Continuous Antibiotic Research Articles

Comparison of Intravenous Microdialysis and Standard Plasma Sampling for Monitoring of Vancomycin and Meropenem Plasma Concentrations-An Experimental Porcine Study.

Microdialysis is a catheter-based method suitable for dynamic sampling of unbound antibiotic concentrations. Intravenous antibiotic concentration sampling by microdialysis has several advantages and may be a superior alternative to standard plasma sampling. We aimed to compare concentrations obtained by continuous intravenous microdialysis sampling and by standard plasma sampling of both vancomycin and meropenem in a porcine model. Eight female pigs received 1 g of both vancomycin and meropenem, simultaneously over 100 and 10 min, respectively. Prior to drug infusion, an intravenous microdialysis catheter was placed in the subclavian vein. Microdialysates were collected for 8 h. From a central venous catheter, plasma samples were collected in the middle of every dialysate sampling interval. A higher area under the concentration/time curve and peak drug concentration were found in standard plasma samples compared to intravenous microdialysis samples, for both vancomycin and meropenem. Both vancomycin and meropenem concentrations obtained with intravenous microdialysis were generally lower than from standard plasma sampling. The differences in key pharmacokinetic parameters between the two sampling techniques underline the importance of further investigations to find the most suitable and reliable method for continuous intravenous antibiotic concentration sampling.

PD37-10 THE TRUE INCIDENCE OF URINARY TRACT INFECTIONS AMONG INFANTS WITH ISOLATED HYDRONEPHROSIS

You have accessJournal of UrologyCME1 Apr 2023PD37-10 THE TRUE INCIDENCE OF URINARY TRACT INFECTIONS AMONG INFANTS WITH ISOLATED HYDRONEPHROSIS Margarita Chancy, Jin K Kim, Michael Chua, Joana Santos, Natasha Brownrigg, Juliane Richter, Tim Van Mieghem, Armando J Lorenzo, and Mandy Rickard Margarita ChancyMargarita Chancy More articles by this author , Jin K KimJin K Kim More articles by this author , Michael ChuaMichael Chua More articles by this author , Joana SantosJoana Santos More articles by this author , Natasha BrownriggNatasha Brownrigg More articles by this author , Juliane RichterJuliane Richter More articles by this author , Tim Van MieghemTim Van Mieghem More articles by this author , Armando J LorenzoArmando J Lorenzo More articles by this author , and Mandy RickardMandy Rickard More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003335.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rate of UTI in healthy febrile infants is 7%. Isolated hydronephrosis (HN) refers to dilation of the renal pelvis and has been associated with an increased risk of UTI resulting in continuous antibiotic prophylaxis (CAP) use. Our goal was to determine the overall rate of UTI stratified by type, CAP, VUR. METHODS: A HN database from 2015-22 was examined. Included patients were less than 24 m at baseline with isolated HN, and those with other abnormalities were excluded. Captured variables included age, sex, circumcision status, HN severity and VUR. UTI was defined as fever with pyuria and positive culture from catheterized specimens. UTIs were categorized as index (pre-presentation), surveillance (while being followed), and post-procedural (associated with surgery/tests). RESULTS: A total of 689 patients were included. The median age at baseline was 2 m (0-24 m) and follow-up was 23 m (6-195). A total of 52% were prescribed CAP and received it for 6 m (0-53). The overall UTI rate was 9% which developed at 5 months (0-32 m) of age. UTIs were index in 32 (5%), surveillance in 11 (2%) and post-procedural in 20 (3%). After excluding procedural UTIs, the actual rate was 7%. Most patients were male (81%) and 62% were uncircumcised. Uncircumcised males comprised 77%, 64% and 63% of index, surveillance and post-procedural UTI respectively. 96% had isolated HN and 53% had high grade (SFU 3-4) 1% of had concomitant UPJ+UVJ obstruction and 3% were known to have VUR, however only 30% were investigated with VCUG. When comparing surveillance UTI to none, the only significant finding was more VUR in the surveillance group (18%) vs. 2% in the no infection group (p<0.01). UTI characteristics by category can be reviewed in Table 1. Comparisons between surveillance and no UTIs can be reviewed in Table 2. CONCLUSIONS: The overall incidence of UTI in children with isolated HN is low. We demonstrated that the rate of UTI is similar to the general population, generating controversy regarding the necessity of CAP. This presents an opportunity to limit exposure to antibiotics to children with isolated HN. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e991 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Margarita Chancy More articles by this author Jin K Kim More articles by this author Michael Chua More articles by this author Joana Santos More articles by this author Natasha Brownrigg More articles by this author Juliane Richter More articles by this author Tim Van Mieghem More articles by this author Armando J Lorenzo More articles by this author Mandy Rickard More articles by this author Expand All Advertisement PDF downloadLoading ...

MP70-03 THE ROLE OF CIRCUMCISION IN PREVENTING URINARY TRACT INFECTIONS IN CHILDREN WITH ANTENATAL HYDRONEPHROSIS: SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP70-03 THE ROLE OF CIRCUMCISION IN PREVENTING URINARY TRACT INFECTIONS IN CHILDREN WITH ANTENATAL HYDRONEPHROSIS: SYSTEMATIC REVIEW AND META-ANALYSIS Justin Chan, Adree Khondker, Min Joon Lee, Jin Kyu Kim, Michael Chua, Joana Dos Santos, Natasha Brownrigg, Juliane Richter, Armando Lorenzo, and Mandy Rickard Justin ChanJustin Chan More articles by this author , Adree KhondkerAdree Khondker More articles by this author , Min Joon LeeMin Joon Lee More articles by this author , Jin Kyu KimJin Kyu Kim More articles by this author , Michael ChuaMichael Chua More articles by this author , Joana Dos SantosJoana Dos Santos More articles by this author , Natasha BrownriggNatasha Brownrigg More articles by this author , Juliane RichterJuliane Richter More articles by this author , Armando LorenzoArmando Lorenzo More articles by this author , and Mandy RickardMandy Rickard More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Circumcision has been reported to reduce the risk of urinary tract infection (UTI) in boys with congenital urinary tract anomalies, a diverse group of conditions that includes hydronephrosis. Our aim was to specifically compare the rates of UTIs in circumcised vs. uncircumcised boys with antenatal hydronephrosis by conducting a systematic review and meta-analysis. METHODS: A comprehensive search was performed until December 2021. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included UTIs, continuous antibiotic prophylaxis (CAP) use, renal function, development of cortical scarring, as well as circumcision complications. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analysis were performed, and confounders were assessed with subgroup analysis. RESULTS: Sixteen studies describing 7,503 boys with antenatal hydronephrosis were identified, including 4,116 boys who were uncircumcised and 3,387 boys who were circumcised. The median follow-up time was 24.0 months (range: 6.0 - 152.4 months). Uncircumcised and circumcised boys were found to have UTI rates of 19.1% and 6.1%, respectively. This translates to a number needed to treat (NNT) of 8. Overall effect estimates demonstrate that circumcised boys have a significantly reduced odds of developing any UTI [OR 0.23, 95% CI 0.17, 0.31; p<0.001]. Furthermore, there was a significantly reduced odds of developing UTI on CAP [OR 0.18, 95% CI 0.11, 0.32; p<0.001]. When stratifying by etiology of antenatal hydronephrosis, circumcision reduced the odds of UTI in boys with vesicoureteral reflux [OR 0.24, 95% CI 0.12, 0.47; p<0.00001], or posterior urethral valve [OR 0.29, 95% CI 0.13, 0.64; p=0.002]. Long term renal function, development of renal scarring, and postoperative complications were not consistently reported, which prohibited pooling. Most studies had moderate risk of bias. CONCLUSIONS: Current evidence suggests that circumcision reduces the frequency of UTIs in boys with antenatal hydronephrosis. Based on these findings, circumcision should be considered in boys with antenatal hydronephrosis to prevent the risk of developing UTI. Further research is warranted to individualize the prophylactic role of circumcision for patients with different etiologies and grade of hydronephrosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1003 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Chan More articles by this author Adree Khondker More articles by this author Min Joon Lee More articles by this author Jin Kyu Kim More articles by this author Michael Chua More articles by this author Joana Dos Santos More articles by this author Natasha Brownrigg More articles by this author Juliane Richter More articles by this author Armando Lorenzo More articles by this author Mandy Rickard More articles by this author Expand All Advertisement PDF downloadLoading ...

MP70-13 THE EFFECT OF CIRCUMCISION/CONTINUOUS ANTIBIOTIC PROPHYLAXIS ON PREVENTING THE RECURRENCE OF FEBRILE URINARY TRACT INFECTION IN BOYS WITH PRIMARY VESICOURETERAL REFLUX

You have accessJournal of UrologyCME1 Apr 2023MP70-13 THE EFFECT OF CIRCUMCISION/CONTINUOUS ANTIBIOTIC PROPHYLAXIS ON PREVENTING THE RECURRENCE OF FEBRILE URINARY TRACT INFECTION IN BOYS WITH PRIMARY VESICOURETERAL REFLUX Fang Chen and Yichen Huang Fang ChenFang Chen More articles by this author and Yichen HuangYichen Huang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To explore the preventing effect of circumcision and continuous antibiotic prophylaxis on the recurrence of febrile urinary tract infection in boys with primary vesicoureteral reflux. METHODS: The clinical data of 88 boys with primary vesicoureteral reflux diagnosed in our hospital were retrospectively analyzed. The median age of the enrolled children was 10.2 months, and the average age was (15.3±15.9) months. The 88 boys were divided into 4 groups, including 3 cases in the watchful waiting group, 50 cases in the continuous antibiotic prophylaxis group, 22 cases in the circumcision group, and 13 cases in the continuous antibiotic prophylaxis+circumcision group. The follow-up time was 1 to 3 years. The recurrence of febrile urinary tract infection in each group was counted, and the effective conservative treatment strategy was analyzed. RESULTS: There were 21 cases (23.9%) of febrile urinary tract infection recurrence among 88 children, 2 cases (66.7%) in the watchful waiting group, 16 cases (32.0%) in the continuous antibiotic prophylaxis group, and 3 cases in the circumcision group (13.6) %). There was no recurrence in 13 patients in the continuous antibiotic prophylaxis+circumcision group. There was a statistical difference in the recurrence rate between the 4 treatment groups (χ2=10.181, p=0.011). Factorial analysis suggests that circumcision is the main factor in reducing the recurrence of febrile urinary tract infections (p=0.003). CONCLUSIONS: For boys with primary vesicoureteral reflux, circumcision is the main factor in reducing the recurrence of febrile urinary tract infections. Circumcision combined with continuous antibiotic prophylaxis can prevent the recurrence of febrile urinary tract infection to the greatest extent. There is no significant difference between continuous antibiotic prophylaxis and watchful waiting in preventing the recurrence of febrile urinary tract infection. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1008 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Fang Chen More articles by this author Yichen Huang More articles by this author Expand All Advertisement PDF downloadLoading ...

Periprocedural antibiotics for urodynamic studies of pediatric neurogenic bladder, empiric or culture-guided? A retrospective cohort study

Urodynamic studies are fundamental in the care of children with neurogenic bladder. Children with neurogenic bladder who perform clean intermittent catheterization (CIC) are considered a high-risk group for infection after urodynamic studies. Current guidelines are not uniform regarding the duration, type, the need of prophylactic antibiotic treatment or performance of urine culture before urodynamic studies. To assess whether antibiotic prophylactic therapy before urodynamic studies should be empiric or culture-guided in children with neurogenic bladder who perform CIC. Urine samples were collected from children with neurogenic bladder who require CIC before undergoing a urodynamic study. Urine cultures were collected via sterile urethral catheterization one week before urodynamic studies between 2010 and 2018. Children with signs of urinary tract infection (UTI) or children with bladder augmentation were excluded. Resistance to commonly prescribed periprocedural antibiotic treatments was documented. The probability of antibiotic resistance according to sex, vesicoureteral reflux (VUR) status, consumption of prophylactic antibiotics, and self/caregiver performed CIC was determined by a χ2-test. A total of 278 urine cultures were collected from 185 children with neurogenic bladder. The median age was 8 years (IQR 5-12). The most common etiology for neurogenic bladder was spinal dysraphism (n=146, 77%). Bacterial growth was detected in 216 (78%) cultures, and the most commonly detected bacterial species was Escherichia. coli (n=155, 72%). Thirty-six (19%) children had VUR, and 14 of them received continuous prophylactic antibiotics. The probability of resistance to oral antibiotics was amoxicillin (22%), cephalexin (21%), cefuroxime (14%), ciprofloxacin (10%), nitrofurantoin (21%), and sulfamethoxazole/trimethoprim (SMX/TMP) (23%) (See "summary table") No significant differences were found by χ2-test in the probability of resistance to antibiotics according to sex, VUR status, continuous antibiotic prophylaxis or self/caregiver performed CIC. The study reveals high resistance level to commonly prescribed oral antibiotic treatments (20-30%). Several studies have challenged the need of routine urine cultures before urodynamic studies due to low risk of post-procedural infection. However, it should be mentioned that not all the patients participating in those studies were with neurogenic bladder or routinely performed CIC. Hence, in this specific group of children, routine urine cultures should not be abandoned. The limitations of the study are: Single-center, retrospective study with no data availability regarding the development of UTI after the urodynamic studies. Urine cultures of children with neurogenic bladder who require CIC demonstrate significant levels of resistance to commonly prescribed oral antibiotics. These findings support culture-guided periprocedural antibiotic prophylaxis.

Leprosy-like reaction occurred during the treatment of a cutaneous Mycobacterium haemophilum infection: A case report

Rationale: Mycobacterium haemophilum is a rare pathogen, belongs to the slowly-growing nontuberculous mycobacterium family, and shares a close evolutionary relationship with Mycobacterium leprae. It is a fastidious organism that requires special media(iron or hemin supplementation)and conditions (incubation at 30–32°C) for growth, which differs from most other pathogenic mycobacteria. Patient concerns: A 43-year-old Asian male presented to our outpatient department due to the appearance of multiple infiltrative erythematous nodules and ulcerations on the extremities for more than 2 months. Diagnoses: Acid-fast bacteria were detected in the specimen and sequencing for hsp65 and 16S rRNA genes of the pathogen extracted from the biopsy tissue identified as M haemophilum. The diagnosis of cutaneous M haemophilum infection was established. Interventions: The patient received a 3-drug regimen (oral clarithromycin 1.0 g/d, rifampicin 0.6 g/d, and moxifloxacin 1.0 g/d) and local hot compression therapy, the dose of immunosuppressant was reduced. Outcomes: The lesions gradually improved after 6 months of continuous antibiotic therapy. There is no recurrence of erythema papules and nodules. Lessons: This case shows that the patient’s condition may be exacerbated immediately after the initiation of anti-nontuberculous mycobacterium therapy, which is analogous to the leprosy reaction. A high degree of clinical suspicion for the underlying disease is critical to avoid unnecessary interruption of treatment.

Long-term antibiotic prescribing in the community: 6 years of Australian national data.

Prolonged or indefinite courses of antibiotics are sometimes prescribed for suppression of chronic infection, prophylaxis, and noninfective indications. Little is known about long-term prescribing practices in the community. In Australia, 75% of outpatient prescribing is funded through the Pharmaceutical Benefits Scheme (PBS), a government program for subsidized medications. To describe the landscape of outpatient prescribing of long-term antibiotics in Australia. We descriptively analyzed a randomized 10% sample of PBS prescription data from 2014 to 2020. "Long term" was defined as continuous prescribing 12 months or more. Patients were identified using a rolling window algorithm with 12-month look-back from each script provided. Prolonged continuous antibiotics (> 12 months) were prescribed to 339/100,000 population; 50% of patients were aged more than 65 years and prescribing increased with age (1440/100,000 population in patients > 75 years). Frequently prescribed antibiotic classes were tetracyclines (43% of all long-term antibiotics), sulfonamides/trimethoprim (21%, predominantly cotrimoxazole), cephalosporins (15%, predominantly cefalexin), and penicillins (13%). Prophylaxis of infection and immunomodulatory indications were most common. Patients were co-prescribed analgesics (30%), antidepressants (30%), corticosteroids (20%), and immunosuppressive drugs (6%). Prolonged community prescribing of antibiotics is an important target for antibiotic stewardship, particularly in older adults.

La profilassi antibiotica nei lattanti con reflusso vescicoureterale di grado elevato: più svantaggi che vantaggi

Antibiotic prophylaxis in infants with high-grade vesicoureteral reflux: more disadvantages than advantages The effectiveness of continuous antibiotic prophylaxis in high-grade reflux (III-V) is controversial. This prospective multicenter randomized open-label phase 3 study highlights how in infants with high-grade reflux without previous UTI, continuous antibiotic prophylaxis guarantees a small but significant benefit in terms of prevention of a first UTI compared to placebo (21.2% vs 35.6%, 95% CI 0.35-0.86, p= 0.008), despite an increased incidence of infections from non-coli germs and increased antibiotic resistance. Furthermore, no difference was highlighted between the two groups in terms of long-term renal scarring and renal function two years after enrollment. The use of continuous antibiotic prophylaxis, in patients without previous history of urinary tract infection must therefore be evaluated judiciously depending on the patient's sex, the severity of vesicoureteral reflux, the presence of bladder dysfunction.

Does Secondary Antibiotic Prophylaxis Improve Clinical Outcomes in Adult Rheumatic Heart Disease Patients Post-Valve Replacement?

Secondary prevention of recurrent rheumatic fever in individuals with rheumatic heart disease (RHD) requires continuous antibiotic prophylaxis. However, the impact of antibiotic prophylaxis on the outcome of patients with severe RHD who underwent heart valve replacement is unknown. The objective of the study was to assess the relationship between the use of antibiotics as secondary prophylaxis in RHD patients who underwent valve replacement and clinical outcomes including mortality, reoperation, and valve-related hospitalization. We retrospectively compared outcomes of adult patients who underwent heart valve replacement for RHD at our institution from 1990 through 2014 and who received secondary antibiotic prophylaxis (prophylaxis group) with those who did not receive prophylaxis (nonprophylaxis group) using propensity score matching analysis. A total of 1094 patients (56% females, median age 40 years, range 31-53 years) were included with a median follow-up of 9.6 years (range 2.9-12.6 years). Antibiotic prophylaxis was prescribed in 201 patients (18%). Propensity score matching analysis demonstrated no significant difference in overall survival (95% [92%-98%] vs 97% [95%-99%], respectively; P = .7), valve-related hospitalization-independent survival (72% [range 65%-78%] vs 81% [range 76%-88%]; P = .25), and redo valve surgery-independent survival [76% [range 70%-83%] vs 75% [range 72%-79%]; P = .41) at 10-year follow-up in the nonantibiotic prophylaxis versus the antibiotic prophylaxis group. Secondary antibiotic prophylaxis among adult RHD patients following valve replacement is not associated with improved clinical outcomes.

985. Practice Patterns of Antimicrobial Suppression Therapy in Total Knee Arthroplasty Infections

Abstract Background There are no current established guidelines for the role of antimicrobial suppression therapy in management of prosthetic joint infection (PJI). In 2013, the IDSA provided initial treatment guidelines for PJI but did not address suppressive therapy. The guidelines do not address suppressive therapy beyond the initial 4-6 weeks for non-staphylococcal infections nor do they address suppressive therapy after 3-6 months of treatment for Staphylococcal infections. Practitioners must delicately balance the risk of PJI recurrence and the negative effects of continued antibiotic therapy including toxicity and resistance. In this study, we surveyed Infectious Disease providers to better understand their antimicrobial suppression practice patterns in different clinical scenarios. Methods We surveyed Infectious Disease providers across the United States from April 2022 to May 2022. We received 78 unique response from 31 different states. Basic demographic data was obtained. Providers presented six multiple choice clinical scenarios and were asked if they would start suppressive therapy and the duration of suppressive therapy. Results The preliminary data revealed that practice patterns vary greatly amongst providers in the management of antibiotic suppressive therapy in PJI. Of the 6 scenarios, only half had greater than 50% consensus (50.6%, 51.3% and 70.1%). Scenario 1 involved a patient who underwent a single stage revision. It was of particular interest as 51.3% of providers indicated they would stop antimicrobial therapy and 48.7% indicated they would extend antimicrobial therapy with 25.6% electing for lifelong suppressive therapy. Conclusion Practice patterns for antimicrobial suppression therapy in knee PJI varies significantly among providers. Even with IDSA guidelines addressing Staphylococcal PJI, the practice patterns among infectious diseases providers still varied greatly especially with regards to single stage revisions. Additional randomized controlled trials examining the best way to manage antimicrobial suppression in PJI would be helpful, and would allow for development of evidence-based guidelines. We also plan to survey orthopedic surgeons using the same clinical scenarios to see if there is a difference in management styles. Disclosures All Authors: No reported disclosures.

Diagnostic and therapeutic management of vesico-ureteral reflux in pediatric kidney transplantation-Results of an online survey on behalf of the European Society for Paediatric Nephrology.

Vesico-ureteral reflux (VUR) is considered to be a risk factor for recurrent febrile urinary tract infections and impaired renal transplant survival. An online survey supported by the European Society for Paediatric Nephrology was designed to evaluate current management strategies of VUR in native and transplanted kidneys of recipients aged <18 years. Seventy-three pediatric transplant centers from 32 countries contributed to the survey. All centers performed urological evaluation prior to pediatric kidney transplantation (KTx) with subsequent interdisciplinary discussion. Screening for VUR in native kidneys (30% in all, 70% in selected patients) led to surgical intervention in 78% (11% in all, 89% in selected patients) with a decided preference of endoscopic intervention over ureterocystoneostomy. Following KTx, continuous antibiotic prophylaxis was applied in 65% of the patients and screening for allograft VUR performed in 93% of selected patients. The main management strategies of symptomatic allograft VUR were continuous antibiotic prophylaxis (83%) and surgical treatment (74%) (endoscopic intervention 55%, redo ureterocystoneostomy 26%). This survey demonstrates the high variability in the management of VUR in pediatric KTx recipients, points to knowledge gaps, and might serve as a starting point for improving the care for patients with VUR in native and transplanted kidneys.

Increased short- and long-term mortality amongst patients with early periprosthetic knee joint infection

BackgroundPeriprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a severe complication in terms of disability, morbidity, and cost. We performed a study to investigate whether early PJI (within 90 days of primary TKA) is associated with increased mortality. Secondary aims were to compare mortality rates over time and between surgical treatment methods.MethodsPatients with suspected PJI were identified by linkage of the Swedish Knee Arthroplasty Register (SKAR) and the Swedish Prescribed Drug Register (SPDR) in 2007–2008 and 2012–2013. Medical records of patients receiving more than 4 weeks of continuous antibiotic therapy were subsequently reviewed to verify the PJI diagnosis. Information on mortality was obtained through the SKAR which is updated daily from the tax agency and patients with PJI were compared to patients without PJI.ResultsFour hundred sixty-six patients were diagnosed with PJI within 90 days and compared to 40,362 patients without PJI. Mortality rates were significantly higher for PJI patients in both short- and long term: 2.6% vs. 0.8% at 1 year, 4.9% vs. 1.9% at 2 years, 15.7% vs. 7.1% at 5 years, and 38% vs. 21.4% at 10 years. The difference in mortality rate remained after adjusting for sex, age, diagnosis, and time period for surgery with Hazard Ratio 1.8 (95% CI:1.6–2.1). Mortality rates did not differ between time periods, and we found no correlation to surgical treatment.ConclusionPatients with early PJI after primary TKA have an increased mortality rate compared to TKA patients without PJI. Improvements in surgical treatment strategy has not resulted in better survival. Long term difference in mortality rates indicates that PJI is not the sole reason for mortality suggesting a general frailty in PJI patients.

Antibiotic Resistance in COVID-19 with Bacterial Infection: Laboratory-Based Surveillance Study at Single Tertiary Hospital in Indonesia.

PurposeCoronavirus disease 2019 (COVID-19) is a new pandemic affecting the respiratory system and caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition to the increased use of antibiotics, the length of stay of hospitalized patients affects the risk of bacterial infections among the COVID-19 patients. However, this pandemic has interrupted antibiotic surveillance activity and led to an information gap about the prevalence and characteristics of bacterial infection. This study aims to describe the antibiotic resistance in COVID-19 patients with culture-proven bacterial infection using a laboratory-based surveillance approach.Patients and MethodsA retrospective study with a cross-sectional design was conducted on adult patients that confirmed positive for COVID-19 according to the International Classification of Diseases 10th Revision (ICD-10). From March 2020 to October 2021, data were obtained from the hospital information system and merged with the culture and antibiotic susceptibility test from laboratory information system at Hasan Sadikin General Hospital. The outcome is the prevalence percentage of resistance to selected antibiotics in patients with COVID-19. The resistance percentage is considered high when equal to or more than 20%.ResultsThere was 2786 adult patient confirmed for COVID-19 according to the ICD-10, and 26.3% (n = 733) of them submitted clinical specimen for culture. The prevalence of bacterial infection among COVID-19 patients was 16.4%, predominating Gram-negative bacteria (GNB). The respiratory specimen dominated the positive growth culture. The GNB were predominantly discovered among the respiratory and non-respiratory specimens. High range resistance to ampicillin-sulbactam (24–100%), ceftriaxone (22–81%), cefotaxime (22–73%) and ciprofloxacin (20–86%) are observed among the GNB.ConclusionThere is high resistance to fluoroquinolone and cephalosporins in identified isolate, commonly used as the first-line empirical treatment for respiratory and non-respiratory infection in Indonesia. The continuous antibiotic surveillance is mandatory and crucial to prevent the long-term effects of the COVID-19 pandemic, particularly bacterial infection.

Caecocolic ligament hypoplasia in a Thoroughbred filly with volvulus of the large colon

SummaryAn 11‐month‐old Thoroughbred filly was referred to the hospital with signs of severe abdominal pain unresponsive to medical treatment. Upon arrival, the filly had a heart rate of 60 beats/min, pink mucous membranes and continued to show severe colic signs despite sedation. Due to the severity of colic signs, general anaesthesia was induced immediately. Exploratory celiotomy revealed a large colon volvulus of more than 360 degrees and hypoplasia of the caecocolic ligament between the caecum and right dorsal colon. The large colon volvulus was corrected, and the filly recovered uneventfully from general anaesthesia. Post‐operative treatment included intravenous fluids and intravenous lidocaine continuous rate infusion, parenteral nutrition, systemic antibiotics, nonsteroidal anti‐inflammatories, gastroprotectants and restricted feeding. The filly experienced several post‐operative complications associated with severe enterocolitis including pyrexia, leukopenia and diarrhoea but made a full recovery and was discharged to the farm after 16 days of hospitalisation. Long‐term follow‐up was available for 22 months after surgery without further reports of colic and the filly had entered race training. Hypoplasia of the caecocolic ligament in association with colic in horses has rarely been reported in the equine literature. To date, only two further case reports of young horses with large colon volvulus and hypoplasia of the caecocolic ligament have been published. In contrast to the presenting case, several other mesenteric abnormalities were present in these two cases in addition to the hypoplastic caecocolic ligament and both horses were eventually euthanised. The pathogenesis of hypoplasia of the caecocolic ligament remains unclear but may include the disruption of early stages of embryogenesis. An abnormal caecocolic ligament has been suggested to potentially predispose horses to large colon volvulus. The presenting case indicates that as an isolated abnormality, a hypoplastic caecocolic ligament may not result in reduced long‐term survival in horses with large colon volvulus.

Efficacy and safety of tailin formulation combined with continuous low-dose antibiotic therapy in patients with recurrent urinary tract infection: A multicenter, randomized, controlled clinical trial

Persistent inflammation associated with recurrent urinary tract infection (rUTI) is a crucial inducement of inflammation-driven renal fibrosis (IDRF). Although continuous low-dose antibiotic therapy (CLAT) is the common treatment for rUTI, its clinical efficacy remains unsatisfactory. Tailin formulation (TLF), a Chinese herbal formulation prescribed for treating rUTI, is effective in alleviating symptoms and reducing recurrence. This study was to evaluate the efficacy and safety of TLF combined with CLAT compared with CLAT used alone in patients with rUTI. In this multicenter, randomized, controlled clinical trial, patients were assigned (1:1) to receive either TLF + CLAT or CLAT for 12 weeks. The primary outcome was the effective rate at week 12 of the treatment. The secondary outcomes were the recurrent rate at week 4 and week 12 post treatment; the post-treatment changes in renal tubular injury markers (urinary N-acetyl-β-d-glucosaminidase (NAG) and β2-microglobulin (β2-MG)), profibrotic factors (urinary monocyte chemoattractant protein-1 (MCP-1) and transforming growth factor beta1 (TGF-β1)), and traditional Chinese medicine (TCM) symptoms, and vital signs indicators and serious adverse events (SAEs) were also monitored throughout the trial. A total of 195 patients were included in the final analysis. The TLF + CLAT group had a higher effective rate and a lower recurrence rate than the CLAT group (p < 0.01). Significant decrease of urinary NAG and β2-MG was observed in the TLF + CLAT group vs. CLAT group (p < 0.01), and similar changes were observed in profibrotic factors (urinary MCP-1 and TGF-β1) (p < 0.05), which indicated that TLF might have potential renal tubular protection and anti-fibrosis effects. Additionally, a positive correlation within a certain range was shown in the correlation analysis of medical history (months) of rUTI patients with urinary MCP-1 (r = 0.50, p < 0.05) and TGF-β1 (r = 0.78, p < 0.01). A significant difference was also observed in TCM symptoms (p < 0.01). There were no obvious adverse reactions that occurred during this study. We conclude that TLF combined with CLAT was superior to CLAT used alone in reducing rUTI recurrence, alleviating the non-infection-related physical symptoms and protecting renal tubular and anti-fibrosis, which suggests this novel therapy might be an available treatment with great promise in treating rUTI.

Diagnosis and treatment of women with recurrent urinary tract infection

Background: Uncomplicated urinary tract infection (cystitis) is the most common bacterial infection among women visiting primary care clinics, and approximately 50% experience recurrence. Recurrent cystitis represents a substantial burden on the patients’ quality of life, healthcare costs, and antibiotics overuse.Current Concepts: Symptoms remain the cornerstone of cystitis diagnosis, and urine culture is necessary if recurrent cystitis is suspected. Antibiotics (typically nitrofurantoin and fosfomycin) are the first-line treatment. Based on the resistance data, cephalosporins and amoxicillin-clavulanate are the second-line treatment recommendations. Fluoroquinolones are not the first-line options because of safety concerns and rising resistance rates. In considering patients with recurrent cystitis, it is important to assess the patient’s risk factors. Postmenopausal women may present differently and require different diagnostic and treatment approaches from that of younger women. Non-antimicrobial approaches to prevent recurrent cystitis are preferred due to tolerability, safety, antimicrobial resistance concerns, and patient choice. Oral immunostimulant is effective for any age, and vaginal estrogen therapy is additionally recommended in postmenopausal women. Self-start and post-coital antibiotic therapy and non-antimicrobial prophylaxis may be combined. Low-dose continuous antibiotic therapy may be considered for women in whom other regimens fail.Discussion and Conclusion: To improve the quality of life and medical care of women, closing the gap between the physicians’ perceptions and patients’ needs is necessary. Furthermore, various preventive therapies for recurrent cystitis should be fully utilized.

Vesicoureteral Reflux – Insights into Diagnosis and Management

Abstract Vesicoureteral reflux (VUR) is the most common congenital condition of the urinary tract. A plethora of imaging methods and treatment plans are described in literature and are used in clinical practice. The aim of this article is to analyze the available diagnostic tests and the pharmaceutical, endoscopic, and surgical options of our therapeutic armamentarium. A literature search on the PubMed database was conducted by two writers. Randomized controlled trials and meta-analyses were included, all published in PubMed and in the English language from 2011 to this day. After reviewing the full texts, we excluded duplicates, papers regarding secondary disease and those without a pediatric reference population. Regarding the mostly used imaging tests, voiding cystourethrography is considered the reference method for the diagnosis and grading of the disease, but it entails exposure of patients to ionizing radiation. Voiding urosonography has a similar sensitivity but is highly dependent on the operator’s experience. Renal scintigraphy with dimercaptosuccinic acid remains a useful test for detecting renal scars. As far as management is concerned, continuous antibiotic prophylaxis, though previously doubted, remains a valid therapeutic option, especially for lower grades of VUR. Open surgical techniques and their modern–laparoscopic and robotic–variations are useful for dealing with high-grade disease, while endoscopic methods have sufficient efficacy and are utilized more and more. The diagnosis and treatment of VUR are constantly evolving areas. New diagnostic methods are replacing the older ones, while the treatment algorithm is individualized.

Evaluation of Renal Function and Scars in Children With Primary Vesicoureteral Reflux

ObjectiveTo evaluate growth, glomerular and tubular function, renal damage, scars in children affected by primary VUR. MethodsWe retrospectively evaluated the clinical records of our Unit from January 2006 to September 2020. For each patient we evaluated growth, laboratoristic and scintigraphic glomerular and tubular function, renal damage and collective system urodynamics at baseline and at the last visit. ResultsWe enrolled 41 patients affected by primary VUR and treated with continuous antibiotic prophylaxis. Glomerular function and urodynamics did not change over time. EFNa directly correlated with weight (r 0.44 P .004) and TRP inversely correlated with severity of reflux (r -0.32, P .04). Female sex was associated to nephrolithiasis (OR 17.0, P .02) and proteinuria (at T0 OR 5.8 P .03 at T1 OR 5.8, P .03). Daily proteinuria increased with age (r 0.66, P <.0001 at T0 and r 0.44 P .004 at T1) while protein-to-creatinine ratio decreased. Renal scars at T0 inversely correlated with glomerular and tubular function at T1 but they did not correlate with severity or laterality of reflux. ConclusionEven if renal function remains stable through years, it is critical to identify the subjects with significant congenital renal damage.

371-P: Predicting Real-World Nonsevere Hypoglycemia in Americans with Diabetes (iNPHORM)

Iatrogenic non-severe hypoglycemia (NSH) is a common and known precursor of severe hypoglycemia. Still, virtually no valid risk estimators exist to predict daytime and nocturnal NSH (NSDH, NSNH) in the general US population with diabetes. To redress this gap, we analyzed primary, self-reported data from the 1-year, prospective iNPHORM study. Adults (18-90 years old) with insulin- and/or secretagogue-treated type 1 or 2 diabetes (T1D, T2D) were recruited from a US-wide probability-based internet panel. Twelve monthly emailed questionnaires assessed NSH risk. Prognostic models were built for recurrent 30-day NSDH and NSNH using negative binomial and machine learning penalized regression with lasso. Missing data were multiply imputed with chained equations. N=986 were analyzed (T1D: 17%; age: 51 [SD: 14.3] years; male: 49.6%; T1D/T2D duration: 12 [IQR: 14] years; retention rate: 86.2%) . Among T2D respondents, 38% were on insulin alone, 38% secretagogues alone, and 24% insulin plus secretagogues. Follow-up incidence proportions and 30-day rates of NSDH and NSNH were 79.6% (95% CI: 77.0-82.0%) and 1.70 (95% CI: 1.59-1.82) , and 53.7% (95% CI: 50.5-56.7%) and 0.69 (95% CI: 0.64-0.75) , respectively. Risks of 30-day NSDH and NSNH increased with insulin+secretagogue therapy; A1C≤7%; insulin pump, continuous glucose monitoring, beta blockers, and antibiotics use; decreased number of medications; T1D and diabetes education; increased past severe hypoglycemia requiring healthcare; chronic kidney disease; depression; food insecurity; lack of insurance; younger age; female sex; and White race; risks decreased with A1C≥7.1%, cognitive impairment, hypoglycemia unawareness, and insurance. As well, higher income predicted NSNH risk. The optimism adjusted c-statistics for NSDH and NSNH risks were 0.78 and 0.77, respectively. As the first US study to prospectively estimate real-world NSDH and NSNH risk, iNPHORM provides important insight into individual-level event detection and prevention. Disclosure A.Ratzki-leewing: Consultant; Eli Lilly and Company, Other Relationship; Sanofi. S.B.Harris: Consultant; Abbott, AstraZeneca, Eli Lilly and Company, Novo Nordisk, Sanofi, Other Relationship; Abbott, AstraZeneca, Bayer Inc., Dexcom, Eli Lilly and Company, HLS Therapeutics, Janssen Pharmaceuticals, Inc., Novo Nordisk, Sanofi, Research Support; Applied Therapeutics Inc., AstraZeneca, Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation (JDRF) , Novo Nordisk, Sanofi, The Lawson Foundation. J.E.Black: None. G.Zou: None. S.Webster-bogaert: None. B.L.Ryan: None. Funding Sanofi Global

Potential of Continuous Local Antibiotic Perfusion Therapy for Fracture-Related Infections

IntroductionFracture-related infections (FRIs) are challenging for orthopedic surgeons, as conventional surgical treatment and systemic antimicrobial therapy cannot completely control local infections. Continuous local antibiotic perfusion (CLAP) is a novel and innovative therapy for bone and soft-tissue infections, and is expected to eradicate biofilms by maintaining a sustained high concentration of antimicrobial agents at the infected site. If CLAP therapy can eradicate infection even in cases with implants while preserving the implants, it would be an ideal and effective treatment for local refractory infections. This study aimed to evaluate the usefulness of novel CLAP therapy for FRIs.MethodsNine patients treated with CLAP therapy were retrospectively analyzed. The mean age was 65.9 (43–82) years, and the mean follow-up period was 14.9 (6–45) months. In all cases, the infected sites were related to the lower extremities (tibia, n = 6; fibula, n = 1; hip joint, n = 1; foot, n = 1). All patients underwent similar procedures for this therapy combined with negative-pressure wound therapy after thorough irrigation and debridement of infected tissues.ResultsThe pathogens identified were Staphylococcus aureus (methicillin-resistant S. aureus, n = 5; methicillin-susceptible S. aureus, n = 1), Pseudomonas aeruginosa (n = 3), Enterococcus faecalis (n = 2), Corynebacterium (n = 1), and Enterobacter (n = 1); pathogens were not detected in one case. The mean duration of CLAP was 17.0 (7–35) days. In all cases, implants were preserved until bone union was achieved. Five cases relapsed; however, infection was finally suppressed in all cases by repeating this method. No side effects were observed.ConclusionThis novel case series presents treatment outcomes using CLAP therapy for FRIs. This method has the potential to control the infection without removing the implants, because of the sustained high concentration of antimicrobial agents at the infected site, and could be a valuable treatment option for refractory FRIs with implants, in which bone union has not been achieved.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-022-00653-5.