Initiation Of Broad-spectrum Antibiotics Research Articles

Pink hypopyon in a patient with Serratia marcescens corneal ulceration.

A 65-year-old woman presented to the emergency ward at the Massachusetts Eye and Ear Infirmary with 2 days of redness, irritation, photophobia, and diminished vision in her left eye. She was found to have a large central corneal ulcer with a small hypopyon. On the following day, after initiation of broad-spectrum antibiotics, the patient had improved symptoms but now had a 2-mm hypopyon that was distinctly pink in color. Cultures were positive for Serratia marcescens. A pink hypopyon, a rare occurrence, alerted the authors to a causative agent of Enterobacteriacae, either Klebsiella or Serratia. Immediate and intensive treatment was subsequently initiated.

62-Year-Old Man With Persistent Postoperative Nausea and Vomiting

dicine, te ester, visor tant in linic, .). A 62-year-old man with a history of type 2 diabetes mellitus, hypogonadotropic hypogonadism (diagnosed 6 months before presentation), stage 3 chronic kidney disease, and coronary artery disease was admitted to the hospital for treatment ofmitral valve endocarditis. Broad-spectrum antibiotics, including vancomycin and rifampin, were initiated, and in addition, he underwent mitral valve replacement because of vegetations causing severe valvular stenosis. On hospital admission and initiation of broad-spectrum antibiotics, progressive nausea, vomiting, fatigue, and anorexia developed. These symptoms persisted for up to 15 days postoperatively. The symptoms were constant and not necessarily postprandial. He also had fevers and chills, but these symptoms resolved with antibiotic therapy. He reported no abdominal pain and had no history of abdominal surgery. His bowel movements remained regular. The patient had no symptoms of gastroesophageal reflux, headaches, or vertigo. His diabetes was recently diagnosed and was controlled with diet. His symptoms continued despite maximum doses of antiemetics. He had not had similar symptoms before the current episode. Vital signs on evaluation included a temperature of 37.1 C, heart rate of 65 beats/ min, blood pressure of 138/73 mm Hg, and oxygen saturation of 96% while breathing room air. On physical examination, the patient was cachexic and had generalized nonfocal weakness. His body mass index was 19 kg/m. His abdomen was soft, nondistended, and nontender, and normal bowel sounds were present. He had no rashes or lower extremity edema.

Diagnosis of autoimmune disease in the setting of immunodeficiency

Case A 41-year-old male presented with abdominal pain, diarrhea, weakness, and shock. He was diagnosed with cardiac tamponade, underwent pericardial drainage and initiation of broad-spectrum antibiotics. The patient had a recent admission with bilateral pleural effusions, with negative infectious and malignancy workup. Macrocytic anemia, increased white blood cells, incidental abdominal abscess and splenic infarcts were found during this admission. Investigations again demonstrated elevated white blood cells (53.8% neutrophils, 12.1% lymphocytes, 29.7% monocytes) and anemia. Autoimmune workup was unremarkable except for presence of atypical ANCA and lupus inhibitor. Bone marrow biopsy was non-specific. He had low IgM and IgG levels suggesting a diagnosis of Common Variable Immunodeficiency (CVID). He received intravenous Solumedrol after his respiratory status deteriorated. He improved and was transitioned to prednisone, but a pathogen was never found. His positive response to steroids with worsening symptoms with prednisone taper initiation suggested that this was an autoimmune process. He was started on Hydroxychloroquine and intravenous immunoglobulin by Rheumatology. However he was subsequently diagnosed with Chronic Myelomonocytic Leukemia (CMML) based on cytogenetic studies by Hematology. Current treatment includes hydroxyurea and prednisone. Discussion This patient demonstrates the challenge of diagnosing autoimmunity in a patient with low levels of immunoglobulins such as in CVID. How to interpret autoimmune antibody titres in autoimmune conditions is unknown. Most literature describes immunodeficiency being diagnosed after the autoimmune condition [1] and often after immunosuppressant use. Studies on systemic lupus erythematosus and CVID have shown low levels of autoantibodies after immunodeficiency diagnosis.

Nonchemotherapy Drug-Induced Neutropenia and Agranulocytosis

Drug-induced agranulocytosis is a severe complication that has been implicated with most classes of medications. Medications such as clozapine, trimethoprim-sulfamethoxazole and methimazole have been more commonly associated with agranulocytosis than other agents. Although the pathogenesis isn't fully elucidated, it appears to be two-fold with a direct toxicity to the myeloid cell line and immune-mediated destruction. Patients may be asymptomatic at the time neutropenia is discovered or may present with more severe complications such as sepsis. In approximately 5% of cases drug-induced agranulocytosis may be fatal. Management of drug-induced agranulocytosis includes the immediate discontinuation of the offending medication, initiation of broad-spectrum antibiotics and consideration of the use of granulocyte colony-stimulating factors in high-risk patients.

Systemic BCG-Osis as a Rare Side Effect of Intravesical BCG Treatment for Superficial Bladder Cancer

Intravesical Bacilli Calmette-Guérin (BCG) immunotherapy is a commonly used treatment for superficial bladder cancer. Although the treatment is well tolerated in 95% of cases, life-threatening side effects including BCG sepsis can occur. This report describes the case of an 82-year-old man with a background of lung disease. He developed septic shock and type two respiratory failure after receiving the sixth installation of intravesical BCG (TICE strain) immunotherapy for recurrent bladder Transitional Cell Carcinoma in situ. Despite the early initiation of broad spectrum antibiotics (tazocin and gentamicin), he remained pyrexial. There was a rapid deterioration, and on the second day of his admission, he developed type two respiratory failure secondary to Acute Respiratory Distress Syndrome (ARDS) prompting transfer to Intensive Care for Bilevel Positive Airway Pressure (BiPAP) Ventilation. The blood cultures taken before the induction of antibiotics results were negative. Increasing clinical suspicion of systemic BCG-osis prompted the initiation of antituberculosis therapy (ethambutol, isoniazid rifampicin) and steroids. Following six days of BiPAP and anti-tuberculosis therapy in ITU, his condition started to improve. Following a prolonged hospital stay he was discharged on long term ethambutol therapy. BCG-osis is a well-known though rare side effect of intravesical BCG therapy. We would like to highlight the importance of having a low threshold for starting anti-TB treatment.

A Necrotizing Wound After Caesarean Delivery

A previously healthy 23-year-old female developed a painful necrotizing wound approximately 5 days after a caesarean section (Fig. 1). Her laboratory results showed a leukocytosis of 43,200/mm³ (reference 4,500–11,000) and a C-reactive protein (CRP) level of 462 mg/L (reference 0–5 mg/L). Figure 1 Wound seen twenty-seven days postoperatively. Based on appearance and lack of clinical improvement after the initiation of broad spectrum antibiotics, a presumptive diagnosis of pyoderma gangrenosum (PG) was made. Cyclosporine therapy was initiated with prompt improvement of the wound (Figs. 2 and ​and33). Figure 2 Wound seen four days after the initiation of cyclosporine therapy. There was already an improvement with a diminished swelling of the surrounding skin and the disappearance of the erythematous margin. Figure 3 Wound seen fifty-five days after the start of cyclosporine therapy. PG is an uncommon skin disease that frequently presents as a painful ulcer. It is more frequent in women and has the highest incidence between 25 and 55 years of age. Approximately 50% of cases are associated with systemic diseases such as inflammatory bowel disease (mainly UC), rheumatoid arthritis, systemic lupus erythematosus and hematological malignancies or solid tumours of colon, bladder, breast, lung or ovarium 1,2. Minor trauma or surgery of the skin can initiate the pathologic process—called the ‘pathergy phenomenon’—although it is less frequently associated with a caesarean section 3. Diagnosis depends on clinical presentation, exclusion of other causes—such as infection, malignancy and vasculitis—as well as response to treatment. Biopsy in PG is non-specific but can be helpful to rule out other diseases. Corticosteroids are first-choice therapy and often lead to a rapid and persisting healing 1,4–6. In steroid refractory cases, immunomodulatory therapy such as cyclosporines (typically 5 mg/kg.day) may give long-lasting remission. Intravenous immunoglobulins, infliximab, mycophenolate mofetil, tacrolimus and plasmapheresis have been used.

Complications of obstructed labour: pressure necrosis of neonatal scalp and vesicovaginal fistula

In August 2004 a 16-year-old primigravida was referred to our regional hospital from a health centre with prolonged obstructed labour. She had been in labour with ruptured membranes for 3 days. The patient could not be transferred earlier because no transport was available. On admission she had fever (temperature 40°C) and foul-smelling meconium-stained discharge; the fetus was tachycardic. The cervix was fully dilated and the caput succedaneum was visible in the vulva. No signs of female genital cutting were present. Vacuum extraction with a 5 cm Malmstrom metal cup failed and after initiation of broad-spectrum antibiotics a caesarean section was done successfully. Mother and baby received prophylactic antibiotic treatment for 8 days. The baby boy did not show lacerations from the vacuum cup which had been normally positioned over the posterior fontanelle. The mothers urinary catheter was left in situ for 2 weeks for vesicovaginal fistula prophylaxis. (excerpt)

Bacterial tracheitis in children: Approach to diagnosis and treatment

Bacterial tracheitis is due to a secondary bacterial infection of the trachea, resulting in the formation of mucopurulent exudates that may acutely obstruct the upper airway, resulting in a life-threatening condition. Bacterial tracheitis should be considered in the differential diagnosis of any child with acute upper airway obstruction. This diagnosis should also be considered in any child with viral croup that is nonresponsive to conventional therapy. The only definitive way to diagnose bacterial tracheitis is by direct visualization of the trachea via bronchoscopy; however, this may not be required in all cases. Management includes close observation and monitoring, early initiation of broad spectrum antibiotics, pain management and aggressive airway clearance techniques. The decision to intubate should be individualized based on the severity of symptoms, age of child and accessibility of personnel skilled at emergency intubation techniques. If diagnosed and treated early, complete recovery is expected.

Serratia Marcescens Necrotizing Fasciitis in a Bone Marrow Transplant Patient

Serratia Marcescens Necrotizing Fasciitis in a Bone Marrow Transplant Patient

Fournier's gangrene: therapeutic impact of hyperbaric oxygen.

Many controversial issues exist surrounding the disease pathogenesis and optimal management of Fournier's gangrene. In Fournier's original descriptions, the disease arose in healthy subjects without an obvious cause. Most contemporary studies, however, are able to identify definite urologic or colorectal etiologies in a majority of cases. To investigate disease presentation, treatment modalities, and overall mortality, a retrospective analysis of Fournier's gangrene from a single institution is presented. Since 1990, 26 cases of Fournier's gangrene have been diagnosed at the University of Tennessee. An evaluation of intercurrent disease revealed that 38 percent of the patients had diabetes mellitus, 35 percent manifested ethanol abuse, and 12 percent were systemically immunosuppressed. Fifteen patients (58 percent) presented with identifiable etiologies for their disease: 31 percent (8) urethral disease or trauma, 19 percent (5) colorectal disease, and 8 percent (2) penile prostheses. Management in all cases involved prompt surgical debridement with initiation of broad-spectrum antibiotics. Multiple debridements, orchiectomy, urinary diversion, and fecal diversion were performed as clinically indicated. Fourteen patients received hyperbaric oxygen as adjuvant therapy. Statistically significant results were noted with mortality rates of 7 percent in the group receiving hyperbaric oxygen (n = 14) versus 42 percent in the group not receiving hyperbaric oxygen (n = 12). Overall mortality was 23 percent. Controversy still surrounds disease pathogenesis in Fournier's gangrene, particularly in regard to etiology. Our study corroborates current trends in that a clear focus or origin was identified in a majority of the cases. Although a grim prognosis usually accompanies the diagnosis, this study shows significant improvement combining traditional surgical and antibiotic regimens with hyperbaric oxygen therapy.