A Case of Ertapenem-Induced Delirium.

Ertapenem is a carbapenem antibiotic that is typically prescribed in cases of moderate-to-severe infections, especially ones involving abscess formation. We describe the case of an 82-year-old gentleman who presented with osteomyelitis and abscess formation who developed delirium after 15 days of ertapenem treatment. The patient experienced delusions, insomnia, agitation, and disorientation. The patient's mental status improved and returned to his baseline within 48 hours of halting ertapenem treatment. A high index of suspicion is required to identify and treat ertapenem-induced delirium. Withdrawal of ertapenem treatment in such cases usually results in a complete resolution of symptoms.

Identification of antibiotic resistance patterns in Helicobacter pylori strains isolated from gastric biopsies using real-time PCR and genotypic analysis.

BACKGROUND: Helicobacter pylori (H. pylori) is associated with dyspepsia, mucus-associated lymphoid tissue lymphoma, gastritis, and peptic ulcer disease. Treatment in Malta consists of triple therapy, which consists of a proton pump inhibitor and 2 of the antibiotics amoxicillin, clarithromycin, metronidazole and fluoroquinolones. We aimed to determine the resistance rates for clarithromycin and fluoroquinolones in patients with H. pylori, and its incidence, in patients undergoing an esophagogastroduodenoscopy (EGD) using real-time polymerase chain reaction (RT-PCR). METHODS: Patients undergoing an EGD were recruited. A rapid urease test (RUT) was performed, and 4 gastric biopsies were also taken (2 from antrum, 2 from corpus) and analyzed using RT-PCR. Positive samples were tested for antibiotic resistance using amplification and reverse hybridization techniques. RESULTS: Two hundred patients (mean age 53.6 [range 20-92] years; 53.1% female) were recruited; the majority were (78%) non-smokers. H. pylori was identified in 21.0% of the patients. Fluoroquinolone resistance was detected in 21.4% of the patients. Clarithromycin resistance was observed in 26.2%, with dual resistance identified in 4.8% of the patients. A high concordance was present with patients testing negative for H. pylori with both RUT and RT-PCR (94.3%). Only 57.6% of patients tested positive with both tests. However, 92.9% of RT-PCR positive patients had a positive genotype HelicoDR test. CONCLUSIONS: This data demonstrates a high rate of H. pylori resistance to both clarithromycin and fluoroquinolones. These should be avoided when treating H. pylori by utilizing different treatment regimes. Furthermore, we derived important data on the role of RT-PCR, which may be implemented in routine clinical practice.

Consultant versus trainee led surgery and impact on outcome following an emergency colonic resection.

PURPOSE: Emergency colonic surgery carries a high mortality rate. In the UK, strategies to improve outcomes in emergency general surgery recommend a consultant surgeon to be physically present during all operations involving a patient with a predicted mortality > 5%. To test the assertion of the consultant surgeon's presence in theatre as a determinate of improved outcome, we assessed patients following an emergency colonic resection and the effect of operator seniority. METHODS: A retrospective analysis was undertaken for all patients undergoing an emergency colonic resection during a 4-year period between 2013 and 2017. Patient's pre-operative risk was assessed using P-POSSUM score and ASA grade. Outcomes assessed were post-operative morbidity (recorded using Clavien-Dindo classification), 30 day/inpatient mortality and length of stay (LOS). Outcomes were then compared between consultant and trainee led cases using univariate logistic regression techniques with results presented in terms of odds ratios (95% confidence intervals). A p value of 0.05 is used to determine statistical significance. RESULTS: A total of 130 patients were identified over the 4-year study period. 65% had their operation performed by a consultant and 35% by a trainee. Pre-operative P-POSSUM scores were the same between the groups (9.4% [5.0-25.2] vs 9.4% [4.9-28.6] p 0.75). There was no significant difference in post-operative complication rates between consultant and trainee led cases for minor (OR 1.58 [0.76-3.20] p 0.27) or major complications (OR 1.08 [0.50-2.31] p 0.84). Overall post-operative mortality was 14% with a trend for higher mortality rates in consultant led cases (15% vs 9%) albeit not statistically significant (p 0.57). Despite similar complication rates, trainee led operations were associated with slightly longer LOS at 19 (IQR 12-38) vs 15 (IQR 9-23) days (p 0.56). CONCLUSION: Emergency colonic surgery remains associated with a high level of morbidity and mortality. However, consultant presence at the operating table does not appear to be the sole determinant of outcome following an emergency colonic resection.

Solitary Fibrous Tumour A rare cause of acute abdomen.

Solitary Fibrous Tumours(SFT), previously known as haemangiopericytoma, are rarely encountered in surgery. They arise from mesenchyme tissue and can occur at several sites in the body - head and neck, extremities, thorax, abdomen and retroperitoneal space. In the thorax, where they arise from the pleura, and abdomen they may attain a large size before giving rise to symptoms. Most SFT behave in a benign manner. However a number of them recur locally or metastasize. Recurrences can occur several years after excision of the primary tumour. Complete surgical excision remains the primary modality of treatment. But, in sites where complete excision is not possible, other modalities have been tried with varying success. Here, we describe a SFT of the mesentery of the small intestine, an uncommon manifestation of the tumour, recurring after a period of 19 years in a 55 year old female, and presenting to the Emergency Department as an acute abdomen caused by acute intestinal obstruction. Surgical excision of the tumour was performed together with primary anastomosis of the small intestine. KEY WORDS: Acute abdomen, Late recurrence, Mesentery, Solitary Fibrous tumour.