Annals for Educators - 17 September 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives17 September 2019Annals for Educators - 17 September 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201909170 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsCandida auris: An Emerging Antimicrobial Resistance ThreatCandida auris is an emerging, multidrug-resistant yeast that is now known to have caused invasive infections in more than 30 countries spanning every inhabited continent. It is an urgent antimicrobial resistance threat because many strains are resistant to at least 2 of 3 major classes of antifungal drugs and because it causes outbreaks in health care settings to an extent not seen with other Candida species.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether they have heard of Candida auris. What kinds of infections have been reported to be caused by this fungus?In what key ways does Candida auris differ from other, more commonly known Candida species?What antimicrobial agents are commonly effective for Candida infections? What about for Candida auris?How do most invasive Candida infections occur? What is different about Candida auris? What is known about its transmission in the health care setting?What implications does this have for prevention efforts? Invite your hospital epidemiologist to discuss your center's preventive efforts. What are the challenges?Menopausal Estrogen-Alone Therapy and Health Outcomes in Women With and Without Bilateral Oophorectomy. A Randomized TrialThe Women's Health Initiative (WHI) included a large-scale, randomized trial of estrogen-alone therapy in women aged 50 to 79 years with prior hysterectomy. It is still uncertain whether the risks and benefits of this therapy differ between women with prior surgical removal of their ovaries and those with conserved ovaries, and whether results differ by age group. This study analyzes data from the WHI to address these questions.Use this study to:Ask your learners what they know about the risks and benefits of hormone replacement therapy.What did the WHI study show? What does the U.S. Preventive Services Task Force recommend regarding both combined estrogen–progestin and unopposed estrogen use to prevent chronic conditions?Why did the investigators of this study evaluate women according to whether they had undergone bilateral oophorectomy? What did they find?Do your learners think women who have undergone hysterectomy should be treated with estrogen?Diabetes Technology: Review of the 2019 American Diabetes Association Standards of Medical Care in DiabetesThis synopsis of the 2019 American Diabetes Association Standards of Medical Care in Diabetes focuses on technology that may help manage blood glucose levels in adults with diabetes. Recommendations address techniques for self-monitoring of blood glucose, continuous glucose monitors, and automated insulin delivery systems.Use this paper to:Ask your learners what regimen of blood glucose monitoring they prescribe to their patients with diabetes. What are the options, and what are their advantages and disadvantages?In whom should continuous glucose monitoring be considered? What about automated insulin delivery systems? Invite an expert in diabetes management to join your discussion.What factors limit the accuracy of glucose monitors?How do your learners arrange for patient education?High-Dose Spironolactone When Patients With Acute Decompensated Heart Failure Are Resistant to Loop Diuretics: A Pilot StudyThis small, nonrandomized, uncontrolled trial evaluated the effect of high-dose spironolactone in hospitalized patients with heart failure not responding to furosemide.Use this study to:Review the mechanisms of loop diuretics and aldosterone antagonists.Have your learners heard of “diuretic resistance”?Listen to the Annals On Call podcast, “Diuretic Resistance.”What do your learners do when patients with fluid overload do not respond to furosemide?Do your learners think the results of this study are sufficiently definitive to influence patient care? Why or why not? What are the study's limitations? How are preliminary studies such as these useful, and what more needs to be done to guide care?Humanism and ProfessionalismOn Being a Doctor: Reciprocal TearsDr. Fitzgerald recalls propelling the impolite house officer away and rushing into the crying patient's room.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether health care providers scorn patients who struggle with obesity.Do we ever make inappropriate remarks among ourselves when we think no one is listening? Does it matter?Do we perform equally thorough examinations of patients who are obese and those who are not? Does it make a difference? Do we think patients notice the difference? How does it make them feel?Do your learners think their obese patients feel judged by them? How can we address this?Are we too quick to ascribe a patient's symptoms to their weight? Are we as empathic of patients' struggles with their weight as we are of their struggles with other health challenges?On Being a Doctor: Of What RemainsDr. Pyzer wonders, “Is it better or worse to know that something remains of our past once dementia robs us of our present?”Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they “give up” on talking to patients with dementia. Why?Why do patients' families continue to whisper into the ears of their comatose loved ones? Do we ever do this as clinicians? Why or why not? Do we feel silly doing so?Ask your learners if they have ever witnessed a sudden expression of clairvoyance from a patient previously assumed to have lost all ability for organized or coherent thought.At such a moment, Dr. Pyzer remarks, “We rejoiced, failing to appreciate how this revelation was a contradiction to our previous consolation; its implications for his continuing suffering; and how it ultimately highlighted the ever-present struggle to reconcile what we want for our patients, and for those left behind.” What does she mean? How does believing the “person” is no longer present console us as doctors? As family members? Might knowing there is still a “person inside” also make our jobs easier or more rewarding?MKSAP 18 QuestionA 47-year-old woman is evaluated in the hospital for pyelonephritis not responding to antibiotic therapy. Five days ago she was evaluated in an urgent care center for abdominal and back pain, nausea, fever, and dysuria. She was started on oral ciprofloxacin for a urinary tract infection (UTI). Symptoms did not respond to this treatment, and two days ago, she was hospitalized. Acute pyelonephritis was diagnosed, and she was treated with intravenous fluids, vancomycin, and cefepime. Since hospitalization, her clinical condition has deteriorated, with continued fever and worsening flank pain. She also has stage 2 chronic kidney disease, recurrent UTIs, and a 6-year history of poorly controlled type 2 diabetes mellitus. Medications are amoxicillin, metformin, and insulin glargine.On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 130/60 mm Hg, pulse rate is 106/min, and respiration rate is 22/min. Abdominal examination reveals diminished bowel sounds, bilateral costovertebral angle tenderness, and suprapubic pain. Other examination findings are unremarkable.Laboratory studies:Hemoglobin11 g/dL (110 g/L)Leukocyte count21,000/µL (21 × 109/L) with 91% neutrophils and 9% lymphocytesPlatelet count167,000/µL (167 × 109/L)Creatinine1.8 mg/mL (159 µmol/L)Urinalysis10 erythrocytes/hpf, leukocytes too numerous to count, many yeast forms, trace protein, and 4+ glucoseUrine culture results show 10,000 colony-forming units of Candida glabrata. Blood culture results are negative.A CT scan of the abdomen with contrast shows bilateral perinephric stranding, no masses, and no renal abscesses.Which of the following is the most likely diagnosis?A. Acute diverticulitisB. Antibiotic-resistant bacterial pyelonephritisC. Candida pyelonephritisD. Renal infarctionCorrect AnswerC. Candida pyelonephritisEducational ObjectiveDiagnose invasive candidiasis.CritiqueThis patient has Candida pyelonephritis, a form of invasive candidiasis. She has several risk factors for candidiasis, such as recently taking broad-spectrum antibiotics, uncontrolled diabetes mellitus, and a history of recurrent urinary tract infections. These risk factors, in combination with the findings of yeast, leukocytes, and erythrocytes in the urine, is classic for this infection. Although the urine culture only grew 10,000 colony-forming units of Candida glabrata, the colony count may not correlate with active infection in Candida infections of the urinary tract. Thus, antifungal therapy with an echinocandin should be initiated immediately. After identification of the species, the antifungal agent may be de-escalated to an oral azole if the Candida species is susceptible to azoles. The total duration should be 10 to 14 days of antifungal therapy.Acute diverticulitis may present with the same manifestations this patient had. However, the bilateral flank pain and the lack of abdominal pain make diverticulitis less likely. In addition, the urinalysis results showing leukocytes too numerous to count and the classic CT scan finding of perinephric stranding point to a kidney infection.Antibiotic-resistant bacterial pyelonephritis is a possibility and could explain her progressive symptoms despite appropriate antibiotic therapy for pyelonephritis. However, this diagnosis is excluded by the patient's urine culture, which showed only Candida species.Patients with acute kidney infarction typically present with acute flank pain or generalized abdominal pain, often associated with nausea and vomiting and, less commonly, with fever; hematuria is present in one third of patients. Over half of kidney infarctions are cardioembolic, and atrial fibrillation is commonly found in patients with this diagnosis. A contrast-enhanced CT scan will show a wedge-shaped perfusion defect. This patient's normal abdominal contrast-enhanced CT scan and urinalysis argue against kidney infarction.Key PointIn patients with invasive candidiasis, antifungal therapy with an echinocandin should be initiated immediately, followed by de-escalation to an oral azole if the identified Candida species is susceptible; the total duration of antifungal therapy should be 10 to 14 days.BibliographyPappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Executive summary: clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62:409-17. doi:10.1093/cid/civ1194Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 September 2019Volume 171, Issue 6Page: ED6KeywordsAbdominal painAntifungalsCandidaCandidiasisGlucoseInfarctionKidneysPyelonephritisUrinary tract infectionsUrine ePublished: 17 September 2019 Issue Published: 17 September 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...