VA MTC 5/17/22: Enterococcal bacteremia

This morning we discussed a patient who was recently admitted to the VA with enterococcal bacteremia. We reviewed the workup and treatment of enterococcal bacteremia. Key points to remember include:

  • Enterococcus faecium is more likely to be resistant to ampicillin, while Enterococcus faecalis is more likely to be resistant to Vancomycin.
    • However, remember that VRE faecalis may still be susceptible to Ampicillin! In fact, Ampicillin is the preferred treatment in the absence of resistance or allergy.
  • In the absence of endocarditis, critical illness or resistance, Enterococcus bacteremia may be treated with monotherapy with Ampicillin (or Penicillin, Vancomycin, Daptomycin, or Linezolid).
  • Combination therapy is indicated in cases of suspected endocarditis or critical illness. Common regimens include:
    • Ampicillin + Ceftriaxone
    • Ampicillin + Gentamicin
    • Vancomycin + Gentamicin

However, this patient expressed that several interventions, including PIV placement and the use of IV antibiotics, were not within his goals of care. He was amenable to PO antibiotics, though. We were lucky to be joined by Dr. Looney, an expert ID physician who consulted on this case, as well as Dr. Pardee, an experienced hospitalist. They gave their valuable insight into how we can individualize care in a respectful and informed way when patients decline our treatment recommendations. Thanks for the interesting discussion!

VA MTC 5/16/22: Stones Galore!

Today’s VA morning report was all about nephrolithiasis! We discussed a case of a young woman with recurrent nephrolithiasis, whose stones were a combination of calcium phosphate and calcium oxalate. Our residents worked together to compile the chart above with the crystal shapes, risk factors, underlying conditions and lab findings associated with the most common types of kidney stones. Dr. Beben, our expert nephrologist, also gave his valuable insight.

When seeing recurrent nephrolithiasis in the clinic, on the wards, or on the boards, it is important to remember:

  • Pay attention to the urine pH! This can be a helpful clue to the type of stone.
  • 24-hour urine collection, collected at least 1 month after an acute episode of nephrolithiasis, UTI, or urologic procedure, can also help to identify underlying problems such as hypercalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria, and cystinuria.
  • Citrate is an important inhibitor of calcium crystallization in the urine. Therefore hypocitraturia can predispose patients to calcium stone formation.
  • Increasing fluid intake to a goal OUP of >2.5 L is an important recommendation regardless of the type of stone!
  • Other useful dietary changes, depending on the type of stone, include:
    • Low dietary sodium (Remember: calcium follows sodium and water!)
    • Low oxalate diet
    • Limit animal protein
  • *Limiting dietary calcium is NOT recommended
  • Some of the most common pharmacologic interventions may include:
    • Potassium citrate or potassium bicarbonate (helps with most types of stones by various mechanisms)
    • Thiazide diuretics (helps with calcium stones by decreasing urinary calcium)
    • Allopurinol (for uric acid stones)

VA MTC 5/10/22: Post-ERCP Complications

Today at the VA, we discussed a patient who was recently seen for choledocholithiasis and underwent ERCP with sphincterotomy, stone extraction, and biliary stent placement. Unfortunately, this patient’s course was complicated by post-ERCP pancreatitis and post-sphincterotomy bleeding. We used this case to discuss a variety of post-ERCP complications, including pancreatitis, bleeding, infection (ascending cholangitis, cholecystitis, infected pancreatic fluid collection, peritonitis, bacteremia), perforation, and complications from the anesthesia.

5/5 VA MTC: The Art of the One Pager

Today during morning report, we participated in a RACE4All session in which teams created their own One Pagers to teach topics related to their current patients. We discussed the intent of a one pager, how to define learning objectives and the target audience for our one pagers, and then spent time planning and creating one pagers! Thank you all for your participation!

VA MTC 5/3/22: Mastitis

This morning at the VA, we walked through a case of a young breastfeeding woman presenting to the outpatient clinic with acute unilateral breast pain, fever, and chills. We discussed the differential diagnosis for acute unilateral breast pain, including mastitis, abscess, clogged duct, and inflammatory breast cancer. We determined that the most likely diagnosis is mastitis, which is a clinical diagnosis. Next, we answered some common questions that patients might ask in the setting of this diagnosis:

  • “How did this happen to me?”
    • Nipple trauma while breastfeeding can allow for bacteria entry. Prolonged engorgement and/or poor drainage of the breast then allows the organism to grow in the stagnant milk, leading to infection.
  • “Did I do something wrong?”
    • No! Unfortunately, mastitis is relatively common, occurring in about 2-10% of breastfeeding women. There are certain breastfeeding problems that can predispose women to mastitis, but it is not your fault! It’s mostly bad luck.
  • “Do I need to stop breastfeeding?”
    • No! In fact, continued emptying of the breast is a key part of treatment! Even if you decide to stop breastfeeding in the near future, it is very important to continue emptying the breast (via nursing, pumping, or hand expression) during the acute infection.
  • “How do we treat this?”
    • Continued emptying of the breast
    • Cold compresses
    • NSAIDs
    • Antibiotics if persistent symptoms beyond 12-24 hours and/or presence of fever:
      • If non-severe and no MRSA risk factors –> Dicloxacillin
      • If non-severe and MRSA risk factors –> TMP-SMX
      • If severe (hemodynamically unstable or worsening despite empiric treatment with PO antibiotics) –> Vancomycin (+ 3rd generation cephalosporin or a beta-lactam-beta-lactamase if found to have GNRs on gram stain)
  • “Is it safe for me to take these medications while breastfeeding?”
    • Yes! (Although avoid TMP-SMX if baby is <1 month old or has G6PD deficiency; caution if baby is premature, jaundiced, or otherwise ill)
    • Some great resources for verifying medication safety with pregnancy and lactation include:
  • “How can I prevent this from happening again?”
    • Unfortunately, a history of mastitis is a risk factor for recurrence.
    • It is important to complete the antibiotic course and to continue to completely drain the breast. Evaluation by a lactation consultant can be helpful to correct problems with breastfeeding technique.
    • If symptoms do not improve, consider an ultrasound to evaluate for abscess. Persistent or recurrent symptoms in the same location should also prompt consideration of inflammatory breast cancer.

Thank you, Dr. Alice Sutton, for joining the conference and providing your valuable insight as an OBGYN!

VA MTC 5.2.22

Today, we used relatively “real-time inbox messages” to guide our teaching topics! We discussed 4 scenarios that were brought up at the Kearny Mesa resident continuity clinic and how to manage these messages when you’re at home. The 4 cases were:

  • Message from patient with worsening chest palpitations after reducing Metoprolol dose for chronic (20+ years) tachycardia syndrome of unclear diagnosis/etiology
  • Return of abnormal lab result with A1c going from 7.1 to 7.9 in a patient currently only on Metformin 1g BID
  • Return of abnormal lab result with Cr from 0.8 to 1.1 in a patient who was just started on Lisinopril for essential HTN
  • Return of mildly elevated lipid panel on routine annual labs

Hillcrest MTC 5/2/2022

This morning we discussed a case in which an older man was found unresponsive at home with his car running in the garage. Another family member at home had headache and confusion. Garry Winkler, toxicology fellow, joined us to discuss the evaluation of suspected carbon monoxide poisoning as well as acute management. Patients often present with vague symptoms, often mistaken for flu. CO poisoning can be diagnosed with cooximetry.

4/27 Grand Rounds: G Protein Coupled Receptors

This morning, Dr. Brian Kobilka from Stanford University joined us to discuss challenges and new approaches to medication discovery. Dr. Kobilka was awarded the Nobel Prize in Chemistry in 2012 for his work on g protein coupled receptors (GPCRs) and is a member of the National Academy of Sciences. He started with an over view on GPCRs, then went on to highlight the challenges in drug design and explained why we have few effective medications that target GPCRs.