Current management of Staphylococcus aureus bacteremia in a Japanese university hospital.

Objectives: Consultation with infectious disease specialists is associated with reduced patient mortality in the care of patients with Staphylococcus aureus bacteremia (SAB) through appropriate management of complications including infective endocarditis. This study aimed to determine the rates of confirmation of a negative blood culture, implementation of echocardiography, and administration of appropriate antibiotics in patients with SAB at a university hospital in Japan that provides general internal medicine and not an infectious disease consultation service. Methods: We conducted a retrospective cohort study at Dokkyo Medical University Hospital in Japan. Patients eligible for inclusion in the study were ≥20 years of age with ≥1 positive blood culture for S. aureus identified in a clinical microbiology laboratory. The primary outcome was the proportion of patients with confirmation of a negative blood culture, implementation of echocardiography, and administration of appropriate antimicrobial agents. Results: A total of 109 patients with SAB were included in the analysis. Follow-up blood cultures were collected in 91 patients and negative results were documented in 88 patients. Follow-up blood culture collection was performed within 4 days of the initial blood culture collection in 49 patients. Echocardiography was performed appropriately in 40 patients. Appropriate antibiotic therapy was administered in 36 patients. Conclusions: Quality-of-care indicators were more commonly implemented in patients with SAB who received general internal medicine consultation than in those who did not.

Survey of Inpatient Consultations with General Internal Medicine Physicians in a Tertiary Hospital: A Retrospective Observational Study.

Purpose: The general internal medicine (GIM) department can be an effective diagnostic coordinator for undiagnosed outpatients. We investigated the contribution of GIM consultations to the diagnosis of patients admitted to specialty departments in hospitals in Japan that have not yet adopted a hospitalist system. Patients and Methods: This single-center, retrospective observational study was conducted at a university hospital in Japan. GIM consultations from other departments on inpatients aged ≥20 years, from April 2016 to March 2021, were included. Data were extracted from electronic medical records, and consultation purposes were categorized into diagnosis, treatment, and diagnosis and treatment. The primary outcome was new diagnosis during hospitalization for patients with consultation purpose of diagnosis or diagnosis and treatment. The secondary outcomes were the purposes of consultation with the Diagnostic and Generalist Medicine department. Results: In total, 342 patients were included in the analysis. The purpose of the consultations was diagnosis for 253 patients (74%), treatment for 60 (17.5%), and diagnosis and treatment for 29 patients (8.5%). In 282 consultations for diagnosis and diagnosis and treatment, 179 new diagnoses were established for 162 patients (57.5%, 95% confidence interval [CI], 51.5-63.3). Conclusion: The GIM department can function as a diagnostic consultant for inpatients with diagnostic problems admitted to other specialty departments in hospitals where hospitalist or other similar systems are not adopted.

Effect of Prior Antibiotic Treatment on Blood Culture in an Outpatient Department of General Internal Medicine: A Retrospective Case-Control Analysis.

Purpose: The effect of antibiotics administered before blood cultures performed in general internal medicine outpatient settings is not well known. Patients and Methods: We conducted a retrospective case-control study including adult patients who underwent blood cultures in the general internal medicine outpatient department of a Japanese university hospital between 2016 and 2022. Patients with positive blood cultures were included as cases and matched patients with negative blood cultures were included as controls. Univariable and multivariable logistic regression analyses were performed. Results: A total of 200 patients and 200 controls were included. Antibiotics were administered prior to blood culture in 20% of patients (79/400). Oral antibiotics were prescribed to 69.6% of the prior antibiotics (55/79). Prior antibiotic use was significantly lower among patients with positive than negative blood cultures (13.5% vs 26.0%, p = 0.002) and was an independent predictive factor in univariable (odds ratio, 0.44; 95% confidence interval, 0.26-0.73; p = 0.002) and multivariable (adjusted odds ratio, 0.31; 95% confidence interval, 0.15-0.63; p = 0.002) logistic regression models for positive blood culture. The area under the receiver operating characteristic (AUROC) curve of the multivariable model for predicting positive blood cultures was 0.86. Conclusion: There was a negative correlation between prior antibiotic use and positive blood cultures in the general internal medicine outpatient department. Therefore, physicians should interpret the negative results of blood cultures performed after the administration of antibiotics with care.

Outcomes of General Internal Medicine Consultations for Diagnosis from Specialists in a Tertiary Hospital: A Retrospective Observational Study.

Purpose: The data on the diagnostic contribution of general internal medicine (GIM) consultations for undiagnosed health problems from specialists are scarce. This study aims to explore the role of generalists as diagnostic medicine consultants in tertiary care settings. Patients and Methods: We conducted a retrospective observational study at a Japanese university hospital. GIM consultations for diagnosis from other departments on outpatients aged ≧ 20 years from January 2018 to December 2020 were included. Data were extracted from electronic medical records. The primary outcome was new diagnosis rates. The secondary outcomes were new diagnosis rates with clinical significance and clinical outcomes at 90 days from the index visit. Results: A total of 328 patients were included. The top five consulting departments were orthopedics (17.0%), cardiovascular (10.3%), otorhinolaryngology (8.8%), neurology (8.8%), and gastroenterology (7.9%). GIM identified 456 chief complaints (CCs), and the top five were fever (10.9%), abnormal laboratory results (8.3%), fatigue (5.9%), and pain (7.4%) or numbness (4.6%) in the extremities. There were 139 (104/328 patients: 31.8%) specialty consultations from GIM, and the top five departments were rheumatology (21.1%), gastroenterology (19.2%), orthopedics (9.6%), psychiatry (9.6%), and neurology (9.6%). In total, 277 new diagnoses were established in 232 patients (70.7%), and 203 patients had new diagnoses with clinical significance (61.8%). Clinical outcomes at 90 days from the time of the index visit were resolution/improvement (60.7%), unchanged/worsened (22.3%), and unknown (17.0%). Conclusion: Over 70% of GIM consultations from other departments established new diagnoses with favorable outcomes in >60% of the patients.

Association of Repeated Blood Cultures With Mortality in Adult Patients With Gram-Negative Bacilli Bacteremia: A Systematic Review and Meta-analysis.

Background: Performing repeat blood cultures after an initial positive culture (ie, follow-up blood cultures [FUBCs]) in patients with gram-negative bacilli (GNB) bacteremia is controversial. We aimed to comprehensively review the association of FUBCs with improvement in patient-relevant clinical outcomes in GNB bacteremia. Methods: We performed a systematic review and random-effects meta-analysis to calculate summary effect estimates. We used hazard ratios as the effect measure. The primary outcome was 30-day or in-hospital mortality, and secondary outcomes were length of treatment and length of hospital stay. We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials (Central) without language restrictions from inception to April 29, 2022. Original clinical studies evaluating the association between FUBCs and mortality in adult patients with GNB bacteremia were included. FUBC details were reviewed. Two independent reviewers used the Risk of Bias in Non-randomised Studies of Interventions tool. Results: We identified 9 eligible retrospective studies. In total, 7778 hospitalized patients with GNB bacteremia were included. The studies were clinically heterogeneous and had a critical risk of bias. The utilization of FUBCs varied across studies (18%-89%). Random-effects meta-analysis of covariate-adjusted estimates found that FUBC use was associated with reduced mortality. Although not a result of the meta-analysis, lengths of treatment and hospital stay were longer for patients with FUBCs than for those without. Adverse events were not reported. Conclusions: FUBC acquisition was associated with lower mortality and longer hospital stay and treatment duration in GNB bacteremia. The risk of bias was critical, and no firm data were available to support mechanisms.

Relapsing Hypoglycemia Associated with Hypocarnitinemia Following Treatment with Cefcapene Pivoxil in an Elderly Man.

Pivoxil-containing cephalosporins can result in symptomatic hypocarnitinemia in children. We herein report a case of an 85-year-old man at risk of carnitine deficiency who developed relapsing symptomatic hypoglycemia after treatment with cefcapene pivoxil for urinary tract infection. On admission, laboratory tests showed low blood carnitine concentrations with low normal blood ketone levels. The patient was successfully treated by the oral administration of levocarnitine and dietary modification, including aggressive consumption of meat and dairy products, and remained symptom-free for nine months after the correction of carnitine concentrations. Healthcare providers should be cautious when prescribing pivoxil-containing antimicrobials to patients at high risk of hypocarnitinemia.

Hypercalcaemia caused by active pulmonary tuberculosis in an elderly person without fever or pulmonary symptoms.

Many diseases can cause hypercalcaemia, including primary hyperparathyroidism, cancer, drugs and granulomatous diseases. A nursing home resident aged 81 years was admitted because of altered mental status. The patient did not have fever, cough, sputum or night sweat. Hypercalcaemia was identified as a cause of the consciousness disturbance. Chest radiograph showed no acute process. Laboratory workups revealed elevated serum levels of 1,25-(OH)2 vitamin D3 and positive T-spot test. Microscopic examination of the suctioned sputum identified acid-fast bacilli, which was confirmed as Mycobactrium tuberculsosis Tuberculosis should be considered as the important cause of hypercalcaemia since early diagnosis and treatment is recommended for preventing its outbreak among people with close contacts with patients.

A disclosed diagnosis for 24 year's unknown illness.

IgG4-related disease (IgG4-RD) is a newly described illness over the last several years. A 57-year-old man, who had been followed for chronic kidney disease (CKD), chronic pancreatitis and history of operated cholangitis, was admitted to our hospital for abdominal pain and worsening renal function. Serum levels of IgG and IgG4 were elevated. CT scan showed the characteristic findings of IgG4-related retroperitoneal fibrosis, pancreas and kidney disease. An endoscopic biopsy revealed the finding compatible with IgG4-RD. Steroid therapy led to the remission of his abdominal pain. Patients with CKD of unknown aetiology may have IgG4-RD.