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Background: In light of rising healthcare costs and evidence of inefficient use of medical resources, there is growing interest in reducing healthcare waste by clinicians. Unwarranted lab tests may lead to further tests, prolonged hospital stays, unnecessary referrals and procedures, patient discomfort, and iatrogenic anemia, resulting in significant economic and clinical effects. Blood tests are essential in guiding medical decisions, but they are also associated with significant financial and clinical costs. We designed a quality improvement study that attempted to decrease inappropriate ordering of laboratory tests while maintaining quality of care in a large residency program., Methods: An algorithm outlining indications for complete blood count (CBC), coagulation profile (PT/INR) and basic metabolic profile (BMP) was created by the study team. Data from 1,312 patients over a 3-month period in the pre-intervention phase and 1,255 patients during the selected intervention phase were analyzed. The primary endpoint was mortality rate and secondary endpoints were length of stay and laboratory costs., Results: There were significant decreases in the number of PT/INR orders (20.6%), followed by BMP orders (12.4%), and CBC orders (9.3%). The mortality rate was 5.3% for the pre-intervention phase and 5.8% for the selected intervention phase, with a difference of 0.5% (P = 0.44)., Conclusion: Our approach leads to a decrease in costs, preventing unnecessary downstream testing, and improving patient experience. It also brought a mental discipline while ordering blood tests amongst residents., Competing Interests: The authors declare that there is no conflict of interest.

Objectives: Clostridium difficile caused nearly 500,000 infections and was associated with approximately 29,000 deaths in 2011, according to data from the Centers for Disease Control and Prevention. C. difficile is a bacterium that causes diarrhea and, often, severe illness in healthcare facilities, as well as the community. Our objective was to determine whether alkaline colonic pH predisposes to colonization and infection with C. difficile., Methods: A total of 228 patients with diarrhea and/or abdominal pain, leukocytosis, and fever were included. Stool pH was measured, and C. difficile antigen and toxin in stool were detected., Results: Of 228 patients, 30 (13.2%) tested positive for C. difficile (antigen+/toxin+) and 171 (75%) were C. difficile negative (antigen-/toxin-). Of 171 patients who tested negative, 93 (54.4%) had stool pH >7.0 and 78 (45.6%) had pH ≤7.0. Among the 30 patients who tested positive, 26 (86.7%) had stool pH >7.0 (P = 0.002). Among the 27 colonized patients (antigen+/toxin-), 12 (44.4%) had stool pH >7.0 (P = 0.34). For all patients with stool pH ≤7.0, 96% tested negative for C. difficile infection (P = 0.002)., Conclusions: A strong association between C. difficile infection and alkaline stool pH was found.

Malaria is a serious and sometimes fatal disease caused by an intraerythrocytic parasite, and is commonly seen in developing countries. Approximately 1500 cases of malaria are diagnosed in the United States each year, mostly in travelers and immigrants returning from endemic areas [1]. There are many different regimens used to treat malaria, some of which are not approved in the USA. The side effects of these medications may not be familiar to physicians in the USA. We report a case of a returning traveler from Nigeria presenting with fever and hemolytic anemia caused by a delayed response to artesunate given 3 weeks earlier while in Nigeria. To our knowledge, there are few cases reported in the United States of hemolytic anemia secondary to artesunate therapy [2].

We conducted a cross-sectional study to assess physicians' attitudes towards self-treatment of latent tuberculosis infection (LTBI) based on real-time responses related to actual purified protein derivative (PPD) results, in addition to using hypothetical situations for those who were PPD-negative. We also obtained information on physicians' recommendations for their patients to treat this condition. Although the physicians claimed to recommend optimal treatment to their patients, the majority of them had different attitudes when considering treatment for themselves. There appears to be a discrepancy between physicians' attitudes to self-treatment and their management of patients with LTBI.

The authors present a single-patient interventional case report of endogenous fungal endophthalmitis (EFE) in a patient with an implanted prosthetic device. A 74-year-old man underwent a double coronary artery bypass graft with a bioprosthetic pericardial valve and transvenous dual chamber pacemaker. Four months later, he presented with EFE. Despite aggressive local and systemic antifungal therapy, the patient died of septic shock due to a fungally infected pacemaker. Successful management of post-cardiac surgery EFE requires aggressive local and systemic antifungal therapy, but without surgical removal of implanted thoracic hardware these modalities alone may be insufficient for a cure., (Copyright 2010, SLACK Incorporated.)

Drug induced toxic epidermal necrolysis and Stevens Johnson syndrome are more commonly associated with medications such as sulfonamides, penicillin, anticonvulsants, oxicam non-steroidal anti-inflammatory drugs, allopurinol and corticosteroids. Isolated instances secondary to drugs outside of the aforementioned classes have also been reported. We report a case of probable toxic epidermal necrolysis induced by fluconazole in a 52 year old woman.

Sequestration of bacteria within the capsular fornices after cataract extraction with intraocular lens implantation can cause both acute and chronic inflammation. A case of persistent postoperative endophthalmitis caused by capsular sequestration of Cellulomonas is described. The patient underwent uncomplicated cataract extraction with intraocular lens implantation and subsequently developed acute postoperative endophthalmitis. Inflammation persisted despite several vitreous taps and the injection of intravitreal antibiotics. Definitive treatment required pars plana vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal and parenteral antibiotics. In patients with postoperative endophthalmitis, one must consider atypical organisms as the source and should consider explantation of the intraocular lens with capsular bag removal.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has rarely been reported in the hospital setting. We report an outbreak of 7 cases of skin and soft tissue infections due to a strain of CA-MRSA. All patients were admitted to the labor and delivery, nursery, or maternity units during a 3-week period. Genetic fingerprinting showed that the outbreak strain was closely related to the USA 400 strain that includes the midwestern strain MW2. All isolates contained the staphylococcal chromosome cassette mec type IV. Genes for Panton-Valentine leukocidin and staphylococcal enterotoxin K were detected in all isolates, and most contained other enterotoxin genes. Testing of nearly 2,000 MRSA isolates collected during citywide surveillance studies from 1999 to 2003 showed that approximate, equals 1% were genetically related to MW2. CA-MRSA strain MW2 has been present in this region at least since 1999. This study documents the spread of this strain among healthy newborns at 1 hospital.

Design: To report the second known case of post-traumatic endophthalmitis caused by Neisseria subflava., Design: Interventional case report., Methods: A two-year-old child with post-traumatic corneal laceration and uveal prolapse required medical and surgical therapy for endophthalmitis caused by multiple organisms including N. subflava., Results: After aggressive therapy, patient had a favorable outcome without vision compromise., Conclusions: As there is still not a standard protocol for therapy for post-traumatic endopthalmitis, we recommend the use of broad-spectrum antibiotics via intravitreal, intravenous, and topical routes. Consideration of typical and unusual bacteria that have been reported to cause endopthalmitis, as well as the source of injury, should guide antibiotic choice.

Objective: To report five new cases of Pneumocystis carinii pneumonia (PCP) and to review and analyze the existing reports on the subject., Method: Five new cases of PCP during pregnancy are described. The cases, case series, and related articles on the subject in the English language were identified through a comprehensive MEDLINE search and reviewed., Results: More than 80% of women with AIDS are of reproductive age, and PCP is the most common cause of AIDS-related death in pregnant women in the United States. Among 22 reviewed cases, the mortality rate was 50% (11 of 22 patients), which is higher than that usually reported for HIV-infected individuals with PCP. Respiratory failure developed in 13 patients (59%), and mechanical ventilation was therefore required, and the survival rate in patients requiring mechanical ventilation was 31%. Maternal and fetal outcomes were better in cases of PCP during the third trimester of the pregnancy. A variety of treatment regimens were used, including sulfamethoxazole-trimethoprim (SXT) alone or in combination with pentamidine, steroids, and eflornithine. The survival rate in patients treated with SXT alone was 71% (5 of 7 patients) and for those treated with SXT and steroids was 60% (3 of 5 patients), with an overall survival rate in both groups of 66.6% (8 of 12 patients)., Conclusion: PCP has a more aggressive course during pregnancy, with increased morbidity and mortality. Maternal and fetal outcomes remain dismal. Treatment with SXT, compared to other therapies, may result in an improved outcome. Withholding appropriate PCP prophylaxis may adversely affect maternal and fetal outcomes.

We describe a case of late PVE in a 78-year-old man that was caused by Stapylococcus hemolyticus and occurred 5 years after aortic valve replacement. This is the first reported case of PVE due to this organism.

We performed a randomized prospective study of 5-day treatment with topical mupirocin or bacitracin for the elimination of Staphylococcus aureus nasal colonization in healthcare workers (HCWs). Nasal cultures were obtained from 141 HCWs, 37 (26%) of whom showed S. aureus. After 72 to 96 hours of treatment, the organism was eradicated in 15 (94%) of 16 by mupirocin and in 8 (44%) of 18 by bacitracin (P = .0031). Similar efficacy was demonstrated at 30 days. Mupirocin may be more effective than bacitracin for eradication of S. aureus in healthy HCWs.

The joining of polysaccharide antigens to various proteins can result in increased immunogenicity of vaccines composed of such antigens. This article discusses conjugated polysaccharide vaccines for Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitis. Increased availability and use of such vaccines may result in the ability to give more effective vaccines earlier in life, further reducing the incidence of diseases caused by these organisms.

Necrotizing soft-tissue infections may be rapidly fatal because of toxin-induced circulatory collapse. Because of the often nonspecific clinical presentation, prompt diagnosis may be difficult but is imperative as prompt treatment can be lifesaving. This article discusses necrotizing fasciitis and clostridial myonecrosis, and highlights pathogenesis, clinical presentation, diagnosis, and treatment.

The in vitro activities of bacitracin and mupirocin were compared for seven different strains of methicillin-resistant Staphylococcus aureus. Six of seven strains showed bacitracin minimum inhibitory concentrations (MICs) of 0.5 to 1.0 units/mL, and all seven had mupirocin MICs of 0.5 to 2 micrograms/mL. Time-kill studies revealed 2.6- to 4.5-log reduction in 24 hours with strains susceptible to bacitracin (4 units/mL) and 0 to 2.2 reduction with mupirocin (16 micrograms/mL). Bacitracin should be considered further for in vivo studies because of enhanced bacteriocidal effect and lower cost.

In a community hospital in Brooklyn, New York, over a 3-year period, 79 methicillin-resistant Staphylococcus aureus (MRSA) isolates from five different case clusters were subtyped by Southern blot hybridization with two previously characterized gene probes, mec and Tn554. Together, the genotyping enabled the hospital infection control team to differentiate simultaneous MRSA clusters in the surgical intensive care unit (type I:A) and the open heart unit (type II:J), document the spread of one strain (type I:A) between roommates, identify an endemic strain (type II:J) from cardiac monitors and medical personnel, and identify an unrelated outbreak strain (type II:NH) in the labor and delivery unit. On the basis of this investigation it is clear that the routine DNA fingerprinting of MRSA in health care facilities, to monitor their spread and identify cases of nosocomial infections, is an important infection control measure.

Neurocysticercosis cases were identified in 1991 in an Orthodox Jewish community. Transmission was linked to tapeworm-infected immigrant housekeepers from countries where Taenia solium is endemic. To evaluate the extent of and risks for locally acquired cysticercosis, a seroprevalence survey was conducted in 9% of the households in this community. Cysticercosis antibodies were detected in 23 (1.3%) of 1,789 persons from 612 families. All 23 seropositive persons were asymptomatic, and no intracerebral lesions were found for the 21 seropositive persons who underwent brain imaging. Seropositivity was associated with female sex (relative risk [RR] = 2.45, P = 0.049), hiring a domestic worker for child care duties (RR = 3.79, P = 0.05), and with employees from Central America (RR = 2.70, P = 0.0001). Exposure to T. solium in this community is unexpectedly high. Widespread employment of domestic workers from endemic regions and high employee turnover contributes to exposure risk.

Objective: To report a case of pancreatitis related to paromomycin administration., Case Summary: A 39-year-old man with AIDS developed pancreatitis concurrent with successful treatment of intestinal cryptosporidiosis with paromomycin. The hyperamylasemia resolved with discontinuation of the agent and recurred when paromomycin treatment was reinstituted., Discussion: To our knowledge, this is the first reported case of pancreatitis believed to be induced by paromomycin. Although pancreatitis in HIV-infected patients has multiple causes, the nature of this case suggests the involvement of paromomycin. The mechanism of action is unclear., Conclusions: Pancreatitis should be considered in the differential diagnosis of abdominal pain in patients who are treated with paromomycin.

Mucormycosis is an unusual complication of cardiothoracic surgery. The fungi may infect the sternotomy wound causing a progressive gangrene or seed the implanted prosthetic valve or graft resulting in endocarditis or graft failure. There have been six previous reports of mucormycosis following cardiothoracic surgical procedures. Four cases involved prosthetic devices, the remaining two are examples of sternal wound mucormycosis acquired from the use of contaminated elasticized bandages. The first case of sternal wound mucormycosis not associated with elasticized bandages is reported here. The infection occurred in a diabetic patient who had undergone coronary artery bypass surgery and mitral valve replacement. The patient received corticosteroids and broad-spectrum antibiotics at the time of and after operation. The patient developed invasive sternal mucormycosis and died on day 10 after surgery, despite aggressive surgical débridement and amphotericin B therapy. No elasticized bandages were used and the source of the infection was not identified. Previous cases of mucormycosis in cardiothoracic surgery are reviewed and the specific clinical setting in which this fungal disease should be suspected defined.

Intrapartum transmission of group A streptococcus has not been well documented. As the incidence of severe infections due to this organism has recently increased, it is important to assess if such transmission occurs. We observed two cases of severe neonatal infections due to group A streptococcus, one of which was fatal, that appeared to have been transmitted from the mother during birth. Perinatal prophylaxis, which has been recommended for infections due to group B streptococcus, should be evaluated for infections due to group A streptococcus.

A case of community-acquired infective endocarditis of a native valve that was caused by Acinetobacter calcoaceticus subspecies anitratus is presented. The previously reported cases are reviewed, and therapy for this disorder is discussed. The presence of a transient maculopapular rash involving the palms and soles but sparing the face is suggested as a possible early clinical clue to the diagnosis. Native valve endocarditis caused by Acinetobacter species is an acute, aggressive illness that is more likely to be fatal than the prosthetic valve form; of the previously described patients, five of 15 with native valve endocarditis and one of six with prosthetic valve endocarditis died. In the appropriate clinical setting, we recommend therapy with an antimicrobial agent known to be active against Acinetobacter organisms when blood cultures are reported to yield oxidase-negative, gram-negative coccobacilli until the final identification of the microorganism is known.

Serious infections due to group A beta-hemolytic streptococcus (GABHS) have been reported with increasing frequency in recent years. We report a case of toxic shock syndrome (TSS) due to GABHS pharyngitis in an otherwise healthy 14-year-old boy. The organism was found to produce toxin A. To our knowledge, this is the second reported case of streptococcal TSS associated with the production of toxin A that is not associated with an invasive disease and the first case associated with a documented rise in the level of antibody to the streptococcal toxin itself. Clinicians must be especially vigilant for this entity in patients who have streptococcal pharyngitis because early recognition and institution of aggressive supportive therapy can be lifesaving.

A case of acute hepatitis induced by zidovudine in a 38-year-old patient with AIDS is presented. The mechanism whereby the hepatitis was induced is not known. However, the patient tolerated well an alternative reverse transcriptase inhibitor, 2'3' dideoxyinosine. Physicians caring for patients with AIDS should be aware of this hitherto rarely reported complication.

Unremitting diarrhea is a common problem in patients with AIDS. We have reported the case of such a patient who was treated with the somatostatin analogue octreotide for chronic diarrhea and who had acute pancreatitis as a consequence of this therapy. We postulate that the possible mechanism for the pathogenesis of this pancreatic damage was octreotide-induced prevention of pancreatic exocrine secretion. We believe this acted as a "physiologic gallstone", inducing an attack of acute pancreatitis.

After drawing blood for culture, medical students and house officers are often taught to change needles before inoculating the culture media. Data to support this practice have been scarce. We obtained simultaneous blood cultures on 75 hospital patients using two techniques: changing needles (C) or not changing needles (NC) before inoculating the cultures. Positive cultures judged to be contaminants were obtained in 4/75 patients in the NC group (5.3%) and in 1/75 patients in the C group (1.3%). This difference was not statistically significant. The practice of changing needles after drawing blood for culture may not be necessary, thus reducing the risk of needlestick injury.