The patient continued to have episodes of fever, which had been occurring since admission. On day 14, the patient developed leucocytosis and blood cultures were drawn, which grew MRSA. The MIC of vancomycin increased to 2 mg/L, with that of daptomycin remaining at 0.38 mg/L. Since the patient continued to be symptomatic, irrigation and debridement was scheduled, but due to surgeon availability issues this was not performed until hospital day 19. A sample was obtained during the procedure and cultured, and on day 22, after .2 weeks of treatment with daptomycin, MRSA grew with a daptomycin MIC of 3 mg/L [daptomycin-non-susceptible S. aureus (DNSSA)]. The primary cause of the daptomycin failure was most likely a delay in incision and drainage of the abscesses. Experimental osteomyelitis models have shown selective resistance with daptomycin monotherapy, 2 which possibly contributed to the resistance in this case. Daptomycin was discontinued and, unfortunately, vancomycin was restarted over the weekend. After the patient became bacteraemic on day 14, we recommended a TEE, which was ordered but not performed until day 23. Lesions were found on the left coronary cusp (LCC) and the tricuspid valve, consistent with endocarditis. Vancomycin was discontinued, since current expert opinion states alternative antimicrobials should be considered when the vancomycin MIC is ≥2 mg/L, due to treatment failures. 3,4 Considering this and the severity of infection in this patient, we turned to salvage therapy options and ceftaroline (600 mg intravenously every 12 h), which had an Etest MIC of 0.5 mg/L, was chosen. Ceftaroline is a fifth-generation cephalosporin with activity against MRSA. Ceftaroline was chosen for a number of reasons. First, it is rapidly bactericidal. Ho et al. 5 reported sterilization in 13 days in a case of endocarditis. Also, the incidence of thrombocytopenia with long-term use is low, which was particularly important since our patient had a history of thrombocytopenia secondary to hepatitis. Finally, a literature search revealed a series of case reports showing successful use of ceftaroline in the treatment of MRSA endocarditis 5 and an experimental model demonstrating potential use in osteomyelitis. 6 Subsequent blood cultures drawn on days 29 and 32 were negative. On day 32, a repeat irrigation and debridement was performed. After 37 consecutive days of ceftaroline treatment, a TEE showed resolution of echodensities at the base of the tricuspid valve and a stable, fibronodular lesion on the LCC. Ceftaroline was continued for a total of 44 days, with no further episodes of bacteraemia, leucocytosis or fever, which completed his treatment. The patient was discharged home but was lost to follow-up. This case report demonstrates the importance of surgery for the primary treatment of abscesses and osteomyelitis. A delay in surgical intervention was likely the cause of endocarditis and the development of daptomycin resistance in this patient. Elevated vancomycin MICs have been associated with increased daptomycin M...
Due to the early administration of antibiotics, meningococcal disease is increasingly difficult to diagnose by culturing. Laboratory studies have shown PCR to be sensitive and specific, but there have been few clinical studies. The objectives of this study were to determine the diagnostic accuracy and clinical usefulness of meningococcal PCR through a prospective comparison of real-time PCR, nested PCR, and standard culturing of blood and cerebrospinal fluid (CSF). The setting was a tertiary-care pediatric hospital in Australia, and the participans were 118 children admitted with possible septicemia or meningitis. The main outcome measuressensitivity, specificity, and positive and negative predictive values-were compared to a "gold standard " fulfilling clinical and laboratory criteria. For 24 cases of meningococcal disease diagnosed by the gold standard, culturing of blood or CSF was positive for 15 (63%), nested PCR was positive for 21 (88%), and real-time PCR was positive for 23 (96%). The sensitivity, specificity, and positive and negative predictive values of real-time PCR (the most sensitive test) for all specimens were, respectively, 96% (95% confidence interval, 79 to 99%), 100% (95% confidence interval, 96 to100%), 100% (95% confidence interval, 85 to 100%), and 99% (95% confidence interval, 94 to 100%). Of 54 patients with suspected meningococcal disease at admission, 23 had positive PCR results. Only one PCR specimen was positive in a patient thought unlikely to have meningococcal disease at admission. Blood PCR remained positive for 33% of patients tested at up to 72 h. Real-time PCR has high positive and negative predictive values in this clinical setting, with better confirmation of cases than nested PCR. Targeting patients for PCR based on admission criteria appears to be practical, and the test may remain useful for several days after the start of antibiotic administration.Meningococcal septicemia and meningitis are life-threatening diseases. Rapid, accurate diagnosis is essential for optimal management of patients and the provision of prompt prophylaxis to contacts. Confirmation of the diagnosis allows physicians to use narrow-spectrum antibiotics, limit the duration of treatment, and provide prognostic information. It also provides vital disease burden information, including data to inform vaccine policy.It is becoming increasingly difficult to confirm the diagnosis of meningococcal infection by conventional microscopy and culturing techniques (6). Blood cultures are positive in about 50% of untreated patients with clinically suspected meningococcal septicemia. This rate is reduced to 5% when antibiotics have been administered prior to admission; primary care practitioners are encouraged in this practice early for suspected cases (8,9,19). Cerebrospinal fluid (CSF) microscopy or culturing is positive in 80 to 90% of untreated cases of meningococcal meningitis, but this rate is also reduced by prior antibiotic administration. In addition, many patients do not undergo a lumbar puncture early in t...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.