JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
SEVERE SEPSIS AND SEPTIC SHOCK CASES MEETING GUIDELINES AMONG PATIENTS IN A UNIVERSITY HOSPITAL SETTING J.A. Charrier, MS, DO; C.L. Steen, MD; E. Borrero, MD Department of Internal Medicine, University Hospital and Clinics, LSU Health, Lafayette Background: A diagnosis of severe sepsis or septic shock has been shown to significantly increase mortality rate independent of other factors. Research has revealed all cause hospital case fatality rates have declined yet the percentage of severe sepsis cases continues to increase and age-adjustedmortality rates from severe sepsis and septic shock has significantly increased during the same time period. Patients with severe sepsis demonstrate ongoing mortality rate increases for up to 2 years following hospitalizationwhen compared to agedmatched controls of non- septic patients. International guidelines withmortality benefit for the management of severe sepsis and septic shock have been illustrated in the latest surviving sepsis campaign. Objective: The objective of this study was to increase the percentage of patients admitted to the hospital with a diagnosis of severe sepsis or septic shock who met guidelines based on surviving sepsis campaign. Methodology: A retrospective chart review was conducted for patients admitted to UHC from January 2016 to present to identify cases with a diagnosis of severe sepsis or septic shock, and whether they met guidelines set forth by surviving sepsis campaign both before and after an intervention program which included interviews with providers failing to meet protocol, educational sessions on guidelines tomeet protocol, resident led quality improvement workshops to address barriers to meeting protocol, and development of an EMR power plan to assist providers on meeting protocol. Results: 139 cases with a diagnosis, or meeting criteria for, severe sepsis or septic shock were identified during the period of 1/1/2016-9/30/2016 with an average of 43% of total cases which met guidelines. Trend analysis revealed increased compliance following resident lead intervention programwith 31% and 49% before and after intervention, respectively. ICU data is currently being analyzed for meeting guidelines and have not been included in current data. The most common reason for failing guidelines was failure to obtain or repeat lactic acid on time (46%) and failure to give timely antibiotics (22%). Conclusions: The percentage of patients admitted to the hospital with a diagnosis of severe sepsis or septic shock at UHC meeting guidelines set forth by surviving sepsis campaign has improved following resident lead intervention program. Intervention strategies to further improve compliance with guidelines with a goal >60% are currently being analyzed.
DISSEMINATED CRYPTOCOCCAL DISEASE WITH DIFFUSE PULMONARY INFILTRATES IN A NON-HIV HOST
M. Hughes, MD; K. Trivedi, MD; M. Rudrappa, MD
Department of Internal Medicine, LSU Health Sciences Center - Shreveport, LA
Introduction:We present a case of disseminated Cryptococcus in a non-HIV host, where the primarymanifestationwas pulmonary with diffuse pulmonary infiltrates. This patient was on high dose corticosteroids for autoimmune hemolytic anemia. Case: A 79 year old Caucasian man with a history of autoimmune hemolytic anemia on 100mg of prednisone daily, coronary artery disease s/p bypass surgery, ischemic cardiomyopathy, chronic obstructive pulmonary disease, sleep apnea, chronic kidney disease, and history of bilateral pulmonary emboli presented to Hematology/Oncology clinicwith symptoms of productive cough, worsening shortness of breath, hemoptysis. Anticoagulation had been stopped due to symptoms. The patient was referred to the emergency department from clinic where a chest CT demonstrated numerous calcified lymph nodes and diffuses grand glass opacities worse on the right and new compared to imaging from 6 months prior. The patient was placed on empiric antibiotics for treatment of pneumonia after blood and sputum cultures were obtained. Initial blood cultures grewCryptococcus neoformans in both sets. CSF obtained by Lumbar puncture was negative for Cryptococcal. Serum Cryptococcal antigen titer was 1:2560. Infectious disease was consulted and the patient was started on induction therapy with liposomal Amphotericin B, followed by Fluconazole consolidation therapy. Hematology/ Oncology reduced the patient’s prednisone dose gradually but further complications attributed to corticosteroids eventually necessitated the need to transition to Rituximab therapy. Follow up imaging on return to pulmonary clinic demonstrated marked improvement in the bilateral infiltrates. Discussion: This patient was unique in that he demonstrated disseminated Cryptococcus but lacked neurologic complications, which is often how disseminated disease is clinically suspected. Blood cultures resulted positive for Cryptococcus and appropriate antifungal therapy was initiated before other sites were affected. Thepatientwas HIVnegative andnot a post-transplant patient but was on high dose chronic prednisone for his AIHA, and therefore immunosuppressed. Opportunistic and atypical infections should be considered in all immunosuppressed patients to aid in earlier diagnosis and prevention of further dissemination of disease and further complications.
J La State Med Soc VOL 169 MARCH/APRIL 2017 57
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