Duration Of Intravenous Antibiotic Treatment Research Articles

Implementation of a program for treatment of acute infections in nursing homes without hospital transfer.

Nursing care residents have high hospitalization rates. To address this, we established a unique virtual geriatric unit that has developed a program aimed at providing support to nursing homes. We aimed to evaluate effectiveness of in-house intravenous antibiotic treatment in nursing hospitals after the implementation of the specially designed training program. A cohort study of nursing home residents to evaluate a training program for providers, designed to increase awareness and give practical tools for in-house treatment of acute infections. Data obtained included types of infections, antibiotics used, hospital transfer, and length of treatment. Primary outcomes were in-house recovery, hospitalization and mortality. Univariate analysis and multivariable logistic regression analysis to assess association between different factors and recovery. A total of 890 cases of acute infections were treated with intravenous antibiotics across 10 nursing homes over a total of 4,436 days. Of these cases, 34.8% were aged 90 years or older. Acute pneumonia was the most prevalent infection accounted for 354 cases (40.6%), followed by urinary tract infections (35.7%), and fever of presumed bacterial infection (17.1%). The mean duration of intravenous antibiotic treatment was 5.09 ± 3.86 days. Of the total cases, 800 (91.8%) recovered, 62 (7.1%) required hospitalization and nine (1.0%) resulted in mortality. There was no significant difference observed in recovery rates across different types of infections. Appling a simple yet unique intervention program has led to more "in-house" residents receiving treatment, with positive clinical results. Treating in-house nursing home residents with acute infections resulted in high recovery rates. Special education programs and collaboration between healthcare organizations can improve treatment outcomes and decrease the burden on the healthcare system.

Combination of Antistaphylococcal β-Lactam With Standard Therapy Compared to Standard Therapy Alone for the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia: A Post Hoc Analysis of the CAMERA2 Trial Using a Desirability of Outcome Ranking Approach.

Desirability of outcome ranking (DOOR) is an emerging approach to clinical trial outcome measurement using an ordinal scale to incorporate efficacy and safety endpoints. We applied a previously validated DOOR endpoint to a cohort of CAMERA2 trial participants with methicillin-resistant Staphylococcus aureus bacteremia (MRSAB). Participants were randomly assigned to standard therapy, or to standard therapy plus an antistaphylococcal β-lactam (combination therapy). Each participant was assigned a DOOR category, within which they were further ranked according to their hospital length of stay (LOS) and duration of intravenous antibiotic treatment. We calculated the probability and the generalized odds ratio of participants receiving combination therapy having worse outcomes than those receiving standard therapy. Participants assigned combination therapy had a 54.5% (95% confidence interval [CI], 48.9%-60.1%; P = .11) probability and a 1.2-fold odds (95% CI, .95-1.50; P = .12) of having a worse outcome than participants on standard therapy. When further ranked according to LOS and duration of antibiotic treatment, participants in the combination group had a 55.6% (95% CI, 49.5%-61.7%) and 55.3% (95% CI, 49.2%-61.4%) probability of having a worse outcome than participants in the standard treatment group, respectively. When considering both efficacy and safety, treatment of MRSAB with a combination of standard therapy and a β-lactam likely results in a worse clinical outcome than standard therapy. However, a small benefit of combination therapy cannot be excluded. Most likely the toxicity of combination therapy outweighed any benefit from faster clearance of bacteremia.

Primary Aortic Endograft Infections Have Worse Outcomes Compared to Infections Involving Aortic Surgical Grafts or Primary Mycotic Aortic Infections

Aortic infection is associated with high morbidity and mortality, but the outcomes of prosthetic (surgical or endovascular) grafts compared to primary aortic infections are poorly defined. This large single-center retrospective study aims to compare the outcomes of primary and prosthetic aortic graft infections. Patients diagnosed with primary or infected aortic grafts between January 2000 and December 2022 were included. Patients were group based on the infection type (primary, surgical graft and endograft). Baseline demographics, symptoms, imaging, interventions, and outcomes were evaluated. Primary outcomes included overall and reintervention-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed. A total of 145 patients presented during the study period with infections of the native aorta (34.5%) and aortic graft (65.5%). Baseline characteristics and treatments are summarized in the Table. In-hospital mortality (36.7% vs 15.4% vs 10%; P = .01) and 30-day complication rates (67% vs 40% vs 38%; P = .03) were highest among endografts, followed by surgical grafts, and lowest among primary infections respectively. Primary aortic infections had the highest 30-day, 1-year, and 5-year survival on Kaplan-Meier analysis compared to surgical and endograft infections (Figure). Reintervention-free survival was also highest in primary infections at 1 and 5 years (log-rank P < .001), while no difference was found at 30 days. On multivariate analysis, infected surgical grafts and endografts were associated with a significantly higher 30-day mortality (hazard ratio [HR], 9.18; P = .015 and HR 7.58; P = .02, respectively). Visceral artery involvement or isolated groin infections did not influence mortality at any timepoint nor did treatment type (in situ repair vs extra-anatomical vs endovascular), while gram-positive tissue cultures were associated with higher 30-day and 1-year mortality (HR, 17.6; P = .01 and HR 4.14; P = .004, respectively) when compared to patients who had no growth on tissue cultures. There was no difference in the duration of intravenous antibiotic treatment between groups (42 vs 45 vs 44 days; P = .84). Infected aortic endografts have lower short and long-term survival independent of treatment type as well as a lower rate of long-term intervention-free survival when compared to surgical graft and primary aortic infections. Gram positive intraoperative cultures were associated with increased mortality. Predictors of endograft infection need to be determined to minimize complications and careful consideration is necessary before employing endovascular interventions if there is concern an underlying mycotic process.TableBaseline demographics, presenting symptoms, and treatmentsPrimary infections, n = 50 (34.5%)Surgical grafts, n = 65 (44.8%)Endografts, n = 30 (20.7%)P valuePrior aortic pathology Aneurysmal disease26 (40%)27 (90%)<.001 Occlusive disease8 (12%)1 (3%) Other (dissection)5 (8%)1 (3%) Unknown26 (40%)1 (3%)Visceral involvement8 (16.3%)5 (7.8%)3 (9.7).35Infected graft location Groin4 (6.3%)0 (0%).01 Abdomen38 (59.4%)28 (93.4%) Abdomen + groin15 (23.4%)1 (3.3%) Chest7 (10.9%)1 (3.3%)Age, mean (SD)64.9 (9.1)67.8 (10.9)73.1 (10.5).003Gender Male34 (68%)42 (65%)26 (87%).078 Female16 (32%)23 (35%)4 (13%)Race Non-Hispanic White44 (88%)61 (94%)24 (80%).059 Black5 (10%)1 (2%)2 (7%) Other1 (2%)3 (5%)4 (13%)History of peripheral artery disease2 (4%)31 (48%)9 (30%)<.001Diabetes15 (30%)9 (14%)3 (10%).046End-stage renal disease4 (8%)1 (2%)3 (10%).13Hypertension36 (72%)48 (74%)19 (63%).56Coronary artery disease15 (30%)19 (29%)16 (53%).060Recent infection (3 weeks)24 (48%)15 (23%)6 (20%).007Recent surgery (3 weeks)1 (2%)8 (12%)3 (10%).11Antibiotics on presentation2 (4%)17 (26%)9 (30%).001Abdominal pain30 (60%)21 (32%)11 (37%).010Back pain26 (52%)6 (9%)10 (33%)<.001Groin symptoms0 (0%)15 (23%)2 (7%)<.001Fever2 (4%)8 (12%)10 (33%).002Rupture on computed tomography26 (53%)3 (6%)3 (11%)<.001Surgical/tissue culture results Fungal0 (0%)2 (5%)1 (4%).015 Gram negative4 (13%)9 (21%)1 (4%) Gram positive10 (32%)7 (17%)9 (36%) Mixed0 (0%)7 (17%)6 (24%) No growth17 (55%)17 (40%)8 (32%)Blood culture results Fungal0 (0%)1 (2%)0 (0%).017 Gram negative4 (9%)2 (4%)2 (7%) Gram positive15 (34%)5 (9%)6 (22%) No growth25 (57%)47 (85%)19 (70%)Antibiotics given21 (42%)64 (98%)30 (100%)<.001Antibiotic duration, median (IQR), days42 (9, 96)45 (30, 61)44 (29, 52).84Intraoperative purulence noted0 (0%)27 (55%)25 (100%)<.00130-day complications19 (38%)26 (40%)20 (67%).02830-Day readmission12 (27%)11 (19%)3 (11%).29Treatment Open in situ repair18 (36%)13 (20%)7 (23%).007 Extra-anatomical bypass15 (30%)31 (48%)16 (53%) Endovascular16 (32%)8 (13%)1 (3%) Medical0 (0%)5 (8%)3 (10%) Palliative0 (0%)2 (3%)1 (3%) Other (debridement)1 (2%)5 (8%)2 (8%)Recurrent infections3 (33.3%)6 (27.3%)1 (14.3%).6830-Day survival44 (89.8%)52 (89%)21 (66.7%).041-Year survival35 (73.3%)41 (69.1%)10 (36.7%)<.0015-Year survival20 (58.8%)22 (42.8%)10 (36.7%).0230-Day reintervention-free survival41 (83.7%)45 (61.4%)19 (62.7%).121-Year reintervention-free survival31 (65.1%)31 (52.3%)5 (20.7%)<.0015-Year reintervention-free survival16 (48.3%)15 (27.1%)2 (16.5%)<.001 Open table in a new tab

Long-term effectiveness of dual CFTR modulator treatment of cystic fibrosis.

Although short-term efficacy of lumacaftor/ivacaftor and tezacaftor/ivacaftor is clearly established in clinical trials, data on long-term effectiveness is limited. This registry-based cohort study assessed real-world longitudinal outcomes of F508del-homozygous people with cystic fibrosis (pwCF) ≥12 years, up to 3 years after the introduction of dual cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Annual data (2010-2019) were retrieved from the Dutch Cystic Fibrosis Registry. Longitudinal trends of per cent predicted forced expiratory volume in 1 s (FEV1 % pred) decline, body mass index (BMI), BMI Z-score and intravenous antibiotic treatment duration before and after CFTR modulator initiation were assessed with linear and negative binomial mixed models. We included 401 participants (41.9% female, baseline age 24.5 years (IQR 18.0-31.5 years), baseline mean±sd FEV1 70.5±23.4% pred). FEV1 decline improved from -1.36% pred per year to -0.48% pred per year after modulator initiation (change: 0.88% pred, 95% CI: 0.35-1.39%, p=0.001). This change was even 1.40% pred per year (95% CI: -0.0001-2.82%, p=0.050) higher in participants with baseline FEV1 <40% pred. In adults, annual BMI trend was not altered (change: 0.10 kg·m-2·year-1, 95% CI:-0.01-0.21, p=0.079). Annual BMI Z-score in children reversed from -0.08 per year before modulator treatment to 0.06 per year afterwards (change: 0.14 per year, 95% CI: 0.06-0.22, p<0.001). Intravenous antibiotic treatment duration showed a three-fold reduction in the first year after modulator initiation (incidence rate ratios (IRR): 0.28, 95% CI: 0.19-0.40, p<0.001), but the annual trend did not change in the subsequent years (IRR: 1.19, 95% CI: 0.94-1.50, p=0.153). Long-term effectiveness of dual CFTR modulator therapies on FEV1 decline, BMI and intravenous antibiotic treatment duration is less pronounced in a real-world setting than in clinical trials and varies considerably between pwCF and different baseline FEV1 levels.

Treatment outcome of continuation of intravenous amikacin for Mycobacterium abscessus pulmonary disease with a persistent culture positivity after the treatment initiation

IntroductionWhether prolonged intravenous amikacin treatment would lead to better treatment results in patients with Mycobacterium abscessus subspecies abscessus (M. abscessus) pulmonary disease (PD) is unknown. We investigated the efficacy of continued amikacin treatment for the microbiological outcome of M. abscessus PD patients with persistent culture positivity after treatment initiation. MethodsWe retrospectively evaluated 62 patients with M. abscessus PD who were treated with intravenous amikacin and beta-lactams along with a macrolide-based regimen at 3 tertiary referral centers in South Korea. The intravenous antibiotic treatment duration was determined by the attending physician. ResultsThe median treatment durations with amikacin and beta-lactam in the 62 patients were 25.1 and 8.2 weeks, respectively. The overall microbiological cure rate was 29.0%. Among the 62 patients, 44 showed persistent culture positivity at 8 weeks after treatment with an amikacin-containing multidrug regimen. The median parenteral amikacin treatment duration after 8 weeks in these patients was 18.0 weeks. The conditional probability of microbiological cure with continuation of the amikacin-containing regimen in these patients was 18.2% (95% confidence interval 8.2–32.7). Additionally, the conditional probability of microbiological cure in the 34 patients with persistent culture positivity at 12 weeks was 8.8% (95% confidence interval 1.9–23.7). After 16 weeks, the conditional probability of microbiological cure decreased further, reaching 0% at 28 weeks after treatment initiation. ConclusionThe continuation of intravenous amikacin therapy was usually not followed by culture conversion in M. abscessus PD patients with persistent sputum culture positivity after treatment initiation.

Clinical and Microbial Etiology Characteristics in Pediatric Urinary Tract Infection.

BackgroundUrinary tract infection (UTI) is a common occurrence in children. UTI and urological malformations are intimately linked. However, whether urinary tract malformations affect the clinical features of pediatric UTI remains unclear. The purpose of this study was to characterize the clinical features and microbial etiology of UTI in children.MethodsWe retrospectively reviewed the records of 741 patients with UTI treated at the Chongqing Medical University Affiliated Children's Hospital between 2015 and 2020. Patients with and without urological malformations were compared using propensity score matching (PSM).ResultsEscherichia coli was the most common causative microorganism of UTI, accounting for 40.5% of infections. One hundred twenty-two patients (16.5%) had urological malformations. PSM identified 122 matched pairs of patients with or without urological malformations. The proportion of patients with UTI caused by atypical microorganisms was significantly higher in patients with urological malformations (P = 0.048). Children with urological malformations showed longer duration of intravenous antibiotic treatment (P = 0.010), higher cost of treatment (P < 0.001), and higher prevalence of recurrence (23.8 vs. 10.7%, P < 0.001), compared with the normal group.ConclusionChildren with urological malformations are more likely to develop UTI with atypical microorganisms. Appropriate imaging examination and urine culture are strongly recommended for the diagnosis and management of pediatric UTI.

Impact of COVID-19 on appendicitis presentations in children in Australia and New Zealand.

BackgroundIn contrast to many countries, the prevalence of COVID‐19 in Australia and New Zealand has been low. We hypothesised, however, that a potential secondary effect of the COVID‐19 pandemic would be delayed presentation of paediatric appendicitis, with resultant higher rates of complicated appendicitis. This study was an initiative of the Australian and New Zealand Surgery in Children Registrars' Association for Trials collaborative, a trainee‐led research group based in Australia and New Zealand.MethodsA binational multicentre, retrospective review was undertaken of paediatric patients with appendicitis early in the COVID‐19 pandemic (20 March–30 April 2020), compared with previous years (2018, 2019). Primary outcomes were the duration of symptoms prior to presentation and the severity of disease.ResultsA total of 400 patients from six centres were included. Duration of symptoms prior to presentation, sepsis at presentation, complicated disease and presence of complications did not differ significantly between time periods. Duration of intravenous antibiotic treatment and overall antibiotic treatment were both significantly shorter during 2020 (2.4 days versus 3.5 in 2018 and 3.0 in 2019 [P = 0.0038] and 3.7 days versus 5.2 in 2018 and 4.6 in 2019 [P = 0.04], respectively). Management approach did not differ, with the majority of patients managed operatively.ConclusionsWe did not demonstrate any difference in duration of symptoms prior to presentation or other markers of disease severity early in the pandemic. Duration of antibiotic treatment was shorter during this period compared with previous years. Management of children with appendicitis, both simple and complicated, did not appear to change as a result of COVID‐19.

Application of local gentamicin in the treatment of deep sternal wound infection: a randomized controlled trial.

In patients with deep sternal wound infection (DSWI), primary closure of the sternal bone over high negative pressure Redon drains has shown to be a safe and feasible treatment method. Addition of local gentamicin could accelerate healing and improve clinical outcomes. We conducted a randomized controlled trial to evaluate the effectiveness of local gentamicin in the treatment of DSWI. In the treatment group, collagenous carriers containing gentamicin were left between the sternal halves during sternal refixation. In the control group, no local antibiotics were used. Primary outcome was hospital stay. Secondary outcomes were mortality, reoperation, wound sterilization time, time till removal of all drains and duration of intravenous antibiotic treatment. Forty-one patients were included in the trial of which 20 were allocated to the treatment group. Baseline characteristics were similar in both groups. Drains could be removed after a median of 8.5 days in the treatment group and 14.5 days in the control group (P-value: 0.343). Intravenous antibiotics were administered for a median of 23.5 days in the treatment group and 38.5 days in the control group (P-value: 0.343). The median hospital stay was 27 days in the treatment group and 28 days in the control group (P-value: 0.873). Mortality rate was 10% in the treatment group and 9.5% in the control group (P-value: 0,959). No side effects were observed. This randomized controlled trial showed that addition of local gentamicin in the treatment of DSWI did not result in shorter length of stay. 2014-001170-33.

Duration of intravenous antibiotic treatment for acute exacerbations of cystic fibrosis: A systematic review

BackgroundAcute exacerbations of Cystic Fibrosis (AECF) are associated with significant morbidity. Recommendations are to treat for 2-3 weeks despite limited data. Spirometry is a measure of clinical response yet appears to plateau at 7-10 days. While durations <9 days have been associated with poorer outcomes, a duration of 10 days may be as effective as 14 days, potentially conferring advantages in terms of cost and adverse events. A 2019 Cochrane review by Abbott et al. did not identify any randomised controlled trials (RCT) comparing durations of treatment. Utilising data from non-randomised studies (NRS), we report a systematic review of intravenous antibiotic treatment, exploring changes in FEV1 (Forced Expiratory Volume in 1 second), CRP (C-reactive protein) and peripheral WBC (white blood cell) count in studies with different treatment durations. Study design and methodsSystematic review of published literature following a search of MEDLINE, Embase, CINAHL and the Cochrane Clinical Trials register. Guidelines from the Preferred Reporting items for Systematic reviews and Meta-Analysis (PRISMA) and reporting Meta-analysis of Observational studies (MOOSE) statement were followed. ResultsNo randomised controlled trials were identified that specifically examined duration of treatment during AECF. This study included all relevant RCTs and also NRS, grouping according to study characteristics, such as length of treatment, location, year, and also characteristics of the patient population. 52 studies, comprising 79 subgroups, and 1,597 patients, were identified. Mean change (95%CI) in ppFEV1 was 10.13 (9.21-11.05). There was no significant difference in change in ppFEV1 for studies treating for 10-12 days; 8.85 (7.47-10.23), vs 13-15 days; 10.68 (9.53-11.82). Similar changes in CRP and WBC were seen irrespective of treatment duration. ConclusionThis systematic review provides evidence that shorter durations of treatment may be associated with similar changes in FEV1, CRP and WBC compared with longer durations.

IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy.

Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.

Effectiveness of early switching from intravenous to oral antibiotic therapy in Staphylococcus aureus prosthetic bone and joint or orthopedic metalware-associated infections

BackgroundThe optimal duration of intravenous antibiotic therapy in Staphylococcus aureus prosthetic bone and joint infection has not been established. The objective of this study was to compare the effect of early and late intravenous-to-oral antibiotic switch on treatment failure.Patients and methodsWe retrospectively analyzed all adult cases of S. aureus prosthetic bone and joint or orthopedic metalware-associated infection between January 2008 and December 2015 in a French university hospital. The primary outcome was treatment failure defined as the recurrence of S. aureus prosthetic bone and joint or orthopedic metalware-associated infection at any time during or after the first line of medical and surgical treatment within 2 years of follow-up. A Cox model was created to assess risk factors for treatment failure.ResultsAmong the 140 patients included, mean age was 60.4 years (SD 20.2), and 66% were male (n = 92). Most infections were due to methicillin-susceptible S. aureus (n = 113, 81%). The mean duration of intravenous antibiotic treatment was 4.1 days (SD 4.6). The majority of patients (119, 85%) had ≤5 days of intravenous therapy. Twelve patients (8.5%) experienced treatment failure. Methicillin-resistant S. aureus infections (HR 11.1; 95% CI 1.5–111.1; p = 0.02), obesity (BMI > 30 kg/m2) (HR 6.9; 95% CI1.4–34.4, p = 0.02) and non-conventional empiric antibiotic therapy (HR 7.1; 95% CI 1.8–25.2; p = 0.005) were significantly associated with treatment failure, whereas duration of intravenous antibiotic therapy (≤ 5 or > 5 days) was not.ConclusionThere was a low treatment failure rate in patients with S. aureus prosthetic bone and joint or orthopedic metalware-associated infection with early oral switch from intravenous to oral antibiotic therapy.

Outcomes of primary sternal closure for postoperative mediastinitis in children.

We retrospectively analysed outcomes of debridement and primary sternal closure for postoperative mediastinitis in children. Between January 2007 and July 2019, 1285 patients under the age of 20 years underwent congenital heart surgery at the Iwate Medical University. Of these, 22 children had postoperative mediastinitis (1.7%). We performed adequate debridement and primary sternal closure with pectoralis major muscle advancement flaps. We evaluated hospital survival rates, reintervention, duration of intravenous antibiotic treatment, intensive care unit (ICU) stay and hospital stay. The median age and weight at surgery were 12.5 months (range 0-228 months) and 7.8 kg (range 2.2-64.2 kg), respectively. Two patients (9%) had a history of delayed sternal closure. Staphylococcus was the most common causative agent for infection (82%). All cases were categorized as Robicsek's classification type II mediastinitis. The hospital survival rate was 95%, and freedom from reintervention for infectious complications was observed in 91% of the patients. The median durations of intravenous antibiotic treatment, ICU stay and hospital stay were 18 days (range 9-46 days), 4 days (range 1-87 days) and 22.5 days (range 11-87 days). The median follow-up time was 89 months (range 2-148 months), and there was no evidence of recurrent mediastinitis, musculoskeletal growth, physical deformity, breast development and upper trunk or limb movement. Primary sternal closure is an effective procedure for children as it can significantly shorten treatment duration and reduce physical and psychological burdens. Its results compare favourably with those of conventional therapy in terms of mortality and complications.

Impact of a Rapid Diagnostic Meningitis/Encephalitis Panel on Antimicrobial Use and Clinical Outcomes in Children.

Rapid molecular diagnostic assays are increasingly used to guide effective antimicrobial therapy. Data on their effectiveness to decrease antimicrobial use in children have been limited and varied. We aimed to assess the impact of the implementation of the FilmArray Meningitis Encephalitis Panel (MEP) on antimicrobial use and outcomes in children. In an observational retrospective study performed at Atlantic Health System (NJ), we sought to evaluate the duration of intravenous antibiotic treatment (days of therapy (DoT)) for patients <21 years of age hospitalized and evaluated for presumptive meningitis or encephalitis before and after the introduction of the MEP. A secondary analysis was performed to determine if recovery of a respiratory pathogen influenced DoT. The median duration of antibiotic therapy prior to the implementation of the MEP was 5 DoT (interquartile range (IQR): 3–6) versus 3 DoT (IQR: 1–5) (p < 0.001) when MEP was performed. The impact was greatest on intravenous third-generation cephalosporin and ampicillin use. We found a reduction in the number of inpatient days associated with the MEP. In the regression analysis, a positive respiratory pathogen panel (RPP) was not a significant predictor of DoT (p = 0.08). Furthermore, we found no significant difference between DoT among patients with negative and positive RPP (p = 0.12). Our study supports the implementation of rapid diagnostics to decrease the utilization of antibiotic therapy among pediatric patients admitted with concerns related to meningitis or encephalitis.

Duration of intravenous antibiotic therapy in people with cystic fibrosis.

Progressive lung damage from recurrent exacerbations is the major cause of mortality and morbidity in cystic fibrosis. Life expectancy of people with cystic fibrosis has increased dramatically in the last 40 years. One of the major reasons for this increase is the mounting use of antibiotics to treat chest exacerbations caused by bacterial infections. The optimal duration of intravenous antibiotic therapy is not clearly defined. Individuals usually receive intravenous antibiotics for 14 days, but treatment may range from 10 to 21 days. A shorter duration of antibiotic treatment risks inadequate clearance of infection which could lead to further lung damage. Prolonged courses of intravenous antibiotics are expensive and inconvenient. The risk of systemic side effects such as allergic reactions to antibiotics also increases with prolonged courses and the use of aminoglycosides requires frequent monitoring to minimise some of their side effects. However, some organisms which infect people with cystic fibrosis are known to be multi-resistant to antibiotics, and may require a longer course of treatment. This is an update of previously published reviews. To assess the optimal duration of intravenous antibiotic therapy for treating chest exacerbations in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals, abstract books and conference proceedings. Most recent search of the Group's Cystic Fibrosis Trials Register: 30 May 2019.We also searched online trials registries. Most recent search of the ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) portal: 06 January 2019. Randomised and quasi-randomised controlled trials comparing different durations of intravenous antibiotic courses for acute respiratory exacerbations in people with CF, either with the same drugs at the same dosage, the same drugs at a different dosage or frequency or different antibiotics altogether, including studies with additional therapeutic agents. No eligible trials were identified for inclusion. A trial looking at the standardised treatment of pulmonary exacerbations is currently ongoing and will be included when the results are published. MAIN RESULTS: No eligible trials were included. There are no clear guidelines on the optimum duration of intravenous antibiotic treatment. Duration of treatment is currently based on unit policies and response to treatment. Shorter duration of treatment should improve quality of life and adherence, result in a reduced incidence of drug reactions and be less costly. However, the shorter duration may not be sufficient to clear a chest infection and may result in an early recurrence of an exacerbation. This systematic review identifies the need for a multicentre, randomised controlled trial comparing different durations of intravenous antibiotic treatment as it has important clinical and financial implications. The currently ongoing STOP2 trial is expected to provide some guidance on these questions when published.

Appropriate duration of post-surgical intravenous antibiotic therapy for pyogenic spondylodiscitis

BackgroundMost guidelines recommend 6 to 12 weeks of parenteral antibiotic treatment for pyogenic spondylodiscitis. When surgical debridement is adequately performed, further intravenous antibiotic treatment duration can be reduced than that of conservative treatment alone theoretically. However, the appropriate duration of post-surgical parenteral antibiotic treatment is still unknown. This study aimed to identify the risk factors of recurrence and evaluate the appropriate duration after surgical intervention.MethodsThis 3-year retrospective review included 102 consecutive patients who were diagnosed with pyogenic spondylodiscitis and underwent surgical intervention. Recurrence was defined as recurrent signs and symptoms and the need for another unplanned parenteral antibiotic treatment or operation within one year. This study included two major portions. First, independent risk factors for recurrence were identified by multivariable analysis, using the database of demographic information, pre-operative clinical signs and symptoms, underlying illness, radiographic findings, laboratory tests, intraoperative culture results, and treatment. Patients with any one of the risk factors were considered high-risk; those with no risk factors were considered low-risk. Recurrence rates after short-term (≤3 weeks) and long-term (> 3 weeks) parenteral antibiotic treatment were compared between the groups.ResultsPositive blood culture and paraspinal abscesses were identified as independent risk factors of recurrence. Accordingly, 59 (57.8%) patients were classified as low-risk and 43 (42.2%) as high-risk. Among the high-risk patients, a significantly higher recurrence rate occurred with short-term than with long-term antibiotic therapy (56.2% vs. 22.2%, p = 0.027). For the low-risk patients, there was no significant difference between short-term and long-term antibiotic therapy (16.0% vs. 20.6%, p = 0.461).ConclusionsThe appropriate duration of parenteral antibiotic treatment in patients with pyogenic spondylodiscitis after surgical intervention could be guided by the risk factors. The duration of postoperative intravenous antibiotic therapy could be reduced to 3 weeks for patients without positive blood culture or abscess formation.

P094 Design, enrollment, and feasibility of the STOP-2 randomised study of intravenous antibiotic treatment duration in cystic fibrosis pulmonary exacerbations

P094 Design, enrollment, and feasibility of the STOP-2 randomised study of intravenous antibiotic treatment duration in cystic fibrosis pulmonary exacerbations

Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis

Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost. To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis. This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups. Dermatology consultation within 24 hours of hospitalization. Length of hospital stay and duration of intravenous antibiotic treatment. Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines. Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment. clinicaltrials.gov Identifier: NCT01706913.

Duration of intravenous antibiotic therapy in people with cystic fibrosis.

Respiratory disease is the major cause of mortality and morbidity in cystic fibrosis. Life expectancy of people with cystic fibrosis has increased dramatically in the last 40 years. One of the major reasons for this increase is the mounting use of antibiotics to treat chest exacerbations caused by bacterial infections. The optimal duration of intravenous antibiotic therapy is not clearly defined. Individuals usually receive intravenous antibiotics for 14 days, but treatment may range from 10 to 21 days. A shorter duration of antibiotic treatment risks inadequate clearance of infection which could lead to further lung damage. Prolonged courses of intravenous antibiotics are expensive and inconvenient and the incidence of allergic reactions to antibiotics also increases with prolonged courses. The use of aminoglycosides requires frequent monitoring to avoid some of their side effects. However, some organisms which infect people with cystic fibrosis are known to be multi-resistant to antibiotics, and may require a longer course of treatment. This is an update of previously published reviews. To assess the optimal duration of intravenous antibiotic therapy for treating chest exacerbations in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals, abstract books and conference proceedings.Most recent search of the Group's Cystic Fibrosis Trials Register: 05 May 2016. Randomised and quasi-randomised controlled trials comparing different durations of intravenous antibiotic courses for acute respiratory exacerbations in people with CF, either with the same drugs at the same dosage, the same drugs at a different dosage or frequency or different antibiotics altogether, including studies with additional therapeutic agents. No eligible trials were identified. No eligible trials were identified. There are no clear guidelines on the optimum duration of intravenous antibiotic treatment. Duration of treatment is currently based on unit policies and response to treatment. Shorter duration of treatment should improve quality of life and compliance; result in a reduced incidence of drug reactions; and be less costly. However, this may not be sufficient to clear a chest infection and may result in an early recurrence of an exacerbation. This systematic review identifies the need for a multicentre, randomised controlled trial comparing different durations of intravenous antibiotic treatment as it has important clinical and financial implications.

A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study.

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were <euro>5,798 (<euro>20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

Experience of managing acute osteomyelitis in a district general hospital

Introduction A cute Osteomyelitis (AO) is a suppurative bone infection caused by haematogenous spread within the metaphysis of long bones. Unlike septic arthritis, children with AO are usually systemically well and the classic text book description of fever, swelling and limp is often absent. Prompt diagnosis and treatment is important to avoid complications such as growth arrest, septic arthritis and chronic infection. Objective 1) To review the clinical presentation and value of laboratory and radiological investigations in diagnosing Acute Osteomyelitis; 2) To review current treatment of Acute Osteomyelitis and follow up of patients for complications. Method We retrospectively reviewed case notes of 12 children who were diagnosed with acute osteomyelitis over a two year period. Results Temperature of 38 degrees and above was present only in one third of patients whereas loss of function and pain were present in all the patients. Recent infection or trauma was present in most of the cases. An elevated ESR (>35 in 10 patients) and high platelet count (>400 in 11 patients) were the most consistent laboratory results. CRP was less than 15 in 3 patients. Blood cultures were negative in all but one case where group B streptococcus was isolated in a neonate from blood and aspiration of joint. MRI was helpful in confirming equivocal diagnosis. Bone scan when done in 4 cases helped in diagnosing AO. Flucloxacillin was an effective antibiotic in the majority except for neonatal osteomyelitis. 6 children received antibiotics for 42 days, 1 child for 5 days and 1 for 70 days, the rest received antibiotics for 14 days. Intravenous antibiotic treatment duration was very variable and was guided by resolution of inflammatory markers to normal levels. Antibiotics was started on the 12th day of presentation for a baby and 3 en had complications where one child required a sequestrectomy, one developed a Brodie9s abscess and one developed chronic recurrent multifocal osteomyelitis. Conclusions Acute osteomyelitis still remains a difficult diagnosis. A high index of suspicion together with a combination of clinical signs, laboratory and radiological tests are essential to facilitate prompt diagnosis and treatment to avoid long term complications. Good team working, information sharing and communication with our orthopaedic colleagues is essential to reduce morbidity and improve quality of care.