Fluoroquinolones (FQs) are often preferred as oral step-down therapy for bloodstream infections (BSIs) due to favorable pharmacokinetic parameters; however, they are also associated with serious adverse events. The objective of this study was to compare clinical outcomes for patients who received an oral FQ versus an oral beta-lactam (BL) as step-down therapy for uncomplicated streptococcal BSIs. This multi-center, retrospective cohort study analyzed adult patients who completed therapy with an oral FQ or BL with at least one blood culture positive for a Streptococcus species from January 1, 2014 to June 30, 2019. The primary outcome was clinical success, defined as lack of all-cause mortality, recurrent BSI with the same organism, and infection-related readmission at 90 days. A multivariable logistic regression model for predictors of clinical failure was conducted. A total of 220 patients were included, with 87 (40%) receiving a FQ and 133 (60%) receiving a BL. Step-down therapy with an oral BL was non-inferior to an oral FQ (93.2% vs. 92.0%; mean difference 1.2%, 90% CI -5.2 to 7.8). No differences were seen in 90-day mortality, 90-day recurrent BSI, 90-day infection-related readmission, or 90-day incidence of C. difficile-associated diarrhea. Predictors of clinical failure included: oral step-down transition before day three (OR = 5.18, 95% CI 1.21, 22.16) and low dose oral-step down therapy (OR = 2.74, 95% CI 0.95, 7.90). Our results suggest that oral step-down therapy for uncomplicated streptococcal BSI with a BL is non-inferior to a FQ.

The American Society of Plastic Surgeons' Clinical Guidelines specifically focuses on reducing complications from deep vein thrombosis and pulmonary embolism (PE). The incidence of these problems in plastic surgery is low. A 1998 survey of plastic surgeons found the incidence of deep vein thrombosis and PE in facelift patients to be 0.39% and 0.16% respectively (McDevitt, 1999). Despite the low occurrence of these complications in plastic surgical patients, PE is the third leading cause of death in the United States. PE is evasive and often deadly and therefore requires respect and understanding by all members of the health care team.

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METHODS:The registry of an urban level 1 trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Bivariate analysis, multiple logistic regression, and propensity score matching were performed.RESULTS: 441 patients were included. Cryoprecipitate was more commonly administered to patients with lower revised trauma scores (6.8174 vs 7.5500, p¼0.008), decreased Glasgow coma scale (12 vs 15, p¼0.004), and increased lactate (7.53 vs 4.90, p<0.0001). Early (4 hour) mortality was greater among patients who did not receive cryoprecipitate in univariate analysis (15.6% vs 6.1%, p¼ 0.013). Neither multiple logistic regression nor propensity score matching revealed that cryoprecipitate administration was associated with a difference in inpatient mortality (OR 0.809, p¼0.543; average treatment effect on the treated 0.07%, p¼0.496).CONCLUSION: Patients receiving cryoprecipitate were more severely injured at presentation and had increased mortality at four hours. Both multivariable logistic regression and propensity score analysis failed to show that early administration of cryoprecipitate impacts mortality for exsanguinating trauma patients. The prospect of definitively assessing the utility of cryoprecipitate in exsanguinating hemorrhage warrants prospective investigation.