For over 21 years, United Family Healthcare (UFH) has been attracting many experts from the North America and Europe. With more than 400 doctors in the UFH network in China and Mongolia, 50% of the team is from over 25 countries. There’s persisted Antimicrobial Stewardship Program to guide antibiotics use by ordering with Antimicrobial Order Pop-up Alert System, using latest guidelines and local UFH antibiogram to guide treatment decisions, consulting with ID expert per UFH policy on complex cases, and supporting development of patient education. It helps reasonable antibiotics application in China.
Patient 1059732, female, vaginal delivery on 2nd March. G1P1, 40w +1. On 9th March, postpartum day 9, she came to ER of Qingdao United Family Hospital from a postpartum care center with high fever for 1 day, and one episode of vomiting and flank pains. According to clinical findings and urinalysis, urinary tract infection was diagnosed. Stat dose of Cefatriaxone IV was given and patient was discharged with oral Cefixime. Although symptoms were better after treatment, she was admitted to another local hospital due to concerns of infectious disease during postpartum, with several kinds of broad-spectrum antibiotics use for several days (including Quinolones and 3rd generation cephalosporins IV). On 16th March patient came back to our hospital again for high fever 40.1°C with fatigue/sore throat/coughing/runny nose/ oral mucosa pain. Fungal infection in oral mucosa/ influenza A/ acute bronchitis were diagnosed with laboratory and radiological examinations. After oral Oseltamivir and topical Nystatin, with antibiotics reduction and IV rehydration fluids, her general condition was getting better and was discharged home after 3 days admission. There’s concern about multiple pathogens infection related to excessive application of antibiotics in China for a long time. Several factors were most related: lack of antibiotics management and monitor, difficulties of extensive clinical data collection and excessive prescription due to concerns of less effective.
Randolf A. Perez is currently affiliated with the World Citi medical Center, Philippines.
Background: Bullous pemphigoid (BP) is the most common autoimmune blistering skin disease. The significance of the association of bullous pemphigoid with other autoimmune diseases is still unknown. There have been reports of an association of skin diseases with other autoimmune disease. We report the simultaneous occurrence of bullous pemphigoid and thyroid disease in an 89-year-old patient. There is a common underlying pathogenic mechanism involved in these two diseases which explains their relationship and co-existence. This association adds to the documentation of bullous pemphigoid co-existing with other autoimmune disorders. Case: An 89-year-old Filipino man was seen in April 2017 at the OPD Clinic of World Citi Medical Center due to multiple skin blisters of two weeks duration. He did not complain of fever, difficulty of breathing, abdominal pain or body malaise. His vital signs were within normal range. Examination of the skin showed dry, cool with multiple, tense vesicles and bullae, some erythematous erosions over the arms, axillae, inner thighs, and legs. Nikolsky and Asboe-Hansen signs were both negative. Mucosal and genital areas were free of lesions. Baseline CBC, blood chemistries and chest x-ray were within normal limits. A diagnosis of Bullous Pemphigoid was confirmed by a skin punch biopsy and Direct Immunofluorescence (DIF) which revealed the presence of subepidermal blisters and linear deposition of IgG and C3 at the dermo-epidermal junction respectively. Oral Prednisone and Erythromycin was started and discharged improved with skin lesions 70-80% partially improved. However, three-weeks post discharge, he was readmitted for palpitations. Thyroid function tests were done which revealed Hyperthyroidism (FT3: 4.2pg/ml, normal 2.5-3.9 pg/ml; FT4: 2.33 ng/dl, normal 0.58-1.64 ng/dl; TSH: 0.08 mIU/l, normal 0.34-5.60 mIU/l). Methimazole 5mg tab once daily was then added to his medications. General conditions gradually improved hence discharged. The skin lesions are almost completely controlled with oral Prednisone, Erythromycin, Nicotinamide and Clobetasol cream. Conclusion: We conclude that there exists an association between Bullous pemphigoid & Thyroid disease. Based on Humbert and Dupond classification, they belong to two different types of class of Multiple Autoimmune syndrome (MAS). Although not typical of MAS, a common pathophysiologic mechanism can explain their co-existence. Both Autoimmune thyroid disease (AITD) and BP have autoantibodies belonging to IgG class. The presence of one autoimmune disease requires a high index of suspicion for prompt evaluation for the others. The occurrence of multiple autoimmune phenomena indicates the need for continued surveillance for the development of new autoimmune disease in predisposed patients.