Clindamycin Plus Vancomycin Versus Linezolid for Treatment of Necrotizing Soft Tissue Infection

Background

Necrotizing soft tissue infections (NSTIs) are life-threatening infections. The aim of this study is to evaluate the safety of clindamycin plus vancomycin versus linezolid as empiric treatment of NSTIs.

Methods

This was a retrospective, single-center, quasi-experimental study of patients admitted from 1 June 2018 to 30 June 2019 (preintervention) and 1 May 2020 to 15 October 2021 (postintervention). Patients who received surgical management within 24 hours of NSTI diagnosis and at least 1 dose of linezolid or clindamycin were included. The primary endpoint was death at 30 days. The secondary outcomes included rates of acute kidney injury (AKI) and Clostridioides difficile infection (CDI).

Results

A total of 274 patients were identified by admission diagnosis code for NSTI or Fournier gangrene; 164 patients met the inclusion criteria. Sixty-two matched pairs were evaluated. There was no difference in rates of 30-day mortality (8.06% vs 6.45%; hazard ratio [HR], 1.67 [95% confidence interval {CI}, .32-10.73]; P = .65). There was no difference in CDI (6.45% vs 1.61%; HR, Infinite [Inf], [95% CI, .66-Inf]; P = .07) but more AKI in the preintervention group (9.68% vs 1.61%; HR, 6 [95% CI, .73-276]; P = .05).

Conclusions

In this small, retrospective, single-center, quasi-experimental study, there was no difference in 30-day mortality in patients receiving treatment with clindamycin plus vancomycin versus linezolid in combination with standard gram-negative and anaerobic therapy and surgical debridement for the treatment of NSTIs. A composite outcome of death, AKI, or CDI within 30 days was more common in the clindamycin plus vancomycin group.

Jejuno-jejunal intussusception in a post-lung transplant patient from a gastrojejunostomy tube: A case report

INTRODUCTION

Gastro-jejunostomy tube is used for post-pyloric feeding for critical-ill patient who cannot tolerate oral alimentation. Jejuno-jejunal intussusception is a rare complication of gastrojejunostomy tube.

PRESENTATION OF CASE

A 39-year-old male with history of severe combined immunodeficiency, Achalasia and end-stage lung disease underwent double lung transplantation. After lung transplantation, he required gastrojejunostomy(GJ) tube placement due to his esophageal disease. Four days after gastrojejunostomy tube placement, he developed jejuno-jejunal intussusception. A 15 cm segment of thickened and enlarged bowel, which consisted of the intussusception were identified laparoscopically. Surgical reduction was performed without bowel resection.

DISCUSSION

Intussusception is uncommon in adults compared to pediatric population. In this rare case, the jejunal limb of the GJ tube placed in jejunum was the cause of jejunojejunal intussusception serving as the lead point. The GJ tube should not be placed farther down from ligaments of Treiz to prevent jejuno-jejunal intussusception.

CONCLUSIONS

A heightened index of suspicion for this rare complication should exist with a presenting patient has signs of proximal bowel obstruction and CT evidence of intussusception.

Vascular Shunts in Civilian Trauma

Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management.

Minimally invasive management of lesser sac bronchogenic cyst

This is a rare case of a bronchogenic cyst found below the diaphragm within the lesser sac successfully resected by laparoscopic means.

Bronchogenic cysts rarely develop in the abdomen they typically reside in the mediastinum. We present a unique case of a bronchogenic cyst within the lesser sac. Endoscopic ultrasound proved to be a critical diagnostic tool, and the patient underwent a laparoscopic resection of the lesion.

Effects of trimetazidine on lipid peroxidation and phosphorus metabolites during cold storage and reperfusion of isolated perfused rat kidneys

This study was undertaken to evaluate the effect of trimetazidine (TMZ) during cold storage (CS) and the consequence during normothermic reperfusion in an isolated perfused rat kidney model (IPK). IPK was used to assess the rate of perfusion flow, the ratio of ATP to inorganic phosphate (ATP/Pi) as a reflection of the energetic status during reperfusion, intracellular pH (pHi), tissue water content and malondialdehyde (MDA) tissue levels in four different preservation solutions after 48-hr preservation at 4 degreesC and 2-hr reperfusion at 37.5 degreesC: EuroCollins (EC), University of Wisconsin (UW), EC plus TMZ (10(-)6 M) (EC + TMZ) and UW plus TMZ (10(-)6 M) (UW + TMZ). When TMZ was added to the preservation solutions, perfusion flow rate (PFR) was significantly improved during reperfusion. Tissue water content, which reflected tissue edema, was significantly lower in TMZ groups than in groups without TMZ during both CS and reperfusion conditions. In TMZ groups, ATP/Pi ratio was also significantly improved during CS and reperfusion. In addition, TMZ lowered the pHi both during preservation and after reperfusion. MDA renal tissue level significantly decreased with TMZ both during the preservation period and after reperfusion. These overall results strongly suggested that TMZ contributes to renal protection from cold ischemia-reperfusion injury in this IPK model, especially when TMZ was added to UW solution and during prolonged hypothermic ischemia.

Proton nuclear magnetic resonance spectroscopy reveals cellular lipids involved in resistance to adriamycin and taxol by the K562 leukemia cell line

Proton nuclear magnetic resonance spectroscopy was performed on whole cells to study lipids and metabolites in Adriamycin- and Taxol-resistant K562 cells expressing multidrug resistance (MDR) and their sensitive counterparts. With one-dimensional spectra, both resistant cell lines showed lower fatty acid methylene:methyl ratios and higher choline:methyl ratios than sensitive cells. Using two-dimensional COSY spectra, a decrease in the glutamine content was evidenced in resistant cells. When these cells were maintained in culture medium without the drug, the fatty acid signals were partially recovered. Adriamycin-resistant K562 cells were also treated for 4 days with a high dose of verapamil, a MDR-reversing agent. The nuclear magnetic resonance spectra of verapamil-treated cells also showed partial recovery of fatty acid signals. These results could be paralleled with the reversion of the resistant phenotype, as evidenced by measuring the inhibiting concentration of Adriamycin and vinblastine in K562adr cells cultured without the drug or after short-term exposure to verapamil. Conversely, P-glycoprotein and mRNA expression and DNA amplification of the mdr gene were not modified when compared to resistant cells, suggesting that the MDR phenotype could be partially reversed independently of the mdr gene amplification and expression. These results demonstrate the role of lipids in the resistance phenomenon.

pH regulation during ischaemia-reperfusion of isolated rat hearts, and metabolic effects of 2,3-butanedione monoxime

We investigated changes in pHi during ischaemia-reperfusion of isolated rat hearts using phosphorus nuclear magnetic resonance spectroscopy (31P NMR). Hearts were separated into three groups according to the perfusion buffer: bicarbonate-buffered Krebs solution, HEPES-buffered Krebs solution, or bicarbonate-buffered Krebs solution plus 10(-6) M 5-(N-ethyl-N-isopropyl) amiloride (EIPA). In HEPES buffer and in bicarbonate buffer plus EIPA, pH at the end of 30 min of ischaemia and pH oscillations observed during early reperfusion were lower than in bicarbonate buffer. Thus, the presence of two pH regulation mechanisms (Na(+)-H+ antiport and Na(+)-HCO3- symport) was confirmed in the isolated rat heart, while in HEPES buffer, pH was regulated by Na(+)-H+ antiport, and in bicarbonate buffer plus EIPA, by Na(+)-HCO3- symport. When cardiac contraction was inhibited by 10 mM 2, 3-butanedione 2-monoxime (BDM), we observed, in all cases, a less pronounced decrease in pHi at the end of ischaemia, and in pHi oscillations at the onset of reperfusion. These effects were similar to those observed with 150 x 10(-8) M verapamil and might thus be related to a decrease in intracellular calcium. However, with BDM, a greater reduction in the pH recovery rate was observed only in HEPES buffer, suggesting a possible phosphatase-like effect affecting the Na(+)-H+ exchange. Whatever the buffer used, the protective effect of BDM was reflected by an increase in the rate pressure product, which was not observed with verapamil.