RESUMO
Cryptococcus neoformans is a fungus that can cause pulmonary, central nervous system, and dermatological infections, especially in an immunocompromised patient. This is a case report of a patient, who was presumptively immunocompetent that developed isolated cryptococcemia while being treated for coronavirus disease 19 (COVID-19) infection. We report a case of a 59-year-old Hispanic man with a past medical history of hypertension, well-controlled diabetes mellitus, and class I obesity who was admitted for severe acute respiratory distress syndrome coronavirus 2 (SARS-COV-2) and subsequently was diagnosed with cryptococcal fungemia. The patient received 21 days of dexamethasone and during this period, blood and fungal cultures grew C. neoformans. The patient was alert and oriented, did not have focal neurological deficits or meningeal irritation signs; nonetheless, a lumbar puncture was attempted, but not successful. He was treated with intravenous amphotericin B for two weeks, followed by oral fluconazole for six weeks. Repeat blood cultures demonstrated clearance and he improved clinically. In conclusion, this case report describes the possibility of an association between the use of dexamethasone in COVID-19 patients and the development of cryptococcal fungemia. In the review of literature, rare case reports worldwide have discussed this topic. This is clinically challenging as the emergence of opportunistic infections in these debilitated hosts can be detrimental. Maintaining a high clinical suspicion for this opportunistic infection while treating COVID-19 patients is necessary to prevent further mortality associated with this pandemic.
RESUMO
BACKGROUND: Approaches to changing providers' behavior around Clostridium difficile (CD) management are needed. We hypothesized that case-specific teaching points and face-to-face discussions with prescribers and nurses would improve management of patients with a positive CD test. METHODS: Charts of patients age ≥18 years with positive CD tests hospitalized July 2016 to May 2017 were prospectively reviewed to assess CD practices and generate management recommendations. The study had 4 periods: baseline (pre-intervention), intervention #1, observation, and intervention #2. Both interventions consisted of an in-person, real-time, case-based discussion and education by a CD Action Team (CDAT). Assessment occurred within 24 hours of a positive CD test for all periods; during the intervention periods, management was also assessed within 48 hours after CDAT-delivered recommendations. Outcomes included proportion of patients receiving optimized treatment and incidence rate ratios of practice changes (both CDAT-prompted and CDAT-independent). RESULTS: Overall, the CDAT made recommendations to 84 of 96 CD cases during intervention periods, and providers accepted 43% of CDAT recommendations. The implementation of the CDAT led to significant improvement in bowel movement (BM) documentation, use of proton pump inhibitors, and antibiotic selection for non-CD infections. Selection of CD-specific therapy improved only in the first intervention period. Laxative use and treatment of CD colonization cases remained unchanged. Only BM documentation, a nurse-driven task, was sustained independent of CDAT prompting. CONCLUSIONS: A behavioral approach to changing the management of positive CD tests led to self-sustained practice changes among nurses but not physicians. Better understanding of prescribers' decision-making is needed to devise enduring interventions.
RESUMO
We investigated serum ß-d-glucan (BDG) testing among non-neutropenic adult inpatients at an academic center where the test is unrestricted. BDG orders were inappropriate in 49% of cases due to absence of predisposing host factors or clinical picture consistent with fungal infection. Providers' knowledge about BDG was insufficient.
