Long-standing laryngeal rhinoscleroma with rare Mikulicz cells.

Rhinoscleroma is an infectious granulomatous disease. It is important to identify pathognomonic Mikulicz cells on microscopy, as these can be rare and the chronic inflammatory infiltrate can appear otherwise nonspecific on biopsies.

Long-Term Effects of Phased Implementation of Antimicrobial Stewardship in Academic ICUs: 2007-2015.

OBJECTIVES: Antimicrobial stewardship is advocated to reduce antimicrobial resistance in ICUs by reducing unnecessary antimicrobial consumption. Evidence has been limited to short, single-center studies. We evaluated whether antimicrobial stewardship in ICUs could reduce antimicrobial consumption and costs. DESIGN: We conducted a phased, multisite cohort study of a quality improvement initiative. SETTING: Antimicrobial stewardship was implemented in four academic ICUs in Toronto, Canada beginning in February 2009 and ending in July 2012. PATIENTS: All patients admitted to each ICU from January 1, 2007, to December 31, 2015, were included. INTERVENTIONS: Antimicrobial stewardship was delivered using in-person coaching by pharmacists and physicians three to five times weekly, and supplemented with unit-based performance reports. Total monthly antimicrobial consumption (measured by defined daily doses/100 patient-days) and costs (Canadian dollars/100 patient-days) before and after antimicrobial stewardship implementation were measured. MEASUREMENTS AND MAIN RESULTS: A total of 239,123 patient-days (57,195 patients) were analyzed, with 148,832 patient-days following introduction of antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50 defined daily dose/100 patient-days following introduction of antimicrobial stewardship (adjusted intervention effect -12.12 defined daily dose/100 patient-days; 95% CI, -16.75 to -7.49; p < 0.001) and total antifungal use decreased from 30.53 to 27.37 defined daily doses/100 patient-days (adjusted intervention effect -3.16 defined daily dose/100 patient-days; 95% CI, -8.33 to 0.04; p = 0.05). Monthly antimicrobial costs decreased from $3195.56 to $1998.59 (adjusted intervention effect -$642.35; 95% CI, -$905.85 to -$378.84; p < 0.001) and total antifungal costs were unchanged from $1771.86 to $2027.54 (adjusted intervention effect -$355.27; 95% CI, -$837.88 to $127.33; p = 0.15). Mortality remained unchanged, with no consistent effects on antimicrobial resistance and candidemia. CONCLUSIONS: Antimicrobial stewardship in ICUs with coaching plus audit and feedback is associated with sustained improvements in antimicrobial consumption and cost. ICUs with high antimicrobial consumption or expenditure should consider implementing antimicrobial stewardship programs.

Point-of-Care ß-Lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation.

Background: ß-lactam allergy skin testing (BLAST) is recommended by antimicrobial stewardship program (ASP) guidelines, yet few studies have systematically evaluated its impact when delivered at point of care. Methods: We conducted a pragmatic multicenter prospective evaluation of the use of point-of-care BLAST by ASPs. In staggered 3-month intervals, ASP teams at 3 hospitals received training by allergists to offer BLAST for eligible patients with infectious diseases receiving nonpreferred therapy due to severity of their reported allergy. The primary outcome was the proportion of patients receiving the preferred ß-lactam therapy. Results: Of 827 patients with reported ß-lactam allergy over 15 months, ß-lactam therapy was preferred among 632 (76%). During baseline periods, 50% (124/246) received preferred ß-lactam therapy based on history, compared with 60% (232/386) during the intervention periods (P = .02), which improved further to 81% (313/386) upon provision of BLAST (P < .001) without any increase in incidence of adverse drug reactions (4% vs 3%; P = .4). After adjusting for patient variables and the correlation between hospitals, the intervention period was associated with a 4.5-fold greater odds of receiving preferred ß-lactam therapy (95% confidence interval, 2.4-8.2; P < .0001). Conclusions: The use of BLAST at the point of care across 3 hospital ASPs resulted in greater use of preferred ß-lactam therapy without increasing the risk of adverse drug reactions. Longer-term studies are needed to better assess the safety and clinical impact of this ASP intervention.

Clinical characteristics and outcome associated with pandemic (2009) H1N1 influenza infection in patients with hematologic malignancies: a retrospective cohort study.

Pandemic H1N1 (pH1N1) influenza has been associated with a worldwide outbreak of febrile respiratory illness. Although impaired immunity, such as that caused by hematologic malignancy, has been identified as a risk factor for severe infection with this virus, the course of this infection has not been adequately characterized in patients with underlying hematologic malignancy in comparison with immune competent controls. We report our experience with severe pH1N1 infection in patients with hematologic cancers and compare this group to non-immunosuppressed patients. Data were retrospectively collected on all patients admitted to our institution with confirmed pH1N1 infection. Clinical characteristics, treatments and outcomes were compared between patients with hematologic malignancies and non-immunocompromised controls. Fifteen patients with hematologic malignancy and 49 controls were identified. The control group had higher baseline rates of asthma (p = 0.01) and smoking (p = 0.05) at baseline. Clinical features of infection in the two groups were similar, except for a higher prevalence of abnormalities on chest imaging in the group with malignancy (p = 0.05). No statistically significant difference in mortality was observed between the groups. Mean duration of hospitalization (22.1 days vs. 9.2 days, p = 0.04) and duration of antiviral treatment (9.9 days vs. 6.7 days, p < 0.05) were greater in the hematologic malignancy group. Hospitalized patients with hematologic malignancies with pH1N1 infection had greater durations of hospitalization and treatment than non-immunocompromised controls, possibly reflecting decreased clearance of the virus as a consequence of impaired immunity.

Comparison of hospitalized solid organ transplant recipients and nonimmunocompromised patients with pandemic H1N1 infection: a retrospective cohort study.

BACKGROUND: Pandemic H1N1 influenza has been associated with a worldwide outbreak of febrile respiratory illness. Although impaired cell mediated immunity, such as that caused by transplant immunosuppression, has been identified as a risk factor for severe infection with this virus, the course of this infection has not been adequately characterized in solid organ transplant (SOT) recipients in comparison with nontransplanted controls. We report our experience with severe pH1N1 infection in transplant recipients and compare this group with nonimmunosuppressed patients. METHODS: Data were retrospectively collected on all patients admitted to our institution with proven pH1N1 infection. Clinical characteristics, treatments, and outcomes were compared between SOT recipients and nonimmunocompromised controls. RESULTS: Seventeen SOT recipients and 49 controls were identified. The control group had higher baseline rates of asthma (P = 0.02) and smoking (P = 0.05) at baseline. No difference in clinical features of H1N1 infection was detected except for a greater prevalence of wheeze in the non-SOT group (P = 0.02). No statistical differences in outcomes could be detected between the groups. Several markers of severity, including use of high frequency oscillatory ventilation, extracorporeal membrane oxygenation, and death were slightly more frequent in the control group. CONCLUSION: SOT recipients admitted to hospital with pH1N1 infection did not have significantly more severe outcomes of their infection compared with their nonimmunocompromised counterparts, despite their immune suppressed status.

Bacterial infections complicating tongue piercing.

Tongue piercing has become an increasingly popular form of body art. However, this procedure can occasionally be complicated by serious bacterial infections. The present article reports a case of prosthetic valve endocarditis caused by a Gemella species in a patient with a pierced tongue, and reviews 18 additional cases of local and systemic bacterial infections associated with tongue piercing. Infections localized to the oral cavity and head and neck region included molar abscess, glossal abscess, glossitis, submandibular lymphadenitis, submandibular sialadenitis, Ludwig's angina and cephalic tetanus. Infections distal to the piercing site included eight cases of infective endocarditis, one case of chorioamnionitis and one case of cerebellar abscess. Oropharyngeal flora were isolated from all cases. While bacterial infections following tongue piercing are rare, there are reports of potentially life-threatening infections associated with the procedure. Both piercers and their clients should be aware of these potential complications, and standardized infection prevention and control practices should be adopted by piercers to reduce the risk.

A case of occult compartment syndrome and nonresolving rhabdomyolysis.

CASE REPORT: A 32-year-old African male presented with 10 hours of severe back pain. Initial computed tomography scan of the back showed no abnormality, and initial laboratory investigations were consistent with rhabdomyolysis. Despite stopping potential causative medications, aggressive intravenous hydration, and urine alkalinization, his creatinine kinase continued to steadily climb. Thirty-six hours after admission, a magnetic resonance imaging of his back was done because of new swelling over the right paraspinal muscles and loss of sensation in this region. Marked swelling of the right erector spinae muscles was observed, and right and left compartment pressure measurements were 108 and 21 mm Hg, respectively. He had urgent fasciotomy after which his rhabdomyolysis and pain recovered. CONCLUSION: Our case highlights the need for early consideration of compartment syndrome as a possible cause of back pain in the setting of rhabdomyolysis. Rhabdomyolysis can present in the absence of late complications such as neurological and vascular compromise.

Risk factors for surgical-site infection following primary total knee arthroplasty.

OBJECTIVE: To identify risk factors associated with the development of surgical-site infection (SSI) following total knee arthroplasty (TKA). DESIGN: A case-control study. SETTING: A 1,100-bed, university-affiliated, tertiary-care teaching hospital. METHODS: Case-patients with SSI occurring up to 1 year following primary TKA performed between January 1999 and December 2001 were identified prospectively by infection control practitioners using National Nosocomial Infections Surveillance (NNIS) System methods. Three control-patients were selected for each case-patient, matched by date of surgery. Stepwise logistic regression analysis was used to determine the relation of potential risk factors to the development of infection. RESULTS: Twenty-two patients with infections (6 superficial and 16 deep) were identified. Infection rates per year were 0.95%, 1.07%, and 1.19% in 1999, 2000, and 2001, respectively. Logistic regression analysis identified two variables independently associated with the development of infection: the use of closed suction drainage (odds ratio [OR], 7.0; 95% confidence interval [CI95], 2.1-25.0; P = .0015) and increased international normalized ratio (INR) (OR, 2.4; CI95, 1.1-5.7; P = .035). Factors not statistically associated with the development of infection included age, NNIS System risk index score, presence of various comorbidities, surgeon, duration of procedure or tourniquet time, type of bone cement or prosthesis used, or receipt of blood product transfusions. CONCLUSIONS: The use of closed suction drainage and a high postoperative INR were associated with the development of SSI following TKA. Avoiding the use of surgical drains and careful monitoring of anticoagulant prophylaxis in patients undergoing TKA should reduce the risk of infection.