Adequate Source Control Research Articles

In vivo selection of carbapenem resistance during persistent Klebsiella pneumoniae sequence type 395 bloodstream infection due to OmpK36 deletion.

Non-carbapenemase-producing carbapenem-resistant Enterobacterales (non-CP CRE) may be associated with a grave outcome. The common underlying mechanism is beta-lactamases and mutations in outer membrane porins. We report a case of a deep-seated infection caused by Klebsiella pneumoniae ST395 not amenable to source control, involving recurrent bloodstream infection, resulting in in vivo selection of carbapenem resistance under therapy. Three consecutive K. pneumoniae blood isolates were studied using short- and long-read sequencing. The genomes were subject to resistome and virulome, phylogenetic, and plasmid analyses. ompK36 porins were analyzed at the nucleotide and amino acid levels. Genomes were compared to 297 public ST395 K. pneumoniae genomes using cgMLST, resistome, and porin analyses and the EuSCAPE project. Relevant ompK36 and micF sequences were extracted and analyzed as above. The three sequential K. pneumoniae blood isolates belonged to the same clone. Subsequent CR isolates revealed a new large deletion of the ompK36 gene also involving the upstream region (deletion of micF). Comparison with public ST395 genomes revealed the study isolates belonged to clade B, representing a separate clone. N-terminal large ompK36 truncations were uncommon in both public data sets. In vivo selection of non-CP CRE K. pneumoniae could have substantial clinical implications. Such selection should be scrutinized through repeated cultures and frequent susceptibility testing during antimicrobial treatment, especially in the context of persistent or recurrent bloodstream infections and when adequate source control cannot be achieved. The occurrence of an unusually large deletion involving the ompK36 locus and upstream micF should be further studied.

Intravenous fosfomycin for treatment of severe infections caused by carbapenem-resistant Acinetobacter baumannii: A multi-centre clinical experience

Severe infections caused by carbapenem-resistant Acinetobacter baumannii (CRAB) have been reported increasingly over the past few years. Many in-vivo and in-vitro studies have suggested a possible role of intravenous fosfomycin for the treatment of CRAB infections. This multi-centre, retrospective study included patients treated with intravenous fosfomycin for severe infections caused by CRAB admitted consecutively to four hospitals in Italy from December 2017 to December 2022. The primary goal of the study was to evaluate the risk factors associated with 30-day mortality in the study population. A propensity score matched analysis was added to the model. One hundred and two patients with severe infections caused by CRAB treated with an intravenous fosfomycin-containing regimen were enrolled in this study. Ventilator-associated pneumonia (VAP) was diagnosed in 59% of patients, primary bacteraemia in 22% of patients, and central-venous-catheter-related infection in 16% of patients. All patients were treated with a regimen containing intravenous fosfomycin, mainly in combination with cefiderocol (n=54), colistin (n=48) or ampicillin/sulbactam (n=18). Forty-eight (47%) patients died within 30 days. Fifty-eight (57%) patients experienced clinical therapeutic failure. Cox regression analysis showed that diabetes, primary bacteraemia and a colistin-containing regimen were independently associated with 30-day mortality, whereas adequate source control of infection, early 24-h active in-vitro therapy, and a cefiderocol-containing regimen were associated with survival. A colistin-based regimen, A. baumannii colonization and primary bacteraemia were independently associated with clinical failure. Conversely, adequate source control of infection, a cefiderocol-containing regimen, and early 24-h active in-vitro therapy were associated with clinical success. Different antibiotic regimens containing fosfomycin in combination can be used for treatment of severe infections caused by CRAB.

THE PIPERACILLIN/TAZOBACTAM ROLE IN THE TREATMENT OF COMPLICATED INTRA-ABDOMINAL INFECTIONS (CIAI) IN UKRAINIAN HOSPITALS: 40 CLINICAL CASES SERIES ANALYSIS

Resume. Antibiotic therapy is one of the key components of complicated intra-abdominal infection (cIAI) treatment. The challenge of effective treatment of cIAI is early recognition, adequate source control, appropriate antibacterial therapy, and fluid resuscitation in patients with sepsis. According to WHO recommendations, piperacillin / tazobactam is the first-line antibiotic for the treatment of complicated intra-abdominal infections, although it used quite rare as the first-choice agent in Ukraine. Materials and methods: Analysis was conducted in the period from December 1, 2022 to June 30, 2023. The research centers were 4 health care facilities: Communal non-commercial enterprise “Kyiv City Clinical Hospital of Emergency Medical Care”, Emergency medical care hospital of Vinnytsia, Communal noncommercial enterprise “Odesa Regional Clinical Hospital of the Odesa Regional Council”, Communal non-commercial enterprise ”Kyiv City Clinical Hospital №4”. After inclusion in the research, patients were prescribed empiric therapy with piperacillin/tazobactam (Refex) and patient data were entered into a form. The results of drug therapy were recorded before the start of therapy (day 0), on the 3-rd day after the start of therapy and on the 6th day after the start of therapy. Results: 40 patients were included in the research. The most common pathogens cultured from patients’ wounds were: 24 cases (60 %) from the "ESKAPE" group: E. Coli 9 cases (22.5 %), S. Aureus 1 case (2.5 %), St. Haemolyticus accounted for 3 cases (7.5 %), Kl. Pneumonia 4 cases (10 %), Acinetobacter spp. 1 case (2.5 %) of Ps. Aeruginosa 3 cases (7.5%), Enterobacter 1 case (2.5 %), Enterobacter cloaceae accounted for 2 cases (5 %). Other pathogens were cultured in 16 cases. Pathogens sensitivity was as follows: 2 cases (5 %) were sensitive to amoxicillin clavunate, 3 cases (7.5 %) were sensitive to ampicillin and cefepime, 4 cases (10% of pathogens) were sensitive to ceftriaxone, 12.5 % of pathogens were sensitive to imipenem and clindamycin (5 cases each), 7 cases were sensitive to amikacin (17.5 %). 47.5 % of flora (19 cases) were sensitive to piperacillin/tazobactam. Pan-resistant strains that were not sensitive to any of the studied drugs accounted for 37.5 % (15 cases). Conclusions: Therapy with piperacillin / tazobactam (Refex) in all analyzed clinical cases was evaluated by doctors as effective and safe. All patients survived and were discharged from the hospital, none of them developed sepsis or acute kidney injury. Among the analyzed cases, the sensitivity to piperacillin/tazobactam was the highest.

A91 PYOGENIC LIVER ABSCESSES DUE TO FUSOBACTERIUM NUCLEATUM ARE ASSOCIATED WITH SEVERE INFLAMMATORY RESPONSE AND ACUTE LIVER FAILURE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background Pyogenic liver abscesses (PLAs) are uncommon entities with potentially devastating consequences requiring early diagnosis and treatment. Fusobacterium nucleatum is an anaerobic, gram-negative bacterium that is a rare cause of liver abscesses. F. nucleatum initiates a severe pro-inflammatory cascade that promotes abscess formation through the gut-liver axis especially when the gastrointestinal (GI) barrier is compromised. Aims In this study, we explore the characteristics of PLAs due to F.nucleatum, including the duration and mode of therapy. This may inform clinical decisions when treating persons with suspected F.nucleatum PLAs and improve mortality. Methods A systematic literature search was conducted in MEDLINE, PubMed, and the Cochrane Library, from 1977 to September 2023. We included full-text abstracts and articles written in English that reported patients with F.nucleatum PLA aged ampersand:003E18. Demographics, history of GI diseases, pertinent laboratory markers, abscess characteristics, and the approaches taken to treat the abscess were collected. Pooled data were assessed qualitatively and reported as mean±SEM when appropriate. Results We included 32 studies. The mean patient age was 52±20 years with 71% being male. In total, 47% of patients had a recent history of GI disease: sigmoid diverticulosis (n=6), colonic adenomas (n=5), duodenitis (n=2), appendicitis (n=1) and ulcerative colitis (n=1). On presentation, only 53% (n=17) reported abdominal pain. Labs were significant for leukocytosis at 22±2 K/µL, C-reactive protein 199±37 mg/L, aspartate transferase (AST) 128±24 U/L, alanine aminotransferase (ALT) 116±16 U/L, Alkaline phosphatase (ALP) 275±35 IU/L, and bilirubin 11±3 mg/dL suggestive of severe inflammatory response and cholestatic liver injury. The average abscess size was approximately 10.2±0.7 cm, 28% of which had loculations (n=9) requiring multiple drainages (n=7) or laparoscopy (n=2). The initial antibiotic of choice was piperacillin/tazobactam (Zosyn) (n=12), ceftriaxone + metronidazole (n=7), Ampicillin/Sulbactam (Unasyn) (n=5), followed by Meropenem, Metronidazole, and Ciprofloxacin. The estimated length of stay was 23±4 days with a need for long-term antibiotic therapy (54±10 days) upon discharge. The majority of patients were discharged on Metronidazole (n=11), or Amoxicillin/Clavulanic acid (Augmentin) (n=6). With appropriate source control, the estimated survival was 91% (n=29). Conclusions Our findings suggest that PLAs due to F.nucleatum are associated with large abscesses, a severe inflammatory response, cholestatic liver injury, and prolonged hospitalization. Multiple drainages with targeted gram-negative coverage may be required for adequate source control and favorable outcomes. Funding Agencies None

Management of acute necrotizing pancreatitis with duodenal fistula

Severe acute pancreatitis (SAP) is often accompanied by severe infected pancreatic necrosis. Gastrointestinal fistula is a common complication during the infectious period of SAP, with the incidence of duodenal fistula coming in second place after colon fistula and a high mortality rate. Percutaneous catheter drainage (PCD) is the most commonly used surgical technique for necrotizing infection in SAP. However, the traditional PCD method cannot achieve adequate source control in SAP necrotizing infection patients with gastrointestinal fistulas. This report describes a case of SAP necrotizing infection complicated with a duodenal fistula treated with trocar-assisted percutaneous abscess drainage combined with manual irrigation. After treatment with double-lumen catheter irrigation and drainage combined with manual irrigation and other standards of care for SAP, the patient’s infection symptoms were gradually relieved. A review of abdominal computed tomography and gastrointestinal radiography showed that the intra-abdominal infection was gradually relieved, and the duodenal fistula was completely healed.

Operative treatment for umbilical venous catheter-related Staphylococcus aureus infective endocarditis with subsequent septic thrombosis: A case report

especially with the increasing use of indwelling catheters. In some cases, surgical excision becomes imperative to ensure adequate source control and mitigate the burden of infection. Herein, we present a compelling case involving a term neonate who developed refractory Staphylococcus aureus infective endocarditis, followed by septic emboli due to a thrombus associated with a malpositioned indwelling umbilical venous catheter (UVC). Thrombosis and infective endocarditis resolved after surgical resection, a 6-week course of antibiotics, and anticoagulation therapy for 3 months. This case report highlights the risk of thrombosis arising from malpositioned UVCs, the potential complications, and the treatment options.

Reducing the duration of antibiotic therapy in surgical patients through a specific nationwide antimicrobial stewardship program. A prospective, interventional cohort study

Guidelines recommend 5-7 days of antibiotic treatment in patients with surgical infection and adequate source control. This nationwide stewardship intervention aimed to reduce the duration of treatments in surgical patients to <7 days. Prospective cohort study evaluating surgical patients receiving antibiotics ≥7 days in 32 hospitals. Indication for treatment, quality of source control, type of recommendations issued, and adherence to the recommendations were analysed. Temporal trends in the percentages of patients with treatment >7 days were evaluated using a linear regression model and Pearson's correlation coefficients. A total of 32 499 patients were included. Of these, 13.7% had treatments ≥7 days. In all, 3912 stewardship interventions were performed, primarily in general surgery (90.7%) and urology (8.1%). The main types of infection were intra-abdominal (73.4%), skin/soft tissues (9.8%) and urinary (9.2%). The septic focus was considered controlled in 59.9% of cases. Out of 5458 antibiotic prescriptions, the most frequently analysed drugs were piperacillin/tazobactam (21.7%), metronidazole (11.2%), amoxicillin/clavulanate (10.3%), meropenem (10.7%), ceftriaxone (9.3%) and ciprofloxacin (6.7%). The main recommendations issued were: treatment discontinuation (35.0%), maintenance (40.0%) or de-escalation (15.5%), and the overall adherence rate was 91.5%. With adequate source control, the most frequent recommendation was to terminate treatment (51.2%). Throughout the study period, a significant decrease in the percentage of prolonged treatments was observed (Pc=-0.69;P < 0.001). This stewardship programme reduced the duration of treatments in surgical departments. Preference was given to general surgery services, intra-abdominal infection, and beta-lactam antibiotics, including carbapenems. Adherence to the issued recommendations was high.

Impact of the COVID-19 Pandemic on the Management of Staphylococcus aureus Bloodstream Infections in a Tertiary Care Hospital.

Staphylococcus aureus bacteremia (SAB) is associated with a high mortality rate. The clinical outcome of SAB patients highly depends on early diagnosis, adequate antibiotic therapy and source control. In the context of the COVID-19 pandemic, the health care system faced additional organizational challenges and the question arose whether structured screening and triaging for COVID-19 and shifting resources influence the management of SAB. Patients (n = 115) with SAB were enrolled in a retrospective comparative study with historical controls (March 2019-February 2021). The quality of SAB therapy was assessed with a point score, which included correct choice of antibiotic, adequate dosage of antibiotic, sufficient duration of therapy, early start of therapy after receipt of findings, focus search and taking control blood cultures 3-4 days after starting adequate antibiotic therapy. The quality of treatment before and after the onset of the COVID-19 pandemic were compared. No significant differences in the total score points were found between the pre-COVID-19 and COVID-19 cohort. All quality indicators, except the correct duration of antibiotic therapy, showed no significant differences in both cohorts. Furthermore, there were no significant differences in the outcome between both cohorts. The treatment quality of SAB therapy was comparable before and during the COVID-19 pandemic.

Efficacy of ceftazidime-avibactam in solid organ transplant recipients with bloodstream infections caused by carbapenemase-producing Klebsiella pneumoniae

We aimed to compare the efficacy of ceftazidime-avibactam (CAZ-AVI) versus the best available therapy (BAT) in solid organ transplant (SOT) recipients with bloodstream infection caused by carbapenemase-producing Klebsiella pneumoniae (CPKP-BSI). A retrospective (2016-2021) observational cohort study was performed in 14 INCREMENT-SOT centers (ClinicalTrials.gov identifier: NCT02852902; Impact of Specific Antimicrobials and MIC Values on the Outcome of Bloodstream Infections Due to ESBL- or Carbapenemase-producing Enterobacterales in Solid Organ Transplantation: an Observational Multinational Study). Outcomes were 14-day and 30-day clinical success (complete resolution of attributable manifestations, adequate source control, and negative follow-up blood cultures) and 30-day all-cause mortality. Multivariable logistic and Cox regression analyses adjusted for the propensity score to receive CAZ-AVI were constructed. Among 210 SOT recipients with CPKP-BSI, 149 received active primary therapy with CAZ-AVI (66/149) or BAT (83/149). Patients treated with CAZ-AVI had higher 14-day (80.7% vs 60.6%, P = .011) and 30-day (83.1% vs 60.6%, P = .004) clinical success and lower 30-day mortality (13.25% vs 27.3%, P = .053) than those receiving BAT. In the adjusted analysis, CAZ-AVI increased the probability of 14-day (adjusted odds ratio [aOR], 2.65; 95% confidence interval [CI], 1.03-6.84; P = .044) and 30-day clinical success (aOR, 3.14; 95% CI, 1.17-8.40; P = .023). In contrast, CAZ-AVI therapy was not independently associated with 30-day mortality. In the CAZ-AVI group, combination therapy was not associated with better outcomes. In conclusion, CAZ-AVI may be considered a first-line treatment in SOT recipients with CPKP-BSI.

Interpretation of the World Society of the Emergency Surgery/the Global Alliance for Infection in Surgery/the Surgical Infection Society-Europe/the World Surgical Infection Society/the American Association for the Surgery of Trauma global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAI) is common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The principles of IAI management included early diagnosis, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using critical care resources, combined with an optimal surgical approach. In order to facilitate clinical management, establish a global standard and provide guidance for clinicians, the World Society of Emergency Surgery (WSES), the Global Alliance for Infection in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) worked together to complete an international multi-society document, which provided the evidence-based clinical pathways. Herein, we made a comprehensive interpretation for the clinical pathways combined with the latest domestic and international research developments, aiming to provide evidence for domestic doctors on the diagnosis and treatment of IAI, and ultimately benefit patients.

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study.

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials. We carried out a prospective international cohort study of adult patients (≥ 18years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021. 2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) waspresent in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alivefrom hospital by day-28. HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

1782. Antimicrobial Stewardship Opportunities in Gram-Negative Bacteremia Treatment at a Community Teaching Hospital

Abstract Background Gram Negative Bacteremia (GNB) is frequently encountered among hospitalized patients. In contrast to traditional 14-day lengths of treatment (LOT), recent literature supports a shorter (7-day) LOT for uncomplicated GNB with adequate source control, and the effectiveness of oral antibiotics. The goal of the following is to outline current practices of GNB treatment and identify opportunities for antibiotic stewardship (AS). Methods This study retrospectively reviewed all cases of uncomplicated GNB at a 528-bed community teaching hospital in Rochester, NY from January 2021 through March 2022. Demographic, laboratory, microbiologic, antibiotic therapy data, results of follow-up blood cultures (FUBC), hospital length of stay and 30-day readmission were collected. Exclusions were complicated or polymicrobial bacteremia, deaths during treatment, or prolonged hospitalization due to other medical factors. Influences of Infectious diseases (ID) or AS consult on treatment and outcomes were compared to cases with no consult. Continuous variables were analyzed using unpaired t-tests; categorical variables were analyzed using Fischer’s exact test and Chi-square as appropriate. Results 133 cases met inclusion criteria. Demographic and laboratory data are in Table 1. The frequency of bacteria isolated and source of infection are in Figure 1 and Figure 2. ID was significantly more often consulted for central line infections (17% vs 3%, p=0.01), and significantly less frequently involved in urinary tract infections (39% vs 69%, p=0.009). While total LOT were similarly longer than current literature supports (11.7 vs 12.5 days, p=0.2644), cases without ID consultation received significantly more days of oral treatment (4.7 vs 7.1 days, p=0.0275). There were no significant differences between receipt and no receipt of AS recommendations. Conclusion GNB continued to receive longer LOTs than current literature recommends, with longer IV durations recommended by ID consultants compared to those without ID consult. Educational initiatives regarding the safety of shorter LOT for GNB, including the efficacy of oral antibiotics, are needed and should include ID specialists. Disclosures All Authors: No reported disclosures.

895. Comparing Antibiotic Durations in Acute Appendicitis After Source Control

Abstract Background Community-acquired acute appendicitis is a common intra-abdominal infection that often requires surgical intervention and antibiotics. Despite guideline recommendations for narrow-spectrum regimens and shorter durations, broad-spectrum agents are frequently used for extended durations in community-acquired cases of appendicitis. Methods We conducted a retrospective chart review of 95 adult patients admitted to a community hospital in rural northern Michigan with acute appendicitis with or without perforation who underwent source control and received at least 72 hours of antibiotics after source control. Patients were assigned to a short course group (4-7 days) or a long course group (≥ 8 days). Total antibiotics is the sum of the inpatient duration and outpatient duration after source control. The primary outcome was hospital readmission within 30 days of discharge due to complications related to appendectomy or antibiotic failure. Secondary outcomes included hospital mortality, surgical site infection within 30 days, additional source control needed during initial stay, number of patients receiving piperacillin-tazobactam, and proportion of patients who received guideline concordant duration of therapy. Baseline characteristics between treatment groups Results The primary outcome was met in 1/32 patients (3.13%) from the 4–7 day group and 4/63patients (6.35%) in the ≥8-day group (P = 0.66). There were no cases of mortality. Surgical site infection occurred in 1/63 patients (1.6%) in the ≥8-day group (P = 1). Additional source control was needed in 1/32 patients (3.13%) from the 4-7 day group and 3/63 patients (4.76%) in the ≥ 8 day group (P = 1). Piperacillin-tazobactam was prescribed to 21/32 patients (65.6%) in the 4-7-day group and 42/63 patients (67%) in the ≥ 8day group (P =0.91) Piperacillin-tazobactam was appropriately used in 1/21 patient (4.76%) in the 4-7 day group and 6/42 patients (9.5%) in the ≥ 8 day group (P = 0.41). Outcomes Results of the primary outcome and the piperacillin/tazobactam based secondary outcomes Treatment Duration Between Groups Comparison of total treatment duration between groups with inpatient and outpatient averages Total Antibiotic Duration Frequency Distribution of total antibiotic days of patients analyzed in this study Conclusion In patients with community-acquired acute appendicitis with or without perforation who had undergone adequate source control, outcomes were similar between a 4-7 day course of antibiotics and ≥ 8 day course. Piperacillin-tazobactam was often prescribed for community-acquired appendicitis cases despite guideline recommendations. Disclosures All Authors: No reported disclosures.

Prompt Identification of Sepsis on Hospital Floors: Are Healthcare Professionals Ready for the Implementation of the Hour-1 Bundle?

Early intervention in sepsis management with recognized therapeutic targets may be effective in lowering sepsis-related morbidity and mortality, although this necessitates timely identification of sepsis by healthcare professionals. The present study aimed to assess knowledge levels, attitudes, and agreement among physicians regarding the Surviving Sepsis Campaign (SSC) guidelines (more specifically, the Hour-1 bundle). A quantitative, descriptive, cross-sectional study was conducted among physicians working in different clinical settings in Karachi, Pakistan, using a self-administered questionnaire. The mean cumulative knowledge score of the respondents towards SSC was 6.8 ± 2.1 (out of 10), where a total of n = 127 respondents (51.62%) had a strong understanding of the SSC guidelines, compared to n = 78 (31.7%) and n = 41 (16.7%) respondents with fair and inadequate knowledge, respectively. The majorly known bundle elements by the respondents were to administer broad-spectrum antibiotics (89.8%, n = 221), the need for taking blood cultures before administering antibiotics (87.8%, n = 216), and measurement of blood lactate levels (75.6%, n = 186). Experienced physicians were more likely to use norepinephrine as the first-choice vasopressor (p < 0.001). Female respondents were more likely to consider the duration of antibiotic therapy to be determined according to the site of infection, the microbiological etiology, the patient’s response to treatment, and the likelihood of achieving adequate source control (p = 0.001). The current study concluded that respondents had an optimistic approach and frequently practice in accordance with the SSC guidelines, while some respondents were not up to date with the most recent guidelines. There is a need for further interventions and continuous medical education to encourage physicians towards appropriate use of the recommended guiding principles for improving treatment outcomes in sepsis patients.

S2496 Endoscopic Source Control of Gram-Negative Bacteremia Secondary to Foreign Body Ingestion - A Rare Case

Introduction: Foreign body (FB) ingestion is usually observed in the pediatric population; however, adult cases of FB ingestion are not uncommon. Usual FB culprits seen in adults include fish bones, chicken bones, and dentures. Possible complications include dysphagia, complete occlusion with risk of aspiration, and perforation. Such complications warrant retrieval of FB via endoscopic removal or surgical on case-to-case basis. We present a very rare case of FB ingestion resulting in bacteremia necessitating endoscopic removal leading to source control. Case Description/Methods: The patient is a 58-year-old male with a past medical history of diabetes mellitus, hypertension, and chronic venous stasis. He was initially admitted for sepsis secondary to cellulitis and had to be readmitted due to cultures from the initial admission being positive for slow-growing gram-negative anaerobic rods (GNAR). The most common sources of GNAR are recognized to be genitourinary and gastrointestinal in origin. The patient had no history of benign prostatic hyperplasia, and denied any urinary complaints, with negative urine cultures from the initial admission. The patient did not have any abdominal complaints either; however, cross-sectional abdominal imaging was obtained to assess for any intra- abdominal collections/abscess, which surprisingly showed a 5.3 cm tubular radiopaque focus in the cecum suggestive of a foreign body. Blood cultures from the second admission also grew GNAR, which speciated into capnocytophaga. Gastroenterology was consulted to assist with endoscopic evaluation of this finding with possible retrieval of the foreign body. Colonoscopy was attempted and a chicken bone was found in the cecum which was successfully removed with a snare. Possible inflammation of this bowel segment from cecal trauma could have resulted in transient translocation of the bacteria from the cecum with resultant bacteremia. Subsequent blood cultures after FB removal were negative suggesting adequate source control. Discussion: GNAR bacteremia warrants workup for genitourinary and gastrointestinal sources. Our case highlights a rare clinical scenario where FB ingestion led to GNAR bacteremia. Though this is a very rare phenomenon, clinicians investigating the causes of GNAR bacteremia should have a broad differential in cases where the culprit is not obvious. Timely identification of the GNAR source and its control is very crucial in treating such population.

Oral sequential therapy in the treatment of post-surgical epidural abscess and subdural empyema.

The management of post-surgical subdural empyema and subdural abscess is not standardised. The objective was to analyse the efficacy and safety of oral sequential therapy (OST). Retrospective observational study in a tertiary hospital in Vigo (Spain). We included adult patients with subdural abscess or epidural empyema with microbiological isolation. Clinical and demographic variables, isolated microorganisms and treatment regimens were included, as well as mortality and adverse effects during the follow-up period. Thirty patients were reviewed, two died due to causes other than infection. Six-month recurrence rate was 2/28 and all other patients (26/28) had clinical cure at the end of the treatment. The commonest isolated microorganisms were Gram-positive, especially Staphylococcus aureus. The most widely used oral antibiotic was trimethoprim-sulfamethoxazole (80%). No side effects related to oral treatment were observed. After adequate source control, OST can be a safe practice in the management of post-surgical epidural abscess and subdural empyema.

Duration of Antibiotic Therapy in Necrotizing Soft Tissue Infections: Shorter is Safe.

Background: Early debridement improves outcome in necrotizing soft tissue infection (NSTI), but there is no consensus on duration of antimicrobial therapy. We recently changed practice to discontinue antibiotic agents early with a goal of 48 hours after adequate source control. We hypothesized that discontinuing antibiotic agents after a short course is safe in the treatment of NSTI. Patients and Methods: This was a prospective study of patients with NSTI comparing short duration of antibiotic agents to a control population after a change in practice. In 2018 we began discontinuing antibiotic agents within 48 hours of source control (absence of cellulitis and no evidence of active infection). Previously, antibiotic duration was at the discretion of the attending surgeon (generally 7-10 days). Patients were excluded from analysis if they were initially debrided at a referring facility, immune compromised, or died prior to source control. Patient characteristics and outcomes were evaluated. The primary outcome was treatment failure requiring antibiotic agents to be restarted with or without further debridement of infected tissue. Secondary outcomes included the duration of antibiotic therapy after source control. Results: We evaluated 151 patients; 119 admitted between January 1, 2011 and January 31, 2018 (PRE) and 32 admitted after January 31, 2018 (POST). Patients were not statistically different regarding characteristics, admission physiologic variables, and comorbidities. The median duration of antibiotic agents after source control in the PRE group was 180.3 hours (interquartile range [IQR], 100.7-318.8) versus 48 hours (IQR, 32.3-100.8) in the POST group (p < 0.01). Patients in each group were treated as described above, and treatment failure occurred in seven (5.9%) PRE patients and two (6.3%) POST (99.3% post hoc power at non-inferiority limit 20%, significance p < 0.05). Thirty-day all-cause mortality was not different between groups (6.7% vs. 6.3%; p = 0.94). Conclusions: Short-duration (48 hours) antibiotic agents after NSTI source control is as safe and effective as a longer course.

Mass spectrometry in research laboratories and clinical diagnostic: a new era in medical mycology.

Diagnosis by clinical mycology laboratory plays a critical role in patient care by providing definitive knowledge of the cause of infection and antimicrobial susceptibility data to physicians. Rapid diagnostic methods are likely to improve patient. Aggressive resuscitation bundles, adequate source control, and appropriate antibiotic therapy are cornerstones for success in the treatment of patients. Routine methods for identifying clinical specimen fungal pathogen are based on the cultivation on different media with the subsequent examination of its phenotypic characteristics comprising a combination of microscopic and colony morphologies. As some fungi cannot be readily identified using these methods, molecular diagnostic methods may be required. These methods are fast, but it can cost a lot. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) is suitable for high-throughput and rapid diagnostics at low costs. It can be considered an alternative for conventional biochemical and molecular identification systems in a microbiological laboratory. The reliability and accuracy of this method have been scrutinized in many surveys and have been compared with several methods including sequencing and molecular methods. According to these findings, the reliability and accuracy of this method are very high and can be trusted. With all the benefits of this technique, the libraries of MALDI-TOF MS need to be strengthened to enhance its performance. This review provides an overview of the most recent research literature that has investigated the applications and usage of MT-MS to the identification of microorganisms, mycotoxins, antifungal susceptibility examination, and mycobiome research.

Predictors of Digital Amputation in Diabetic Patients With Surgically Treated Finger Infections.

Diabetes is a well-established risk factor for severe digital infection, and patients are more likely to require digital amputation for adequate source control. This study aims to identify factors predictive of digital amputation compared with preservation in patients with diabetes who present with surgically treated finger infections. Current Procedural Terminology (CPT) and International Classification of Diseases Versions 9 and 10 (ICD-9/10) databases from a single academic medical center were queried to identify patients with type 1 or type 2 diabetes mellitus who underwent surgical treatment in the operating room for treatment of a digital infection from 2010 to 2020. Electronic medical records were reviewed to obtain historical and acute clinical variables at the time of hospital presentation. Bivariate and multivariable regression were used to identify factors associated with amputation. In total, 145 patients (61 digital amputation, 84 digital preservation) met inclusion criteria for this retrospective cohort study. Mean hospital stay was 6 days, and the average patient underwent 2 operations. Multivariable analysis revealed that the presence of osteomyelitis, ipsilateral upper extremity dialysis fistula, end-stage renal disease, and vascular disease each had significant independent predictive value for amputation rather than digital preservation. Digital amputation is common in the setting of diabetic finger infection. The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. Further study should focus on clinical factors affecting surgical decision making and how the treatment rendered affects patient outcomes.

Abstract 32: Acute suppurative thyroiditis in HIV – Non typhoidal salmonella: Case report and review of the literature

Background: Acute suppurative thyroiditis is a rare disease of thyroid gland. Incidence is less than 1% in immunocompromised hosts. Most common pathogens isolated are Gram positive aerobic cocci. Infections with Gram negative facultative aerobes such as Salmonella are rare.Case Presentation: A 39-year-old retropositive female presented with rapid enlargement of swelling in front of neck, fever and weight loss x 2 weeks. Examination revealed symmetric diffuse swelling that moved with degglutition with overlying erythema and tenderness. Relevent investigations done and CT neck revealed thyroid abscess, covid -19 RAT positive status, microcytic hypochromic anemia. A needle aspiration for symptomatic and diagnostic purposes was performed. Cultures grew Nontyphoidal salmonella. She was treated with 4-week course of oral antibiotics.Conclusion: A thyroid abscess is rare, potentially life threatening disease. However, a high index of suspicion is required to make diagnosis and differentiate from subacute thyroiditis a relatively benign condition. Management is directed at minimizing morbidity. The mainstay treatment is medical, but surgery is sometimes necessary to achieve adequate source control, particularly when complications arise.Keywords: Acute suppurative thyroiditis, COVID 19 infection, retrovirus, Salmonella sp., thyroid abscess