Lee Memorial Health System

BackgroundMany outpatient infections can be effectively treated with shorter (5-day) rather than longer (7-14 day) antimicrobial courses. While emergency department (ED)-focused antimicrobial stewardship (AMS) efforts are expanding, electronic health record (EHR) optimizations to impact prescribing of antimicrobial durations have not been robustly defined.MethodsThis quality improvement initiative occurred at five EDs within a community health system. An update was made in the EHR to change the default dispense quantity of all oral antimicrobials at ED discharge to a 5-day supply. Adult patients receiving ≥1 oral antimicrobial at ED discharge were included. Pre- (2022) and post-intervention (2023) data were compared. The primary endpoint was the average antimicrobial days supply prescribed. Other endpoints included patient demographic and encounter data, primary diagnoses, antimicrobials prescribed, and 30-day ED readmission.ResultsThere were 33,226 ED encounters (39,253 antimicrobial prescriptions) pre-intervention vs. 37,545 post-intervention (44,824 antimicrobial prescriptions). Mean age was 49 years; 59% of patients were female. Top primary diagnoses were respiratory viruses, urinary tract infections, skin and soft tissue infections, intra-abdominal infections, and dental infections. Cephalosporins (34% vs. 36%) and penicillins (17% vs. 19%) were the most common antimicrobial classes prescribed in the pre- and post- groups, respectively. Average oral antibiotic days supply was reduced by 1 day pre-post intervention (7.9 days vs. 6.9 days; p < 0.001), resulting in an estimated 36,000 days of antibiotics saved over the 1-year timeframe. There were no differences in 30-day ED readmission (17.6% vs. 17.8%, p=0.37).ConclusionThis high impact, low resource EHR update to default dispense quantities for ED-discharge oral antimicrobial prescriptions was associated with a significant reduction in antimicrobial days’ supply with no difference in 30-day ED readmission. Similar interventions could be considered to help support appropriate antibiotic prescribing in community health system ED environments with limited AMS resources.DisclosuresAll Authors: No reported disclosures

Ventricular tachycardia (VT) is a potentially fatal arrhythmia that must be promptly distinguished from supraventricular tachycardia with aberrancy, including wide-complex atrial fibrillation with rapid ventricular response. Diagnostic algorithms such as the Brugada and Vereckei criteria aid clinicians in differentiating these rhythms and guiding urgent management. Chronic myocardial ischemia is a well-recognized substrate for VT due to scar formation and reentrant conduction pathways. We report the case of an 85-year-old woman with a history of coronary artery disease (CAD) and prior stenting who presented with dizziness, palpitations, hypotension, and wide-complex tachycardia. The initial differential diagnosis included VT vs. wide-complex atrial fibrillation. Application of the Brugada and Vereckei criteria supported the diagnosis of VT. The patient underwent successful synchronized cardioversion and was started on intravenous amiodarone, later transitioned to oral therapy. Further evaluation revealed complete thrombotic occlusion of the left circumflex artery consistent with chronic ischemic disease. Echocardiography demonstrated reduced ejection fraction and structural changes indicative of prior infarction. After cardioversion, she remained in sinus rhythm but exhibited QT interval prolongation. Troponin elevation was deemed nondiagnostic in the setting of recent cardioversion. She was discharged on optimal medical therapy for CAD with outpatient follow-up for possible implantable cardioverter-defibrillator evaluation. This case underscores the importance of applying validated criteria to distinguish VT from other wide-complex tachycardias, recognizing chronic ischemia as an arrhythmogenic substrate, and considering pharmacologic nuances of antiarrhythmic therapy. Amiodarone remains a cornerstone in VT management due to its broad efficacy and relative hepatic safety, but requires careful monitoring for QT interval prolongation and avoidance of interacting agents. Prompt rhythm identification, recognition of ischemic mechanisms, and individualized therapy are essential to improving outcomes in elderly patients with structural heart disease presenting with sustained VT.

Stenotrophomonas maltophilia is an opportunistic, multidrug-resistant gram-negative bacterium often affecting patients with significant comorbidities. This case report examines the hospital course of a 75-year-old male with a history of atrial fibrillation and heart failure with preserved ejection fraction (HFpEF), who presented with compromised respiratory status and recurrent infections, highlighting the complexities of clinical management in the setting of multidrug-resistant HFpEF organisms and postoperative complications. The patient was admitted following an episode of ventricular tachycardia and acute respiratory failure, requiring rapid airway management and intensive clinical intervention. His recent hospitalization for sepsis, pneumonia, and osteomyelitis complicated his clinical profile, particularly given his recurrent urinary tract infections (UTIs), which prevented the use of sodium-glucose cotransporter-2 inhibitor therapy for heart failure management. Respiratory cultures confirmed the presence of S. maltophilia, prompting treatment with minocycline and piperacillin-tazobactam. This case highlights the significant risks associated with postoperative arrhythmias in patients with underlying cardiac disease, particularly when superimposed with sepsis. Furthermore, the management of recurrent UTIs posed a barrier to optimizing heart failure therapy, further complicating the patient's clinical stability. The need for vigilant monitoring and tailored therapeutic strategies is essential to improve outcomes in this vulnerable patient population. The interplay between multidrug-resistant infections, arrhythmias, and comorbidities emphasizes the importance of comprehensive clinical management and the need for further research to develop targeted therapies and clinical plans for at-risk populations.

Abstract Background The clinical outcomes of ADHF have been extensively studied; however, the impact of household income still needs to be better understood. This study aimed to elucidate the relationship between household income and outcomes in patients with ADHF. Methods This national retrospective cohort study used data from the 2016-2020 National Inpatient Database, focusing on patients admitted with ADHF. We stratified the cohort into two groups based on the median household income: below $50k and above $86k. The selection criteria included patients aged ≥ 18 years diagnosed with ADHF, excluding those with incomplete income data. The primary outcome was all-cause inpatient mortality, with a length of stay (LOS) and total hospital charges as secondary outcomes. Statistical analysis employed logistic and linear regressions adjusted for confounders, with the significance level set at p&amp;lt;0.05. We accounted for missing data using multiple imputation analyses. Results 1,123,024 patients admitted with ADHF met the inclusion criteria. We divided the groups into two cohorts: low-income (64%, N=718,735) and high-income (36%, N=404,289). No increase in mortality was identified (adjusted aOR: 1.05; p = 0.212). The study revealed that high-income patients had marginally longer average LOS (5.62 days vs. 5.35 days, p &amp;lt; 0.0001) and higher hospital charges ($62,512.46 vs. $49,440.14, p &amp;lt; 0.0001) compared to their low-income counterparts. Low-income patients exhibited a higher prevalence of hypertension and obesity, whereas high-income individuals were more affected by atrial fibrillation and hyperlipidemia (hypertension and obesity, p &amp;lt; 0.0001; atrial fibrillation, p &amp;lt; 0.0001). Conclusion In this national retrospective cohort of patients admitted for ADHF over five years, income did not affect mortality. However, LOS and total charges were affected by the median household income.

Pure primary gastric squamous cell carcinoma (PGSCC) is a notably rare gastric malignancy. We present the case of a 51-year-old woman with advanced gastric squamous cell carcinoma characterized by a 7.6 cm necrotic mass invading the proximal stomach, liver metastasis, and lymphadenopathy at diagnosis. Despite the lack of standardized treatment protocols, we review tumor markers and potential management strategies, including surgical and chemotherapeutic interventions. The rarity and aggressive nature of PGSCC necessitates further research to develop effective detection and treatment methods to improve patient prognosis and survival outcomes.

Micronutrient deficiencies associated with malnutrition in patients with inflammatory bowel disease (IBD) can lead to complications including anemia, coagulopathy, poor wound healing, and colorectal cancer. This study aimed to investigate micronutrient deficiencies (copper, vitamins A, B 9 , E, and K) in IBD patients and highlight associated symptoms to aid in the recognition of micronutrient deficiencies. A retrospective electronic chart review was performed on adults diagnosed with Crohn's disease or ulcerative colitis hospitalized at a tertiary care center for IBD flare between January 2013 and June 2017. Patients with serum or whole blood micronutrient levels were included. Pregnant and incarcerated patients were excluded. A total of 611 IBD patients (440 Crohn's disease, 171 ulcerative colitis) met the inclusion criteria. Micronutrients were assessed in a subset of IBD patients (copper: 12.3%, A: 10.1%, B 9 : 95.9%, E: 10.3%, and K: 4.6%). Overall, 10.1% of patients had micronutrient deficiencies. The proportion of patients with copper, A, B 9 , E, and K deficiencies were 25.4, 53.3, 1.9, 23.7, and 29.4% for Crohn's disease and 50, 52.9, 1.2, 43.8, and 18.2% for ulcerative colitis, respectively. The most common symptoms or historical features associated with micronutrient deficiency were anemia (copper, B 9 ), muscle weakness (copper, E) thrombocytopenia, fatigue (copper, B 9 ), diarrhea (B 9 ), dry skin, hyperkeratosis, pruritus, significant weight loss, elevated C-reactive protein (A), bleeding, and osteoporosis (K). Micronutrient deficiencies are common in IBD patients, yet they are not routinely assessed. Copper, vitamins A, E, and K deficiencies are particularly underrecognized. Associated historical features should raise suspicion and prompt assessment and treatment.