Course Of Clindamycin Research Articles

P06 Improving antibiotic prescribing practice in a tertiary burns and plastic surgery department

Abstract Background Antimicrobial resistance is an ever-emerging global public health issue. In the healthcare setting, it is essential to use antimicrobials appropriately and manage infections effectively to help tackle antimicrobial resistance. Objectives To review local antibiotic resistance data, update the plastic surgery infection guidelines based on this data, implement interventions to facilitate compliance with the guidelines and re-audit to assess if these interventions have been effective. Methods A review was undertaken of the previous 3 months of antibiotic susceptibility results for significant staphylococci and streptococci species isolated from blood cultures and wound swabs, and the microbiology results of all local cases of necrotizing fasciitis over a 5-year period. The plastic surgery infection guidelines were updated to reflect the changes in local antibiotic resistance rates. Following implementation of the new guideline, various interventions were undertaken including provision of departmental teaching sessions, ensuring availability of appropriate antibiotics in the burns and plastics theatres and redesigning the guideline to include all plastic surgery and infection guidelines within the one document (previously multiple specific guidelines). Between each intervention, compliance with the guideline was measured to establish if the intervention had made a difference. Results Changes to the guideline included using clindamycin rather than doxycycline for the treatment of cellulitis in penicillin allergic patients, as 44% of Group A Streptococcus isolates identified in wound swabs were resistant to doxycycline. Other changes included the introduction of linezolid if the patient had received a recent or failed course of clindamycin, and the use of cefazolin rather than clindamycin for patients with severe cellulitis with a penicillin allergy, due to the increase in rates of clindamycin resistance. After the three intervention cycles, prescriber compliance with the guideline increased from 50% to 71% demonstrating the need for ongoing intervention and re-evaluation. Conclusions Co-amoxiclav and clindamycin were the most commonly prescribed antibiotics in those patients whose antibiotic prescriptions did not comply with the guidelines. The main reason for this is historical usage of these antibiotics within the specialty; this project demonstrates the challenges in changing established practices in individual clinicians. Interventions to ‘make it easy’ for prescribers to follow antibiotic guidelines (for example, the right antibiotic being easily available at the site of prescription), along with targeted education, can be effective but long-standing prescribing habits within specialist areas may be difficult to change.

Hiding in Plain Sight

Question: A 68-year-old man with a history of diabetes mellitus presented with 1 month of persistent diarrhea. Two months before presentation, he was found to have an odontogenic keratocyst with adjacent abscess requiring incision and drainage. He was prescribed a 10-day course of clindamycin. One month later, he underwent surgical resection and was prescribed a 7-day course of amoxicillin-clavulanate. Shortly after initiation of amoxicillin-clavulanate, he developed numerous episodes of watery diarrhea daily, which persisted after completing antibiotics.

Microbiome Resilience despite a Profound Loss of Minority Microbiota following Clindamycin Challenge in Humanized Gnotobiotic Mice.

ABSTRACTAntibiotics are known to induce gut dysbiosis and increase the risk of antibiotic resistance. While antibiotic exposure is a known risk factor leading to compromised colonization resistance against enteric pathogens such as Clostridioides difficile, the extent and consequences of antibiotic perturbation on the human gut microbiome remain poorly understood. Human studies on impacts of antibiotics are complicated by the tremendous variability of gut microbiome among individuals, even between identical twins. Furthermore, antibiotic challenge experiments cannot be replicated in human subjects for a given gut microbiome. Here, we transplanted feces from three unrelated human donors into groups of identical germfree (GF) Swiss-Webster mice, and examined the temporal responses of the transplanted microbiome to oral clindamycin challenge in gnotobiotic isolators over 7 weeks. Analysis of 177 longitudinal fecal samples revealed that 59% to 81% of human microbiota established a stable configuration rapidly and stably in GF mice. Microbiome responses to clindamycin challenge was highly reproducible and microbiome-dependent. A short course of clindamycin was sufficient to induce a profound loss (∼one third) of the microbiota by disproportionally eliminating minority members of the transplanted microbiota. However, it was inadequate to disrupt the global microbial community structure or function, which rebounded rapidly to resemble its pre-treatment state after clindamycin discontinuation. Furthermore, the response of individual microbes was community-dependent. Taken together, these results suggest that the overall gut microbiome structure is resilient to antibiotic perturbation, the functional consequences of which warrant further investigation.IMPORTANCE Antibiotics cause imbalance of gut microbiota, which in turn increase our susceptibility to gastrointestinal infections. However, how antibiotics disrupt gut bacterial communities is not well understood, and exposing healthy volunteers to unnecessary antibiotics for research purposes carries clinical and ethical concerns. In this study, we used genetically identical mice transplanted with the same human gut microbiota to control for both genetic and environmental variables. We found that a short course of oral clindamycin was sufficient to eliminate one third of the gut bacteria by disproportionally eliminating minority members of the transplanted microbiota, but it was inadequate to disrupt the overall microbial community structure and function, which rebounded rapidly to its pre-treatment state. These results suggest that gut microbiome is highly resilient to antibiotic challenge and degradation of the human gut ecosystem may require repeated or prolonged antibiotic exposure.

Rekurentni akutni tonzilitis - terapijski izazovi

Introduction: Acute tonsillopharyngitis is one of the most common infections of the upper respiratory tract, and in a number of patients a relapse of the infection may occur shortly after the termination of antibiotic treatment. It is more likely that recurrent acute tonsillopharyngitis (RATP) is primarily a result of therapeutic failure in pathogen eradication. Penicillin failure in the treatment of bacterial tonsillopharyngitis. The explanation for the penicillin failure in the treatment of bacterial tonsillopharyngitis should be sought in its inability to eradicate intracellular beta-hemolytic streptococci group A (GABHS), as well as its inability to achieve therapeutic concentration in the tonsillar surface fluid. Furthermore, betalactamase-producing bacteria (BLPB) act protectively against GABHS by inactivating penicillin. The synergistic effect with GABHS is frequently achieved with Moraxella catarrhalis, which in addition to the production of this enzyme, also enhances the adherence of GABHS to human epithelial cells. Normal bacterial flora with its various mechanisms influences on the colonization of pathogens and subsequent infection. It behaves competitively for nutrients and suppresses the growth of other strains with its products. This behavior is called bacterial interference and the best-known interfering bacterium is Alpha-hemolytic streptococcus. The presence of bacteria with interfering capacity was found in 30% of children with RATP, while in children without RATP it was found in as many as 85% of cases. Tonsillopharyngitis treatment: Current evidence suggests that the decrease in the number of acute tonsillopharyngitis episodes can be achieved with long-term prophylactic administration of cefpodoxime or 10-day course of clindamycin. Spontaneous resolution occurs in a number of patients, therefore the antibiotic treatment in the absence of an acute infection is not recommended. Penicillin should not be used in cases of confirmed presence of BLPB, when there is coaggregation of GABHS with Moraxella catarrhalis, in cases of absence of bacteria with interfering capacity, in patients that experienced failure of GABHS eradication with previous treatment, in recurrent GABHS tonsillopharyngitis, in the community with a high degree of unsuccessful treatment with penicillin (resistant bacterial strains) and in cases of allergic reaction to penicillin. The national guideline of good clinical practice for rational use of antibiotics does not recommend amoxicillin with clavulanate as the antibiotic of choice in the treatment of acute tonsillitis; also, according to other guidelines it is not the antibiotic of the first choice in recurrent tonsillitis. Macrolides were used as an effective alternative to penicillin, however, over time GABHS developed high resistance to macrolides and they should not be used routinely for the treatment of acute tonsillopharyngitis. Clindamycin has shown superiority in the tonsillar GABHS eradication of patients with RATP. Cephalosporins have been shown to be quite effective in patients with prior treatment failure or with RATP. High efficacy of cephalosporins is based on the ability to eradicate GABHS as well as concomitant BLPB and preserve interfering, protective bacterial strains. Conclusion: Tonsillectomy is recommended in patients with RATP. Antibiotic treatment may be offered to patients who do not meet criteria for tonsillectomy, in spite of their suffering from recurrent infections and to patients with contraindications or reluctance to tonsillectomy. Penicillin is not effective in eradicating GABHS and BLPB, as well as preventing future acute infections in patients with RATP, therefore it is preferable to use broad-spectrum antibiotics, such as cephalosporins. Prophylactic use of antibiotics in the treatment of RATP is not recommended.

CAPNOCYTOPHAGA CANIMORSUS CAUSING SEPTIC SHOCK IN AN ASPLENIC PATIENT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The Capnocytophaga spp. are fusiform, gram-negative rods with gliding motility and grow best in capnophilic environments. There has been concern for antimicrobial resistance among the Capnocytophaga spp. The purpose of this case is to present a patient with isolated C. canimorsus bacteremia causing septic shock and to discuss antimicrobial treatments. CASE PRESENTATION: The patient is a 63-year-old male with a past medical history of Epstein Barr Virus infection resulting in a splenectomy however, his vaccinations were up to date. The patient presented with fatigue for one day and had petechiae on his abdomen, lower extremities and nose. He was febrile at 38.9 degrees Celsius and was started on vancomycin, azithromycin and piperacillin-tazobactam. He then became hypotensive and received the sepsis fluid bolus with no change in his blood pressure. The patient required vasopressor support and then became hypoxic requiring endotracheal intubation. Due to worsening acidosis and vasopressor support the patient was started on continuous renal replacement therapy. The patient's initial blood cultures revealed gram negative rods however, the Biofire BCID (Biomérieux) molecular probe was negative. C. canimorsus was isolated from blood cultures. The antibiotic was then de-escalated to ceftriaxone. Literature review showed the possibility of beta-lactamase production in this bacterium. Given the overall critical illness of the patient, his antibiotic was changed to a combination of ampicillin-sulbactam and clindamycin. He finished a 7-day course of clindamycin and 14-day course of ampicillin-sulbactam. He received a total of 21 days of antibiotic therapy. DISCUSSION: The Capnocytophaga spp. found in the oral cavity of cats and dogs can cause wound infections, endocarditis, sepsis and meningitis. Capnocytophaga spp. have been known to cause more severe infections in immunocompromised patients. The Capnocytophaga spp. have been susceptible to many different classes of antibiotics including penicillins, macrolides, fluoroquinolones, cephalosporins and clindamycin. Recent literature has shown that there are strains of Capnocytophaga that produce beta-lactamase. Other literature has shown some Capnocytophaga spp. to be resistant to 3rd generation cephalosporins and fluoroquinolones. There was one report of a strain of C. sputigena with production of an extended spectrum beta-lactamase. CONCLUSIONS: The patient presented had C. canimorsus bacteremia. Sensitivities were unable to be done as there are no clear Clinical Laboratory and Standards Institute breakpoints for this organism. Literature had shown that C. canimorsus to be sensitive to penicillins. However, there have also been reports of beta-lactam production among other Capnocytophaga spp. Since the patient was critically ill and, sensitivities were unable to be done, the patient was switched to ampicillin-sulbactam and clindamycin. REFERENCE #1: Jolivet-Gougeon, A., Sixou, J., Tamanai-Shacoori, Z., & Bonnaure-Mallet, M. (2007). Antimicrobial treatment of Capnocytophaga infections. International Journal of Antimicrobial Agents, 29(4), 367-373. doi:10.1016/j.ijantimicag.2006.10.005 REFERENCE #2: Zangenah, S., Andersson, A. F., Özenci, V., & Bergman, P. (2017). Genomic analysis reveals the presence of a class D beta-lactamase with broad substrate specificity in animal bite associated Capnocytophaga species. European Journal of Clinical Microbiology & Infectious Diseases?: Official Publication of the European Society of Clinical Microbiology, 36(4), 657–662. https://doi-org.cuhsl.creighton.edu/10.1007/s10096-016-2842-2 REFERENCE #3: Gomez-Garces, J. L., Alos, J. I., Sanchez, J., & Cogollos, R. (1994). Bacteremia by multidrug-resistant Capnocytophaga sputigena. Journal of Clinical Microbiology, 32(4), 1067-1069. doi:10.1128/jcm.32.4.1067-1069.1994 DISCLOSURES: No relevant relationships by Muhammad Khan, source=Web Response No relevant relationships by Kenneth Mueller, source=Web Response No relevant relationships by David Quimby, source=Web Response

PULMONARY ACTINOMYCOSIS PRESENTING AS A SUBCARINAL MASS IN A HEALTHY FEMALE

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary actinomycosis, a rare chronic infection, is often misdiagnosed due to non-specific presentation. Here we present a case of a woman initially treated for aspiration pneumonia and histoplasmosis and was eventually found to have pulmonary actinomycosis on biopsy. CASE PRESENTATION: A healthy 38-year-old woman, 35-weeks-pregnant, was admitted for chest pain. Computerized tomography (CT) of the chest revealed a 4 cm subcarinal mass adjacent to the esophagus. Endobronchial ultrasound revealed multiple enlarged heterogeneous subcarinal lymph nodes. Transbronchial needle aspiration was negative for malignancy. The patient had an aspiration event 2 weeks prior to admission and completed a 14 day course of clindamycin. The mass significantly regressed radiographically after treatment. Upon follow-up, histoplasma antibody titer was positive at 1:32 (normal < 1:8) and she was started on a 3 month course of Itraconazole. Three months after discharge, she was readmitted for stabbing chest pain. CT chest re-demonstrated the subcarinal mass. Transbronchial needle aspiration specimens grew Actinomyces on tissue cultures. She was treated with a 4 month course of amoxicillin with complete resolution of symptoms and subcarinal mass on imaging. DISCUSSION: Actinomycosis is a slowly progressive granulomatous disease caused by actinomyces, a Gram–positive, filamentous microaerophilic bacterium. This bacteria normally colonizes the mouth and colon. Pulmonary actinomycosis is believed to be a result of inhalation or aspiration of oropharyngeal or upper gastrointestinal materials, and account for 15% of all actinomycosis cases. The clinical presentation, laboratory tests and radiological findings of pulmonary actinomycosis are non-specific, resulting in misdiagnosis with other chronic suppurative lung diseases and/or malignancies [1]. The infection can occur at all ages, with higher incidences in patients with poor oral hygiene, alcohol abuse disorder and underlying respiratory disorders. It starts as an acute inflammation followed by a chronic indolent phase with necrosis, fibrosis and pulmonary cavitation, and can progress to invasion of the pleura and chest wall [2]. There are no guidelines regarding the appropriate duration or route of antibiotic treatment; penicillin G for 2–6 weeks followed by oral penicillin or amoxicillin for 6-12 months, based on clinical and radiological response, has been the most common treatment regimen [3]. CONCLUSIONS: A high index of suspicion is required in order to diagnose pulmonary actinomycosis. Clinicians must be aware of its chronic and persistent presentation if left untreated, as early diagnosis will prevent significant physical and psychological morbidity. Reference #1: Farrokh D, Rezaitalab F, Bakhshoudeh B. Pulmonary actinomycosis with endobronchial involvement: a case report and literature review. Tanaffos. 2014; 13(1):52-6. Reference #2: Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003; 21(3):545-51. Reference #3: Choi J, Koh WJ, Kim TS, et al. Optimal duration of IV and oral antibiotics in the treatment of thoracic actinomycosis. Chest. 2005; 128(4):2211-7. DISCLOSURES: No relevant relationships by Violeta Alvarez-Retamales, source=Web Response No relevant relationships by Moses Hayrabedian, source=Web Response No relevant relationships by Jessica Moja, source=Web Response No relevant relationships by Suhayb Ranjha, source=Web Response

P089 Small bowel Clostridium difficile masquerading as Crohn's disease

CASE: A 38-year old man with a history of perforated diverticulitis s/p sigmoid colectomy presented to the emergency room with 2 days of abdominal pain. He was without any symptoms of diarrhea, hematochezia or melena. He was previously admitted to the hospital for 4 days approximately one month prior to presentation with similar symptoms of abdominal pain. He had a CT scan of the abdomen and pelvis performed during that admission with wall thickening of the terminal ileum, but no colonic inflammation seen. He was treated with a week of ciprofloxacin and metronidazole with transient improvement in his symptoms. He denied any significant social history. Family history was negative for inflammatory bowel disease. He denied any NSAID use, but he did report a 3-day course of clindamycin approximately 3 weeks ago for a dental procedure. His lab values were notable for a mild leukocytosis of 12.6 × 109/L (ref range 4.8–10.8 × 109/L), elevated C-reactive protein at 1.89 mg/dL (ULN ≤ 0.60 mg/dL), normal lactate at 1.0 mmol/L (ref range 0.6–2.2 mmol/L), and a negative QuantiFERON TB Gold Plus. He had CT imaging repeated of his abdomen and pelvis that was significant for multiple loops of ileal wall thickening consistent with severe ileitis without any inflammation of the large intestine. Given the concern for Crohn's disease, a colonoscopy was performed and a normal terminal ileum was seen for 30 cm. There were multiple small-mouth diverticula seen in the descending, transverse and ascending colon along with a prior end-to-end colo-colonic anastomosis in the sigmoid colon. The mucosa appeared to be normal and healthy in the colon. Random biopsies taken of the terminal ileum and colon were negative for any significant pathological diagnosis. No antibiotics were given prior to colonoscopy. Stool studies returned with a positive Clostridium difficile result, but negative stool culture and parasite screen. He was treated with a 14-day course of metronidazole 500 mg Q8H with resolution of his symptoms. DISCUSSION: This case is atypical given the patient's lack of significant diarrhea, CT imaging findings of distal ileal involvement without any colonic inflammation, and normal findings on both endoscopic evaluation and pathology. While C. difficile is the most common cause of healthcare associated infectious diarrhea, small bowel infection with C. difficile is a rare presentation. The pathophysiology of C. difficile enteritis is not well understood, but most cases reported in the literature have been described in patients with altered bowel anatomy such as colectomy, pouch construction or other large and small bowel surgery. In these cases, the small bowel is postulated to be more susceptible to colonization and infection in the setting of surgical intervention. This case highlights that C. difficile can solely affect the small bowel of patients with limited colonic resections which is important for practicing gastroenterologists.

Perioperative antibiotic use in vagus nerve stimulator implantation: a clinical series.

Preoperative antibiosis contributes up to one third of total antibiotic use in major hospitals. Choice of antibiotic is not uniformly standardized, and polypharmacy regimens may be used without knowing the effect on rates of surgical site infection, nonsurgical infections, or antibiotic resistance. Careful examination of trends in surgical prophylaxis is warranted. In this study, we aimed to examine our institution's experience with vagus nerve stimulator (VNS) implantation, focusing on association between perioperative antibiotic practices and postoperative infectious outcomes. We conducted a single-center case-control study using a retrospective chart review of 50 consecutively operated patients undergoing VNS implantation over 24months by two experienced surgeons at our institution from April 2014 to March 2016. In each surgery, the technical procedure, operating room, and surgical team were the same, while surgeon's preference in antibiotic prophylaxis differed. Group 1 received a single dose of intravenous (IV) cefazolin (n=26), and Group 2 received IV cefazolin, paired with one or both of gentamicin/vancomycin, in addition to a 10-day outpatient oral course of clindamycin (n=24). Patient demographics, perioperative details, and minimum 3-month follow-up for infection and healthcare utilization were recorded. Student t tests were computed for significance. Group 1 patients on average were older than group 2 patients (10.2, 7.1years, p=0.01), and length of surgery was longer (115.5, 91.9min, p=0.007). There were no differences in number of surgeons gowned (p=0.11), presence of tracheostomy (p=0.43) or gastrostomy (p=0.20) tube, nonsurgical infections (p=0.32), and number of postoperative emergency department (ED) visits (p=0.22) or readmissions (p=0.23). Neither group had VNS infections in the follow-up period. Single preoperative dosing of one antibiotic appropriately chosen to cover typical skin flora conferred equal benefit to perioperative prophylactic polypharmacy in this study. There were no differences in postoperative infection events or ED visits/readmissions. Restraint with preoperative antibiosis shows equipoise in postoperative infection and overall resource utilization.

Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis

ObjectiveTo compare flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis.DesignParallel, double-blinded, randomised controlled trial.SettingEmergency department attendances and general practice referrals within 20 hospitals in England.InterventionsFlucloxacillin, at...

Diagnosis, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: A Review.

Lyme disease, human granulocytic anaplasmosis (HGA), and babesiosis are emerging tick-borne infections. To provide an update on diagnosis, treatment, and prevention of tick-borne infections. Search of PubMed and Scopus for articles on diagnosis, treatment, and prevention of tick-borne infections published in English from January 2005 through December 2015. The search yielded 3550 articles for diagnosis and treatment and 752 articles for prevention. Of these articles, 361 were reviewed in depth. Evidence supports the use of US Food and Drug Administration-approved serologic tests, such as an enzyme immunoassay (EIA), followed by Western blot testing, to diagnose extracutaneous manifestations of Lyme disease. Microscopy and polymerase chain reaction assay of blood specimens are used to diagnose active HGA and babesiosis. The efficacy of oral doxycycline, amoxicillin, and cefuroxime axetil for treating Lyme disease has been established in multiple trials. Ceftriaxone is recommended when parenteral antibiotic therapy is recommended. Multiple trials have shown efficacy for a 10-day course of oral doxycycline for treatment of erythema migrans and for a 14-day course for treatment of early neurologic Lyme disease in ambulatory patients. Evidence indicates that a 10-day course of oral doxycycline is effective for HGA and that a 7- to 10-day course of azithromycin plus atovaquone is effective for mild babesiosis. Based on multiple case reports, a 7- to 10-day course of clindamycin plus quinine is often used to treat severe babesiosis. A recent study supports a minimum of 6 weeks of antibiotics for highly immunocompromised patients with babesiosis, with no parasites detected on blood smear for at least the final 2 weeks of treatment. Evidence is evolving regarding the diagnosis, treatment, and prevention of Lyme disease, HGA, and babesiosis. Recent evidence supports treating patients with erythema migrans for no longer than 10 days when doxycycline is used and prescription of a 14-day course of oral doxycycline for early neurologic Lyme disease in ambulatory patients. The duration of antimicrobial therapy for babesiosis in severely immunocompromised patients should be extended to 6 weeks or longer.

Mycoplasma hominis as a cause of septic hip arthritis in a neonate

Introduction: Mycoplasma hominis frequently colonizes the adult genitourinary tract and causes significant diseases such as chorioamnionitis in adults. It also causes systemic infections such as pneumonitis and meningoencephalitis in neonates via vertical transmission. Here, we present a case of septic hip arthritis in a full-term neonate born to a woman who had intrapartum fever with premature rupture of the membranes. Case presentation: A 0-day-old newborn female, whose mother had a significant history of intrapartum fever and 52 h of premature rupture of the membranes, developed a fever after birth. Empiric antimicrobial therapy was initiated for sepsis; however, the fever did not subside. Subsequently, she developed a subcutaneous scalp abscess and right hip joint arthritis despite continued cell-wall-active antimicrobial therapy. Blood and scalp lesion samples were found to be positive by bacterial culture, and pinpoint non-haemolytic colonies were observed on blood agar plates; however, no organisms were observed by Gram staining. Microbiological analyses using Mycoplasma-specific growth plates demonstrated that the samples were positive for Mycoplasma hominis, and PCR analysis was positive for 16S rRNA in blood, abscess and joint fluid samples. The patient was treated with surgical debridement and a 3-week course of clindamycin and was discharged from hospital without sequelae. Conclusion: To the best of our knowledge, this is the first report of M. hominis causing septic hip arthritis in a neonate. Therefore, M. hominis should be included as a causative organism when treatment with empiric antimicrobial therapy is not effective in septic neonates.

New Tender Nodules After Arthroscopy

A woman in her 20s with a medical history significant for systemic lupus erythematosus (SLE) presented with tender erythematous nodules after undergoing right knee arthroscopy (Figure, A). SLE had been diagnosed ten years previously after she presented with a positive antinuclear antibody titer (most recent titer, 1:1280), arthralgias, leukopenia, oral ulcers, and a malar erythematous eruption. There was no history of discoid or tumid lupus lesions. Initially, the lesions were thought secondary to soft-tissue infection and were treated with courses of clindamycin, vancomycin, and doxycycline. Physical examination revealed poorly demarcated erythematous plaques and nodules, tender to palpation, ranging from the distal thigh to the lower leg, adjacent to arthroscopy sites. Lesions around the suture sites appeared more violaceous. A punch biopsy of the lesion was performed (Figure, B and C). B A

It Took a Village: Good's Syndrome

PRESENTATION A complex medical history became even more tangled when a 52-year-old man presented with a 4-week history of dry cough, dyspnea, weight loss, chills, subcutaneous nodules on his extremities, and fatigue. He had no fever. Initially, his primary care physician examined him and prescribed a course of clindamycin. Although the patient completed therapy, the nodules continued to progress, and they began to drain purulent material. He had been diagnosed with myasthenia gravis 7 years prior to this episode, and he was maintained on prednisone 20 mg daily and pyridostigmine. An associated thymoma had metastasized to his lung, and he had been treated with chemotherapy and radiation 2 years before this presentation. The course of his illness was further complicated by thymoma-associated pure red cell aplasia, which was successfully managed with cyclosporine.

A case of a patient with stage III familial hidradenitis suppurativa treated with 3 courses of infliximab and died of metastatic squamous cell carcinoma.

Although rare, severe hidradenitis suppurativa (HS) of the anal, perianal, gluteal, thigh, and groin regions can evolve into squamous cell carcinoma (SCC). This usually does not occur until the HS has been present for more than 20 years. Malignant degeneration of HS in the axilla has not been reported. SCC has developed in dissecting cellulitis, acne conglobata, and pilonidal cysts (other members of the follicular tetrad). Whereas the male to female ratio of HS is 1:3, SCC in HS has a male to female ration of 5:1. The reasons behind malignant degeneration in HS are complex and might differ from the malignant degeneration causing Marjolin ulcers. It likely involves the presence of human papilloma virus (HPV) in affected areas (a rarity in the axilla), and impaired defensins, which combat HPV, in the skin of Hurley Stage III HS. In familial HS, the odds of developing SCC are likely greater because of independent loss-of-function mutations in the γ-secretase multiprotein complex, which regulates the Notch signaling pathway. Compromise of the Notch signaling pathway can undermine immune function and increase the risk of neoplastic development. Coincident SCC with use of tumor necrosis factor α blockers has been reported. I report a patient with long standing Hurley Stage III, familial HS, wwho developed metastatic SCC after 3 courses of infliximab and expired 11 months after the infliximab was started. A 47-year-old male presented with progressive HS since early adulthood. His stage III hidradenitis suppurativa (HS) involved his groin, legs buttocks, and perineal areas. Interestingly, his HS was familial; one daughter also suffered from HS. A pilonidal cyst had been excised in the past. He suffered from hypertension for which he took ramipril, 2.5 mg per day. He did not admit to smoking. He had undergone numerous surgeries and courses of clindamycin with rifampin and clindamycin with minocycline. He used pregablin among other stronger medications for pain control. He had also taken isotretinoin years before without substantial long-term benefit. The various treatments were palliative but the HS always returned. He expressed that the pain from his HS was not bearable. He decided in consultations with his doctors to try infliximab owing to the positive clinical data for its efficacy in HS. He took 3 courses of infliximab 500mg, each of which was followed by surgical debridement of the perineal and anal areas. At the 3rd surgical debridement his physician noted the presence of squamous cell carcinoma (SCC) on July 28, 2008. The infliximab was stopped. However, the patient developed the patient underwent scanning soon after that showed soon after that the SCC had metastasized. He expired in June of 2009.

Severe Myelosuppression and MRSA Infection as the Presentation of Perinatal HIV Infection

Severe Myelosuppression and MRSA Infection as the Presentation of Perinatal HIV Infection

Bilateral Peritonsillar Abscesses: A Case Presentation and Review of the Current Literature with regard to the Controversies in Diagnosis and Treatment

Although unilateral peritonsillar abscess is a common complication of acute bacterial tonsillitis, bilateral peritonsillar abscesses are quite rare. The incidence of unsuspected contralateral peritonsillar abscess identified at tonsillectomy has been reported to be between 1.9% and 24%, while the overall incidence of bilateral peritonsillar abscess is reported to reach 4.9%. Diagnosis can be based on clinical criteria or imaging techniques. As far as the treatment is concerned, it is generally accepted that the basic strategy consists of systemic antibiotics and drainage of the pus. We report the case of a 19-year-old girl, treated in the emergency room with a bilateral diagnostic needle aspiration followed by bilateral incision and drainage along with intravenous clindamycin plus anti-inflammatory agents and hydration. Following treatment, the patient progressively experienced a marked alleviation of her odynophagia. She was discharged 48 hours later on a 10-day course of clindamycin.

Lactobacillus rhamnosus Meningitis following Recurrent Episodes of Bacteremia in a Child Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

We report a case of meningitis due to Lactobacillus rhamnosus in a child undergoing allogeneic hematopoietic stem cell transplantation for acute leukemia. Four episodes of bacteremia involving strains with pulsotypes identical to that of the cerebrospinal fluid isolate preceded meningitis. After several courses of clindamycin, no relapse occurred during the patient follow-up.

Pyomyoma in a Premenopausal Woman With Fever of Unknown Origin

Pyomyoma (suppurative leiomyoma) is a rare disease that is a serious complication. Most cases have occurred in pregnant or postmenopausal women. A perimenopausal woman presented with fever and shoulder pain. She had no predisposing factors or history of leiomyoma. Ultrasonographic as well as abdominal and pelvic computed tomography scans showed an enlarged uterus with two large masses. Internal heterogeneous echogenicity was noted in the lower segment and body of the uterus. The elevated temperature continued despite a 3-day antibiotic course of clindamycin, ceftriaxone, and gentamicin. With a clinical impression of infected leiomyoma, she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathological findings showed a leiomyoma with abscess formation. The patient responded well to surgery. Pyomyoma may be difficult to diagnose, especially in women with a nonspecific clinical presentation. Delayed diagnosis may result in serious complications, and surgery and broad spectrum antibiotics are indicated.

Pyomyositis due to Streptococcus pneumoniae

Pyomyositis is an unusual but potentially serious disease in children. Staphylococcus aureus is the most commonly implicated pathogen, but pneumococcal pyomyositis is very rare. Clinical diagnosis of pyomyositis can be difficult often mimicking septic arthritis of the hip or appendicitis. We report a 12-year-old male with pyomyositis caused by Streptococcus pneumoniae who presented with fever and severe right hip and abdominal pain. Magnetic resonance imaging of the right hip revealed the diagnosis of pyomyositis. Blood cultures grew Streptococcus pneumoniae, sensitive to penicillin, ceftriaxone, and clindamycin. He was successfully treated with a 3-week course of clindamycin. Early recognition, appropriate antibiotic therapy, and if indicated, drainage of the muscle abscess is critical to reduce morbidity and mortality.

Comparison of the efficacy of artesunate-amodiaquine with quinine ... clindamycin for treatment of uncomplicated falciparum malaria in children

Background Drug-resistant Plasmodium falciparum malaria is amajor contributor to increasing malaria-related morbidity andmortality. Artesunate-amodiaquine is a potential combinationtherapy that shows improved treatment efficacy. Clindamycin incombination with quinine is also a safe and effective treatmentfor multidrug-resistant P. falciparum malaria.Objectives To compare the efficacy of artesunate-amodiaquine andquinine-clindamycin combination therapies for the treatment ofuncomplicated falciparum malaria.Methods This randomized open label trial in 23 2 children agedbetween one month and 18 years old took place in MandailingNatal, North Sumatra, from August to September 2006. The AAgroup received a 3-day oral course of artesunate (4 mg/kg BWonce a day) plus amodiaquine (10 mg/kg BW once a day). TheQC group received a 3-day course of clindamycin (5 mg of base/kgBW twice a day) plus a 7-day course of quinine (10 mg of salt/kgBW orally for the first four days, then 5 mg of quinine salt/kg BWfor the next three days). We performed thin and thick peripheralblood smears on days 0, 2, 7, and 28.Results A total of 232 eligible children were enrolled but only22 7 completed the study (114 in group AA, 113 in group QC).The cure rates were lOOo/o in both groups by the second day, andthere was no recrudescence in either group. We found more sideeffects in AA group compared with in QC group, i.e., headacheand vomiting.Conclusion Artesunate-amodiaquine and quinine-clindamycincombinations showed similar efficacy for the treatment of uncomplicatedP. falciparum.