Acute bacterial skin and soft tissue infections: new drugs in ID armamentarium.

Acute bacterial skin and soft tissue infections (SSTI) are among the most common reasons for hospitalization of adults in the USA today. Cellulitis or SSTI can cause significant morbidity and mortality. The 2014 IDSA guideline update for the management of skin and soft tissue infections classified skin infections as purulent cellulitis (causative pathogen - Staphylococcus aureus including MRSA) and nonpurulent cellulitis (causative pathogens include Streptococcus). Understanding the key difference and categorization will allow a physician to determine the appropriate treatment approach and antibiotic choice. In recent years, there have been several new antibiotics which received fast track approval by FDA as a Qualified Infectious Disease Product (QIDP) for the indication of SSTI. They Include Ceftaroline (Teflaro), Dalbavancin (Dalvance), Oritavancin (orbativ), Tedizolid (Sevixtro), Delafloxacin (Baxdela) and Omadacycline (Nuzyra). This article will briefly review each of these new antibiotics and summarize their roles in avoiding hospital admissions and reducing the duration of stay in patients with SSTI.

Non-islet Cell Hypoglycemia: Case Series and Review of the Literature.

Non-islet cell hypoglycemia (NICH) is hypoglycemia due to the overproduction of insulin-like growth factor-2 (IGF-2) and its precursors which can activate the insulin receptor. Typically, large mesenchymal and epithelial tumors can cause NICH. Diagnosis is confirmed by finding an elevated IGF-2/IGF-1 ratio. The mainstay of treatment is surgical excision. Glucocorticoids may be used in cases where surgery is not possible. We present two cases of NICH with different outcomes. A 33-year-old male patient admitted with altered mental. He was found walking naked outside his house. Laboratory assessment revealed severe hypoglycemia. Further evaluation showed low levels of insulin, C-peptide, and beta-hydroxybutyrate along with an elevated IGF-2/IGF-1 ratio confirming the diagnosis of NICH. Computed tomography (CT) of the abdomen showed a massive tumor of the liver consistent with hepatocellular carcinoma. Since the patient refused surgery, he was started on prednisone however the hypoglycemia persisted. A 54-year-old female patient with a history of type 2 diabetes mellitus (DM) admitted with recent onset hypoglycemia. Despite stopping her insulin, she continued to have hypoglycemia necessitating the administration of high concentrations of intravenous dextrose. Further evaluation showed low levels of insulin, C-peptide, and beta-hydroxybutyrate along with an elevated IGF-2/IGF-1 ratio consistent with the diagnosis of NICH. CT abdomen showed a 24 cm tumor near the uterus. The pathology was consistent with a gastrointestinal stromal tumor (GIST). After surgical excision of the tumor, the hypoglycemia resolved.