Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria.

Background: Prior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a syringe bolus push. However, intravenous drip infusions subsequently became the standard of care. Puerto Rico is the largest supplier of IV fluid bags and in the aftermath of Hurricane Maria, there was a nationwide fluid bag shortage. This shortage required stewardship measures to maintain the operation of the self-administered outpatient parenteral antimicrobial therapy (OPAT) program at Parkland Health. Methods: Parkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV syringe bolus push (IVP) instead of an IV-drip infusion. Medications deemed appropriate were transitioned to IVP. The hospital EMR was used to identify patients discharged to the OPAT clinic using all methods of parenteral drug delivery. Data was collected for patient demographics, patient satisfaction, and clinical outcomes. Finally cost of care was calculated for IVP and IV drip administration. Results: One-hundred and thirteen self-administered IVP and 102 self-administered IV drip treatment courses were identified during the study period. Individuals using IVP had a statistically significant decrease in hospital length of stay. Patient satisfaction was greater with IVP and IVP saved 504 liters of normal saline resulting in a savings of $43,652 over 6 months. The 30-day readmission rate and mortality were similar. Conclusion: The abrupt IV fluid shortage following a natural disaster led to implementation of a high value care model that improved efficiency, reduced costs, and did not affect safety or efficacy.

Characteristics and Outcomes of Infectious Diseases Electronic COVID-19 Consultations at a Multisite Academic Health System.

Objective The need for clinicians to access Infectious Diseases (ID) consultants for clinical decision-making support increased during the Coronavirus Disease 2019 (COVID-19) pandemic. Traditional ID consultations with face-to-face (FTF) patient assessments are not always possible or practical during a pandemic and involve added exposure risk and personal protective equipment (PPE) use. Electronic consultations (e-consults) may provide an alternative and improve access to ID specialists during the pandemic. Methods We implemented ID e-consult platforms designed to answer clinical questions related to COVID-19 at three academic clinical institutions in Dallas, Texas. We conducted a retrospective review of all COVID-19 ID e-consults between March 16, 2020 and May 15, 2020 evaluating characteristics and outcomes of e-consults among the clinical sites. Results We completed 198 COVID-19 ID e-consults at participating institutions. The most common e-consult indications were for 63 (32%) repeat testing, 61 (31%) initial testing, 65 (33%) treatment options, and 61 (31%) Infection Prevention (IP). Based on the e-consult recommendation, 53 (27%) of patients were initially tested for COVID-19, 45 (23%) were re-tested, 44 (22%) of patients had PPE precautions initiated, and 37 (19%) had PPE precautions removed. The median time to consult completion was four hours and 8 (4%) consults were converted to standard FTF consults. Conclusion E-consult services can provide safe and timely access to ID specialists during the COVID-19 pandemic, minimizing the risk of infection to the patient and health care workers, while preserving PPE and testing supplies.

Left hand necrosis as the initial presentation of disseminated mucormycosis: A case report and literature review.

Cutaneous mucormycosis typically occurs as a primary infection following traumatic inoculation or as a secondary disseminated disease in immunocompromised patients with hematologic malignancy or organ transplantation. We describe an unusual case of a poorly controlled type 1 diabetic patient presenting with wet gangrene of the hand due to angioinvasive dissemination from a primary pulmonary infection, with additional suspected foci of cardiac and central nervous system involvement. Despite combined medical and surgical treatment, the patient ultimately died due to complications of her infection. This case and the associated literature review of secondary cutaneous mucormycosis highlight that invasive fungal infections can present peripherally, and identifying the primary source is important in order to promptly pursue aggressive combined medical and surgical treatment for this highly fatal disease.

A Wandering Missionary's Burden: Persistent Fever and Progressive Somnolence in a Returning Traveler.

Human African trypanosomiasis incidence has declined, but diagnosis remains difficult, especially in nonendemic areas. Our patient presented with fever, progressive lethargy, and weight loss for 5 months and had previously traveled to Ghana and Cameroon but had not been to areas with recently reported African trypanosomiasis. Extensive workup was negative, except for lymphocytic pleocytosis in cerebrospinal fluid; ultimately, a bone marrow aspiration revealed necrotizing granulomatous inflammation with 2 trypanosomes discovered on the aspirate smear, consistent with Trypanosoma brucei. The patient was treated with combination nifurtimox and eflornithine with full recovery.

Sexual Harassment Experiences Across the Academic Medicine Hierarchy.

Background Current estimates of sexual harassment across the academic hierarchy are subject to recall bias and have limited comparability between studies due to inconsistent time frames queried for each stage of training. No studies have surveyed medical students, residents/fellows, and faculty collectively and many studies exclude a wide range of sexual harassment behaviors. We assessed the incidence of sexual harassment across the different stages of academic medicine over the same time frame and within the same institutional culture. Methodology Medical students, residents/fellows, and faculty at the same academic medical campus completed a prospective online study of sexual harassment experiences in 2018. We used a tool that comprehensively assessed sexual harassment behaviors and asked about the perpetrators. Pearson's chi-square and Fisher's exact tests (for cell counts <5) were used to compare responses by academic status and gender. Participants were also asked to suggest ways to improve knowledge about university/hospital policies, support services, and reporting process on sexual harassment. Results One-third of 515 respondents (18% of invitations) reported experiencing sexual harassment in 2018. Overall, 52% of medical students, 31% of residents/fellows, and 25% of faculty respondents experienced sexual harassment. Of these, 46% of women and 19% of men reported sexual harassment experiences. The most common experiences across all levels of academic hierarchy were offensive and sexually suggestive comments or jokes and offensive and intrusive questions about one's private life or physical appearance. The most common perpetrators were "student, intern, resident, or fellow," followed by "patient or patient's family member." To improve knowledge about the policies and services regarding sexual harassment, participants suggested facilitating easy access to resources, increasing awareness, assuring confidentiality, protecting against retaliation, and continued education and reminders about the topic. Conclusions Sexual harassment may be more prevalent than the literature suggests and incidence tends to decrease with increasing academic hierarchy. Harassment can often be subtle and can pass under the radar.

Outbreak of Acinetobacter baumannii associated with extrinsic contamination of ultrasound gel in a tertiary centre burn unit.

BACKGROUND: During 2011 and 2012, an increase in occurrence of multidrug-resistant Acinetobacter baumannii infections was recorded in the Shands Hospital Burn Intensive Care Unit (BICU). An epidemic curve together with strain typing was consistent with an intermittent common source outbreak. An investigation was therefore initiated. AIM: To identify risk factors for A. baumannii infection, characterize the source of the pathogen, implement control measures to terminate the outbreak, and institute preventive measures. METHODS: We conducted a retrospective case-control study; reviewed BICU infection control policies, practices and procedures, and patient exposure to healthcare workers (HCWs), and obtained epidemiologically-directed environmental cultures. FINDINGS: Eleven patients met the case definition. On multivariate analysis, case-patients were more likely to have undergone an ultrasound procedure in the BICU (adjusted odds ratio [AOR]: 19.5; confidence interval [CI]: 2.4-435) or have a FlexiSeal™ device (AOR: 11.9, CI:1.3-276). Epidemiologically-directed cultures of the environment, ultrasound equipment, and ultrasound gel from opened containers on the ultrasound trolley and in the Ultrasound Department were negative for the outbreak pathogen. Culture of an open ultrasound gel dispenser stored in the Ultrasound Department yielded an A. baumannii strain with DNA banding patterns identical to the outbreak strain. CONCLUSIONS: Based on data from our epidemiologic, microbiologic, and observational studies, we believe that inadvertent extrinsic contamination of the gel dispenser occurred in the Ultrasound Department. Contaminated gel was then dispensed into multiuse vials of gel stored on the mobile carts. The outbreak was stemmed by instituting changes in practices in the Ultrasound Department, including introduction of single-use ultrasound vials and storage of ultrasound gel.

A rare case of disseminated Sporothrix schenckii with bone marrow involvement in a patient with idiopathic CD4 lymphocytopenia.

Sporothrix schenckii is a pathogen with a predilection for dissemination in immunocompromised individuals, often with HIV. We report a case of disseminated sporotrichosis in an unfortunate 25 year old male (without HIV) who was originally treated for presumed pneumonia. The patient continued to worsen clinically and further work-up eventually revealed Sporothrix schenckii species with involvement of multiple organs including the skin, heart, lungs and bone marrow. Despite treatment with multiple antibacterials and antifungals, he ultimately passed away. This case illustrates the aggressive nature of this disease along with the importance of early/proper diagnosis and treatment.