An evaluation of antimicrobial prophylaxis for transrectal prostate biopsies: A potential stewardship target.

BACKGROUND: Transrectal prostate biopsy (TRPB) is a common procedure used to obtain a prostate biopsy. Although generally safe, complications may occur including infection. Preprocedural antimicrobial prophylaxis is recommended to minimize risk of subsequent infection. METHODS: This study is a retrospective chart review via the computerized patient record system from January 1, 2018 to February 28, 2022. The study included patients who underwent a TRPB at the Western New York, Syracuse, or Albany Stratton Veterans Affairs Healthcare Systems. RESULTS: This study included a total of 932 patients who underwent TRPB. Postoperative infection occurred in 3.2% (n = 30) of patients within 14days of the TRPB. Of the 30 patients who developed an infection, 30% (n = 9) resulted in bacteremia. For the 932 patients evaluated, 24 different antibiotic regimens were used, none of which followed guideline recommendations. None of the regimens were found to have an impact on rates of subsequent infection. CONCLUSIONS: The results of this study suggest a need for guideline adherence. There was no benefit to using the guideline-discordant regimens as they were not associated with a decreased risk of infection, and in many cases exposed patients to unnecessarily broad and prolonged antibiotic regimens.

Smoking status related to Covid-19 mortality and disease severity in a veteran population.

INTRODUCTION: Cigarette smoking is associated with development of significant comorbidities. Patients with underlying comorbidities have been found to have worse outcomes associated with Coronavirus Disease 2019 (Covid-19). This study evaluated 30-day mortality in Covid-19 positive patients based on smoking status. METHODS: This retrospective study of veterans nationwide examined Covid-19 positive inpatients between March 2020 and January 2021. Bivariate analysis compared patients based on smoking history. Propensity score matching adjusted for age, gender, race, ethnicity, Charlson comorbidity index (0-5 and 6-19) and dexamethasone use was performed. A multivariable logistic regression with backwards elimination and Cox Proportional Hazards Ratio was utilized to determine odds of 30-day mortality. RESULTS: The study cohort consisted of 25,958 unique Covid-19 positive inpatients. There was a total of 2,995 current smokers, 12,169 former smokers, and 8,392 non-smokers. Death was experienced by 13.5% (n = 3503) of the cohort within 30 days. Former smokers (OR 1.15; 95% CI, 1.05-1.27) (HR 1.13; 95% CI, 1.03-1.23) had higher risk of 30-day mortality compared with non-smokers. Former smokers had a higher risk of death compared to current smokers (HR 1.16 95% CI 1.02-1.33). The odds of death for current vs. non-smokers did not significantly differ. CONCLUSION: Compared to veteran non-smokers with Covid-19, former, but not current smokers with Covid-19 had a significantly higher risk of 30-day mortality.

Successful cure of daptomycin-non-susceptible, vancomycin-intermediate Staphylococcus aureus prosthetic aortic valve endocarditis directed by synergistic in vitro time-kill study.

Infectious complications following surgical valve replacements are extremely difficult to treat, often requiring prolonged antimicrobials therapy with or without surgery. Vancomycin-intermediate Staphylococcus aureus is an infrequent pathogen, with an estimated prevalence of less than 0.3%, but presents even greater challenges. We report a case of successful cure of daptomycin-non-susceptible and vancomycin-intermediate Staphylococcus aureus prosthetic valve endocarditis using an eight-week course of combination antimicrobial therapy. Using time-kill study, the combination of daptomycin plus ceftaroline and rifampin resulted in a greater than 4 log reduction of bacterial growth at 24 hours. This antimicrobial combination was used for a total of eight weeks with a successful outcome.

Successful treatment of multidrug-resistant Pseudomonas aeruginosa pubic symphysis osteomyelitis with ceftolozane/tazobactam.

New antibiotic options are needed for the treatment of multidrug-resistant (MDR) Pseudomonas infections. We present a case of a man aged 64 years with a bladder fistula due to radiation, ultimately causing osteomyelitis of the pubic symphysis. Repeated antibiotic courses, without correcting the fistula, resulted in infection with MDR Pseudomonas aeruginosa. He was successfully treated for his osteomyelitis through cystectomy, aggressive debridement and a prolonged course of antimicrobials directed at the MDR Pseudomonas isolate.

Yersinia Enterocolitica Bacteremia in a Chronic, Mildly Iron-Overloaded Dialysis Patient.

OBJECTIVE: To report an unusual case of Yersinia enterocolitica in a chronic, mildly iron-overloaded dialysis patient lacking other typical risk factors for bacteremia, who was treated successfully with a third-generation cephalosporin as monotherapy for a short duration of treatment. CASE SUMMARY: A 76-year-old dialysis-dependent man developed Y. enterocolitica bacteremia after 8 days of hospitalization. One month prior to presentation, his ferritin level was mildly elevated at 571.5 ng/mL, while receiving both intravenous and oral iron supplements. On day 14 of hospitalization, his ferritin level was acutely increased to 885.8 ng/mL. No risk factors commonly associated with Yersinia were present. He was treated successfully with a 14-day course of intravenous ceftriaxone, with negative surveillance blood cultures 2 months after treatment. One year after the infection, there was no evidence of recurrence, despite reinitiation of intravenous iron therapy, albeit with lower ferritin levels. DISCUSSION: Y. enterocolitica is most commonly associated with patients receiving deferoxamine mesylate or those with iron overload, as the bacteria thrive in the presence of chelated iron. There has been limited experience with the use of third-generation cephalosporins as monotherapy for the treatment of Y. enterocolitica bacteremia; most of the data are from in vitro studies. Historical treatment choices have included aminoglycosides, doxycycline, trimethoprim/ sulfamethoxazole, and ciprofloxacin. Ceftriaxone was used in our patient because of the once-daily ease of administration, with complete resolution of bacteremia. Reinitiation of intravenous iron therapy, while keeping the ferritin levels below 300 ng/mL, allowed for treatment of his anemia without recurrence of infection. CONCLUSIONS: This is the first English-language case of a dialysis patient with mild iron overload leading to Y. enterocolitica, despite having no known risk factors for the infection. Treatment success was obtained after a 14-day course of intravenous ceftriaxone. Intravenous iron was restarted without recurrence of infection, underscoring the importance of monitoring iron status in chronic dialysis patients.

Octreotide for symptomatic treatment of diarrhea due to cytomegalovirus colitis.

OBJECTIVE: To report the improvement of diarrhea in a patient with cytomegalovirus (CMV) colitis who was treated with octreotide after failure of loperamide. CASE SUMMARY: An 84-year-old male presented with chronic diarrhea and CMV colitis; he had been experiencing protracted diarrhea since 2006. In October 2009 he failed a 21-day course of valgancyclovir 900 mg orally twice daily. Several months later, due to continuing diarrhea and progressive malnutrition, a colonoscopy and subsequent biopsy again showed CMV. In March 2010 he was started on a 28-day course of intravenous ganciclovir 130 mg daily. Three weeks into treatment he continued with copious amounts of diarrhea, with no relief from loperamide, which was titrated from 2 mg/day to 2 mg every 6 hours. On day 20 of ganciclovir treatment he was started on octreotide 50 µg subcutaneously every 8 hours; within a few days, the patient began to experience decreased stool frequency and consistency. He completed the full 28-day course of ganciclovir, with octreotide continuing unchanged, with much improvement in his diarrheal symptoms and improvement in appetite, nutritional status, and quality of life. DISCUSSION: Studies regarding the treatment of CMV colitis-associated diarrhea are scarce, and are typically limited to treating the underlying cause with antiviral medications and with the addition of antimotility agents. Three cases have been reported in the literature in which octreotide was used for the symptomatic treatment of diarrhea, none of which was refractory to loperamide. CONCLUSIONS: This is the first known case of a patient with chronic diarrhea due to CMV colitis that was unresponsive to loperamide, required protracted antiviral treatment (valgancyclovir and gancyclovir), and subsequently experienced relief by the use of octreotide 50 µg subcutaneously every 8 hours.