Palraj, Raj

Abstract Background Infective endocarditis (IE) is the most feared complication of Staphylococcus aureus bacteremia (SAB). Transesophageal echocardiogram (TEE) is generally recommended for all patients with SAB; however, supporting data for this are limited. We previously developed a scoring system, “PREDICT,” that quantifies the risk of IE and identifies patients who would most benefit most from undergoing TEE. The current prospective investigation aims to validate this score. Methods We prospectively screened all consecutive adults (≥18 years) hospitalized with SAB at 3 Mayo Clinic sites between January 2015 and March 2017. Results Of 220 patients screened, 199 with SAB met study criteria and were included in the investigation. Of them, 23 (11.6%) patients were diagnosed with definite IE within 12 weeks of initial presentation based on modified Duke’s criteria. Using the previously derived PREDICT model, the day 1 score of ≥4 had a sensitivity of 30.4% and a specificity of 93.8%, whereas a day 5 score of ≤2 had a sensitivity and negative-predictive value of 100%. Additional factors including surgery or invasive procedure in the past 30 days, prosthetic heart valve, and higher number of positive blood culture bottles in the first set of cultures were associated with increased risk of IE independent of the day 5 risk score. Conclusions We validated the previously developed PREDICT scoring tools for stratifying risk of IE, and the need for undergoing a TEE, among cases of SAB. We also identified other factors with predictive potential, although larger prospective studies are needed to further evaluate possible enhancements to the current scoring system.

Background: Antibiotic therapy with a macrolide and β-lactam or a fluoroquinolone for the empirical treatment of community-acquired pneumonia (CAP) in an inpatient non–intensive care setting is recommended per guidelines. Studies show that these treatments have similar outcomes, including death, adverse effects, and bacterial eradication. However, a comparison of 30-day readmission rates between these treatments is limited. Study Question: To determine whether 30-day readmissions for patients treated for CAP in a regional hospital differed between a fluoroquinolone monotherapy and a β-lactam plus macrolide combination therapy. Study Design: Retrospective cohort study of patients aged ≥18 years with a CAP diagnosis who were admitted to the same regional hospital from December 1, 2011, through December 1, 2016. Measures and Outcomes: Patients receiving a third-generation cephalosporin plus macrolide were compared with those receiving a respiratory fluoroquinolone. Exclusion criteria were concurrent or recent use of the study antibiotics; death, transfer, or transition to hospice; and diagnosis of hospital-acquired pneumonia or health care–associated pneumonia. The collected data were 30-day readmission rates, antibiotic regimens, demographic characteristics, and pneumonia severity index and comorbidity scores. Association between treatment group and readmissions was assessed with logistic regression. Association between readmissions and individual data points between the 2 treatment groups was calculated with multivariate regression and odds ratio (95% confidence interval). Results: Of 432 patients, 171 met inclusion criteria (fluoroquinolone group, n = 101; β-lactam plus macrolide group, n = 70). Thirty-day readmissions were not significantly different between the fluoroquinolone group and β-lactam plus macrolide group (P = 0.58). Increased 30-day readmissions were independently associated with male sex and hospital length of stay (P < 0.05). Length of stay was approximately 3 days and did not differ between treatment groups. Conclusions: No difference was seen in 30-day readmissions between CAP patients who received fluoroquinolone monotherapy and those who received β-lactam plus macrolide combination therapy.

Lactobacilli are common commensal bacteria found in the gastrointestinal and genitourinary tract. Although they are usually thought to be nonpathogenic, there have been several cases that demonstrate severe infections caused by these microorganisms. This is a case of a 49-year-old male with previously undiagnosed type two diabetes mellitus who presented with a 3-month history of cough and was found to have right sided Lactobacillus gasseri empyema for which he underwent video-assisted thoracoscopic surgery (VATS) with chest tube placement. He subsequently developed a left sided pleural empyema for which the aspiration also grew out L. gasseri. The patient made a complete recovery and was seen for four months in follow-up after his initial presentation.

A 66-year-old, Caucasian male presented with pain and swelling involving the left knee of one-week duration. Arthrocentesis was negative for evidence of septic arthritis. Magnetic resonance imaging (MRI) study of the left knee showed degenerative arthritis, partial tear of medial meniscus, and a complex fluid collection along the posteromedial aspect of the left knee suggestive of popliteal cyst. He underwent arthroscopy with partial medial meniscectomy. Intraoperative joint fluid was noted to be cloudy but cultures were negative. Arthroscopic procedure provided him with temporary relief but the pain and swelling in the posterior aspect of the left knee recurred in 6 weeks. Repeat MRI showed complex fluid collection in the posterolateral aspect of left knee. Ultrasound guided aspiration of the fluid collection revealed purulent material and cultures grewActinomyces meyeri. He was treated with 6 weeks of intravenous penicillin regimen followed by 18 months of oral penicillin.

A 65-year-old woman with osteoarthritis, who underwent knee replacement 5 years prior, developed sudden onset knee pain and swelling. She had voluntarily starting a vigorous dental flossing regimen prior to the onset of symptoms. The patient underwent right knee arthrotomy, irrigation and debridement of right total knee arthroplasty and exchange of polyethylene with retention of the prosthesis. Intraoperative cultures grew Streptococcus gordonii. She was treated with 6 weeks of ceftriaxone and was later placed on oral antibiotic suppression.

Background— Prompt recognition of underlying cardiovascular implantable electronic device (CIED) infection in patients presenting with Staphylococcus aureus bacteremia (SAB) is critical for optimal management of these cases. The goal of this study was to identify clinical predictors of CIED infection in patients presenting with SAB and no signs of pocket infection. Methods and Results— All cases of SAB in CIED recipients at Mayo Clinic from 2001 to 2011 were retrospectively reviewed. We identified 131 patients with CIED who presented with SAB and had no clinical signs of device pocket infection. Forty-five (34%) of these patients had underlying CIED infection based on clinical or echocardiographic criteria. The presence of a permanent pacemaker rather than an implantable cardioverter-defibrillator (odds ratio, 3.90; 95% confidence interval, 1.65–9.23; P =0.002), >1 device-related procedure (odds ratio, 3.30; 95% confidence interval, 1.23–8.86; P =0.018), and duration of SAB ≥4 days (odds ratio, 5.54; 95% confidence interval, 3.32–13.23; P <0.001) were independently associated with an increased risk of CIED infection in a multivariable model. The area under the receiver operating characteristics curve for the multivariable model was 0.79, indicating a good discriminatory capacity to distinguish SAB patients with and without CIED infection. Conclusions— Among patients presenting with SAB and no signs of pocket infection, the risk of underlying CIED infection can be calculated based on the type of device, number of device-related procedures, and duration of SAB. We propose that patients without any of these high-risk features have a low risk of underlying CIED infection and may be monitored closely without immediate device extraction. Prospective studies are needed to validate this risk prediction model.