A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis.

OBJECTIVES: Image-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis. METHODS: Patients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed. RESULTS: Of eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage. CONCLUSION: Ultrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

European candidaemia is characterised by notable differential epidemiology and susceptibility pattern: Results from the ECMM Candida III study.

The objectives of this study were to assess Candida spp. distribution and antifungal resistance of candidaemia across Europe. Isolates were collected as part of the third ECMM Candida European multicentre observational study, conducted from 01 to 07-07-2018 to 31-03-2022. Each centre (maximum number/country determined by population size) included ∼10 consecutive cases. Isolates were referred to central laboratories and identified by morphology and MALDI-TOF, supplemented by ITS-sequencing when needed. EUCAST MICs were determined for five antifungals. fks sequencing was performed for echinocandin resistant isolates. The 399 isolates from 41 centres in 17 countries included C. albicans (47.1%), C. glabrata (22.3%), C. parapsilosis (15.0%), C. tropicalis (6.3%), C. dubliniensis and C. krusei (2.3% each) and other species (4.8%). Austria had the highest C. albicans proportion (77%), Czech Republic, France and UK the highest C. glabrata proportions (25-33%) while Italy and Turkey had the highest C. parapsilosis proportions (24-26%). All isolates were amphotericin B susceptible. Fluconazole resistance was found in 4% C. tropicalis, 12% C. glabrata (from six countries across Europe), 17% C. parapsilosis (from Greece, Italy, and Turkey) and 20% other Candida spp. Four isolates were anidulafungin and micafungin resistant/non-wild-type and five resistant to micafungin only. Three/3 and 2/5 of these were sequenced and harboured fks-alterations including a novel L657W in C. parapsilosis. The epidemiology varied among centres and countries. Acquired echinocandin resistance was rare but included differential susceptibility to anidulafungin and micafungin, and resistant C. parapsilosis. Fluconazole and voriconazole cross-resistance was common in C. glabrata and C. parapsilosis but with different geographical prevalence.

Guideline adherence and survival of patients with candidaemia in Europe: results from the ECMM Candida III multinational European observational cohort study.

BACKGROUND: The European Confederation of Medical Mycology (ECMM) collected data on epidemiology, risk factors, treatment, and outcomes of patients with culture-proven candidaemia across Europe to assess how adherence to guideline recommendations is associated with outcomes. METHODS: In this observational cohort study, 64 participating hospitals located in 20 European countries, with the number of eligible hospitals per country determined by population size, included the first ten consecutive adults with culture-proven candidaemia after July 1, 2018, and entered data into the ECMM Candida Registry (FungiScope CandiReg). We assessed ECMM Quality of Clinical Candidaemia Management (EQUAL Candida) scores reflecting adherence to recommendations of the European Society of Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of America guidelines. FINDINGS: 632 patients with candidaemia were included from 64 institutions. Overall 90-day mortality was 43% (265/617), and increasing age, intensive care unit admission, point increases in the Charlson comorbidity index score, and Candida tropicalis as causative pathogen were independent baseline predictors of mortality in Cox regression analysis. EQUAL Candida score remained an independent predictor of mortality in the multivariable Cox regression analyses after adjusting for the baseline predictors, even after restricting the analysis to patients who survived for more than 7 days after diagnosis (adjusted hazard ratio 1·08 [95% CI 1·04-1·11; p<0·0001] in patients with a central venous catheter and 1·09 [1·05-1·13; p<0·0001] in those without one, per one score point decrease). Median duration of hospital stay was 15 days (IQR 4-30) after diagnosis of candidaemia and was extended specifically for completion of parenteral therapy in 100 (16%) of 621 patients. Initial echinocandin treatment was associated with lower overall mortality and longer duration of hospital stay among survivors than treatment with other antifungals. INTERPRETATION: Although overall mortality in patients with candidaemia was high, our study indicates that adherence to clinical guideline recommendations, reflected by higher EQUAL Candida scores, might increase survival. New antifungals, with similar activity as current echinocandins but with longer half-lives or oral bioavailability, are needed to reduce duration of hospital stay. FUNDING: Scynexis.

A case of Capnocytophaga canimorsus endocarditis in a non-immunosuppressed host: the value of 16S PCR for diagnosis.

Capnocytophaga canimorsus is a rare cause of endocarditis and is particularly unusual in non-immunosuppressed hosts. It is associated with animal bites, particularly those from dogs. This case describes a healthy 59-year-old woman, with no identifiable risk factors or dog bite history, who presented with fever of unknown origin. Echocardiography demonstrated an aortic valve mass and root abscess, in keeping with endocarditis, requiring urgent valve replacement surgery. Eight sets of blood cultures were drawn in total; after prolonged incubation, one set grew C. canimorusus. There was initial uncertainty over this being the causative organism, given the lack of immunosuppression or dog bite history, but 16S PCR of the valve identified the same organism, permitting targeted treatment. This case highlights the value of valve 16S PCR as a diagnostic tool in endocarditis.

Pulmonary Aspergillosis in Patients with Suspected Ventilator-associated Pneumonia in UK ICUs.

Rationale:Aspergillus infection in patients with suspected ventilator-associated pneumonia remains uncharacterized because of the absence of a disease definition and limited access to sensitive diagnostic tests.Objectives: To estimate the prevalence and outcomes of Aspergillus infection in adults with suspected ventilator-associated pneumonia.Methods: Two prospective UK studies recruited 360 critically ill adults with new or worsening alveolar shadowing on chest X-ray and clinical/hematological parameters supporting suspected ventilator-associated pneumonia. Stored serum and BAL fluid were available from 194 nonneutropenic patients and underwent mycological testing. Patients were categorized as having probable Aspergillus infection using a definition comprising clinical, radiological, and mycological criteria. Mycological criteria included positive histology or microscopy, positive BAL fluid culture, galactomannan optical index of 1 or more in BAL fluid or 0.5 or more in serum.Measurements and Main Results: Of 194 patients evaluated, 24 met the definition of probable Aspergillus infection, giving an estimated prevalence of 12.4% (95% confidence interval, 8.1-17.8). All 24 patients had positive galactomannan in serum (n = 4), BAL fluid (n = 16), or both (n = 4); three patients cultured Aspergillus sp. in BAL fluid. Patients with probable Aspergillus infection had a significantly longer median duration of critical care stay (25.5 vs. 15.5 d, P = 0.02). ICU mortality was numerically higher in this group, although this was not statistically significant (33.3% vs. 22.8%; P = 0.23).Conclusions: The estimated prevalence for probable Aspergillus infection in this geographically dispersed multicenter UK cohort indicates that this condition should be considered when investigating patients with suspected ventilator-associated pneumonia, including patient groups not previously recognized to be at high risk of aspergillosis.

The role of adjuvant radiotherapy in management of recurrent pleomorphic adenoma of the parotid gland: a systematic review.

PURPOSE: Recurrent pleomorphic adenoma poses a significant treatment challenge, considering its propensity for further recurrence and potential for malignant transformation. The role of adjuvant radiotherapy in its management is widely debated. The aim of this study was to determine whether adjuvant radiotherapy is more effective than surgical resection alone in patients with recurrent pleomorphic adenoma of the parotid gland, in terms of further recurrence, malignant transformation and treatment-related complications. METHODS: Using PRISMA guidelines, a systematic review comparing adjuvant radiotherapy with surgery alone in the treatment of recurrent pleomorphic adenoma was conducted. Pubmed, OVID, EBSCO, Embase, The Cochrane Library, SCOPUS and OpenGrey databases from 1988 to 2018 were searched. Quality analysis was carried out using the Newcastle-Ottawa Scale and narrative synthesis used to summarise results. RESULTS: Of 891 records screened, eight studies were included, assessing 366 participants. Two noted a benefit of adjuvant radiotherapy in reducing further recurrence. The remainder did not show significant benefit, although four showed a trend towards lower rates. Only one case of malignant transformation was identified in a patient not irradiated. Similar rates of facial nerve dysfunction were identified between groups. CONCLUSION: The available evidence suggests that adjuvant radiotherapy reduces recurrence rates in patients with recurrent pleomorphic adenoma and certain adverse prognostic factors. While it appears not to have significant adverse effects, given the lack of prospective evidence, we recommend careful use in patients at high risk of further recurrence and further research in the form of well-designed randomised controlled trials.

Vocal Cord Palsy as a Complication of Epidural Anaesthesia.

Cranial nerve palsy is a rare but recognised complication of epidural anaesthesia, most commonly presenting as diplopia secondary to abducens nerve palsy. While upper cranial nerve palsies have been documented on numerous occasions, lower cranial nerve palsies, including recurrent laryngeal nerve palsy, are exceedingly rare. This case describes a 37-year-old female who, following epidural anaesthesia for spontaneous vaginal delivery of her first child, presented with dysphonia. Flexible laryngoscopy confirmed a left vocal cord palsy, and computed tomography ruled out any mass lesions along the course of the recurrent laryngeal nerve. Here, we discuss a case of vocal cord palsy secondary to epidural anaesthesia, an extremely rare complication. We also discuss the proposed etiology, treatment, and outcomes in patients with this condition. Cranial nerve palsy should be an important differential in patients presenting with dysphonia following spinal or epidural anaesthesia.