Broad-spectrum Antibiotic Coverage Research Articles

Effect of photobiomodulation therapy as a multimodal approach to treatment of dermal abrasions in cownose rays (Rhinoptera bonasus).

Photobiomodulation therapy (PBMT) has become increasingly utilized in the zoo and aquarium fields to treat ailments in various species; however, its use in teleosts and elasmobranchs is relatively underrepresented in the literature. This study examined the efficacy of PBMT as an adjunct treatment to reduce the healing time of dermal abrasions in cownose rays (Rhinoptera bonasus). Ten cownose rays were included in this study and separated into control (n = 5) and treatment groups (n = 5). Animals in both treatment and control groups received intramuscular injections of enrofloxacin every 72 h to provide broad-spectrum antibiotic coverage. Cownose rays in the treatment group additionally received PBMT using the Companion® CTC-12 unit using the large, noncontact head. Control group rays were subjected to identical handling without the use of PBMT. A total of 196 Joules were delivered at a power of 2 W based on a dose of 5 J/cm2 at each session. Observational analysis revealed a lack of appreciable difference in healing time between the treatment and control groups in the aforementioned settings; however, it is recommended that PBMT protocols should be re-evaluated if there is little to no response in healing after three to four sessions. PBMT use on acute superficial dermal abrasions in cownose rays was well-tolerated in this study and may have utility in a multimodal treatment approach to wound healing. This study also produced a wound scoring metric based on photographs captured at each treatment. Future studies should utilize increased fluence (J/cm2) and irradiance (W/cm2) and incorporate synchronous histological analysis and increased sample size.

Design and development of dual drug-loaded nanofibrous inserts for ophthalmic sustained delivery of AMK and VAN: Pharmacokinetic study in rabbit’s eye

Bacterial corneal keratitis is a damage to the corneal tissue that if not treated, can cause various complications like severe vision loss or even blindness. Combination therapy with two antibiotics which are effective against Gram-positive and Gram-negative bacteria offers sufficient broad-spectrum antibiotic coverage for the treatment of keratitis. Nanofibers can be a potential carrier in dual drug delivery due to their structural characteristics, specific surface area and high porosity. In order to achieve a sustained delivery of amikacin (AMK) and vancomycin (VAN), the current study designed, assessed, and compared nanofibrous inserts utilizing polyvinyl alcohol (PVA) and polycaprolactone (PCL) as biocompatible polymers. Electrospinning method was utilized to prepare two different formulations, PVA-VAN/AMK and PCL/PVA-VAN/AMK, with 351.8 ± 53.59 nm and 383.85 ± 49 nm diameters, respectively. The nanofibers were simply inserted in the cul-de-sac as a noninvasive approach for in vivo studies. The data obtained from the physicochemical and mechanical properties studies confirmed the suitability of the formulations. Antimicrobial investigations showed the antibacterial properties of synthesized nanofibers against Staphylococcus aureus and Pseudomonas aeruginosa. Both in vitro and animal studies demonstrated sustained drug release of the prepared nanofibers for 120 h. Based on the in vivo findings, the prepared nanofibers' AUC0-120 was found to be 20 to 31 times greater than the VAN and AMK solutions. Considering the results, the nanofibrous inserts can be utilized as an effective and safe system in drug delivery.

Perihepatic Packing: A Life Saving Procedure in Liver Trauma

Objective: Liver is one of the most common organ injured in Blunt and penetrating abdominal trauma and is the 2nd most common cause of mortality in these patients. The main objective of this study is to analyse the role and success rate of perihepatic packing in liver trauma Materials & Methods: This is a prospective study conducted on 200 patients of Liver trauma admitted in a tertiary care hospital over 2 year period with 3 months postoperative followup. Most of the High Grade liver injuries with uncontrolled venous bleeding were subjected to perihepatic Packing. The patient were shifted to ICU postoperatively and reexplored after 48 hours for pack removal. Results: 30 patients were subjected to Perihepatic packing with success rate of 80% in achieving haemostasis.24 cases were due to blunt while 6 due to penetrating trauma. Commonly seen in younger age group with male dominance. Majority of the injuries were AAST Grade III and IV type. Discussion: In Liver trauma the prime goal is Life Saving by control of Haemorrhage. Various advanced procedures are performed for the same, however it may not be possible to carry out all these in an emergency setting of Haemodynamically unstable patients. In these selected cases, Perihepatic packing is the Gold standard to achieve haemostasis as damage control or Definitive procedure. Conclusion: Perihepatic Packing is a highly recommended procedure in selected cases of High Grade liver injuries mainly for control of venous bleeding. Good postoperative ICU ventilator support under Broad spectrum Antibiotic cover is mandatory to minimize morbidity and mortality associated with the procedure. Keywords: Liver trauma, Perihepatic Packing, Blunt abdominal trauma, Reexploration.

Protocol of a multicenter, single-blind, randomized, parallel controlled trial evaluating the effect of microbiological rapid on-site evaluation (M-ROSE) guiding anti-infection treatment in patients with severe hospital-acquired pneumonia

IntroductionThe mortality rate of hospitalized patients with severe hospital-acquired pneumonia (SHAP) remains high. Empirical broad-spectrum antibiotic coverage and the misuse of high-grade antibiotics could lead to the emergence of multi-drug and even pandrug-resistant bacteria. In addition to metagenomic next-generation sequencing (mNGS), microbiological rapid on-site evaluation (M-ROSE) might be a useful technique to identify the pathogens in the early stage; however, the effect of M-ROSE guiding anti-infection treatment on prognostic outcomes of SHAP patients is still unclear.Methods/designThis is a multicenter, single-blind, prospective, randomized controlled trial to evaluate the effect of M-ROSE guiding anti-infection treatment in SHAP patients, which will provide new strategies for the prevention and control of clinical multi-drug resistance bacteria. A total of 166 patients with SHAP, aged 18 years and over, will be recruited from seven centers in Beijing and randomly assigned to the intervention group (M-ROSE combined with mNGS) or the control group (mNGS only) in a 1:1 ratio using the central randomization system. Patients in the intervention group will accept M-ROSE and mNGS analysis, and the control group will accept mNGS analysis. Individualized anti-infective treatment and routine treatment will be selected according to the analysis results. The primary outcome is the ICU outcome (mortality). The safety of the intervention measures will be evaluated during the entire trial period. This trial will be the first randomized controlled trial to evaluate the effect of M-ROSE guiding treatment on mortality in patients with SHAP and may change the prevalence of multi-drug resistant bacteria.Ethics and disseminationThis trial adheres to the Declaration of Helsinki and guidelines of Good Clinical Practice. Signed informed consent will be obtained from all participants. The trial has been approved by the Chinese PLA General Hospital (Approval Number: 20220322001).Trial registrationClinicalTrials.gov NCT05300776. Registered on 25 March 2022.

Necrotizing fasciitis after total abdominal hysterectomy: A case report.

Necrotizing fasciitis is rapidly progressive infection with high mortality rate. This study aimed to summarize the clinical and pathological presentation of this case. A 46-year-old woman patient presented to our emergency department of an obstetric and gynecology clinic on the 8th day after total abdominal hysterectomy. The abdominal wall showed pronounced signs of inflammation. Abundant purulent content was oozing from the abdominal wound. The patient underwent surgery. Areas of necrosis were observed on the skin around the wound, the subcutaneous fatty tissue was necrotic around the incision site, and the fascia was completely dehisced. Wound debridement and flap cutting of the anterior abdominal wall were performed. Metronidazole, ceftriaxone, and vancomycin were administered intravenously. A plastic surgeon suggested daily debridement and toileting of the wound in the operating room. Swabs of the abdominal cavity, abscess cavity, and abdominal wound were obtained, and Enterococcus faecalis was isolated. After the negativism of microbiological swabs, excochleation of granulation tissue was performed by a plastic surgeon. Nineteen days after the relaparotomy, the patient was discharged in good general condition with advice for further monitoring and therapy. Successful treatment of necrotizing fasciitis can be achieved through an initial diagnosis, adequate debridement, empirical broad-spectrum antibiotic coverage, and multidisciplinary treatment.

Identify Drug-Resistant Pathogens in Patients with Community-Acquired Pneumonia.

A substantial increase in broad-spectrum antibiotics as empirical therapy in patients with community-acquired pneumonia (CAP) has occurred over the last 15 years. One of the driving factors leading to that has been some evidence showing an increased incidence of drug-resistant pathogens (DRP) in patients from a community with pneumonia, including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Research has been published attempting to identify DRP in CAP through the implementation of probabilistic approaches in clinical practice. However, recent epidemiological data showed that the incidence of DRP in CAP varies significantly according to local ecology, healthcare systems and countries where the studies were performed. Several studies also questioned whether broad-spectrum antibiotic coverage might improve outcomes in CAP, as it is widely documented that broad-spectrum antibiotics overuse is associated with increased costs, length of hospital stay, drug adverse events and resistance. The aim of this review is to analyze the different approaches used to identify DRP in CAP patients as well as the outcomes and adverse events in patients undergoing broad-spectrum antibiotics.

Fournier’s Gangrene: A Report of Two Cases and Literature Review

Fournier's gangrene is a severe surgical emergency that occurs worldwide. The mortality and morbidity of this condition have greatly decreased over time due to improvements in surgical methods and critical care treatment. For a successful result and to lessen the high mortality and morbidity of this condition, an early diagnosis that includes evaluation of predisposing and etiological factors, metabolic and physiological parameters, prompt resuscitation, aggressive surgical debridement, broad-spectrum antibiotic coverage, and continuous monitoring of all the parameters is essential.
 In this study, we present two patients who reported to the hospital with Fournier’s gangrene. Our first patient was a 47 year-old alcoholic whose gangrene involved the scrotum and perianal area and was successfully managed. The second case involved a 67-year-old man, a known diabetic on irregular treatment who presented with Fournier’s gangrene involving the scrotum. He made a full recovery, though the postoperative period was turbulent and prolonged.

The association between mortality and door-to-antibiotic time: a systematic review and meta-analysis.

Previous studies evaluating the impact of antibiotic timing on mortality in sepsis have shown conflicting results. We performed a meta-analysis to evaluate the association between door-to-antibiotic time (each hour of delay) and mortality in sepsis. We searched PubMed and Embase through 10 November 2022 to identity cohort studies that evaluated the adjusted association between door-to-antibiotic time (each hour of delay) and mortality in adult patients with sepsis. The primary outcome was mortality. Analysis was based on inverse-variance weighting using a fixed-effects model. The variances were derived from the logarithms of the reported confidence intervals (CIs) for associations. We estimated the odds ratio, 95% CI, and number needed to treat for the pooled data. Fifteen cohort studies involving 106 845 patients were included in the meta-analysis. Door-to-antibiotic time (each hour of delay) was associated with increased risk of mortality (odds ratio: 1.07; 95% CI: 1.06-1.08; P < 0.0001; number needed to treat = 91), with high heterogeneity (I2 = 82.2%). The association was robust in sensitivity analyses and consistent in subgroup analyses. No publication bias was found. In adult patients with sepsis, each hour of delay in antibiotic administration is associated with increased odds of mortality. Key messages What is already known on this topic Sepsis is a common and lethal syndrome that affects millions of people worldwide. The updated 2018 Surviving Sepsis Campaign guidelines recommended initiating empirical broad-spectrum antibiotic coverage within 1 hour of identification of sepsis and septic shock. Delay in antibiotic administration may increase the risk of mortality in patients with sepsis. What this study adds This meta-analysis evaluates and quantifies the association between door-to-antibiotic time (each hour of delay) and mortality in patients with sepsis. Each hour of delay in antibiotic administration is associated with increased odds of mortality in sepsis. The number needed to treat (NNT) with delayed antibiotic administration for one additional death was 91. How this study might affect research, practice, or policy: More efforts should be made to speed up the diagnosis of sepsis or sepsis shock.

Acute Spontaneous Colonic Perforation in a Case of Newly Confirmed Scleroderma: Case Report.

Scleroderma is a group of autoimmune diseases that principally affects the skin, blood vessels, muscles, and viscera. One of the more well-known subgroups of scleroderma is the limited cutaneous form of the multisystem connective tissue disorder known as CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasis) syndrome. In this report, we present a case of a spontaneous colonic bowel perforation in a patient with incomplete features of CREST. Our patient underwent a complicated hospital course involving broad-spectrum antibiotic coverage, surgical hemicolectomy, and immunosuppressives. She was eventually discharged home with a return to functional baseline status after esophageal dysmotility confirmation via manometry. Physicians managing patients with scleroderma ensuing to an emergency department encounter must anticipate the multitude of complications that can occur, as was seen in our patient. The threshold for pursuing imaging and additional tests, in addition to admission, should be relatively low, given the extremely high rates of complications and mortality. Early multidisciplinary involvement with infectious disease, rheumatology, surgery, and other respective specialties is crucial for patient outcome optimization.

Necrotizing fasciitis complicating perforated Meckel's diverticulum in a patient with acute lymphoblastic leukemia relapse: A case report

The occurrence of necrotizing fasciitis in children with acute lymphoblastic leukemia (ALL) has been reported with malignancies during granulocytopenic episodes from chemotherapy. Perforation of Meckel's diverticulum in children with leukemia is very rare. Only one case has been reported in the literature till now. A 10-year-old male presented with acute abdomen and was diagnosed with perforation peritonitis due to a perforated Meckel diverticulum receiving chemotherapy for relapse of B-cell ALL. In addition, the patient was a known case of celiac disease. Intraoperatively, due to the hemodynamic instability and thrombocytopenia, it was decided to perform a resection of the ileum bearing the pathology with a double-barrel ileostomy. He developed necrotizing fasciitis of the anterior abdominal wall due to Group A streptococci and overwhelming Gram-positive sepsis. The patient was managed comprehensively with multiple platelets concentrates, fasciotomy of the abdominal wall, and multiple debridements under the cover of broad-spectrum antibiotics. Histopathology of the resected Meckel's diverticulum showed ectopic gastric mucosa. Two months later, split-thickness skin grafting was performed. Early diagnosis and prompt surgical management may prevent mortality associated with both the delayed presentation of bowel perforation and necrotizing fasciitis in ALL patients.

Impact of Bridging Therapy on Infectious Complications Post CAR T-Cell Therapy: The UT Southwestern Experience

Background: CAR T-cell therapy (CAR T) has become a powerful new tool in the treatment of relapsed/refractory (r/r) hematologic malignancies. Infections are well-recognized risks of CAR T. Bridging therapy is often employed to allow patients to reach successful infusion but may also further immunosuppress this already vulnerable group. This study aims to identify patterns of infections post-CAR T and the potential impact of bridging therapy. Methods: Medical records of patients who underwent apheresis for CAR T from 2018-2022 for r/r lymphomas or multiple myeloma (MM) at UT Southwestern were analyzed. Demographics, treatment characteristics and infection data were collected via retrospective chart review. Post-CAR T infections were identified by reviewing patient hospitalizations after CAR T infusion for infectious complications confirmed by positive diagnostic studies during admission. Infections were categorized as bacterial, viral, fungal, or multi-pathogenic. Time-to-infection was calculated from lymphodepletion (LD) date. Categorical variables were compared using Fisher's exact test. Continuous variables were compared using Mann-Whitney U test. Overall- and progression-free survival (OS and PFS) were calculated from CAR T infusion date, estimated by the Kaplan-Meier method, and compared using a log-rank test. Results: Data were collected on 75 total patients, 44 with lymphoma and 31 with MM, who underwent apheresis and 74 (98.7%) underwent CAR T. Baseline patient characteristics are shown in Table 1. All patients received standardized opportunistic infection (OI) prophylaxis and intravenous immunoglobulin (IVIG) and growth factor support based on institutional guidelines. Thirty-eight patients (51%) had a post-CAR T infection. Post-CAR T infections manifested at a median of 117 days (range: 12 - 1344 days) after LD. Patients who received bridging therapy had an earlier median incidence of post CAR T infections (92 vs 113 days post-LD, p = 0.03). Number of prior lines of therapy did not predict infection rates or time to infection. Time-to-infection did not vary by lymphoma versus MM or by cytokine release syndrome (CRS) or immune effector cell-associated neurotoxicity (ICANS) grade. MM patients had a numerically higher rate of viral infections (77% vs 41%) while lymphoma patients had a higher bacterial infection rate (65% vs 55%). A majority (58%) of these patients had infectious events between 31- and 100-days post lymphodepletion [Figure 2]. Infection rates were not significantly associated with tocilizumab or steroid usage during CAR T. In our cohort, 77% of patients received bridging. Bridging therapy was associated with a significantly higher neutropenic fever rate (73% vs 37%, p = 0.006), which persisted after adjusting for prior lines of therapy. All patients with neutropenic fever received broad-spectrum antibiotic coverage. In lymphoma patients, bridging therapy was associated with higher grades of CRS (p = 0.018). Being hospitalized for infection within 6 months (p=0.01) or receiving antibiotics in the month (p=0.02) prior to lymphodepletion, were associated with grade ≥3 CRS. One-year PFS and OS were 55% and 74% for the entire cohort. Four patients died due to infectious complications after successful CAR T infusion at a median of 163 days post infusion. Patients who had post-CAR T infections trended towards worse progression-free survival (1-year PFS 65% vs 46%, p = 0.1) and had similar OS (1-year OS 70% vs 77%, p = 0.75). Conclusions: Bridging therapy prior to CAR T may increase the risk of neutropenic fever and be associated with earlier infectious risk. Febrile neutropenia and high-grade CRS drive more intensive resource utilization, which may be mitigated with more intentional patient selection for bridging therapy.Our findings show that post-CAR T infections contribute to significant morbidity, and thus calls for personalizing bridging strategies, peri-CAR T OI prophylaxis and infection management. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Infectious Complications of Abortion.

This article reviews the infectious complications of abortion (both spontaneous and induced) and the management of this condition. The key points are: (1) Making abortion illegal does not reduce its incidence or prevalence; rather, it only makes abortions unsafe, increasing the likelihood of infectious complications. (2) Timely recognition of developing sepsis in the pregnant patient is critical. This requires constant vigilance and a high index of suspicion. (3) Rapid intravenous administration of broad-spectrum antibiotics targeted to the likely intrauterine source of infection as soon as sepsis is diagnosed is critical to prevent severe sepsis, septic shock, and multisystem organ failure. (4) The mainstay of treatment is prompt evacuation of any residual products of conception from within the uterine cavity under broad-spectrum antibiotic cover targeting the likely intrauterine source of infection. (5) Prompt engagement of specialists in both critical care and obstetrics-gynecology is necessary to optimize outcomes in patients with septic abortion.

Community-Acquired Acinetobacter radioresistens Bacteremia in an Immunocompetent Host

Acinetobacter species are gram-negative coccobacilli ubiquitousin nature and widely distributed in the environment. Acinetobacter baumannii isa bacteria commonly seen in the hospital setting, responsible for causinga wide range of bloodstream infections, urinary tract infections, secondary meningitis, infective endocarditis, and wound infections, and is the cause of outbreaks mainly due to its antimicrobial resistance patterns. The use of broad-spectrum antibiotic coverage with carbapenems is essential in the hospital setting. Therefore, carbapenem-resistantAcinetobacter baumannii(CRAB) poses as a very challenging pathogen.Acinetobacter radioresistens, a rare species in comparison to the more prevalentAcinetobacter baumannii, isan underestimated agent in causing nosocomial infections and also is a potential disseminator of resistance genes.It is also resistant to gamma radiation at 4-8 times higher than other Acinetobacter spp. andis the source of the class D OXA-23 carbapenemase that can confer carbapenem resistance. Therefore,immediate and precise identification of A. radioresistens is crucial for the clinical management of multidrug-resistant bacteremia.

Clinical Approach to Nosocomial Bacterial Sepsis.

Bacterial sepsis and septic shock are associated with a high mortality, and when clinically suspected, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Thorough review of prior cultures involving multidrug-resistant (MDR) pathogens along with other likely pathogens should be performed to provide an appropriate broad-spectrum empiric antibiotic coverage. The appropriate antibiotic loading dose followed by individualized modification of maintenance dose should be implemented based on the presence of hepatic or renal dysfunction. Use of procalcitonin is no longer recommended to determine need for initial antibacterial therapy and for de-escalation. Daily reevaluation of appropriateness of treatment is necessary based on the culture results and clinical response. All positive cultures should be carefully screened for possible contamination or colonization, which may not represent the true organism causing the sepsis. Culture negative sepsis accounts for one-half of all cases, and de-escalation of initial antibiotic regimen should be done gradually in these patients with close monitoring.

A Fatal Case of Nocardia Bacteremia in a Lung Transplant Recipient

<h3>Introduction</h3> <i>Nocardia</i> bacteremia is an extremely rare disease. Although closely associated with immunocompromised states, only a few cases have been reported after lung transplant (LT). <h3>Case Report</h3> We present a case of <i>Nocardia</i> bacteremia in a 75-year-old man after bilateral LT (11/2017) for combined pulmonary fibrosis and emphysema. Nearing 3 years posttransplant, pulmonary function tests (PFTs) revealed an obstructive pattern with downtrending FEV₁ from baseline; work-up for acute cellular rejection, infection, and antibody-mediated rejection was unremarkable. Serial PFTs ultimately suggested CLAD-BOS phenotype, and he received photopheresis with some stabilization. However, over the next 2 months, he required 2 hospital admissions with need for high-dose intravenous steroids given hypercapnia in the setting of underlying rejection. At 38 months posttransplant, he developed lower extremity cellulitis and new-onset anorexia, generalized weakness, and rapid decline in mental status with need for a third hospitalization and mechanical ventilation with vasopressor support. Infectious work-up and empiric broad-spectrum antibiotic coverage were initiated. Within 12 hours, both blood cultures were positive for <i>Nocardia cyriacigeorgica</i> (Gram stain, <b>Figure A</b>). Meropenem and trimethoprim/sulfamethoxazole were substituted without clinical improvement over the next several days. Brain MRI ruled out cerebral nocardiosis; chest CT showed bibasilar consolidations with air space opacities. An echocardiogram estimated a left ventricular ejection fraction between 20-25% with severe diffuse hypokinesis, likely stress-induced cardiomyopathy, with no evidence of vegetations. Bronchoscopy revealed superinfection with pan-sensitive <i>Pseudomonas</i> spp, without isolation of <i>Nocardia</i> spp. The patient deteriorated and died 39 months after transplant. <h3>Summary</h3> <i>Nocardia</i> bacteremia, scarcely reported in LT recipients, portends a poor prognosis despite aggressive combination antimicrobial therapy.

The bacteriology of pleural infection (TORPIDS): an exploratory metagenomics analysis through next generation sequencing

SummaryBackgroundPleural infection is a common and severe disease with high morbidity and mortality worldwide. The knowledge of pleural infection bacteriology remains incomplete, as pathogen detection methods based on culture have insufficient sensitivity and are biased to selected microbes. We designed a study with the aim to discover and investigate the total microbiome of pleural infection and assess the correlation between bacterial patterns and 1-year survival of patients.MethodsWe assessed 243 pleural fluid samples from the PILOT study, a prospective observational study on pleural infection, with 16S rRNA next generation sequencing. 20 pleural fluid samples from patients with pleural effusion due to a non-infectious cause and ten PCR-grade water samples were used as controls. Downstream analysis was done with the DADA2 pipeline. We applied multivariate Cox regression analyses to investigate the association between bacterial patterns and 1-year survival of patients with pleural infection.FindingsPleural infection was predominately polymicrobial (192 [79%] of 243 samples), with diverse bacterial frequencies observed in monomicrobial and polymicrobial disease and in both community-acquired and hospital-acquired infection. Mixed anaerobes and other Gram-negative bacteria predominated in community-acquired polymicrobial infection whereas Streptococcus pneumoniae prevailed in monomicrobial cases. The presence of anaerobes (hazard ratio 0·46, 95% CI 0·24–0·86, p=0·015) or bacteria of the Streptococcus anginosus group (0·43, 0·19–0·97, p=0·043) was associated with better patient survival, whereas the presence (5·80, 2·37–14·21, p<0·0001) or dominance (3·97, 1·20–13·08, p=0·024) of Staphylococcus aureus was linked with lower survival. Moreover, dominance of Enterobacteriaceae was associated with higher risk of death (2·26, 1·03–4·93, p=0·041).InterpretationPleural infection is a predominantly polymicrobial infection, explaining the requirement for broad spectrum antibiotic cover in most individuals. High mortality infection associated with S aureus and Enterobacteriaceae favours more aggressive, with a narrower spectrum, antibiotic strategies.FundingUK Medical Research Council, National Institute for Health Research Oxford Biomedical Research Centre, Wellcome Trust, Oxfordshire Health Services Research Committee, Chinese Academy of Medical Sciences, and John Fell Fund.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Severe acute necrotising Community Acquired Pneumonia with Pyopneumothorax due to Pseudomonas aeruginosa in a healthy young girl

Aim: We report this case to acknowledge the presence of multi drug resistant Pseudomonas aeruginosa in the community setting, which transpired in a young female, without any known comorbidity or exposure risk.&#x0D; Background: Pseudomonas aeruginosa is an extremely unusual pathogen in community acquired pneumonia (CAP), especially in previously healthy young adults. Immune status, underlying lung disease and possible exposures like hot tub use, should always be ruled out. There have been reports of bacterial aetiology being next common after Tuberculosis for Pyopneumothorax, but ours is the first case to report P.aeruginosa as a cause of CAP and pyopneumothorax in an absolutely healthy young adult.&#x0D; Case description: A young female, developed Pneumonia from the community setting which grew a nosocomial organism. Complications involved cavity formation and Pyopneumothorax, which required Intercostal Drainage (ICD) and extensive intravenous antibiotics. Immediate and appropriate management is life saving.&#x0D; Conclusion: CAP due to heinous organisms like Pseudomonas aeruginosa should be suspected in any patient who presents with a rapidly progressive course, even in the absence of risk factors and exposures. In cases of Pleural effusion or Pneumothorax or both, ICD drain should be inserted. Broad spectrum antibiotic coverage especially in hemodynamically unstable patients should be initiated immediately, followed by antibiotic stewardship protocols.&#x0D; Clinical significance: We would like to emphasize the importance of acquiring cultures from respiratory site, for early initiation/switching of appropriate antibiotics. Also Pseudomonas being an ominous organism yields a finer prognosis only when treated with appropriate anti-pseudomonal antibiotics.

Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician

BackgroundSkin and soft tissue infections are common emergency department (ED) presentations. These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing fasciitis. Despite the commonality, a subset of skin and soft tissue infections known as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and mortality. ObjectiveThis review evaluates the current evidence regarding the presentation, evaluation, and management of NSTI from the ED perspective. DiscussionNSTIs are commonly missed diagnoses. History and physical examination findings are inconsistent, and the risk factors for this high mortality disease are common amongst ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis (LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging are highly sensitive and specific, but may delay definitive management. The gold standard for diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum antibiotic coverage are the foundations of treatment. Adjuvant therapies including hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial or to improve outcome. ConclusionNSTIs are associated with significant morbidity and mortality. Knowledge of the history, examination, evaluation, and management is vital for emergency clinicians.

A Case of Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis Masquerading as Septic Shock.

Trimethoprim-sulfamethoxazole-induced aseptic meningitis (TSIAM) is a rare adverse reaction to a commonly prescribed antibiotic. We describe a case of severe TSIAM which resembled septic shock. A 30-year-old male with relapsed Hodgkin's lymphoma 25 days status post autologous stem cell transplant presented to our clinic for evaluation of trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity. After review of patient's history and records, we had a low suspicion for a TMP-SMX adverse reaction and conducted an oral challenge to one 160 mg/800 mg tab of TMP-SMX. Four hours later, the patient developed vomiting, lightheadedness, and disorientation with progression to rigors, fever, tachycardia, and hypotension. He was admitted for fluid resuscitation and broad-spectrum antibiotic coverage for neutropenic fever and possible septic shock. A lumbar puncture performed due to complaints of headache, photophobia, and neck pain showed 375 white blood cells/µL with 73% neutrophil predominance, normal glucose (75 mg/dL), and elevated protein (101 mg/dL); additional cerebrospinal fluid (CSF) studies were negative for infectious etiologies. Fever and headache resolved by hospital day 4, at which time patient was discharged home. We believe this case represents TSIAM given the characteristic timing of symptom onset, CSF findings, and timing of symptom resolution without other clear etiology found on extensive infectious evaluation. It is important for allergists to recognize TSIAM, including its potential presentation as shock, in order to appropriately diagnose and counsel patients who seek evaluation for TMP-SMX adverse reactions.