A case report of iatrogenic deterioration of yet undiagnosed Rhombencephalitis; always be careful with corticoids

In order to measure the impact on survival of the early introduction of adequate antibiotic treatment for nosocomial bacteremia and pneumonia, a retrospective, cohort study was carried out over a period of 17 months in a 6-bed respiratory ICU. All patients presenting with a first episode of ICU-acquired nosocomial bacteremic infection (Centers for Disease Control criteria) or pneumonia [BAL culture > or = 10(4) colony-forming units (CFU)/ml or protected specimen brush culture > or = 10(3) CFU/ml] were included. The organ failure score (Fagon criteria) was recorded on the day of diagnosis. Adequate antibiotic treatment was defined by the sensitivity of each etiologic organism to at least 1 prescribed antibiotic. A total of 25 patients (Simplified Acute Physiology Score II = 44) were included in the study with pneumonia (n = 17) or bacteremia (n = 8), on average 6.5 +/- 4.6 d after admission. At the time of diagnosis, 23 patients were receiving mechanical ventilation. The overall mortality rate was 48% and was significantly associated with the length of time without adequate antibiotic treatment (p = 0.011) and the number of organ failures on the day of diagnosis (p = 0.017). Adequate antibiotic treatment only had an impact on survival if it was started within the first 24 h after sampling (p < 0.02 on Day 0 and < 0.04 on Day 1). On the day of diagnosis, a failure score > 2 was associated with increased mortality (p = 0.009). After adjusting for the number of organ failures, the length of time without adequate antibiotic treatment remained associated with mortality (< or = 2 organ failures, p < 0.02; > 2 organ failures, p = 0.05). This study suggests that, during the course of nosocomial pneumonia and bacteremia, the time at which adequate antibiotic treatment is started is a key factor influencing survival.

Pattern of Cerebrospinal Fluid Lactic Dehydrogenase During Treatment of Bacterial Meningitis

Background: Listeria rhombencephalitis is a rare and serious complication of Listeria monocytogenes infection. We present a case of presumed Listeria rhombencephalitis with dramatic recovery from a highly morbid state. Methods: A previously healthy 64 year old woman with a remote and stable history of a major depressive episode and no history to suggest immune compromise presented with nausea and vomiting followed by the acute onset of diplopia and gait disturbance 28 days after exposure to an identified infectious source of spring rolls and 21 days after a severe diarrheal illness from that exposure. Our patient was evaluated by emergency physicians and general internists over a period of 1 week after the onset of diplopia and gait disturbance and given a diagnosis of serotonin syndrome before receiving a consultation from Neurology. Her presentation featured a deep encephalopathy and an unusual hyperkinetic movement disorder with startle myoclonus, palatal myoclonus and diffuse tremor. Results: Her MRI scan showed FLAIR hyperintensities in the bilateral cerebellum and pons with adjacent pial enhancement, characteristic of Listeria rhombencephalitis. Her CSF showed a lymphocytic pleocytosis with normal chemistry. Conclusions: She recovered dramatically to treatment with IV ampicillin. This case report illustrates the importance of considering Listeria rhombencephalitis in immunocompetent patients with brainstem symptoms following a diarrheal illness.

In the intensive care unit (ICU), infection-related mortality is high. Although adequate antibiotic treatment is essential in infections, beta-lactam target non-attainment occurs in up to 45% of ICU patients, which is associated with a lower likelihood of clinical success. To optimize antibiotic treatment, we aimed to develop beta-lactam target non-attainment prediction models in ICU patients. Patients from two multicenter studies were included, with intravenous intermittent beta-lactam antibiotics administered and blood samples drawn within 12-36 h after antibiotic initiation. Beta-lactam target non-attainment models were developed and validated using random forest (RF), logistic regression (LR), and naïve Bayes (NB) models from 376 patients. External validation was performed on 150 ICU patients. We assessed performance by measuring discrimination, calibration, and net benefit at the default threshold probability of 0.20. Age, sex, serum creatinine, and type of beta-lactam antibiotic were found to be predictive of beta-lactam target non-attainment. In the external validation, the RF, LR, and NB models confirmed good discrimination with an area under the curve of 0.79 [95% CI 0.72-0.86], 0.80 [95% CI 0.73-0.87], and 0.75 [95% CI 0.67-0.82], respectively, and net benefit in the RF and LR models. We developed prediction models for beta-lactam target non-attainment within 12-36 h after antibiotic initiation in ICU patients. These online-accessible models use readily available patient variables and help optimize antibiotic treatment. The RF and LR models showed the best performance among the three models tested.

A case of severe allergic reaction arising during treatment with Ambisome and unresponsive to antihistamine and steroid medication is reported. A 2.9-year-old female child with Hurler's syndrome received an allogeneic cord blood transplant from an unrelated donor. During the aplastic phase, liposomal amphotericin B (Ambisome) was administered as part of an empirical treatment for persistent fever. The patient developed an extensive maculopapular rash and severe itching that resolved only on discontinuation of the drug. The patient subsequently had interstitial pneumonia with ingravescent respiratory failure in spite of adequate antibiotic and antiviral treatment. Treatment with conventional amphotericin B was considered essential in this critically ill patient, and the conventional formulation was administered for 20 days without causing any reaction. Severe allergic reaction to Ambisome is a rare event but, taking into account that premedication or dose testing is not recommended for this formulation, careful monitoring of the patient being treated for the first time is warranted.

The high mortality and morbidity of severe sepsis and septic shock had not been reduced during the two recent decades, despite a number of advances in the field of supportive and adjunctive sepsis therapies. The reason might be that important steps towards overcoming of sepsis - early diagnosis, the surgical resection of the infectious focus and an adequate antibiotic treatment - at present are still suboptimal and have to be improved. However, worldwide growing resistances of pathogens against the common antibiotics are detected. In opposite, no major progress in the development of new antibiotics, mainly for the treatment of Gram-negative non-fermenter infections like Pseudomonas aeruginosa, can be predicted for the next years. Therefore, sepsis treatment must be focused on prevention of infection, and on an optimised application of current antibiotic substances. The key factors are a broad, high dose, and early applicated initial treatment, a de-escalation strategy according to the clinical course supported by the application of novel molecular markers, and - with exceptions - a limitation of treatment to 7 to 10 days. A closer cooperation between microbiologists, infection control specialists and clinical infectious disease consultants may be a key factor to overcome the raising problems in the future.

Amniotic Membrane Transplantation Combined with Antiviral and Steroid Therapy for Herpes Necrotizing Stromal Keratitis

Impact of prompt catheter withdrawal and adequate antimicrobial therapy on the prognosis of hospital-acquired parenteral nutrition catheter-related bacteraemia

Escherichia coli is the most frequent Gram-negative organism causing bacteraemia. There are few data about prognostic factors of bloodstream infections due to E. coli. In particular, the consequences of antibiotic resistance and of adequate empirical antibiotic treatment on outcome remain broadly unknown. We conducted a retrospective cohort study of patients with E. coli bacteraemia between January 1997 and June 2005 to identify any association between antibiotic resistance, adequacy of empirical antibiotic therapy and mortality. Of 663 patients with E. coli bacteraemia, 36 (5.4%) died. Patients with multidrug-resistant (MDR) E. coli bacteraemia had a significantly lower frequency of correct empirical antibiotic treatment than patients with non-MDR E. coli bacteraemia [relative risk (RR) 0.53; 95% confidence interval (CI) 0.48-0.67], and also had a significantly higher mortality (RR 3.31; 95% CI 1.72-6.36). An association between the number of antibiotics to which E. coli was resistant with adequacy of empirical antibiotic (P < 0.001) and with mortality (P < 0.001) was detected. After adjustment for other significant risk factors and confounders, the inadequacy of empirical antibiotic treatment was associated with an increased mortality (adjusted OR 2.98; 95% CI 1.25-7.11). When the adequacy of empirical treatment was excluded from the model, the presence of MDR E. coli in blood cultures was also associated with the prognosis (adjusted OR 3.11; 95% CI 1.3-7.44). In multivariate analysis, other variables associated with the outcome were age, the presence of severe sepsis or shock, Charlson index score and a non-urinary origin of the bacteraemia. Adequacy of empirical antibiotic treatment is an independent risk factor for mortality in patients with E. coli bacteraemia. MDR E. coli bacteraemia had a worse prognosis due, at least in part, to a lower frequency of correct empirical treatment.

Do Antiviral Medications Improve Recovery in Patients With Bell's Palsy?

Listeria rhombencephalitis mimicking stroke in a patient with giant cell arteritis

As part of the Monoclonal Anti-TNF: A Randomized Controlled Sepsis (MONARCS) trial, which enrolled patients with suspected sepsis, we sought to determine whether adequate antibiotic therapy was associated with a decreased mortality rate. The study enrolled 2634 patients, 91% of whom received adequate antibiotic therapy. The mortality rate among patients given adequate antibiotic treatment was 33%, versus 43% among patients given inadequate treatment (P<.001). We conclude that adequate antibiotic therapy results in a significant decrease in the crude mortality rate among patients suspected of sepsis.

Mycobacterium chelonae is a rapidly growing non-tuberculous mycobacterium, which causes infections of the human skin and soft tissue. Despite an increasing incidence of such infections, patients are often misdiagnosed. We report here 5 patients with cutaneous and/or soft tissue infection due to M. chelonae who were diagnosed and treated at our centre. Two of the 5 patients were on immunosuppressive treatment. While clinical presentations differed in each patient, all had a long history of skin lesions. In addition to careful history-taking, tissue biopsies were obtained for mycobacterial culture and histopathological examination. Culture-directed antibiotic therapy was initiated, which resulted in a slow, but continuous, healing of the lesions. In summary, M. chelonae infections are still relatively rare, but should be considered in both immunocompromised and immunocompetent patients with prolonged skin lesions resistant to standard antibiotic treatment. For diagnosis, tissue analysis for mycobacterial culture and histopathological examination, and once diagnosed, adequate antibiotic treatment, is needed.

It remains uncertain why immunocompetent patients with bacterial community-acquired pneumonia (CAP) die, in spite of adequate antibiotics. This is a secondary analysis of the CAPUCI database which was a prospective observational multicentre study. Two hundred and twelve immunocompetent patients admitted to 33 Spanish ICUs for CAP were analyzed. Comparisons were made for lifestyle risk factors, comorbidities and severity of illness. ICU mortality was the principal outcome variable. Bacteremic CAP (43.3 vs. 21.1%) and empyema (11.5 vs. 2.2%) were more frequent (P < 0.05) in patients with Streptococcus pneumoniae CAP. Higher rates of adequate empiric therapy (95.8 vs. 75.5%, P < 0.05) were observed in patients with S. pneumoniae CAP. Patients with non-pneumococcal CAP experienced more shock (66.7 vs. 50.8%, P < 0.05), and need for mechanical ventilation (83.3 vs. 61.5%, P < 0.05). ICU mortality was 20.7 and 28% [OR 1.49(0.74-2.98)] among immunocompetent patients with S. pneumoniae (n = 122) and non-pneumococci (n = 90), in spite of initial adequate antibiotic. Multivariable regression analysis in these 184 immunocompetent patients with adequate empirical antibiotic treatment identified the following variables as independently associated with mortality: shock (HR 13.03); acute renal failure (HR 4.79), and APACHE II score higher than 24 (HR 2.22). Mortality remains unacceptably high in immunocompetent patients admitted to the ICU with bacterial pneumonia, despite adequate initial antibiotics and comorbidities management. Patients with shock, acute renal failure and APACHE II score higher than 24 should be considered for inclusion in trials of adjunctive therapy in order to improve CAP survival.

Percutaneous electrical nerve stimulation: an alternative to antiviral drugs for acute herpes zoster.