for APS, RSV should also be included in the differential diagnosis.

Pseudomonas bacteremia as an initial presentation of SLE.

Infections have been commonly implicated in lupus relapses and in some cases as initiating the diagnostic work up of systemic lupus erythematosus (SLE). We describe here the case of a young patient who presented with Pseudomonas aeruginosa bacteremia and was found to have a new diagnosis of SLE. 53% of patients with active SLE and abdominal pain have intestinal vasculitis. These vasculitic changes can cause intestinal ischemia with consequent translocation of pathogens from the gastrointestinal tract to the bloodstream causing sepsis.

Nested case-control study of the emergence of tigecycline resistance in multidrug-resistant Klebsiella pneumoniae.

We performed a nested case-control study (ratio of 1:4) on the emergence of tigecycline-resistant multidrug-resistant Klebsiella pneumoniae (TR-MDRKP) isolates among patients who initially presented with a tigecycline-susceptible MDRKP isolate. Out of 260 patients, 24 (9%) had a subsequent clinical culture positive for a TR-MDRKP isolate within the 90-day follow-up period. On logistic regression analyses, receipt of tigecycline (adjusted odds ratio [OR], 5.06; 95% confidence interval [CI], 1.80 to 14.23; P = 0.002) was the only independent predictor of subsequent isolation of a TR strain.