Clear Source Of Infection Research Articles

Intratumoral abscess complicating a postradiation-induced World Health Organization grade II meningioma: illustrative case.

Cerebral meningiomas and brain abscesses are common independently, but intrameningioma abscesses rarely occur, with only 15 cases in the literature. These abscesses most frequently develop in patients with a known source of bacteremia; only one case of intrameningioma abscess without a known source of infection has been reported previously. This is the second reported case of an intrameningioma abscess without a clear source of infection, occurring in a 70-year-old female with a history of transsphenoidal craniopharyngioma resection and radiation many years prior. She presented with severe fatigue and altered mental status initially ascribed to adrenal insufficiency, and magnetic resonance imaging showed a new heterogeneously enhancing left temporal mass with surrounding edema. After urgent tumor resection, pathology demonstrated a World Health Organization grade II meningioma (radiation induced). After a course of steroids and intravenous nafcillin, the patient recovered without neurological deficits. The natural history of intrameningioma abscesses is not fully understood. These uncommon lesions can form secondary to hematogenous spread facilitated by meningiomas' robust vascularization, typically in patients with bacteremia. Even when no significant source of infection is identified, the differential diagnosis of intrameningioma abscess should be considered because this pathology can be rapidly progressive, even fatal, but is treatable if recognized promptly.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Causes of fever in returning travelers: a European multicenter prospective cohort study.

Etiological diagnosis of febrile illnesses in returning travelers is a great challenge, particularly when presenting with no focal symptoms [acute undifferentiated febrile illnesses (AUFI)], but is crucial to guide clinical decisions and public health policies. In this study, we describe the frequencies and predictors of the main causes of fever in travelers. Prospective European multicenter cohort study of febrile international travelers (November 2017-November 2019). A predefined diagnostic algorithm was used ensuring a systematic evaluation of all participants. After ruling out malaria, PCRs and serologies for dengue, chikungunya and Zika viruses were performed in all patients presenting with AUFI ≤ 14days after return. Clinical suspicion guided further microbiological investigations. Among 765 enrolled participants, 310/765 (40.5%) had a clear source of infection (mainly traveler's diarrhea or respiratory infections), and 455/765 (59.5%) were categorized as AUFI. AUFI presented longer duration of fever (p < 0.001), higher hospitalization (p < 0.001) and ICU admission rates (p < 0.001). Among travelers with AUFI, 132/455 (29.0%) had viral infections, including 108 arboviruses, 96/455 (21.1%) malaria and 82/455 (18.0%) bacterial infections. The majority of arboviral cases (80/108, 74.1%) was diagnosed between May and November. Dengue was the most frequent arbovirosis (92/108, 85.2%). After 1month of follow-up, 136/455 (29.9%) patients with AUFI remained undiagnosed using standard diagnostic methods. No relevant differences in laboratory presentation were observed between undiagnosed and bacterial AUFI. Over 40% of returning travelers with AUFI were diagnosed with malaria or dengue, infections that can be easily diagnosed by rapid diagnostic tests. Arboviruses were the most common cause of AUFI (above malaria) and most cases were diagnosed during Aedes spp. high season. This is particularly relevant for those areas at risk of introduction of these pathogens. Empirical antibiotic regimens including doxycycline or azithromycin should be considered in patients with AUFI, after ruling out malaria and arboviruses.

Bloodstream infections in hospitalized patients before and during the COVID-19 surge in a community hospital in the South Bronx

Bloodstream infections in hospitalized patients before and during the COVID-19 surge in a community hospital in the South Bronx

A CASE OF DEXMEDETOMIDINE-INDUCED DRUG FEVER: AN IMPORTANT AND PRESS-EDEX-ING ISSUE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dexmedetomidine has revolutionized the field of critical care medicine, providing clinicians a short-acting, well-tolerated sedative. Cardiovascular adverse effects are well described with this agent (1). Less common adverse effects such as fever are increasingly being reported (2). Previous studies demonstrated no appreciable rate of dexmedetomidine-related fever (1, 3). Here we report a case of high-grade fever in the intensive care unit (ICU) after initiation of dexmedetomidine, with resolution after discontinuation. CASE PRESENTATION: A 34-year-old male with a past medical history of alcohol abuse and asthma was admitted to the general ward with Coronavirus disease 2019 (COVID-19) pneumonia. His course was complicated by severe hypoxia and subsequent pulseless electrical activity (PEA) arrest, requiring ICU transfer after achieving return of circulation and undergoing mechanical ventilation. On hospital day 7, after improvement in respiratory status with COVID-19 management including corticosteroids, as well as treatment with ceftriaxone and azithromycin given concern for superimposed bacterial pneumonia, he was transitioned to dexmedetomidine in preparation for a ventilator weaning trial. He developed fevers over the following 12 hours, initially to 39.4 C (102.9 F) prompting empiric sepsis management with intravenous fluids and broad-spectrum antibiotics (see figure-1). Despite this, he continued to have fevers to a maximum core temperature of 41.1 C (106 F). Blood, fungal, and respiratory cultures were unremarkable. With no clear infectious source or alternative explanation for severe hyperthermia, the decision was made to wean off dexmedetomidine given suspicion for drug-induced fever, upon which core temperature returned to 37.8 C (100.1 F). He remained afebrile, and eventually extubated and discharged in stable condition. DISCUSSION: We present a case of severe hyperthermia corresponding to, with a probable association using the Naranjo Adverse Drug Reaction Probability Scale, dexmedetomidine initiation, followed by resolution of fever after discontinuation. Antimicrobial therapy had no observable effect on the fever, and extensive infectious work-up was unremarkable. Completely attributing a febrile episode in the ICU setting to a medication is a difficult task. Furthermore, adequately powering studies to identify rare medication adverse effects in the ICU is a challenge, which may explain the absence of fever as a documented adverse effect of dexmedetomidine (1,2,4). In this case, no alternate diagnoses were evident, thus management was focused on discontinuing the presumed inciting agent. CONCLUSIONS: Recognizing dexmedetomidine as an etiology of severe hyperthermia in the ICU may help mitigate excessive therapies and improve outcomes. Further research is warranted to describe risk factors and proper recognition for when fevers occur with dexmedetomidine. REFERENCE #1: Hospira (2014) Precedex® (dexmedetomidine hydrochloride) [package insert]. Lake Forest, IL: Hospira, Inc. REFERENCE #2: Peterson J, Thomas W, Michaud C, et al. Incidence of Fever Associated With Dexmedetomidine in the Adult Intensive Care Unit. J Pharm Pract. 2021 Apr 5:8971900211004828. REFERENCE #3: Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine for Long-Term Sedation Investigators. JAMA. 2012 Mar 21;307(11):1151-60. DISCLOSURES: No relevant relationships by Raef Fadel, source=Web Response No relevant relationships by Sara Hegab, source=Web Response No relevant relationships by Michael Reaume, source=Web Response No relevant relationships by Zachary Smith, source=Web Response

Urine Cultures at the Onset of Febrile Neutropenia (FN) in Patients with Haematological Malignancies Rarely Impact Antibiotic Management in the Absence of Urinary Symptoms

IntroductionThe Choosing Wisely initiative aims to reduce wasteful testing. Our institution is participating in this initiative and hence has a focus on evidence-based approaches to the investigation of FN. We have previously shown that routine chest x-rays are not generally useful in this scenario. Urine cultures are also commonly performed in this context. However, specimen collection may delay the administration of antibiotics, laboratory costs are not inexpensive and the impact of culture results on subsequent antibiotic management is not well documented in patients receiving protocol specified broad spectrum antibiotics. We assessed this latter issue by evaluating the impact of urine cultures on the management of FN in haematology inpatients at a major tertiary hospital.Methods:A retrospective single-centre analysis of adult (≥16years) patients with haematological malignancy undergoing recent chemotherapy admitted to a large cancer centre with FN was performed over a 5-year period (2011-2015). FN was defined as fever ≥37.5°C and a neutrophil count <0.5 x 109/L or <1.5 x 109/L and predicted decline to <0.5 x 109/L over the next 48 hours. Local protocolised investigations for newly diagnosed FN included a urine culture. Empiric antibiotic therapy for FN consisted of IV tazocin in stable patients or, if systemically compromised, IV meropenem, gentamicin and vancomycin. Patients were identified from electronic hospital records. For each episode, baseline demographic data, urinary tract symptoms and signs (absence of which was termed ‘asymptomatic‘), beside urinalysis results (nitrites and leucocytes), urine culture results (chemistry, microscopy, culture and sensitivity) and any consequent change in antibiotic management were collected. A urine culture was considered positive if >108 organisms/L of a predominant organism were detected. Cultures were considered contaminated if mixed growth was present. Each positive culture and impact on antibiotic therapy was reviewed by an infectious disease physician.Results:Four hundred and thirty-three episodes of FN were identified in 317 patients, the baseline characteristics of which are summarized in Table 1. A urine culture was performed in 365 (84%) cases of which 16 (4.4%) were positive, 77 were contaminated (21%), and 272 (75%) had no growth. Cultures were positive in 7 of 317 (2.2%) asymptomatic patients; all were gram-negative bacteria of which 2 were extended spectrum beta-lactamase (ESBL) E. coli. Nine of 48 (19%) symptomatic patients had positive cultures of which 8 were non-ESBL E. coli. Four patients had a catheter, all of whom were asymptomatic with a negative culture. Bedside urinalysis was documented in 186 (43) patients who had urine cultures. Nitrites were detected in 5 of 12 evaluable patients with positive cultures compared with 4 of 174 patients with negative cultures; the positive and negative predictive values were 56%and 96%respectively. Only 5 patients (1.4%) had a change in antibiotic management due a positive urine culture: 3 of 48 (6.3%) symptomatic and 2 of 317 (0.6%) asymptomatic patients.Conclusion:Urinary tract infections are a rare source of infection in haematology patients with FN in the absence of focal urinary symptoms. Urine cultures rarely impact on antibiotic management in this context without urinary tract symptoms. As a result of this study we no longer perform urine cultures routinely in FN, restricting this investigation to symptomatic or catheterised patients without another clear source of infection, and those with nitrite positivity. [Display omitted] DisclosuresHawkes:Roche: Other: Travel expenses, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Other: Travel expenses; Celgene: Research Funding; Bristol-Myers Squibb: Research Funding; Roche: Other: Travel expenses; Merck Serono: Research Funding; Merck Sharpe Dohme: Research Funding. Grigg:Merck Sharpe Dohme: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees, Other: Travel expenses; Takeda: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees, Other: Travel expenses.

Decreasing Hospital Observation Time for Febrile Infants.

Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months. This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge. In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge. Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen.

To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. Retrospective cohort study. Two affiliated academic medical centers in Los Angeles, California. Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

Presence of urinary symptoms in bacteremic urinary tract infection: a retrospective cohort study of Escherichia coli bacteremia

BackgroundIt is important to understand clinical features of bacteremic urinary tract infection (bUTI), because bUTI is a serious infection that requires prompt diagnosis and antibiotic therapy. Escherichia coli is the most common and important uropathogen. The objective of our study was to characterize the clinical presentation of E coli bUTI.MethodsRetrospective cohort study of consecutive adult patients admitted for community acquired E. coli bacteremia from January 1, 2015 to December 31, 2016 was conducted at 4 acute care academic and community hospitals in Toronto, Ontario, Canada. Logistic regression models were developed to identify E coli bUTI cases without urinary symptoms.ResultsOf 462 patients with E. coli bacteremia, 284 (61.5%) patients had a urinary source. Of these 284 patients, 161 (56.7%) had urinary symptoms. In a multivariable model, bUTI without urinary symptoms were associated with older age (age < 65 years as reference, age 65–74 years had OR of 2.13 95% CI 0.99–4.59 p = 0.0523; age 75–84 years had OR of 1.80 95% CI 0.91–3.57 p = 0.0914; age > =85 years had OR of 2.95 95% CI 1.44–6.18 p = 0.0036) and delirium (OR of 2.12 95% CI 1.13–4.03 p = 0.0207). Sepsis by SIRS criteria was present in 274 (96.5%) of all bUTI cases and 119 (96.8%) of bUTI cases without urinary symptoms.ConclusionThe majority of patients with E. coli bacteremia had a urinary source. A significant proportion of bUTI cases had no urinary symptoms elicited on history. Elderly and delirious patients were more likely to have bUTI without urinary symptoms. In elderly and delirious patients with sepsis by SIRS criteria but without a clear infectious source, clinicians should suspect, investigate, and treat for bUTI.

27-Year-Old Woman With Fever, Headache, and Anemia

27-Year-Old Woman With Fever, Headache, and Anemia

Shedding light on a hidden source of septic shock with POCUS

A 77-year old male was admitted in the emergency department for septic shock, yet no clear source of infection was noted upon physical examination and a portable chest x-ray. Due to his unstable condition, bedside ultrasound was performed. A heterogeneous mass in the liver was noted, hence a tentative diagnosis of liver abscess was made. This was latter confirmed by abdominal computed tomography. This case highlights that point-of-care ultrasound, when performed by expert physicians, can significantly decrease time to diagnosis for septic patients.

UNUSUAL PATH FOR DISCOVERY OF SEPSIS ETIOLOGY

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Sepsis-3 defines sepsis as a life-threatening organ dysfunction caused by dysregulated host response to infection. The most challenging patients are the ones who have no clear source of infection. Current guidelines recommend empiric coverage for aerobic gram-positive and aerobic enteric gram-negative bacteria. When broad spectrum antibiotics fail, review of antibacterial spectra of activity and assistance of differential diagnosis generators may pave the path for culprit discovery. We present a case where the differential diagnosis generator helped us accurately diagnose and guide the appropriate therapy. CASE PRESENTATION: A female of 70-years with a history of osteoarthritis presented with four weeks of fever, weight loss, night sweats, and fatigue. She was hypotensive, febrile, tachycardic and tachypneic. Sepsis protocol was activated. Laboratory data revealed WBC 2.7 K/UL, Hgb 9.8 g/dL, PLT 77 K/DL, AST 71 IU/L ALT 49 IU/L, CRP 12 mg/dL, ESR 41 mm/hr. Ferritin 7138 ng/mL, LDH 570 IU/L. She failed to improve for the first 48 hours despite IV Vancomycin and Cefepime. A contrast-enhanced CT scan of the abdomen revealed splenic hypodensities; laboratory workup for Q-fever, RMSF, salmonella, and Lyme’s disease was sent to evaluate for secondary hemophagocytic lymphohistiocytosis (HLH). A liver biopsy was also obtained. Lack of clinical and laboratory improvement prompted us to review our empiric coverage. The clinical picture was thought to be secondary to an infection, therefore, we had narrowed our antibiotics to only doxycycline for non-enteric gram-negative bacilli. We also utilized Isabel Healthcare Differential Diagnosis (DDX) Tool, which generated ten differential diagnosis including Brucellosis. Our patient later admitted to consuming homemade cheese on her last visit to Mexico. Brucella serology and blood cultures were obtained. Fever resolved 48 hours after doxycycline was initiated. Later, blood cultures grew Brucella spp. Currently, our patient remains symptom-free and all laboratory abnormalities have normalized. DISCUSSION: Sepsis guidelines recommend empiric coverage for common pathogens with no clear advice on uncommon infectious agents. A detailed travel and social history are crucial, especially in patients who do not improve on empiric broad spectrum antibiotics. In addition, medical decision making relies on pattern recognition of illness scripts accumulated over time. Historically, we refer to textbooks for the DDX of each symptom. Nowadays, we have more sophisticated DDX generators that incorporate epidemiological data, clinical and laboratory findings to create a DDX list. In a study, the pooled accurate diagnosis retrieval rate for DDX tools was as high as 0.70. CONCLUSIONS: It is imperative to identify significant and clinically relevant data. DDX generators may be useful resources for clinicians and it may also increase the medical knowledge. Reference #1: PMID: 26157077 DISCLOSURES: No relevant relationships by Jose Zabala-Genovez, source=Web Response

SAT-601 Navigating The Storm: A Case of Thyroid Storm and Recurrent Grave's Disease after Radioactive Iodine Therapy

Introduction: Graves’ disease is an autoimmune condition that affects the thyroid and is the most common cause of hyperthyroidism. There are three treatment options for Graves’ disease: oral antithyroid drugs, radioactive iodine (RAI) therapy and thyroidectomy. RAI therapy and thyroidectomy are considered definitive treatments. Case: A 28 year old female with a history of Grave’s Disease for 5 years ago s/p RAI-131 presented with complaints of persistent fever and chills for 1 day. The patient was diagnosed with Grave’s Disease at 22 years old and opted for RAI therapy on initial presentation of the disease as definitive therapy. The patient has been euthyroid for 5 years since RAI therapy and has never required thyroid medications. Vitals on admission were BP 132/79, T 105.6 F, & HR 113. Urinalysis on admission indicated WBCs, positive leukocyte esterase, negative nitrates, and patient was treated for possible UTI with antibiotics. On day 2 of admission, patient was found to be septic with a temperature of 101.9 F and tachycardic at 110 bpm. On day 3, patient had an episode loss of consciousness and continued to be febrile with her vitals at T 102 F, HR 100, & BP 115/80. Although the patient was euthyroid for 5 years, suspicions were raised for thyroid storm by day 3, as the patient was not clinically improving with no clear source of infection. Free thyroxin levels at this time were 2.94 (N: 0.61-1.24) and TSH 0.03 (N: 0.34-5.6). Once thyroid storm was added as a differential, the patient rapidly improved with subsequent treatment. On day 6, patient was discharged and asked to follow up with her endocrinologist. Discussion: RAI therapy and thyroidectomy are considered definitive treatments for patients with Grave’s Disease. A 2017 article by the American Thyroid Association (ATA) quoted a Mayo Clinic study outlining RAI therapy as having less than 8% failure rate compared to antithyroid medication failure rate of 48%. ATA and Mayo Clinic state that RAI therapy has the most favorable profile for the treatment of Graves’ disease. Although rare, physicians should be aware of thyroid storm and recurrent disease as a differential in any patient with a history of Grave’s Disease, despite duration of or current euthyroid status. This patient had no clinical improvement until thyroid storm was added as a differential, and with subsequent treatment, the patient rapidly improved. Conclusion: It is important to recognize that RAI therapy for Grave’s Disease may not be a definitive treatment for every patient. Physicians should consider thyroid storm in any patient with a history of Grave’s Disease, despite duration of euthyroid status.

Fecal Microbiota Transplantation for the Critically Ill Patient.

The gut microbiome has been implicated in a diversity of diseases, such as irritable bowel syndrome, inflammatory bowel disease, hepatic steatosis, metabolic syndrome, obesity, and anxiety. Current research also suggests the presence of a bidirectional relationship between the composition of the gut microbiome and critical illness. In the critical care setting, multiple factors (eg, use of antibiotics, aberrant nutrition, bloodstream infections, bowel ischemia, and abnormal bowel motility) strongly contribute to intestinal dysbiosis. Conversely, early studies have associated intestinal dysbiosis with worse clinical outcomes in the intensive care unit (ICU), such as infection, organ failure, and mortality. The possibility of intestinal dysbiosis influencing these clinical outcomes has prompted the question of whether microbiome manipulation strategies, such as fecal microbiota transplantation (FMT), may have a role in the management of critical illness. After a literature search of FMT used in the ICU for indications other than Clostridium difficile infections, we found 4 case reports that describe the use of FMT in 5 critically ill patients with systemic inflammatory responses and no clear source of infection. This review discusses the relationship between the gut microbiome and critical illness, early data on the use of FMT in critical care, and safety considerations of FMT in the critically ill and immunocompromised populations.

O7-4 - A Case of Left Ventricular Pseudoaneurysm Developed from Myocardial Abscess

The patient was a 57-year-old woman who had undergone maintenance hemodialysis due to diabetic nephropathy. She suddenly developed high fever of 40°C, lumbago and epigastralgia with hypotension and was diagnosed as having septic shock requiring vasopressors and endotoxin adsorption therapy. Laboratory test demonstrated severe inflammation and methicillin sensitive Staphylococcus aureus was cultured from blood samples, but clear source of infection was not detected. After the administration of specific intravenous antibiotics, inflammatory data gradually declined, but 10 days later, she developed high fever and pericarditis. Echocardiogram disclosed pericardial effusion and calcification of the posterior mitral leaflet but vegetation was not detected. Although the aspiration was negative for bacterial growth, we diagnosed her as bacterial pericarditis and continued the administration of antibiotics for four weeks. Thereafter she got well and discharge. One month later, she visited our hospital with anorexia and computed tomography revealed a large pseudoaneurysm of the posterior left ventricular wall just below the posterior mitral valve leaflet. She underwent emergent surgery. The left ventricular aneurysm orifice was closed. If patients on hemodialysis become complicated by long term fever, we need to pay attention to the onset of infective endocarditis.

Percutaneous drainage as a first therapeutic step prior to surgery in liver hydatid cyst abscess: Is it worth it?

AIMTo delay surgery until the patient is in a better condition, and thus to decrease postoperative morbidity.METHODSUsing this algorithm we treated three patients aged 55, 75 and 80 years. In all three patients the clinical presentation was fever without a clear source of infection; all had nonspecific symptoms such as general malaise, dyspnea, and abdominal discomfort in the previous 15 d. They came to the emergency room at our hospital due to deterioration of their general condition. Analytical tests showed leukocytosis, neutrophilia and increased polymerase chain reaction. In all cases an abdominal computed tomography (CT) was performed and liver hydatid abscess (LHA) was detected. The mean size of the LHA was 12 cm.RESULTSAll patients underwent CT-guided percutaneous drainage. The purulent material obtained was cultured, and Klebsiella pneumoniae, Streptococcus viridans and Streptococcus salivarius were identified. Antibiotic treatment was given adapted to antibiotic sensitivity testing. Surgery was performed two weeks after admission, once the patient’s condition had improved. All three patients underwent an almost total cystectomy, cholecystectomy and omentoplasty in the residual cavity. Complications were: Clavien I (atelectasis and pleural effusion) and Clavien II (transfusion). The average length of stay (pre and postoperative) was 23 d. At the follow-up, no relapses were recorded.CONCLUSIONLHA management is not standardized. Emergency surgery offers suboptimal results. Percutaneous drainage plus antibiotics allows improving patient’s general condition. This enables treating patients in greater safety and also reduces complications.

Emergency Department Management of Patients With Febrile Neutropenia: Guideline Concordant or Overly Aggressive?

The Infectious Diseases Society of America and the American Society of Clinical Oncology recommend risk stratification of patients with febrile neutropenia (FN) and discharge with oral antibiotics for low-risk patients. We studied guideline concordance and clinical outcomes of FN management in our emergency department (ED). Our urban, tertiary care teaching hospital provides all emergency and inpatient services to a large comprehensive cancer center. We performed a structured chart review of all FN patients seen in our ED from January 2010 to December 2014. Using electronic medical records, we identified all visits by patients with fever and an absolute neutrophil countof <1000 cells/mm3 and then included only patients without a clear source of infection. Following national guidelines, we classified patients as low or high risk and assessed guideline concordance in disposition and parenteral versus oral antibiotic therapy by risk category as our main outcome measure. Of 173 qualifying visits, we classified 44 (25%) as low risk and 129 (75%) as high risk. Management was guideline concordant in 121 (70%, 95% confidence interval [CI]= 63% to 77%). Management was guideline discordant in 43 (98%, 95% CI= 88% to 100%) of low-risk patients versus 9 (7%, 95% CI= 3% to 13%) of high-risk patients (relative risk [RR]= 14, 95% CI= 7.5 to 26). Of 52 guideline-discordant cases, 36 (83%, 95% CI= 72% to 93%) involved low-risk cases with treatment that was more aggressive than recommended. Guideline concordance was low among low-risk patients, with management tending to be more aggressive than recommended. Unless data emerge that undermine the guidelines, we believe that many of these hospitalizations and parenteral antibiotic regimens can be avoided, decreasing the risks associated with hospitalization, while improving antibiotic stewardship and patient comfort.

Weathering a Cytokine Storm: A Case of EBV-Induced Hemophagocytic Lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening disease caused by excessive immune activation. Acquired HLH is seen in adults and is often caused by infection or malignancy. Diagnosis is difficult and usually missed as clinical and laboratory findings are nonspecific. Moreover, the pathophysiology of the systemic inflammatory response syndrome and/or sepsis is remarkably similar to HLH. Thus, in patients presenting with presumed severe sepsis or septic shock complicated by multiorgan failure without a clear infectious source, HLH should be considered. A disproportionately high ferritin may be one of the earlier laboratory findings to suggest HLH. We discuss a case of a young male who presented with presumed septic shock with multiorgan failure who was eventually found to have Epstein-Barr virus–induced HLH.

PO-0276 Feverish Children In A Dgh In Northern Ireland –what Are We Doing?

Aims We undertook this audit to review the management of feverish children in our emergency departments (ED) compared to The College of Emergency Medicine (CEM) standards. Methods The data was collected using a tool designed by CEM. Entry criteria: under 5 years old and temp >38 o C on arrival. Results Total number of patients was 50. The assessed risk profile for this population (using NICE guidelines) were 24 low risk, 14 intermediate risk, 11 high risk and 1 we were unable to risk stratify from the clinical notes. Nine children were prescribed antibiotics (5 low risk, 2 intermediate and 2 high risk). Of the 11 patients who were high risk, 7 had a clear source of infection. Of the 4 who had no source identified, one had bloods and urine performed in ED but these were not recorded in the notes. 2 had bloods performed on the paediatric ward. For the 14 patients in the intermediate risk, 8 had a source of infection, 5 had no obvious source identified and one was not clearly documented. No patients without a source were presecribed antibiotics. No documentation was recorded about discharge advice. 18 patients (36%) did not have a blood pressure (BP) or a capillary refill time (CRT) documented in the notes and 10 patients (20%) did not have their GCS or APVU recorded. Conclusions There are areas that require review. Improvements must be made to ensure a full set of observations are recorded, emphasising the importance of BP/CRT as well as GCS/AVPU.

A molecular survey of Rickettsia felis in fleas from cats and dogs in Sicily (Southern Italy).

Rickettsia felis, the agent of flea-borne spotted fever, has a cosmopolitan distribution. Its pathogenic role in humans has been demonstrated through molecular and serologic tests in several cases. The cat flea (Ctenocephalides felis) is considered the main reservoir and the biological vector. The aim of this study was to assess the presence and occurrence of R. felis in fleas collected from dogs and cats in various sites of Palermo (Sicily). Between August and October 2012, 134 fleas were collected from 42 animals: 37 fleas from 13 dogs and 97 fleas from 29 cats. Two species of fleas were identified: 132 Ctenocephalides felis (98.51%) collected on all animals and only two C. canis (1.49%) on one dog. Out of 132 C. felis, 34 (25.76%), 12 from dogs (32.43%) and 22 (22.68%) from cats, were positive for R. felis DNA by a polymerase chain reaction (PCR), confirmed by sequencing. The only two C. canis fleas were negative. About half of examined animals (47.62%, 20/42) were infested with at least one infected flea; in particular 46.15% of dogs (6/13) and 48.28% of cats (14/29). It seems that in the Palermo district there is a peri-domestic cycle, with a relatively high prevalence of R. felis infection in the cat flea, an insect widely diffused in home environments and which can frequently bite humans. The results also suggest that R. felis should be considered in the human differential diagnosis of any spotted-like fever or febrile illness without a clear source of infection in Sicily, especially if the patient is known to have been exposed to flea bites.