Septicemia secondary to Vibrio cholerae (non-O1/non-O139) in wound.

A 63-year-old woman with a prior history of chronic lower extremity lymphedema came to the hospital for evaluation of new-onset left leg pain and swelling associated with haemorrhagic blisters and foul-smelling discharge. Relevant history included a recent trip to a Hudson River Valley beach in New York 1 week prior to hospitalisation. Laboratory evaluation revealed significant leukocytosis and lactic acidosis. She was found to have sepsis and bacteremia secondary to Vibrio cholerae (serotype non-O1, non-O139). During a prolonged intensive care unit course requiring intravenous pressor support and broad-spectrum antibiotics, she underwent debridement of her left foot eschar along with skin grafting. Once clinically stable and improved, she was discharged to a subacute rehabilitation centre with close follow-up for wound care. V. cholerae infection is rare and often benign but can be transmitted from contaminated seawater to individuals with underlying chronic illness and cause severe symptoms, including sepsis.

A unique approach to faculty development using an Observed Structured Teaching Encounter (OSTE).

We have challenges with poor patient satisfaction scores (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) and internal medicine resident (IMR) evaluations of voluntary attending physicians. Using an Observed Structured Teaching Encounter (OSTE), we designed a faculty development project that focused on attendings' teaching and feedback skills. To assess attending communication with interns and improve attending teaching and feedback skills. All IM attendings on the Long Island Jewish Forest Hills (LIJFH) Emergency Department (ED) call schedule participated. OSTE simulation sessions included two clinical scenarios, standardized patients (SPs), fourth-year medical students trained as 'interns,' OSTE checklists, and debriefing. We analyzed 'intern' ratings of communication with attendings and attending self-assessment during the OSTE, and attending HCAHPS scores and IMR evaluations of attendings pre- and post-OSTE. Twenty-nine of 29 attendings completed the OSTE. Although an increase was demonstrated pre- to post- for 'intern' OSTE ratings of attendings and LIJFH attending self-assessment ratings, there was no statistically significant difference. Mean HCAHPS scores and resident evaluations of attendings also increased from pre- (22% and 3.59) to post-OSTE (30% and 3.87) but did not reach statistical significance. A statistically significant difference for both cases was demonstrated when comparing mean attending self-assessment ratings with 'intern' evaluation of attendings. Attending teaching/feedback skills improved between cases, attending self-ratings were higher than 'intern' ratings of attendings. HCAHPS and IMR evaluations of attendings improved post-OSTE. Regular intervention utilizing an OSTE may provide a sustained benefit for enhancing attendings' skills, patient satisfaction, and resident training.

Antimicrobial Resistant Streptococcus pneumoniae: Prevalence, Mechanisms, and Clinical Implications.

BACKGROUND: Streptococcus pneumoniae is a major cause of pneumonia, meningitis, sepsis, bacteremia, and otitis media. S. pneumoniae has developed increased resistance to multiple classes of antibiotics. STUDY DESIGN: Systematic literature review of prevalence, mechanisms, and clinical implications in S. pneumoniae resistance. AREAS OF UNCERTAINTY: Since S. pneumoniae resistance to penicillin was first reported with subsequent development of resistance to other classes of drugs, selection of appropriate antibiotic treatment is challenging. DATA SOURCES: We searched PubMed (English language) for citations to antibiotic resistance in S. pneumoniae published before March 1, 2016. RESULTS: We present a review of S. pneumoniae resistance to beta-lactams, macrolides, lincosamides, fluoroquinolones, tetracyclines, and trimethoprim-sulfamethoxazole (TMP-SMX). There has been a steady decline in susceptibility of S. pneumoniae to commonly used beta-lactams. Phenotypic expression of penicillin resistance occurs as a result of a genetic structural modification in penicillin-binding proteins. Between 20% and 40% of S. pneumoniae isolates are resistant to macrolides. Macrolide resistance mechanisms include ribosomal target site alteration, alteration in antibiotic transport, and modification of the antibiotic. Approximately 22% of S. pneumoniae isolates are resistant to clindamycin. Similar to macrolide resistance, clindamycin involves a target site alteration. The prevalence of fluoroquinolone resistance is low, although increasing. S. pneumoniae resistance to fluoroquinolones occurs by accumulated mutations within the bacterial genome, increased efflux, or acquisition of plasmid-encoded genes. S. pneumoniae resistance has also increased for the tetracyclines. The primary mechanism is mediated by 2 genes that confer ribosomal protection. The prevalence of TMP-SMX resistance is around 35%. As with fluoroquinolones, resistance to TMP-SMX is secondary to mutations in the bacterial genome. CONCLUSIONS: Effective treatment of resistant S. pneumoniae is a growing concern. New classes of drugs, newer formulations of older drugs, combination antibiotic therapy, nonantibiotic modalities, better oversight of antibiotic usage, and enhanced preventive measures hold promise.