Necrotizing descending mediastinitis by Acinetobacter Baumannii in an out-patient: a case report

Abstract Background Complicated cervico-facial cellulitis is an infectious disease which can have fatal prognosis. Necrotizing descending mediastinitis is a rare and fatal complication of cervico-thoracic cellulitis. This is the case of necrotizing descending mediastinitis complicating by a multi-resistant Acinetobacter Baumannii in a 27-year-old female, with early management of hemodynamic, respiratory and surgical emergencies, and very careful post-operative care, resulting in very satisfying outcome. Case presentation The patient presented was first treated with broad spectrum antibiotics for Ludwig’s angina for 10 days, then presented with a swelling of sub-mandibular, sub-mental, and cervical regions, a mild respiratory distress, with clinical enhancement of dyspnea in proclive position, tachycardia of 100 beats per minute, and arterial blood pressure of 10/5. Clinical exam showed a tight trismus, with oral opening inferior to 1 cm, no inflammatory signs in facial and cervical swollen areas, and a saturation of 95% in proclive position. Auscultation suspected a pericardial effusion. CT scan with and without injected contrast medium showed diffuse abscesses of sub-mental, sub-mandibular, retro-pharyngeal, para-pharyngeal regions, along with mediastinal abscesses and pericardial effusion. Trans-thoracic ultrasound showed 2 cm pericardial effusion, preserved function of myocardium, and without signs of tamponade. The diagnosis of necrotizing descending mediastinitis with pericardial effusion was established. The patient underwent a course of wide spectrum antibiotic therapy, low doses of cathecholamine, and a surgical drainage through cervical approach of all implicated zones. The surgical dissection was thorough and difficult due to diffuse fibrosis found in tissues of cervical regions. Two hundred milliliters of pus was evacuated, with a placement of surgical drains and Delbet blades. Bacteriological exam found an Acinetobacter Baumannii sensitive to colistin only. The post-operative outcome showed clinical and biological enhancement; however, a residual mediastinal collection appeared in control CT scan after 48 h, which indicated a surgical revision through mediastinoscopy. The post-operative outcome was satisfying with stabilized clinical, biological, and radiological aspects. Conclusions Necrotizing descending mediastinitis is an infectious disease correlated with a very elevated mortality rate, and management is based on airway control, antibiotic therapy, and surgical treatment, as well as the post-operative intensive unit care. Early diagnosis and appropriate management enhances outcome and decreases mortality significantly.

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Febrile torticollis in an infant: what is your diagnosis?

International Journal of Scientific Reports ◽

10.18203/issn.2454-2156.intjscirep20211954 ◽

2021 ◽

Vol 7 (6) ◽

pp. 316

Author(s):

Ilham Rkain ◽

Safaa Toutimi

Keyword(s):

Antibiotic Therapy ◽

Ct Scan ◽

Retropharyngeal Abscess ◽

Retropharyngeal Space ◽

Upper Respiratory Tract ◽

Early Management ◽

Space Management ◽

Computed Tomographic ◽

Contrast Agent Injection ◽

Life Threatening

Retropharyngeal abscess is a rare but serious infection, in children, it is often secondary to upper respiratory tract infections.We report the case of an 18-month-old infant admitted to the emergencies for acute febrile torticolis. A computed tomographic (CT) scan with contrast agent injection revealed a collection of the retropharyngeal space; management consisted of triple antibiotic therapy and transoral drainage. The evolution was made towards a clinical and biological improvement. Retropharyngeal abscess should be suspected in front of dysphagia, cervical stiffness associated with a febrile syndrome, CT scan confirms the diagnosis and early management by intravenous antibiotic therapy whether or not combining surgical drainage, which remains a subject of discussion. Early diagnosis and management help to avoid life-threatening complications.

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COVID-19: how nuclear medicine can provide a differential diagnosis in very dubious case

Coronaviruses ◽

10.2174/2666796701999201209142919 ◽

2020 ◽

Vol 01 ◽

Author(s):

Maria Silvia De Feo ◽

Viviana Frantellizzi ◽

Giuseppe De Vincentis

Keyword(s):

Infectious Disease ◽

Differential Diagnosis ◽

Ct Scan ◽

Imaging Technique ◽

False Negative ◽

Clinical Signs ◽

Negative Results ◽

Infectious Disease Department ◽

False Negative Results ◽

99Mtc Hmpao

Background: We present the case of a 55-year-old woman, admitted to the Infectious Disease Department of Policlinico Umberto I, Rome, in mid-March 2020, with suspicion of COVID-19 infection. Objective: The rRT-PCR was negative and the following CT scan, performed to exclude false-negative results and help diagnosis, was inconclusive. Methods: It was decided to submit the patient to 99mTc-HMPAO-labelled leukocyte scan. Results: This exam led to the diagnosis of infective endocarditis. Conclusion: In the present pandemic scenario, 99mTc-HMPAO-labelled leukocyte scan represents a reliable imaging technique for differential diagnosis with COVID-19 in patients with confusing clinical signs, possible false-negative rRT-PCR results and inconclusive CT scan.

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Visceral Mycotic Aneurysm: Superior Mesenteric Artery Aneurysm Caused by K. pneumoniae

Dubai Medical Journal ◽

10.1159/000517222 ◽

2021 ◽

pp. 1-4

Author(s):

Reham Almasoud ◽

Alaaeddin Nwilati ◽

Saeb Bayazid ◽

Mamoun Shafaamri

Keyword(s):

Infectious Disease ◽

Antibiotic Therapy ◽

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Mycotic Aneurysm ◽

Artery Aneurysm ◽

Management Plan ◽

Resected Tissue ◽

Infectious Disease Specialists

We herein report a rare case of mycotic aneurysm of the superior mesenteric artery caused by <i>Klebsiella pneumoniae</i>. A 66-year-old man, a known case of hypertension and aorto-oesophageal fistula with stented aorta in 2010 and 2018, presented to the emergency department multiple times over 2 months with severe postprandial abdominal pain associated with vomiting and fever. On his last presentation, the obtained blood cultures grew ESBL positive <i>K. pneumoniae</i> and a repeated computed tomography (CT) showed a growing aneurysm at the origin of the ileocecal branch of the superior mesenteric artery measuring 17 × 10 mm (the aneurysm was 8 × 7.5 mm in the CT angiography on the previous admission). Extensive workup did not reveal the underlying cause of the mycotic aneurysm, thus we believe the cause to be the infected aortic stent, leading to bacteraemia and vegetations to the mesenteric artery causing the aneurysm. The management plan was placed by a multidisciplinary team consisting of vascular surgeons and infectious disease specialists along with review from a dietician to evaluate the patient’s nutritional status. The patient was started on total parenteral nutrition due to his postprandial pain and on antibiotic therapy according to the infectious disease team’s recommendation. He underwent surgical resection of the mycotic aneurysm, which showed a thrombosed aneurysm in the jejunoileal mesenteric area. The histopathology of the resected tissue demonstrated inflammatory aneurysm of the mesenteric artery. Following the surgery, the patient continued his antibiotic therapy and was discharged on the 13th post-operative day with follow-up appointments in the vascular surgery and infectious disease clinic.

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A randomised placebo-controlled double-blind multicentre trial comparing antibiotic therapy with placebo in the treatment of uncomplicated acute appendicitis: APPAC III trial study protocol

BMJ Open ◽

10.1136/bmjopen-2018-023623 ◽

2018 ◽

Vol 8 (11) ◽

pp. e023623 ◽

Cited By ~ 12

Author(s):

Suvi Sippola ◽

Juha Grönroos ◽

Ville Sallinen ◽

Tero Rautio ◽

Pia Nordström ◽

...

Keyword(s):

Acute Appendicitis ◽

Antibiotic Therapy ◽

Ct Scan ◽

Symptomatic Treatment ◽

Spontaneous Resolution ◽

University Hospital ◽

Controlled Study ◽

Double Blind ◽

Uncomplicated Acute Appendicitis

IntroductionRecent studies show that antibiotic therapy is safe and feasible for CT-confirmed uncomplicated acute appendicitis. Spontaneous resolution of acute appendicitis has already been observed over a hundred years ago. In CT-confirmed uncomplicated acute diverticulitis (left-sided appendicitis), studies have shown no benefit from antibiotics compared with symptomatic treatment, but this shift from antibiotics to symptomatic treatment has not yet been widely implemented in clinical practice. Recently, symptomatic treatment of uncomplicated acute appendicitis has been demonstrated in a Korean open-label study. However, a double-blinded placebo-controlled study to illustrate the role of antibiotics and spontaneous resolution of uncomplicated acute appendicitis is still lacking.Methods and analysisThe APPAC III (APPendicitis ACuta III) trial is a multicentre, double-blind, placebo-controlled, superiority randomised study comparing antibiotic therapy with placebo in the treatment CT scan-confirmed uncomplicated acute appendicitis aiming to evaluate the role of antibiotics in the resolution of uncomplicated acute appendicitis. Adult patients (18–60 years) with CT scan-confirmed uncomplicated acute appendicitis (the absence of appendicolith, abscess, perforation and tumour) will be enrolled in five Finnish university hospitals.Primary endpoint is success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without surgical intervention within 10 days after initiating randomised treatment (treatment efficacy). Secondary endpoints include postintervention complications, recurrent symptoms after treatment up to 1 year, late recurrence of acute appendicitis after 1 year, duration of hospital stay, sick leave, treatment costs and quality of life. A decrease of 15 percentage points in success rate is considered clinically important difference. The superiority of antibiotic treatment compared with placebo will be analysed using Fisher’s one-sided test and CI will be calculated for proportion difference.Ethics and disseminationThis protocol has been approved by the Ethics Committee of Turku University Hospital and the Finnish Medicines Agency (FIMEA). The findings will be disseminated in peer-reviewed academic journals.Trial registration numberNCT03234296; Pre-results.

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Lipoglycopeptides, Outpatient Parenteral Antibiotic Therapy, and the Infectious Disease Doctor—Moving Forward

Infectious Diseases in Clinical Practice ◽

10.1097/ipc.0000000000000640 ◽

2018 ◽

Vol 26 (3) ◽

pp. 121-122 ◽

Cited By ~ 1

Author(s):

Donald M. Poretz

Keyword(s):

Infectious Disease ◽

Antibiotic Therapy ◽

Parenteral Antibiotic ◽

Outpatient Parenteral Antibiotic Therapy

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P1339 Clinical masks of aortic aneurysm: staged rupture of an aortic aneurysm under the guise of a recurrent infection

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.777 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

A L Volkova ◽

V A Bykov ◽

E V Petrova ◽

V A Grigoryev ◽

M Y U Tyurin ◽

...

Keyword(s):

Pericardial Effusion ◽

Aortic Aneurysm ◽

Ct Scan ◽

Ascending Aorta ◽

Chest Ct ◽

Military Hospital ◽

Cerebrovascular Event ◽

Suspected Sepsis ◽

Norepinephrine Infusion ◽

Chest Ct Scan

Abstract A 63-year-old man was admitted to the medical intensive care unit because of hypotension and suspected sepsis. Two months before he was admitted to military hospital for cerebrovascular event, considered as transient ischemic attack. Few days after discharge the fever (with a temperature of 39.5°C) occurred and patient was readmitted to the same hospital. Empirical treatment with cefalosporine was inefficient. Only combination carbapenem and vancomycin after E.coli was verified in blood culture stopped the infection. With normal body temperature, normal leukocytes count, mild azotemia, sterile blood and urine cultures and diagnosis of treated urosepsis patient was discharged. Two echocardiogram during hospital stay found no abnormal findings and chest CT scan was also normal. Seven days later, he was seen in our hospital because of fever (with a temperature of 40°C), severe sweating and arterial hypotension. Immediately fluids and norepinephrine infusion was started. Fluoroquinolone was chosen as an antibiotic. There was complete LBBB on ECG that had been registered previously. Leucocyte count at admission was 14 x 109/l and creatinine 300 µmol/l. Transthoracic echo (TTE) reportedly showed evidence of mild aortic and mitral regurgitations, pericardial effusion (1.0 – 1.3 cm with signs of right atrium compression). Aortic root seemed quite normal. On the third day, the number of leukocytes and creatinine increased significantly, reaching 450 µmol/l and 41 x 109/l respectively. Chest CT scan revealed signs of bilateral pneumonia, pericardial and left-sided pleural effusions. Vancomycin and ceftriaxone intravenously were started. Transesophageal echo revealed degenerative changes of aortic valve with mild insufficiency, mild mitral regurgitation. The amount of fluid in the pericardium was approximately unchanged. Patient became normotensive and norepinephrine infusion was discontinued. On the 6th day after admission patient’s temperature became normal, level of creatinine decreased to 230 µkmol/l and leukocytes reached 11.4 x 109/l. On the same day, the patient"s condition worsened. He complained of mild heartburn and progressive weakness, the number of leukocytes and the activity of transaminases increased, his blood pressure dropped to 75/40 mm Hg. This has led to the resumption of norepinephrine infusion. Repeated CT scan revealed inhomogeneous contents in the pericardium. Repeated TTE found increase of pericardial effusion with heterogenous content and signs of cardiac tamponade. Patient was transferred to operating room. After pericardiotomy multiple blood clots and active bleeding from pseudoaneurysm of ascending aorta were found. Despite surgical attempts and massive transfusion, patient died. Autopsy revealed the rupture of pseudoaneurysm of ascending aorta and flat hematoma in pericardium. Abstract P1339 Figure.

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How Does Antimicrobial Stewardship Affect Inappropriate Antibiotic Therapy in Urological Patients?

Antibiotics ◽

10.3390/antibiotics9020063 ◽

2020 ◽

Vol 9 (2) ◽

pp. 63 ◽

Cited By ~ 3

Author(s):

Atsushi Uda ◽

Katsumi Shigemura ◽

Koichi Kitagawa ◽

Kayo Osawa ◽

Kenichiro Onuma ◽

...

Keyword(s):

Infectious Disease ◽

Disease Management ◽

Antibiotic Therapy ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Retrospective Review ◽

Antibiotic Use ◽

University Hospital ◽

Annual Changes ◽

Inappropriate Medications

Antimicrobial stewardship teams (ASTs) have been well-accepted in recent years; however, their clinical outcomes have not been fully investigated in urological patients. The purpose of this study was to evaluate the outcomes of intervention via a retrospective review of urological patients, as discussed in the AST meetings, who were treated with broad-spectrum antibiotics between 2014 and 2018 at the Department of Urology, Kobe University Hospital in Japan. Interventions were discussed in AST meetings for patients identified by pharmacists as having received inappropriate antibiotic therapy. The annual changes in numbers of inappropriate medications and culture submissions over five years at the urology department were statistically analyzed. Among 1,033 patients audited by pharmacists, inappropriate antibiotic therapy was found in 118 cases (11.4%). The numbers of inappropriate antibiotic use cases and of interventions for indefinite infections had significantly decreased during the study period (p = 0.012 and p = 0.033, respectively). However, the number of blood and drainage culture submissions had significantly increased (p = 0.009 and p = 0.035, respectively). Our findings suggest that urologists have probably become more familiar with infectious disease management through AST intervention, leading to a decrease in inappropriate antibiotic use and an increase in culture submissions.

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Influence of Infectious Disease Physician Approval on Appropriateness of PICC Use and Outcomes

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1162 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s485-s487

Author(s):

Valerie M Vaughn ◽

Megan O’Malley ◽

Scott A. Flanders ◽

Tejal N. Gandhi ◽

Lindsay A. Petty ◽

...

Keyword(s):

Infectious Disease ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Antibiotic Therapy ◽

Hospital Medicine ◽

Severity Of Illness ◽

Central Line ◽

Medical Patients ◽

Infectious Disease Physician ◽

Single Lumen

Background:Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous (IV) antibiotic therapy after discharge from the hospital. Infectious disease (ID) physicians are often consulted prior to PICC placement, but whether their approval influences PICC appropriateness and complications is not known. Methods: Using data from the Michigan Hospital Medicine Safety Consortium (HMS) on PICCs placed in critically ill and hospitalized medical patients between January 1, 2015, and July 26, 2019, we examined the association between ID physician approval of PICC insertion for IV antibiotics and device appropriateness and outcomes. Appropriateness was defined according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) as a composite measure of (1) avoiding PICC use for durations ≤5 days; (2) using single-lumen instead of multilumen catheters; and (3) avoiding PICC use in patients with chronic kidney disease (eGFR>45 mL/min). The associations between ID approval of PICC use and odds of PICC-related complications (eg, deep vein thrombosis, central-line–associated bloodstream infection, and catheter occlusion) were also assessed. Multivariable models adjusting for patient severity of illness and hospital-level clustering were fit to both outcomes. Results were expressed as odds ratios (ORs) with corresponding 95% CIs. Results: Data from 36,594 patients who underwent PICC placement across 42 Michigan hospitals were included in the analysis. In total, 21,653 (55%) PICCs were placed for the indication of IV antibiotics; 14,935 (69%) of these had a documented ID consultation prior to placement, whereas 6,718 (31%) did not. Of the 14,935 PICCs with an ID consultation, 10,238 (69%) had ID approval documented prior to device placement (Fig. 1). Compared to no approval, PICCs approved by ID prior to insertion were more likely to be appropriate (OR, 3.51; 95% CI, 3.28–3.77; P < .001). Specifically, approval was associated with higher single-lumen use (OR, 5.13; 95% CI, 4.72–5.58; P < .001), less placement of PICCs with dwell times ≤ 5 days (OR, 0.29; 95% CI, 0.25–0.32; P < .001), and less frequent use in patients with chronic kidney disease (OR, 0.80; 95% CI, 0.73–0.87; P < .001). ID approval of PICCs prior to insertion was associated with a significantly lower odds of PICC-related complications (OR, 0.57; 95% CI, 0.51–0.64) (Table 1). Conclusions: ID approval of PICC use for IV antibiotic therapy in hospitalized patients was associated with greater appropriateness and fewer complications. Policies aimed at ensuring ID review prior to PICC use may help improve patient and device safety.Funding: NoneDisclosures:Valerie M. Vaughn reports contract research for Blue Cross and Blue Shield of Michigan, the Department of Veterans’ Affairs, the NIH, the SHEA, and the APIC. She also reports fees from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and The Hospital and Health System Association of Pennsylvania.

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Intraventricular hemorrhage from ruptured aneurysm

Journal of Neurosurgery ◽

10.3171/jns.1983.58.4.0482 ◽

1983 ◽

Vol 58 (4) ◽

pp. 482-487 ◽

Cited By ~ 114

Author(s):

Gerard Mohr ◽

Gary Ferguson ◽

Moe Khan ◽

David Malloy ◽

Reginald Watts ◽

...

Keyword(s):

Blood Pressure ◽

Ct Scan ◽

Intraventricular Hemorrhage ◽

Prognostic Significance ◽

Aneurysm Rupture ◽

Intracerebral Hematoma ◽

Early Management ◽

Content Type ◽

Medical Centers ◽

Number Of Patients

✓ Intraventricular hemorrhage (IVH) from aneurysm rupture is generally considered to be of grave prognostic significance. Ninety-one cases have been studied retrospectively from seven medical centers. The overall mortality rate was 64%. The dramatically poor condition of these patients leads to their rapid admission to the hospital. Eighty-seven percent were admitted on Day 0 or 1, and more than half were classified neurologically as Grade 4 or 5. A multiple regression analysis explained 56% of the variance in survival, using the variables of ventriculocranial ratio (VCR), day of admission, diastolic blood pressure, location of aneurysm, associated intracerebral hematoma, age, grade on admission, sex, and systolic blood pressure. No patient with a VCR of more than 0.25, as calculated from the initial computerized tomography (CT) scan, survived. No patient whose smallest VCR was 0.23 or more survived. This ratio can be simply measured with a millimeter ruler from the CT scan. Patients with IVH usually had enlarged ventricles, even initially. The overall results suggest that early management of intracranial hypertension should be more generally considered, although even when this was done the prognosis was still guarded. The timing of surgery was not an important determinant of outcome, although a significant number of patients died awaiting surgery.

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