Administration Of Broad-spectrum Antibiotics Research Articles

Prehospital management of sepsis with IV antibiotics: a UK literature review

Background: Sepsis mortality rates increase if prompt treatment is not administered. The Sepsis Six care bundle advocates the early administration of broad-spectrum intravenous antibiotics to reduce mortality and morbidity but this is not routinely practised nationally in UK prehospital settings, although UK ambulance services regularly attend septic patients. Aims: A literature review was conducted to investigate knowledge around paramedics' ability to recognise and treat prehospital sepsis with intravenous antibiotics in the UK and the impact of this on patient outcomes. Methods: A search was conducted and the three eligible studies included underwent a structured critical appraisal and thematic analysis. Findings: Three themes emerged: diagnostic accuracy; administration of prehospital antibiotics; and impact on patient outcomes. Conclusion: There is a significant gap in evidence in this field in the UK, and it was difficult to make generalised recommendations from the studies. Paramedics have the potential to be highly accurate in the recognition of sepsis and administer intravenous antibiotics when following a protocol. No major studies measure patient outcomes following prehospital intravenous antibiotics administration by paramedics in the UK and large empirical studies should be conducted to assess the effectiveness of this.

Prevalence and predictors of multidrug-resistant bacteremia in liver cirrhosis.

Improved knowledge of local epidemiology and predicting risk factors of multidrug-resistant (MDR) bacteria are required to optimize the management of infections. This study examined local epidemiology and antibiotic resistance patterns of liver cirrhosis (LC) patients and evaluated the predictors of MDR bacteremia in Korea. This was a retrospective study including 140 LC patients diagnosed with bacteremia between January 2017 and December 2022. Local epidemiology and antibiotic resistance patterns and the determinants of MDR bacteremia were analyzed using logistic regression analysis. The most frequently isolated bacteria, from the bloodstream, were Escherichia coli (n = 45, 31.7%) and Klebsiella spp. (n = 35, 24.6%). Thirty-four isolates (23.9%) were MDR, and extended-spectrum beta-lactamase E. coli (52.9%) and methicillin-resistant Staphylococcus aureus (17.6%) were the most commonly isolated MDR bacteria. When Enterococcus spp. were cultured, the majority were MDR (MDR 83.3% vs. 16.7%, p = 0.003), particularly vancomycin-susceptible Enterococcus faecium. Antibiotics administration within 30 days and/or nosocomial infection was a significant predictor of MDR bacteremia (OR: 3.40, 95% CI: 1.24-9.27, p = 0.02). MDR bacteremia was not predicted by sepsis predictors, such as positive systemic inflammatory response syndrome (SIRS) or quick Sequential Organ Failure Assessment (qSOFA). More than 70% of strains that can be treated with a third-generation cephalosporin have been cultured. In cirrhotic patients, antibiotic administration within 30 days and/or nosocomial infection are predictors of MDR bacteremia; therefore, empirical administration of broad-spectrum antibiotics should be considered when these risk factors are present.

L-fucose and fucoidan alleviate high-salt diet-promoted acute inflammation.

Excessive salt intake is a widespread health issue observed in almost every country around the world. A high salt diet (HSD) has a strong correlation with numerous diseases, including hypertension, chronic kidney disease, and autoimmune disorders. However, the mechanisms underlying HSD-promotion of inflammation and exacerbation of these diseases are not fully understood. In this study, we observed that HSD consumption reduced the abundance of the gut microbial metabolite L-fucose, leading to a more substantial inflammatory response in mice. A HSD led to increased peritonitis incidence in mice, as evidenced by the increased accumulation of inflammatory cells and elevated levels of inflammatory cytokines, such as tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), and monocyte chemotactic protein-1 (MCP-1, also known as C-C motif chemokine ligand 2 or CCL2), in peritoneal lavage fluid. Following the administration of broad-spectrum antibiotics, HSD-induced inflammation was abolished, indicating that the proinflammatory effects of HSD were not due to the direct effect of sodium, but rather to HSD-induced alterations in the composition of the gut microbiota. By using untargeted metabolomics techniques, we determined that the levels of the gut microbial metabolite L-fucose were reduced by a HSD. Moreover, the administration of L-fucose or fucoidan, a compound derived from brown that is rich in L-fucose, normalized the level of inflammation in mice following HSD induction. In addition, both L-fucose and fucoidan inhibited LPS-induced macrophage activation in vitro. In summary, our research showed that reduced L-fucose levels in the gut contributed to HSD-exacerbated acute inflammation in mice; these results indicate that L-fucose and fucoidan could interfere with HSD-promotion of the inflammatory response.

Porcine Monocyte DNA Traps Formed during Infection with Pathogenic Clostridioides difficile Strains.

Clostridioides (Clostridium) difficile is an enteric pathogen of several mammalian species including man, frequently involving nosocomial resurgence, following oral administration of broad-spectrum antibiotics, but also with human-to-human infection occurring, and neonatal pigs with zoonotic transmission. To date, the immune response to C. difficile has mostly focused on neutrophils and cytokine/chemokines, particularly in human infection. The neonatal pig is now recognized as a valuable model for human infection. We show that porcine monocytes respond to C. difficile differently compared with many other bacterial infections. Infection of porcine monocytes with human C. difficile strains CD630 (Ribotype 078) or R20291 (Ribotype 027) for 3 or 24 h post-infection (pi) resulted in a lack of oxidative burst or nitrite ion production when compared to uninfected controls (p > 0.05). The survival dynamics of both CD630 and R20291 in monocytes were similar with intracellular bacterial numbers being similar at 3 h pi and 24 h pi (p > 0.05). However, we show that porcine monocytes entrap C. difficile via extracellular DNA traps. This process began as early as 3 h pi, and at 24 h pi the nuclei appeared to be depleted of DNA, although extracellular DNA was associated with the cell membrane. Our preliminary study also suggests that entrapment of C. difficile by extracellular DNA may occur via a process of monocyte etosis.

REGγ Mitigates Radiation-Induced Enteritis by Preserving Mucin Secretion and Sustaining Microbiome Homeostasis

Radiation-induced enteritis, a significant concern in abdominal radiation therapy, is closely associated with gut microbiota dysbiosis. The critical mucus layer plays a pivotal role in preventing the translocation of commensal and pathogenic microbes. While the significant expression of REGγ in intestinal epithelial cells is well established, its role in modulating mucus layer and gut microbiota remains enigmatic. Current study revealed notable changes in gut microorganisms and metabolites in irradiated mice lacking REGγ, as opposed to wild-type mice. Concomitant with gut microbiota dysbiosis, REGγ deficiency facilitated the infiltration of neutrophils and macrophages, thereby exacerbating intestinal inflammation following irradiation. Furthermore, fluorescence in situ hybridization assays unveiled an augmented proximity of bacteria to intestinal epithelial cells in REGγ knockout mice post-irradiation. Mechanistically, deficiency of REGγ led to diminished goblet cell populations and reduced expression of key goblet cell markers, Muc2 and Tff3, observed in both murine models, mini-gut organoid system and human intestinal goblet cells, indicating the intrinsic role of REGγ within goblet cells. Interestingly, while administration of broad-spectrum antibiotics didn't impact the alteration of goblet cell numbers and MUC2 secretion, it did effectively attenuate inflammation levels in the ileum of irradiated REGγ absent mice, aligning them with their wild-type counterparts. Collectively, these findings highlight the crucial contribution of REGγ in counteracting radiation-triggered microbial imbalances and cell-autonomous regulation of mucin secretion.

Pathogens and their resistance behavior in necrotizing fasciitis.

Necrotizing fasciitis (NF) is a rare but life-threatening condition in which extensive soft tissue destruction can occur very quickly if left untreated. Therefore, timely broad-spectrum antibiotic administration is of prognostic importance in addition to radical surgical debridement. This study evaluates the cases of NF in our hospital during the last ten years retrospectively with respect to the pathogens involved and their antimicrobial resistance. This approach aims to provide guidance regarding the most targeted initial antibiotic therapy. We performed a retrospective microbiological study evaluating pathogen detection and resistance patterns including susceptibility testing of 42 patients with NF. Type 1 NF (polymicrobial infection) occurred in 45% of the patients; 31% presented type 2 NF (monomicrobial infection). The most common pathogens detected were E. coli, staphylococci such as Staphylococcus aureus and Staphylococcus epidermidis, Proteus mirabilis, enterococci, and streptococci such as Streptococcus pyogenes. Twelve percent presented an additional fungus infection (type 4). Ten percent showed no cultivation. Two percent (one patient) presented cocci without specification. Most pathogens were sensitive to antibiotics recommended by guidelines. This confirms the targeting accuracy of the guidelines. Further studies are necessary to identify risk factors associated with multidrug resistant infections requiring early vancomycin/meropenem administration.

Leukemoid reaction in paraplegic male with pressure injuries: A case report

<abstract> <p>Leukemoid reaction is defined as leukocytosis of more than 50 × 10<sup>3</sup> cells/µL of blood, which is a physiological response to stress or infections, as opposed to a primary blood malignancy (leukemia). It is seen in various conditions including sepsis, burns, and inflammatory states associated with systemic inflammatory response syndrome (SIRS). Here, we report a 40-year-old cachexic and paraplegic male who presented with a leukemoid reaction and pressure injuries at the gluteal region with a total leukocyte count (TLC) of 103 × 10<sup>3</sup> cells/µL of blood and reactive thrombocytosis. A bone marrow (BM) examination revealed no malignancy. With the administration of broad-spectrum antibiotics, the TLC after two weeks at the time of discharge was reduced to 18.83 × 10<sup>3</sup> cells/µL of blood and the patient was referred to surgical unit for further management of pressure injuries. BM examination is mandatory in patients with suspected malignancies; however, for bed-bound patients with longer durations, pressure injuries should be inspected and treated with broad spectrum antibiotics before performing invasive procedures such as a BM examination.</p> </abstract>

Clinical and Microbiological Spectrum of Invasive Trichosporonosis at a Tertiary Care Institute: A Retrospective Observational Study

Introduction: Invasive trichosporonosis was considered rare in the past decades, but it has emerged as an opportunistic pathogen causing invasive infections in immunocompromised patients. It can colonise various parts of the body, and it is important to differentiate between colonisation and infection. Moreover, knowledge of the epidemiology and risk factors associated with the disease is limited. Its inherent resistance to echinocandins poses a therapeutic challenge in treating patients. If not treated appropriately, it may lead to disseminated infections. Aim: To understand the clinical and microbiological spectrum of infections caused by Trichosporon spp. Materials and Methods: This retrospective observational study was conducted in the Department of Microbiology at Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India for a peroid of one year period from January 2019 to December 2019. The study analysed demographic data such as age, sex, risk factors, clinical features, microbiological diagnosis, treatment, and patient outcomes related to invasive trichosporonosis from the case records. The final sample size was 14 cases. Samples were processed for both aerobic and fungal cultures. The samples were inoculated into Chromogenic agar plates (bioMeriux), 5% sheep blood agar plates (bioMeriux), and Sabouraud dextrose agar. The plates were incubated at 37°C for 48 hours. Culture identification was performed using the Vitek® 2 compact system with the yeast panel YST, and antifungal susceptibility was determined by Broth Microdilution (BMD). Descriptive statistics were used for analysis, and categorical data were described as frequencies with percentages. The data was entered into a Microsoft Excel sheet and analysed using Statistical Packages for the Social Sciences (SPSS) Version 20.0. Results: During the study period, there were 14 cases of invasive trichosporonosis. The predominant age group was 60-70 years. Risk factors included the administration of broad-spectrum antibiotics in 13 (92.8%) of patients, followed by prolonged Intensive Care Unit (ICU) stay in 8 (57.1%) of the patients. Trichosporon spp. were isolated from urine in 10 (71.4%) cases, blood in 2 (14.2%) cases, and tissue in 2 (14.2%) cases. Trichosporon asahii was the predominant species isolated in 12 (85.7%) patients. All isolates were sensitive to voriconazole and amphotericin B. Mortality was reported in 5 (35.7%) of the patients. Conclusion: In present study, Trichosporon spp. was predominantly isolated from urine in the majority of patients. The pathogen was isolated from patients with various risk factors. Hence, proper identification of the pathogen, understanding its clinical significance, and determining antifungal susceptibility would aid in the appropriate management of patients.

A Retrospective Study on Mucormycosis and Other Fungal Infections Associated With COVID-19

A drastic increase in mucormycosis and other opportunistic infections was observed during the Covid-19 pandemic owing to multisystem involvement and related Immunosuppression. This retrospective study was carried out among SARS-COV-2 infected patients having invasive fungal infections [IFI] admitted to a tertiary care hospital in the southern part of India, for one year from August 2020. Among a total of 115 suspected cases, 54 patients were diagnosed to have IFI, during or immediately after Covid 19 disease. The most common fungal pathogens isolated were Mucorales (57.4%) followed by Aspergillus spp. (20.3%), Candida spp. (9.2%) and mixed infections (13.1%). Important predisposing factors identified were diabetes mellitus (70.7%), prolonged use of corticosteroids (85%), and administration of broad-spectrum antibiotics (90%). The predominant species identified among the diagnosed mucormycosis cases were Rhizopus spp. (54%) and Mucor spp. (25%); the site of involvement was paranasal sinus (70.1%), and rhino-orbital in 48.7% of the cases. Increased incidence of invasive Aspergillus infection in COVID-19 was seen mainly among ICU patients on ventilators, with Covid-19 induced lung damage. Common presentations were Chronic Pulmonary Aspergillosis, Rhino sinusitis, and Asthma. Of the total IFI, 9.2 % were caused by Candida spp. Of which 75% were due to Non- albicans candida species. Candidemia was the major presentation observed (90%). Of the patients with IFI, 90 % of them recovered, and the rest of them (7.4%) succumbed to infection. Of the patients with rhino-orbital mucormycosis who survived, 10 (39 %) had facial disfigurement and 11 (45 %) had a loss of vision.

A Multicentre, Randomized, Double-Blinded, Phase 2b Study Evaluating the Efficacy and Safety of MaaT033, an Oral, Pooled Microbiome Ecosystem Therapy in Patients Undergoing Allogenic Hematopoietic Cell Transplantation to Improve Overall Survival: The Phoebus Trial

Background and significance: Allogenic hematopoietic cell transplantation (alloHCT) is a well-established therapy for various life-threatening hematologic malignancies. The use of alloHCT is constantly increasing, with nearly 20 000 transplantations reported to the European Society for Blood and Marrow Transplantation (EBMT) per year. However, this treatment is limited by high morbidity and mortality, mainly related to relapse, infection, graft-versus-host disease (GvHD), and conditioning-related toxicity. Several pioneering studies have shown that the diversity of the gut microbiota of patients not only correlates with the occurrence of medical complications after alloHCT, including GvHD (Jenq et al. 2012, Stein-Thoeringer et al. 2019) and bloodstream infections (Taur et al. 2012), but also with relapse of the underlying disease (Peled et al. 2017). Gut microbiota diversity restoration with fecal microbiotherapy could be an effective treatment to improve patients' clinical outcomes including overall survival (OS) after alloHCT, through the prevention and resolution of gut microbiota dysbiosis. MaaT033 is a freeze-dried, full-ecosystem, high-diversity, fecal microbiota medicinal product, formulated as delayed-release capsules and derived from pooled allogenic human fecal material. The PHOEBUS trial is a phase 2b study to evaluate the efficacy of MaaT033 in improving survival of adult alloHCT patients (Clinicaltrials.gov identifier: NCT05762211) Study design and Methods: 387 subjects aged ≥ 50 years with hematologic malignancies for which an alloHCT is indicated will be randomized 1:1 to receive either MaaT033 (experimental arm) or placebo (control arm) before initiation of the conditioning regimen and after hematopoietic recovery following alloHCT. Stratification of patients will be performed based on disease risk index (low-intermediate versus high-very high) and donor-host compatibility (HLA-identical versus HLA-mismatch). Inclusion criteria include age ≥ 50 years, alloHCT with a reduced-toxicity or reduced-intensity conditioning regimen, neutrophils > 0.5 G/L, and administration of broad-spectrum antibiotics within the last 90 days prior to inclusion. Exclusion criteria comprise non-myeloablative conditioning regimen, conventional myeloablative conditioning regimen, in-vitro T-cell depletion, alloHCT with cord blood cells, alloHCT from an unrelated donor with ≥ 3/10 HLA-mismatches, use of alemtuzumab, vedolizumab or abatacept for GvHD prophylaxis, history of chronic digestive disease. The primary endpoint is to evaluate OS at 12 months after randomization. Secondary endpoints will include evaluation of the safety of MaaT033, GvHD-free survival, cumulative incidence of acute GvHD and chronic GvHD, non-relapse mortality, relapse-free survival, GvHD-free, relapse-free survival, the proportion of patients with severe infections, gut microbiota composition, and quality of life. Exploratory endpoints will describe the impact of MaaT013 on immune recovery, the nutritional status of the patients, and resource utilization. Patients will receive MaaT033 or placebo (3 capsules per day) for 1 week before the start of the conditioning regimen. Experimental treatment (3 capsules per day) will be resumed at neutrophil recovery and pursued up to 90 days after alloHCT. Patients will be followed monthly up to 6 months post alloHCT and then every 3 months up to 12 months. The study is approved in France and Germany; expansion to other countries is planned for 2024. Study start is expected in September 2023.

Esketamine mitigates cognitive impairment following exposure to LPS by modulating the intestinal flora/subdiaphragmatic vagus nerve/spleen axis

IntroductionSusceptibility to secondary infection often increases after primary infection. Secondary infections can lead to more severe inflammatory injuries; however, the underlying mechanisms are not yet fully elucidated. ObjectiveTo investigate whether esketamine treatment immediately after primary lipopolysaccharide (LPS) exposure could alleviate cognitive impairment caused by secondary infection. MethodsMice were injected intraperitoneally (IP) with LPS (5 mg/kg) 10 days apart. Esketamine (10, 15, or 30 mg/kg) was administered IP immediately after the primary LPS injection. Splenectomy or subdiaphragmatic vagotomy (SDV) was performed 7 days before secondary LPS exposure or broad-spectrum antibiotic administration. ResultsSplenomegaly was observed after the primary LPS injection on Days 3 and 10. Splenomegaly was attenuated by treatment with 30 mg/kg esketamine. Esketamine treatment prevented increased plasma proinflammatory cytokines levels and cognitive dysfunction induced by secondary LPS exposure. Mice that underwent splenectomy or SDV had lower proinflammatory cytokines levels, higher hippocampal brain-derived neurotrophic factor (BDNF) levels, and improved cognitive function 1 day after secondary infection, which was not further improved by esketamine. Fecal microbiota transplantation (FMT) from endotoxic mice treated with esketamine attenuated hippocampal BDNF downregulation and cognitive dysfunction only in pseudo germ-free (PGF) mice without splenectomy. FMT with fecal suspensions from esketamine-treated endotoxic mice abrogated splenomegaly only in PGF mice without SDV. Blocking BDNF signaling blocked esketamine’s ameliorating effects on secondary LPS exposure-induced cognitive dysfunction. ConclusionThe intestinal flora/subdiaphragmatic vagus nerve/spleen axis-mediated hippocampal BDNF downregulation significantly affected secondary LPS-induced systemic inflammation and cognitive dysfunction. Esketamine preserves cognitive function via this mechanism.

Optimal Management of Patients with Phlegmonous Esophagitis: A Systematic Review and Meta-Analysis.

To assess the characteristics and prognosis-influencing factors of phlegmonous esophagitis, a rare condition marked by suppurative inflammation of the esophageal submucosa and muscular layers. Effective management strategies for phlegmonous esophagitis are lacking. This study aims to systematically review cases to better understand the disease's features and prognostic determinants. A systematic search was performed using PubMed/MEDLINE and Google Scholar from inception to 20 April 2023. Phlegmonous esophagitis case reports and studies with patient information were included; clinical manifestations, laboratory results, imaging findings, other diagnostic findings, and outcomes were analyzed. A pooled analysis was performed to investigate mortality-related risk factors. A total of 35 cases of phlegmonous esophagitis were selected from 31 case reports and 2 case series (median age, 57.0 years; male, 54.3%). The patients presented various clinical symptoms, with neck-to-epigastric pain and dysphagia being the most common. Comorbid diabetes mellitus was a major predisposing factor; one-third of the patients had no previous medical history. Computed tomography (CT) and endoscopic examinations were predominantly used for phlegmonous esophagitis diagnosis. Radiological findings showed that the upper and middle esophagus were most frequently involved. Treatments included administration of broad-spectrum antibiotics and drainage via endoscopy or surgery. There were three cases of mortality, and non-survivors tended to have shorter hospital stays, indicating rapid disease progression. In logistic regression, thoracic surgery was a significant mortality-related risk factor (odds ratio, 19.30; 95% confidence interval, 1.33-282.00, p = 0.03). Advancements in CT and endoscopy have led to less-invasive diagnostic and treatment methods for phlegmonous esophagitis. Endoscopic localized abscess treatment is associated with positive outcomes.

The hidden star: mastoiditis as a late sequela of retained foreign body in the nose

BackgroundAcute mastoiditis is an intratemporal complication due to acute otitis media (AOM). Common risk factors include young age (often < 24 months), high values of C-reactive protein and previous antibiotic therapy, previous middle ear infection, or history of ear surgery. The main factor of acute mastoiditis is obstruction of the aditus antrum by granulation tissue or mucosa edema, inhibiting purulent drainage from the mastoid. Retained foreign body in the nose is a rare indirect cause of acute mastoiditis. It may be due to mucosal inflammation and accumulation of secretion causing nasal tract or nasopharyngeal infection leading to otitis media and later manifesting as an intratemporal complication.Case presentationWe report a case of acute mastoiditis as a late sequela of retained foreign body in the nose, and we also emphasize the incidental radiological finding of a star-shaped foreign body in the nose, which was a miss during the initial presentation. Further questioning revealed a history of recurrent unilateral blood-stained, foul-smelling nasal discharge, which was left untreated for years, leading to a delayed presentation of acute mastoiditis. After removing the foreign body and broad-spectrum antibiotic administration, complete disease resolution was achieved.ConclusionAlthough rare, retained foreign bodies of the nose must be ruled out in certain cases of mastoiditis. A thorough history with a high index of clinical suspicion is recommended for early diagnosis to prevent complications.

The Role of Fecal Microbiota Transplantation in the Allogeneic Stem Cell Transplant Setting.

Microbiota changes during allogeneic hematopoietic stem cell transplantation has several known causes: conditioning chemotherapy and radiation, broad-spectrum antibiotic administration, modification in nutrition status and diet, and graft-versus-host disease. This article aims to review the current knowledge about the close link between microbiota and allogeneic stem cell transplantation setting. The PubMed search engine was used to perform this review. We analyzed data on microbiota dysbiosis related to the above-mentioned affecting factors. We also looked at treatments aimed at modifying gut dysbiosis and applications of fecal microbiota transplantation in the allogeneic stem cell transplant field, with particular interest in fecal microbiota transplantation for graft-versus-host disease (GvHD), multidrug-resistant and clostridium difficile infections, and microbiota restoration after chemotherapy and antibiotic therapy.

Impact of a sepsis tracking sheet and emergency department pharmacists on sepsis compliance measures: a prospective emergency department analysis.

Compliance with core sepsis measures in Emergency Departments (ED) remains low, with a limited number of prospective trials highlighting strategies for improvement. A prospective historically case-controlled observational analysis assessing the pre- and post -intervention impact of a sepsis tracking sheet (STS) and the involvement of ED pharmacists. PrimaryThe primary outcome was the improvement in compliance with core sepsis measures. SecondaryThe secondary outcome was to assess the frequency of respiratory interventions and mortality with pre-defined strata of fluid resuscitation (≤10, 10-20, 20-30, 30, ≥30cc/kg of ideal body weight). 194 patients were enrolled over a six -month period with a 9.3% all-cause mortality and a 10.3% rate of new respiratory interventions after fluid boluses. Post-STS implementation compliance of repeat lactate measurement was 88% (vs. 33% pre-STS), broad-spectrum antibiotic administration within 3h of presentation improved to 96% (vs. 20% pre-STS), blood cultures were drawn on 98% of patients (vs. 9% pre-STS), and 30cc/kg fluid boluses were administered to 39% of patients (vs. 25% pre-STS). Of the 18 deaths and 21 respiratory interventions, only two patients fell into both categories. Mortality was highest in those patients that received greater than 30cc/kg of fluid resuscitation (50%). Respiratory interventions were greatest in the strata receiving 10-20cc/kg of fluids (47.6%). Patients receiving the lowest fluid aliquots of <10cc/kg had the highest clinical severity scores but did not have higher rates of historical diagnoses of volume overload. The ED -based implementation of a sepsis tracking sheet and the involvement of dedicated ED pharmacists was effective in improving core measures of sepsis compliance. Patients receiving higher fluid aliquots did not experience higher rates of respiratory interventions, though had higher all-cause mortality. No relationship could be identified between patients getting lower aliquots of fluid and prior diagnoses of volume overload.

Laparoscopic approach in postpartum pyoperitoneum: A guide to early rehabilitation.

Sepsis is a leading cause of maternal mortality and morbidity worldwide. Pyoperitoneum is a grave and life-threatening manifestation of puerperal sepsis. Administration of broad-spectrum antibiotics and drainage of pus by laparotomy has long been the cornerstone of treatment for pyoperitoneum in a parturient. In this series of six cases, the successful laparoscopic management of postpartum pyoperitoneum is discussed. The latter offers the advantage of a magnified view of the surgical field, thorough lavage and drainage, and avoidance of long incisions to explore the abdomen, resulting in faster recovery, less pain, greater patient satisfaction, and lower economic burden.

Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study

IntroductionNon-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis.MethodsThe study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon’s preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay.Results30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of—3.80% 97.5% CI (− 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1–4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001).ConclusionsOutpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.

713 Acute Change in qSOFA Score as a Prognostic Tool for Diagnosing Sepsis in Burn Patients

Abstract Introduction Sepsis is a diagnostic challenge in all critically ill patients, but particularly so in the burn patient population. The objective of this study was to evaluate if the modified sepsis-3 criteria defined as an acute change in SOFA score ≥2 was predictive of clinical infection. Methods The hospital database was reviewed between 2016 and 2019 to identify patients who received broad spectrum antibiotics within 2 days of sustaining their injury. Culture specimens taken at the time of antibiotic administration determined presence of a clinical infection. Results Between 2016 and 2019, a total of 98 patients were admitted to the burn unit within 2 days of their injury and received prophylactic meropenum and/or piperacillin/tazobactam for suspicion of clinical infection. When stratified based on an acute change in SOFA score within 48 hours prior to receiving antibiotics, 67 (72%) patients received antibiotics with an acute change in SOFA score ≤1, and 26 (27%) patients received antibiotics with an acute change in SOFA score ≥2. Of those patients with the acute change in SOFA score ≥2, 22 patients (85%) had positive cultures associated with the timing of prophylactic antibiotics, as compared to 60 patients (90%) with a change in SOFA score ≤1 (p value 0.05). Conclusions Our data suggests that the modified sepsis-3 criteria is not a reliable tool for diagnosing burn sepsis. Applicability of Research to Practice Improving our ability to accurately predict sepsis in burn patients can improve patient outcomes and decrease unnecessary administration of broad spectrum antibiotics.

505 Risk Stratification by TBSA for Acute Kidney Injury in Burn Patients Following Combination Antibiotic Therapy

Abstract Introduction Burn patients are susceptible to infections and are often treated with broad-spectrum antibiotics. Vancomycin is a common antibiotic administered alone, or in combination with piperacillin-tazobactam (Pip/Tazo). This combination therapy was associated with increased rates of acute kidney injury (AKI) in burn patients when compared to Vancomycin alone or in combination with other antibiotics. However, recent studies failed to demonstrate these findings. We sought to determine the degree of nephrotoxicity of Vancomycin, Pip/Tazo, and their combination, with burn severity. Methods A retrospective, multi-institutional study was performed utilizing TriNetX Global Health Research Network that encompasses de-identified patient records from 55 health care organization across the US. We identified the population of burn patients between 2000-2020 and stratified them into 3 groups by TBSA &amp;lt; 10%, 10-39%, or 40%+. Patients were further stratified into cohorts by administration of broad-spectrum antibiotics within 3 months of their burn: Vancomycin, Pip/Tazo alone, in combination (Combo), or neither. Cohorts were propensity score matched for age at index, gender, race, ethnicity, and pre-existing conditions that predispose to AKI. We explored patient distribution and conducted a comparative outcome analysis to determine the risk of developing AKI in 7- and 90-day outcome windows. Results Vancomycin and Pip/Tazo were compared to control groups and showed increased risk of AKI in all TBSA groups and time outcomes(p&amp;lt; 0.0001). Before stratifying by TBSA, all burn patients administered combination antibiotics showed increased risk of AKI when compared to control, Vancomycin alone, and Pip/Tazo. In patients under &amp;lt; 10% TBSA, combo antibiotics increased AKI incidence in both 7- and 90-days when compared to all other groups. In the 10-39% TBSA group, combination therapy increased the risk of AKI when compared to Pip/Tazo at 7-days. Increased risk of AKI occurred in the combo group when compared to both Vancomycin and Pip/Tazo in 90-days. In the 40%+ TBSA cohort, combination antibiotics did not increase the incidence of AKI in either time period or when compared to Vancomycin and Pip/Tazo. The results of the comparative analysis are included in Table 1. Conclusions Broad-spectrum antibiotics use in burn patients is associated with increased risk of AKI, this risk is higher with Vancomycin and Piperacillin/Tazobactam combination. Combo therapy increased AKI in &amp;lt; 10% and 10-39% but not 40%+ TBSA. These findings can be used to monitor for early manifestations of AKI when using broad-spectrum antibiotics. Applicability of Research to Practice The decision to initiate antimicrobial therapy is crucial in burn patients as they are already at risk for AKI. TBSA can be a useful tool for guiding risk stratification.

Effective treatment of severe forms of RSV and Pneumocystis jirovecii infections in a child with Down syndrome and acute lymphoblastic leukemia treated with chemotherapy

There has been significant progress in acute lymphoblastic leukemia (ALL) treatment throughout the previous decades. However, infectious complications are still the main problem during cancer treatment. Literature reports show that treatment-related mortality is 2–4% and is mainly related to infection. Here, the authors report a 3-year-old patient with Down syndrome and ALL who was hospitalized in the Department of Pediatric Hematology, Oncology and Transplantology of the Medical University of Lublin. The patient was treated according to the AIEOP-BFM 2017 protocol and developed a severe co-infection of Pneumocystis jiroveci and respiratory syncytial virus during the induction phase of chemotherapy and P. jiroveci re-infection while receiving Protocol II. As a result, chemotherapy was interrupted for 51 and 31 days, respectively. The patient required the administration of broad-spectrum antibiotics, antiviral and antifungal therapy and passive oxygen therapy. Due to a severe clinical condition, the patient was also temporarily hospitalized in the Intensive Care Unit. Research revealed several risk factors for infectious complications in patients with ALL including intensive chemotherapy or Down syndrome. Therefore, despite anti-infective prophylaxis, increased medical vigilance is necessary. In the case of infectious symptoms, early diagnosis and prompt treatment should be implemented to enable the continuation of the ALL therapeutic protocol.