Friday, December 31, 2010

UNC Orthopedics denied me medical care based on Duke Orthopedics' lies

After the Saturday September 18, 2010 discharge, where no Duke physician would even look at my open wound ...


and even after the Tuesday September 21, 2010, office visit in my Duke orthopedic surgeon Dr. Michael Bolognesi's clinic, where PA Diane Covington effectively shrugged her shoulders at my open wound


What next?


I knew I had an ally at Duke in my cardiologist, Dr. Michael Blazing and he set up a second opinion for me at UNC Orthopedics with Laurence Dahners, MD. 


From my perspective (and by the stated purpose of even UNC Orthopedics "Final Report"), the second opinion was because I had an open wound and absolutely no physician at Duke would acknowledge (much less treat) my open wound.


Oh, was I in for a "special treat" at UNC Orthopedics.


You see, the good Dr. Bolognesi faxed a copy of the "Elopement Report" to UNC Orthopedics' Dr. Laurence Dahners. Funny. I don't recall signing a medical authorization release. But it would not really matter - if Dr. Bolognesi is determined to sabotage my ability to receive medical care, he can frame the lies/distortions as "necessary for continuing care" or Dr. Bolognesi could just engage in good ole "gossip" between boys. HIPAA is a joke.


I did manage to get a copy of the Report from UNC. It's fun to read because the boy doctor (David McNabb, MD) was charged with the responsibility of "reconciling the discrepancies between Duke's version of events and the patient's version of events." Specifically, boy doctor (David McNabb, MD) charted that he told me (as I was scared, in pain and in tears with a gaping wound) "I was just trying to resolve the discrepancies between her reported history and documented history from Duke University Medical records that had been faxed to us prior to her visit."


And despite the ridiculous UNC Orthopedic Report by the boy doctor (David McNabb, MD), he does in fact chart the actual discrepancy -- and in my favor -- check out the "assessment" - "left tibial open wound."


Ahh, finally a physician (perhaps not board certified but a physician none the less) acknowledges my open wound. The boy doctor was still focused on the "elopement report" that never mentioned the wound.

FINAL REPORT
UNIVERSITY OF NORTH CAROLINA HOSPITALS
Chapel Hill, NC 27599
Patient Name HANDY, CHERYL
Medical Record Number 173-xx-xx
Date of Service 09/23/2010
Teaching Physician Laurence Dahners, MD
Dictated by David C McNabb M.D.
REFERRING PHYSICIAN: Michael Blazing, M.D.
Duke Cardiology
REASON FOR VISIT: Ms. Handy is a female, who comes to clinic today for evaluation of her left tibial wound.
HISTORY OF PRESENT ILLNESS: Ms. Handy ie a female, who underwent left high tibial osteotomy at Duke University Medical Center in 12/2004 for varus alignment of her leg. The patient reports that she attempted rehabilitation starting in O8/2005 and developed symptomatic hardware. The patient reports that she had her hardware out in 07/2005 at Rush Medical Center in Chicago and returned to North Carolina. The patient reports that she was going to go back to Rush Medical Center due to feelings of pain and warmth in her left tibia where the prior hardware removal had taken place.
The patient was scheduled an MRI through her cardiologist at Duke University on O9/10/2O10 and the results of the MRI prompted her cardiologist to send her to the emergency room under consultation with her Orthopaedist at Rush, however, it seems from a clinic note at Duke University that the patient left the emergency room ama due to a long wait. The patient then returned to clinic and Dr. Blazing told the patient to present to the emergency room and Dr. Blazing spoke with the orthopaedic department and that she would be seen by them soon in the Emergency Department this did occur and the patient was taken to the operating room on 09/13/2010 for a washout of her left proximal tibial osteomyelitis.
The patient remained in-house postoperatively for a therapy and follow up for her cultures. Cultures showed according to the patient that she had coac-negative staph. From discharge paperwork at Duke the patient "had been set up for home IV antibiotic therapy with nafcillin.

Again according to medical documentation the patient was dubious of the IV antibiotic therapy and cancelled the home infusion therapy. On the cay of discharge, the patient could not be found in her room and had left AMA with elopement. The treating team had planned to have her PICC line removed as she had refused home IV antibiotic therapy; however, this did not occur and the patient was not given any discharge instructions as she left without anyone knowing. The patient was referred to our clinic by Dr. Blazing for a second opinion. In discussion with the patient today was told that if she did have a coag-negative Staph that the treatment and treatment plan she had had thus far seemed appropraiate.

Then the patient was asked if she would like any further explanation of this and the patient became disgruntled, picked up her clothing and belongings and left the room only to return a few seconds later- To explain that she was a patient and "just wanted to be treated." Upon further questioning, I mentioned that the patient that I was trying to resolve two conflicting sets of information one that she was telling me that her caregivers at Duke did not want to treat her properly or explain her-therapy - and the — information -ie

On the way, I told the patient that I was sorry for her feelings that she was not being cared for properly and I was just trying to resolve the discrepancies between her reported history and documented history from Duke University Medical records that had been faxed to us prior to her visit. The patient left the clinic against medical advice and without belng thoroughly evaluated or seen by the attending physician Dr. Dahners.

ASSESSMENT: Left open tibial wound.
PLAN: The patient left AMA; therefore, examination was not able to be undertaker, and a plan of care was not able to be developed for the patient.
DAVID C MCNABB M.D. dd 09/23/201010:48 dt: 09/23/10 23:41
eScription document:1-10446902
Electronically signed on 09/26/2010 by DAVID MCKABB
Pt. left in the middle of being seen by the resident Dr. McNabb so I never saw the patient.

Electronically signed on 09/26/2010 by LAURENCE DAHNERS

I hope that medical school graduates are better at charting than boy doctor David McNabb, MD. Lets have some fun on New Years Eve and count Dr. David McNabb's errors.



  • There is no evidence (because it is untrue) that I left the Duke ED AMA because of a long wait, returned to Dr. Blazing's Clinic and then returned to the ED. That would be silly. I arrived at the ED via ambulance at 5:00 pm on a Friday.  How would I get to my cardiologist's office (not walking distance) and then return back to the ED?




  • The "reason for the visit" says to evaluate the wound.  But Dr. McNabb charts "[t]he patient was referred to our clinic by Dr. Blazing for a second opinion. In discussion with the patient today was told that if she did have a coag-negative Staph that the treatment and treatment plan she had had thus far seemed appropriate."




  • By his own charting, the reason for my visit was to evaluate the wound, not discuss the antibiotic plan. My concern was "why did the surgical wound for a bone infection open"?"Is there still an infection in there" I specifically asked Duke Infectious Disease Expert (and my assigned physician) Dr. Robert Wolfe and he said "I do not know."




  • Contrary to Dr. McNabb's charting, I did not "pick up my clothing" because my clothing was not off. That would have been weird since I had shorts on and the wound is on my upper tibia. I did pick up the bandages that were on the floor. Dr. McNabb did not even attempt to help me.




  • I am not sure how Dr. McNabb made the assessment despite the fact the wound is obvious. Dr. McNabb went out of his way to avoid looking at the oozing wound.




  • As I left the exam room in tears, I passed directly by Dr. Laurence Dahners.  I could have reached out and touched him (or vice versa). In fact, there was a group of orthopedic surgeons in a common area that I passed as I limped in tears. My wound was completely open to the elements. UNC Hospitals did not care about my well-being.



Again, no medical care professional cared that I hurt or was scared or crying.


UNC Orthopedics got their $45 co-pay. Dr. David McNabb flat out told me that he could not treat me until he "resolved the discrepancies between what Duke said happened and what I said happened."


Why?


Doesn't the tie go to the side with the open surgical wound?

Thursday, December 30, 2010

Patient Discharge Email versus "Elopement Report"

Why would Duke University Hospital (and specifically Duke Orthopedics) lie?  


I just cannot wrap my hands around it.  I trusted Duke with my dad's life.  With a push from two physicians that I respected (one an amazing orthopedic surgeon from Chicago and the other a Duke cardiologist I barely knew named Dr. Michael Blazing), I trusted Duke with my life in September 2010.
  • Bone infection surgery failed.  
  • Duke Orthopedics refused to acknowledge that the wound was still open at discharge.
  • Duke Orthopedics writes an "elopement report" that reads like a fiction story.  
  • Duke Orthopedics sends the "elopement report" w/o authorization to doctors that I hope will help me.
  • Now I still have osteomyelitis, dead tibia and no doctor to help me.

But how can the reader be certain that I am honest when I state that Duke Orthopaedics' "elopement report" is a fraud.  Here is a true and correct copy of the email communication that I had with Duke Risk Management as I left the Hospital. 


Remember


(1) Duke Orthopedic Surgeon Dr. Mark Easley told me that I should not start PICC line antibiotics post osteomyelitis surgery if the surgical wound reopens because it means that there is still an unidentified infection in the bone.  The PICC line antibiotic will complicate the Infectious Disease Specialists' ability to diagnose the bone infection.  


(2) My surgical wound was open.  I told the resident at discharge that the wound was open.  The resident refused to look at the wound.  The Duke orthopedic resident said to me "there is nothing more we [Duke Hospital] can do for you here."  From my perspective as a patient, that meant that I could go home.


(3) I asked the Duke Orthopedic resident if I could please speak to someone about the open wound.  The Duke Orthopedic Resident said "No, but you can talk to Duke Risk Management." 


(4) The nurse said I could not leave because the Duke Orthopedic Resident was on the telephone with Risk Management.  


(5) Even thought the Resident specifically stated that "there is nothing else we can do for you here," I did not want to leave without informing someone I knew in Duke Risk Management because I did not want to be disrespectful.


Re:     Cheryl Handy dc on 9-18-2010
From:  Sharon S Maddox (xxx@mc.duke.edu)
To:     Cheryl Handy  (handylaw@mac.com)
Cc:     Michael A Blazing (xxx@duke.edu)
Date:  September 20, 2010 7:48:38 AM
Ms. Handy,
I am unclear as to why you are requesting paperwork from me or why you were expecting Risk Management to meet with you. As you know, discharge plans and documentation are to be obtained from your clinical team. Please work with them for any medical information that you need.
Sharon Maddox, ARM
Risk Manager
DUMC Risk Management
684.32xx
681.86xx (Fax)
This message and any included attachments are confidential and are intended only for the addressee(s). The information contained herein may be confidential under the attorney/client privilege and/or the quality assurance and peer review privilege. Unauthorized review, forwarding, printing, copying, distributing, or using such information is strictly prohibited and may be unlawful. If you received this message in error, or if you have reason to believe you are not authorized to receive it, please promptly notify the sender by e-mail or telephone, and delete the message.
From:     Cheryl Handy (handylaw@me.com)
To:         Sharon S Maddox (xxx@mc.duke.edu)
Cc:         Michael A Blazing (xxx@duke.edu)
Date:      09/18/2010 11:17 AM
Subject:  Cheryl Handy dc on 9-18-2010
I couldn't wait for RM to come talk to me about dc and getting 2nd opinion.
Docs said ok to leave today.
I would like a dc plan so I can show other docs when I get 2nd opinion.
My mom is in driving lot. She is old and crying.
Pl fax paperwork to me
630-689-58xx
Cheryl Handy
Sent from my iPhone

Duke Orthopaedics's "elopement report" refers to 
(1) my being in the Hospital in afternoon (but the email clearly shows I left the Hospital in morning) and 
(2) Risk Management being involved (but the email clearly shows that Risk Management was not involved). 


The "elopement report" indicates that I did not want to take the IV antibiotic.  But if that was my issue, why didn't the Resident Dr. Schweitzer ask me why I did not want the IV antibiotic?
  1. I had PICC line antibiotic from the Monday September 13 until Saturday September 18 without any problem.
  2. I had IV chemotherapy without any problem.
  3. I administered push antibiotics in my dad's port-a-cath without a problem.
I did not have a problem with the PICC line or IV antibiotics.  The problem was always and only the open wound.  Duke Orthopedics refused to acknowledge that I had the open wound at discharge.


But Dr. Michael Bolognesi's PA Diane Covington examined the open wound three days after discharge and it looked bad.  Stitches were pulling and popping out.   Below is a true and correct copy of my appointment statement from Duke Medical:


Tuesday September 21, 2010
11:30AM
COVINGTON PA,DIANE B             Duke Clinic 200 Trent Drive
ORTHOPAEDICS                         Clinic 1F
919-684-4007                            Durham, North Carolina 27710

Diane Covington, PA knew the wound was open three days after the discharge. I removed the gauze bandage that revealed 3 or 4 butterfly bandages stretched tightly to precariously hold together the opened surgical wound.  I placed the bandaging prior to arriving at the Clinic.  


PA Covington just looked at the wound as if it was completely normal.  PA Covington said nothing to me at all.  Weird.  PA Covington just replaced my gauze bandage with a new bandage and left the room.  She did not have a physician look at the wound. She did not give me any further instructions.


A group of paraprofessionals entered the room and, as planned, the PICC Line was removed in completely unsanitary conditions.


Two days later (September 23, 2010) I was at UNC Orthopedics.  By the time I arrived at UNC Orthopedics, Dr. Michael Bolognesi already faxed the "elopement report" with no information at all about the open wound (that his PA Diane Covington saw two days earlier) to UNC Orthopedics.  


Why would Dr. Michael Bolognesi do that?  Why would Duke cardiologist 
Dr. Michael Blazing do that?


I was denied care by UNC Orthopedics because of the "elopement report."  UNC Orthopedics actually sent a report indicating exactly that fact.


Again, what the heck is Duke Orthopaedics' end game here?  Me dying or something else?

Wednesday, December 29, 2010

Request for Accountability to Duke Orthopedics

For months, I asked Duke Hospital for a copy of the report that Duke Orthopedics sent to UNC and Cleveland Clinic.  UNC Orthopedics flatly refused to treat me because of the report.  It just did not make sense.  


Why would Duke Medical want to interfere with me obtaining medical care?  My dad just died in January 2010.  I was always a compliant patient.  I was not a difficult patient.  Why was Duke treating me like this?


And so I sent an e-mail to Duke Medical on Wednesday December 29, 2010, and  asked:
I finally received the "elopement report" that Duke sent to UNC and Cleveland Clinic without my authorization.  It is frankly shocking to me to read such "misstatements."  My only concern was the open wound at discharge.  
My metal from the high tibial osteotomy was placed by Dr. Easley in December 2004.  It always hurt. I was never able to rehab the leg.  I lost a job in Chicago because I was in such pain. 
I had to go to a Chicago orthopedic surgeon because no one at Duke would remove the metal.  I have seen the x-rays.  The infection and dead tibia in my leg run the track lines of the screws placed by Dr. Easley.  As soon as the painful metal was removed, the bone infection was doomed to manifest itself. However, I would be doomed to a life of pain so long as Duke continued to ignore my complaints of pain just to avoid the inevitable osteomyelitis.
I know there was an issue of elevator oil accidentally cleaning surgical supplies.  I know the osteotomy packs were among the items contaminated.  How can Duke be certain that no contaminated instruments were used at Duke University Hospital (DUH)?   Or, perhaps, instruments were taken from the Ambulatory Surgery Center (ASC) to DUH.  I cannot imagine how else the screws could have infected my bone.
My dad was a research medicinal scientist for over 40 years at RTI International.  Of course, he had many friends at RTI (chemistry and analytics) and throughout the scientific community at other labs.  The Chicago orthopedic surgeon gave me the metal he removed. Maybe my having the metal tested would be useful and then I could alert people who had surgery at DUH to get checked.
Cheryl Handy
No response yet.  I will keep all updated. 

The Discharge Summary that Duke Hospital gave me (and the oddities)

I did receive a Discharge Summary from Duke University Hospital on Saturday September 18 in the morning.  Actually, Matthew Peter Gunn, PA provided me with a Discharge Summary indicating that I was to be discharged Friday September 17 morning.  


In fact, when I mentioned the error to PA Gunn (after I found him alone in my hospital room near my personal belongings as I entered - a story I will save for later).  The PA yelled at me and stormed out of my hospital room.  


I calmly asked Matthew Peter Gunn, PA why the Discharge Summary stated that I was diabetic when I was not. And in fact I have never been diagnosed as diagnosed as diabetic or even pre-diabetic.   


I also calmly asked why the Discharge Summary did not state that I was treated for osteomyelitis.  PA Matthew Peter Gunn's response was to throw a piece of paper on the hospital bed with my diagnosis and retort "what part of preliminary don't you understand"?  Huh? About two hours later the first Discharge Summary was off the Duke Healthview (but I saved a copy).  


Of course, the final report was identical to the report Matthew Peter Gunn PA gave me on Friday September 17, 2010.











Duke University Hospital
DUKE UNIVERSITY HEALTH SYSTEM
UNIVERSAL PATIENT DISCHARGE INSTRUCTIONS
Corrected
Facility:DUMC, Medical Record # R542xx
Patient: HANDY, CHERYL ANN
Admission Date: 09/10/2010 11:54:00 PM 
Encounter: 3836NF
Discharged: 09/18/2010
10:30:20 AM
DOB: 09/10/19xx Age: Gender: F
Language: English 
Completed By: MATTHEW PETER GUNN,PA
Reason for admission:
Incision and drainage of left proximal tibia
Discharge status:
To home under care of health service
     Allergies
Reaction
Severity
Reported by
     Neupogen     
Rash
Moderate
Self
     STERI STRIPS     
itching and rash
Moderate
Self
      Medications                                                                  
      Take these medications:


1.
Metoprolol {LOPRESSOR}
100 MGBy mouthEvery 8 Hours


2.
Pravastatin {PRAVACHOL}
40 MGBy mouthBefore bedtime


3.
Tamoxifen {NOLVADEX}
20 MGBy mouthDaily


4.
Zolpidem {AMBIEN}
10 MGBy mouthEvery Bedtime As Needed


5.
Topiramate {TOPAMAX}
100 MGBy mouthBefore bedtime


6.
Duloxetine {CYMBALTA}
60 MGBy mouthBefore bedtime
(New)

7.
Sennosides - Docusate {SENOKOT-S}
2 TABBy mouthTwice a day
(New)

8.
Laxative/Enema of Choice
1 DOSEMiscelaneousAs needed
(New)

9.
Multivitamin {ONE-A-DAY}
1 TABBy mouthDaily
(New)

10.
Hydrocodone-Acetaminophen 10/400 mg {ZYDONE}
1 TABBy mouthEvery 4 Hours As Neededfor pain#60
(New)

11.
Acetaminophen {TYLENOL}
650 MGBy mouthEvery 4 Hours As Needed
(New)

12.
Oxacillin Inj
12gIntravenousEvery 24 Hourscontinuous infusion x 6 wks
This medication list was created on:2010-09-15 10:35 and last    updated: 2010-09-18 08:25
The above list was verified against your home and hospital medications prior to discharge
Follow pharmacist's instructions on medication labels. Please consult with your doctor before resuming any medications that are not listed above. Please take this form with you to your pharmacy and health care provider.
 Diet
l
High Fiber.
l
Diabetic. 
Activity
l
Light.
l
May drive inwhen off all narcotics and cleared by your doctorday(s).
Special Instructions
l
May shower in 1-2day(s).
l
Waterproof cover over dressing when showering.
l
No tub bathing or soaking.
l
Change dressing in 1-2day(s) per instructions.
l
Sutures/staples out in 10-12day(s) (by healthcare provider).
l
Full Weight Bearing (WB) Status of:left leg.
l
If you smoke (or have smoked within the last year), we strongly recommend that you do not smoke.
l
Keep your legs elevated.
l
Wear your white TED hose on both legs for 8-10 hours a day for 4-6 weeks.
Report any of the following
l
Bladder or bowel symptoms.
l
Temperature is greater than101.5 F (38.1 C) degrees.
l
Numbness or weakness.
l
Severe pain.
l
Nausea, vomiting, chills.
l
Redness, swelling, or draining from incision.
Report issues to:
Orthopaedic Resident on call (919) 684-8111.
If life threatening emergency call 911.
Follow up
The following appointments have been scheduled for you:
l
10/21/2010 08:30 AM - Dr.TIMOTHY A COLLINS - Pain and Pallative Care
l
11/30/2010 04:00 PM - Dr.MICHAEL A BLAZING - Primary Care Fayetteville Road
Additional follow up appointments:                                          
l
Patient to call appointment hub at (919)613-7797 or (800)851-5811 on the first business day after discharge and make appointment in7 days for suture removal in Dr. Bolognesi's office(indicate value for days or weeks).
l
Medication Refills: Call your orthopaedic physician's office during office hours. Refills will not be filled after hours.
f/u 10/8/10 Dr. Maziarz Clinic 2J Duke South with Infectious Disease 930am, weekly CBC/ESR/CRP faxed to 919 6817494
Remember to make healthcare providers aware that you were diagnosed with and/or treated for the following conditions during this Hospital stay:
l
Asthma
l
High Cholesterol
l
Migraines
Breast cancer
KARL M SCHWEITZER, MD   
Department of Orthopaedics
       
ELECTRONICALLY SIGNED ON  

MD/PA/MP Signature and ID
PDIV04



But there is even more interesting stuff associated with the discharge.  Physicians and surgeons are very busy people at Duke Medical.  After I surprised Matthew Peter Gunn, PA in my hospital room on Friday evening September 17, 2010, Gunn told me what the cultures determined caused the osteomyelitis and what the IV antibiotic would be.  


I asked Gunn PA to write the diagnosis and treatment plan down.  Gunn, PA was very busy too.  He write two words:  staph coag negativeNafcillin 


According to my medical records, it was Matthew Peter Gunn, PA and the Home Health Nurse and Pharmacist that decided on my treatment plan.  There is no indication that any board certified physician participated in the treatment plan.  (Remember, they are very busy and no one would look at my open wound.)  This might explain why Dr. Karl Schweitzer was "sensitive" about the antibiotic treatment issue.  I did not even know it was an issue at the time of discharge.


Again, I was just concerned about the open wound.








ROI - Browser Chart - ROI Request #: 278702
09/17/2010     09:31 PM    Arcus,     Joyce     RN,     PRM     ID consult     still waiting culture results today.     Final culture results received after 5pm.     Received Rx from Peter Gunn, PA for Nafcillin 12 grams IV Q24H by continuous infusion.     Spoke     with     Vicky,     on-call pharmacist     from Mid-Carolina Homecare Specialists on her cell phone 919-632-39xx and faxed Rx to their office at 919-465-93xx.     
They do not have enough Nafcillin in stock and suggest Oxycillin as an alternative; discussed with Dr. Eileen Maziarz (RTL) and then Peter Gunn, PA after hours and facilitated a phone call between Vicky and Peter with the outcome that Oxycillin can be substituted.     Vicky is now working on finding an on-cail Mid-Carolina Homecare Specialists RH who can open the referral/case this weekend. Waiting call back from Vicky.     Will discuss with patient if Mid-Carolina Homecare can accept start of care this weekend.     Charge nurse aware.

NOTE BY AUTHOR ***RTL-“resident training license” Dr. Maziarz does not have a full North Carolina medical license and, to my recollection, Dr. Maziarz never met or examined me.  So, Dr. Maziarz probably did not know about my open surgical wound

No one ever told me that there was any issue with the Nafcillin that Matthew Peter Gunn, PA scribbled on the paper and threw on my hospital bed (without any explanation) on Friday September 17, 2010.  I did not know about an issue with the IV antibiotic until last week when I received the medical records.  



John Hopkins has an opinion about how to treat Staphylococci, coagulase negative.  Of course that opinion might have been written by a PA or RN.  I can not be certain - but it does differ from Matthew Peter Gunn PA's recommendation.




Staphylococci, coagulase negative 

John G. Bartlett, M.D.
09-01-2010 


MICROBIOLOGY

  • Coagulase negative staphylococci (CNS) are aerobic, gram positive coccus, occuring in clusters. Frequently found on skin and mucous membranes.
  • Catalase positive, coagulase negative. Major pathogen is S. epidermidis, colonies typically small, white-beige (about 1-2 mm in diameter).
  • Over forty recognized species of CNS, with other major entities including S. lugdunensis, S. haemolyticus. 
  • Many strains with propensity to produce biofilm, allowing for adherence to medical devices.
  • Usually resistant of penicillin and methicillin.

CLINICAL

  • Nearly always a nosocomial pathogen. The usual source is skin flora. Pathogen primarily associated with foreign bodies and biofilm.
  • Staphylococcus epidermis--the major pathogen of the coagulase negative staphylococcus category.
  • #1 cause of nosocomial bacteremia, but also #1 contaminant.
  • #1 infection of plastic/metal: lines, artificial valves, joints, pacemakers and central nervous system shunts, etc.
  • Diagnosis by cultures: need at least 2 positive blood cultures, or heavy growth in presence of e.g., foreign body.
  • Outbreaks in hospitals, ICUs, oncology centers may represent clonal spread.
  • S. lugdunensis infections more similar in type to S. aureus than other coagulase-negative staphylococci. After S. epidermidis, second leading cause of CNS endocarditis. May be cause of aggressive infection. Organism often susceptible to methicillin, only ~25% of strains produce beta-lactamase.
  • S. haemolyticus is second leading cause of CNS neonatal bloodstream infections. Often has reduced susceptibility to glycopeptide abxs (teicoplanin > vancomycin).
  • S. saprophyticus: often listed as second leading cause of UTI (after E. coli) in young, sexually active women.

SITES OF INFECTION

  • Bacteremia: most often due to IV lines, vascular grafts, cardiac valves (30-40% of all coag-neg staph infections)
  • CSF shunt: meningitis
  • Peritoneal dialysis catheter:  peritonitis
  • Prosthetic joint: septic arthritis
  • Prosthetic or natural cardiac valve: endocarditis
  • Post sternotomy: osteomyelitis
  • Implants (breast, penile, pacemaker) and other prosthetic devices: local infection
  • Post ocular surgery: endophthalmitis
  • Surgical site infections

TREATMENT

General principles

  • Most common cause of infection with any foreign material. Pathophysiology is based on biofilm on plastic or metal by relatively avirulent bacterium. Treat bacteremia only if > 2 positive blood cultures (preferably from peripheral sources) or heavy/repeated growth from device.
  • Abx: >80% are beta-lactamase positive and methicillin-resistant. Most active: vancomycintelavancinlinezoliddaptomycin; often addrifampin due to biofilm penetration, but need second agent to prevent resistance.
  • Standard for deep infection: vancomycin 15mg/kg IV q 12 h +/-rifampin 300 mg q8h IV/PO.  Gentamicin 3 mg/kg/d IV divided q8h added to vancomycin + rifampin for prosthetic valve IE.
  • Alt (MRSE): linezolid 600 mg IV/PO twice daily, daptomycin IV 6 mg/kg/d, telavancin 10 mg/kg IV once-daily (infuse over 1 hr). Each +/- rifampin.
  • Alt (methicillin-sensitive): oxacillin/nafcillin 1.5-3 gm IV q6h,cefazolin 1-2 gm IV q8h, ciprofloxacin 400 mg IV q12h,clindamycin 600 mg IV q8h, TMP-SMX. Use sensitivities to guide choice. Note, only assume methicillin susceptible if multiple isolates are so identified.
Site specific recommendations

  • Prosthetic valve: consider valve replacement, abx x 6 wks. Seeprosthetic valve endocarditis module.
  • Peripheral line: remove line, abx x 5-7 days.
  • Central line: may often keep line & systemic abx x 2 wks + abx lock.
  • Prosthetic joint: typically remove joint (two stage more common than single stage replacement), abx x 6 wks. If very early infection (less than 3 wks post-op, debridement and retention an option).
  • Dialysis catheter: keep catheter (at least for first effort) and IVvancomycin (usually 2g IV/week and redose when level <15 mcg/mL) + Abx lock x 10-14 days.
  • Vascular graft: remove graft, abx x 6 wks.
  • CSF shunt: shunt removal usually recommended but variable. IVvancomycin 22.5 mg/kg q12h and PO/IV rifampin plus possible intraventricular antibiotics: vancomycin 20 mg/d +/- gentamicin 4-8 mg/d.
S. saprophyticus UTI

  • When occuring in males, suggestive of anatomic abnormality or recent or present catheterization.
  • High incidence of failure with single dose antibiotic regimens.
  • Variably susceptible to vancomycin.
  • See "Bacterial Cystitis, Acute, Uncomplicated" module for details on multiple regimens.

OTHER INFORMATION

  • Most common cause of bacteremia, but also the most common contaminant in all specimens.
  • CDC: "Never treat a single positive blood culture for Staphylococcus epidermidis."
  • Major cause of all foreign body infections: lines, joints, implants, shunts, valves, etc.
  • Usually need foreign body plus 2 positive cultures or heavy growth to implicate as causative pathogen.

Basis for Recommendations

  • McCann MT, Gilmore BF, Gorman SP; Staphylococcus epidermidis device-related infections: pathogenesis and clinical management.; J Pharm Pharmacol; 2008; Vol. 60; pp. 1551-71;
    ISSN: 0022-3573;
    PUBMED: 19000360
    Rating: Basis for recommendation
    Comments:Source document for most recommendations. Note that S. epidermidis as the cause of implanted medical devices is due to its ability to establish a multilayered highly structured biofilm. These are easier to prevent than to treat so the device often needs to be removed once the biofilm is established.
  • No authors listed ; Choice of antibacterial drugs.; Treat Guidel Med Lett; 2007; Vol. 5; pp. 33-50;
    ISSN: 1541-2784;
    PUBMED: 17450114
    Rating: Basis for recommendation
    Comments:Basis for recommendations in this module.
  • Archer G ; Staphylococcus epidermidis and other coagulase-negativestaphylococci; ; Chapter 184 in Principles & Practice of Infectious Disease, Mandell JL, Bennett JE & Dolin R (Editors) Churchill Livingston Phil 5th Ed ; 2000 ; Vol. 2092-2100 ;
    Rating: Basis for recommendation
    Comments:Coagulase neg. staph include 32 species with 15 indigenous to humans. The value for routine speciation is unclear. Most pathogenic in humans are S. epidermidis (foreign bodies) and S. saprophyticus (UTI's). Other less common pathogens- S. haemolyticusS. lugdunensis, and S. scheiferi. Nearly all S. epidermidisinfections are nosocomial and come from patient or HCW indigenous flora. 



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With my sincere thanks to John Hopkins for the use of the information in this informational blog.