HIV-associated nemaline myopathy manifesting as bent spine syndrome.

HIV-associated myopathies include HIV-associated polymyositis, inclusion body myositis, diffuse infiltrative lymphocytosis syndrome and sporadic late-onset nemaline myopathy (HIV-NM). HIV-NM typically manifests as a painless, progressive proximal and axial muscle weakness with characteristic histological findings of intracytoplasmic rods, or nemaline bodies, seen in atrophic muscle fibres. HIV-NM presents prior to or shortly after initiation of antiretroviral therapy (ART) and is treated with intravenous immunoglobulin, glucocorticoids or immunosuppression. We present a case of HIV-NM in a patient with well-controlled HIV on decades-long ART with progressive bent spine syndrome, or camptocormia. This case highlights the importance of considering HIV-associated myopathies such as HIV-NM in patients with HIV who present with musculoskeletal complaints.

Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria.

BACKGROUND: Pyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. OBJECTIVES: The purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. METHODS: This retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. RESULTS: Two-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. CONCLUSIONS: Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.

Many hands, light work: A partnership approach to reducing Clostridioides difficile burden on an oncology unit.

An increase in hospital-onset Clostridioides difficile prompted an interprofessional team to implement enhanced environmental service cleaning practices and adopt a routine cleaning program undertaken by clinical staff. These interventions resulted in a reduction of hospital-onset Clostridioides difficile from 7.27 cases per 10,000 patient days to 1.54 cases per 10,000 patient days.

HPV vaccination rates in 9- and 10-year-olds following a pharmacist-led intervention.

BACKGROUND: The American Cancer Society and the American Academy of Pediatrics recommend administering the human papillomavirus (HPV) vaccine to children aged 9 and 10 years to improve on-time vaccination rates as they continue to be below national goal. Pharmacist-led interventions using the electronic health record (EHR) may be an effective way to increase these rates. OBJECTIVE: This study aimed to evaluate change in first-dose HPV vaccination rate in 9- and 10-year-olds before and after a multifaceted HPV outreach initiative. METHODS: A pre-post, quasi-experimental study involving a pharmacist-led intervention was implemented at 2 primary care offices within a large health care network. Adolescents aged 9 and 10 years during the entire intervention period were included. Between November 1, 2021, and March 31, 2022, an education session was provided by an ambulatory care pharmacist to each primary care team regarding the HPV vaccine and eligibility of 9- and 10-year-olds. On June 1, 2022, a direct message was sent via the EHR to parents or guardians of eligible patients describing eligibility, risks and benefits, and best practice recommendations. The primary end point evaluated change in first-dose HPV vaccination rates in 9- and 10-year-olds measured 6 months after direct messaging. Secondary outcomes evaluated EHR message receipt, adverse events, and program revenue. Nominal outcomes were assessed with McNemar's test or Cochran's Q test using SPSS software; P < 0.05 was considered significant. RESULTS: A total of 367 patients aged 9 and 10 years were eligible for HPV vaccination. After the intervention, 45 patients were vaccinated with vaccination rate increasing from 0.5% to 12.8% (P < 0.001). A total of 288 (78.5%) had access to EHR messaging with 203 (55.3%) having confirmed receipt of the message. No adverse reactions were reported within 7 days of vaccination. Most patients (76%) had private insurance, followed by Medicaid (22.6%) and uninsured (1.4%). Approximate revenue of the program was $4129.89. CONCLUSIONS: A multifaceted intervention using education and EHR direct messaging significantly increased HPV vaccination rates in 9-and-10-year-olds.

Evaluation of appropriate transmission-based precautions for non-SARS-CoV-2 respiratory viruses.

Appropriateness of transmission-based precautions after positive result for a non-SARS-CoV-2 virus was evaluated. Most patients (77.2%) lacked appropriate precautions within 3 hours of virus detection; 36.9% remained without appropriate precautions during their stay. With recent cessation of universal masking, adherence to infection control best practices is needed to optimize safety.

Metagenomic next-generation sequencing identifying a rare case of Mycobacterium xenopi discitis.

Mycobacterium xenopi is a non-tuberculous mycobacterium (NTM) that sporadically causes infections in humans and can cause rare bone and joint infections in immunocompromised hosts with history of spinal surgery. This slow-growing mycobacterium takes 8-12 weeks to grow on culture. Metagenomic next-generation sequencing (MNGS) is a highly sensitive and specific plasma-based microbial cell-free DNA test that can detect M. xenopi weeks prior to culture growth. We present a case of M. xenopi lumbosacral discitis with presacral abscess in an immunocompromised woman without history of spinal surgery which was detected by MNGS 8 weeks prior to culture growth. The patient's discitis resolved with an M. xenopi-directed regimen of ethambutol, rifampin and azithromycin. This case illustrates the utility of next-generation sequencing tests in rapid diagnosis of rare and opportunistic infections, as compared with traditional diagnostic tests, with supporting contextual clinical and diagnostic findings.

Two Times Versus Four Times Daily Cephalexin Dosing for the Treatment of Uncomplicated Urinary Tract Infections in Females.

Background: The current treatment guidelines of the Infectious Diseases Society of America recommend ß-lactam antibiotics as alternative rather than first-line agents for the treatment of uncomplicated urinary tract infection (uUTI). Cephalexin is a commonly prescribed first-generation cephalosporin with excellent bioavailability and urinary penetration; however, little data exist to support optimal dosing for uUTI. Methods: This retrospective multicenter cohort study included adult female patients who received 5 to 7 days of cephalexin for symptomatic uUTI with a cefazolin-susceptible urine culture. The primary objective was to compare uUTI treatment failure (eg, continued or recurrent symptoms within 30 days) between patients treated with cephalexin 500 mg twice daily (BID group) and 500 mg 4 times daily (QID group) in the outpatient setting. Secondary outcomes included time to treatment failure, reported adverse events within 7 days of treatment, and occurrence of Clostridioides difficile within 30 days of treatment. Results: A total of 261 patients were included (BID, n = 173; QID, n = 88). Baseline characteristics were similar between the groups. Escherichia coli was the most commonly isolated pathogen (85.4%). There was no difference in treatment failure observed between the groups (BID 12.7% vs QID 17%, P = .343), including failure while undergoing therapy (BID 2.3% vs QID 5.7%, P = .438) or recurrence within 30 days (BID 10.4% vs QID 11.3%, P = .438). No differences in reported adverse events (BID 4.6% vs QID 5.6%, P = .103) were observed between groups. Conclusions: Twice-daily cephalexin is as effective as 4-times-daily dosing for uUTI. A twice-daily dosing strategy may improve patient adherence.

Outcomes of high-dose oral beta-lactam definitive therapy compared to fluoroquinolone or trimethoprim-sulfamethoxazole oral therapy for bacteremia secondary to a urinary tract infection.

Objective: Compare outcomes of patients receiving high-dose oral beta-lactam versus standard oral therapy for Enterobacterales bacteremia from a urinary tract infection (UTI). Design: Retrospective, multicenter, observational cohort. Setting: Three Michigan community teaching hospitals. Patients: Adult patients admitted between February 1, 2020, and October 1, 2022, with gram-negative bacteremia from a urinary source were evaluated. Patients receiving active empiric intravenous (IV) antibiotics and transitioned to appropriately dosed oral cephalexin, amoxicillin, fluoroquinolone (FQ), or trimethoprim/sulfamethoxazole (TMP/SMX) were included. Patients receiving less than 72 hours of oral therapy, diagnosed with renal abscess, lobar nephronia, or expired during admission were excluded. Methods: Standard oral therapy was defined as FQ or TMP/SMX. The primary outcome compared the composite of recurrent bacteremia or mortality within 30 days of therapy between groups. Secondary outcomes compared recurrent UTI, emergency department or hospital readmission, and Clostridioides difficile within 30 days. Results: 194 patients were included (beta-lactam, n = 75 vs standard therapy, n =119). Patients in both groups were treated for a median of 11 days, with 4 days IV and 7 days oral therapy. There was no difference in the primary outcome between groups (beta-lactam 1.3% vs standard therapy 1.7%, OR 1.27 [95% CI 0.11-14.2]). No patients experienced C. difficile in either group (p = 1.0). Infectious disease consultation was independently associated with standard therapy prescribing (OR 4.4 [95% CI 2.24-8.26]). Conclusion: High-dose oral beta-lactams were as safe and effective as oral FQ or TMP/SMX for the treatment of bacteremia from a urinary source. Most patients received 8-10 days of therapy in both groups.

Three-day ceftriaxone versus longer durations of therapy for inpatient treatment of uncomplicated urinary tract infection.

Current guidelines do not address a recommended duration of parenteral therapy for uncomplicated urinary tract infection (uUTI) treatment in the inpatient setting. We compared a 3-day course of ceftriaxone with longer antibiotic durations for inpatients with a uUTI. Our findings indicate that a 3-day course of ceftriaxone was as efficacious as longer antibiotic courses.

Prosthetic Joint Infection Due to Mycobacterium senegalense After Exposure to Zebu Cattle: A Case Report.

CASE: A 69-year-old male patient, 5 years after a well-functioning total hip arthroplasty for severe osteoarthritis, presented with a 3-month history of progressive, unrelenting, "burning" pain in his right hip with accompanying fullness of the right thigh. Inflammatory markers were elevated, and imaging revealed a large unilocular fluid collection with communication to the hip joint. Aspiration was positive for Mycobacterium senegalense. A combination of surgical and antibiotic therapy successfully treated this patient. CONCLUSION: Mycobacterium senegalense is a rare cause of prosthetic joint infection. A combination of surgical and antimicrobial management is required for effective treatment.

Antipseudomonal Versus Narrow-Spectrum Agents for the Treatment of Community-Onset Intra-abdominal Infections.

BACKGROUND: Antipseudomonal antibiotics are often used to treat community-acquired intra-abdominal infections (CA-IAIs) despite common causative pathogens being susceptible to more narrow-spectrum agents. The purpose of this study was to compare treatment-associated complications in adult patients treated for CA-IAI with antipseudomonal versus narrow-spectrum regimens. METHODS: This retrospective cohort study included patients >18 years admitted for CA-IAI treated with antibiotics. The primary objective of this study was to compare 90-day treatment-associated complications between patients treated empirically with antipseudomonal versus narrow-spectrum regimens. Secondary objectives were to compare infection and treatment characteristics along with patient outcomes. Subgroup analyses were planned to compare outcomes of patients with low-risk and high-risk CA-IAIs and patients requiring surgical intervention versus medically managed. RESULTS: A total of 350 patients were included: antipseudomonal, n=204; narrow spectrum, n=146. There were no differences in 90-day treatment-associated complications between groups (antipseudomonal 15.1% vs narrow spectrum 11.3%, P=.296). In addition, no differences were observed in hospital length of stay, 90-day readmission, Clostridiodes difficile, or mortality. In multivariate logistic regression, treatment with a narrow-spectrum regimen (odds ratio [OR], 0.75; 95% confidence interval, 0.39-1.45) was not independently associated with the primary outcome. No differences were observed in 90-day treatment-associated complications for (1) patients with low-risk (antipseudomonal 15% vs narrow spectrum 9.6%, P=.154) or high-risk CA-IAI (antipseudomonal 15.8% vs narrow spectrum 22.2%, P=.588) or (2) those who were surgically (antipseudomonal 8.5% vs narrow spectrum 9.2%, P=.877) or medically managed (antipseudomonal 23.1 vs narrow spectrum 14.5, P=.178). CONCLUSIONS: Treatment-associated complications were similar among patients treated with antipseudomonal and narrow-spectrum antibiotics. Antipseudomonal therapy is likely unnecessary for most patients with CA-IAI.

Fulminant granulomatosis with polyangiitis presenting with diffuse alveolar haemorrhage following COVID-19.

A 40-year-old man developed granulomatosis with polyangiitis (GPA) following a mild case of COVID-19. Initially, he experienced mild migrating joint pain for 2 months prior to testing positive for SARS-CoV-2 but dramatically worsened following resolution of his infection. The pain continued to progress until he suddenly develope haemoptysis, prompting him to present to a local hospital. The diagnosis of diffuse alveolar haemorrhage secondary to GPA was confirmed with labs, imaging and histopathology. Precipitous deterioration of GPA with concurrent COVID-19 infection indicates a possible temporal relationship. Since the onset of the pandemic, SARS-CoV-2 has been anecdotally associated with the development of various connective tissue disorders. The overlapping clinical presentations and similar appearance on lung imaging present clinicians with a diagnostic challenge. This underscores the importance of having a high index of suspicion of autoimmune diagnoses in patients who present with new or worsening findings following a COVID-19 infection.

Comparison of procalcitonin testing to a targeted audit-and-feedback strategy on prescribed durations of therapy for community-acquired pneumonia.

The procalcitonin (PCT) assay is FDA-approved to help guide antimicrobial treatment, however, conflicting data exist regarding its impact on durations of therapy. The purpose of this study was to compare the impact of PCT to a targeted audit-and-feedback (TAF) strategy on antibiotic durations of therapy for community-acquired pneumonia (CAP). A retrospective cohort study was conducted at two community teaching hospitals, one implementing PCT with routine audit-and-feedback and one implementing TAF recommending 5 days of therapy for uncomplicated CAP. Three hundred eleven patients with antibiotics ordered having an indication of pneumonia were included (Pre-TAF n = 80, Pre-PCT n = 80, Post-TAF n = 80, Post-PCT n = 71). Average duration of therapy was similar at baseline (Pre-TAF = 7.0 days vs Pre-PCT = 7.8 days, p = 0.1) and post-intervention (Post-TAF = 5.5 days vs Post-PCT = 5.4 days, p = 0.8) between groups. PCT and TAF were equally effective antimicrobial stewardship strategies in reducing total days of antibiotic therapy prescribed for CAP with no differences observed in patient outcomes.

Evaluation of a multifaceted approach to antimicrobial stewardship education methods for medical residents.

OBJECTIVE: Medical residents are an important group for antimicrobial stewardship programs (ASPs) to target with interventions aimed at improving antibiotic prescribing. In this study, we compared antimicrobial prescribing practices of 2 academic medical teams receiving different ASP training approaches along with a hospitalist control group. DESIGN: Retrospective cohort study comparing guideline-concordant antibiotic prescribing for 3 common infections among a family medicine (FM) resident service, an internal medicine (IM) resident service, and hospitalists. SETTING: Community teaching hospital. PARTICIPANTS: Adult patients admitted between July 1, 2016, and June 30, 2017, with a discharge diagnosis of pneumonia, cellulitis, and urinary tract infections were reviewed. METHODS: All 3 medical teams received identical baseline ASP education and daily antibiotic prescribing audit with feedback via clinical pharmacists. The FM resident service received an additional layer of targeted ASP intervention that included biweekly stewardship-focused rounds with an ASP physician and clinical pharmacist leadership. Guideline-concordant prescribing was assessed based on the institution's ASP guidelines. RESULTS: Of 1,572 patients, 295 (18.8%) were eligible for inclusion (FM, 96; IM, 69; hospitalist, 130). The percentage of patients receiving guideline-concordant antibiotic selection empirically was similar between groups for all diagnoses (FM, 87.5%; IM, 87%; hospitalist, 83.8%; P = .702). No differences were observed in appropriate definitive antibiotic selection among groups (FM, 92.4%; IM, 89.1%; hospitalist, 89.9%; P = .746). The FM resident service was more likely to prescribe a guideline-concordant duration of therapy across all diagnoses (FM, 74%; IM, 56.5%; hospitalist, 44.6%; P < .001). CONCLUSIONS: Adding dedicated stewardship-focused rounds into the graduate medical curriculum demonstrated increased guideline adherence specifically to duration of therapy recommendations.

Cost Justification of the BioFire FilmArray Meningitis/Encephalitis Panel Versus Standard of Care for Diagnosing Meningitis in a Community Hospital.

BACKGROUND:: Cerebrospinal fluid (CSF) Gram stain and culture along with CSF viral polymerase chain reaction (PCR) are the current standard of care (SOC) to diagnose meningitis. Unfortunately, these tests take up to 72 hours to provide results and are not always sensitive to detect a pathogen. BioFire FilmArray (FA) meningitis/encephalitis (ME) panel uses PCR to provide quick, accurate identification of the causative organism. For community hospitals, the cost of this technology may be prohibitive. OBJECTIVE:: To compare the institution cost of current SOC versus the anticipated cost of the FA ME panel to diagnose and treat suspected meningitis. METHODS:: A retrospective cohort study was conducted evaluating adult patients with a lumbar puncture performed and empiric antimicrobials administered for a diagnosis of meningitis. The time to receive CSF culture results and cost associated with empiric antimicrobials were assessed and compared to the theoretical time to results and cost of treatment using the FA ME panel. RESULTS:: Thirty-three patients were included in the analysis. The cost of antimicrobials using SOC was $63.43 versus $24.70 per treatment course if using the FA ME panel ( P < .001). When the cost of diagnostic testing supplies per patient was included, the median cost of SOC was $239.63 versus $239.14 per treatment course when using the FA ME panel ( P = .15). CONCLUSION:: There is potential for significant cost savings in direct antibiotic utilization if FA ME is used versus SOC to diagnose meningitis in a community hospital. Antimicrobial cost savings were able to offset the increased cost of testing.

Implementation of Rapid Diagnostic Testing without Active Stewardship Team Notification for Gram-Positive Blood Cultures in a Community Teaching Hospital.

In community hospitals, antimicrobial stewardship team notification of rapid diagnostic testing (RDT) results may not be feasible. A retrospective quasi-experimental study was conducted evaluating 252 adult inpatients with blood cultures positive for Gram-positive cocci in clusters (pre-RDT, n = 143; post-RDT, n = 109). The median time to appropriate therapy was significantly shorter in the post-RDT group (15 versus 0 h, P < 0.001), and the mean length of stay for patients with coagulase-negative staphylococcus was significantly shorter (10.5 versus 7.7 days; P = 0.015).

Graft Infection Masquerading as Rheumatologic Disease: a Rare Case of Aortobifemoral Graft Infection Presenting as Hypertrophic Osteoarthropathy.

BACKGROUND: Prosthetic vascular graft procedures are a common treatment modality for peripheral vascular disease. A relatively common complication is graft infection, occurring at a rate of 0.5-5%. When they occur, graft infections are associated with significant morbidity and mortality. Vascular graft infections also represent a diagnostic and therapeutic challenge for the physician METHODS: Here, we report a case where the rare finding of secondary hypertrophic osteoarthropathy was an important indication of underlying aortic graft infection that was initially misdiagnosed. A review of the literature revealed 34 cases of vascular graft infection associated with hypertrophic osteoarthropathy. RESULTS: The mean interval from surgery to time of infection was approximately 5 years. Mortality was 35%. When combined with hypertrophic osteoarthropathy, vascular graft infection was complicated by an aortoenteric fistula in 53% of the cases. CONCLUSION: The complexity of this case highlights the challenges physicians face in order to diagnose and treat this condition.