Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department.

Background: The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. Methods: A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Results: Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026). Conclusion: Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.

Implementation of a Meningitis Care Bundle in the Emergency Room Reduces Mortality Associated With Acute Bacterial Meningitis.

BACKGROUND: Prompt administration of antibiotics, adjunctive steroid therapy, and optimization of antibiotic delivery to cerebrospinal fluid (CSF) are factors associated with improved outcome of patients hospitalized for acute bacterial meningitis (ABM). However, the impact of a bundle of these procedures has not been reported. OBJECTIVE: To assess mortality and neurological sequelae at hospital discharge in a cohort of patients with ABM managed according to a predefined bundle. METHODS: Prospective study of all the patients hospitalized for ABM in two provinces of Northern Italy, over two consecutive periods (2005-2009, 2010-2013). The bundle included: i) supportive care if needed; ii) immediate administration of dexamethasone and 3rd generation cephalosporin; and iii) addition of levofloxacin if turbid CSF. Patients managed according to the bundle were compared with a historical group of patients cared for ABM before the bundle was implemented. RESULTS: Overall, 85 patients with ABM were managed according to the bundle and were compared with 92 historical controls. In-hospital mortality rates for bundle and control group were 4.7% and 14.1% (p=0.04). Among survivors, 13.5% and 18.9% (p=0.4) of bundle and control-group patients presented neurological sequelae. The only variable associated with mortality at multivariate analysis was ICU admission (HR 3.65). After adjusting for ICU admission, patients managed according with the ABM bundle had significantly lower mortality rate compared to historical controls. CONCLUSIONS: Use of a bundled protocol and antibiotics with excellent CSF penetration for the initial management of ABM in emergency department is feasible and associated with significant reduction in mortality.

Combined computed tomography and fluorodeoxyglucose positron emission tomography in the diagnosis of prosthetic valve endocarditis: a case series.

BACKGROUND: The diagnosis of prosthetic valve endocarditis is challenging. The gold standard for prosthetic valve endocarditis diagnosis is trans-esophageal echocardiography. However, trans-esophageal echocardiography may result in negative findings or yield images difficult to differentiate from thrombus in patients with prosthetic valve endocarditis. Combined computed tomography and fluorodeoxyglucose positron emission tomography is a potentially promising diagnostic tool for several infectious conditions and it has also been employed in patients with prosthetic valve endocarditis but data are still scant. CASE PRESENTATIONS: We reviewed the charts of 6 patients with prosthetic aortic valves evaluated for suspicion of prosthetic valve endocarditis, at two different hospital, over a 3-year period. We found 3 patients with early-onset PVE cases and blood cultures yielding Pseudomonas aeruginosa, Staphylococcus epidermidis and Staphylococcus lugdunensis, respectively; and 3 late-onset cases in the remaining 3 patients with isolation in the blood of Streptococcus bovis, Candida albicans and P. aeruginosa, respectively. Initial trans-esophageal echocardiography was negative in all the patients, while fluorodeoxyglucose positron emission tomography showed images suspicious for prosthetic valve endocarditis. In 4 out of 6 patients valve replacement was done with histology confirming the prosthetic valve endocarditis diagnosis. After an adequate course of antibiotic therapy fluorodeoxyglucose positron emission tomography showed resolution of prosthetic valve endocarditis in all the patients. CONCLUSION: Our experience confirms the potential role of fluoroseoxyglucose positron emission tomography in the diagnosis and follow-up of prosthetic valve endocarditis.

Associated thyreoiditis, myasthenia gravis, thymectomy, Chron's disease, and erythema nodosum: pathogenetic and clinical correlations, immune system involvement, and systemic infectious complications.

The case of a young woman suffering from multiple autoimmune-dysreactive disorders (including thyreoiditis, myasthenia gravis, thymectomy, Crohn's disease, and erythema nodosum), while undergoing steroideal therapy, was complicated by a severe infectious disorder (severe upper urinary tract infection). While the pathogenetic and clinical relationship between the different autoimmune-dysreactive complications is still unclear, and the supporting role of the frequent immunosuppressive treatment may add significantly to these risk factors, clinicians who are engaged in the management of these patients should be aware that multiple, concurrent or subsequent disorders might occur in these subjects, and also that severe infections might be of relevant concern.

HIV-associated early gastric adenocarcinoma successfully cured with surgery, and followed over eight years.

An extremely rare case report of HIV-associated gastric adenocarcinoma surgically treated in the year 1998 in a 37-year-old male patient already HIV positive for 10 years, with a complete post-surgery disease-free follow-up of eight years, is described. An international literature search allowed us to report the available details of the only nine cases of HIV-associated gastric cancer yet published. Seven occurred prior to the introduction of highly active antiretroviral therapy (HAART) and were burdened by a rapid disease evolution, while only two patients were reported after the introduction of HAART (like ours) and obtained surgical cure. Detailed data regarding complications, sequelae and overall survival are not given. Notably, even four of the nine published reports came from Japan, and an early disease development was usual (37-50 years of age at diagnosis). Due to its relevant differential diagnosis implications with many other HIV-related gastrointestinal disturbances caused by functional and organic diseases (drug-related disturbances, HIV infection itself, opportunistic infections, and Kaposi's sarcoma and malignant lymphomas being the most frequent disorders) and the possibility of maintaining an adequate life-expectancy when diagnosis and aggressive treatment are not delayed, gastric cancer should be considered carefully by all clinicians dealing with HIV disease.

[Brain cysticercosis: review and case report]. / Cisticercosi cerebrale: rassegna e descrizione di un caso clinico.

After thorough biological, epidemiological and clinical analysis as well as diagnosis and therapy of neurocysticercosis, the Authors describe a case they have encountered. Given the increase in the emigration rate from developing countries, the epidemiological nature of this case indicates that brain parasitosis due to helminths requires more attention. As seen in the last 20 years in the United States, these pathologies might increase significantly in Italy in the near future.