Sudden Visual Loss due to Arteritic Anterior Ischaemic Optic Neuropathy: A Rare Manifestation of Eosinophilic Granulomatosis with Polyangiitis.

Background: eosinophilic granulomatosis with polyangiitis (EGPA) is a rare multisystem inflammatory disease characterized by asthma, eosinophilia and granulomatous or vasculitic involvement of various organs. While the eye is uncommonly affected in patients with EGPA, multiple ophthalmic manifestations have been reported, which can result in serious visual impairment without timely treatment. Case report: we report the case of a 79-year-old woman with a history of asthma and nasal polyps who presented with low-grade fever, mild alteration of mental status, and fatigue. Chest X-ray revealed bilateral interstitial infiltrates. Lab tests showed elevated C-reactive protein level and eosinophilia (eosinophil count, 4.6 x109 cells/l); blood cultures and parasitological examination of stools tested negative. Four days after presentation, the patient reported sudden and severe blurring of vision in her left eye. Ophthalmological examination revealed bilateral swollen optic disc and visual field loss, more severe in the left eye. A diagnosis of EGPA complicated by arteritic anterior ischaemic optic neuropathy (A-AION) was proposed, while an alternative or concurrent diagnosis of giant cell arteritis was ruled out based on clinical picture. Immunosuppressive treatment with high-dose intravenous glucocorticoids was promptly started. The patient's visual defect did not improve; however, two months later, no worsening was registered on ophthalmic reassessment. Conclusions: A-AION is an infrequent but severe manifestation of EGPA, requiring prompt diagnosis and emergency-level glucocorticoid therapy to prevent any further vision loss. Disease awareness and a multidisciplinary approach are crucial to expedite diagnostic work-up and effective management of EGPA-related ocular complications. LEARNING POINTS: Arteritic ischaemic optical neuropathy is a potential cause of sudden and severe visual loss in eosinophilic granulomatosis with polyangiitis (EGPA) patients.Visual loss due to arteritic ischaemic optical neuropathy is rarely reversible; however, a timely glucocorticoid treatment may prevent further progression of visual impairment.Multidisciplinary approach is crucial to expedite diagnostic work-up and effective management of EGPA patients with ocular complications.

Anti-SARS-CoV-2 vaccination does not influence anticoagulation levels in stable long-term warfarin treatment.

BACKGROUND: Since the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, administration of the currently available vaccines has mostly been recommended for subjects at high risk, including elderly populations on long-term oral anticoagulation therapy (OAT) with warfarin. However, there is no clear evidence of the stability of the International Normalised Ratio (INR) after vaccine administration in those subjects on long-term OAT. The present study aimed to investigate the effects of COVID-19 vaccination on anticoagulation levels in patients on long-term OAT. MATERIALS AND METHODS: INR values of patients on long-term OAT who had undergone anti-SARS-CoV-2 vaccination from January to June 2021 were monitored for a total of 90 days follow-up after the first vaccination dose. These were then compared with INR values before vaccination. The second dose, when required, was administered during follow-up. Inclusion criterion was stable long-term INR for at least 6 months before vaccination. Exclusion criteria were recent surgery, intercurrent diseases, or treatment with medication that could compromise findings in the 3 months before vaccination and during follow-up. RESULTS: No differences were observed in the anticoagulation levels before and after COVID-19 vaccination in any of the patients studied: mean INR values were 2.39 (range 2.20-2.63) before vaccination and 2.40 (range 2.16-2.76) after vaccination (p=0.5). There was no difference in anticoagulation levels in relation to age, sex, indication for OAT, or type of vaccine (p>0.5). No bleeding or thrombotic complications were documented during follow-up. DISCUSSION: These are the first data to be reported on anticoagulation levels in patients on stable OAT after COVID-19 vaccination. No influence on the quality of OAT was detected after the vaccination; no bleeding or thrombotic complications were recorded in the follow-up. No difference between the four available COVID vaccines was found. Dose adjustment was only required in a few cases, thus confirming the stability of anticoagulation levels.

Inappropriate use of carbapenems in an internal medicine ward: Impact of a carbapenem-focused antimicrobial stewardship program.

PURPOSE: Carbapenem consumption is a major driver for selection and spread of carbapenem-resistant Enterobacterales (CRE). We assessed the impact of a carbapenem-focused multimodal antimicrobial stewardship program (ASP) in the internal medicine unit of a medium-size acute-care hospital. METHODS: We compared the percentage of inappropriate carbapenem prescriptions and the proportion of carbapenem treated patients registered in a 12-month pre-intervention and in a 24-month post-intervention period by using an interrupted time series analysis. The consumption of carbapenems, expressed in defined daily doses (DDD), was also assessed. As a secondary objective, the incidence of infections by carbapenem-resistant Klebsiella pneumoniae (CRKP) and the percentage of CRKP invasive isolates in the same time periods were compared. RESULTS: After the ASP intervention, the mean monthly percentage of inappropriate carbapenem prescriptions dropped from 59% to 25%, and the mean monthly proportion of carbapenem treated patients decreased from 3% to 1%. The interrupted time series analysis confirmed a significant decrease in the percentage of inappropriate carbapenem prescriptions (-41.6%, p = 0.0262) and in the proportion of carbapenem treated patients (-2.1%, p < 0.0001). Carbapenem consumption decreased from 5.2 to 1.6 DDD x 100 patient-days. The incidence of CRKP infections remained unchanged (29.1 × 100,000 patient-days vs 28.9 × 100,000 patient-days, p = 0.9864) and the percentage of CRKP invasive isolates decreased, though not significantly, from 36.4% to 13.3% (p = 0.3478). CONCLUSIONS: The implementation of a carbapenem-focused ASP was effective at limiting the inappropriate use of carbapenems and was associated with a significant decrease in carbapenem consumption. Such effects were sustained during a 24-month post-intervention period.

Antimicrobial stewardship in an Internal Medicine ward: effects on antibiotic consumption and on the use of carbapenems.

Assessing the effects of an antimicrobial stewardship program (ASP) implemented in a 78-bed Internal Medicine ward of an Italian mid-sized acute care hospital of 296 beds (26,820 bed days/year in 2015 and 26,653 in 2016). The ASP, implemented in May 2016, included: (a) formulation and dissemination of local guidelines on empiric antibiotic therapy; (b) educational training; and (c) restrictive control on the use of carbapenems. We included in the study all the patients who had received at least one systemic antibiotic as empiric therapy and who were discharged in two comparable time periods (Oct-Nov 2015: period 1 and Oct-Nov 2016: period 2), before and after the implementation of the ASP. Clinical data were collected to compare the two study periods. The percentage of patients treated with antibiotics was significantly lower in period 2 (272/635 = 42.8% vs 238/648 = 36.7%, - 6.1%, p < 0.01). A similar reduction was observed in terms of defined daily doses per 100 bed days (from 49.5 to 46.9; - 5.3%). In period 2, we observed a significant reduction of patients treated with carbapenems (5.7 vs 2.1%, p < 0.05). The length of hospital stay and in-hospital mortality was similar in the two study periods. The implementation of an ASP in our Internal Medicine ward has been associated with a significant reduction of patients treated with antibiotics. The reduction was particularly relevant for carbapenems, antibiotics which should be used only in selected cases. These results have been obtained without increasing length of hospital stay and in-hospital mortality.