Background: Covid-19 pandemic has resulted in the development of severe and persistent respiratory failure requiring long term ventilatory support. This necessitates the need for a reliable and easy to implement tracheostomy protocol given the concern for viral transmission risk to the involved healthcare personnel due to the aerosol generating nature of the procedure. We describe a protocol with unique and novel modifications to the Ciaglia dilatational percutaneous tracheostomy, effectively implemented during the Covid-19 pandemic at our institution. Methods: We describe the baseline characteristics of our initial 11 patients who underwent the procedure. Outlined are the healthcare personnel involved and the steps which are organized into 4 phases: planning, pre-procedure, intra-procedure and post-procedure. We have tracked procedural duration, provider safety as well as the development of new complications. Results: We describe use of this protocol for 11 bedside percutaneous tracheostomies performed on patients with COVID-19. The average total procedural duration as well as incision to tracheostomy tube placement times was 32.6 minutes and 5.8 minutes respectively. All 3 providers performing the tracheostomies remained asymptomatic with negative COVID-19 RT-PCR testing at 3 weeks. Conclusions: We report an efficacious and adaptable protocol for elective bedside percutaneous tracheostomies for patients with persistent ventilatory requirements due to COVID-19 with an intent to provide standardized and safe care for the patient and the involved healthcare personnel.

Escherichia coli community-acquired pneumonia (CAP) is an under-recognized condition associated with higher mortality compared to the other well-studied causes of pneumonia. E. coli pneumonia is frequently associated with bacteremia. Despite the absence of abdominal or urinary symptoms, the infection may originate from an occult gastrointestinal (GI) source since it is a common commensal bacteria of the GI tract. Conditions related to extraintestinal pathogenic E. coli (ExPEC) are gaining attention, and there has been a trend toward the rise of pneumonia secondary to gram-negative bacteria. This presents a diagnostic stewardship dilemma in a patient with sepsis, E. coli bacteremia, and apparent pneumonia - to assume and treat for E. coli CAP or to look for a GI/genitourinary source which may, in turn, lead to incidental findings and further studies. We report a case of E. coli CAP in a 62-year-old patient and our approach regarding the treatment and imaging course.

A lung abscess is a walled necrotizing infection involving the lung parenchyma, characterized by a cavitary lesion filled with fluid. It is usually caused by microbial infection with aspiration of oropharyngeal contents being the most common mechanism for primary lung abscesses. Secondary lung abscesses occur in the presence of predisposing lung conditions like bronchial obstruction, vascular or septic emboli or impaired host defenses. Lung abscesses caused by electronic cigarette use have gained relevance in the recent years since the outbreak of EVALI, that is, e-cigarette or vaping product use-associated lung injury, in 2019. First-line therapy involves prompt initiation of antibiotics given their success rate in the treatment of lung abscess in the current potent antibiotic era. Percutaneous aspiration and catheter drainage is considered a second line approach due to concerns for potential complications including catheter blockage necessitating repeat procedures, pneumothorax, hemothorax, hemoptysis, need for surgical intervention, infection of pleural space and bronchopleural fistula. We describe a case of a 21-year-old female with a history of electronic cigarette use presenting with a large left upper lobe lung abscess (14.5 x 8.5 x 13.3 cm) treated successfully with broad-spectrum antibiotics alone resulting in clinical and radiologic improvement.

Daptomycin is a canonical antibiotic used very commonly in practice for its bactericidal activity against Gram-positive bacteria, including vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, bone infections, skin and soft tissue infections, meningitis, urinary tract infections, and endocarditis. Although daptomycin in conventional doses is usually well tolerated, it is paramount to be aware of the possible adverse effects. Daptomycin is reported to cause an elevation in creatine kinase levels, although frank rhabdomyolysis is rare. An even more infrequent occurrence is the simultaneous development of acute kidney injury and drug-induced liver injury with rhabdomyolysis. Daptomycin and rifampin combination are used for synergistic bactericidal action against MRSA. Still, data on the efficacy and safety of the combination is limited due to a lack of extensive studies. Herein, we present a clinical case of septic arthritis of a prosthetic knee, which resulted in bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA) and subsequently led to infective endocarditis of the aortic valve. The patient was treated with a combination of daptomycin and rifampin, complicated by the development of rhabdomyolysis, acute kidney injury, and drug-induced liver injury. This case highlights the significance of timely recognizing adverse drug effects and identifying risk factors to ensure successful patient outcomes.

We report a case of an 86-year-old Hispanic male who presented with generalized itching and jaundice. Computed tomography (CT) imaging revealed a hepatic mass and an extensive spontaneous biloma, a condition rarely associated with malignancy. Subsequent biopsy of the mass confirmed moderately differentiated adenocarcinoma of the pancreaticobiliary tract. The patient underwent successful percutaneous drainage of the biloma and was discharged with a plan for further outpatient management. This case study highlights a rare manifestation of spontaneous biloma related to malignancy, broadening the clinical understanding of its association with malignancy, diagnosis, and management.