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Vancomycin plus piperacillin–tazobactam (VPT) is a commonly used antimicrobial regimen for septic patients. VPT is more nephrotoxic than other regimens such as vancomycin plus cefepime (VC) when given over several days. This risk of nephrotoxicity is less clear when VPT is given for initial empiric therapy in sepsis and de-escalated quickly based on evolving clinical information. The objective of this study was to assess nephrotoxicity among septic patients empirically treated with either VPT or VC at initial clinical presentation. We conducted a retrospective study of septic patients who received VPT or VC within 12 h of presentation to the emergency department. The primary outcomes were acute kidney injury (AKI) and renal recovery 72 h after presentation. For the total of 418 patients, 306 received VPT and 112 received VC. Rates of AKI at 72 h were 15.2% for VPT patients and 11.0% for VC patients [p = 0.44]. Among patients with AKI at presentation, 16.3% of VPT patients had AKI at 72 h compared to 8.9% of VC patients [p = 0.19]. Among those without AKI at presentation, 14.2% VPT patients and 16.7% VC patients had AKI at 72 h [p = 0.71]. Renal recovery rates for patients with AKI at presentation were 42.3% for VPT patients versus 40.3% for VC patients [p = 0.78]. In-hospital renal replacement therapy occurred in 6.2% VPT patients and 0.9% VC patients [p = 0.024]. Therefore, initial empiric therapy with VPT in sepsis may not confer increased risk of AKI when de-escalated appropriately.

Background Community-acquired pneumonia (CAP) guidelines have improved the treatment and outcomes of patients with CAP, primarily by standardization of initial empirical therapy. But current society-published guidelines exclude immunocompromised patients. Research Question There is no consensus regarding the initial treatment of immunocompromised patients with suspected CAP. Study Design and Methods This consensus document was created by a multidisciplinary panel of 45 physicians with experience in the treatment of CAP in immunocompromised patients. The Delphi survey methodology was used to reach consensus. Results The panel focused on 21 questions addressing initial management strategies. The panel achieved consensus in defining the population, site of care, likely pathogens, microbiologic workup, general principles of empirical therapy, and empirical therapy for specific pathogens. Interpretation This document offers general suggestions for the initial treatment of the immunocompromised patient who arrives at the hospital with pneumonia.

Background Antibiotic stewardship programs improve clinical outcomes and patient safety and help combat antibiotic resistance. Specific guidance on resources needed to structure stewardship programs is lacking. This manuscript describes results of a survey of US stewardship programs and resultant recommendations regarding potential staffing structures in the acute care setting. Methods A cross-sectional survey of members of 3 infectious diseases subspecialty societies actively involved in antibiotic stewardship was conducted. Survey responses were analyzed with descriptive statistics. Logistic regression models were used to investigate the relationship between stewardship program staffing levels and self-reported effectiveness and to determine which strategies mediate effectiveness. Results Two-hundred forty-four respondents from a variety of acute care settings completed the survey. Prior authorization for select antibiotics, antibiotic reviews with prospective audit and feedback, and guideline development were common strategies. Eighty-five percent of surveyed programs demonstrated effectiveness in at least 1 outcome in the prior 2 years. Each 0.50 increase in pharmacist and physician full-time equivalent (FTE) support predicted a 1.48-fold increase in the odds of demonstrating effectiveness. The effect was mediated by the ability to perform prospective audit and feedback. Most programs noted significant barriers to success. Conclusions Based on our survey's results, we propose an FTE-to-bed ratio that can be used as a starting point to guide discussions regarding necessary resources for antibiotic stewardship programs with executive leadership. Prospective audit and feedback should be the cornerstone of stewardship programs, and both physician leadership and pharmacists with expertise in stewardship are crucial for success.

Background. Histoplasmosis may complicate tumor necrosis factor (TNF)–α blocker therapy. Published case series provide limited guidance on disease management. We sought to determine the need for long-term antifungal therapy and the safety of resuming TNF-α blocker therapy after successful treatment of histoplasmosis. Methods. We conducted a multicenter retrospective review of 98 patients diagnosed with histoplasmosis between January 2000 and June 2011. Multivariate logistic regression was used to evaluate risk factors for severe disease. Results. The most commonly used biologic agent was infliximab (67.3%). Concomitant corticosteroid use (odds ratio [OR], 3.94 [95% confidence interval {CI}, 1.06–14.60]) and higher urine Histoplasma antigen levels (OR, 1.14 [95% CI, 1.03–1.25]) were found to be independent predictors of severe disease. Forty-six (47.4%) patients were initially treated with an amphotericin B formulation for a median duration of 2 weeks. Azole treatment was given for a median of 12 months. TNF-α blocker therapy was initially discontinued in 95 of 98 (96.9%) patients and later resumed in 25 of 74 (33.8%) patients at a median of 12 months (range, 1–69 months). The recurrence rate was 3.2% at a median follow-up period of 32 months. Of the 3 patients with recurrence, 2 had restarted TNF-α blocker therapy, 1 of whom died. Mortality rate was 3.2%. Conclusions. In this study, disease outcomes were generally favorable. Discontinuation of antifungal treatment after clinical response and an appropriate duration of therapy, probably at least 12 months, appears safe if pharmacologic immunosuppression has been held. Resumption of TNF-α blocker therapy also appears safe, assuming that the initial antifungal therapy was administered for 12 months.

Background Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections. Methods We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge. Results Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality. Conclusions Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending.

Objectives Infections of the spine lead to considerable morbidity and a high cost to the global healthcare system. Currently, evidence for using ceftaroline, an advanced-generation cephalosporin active against methicillin-resistant Staphylococcus aureus (MRSA), in spine infections is limited. Methods Describing Infections of the Spine treated with Ceftaroline (DISC) is a multicentre, retrospective, cohort study that evaluated ceftaroline for treating spine infections. Patients were included if they were aged ≥18 years, diagnosed with a spine infection and treated with ceftaroline for ≥28 days. A control group was identified with the same inclusion criteria as the study population except they were treated with a comparator antibiotic for ≥28 days. Results Thirty-seven patients were included each in the ceftaroline and control groups. MRSA was the most commonly identified pathogen. With no differences between groups in age, sex, race or co-morbidities (with the exception of chronic kidney disease), treatment with ceftaroline led to similar clinical success compared with the control group. Multivariate regression analysis did not show a significant difference between the two groups in terms of clinical success after controlling for other covariates (adjusted odds ratio = 1.49; P = 0.711). More patients who received ceftaroline were discharged to an extended-care or rehabilitation facility than home compared with controls (81% vs. 54%, respectively; P = 0.024). Side effects and toxicities were rare, including one case of eosinophilic pneumonia in the ceftaroline group. Conclusions Ceftaroline appears to be a safe and effective therapy for infections of the spine, including from MRSA.

We present a case of eosinophilic pneumonia due to ceftaroline used for the treatment of methicillin-resistant Staphylococcus aureus bacteremia associated with a postoperative spinal infection. Our patient developed shortness of breath and hypoxemia on the fifth week of ceftaroline therapy. Chest imaging disclosed diffuse bilateral infiltrates. Laboratory abnormalities included peripheral eosinophilia and eosinophilic predominant bronchoalveolar lavage fluid. The combination of ceftaroline discontinuation plus initiation of steroid treatment resulted in complete resolution of signs, symptoms, and radiologic abnormalities. We speculate about possible mechanisms underlying this adverse event and diagnostic criteria for drug-induced eosinophilic pneumonia.

Clostridium difficile infection (CDI) is a commonproblem encounteredin solid-organ transplant (SOT) recipients and the incidence is increasing. SOT recipients have an incidence of CDI that is higher than other postoperative patients, and this group has several unique risk factors that may contribute to more severe disease. Recent publications in nontransplant patients have indicated that treatment choices should be based on the severity of the illness (1). Although there continues to be a lack of well-designed, randomized, controlled trials to support the management decisions that must be made for SOT recipients with CDI, the available evidence is reviewed and summarized for these treatment guidelines.

Summary Objectives Pyomyositis is an acute bacterial infection of skeletal muscle not arising from contiguous infection. It is often hematogenous in origin and typically associated with abscess formation. Our objective was to determine if there were any differences in the clinical presentation of disease between Staphylococcus aureus (SA) and non- Staphylococcus aureus pyomyositis. We also sought to determine if methicillin-resistant SA (MRSA) occurred more frequently during the final years of the study period. Methods A retrospective chart review study at three institutions in two cities. Results Sixty cases of pyomyositis were identified between 1990 and 2010. Twenty-nine patients were infected with SA while 31 had other bacterial etiologies or were culture negative. Those with a traumatic event prior to the onset of infection were more likely to have a SA infection while SA infected patients were younger. Our first documented case of MRSA occurred in 2005, but the frequency of MRSA infection remained static over the following five years. Conclusions Pyomyositis is an emerging infection that is underappreciated by many physicians. While MRSA has emerged as the foremost cause of SA infections in a majority of clinical conditions, in this series most patients still had methicillin-sensitive SA as their cause of pyomyositis. In light of the severity of pyomyositis and the potential for bacteremia (either as a source or complication of the infection), empiric SA therapy should be initiated in all patients until the culture results are available.

Background Methicillin-resistant Staphylococcus aureus (MRSA) infection is increasingly common. Treatment with vancomycin-based therapy is often unsuccessful. Daptomycin is a relatively new lipopeptide antibiotic with potent activity against MRSA. Purpose To describe the successful management of MRSA infection involving the spine. Study design Two case reports of MRSA infection, one involving epidural and lumbar subdural abscesses, the other with osteomyelitis and discitis. Methods Two cases are described, one with lumbar epidural and subdural abscesses and the other with osteomyelitis and discitis of the spine. Switching from vancomycin to daptomycin plus rifampin-based therapy resulted in patient improvement that allowed discharge from the hospital. Results Both patients recovered fully from their infection. Conclusions Daptomycin is a safe and effective option for the treatment of MRSA infection involving the spine.

Tedizolid phosphate is the second commercially available oxazolidinone antibiotic, although the first one in class that is dosed once daily. It is a prodrug that is rapidly converted to the active compound tedizolid. Tedizolid has activity against a wide range of gram-positive pathogens, including methicillin-resistant Staphylococcus aureus. It is approved to treat acute bacterial skin and skin structure infections (ABSSSIs). In 2 randomized controlled phase 3 trials, 6 days of tedizolid (200 mg once daily) has been proven to be noninferior to 10 days of linezolid (600 mg twice daily). These 2 ABSSSI studies have positioned tedizolid among the growing armamentarium of newer, novel, anti-gram-positive agents. Tedizolid appears to differ from linezolid in the incidence of gastrointestinal and hematologic side effects and appears to lack drug interactions with selective serotonin reuptake inhibitors. Conditions other than ABSSSI are currently being evaluated in clinical studies.

Antimicrobe.org (http://www.antimicrobe.org) is a World Wide Web-based version of the textbook Antimicrobial Therapy and Vaccines, volumes I and II. The Web site currently consists of 3 texts (Microbes, Antimicrobial Agents, and HIV Clinical Manual) and will soon include a fourth, Empiric. The Web site focuses on therapy for infectious diseases, and it covers, in comprehensive detail, a great majority of infections encountered today. The dynamic nature of a Web-based reference allows for information to be frequently updated and enhances a physician's searching capabilities to find answers to very specific clinical questions and the latest available evidence. A Smart Search engine allows users to ask specific questions and to find focused answers, either within the textbook or through PubMed via a guided PubMed references option. The Web site also provides clinical vignettes and minireviews on hot topics in infectious diseases and hyperlinks to other important articles or Web sites. Chapters are written by experts in their field who provide evidence-based information, as well as anecdotal reports about rare infections. Antimicrobe.org would be of great benefit to physicians who treat infections on a routine basis.

Diagnosis: Scurvy. The patient's serum ascorbic acid level was 0.1 mg/dL (normal range, 0.4-1.5 mg/dL). The punch biopsy of the skin of the right lower leg (figures 1 and 2) revealed minimal hyperkeratosis and thin epidermis (figure 3). There was extravasated blood in superficial dermis, admixed with karyorrhectic debris. Some of the dermal capillaries showed mild leukocytoclastic changes. There was no hair follicle in the specimen. Scurvy was diagnosed, and the patient was treated with high doses of ascorbic acid for 1 week. The leg edema and purpura quickly resolved during treatment (figure 4). Endoscopy of the upper gastrointestinal tract disclosed esophagitis with strictures, which were dilated. The pancytopenia was secondary to alcohol abuse, liver disease, and HIV infection. Scurvy is an uncommon disorder in developed countries. It is typically associated with malnutrition, alcoholism, severe gastroesophageal reflux, or/and advanced age [1-4]. Ascorbic acid deficiency leads to defective collagen formation. Histopathologic examination reveals RBC extravasation into the dermis, with a perivascular and perifollicular distribution; there may be sparse superficial perivascular infiltrate of inflammatory cells. Follicular hyperkeratosis with coiled, fragmented, cork

A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a "rash." His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with "chickenpox" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy.

Purpose A case series in which a novel dosing strategy for managing mild, asymptomatic creatine kinase (CK) increases associated with daptomycin therapy is presented. Summary Eight patients received a mean daptomycin dosage of 7.75 mg/kg/day for a median duration of 42 days. Seven of the eight patients were being treated for a bone and joint infection, and all but one had methicillin-resistant Staphylococcus aureus . All patients had asymptomatic increases in CK concentrations during daptomycin therapy (peak range, 400–1200 IU/L). A single daptomycin dose was withheld from each patient, and therapy was resumed 24 hours later, most often at the same dosage. The elevated CK values in these patients resolved, and all patients were able to complete daptomycin therapy without further increases in CK elevations. These findings indicate that withholding one dose of daptomycin during treatment may allow patients with asymptomatic, elevated CK concentrations to continue therapy with CK level normalization. Although the mechanism of daptomycin-mediated muscle injury is not fully understood, a reduction in daptomycin exposure via a one-dose cessation of therapy may allow for physiological restoration of sarcolemma membrane integrity that may be disrupted by daptomycin in individuals exhibiting CK elevation. Conclusion A single daptomycin dose was withheld from eight patients with asymptomatic increases in serum CK concentrations, then daptomycin therapy was resumed 24 hours later, most often at the previous dosage. The CK concentrations returned to normal, and all patients were able to complete daptomycin therapy without further increases in CK concentrations.

To improve our understanding of risk factors, management, diagnosis, and outcomes associated with histoplasmosis after solid organ transplant (SOT), we report a large series of histoplasmosis occurring after SOT.All cases of histoplasmosis in SOT recipients diagnosed between 1 January 2003 and 31 December 2010 at 24 institutions were identified. Demographic, clinical, and laboratory data were collected.One hundred fifty-two cases were identified: kidney (51%), liver (16%), kidney/pancreas (14%), heart (9%), lung (5%), pancreas (2%), and other (2%). The median time from transplant to diagnosis was 27 months, but 34% were diagnosed in the first year after transplant. Twenty-eight percent of patients had severe disease (requiring intensive care unit admission); 81% had disseminated disease. Urine Histoplasma antigen detection was the most sensitive diagnostic method, positive in 132 of 142 patients (93%). An amphotericin formulation was administered initially to 73% of patients for a median duration of 2 weeks; step-down therapy with an azole was continued for a median duration of 12 months. Ten percent of patients died due to histoplasmosis with 72% of deaths occurring in the first month after diagnosis; older age and severe disease were risk factors for death from histoplasmosis. Relapse occurred in 6% of patients.Although late cases occur, the first year after SOT is the period of highest risk for histoplasmosis. In patients who survive the first month after diagnosis, treatment with an amphotericin formulation followed by an azole for 12 months is usually successful, with only rare relapse.

Background Metronidazole (MTZ) is an imidazole that is used to treat parasites and anaerobic infections. The traditional dose of 500 mg every 6 to 8 hours achieves adequate serum concentration to treat most anaerobic infections. MTZ has a concentration dependent bactericidal activity with a long half-life of 8 hours and also exhibits post-antibiotic effect. The literature lacks clinical data in regards to a once daily higher dose of IV MTZ. Methods A retrospective quality improvement project via electronic medical record review of 88 adults who received MTZ 1 gm IV daily at a single tertiary medical center, from April 2014 to October 2016. Inclusion criteria were patients >/=18 years who received MTZ 1 gm IV every daily for >/= 48 hours. Results Of the 88 patients who received 1 gm of MTZ, 66 met inclusion criteria. Mean age was 58 years (range 24 to 90 years). Indications for use are shown in Figure 1. Mean duration of therapy was 10 days (range 2 to 42 days). Twenty-nine (43.9%) received /= 7 days. Fourteen (21%) were discharged home on MTZ 1 gm IV daily for 4–6 weeks duration. One patient had a documented adverse reaction (severe nausea) while the other 65 tolerated well. No documented treatment failure was reported. Conclusion MTZ has been used in combination with other antimicrobial agents to treat polymicrobial infections. It is generally well tolerated when administered in dosages of Disclosures All authors: No reported disclosures.

Come with us while our clinical team makes rounds. As each patient is seen and discussed, we often find that we have gaps in our knowledge related to the clinical decisions we‘re making. In this Practice Corner, we‘ll illustrate how we meet some of those information needs rapidly using resources stored in a personal digital assistant (PDA),1 placing in brackets the time it takes us to retrieve the evidence. We‘ll provide contact information in a table for selected resources and more information is available on our website (www.wsuim.org/PDA). Wherever possible, we use PDA resources that are evidence-based, meaning that their manufacturers are fully explicit about how they searched for evidence on clinical questions, appraised that evidence critically and rated its strength, and tied the strength of the evidence to the recommendations made.2 Our first patient is an older man admitted for pneumonia, in whom the medical student found a surprising abdominal pulsation. On examination we confirm that the aortic pulse contour is 3 cm wide. How accurate is this finding for detecting abdominal aortic aneurysm? On our Palm OS-based PDA, we tap the “Find” function, enter “AAA”, and then tap open a memo that tells us that the positive likelihood ratio of this clinical finding for abdominal aortic aneurysm is 12.0 [4 seconds]. In this memo we‘d written a synopsis of the evidence, similar in structure to the larger Critically Appraised Topic (CAT)2 …

Point-of-care access to current medical information is easily available to the practitioner through the use of smartphones, iPads, and other personal digital assistants. There are numerous mobile applications (apps) that provide easy-to-use and often well-referenced medical guidance for the infectious diseases practitioner. We reviewed 6 commonly utilized mobile apps available for handheld devices: the Emergency Medicine Residents' Association's (EMRA's) Antibiotic Guide, Epocrates Deluxe, Johns Hopkins Antibiotic Guide, Sanford Guide, the Medscape mobile app, and the Infectious Diseases Compendium. We evaluated several basic infectious diseases topics (including but not limited to endocarditis, vancomycin, and Acinetobacter infection) and attempted to objectively score them for metrics that would help the provider determine which mobile app would be most useful for his or her practice. The Johns Hopkins Antibiotic Guide and the Sanford Guide had the highest cumulative scores, whereas EMRA scored the lowest. We found that no single app will meet all of the needs of an infectious diseases physician. Each app delivers content in a unique way and would meet divergent needs for all practitioners, from the experienced clinician to the trainee. The ability to rapidly access trusted medical knowledge at the point of care can help all healthcare providers better treat their patients' infections.

Infectious disease (ID) physicians were surveyed concerning knowledge and management of potential transplant-transmitted infections (TTIs). On the basis of cumulative responses to 4 questions that assessed solid organ transplant-related clinical exposures and experience, respondents were divided into 3 groups: most, some, or little transplant experience. Rapid access to donor data was identified as the most important factor when evaluating a potential TTI. Despite varying experience in transplant infections, ID physicians are frequently asked for opinions regarding donor suitability and TTI management. Improved ID physician access to donor information and educational resources will allow more optimal management of potential TTIs.

This case report describes the differential diagnosis of cutaneous ulcerations and the utility of the interferon-gamma release assays as a tool to aid in the diagnosis. These new assays can be used to identify mycobacterial infections (specifically Mycobacterium marinum) as the etiologic agents.

Combination antibiotic therapy is often indicated for health care-associated pneumonia due to resistant pathogens and is recommended in the Infectious Diseases Society of America/American Thoracic Society guidelines on the management of community-acquired pneumonia and health care-associated

A 56-year-old man presented with a cutaneous lesion on his right hand (Figure 1). Approximately 6 weeks previously, he had traveled to Costa Rica for missionary work. During his travel he used a diethyltoluamide-containing insect repellant, but spent one night in the jungle without a mosquito net. Four weeks after his return, he noted a 3 × 2.5-cm ulcer with raised edges and surrounding erythema on the dorsum of his right hand. The patient recalled applying insect repellant with his right hand to other exposed areas of his body but was remiss in applying it to the right hand itself. On examination, the patient was noted to have an ulcerated nodule near his right earlobe (Figure 2) and a second 2 × 1-cm ulcer on the volar aspect of his right wrist (Figure 3). There were no mucocutaneous lesions noted. During the next several weeks, numerous nodules developed in a sporotrichoid pattern on the extensor surface of his right arm (Figure 4). Skin biopsy was performed at the time of initial evaluation and revealed cutaneous leishmaniasis due to Leishmania panamensis. After discussing the different treatment options, miltefosine was administered orally for 28 days. The patient experienced an excellent response to therapy. Figure 1. Ulcer, dorsum, right hand. Figure 2. Eschar, anterior to right ear. Figure 3. Ulcer, volar surface, right forearm. Figure 4. Sporotrichoid lesions, right forearm.

Case 1: A 39-year-old man with chronic lower extremity lymphedema was admitted to the hospital with acute fever, chills, and left lower extremity pain, swelling, and erythema for the third time in as many months. Examination revealed a temperature of 39 degrees C (102.2 degrees F), and erythmatous induration on the left leg (Figure). The patient was treated with IV clindamycin and cefazolin, with clinical improvement. He was discharged with azithromycin, 500 mg daily for 3 days, done twice monthly. Case 2: A 52-year-old morbidly obese man with stasis dermatitis presented with acute lower extremity pain, swelling, and associated fever. He had been taking prophylactic antibiotics for his recurrent cellulitis for more than a decade and had significantly decreased his number of reoccurrences while on this therapy. He was admitted to the hospital, treated with IV cefazolin, and had a rapid improvement over 48 hours. He was subsequently discharged with continued suppressive antibiotic therapy.

A 28-year-old white man presented to the Emergency Department with a 24-hour history of an eruption on his extremities, trunk, and face. The patient was known to be HIV positive with a CD4 count of 527 and a viral load of 20,300. He denied fever, chills, malaise, and headache. His social history was significant for the fact that he was in a monogamous homosexual relationship. He had no recent travel, pet exposures, or sick contacts. Physical examination revealed stable vital signs and no documented fever. A maculopapular eruption was present on his face, trunk, and extremities (Figures 1 and 2). There was no palmar or plantar involvement. He was treated with diphenhydramine and topical 2.5% hydrocortisone and advised to return if his condition did not improve. Twelve days after the initial evaluation, the patient consulted us again due to progression of his dermatitis. He had no additional complaints other than an eruption on both palms but neither sole. (Figure 3). The eruption now demonstrated erythematous pink-red oval macules and papules 1-2 cm in size distributed on his scalp, face, trunk, and arms. A few papules contained fine collarettes of scale. Further questioning revealed that the patient had experienced a tender rectal ulcer 2 months previously. A punch biopsy and rapid plasma reagin were performed. The histopathologic examination revealed interface dermatitis with lymphocytes, plasma cells, occasional neutrophils, and a prominent lymphoplasmacytic perivascular dermatitis with infiltration of the vessel walls. Warthrin-Starry and Steiner methods demonstrated spirochetes at the dermal-epidermal junction and in vessel walls, consistent with Treponema pallidum (Figure 4). Rapid plasma reagin and fluorescent Treponema antibody were both reactive with a Venereal Disease Research Laboratory (VDRL) of 1:16. The patient was diagnosed as having secondary syphilis and treated with 2.4 million units of IM benzathine penicillin for 3 weeks. His eruption resolved after the initial treatment and he did not experience a Jarisch-Herxheimer reaction.

Background We sought to describe the characteristics of patients who had Clostridium difficile colitis complicated by leukemoid reactions (total leukocyte count greater than 35 x 10(9)/L) and to determine whether this complication is associated with higher morbidity or mortality than C difficile colitis without leukemoid reactions. Methods We performed a retrospective case series analysis of patients with a positive fecal assay for C difficile toxin and a peak leukocyte count greater than 35 x 10(9)/L during 1998 and 1999. Twenty cases that met these criteria were compared with 65 randomly selected control patients (patients with a positive C difficile toxin and a peak leukocyte count less than 35 x 10(9)/L). Results The mean peak leukocyte count was 52 +/- 18.2 x 10(9)/L (+/- SD) in the case group and 14.9 +/- 6.5 x 10(9)/L in the control group. Patients with a leukemoid reaction had a lower temperature, a lower serum albumin level, and a higher hematocrit value. Multivariable logistic regression showed respiratory tract infection and lower temperature to be independent predictors of a leukemoid reaction. There were 10 deaths (50%) in the leukemoid reaction group and 5 deaths (7.7%) in the control group. All seven patients with a peak leukocyte count greater than 50 x 10(9)/L died, compared with eight deaths (10.3%) among the remaining 78 patients whose peak leukocyte count was less than 50 X 10(9)/L. Conclusion Patients with C difficile colitis and a leukocyte count greater than 35 x 10(9)/L have a poor prognosis with a much higher mortality rate than patients who have C difficile colitis without a leukemoid reaction.

A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a "rash." His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with "chickenpox" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy.

Personal Digital Assistants (PDAS) are rapidly becoming popular tools in the assistance of managing hospitalized patients, but little is known about how often expert recommendations are available for the treatment of infectious diseases in hospitalized patients. To determine how often PDAs could provide expert recommendations for the management of infectious diseases in patients admitted to a general medicine teaching service. Prospective observational cohort study Internal medicine resident teaching service at an urban hospital in Dayton, Ohio 212 patients (out of 883 patients screened) were identified with possible infectious etiologies as the cause for admission to the hospital. Patients were screened prospectively from July 2002 until October 2002 for infectious conditions as the cause of their admissions. 5 PDA programs were assessed in October 2002 to see if treatment recommendations were available for managing these patients. The programs were then reassessed in January 2004 to evaluate how the latest editions of the software would perform under the same context as the previous year. PDAs provided treatment recommendations in at least one of the programs for 100% of the patients admitted over the 4 month period in the 2004 evaluation. Each of the programs reviewed improved from 2002 to 2004, with five of the six programs offering treatment recommendations for over 90% of patients in the study. Current PDA software provides expert recommendations for a great majority of general internal medicine patients presenting to the hospital with infectious conditions.