Delays in diagnosis and treatment of vaccine preventable community acquired bacterial meningitis (CABM): a retrospective analysis at three tertiary care centers

Abstract Background Outcomes in community-acquired bacterial meningitis (CABM) are significantly impacted by delays in diagnosis and treatment. This retrospective case series aims to describe the sociodemographic, epidemiological, and clinical variables including time to diagnosis and treatment of vaccine preventable CABM in three tertiary care settings in New York City (NYC). Methods A retrospective chart review was conducted of patients at Columbia University Irving Medical Center (CUIMC), Children’s Hospital of New York (CHONY), Mount Sinai Health System, and Weill Cornell Medical Center with CABM due to Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis between January 1, 2012 and December 31, 2017. A descriptive statistical analysis was performed. Results Our case series consisted of 36 patients, 24 (66.7%) females, and 12 (33.33%) males with a median age of 42 years (IQR 55 years). Median time from presentation to lumbar puncture (LP) was eight hours (IQR 7). The median time from hospital presentation to diagnosis was 12 hours (IQR 9), and the median time from LP to diagnosis was three hours (IQR 5). Delay in diagnosis which is defined by more than 8 hours from hospital presentation, occurred in 13 patients (36.1%) due to initial misdiagnosis, most commonly systemic febrile and/or viral infections and otitis media. Conclusions Despite evidence of the importance of early diagnosis and treatment for CABM, this case series shows the ongoing challenges with early clinical diagnosis. Misdiagnoses were an underlying reason for delays from presentation to LP and to antibiotic treatment in the majority of our patients. This study in NYC identifies ongoing major delays in diagnosis and antimicrobial treatment in CABM, and future studies are needed to identify mechanisms to improve time to antibiotic treatment and LP in CABM.

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Delays in Diagnosis and Treatment of Bacterial Meningitis in NYC: Retrospective Cohort Analysis

The Neurohospitalist ◽

10.1177/19418744211037319 ◽

2021 ◽

pp. 194187442110373

Author(s):

Sarah D. Torres ◽

Carla Y. Kim ◽

Mitashee Das ◽

Jyoti V. Ankam ◽

Nicole Luche ◽

...

Keyword(s):

Bacterial Meningitis ◽

Retrospective Cohort ◽

Viral Infections ◽

Medical Center ◽

Cohort Analysis ◽

Retrospective Chart Review ◽

Diagnosis And Treatment ◽

Haemophilus Influenzae Type ◽

Antibiotic Administration ◽

Delays In Diagnosis

Community-acquired bacterial meningitis (CABM) morbidity and mortality remains high in those infected. Rapid diagnosis and treatment is paramount to reducing mortality and improving outcome. This retrospective cohort study aims to assess the time from presentation to diagnosis and treatment of vaccine preventable CABM as well as identify possible factors associated with delays in diagnosis and antibiotic administration. A retrospective chart review was conducted of individuals who presented to Columbia University Irving Medical Center (CUIMC), Children’s Hospital of New York (CHONY), Mount Sinai Medical Center, and Weill Cornell Medical Center with BM due to Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis between January 1, 2012 and December 31, 2017. Diagnosis was delayed by more than 8 hours in 13 patients (36.1%) and 5 individuals (13.9%) had a delay of 4 hours or more from presentation to the administration of antibiotics with appropriate CNS coverage. All of these patients were also initially misdiagnosed at an outpatient clinic, outside hospital, or emergency department. This retrospective study identified febrile and/or viral infections not otherwise specified and otitis media as the most common misdiagnoses underlying delays from presentation to diagnosis and to antibiotic treatment in those with BM.

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Characteristics and Outcomes Among Hospitalized COVID-19-Positive Patients in a Nonurban Environment

Military Medicine ◽

10.1093/milmed/usab044 ◽

2021 ◽

Author(s):

Robert P Lennon ◽

Theodore J Demetriou ◽

M Fahad Khalid ◽

Lauren Jodi Van Scoy ◽

Erin L Miller ◽

...

Keyword(s):

New York ◽

Medical Center ◽

Academic Medical Center ◽

Military Medicine ◽

Case Series ◽

Outcome Data ◽

Urban Environments ◽

Urban Setting ◽

Published Data ◽

Retrospective Case

ABSTRACT Introduction Virtually all hospitalized coronavirus disease-2019 (COVID-19) outcome data come from urban environments. The extent to which these findings are generalizable to other settings is unknown. Coronavirus disease-2019 data from large, urban settings may be particularly difficult to apply in military medicine, where practice environments are often semi-urban, rural, or austere. The purpose of this study is compare presenting characteristics and outcomes of U.S. patients with COVID-19 in a nonurban setting to similar patients in an urban setting. Materials and Methods This is a retrospective case series of adults with laboratory-confirmed COVID-19 infection who were admitted to Hershey Medical Center (HMC), a 548-bed tertiary academic medical center in central Pennsylvania serving semi-urban and rural populations, from March 23, 2020, to April 20, 2020 (the first month of COVID-19 admissions at HMC). Patients and outcomes of this cohort were compared to published data on a cohort of similar patients from the New York City (NYC) area. Results The cohorts had similar age, gender, comorbidities, need for intensive care or mechanical ventilation, and most vital sign and laboratory studies. The NYC’s cohort had shorter hospital stays (4.1 versus 7.2 days, P < .001) but more African American patients (23% versus 12%, P = .02) and higher prevalence of abnormal alanine (>60U/L; 39.0% versus 5.9%, P < .001) and aspartate (>40U/L; 58.4% versus 42.4%, P = .012) aminotransferase, oxygen saturation <90% (20.4% versus 7.2%, P = .004), and mortality (21% versus 1.4%, P < .001). Conclusions Hospitalists in nonurban environments would be prudent to use caution when considering the generalizability of results from dissimilar regions. Further investigation is needed to explore the possibility of reproducible causative systemic elements that may help improve COVID-19-related outcomes. Broader reports of these relationships across many settings will offer military medical planners greater ability to consider outcomes most relevant to their unique settings when considering COVID-19 planning.

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Utilization of Diagnostic Testing for Renal Anomalies and Congenital Heart Disease in Patients with Microtia

Otolaryngology ◽

10.1177/0194599820901351 ◽

2020 ◽

Vol 162 (4) ◽

pp. 554-558

Author(s):

Vaibhav H. Ramprasad ◽

Amber D. Shaffer ◽

Noel Jabbour

Keyword(s):

Congenital Heart ◽

Medical Center ◽

Tertiary Care ◽

Diagnostic Testing ◽

Case Series ◽

Standard Of Care ◽

Renal Ultrasound ◽

Renal Anomalies ◽

Children's Hospital ◽

Children’S Hospital

Objective Congenital ear anomalies are associated with congenital cardiac and renal defects. Renal ultrasounds, electrocardiogram, and echocardiogram can be utilized for diagnosis of these concurrent defects. No standard of care exists for the workup of patients with microtia. The goals of this study were to describe the utilization of diagnostic testing for cardiac and renal anomalies and to identify their prevalence in patients with microtia. Study Design Case series with chart review. Setting Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center. Subjects and Methods This study is an Institutional Review Board–approved retrospective review of consecutive patients born between 2002 and 2016 who were diagnosed with microtia and seen in the otolaryngology clinic at a tertiary care children’s hospital. Demographics, sidedness and grade of microtia, comorbid diagnoses, and details of renal and cardiovascular evaluations were recorded. Factors associated with retroperitoneal ultrasound and cardiac testing were assessed with logistic regression. Results Microtia was present in 102 patients, and 98 patients were included as they received follow-up. Microtia was associated with craniofacial syndrome in 34.7% of patients. Renal ultrasound was performed in 64.3% of patients, and 12.9% of patients with ultrasounds had renal aplasia. Cardiac workup (electrocardiogram or echocardiogram) was completed in 60.2% of patients, and of this subset, 54.2% had a congenital heart defect. Conclusion Diagnostic testing revealed renal anomalies and cardiac defects in patients with isolated microtia at a higher rate than in the general population. This suggests the need for further evaluation of the role of routine screening in patients with microtia.

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Labyrinthitis ossificans: How accurate is MRI in predicting cochlear obstruction?

Otolaryngology ◽

10.1016/j.otohns.2008.12.029 ◽

2009 ◽

Vol 140 (5) ◽

pp. 692-696 ◽

Cited By ~ 59

Author(s):

Brandon Isaacson ◽

Timothy Booth ◽

Joe W. Kutz ◽

Kenneth H. Lee ◽

Peter S. Roland

Keyword(s):

High Resolution ◽

Bacterial Meningitis ◽

Cochlear Implant ◽

Tertiary Care ◽

Fibrous Tissue ◽

Case Series ◽

Prior History ◽

Basal Turn ◽

Labyrinthitis Ossificans ◽

History Of

Objective: To determine the accuracy of preoperative MRI in predicting cochlear obstruction in pediatric patients with a history of bacterial meningitis. Methods: A case series with chart review was performed at a tertiary care multidisciplinary cochlear implant program. Forty-five children with hearing loss that resulted from bacterial meningitis were implanted from 1991 to 2006. Twenty-five children had preoperative MRI with high-resolution axial T2-weighted images to assess for cochlear patency. Results: Seventeen of 25 patients (68%) had surgical evidence of cochlear obstruction. Six patients (37.5%) required circummodiolar drill-outs, and one patient (6.25%) underwent placement of a double array cochlear implant. The nine remaining patients (56%) with cochlear obstruction required removal of fibrous tissue or drilling of the inferior basal turn, but did not require manipulation of the ascending basal turn to achieve full electrode insertion. The sensitivity, specificity, and positive and negative predictive value of MRI predicting intraoperative cochlear obstruction with 95 percent confidence intervals was 94.1 percent (71–99), 87.5 percent (47–99), 94.1 percent (71–99) and 87.5 percent (47–99), respectively. Conclusion: Preoperative high-resolution T2 MRI may be useful in predicting cochlear obstruction in patients with a prior history of bacterial meningitis.

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Indocyanine Green Fluorescence to Evaluate Nasoseptal Flap Viability in Endoscopic Endonasal Cranial Base Surgery

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1602777 ◽

2017 ◽

Vol 78 (05) ◽

pp. 408-412 ◽

Cited By ~ 6

Author(s):

Edward Kerr ◽

Ali Jamshidi ◽

Ricardo Carrau ◽

Raewyn Campbell ◽

Leo Filho ◽

...

Keyword(s):

Indocyanine Green ◽

Early Recognition ◽

Medical Center ◽

Tertiary Care ◽

Case Series ◽

Arterial Supply ◽

Cerebrospinal Fluid Leakage ◽

Nasoseptal Flap ◽

Endoscopic Endonasal ◽

Flap Viability

Objectives The pedicled nasoseptal flap (NSF) has dramatically reduced postoperative cerebrospinal fluid leakage following endoscopic endonasal approach (EEA) surgery. Although rare, its arterial supply may be damaged during harvest or may be preoperatively damaged for numerous reasons. Early recognition permits harvesting a contralateral flap before sacrificing its pedicle as part of the surgical exposure or use of an alternative flap. Design Technical feasibility study and case series. Setting Tertiary care university-associated medical center. Participants Five patients requiring an EEA with NSF reconstruction. Main Outcome Measures During NSF harvest, intravenous indocyanine green (IVICG) was administered, and a customized endoscopic system was used to visualize the emerging fluorescence. At the end of each case, just before final positioning of the NSF, additional IVICG was administered, and the custom endoscope was again introduced to evaluate fluorescence. Results In four patients, the entire NSF fluoresced brightly with IVICG on initial harvest and before final positioning. One patient showed heterogeneous fluorescence of the pedicle and distal parts of the NSF at both stages. All NSFs healed well without complication. Conclusion IVICG facilitates real-time evaluation NSF's arterial supply. This may provide early recognition of arterial compromise, allowing the harvest of alternate flaps or modification of surgery.

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COVID-19 Related Deaths in an Urban Academic Medical Center in Brooklyn – A Descriptive Case Series

10.21203/rs.3.rs-37896/v1 ◽

2020 ◽

Author(s):

James Andrew McCracken ◽

Mohamed Nakeshbandi ◽

Jeffrey Arace ◽

Wayne J Riley ◽

Roopali Sharma

Keyword(s):

New York ◽

Medical Center ◽

Academic Medical Center ◽

Case Series ◽

Retrospective Chart Review ◽

Black Population ◽

International Travel ◽

Normal Limits ◽

Academic Medical ◽

Patients At Risk

Abstract Background Available studies are lacking in analysis of baseline demographics and hospital presentation of patients at risk of expiring due to coronavirus disease 2019 (COVID-19), particularly Black American patients. We conducted a retrospective chart review to determine similarities in demographics and hospital presentation among patients who expired due to COVID-19 at an academic medical center in Brooklyn, New York.Study design and methods This is a retrospective observational study of 200 patients who expired due to complications of COVID-19. Patients were included in this study if they had laboratory-confirmed SARS-CoV-2 infection and expired during their admission. Data were collected on patients who expired between March 17 and April 16, 2020. Results A vast majority of patients were Black Americans (89%) with no history of international travel who had more than one comorbidity (81%), with the most common comorbidities being hypertension (84·5%), diabetes mellitus (57·5%), and obesity (41·5%). Fifty-five percent of our patient population had three or more comorbidities. Among patients with available data, C-reactive protein, lactate dehydrogenase, and ferritin values were elevated above normal limits at admission. Dyspnea was the most common presenting symptom (92·5%). Most (90·5%) presented within the first week of symptoms, with a median time of symptoms prior to expiration being 8·42 days (IQR 5·57 – 12·72). Interpretation Socioeconomic status and healthcare inequalities have greatly affected the Black population of Brooklyn, New York, and these disparities become even more apparent in COVID-19 infection. Patients presenting with numerous comorbidities and elevated inflammatory markers represent a population at high risk of in-hospital mortality.

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Risk Factors for Otolaryngological Foreign Bodies in Eastern Poland

Otolaryngology ◽

10.1177/0194599812455297 ◽

2012 ◽

Vol 147 (5) ◽

pp. 889-893 ◽

Cited By ~ 3

Author(s):

Beata Rybojad ◽

Artur Niedzielski ◽

Grażyna Niedzielska ◽

Paweł Rybojad

Keyword(s):

Risk Factors ◽

Foreign Body ◽

Elementary Education ◽

Urban Areas ◽

Foreign Bodies ◽

Medical Center ◽

Tertiary Care ◽

Case Series ◽

Psychomotor Development ◽

Tertiary Care Medical Center

Objective To identify the sociodemographic characteristics and risk factors associated with suspected foreign bodies in the ear, nose, throat, airway, and esophagus among Polish children. Study Design Case series with chart review. Setting Tertiary care medical center. Subjects and Methods A retrospective analysis of the medical records of patients hospitalized for a suspected foreign body (FB) between 1998 and 2008 was conducted. Data regarding place of residence, presence of siblings, parents’ educational status, seasonality, psychomotor development, age, and sex were collected and statistically analyzed. Results Of the 1011 patients with suspected foreign body insertion, 849 (84%) had a positive diagnosis. Of the confirmed foreign bodies, 96 were found in the tracheobronchial tree, 142 were found in the esophagus, and 611 were located in the external auditory canals, nasopharyngeal passage, tonsils, auricles, or lips. Sociodemographically, 596 of the children came from urban areas, with a preponderance of males (55%). Objects were removed more frequently in summer and autumn (60%). Children with siblings (53%) predominated. The majority of patients (52%) had parents with an elementary education. Food was the most frequent foreign body in children under 3 years of age. Patients with delayed psychomotor development constituted 1.6% of the analyzed population. Conclusions Being male, 1 to 3 years of age, belonging to an urban family with siblings, and having parents with an elementary education increased the risk of foreign body insertion. Training caregivers about proper nutrition and safety rules when playing with children can reduce the risk of accidents related to foreign body insertion.

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1530. A Cluster of Disseminated Gonococcal Infections in a Non-Immunocompromised Veteran Population

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1710 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S765-S766

Author(s):

Nicole C Vissichelli ◽

Emily Hill ◽

Linda E Anderson ◽

Angela Eckert ◽

Cynthia M Fagan ◽

...

Keyword(s):

Risk Factors ◽

Whole Genome Sequencing ◽

Genome Sequencing ◽

Medical Center ◽

Tertiary Care ◽

Case Series ◽

Clinical History ◽

Nucleic Acid Amplification ◽

Whole Genome ◽

Gonococcal Infection

Abstract Background Disseminated gonococcal infection (DGI) is an uncommon manifestation of N. gonorrhoeae that is estimated to occur in 0.5-3% of cases, with a decreasing incidence that has been attributed to changes in circulating serotypes. At a Veterans Affairs Medical Center (VAMC), 3 cases were identified within 4 months in 2019. Methods A case series of patients with DGI between March and July 2019 was conducted at a 399-bed tertiary care VAMC that serves central Virginia. Clinical case data was abstracted from the medical record, and data regarding prior gonorrhea cases at the facility was obtained from the laboratory information system. Results In 2019, the rate of DGI was 4.9%, with 3 cases out of 61 reported. All occurred in immunocompetent, African-American males with a mean age of 59 years, and all had female sexual partners (Table 1). All presented with joint symptoms, 2 had skin manifestations, and none had genital symptoms. Two patients had positive synovial fluid cultures and the third had a positive blood culture. All isolates were beta-lactamase negative. Orogenital testing by nucleic acid amplification was only positive in 1 patient. No other sexually transmitted infections were identified. One patient underwent surgical washout of the involved shoulder joint, but the others were managed non-operatively. All received a single dose of azithromycin and a 14-day course of ceftriaxone with full symptom resolution. These were the first positive N. gonorrhoeae isolates from invasive specimens at this VAMC since at least 2016. Table 1. Clinical History and Laboratory Results at Presentation for Patients with Disseminated Gonococcal Infection Conclusion This cluster of DGI cases was unusual given the recent rarity at this VAMC, the age of the patients, and lack of overt risk factors. In Virginia, DGI is reported to the health department no differently than uncomplicated infections, so the actual rate of DGI regionally is unknown. One isolate was preserved and sent to the Centers for Disease Control and Prevention for deidentified whole genome sequencing. More refined reporting is necessary to improve understanding of local gonorrhea epidemiology, as well as coupling with additional methodologies such as serotyping or whole genome sequencing. Clinicians should be aware of the possibility of DGI, even in older patients without classic risk factors. Disclosures All Authors: No reported disclosures

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Acinetobacter species meningitis in children: a case series from Karachi, Pakistan

The Journal of Infection in Developing Countries ◽

10.3855/jidc.1697 ◽

2011 ◽

Vol 5 (11) ◽

pp. 809-814 ◽

Cited By ~ 6

Author(s):

Ali Faisal Saleem ◽

Muhammad Shafaat Shah ◽

Abdul Sattar Shaikh ◽

Fatima Mir ◽

Anita K M Zaidi

Keyword(s):

Antimicrobial Agents ◽

Medical Center ◽

External Ventricular Drain ◽

Tertiary Care ◽

Case Series ◽

Polymyxin B ◽

Multidrug Resistant ◽

Resistant Isolate ◽

Acinetobacter Species ◽

Tertiary Care Medical Center

Introduction: Multidrug-resistant strains of Acinetobacter pose a serious therapeutic dilemma in hospital practice, particularly when they cause meningitis, as the few antimicrobial agents to which these isolates are susceptible have poor central nervous system (CNS) penetration. Methodology: We retrospectively reviewed the clinical course and outcome of eight consecutive cases of meningitis due to Acinetobacter spp. in children ages 15 years or less, seen in a tertiary care medical center in Karachi, Pakistan. Results: Of the eight cases of Acinetobacter meningitis, isolates from five patients were pan-resistant, and two were multidrug-resistant. A neurosurgical procedure was performed in five of eight patients followed by external ventricular drain insertion prior to the development of infection. Seven received intravenous (IV) polymyxin (mean; 12.8 days), while 5/8 also received intrathecal (IT) polymyxin (mean; 12.0 days). The mean length of hospitalization was 38.7 ± 19 days. All patients achieved cerebrospinal fluid (CSF) culture negativity by the end of treatment (mean; 5.4 days). Two patients died: one with pan-resistant Acinetobacter, and the second with a multi-drug resistant isolate. Conclusion: Post-neurosurgical multidrug-resistant and pan-resistant Acinetobacter meningitis can be successfully treated if appropriate antimicrobial therapy is instituted early. The role of IT polymyxin B administration alone versus combination therapy (IV and IT) needs further study.

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EFFICACY OF INFLIXIMAB DOSE ESCALATION IN PATIENTS WITH REFRACTORY IMMUNOTHERAPY-RELATED COLITIS: A CASE SERIES

Inflammatory Bowel Diseases ◽

10.1093/ibd/izaa347.139 ◽

2021 ◽

Vol 27 (Supplement_1) ◽

pp. S58-S58

Author(s):

Jessica Harris ◽

David Faleck

Keyword(s):

New York ◽

Clinical Response ◽

Dose Escalation ◽

Fecal Microbiota Transplantation ◽

Standard Dose ◽

Care Center ◽

Tertiary Care ◽

Case Series ◽

Fecal Microbiota ◽

High Dose

Abstract Introduction Immune checkpoint inhibitor (ICI)-related colitis (irColitis) is a frequent complication of ICI use in cancer. Treatment algorithms have been adapted from the treatment of inflammatory bowel disease (IBD), including the use of infliximab (IFX) for patients with irColitis refractory to corticosteroids. The efficacy of IFX dose-escalation in patients not responding to standard dose IFX, a common practice in patients with severe IBD, has not been reported in irColitis. Methods We describe a retrospective study of patients treated with IFX dose escalation (i.e. 10mg/kg dose) after failure of standard dose IFX (5mg/kg) for irColitis at a tertiary care center in New York City between 2016–2020. Clinical response was defined as improvement in diarrhea to CTCAE Grade ≤1. Results Ten patients were treated with high dose IFX for refractory irColitis. High dose IFX was started after a median of 2 (IQR 2-2) doses of standard dose IFX for non-response (n=2) or incomplete response (n=8). Five (50%) patients had a clinical response to high dose IFX after a median of 4 (IQR 3–6) days. Five (50%) patients were refractory to high dose IFX and were treated with Vedolizumab (n= 5) and/or fecal microbiota transplantation (n=2). Patients were followed for a median 457 (IQR 325–567) days from initiation of ICI therapy. No adverse events attributed to IFX were observed in any of the patients. Discussion In this series of patients with irColitis refractory to standard dose IFX, high dose IFX was successful in inducing response in 50% of patients. Prospective studies are needed to further elucidate the role and optimal dosing of IFX in irColitis.

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