1Purpose: Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of 2 pneumonia in ventilated patients. Our objective was to evaluate the GeneXpert 3 MRSA/SA SSTI Assay (Xpert MRSA/SA) (Cepheid, Sunnyvale, CA) for use in lower 4 respiratory tract (LRT) specimens for rapid MRSA detection and to determine the 5 potentially saved antibiotic-days if a culture-based identification method was replaced 6 by this assay. 7 Methods:Remnant LRT samples from ventilated patients submitted to the 8 microbiology laboratory for routine culture were tested using conventional culture and 9Xpert MRSA/SA.

Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. Materials and methods: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. Results: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. Conclusions: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Propionibacterium acnes is a known cause of postneurosurgical meningitis; however, it is rarely implicated in de novo meningitis. Herein we report a case of a 49-year-old male with de novo meningitis caused by P. acnes with metastatic melanoma as the only identified risk factor for his infection. CASE REPORTA 49-year-old Caucasian male presented to his primary care physician with an 11-week history of bifrontal headaches associated with nausea and emesis but without other symptoms of meningismus. Symptomatic relief was provided with over-thecounter pain medications and antiemetics. Five weeks prior to arrival at our institution, the patient was admitted to an outside hospital for intractable vomiting and headaches. A computed tomography (CT) scan of the head and abdomen were performed, both of which were normal. Two weeks prior to admission, his headache and nausea worsened with the onset of subjective fevers, low back pain, lethargy, and confusion.Roughly 2 years prior to admission, the patient was diagnosed with stage IIIC melanoma of the right lower extremity, for which he underwent resection and lymphadenectomy. In the intervening period, he was thought to be in remission. Eight weeks prior to admission, a left-lower-extremity skin biopsy specimen demonstrated a melanocytic nevus.At the time of admission, his vital signs were as follows: temperature, 36.7°C; blood pressure, 168/92 mm Hg; heart rate, 87 beats per minute; respiratory rate, 20 breaths per minute; oxygen saturation of 98% on room air; height, 188 cm (74 in.); and weight, 142 kg (312.4 lb). The physical exam showed a well-developed male in no acute distress, alert, and oriented to place, year, self, and situation. Notable findings included right-lower-extremity swelling, a healed scar at the site of his prior melanoma, and ecchymosis surrounding a left-lower-extremity biopsy site. He did not have signs of meningismus.Laboratory findings on admission included a hemoglobin level of 14.1 g/dl, hematocrit of 40.3%, white blood cell count of 10,300/mm 3 , mildly elevated absolute neutrophil count of 7,600/ mm 3 (range, 1,800 to 6,600/mm 3 ), normal chemistry panel, an alanine transaminase level of 89 U/liter (range, 7 to 53 U/liter) but otherwise normal hepatic function panel, and a normal urinalysis.A repeat CT scan of the head was obtained on hospital day 2, 5 weeks after the prior scan, which revealed a communicating hydrocephalus. CT myelography was also performed on day 2, which showed clumping of the nerve roots within the lumbar spine and nodular thickening surrounding L2-L3 nerve roots consistent with arachnoiditis versus metastatic disease.A fluoroscopically guided lumbar puncture (LP) was performed on hospital day 2, which yielded clear, yellow cerebrospinal fluid (CSF) with a glucose concentration of 26 mg/dl (serum glucose, 96 mg/dl), protein concentration of 518 mg/dl, 145 nucleated cells/l (1% neutrophils, 32% macrophages, 10% monocytes, 6% lymphocytes, and 51% unclassified cells due to poor cell viability), 576 red blood cells/l, and an...