Case Commentary: Imipenem/Cilastatin and Fosfomycin for Refractory Methicillin-Resistant Staphylococcus aureus Infection: a Novel Combination Therapy

ABSTRACTGiven that it is unlikely that randomized clinical trials will yield answers for treating the most challenging bacteremic infections caused by methicillin-resistant Staphylococcus aureus, clinicians, microbiologists, and pharmacists will have to cooperate to discover novel ways to select successful individualized antimicrobial therapy for these patients. An example of such a strategy was demonstrated in the identification and utilization of imipenem/cilastatin plus fosfomycin to treat a particularly recalcitrant MRSA bacteremia and spinal abscess.

COVID-19 Infection Leading to Lethal Spondylodiscitis with Spinal Abscess

Background and Importance: Secondary complications after SARS-CoV-2 virus infection including cardiovascular and neurological pose additional morbidity and mortality. The data on spondylodiscitis with spinal abscess after COVID-19 infection is very limited. Case Presentation: A 71-year-old man presented with tachypnea and cough since 24 hours before admission. He was febrile and his chest CT showed typical picture of bilateral covid-19 pneumonia. Nasopharyngeal swabs showed a positive PCR for COVID-19. The patient was admitted to the intensive care unit (ICU) due to low oxygen saturation. Forty-eight hours after admission, the patient started to develop paraparesis which rapidly progressed to paraplegia within a few hours. In MRI scan, multilevel spondylodiscitis and epidural abscess in the thoracic spine were observed. Urgent surgery was performed and the patient was treated medically with hydroxychloroquine and Favipiravir for COVID-19. Calculated antibiotic treatment with meropenem and vancomycin. No COVID-19 was detected in the abscess samples. The patient passed away later due to multiorgan failure. Conclusion: Spondylodiscitis with spinal abscess secondary to COVID-19 infection is a severe condition and might be a consequence of dysbalanced immune response with immunodepression after COVID-19 infection.

Spinal Epidural Abscess in COVID-19 patients

Objective: To report the peculiarities of spinal epidural abscess in COVID-19 patients, because we observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2.Methods: We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we had to surgically manage during a two-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess.Results: Abscess was primary in all cases meaning that no evident infective source was found. Primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spreading from adjacent infective sites, such as spondylodiscitis and generally occurs in patients with diabetes, obesity, cancer, or other chronic disease. In all cases, there was mild lymphopenia but the spinal abscess occurred regardless the severity of the viral disease, the immunologic state, and the presence of bacteremia. Obesity was the only risk factor and was reported just in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas the classic abscess generally occurs at lumbar level. No patient had history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases.Conclusion: We wonder about the concentration of this uncommon disease in a so short period. To our knowledge, cases of epidural spinal abscess in COVID-19 patients have been not yet reported. Accordingly, we ignore if the SARS-Corona Virus-2 may really predispose to spinal epidural abscesses. However, we hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion of the correspondent spinal epidural space. Anyway, the spinal epidural abscess carries significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but it should be kept in mind because early diagnosis and treatment are crucial.

Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the “Big Three”

BackgroundMissed vascular events, infections, and cancers account for ~75% of serious harms from diagnostic errors. Just 15 diseases from these “Big Three” categories account for nearly half of all serious misdiagnosis-related harms in malpractice claims. As part of a larger project estimating total US burden of serious misdiagnosis-related harms, we performed a focused literature review to measure diagnostic error and harm rates for these 15 conditions.MethodsWe searched PubMed, Google, and cited references. For errors, we selected high-quality, modern, US-based studies, if available, and best available evidence otherwise. For harms, we used literature-based estimates of the generic (disease-agnostic) rate of serious harms (morbidity/mortality) per diagnostic error and applied claims-based severity weights to construct disease-specific rates. Results were validated via expert review and comparison to prior literature that used different methods. We used Monte Carlo analysis to construct probabilistic plausible ranges (PPRs) around estimates.ResultsRates for the 15 diseases were drawn from 28 published studies representing 91,755 patients. Diagnostic error (false negative) rates ranged from 2.2% (myocardial infarction) to 62.1% (spinal abscess), with a median of 13.6% [interquartile range (IQR) 9.2–24.7] and an aggregate mean of 9.7% (PPR 8.2–12.3). Serious misdiagnosis-related harm rates per incident disease case ranged from 1.2% (myocardial infarction) to 35.6% (spinal abscess), with a median of 5.5% (IQR 4.6–13.6) and an aggregate mean of 5.2% (PPR 4.5–6.7). Rates were considered face valid by domain experts and consistent with prior literature reports.ConclusionsDiagnostic improvement initiatives should focus on dangerous conditions with higher diagnostic error and misdiagnosis-related harm rates.