Review of high dose vancomycin in the treatment of Clostridioides difficile infection.

BACKGROUND: Guidelines recommend oral vancomycin as first-line therapy for Clostridioides difficile infection. Guideline recommendations vary regarding dosing of vancomycin. Our aim was to summarize the current evidence on the efficacy and adverse effects of high dose oral and vancomycin retention enema (>500 mg/day) for the treatment of C. difficile infection. METHODS: We searched clinical studies and major guidelines in the English language using MEDLINE, the Cochrane Library and Embase from 1985 until 15 April 2020. RESULTS: No evidence supports the use of high dose oral vancomycin in the treatment of severe C. difficile infection. Weak evidence from observational studies supports the use of high dose oral vancomycin in addition to intravenous metronidazole and high dose vancomycin retention enema in fulminant C. difficile infection. Vancomycin retention enema can be used in severe C. difficile infection when oral administration is not possible, or in conditions when the oral formulation cannot reach the colon such as Hartman's pouch, ileostomies, or colon diversions. CONCLUSIONS: The dosing schedules for oral vancomycin and vancomycin enemas are not clearly defined due to widely varying results in clinical studies. Large, comparative multicenter trials are urgently needed to define the role of high dose vancomycin in C. difficile infection.

Disseminated Echinococcus multilocularis Infection without Liver Involvement in Child, Canada, 2018.

An immunocompetent child in Canada received a diagnosis of disseminated alveolar Echinococcus multilocularis infection. The case lacked typical features of liver involvement and was possibly related to a rare congenital portosystemic shunt. We summarize the rapidly evolving epidemiology of E. multilocularis parasites in Canada.

Clinical impact of cerebrospinal fluid Gram stain and culture testing: A retrospective cohort study.

Background: Stewardship of microbiological tests can improve laboratory efficiency. One indicator of appropriate test stewardship is test impact on patient management decisions. We sought to assess the impact of cerebrospinal fluid (CSF) Gram stain and culture results on treatment decisions. Our hypothesis was that CSF Gram stain and culture have low impact on patient management. Methods: CSF specimens received at a tertiary microbiology laboratory between January 1, 2013, and December 31, 2013, were included. Clinical information and data on antibiotic treatment before CSF collection, antibiotic treatment after CSF Gram stain results, and antibiotic treatment after CSF culture results were collected. Ethics approval for secondary use of data was obtained. Results: We received 242 CSF specimens for Gram stain and culture during the study period; 120 were excluded (84 from children, 2 from indwelling ventricular drains, 12 collected at outside hospitals, 21 data missing, 1 duplicate). No Gram stains or cultures were positive among patients not already treated empirically. The number needed to test to influence treatment was 17 for Gram stain (11 for abnormal cytochemistry, 29 for normal cytochemistry) and 6 for culture (3 for abnormal cytochemistry, 6 for normal cytochemistry). Conclusions: CSF Gram stain and culture are rarely positive and are being performed on inappropriate specimens. CSF results never prompt physicians to start treatment, so results are affecting not outcome but antibiotic stewardship. Negative CSF culture often leads to discontinuation of antibiotics. Labs could consider rejecting CSF Gram stain if cytochemistry is normal.

Historique: La gestion des tests microbiologiques peut améliorer l'efficacité des laboratoires. L'effet des tests sur les décisions de prise en charge des patients est un indicateur de leur bonne gestion. Les chercheurs ont cherché à évaluer l'effet des résultats de la coloration de Gram et des cultures du liquide céphalorachidien (LCR) sur les décisions thérapeutiques. Ils ont postulé que la coloration de Gram et la culture du LCR avaient de faibles effets sur la prise en charge des patients. Méthodologie: Les chercheurs ont inclus les échantillons de LCR reçus dans un laboratoire de microbiologie tertiaire entre le 1er janvier et le 31 décembre 2013. Ils ont colligé l'information clinique et les données sur les traitements antibiotiques avant la collecte de LCR, le traitement antibiotique après les résultats de la coloration de Gram du LCR et le traitement antibiotique après les résultats de la culture du LCR. Ils ont obtenu l'approbation éthique autorisant l'utilisation secondaire des données. Résultats: Pendant la période de l'étude, les chercheurs ont reçu 242 échantillons du LCR en vue de la coloration de Gram et de la mise en culture; 120 échantillons ont été exclus (84 d'enfants, deux de drainages ventriculaires à demeure, 12 prélevés dans d'autres hôpitaux, 21 données manquantes, un dédoublement). Aucune coloration de Gram et aucune culture n'ont été positives chez les patients qui ne recevaient pas déjà un traitement empirique. Le nombre de sujets à traiter pour influer sur le traitement était de 17 pour la coloration de Gram (11 pour la cytochimie anormale, 29 pour la cytochimie normale) et six pour les cultures (trois pour la cytochimie anormale, six pour la cytochimie anormale). Conclusions: La coloration de Gram et les cultures du LCR sont rarement positives et sont effectuées sur des échantillons inappropriés. Les résultats des tests du LCR n'incitent jamais les médecins à entreprendre un traitement. Les résultats n'influent donc pas sur les résultats, mais sur la gestion des antibiotiques. Une culture négative du LCR entraîne souvent l'arrêt de l'antibiotique. Les laboratoires devraient envisager de rejeter la coloration de Gram du LCR lorsque la cytochimie est normale.

Should Caesarian Section Be Offered to Women With Recurrent Genital Herpes Simplex Lesions After >4 Hours of Ruptured Membranes?

BACKGROUND: Neonatal herpes simplex virus (HSV) infection and its implications have been well defined. Several methods are recommended to mitigate the risk of maternal transmission of HSV to the neonate, including CS, suppressive antiviral therapy for the mother, and prophylaxis for the infant. The utility of CS in women who present with a duration of rupture of membranes greater than 4 hours remains a question. CASE: We present a case of a woman who presented following 10 hours of rupture of membranes with HSV genital lesions, suspected to be the result of untreated recurrent infection. A CS was done. CONCLUSION: Extensive studies for the presence of HSV by PCR of the placenta and infant failed to detect the virus.