Days Of Oral Antibiotics Research Articles

One-Stage Deep Inferior Epigastric Perforator Flap Salvage of Infected Tissue Expanders

Background Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of definitive breast reconstruction and adjuvant therapy. In this study, we describe a single-stage technique where deep inferior epigastric artery perforator (DIEP) flaps are used to salvage actively infected tissue expanders among patients originally planning for free flap reconstruction. Methods In this technique, patients with tissue expander infections without systemic illness are maintained on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant is performed in conjunction with aggressive attempt at total capsulectomy and immediate DIEP flap reconstruction. Patients are maintained on 1–2 weeks of oral antibiotics tailored to culture data. Patients undergoing this immediate salvage protocol were retrospectively reviewed, and complications and length of stay were assessed. Results In a retrospective series, a total of six consecutive patients with culture-proven tissue expander infections underwent tissue expander removal and DIEP flap reconstruction in a single stage and were maintained on 7–14 days of oral antibiotics postoperatively. Within this cohort, no surgical site infections, microvascular complications, partial flap losses, reoperations, or returns to the operating room were noted within a 90-day period. Conclusions Among a select cohort of patients, actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery with a low incidence of postoperative complications. Prospective studies are needed to evaluate the influence of this treatment strategy on costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander infections.

WTP7.12 Investigating the duration of empirical antibiotic treatment and subsequent reduction in hospital readmission rates for perforated appendicitis in the paediatric patient population

Abstract Background and Aim Acute appendicitis is the most common surgical emergency in the paediatrics. Complicated appendicitis often involves perforation, requiring a longer course of antibiotics post-appendicectomy [1]. There is considerable variability on post-operative antibiotic regimes and duration within hospital trusts with no national guidelines. Local Trust-based consensus [2] recommends a 5-day course IV co-amoxiclav with American Paediatric Surgical Association guidelines suggesting oral conversion if IV antibiotic duration is less than 5 days [3, 4]. Therefore, we measured compliance with local and international guidelines. Methods Paediatric patients aged 5-17 years were selected for the study using ICD-10 codes for ‘Perforated Appendicitis’ (K35.2 and K35.3). Patients were included if they had operative management for perforated appendicitis between 1 April 2021 and 31 March 2022. Key parameters collated included; re-admission, duration of re-admission, complication, post-operative antibiotic use (selection, intravenous/oral dose and duration of use). Results Twenty-six paediatric appendicectomies for perforated appendicitis occurred within the time frame. Nine had IV antibiotics for >5 days, of this cohort, 7 had oral conversion and completed 2-5 days of oral antibiotics with re-admission rate 33%. Eleven had IV antibiotics for < 5 days with oral conversion for 4-7 days, readmission rate was 18.2% on days 4 & 5 respectively. Six had IV antibiotics for <5 days with no oral conversion and no patients were re-admitted. Conclusions A longer duration of antibiotics with an earlier conversion from IV to oral, reduced readmission rates. However, greater research with more participants and standardised antibiotics can explore other influencing factors.

Association of Antibiotic Receipt With Survival Among Patients With Metastatic Pancreatic Ductal Adenocarcinoma Receiving Chemotherapy

The prognosis for patients with metastatic pancreatic ductal adenocarcinoma (PDAC) is dismal, due in part to chemoresistance. Bacteria-mediated mechanisms of chemoresistance suggest a potential role for antibiotics in modulating response to chemotherapy. To evaluate whether use of peritreatment antibiotics is associated with survival among patients with metastatic PDAC treated with first-line gemcitabine or fluorouracil chemotherapy. Using the population-based Surveillance, Epidemiology, and End Results-Medicare linked database, this retrospective cohort study analyzed data for patients diagnosed with PDAC between January 1, 2007, and December 31, 2017. Data analysis was conducted between September 1, 2021, and January 15, 2023. The population-based sample included 3850 patients with primary metastatic PDAC treated with first-line gemcitabine or fluorouracil chemotherapy. Patients who received antibiotics were matched based on propensity scores to patients who did not receive antibiotics. Receipt of 5 or more days of oral antibiotics or 1 injectable antibiotic in the month before or after beginning first-line chemotherapy. Overall survival and cancer-specific survival. The end of follow-up was December 31, 2019, for overall survival and December 31, 2018, for cancer-specific survival. Of the 3850 patients treated with first-line gemcitabine (3150 [81.8%]) or fluorouracil (700 [18.2%]), 2178 (56.6%) received antibiotics. The mean (SD) age at diagnosis was 74.2 (5.8) years and patients were predominantly women (2102 [54.6%]), White (3396 [88.2%]), and from metropolitan areas (3393 [88.1%]) in the northeastern or western US (2952 [76.7%]). In total, 1672 propensity-matched pairs were analyzed. Antibiotic receipt was associated with an 11% improvement in overall survival (hazard ratio [HR], 0.89; 95% CI, 0.83-0.96; P = .003) and a 16% improvement in cancer-specific survival (HR, 0.84; 95% CI, 0.77-0.92; P < .001) among patients treated with gemcitabine. In contrast, there was no association between antibiotic receipt and overall survival (HR, 1.08; 95% CI, 0.90-1.29; P = .41) or cancer-specific survival (HR, 1.12; 95% CI, 0.90-1.36; P = .29) among patients treated with fluorouracil. In a subgroup of gemcitabine-treated patients who received antibiotics, nonpenicillin β-lactams were associated with an 11% survival benefit (HR, 0.89; 95% CI, 0.81-0.97; P = .01). In this cohort study, receipt of perichemotherapy antibiotics was associated with improved survival among patients treated with gemcitabine, but not fluorouracil, suggesting that antibiotics may modulate bacteria-mediated gemcitabine resistance and have the potential to improve PDAC outcomes.

981. Inducing Antimicrobial Resistance with Long-Term Antibiotics at Stage 2 Revision for Periprosthetic Joint Infection

Abstract Background Studies have shown reduced rates of recurrence of periprosthetic joint infection (PJI) with the use of oral antibiotics after stage-two revision. We examined the effects of these antibiotics on the antibiotic susceptibility patterns of subsequent PJI. Methods We conducted a retrospective cohort study of patients who underwent two-stage exchange for PJI in the Veterans Affairs system from 1/1/2015 – 6/1/2020. We compared patients who were prescribed oral antibiotic prophylaxis for ³14 days following stage-two revision arthroplasty with those who received &amp;lt; 14 days of antibiotics. The primary outcome was the presence of antibiotic-resistant organisms isolated in cultures from subsequent infections of the same joint. Secondary outcomes included comparisons of rates of recurrent PJI and time-to-subsequent PJI between each group. We used Chi square and Fisher exact tests to compare the two groups. Results 605 patients met inclusion criteria. Of these, 154 received ³14 days of oral antibiotics following stage 2 surgery. Tetracyclines (48.1%), beta-lactams (27.3%) and trimethoprim-sulfamethoxazole, TMP-SMX (18.8%) were the most common antibiotics used. There was decreased susceptibility to tetracyclines (58 vs 73%, p 0.24), TMP-SMX (48 vs 70%, p 0.059), and clindamycin (38 vs 57%, p 0.22) in organisms isolated from subsequent PJI in the antibiotic prophylaxis group compared to the control group. Subsequent PJI was diagnosed in 29 out of 154 (18.8%) in those who received antibiotic prophylaxis, compared with 80 of 451 (17.7%) who did not. Days to subsequent infection was higher for those who received antibiotics compared to those who did not (101 vs 65 days, respectively). Conclusion Prophylactic antibiotics following stage 2 revision for PJI may increase the risk for drug-resistant organisms in subsequent index joint infections, most notably against tetracyclines and TMP-SMX. Based on our data, antibiotics given after stage 2 revision postponed, rather than prevented, subsequent infection. Disclosures All Authors: No reported disclosures.

Improving Duration of Antibiotics for Skin and Soft-tissue Infections in Pediatric Urgent Cares.

National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021. We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers' concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations. After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days. By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.

Impact of antibiotics on stage IV pancreatic ductal adenocarcinoma treated with gemcitabine or 5-fluorouracil.

e16292 Background: Recent studies have suggested a role for the tumor microbiome in conferring chemoresistance to gemcitabine (GEM) in patients with pancreatic ductal adenocarcinoma (PDAC). One proposed resistance mechanism is the presence of bacterial enzymes that metabolize GEM, but not 5-fluorouracil (5-FU). We therefore assessed the impact of antibiotic receipt in the month before and after initiation of either GEM- or 5-FU-based chemotherapy on PDAC overall survival (OS). Methods: We used the SEER-Medicare database to identify adults &gt;66 years old with stage IV PDAC treated with either first-line GEM or 5-FU between 2007-2017. Antibiotic receipt was defined as a claim for &gt;5 days of oral antibiotics or &gt;1 intravenous antibiotic in the month before or after chemotherapy initiation. Demographic and clinical characteristics were compared using chi-squared and student t-tests, and univariable survival was assessed using Kaplan-Meier methods. Propensity scores (PS) were created to account for potential allocation bias in the receipt of antibiotics. We fit PS-adjusted Cox proportional-hazard models to evaluate the association between antibiotic receipt and OS. Results: We identified 3,990 stage IV PDAC patients treated with first-line GEM-based (n = 3,219) or 5-FU-based (n = 771) chemotherapy, of whom 2,318 (58.1%) received antibiotics. In univariable analyses, antibiotic receipt in the month surrounding chemotherapy initiation was associated with improved median OS in patients treated with GEM (214 days vs 199 days, p = 0.04) but not in patients treated with 5-FU (255 days vs 284 days, P = 0.14). In PS-adjusted multivariable analyses, the significant association between antibiotic receipt and improved OS in patients who received GEM remained (HR 0.89, 95% CI 0.83-0.96). However, no significant association between antibiotic receipt and OS was seen in patients treated with 5-FU (1.10, 95% CI 0.94-1.28). Conclusions: Antibiotic receipt in the month before or after chemotherapy initiation was associated with improved OS in stage IV PDAC patients who received GEM but not 5-FU. These findings support the concept that antibiotics may impact the activity of GEM-metabolizing bacteria proposed to confer chemoresistance. Further studies are needed to characterize the potential role for antibiotics in PDAC treatment.[Table: see text]

236 E-Prescribing and Smart Antimicrobial Stewardship in Upper Limb Infections

Abstract Aim Upper limb infections secondary to traumatic wounds, animal bites and other causes are a common reason for admission to the plastic surgery service for intravenous antibiotics. This audit investigated the compliance of treatment of upper limb infections with trust guidance. The guidance stipulated an antibiotic treatment duration of five to seven days total and microbiology advice suggested that in cases requiring multiple washouts, this should start from the date of the last surgical washout where pus was present. Method There was retrospective sampling for four months using inpatient lists to include patients admitted for intravenous antibiotics for upper limb infections. Notes were requested by the secretaries and data was collected using patient notes, discharge summaries and electronic drug charts. Results The analysis included twenty-seven suitable patients. All patients had the correct antibiotics prescribed according to guidance, however only 22% of patients had five to seven days total of antibiotics either from the start of therapy or from the date of last infected washout in those who underwent surgical treatment. 14/27 patients had more than seven days total antibiotics. 13/27 patients were discharged with an additional seven days of oral antibiotics regardless of the total duration. Conclusions These infections are significantly over-treated with antibiotics, which has serious potential consequences for antimicrobial resistance. The findings of the audit prompted new trust guidelines to be produced and prescribing guidance was sent to the junior doctors to calculate the total antibiotic duration when preparing discharge summaries. There is a plan for re-audit in a few months’ time.

139. Improving Skin and Soft Tissue Infection Antibiotic Duration Concordance with National Guidelines in Pediatric Urgent Care Clinics

Abstract Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive &amp;gt; 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart. Results After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers. Run Chart Conclusion Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

TP7.2.1 Outcomes of Modified Karydakis flap in the surgical management of sacrococcygeal pilonidal disease: A single surgeon’s experience

Abstract Aim To determine the incidence of post-operative complications of patients with sacrococcygeal pilonidal disease who were treated with the Modified Karydakis flap with a specific management bundle. Primary outcomes assessed included the post-operative incidence of seroma, haematoma, SSI, deep SSI, wound dehiscence, re-admissions, return to theatre and flap necrosis. Secondary outcome evaluated was recurrence at 6 month follow up. Method It was a retrospective analysis of a single surgeon’s (FA’s) practice results of Modified Karydakis flaps on patients with sacrococcygeal pilonidal disease who were managed according to a specific protocol. Data was collected between June 2017 and June 2020. 96 patients were analysed, of which 9 were excluded as they had excision without closure. Pre, per and post-operative management for the remaining 87 patients was according to a standardised protocol. Data was collected from patient’s notes and from prospectively and retrospectively maintained patient data bases (Theatre System, Medway). Results Primary outcomes: • Seroma: 8/87 (9.2%) • Haematoma: 1/87 (1.2%) • SSI: 10/87 (11.5%) • Deep SSI: 4/87 (4.6%) • Superficial dehiscence: 7/87 (8.0%) • Re-admission: 4/87 (4.6%) • Return to theatre: 0 (0%) • Flap necrosis: 0 (0%) Secondary outcome: • Recurrence at 6 months: 2/87 (2.3%) Conclusions Good surgical results can be obtained with Modified Karadakis flap, provided meticulous surgical technique is applied. Placement of a suction drain for a minimum of 72 hours reduces incidence of post-operative haematoma and seroma formation. Three post-operative doses of broad spectrum intravenous antibiotics followed by 5 days of oral antibiotics helps reduce post-operative infections.

269 Outcomes of Modified Karydakis Flap in The Surgical Management of Sacrococcygeal Pilonidal Disease: A Single Surgeon’s Experience

Abstract Aim To determine the incidence of post-operative complications of patients with sacrococcygeal pilonidal disease who were treated with the Modified Karydakis flap with a specific management bundle. Primary outcomes assessed included the post-operative incidence of seroma, haematoma, SSI, deep SSI, wound dehiscence, re-admissions, return to theatre and flap necrosis. Secondary outcome evaluated was recurrence at 6 months follow up. Method It was a retrospective analysis of a single surgeon’s (FA’s) practice results of Modified Karydakis flaps on patients with sacrococcygeal pilonidal disease who were managed according to a specific protocol (fig. 1). Data was collected between June 2017 and June 2020. 96 patients were analysed, of which 9 were excluded as they only had excision without closure. Pre, per and post-operative management of the remaining 87 patients was according to a standardised protocol (fig. 1). Data was collected from patient’s notes and from prospectively and retrospectively maintained patient data bases (Theatre System, Medway). Results Primary outcomes: Secondary outcome: Conclusions Good surgical results can be obtained with Modified Karadakis flap, provided meticulous surgical technique is applied. Placement of a suction drain for a minimum of 72 hours reduces incidence of post-operative haematoma and seroma formation. Three post-operative doses of broad-spectrum intravenous antibiotics followed by 5 days of oral antibiotics helps reduce post-operative infections.

Standardized Discharge Antibiotics May Reduce Readmissions in Pediatric Perforated Appendicitis

BackgroundBased on limited evidence, the American Pediatric Surgical Association recommends 5-7 d of postoperative antibiotics in perforated appendicitis for preventing intra-abdominal abscess (IAA). In 2015, our institutional clinical practice guideline was modified to standardize prescription for 7 additional days of oral antibiotics after discharge. We hypothesized that prescribing oral antibiotics after discharge would be associated with fewer complications in perforated appendicitis. Materials and methodsA retrospective cohort study was conducted of pediatric (younger than 18 y) patients who underwent laparoscopic appendectomy for perforated appendicitis (August 1, 2012-April 30, 2019). Patients diagnosed with IAA before discharge or with a postoperative length of stay ≥8 d were excluded. Patient outcomes were compared prestandardization and poststandardization of discharge antibiotics. ResultsOf 617 patients, 212 (34.5%) were admitted prestandardization and 404 (65.5%) poststandardization. Overall, 409 patients (66.3%) received discharge antibiotics. The median total postoperative antibiotic duration was 4 d (interquartile range, 3-5) prestandardization versus 11 d (interquartile range, 10-12) poststandardization (P < 0.001). Prestandardization patients had a higher rate of IAA (8.9% versus 4.5%, P = 0.03) and were readmitted more frequently (13.1% versus 6.4%, P = 0.005). On adjusted analysis, admission poststandardization was associated with reduced odds of IAA (odds ratio, 0.51; 95% confidence interval, 0.25-1.06), but the relationship was imprecise. Admission poststandardization was significantly associated with reduced adjusted odds of readmission (odds ratio, 0.46; 95% confidence interval, 0.25-0.85). ConclusionsPrescription for seven additional days of oral antibiotics after discharge was associated with reduced odds of readmission in pediatric perforated appendicitis. This population may benefit from a longer postoperative antibiotic course than currently recommended.

Early Oral Antibiotic Switch for Staphylococcus aureus Bacteremia: Many Are Called, but Few Are Chosen

Staphylococcus aureus bacteremia (SAB) is a complicated, high-risk disease. For selected low-risk SAB, the role of oral antibiotic stepdown therapy is unknown. Bupha-Intr et al. report a retrospective cohort of low-risk SAB patients who did well with a short duration of intravenous antibiotics, followed by an additional ∼10 days of oral antibiotics, primarily using beta-lactams. Prospective trials will help further define the efficacy of this approach.

Septic shock caused by abscess formation inside cystic adenomyosis after responsive treatment of pelvic inflammatory disease

Objective: To report on septic shock in a patient with an abscess inside cystic adenomyosis after responsive treatment of pelvic inflammatory disease. Case report: A 51-year-old woman with known cystic adenomyosis was admitted to the hospital due to fever and low abdominal pain. In suspicion of pelvic inflammatory disease, intravenous antibiotics were administered. As her symptoms and sings of inflammation improved, she was discharged from the hospital after five days. However, after completing 14 days of oral antibiotics, her symptoms aggravated with decreased blood pressure. Magnetic resonance imaging indicated abscess formation inside cystic adenomyosis, and total hysterectomy was performed. Postoperatively, she fell into shock condition. Intravenous antibiotics were administered for 11 days and she was discharged from the hospital with no adverse event. Conclusion: Physicians should be aware of the possibility of septic shock caused by abscess formation inside known cystic adenomyosis.

Gut-Skin Connection: Role of Intestinal Biome in Rosacea

Introduction: We hypothesized that gut flora may play a role in skin disorders either directly or through effects on the immune system and inflammatory response. To explore this theory, we performed a study in patients with rosacea comparing groups provided with standard of care treatment (SOC) to an experimental cohort (E) who received SOC and probiotics. Methods: 60 patients aged 30 to 59 years old diagnosed with rosacea and 10 healthy normal comparative subjects were identified. Patients with rosacea were randomly divided into 2 groups. The first group received SOC which included 7 days of oral antibiotics, vitamins, antihistamine, and topical permethrin. The second group (E) received SOC and a probiotic containing Bifidobacterium 50 x106 CFU three times a day and an immunomodulator Polioxidonium for 21 days. The following studies were performed before and after therapeutic intervention: stool culture, examination of the skin, and scrapings of their skin pustules for presence of the mite D. folliculorum. These 2 groups were also compared before starting the study to the normal control subjects. Standard statistical comparisons and analysis were made using statistical software. Results: There were 21 male and 39 female patients studied: 30 in SOC and 30 in E. The following clinical improvement was observed in the experimental versus control groups: complete skin remission 56.7% versus 28.3%, significant improvement 38.3% versus 33.7%, minimal improvement 5% versus 24.7% respectively. No improvement was seen in 0% of experimental group and 11.3% of control group (Table I). Compared to the normal subjects there was significantly fewer colony forming units of Lactobacilus and Bifidobacterium in the patients with rosacea pretreatment. In contrast, post therapy stool studies revealed a significant increase in CFU of these microorganisms in the experimental group but not in SOC group controls (Tables 2&3). Conclusion: Gut flora may play a role in the development and clinical course of rosacea and inflammatory acne. Probiotics might be a beneficial adjunct to treatment of these patients. Additional studies are warranted to explore further connections between the gut microbiome and skin diseases.216_A Figure 1. Clinical response to the therapy in patients with rosacea who received SOC therapy and E therapy216_B Figure 2. Indicators of gut biome in patients with rosacea before therapy and healthy controls216_C Figure 3. Indicators of gut flora in patient with rosacea after SOC and E therapy

2412 Cost effectiveness analysis of operative Versus antibiotic management for uncomplicated appendicitis

2412 Cost effectiveness analysis of operative Versus antibiotic management for uncomplicated appendicitis

Fecal microbiota transplantation–early steps on a long journey ahead

“In the early days of oral antibiotics we were plagued by frequent diarrhea in our patients due presumably to killing off intestinal bacteria. I was Chief of Surgery at the VA and simplistically co...

Celiac Crisis: A Rare Presentation of Celiac Disease in Adults

Background: Celiac Disease is an immune-mediated enteropathy resulting from an inappropriate and exaggerated response to dietary gluten [1, 2]. Celiac Crisis is an un-common, life-threatening condition resulting from acute severe diarrheal illness, severe metabolic disturbances, and malabsorption that is usually found in children, with only 22 cases reported in adults [3]. Here we report a case of celiac crisis in a middle aged male with characteristic endoscopic and pathological findings. Case Report: A 58-year-old male with previous history of left facial crush injury necessitating several reconstructive surgeries in 2012 presented with profuse, watery, foul-smelling diarrhea of 2 months duration with episodic fatigue, melena, and 20 kg weight loss. Since his accident in 2012 he had intermittent episodes of loose stools that got significantly worse within 2 months. He had also been diagnosed with Clotridium difficle colitis and received 14 days of oral antibiotics one month prior to his presentation. Physical exam revealed pallor and cachexia. Laboratory findings showed hemoglobin of 4.7 g/dL, INR greater than 10 (without anticoagulation), albumin 1.7 g/dL, potassium 2.9 mmol/L, undetectable levels of fat soluble vitamins, and negative stool studies. Esophagogastroduodenoscopy revealed diffuse granular mucosa in the duodenum with fissuring and scalloping appearance [Fig 1]. Pathologic examination showed severe villous atrophy and hypoplasia (March IV) with increased intra-epithelial lymphocytes [Fig 2]. IgA anti-tissue transglutaminase antibodies titers were >200 U/mL (normal, 0-19 U/mL). He was diagnosed with celiac disease presenting with celiac crisis and was started on a gluten-free diet with vitamin supplementations, following which he made a full recovery.Figure 1Figure 2Discussion: Celiac crisis has been described in association with or following surgery, pregnancy, immunosuppressive therapy, and infection. The probable triggering factor in our patient was clostridium difficle infection. However, another association can also be made between the patient's head trauma and triggering of celiac disease. This link was investigated by a Swedish study, which found a very small excess risk for future celiac disease in individuals with an earlier head trauma [4].Figure 3

Streptococcal septic oligoarthritis after tonsillitis

A 15-year-old boy had tonsillitis with sore throat and acute high fever up to 39.5° for two days. Initially he recovered without presenting to his doctor and without receiving antibiotics.  Eight days later the fever recurred without tonsillitis, but with oligoarthritis. After two days of oral antibiotics (amoxicillin with clavulanic acid) he was admitted to hospital since his symptoms progressed. On admission the patient was febrile (38.5°C), but otherwise his general condition was good. In the painless right hip the internal-external rotation was slightly reduced. The right knee showed hyperthermia, swelling, reduced flexion of 90° (150° in the asymptomatic left knee), and pain around the patella and in the popliteal space. Blood samples indicated inflammation (C-reactive protein 87 mg/L, erythrocyte sedimentation rate 30 mm/hour (normal: < 10 mm/hour), and 16,000 leucocytes/mL with 85% granulocytes, 11% lymphocytes, and 4% monocytes). Sonography identified joint effusion of the right hip and of the swollen, painful right knee. Arthrocentesis of the hip revealed empyema (Fig. 1) with 39,900 leucocytes/mL, 93% granulocytes and Gram-positive cocci at microscopy. Contrast-enhanced magnetic resonance imaging (MRI) of the right knee showed a popliteal abscess (Fig. 2, arrows) ___________________________________________

Short-term Intravenous Antibiotic Treatment in Uncomplicated Diverticulitis Does Not Increase the Risk of Recurrence Compared to Long-term Treatment.

PurposeThis study included all patients treated at the University Hospital of Geneva for a first episode of uncomplicated diverticulitis. Risks of recurrence and treatment failure were evaluated by comparing the results between short-course and long-course intravenous (IV) antibiotic therapy groups.MethodsThe records of all patients hospitalized at our facility from January 2007 to February 2012 for a first episode of uncomplicated diverticulitis (Hinchey Ia), as confirmed by computed tomography, were prospectively collected. We published an auxiliary analysis from this registered study at Clinicaltrials.gov (identifier number: NCT01015378). Two groups of patients were considered: one received a short-course IV antibiotic arm (ceftriaxone and metronidazole) for up to 5 days (followed by 5 days of oral antibiotics); the other received a long-course IV arm between days 5 and 10. The primary outcome was the recurrence-free survival time.ResultsFollow-up was completed for 256 patients-50% men and 50% women, with a median age of 56 years (range, 24-85 years). The average follow-up was 50 months (range, 19-89 months). Of the 256 patients included in the study, 46 patients received a short-course IV antibiotic treatment and 210 received a long-course treatment. The recurrence-free survivals were very similar between the two groups, which was supported by a log rank test (P = 0.772). Four treatment failures, all in the long-course IV antibiotic treatment group, occurred.ConclusionTreatment of diverticulitis with a short IV antibiotic treatment is possible and does not modify the recurrence rate in patients with uncomplicated diverticulitis.

Effect of Intratympanic Steroid Administration on Sensorineural Hearing Loss Associated with Acute Otitis Media

Objectives: Sensorineural hearing loss associated with acute otitis media (acute infective sensorineural hearing loss [AISNHL]) is a well-recognized but rare phenomenon with no accepted treatment pathway. Our objectives were to (1) evaluate the effects of intratympanic steroid (ITS) administration on AISNHL and (2) analyze factors which may be associated with a favorable outcome following ITS. Methods: A retrospective case note review of 7 consecutive patients (5 men, 2 women) seen between November 2006 and October 2013 and diagnosed with AISNHL was performed. Patients were prescribed 7 days of oral antibiotics and prednisolone and offered ITS thereafter if there was no improvement. Up to 3 intratympanic injections of methylprednisolone (40 mg/mL) were administered. Results: Patients were considered to have a significant improvement in their hearing if average change in threshold was equal to or greater than 10 dB following ITS. This was the case in 57% (4/7) of patients. The mean improvement in threshold was 24 dB (range 10-52 dB) in these responders. Three-fourths of responders had a mild high frequency hearing loss. Responders had a smaller sensorineural loss at presentation (responders mean 39 dB pre-ITS,15 dB post-ITS; nonresponders mean 65 dB pre-ITS, 83 dB post-ITS), presented earlier (4 days, range 3-6 days versus 12 days, range 2-21 days) and received their first ITS earlier (24 days, range 13-37 days versus 35 days, range 24-42 days) than nonresponders. Conclusions: ITS may provide a valuable contribution to the treatment of SNHL in acute otitis media. A larger study looking at timing of intratympanic administration after antibiotics and/or oral steroid treatment would be beneficial.