Renal actinomycosis with muscular invasion post-nephrostomy tube placement.

Perinephric abscesses are a rare complication of nephrostomy tube placement. There are several aerobic bacteria that are common culprits of abscess formation. Here we describe a novel report of a perinephric abscess due to Actinomyces odontolyticus. We describe the presentation of illness, imaging and clinical findings, and the prolonged treatment course needed for this medically complex patient.

A case of Cryptococcus gattii infection in South Carolina: A possible challenge to known endemicity.

In the United States, C. gattii is considered to be endemic to the Pacific Northwest and although uncommon, additional cases have been documented in other regions including the Southeastern United States. While it has been hypothesized in the past that C. gattii may be endemic to the Southeastern United States, there remains a paucity of evidence. Here, we present a patient with no history of HIV/AIDS and no organ transplant and document the course of his disease and presentation. There were no adverse long-term neurological outcomes in this patient and the combination of steroid use, antifungal agents, and cerebrospinal fluid drainage resulted in his discharge from the hospital after 12 days. This patient's subacute presentation with vague neurological symptoms highlights the importance of understanding the treatment of rare causes of meningitis.

Cryptococcal lung disease.

PURPOSE OF REVIEW: Cryptococcosis is an important opportunistic fungal infection, especially in the immunocompromised patient. Meningitis is the most common manifestation of cryptococcosis; however, cryptococcal lung disease is probably underdiagnosed, and knowledge of epidemiology, diagnosis, and treatment is necessary. RECENT FINDINGS: Cryptococcal lung disease ranges from asymptomatic colonization or infection to severe pneumonia with respiratory failure. Clinical presentation of pulmonary cryptococcosis is highly variable and often is related to the immune status of the patient. There have been many important clinical trials outlining treatment of cryptococcal meningitis in patients with AIDS, but there is a lack of treatment data available for patients with cryptococcal lung disease. Treatment recommendations for cryptococcal lung disease are made on the basis of host immune status and severity of clinical illness. For less severe disease, fluconazole therapy is recommended. In immunocompromised patients, or those with severe disease, induction therapy with an amphotericin B preparation and flucytosine, followed by fluconazole as consolidation and maintenance therapy, is recommended. SUMMARY: Cryptococcal lung disease is an important and probably underdiagnosed infection. Knowledge of the epidemiology, diagnostic methodologies, and treatment is needed to ensure good patient outcomes.

A prospective evaluation of an algorithm incorporating routine preoperative endoscopic ultrasound-guided fine needle aspiration in suspected pancreatic cancer.

BACKGROUND: Whether tissue diagnosis is required in the preoperative evaluation of patients with suspected pancreatic cancer remains controversial. We prospectively evaluated the accuracy, safety, and potential impact on surgical intervention of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the preoperative evaluation of suspected pancreatic cancer. METHODS: All patients who underwent EUS-FNA at our institution (n = 547) over a 4.5-year period were enrolled. Patients underwent surgical exploration and resection based on their comorbidity status, evidence of resectability based on spiral computed tomography (CT) and EUS imaging reviewed in a multidisciplinary approach. RESULTS: Of 547 patients enrolled (median age 64 years, 60% male), 49% presented with obstructive jaundice. The operating characteristics of EUS-FNA of solid pancreatic masses were: sensitivity 95% (95% CI: 93.2-95.4), specificity 92% (95% CI: 86.6-95.7), positive predictive value 98% (95% CI: 97-99), negative predictive value 80% (95% CI: 74.9-82.7). The overall accuracy of EUS-FNA was 94.1% (95% CI: 92.0-94). Of the 414 true positive patients by EUS-FNA, 138 (33%) were explored. Of patients deemed operable by combined imaging, 42% had surgical resection. Eighty-two percent of true positive patients were ultimately found inoperable and received palliative therapy or chemotherapy. Of the 94 patients with true negative cytology based on extended follow-up, only 7 (7%) underwent surgical resection. Of those with false negative diagnoses (n = 24), 5 patients underwent exploration/resection based on detection of mass lesions by EUS. The remaining patients had unresectable disease. Mild self-limiting pancreatitis occurred in (0.91%). CONCLUSIONS: EUS-FNA is a safe and highly accurate method for tissue diagnosis in suspected pancreatic cancer. This approach allows for preoperative counseling of patients, minimizing surgeon's operative time in cases of unresectable disease, and avoids surgical biopsies in the majority of patients with inoperable disease. In addition, it allows for conservative management of patients with benign biopsies. We still, however, recommend exploration of patients with clinical scenario suspicious for pancreatic cancer, a mass found on EUS or CT, but inconclusive or negative cytology.

Association between vancomycin-resistant Enterococci bacteremia and ceftriaxone usage.

OBJECTIVE: Vancomycin-resistant enterococci (VRE) have become a public health concern with implications for patient mortality and costs. Hospital antibiotic usage may impact VRE incidence, but the relationship is poorly understood. Animal investigations suggest that ceftriaxone may be associated with VRE proliferation. We measured antimicrobial usage and VRE bloodstream infection (VRE-BSI) incidence to test our hypothesis that increased ceftriaxone usage would be associated with a higher incidence of VRE-BSI. DESIGN: Retrospective cohort study. SETTING: University of Alabama at Birmingham Medical Center, a 900-bed urban tertiary care hospital. PARTICIPANTS: All patients admitted during the study period contributed data. METHODS: We conducted a retrospective analysis of antimicrobial usage and VRE-BSI from 2005 to 2008 (43 months). Antimicrobial usage was quantified as days of therapy (DOTs) per 1,000 patient-days. VRE-BSI incidence was calculated as cases per 1,000 patient-days. Negative binomial regression with adjustment for correlation between consecutive observations was used to measure the association between antimicrobial usage and VRE-BSI incidence at the hospital- and care-unit levels. RESULTS: VRE-BSI incidence increased from 0.06 to 0.17 infections per 1,000 patient-days. Hospital VRE-BSI incidence was associated with prior-month ceftriaxone DOTs (incidence rate ratio, 1.38 per 10 DOTs; P = .005). After controlling for ceftriaxone, prior-month cephalosporin usage (class) was not predictive of VRE-BSI (P = .70). Similarly, prior-month usage of piperacillin-tazobactam, ceftazidime, cefepime, cefazolin, or vancomycin was not predictive of VRE-BSI when considered individually (P≥ .4 for all comparisons). The final model suggests that type of intensive care unit was related to VRE-BSI incidence. CONCLUSIONS: Ceftriaxone usage in the prior month, but not cephalosporin (class) or vancomycin usage, was related to VRE-BSI incidence. These findings suggest that an antimicrobial stewardship program that limits ceftriaxone may reduce nosocomial VRE-BSI incidence.

A quality assessment tool for tuberculosis control activities in resource limited settings.

Tuberculosis (TB) is a significant problem, infecting nearly 9 million new patients per year and killing about 2 million a year. The primary means with which to affect TB globally are to decrease transmission locally, mainly by effective identification, diagnosis, and treatment of infectious TB patients. Therefore, quality assurance of TB control efforts at the local level is essential. This study describes the creation of a data extraction tool for retrospective chart review based on the International Standards for TB Care, 2009 for the assessment of TB control programs located in resource limited settings. The tool was field tested at a rural mission hospital in central Kenya. Results were used by host site staff to develop a quality improvement plan. The process prompted revision of the tool to clarify questions and answers. This is a tool that can be used in resource limited settings for data collection to assess the quality of TB care and to inform the design, implementation, and further assessment of future quality improvement initiatives.