Treatment and outcome of gram-positive bacteremia in patients receiving extracorporeal membrane oxygenation.

BACKGROUND: While guidance exists for management of blood stream infections with various invasive devices, there are currently limited data to guide antibiotic selection and duration for bacteremia in patients receiving extracorporeal membrane oxygenation (ECMO). OBJECTIVE: To evaluate the treatment and outcomes of thirty-six patients with Staphylococcus aureus and Enterococcus bacteremia on ECMO support. METHODS: Blood culture data was retrospectively analyzed from patients with Staphylococcus aureus bacteremia (SAB) or Enterococcus bacteremia who underwent ECMO support between March 2012 and September 2021 at Brooke Army Medical Center. RESULTS: Of the 282 patients who received ECMO during this study period, there 25 (9%) patients developed Enterococcus bacteremia and 16 (6%) developed SAB. SAB occurred earlier in ECMO as compared to Enterococcus (median day 2 IQR (1-5) vs. 22 (12-51), p = 0.01). The most common duration of antibiotics was 28 days after clearance for SAB and 14 days after clearance for Enterococcus. 2 (5%) patients underwent cannula exchange with primary bacteremia, and 7 (17%) underwent circuit exchange. 1/3 (33%) patients with SAB and 3/10 (30%) patients with Enterococcus bacteremia who remained cannulated after completion of antibiotics had a second episode of SAB or Enterococcus bacteremia. CONCLUSION: This single center case series is the first to describe the specific treatment and outcomes of patients receiving ECMO complicated by SAB and Enterococcus bacteremia. For patients who remain on ECMO after completion of antibiotics, there is a risk of a second episode of Enterococcus bacteremia or SAB.

It's Not Lupus This Time! A Case of Worsening Hypothyroidism in a Patient With Nephrotic Syndrome.

Nephrotic syndrome can result in worsening of existing hypothyroidism in patients requiring thyroid hormone supplementation. The urinary loss of thyroxine-binding globulin, as well as increased gut edema, likely lead to reduced absorption and retention of exogenous thyroid hormone. Here, we present a case of a patient with Hashimoto's thyroiditis, previously well-controlled on levothyroxine, who developed symptomatic hypothyroidism as a result of newly diagnosed nephrotic syndrome, whose symptoms improved with transition to an alternative formulation of levothyroxine and treatment of her underlying nephrotic syndrome. It is important to consider nephrotic syndrome as a cause of worsening hypothyroidism in a patient on a fixed dose of levothyroxine given the potential morbidity associated with a missed diagnosis and often need for escalation of dosage. There is no standardized therapy for hypothyroidism exacerbated by nephrotic syndrome, but liquid or gel formulations of levothyroxine may be more effective in patients with absorption problems.

Seasonal dynamics of phytoplankton community and functional groups in a tropical river.

Functional classification of phytoplankton could be a valuable tool in water quality monitoring in the eutrophic riverine ecosystems. This study is novel from the Bangladeshi perspective. In this study, phytoplankton cell density and diversity were studied with particular reference to the functional groups (FGs) approach during pre-monsoon, monsoon, and post-monsoon at four sampling stations in Karatoya River, Bangladesh. A total of 54 phytoplankton species were recorded under four classes, viz. Chlorophyceae (21 species) Cyanophyceae (16 species), Bacillariophyceae (15 species), and Euglenophyceae (2 species). A significantly higher total cell density of phytoplankton was detected during the pre-monsoon season (24.20 × 103 cells/l), while the lowest in monsoon (9.43 × 103 cells/l). The Shannon-Wiener diversity index varied significantly (F = 16.109, P = 000), with the highest value recorded during the post-monsoon season. Analysis of similarity (ANOSIM) identified significant variations among the three seasons (P < 0.0001, R = 0.9518). The similarity percentage (SIMPER) analysis pinpointed Ulothrix spp. (Melosira granulate and Cymbella spp.) as the most contributory species are causing such a noticeable difference. Fifty-four phytoplankton species recorded during the study period were classified into 20 functional groups, whereas D/J/M/MP/X1 was considered the most abundant FG in the Karatoya River. FGs of the Karatoya River were influenced mainly by the nutrients (PO4-P and NO3-N) enrichments. As a novel investigation on FGs of phytoplankton in Bangladesh, this study recommends additional surveys in other rivers and floodplains to improve our understanding of phytoplankton diversity and functional groups.

Antibiotic consumption at community pharmacies: A multicenter repeated prevalence surveillance using WHO methodology.

Background: Antibiotics are losing their effectiveness because of the rapid emergence of resistant bacteria. Unnecessary antimicrobial use increases antimicrobial resistance (AMR). There are currently no published data on antibiotic consumption in Pakistan at the community level. This is a concern given high levels of self-purchasing of antibiotics in Pakistan and variable knowledge regarding antibiotics and AMR among physicians and pharmacists. Objective: The objective of this repeated prevalence survey was to assess the pattern of antibiotic consumption data among different community pharmacies to provide a baseline for developing future pertinent initiatives. Methods: A multicenter repeated prevalence survey conducted among community pharmacies in Lahore, a metropolitan city with a population of approximately 10 million people, from October to December 2017 using the World Health Organization (WHO) methodology for a global program on surveillance of antimicrobial consumption. Results: The total number of defined daily doses (DDDs) dispensed per patient ranged from 0.1 to 50.0. In most cases, two DDDs per patient were dispensed from pharmacies. Co-amoxiclav was the most commonly dispensed antibiotic with a total number of DDDs at 1018.15. Co-amoxiclav was followed by ciprofloxacin with a total number of 486.6 DDDs and azithromycin with a total number of 472.66 DDDs. The least consumed antibiotics were cefadroxil, cefotaxime, amikacin, and ofloxacin, with overall consumption highest in December. Conclusion: The study indicated high antibiotic usage among community pharmacies in Lahore, Pakistan particularly broad-spectrum antibiotics, which were mostly dispensed inappropriately. The National action plan of Pakistan on AMR should be implemented by policymakers including restrictions on the dispensing of antimicrobials.