Executive Summary: 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults.

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults.

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

Contrasting patterns of viral load response in transplant recipients with BK polyomavirus DNAemia on leflunomide therapy.

BACKGROUND: Reduction in immunosuppression is considered the therapy of proven benefit for BKV infection in renal transplantation, but the use of leflunomide has also been reported. It was observed at this center that the patterns of viral load response while on leflunomide appear to fall into two distinct types. METHODS: Medical records of 22 kidney and kidney-pancreas recipients at a single center who received leflunomide therapy for BKV DNAemia were reviewed. Information was collected on demographics, BKV viral loads, other antiviral therapy, immunosuppressive drug levels and doses, adverse effects, and graft and patient outcomes. RESULTS: Eighteen of 22 cleared BKV viremia, and 12 of 22 had preserved allograft function; only two graft losses occurred in the screening era among leflunomide-treated patients. Two patterns of viral load reduction were observed, termed the "smooth" and the "zigzag" pattern, which differed in mean time to clear of BKV DNA (2.9 vs. 19.5 months, p = 0.0073). Graft preservation was correlated with lower serum creatinine (SCr) at the start of leflunomide therapy. CONCLUSIONS: Long courses and "zigzag" fluctuations in viral load can occur in patients who eventually clear BKV on leflunomide with preserved allograft function. Intermittent increases in viral load do not necessarily portend therapeutic failure. Although the utility of leflunomide is still debated in the transplant community, this information may be useful to clinicians who choose to use it in selected patients.

Patients with prosthetic joint infection on IV antibiotics are at high risk for readmission.

UNLABELLED: Due to the rise in prosthetic joint implantations, prosthetic joint infections (PJI) are increasing. Most PJI are treated outside the hospital setting via community-based parenteral antiinfective therapy (CoPAT) after initial surgical management, although little is reported about the short-term complications of CoPAT. We therefore ascertained the numbers of unanticipated readmissions, unplanned surgeries, and CoPAT complications within 12 weeks of hospital discharge in patients with PJI on CoPAT. We retrospectively reviewed the charts of 74 patients with PJI. Twenty-seven (73% of readmitted patients) were for unanticipated reasons within 12 weeks of hospital discharge; 16 (43% of readmitted) underwent an unplanned surgery. Nine patients (12% of total cohort) had CoPAT-related adverse events. Our data suggest patients with PJI on CoPAT represent a complex cohort that needs to be monitored closely for complications early after hospital discharge. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Reactive Arthritis.

Reactive arthritis is classified as a spondyloarthropathy. Current concepts of disease suggest an infectious trigger, followed by inflammatory arthritis. Several mechanisms have been proposed to explain the interaction of host susceptibility and microorganism. Diagnosis relies on a compatible clinical syndrome and microbiologic confirmation of the pathogen. Antibiotic therapy seems useful in Chlamydia-triggered arthritis. The role of antibiotics in arthritis triggered by enteric pathogens is less clear. The role of tumor necrosis factor alpha inhibitors in therapy is evolving. Many patients have a course limited to a few months, but others experience extraarticular disease and more prolonged courses.

Osteomyelitis.

Osteomyelitis is an ancient disease with varied pathophysiology. The several clinical syndromes associated with bone infection have specific clinical presentations and microbiology. Successful recognition and management of the disease requires a knowledge of these mechanisms and the organisms most common in each. Diagnosis is made by a combination of clinical examination, supportive blood testing, and appropriate radiography. With these elements in place, patient presentation can be placed in the framework of a staging system, which often helps to suggest the appropriate mix of antimicrobial and surgical therapies.

Systematic reviews of infectious diseases.

The World Wide Web provides ready access to a wealth of information on infectious diseases topics. Systematic reviews and practice guidelines help to focus that evidence with in-depth literature analysis of a specific question. These reviews are typically rigidly structured, often periodically updated, and include critical evaluation of available data. In this article, Web sites of organizations that publish systematic reviews and practice guidelines for infectious diseases are identified and reviewed with regard to ease of use, comprehensiveness, quality of information, and cost. Examples of information available in databases of practice guidelines and systematic reviews are provided. A hypothetical case is used to illustrate the use of electronic resources in evidence-based infectious diseases practice.

Staphylococcus aureus bacteremia: using echocardiography to guide length of therapy.

Echocardiography can help distinguish simple and uncomplicated bacteremias from true cases of infective endocarditis and guide the type and duration of antibiotic therapy in a more precise and cost-effective manner. Empiric long-term antibiotic therapy is no longer uniformly recommended for all cases of S aureus bacteremia, although experts disagree about the optimal length of therapy.

Antimicrobial stewardship at transition of care from hospital to community.

Mandatory infectious disease consultation for parenteral antimicrobials at hospital discharge resulted in avoiding postdischarge parenteral antimicrobials in 28% of patients. No emergency department visit or rehospitalization within 30 days for these patients was a consequence of parenteral antimicrobial avoidance. Antimicrobial stewardship at transition of care is effective in reducing unnecessary antimicrobial use.

Contribution of infectious disease consultation toward the care of inpatients being considered for community-based parenteral anti-infective therapy.

BACKGROUND: In the acute care setting in a multidisciplinary healthcare environment, the contribution of infectious disease (ID) specialists to overall patient care is difficult to measure. This study attempts to quantify the contribution of ID specialists when consulted for an activity specific to ID practice, community-based parenteral anti-infective therapy (CoPAT). METHODS: In February 2010, an electronic form for requesting ID consultations was introduced in the computerized provider order entry (CPOE) system at the Cleveland Clinic. This allowed for easy identification of ID consultations for CoPAT. Hospital records for all patients with CoPAT consultation requests between February 11, 2010 and May 15, 2010 were reviewed for specific defined contributions in the domains of optimization of antimicrobial therapy, significant change in patient assessment, and additional medical care contribution. RESULTS: Over a 3-month period, there were 263 CoPAT consultation requests via CPOE, of which 172 were initial consultations and 91 reconsultations. Antimicrobial treatment was optimized in 84%, a significant change in patient assessment made in 52%, and additional medical care contribution provided in 71% of consultations. In 33% of consultations, there was contribution in all 3 domains. CoPAT was deemed not to be necessary in 27%. For patients requiring CoPAT, effective care transition from the inpatient to outpatient setting was assured at least 86% of the time. CONCLUSION: Infectious disease consultation before discharge on parenteral antibiotics adds value by contributing substantially to inpatient care, and providing antimicrobial stewardship and continuity of care at a critical patient care transition point.

Nontuberculous mycobacterial blood stream and cardiac infections in patients without HIV infection.

Nontuberculous mycobacteria rarely cause bacteremia in HIV-negative patients. We describe 16 cases, including the first Mycobacterium neoaurum endocarditis. Nine cases were line related. Most patients were immunocompromised secondary to hematologic malignancy or other comorbid conditions. Amikacin had the most reliable in vitro activity. Combination therapy was frequently used. Mortality was 25%.

A case of zygomycosis and invasive candidiasis involving the epiglottis and tongue in an immunocompromised patient.

Invasive fungal infections are associated with high morbidity and mortality in immunocompromised patients. We describe an unusual case of concomitant invasive candidiasis and zygomycosis of the tongue and epiglottis that occurred in a young patient with neutropenia during chemotherapy for acute myelogenous leukemia and was successfully treated medically.