"Choosing Wisely Canada" and antimicrobial stewardship: A shared focus on reducing unnecessary care.

There is a growing movement in medicine which recognizes that some tests, treatments or procedures do not add value for patients, and may even cause harm. The "Choosing Wisely Canada" campaign is a grassroots, physician-led campaign to engage physicians and patients in conversations about overuse of unnecessary tests, treatments and procedures to improve the quality of health care. This article reviews the underlying principles of this campaign and its spread across Canada. It also highlights the alignment between the principles of Choosing Wisely Canada with those of antimicrobial stewardship, which share similar motivations, challenges and opportunities.

Thrombogenicity of radiofrequency ablation procedures: what factors influence thrombin generation?

AIMS: Thromboembolic complications have been reported after radiofrequency ablation but the low incidence of overt clinical events has been a limitation to the study of factors affecting thrombogenic risk. The aim of this study was to determine whether radiofrequency ablation has a procoagulant effect and to examine variables that affect thrombio generation. METHODS AND RESULTS: Thirty-seven consecutive patients who underwent radiofrequency ablation were studied prospectively. Blood samples were assayed for thrombin-antithrombin III (TAT) and d-dimer (DD) at five different time points: (1) baseline; (2) after sheath insertion; (3) after electrophysiological study but before radiofrequency ablation; (4) at completion of the procedure; and (5) 24 h post-procedure. TAT levels were within the normal range at baseline and increased significantly after sheath insertion from 2.1 +/- 1.2 microg l(-1) to 13.3 +/- 16.0 microg l(-1) (P<0.01). Levels increased further to 24.0 +/- 19.9 microg l(-1) (P<0.01) after electrophysiological study but did not increase after radiofrequency ablation. TAT normalized at 24 h. DD increased significantly from baseline values (230.2 +/- 176.8 ng ml(-1)) to 285.4 +/- 237.4 ng ml(-1) (P=0.019) after sheath insertion. There was a further significant increase after electrophysiological study to 423.4 +/- 324.3 ng ml(-1) (P<0.01), and a slight but non-significant increase to 464.4 +/- 307.4 ng ml(-1) after radiofrequency ablation (P=0.159). DD remained elevated at 24 h. Procedure duration was the only variable that correlated with the relative increase in TAT and DD. The patients with the longest procedure durations had more catheters inserted, more radiofrequency applications and largely consisted of accessory bypass tract-mediated tachycardias. Heparin administration significantly blunted the relative increase in TAT after radiofrequency ablation (P=0.005). CONCLUSION: Radiofrequency ablation procedures confer an increased risk of thrombosis. Catheterization and diagnostic study contribute largely to the thrombogenic stimulus. Thrombogenicity is increased in prolonged, complex procedures and is decreased in patients who have been administered heparin during the procedure.

Intramedullary abscess of the spinal cord in the antibiotic era: clinical features, microbial etiologies, trends in pathogenesis, and outcomes.

We review the clinical features, microbial etiologies, mechanisms of infection, and outcomes of 25 cases of intramedullary abscess of the spinal cord (IASC) reported between 1977 and 1997, the modern era. All patients presented with motor and/or sensory neurological deficits. Back pain and/or radicular pain was common (60%); fever was present in a minority (40%) of patients. Preexisting abnormalities of the spinal cord and/or vertebral column were present in 44% of cases. Contiguous spread of infection through a congenital dermal sinus was the mechanism of infection in 24% of cases. The infection was fatal in 8% of cases; persistent neurological deficits were documented in 70% of patients who survived. To assess the impact of antimicrobial therapy on the pathogenesis and outcomes of IASC, cases reported in the modern era are compared with 42 cases of IASC reported between 1830 and 1944, the preantibiotic era.

Pyogenic brain abscess caused by Streptococcus pneumoniae: case report and review.

While Streptococcus pneumoniae is the most common cause of bacterial meningitis in adults, cases of pneumococcal brain abscess have rarely been reported. We describe a case of otogenic brain abscess caused by S. pneumoniae that developed in a patient who was receiving ciprofloxacin for the empirical treatment of otitis media. We also review 23 additional cases of pyogenic brain abscess caused by S. pneumoniae that have previously been reported. The development of a pneumococcal brain abscess was associated with a contiguous intracranial focus of infection in 50% of cases. The majority of patients presented with headache (81%) and focal neurological deficits (86%). However, the classic triad of headache, fever, and focal neurological deficits was present in only 24% of patients. The mortality rate for patients with brain abscess caused by S. pneumoniae was 35%; persistent neurological deficits were documented in 40% of patients who survived.

Delayed diagnosis of acute rheumatic fever in adults: a forgotten cause of febrile polyarthritis.

Acute rheumatic fever is a nonsuppurative sequela of upper respiratory tract infection with group A streptococci. We describe our recent experience with the diagnosis and management of 3 cases of acute rheumatic fever to highlight the delays that may arise in the diagnosis of this condition. In adults, febrile polyarthritis is the most common presentation of acute rheumatic fever. Increased awareness on the part of the physician is necessary to ensure both prompt and accurate diagnosis of this cause of febrile polyarthritis.

Can ultrasound probes and coupling gel be a source of nosocomial infection in patients undergoing sonography? An in vivo and in vitro study.

OBJECTIVE: At our institution, ultrasound probes are wiped with a clean, dry, soft, absorbent paper towel after each procedure as a basic standard of probe disinfection. However, it was unclear if this provided a sufficient level of decontamination. This study was designed to determine if the ultrasound probe and coupling gel can act as a vector of nosocomial infection and to describe a cost-effective method of probe handling that allows optimal control of infection. SUBJECTS AND METHODS: In the first part of the study, the ultrasound probe was exposed to the disrupted skin of patients recruited from our inpatient population, using our routine scanning technique to look for subcutaneous collections. Twenty-seven patients were scanned: 17 with surgical wounds, seven with surgical drains, four with enteric stomas, three with biopsy sites, and three with ulcers or excoriation. Fifteen patients had a discharge associated with their disrupted skin, and seven patients had culture-proved skin infections. Each probe was wiped with a clean, dry paper towel after scanning, then immersed in a brain-heart infusion (BHI) broth, and the solution was cultured. In the second part of the study, the ultrasound probe was exposed to a large inoculum of bacteria. Sixty-one probes were used to scan fields of confluent growth of bacteria on agar plates. Twenty-six probes were cleaned by wiping with a dry, clean paper towel, and 25 probes were cleaned by wiping with a dry, clean paper towel followed by immersion in Hibidil (0.05% chlorhexidine weight/volume). Ten probes functioned as controls and were not cleaned after exposure to the bacteria. Each probe was then immersed in BHI broth, and the solution was cultured. In the third part of the study, the coupling gel was evaluated as a culture medium for bacterial growth. Twenty-five agar plates were inoculated with a confluent growth of bacteria. Half of the surface of each agar plate was covered with coupling gel, and the remaining surface was left unexposed. The resulting bacterial growth on each side of the plates was compared. RESULTS: One of the 27 probes exposed to patients with disrupted skin grew Staphylococcus epidermidis (skin flora). For probes exposed to a large inoculum of bacteria, we found no statistically significant difference in the number of probes that showed bacterial growth on culture between probes cleaned by wiping with a towel and those cleaned with Hibidil. Furthermore, the resulting bacterial growth in both sets of probes was scant and was not considered clinically significant. All 10 control probes showed clinically significant growth in all cases. As for evaluation of the coupling gel as a culture medium, the gel permitted bacterial growth and did not show any evidence of bacteriocidal or bacteriostatic properties. CONCLUSION: Ultrasound probes that are wiped with a paper towel until they are visibly clean do not contribute to nosocomial infections. Additional antiseptic solutions such as Hibidil are not necessary. We suggest that probes be simply wiped with a clean, dry, nonsterile paper towel between procedures, including probes used on contaminated scanning fields, open wounds, and cutaneous infections. After the final procedure of the day, probes should be cleaned with a liquid cleaning solution such as Hibidil to remove all traces of coupling gel, which could support the overnight growth of bacteria. This would decontaminate the probes and prevent the overnight growth of bacteria. This method would be both a cost-effective and time-efficient protocol for controlling infection.

Use of fluconazole in the treatment of candidal endophthalmitis.

Candidal endophthalmitis is a sight-threatening ocular infection that most frequently occurs as a complication of candidemia. While amphotericin B is considered the gold standard for the treatment of most invasive fungal infections, the optimal management of candidal endophthalmitis has not been determined. Fluconazole, a triazole antifungal agent, has been shown to be effective in the management of a number of invasive fungal infections in both immunocompromised and immunocompetent hosts. We describe the clinical features and outcomes for six patients with candidal endophthalmitis who were treated with fluconazole at our institutions, and we review 21 additional cases reported in the English-language literature. In total, fluconazole has been used as the sole therapy for candidal endophthalmitis in 14 patients; 16 eyes were infected. Endophthalmitis was cured in 15 of 16 eyes (94%), including five infections that were complicated by vitreitis. Successful treatment required the administration of fluconazole (100-200 mg po) daily for approximately 2 months. In addition, fluconazole has been used in combination with pars plana vitrectomy for the successful treatment of four cases of candidal endophthalmitis that were complicated by moderate to severe vitreitis. Fluconazole appears to be a safe and effective alternative or addition to conventional treatments for the management of candidal endophthalmitis. Prospective evaluation is required to more clearly define the role of this antifungal agent in the management of ocular infections due to Candida species.

Successful treatment of systemic and local infections due to Exophiala species.

We report the successful treatment of three cases of infection due to Exophiala species. These organisms belong to the heterogeneous group of dematiaceous (darkly pigmented) fungi. Two cases of infection occurred in organ transplant recipients who were receiving immunosuppressive medications. Both of these infections remained localized to the subcutaneous tissues and were successfully treated with surgical excision of the lesions. We also describe what is to our knowledge the first reported case of prosthetic valve endocarditis due to Exophiala castellanii that was managed with a combination of medical and surgical therapies. Exophiala species remain an uncommon cause of infection. However, as the population of immunocompromised patients continues to grow and further improvements in the microbiological techniques for identification of these fungi occur, these organisms will be recognized with increasing frequency as a cause of human disease.

Multifocal osteoarticular tuberculosis: report of four cases and review of management.

We report the clinical, microbiological, and radiological features of four cases of multifocal osteoarticular tuberculosis, and we review the management of this condition. In each case the initial clinical diagnosis was one of malignant disease, and the possibility of tuberculous bone infection was overlooked. There was neither clinical nor radiological evidence of pulmonary involvement in any case. Antituberculous chemotherapy was initiated in two instances on the basis of histopathologic findings compatible with tuberculous osteomyelitis; such treatment was delayed in the other two cases until the diagnosis was confirmed by culture. Antituberculous chemotherapy alone was successful in three cases, while the fourth case required emergency anterior spinal decompression as well. Two patients developed additional skeletal lesions after the initiation of appropriate antituberculous chemotherapy. Multifocal osteoarticular tuberculosis must be considered in the differential diagnosis of multiple destructive skeletal lesions in all patients from areas where tuberculosis is endemic. This condition may mimic malignant disease both clinically and radiologically.

Aeromonas hydrophila infections of skin and soft tissue: report of 11 cases and review.

We report the clinical and microbiological characteristics of 11 cases of Aeromonas hydrophila infection of skin and soft tissue, and we review the English-language literature on such infections. Of our 11 patients, seven (64%) presented to the hospital between the months of May and September (inclusive). Three patients (27%) had an underlying systemic illness, and two (18%) had nosocomially acquired infection. The nine patients with community-acquired infection had all experienced antecedent trauma, and seven (78%) of these nine reported recent exposure to freshwater. All patients had clinical evidence of soft-tissue inflammation, and nine (82%) had fever. Four wounds were characterized by a foul odor. The infection was polymicrobial in nine cases (82%). Treatment included the administration of antibiotics in nine instances, but empirical antimicrobial therapy provided coverage against Aeromonas in only two cases. Ten patients required surgical management of their wounds. Posttraumatic wound infections with a history of freshwater exposure should alert the clinician to the possible presence of A. hydrophila. Prompt surgical evaluation of wounds in combination with appropriate antibiotic therapy is recommended for the management of these infections.