How would you answer these 7 most popular clinical questions of 2022 on Pearls4Peers??

Peers,

www.Pearls4Peers.com just turned 7 with 2022 poised to become its best year ever in viewership  (>30,000 views so far)!  To mark this “momentous” occasion, I thought I would share with you, loyal viewers and subscribers, the 7 most viewed posts  of 2022 at its midway point.  Imagine rounding on the wards with your team and someone asks you one or more of these questions.  Take a crack at answering them and compare your answers with those of P4P (Ctrl+Click)! Have fun!

  1. What is the significance of teardrop cells(dacrocytes) on the peripheral smear of my patient with newly-discovered pancytopenia?
  2.  My elderly patient developed a flare-up of her gout few days after receiving covid-19 vaccine. Is there a connection between immunization and gout flare? 
  3. What is the clinical relevance of the “SPICE” organisms? 
  4. What does an “indeterminate” result in QuantiFERON Gold in-Tube Test for latent tuberculosis really mean? 
  5. What is the difference between “moderate” and “high complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule? 
  6. The urine culture of my female patient with urgency is growing Lactobacillus. Should I treat it?
  7. Why is serum AST levels generally higher than ALT in alcohol-induced liver injury?

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Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How would you answer these 7 most popular clinical questions of 2022 on Pearls4Peers??

What is the clinical relevance of “SPICE” organisms?

“SPICE” often stands for the following bacterial species: Serratia spp, Providencia spp, indole-positive Proteae (e.g. Proteus spp. [not mirabilis], Morganella spp., Providencia spp.), Citrobacter spp., and Enterobacter spp.  Some have also included Pseudomonas spp (“P”).

These organisms (as well as Acinetobacter spp., at times “A” in SP”A”CE organisms) often have inducible chromosomal AmpC ß-lactamase genes that may be derepressed during therapy, conferring in vivo ß-lactam resistance despite apparent sensitivity in vitro (1,2). Because AmpC genes in clinical isolates are not routinely screened for in the laboratory, the following treatment approach to these organisms is often adopted (1).

Third generation cephalosporins (e.g. ceftriaxone and ceftazidime) are usually avoided irrespective of in vitro susceptibility. For less serious infections (e.g. urinary tract infections) or severe infections in carefully monitored clinically stable patients, piperacillin-tazobactam and cefepime in particular may be used due to their lower risk of induced resistance. For severe infections (e.g. pneumonia and bacteremia) in seriously ill patients, carbapenems (e.g. meropenem, imipenem-cilastatin) are often the drugs of choice. 

A small retrospective study of patients with infection due to SPICE organisms (about 50% with bacteremia) found cefepime to be as effective as meropenem, but cautioned its use when adequate source control has not been achieved (3). Fluroroquinolones and aminoglycosides may also be considered.

References

  1. MacDougall C. Beyond susceptible and resistant, part I: treatment of infections due to Gram-negative organisms with inducible ß-lactamases. J Pediatr Pharmacol Ther 2011;16:23-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136230/
  2. Jacoby GA. AmpC ß-lactamases. Clin Microbiol Rev 2009;22:161-182. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2620637/
  3. Tamma PD, Girdwood SCT, Gopaul R, et al. The use of cefepime for treating AmpC ß-lactamase-producing Enterobacteriaceae. Clin Infect Dis 2013;57:781-8. https://academic.oup.com/cid/article/57/6/781/330020

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Contributed in part by Avi Geller, Medical Student, Harvard Medical School, Boston, MA

 

What is the clinical relevance of “SPICE” organisms?