The Impact of Antimicrobial Resistance and Aging in VAP Outcomes: Experience from a Large Tertiary Care Center

Background: Ventilator associated pneumonia (VAP) is a serious infection among patients in the intensive care unit (ICU). Methods: We reviewed the medical charts of all patients admitted to the adult intensive care units of the Massachusetts General Hospital that went on to develop VAP during a five year period. Results: 200 patients were included in the study of which 50 (25%) were infected with a multidrug resistant pathogen. Increased age, dialysis and late onset (≥5 days from admission) VAP were associated with increased incidence of resistance. Multidrug resistant bacteria (MDRB) isolation was associated with a significant increase in median length of ICU stay (19 vs. 16 days, p = 0.02) and prolonged duration of mechanical ventilation (18 vs. 14 days, p = 0.03), but did not impact overall mortality (HR 1.12, 95% CI 0.51–2.46, p = 0.77). However, age (HR 1.04 95% CI 1.01–1.07, p = 0.003) was an independent risk factor for mortality and age ≥65 years was associated with increased incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections (OR 2.83, 95% CI 1.27–6.32, p = 0.01). Conclusions: MDRB-related VAP is associated with prolonged ICU stay and mechanical ventilation. Interestingly, age ≥ 65 years is associated with MRSA VAP

Nocardiosis of the Central Nervous System: Experience From a General Hospital and Review of 84 Cases From the Literature

Abstract Central nervous system (CNS) nocardiosis is a rare disease entity caused by the filamentous bacteria Nocardia species. We present a case series of 5 patients from our hospital and a review of the cases of CNS nocardiosis reported in the literature from January 2000 to December 2011. Our results indicate that CNS nocardiosis can occur in both immunocompromised and immunocompetent individuals and can be the result of prior pulmonary infection or can exist on its own. The most common predisposing factors are corticosteroid use (54% of patients) and organ transplantation (25%). Presentation of the disease is widely variable, and available diagnostic tests are far from perfect, often leading to delayed detection and initiation of treatment. The optimal therapeutic approach is still undetermined and depends on speciation, but lower mortality and relapse rates have been reported with a combination of targeted antimicrobial treatment including trimethoprim/sulfomethoxazole (TMP-SMX) for more than 6 months and neurosurgical intervention

The basic characteristics of the more frequently used model hosts.

<p>The blue color indicates that this feature is found in the specific model host. Utilizing the features of the chart can aid in determining which host(s) are most amenable to a particular study. Host genetic tools aiding in understanding host–pathogen interaction include sequenced genomes, available mutant strains, or RNAi. Once infected, some hosts can be used to identify compounds with antifungal activity. Also, while infected, some hosts are large enough that individual portions or tissues from the hosts can be removed and further analyzed either for host responses or to evaluate tissue invasion by the pathogen. As part of the host response, some hosts have phagocytic cells that engulf the foreign fungi and can be studied to elucidate information about host–pathogen interactions. When some fungi are engulfed by phagocytes, or establish an infection within the hosts, they produce hyphae. Because of the transparency or ability to recover tissue from some of the hosts, fungal hyphae formation can be further evaluated. For all of the infecting pathogens, temperature conditions are a consideration. The various hosts have conditions that are ideal for meeting their own survival needs, and the fungi will react differently in terms of gene expression and growth rate based on the temperatures in which the hosts are maintained. Temperature features marked in grey on the chart indicate hosts that can survive at temperature ranges as high as 37°C. Other invertebrate model hosts including <i>Bombyx mori</i>, <i>Culex quinquefasciatus</i>, <i>Blattella germanica</i>, and even a plant model of <i>Arabidopsis thaliana</i> have been developed. They are not as widely used and not mentioned here in detail because of space limitations.</p

Summary of findings generated by using the invertebrate infection models.

<p>Summary of findings generated by using the invertebrate infection models.</p

Fusarium Infection: Report of 26 Cases and Review of 97 Cases From the Literature

Abstract Fusarium species is a ubiquitous fungus that causes opportunistic infections. We present 26 cases of invasive fusariosis categorized according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria of fungal infections. All cases (20 proven and 6 probable) were treated from January 2000 until January 2010. We also review 97 cases reported since 2000. The most important risk factors for invasive fusariosis in our patients were compromised immune system, specifically lung transplantation (n = 6) and hematologic malignancies (n = 5), and burns (n = 7 patients with skin fusariosis), while the most commonly infected site was the skin in 11 of 26 patients. The mortality rates among our patients with disseminated, skin, and pulmonary fusariosis were 50%, 40%, and 37.5%, respectively. Fusarium solani was the most frequent species, isolated from 49% of literature cases. Blood cultures were positive in 82% of both current study and literature patients with disseminated fusariosis, while the remaining 16% had 2 noncontiguous sites of infection but negative blood cultures. Surgical removal of focal lesions was effective in both current study and literature cases. Skin lesions in immunocompromised patients should raise the suspicion for skin or disseminated fusariosis. The combination of medical monotherapy with voriconazole or amphotericin B and surgery in such cases is highly suggested

VAP patients stratified by age.

<p>ARDS: Acute respiratory distress syndrome; ICU: intensive care unit; IQR: interquartile range; LOS: length of stay; MRSA: Methicillin-resistant <i>Staphylococcus aureus</i>; MV: mechanical ventilation; SAPS II: simplified acute physiology score II; VAP: ventilator associated pneumonia.</p><p>*Results shown are percentages of the 167 patients for whom a microbiological diagnosis of VAP was successful.</p><p>**Results shown are percentages of the 147 patients for whom data on antimicrobial sensitivities were available.</p

The effects of provider-prescribed obesogenic drugs on post-laparoscopic sleeve gastrectomy outcomes: a retrospective cohort study

BackgroundLaparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures and has proven effective in providing weight loss. However, considerable variance has been noted in the degree of weight loss. Physician prescription practices may be negatively affecting weight loss post-LSG and, thus, contributing to the broad range of weight loss outcomes. The aim of our study was to determine whether commonly prescribed obesogenic medications negatively affect weight loss outcomes post-LSG.Subjects/methodsThis single center retrospective cohort study performed at a University hospital included 323 patients (≥18 years) within the&nbsp;University California, San Diego Healthcare System who underwent LSG between 2007 and 2016. We identified a list of 32 commonly prescribed medications that have weight gain as a side effect. We compared the percent excess weight loss (%EWL) of patients divided into two groups based on post-LSG exposure to obesogenic medications. A linear regression model was used to analyze %EWL at 12 months post-LSG while controlling for age, initial body mass index (BMI), and use of leptogenic medications.ResultsA total of 150 patients (Meds group) were prescribed obesogenic medications within the one-year post-LSG follow up period, whereas 173 patients (Control group) were not prescribed obesogenic medications. The Meds group lost significantly less weight compared to the Control group (%EWL ± SEM at 12 months 53.8 ± 2.4 n = 78, 65.0 ± 2.6, n = 84 respectively, P = 0.002). This difference could not be attributed to differences in age, gender, initial BMI, co-morbidities, or prescription of leptogenic medications between the two groups.ConclusionsThe use of provider-prescribed obesogenic medications was associated with worse weight loss outcomes post-LSG. Closer scrutiny of patient medications may be necessary to help improve outcomes of weight loss treatments

Etiologic diagnosis of VAP and resistance profiles.

<p>MDR: multidrug resistant; N/A: not applicable; VAP: ventilator associated pneumonia.</p