Similarities and differences between doxycycline and minocycline: clinical and antimicrobial stewardship considerations.

Doxycycline and, to a lesser extent, minocycline, have been used for decades to treat various serious systemic infections, but many physicians remain unfamiliar with their spectrum, interpretation of susceptibility results, pharmacokinetic/pharmacodynamic (PK/PD) properties, optimal dosing regimens, and their activity against MRSA, VRE, and multidrug-resistant (MDR) Gram-negative bacilli, e.g., Acinetobacter sp. This article reviews the optimal use of doxycycline and minocycline to treat a variety of infections and when minocycline is preferred instead of doxycycline.

Nitrofurantoin safety and effectiveness in treating acute uncomplicated cystitis (AUC) in hospitalized adults with renal insufficiency: antibiotic stewardship implications.

Nitrofurantoin remains a key oral antibiotic stewardship program (ASP) option in the treatment of acute uncomplicated cystitis (AUC) due to multi-drug resistant (MDR) Gram negative bacilli (GNB). However, there have been concerns regarding decreased nitrofurantoin efficacy with renal insufficiency. In our experience over the past three decades, nitrofurantoin has been safe and effective in treating AUC in hospitalized adults with renal insufficiency. Accordingly, we retrospectively reviewed our recent experience treating AUC in hospitalized adults with decreased renal function (CrCl < 60 ml/min) with nitrofurantoin. Excluded were complicated urinary tract infections. Urinary isolated susceptibility testing was done by micro broth dilution (MBD). Treatment duration was 5-7 days. Cure was defined as eradication of the uropathogen and failure was defined as minimal/no decrease in urine colony counts. Of 26 evaluable patients with renal insufficiency (CrCl < 60 ml/min), nitrofurantoin eradicated the uropathogen in 18/26 (69%) of patients, and failed in 8/26 (31%). Of the eight failures, five were due to intrinsically resistant uropathogens, e.g., Proteus sp., and one failure was related to an alkaline urine. Of the treatment failures, only two were due to renal insufficiency, i.e., CrCl < 30 ml/min. Since there are few oral antibiotics available to treat AUC due to MDR GNB uropathogens, these results have important ASP implications. Currently, nitfurantoin is not recommended if CrCl < 60 ml/min. In our experience, used appropriately against susceptible uropathogens, nitrofurantoin was highly effective in nearly all patients with CrCl = 30-60 ml/min., and only failed in two patients due to renal insufficiency (CrCl < 30 ml/ml).

Viral influenza-like illnesses: dynamic interrelationships during the 2015-2016 influenza season in hospitalized patients.

In hospitalized children and adults, the temporal relationship of viruses causing influenza-like illnesses (ILIs) and influenza has not been well described. During the 2015-2016 influenza season at our hospital, the dynamic interrelationships between ILI viruses (human metapneumovirus, respiratory syncytial virus, human parainfluenza viruses 3 and 4, rhinoviruses/enteroviruses, and coronaviruses) and influenza A were characterized in 768 hospitalized children and adults.

Are atypical lymphocytes present with viral influenza-like illnesses (ILIs) in hospitalized adults?

The purpose of this investigation was to determine if atypical lymphocytes were of diagnostic value in viral influenza-like illnesses (ILIs) in hospitalized adults during the influenza season. Are atypical lymphocytes present with viral ILIs in hospitalized adults? During the influenza season, hospitals are inundated with influenza and viral ILIs, e.g., human parainfluenza virus-3 (HPIV-3). Without specific testing, clinically, it is difficult to differentiate influenza from ILIs, and surrogate influenza markers have been used for this purpose, e.g., relative lymphopenia. The diagnostic significance of atypical lymphocytes with ILIs is not known. We retrospectively reviewed the charts of 35 adults admitted with pneumonia due to viral ILI. The diagnosis of 14 patients was by respiratory virus polymerase chain reaction (PCR). During the 2015 influenza A season with ILIs, atypical lymphocytes were not present in influenza A (H3N2) patients but atypical lymphocytes were present in some ILIs, particularly HPIV-3. With viral ILIs, atypical lymphocytes should suggest a non-influenza viral diagnosis.

Predictors of ertapenem therapeutic efficacy in the treatment of urinary tract infections (UTIs) in hospitalized adults: the importance of renal insufficiency and urinary pH.

In hospitalized adults acute uncomplicated cystitis (AUC) and catheter associated bacteriuria (CAB) may be treated with oral antibiotics. With AUC or CAB due to extended spectrum ß-lactamase (ESBL) + Gram negative bacilli (GNB) physicians often use intravenous therapy, e.g., ertapenem. We reviewed our recent experience in hospitalized adults with AUC and CAB treated with ertapenem. Therapeutic efficacy of ertapenem was assessed by decreased pyuria/bacteriuria, and elimination of the uropathogen. The effectiveness of ertapenem in the presence of renal insufficiency (CrCl < 50 ml/min) and acid and alkaline urinary pH were evaluated. In addition, rapidity of eradication of bacteriuria was assessed by time to negative urine cultures (TTNC). In those with an acid urinary pH ertapenem was highly effective in eliminating bacteriuria (TTNC < 3 days). TTNC was prolonged ( >3 days) in patients with decreased renal function and alkaline urinary pH. We reviewed 45 hospitalized adults with AUC or CAB to determine if renal insufficiency and or alkaline urinary pH affected ertapenem efficacy. In the 33 adult hospitalized patients with AUC and 12 with CAB, we found that ertapenem was consistently effective in eliminating the GNB bacteriuria. In hospitalized adults, the presence of renal insufficiency and acid urine, bacteriuria was eliminated in < 3 days. However, in those with renal insufficiency and an alkaline urine pH, the rapidity of cure, i.e., time to negative cultures (TTNC) was prolonged, i.e., > 3 days which has not been previously reported.

The clinical usefulness of lymphocyte:monocyte ratios in differentiating influenza from viral non-influenza-like illnesses in hospitalized adults during the 2015 influenza A (H3N2) epidemic: the uniqueness of HPIV-3 mimicking influenza A.

During influenza epidemics, influenza-like illnesses (ILIs) viruses cocirculate with influenza strains. If positive, rapid influenza diagnostic tests (RIDTs) identify influenza A/B, but false-negative RIDTs require retesting by viral polymerase chain reaction (PCR). Patient volume limits testing during influenza epidemics, and non-specific laboratory findings have been used for presumptive diagnosis pending definitive viral testing. In adults, the most useful laboratory abnormalities in influenza include relative lymphopenia, monocytosis, and thrombocytopenia. Lymphocyte:monocyte (L:M) ratios may be even more useful. L:M ratios <2 have been used as a surrogate marker for influenza, but there are no longitudinal data on L:M ratios in hospitalized adults with viral ILIs. During the 2015 influenza A (H3N2) epidemic at our hospital, we reviewed our experience with L:M ratios in 37 hospitalized adults with non-influenza viral ILIs. In hospitalized adults with non-influenza A ILIs, the L:M ratios were >2 with human metapneumovirus (hMPV), rhinoviruses/enteroviruses (R/E), and respiratory syncytial virus (RSV), but not human parainfluenza virus type 3 (HPIV-3), which had L:M ratios <2. HPIV-3, like influenza, was accompanied by L:M ratios <2, mimicking influenza A (H3N2). In influenza A admitted adults, L:M ratios <2 did not continue for >3 days, whereas with HPIV-3, L:M ratios <2 persisted for >3 days of hospitalization.

Unnecessary repeat Clostridium difficile PCR testing in hospitalized adults with C. difficile-negative diarrhea.

The aim of this study was to determine the extent and associated costs of repeat Clostridium difficile stool polymerase chain reaction (PCR) assays in patients with initially negative PCRs. C. difficile stool PCRs were done on adult hospitalized patients with diarrhea. The number/time course of repeat PCRs on initially negative PCR patients was determined. Of 5,027 C. difficile stool PCRs, 814 (16.2 %) were positive and 4,213 (83.8 %) were negative. Ninety-seven of the initially PCR-negative patients had >2 repeat tests 1-59 days after the initial negative stool PCR. Repeat negative PCR testing rarely resulted in a subsequent positive result (0.05 %). The unnecessary costs of 97 repeat PCRs was $32,658.00. Many of these patients were originally given empiric oral anti-C. difficile therapy, in spite of repeatedly negative PCRs.

Fever of unknown origin (FUO) in an immunocompetent adult due to cytomegalovirus (CMV) with polyclonal gammopathy.

Fever of unknown origin (FUO) may be due to infection, malignancy, collagen vascular/inflammatory disorders, or other causes. Cytomegalovirus (CMV) infection is a rare cause of FUO in immunocompetent adults. We present a case of FUO due to CMV in an immunocompetent adult with polyclonal gammopathy on serum protein electrophoresis (SPEP).

Nosocomial swine influenza (H1N1) pneumonia: lessons learned from an illustrative case.

In the spring of 2009, our institution found itself at the epicentre of the "herald wave" of the swine influenza (H1N1) pandemic in New York. We were inundated with hundreds of patients exhibiting influenza-like illnesses (ILIs), presenting for rapid influenza A testing. During this pandemic, an infant with newly diagnosed acute lymphatic leukaemia (ALL) was admitted for induction chemotherapy. After being in hospital for a week, she developed high fever and shortness of breath, although her chest X-ray was clear. She was admitted to the paediatric intensive care unit (PICU) for mechanical ventilation. As we were in the midst of the pandemic, diagnosis of H1N1 pneumonia was considered and reverse transcription-polymerase chain reaction for H1N1 was positive. Contact investigation revealed that none of her family members/visitors had been in recent/close contact with anyone with ILI/H1N1. The investigation also revealed that paediatric healthcare staff, in contact with H1N1 patients, had rotated into PICU to care for the patient. Although no specific individual could be identified, it seems likely that H1N1 was transmitted to the patient by a healthcare worker who worked both in the paediatric ward and the PICU. This is the first known case of nosocomial paediatric transmission of H1N1 pneumonia.