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OBJECTIVE: Examine the use of airborne isolation by identifying reasons for nontimely discontinuation and predictors of compliance with Centers for Disease Control and Prevention (CDC) guidelines. Compliance with guidelines should result in timely (within 48 hours) discontinuation of isolation in patients without infectious pulmonary tuberculosis (TB). DESIGN: Retrospective, observational study. SETTING: A private, university-affiliated, tertiary-care medical center. PATIENTS: All patients in airborne isolation for suspected pulmonary TB from June through December 2011. METHOD: Chart reviews were performed to identify airborne isolation practices and delayed (greater than 48 hours) or very delayed (greater than 72 hours) discontinuation. We used descriptive statistics and logistic regression to determine independent predictors of nontimely discontinuation of isolation. RESULTS: We identified 113 patients (mean age ± standard deviation, [Formula: see text] years; male sex, 75.2%; white race, 15.9%; mean collection interval ± standard deviation, [Formula: see text] hours). Delayed and very delayed isolation discontinuation was noted in 81% and 49% of patients, respectively. No significant differences in demographic characteristics and clinical characteristics were identified between groups. Predictors of timely (within 48 hours) airborne isolation discontinuation included use of alternate diagnosis for discontinuation of isolation ([Formula: see text]), early infectious diseases (ID) consultation ([Formula: see text]), pulmonary consultation ([Formula: see text]), average sputum collection interval less than 24 hours ([Formula: see text]), and need for more than 1 induced sputum specimen ([Formula: see text]). Adjusting for potential confounders, pulmonary consultation (odds ratio [OR] [95% confidence interval (CI)], 0.14 [0.03-0.58]), alternate diagnosis for discontinuation of isolation (OR [95% CI], 4.5 [1.3-15.8]), and early ID consultation (OR [95% CI], 4.0 [1.1-14.8]) were independently associated with timely discontinuation. CONCLUSIONS: Timely airborne isolation discontinuation occurs in only 18.6% of cases and is an opportunity for cost savings, improved efficiency, and potentially patient safety and satisfaction.

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Nodular sclerosing Hodgkin's lymphoma commonly presents with a mediastinal mass, but it rarely compresses or invades mediastinal structures or the anterior chest wall. Histologically, it can cause necrotizing granulomatous inflammation. A woman with a right breast mass extending from an asymptomatic large mediastinal mass selectively compressing the trachea is presented. A computed tomography-guided core needle biopsy from the anterior chest wall mass revealed necrotizing granulomatous inflammation. Finally, the diagnosis of nodular sclerosing Hodgkin's lymphoma was made by incisional biopsy. Clinical suspicion of nodular sclerosing Hodgkin's lymphoma is crucial since an adequate tissue diagnosis is needed when the initial less invasive diagnostic testing is inconclusive.

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The state of Hawai'i has the highest prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection in the United States. Since vancomycin is the most frequently-prescribed antibiotic for healthcare-associated MRSA infection, there is concern for development of vancomycin resistance. We report on a 61 year-old woman with history of previous successful treatments of MRSA bacteremia with vancomycin. She was later hospitalized for catheter-related MRSA bacteremia that persisted despite vancomycin treatment. The vancomycin minimal inhibitory concentration (MIC) was initially 1-2 µg/ml, suggesting susceptibility, but changed to 4 µg/ml. At this level, the organism was classified as a vancomycin-intermediate Staphylococcus aureus (VISA). Therapy was changed from vancomycin to daptomycin, and the patient's blood cultures were sterilized. High suspicion of VISA should be raised in MRSA-infected patients who fail or have a history of vancomycin therapy so that additional susceptibility testing and appropriate antibiotic therapy can be promptly commenced to reduce the morbidity associated with VISA infection.

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Nutritionally Variant Streptococci (NVS) were first grouped under viridans streptococci, although they differed from the latter by variant growth characteristics. NVS cause approximately 5% of cases of bacterial endocarditis. Infective endocarditis caused by NVS has a higher rate of complications than endocarditis caused by other viridans streptococci. Recently NVS were separated from other viridans streptococci to form a new genus Abiotrophia. Since then, only four case reports have described the clinical course of Abiotrophia endocarditis. Therefore, current knowledge on this disease derives from previous data on NVS endocarditis. We present the case of Abiotrophia endocarditis, followed by discussion of relevant literature.

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