Protracted COVID-19 pneumonitis early post-ABO incompatible kidney transplantation: Management considerations and the role of whole genome sequencing

We present the case of a recent ABO incompatible kidney transplant recipient with persistent SARS-CoV-2 infection and pneumonitis. Serial whole genome sequencing confirmed intra-host viral evolution, which was used as a surrogate to confirm active viral replication and support re-treatment with antivirals, late in the course of infection. A prolonged course of remdesivir combined with immunosuppression modulation resulted in successful clearance of virus and clinical improvement. The diagnostic process undertaken in this case provides a useful guide for other clinicians when approaching similar patients.

Is an Abnormal ECG Just the Tip of the ICE-berg? Examining the Utility of Electrocardiography in Detecting Methamphetamine-Induced Cardiac Pathology

BACKGROUND

Methamphetamine use is escalating in Australia and New Zealand, with increasing emergency department attendance and mortality. Cardiac complications play a large role in methamphetamine-related mortality, and it would be informative to assess the frequency of abnormal electrocardiograms (ECGs) amongst methamphetamine users.

OBJECTIVE

To determine the frequency and severity of ECG abnormalities amongst methamphetamine users compared to a control group.

METHODS

We conducted a retrospective cohort analysis on 212 patients admitted to a tertiary hospital (106 patients with methamphetamine use, 106 age and gender-matched control patients). Electrocardiograms were analysed according to American College of Cardiology guidelines.

RESULTS

Mean age was 33.4 years, with 73.6% male gender, with no significant differences between groups in smoking status, ECG indication, or coronary angiography rates. Methamphetamine users were more likely to have psychiatric admissions (22.6% vs 1.9%, p<0.0001). Overall, ECG abnormalities were significantly more common (71.7% vs 32.1%, p<0.0001) in methamphetamine users, particularly tachyarrhythmias (38.7% vs 26.4%, p<0.0001), right axis deviation (7.5% vs 0.0%, p=0.004), left ventricular hypertrophy (26.4% vs 4.7%, p<0.0001), P pulmonale pattern (7.5% vs 0.9%, p=0.017), inferior Q waves (10.4% vs 0.0%, p=0.001), lateral T wave inversion (3.8% vs 0.0%, p=0.043), and longer QTc interval (436.41±31.61ms vs 407.28±24.38ms, p<0.0001). Transthoracic echocardiogram (n=24) demonstrated left ventricular dysfunction (38%), thrombus (8%), valvular lesions (17%), infective endocarditis (17%), and pulmonary hypertension (13%). Electrocardiograms were only moderately sensitive at predicting abnormal TTE.

CONCLUSION

Electrocardiographic abnormalities are more common in methamphetamine users than age and gender-matched controls. Due to the high frequency of abnormalities, ECGs should be performed in all methamphetamine users who present to hospital. Methamphetamine users with abnormal ECGs should undergo further cardiac investigations.

What is the role of catheter antibiotic prophylaxis for patients undergoing joint arthroplasty?

BACKGROUND

Antimicrobial prophylaxis at the time of urinary catheter insertion and removal is commonly administered in patients undergoing joint arthroplasty, despite the lack of evidence to support this practice. The rationale is the theoretical risk of prosthetic joint infection arising from bacterial seeding from the urinary tract at the time of catheterization. In an era of antimicrobial stewardship, further assessment is warranted.

METHODS

This study aimed to investigate the incidence of catheter-associated (CA) bacteriuria and bacteraemia in patients undergoing total joint arthroplasty and to assess the antimicrobial susceptibility of any isolated microorganisms. This prospective observational study undertaken over a 6-month period (May to October 2014) included 99 patients undergoing elective primary hip and knee arthroplasty at St Vincent's Hospital, Melbourne. Urine specimens were collected at insertion and removal of urinary catheters along with blood cultures upon urinary catheter removal.

RESULTS

Overall 98% of the cohort received catheter antimicrobial prophylaxis for urinary catheter insertion and removal; the majority of patients received gentamicin (94%). Bacteriuria on catheter insertion had an incidence of 4.4%. The incidence of CA bacteriuria was 1.3%. All cultured organisms were sensitive to commonly used antibiotics including cephazolin. There were no cases of bacteraemia with urinary catheter removal. Increasing age, American Society of Anesthesiologists status and female gender were associated with the development of bacteriuria.

CONCLUSION

The incidence of CA bacteriuria and bacteraemia with antimicrobial prophylaxis is low. This study provokes discussion about the requirement of catheter prophylaxis in this surgical context and the utility of preoperative urine screening.