Post-traumatic and postsurgical collections of encysted bile (biloma) can be difficult to diagnose. Certain radiographic features may suggest the diagnosis, but puncture of the cystic lesion is essential. Moreover, the lesions may be treated by percutaneous insertion of a drainage catheter without need for surgical exploration. In the last 31/2 years we have encountered 3 patients with this condition, 2 of whom were successfully drained by percutaneous technique. In 1 patient the overall radiographic appearance was suggestive of delayed rupture of the spleen, and the biloma was drained by simple needle aspiration intraoperatively.
BackgroundAsymptomatic bacteriuria (ASB) is a common clinical condition identified by the presence of bacteria in the urine of a patient without signs and symptoms of a urinary tract infection (UTI). Treatment of ASB leads to unnecessary antimicrobial use and can cause more harm than benefit in many patients. This study is to determine the impact of more stringent criteria for urinalysis with culture if indicated (UAC), implemented in September 2016, on the treatment of asymptomatic bacteriuria.MethodsA pre-post descriptive study of patients was conducted with an order placed for UAC in the Emergency Department (ED) or hospital. Data was collected retrospectively via chart reviews. The data on ASB patients from November 2015 to April 2016 was compared with the post-implementation period October 2016 to January 2017. The number of UAC orders and cultures were averaged for 6 months pre and post implementation of the criteria change.ResultsA total of 580 patient charts were assessed post-implementation of the UAC criteria change. A majority of the orders originated from the ED, (N = 430, 72.8%). ASB was treated inappropriately at a rate of 60.4% (N = 64/106) pre-implementation and a rate of 65% (N = 41/63) post implementation, P = 0.542. The total number of UAC ordered before and after implementation did not change, (N = 2852 pre-intervention vs N = 2825 post-intervention, P = 0.744), as seen in Figure 1. However, the number of reflexed urine cultures did significantly decrease post criteria change, (N = 1056 pre-intervention vs. N = 603 post-intervention, P < 0.0001). In addition, the number of positive urine cultures also significantly decreased, (N = 378 pre-intervention vs. N = 289 post-intervention, P = 0.0447). The impact the criteria change had on patient care is the number of potential antibiotic courses saved by reflexing fewer urine cultures off the UAC. Based on the decrease in positive urine cultures, it is estimated 702 courses of inappropriate antibiotics for ASB could be saved per year (59/month).ConclusionMore stringent criteria for reflex urine cultures significantly decreases the number of urine cultures performed, therefore decreasing the number of patients treated with ASB. Additional stewardship measures are necessary to reduce the treatment of ASB for patients who have cultures performed.Figure 1Disclosures All authors: No reported disclosures.
BackgroundTumor necrosis factor (TNF)-α inhibitors increase the risk of reactivating LTBI, hence screening is crucial prior to starting therapy. There is a lack of evidence to support a preferred screening regimen in this population, and either tuberculin skin tests (TST) or interferon-γ release assays (IGRAs) are acceptable. Although difficult to assess, the sensitivity of IGRAs and TST are similar (80–95%), while IGRAs are considered to be more specific.MethodsA 48-year-old White female in rural Iowa with a 30-year history of Crohn’s disease was evaluated for TNF inhibitor therapy. She had no known risk factors for LTBI and was screened using an IGRA which yielded an indeterminate result. A repeat IGRA and a two-step TST were both negative. Subsequently, adalimumab was initiated. Adalimumab was discontinued after 9 months due to progression of Crohn’s, and the patient underwent bowel surgery at a California hospital. Her course was complicated by bilateral pleural effusions requiring thoracentesis twice.ResultsThe patient presented 1 month later with upper lobe infiltrative changes and mediastinal adenopathy. A third IGRA was performed and was non-reactive. A bronchoscopy with biopsy was then performed. The next day her dyspnea, cough and fevers worsened. She was admitted to an Iowa hospital where she was immediately put in airborne precautions. Her bronchoalveolar lavage acid-fast bacilli (AFB) smear was 4+, and an induced sputum showed 3+ AFB. Standard TB treatment was initiated. At least 59 patients (17 immunocompromised) and five employees in a private office and 13 employees at the Iowa hospital were exposed, in addition to an unknown number in California.ConclusionAlthough rare, there appears to be a risk for patients on TNF inhibitors who have multiple negative screening tests to become infected with TB. It is unclear whether this represents reactivation of undetected LTBI or new infection, although new TB cases are less likely in rural Iowa where the incidence is 1.53 per 100,000. Patients should be counseled to report any pulmonary symptoms to providers. As demonstrated by this case, airborne precautions should be implemented as soon as possible if clinical suspicion of TB is high despite negative screening tests to reduce exposure to others.Disclosures All authors: No reported disclosures.
Fig. 1 A and B. Anteroposterior and lateral views of the left foot with special reference to the first toe show a bipartite medial sesamoid bone over the head of the first metatarsal. No other bony abnormality is noted. Soft tissue swelling is present
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