Cutaneous mucormycosis in a chronic lymphocytic leukemia patient on ibrutinib.

BACKGROUND: Mucorales is a zygomycete fungi known to cause opportunistic infections in immunosuppressed hosts. Spores may be inhaled, causing rhinocerebral or pulmonary infections, or gastrointestinal infections if swallowed. Less often, cutaneous mucormycosis develops after inoculation via broken skin. PRESENTATION: A 72-year old male on ibrutinib and prednisone for chronic lymphocytic leukemia (CLL) presented with localized, right forearm cutaneous mucormycosis at the site of a dog-scratch sustained three weeks prior. The patient failed to respond to cephalexin as an outpatient, prompting biopsy showing ribbon-like pseudo septate hyphae and possible vascular invasion suggestive of Mucorales. Treatment course included liposomal amphotericin B 5 mg/kg IV every 24 h for ten days followed by a 90-day course of posaconazole 300 mg daily after general surgery consultation was sought. CONCLUSION: We outline the second reported case of localized cutaneous mucormycosis arising in the setting of ibrutinib use. Because the combination of immunosuppressed states, ibrutinib and skin trauma may serve as a nidus for mucormycosis, practitioners should be vigilant of thorough skin evaluations in these patients and appropriate anti-fungal treatment. Although amphotericin B has been well studied as first line therapy, oral posaconazole has been shown as an efficacious second-line treatment.

Antimicrobial stewardship in the treatment of skin and soft tissue infections.

BACKGROUND: Research on treating skin and soft tissue infections (SSTI) has shown improved patient outcomes with effective pharmaceutic prescribing. Antimicrobial stewardship programs can reduce consequences of broad-spectrum antimicrobial administration in SSTI treatment. METHODS: Prospective and historic control data were collected during two 7-month periods. Intervention consisted of implementing a new SSTI evidence-based treatment algorithm and provider education, including calls and medical record notes targeted at physicians. RESULTS: Of 412 patients, 76 and 86 were found eligible from the historic and intervention groups, respectively. The intervention group had a higher prevalence of appropriate antibiotic usage (33% vs 19%, respectively; P = .04). There was a lower median number of days from intravenous antibiotic therapy to oral conversion (3 vs 5; P < .0001) and a lower median number of days of antipseudomonal antibiotic use (3 vs 5; P = .03) in the intervention group, respectively. The intervention group also had fewer documented SSTI treatment complications (1% vs 8%, respectively; P = .04). The positive outcomes outlined demonstrate potential impacts made from the use of multidisciplinary antibiotic stewardship initiatives. CONCLUSIONS: Appropriate use of antimicrobial agents under the direction of an antimicrobial stewardship program can lead to improved outcomes for patients being treated for SSTIs.

Knowledge, attitudes, and poultry-handling practices of poultry workers in relation to avian influenza in India.

UNLABELLED: Avian influenza (AI) is a viral disease of domestic and wild birds. The recent pandemics caused by highly pathogenic AIA (H5N1) in domestic poultry is currently rated phase 3 by the World Health Organization on the pandemicalert scale. MATERIALS AND METHODS: A pretested and semistructured survey instrument was administered to both live bird market and poultry farm workers in two most populous cities in Karnataka in South India to collect data on demographics, knowledge, attitude, and practices among them. RESULTS: The mean age was similar among both population groups (31.5 years). There was a higher level of biosecurity practices adopted in poultry farms compared with those adopted in live bird market. Knowledge regarding AI was acceptable but poorly correlated with actual biosecurity practices. DISCUSSION: Live bird market and poultry farm workers have been identified as the weakest link in the prevention and control of the spread of AI in the two most populous cities studied in Karnataka. CONCLUSION: Risk reduction models of behavior change targeting these groups are important toward the control and prevention of AI spread.