Admission For Intravenous Antibiotics Research Articles

P087Medical management of early pregnancy in emergency departments compared to outpatient: Evaluating a covid-19 institutional policy change to increase healthcare access

<h3>Objectives</h3> To assess the safety and efficacy of prescribing mifepristone and misoprostol for medical management of abnormal early pregnancy in emergency departments (EDs) compared to outpatient management at a complex family planning office, and to compare post-treatment follow-up. <h3>Methods</h3> We conducted a retrospective cohort study after implementing mifepristone and misoprostol prescription in three Bronx, NY EDs during the COVID-19 pandemic's first wave. All patients receiving medical management between April 1, 2020 and March 31, 2021 were reviewed. Outcomes were compared by treatment setting. Induced abortion only occurred in the outpatient setting. Treatment success was defined as pregnancy resolution after one dose of mifepristone and misoprostol. Safety outcomes included emergent interventions and blood transfusion. We assessed rates of post-treatment follow-up. <h3>Results</h3> Some 167 patients received medical management: 33 (19.8%) in the ED and 134 (80.2%) outpatient. ED patients were older (aged 30.9±6.9 vs. 28.1±5.9, p=0.02) and more likely to have Medicaid insurance (81.8% vs. 51.5%, p=0.003). Treatment success occurred for 23 (69.7%) ED and 119 (88.8%) office patients. A multivariate logistic regression adjusting for age, insurance status, and pregnancy diagnosis showed lower odds of treatment success in the ED vs. outpatient setting, but was not statistically significant (adjusted OR (aOR), 0.60; 95% CI, 0.17–2.09; p=0.42). ED safety outcomes included two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Outpatient safety outcomes included one admission for intravenous antibiotics. Follow-up was similar: 28 (84%) ED vs 121 (90.3%) outpatients (p=0.36). <h3>Conclusions</h3> Medical management of abnormal early pregnancy with mifepristone and misoprostol in the ED is effective. Larger studies are needed to better quantify ED safety outcomes.

Bacterial dacryoadenitis: clinical features, microbiology, and management of 45 cases, with a recent uptick in incidence

ABSTRACT Purpose To review the clinical features, microbiology, management, and incidence of bacterial dacryoadenitis at our institution. Methods This was a case series examining patients with bacterial dacryoadenitis from 2004 to 2020. Charts were reviewed for demographics, comorbidities, presenting symptoms and signs, radiology, microbiology, and management. Main outcomes included need for surgical intervention or inpatient admission. Results Forty-five patients with bacterial dacryoadenitis had a mean age of 46.1 years. Presenting symptoms included eyelid edema (100%), extraocular motility restriction (53.3%), and purulent discharge (75.5%). Based on computed tomography or magnetic resonance imaging, 9 (20.5%) patients presented with definite abscess and 15 (34%) presented with a phlegmon or early abscess. Eleven patients (24.4%) required surgical drainage. Twenty patients (44.4%) required admission, for an average stay of 4 days (range 2–8 days). Common organisms included Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Presence of an early abscess or phlegmon correlated with need for drainage (p < 0.01). Extraocular motility restriction correlated with need for drainage (p = 0.02) and admission (p = 0.05). The incidence of bacterial dacryoadenitis at our institution increased as a percentage of confirmed dacryoadenitis cases; from 2004 to 2010 the incidence was 0 to 9.1% per year, while from 2010 to 2019 the incidence ranged from 7.7 to 36.2%. In 2019, our institution had 17 cases (incidence 36.2%) of bacterial dacryoadenitis. Conclusions Bacterial dacryoadenitis is a major cause of dacryoadenitis, and its incidence may be increasing. It can resolve with minimal complications if managed appropriately, although some patients may require surgical drainage or admission for intravenous antibiotics.

Facial Swelling in the Presence of a COVID-19 Diagnosis: Case Report

COVID-19 became a pandemic with a worldwide impact leading to stay-at-home orders, death, economic difficulties, and a significant influence on daily lives. Dental services became limited at this time, causing increased concerns for patients requiring urgent dental care. We report the case of a 5-year-old previously healthy male who presented to our hospital’s emergency department (ED) with facial swelling secondary to infected maxillary left molars. Extractions were performed in the ED with moderate sedation. He was later found to be COVID-19 positive before admission for intravenous antibiotics. The use of universal precautions during the pandemic in treating patients with possible COVID-19 symptoms and in aerosol-generating procedures is recommended. Evaluating and providing treatment to our patients with urgent dental care should not be delayed to prevent further complications and decrease the burden placed on the ED, which may be limited in its ability to provide definitive care.

Improving the treatment of patients with low-risk neutropenic fever: A quality improvement project at the Cleveland Clinic Taussig Cancer Institute (TCI).

101 Background: NF is an oncologic emergency and has historically resulted in inpatient (inpt) management. The Multinational Association for Supportive Care in Cancer (MASCC) score can be used to identify NF pts at LR for complications who can be safely managed in the outpatient (outpt) setting. Despite established guidelines supporting outpt management of LRNF, provider awareness is low and inpt admission for intravenous antibiotics (abx) continues to be standard of care. Methods: A multidisciplinary team performed a QI project to improve management of LRNF (baseline cohort of LRNF pts treated from Jan - Mar 2014, N = 13). Inpt provider education began in the Q2 2014. Providers calculated MASCC scores for pts with non-leukemia hematologic malignancies and solid tumors at the time of admission. Data was collected in a prospectively maintained registry. Pts identified as LR by MASCC score were admitted under observation and placed on oral abx. If exclusion criteria and social barriers were not identified, discharge (dc) within 24 hrs of admission was planned. To ensure pt safety, close follow up included phone follow up within 48 hrs of dc and a provider visit within 72 hrs. Results: 52 pts were admitted to the TCI inpt oncology unit with NF from Oct 2014 - June 2015. 34 pts (65%) had LRNF (MASCC score, &lt; 21). 9 pts (26%) were dc within 24 hrs. Only 2 LRNF pts had a culture proven infection – both Enterococcus UTIs. 3 pts required readmission for reasons other than scheduled inpt chemotherapy: 1 high risk pt for new symptoms and 2 LRNF pts (22%) dc within 24 hours for recurrent fever; neither had culture proven infection. Pts with LRNF had an average LOS of 3.3 days compared to 6.2 days in the historical cohort. There were no deaths due to NF in either cohort. Conclusions: Calculating a MASCC score at admission identifies pts who are potential candidates for outpt, oral abx therapy. This pilot study demonstrates that provider education followed by implementation of a system to ensure close follow up may result in earlier dc for LRNF pts without increasing risk of complications or readmission. Further follow up will occur Q3 2015 and data will be presented on changes in cost measures.

Who needs admission among infants with acute otitis media?

Management of acute otitis media (AOM) in infants younger than 2 months old is controversial. It varies between treatment on an outside basis, and hospitalization for intravenous antibiotics and sepsis work-up based on variability of the reported AOM pathogens in this particular group. Our aim is to identify clinical indicators that may suggest a need for an invasive medical work-up and/or hospitalization of these young patients, and compare their management to that of older infants. Retrospective chart review. Admitted infants with AOM and a random sample of infants presenting to the emergency room with AOM over a 20-year period. Infants younger than 2 months were designated as 'young infants', and those older as 'older infants'. Demographic data, relevant history, physical examination, laboratory studies and treatment were reviewed. Twenty-nine admitted infants were included (13 young infants). A sample of 58 outpatients was studied, including two young infants. Compared to older inpatient infants, admitted young infants were less febrile (P < 0.05), had more benign white cell count (P < 0.05) but had more otorrhea (P < 0.05). These grew gram-negative organisms. Sepsis work-up was negative. Young infants were more likely to be admitted (P < 0.05). Admitted older infants had more otorrhea than outpatients (P < 0.05) or a complication (P < 0.05). Young infants often need admission for intravenous antibiotics, until middle ear culture is out. Sepsis work-up may be necessary only in toxic patients. Older infants need admission when severely ill or have a complication.

Case Report: Congenital Dacryocystocele and Dacryocystitis

Congenital dacryocystocele is a uncommon type of nasolacrimal duct obstruction. Differential diagnosis for masses in the medial canthal region of a newborn include encephalocele, hemangioma, nasal glioma, and dermoid cyst. Because of the risk of becoming infected (acute dacryocystitis) and potentially lethal due to septicemia, aggressive management, including admission for intravenous antibiotics and surgical removal, is now advocated by many pediatric ophthalmologists if the cyst cannot be decompressed. Because of the commonly associated nasal cyst, infants with nasolacrimal dacryocyctocele may also experience respiratory distress especially when breast-feeding. The following case of dacryocystocele, which had progressed to dacryocystitis, was misdiagnosed as an infantile hemangioma. It is important to diagnose this entity quickly and refer for appropriate antibiotic and surgical management to avoid more serious sequelae of sepsis and possible death.

Increased Incidence of Domestic Animal Bites following a Disaster Due to Natural Hazards

During deployment following Hurricane Ike in September 2008, bites from domestic animals were among the top three trauma complaints seen at the National Disaster Medical System (NDMS) Disaster Medical Assistance Team (DMAT) base of operations. Unlike previous reports of frightened, misplaced dogs and cats biting strangers and rescue workers, there was an increase in bites associated with presumed non-rabid pets who were known to the bite victim. This was an observational sampling of all patients presenting for medical care during deployment to the AL-3 DMAT base of operations in Webster, Texas, following Hurricane Ike. Findings were compared with unofficial local norms and observations from the literature. Of the people with animal bites presenting to the field hospital, dog bites accounted for 55%, cat bites, 40%, and snake bites, 5%. Most of the wounds required suturing and were not simple punctures. Most bites (70%) involved the hand(s). Some patients presented >24 hours after the bite, and already had developed cellulitis. One patient required transfer and inpatient admission for intravenous antibiotics and debridement of a hand injury with spread into the metacarpophalangeal space. Most of the bites were severe and occurred within the first 72 hours after the hurricane, and waned steadily over the following weeks to baseline levels. No animal bites caused by misplaced dogs and cats biting strangers were seen. There was an increase in bites associated with domesticated pets known to the bite victim. The current NDMS cache is stocked adequately to care for most wounds caused by animal bites. However post-exposure rabies treatment is not part of the routine medications offered. For future disaster preparedness training, pet owners should be aware of the increased potential for dog and cat bites.

Exhaled nitric oxide increases following admission for intravenous antibiotics in children with cystic fibrosis

Background: Lack of standardisation for the measurement of exhaled nitric oxide (NO) (FE NO) has resulted in conflicting data in cystic fibrosis (CF). The aim of this study was to assess whether FE NO is a useful non-invasive marker of lung disease in CF by assessing the effect of intravenous (IV) antibiotics on FE NO. Methods: FE NO was measured on line, according to recently published ERS/ATS guidelines, using a chemiluminescence analyser together with pulmonary function in 14 CF children prior to and following a course of IV antibiotics. Results: There was a significant improvement in mean (S.E.M.) % FEV 1 from 60.0 (6.3) to 68.0 (5.4) ( P<0.05) and mean (S.E.M.) % FVC from 66.3 (5.5) to 75.1 (4.9) ( P<0.01). FE NO increased significantly from median (range) 5.8 (2.0–14.3) to 9.2 ppb (0.8–25.1) ( P<0.05). There was no correlation between FE NO and lung function. Subgroup analysis on those with chronic Pseudomonas aeruginosa infection ( n=6) demonstrated no significant change in FE NO. Conclusions: Using a flow of 50 ml/s, FE NO increases following admission for IV antibiotic treatment in children with CF but does not correlate with lung function. It is not a useful marker of lung diseases in CF, which has implications for clinical practice.