Citations

Background— The American Heart Association published updated guidelines for infective endocarditis (IE) prevention in 2007 that markedly restricted the use of antibiotic prophylaxis in certain at-risk patients undergoing dental and other invasive procedures. The incidence of IE caused by viridans group streptococci (VGS) in the United States after publication of the 2007 American Heart Association guidelines has not been reported. Methods and Results— We performed a population-based review of all definite or possible cases of VGS-IE using the Rochester Epidemiology Project of Olmsted County, Minnesota. Patient demographics and microbiological data were collected for all VGS-IE cases diagnosed from January 1, 1999, through December 31, 2010. We also examined the Nationwide Inpatient Sample hospital discharge database to determine the number of VGS-IE cases included between 1999 and 2009. We identified 22 cases with VGS-IE in Olmsted County over the 12-year study period. Rates of incidence (per 100 000 person-years) during time intervals of 1999–2002, 2003–2006, and 2007–2010 were 3.19 (95% confidence interval, 1.20–5.17), 2.48 (95% confidence interval, 0.85–4.10), and 0.77 (95% confidence interval, 0.00–1.64), respectively ( P =0.061 from Poisson regression). The number of hospital discharges with a VGS-IE diagnosis in the Nationwide Inpatient Sample database during 1999–2002, 2003–2006, and 2007–2009 ranged between 15 318 to 15 938, 16 214 to 17 433, and 14 728 to 15 479, respectively. Conclusions— On the basis of data complete through 2010, there has been no perceivable increase in the incidence of VGS-IE in Olmsted County, Minnesota, since the publication of the 2007 American Heart Association endocarditis prevention guidelines.

SummaryBackgroundCommunity‐acquired Clostridium difficile infection (CA‐CDI) is an increasingly appreciated condition. It is being described in populations lacking traditional predisposing factors that have been previously considered at low‐risk for this infection. As most studies of CDI are hospital‐based, outcomes in these patients are not well known.AimTo examine outcomes and their predictors in patients with CA‐CDI.MethodsA sub‐group analysis of a population‐based epidemiological study of CDI in Olmsted county, Minnesota from 1991–2005 was performed. Data regarding outcomes, including severity, treatment response, need for hospitalisation and recurrence were analysed.ResultsOf 157 CA‐CDI cases, the median age was 50 years and 75.3% were female. Among all CA‐CDI cases, 40% required hospitalisation, 20% had severe and 4.4% had severe‐complicated infection, 20% had treatment failure and 28% had recurrent CDI. Patients who required hospitalisation were significantly older (64 years vs. 44 years, P < 0.001), more likely to have severe disease (33.3% vs. 11.7%, P = 0.001), and had higher mean Charlson comorbidity index scores (2.06 vs. 0.84, P = 0.001). They had similar treatment failure and recurrence rates as patients who did not require hospitalisation.ConclusionsCommunity‐acquired Clostridium difficile infection can be associated with complications and poor outcomes, including hospitalisation and severe Clostridium difficile infection. As the incidence of community‐acquired Clostridium difficile infection increases, clinicians should be aware of risk factors (increasing age, comorbid conditions and disease severity) that predict the need for hospitalisation and complications in patients with community‐acquired Clostridium difficile infection.

Abstract INTRODUCTION: Surgical site infection (SSI) is a problematic cause of morbidity following breast/axillary surgery. The breast/axilla has a higher rate of SSI than expected for clean wounds. We evaluated risk factors associated with SSI after breast/axillary operations. Methods: A retrospective review of breast/axillary procedures from July 2004 to July 2006 was performed. SSI was defined using Centers for Disease Control and Prevention criteria, including cases with cellulitis as the only criterion of infection. Data collected included patient demographics, BMI, surgical procedure, ASA class, antibiotic use, drains, and prior radiation (RT). RESULTS: We identified 389 patients who underwent 678 procedures. Thirty-seven SSI (5.5% of procedures) were identified, of which 24 (65%) had only cellulitis. Median time from surgery to SSI diagnosis was 9 days (range 2-112), with 81% occurring in the first 30 days. Univariate analysis identified prior RT, BMI, type of procedure, operative time, use of drain, and postoperative seroma to be associated with SSI (all P&lt;0.05). With multivariate analysis, procedure type remained significant overall (p=0.04). Specifically, mastectomy with sentinel lymph node biopsy (SLNB) and modified radical mastectomy remained significantly associated with higher risk of SSI, with hazard ratios (HR) of 6.3 and 13.5 fold respectively compared to SLNB alone. Seroma (HR 9.0, 95% CI 2.7-29.3), prior RT (HR 3.4, 1.2-9.9), and BMI &gt;=30 (HR 3.1, 1.6-6.2) also remained significantly associated with SSI. CONCLUSION(S): SSI are more frequent after breast/axillary operations than other clean wounds and are associated with prior RT, obesity, more extensive and longer procedures, and postoperative seroma. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-10.

Abstract Abstract #3103 Introduction: Lymphedema is well-known in the arm but can also occur in the breast. Diagnosis is currently non-standardized and based on clinical impression. We sought to determine if skin thickness could serve as a useful measure in the diagnosis of breast lymphedema (BLE).&#x2028; Methods: Patients undergoing unilateral non-mastectomy procedures were enrolled on this prospective clinical study preoperatively and evaluated for signs and symptoms of lymphedema in the operated breast in the postoperative period. Patients with established BLE were also studied. BLE diagnosis was independent of ultrasound findings and was based on a graded physical exam targeting clinical signs of edema and erythema. Skin thickness was measured with ultrasound at the 6 o'clock position of both breasts. Differences in skin thickness were assessed by the ratio of skin thickness in the operated and contralateral breasts, with comparison of means by two-sample t-test. Receiver operating characteristic curves were constructed to estimate the area under the curve (AUC) and to determine optimal cutpoints.&#x2028; Results: Ninety-seven women were studied; 85 were enrolled preoperatively and 12 postoperatively after a diagnosis of BLE. Median length of follow-up overall was 8 months. Of the 97 women, 46 had BLE at one or more follow-up visit with median time to first diagnosis of 3 months. Mean measured skin thickness was 2.3 ± 0.5mm in unaffected breasts and 3.2 ± 1.0 mm in operated breasts. Women with BLE had significantly greater skin thickness in the operated breast compared to the contralateral breast, with a mean skin thickness ratio of 1.83 ± 0.57 in patients with BLE compared to 1.18 ± 0.40 among those without BLE (p&lt;0.0001). Skin thickness ratio provided excellent discrimination for BLE, with an area under the curve (AUC) of 0.86. At a ratio of 1.32 or greater (32% greater skin thickness in operated versus contralateral breast), sensitivity and specificity for diagnosing BLE were 81% and 82% respectively. A single measure of skin thickness in the operated breast also correlated well with diagnosis of BLE, with skin thickness of 3.2 mm or greater demonstrating sensitivity of 78% and specificity of 82%, AUC 0.82.&#x2028; Conclusions: Breast lymphedema results in skin edema and increased skin thickness that can be quantified with ultrasound. Measuring breast skin thickness- either as a single reading or as a ratio to the unaffected breast- may be useful in the diagnosis of breast lymphedema. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3103.

Background— Infection is a serious complication of cardiovascular implantable electronic device (CIED) placement and requires device removal for attempted cure. Methods and Results— We studied the rate, risk factors, and outcomes of CIED infection in 74 consecutive patients with bacteremia caused by Gram-positive cocci (GPC) other than Staphylococcus aureus between 2001 and 2007. CIED infection was defined as the presence of signs of infection at the generator site, lead vegetations seen on echocardiography, or microbiological growth from device cultures. Twenty-two (30%) of 74 patients with non– S aureus GPC bacteremia had CIED infections. Coagulase-negative staphylococci (CoNS) accounted for 73% of CIED infections. The rate of CIED infection in patients with CoNS bacteremia was almost 2-fold that of non-CoNS GPC bacteremia (36% versus 20%, P =0.13). The number of leads, the presence of abandoned leads, and prior generator replacement were associated with CIED infection. Among 33 patients without identifiable CIED infection at initial evaluation who did not undergo device removal, 5 (15%) had relapsing bacteremia within 12 weeks of completing antibiotic therapy. CoNS accounted for all relapses, and none had evidence of CIED infection at relapse. Conclusions— Patients with a CIED and bacteremia caused by GPC other than S aureus frequently had evidence of underlying CIED infection on clinical evaluation that included transesophageal echocardiography. This was particularly true among those with CoNS bacteremia. No evidence of underlying CIED infections was identified in the subgroup of patients who did not have manifestations of CIED infection on initial evaluation but subsequently had relapsing bacteremia caused by CoNS.

ABSTRACT The role of combination antibiotic therapy with a beta-lactam and a fluoroquinolone for bacteremia caused by gram-negative bacilli, to our knowledge, has not been previously described. Much of the previous study of combination therapy has included beta-lactams and aminoglycosides. We conducted a large retrospective cohort study to evaluate 28-day all-cause mortality in patients with monomicrobial bacteremia due to aerobic gram-negative bacilli who received either a combination of beta-lactams and fluoroquinolones or beta-lactam monotherapy. We enrolled adult patients admitted to Mayo Clinic hospitals from 1 January 2001 to 31 October 2006 in the study. After stratification of patients by Pitt bacteremia scores, we used Cox regression models to estimate the hazard ratios (HR) for 28-day all-cause mortality after adjusting for the propensity to receive combination therapy. We identified 398 and 304 unique patients with bacteremia caused by gram-negative bacilli who received single and combination antibiotic therapy, respectively. In less severely ill patients with Pitt bacteremia scores of <4, combination therapy was associated with lower 28-day mortality than single therapy (4.2% [9 of 214] versus 8.8% [28 of 319]; adjusted HR, 0.44; 95% confidence interval [CI], 0.20 to 0.98; P = 0.044). In critically ill patients with Pitt bacteremia scores of ≥4, there was no difference in 28-day mortality between combination and single therapy (25.6% [23 of 90] versus 27.8% [22 of 79]; adjusted HR, 0.87; 95% CI, 0.47 to 1.62; P = 0.660). These findings were consistent for 14-day all-cause mortality. In this large cohort, we found for the first time that combination therapy with beta-lactams and fluoroquinolones was associated with a reduction in 28-day all-cause mortality among less severely ill patients with bacteremia caused by gram-negative bacilli.

ABSTRACT In a retrospective review of 24 patients with histoplasmosis, blastomycosis, or coccidioidomycosis treated with voriconazole (most for salvage therapy), the outcome was favorable (improved or stable) for 22 (95.8%) within 2 months of starting voriconazole and for 20 (83.3%) at the last follow-up. Prospective studies are required to determine its role in the treatment of endemic mycoses.