Clostridium difficile-associated disease:Adherence with current guidelines at a tertiary medical center

AIM:To assess adherence with the the Society for Healthcare Epidemiology of America(SHEA)/the Infectious Diseases Society of America(IDSA)guidelines for management of Clostridium difficile(C.difficile)-associated disease(CDAD)at a tertiary medical center.METHODS:All positive C.difficile stool toxin assays in adults between May 2010 and May 2011 at the University of Maryland Medical Center were identified.CDAD episodes were classified as guideline adherent or nonadherent and these two groups were compared to determine demographic and clinical factors predictive of adherence.Logistic regression analysis was performed to assess the effect of multiple predictors on guideline adherence.RESULTS:320 positive C.difficile stool tests were identified in 290 patients.Stratified by disease severity criteria set forth by the SHEA/IDSA guidelines,42.2%of cases were mild-moderate,48.1%severe,and 9.7%severe-complicated.Full adherence with the guidelines was observed in only 43.4%of cases.Adherence was65.9%for mild-moderate CDAD,which was significantly better than in severe cases(25.3%)or severe-complicated cases(35.5%)(P<0.001).There was no difference in demographics,hospitalization,ICU exposure,recurrence or 30-d mortality between adherent and non-adherent groups.A multivariate model revealed significantly decreased adherence for severe or severecomplicated episodes(OR=0.18,95%CI:0.11-0.30)and recurrent episodes(OR=0.46,95%CI:0.23-0.95).CONCLUSION:Overall adherence with the SHEA/IDSA guidelines for management of CDAD at a tertiary medical center was poor;this was most pronounced in severe,severe-complicated and recurrent cases.Educational interventions aimed at improving guideline adherence are warranted.

Cryptococcal Meningitis in Patient with Chronic Myeloid Leukemia

Objective: This study aimed to report the case of a female patient with chronic myeloid leukemia affected by cryptococcal meningitis. Case report: ML, white, 48 years old, female sex, previously diagnosed with chronic myeloid leukemia that has been refractive to the use of imatinib and who has recently begun using nilotinib, was admitted complaining of sudden and disabling migraine in the last 1 month associated with asthenia, adinamia, anorexia, disinterest for daily activities, dizziness, nausea, and vomiting. She evolved with ataxia, and started to stroll with help and showed decrease of muscular strength in her upper limbs. She also presented episodes of decrease of consciousness, with look fixation, no respond to sound stimulation, and short-term hearing loss. The cerebrospinal fluid showed presence of Cryptococcus sp. and, therefore, we began treatment with intravenous liposomal amphotericin B in the dose of 3 mg/kg/day, for 6 weeks. A new cerebrospinal fluid analysis, at the end of treatment, also showed rare structures that are compatible with Cryptococcus sp. As sequelae, she continued with hearing loss in her right ear and enhancement in her right auditory canal, seen in the magnetic resonance imaging. After stabilization and clinical improvement, she was discharged. After 3 weeks, she was hospitalized again with degeneration of the condition, and died due to intracranial hypertension secondary to cryptococcal infection. Final Considerations: This report reinforces the need of reflecting on fungi pathologies, especially in immunosuppressant patients, as well as the importance of early diagnosing and making a fast intervention, with the aims of providing quality of life and comfort to the patient and of minimizing neurological sequelae to the patient.

The Pattern of Neurological Disorders;Revisited Prevalence Data of a Dedicated Neurology Clinic in Sudan

Background: The diverse modes in geographical locations, environmental factors, genetic and racial characteristics play a complex role in determining the pattern of neurological disorders worldwide. Determining the pattern of neurological disorders enables health policymakers to plan evidently for service, training, and research priorities. Few prevalence studies in neurology were conducted in Sudan. Methods: This is a retrospective hospital-based study that reviewed the medical records of patients who attended a Dedicated Neurology Clinic (DNC) in Omdurman, the national Capital of Sudan, for 24 months, from January 2016 to January 2018. This study aimed to determine the DNC pattern of neurological disorders as a representative subset prevalence in Sudan. Neurologists conducted the medical workup for diagnosis after at least two visits. All patients have ethically consented. Results: The total number of patients was 1050. Only 749 patients (71.3%) fulfilled the inclusion criteria. The mean age was 46.5 ± 1.9, and males were 45.3%. 72% were from the Capital. The presenting symptoms were headache (16.6%), seizures (11.5%), limbs weakness (11.2%), and lower percentages for other neurological symptoms. The commonest diagnoses were Stroke 12.4%, Epilepsy 9.3%, Primary Headache 8.8%, Movement Disorders 7.3%, Peripheral Neuropathy 6%, Dementia 4% Neuroinfections 1.4%, Demyelinating Disorders 2.6%, Spinal Spondylotic Radiculopathy 2.6% and 1.7% for Cerebral Venous Thrombosis. Conclusion: The data from Sudan-DNC showed that the most common neurological disorders descendingly were Stroke, Epilepsy, Headache, Movement Disorders, Peripheral Neuropathy, Dementia, Infections, Demyelinating Disorders, Spinal Spondylotic Radiculopathy, and Cerebral Venous Thrombosis. The demyelinating disorders and peripheral neuropathy showed a higher percentage than our previous preliminary prevalence study in 2012 compared to the other conditions, which showed similar rates in that study.