Mark Crislip, MD, Infectious Diseases, 11:44PM Jul 15, 2013
One day of vacation time equals three days of work day. Or so it seems. I was gone for 4 days to talk at TAM in Las Vegas, and I get back and the work that piled up in such a short absence seems so much more than what would have occurred had I been at work. Vacation is like Fairie, it moves at a different rate than the mortal world. I am spending all my reading time in the Dresden Files, so some of you may understand.
Two consults today were cares for things I have railed about in the past.
The first was a chronic cellulitis. Remember, cellulitis, diffuse erythroderma from bacteria, is never, ever, never, ever, never, ever chronic. Never. Ever.
I cured the alleged chronic infection the same way I always do: I held the leg higher than the heart and within seconds the redness was gone. Post infectious swelling and redness.
Listen up: you cannot tell anything about a cellulitis if the leg is not higher than the heart. The rubor, dolor, calor, tumor of cellulitis does not recede with elevation. The patient was happy to stop the antibiotics and go on his way.
The other was less benign. The patient has MRSA bacteremia without an obvious source. Maybe skin, maybe dialysis site. A TTE is negative and she is sent out on two weeks of vancomycin, despite the fact the MIC is 1.0 and the patient has both an aortic valve replacement and a mitral valve repair.
Needless to say, the patient relapsed with MRSA bacteremia and the TEE shows a mitral valve vegetation and the AVR looks clean. It isn't. If the patient has endovascular hardware, prosthetic valve or pacer, you have to evaluate and treat as if the endovascular hardware is infected.
"In this investigation, approximately half of all patients with prosthetic valves who developed S. aureus bacteremia had definite endocarditis. The risk of endocarditis was independent of the type, location, or age of the prosthetic valve. The mortality of prosthetic valve endocarditis is high. All patients with a prosthetic valve who develop S. aureus bacteremia should be aggressively screened and followed for endocarditis."
Two weeks of IV therapy is limited to the totally normal people with MSSA.
And call an ID doc for S. aureus bacteremia. An ID consult is beneficial. It improves morbidity and mortality.
"Only one third of patients with S. aureus bacteremia in this cohort had an infectious diseases specialist consultation. Infectious diseases consultation was independently associated with a reduction in 28-day mortality. Routine infectious diseases consultation should be considered for patients with S. aureus bacteremia, especially those with greater severity of illness or multiple comorbidities."
Don't wing it unless your name is Dunning-Kruger.
Look what happens when I go away for even a short time:
"Things fall apart; the centre cannot hold;
Mere bacteremia is loosed upon the world,
The blood-dimmed tide is loosed, and everywhere
The correct diagnosis and treatment is drowned;
The best lack all knowledge, while the worst
Have prescription privileges."
Am J Med. 2010 Jul;123(7):631-7. doi: 10.1016/j.amjmed.2010.01.015. Epub 2010 May 20. The value of infectious diseases consultation in Staphylococcus aureus bacteremia. http://www.ncbi.nlm.nih.gov/pubmed/20493464. One of many.
Am J Med.]2005 Mar;118(3):225-9. Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia. http://www.ncbi.nlm.nih.gov/pubmed/15745719