Background Potassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is ...poorly described. Aims This study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness. Methods Post-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed. Results A total of 1242 patients were included. The mean age was 57.2#177;22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia3.5mmol/L was 8% (n = 101). Renal insufficiency (OR 95% CI = 3.561.94-6.52, p-value 0.001) and hemoglobin 12g/dl (OR 95% CI = 2.621.50-4.60, p-value = 0.001) were associated with hyperkalemia. Female sex (OR 95% CI = 1.311.03-1.66, p-value = 0.029), age 45years (OR 95% CI = 1.69 1.20-2.37, p-value = 0.002) and the use of thiazide diuretics (OR 95% CI = 2.04 1.28-3.32, p-value = 0.003), were associated with hypokalemia4mmol/l. Two patients died in the ED and 629 (52.7%) were hospitalized. Hypokalemia 3.5mmol/L was independently associated with increased odds of hospitalization or death (OR 95% CI = 1.47 1.00-2.15, p-value = 0.048). Conclusions Hypokalemia is frequently found in the ED and was associated with worse outcomes in a low-risk ED population.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Ludwig’s angina: A diagnostic and surgical priority Vallée, Maxime; Gaborit, Benjamin; Meyer, Jérémy ...
International journal of infectious diseases,
April 2020, 2020-Apr, 2020-04-00, 2020-04-01, Letnik:
93
Journal Article
Recenzirano
Odprti dostop
•Ludwig’s angina is a frequently fatal rapidly progressive necrotizing cellulitis of the floor of the mouth, the throat and the neck.•Ludwig’s angina should not be confused with Lemierre’s syndrome, ...different in terms of pathophysiology and therapeutic.•We present four cases of severe necrotizing cervical cellulitis notably associated to concomitant self-medication with NSAIDs.•To treat anaerobic bacteria and streptococci, B-lactams(penicillin with βLase inhibitors) +/- combination with clindamycin, should be used.
Ludwig’s angina has been known for two centuries as a rapidly and frequently fatal progressive gangrenous cellulitis or necrotizing fasciitis of the neck and the floor of the mouth. The management of the usually young patients affected requires a trained team combining medical skills in surgery, antibiotic therapy, and resuscitation. The prognosis is directly related to early surgical debridement and the experience of the team managing these patients. We present four cases of severe necrotizing cervical cellulitis notably associated with concomitant self-medication with non-steroidal anti-inflammatory drugs. Through these cases, we conclude that several surgical steps could be required, combined with broad-spectrum antibiotic therapy. An optimal surgery, draining all collections and excising all necrotic tissues, seems to be a condition needed for antibiotic efficacy and finally healing.
Background
Pneumocystis jirovecii
pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to ...assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis.
Methods
We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of
P. jirovecii
cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO
2
, non-invasive ventilation, or MV.
Results
Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for
P. jirovecii
. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (
n
= 37, 35%), followed by solid organ transplantation (
n
= 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (
n
= 13, 12%), solid tumors (
n
= 12, 11%) and primary immunodeficiency (
n
= 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5;
p
< 0.05), a
P. jirovecii
microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3;
p
< 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8;
p
< 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09;
p
< 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96;
p
< 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55;
p
< 0.05).
Conclusions
Older age and
P. jirovecii
oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation.
Abstract
Objectives
Brain abscess is one of the most serious diseases of the CNS and is associated with high morbidity and mortality. With regard to the lack of data supporting an optimal therapeutic ...strategy, this study aimed to explore the prognostic factors of brain abscess, putting emphasis on the impact of therapeutic decisions.
Methods
We retrospectively included patients hospitalized for brain abscess during a period of 13 years. Comorbidities (Charlson scale), clinical presentation, microbiology culture, radiological features and therapeutic management were collected. Glasgow Outcome Scale (GOS) at 3 months and length of hospital stay were, respectively, the main and the secondary outcomes. Logistic regression was used to determine factors associated with outcome independently.
Results
Initial Glasgow Coma Scale (GCS) ≤14 and comorbidities (Charlson scale ≥2) were associated with poor neurological outcome while oral antibiotic switch was associated with better neurological outcome. Oral switch did not appear to be associated with an unfavourable evolution in the subset of patients without initial neurological severity (GCS >14) on admission. Duration of IV regimen and time to oral switch were associated with the length of inpatient stay.
Conclusions
This study confirms the role of GCS and comorbidities as prognostic factors and presents reassuring data regarding the safety of oral switch for the antibiotic treatment of brain abscesses. Oral switch could prevent catheter-induced iatrogenic complications and allow a higher quality of life for patients.
•The treatment of prosthetic joint infections (PJIs) due to Streptococcus agalactiae is associated with a high risk of relapse.•The conservative approach with debridement and implant retention has a ...poor prognosis.•Debridement, antibiotics and implant retention (DAIR) with polyethylene exchange is probably associated with a higher chance of success.•The one-stage exchange strategy in selected patients has an excellent cure rate.•No antimicrobial treatment seems to be superior for PJIs with streptococcal species.
The optimal treatment of streptococcal prosthetic joint infections (PJIs) is unclear.
A cohort of streptococcal PJIs was reviewed retrospectively in seven reference centers for the management of complex bone and joint infections, covering the period January 1, 2010 to December 31, 2012.
Seventy patients with monomicrobial infections were included: 47 had infections of total hip arthroplasty and 23 had infections of total knee arthroplasty. The median age was 77 years (interquartile range (IQR) 69–83 years), the median Charlson comorbidity score was 4 (IQR 3–6), and 15.6% (n=11) had diabetes. The most commonly identified streptococcal species were Streptococcus agalactiae and Streptococcus dysgalactiae (38.6% (n=27) and 17.1% (n=12), respectively). Debridement, antibiotics and implant retention (DAIR) was performed after a median time of 7 days (IQR 3–8 days), with polyethylene exchange (PE) in 21% of cases. After a minimum follow-up of 2 years, 27% of patients had relapsed, corresponding to 51.4% of DAIR treatment cases and 0% of one-stage (n=15) or two-stage (n=17) exchange strategy cases. Rifampicin or levofloxacin in combination therapy was not associated with a better outcome (adjusted p= 0.99). S. agalactiae species and DAIR treatment were associated with a higher risk of failure. On multivariate analysis, only DAIR treatment and S. agalactiae were independent factors of relapse. Compared to DAIR without PE, DAIR with PE was only associated with a trend towards a benefit (odds ratio 0.33, 95% confidence interval 0.06–1.96; adjusted p= 0.44).
Streptococcal PJIs managed with DAIR have a poor prognosis and S. agalactiae seems to be an independent factor of treatment failure.
Amoxicillin is the first-line treatment for streptococcal or enterococcal infective endocarditis (IE) with a dose regimen adapted to weight.
Covariates influencing pharmacokinetics (PK) of ...amoxicillin were identified in order to develop a dosing nomogram based on identified covariates for individual adaptation.
Patients treated with amoxicillin administered by continuous infusion for IE were included retrospectively. The population PK analysis was performed using the Pmetrics package for R (NPAG algorithm). Influence of weight, ideal weight, height, BMI, body surface area, glomerular filtration rate adapted to the body surface area and calculated by the CKD-EPI method (mL/min), additional ceftriaxone treatment and serum protein level on amoxicillin PK was tested. A nomogram was then developed to determine the daily dose needed to achieve a steady-state free plasma concentration above 4× MIC, 100% of the time, without exceeding a total plasma concentration of 80 mg/L.
A total of 160 patients were included. Population PK analysis was performed on 540 amoxicillin plasma concentrations. A two-compartment model best described amoxicillin PK and the glomerular filtration rate covariate significantly improved the model when included in the calculation of the elimination constant Ke.
This work allowed the development of a dosing nomogram that can help to increase achievement of the PK/pharmacodynamic targets in IE treated with amoxicillin.
Abstract Background Many adverse drug events (ADEs) are not identified by emergency physicians. Research has been done to study risk factors for ADEs and help emergency physicians diagnose ADEs. ...However, no research has specifically examined the causes underlying a lack of attribution of ADEs to medications in emergency department (ED) patients. Objective We conducted an exploratory study in a medical ED to search for the factors associated with ADE nonrecognition that are related to ED patients and ADEs. Methods We conducted an observational study in the medical ED of a French tertiary care hospital between January and December 2009. The study focused on all ADEs, whether or not they were related to the patient's chief complaint. ADEs were identified by an expert physician and pharmacist based on National Electronic Injury Surveillance System criteria. An ADE was considered “attributed” if any evidence of ADE suspicion, ADE diagnosis, or ADE management was documented on ED charts. Factors associated with ADE nonrecognition were identified using multiple logistic regression analysis. Results Of the 465 included patients, 90 experienced an ADE at ED visit (19.4%; 95% confidence interval CI 15.9%–23.2%). Emergency physicians correctly recognized 36 of these cases (40.0%; 95% CI 29.8%–50.9%). On multivariate analysis, ADE nonrecognition was significantly associated with the following variables: nonrelation between the ADE and the patient's chief complaint; daily prescription of four drugs or more; and hospitalization ADE severity category. Conclusions Our results emphasize the importance of searching for ADEs in patients with daily polypharmacy or whose chief complaint does not seem to be drug related.
Optimal dosing of continuous-infusion cefazolin can be challenging in patients being treated for bacteremia or infective endocarditis. The aim of this work is to describe and analyze the ...pharmacokinetics of cefazolin in those patients using a population pharmacokinetics modeling approach and to establish a nomogram to determine the optimal daily dose. Population pharmacokinetics were modeled using the Pmetrics package for R. Plasma concentrations were collected retrospectively from patients treated with continuous-infusion cefazolin for bacteremia or infective endocarditis. The influence of multiple parameters, including renal function, total body weight, body mass index, body surface area (BSA), ideal weight, lean body weight, height, and age, was tested. The probabilities of target attainment for selected target concentrations (40, 60, and 80 mg/liter) were calculated. A dosing nomogram was then developed, using the absolute value of the glomerular filtration rate (aGFR), to determine the optimal daily dose required to achieve the target concentrations in at least 90% of patients. In total, 346 cefazolin plasma concentrations from 162 patients were collected. A one-compartment model best described the data set. The only covariate was aGFR, calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula and the patient's body surface area, for the rate of elimination. Using the nomogram, achieving a cefazolin concentration target of 40 mg/liter with a success rate of at least 90% and with an aGFR of 30, 60, 90, and 120 ml/min requires a daily dose of 2.6, 4.3, 6.1, and 8.0 g/day, respectively. These results confirm the interest of posology adaptation of cefazolin according to aGFR.
A patient received continuous infusion of cefazolin 10 g then 8 g daily for an external ventricular drainage-related methicillin-susceptible
(MSSA) ventriculitis. Median free concentrations in the ...cerebrospinal fluid were 11.9 and 6.1 mg/liter after 10- and 8-g doses, respectively. Free concentrations in the cerebrospinal fluid were always above the MIC usually displayed by methicillin-susceptible
(MSSA) isolates. These results support the use of high-dose cefazolin to achieve sufficient meningeal concentrations.
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