A Delphi Consensus to Identify Perioperative Antibiotic Prescribing Best Practices in Mohs Surgery

Abstract: Surgical site infections (SSI) make a significant global contribution to morbidity, mortality, and cost while remaining one of the most preventable causes of healthcare-associated infection. Perioperative antibiotics are a mainstay of prevention, but antibiotics are also associated with cost, risk, and increasing resistance. Dermatology is responsible for more oral antibiotic prescriptions than any other discipline. Despite a trend toward conservative prescribing practices and antibiotic stewardship in dermatology overall, antibiotic prescriptions in dermatologic surgery continue to increase, with a notable rise in short-term perioperative prescribing. There is currently a lack of evidence-based perioperative antibiotic prescribing guidelines within the dermatology literature. Evidence supports the need for specific, up-to-date recommendations regarding antibiotic management in the setting of dermatologic surgery. This QI project aims to review and synthesize current recommendations in the literature and identify best practices for developing standardized, appropriate use criteria for perioperative use of antibiotics in dermatologic surgery

Mycobacterial Disease Overlooked in a Frail Diabetic Male Treated for Pneumonia

Mycobacterial disease has been characterized to cause human illness since the 1950’s but practitioners whom address pulmonary disease can overlook its insidious presentation. This case report documents the presentation of a mycobacterial illness treated as a severe pneumonia. This is the case of a critically ill 43-year-old male, with poorly treated diabetes who presented with severe, long-standing respiratory distress in DKA. He had a history of weight loss, night sweats, decreased oral intake, and weakness for about a month. He was treated for euglycemia and his pulmonary disease was characterized as a bacterial pneumonia. Common pathogens were ruled out in an RIDP and he was treated with broad-spectrum antibiotics and discharged. On hospital follow up, careful examination of imaging report and history taking consisted with a timely screening for TB. A quantiferon gold test was positive and our patient was admitted to isolation on our inpatient service for evaluation. His AFB smear being positive, he was started on RIPE therapy. He was discharged with three negative sputum smears on the same therapy with cultures pending final characterization. This report documents a common treatment algorithm, based on a differential focused on typical culprits for pulmonary infection. Latent mycobacterial infections in our community are on the rise, especially in individuals whom are immunocompromised such as HIV+ or diabetics. First, these individuals must be identified using a screening tool such as a questionnaire. Second, obtaining screening labwork, even in non-compliant individuals are easily obtainable. Quantiferon gold assays could be administered to those identified as high risk even with no previous testing or prior negative test results. As these tests result, evaluation with a chest X-ray will stratify our groups to either further evaluation for latent mycobacterial infections or for treatment based on a positive chest X-ray. There needs to be a focus on identifying patients at risk for exposure to TB and providing diagnosis and treatment for latent infection or active disease. This will decrease the spread of tuberculosis

Screening for Inhalational Anthrax Due to Bioterrorism: Evaluating Proposed Screening Protocols

Eleven known cases of bioterrorism-related inhalational anthrax (IA) were treated in the United States during 2001. We retrospectively compared 2 methods that have been proposed to screen for IA. The 2 screening protocols for IA were applied to the emergency department charts of patients who presented with possible signs or symptoms of IA at Inova Fairfax Hospital (Falls Church, Virginia) from 20 October 2001 through 3 November 2001. The Mayer criteria would have screened 4 patients (0.4%; 95% CI, 0.1%-0.9%) and generated charges of 1900 dollars. If 29 patients (2.6%; 95% CI, 1.7%-3.7%) with \u3eor=5 symptoms (but without fever and tachycardia) were screened, charges were 13,325 dollars. The Hupert criteria would have screened 273 patients (24%; 95% CI, 22%-27%) and generated charges of 126,025 dollars. In this outbreak of bioterrorism-related IA, applying the Mayer criteria would have identified both patients with IA and would have generated fewer charges than applying the Hupert criteria

Errors in medical interpretation and their potential clinical consequences in pediatric encounters.

ABSTRACT. Background. About 19 million people in the United States are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation. Objectives. To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation. Methods. During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation and determined whether errors had a potential clinical consequence. Results. Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media. Conclusions. Errors in medical interpretatio