Harper University Hospital is one of eight hospitals and institutes that compose the Detroit Medical Center. Harper offers services in a broad range of clinical areas, including cardiology, neurology, neurosurgery, organ transplant, plastic surgery, general surgery, bariatric (weight loss surgery) endocrinology and sleep disorders.
BACKGROUND:Current data suggest that short-course therapy for Pseudomonas aeruginosa ventilator-associated pneumonia (PA-VAP) may increase the risk of recurrent pneumonia. To decrease antibiotic exposure without adversely impacting clinical outcomes, risk stratification based on clinical response may identify optimal candidates for short-course therapy. OBJECTIVE:The purpose of this study was to determine whether early response to therapy correlated with the risk of recurrence in patients with PA-VAP. METHODS:This was a retrospective cohort study of patients with PA-VAP admitted to the Detroit Medical Center from January 2020 to July 2022. Those with improvements in at least 2 out of 3 objective measures of clinical response (PaO2/FiO2, fever, and leukocyte count) at 72 hours after therapy initiation were classified as early responders. The primary outcome was PA-VAP recurrence within 28 days of initial VAP onset. RESULTS:A total of 73 patients were included in the analysis: early response (n = 43) and delayed response (n = 30). Patients with an early response had a significantly decreased risk of 28-day PA-VAP recurrence compared to those with a delayed response (21% vs 43%, P = 0.04). Multivariable logistic regression found that PaO2/FiO2 > 240 mm Hg at 72 hours was associated with a decreased risk of 28-day PA-VAP recurrence (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.07 to 0.90), whereas duration of antibiotics ≤8 days was associated with an increased risk of 28-day PA-VAP recurrence (OR = 4.74, 95% CI = 1.31 to 17.18). CONCLUSION AND RELEVANCE:This study found that early clinical response and improvement in PaO2/FiO2 were associated with a decreased risk of PA-VAP recurrence. Individualized treatment durations based on clinical response may allow clinicians to safely utilize shorter antibiotic courses for PA-VAP.
Background: Hypereosinophilic syndrome (HES) is a rare systemic condition characterized by persistent eosinophilia with potential cardiac involvement, manifesting as Loeffler endocarditis. Cardiac involvement in HES can closely resemble infective endocarditis both clinically and echocardiographically, complicating diagnosis and appropriate management. Case Presentation: A 33-year-old woman with sickle cell disease (HbSS) presented with vaso-occlusive crisis, persistent fever, and a new cardiac murmur suggestive of mitral regurgitation. Initial transthoracic echocardiography revealed a mobile, vegetation-like mass (0.9×1.5 cm) on the posterior mitral leaflet (Figure 1). Blood cultures transiently yielded Escherichia coli, prompting treatment with antibiotics for suspected infective endocarditis. Despite antibiotic treatment, the patient continued to have febrile episodes and labs were notable for significant eosinophilia (>1500/µL), raising suspicion for a non-infectious etiology such as Loeffler endocarditis. Methodology: Transesophageal echocardiography demonstrated an extensive lesion (1.4×1.3 cm) contiguous with the subvalvular myocardium, consistent with mural involvement and fibrotic changes atypical for bacterial endocarditis but highly suggestive of eosinophilic endocarditis (Figures 2-3). Comprehensive hematologic evaluation identified elevated serum IgE, tryptase levels, and confirmed the presence of the FIP1L1-PDGFRA fusion gene, supporting a diagnosis of myeloproliferative HES. Results: The patient's management subsequently shifted to targeted HES therapy with high-dose corticosteroids, alongside supportive treatments with hydroxyurea and exchange transfusions for sickle cell disease. Following this adjustment, the patient showed rapid clinical improvement, and follow-up imaging confirmed regression of the cardiac lesion. Discussion: This case highlights the essential role of multimodal echocardiography for differentiating Loeffler endocarditis—with significant myocardial infiltration and fibrosis—from infective endocarditis, especially in atypical cases involving rare pathogens like Gram-negative bacteria. Clinicians should maintain a high index of suspicion for underlying inflammatory causes when faced with persistent symptoms refractory to antibiotics. Early recognition of Loeffler endocarditis enables prompt targeted anti-inflammatory therapy with steroids--thereby improving patient outcomes and preventing progression to restrictive cardiomyopathy.
