A Stewardship Approach To Optimize Antimicrobial Therapy through Use of a Rapid Microarray Assay on Blood Cultures Positive for Gram-Negative Bacteria.

A Gram-negative (GN) blood culture microarray assay with an antimicrobial stewardship program (ASP) intervention was evaluated in 126 patients with GN bacteremia. The median time to optimal therapy was shorter in the postintervention group than in the preintervention group (49.3 h versus 38.5 h, respectively; P = 0.0199). ASP can utilize microarray technology to decrease the time to optimal antimicrobial therapy.

Prevalence of Failed Back Surgery Syndrome Across Hospital Corporation of America Healthcare in the United States, Their Correlation With Mood Disorders and Other Lifestyle-Related Comorbidities.

About 16 million adults present with chronic back pain, the sixth most costly condition in the United States (US). Estimates suggest that about 60% of initial back surgeries have a successful outcome; however, many don't, leaving over 80,000 failed back surgeries per year. Failed Back Surgery Syndrome (FBSS) is defined by the International Association for the Study of Pain as back pain, with or without radiating pain, located in the lower limbs, of unknown origin, which persists or begins after surgical procedures are performed to treat lumbar disc herniations. Psychiatric comorbidities and psychosocial factors have been associated with patients presenting with this syndrome. A retrospective cross-sectional study was performed to identify the prevalence of FBSS in a population of patients during the period of January 2019-December 2020 across Hospital Corporation of America (HCA) Healthcare in the US. With a sample of 28,426 patients who underwent back surgery only 8% had FBSS. Those with FBSS (N = 2434) were mainly females (54.27%) with a mood disorder (61.18%), P-value <.0001. Among those with FBSS, there was a statistically significant relationship between mood disorder and smoking (57.37%) and obesity (54.61%) compared to non-smokers and non-obese. Lifestyle interventions may ameliorate disabling symptoms and improve the well-being of this population.

Idiopathic Granulomatous Lobular Mastitis: A Case Report.

Introduction: Idiopathic granulomatous mastitis (IGM), also known as nonpuerperal mastitis or granulomatous lobular mastitis, is a rare, benign, chronic inflammatory breast disease first characterized in 1972. IGM is characterized by sterile noncaseating lobulocentric granulomatous inflammation, usually affecting parous premenopausal women with a history of lactation. Case Presentation: We present a 38-year-old African American woman presenting to our continuity clinic complaining of a painful right breast mass discovered during a self-breast examination. An initial right breast ultrasound demonstrated an area of concern with asymmetry, architectural distortion, and a questionable mass correlating to a 5.1 cm hypoechoic mass at the 12:30 position. Additionally, a mammogram showed a suspicious, indeterminate, large hypoechoic region or mass with angular margins measuring 5.1 x 1.7 x 3.7 cm with slight internal vascularity. An ultrasound-guided stereotactic biopsy revealed extensive mixed inflammatory and focal granulomatous lobular mastitis. Conclusion: Idiopathic granulomatous mastitis is a rare disorder that often mimics breast malignancies and infectious processes. This case highlights the need for further research on IGM pathogenesis to prevent unnecessary life-altering therapeutic procedures and bring awareness to the medical community.

Response of FGFR-2 Positive Adenoid Cystic Carcinoma to Futibatinib: A Case Report.

Adenoid cystic carcinoma (ACC) is an uncommon and aggressive head and neck cancer mainly affecting minor salivary glands. It affects more women than men in their 60s and 70s. The tumor is typically locally aggressive and has a high rate of distant metastatic disease. This report unveils a potential avenue for targeted therapy for the management of metastatic disease: a patient with ACC who harbored a specific fibroblast growth factor receptor 2 (FGFR-2) mutation and responded significantly to a novel FGFR-2 inhibitor. This finding could pave the way for personalized treatment options for ACC patients with similar genetic alterations. Nevertheless, the use of futibatinib requires further investigation to optimize treatment protocols, including exploring combination therapies, identifying predictive biomarkers for treatment response, and developing strategies to overcome potential resistance.

Stewardship approach for optimizing antimicrobial therapy through use of a rapid microarray assay on blood cultures positive for Enterococcus species.

Enterococci are a major cause of bloodstream infections in hospitalized patients and have limited antimicrobial treatment options due to their many resistance mechanisms. Molecular technologies have significantly shortened the time to enterococcal isolate identification compared with conventional methods. We evaluated the impact of rapid organism identification and resistance detection with the Verigene Gram-positive blood culture microarray assay on clinical and economic outcomes for patients with enterococcal bacteremia. A single-center preintervention/postintervention quasiexperimental study compared inpatients with enterococcal bacteremia from 1 February 2012 to 9 September 2012 (preintervention period) and 10 September 2012 to 28 February 2013 (postintervention period). An infectious disease and/or critical care pharmacist was contacted with the microarray assay results, and effective antibiotics were recommended. The clinical and economic outcomes for 74 patients were assessed. The mean time to appropriate antimicrobial therapy was 23.4 h longer in the preintervention group than in the postintervention group (P = 0.0054). A nonsignificant decrease in the mean time to appropriate antimicrobial therapy was seen for patients infected with vancomycin-susceptible Enterococcus isolates (P = 0.1145). For patients with vancomycin-resistant Enterococcus bacteremia, the mean time to appropriate antimicrobial therapy was 31.1 h longer in the preintervention group than in the postintervention group (P < 0.0001). In the postintervention group, the hospital length of stay was significantly 21.7 days shorter (P = 0.0484) and mean hospital costs were $60,729 lower (P = 0.02) than in the preintervention group. The rates of attributed deaths in the two groups were not statistically different. Microarray technology, supported by pharmacy and microbiology departments, can decrease the time to appropriate antimicrobial therapy, the hospital length of stay, and health care costs.

An Isolated Splenic Hydatid Cyst.

An isolated hydatid cyst of the spleen is a rare presentation of echinococcal diseases, especially in non-endemic areas where it may end up with unnecessary work-up and misdiagnosis. Here, we present the case of a 28-year-old female presenting with generalized abdominal pain, constipation, and early satiety who had a delayed diagnosis of isolated splenic hydatid cyst which was partially treated with albendazole, eventually requiring splenectomy.

Cerebral Venous Thrombosis in Young Adults: Unknown Origins.

Cerebral venous thrombosis (CVT) is a relatively rare neurological disorder that may result in significant morbidity if not diagnosed and managed promptly. The clinical presentation of CVT is nonspecific and highly variable with acute, subacute, or chronic onset. It most often presents as a headache but may present with focal neurological symptoms, symptoms of intracranial hypertension, or encephalopathy. The predisposing factors for CVT are mainly acquired and genetic hypercoagulable conditions. However, the epidemiology, predisposing factors, and clinical presentation of CVT are not clearly established given the rare nature of the condition. We present a case series of three young patients who did not have any classic underlying etiology for CVT or any prior diagnosis of venous thrombosis. We want to report this case series to show that a high index of suspicion should be maintained regardless of the absence of risk factors.

Diagnostic Dilemma: Infective Endocarditis in the Setting of an Esophageal Abscess.

Transesophageal echocardiography (TEE) is the preferred imaging modality to diagnose infective endocarditis (IE). However, esophageal disease can preclude performing a TEE. We present such a scenario. A patient with an esophageal abscess, methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, and septic pulmonary emboli with suspicion for IE based on the modified Duke criteria. However, due to the patient's esophageal abscess, TEE could not be performed safely. We present this case to demonstrate a rare scenario in which a patient with an esophageal abscess also had presumed IE.

Cerebral Venous Thrombosis in a Patient With Smith-Magenis Syndrome.

Smith-Magenis syndrome (SMS) is a complex genetic developmental disorder characterized by distinctive physical features, cognitive impairment, developmental delay, and behavioral abnormalities. It is caused by a microdeletion of chromosome band 17p11.2 encoding for multiple genes including the Retinoic-acid-induced (RAI1) gene. RAI1 gene is expressed in many tissues, acting as a transcriptional regulator. It is a dosage-sensitive gene. The variants of the RAI1 gene have been explored with some contributing to systemic manifestations. The hematological manifestations such as venous thrombosis (VT) including cerebral venous thrombosis (CVT) have not been reported to date. We report a case of a 25-year-old female with SMS who presented with lethargy and gastrointestinal symptoms and was diagnosed with CVT. Our case highlights the risk of VT in patients with SMS and therefore holding a high index of suspicion for early diagnosis and management.

Atypical Mycobacterial Tenosynovitis in the Setting of Adalimumab Use.

Tumor necrosis factor-alpha (TNF-α) inhibitors indicated in the management of psoriasis, rheumatoid arthritis, ulcerative colitis, Crohn's disease, and other autoimmune diseases have been associated with the development of mycobacterial and other opportunistic infections. The majority of mycobacterial infections diagnosed in patients taking TNF-α inhibitors are secondary to Mycobacterium tuberculosis. Atypical mycobacteria have also been identified in this patient population, most commonly manifested by pulmonary or disseminated infections. Extra-pulmonary manifestations such as bone and joint infections are rare. We describe a case of atypical mycobacterial tenosynovitis in the setting of adalimumab use in a patient with psoriasis. This is a rarely reported complication that one should be aware of when prescribing these medications.

Reverse Takotsubo Cardiomyopathy in the Setting of Acute Asthma Exacerbation.

Takotsubo cardiomyopathy (TTC) is a reversible form of myocardial injury characterized by transient systolic and diastolic dysfunction secondary to regional left ventricle (LV) wall motion abnormalities. We present a case of a rare variant of TTC, termed reverse TTC (rTTC), involving basal hypokinesis with apical hyperkinesis accounting for less than 5% of identified cases of TTC. Our patient is a 49-year-old Hispanic female who presented for evaluation of dyspnea. She was diagnosed with acute asthma exacerbation. The patient admitted to more frequent use of her albuterol rescue inhaler. Over the course of her hospitalization the patient had elevation of Troponin I and underwent an echocardiogram and coronary angiogram, which revealed the diagnosis of rTTC in the setting of inhaled beta agonist overuse for acute asthma exacerbation. Our case highlights the importance of adequately managing asthma to prevent exacerbation and overuse of inhaled sympathomimetic agents in an effort to decrease the incidence of TTC in the asthmatic population.

Tuberculous Enteritis: A Rare Complication of Miliary Tuberculosis.

Tuberculous enteritis is a clinical rarity even in immunocompromised patients. We present a case of miliary tuberculosis with gastrointestinal involvement. A 47-year-old homosexual male from Philippines with no significant medical history presented with productive cough, night sweats, subjective fevers, shortness of breath, watery diarrhea, and 25-pound weight loss in past one year. On physical exam he was afebrile, mildly hypotensive, tachycardic, and tachypneic, but saturating well on room air. He was cachectic with oral thrush and bilateral fine rales. Chest X-ray revealed a miliary pattern. His sputum AFB smear was strongly positive. PCR and sputum culture were positive for Mycobacterium tuberculosis. He was started on Rifampin, Isoniazid, Ethambutol, and Pyrazinamide. He was found to be HIV positive with an absolute CD4 count of 4 cells/µL. Due to persistent diarrhea, stool was sent for AFB culture and grew M. tuberculosis. He responded well to treatment with resolution of symptoms. Tuberculous enteritis occurs in about 2% of the patients with pulmonary tuberculosis. Although it is uncommon, it should be considered in patients with active pulmonary tuberculosis and abdominal complaints. A presumptive diagnosis of tuberculous enteritis can be made in the setting of active pulmonary tuberculosis with suggestive clinical, endoscopic, and/or radiographic findings.

An unusual case of acute transverse myelitis caused by HSV-1 infection.

Transverse myelitis is a neurological disorder of the spinal cord that can have a variety of etiologies. Herpes simplex virus (HSV) infection has been described as one of the causes, most commonly HSV type 2. We report here a case of an 18 year old male who presented with weakness that started in his upper extremities and rapidly evolved to quadriplegia. Magnetic resonance imaging of spine was consistent with transverse myelitis. HSV type 1 PCR testing on cerebrospinal fluid (CSF) was positive. He was started on acyclovir and steroids, but despite therapy, patient did not recover motor function.

HTLV-1 and HIV-1 co-infection: A case report and review of the literature.

HTLV type 1 and 2 are both involved in actively spreading epidemics, affecting over 15 million people worldwide. HTLV-1 has been described as the more clinically significant one, being associated with diseases such as adult T-cell leukemia and tropical spastic paraparesis. We report here a case of tropical spastic paraparesis in an HIV-positive patient who did not report any history of travel or residence in an HTLV endemic area. A 57 year old African-American male was admitted to the hospital due to bilateral upper and lower extremity weakness associated with stiffness. He had recently been diagnosed with HIV. His physical examination showed mild to moderate decreased motor strength, in both upper extremities and marked loss in both lower extremities. This was associated with hyperreflexia and clonus. Sensory function was intact. He looked cachectic and had several psoriatic plaques on both lower and upper extremities. Laboratory work-up showed a CD4 count decreased to 94 cells/mm(3) and a HIV viral load of 273,000 copies/mL. Based on serum positivity for HTLV type 1 and the patient's clinical presentation suggestive of upper and lower motor neuron dysfunction, the diagnosis of tropical spastic paraparesis was made. HTLV and HIV share the same routes of transmission and the same tropism for T-lymphocytes. Co-infection occurs probably more frequently than we are aware, since testing for HTLV is not routinely performed in outpatient HIV clinics.

Whole-genome sequencing for outbreak investigations of methicillin-resistant Staphylococcus aureus in the neonatal intensive care unit: time for routine practice?

BACKGROUND Infants in the neonatal intensive care unit (NICU) are at increased risk for methicillin-resistant Staphylococcus aureus (MRSA) acquisition. Outbreaks may be difficult to identify due in part to limitations in current molecular genotyping available in clinical practice. Comparison of genome-wide single nucleotide polymorphisms (SNPs) may identify epidemiologically distinct isolates among a population sample that appears homogenous when evaluated using conventional typing methods. OBJECTIVE To investigate a putative MRSA outbreak in a NICU utilizing whole-genome sequencing and phylogenetic analysis to identify recent transmission events. DESIGN Clinical and surveillance specimens collected during clinical care and outbreak investigation. PATIENTS A total of 17 neonates hospitalized in a 43-bed level III NICU in northeastern Florida from December 2010 to October 2011 were included in this study. METHODS We assessed epidemiological data in conjunction with 4 typing methods: antibiograms, PFGE, spa types, and phylogenetic analysis of genome-wide SNPs. RESULTS Among the 17 type USA300 isolates, 4 different spa types were identified using pulsed-field gel electrophoresis. Phylogenetic analysis identified 5 infants as belonging to 2 clusters of epidemiologically linked cases and excluded 10 unlinked cases from putative transmission events. The availability of these results during the initial investigation would have improved infection control interventions. CONCLUSION Whole-genome sequencing and phylogenetic analysis are invaluable tools for epidemic investigation; they identify transmission events and exclude cases mistakenly implicated by traditional typing methods. When routinely applied to surveillance and investigation in the clinical setting, this approach may provide actionable intelligence for measured, appropriate, and effective interventions.

Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida.

OBJECTIVE: To determine healthcare-associated infection (HAI) prevalence in 9 hospitals in Jacksonville, Florida; to evaluate the performance of proxy indicators for HAIs; and to refine methodology in preparation for a multistate survey. DESIGN: Point prevalence survey. PATIENTS: Acute care inpatients of any age. METHODS: HAIs were defined using National Healthcare Safety Network criteria. In each facility a trained primary team (PT) of infection prevention (IP) staff performed the survey on 1 day, reviewing records and collecting data on a random sample of inpatients. PTs assessed patients with one or more proxy indicators (abnormal white blood cell count, abnormal temperature, or antimicrobial therapy) for the presence of HAIs. An external IP expert team collected data from a subset of patient records reviewed by PTs to assess proxy indicator performance and PT data collection. RESULTS: Of 851 patients surveyed by PTs, 51 had one or more HAIs (6.0%; 95% confidence interval, 4.5%-7.7%). Surgical site infections ([Formula: see text]), urinary tract infections ([Formula: see text]), pneumonia ([Formula: see text]), and bloodstream infections ([Formula: see text]) accounted for 75.8% of 58 HAIs detected by PTs. Staphylococcus aureus was the most common pathogen, causing 9 HAIs (15.5%). Antimicrobial therapy was the most sensitive proxy indicator, identifying 95.5% of patients with HAIs. CONCLUSIONS: HAI prevalence in this pilot was similar to that reported in the 1970s by the Centers for Disease Control and Prevention's Study on the Efficacy of Nosocomial Infection Control. Antimicrobial therapy was a sensitive screening variable with which to identify those patients at higher risk for infection and reduce data collection burden. Additional work is needed on validation and feasibility to extend this methodology to a national scale.

Mycobacterium tuberculosis osteomyelitis in a patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS): a case report.

The incidence of tuberculosis is increasing in the United States. Extra-pulmonary involvement is more common in patients with HIV/AIDS. The diagnosis of Tuberculosis osteomyelitis requires a high degree of suspicion for accurate and timely diagnosis.We present a case of a 49 year old Caucasian male with HIV/AIDS who presented with a four-month history of soft tissue swelling in the left proximal thigh unresponsive to various broad spectrum antibiotics who was eventually diagnosed with Mycobacterium tuberculosis osteomyelitis of the left proximal femur.