Cryptococcal pneumonia and meningitis in a renal transplant recipient with a false negative serum cryptococcal antigen due to postzone phenomenon.

Cryptococcal infection can cause significant morbidity and mortality in immunocompromised patients. We present a patient who was diagnosed with cryptococcal meningitis and pulmonary disease in the setting of a history of renal transplantation. The diagnosis was made based on growth of Cryptococcus neoformans in blood cultures and identification of cryptococcal antigen (CrAg) in cerebral spinal fluid (CSF) using a lateral flow assay (LFA). Our case is unique since the initial serum CrAg was falsely negative due to excess cryptococcal antigen preventing the formation of antigen-antibody complexes, referred to as the postzone phenomenon. This phenomenon has been reported on CSF samples but rarely reported on serum samples in patients without an HIV diagnosis.

Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting.

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010.

INTRODUCTION: Sexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. METHODS: This study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. RESULTS: We analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). CONCLUSION: Although patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured.

A Randomized Controlled Trial Comparing the Treatment of Patients Tested for Chlamydia and Gonorrhea After a Rapid Polymerase Chain Reaction Test Versus Standard of Care Testing.

BACKGROUND: We tested the effect of a rapid molecular test for Chlamydia trachomatis (CT)/Neisseria gonorrhoeae (NG) diagnosis on clinical emergency department decision making compared with standard care. The new test presents an opportunity to improve antibiotic management and patient outcomes. METHODS: We conducted a randomized controlled trial of 70 consenting patients 18 years or older presenting to an urban emergency department with sexually transmitted infections complaints (vaginal/penile discharge, dysuria, vaginal/penile itching/pain, dyspareunia). Participants were randomized to rapid testing or standard care if a sexually transmitted infection was suspected. Follow-up phone calls were performed 7 to 10 days postdischarge. The primary outcomes included: antibiotic overtreatment rates, partner notification, and health care utilization. RESULTS: A total of 12.9% tested positive for CT or NG and received antibiotics. Test patients with negative results were less likely to receive empirical antibiotic treatment than control patients, absolute risk difference [RD], 33.4 (95% confidence interval [CI], 7.9%-58.9%), risk ratio [RR], 0.39 (95% CI, 0.19-0.82). Thirty-seven participants (53%) were contacted for follow-up 7 to 10 days postdischarge. Test patients were less likely to report missed antibiotic doses (RD, -51.3%; 95% CI, -84.4% to -18.2%; RR, 0.23; 95% CI, 0.06-0.88). Test patients were more likely to be notified of their results (RD, 50.6%; 95% CI, 22.7%-78.5%; RR, 2.72; 95% CI, 1.26-5.86). There were no significant differences in charges or health care utilization measures. CONCLUSIONS: We found a significant reduction in unnecessary antibiotic treatment for CT/NG in subjects receiving the rapid molecular test compared with those receiving nucleic acid amplification test.

Treatment Failure Outcomes for Emergency Department Patients with Skin and Soft Tissue Infections.

INTRODUCTION: Skin and soft tissue infections (SSTIs) are commonly evaluated in the emergency department (ED). Our objectives were to identify predictors of SSTI treatment failure within one week post-discharge in patients with cutaneous abscesses, as well as to identify predictors of recurrence within three months in that proportion of participants. METHODS: This was a sub-analysis of a parent study, conducted at two EDs, evaluating a new, nucleic acid amplification test (NAAT) for Staphylococcus aureus in ED patients. Patients≥18 years receiving incision and drainage (I&D) were eligible. Patient-reported outcome data on improvement of fever, swelling, erythema, drainage, and pain were collected using a structured abstraction form at one week, one month, and three months post ED visit. RESULTS: We enrolled 272 participants (20 from a feasibility study and 252 in this trial), of which 198 (72.8%) completed one-week follow up. Twenty-seven additional one-week outcomes were obtained through medical record review rather than by the one-week follow-up phone call. One hundred ninety-three (73%) patients completed either the one- or three-month follow up. Most patients recovered from their initial infection within one week, with 10.2% of patients reporting one-week treatment failure. The odds of treatment failure were 66% lower for patients who received antibiotics following I&D at their initial visit. Overall SSTI recurrence rate was 28.0% (95% CI [21.6%-34.4%]) and associated with contact with someone infected with methicillin resistant S. aureus (MRSA), previous SSTI history, or clinician use of wound packing. CONCLUSION: Treatment failure was reduced by antibiotic use, whereas SSTI recurrence was associated with prior contact, SSTI, or use of packing.

A Randomized Clinical Trial Comparing Use of Rapid Molecular Testing for Staphylococcus aureus for Patients With Cutaneous Abscesses in the Emergency Department With Standard of Care.

OBJECTIVE: To determine whether real-time availability of rapid molecular results of Staphylococcus aureus would impact emergency department clinician antimicrobial selection for adults with cutaneous abscesses. DESIGN: We performed a prospective, randomized controlled trial comparing a rapid molecular test with standard of care culture-based testing. Follow-up telephone calls were made at between 2 and 7 days, 1 month, and 3 months after discharge. SETTING: Two urban, academic emergency departments. PATIENTS: Patients at least 18 years old presenting with a chief complaint of abscess, cellulitis, or insect bite and receiving incision and drainage were eligible. Seven hundred seventy-eight people were assessed for eligibility and 252 met eligibility criteria. METHODS: Clinician antibiotic selection and clinical outcomes were evaluated. An ad hoc outcome of test performance was performed. RESULTS: We enrolled 252 patients and 126 were randomized to receive the rapid test. Methicillin-susceptible S. aureus-positive patients receiving rapid test results were prescribed beta-lactams more often than controls (absolute difference, 14.5% [95% CI, 1.1%-30.1%]) whereas methicillin-resistant S. aureus-positive patients receiving rapid test results were more often prescribed anti-methicillin-resistant S. aureus antibiotics (absolute difference, 21.5% [95% CI, 10.1%-33.0%]). There were no significant differences between the 2 groups in 1-week or 3-month clinical outcomes. CONCLUSION: Availability of rapid molecular test results after incision and drainage was associated with more-targeted antibiotic selection. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01523899.