Archive for July 30, 2014

Case 20-2014 — A 65-Year-Old Man with Dyspnea and Progressively Worsening Lung Disease

N Engl J Med June 26, 2014 V.370 P.2521-2530


Kathleen M. Finn, M.D., Leo C. Ginns, M.D., Gregory K. Robbins, M.D., Carol C. Wu, M.D., and John A. Branda, M.D.

From the Departments of Medicine (K.M.F., L.C.G., G.K.R.), Radiology (C.C.W.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (K.M.F., L.C.G., G.K.R.), Radiology (C.C.W.), and Pathology (J.A.B.), Harvard Medical School — both in Boston.


Dr. Gregory K. Robbins: A 65-year-old man with a history of emphysema and inflammatory colitis was admitted to this hospital because of dyspnea, hypoxemia, and worsening lung disease.

The patient had been well until approximately 3 years before admission, when herpes zoster infection (shingles) occurred; shortly thereafter, episodes of bloody diarrhea developed, after which a diagnosis of inflammatory colitis was made at another hospital.

Two years before admission, mesalamine was administered for treatment of the colitis, with improvement of his symptoms. During the next 2 years, progressive dyspnea on exertion occurred.

One year before this admission, pulmonary-function tests were performed, and diagnoses of chronic obstructive pulmonary disease (COPD) and advanced emphysema were made. Tiotropium bromide was administered by inhalation.

During the 6 months before this admission, numerous episodes of worsening dyspnea occurred.

Supplemental oxygen (2 liters per minute through a nasal cannula, as needed), multiple courses of antibiotics, and tapering courses of prednisone were administered, with transient improvement.

Approximately 5 months before this admission, cough with sputum production developed….



July 30, 2014 at 2:39 pm

Clinical Microbiology Costs for Methods of Active Surveillance for Klebsiella pneumoniae Carbapenemase–Producing Enterobacteriaceae

Infection Control & Hospital Epidemiology April 2014 V.35 N.4 P.350-355

Amy J. Mathers, MD,1,2 Melinda Poulter, PhD,2 Dawn Dirks, MS,2 Joanne Carroll, BS,2 Costi D. Sifri, MD,1 and Kevin C. Hazen, PhD2,a

  1. Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
  2. Department of Pathology, University of Virginia Health System, Charlottesville, Virginia

a Present affiliation: Clinical Microbiology Laboratory, Department of Pathology, Duke University Health System, Durham, North Carolina

Address correspondence to Amy J. Mathers, MD, Division of Infectious Diseases and International Health, University of Virginia Health System, PO Box 801361, Charlottesville, VA 22908 (


To compare direct laboratory costs of different methods for perirectal screening for carbapenemase-producing Enterobacteriaceae (CPE) colonization.


Cost-benefit analysis.


A university hospital and affiliated long-term acute care hospital (LTACH).


Inpatients from the hospital or LTACH.


Perirectal samples were collected from inpatients at risk for exposure to CPE. In 2009, we compared the accuracy of the Centers for Disease Control and Prevention (CDC)–recommended CPE screening method with similar methods incorporating a chromogenic agar (CA). We then performed a cost projection analysis using 2012 screening results for the CA method, the CDC method, and a molecular assay with wholesale pricing based on the 2009 analysis. Comparisons of turnaround and personnel time were also performed.


A total of 185 (2.7%) of 6,860 samples were confirmed as CPE positive during 2012. We previously found that the CDC protocol had a lower sensitivity than the CA method and predicted that the CDC protocol would have missed 92 of the CPE-positive screening results, whereas the modified protocol using CA would have missed 26, assuming similar prevalence and performance. Turnaround time was 3 days using the CDC and CA-modified protocols compared with 1 day for molecular testing. The estimated annual total program cost and total technologist’s hours would be the following: CA-modified protocol, $37,441 and 376 hours; CDC protocol, $22,818 and 482 hours; and molecular testing, $224,596 and 343 hours.


The CDC screening protocol appeared to be the least expensive perirectal screening method. However, expense must be weighed against a lower sensitivity and extra labor needed for additional work-up of non-CPE isolates. The molecular test has the shortest turnaround time but the greatest expense.




July 30, 2014 at 2:35 pm

Addressing the Emergence and Impact of Multidrug-Resistant Gram-Negative Organisms: A Critical Focus for the Next Decade

Infection Control & Hospital Epidemiology April 2014 V.35 N.4 P.333-335

Ebbing Lautenbach, MD, MPH, MSCE1 and Eli N. Perencevich, MD, MS2

  1. Division of Infectious Diseases, Department of Medicine, Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
  2. Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, and Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Administration Health Care System, Iowa City, Iowa

Address correspondence to Ebbing Lautenbach, MD, MPH, MSCE, Center for Clinical Epidemiology and Biostatistics, 825 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021 (

Approximately 10% of hospitalizations are complicated by a healthcare-associated infection, and up to 75% of these are due to organisms resistant to first-line antimicrobial therapy.

Furthermore, antimicrobial-resistant bacterial infections are associated with significant increases in morbidity and mortality and incur upward of $20 billion in annual healthcare costs.

Antimicrobial resistance has increased significantly in all spheres of patient care: acute care hospitals, long-term acute care hospitals, long-term care, and the community. Despite these sobering facts, we remain woefully unprepared to address both current and future resistant organisms.

Although antimicrobial resistance has been noted in nearly all bacterial pathogens, multidrug resistance among gram-negative bacteria represents a unique and immediate threat.

In the past decade, there has been a dramatic increase in the prevalence of various types of antimicrobial-resistant gram-negative bacteria, including extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant strains of Pseudomonas aeruginosa and Acinetobacter baumannii.

Infections due to these organisms have been associated with significantly worse clinical outcomes, with mortality rates up to 4 times higher than infections caused by susceptible strains.

Furthermore, the potential for widespread and rapid transmission of these pathogens and/or the underlying genetic determinants of their resistance is of great concern….



July 30, 2014 at 2:32 pm


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