Investigating and Treating a Corneal Ulcer Due to Extensively Drug-Resistant Pseudomonas aeruginosa.

Resistant Gram-negative bacteria are a growing concern in the United States, leading to significant morbidity and mortality. We identified a 72-year-old female patient who presented with unilateral vision loss. She was found to have a large corneal ulcer with hypopyon. Culture of corneal scrapings grew extensively drug-resistant Pseudomonas aeruginosa. Treatment involved a combination of systemic and topical antibiotics. Whole genome sequencing revealed the presence of blaVIM-80, blaGES-9, and other resistance determinants. This distinctive organism was linked to an over-the-counter artificial tears product.

Candida spp. infective endocarditis: Characteristics and outcomes of twenty patients with a focus on injection drug use as a predisposing risk factor.

BACKGROUND: Candida spp. infective endocarditis (CIE) although rare is associated with high morbidity and mortality. Risk factors include prosthetic heart valves and injection drug use (IDU). We reviewed all cases of CIE at our institution to describe the microbiology, treatment and outcomes of patients focusing on IDU as a predisposing factor. METHODS: Retrospective cohort of patients with definite CIE between 2013 and 2019 at a university hospital was analysed. Demographic data collected included IDU, microbiologic, treatment and mortality. The primary outcome of interest was 12-month, all-cause mortality. RESULTS: Twenty patients were included (one had two separate episodes of CIE); CIE accounted for 4% of total infective endocarditis (IE) cases during the study period. The median (IQR) age was 38 (30-58) years, 10 (50%) had a previous history of IE, and 4 (20%) patients had prosthetic heart valves or an implanted cardiac device. Thirteen (65%) patients were IDU. The tricuspid valve was the primary valve involved (8/18, 44%), and C albicans was the most frequently isolated organism (8, 36%). Echinocandin was the most common treatment strategy (8, 40%). Only three (15%) patients underwent valve replacement during hospitalisation. There were no in-hospital fatalities, and 5 (25%) patients died at one year; all were IDU (39% to 0%, p = .11). CONCLUSION: CIE is a rare infectious disease seen more commonly in the IDU population. Cardiac surgery was rarely performed, and long-term mortality was 25%. Additional data are needed to identify ideal management strategies in this population.

Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis.

Objective: Empiric broad-spectrum antibiotic therapy is commonly prescribed for patients hospitalized with diabetic foot infections (DFI) and lower extremity osteomyelitis (OM). The primary objective was to evaluate the concordance between empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy with a focus on methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. The secondary objective was to evaluate the negative predictive values (NPV) of select risk factors for MRSA and resistant gram-negative organisms for microbiologic results with these organisms. Design: Retrospective cohort study. Setting: Safety-net health system in Ohio. Patients: Adults hospitalized and receiving antibiotic therapy for DFI or lower extremity OM in 2021. Results: For 259 unique patients, empiric therapies with activity against MRSA and resistant gram-negative organisms were administered to 224 (86.5%) and 217 (83.8%) patients, respectively. Definitive therapies with activity against MRSA and resistant gram-negative organisms were administered to 91 (35%) and 74 (28.6%) patients, respectively. Of 234 patients with microbiologic testing, 29 (12.4%) had positive cultures with MRSA and 41 (17.5%) with resistant gram-negative organisms. The NPVs of risk factors for MRSA and resistant gram-negative organisms for the absence of these organisms in culture were 91% and 85%, respectively. Conclusions: For patients hospitalized with DFI and lower extremity OM, our data suggest opportunities for substantial reductions in empiric therapies with activity against MRSA and resistant gram-negative organisms. The absence of risk factors for these organisms was reasonably good at predicting negative cultures with these organisms.

Percutaneous Mechanical Aspiration vs Valve Surgery for Tricuspid Valve Endocarditis in People Who Inject Drugs.

BACKGROUND: Valve surgery in tricuspid valve infective endocarditis (TVIE) is controversial in people who inject drugs (PWID) due to perceived risks of reinfection because of recidivism. The study objective was to compare outcomes of percutaneous mechanical aspiration (PMA) using the Penumbra Indigo system to valve surgery in PWID with TVIE. METHODS: Retrospective cohort of adult PWID hospitalized with definite TVIE and received PMA or valve surgery from January 2014 to April 2019. Primary endpoint was all-cause 12-month mortality; secondary endpoints included in-hospital mortality and all-cause 12-month readmission. RESULTS: In total, 85 patients were included: 42 undergoing PMA and 43 undergoing valve surgery. Baseline patient demographics were similar between groups; 62 (73%) patients were women, and the median age was 31 (interquartile range, 27-41) years. Seventy-four (86%) patients had a previous history of infective endocarditis and received long-term antibiotic therapy before surgical intervention; 33 (38%) patients presented with septic shock on admission. The most commonly organism was methicillin-resistant Staphylococcus aureus (n = 32 of 84, 38%). Five (12%) PMA patients died in hospital compared with 1 (2%) patient who received valve surgery (P = .11). All-cause 12-month mortality was 24% and 19% for the PMA and surgery groups, respectively (P = .57). When considering confounders, there was no difference in all-cause 12-month mortality between the PMA and valve surgery groups (adjusted odds ratio, 1.5; 95% confidence interval, 0.48-4.8); no significant differences in secondary outcomes were identified. CONCLUSIONS: PMA was associated with similar outcomes to valve surgery for management of TVIE in PWID. PMA may be an alternative to valve surgery as a treatment or bridging strategy to surgery while PWID undergo addiction treatment.

Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis.

BACKGROUND: Sepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period. METHODS: This was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission. RESULTS: Twenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25-33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23-34) weeks' gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications. CONCLUSIONS: Injection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

Pseudomonas aeruginosa Corneal Ulcer Associated With Artificial Tears Eye Drops.

This case report describes vision loss in a 72-year-old woman following use of EzriCare eye drops.