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Como JD, Abdulmassih R, Guarascio AJ, Sauber T, Sewecke J, Westrick E, Bhanot N. Systemic Absorption Resulting from Tobramycin-Loaded Antibiotic Cement Spacers Used in the Treatment of Prosthetic Joint Infection. Indian J Orthop 2024; 58:144-150. [PMID: 38312906 PMCID: PMC10830980 DOI: 10.1007/s43465-023-01075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/29/2023] [Indexed: 02/06/2024]
Abstract
Purpose Antimicrobial cement spacer (ACS) placement has been a cornerstone of two-stage management of prosthetic hip and knee infection. Pharmacokinetic modelling has described peak systemic antibiotic concentrations within the first 24-48 h post-operatively, followed by rapid clearance. A few studies have, however, identified detectable tobramycin levels in patients with a post-operative decline in creatinine clearance. Our study sought to determine how frequently detectable serum tobramycin levels occurred within the first 72 h following ACS placement in all patients regardless of baseline or subsequent changes in renal function, whether these levels correlated with tobramycin spacer dosage, creatinine clearance, or potential nephrotoxicity risk factors, and whether any patients developed acute kidney injury within the 14-day post-operative period. Methods We prospectively enrolled patients with prosthetic hip or knee infections and subsequent ACS placement from October 2017 to February 2020. Patient comorbidities (chronic kidney disease, diabetes mellitus, chronic liver disease, chronic obstructive pulmonary disease, and atrial fibrillation), Charleston Comorbidity Index score, risk factors for post-operative nephrotoxicity (perioperative hypotension and nephrotoxic agent receipt), total tobramycin dosage, post-operative days 1 and 3 serum tobramycin concentrations, and serum creatinine and creatinine clearance throughout a 14-day post-operative period were recorded. Results A total of 20 patients were enrolled, comprising 20 spacers with a median total tobramycin dosage of 4.80 g with an interquartile range (IQR) of 4.13-7.20 g. Thirteen patients had a median detectable post-operative day 1 serum tobramycin concentration of 0.80 (IQR 0.50-1.60) mcg/mL. Five of these 13 patients had a median detectable post-operative day 3 serum tobramycin concentration of 0.80 (IQR 0.50-1.10) mcg/mL. A correlation was not found between serum tobramycin drug levels and patient comorbidities, receipt of nephrotoxic medications, or baseline and subsequent post-operative creatinine clearance up to day 14. Conclusion The majority of patients who underwent tobramycin ACS placement had detectable serum tobramycin levels in the immediate post-operative period, but most reached undetectable levels within 72 h. There were no reliable perioperative predictors of detectable drug levels.
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Affiliation(s)
- James D. Como
- Division of Infectious Disease, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Rasha Abdulmassih
- Division of Infectious Disease, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Anthony J. Guarascio
- Division of Infectious Disease, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
- Duquesne University School of Pharmacy, 600 Forbes Ave, Pittsburgh, PA 15282 USA
| | - Timothy Sauber
- Division of Orthopedic Surgery, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Jeffrey Sewecke
- Division of Orthopedic Surgery, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Edward Westrick
- Division of Orthopedic Surgery, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212 USA
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Keller SC, Hannum SM, Weems K, Oladapo-Shittu O, Salinas AB, Marsteller JA, Gurses AP, Klein EY, Shpitser I, Crnich CJ, Bhanot N, Rock C, Cosgrove SE. Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition. Infect Control Hosp Epidemiol 2023; 44:1748-1759. [PMID: 37078467 PMCID: PMC10665867 DOI: 10.1017/ice.2023.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation. DESIGN Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches. SETTING This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia. PARTICIPANTS Staff performing home-infusion CLABSI surveillance. METHODS From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation. RESULTS Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive. CONCLUSIONS The home-infusion CLABSI surveillance definition was valid and feasible to implement.
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Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Susan M. Hannum
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kimberly Weems
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, Maryland
- Department of Infection Prevention, Nuvance Health Vassar Brothers Medical Center, Poughkeepsie, New York
| | - Opeyemi Oladapo-Shittu
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandra B. Salinas
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jill A. Marsteller
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Ayse P. Gurses
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Malone Center for Engineering in Health Care, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Eili Y. Klein
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ilya Shpitser
- Department of Computer Science, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Christopher J. Crnich
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Nitin Bhanot
- Division of Infectious Diseases, Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Clare Rock
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, Maryland
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Health System, Baltimore, Maryland
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3
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Wrynn A, Bhanot N. A case of fever in a returning traveler. J Am Assoc Nurse Pract 2023; 35:652-657. [PMID: 37260274 DOI: 10.1097/jxx.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/20/2023] [Indexed: 06/02/2023]
Abstract
ABSTRACT After the lifting of COVID-19 restrictions, international travel has demonstrated recovery to prepandemic levels. Travel, particularly to tropical regions, can be associated with contracting various infectious diseases. For this reason, collecting a travel history is a necessity when assessing any patient with vague infectious symptoms, most notably fever. Early suspicion, identification, and treatment of tropical illnesses can be lifesaving. This case study concerns a patient who recently traveled to Africa and is under evaluation for fever in the emergency department. The proper approach to the febrile traveler and the pathophysiology, diagnosis, and treatment of malaria are reviewed.
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Affiliation(s)
- Alexander Wrynn
- Division of Infectious Diseases, Allegheny Health Network, Coraopolis, Pennsylvania
| | - Nitin Bhanot
- Division of Infectious Diseases, Allegheny Health Network, Drexel University College of Medicine, Philadelphia, Pennsylvania
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4
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Jaber TM, Bangash S, Alvarenga AB, Sicari J, DuMont T, Malik K, Bhanot N. Infectious Diseases Specific to Women. Crit Care Nurs Q 2023; 46:417-425. [PMID: 37684737 DOI: 10.1097/cnq.0000000000000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Female patients are at a greater risk for infections such as urinary tract infections and mastitis, as well as complications from abortions/miscarriages, and sexually transmitted infections. This review highlights risk factors, pathogenesis, complications, diagnostic, and treatment modalities associated with the following infections: mastitis, sexually transmitted diseases, postpartum/abortion-related infections, and urinary tract infections.
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Affiliation(s)
- Tariq M Jaber
- Division of Infectious Disease and Critical Care (Drs Jaber, Bangash, and Alvarenga), Division of Pulmonary and Critical Care Medicine (Drs Sicari, DuMont, and Malik), and Division of Infectious Disease (Dr Bhanot), Allegheny Health Network Medicine Institute, Pittsburgh, Pennsylvania
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5
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Saini H, Mann H, Saini I, Bhanot N, Kelly K, Rana S. Isolated cerebral mucormycosis: A case discussion. IDCases 2023; 33:e01821. [PMID: 37415782 PMCID: PMC10320071 DOI: 10.1016/j.idcr.2023.e01821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 07/08/2023] Open
Abstract
We report a case of a 32-year-old male with a history of type 1 diabetes, inhaled drug use, and alcohol use disorder, who presented with encephalopathy, holocranial headaches, neck pain, confusion, and generalized tonic-clonic seizures. The patient initially presented at a rural community hospital with a fever and was found to be in diabetic ketoacidosis (DKA). He was also hemodynamically stable but stuporous, prompting intubation to protect his airway. Despite initial treatment measures, his neurological condition worsened and he remained ventilator-dependent. Key findings include a high glucose level, presence of ketones, and evidence of drug use. Blood cultures showed no growth, but his febrile state persisted. Cerebrospinal fluid (CSF) analysis revealed mild pleocytosis, hyperglycorrhachia but normal protein, with no growth. Neuroimaging showed right hemispheric slowing on EEG and diffusion restriction in the right frontal lobe on MRI. The patient's neurological status worsened on the second day of admission, manifesting as sluggish pupillary reflexes, right third nerve palsy, and decerebrate posturing. Emergent MRI suggested cerebral edema, leading to initiation of hypertonic saline. This case highlights the diagnostic challenges and critical management considerations in a patient with multiple comorbidities presenting with unexplained neurological deterioration, emphasizing the importance of a comprehensive and timely approach to diagnosis and treatment.
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Affiliation(s)
- Harneel Saini
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Harinoor Mann
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Ishveen Saini
- Lake Erie College of Osteopathic Medicine, 1858 W Grandview Blvd, Erie, PA 16509, United States
| | - Nitin Bhanot
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Kevin Kelly
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Sandeep Rana
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
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Luther VP, Barsoumian AE, Konold VJL, Vijayan T, Balba G, Benson C, Blackburn B, Cariello P, Perloff S, Razonable R, Acharya K, Azar MM, Bhanot N, Blyth D, Butt S, Casanas B, Chow B, Cleveland K, Cutrell JB, Doshi S, Finkel D, Graber CJ, Hazra A, Hochberg NS, James SH, Kaltsas A, Kodiyanplakkal RPL, Lee M, Marcos L, Mena Lora AJ, Moore CC, Nnedu O, Osorio G, Paras ML, Reece R, Salas NM, Sanasi-Bhola K, Schultz S, Serpa JA, Shnekendorf R, Weisenberg S, Wooten D, Zuckerman RA, Melia M, Chirch LM. Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors. Open Forum Infect Dis 2023; 10:ofad289. [PMID: 37397270 PMCID: PMC10313091 DOI: 10.1093/ofid/ofad289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/17/2023] [Indexed: 07/04/2023] Open
Abstract
The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.
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Affiliation(s)
- Vera P Luther
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Uniformed Services University of the Health Sciences, San Antonio, Texas, USA
| | - Victoria J L Konold
- Infectious Disease and Virology, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Tara Vijayan
- Division of Infectious Diseases, Department of Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Gayle Balba
- Division of Infectious Diseases, Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Constance Benson
- Division of Infectious Diseases, Department of Internal Medicine, University of California San Diego Medical Center, San Diego, California, USA
| | - Brian Blackburn
- Division of Infectious Diseases, Department of Internal Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paloma Cariello
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sarah Perloff
- Division of Infectious Diseases, Department of Internal Medicine, Albert Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Raymund Razonable
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kartikey Acharya
- Division of Infectious Diseases, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marwan M Azar
- Division of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nitin Bhanot
- Infectious Diseases Division, Medicine Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Dana Blyth
- Infectious Disease Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Saira Butt
- Division of Infectious Diseases, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Beata Casanas
- Division of Infectious Diseases, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Brian Chow
- Division of Infectious Diseases, Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Kerry Cleveland
- Division of Infectious Diseases, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - James B Cutrell
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Saumil Doshi
- Division of Infectious Diseases, Department of Internal Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Diana Finkel
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Christopher J Graber
- Infectious Diseases Section, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aniruddha Hazra
- Division of Infectious Diseases, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Scott H James
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anna Kaltsas
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Mikyung Lee
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai–Mount Sinai Hospital, New York, New York, USA
| | - Luis Marcos
- Division of Infectious Diseases, Department of Medicine, Stony Brook University Hospital, East Setauket, New York, USA
| | - Alfredo J Mena Lora
- Division of Infectious Diseases, Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Christopher C Moore
- Division of Infectious Diseases, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Obinna Nnedu
- Infectious Diseases Service, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Georgina Osorio
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Molly L Paras
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rebecca Reece
- Division of Infectious Diseases, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Natalie Mariam Salas
- Division of Infectious Diseases, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Kamla Sanasi-Bhola
- Division of Infectious Diseases, Department of Medicine, University of South Carolina School of Medicine–Columbia, Columbia, South Carolina, USA
| | - Sara Schultz
- Division of Infectious Diseases, Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose A Serpa
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Scott Weisenberg
- Division of Infectious Diseases & Immunology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Darcy Wooten
- Division of Infectious Diseases, Department of Internal Medicine, University of California San Diego Medical Center, San Diego, California, USA
| | - Richard A Zuckerman
- Infectious Diseases Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michael Melia
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa M Chirch
- Division of Infectious Diseases, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Saini V, Como J, Abdulmassih R, Min Z, Bhanot N. Utility of Direct Specimen Sequencing in Addition to Conventional Testing in Management of Infections in an Urban Referral Health Center. J Appl Lab Med 2023; 8:559-567. [PMID: 36759952 DOI: 10.1093/jalm/jfac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/06/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND Direct specimen sequencing (DSS) offers the promise of enhanced pathogen detection and disease diagnosis. METHODS A single healthcare network, retrospective chart review over a 3-year period was completed for all cases in which DSS was submitted, in addition to conventional testing (CT) for workup of an infectious disease. We sought to compare results (concordance and discordance) from these 2 techniques in order to evaluate any additional yield from DSS over CT. Additionally, we calculated mean turnaround time (TAT) and average cost for obtaining DSS on all specimens. RESULTS A total of 23 patients' specimens were sent for DSS. DSS and CT concordance occurred in 91% (21/23) of cases. DSS testing was able to identify specific pathogens in 17.4% (4/23) of patients, out of which 4% (1/23) were discordant. The respective mean TAT and total cost per specimen for DSS were 6 days and $821.52 (range $573-$1590), respectively. CONCLUSIONS In our limited cohort of patients, there was significant concordance between the 2 testing modalities primarily due to negative tests. DSS did not provide significant additional yield in the infectious diagnosis in our cohort compared to CT. Short TAT may provide advantage in the detection of fastidious organisms, but high cost remains a limitation. Larger sample size may reveal a clinically meaningful difference.
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Affiliation(s)
- Vikram Saini
- Allegheny Health Network, Pittsburgh, PA, United States
| | - James Como
- Allegheny Health Network, Pittsburgh, PA, United States
| | | | - Zaw Min
- Allegheny Health Network, Pittsburgh, PA, United States
| | - Nitin Bhanot
- Allegheny Health Network, Pittsburgh, PA, United States
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8
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Ogbebor O, Tariq S, Jaber T, Super J, Bhanot N, Rana S, Malik K. Neurological Emergencies in the Intensive Care Unit. Crit Care Nurs Q 2023; 46:17-34. [PMID: 36415065 DOI: 10.1097/cnq.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Neurological emergencies carry significant morbidity and mortality, and it is necessary to have a multidisciplinary approach involving the emergency physician, the neurologist, the intensivist, and the critical care nursing staff. These disorders can be broadly divided into noninfectious and infectious etiologies. In this article, we review a few of the neurological emergencies that present to the neurological intensive unit, with emphasis on convulsive status epileptics, myasthenia gravis, Guillain-Barré syndrome, meningitis, encephalitis, and brain abscess.
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Affiliation(s)
- Osakpolor Ogbebor
- Divisions of Infectious Disease (Drs Ogbebor, Jaber, and Bhanot), Pulmonary/Critical Care (Drs Ogbebor and Malik), Neurology (Drs Tariq and Rana), and Neuro-Critical Care (Mr Super), Allegheny General Hospital, Pittsburgh, Pennsylvania
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Abstract
Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.
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Affiliation(s)
- Vikram Saini
- Division of Infectious Disease (Drs Saini and Bhanot), Division of Pulmonary and Critical Care Medicine (Drs Saini and Ashraf), Department of General Surgery (Dr Babowice), and Division of Trauma Surgery and Surgical Critical Care (Ms Hamilton and Dr Khan), Allegheny Health Network, Pittsburgh, Pennsylvania
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10
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Abalos CCD, Jaber TM, Bangash S, Jacobs MW, Turk M, Bhanot N, Min Z, Abdulmassih R. 2312. Utility of Intrathecal Antibiotic Administration in the Reduction of Ventriculoperitoneal (VP) Shunt Infections in our Urban Referral Health Center. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Infection is one of the primary causes of VP shunt failure, with an incidence rate of 7%-14%. Systemic antibiotics, administered intravenously (IV), are considered the standard of care (SOC) for perioperative prophylaxis. Prophylactic intrathecal (IT) administration of antibiotics, in addition to SOC, is practiced by some surgeons at our institution. Our objective was to study the impact of this modality on VP shunt infections.
Methods
A retrospective review of all VP shunt procedures at our institution from 2018–2020 was performed. Patients with active VP shunt infection were excluded. We compared the incidence of 90-day postoperative shunt infection in patients who received IT and SOC antibiotics (intervention group) to patients who only received SOC IV antibiotics (control group). Data collection included demographics, comorbidities, prophylactic antibiotics used, and pathogens implicated in shunt infections. T-test or Mann-Whitney U test was used for comparison of continuous variables; chi-square or Fisher’s exact test was used to assess the relationship between categorical variables. A value of p < 0.05, on two-tailed testing, was considered statistically significant.
Results
A total of 112 patients were included in the study. Control and intervention arms comprised 54 (48.2%) and 58 patients (51.8%), respectively. All patients received parenteral perioperative antibiotics. The most commonly used agent was cefazolin (83.9%). Patients in the intervention arm received 4 mg of gentamicin and 5 mg of vancomycin intrathecally.
Baseline characteristics were not statistically different between the groups.
Among the 112 patients, 12 (10.7%) developed shunt infection; 4 in the intervention and 8 in the control arm. Infection rates were not statistically different in these groups (χ2 (1) =1.83, p= 0.176). However, there was a statistically significant association between history of prior shunt (uninfected) placement and post-operative shunt infection (Fisher’s exact test, p = 0.025).
Conclusion
Our study did not reveal additional benefit of prophylactic IT antibiotic use in decreasing VP shunt infections. History of prior shunt placement was identified as risk factor, however. Limitations include relatively small sample size, retrospective, and a single-center study.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Max W Jacobs
- Allegheny Health Network , Pittsburgh, Pennsylvania
| | - Michael Turk
- Allegheny Health Network , Pittsburgh, Pennsylvania
| | - Nitin Bhanot
- Allegheny Health Network , Pittsburgh, Pennsylvania
| | - Zaw Min
- Allegheny General Hospital , Pittsburgh, PA
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11
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Saini V, Shah A, Jaber T, Como J, Min Z, Bhanot N. Scedosporium apiospermum mediastinitis in an orthotopic heart transplant recipient. IJID Reg 2022; 5:117-120. [PMID: 36277499 PMCID: PMC9582650 DOI: 10.1016/j.ijregi.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/16/2022] [Accepted: 09/24/2022] [Indexed: 06/16/2023]
Abstract
Scedosporiosis is an opportunistic mycosis that may cause disseminated disease in transplant recipients. This article reports a case of recurrent Scedosporium apiospermum mediastinitis without pneumonia in an orthotopic heart transplant recipient, with durable control achieved by long-term antifungal therapy and serial debridement. This case highlights the importance of an opportunistic scedosporium infection in immunocompromised hosts, given the challenges in microbiological identification and limited treatment options.
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Affiliation(s)
- Vikram Saini
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
- Division of Pulmonary and Critical Care Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Arpan Shah
- Division of Critical Care Medicine, St. John's Hospital, Springfield, IL, USA
| | - Tariq Jaber
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
- Division of Pulmonary and Critical Care Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - James Como
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
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12
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Attah A, Uchin J, Mount C, Min Z, Bhanot N. Atypical Herpetic Rash: 'Knife-Cut' Sign. Am J Med 2022; 135:327-330. [PMID: 34715062 DOI: 10.1016/j.amjmed.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/23/2021] [Accepted: 10/04/2021] [Indexed: 11/01/2022]
Affiliation(s)
| | | | | | - Zaw Min
- Division of Infectious Disease, Medicine Institute, Allegheny Health Network, Pittsburgh, Pa
| | - Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny Health Network, Pittsburgh, Pa.
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13
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Min Z, Saini V, Mount CE, Bhanot N. Type II minocycline-induced cutaneous and scleral hyperpigmentation. Intern Emerg Med 2022; 17:569-571. [PMID: 34549380 DOI: 10.1007/s11739-021-02853-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Zaw Min
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, East Wing, South Tower, Suite 407, Pittsburgh, PA, 15212, USA.
| | - Vikram Saini
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, East Wing, South Tower, Suite 407, Pittsburgh, PA, 15212, USA
| | - Charles E Mount
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, East Wing, South Tower, Suite 407, Pittsburgh, PA, 15212, USA
- Division of Dermatology, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, 490 East North Avenue, Professional Building, Suite 107, Pittsburgh, PA, 15212, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, East Wing, South Tower, Suite 407, Pittsburgh, PA, 15212, USA
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14
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Rothman R, Saini V, Min Z, Bhanot N. Brain abscess associated with Mycoplasma faucium – The initial presentation of pulmonary arteriovenous malformation. IDCases 2022; 29:e01575. [PMID: 35865084 PMCID: PMC9294263 DOI: 10.1016/j.idcr.2022.e01575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/05/2022] Open
Abstract
Brain abscesses represent a pathology with significant morbidity and mortality. An underlying predisposing condition may not be apparent or identifiable in some instances. We present a patient with cerebral abscess who was found to have, previously undiagnosed, pulmonary arteriovenous malformations (PAVMs). PAVMs are rare pulmonary vascular anomalies resulting in intrapulmonary right to left shunt. These have been implicated in the development of brain abscesses. Conventional cultures from the lesion were non-revealing; hence, sample was sent for next-generation sequencing (NGS) which revealed multiple organisms, with predominance of Mycoplasma faucium, a bacterium initially felt to be a commensal of the oropharynx, but recently implicated as a human pathogen. This case, along with other documented associations between brain abscesses and pulmonary AVMs, highlights that brain abscess could be an initial clinical presentation in asymptomatic PAVMs. Additionally, novel testing such as NGS should be utilized in select settings where microbiological diagnosis can be elusive. This will help institute pathogen-directed specific antimicrobial therapy for favorable clinical outcomes.
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15
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Saini V, Jaber T, Como JD, Abdulmassih R, Min Z, Bhanot N. 665. Clinical and Financial Impact of Next Generation Sequencing (NGS) in addition to Conventional Microbiology Testing in our Urban Referral Health Center. Open Forum Infect Dis 2021. [PMCID: PMC8644025 DOI: 10.1093/ofid/ofab466.862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Clinical microbiology traditionally relies on culture methodology and serological testing, that have inherent limitations. Newer diagnostic techniques such as Next Generation Sequencing (NGS) have shown promise to improve microbial identification. In select scenarios, we send clinical specimens to reference laboratories for NGS testing in addition to current standard of care (SOC) diagnostics. We wanted to determine how this diagnostic approach has impacted patient care. We also wanted to review the financial burden through cost-benefit analysis for these ‘send-out’ tests.
Methods
We performed a retrospective chart review of all cases over a 3-year period in which NGS was submitted. Data, including demographics, comorbidities, antimicrobial use, and diagnosis (by SOC and NGS) were gathered. We delineated how often there was concordance or discordance between SOC and NGS. We also obtained information on financial cost (direct and indirect) and turnaround time (TAT) for NGS results.
Results
A total of 33 clinical specimens from 25 patients were sent for NGS. The majority of specimens comprised joint tissue/fluid, organ tissue and CSF.
Concordance occurred between SOC and NGS testing in 75.8% (25/33) of samples; of those, 88% excluded infection. NGS identified a pathogen in 20% (5/25) patients in which concomitant SOC testing was negative. A subsequent change in antimicrobial management occurred in 16% (4/25) of patients. The mean TAT was 14 days and average cost per specimen was &821.52 (range: &573-&1590).
Table 1. Pathogens identified by NGS with negative traditional microbiological test results
Figure 1. Distribution of specimen site (in %) sent for NGS
Conclusion
NGS can provide additional diagnostic sensitivity in infectious diseases, which at our institution identified a new pathogen in 20% and a resultant treatment change in 16% of our patients. This testing may also allow physicians to reaffirm the absence of an infection diagnosis. A larger NGS testing population may reveal more significant benefits. While the attributable cost of NGS was substantial, it should be measured against the costs of administration of unnecessary antibiotics, inaccurate diagnosis, and adverse patient outcomes that may result from SOC testing alone. Considering its financial cost and extended TAT, in-house NGS testing may be warranted to facilitate a higher volume of testing.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- Vikram Saini
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Tariq Jaber
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - James D Como
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Zaw Min
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nitin Bhanot
- Infectious Disease, Allegheny General Hospital, pittsburgh, Pennsylvania
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Jaber T, Saini V, Morris L, Como JD, Bhanot N, Min Z. 799. A Pseudo-Outbreak of Pseudomonas fluorescens Infections. Open Forum Infect Dis 2021. [PMCID: PMC8644160 DOI: 10.1093/ofid/ofab466.995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Pseudomonas fluorescens is a water-borne pathogen that has been associated with outbreaks from transfusion of contaminated blood products or medical equipment. Our institution had a cluster of cultures that grew an uncommonly encountered microbe P. fluorescens within a period of one week. This prompted an internal investigation. We summarize the investigational process that led to the resolution of this pseudo-outbreak.
Methods
We conducted a retrospective chart review of surgical and non-surgical patients with cultures positive for P. fluorescens from July 2nd to July 8th 2020. Baseline patient characteristics, clinical course, laboratory data, use of blood-associated products, and microbiology cultures were analyzed.
Results
Eight patients were identified with positive tissue cultures for P. fluorescens. Among those, 5 specimens (62.5%) were from osteoarticular sites (1 prosthetic hip, 1 prosthetic knee, 1 right foot, 1 sternum, and 1 vertebral source). One culture (12.5%) was obtained from a sacral soft tissue wound. Two tissue specimens (25%) were collected from respiratory sites (1 lung tissue and 1 bronchoalveolar lavage). No association with specific surgical personnel or operating room was identified. During routine specimen processing, a small amount of sterile normal saline is added to the conical grinder prior to culture preparation. It was discovered that a non-sterile normal saline had been inadvertently utilized during that step. These eight tissue specimens were subsequently reprocessed with sterile solution; P. fluorescens was not re-isolated. Specimen processing protocols were reinforced. Adjustment of antimicrobial therapy was made accordingly without reported subsequent adverse clinical outcomes.
Conclusion
A multi-faceted team approach in collaboration with Infection Prevention, Infectious Diseases, Surgery, operating room personnel, and Microbiology identified an unintended breakdown in sterile laboratory protocols which resulted in a cluster of falsely positive cultures. An increased incidence of infection with an uncommon pathogen initiated a prompt investigation that resulted in the identification of a pseudo-outbreak event.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- Tariq Jaber
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Vikram Saini
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Laura Morris
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - James D Como
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nitin Bhanot
- Infectious Disease, Allegheny General Hospital, pittsburgh, Pennsylvania
| | - Zaw Min
- Allegheny Health Network, Pittsburgh, Pennsylvania
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Saini V, Jaber T, Como JD, Lejeune K, Bhanot N. 623. Exploring ‘Slicer Dicer’, an Extraction Tool in EPIC, for Clinical and Epidemiological Analysis. Open Forum Infect Dis 2021. [DOI: 10.1093/ofid/ofab466.821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Electronic Health Record (EHR) implementation has created an unprecedented library of patient data. Data extraction tools provide an opportunity to retrieve clinico-epidemiological information on a wide scale. Slicer Dicer is a data exploration tool in the EPIC EHR that allows one to customize searches on large patient populations. This software contains a variety of models that present de-identified information from EPIC’s Caboodle database. We explored the applicability and potential utility of this tool utilizing the diagnosis of Lyme disease as an example.
Methods
The following steps outline an overview of data extraction utilizing ICD-10 codes around Lyme disease at our health system. Step 1-3: Denominator chosen as ‘All Patients’ over a 3-year period, ‘Slicing’ of the data by ‘Lyme disease, unspecified’ was applied to these results, and the ‘sliced’ data was categorized by year of diagnosis (Slide 1). Step 4: This data was further arranged by month of diagnosis for trend analysis (Slide 2). Step 5: Sub-diagnosis was applied for Lyme arthritis (Slide 3). Step 6: Further ‘slicing’ was/can be done by other variables, such as ‘Hospitalization,’ ‘Encounter Diagnosis,’ and ‘ED Diagnosis’ (Slide 4). Step 7-8: Output was ‘sliced’ by ‘Age’ (Slide 5) and ‘Postal Code’ (Slide 6).
Slide 1. EPIC EHR screen capture showing 3-year period data
Data shown here represents 'All patients' chosen as the denominator further sliced by 'Lyme disease, unspecified' and categorized by the year of diagnosis.
Slide 2. EPIC EHR screen capture showing data further arranged by month of diagnosis
Results
Macro-level data of period prevalence on Lyme disease over 3 years (Slide 1), seasonal trends (Slide 2), specific sub-diagnosis (Slide 3), output by setting of diagnosis (Slide 4), and demographic information of our patient population (Slides 5, 6) was revealed by application of these parameters.
Slide 3. EPIC EHR screen capture showing application of sub-diagnosis for Lyme arthritis
Slide 4. EPIC EHR screen capture showing further slicing by multiple variables like hospitalization and diagnosis
Slide 5. EPIC EHR screen capture showing slicing of data by demographic information (Age)
Conclusion
Slicer Dicer can provide a snapshot for preliminary data analysis prior to investing time and commitment to a project. The appeal of this tool is that it mines de-identified data and thus does not require initial IRB approval. This opens an avenue for potential full research projects based on the results obtained and helps generate preliminary hypotheses through analysis of healthcare.
Slide 6. EPIC EHR screen capture showing slicing of data by demographic information (Postal Code)
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- Vikram Saini
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Tariq Jaber
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - James D Como
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Nitin Bhanot
- Infectious Disease, Allegheny General Hospital, pittsburgh, Pennsylvania
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18
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Ogbebor O, Pawate V, Woo J, Kelly K, Cerejo R, Bhanot N. Bartonella Endocarditis Presenting as Recurrent Cerebral Mycotic Aneurysm. Cureus 2021; 13:e19969. [PMID: 34984129 PMCID: PMC8714346 DOI: 10.7759/cureus.19969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Bartonella henselae is a known cause of culture-negative endocarditis, which can be difficult to diagnose without a high clinical suspicion as specific diagnostic testing is required. We report the case of a 48-year-old male who presented with altered sensorium. A CT of the head showed left-hemispheric intracranial hemorrhage (ICH) likely secondary to ruptured left posterior cerebral artery (PCA) fusiform aneurysm seen on catheter cerebral angiogram, which was treated with endovascular embolization. The patient had a significant history of mitral valve prolapse; however, a transthoracic echocardiogram (TTE) was negative for any vegetation. Blood cultures were also negative. A year later, he presented with another ICH in the PCA territory and was found to have a new left distal PCA aneurysm, which was again treated with endovascular embolization. During that hospitalization, an echocardiogram showed myxomatous changes in the mitral valve with severe mitral regurgitation; however, blood cultures were negative. Further queries about the patient’s social history revealed that his spouse had been a cat owner in 2018, which prompted Bartonella henselae testing. The blood work showed elevated immunoglobulin G (IgG) titers for which he was placed on antibiotics. A follow-up catheter angiogram detected a new distal middle cerebral artery (MCA) M4 branch aneurysm treated with surgical clipping. The aneurysm tested positive for Bartonella henselae on polymerase chain reaction (PCR) testing. The patient subsequently underwent successful mitral valve replacement, which also was positive for Bartonella henselae on PCR testing; however, the Warthin-Starry stain was negative. This case demonstrates how a comprehensive history along with persistent evaluation for the underlying etiology of cerebral aneurysms can lead to the diagnosis of Bartonella henselae endocarditis. Cerebral mycotic aneurysms are known complications of endocarditis; however, the underlying infection can be difficult to diagnose. Recognition of this culture-negative endocarditis is critical for the appropriate treatment and management of patients to prevent morbidity and mortality.
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Guarascio AJ, Bhanot N, Min Z. Voriconazole-associated periostitis: Pathophysiology, risk factors, clinical manifestations, diagnosis, and management. World J Transplant 2021; 11:356-371. [PMID: 34631468 PMCID: PMC8465512 DOI: 10.5500/wjt.v11.i9.356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/19/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Voriconazole use has been associated with osteoarticular pain and periostitis, likely due to high fluoride content in the drug formulation. This phenomenon has been described primarily with high dosage or prolonged course of voriconazole therapy in immunocompromised and transplant patient populations. Patients typically present with diffuse bony pains associated with elevated serum alkaline phosphatase and plasma fluoride levels in conjunction with radiographic findings suggestive of periostitis. We provide a comprehensive review of the literature to highlight salient characteristics commonly associated with voriconazole-induced periostitis.
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Affiliation(s)
- Anthony J Guarascio
- Department of Pharmacy, Duquesne University School of Pharmacy, Pittsburgh, PA 15282, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Zaw Min
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
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20
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Ogbebor O, Seth H, Min Z, Bhanot N. Guillain-Barré syndrome following the first dose of SARS-CoV-2 vaccine: A temporal occurrence, not a causal association. IDCases 2021; 24:e01143. [PMID: 33968610 PMCID: PMC8086372 DOI: 10.1016/j.idcr.2021.e01143] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 01/12/2023] Open
Abstract
Safety monitoring is of paramount importance for vaccines authorized for emergent use (EUA) by the US Food and Drug Administration (FDA) against SARS-CoV-2. Mass immunization is an essential tool to end the current pandemic, but vaccine surveillance is necessary to identify any potentially associated harms. At the same time, probability of temporal bias should be borne in mind before making conclusions about causality between the vaccine and an attributable undesired effect. We report a case of Guillain-Barré syndrome after the first dose of SARS-CoV-2 vaccine and believe this is a temporal, rather than causal association.
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Affiliation(s)
- Osakpolor Ogbebor
- Division of Infectious Disease, Medicine Institute, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Harshit Seth
- Division of Hospitalist Medicine, Medicine Institute, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Zaw Min
- Division of Infectious Disease, Medicine Institute, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny Health Network, Pittsburgh, PA 15212, United States
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21
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Bhanot N, Dimitriou G, McAninch L, Rossi C, Thompson D, Manzi S. Perspectives of Health Care Providers in an Integrated Health Care Delivery Network on Inpatient Electronic Consultation (e-Consult) Use During the COVID-19 Pandemic. J Patient Exp 2021; 8:23743735211007696. [PMID: 34179421 PMCID: PMC8205354 DOI: 10.1177/23743735211007696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A large academic hospital system (Allegheny Health Network) introduced inpatient electronic consultations (e-Consults) during the COVID-19 crisis. Providers were invited to complete an anonymous survey on their perceptions of e-Consults. Descriptive statistics were used to analyze Likert-scale data. Cronbach’s alpha was used to assess internal consistency. Ninety-five providers completed the survey. Requesting and consulting providers agreed that e-Consults were easy to use (100% and 96.2%, respectively). Both groups also concurred that e-Consults either decreased or did not significantly impact their workload (81% and 74%, respectively) and that training was appropriate (77.8% and 86.8%, respectively). The advantage and barrier selected most frequently by specialists was “timelier completion of the consult versus in-person” and “inadequate information to complete the consult,” respectively. The disadvantage selected most frequently by requesting physicians was “lack of communication between providers.” Open-ended comments were categorized into themes. Concerns were raised regarding whether provider–provider communication via this platform offered enough information to make recommendations compared to traditional encounters. The perceived benefits and barriers of e-Consults should be further explored with the goal of improving patient care delivery and provider satisfaction.
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Affiliation(s)
- Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - George Dimitriou
- Department of Internal Medicine, Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Lori McAninch
- Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Caitlan Rossi
- Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Diane Thompson
- Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Susan Manzi
- Medicine and the Autoimmunity Institute, Allegheny Health Network, Pittsburgh, PA, USA
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22
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Walsh TL, Bremmer DN, Moffa MA, Trienski TL, Buchanan C, Stefano K, Hand C, Taylor T, Kasarda K, Shively NR, Bhanot N, Cheronis N, DiSilvio BE, Cho CY, Carr DR. Impact of an Antimicrobial Stewardship Program-bundled initiative utilizing Accelerate Pheno™ system in the management of patients with aerobic Gram-negative bacilli bacteremia. Infection 2021; 49:511-519. [PMID: 33528813 PMCID: PMC8159835 DOI: 10.1007/s15010-021-01581-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
Purpose Gram-negative bacteria (GNB) are a leading cause of bloodstream infections (BSI) and management is complicated by antibiotic resistance. The Accelerate Pheno™ system (ACC) can provide rapid organism identification and antimicrobial susceptibility testing (AST). Methods A retrospective, pre-intervention/post-intervention study was conducted to compare management of non-critically ill patients with GNB BSI before and after implementation of a bundled initiative. This bundled initiative included dissemination of a clinical decision algorithm, ACC testing on all GNB isolated from blood cultures, real-time communication of results to the Antimicrobial Stewardship Program (ASP), and prospective audit with feedback by the ASP. The pre-intervention period was January 2018 through December 2018, and the post-intervention period was May 2019 through February 2020. Results Seventy-seven and 129 patients were included in the pre-intervention and post-intervention cohorts, respectively. When compared with the pre-intervention group, the time from Gram stain to AST decreased from 46.1 to 6.9 h (p < 0.001), and the time to definitive therapy (TTDT) improved from 32.6 to 10.5 h (p < 0.001). Implementation led to shorter median total duration of antibiotic therapy (14.2 vs 9.5 days; p < 0.001) and mean hospital length of stay (7.9 vs 5.3 days; p = 0.047) without an increase in 30-day readmissions (22.1% vs 14%; p = 0.13). Conclusion Implementation of an ASP-bundled approach incorporating the ACC aimed at optimizing antibiotic therapy in the management GNB BSI in non-critically ill patients led to reduced TTDT, shorter duration of antibiotic therapy, and shorter hospital length of stay without adversely affecting readmission rates.
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Affiliation(s)
- Thomas L Walsh
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.
| | - Derek N Bremmer
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Matthew A Moffa
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.
| | - Tamara L Trienski
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Carley Buchanan
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Kelly Stefano
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Catharine Hand
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Tricia Taylor
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Karen Kasarda
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nathan R Shively
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA
| | - Nitin Bhanot
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA
| | - Nicholas Cheronis
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.,Medicine Institute and Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Briana E DiSilvio
- Medicine Institute and Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Christian Y Cho
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Dustin R Carr
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
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23
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Affiliation(s)
- Robert Brunner
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
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24
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Abstract
Ceftaroline fosamil is a novel 5th generation broad-spectrum oxyimino-cephalosporin with activity against Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA), Streptococcus pneumoniae, Haemophilus influenzae, and Gram-negative bacteria. It has been approved by the United States Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. There have been reported cases of successful treatment of MRSA bacteremia with this agent. Common adverse drug reactions from ceftaroline include skin rash, hives, neutropenia, thrombocytopenia, and anemia. Acute eosinophilic pneumonia is a rare untoward drug reaction associated with it. We report a case of fever and acute hypoxic respiratory failure with bilateral interstitial pulmonary infiltrates while on ceftaroline therapy for sternal osteomyelitis and ascending aortic graft infection secondary to MRSA. Laboratory studies revealed peripheral blood eosinophilia (>3000 cells/mm3). After exclusion of infectious, autoimmune, and other extrinsic allergic causes of pneumonia, ceftaroline-related acute eosinophilic pneumonia was suspected. Ceftaroline was discontinued and a therapeutic trial of high-dose steroid was initiated. Significant improvement of clinical symptoms and hypoxia was achieved after 24 h of steroid therapy. There was no recurrence of clinical symptoms after completing steroid course, which supported our suspicion of acute eosinophilic pneumonia from ceftaroline. Radiographic improvement of pulmonary infiltrates occurred 4 weeks later with complete resolution at 3 months from the initial event. The current case adds to this rarely reported adverse effect from this relatively newer antimicrobial agent. Increased awareness, early recognition, discontinuation of medication, and steroid therapy are key in favorable clinical outcome and recovery.
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Affiliation(s)
- Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Rawiya Elrufay
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Christian Y Cho
- Department of Pharmacy, Adventist Health Bakersfield, Bakersfield, California, USA
| | - Subbarao Elapavaluru
- Department of Cardiothoracic Surgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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25
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Ogbebor O, Abdulmassih R, Como JD, Bhanot N. 332. Spinal Infections: Clinical and Microbiological Characteristics in our Urban Referral Health Center. Open Forum Infect Dis 2020. [PMCID: PMC7777605 DOI: 10.1093/ofid/ofaa439.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background There has been an increasing trend in spinal infections (SI) in the U.S. over recent years. We sought to characterize the clinical and microbiological characteristics of SI at our hospital. Methods We conducted a retrospective review of SI over a 3-year period (2016 - 2019) utilizing ICD codes for data retrieval. Search terms included vertebral osteomyelitis, discitis, and epidural abscess. SPSS was used to compute the data. Results Of the initially screened 254 patients, 166 were included for analysis. Pertinent demographics were: mean age 59 years, male (61.4%), obese (44.5%), diabetic (25%), and drug-users (20%). Lumbosacral involvement was most common (69.8%); epidural abscess was present in 51.8% of patients. 15.7% had existing hardware. Overall, 79.5% (132/166) of cases had a positive culture from at least one site: blood 56.6% (94/166), CT-guided 83.5% (56/67), and surgical 51.1% (24/47). Of those patients with negative blood cultures, 22% (16/72) had pathogen recovery by CT-guided methods and 33% (24/72) from surgical specimens. S aureus was the most common pathogen isolated at 53.7% (71/132): MSSA comprised 38.6% (51/132) and MRSA 15.2% (20/132). The mean CRP (8.46 vs 15.83 mg/dL; P< 0.001), and WBC (9.08 vs 13.18 k/mcL; P< 0.001) were higher in culture-positive as compared to culture-negative cases. Mean ESR and temperature more than 100.4 oF did not differ significantly between these two groups. The 8-week median recurrence rate was 11.4%, of which nearly half had index S aureus bacteremia. Frequency of organisms isolated ![]()
Association of mean inflammatory markers with positive cultures ![]()
Conclusion Our study affirmed that S aureus is the most common cause of SI, of which MSSA was predominant. Epidural abscess was encountered in a substantial fraction of our case population. Leukocytosis and elevated CRP tended to predict culture-positive infection, whereas ESR and fever did not. As recommended in the IDSA Vertebral Osteomyelitis guidelines, blood cultures were obtained in all cases, which yielded positive results in more than half of patients. Pathogen recovery was further improved to nearly 80% with supplemental deep tissue sampling, thus highlighting the opportunity to enhance microbiological diagnosis at our institution. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Nitin Bhanot
- Infectious Disease, Allegheny General Hospital, pittsburgh, Pennsylvania
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26
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Ogbebor O, Mortimer TD, Fryling K, Zhang JJ, Bhanot N, Grad YH. Disseminated Gonococcal Infection Complicated by Prosthetic Joint Infection: Case Report and Genomic and Phylogenetic Analysis. Open Forum Infect Dis 2020; 8:ofaa632. [PMID: 33553473 PMCID: PMC7850131 DOI: 10.1093/ofid/ofaa632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022] Open
Abstract
Neisseria gonorrhoeae infections have been increasing globally, with prevalence rising across age groups. In this study, we report a case of disseminated gonococcal infection (DGI) involving a prosthetic joint, and we use whole-genome sequencing to characterize resistance genes, putative virulence factors, and the phylogenetic lineage of the infecting isolate. We review the literature on sequence-based prediction of antibiotic resistance and factors that contribute to risk for DGI. We argue for routine sequencing and reporting of invasive gonococcal infections to aid in determining whether an invasive gonococcal infection is sporadic or part of an outbreak and to accelerate understanding of the genetic features of N gonorrhoeae that contribute to pathogenesis.
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Affiliation(s)
- Osakpolor Ogbebor
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Tatum D Mortimer
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kyra Fryling
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jessica J Zhang
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nitin Bhanot
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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27
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Abstract
Pott’s puffy tumor is characterized by forehead swelling from subperiosteal abscess and frontal bone osteomyelitis. It is encountered mainly in children; rarely in adults. When it does occur in the latter population, the most common risk factors include head trauma, sinusitis, or cocaine abuse. Generally, the organisms thought to be involved include streptococci, staphylococci and oral anaerobic flora. We present a case of a 53 year old female who presented with forehead swelling of 3 month duration after a dental procedure, found to be secondary to Actinomyces naeslundii. Actinomyces is a very rare etiology of this disease and has been reported only twice earlier in the literature. We present an uncommon infectious disease along with summary of clinical characteristics of this entity in the adult population.
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Affiliation(s)
- Holly Bean
- Division of Infectious Disease, Allegheny Health Network, PA, 15212, United States
| | - Zaw Min
- Division of Infectious Disease, Allegheny Health Network, PA, 15212, United States
| | - James Como
- Division of Infectious Disease, Allegheny Health Network, PA, 15212, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny Health Network, PA, 15212, United States
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28
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Ha NT, Lowery M, Woo J, Mehta Y, Bhanot N. Brain lesion in a recreational drug user: Isolated cerebral mucormycosis. IDCases 2020; 22:e00979. [PMID: 33083231 PMCID: PMC7554362 DOI: 10.1016/j.idcr.2020.e00979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 11/19/2022] Open
Abstract
Isolated cerebral mucormycosis is a relatively rare and unique variant of mucormycosis which is seen most commonly in patients with intravenous recreational drug use. While this invasive fungal infection in the brain is thought to spread from the sinuses or the lungs in other hosts such as diabetics and those with malignancy, hematogenous spread and seeding has been attributed in the pathogenesis of isolated cerebral mucormycosis. Clinical features and radiological findings may be non-specific and hence, heightened clinical suspicion for a prompt diagnosis and early medical and surgical intervention is paramount for a favorable outcome in such rare, but potentially fatal infections.
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Affiliation(s)
- Ngoc-Tram Ha
- Division of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, PA, 17882, United States
| | - Megan Lowery
- Division of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, PA, 17882, United States
| | - Jean Woo
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, PA 15212, United States
| | - Yatin Mehta
- Division of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, PA, 17882, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, PA 15212, United States
- Corresponding author at: Division of Infectious Disease, 420 East North ave, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States.
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29
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Shah A, Ma K, Bhanot N, AlhajHusain A, Cheema T. Acute Respiratory Distress Syndrome From an Infectious Disease Perspective. Crit Care Nurs Q 2019; 42:431-447. [PMID: 31449153 DOI: 10.1097/cnq.0000000000000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is an inflammatory form of lung injury in response to various clinical entities or inciting events, quite frequently due to an underlying infection. Morbidity and mortality associated with ARDS are significant. Hence, early recognition and targeted treatment are crucial to improve clinical outcomes. This article encompasses the most common infectious etiologies of ARDS and their clinical presentations and management, along with commonly encountered infectious complications in such patients.
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Affiliation(s)
- Arpan Shah
- Divisions of Infectious Disease (Drs Shah and Bhanot) and Pulmonary-Critical Care (Drs Shah, Ma, AlhajHusain, and Cheema), Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
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30
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Bhanot N, Min Z, Moffa M, Walsh TL, Como JD. 2541. Impact of a Combined Infectious Disease-Critical Care Medicine (ID-CCM) Track on Fellowship Recruitment. Open Forum Infect Dis 2019. [PMCID: PMC6809997 DOI: 10.1093/ofid/ofz360.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background There has been a declining national trend in recent years of resident applications to Infectious Disease (ID) fellowship programs. This dearth of interested and available applicants has resulted in many programs failing to fill some or all of their fellowship slots. Our ID fellowship program, founded in 2013 at Allegheny General Hospital, had met with similar difficulty. Methods To increase the recruitment pool of candidates and combat the challenge to fill our positions, we incorporated a combined 3 year ID-Critical Care Medicine (CCM) track in 2016, initially with one of our two annual fellowship slots allotted to this track. This entailed a collaborative effort between the ID and CCM divisions, an internal application completion outlining the need and rationale for this combined program, and finally, approval from the institutional as well as the Accreditation Council for Graduate Medical Education (ACGME). Results The number of applicants interviewed from 2013 to 2016 for ID (pre-inception of the ID-CCM track), as well as those for ID, ID-CCM, or those interviewing for both tracks following 2016, were counted. We noted a consistent increasing trend in the numbers interviewed for both the ID (4, 8, and 12 total applicants) and ID-CCM (4, 10, and 12 total applicants) tracks over the three since the inception of our combined fellowship program; 3 additional applicants in years 2017 and 2018, and 5 in 2019, expressed interest in either ID or ID-CCM (Graph 1). This favorably amounted to filling our training positions. Conclusion Implementation of a combined ID-CCM fellowship program proved to be a viable strategy to increase the number of applicants at our institution. Given the success of having one dually-accredited slot, we have expanded the combined-track to both positions. As the first fully-integrated ID-CCM fellowship program in the country, we may be pioneering this novel training pathway for future physicians. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Nitin Bhanot
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Zaw Min
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | | | - James D Como
- Allegheny Health Network, Pittsburgh, Pennsylvania
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31
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Chakravarthy M, Lasorda D, Bhanot N, Cherukuri K, Ghosh P, Abbadi D, Mareddy C. TCT-568 Effectiveness and Safety of Vacuum-Assisted Thrombectomy Device (AngioVac) for Extraction of Vegetations on Intra-Cardiac Devices and Valves Prior to Device Removal: A Single Center Experience. J Am Coll Cardiol 2019. [DOI: 10.1016/j.jacc.2019.08.675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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32
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Shah A, Goel K, Uchin J, Patibandla SK, Min Z, Bhanot N. Fever and Rash in an Adult: Varicella Re-infection in Conjunction with Newly Diagnosed Chronic Lymphocytic Leukemia. Am J Med 2019; 132:701-703. [PMID: 30849382 DOI: 10.1016/j.amjmed.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Arpan Shah
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Kanika Goel
- Department of Pathology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Jeffery Uchin
- Department of Pathology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Sai Krishna Patibandla
- Department of Internal Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa.
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33
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Arora S, Kipp G, Bhanot N, Sureshkumar KK. Vaccinations in kidney transplant recipients: Clearing the muddy waters. World J Transplant 2019; 9:1-13. [PMID: 30697516 PMCID: PMC6347668 DOI: 10.5500/wjt.v9.i1.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/13/2018] [Accepted: 01/01/2019] [Indexed: 02/05/2023] Open
Abstract
Vaccine preventable diseases account for a significant proportion of morbidity and mortality in transplant recipients and cause adverse outcomes to the patient and allograft. Patients should be screened for vaccination history at the time of pre-transplant evaluation and vaccinated at least four weeks prior to transplantation. For non-immune patients, dead-vaccines can be administered starting at six months post-transplant. Live attenuated vaccines are contraindicated after transplant due to concern for infectious complications from the vaccine and every effort should be made to vaccinate prior to transplant. Since transplant recipients are on life-long immunosuppression, these patients may have lower rates of serological conversion, lower mean antibody titers and waning of protective immunity over shorter period as compared to general population. Recommendations regarding booster dose in kidney transplant recipients with sub-optimal serological response are lacking. Travel plans should be part of routine post-transplant assessment and pre-travel vaccines and counseling should be provided. More studies are needed on vaccination schedules, serological response, need for booster doses and safety of live attenuated vaccines in this special population.
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Affiliation(s)
- Swati Arora
- Divisions of Nephrology and Hypertension, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Gretchen Kipp
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Nitin Bhanot
- Infectious Diseases, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Kalathil K Sureshkumar
- Divisions of Nephrology and Hypertension, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
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34
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Cheronis N, Carr D, Bhanot N. Cutaneous Nocardia arthritidis infection in an orthotopic liver transplant recipient. IDCases 2019; 18:e00623. [PMID: 31485413 PMCID: PMC6717057 DOI: 10.1016/j.idcr.2019.e00623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022] Open
Abstract
Nocardiosis is a potentially life-threatening infection that affects both immunocompetent and immunosuppressed hosts. We discuss a case of an elderly gentleman with history of orthotopic liver transplantation who presented with cellulitis of his left forearm. When he did not respond to the typical antibiotic coverage for bacterial cellulitis, skin biopsy was performed. N. arthritidis was identified as the pathogen, a relatively newly identified human pathogen first described to cause human disease in 2004.
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Affiliation(s)
- Nicholas Cheronis
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, 15212, United States
| | - Dustin Carr
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, 15212, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, 15212, United States
- Corresponding author at: Division of Infectious Disease, 420 East North ave, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, 15212, United States.
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35
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Brunner R, Min Z, Abdulmassih R, Bhanot N. 1920. Ocular Involvement in Candidemia Patients at an Urban Tertiary Care Center: Is Inpatient Ophthalmologic Consultation Essential? Open Forum Infect Dis 2018. [PMCID: PMC6254029 DOI: 10.1093/ofid/ofy210.1576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Robert Brunner
- Infectious Disease, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital/Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Nitin Bhanot
- Infectious Disease, Allegheny General Hospital, Pittsburgh, Pennsylvania
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36
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Cheronis N, Vietmier S, McGonial S, Kriznik S, Bhanot N, Min Z. 2102. Peripherally Inserted Central Catheter (PICC) Placement: Indications and Financial Impact. Open Forum Infect Dis 2018. [PMCID: PMC6254550 DOI: 10.1093/ofid/ofy210.1758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nicholas Cheronis
- Infectious Disease, Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | | | - Susan Kriznik
- Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Nitin Bhanot
- Infectious Disease, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital/Allegheny Health Network, Pittsburgh, Pennsylvania
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37
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Sandhu R, Mareddy C, Itskowitz M, Mount CE, Bhanot N, Min Z. Mycoplasma-induced rash and mucositis in a young patient with red eyes, oral mucositis, and targetoid cutaneous vesicles. Lancet Infect Dis 2018; 17:562. [PMID: 28447958 DOI: 10.1016/s1473-3099(16)30515-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/15/2016] [Accepted: 11/17/2016] [Indexed: 10/19/2022]
Affiliation(s)
- Rikinder Sandhu
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Chinmaya Mareddy
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Marc Itskowitz
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Charles E Mount
- Division of Dermatology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
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38
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Veer M, Abdulmassih R, Como J, Min Z, Bhanot N. Adenoviral nephritis in a renal transplant recipient: Case report and literature review. Transpl Infect Dis 2017; 19. [PMID: 28467620 DOI: 10.1111/tid.12716] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 01/06/2017] [Accepted: 02/06/2017] [Indexed: 11/27/2022]
Abstract
Adenovirus (AdV) infections in transplant recipients may cause invasive disease. We present a case of granulomatous interstitial nephritis secondary to AdV infection in a renal transplant recipient that was initially interpreted as acute graft rejection on histopathology. Specific testing based on clinical suspicion, however, aided in making an accurate diagnosis. We present a retrospective review of all cases of AdV infection in renal transplant recipients to date, and analyze outcomes based on different treatment modalities for this disease.
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Affiliation(s)
- Manik Veer
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Rasha Abdulmassih
- Division of Infectious Disease, Allegheny General Hospital, Pittsburgh, PA, USA
| | - James Como
- Division of Infectious Disease, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Pittsburgh, PA, USA
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39
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Walsh TL, Bhanot N, Murillo MA, Uchin JM, Min Z. Creeping Skin Lesions: Primary Cutaneous Cryptococcosis. Am J Med 2017; 130:666-668. [PMID: 28223065 DOI: 10.1016/j.amjmed.2017.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/07/2017] [Accepted: 02/08/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas L Walsh
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa.
| | - Nitin Bhanot
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Monika A Murillo
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Jeffrey M Uchin
- Department of Pathology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Zaw Min
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
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40
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Min Z, Veer M, Rali P, Singh A, Bhanot N. Early-onset de novo invasive pulmonary aspergillosis in an orthotopic heart transplant recipient. Lung India 2017; 34:376-379. [PMID: 28671171 PMCID: PMC5504897 DOI: 10.4103/lungindia.lungindia_454_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Invasive aspergillosis generally occurs during the first 1-6 months after heart transplantation. It has been rarely seen in the first 2 weeks postcardiac transplant. We herein describe a unique case of invasive pulmonary aspergillosis (IPA) diagnosed on day 9 postorthotopic heart transplantation. The known risk factors for IPA in cardiac transplant recipients were not identified in our case. The organ recipients from the same donor did not report Aspergillus infection. Hospital environmental samplings failed to demonstrate Aspergillus spores in the patient's room and his adjacent rooms. A diagnosis of early-onset de novo IPA was made. The patient initially received combined antifungal therapy (voriconazole plus micafungin), followed by voriconazole maintenance monotherapy with favorable clinical outcome.
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Affiliation(s)
- Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, USA
| | - Manik Veer
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, School of Medicine, Temple University, Philadelphia, PA, USA
| | - Anil Singh
- Division of Pulmonary and Critical Care Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, USA
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41
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Sandhu R, Murillo M, Wyatt D, Bhanot N, Min Z, Thomas J. Environmental Decontamination of Medical Intensive Care Unit Suites Using High-Intensity Narrow-Spectrum Light. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rikinder Sandhu
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Monika Murillo
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Delia Wyatt
- Department of Quality Management, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nitin Bhanot
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Zaw Min
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John Thomas
- Department of Microbiology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
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Abdulmassih R, Makadia J, Como J, Paulson M, Min Z, Bhanot N. Propionibacterium acnes: Time-to-Positivity in Standard Bacterial Culture From Different Anatomical Sites. J Clin Med Res 2016; 8:916-918. [PMID: 27829959 PMCID: PMC5087633 DOI: 10.14740/jocmr2753w] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Propionibacterium acnes infections are likely under-recognized and underreported. This is partly because of low clinical suspicion, perceived non-pathogenicity, or lack of adequate culture incubation time. We conducted a study to assess the optimal incubation period to recover P. acnes from specimens acquired during the workup of suspected clinical infections. METHODS A 5-year retrospective chart review was conducted between January 2010 and December 2014 at a single tertiary-care hospital. All patient cases from which P. acnes was recovered were included for analysis. Source of infection, antibiotic use, and culture time-to-positivity (TTP) were recorded. RESULTS Implanted devices comprised the single most common source of P. acnes infection. In the majority of cases, P. acnes was the only organism identified. The mean incubation TTP for all isolates was 5.73 days. CONCLUSIONS Standard 5-day culture incubation periods are insufficient to recover P. acnes. As a result, P. acnes is likely a much more common etiology of a variety of clinical infections than previously reported.
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Affiliation(s)
- Rasha Abdulmassih
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Jina Makadia
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - James Como
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Michelle Paulson
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Zaw Min
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
| | - Nitin Bhanot
- Division of Infectious Diseases, Allegheny General Hospital, 420 East North Ave., Pittsburgh, PA 15212, USA
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Rapsinski GJ, Makadia J, Bhanot N, Min Z. Pseudomonas mendocina native valve infective endocarditis: a case report. J Med Case Rep 2016; 10:275. [PMID: 27716406 PMCID: PMC5048412 DOI: 10.1186/s13256-016-1057-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 09/07/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Gram-negative microorganisms are uncommon pathogens responsible for infective endocarditis. Pseudomonas mendocina, a Gram-negative water-borne and soil-borne bacterium, was first reported to cause human infection in 1992. Since then, it has rarely been reported as a human pathogen in the literature. We describe the first case of native valve infective endocarditis due to P. mendocina in the USA. CASE PRESENTATION A 57-year-old white man presented with bilateral large leg ulcers, fever, and marked leukocytosis. His past medical history included gout and chronic alcohol use. P. mendocina was isolated from his blood cultures. A comprehensive review of P. mendocina infection in the literature was performed. A total of eight cases of P. mendocina infection were reported in the literature. More than two-thirds of the cases of P. mendocina septicemia were associated with native valve infective endocarditis. Thus, an echocardiogram was performed and demonstrated mitral valve endocarditis with mild mitral insufficiency. His leg wounds were debrided and were probably the source of P. mendocina bacteremia. Unlike Pseudomonas aeruginosa, P. mendocina is susceptible to third-generation cephalosporins. Our patient received a 6-week course of antimicrobial therapy with a favorable clinical outcome. CONCLUSIONS Our reported case and literature review illuminates a rare bacterial cause of infective endocarditis secondary to P. mendocina pathogen. Native cardiac valves were affected in all reported cases of infective endocarditis, and a majority of affected heart valves were left-sided. The antibiotics active against P. mendocina are different from those that are active against P. aeruginosa, and they notably include third-generation cephalosporins. The outcome of all reported cases of P. mendocina was favorable and no mortality was described.
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Affiliation(s)
| | - Jina Makadia
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, South Tower, East Wing, Suite 407, Pittsburgh, PA, 15212, USA
| | - Nitin Bhanot
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, South Tower, East Wing, Suite 407, Pittsburgh, PA, 15212, USA
| | - Zaw Min
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, South Tower, East Wing, Suite 407, Pittsburgh, PA, 15212, USA.
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Abdulmassih R, Makadia J, Min Z, Como J, Bhanot N. Propionibacterium Acnes: Time-to-Positivity of Cultures From Different Clinical Sites. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.1286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Garcia RR, Bhanot N, Min Z. A mimic's imitator: a cavitary pneumonia in a myasthenic patient with history of tuberculosis. BMJ Case Rep 2015; 2015:bcr-2015-210264. [PMID: 26150643 DOI: 10.1136/bcr-2015-210264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 77-year-old man with myasthenia gravis receiving prednisone and plasmapheresis was found to have right upper lobe cavitary pneumonia on radiological imaging studies after thymectomy. He had a remote history of treated pulmonary tuberculosis (TB) at the age of 19. On the basis of history of TB and current prednisone therapy, reactivation of pulmonary TB was highly suspected. Branching Gram-positive bacilli were identified on bronchoalveolar lavage (BAL). BAL Ziehl-Neelsen Acid-fast bacilli stain was negative, but a modified Kinyoun stain revealed branching, beaded, filamentous bacilli, suggestive of Nocardia spp. Nocardia cyriacigeorgica grew from the BAL culture. Cerebral MRI demonstrated a right frontal lobe lesion, clinically correlated to be nocardial brain abscess. The patient was treated with three-drug antimicrobial therapy (trimethoprim-sulfamethoxazole, meropenem, linezolid) for 2 months, followed by an additional 10 months of trimethoprim-sulfamethoxazole. Amikacin would have been included in the initial three-drug regimen, but its use was contraindicated in our myasthenic patient because aminoglycoside would trigger fatal myasthenic crisis by neuromuscular blockage. Follow-up imaging studies revealed resolution of the lung and brain lesions.
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Affiliation(s)
- Raquel Ramos Garcia
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Nitin Bhanot
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Zaw Min
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Makadia J, Bhanot N, Mancini SA, Min Z. Clinical evolution, management, and resolution of type II necrotizing fasciitis. Intern Emerg Med 2015; 10:389-91. [PMID: 25294738 DOI: 10.1007/s11739-014-1139-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Jina Makadia
- Department of Medicine, Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, 420 East North Avenue, East Wing, Suite 407, Pittsburgh, PA, 15212, USA,
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Sahud AG, Bhanot N. Measuring Hand Hygiene Compliance A New Frontier for Improving Hand Hygiene. Infect Control Hosp Epidemiol 2015; 30:1132. [DOI: 10.1086/647979] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Sahud AG, Bhanot N, Radhakrishnan A, Bajwa R, Manyam H, Post JC. An Electronic Hand Hygiene Surveillance Device: A Pilot Study Exploring Surrogate Markers for Hand Hygiene Compliance. Infect Control Hosp Epidemiol 2015; 31:634-9. [DOI: 10.1086/652527] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To evaluate the feasibility of using an electronic hand hygiene surveillance and feedback monitoring device.Design.A 2-phase pilot study included initial direct observation of hand hygiene practices as part of routine hospital quality assurance (phase I) and subsequent monitoring using an electronic hand hygiene surveillance device (phase II).Setting.A 700-bed tertiary care teaching hospital.Participants.Phase I included a convenience sample of healthcare workers. Phase II included 7 medical interns and 7 registered nurses recruited through email and at work-related meetings.Methods.During phase I, healthcare workers were directly observed at patient room entry and exit during the period April through November 2008. During phase II, hand hygiene data were gathered through indirect observation using the electronic device during a 4-week period in August 2009. Twenty patient rooms were fitted with electronic trigger devices that signaled a reader unit worn by participants when they entered the room, and 70 dispensers for liquid soap or hand sanitizer were fitted with triggers that signaled the reader unit when the dispenser was used. The accuracy of the devices was checked by the principal investigator, who manually recorded his room entries and exits and dispenser use while wearing a reader unit.Results.During phase I, hand hygiene occurred before room entry for 95 (25.1%) and after room exit for 149 (39.4%) of 378 directly observed patient room visits, for a cumulative composite compliance rate of 32.3%. Among the 378 room visits, 347 (91.8%) involved contact with the patient and/or environment. During phase II, electronic monitoring revealed a cumulative composite compliance rate of 25.5%. The electronic device captured 61 (98%) of 62 manually recorded room entries and 133 (95%) of 140 manually recorded dispensing events.Conclusions.The electronic hand hygiene surveillance device seems to be a practical method for routinely monitoring hand hygiene compliance in healthcare workers.
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Bhanot N, Chapnick EK, Sharma S, Tiu C, Ghitan M, Sahud AG. Colonization or Infection of the Urinary Tract Do We Pay Attention? Infect Control Hosp Epidemiol 2015; 30:501-2. [DOI: 10.1086/597063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Garcia RR, Min Z, Narasimhan S, Bhanot N. Fusarium brain abscess: case report and literature review. Mycoses 2014; 58:22-6. [PMID: 25476184 DOI: 10.1111/myc.12271] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 11/29/2022]
Abstract
Severely immunocompromised patients such as those with haematological malignancies and haematopoietic stem cell transplant recipients are at an increased risk of acquiring invasive mould infections. Fusarium, a ubiquitous fungus, can cause potentially fatal infections in such hosts. It usually manifests as skin lesions, fevers and sino-pulmonary infections. Brain abscesses have been reported, but are relatively uncommon. We report a case of a 50-year-old patient with acute lymphocytic leukaemia and failed autologous peripheral stem cell transplant that presented with new onset seizures and was found to have Fusarium solani brain abscess. Nasal route was the presumed mode of entry of the fungus into the cerebrum. Treatment comprised surgical excision of the lesion, and antimycotic therapy with liposomal amphotericin B and voriconazole. Despite aggressive therapy, patient succumbed to the disease. We have provided an overview of infections secondary to Fusarium, along with a review of the central nervous system involvement by this pathogenic mould.
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Affiliation(s)
- Raquel Ramos Garcia
- Division of Infectious Disease, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
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