Podcast #277: Mucor

Author: Don Stader, M.D.

Educational Pearls

  • Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face.
  • The fungus invades the vasculature of the face, causing tissue ischemia and necrosis.
  • The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments.
  • This is a surgical emergency since it is cured only with excision of the affected tissue

References: Vijayabala GS, Annigeri RG, Sudarshan R. Mucormycosis in a diabetic ketoacidosis patient. Asian Pacific Journal of Tropical Biomedicine. 2013;3(10):830-833. doi:10.1016/S2221-1691(13)60164-1.

Podcast #272: More on Temperature in Sepsis

Author: David Rosenberg, M.D.

Educational Pearls

  • A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay.
  • However, correcting fever may help for patient comfort.

References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

Podcast #270: Wound Botulism

 

Author: Don Stader, M.D.

Educational Pearls

  • Wound botulism should be considered in patients with cutaneous lesions and neuromuscular weakness.
  • The toxin produced by clostridium botulinium is the causative agent. If forms spores, so it is very resistant to killing by heat.
  • It presents with weakness, most often in the extrocular muscles.
  • Treatment includes wound care and respiratory support. Anti-toxin is rarely used as it is stored at the CDC and must be flown in.

References: Kalka-Moll WM, Aurbach U, Schaumann R, Schwarz R, Seifert H. Wound Botulism in Injection Drug Users. Emerging Infectious Diseases. 2007;13(6):942-943. doi:10.3201/eid1306.061336.

Podcast #269: Tattoo Ink Complications

Author: Michael Hunt, M.D.

Educational Pearls

  • Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C,  and skin infections.
  • Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos.
  • In one study 14% of inks had ingredients that were banned in cosmetics.
  • Nanoparticles of tattoo pigment can be found in the lymph nodes, and laser removal can precipitate their spread.
  • Those with tattoos could experience complications with MRI because of the metal content of the ink.

References: Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. Journal of Cutaneous and Aesthetic Surgery. 2015;8(1):30-36. doi:10.4103/0974-2077.155072.

Podcast #265: The 2017 Flu Vaccine

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

  • CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy.
  • Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy.
  • The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past.
  • Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset.

References: https://www.cdc.gov/flu/professionals/index.htm

Deep Dive #6: Bacteriuria and the Elderly

Author: Heidi Wald, MD, MSPH 

Associate Professor of Medicine – University of Colorado School of Medicine, Physician Advisor – Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI’s in elderly patients and provides tips on how to properly identify them.

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici  Antibiotics for asymptomatic bacteriuria  Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015.

D’Agata ELoeb MB, and Mitchell.  Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Podcast #254: Myths About Antibiotic Course Length

Author: Chris Holmes, M.D.

Educational Pearls

  • There’s little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs.
  • There’s little incentive for drug companies to fund this type of study.
  • Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, but this may not be feasible in an outpatient setting.

References: Llewelyn, Martin J et al. The antibiotic course has had its day. 2017. BMJ

Podcast #244: Fever in Sepsis

Author: Nick Hatch, M.D.

Educational Pearls

  • A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes.
  • Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively.

References: Paul J Young,  Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

Podcast #240: Pott’s Puffy Tumor

Author: Suzanne Chilton, M.D.

Educational Pearls

  • Pott’s puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling.
  • It is much more common in children and adolescents.
  • Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics.

References: Grewal HS, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill! The American Journal of Case Reports. 2012;13:133-136. doi:10.12659/AJCR.883236.