Infections of the central nervous system (CNS) in individuals with human immunodeficiency virus (HIV) remain a substantial cause of morbidity and mortality despite the introduction of highly active antiretroviral therapy (HAART) especially in the resource-limited regions of the world. Diagnosis of these infections may be challenging because findings on cerebrospinal fluid (CSF) analysis and brain imaging are nonspecific. While brain biopsy provides a definitive diagnosis, it is an invasive procedure associated with a relatively low mortality rate, thus less invasive modalities have been studied in recent years. Diagnosis, therefore, can be established based on a combination of a compatible clinical syndrome, radiologic and CSF findings, and understanding of the role of HIV in these infections. The most common CNS opportunistic infections are AIDS-defining conditions; thus, treatment of these infections in combination with HAART has greatly improved survival.
Introduction Blastomycosis is an endemic mycosis in the United States known to primarily cause pneumonia. However, dissemination to different organs including the musculoskeletal system has been described. Case report We report a case of mandibular blastomycosis in a healthy patient with no evidence of lung involvement. A 28 year-old female presented with recurrent right mandibular osteomyelitis despite courses of antibiotics and surgical debridement. She eventually underwent right hemimandibulectomy. Budding yeasts visualized on Gomori Methenamine-Silver (GMS) and Periodic acid-Schiff (PAS) were morphologically consistent with Blastomyces dermatitidis, and intra-operative cultures showed growth of mold identified as B. dermatitidis by DNA probe. She was placed on a prolonged course of itraconazole with clinical improvement. We also reviewed the literature and found 5 cases of similar presentation which we briefly summarized in this present case report. Conclusion Blastomycosis should be considered in patients with recurrent or persistent mandibular osteomyelitis even in immunocompetent individuals.
Objective:To characterize antifungal stewardship among antimicrobial stewardship programs (ASPs) at a diverse range of hospitals and to correlate antifungal stewardship with hospital characteristics.Design:Cross-sectional survey.Participants:ASP physician and/or pharmacist members at Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) hospitals.Methods:An electronic survey administered August–September 2018 via the SRN to 111 hospitals. The χ2 test was used to test associations between ASP and hospital characteristics and use of antifungal stewardship strategies.Results:Of 111 hospitals, 45 (41%) responded; most were academic medical centers (65%) caring for stem-cell patients (73.3%) and solid-organ transplant patients (80.0%). Most hospitals have large, well-established ASPs: 60% had >5 team members and 68.9% had a duration ≥6 years. In 43 hospitals (95.6%), ASPs used antifungal stewardship strategies, most commonly prospective audit and feedback (73.3%) by a pharmacist (71.4%). Half of ASPs (51.1%) created guidelines for invasive fungal infection (IFI) management. Most hospitals (71.1%) offered rapid laboratory tests to diagnose IFI, but polymerase chain reaction (PCR) testing and antifungal susceptibility testing varied. Also, 29 ASPs (64.4%) perform surveillance of antifungal utilization, but only 9 (31%) reported to the CDC National Healthcare Safety Network. ASP size, duration, and presence of transplant populations were not associated with a higher likelihood of using antifungal stewardship strategies (P > .05 for all).Conclusions:The use of antifungal stewardship strategies was high at SRN hospitals, but they mainly involved audit and feedback. ASPs should be encouraged (1) to disseminate guidelines for IFI management, (2) to promote access to laboratory tests for rapid and accurate IFI diagnosis, and (3) to perform surveillance for antifungal utilization with reporting to the CDC.
Background Infections caused by extended-spectrum ß-lactamase (ESBL) producing organisms pose a unique challenge for infection control. The preferred agents for treatment of infections due to ESBL-producing bacteria are carbapenems. Data from prior studies suggest that hypoalbuminemia may have a profound effect on the pharmacodynamic properties of ertapenem. Our hypothesis is that ertapenem usage in patients with hypoalbuminemia will lead to negative clinical outcomes such as infection recurrence, hospital readmission, and mortality when compared to subjects with higher albumin levels. Methods This was a retrospective, observational, single-centered, cohort study of hospitalized patients at Loyola University Medical Center between January 2010 and August 2020. Patients were divided into 2 groups to include those who received ertapenem with serum albumin >2.5 g/dL and those who received ertapenem with serum albumin < 2.5 g/dL. The primary outcome of interest was 30-day all-cause mortality. Baseline characteristics that were collected included age, sex, nutrition status, patient comorbidities. Data regarding predictors of mortality within 24 hours of initiation of ertapenem including the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Charlson Comorbidity Index (CCI) was also collected. Study Criteria Results Of the 146 subjects that were included, 73 patients had serum albumin levels of < 2.5 g/dL during treatment with ertapenem. 30 day all-cause mortality was 19.7% for subjects with low albumin and 9.6% for subjects with normal albumin levels (p=0.09). Our study found that although not statistically significant, there is potentially a clinical significance between hypoalbuminemia and our primary endpoint, 30-day all-cause mortality, with higher rates of mortality in the low albumin group and a 9.6% between group difference. This data suggests that in subjects with hypoalbuminemia, treatment with once-daily ertapenem may lead to suboptimal outcomes regarding patient mortality. Outcome Data Conclusion The present study data suggests that in subjects with hypoalbuminemia, treatment with ertapenem dosed as a once-daily intravenous infusion may be associated with suboptimal clinical outcomes that may include an increased mortality, hospital readmission, and length of stay. Disclosures All Authors: No reported disclosures.
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