Early Initiation Of Antibiotics Research Articles

Reductions in hospitalisations and emergency department visits with early antibiotic initiation in nontuberculous mycobacterial lung disease.

While antibiotics are recommended for treatment of nontuberculous mycobacterial lung disease (NTMLD), the impact of early antibiotic initiation on healthcare resource utilisation is unclear. This study compared healthcare resource utilisation with early versus delayed antibiotic initiation in NTMLD. A retrospective, claims database study (Merative MarketScan) of patients diagnosed with NTMLD between 1 July 2015 and 30 June 2019. Patients were divided into early antibiotic initiation, i.e. ≤3 months after the first medical claim for NTMLD (index date), and delayed antibiotic initiation groups. Hospitalisations and outpatient visits during a 2-year post-index period were compared to baseline per treatment group; a difference-in-difference analysis compared early and delayed antibiotic initiation groups adjusting for confounding. Out of 481 NTMLD treated patients, 364 (76%) and 117 (24%) comprised the early and delayed antibiotic initiation groups, respectively. The early antibiotic initiation group showed significant reductions from baseline in hospitalisations (all-cause, respiratory) and emergency department (ED) visits at follow-up. A significant increase from baseline in mean number of hospitalisations per patient was observed in the delayed antibiotic initiation group in year 1 post-index. Compared to delayed antibiotic initiation, the early antibiotic initiation group showed significantly greater reductions in all-cause hospitalisations in years 1 and 2 post-index (relative risk 0.62 (95% CI 0.41-0.95) and 0.62 (95% CI 0.39-0.98), respectively), and in respiratory-related hospitalisations. The early antibiotic initiation group showed significant reductions from baseline in hospitalisations and ED visits over time. Compared to delayed antibiotic initiation, early antibiotic initiation was associated with significantly greater reductions in hospitalisations.

Comparative Efficacy of Levofloxacin Versus Amoxycillin/Clavulanic Acid Combined with Azithromycin in Treatment of Community-Acquired Pneumonia

Background: Community-acquired pneumonia (CAP) is an important cause of mortality and morbidity worldwide. Early initiation of antibiotics is highly recommended. In most CAP cases, multiple drug options are increasingly becoming available, but there is often a lack of evidence that allows for a direct comparison of the efficacy of one drug versus another. Aim: The main objective was to compare treatment outcomes using oral levofloxacin alone and combined azithromycin and amoxicillin/Clavulanic acid in outpatient treatment of Community-acquired pneumonia. Methods: This study was a prospective longitudinal design. Patients diagnosed with CAP were randomly assigned to first and second treatment groups. Community-acquired pneumonia was diagnosed according to America Thoracic Society criteria. The sample size of 78 was arrived at by Yamane Taro (1967) formula. Every patient diagnosed and treated in the outpatient department who gave written consent to participate was enrolled in the study and randomly assigned to one of the treatment groups. Minors below 18 years were excluded from the study. Data were analysed using SPSS for Windows version 26. An independent t-test compared the effectiveness of the two treatment groups. Changes in white blood cell count during the follow-up visits were done using a chi-square test. A p-value of <0.05 was considered statistically significant. Results. The majority, 33(50%) of the patients, were aged between 21 and 29 years, and over sixty percent, 42(63.6%) of participants were females. Of all the participants, 66(100%) had a cough and chest pain, 57(86.4%) had crackles, and about ten percent, 6(9.1%) had difficulty breathing at the time of admission into the study. About 29(43.9%) of patients had a fever at baseline, and 14(21.2%) had a respiratory rate between 16 and 29 breaths per minute at baseline. A combination of azithromycin and amoxycillin/clavulanic acid was associated with statistically significant faster resolution of chest pains and cough (mean 1.7 and 3.14 days, respectively) compared to levofloxacin group (mean 2.21 and 3.71 days, respectively) in patients who had community-acquired pneumonia (p=0.009. There was no difference in fever resolution, time to crackles subsidence, resolution of difficulty in breathing, and change in white blood cell count in participants in the two treatment groups. Conclusions: Azithromycin combined with amoxycillin/clavulanic acid reduced chest pain in 1.70 days (SD=0.618) compared to levofloxacin alone (2.21 days, SD=1.204) (p=0.009). Azithromycin combined with amoxycillin/clavulanic acid reduced cough in 3.14 days (SD=0.789) versus levofloxacin alone (3.70 days, SD=0.588) (p=0.014). Hence, the azithromycin plus amoxycillin/clavulanic acid combination was found to be superior for managing CAP.

A retrospective cohort study on early antibiotic use in vaccinated and unvaccinated COVID-19 patients.

The bacteriophage behavior of SARS-CoV-2 during the acute and post-COVID-19 phases appears to be an important factor in the development of the disease. The early use of antibiotics seems to be crucial to inhibit disease progression-to prevent viral replication in the gut microbiome, and control toxicological production from the human microbiome. To study the impact of specific antibiotics on recovery from COVID-19 and long COVID (LC) taking into account: vaccination status, comorbidities, SARS-CoV-2 wave, time of initiation of antibiotic therapy and concomitant use of corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). A total of 211 COVID-19 patients were included in the study: of which 59 were vaccinated with mRNA vaccines against SARS-CoV-2 while 152 were unvaccinated. Patients were enrolled in three waves: from September 2020 to October 2022, corresponding to the emergence of the pre-Delta, Delta, and Omicron variants of the SARS-CoV-2 virus. The three criteria for enrolling patients were: oropharyngeal swab positivity or fecal findings; moderate symptoms with antibiotic intake; and measurement of blood oxygen saturation during the period of illness. The use of antibiotic combinations, such as amoxicillin with clavulanic acid (875 + 125 mg tablets, every 12 h) plus rifaximin (400 mg tablets every 12 h), as first choice, as suggested from the previous data, or azithromycin (500 mg tablets every 24 h), plus rifaximin as above, allows healthcare professionals to focus on the gut microbiome and its implications in COVID-19 disease during patient care. The primary outcome measured in this study was the estimated average treatment effect, which quantified the difference in mean recovery between patients receiving antibiotics and those not receiving antibiotics at 3 and 9 days after the start of treatment. In the analysis, both vaccinated and unvaccinated groups had a median illness duration of 7 days (interquartile range [IQR] 6-9 days for each; recovery crude hazard ratio [HR] = 0.94, p = 0.700). The median illness duration for the pre-Delta and Delta waves was 8 days (IQR 7-10 days), while it was shorter, 6.5 days, for Omicron (IQR 6-8 days; recovery crude HR = 1.71, p < 0.001). These results were confirmed by multivariate analysis. Patients with comorbidities had a significantly longer disease duration: median 8 days (IQR 7-10 days) compared to 7 days (IQR 6-8 days) for those without comorbidities (crude HR = 0.75, p = 0.038), but this result was not confirmed in multivariate analysis as statistical significance was lost. Early initiation of antibiotic therapy resulted in a significantly shorter recovery time (crude HR = 4.74, p < 0.001). Concomitant use of NSAIDs did not reduce disease duration and in multivariate analysis prolonged the disease (p = 0.041). A subgroup of 42 patients receiving corticosteroids for a median of 3 days (IQR 3-6 days) had a longer recovery time (median 9 days, IQR 8-10 days) compared to others (median 7 days, IQR 6-8 days; crude HR = 0.542, p < 0.001), as confirmed also by the adjusted HR. In this study, a statistically significant reduction in recovery time was observed among patients who received early antibiotic treatment. Early initiation of antibiotics played a crucial role in maintaining higher levels of blood oxygen saturation. In addition, it is worth noting that a significant number of patients who received antibiotics in the first 3 days and for a duration of 7 days, during the acute phase did not develop LC.

2235. Characterization of the Adult Sepsis Treatment Guideline Utilization Within the Emergency Department at an Academic Medical Center

Abstract Background The early initiation of antibiotics in patients with sepsis has been identified as the most effective intervention in reducing mortality. Screening tools have been developed for the early identification of sepsis. This study characterized Emergency Department (ED) patients initiated on antibiotics for suspected sepsis of urinary or abdominal sources to identify opportunities to improve institutional sepsis guidelines. Methods A retrospective chart review was performed of patients initiated on empiric antibiotics in the ED for sepsis with a suspected source of urinary tract infection (UTI) or intraabdominal infection (IAI) from September 2021 to September 2022. Epic SlicerDicer, an electronic medical record (EMR) data extraction tool, identified ED patients with an order for broad-spectrum antibiotics. Patients less than 18 years or initiated on antibiotics prior to arrival were excluded. The EMR was utilized to assess the signs of organ dysfunction, antibiotic regimen, EMR-based sepsis pathway use, and patient-specific risk factors. Institutional guidelines defined antibiotic regimen appropriateness. Descriptive statistics were used to characterize the results. Results Among the 6869 patients screened, 190 patients were included. The provider initiated the sepsis pathway in 141 (74.2%) patients, and 21 (14.9%) were initiated on empiric antibiotics determined to be congruent with institutional guidelines. The most common deviation from institutional guidelines was the addition of anti-methicillin-resistant Staphylococcus aureus (MRSA) treatment. Anti-pseudomonal therapy was used in 165 (86.8%) patients and anti-MRSA coverage in 117 (61.6%) patients. Of patients with MRSA coverage, 36 (30.8%) had community-acquired infections. An organism was isolated in 113 (59.5%) patients, and Enterobacterales were most commonly isolated (65.5%). P. aeruginosa was isolated in 15 (7.9%) patients, and no patients had MRSA. Conclusion Most antibiotic regimens used in ED patients for the treatment of sepsis with suspected urinary or abdominal sources of infection were contrary to institutional guidelines. This may be a result of an overestimation of MRSA or P. aeruginosa in community-acquired infections, highlighting an opportunity for education and stewardship. Disclosures Christina Maguire, PharmD, Viiv: Advisor/Consultant Amanda Binkley, PharmD, BCIDP, AAHIVP, Viiv: Advisor/Consultant

Lemierre’s syndrome: The “forgotten disease” that should not be forgotten

Introduction: Lemierre’s syndrome (LS) is often misdiagnosed as a common cold or viral infection. It is characterized by sepsis often evolving after a sore throat or tonsillitis and then complicated by various septic emboli and thrombosis of the internal jugular vein. Fusobacterium necrophorum is the most common causative organism. The recommended management is antibiotic treatment. Case Report: We present a case of LS with positive blood cultures for F. necrophorum and pulmonary septic emboli without internal jugular vein thrombosis. The patient was successfully treated with prolonged antibiotic management. Conclusion: Once observed, LS is unlikely to be forgotten by the spectator. Early antibiotic initiation of septic young patients with tonsillitis or neck infections is essential.

Antibiotic Initiation Timing and Mortality in Trauma Patients With Ventilator-Associated Pneumonia.

Early antibiotic initiation is considered a cornerstone in the management of ventilator-associated pneumonia (VAP). However, recent data suggests that early antibiotic initiation may not be necessary in all cases. Additionally, the benefits of early antibiotic administration for infection have not been studied in a dedicated trauma population. This study's aim was to evaluate the impact of antibiotic administration timing on in-hospital mortality in trauma patients with VAP. This retrospective case-control study identified all trauma patients at a single level 1 academic trauma center from 2016 to 2020. Patients with a TQIP-defined VAP were included and stratified into 2 subgroups by in-hospital mortality. Time interval between airway culture and antibiotic initiation was gathered. Baseline measures of injury and illness severity were collected. Univariate analysis of the data was performed. Forty-five patients met inclusion criteria. Overall, 80% of patients survived admission (n = 36) and 20% of patients did not survive admission (n = 9). There were no significant differences in baseline characteristics or cultured organism between survivors and non-survivors. The median time interval between airway culture and antibiotic initiation was 2 hours (IQR 0-4.5) for survivors, and 0 hours (IQR 0-0) for non-survivors (P = .07). Antibiotics were administered within 1 hour of airway culture for 33.3% of survivors, and 77.8% of non-survivors (P = .02). In a population of trauma patients with VAP, survivors had antibiotics initiated in more delayed fashion than non-survivors. These findings question the primacy of early antibiotic administration for suspected infection.

Aetiology, antimicrobial susceptibility and outcome of children with sepsis, admitted at Muhimbili National Hospital, Dar es Salaam.

Introductionsepsis is defined as a systemic inflammatory host response syndrome (SIRS) to infection, commonly bacterial. The global prevalence of sepsis is 8.2% with a mortality rate of 25%, whilst in Tanzania the prevalence is 6.6%. Treatment of sepsis involves early initiation of antibiotics based on local sensitivity patterns. However, there is an increase in antimicrobial resistance to commonly used antibiotics. Hence to promote rational use of antibiotics, we aimed at establishing the etiology, local susceptibility patterns and outcome of children with sepsis aged 2 months to 15 years, admitted at Muhimbili National Hospital (MNH), Dar es Salaam.Methodsa hospital based prospective cross sectional study was conducted among 245 participants who were consecutively recruited. A standardized structured questionnaire was used to collect information. Blood cultures and complete blood counts were done. Antimicrobial susceptibility was also done on positive cultures using disc diffusion method. Data were analyzed using SPSS version 20. Frequencies and proportions were used to summarize categorical data, whilst median and interquartile range was used to summarize continuous data. Student T test was used to compare means of data which were normally distributed and the differences in proportions were tested using Chi square test or Fisher’s exact test. A p value of = 0.05 was considered to be statistically significant.Resultsthere was predominance of male participants (67.5%) with a median age was 2 years and an interquartile range (IQR) 10 months to 4 years. Culture positive sepsis was detected among 29.8% of the participants, and the common Gram-positive bacterial isolates were S. aureus (39.7%) Coagulase Negative Staphylococcus (CoNS) (35.6%) and Gram-negative isolates were E. coli (12.3%), Klebsiella spp (6.8%) and Pseudomonas aeruginosa (5.5%). All bacteria showed a high resistance to ampicillin (80%- 100%) followed by ceftriaxone (40 - 70%). All Pseudomonas aeruginosawere 100% resistant to ampicillin, gentamycin and ceftriaxone but were sensitive to amikacin. There was less than 40% resistance to co-amoxiclav, meropenem, ciprofloxacin, amikacin, and clindamycin. The overall case mortality rate from sepsis was 9.4%. Among children discharged 59.3% had prolonged hospital stay of more than 7 days. Age group 1 to 5 years, prior use of antibiotics, tachycardia, and leukocytosis were significantly associated with high mortality.Conclusionbacterial sepsis is prevalent at Muhimbili National Hospital contributing to 9.4% of mortality and a prolonged hospital stay of more than 7 days among 59.3% of the participants. Gram-positive bacteria were found to be predominant cause of sepsis, whereas both Gram-positive and Gram-negative bacteria had a high resistance to first and second line antimicrobials including: ampicillin, gentamycin, and ceftriaxone.

MicroRNA as an Early Biomarker of Neonatal Sepsis

Sepsis is a major cause of lethality in neonatal intensive care units. Despite significant advances in neonatal care and growing scientific knowledge about the disease, 4 of every 10 infants born in developed countries and suffering from sepsis die or experience considerable disability, including substantial and permanent neurodevelopmental impairment. Pharmacological treatment strategies for neonatal sepsis remain limited and mainly based upon early initiation of antibiotics and supportive treatment. In this context, numerous clinical and serum-based markers have been evaluated for diagnosing sepsis and evaluating its severity and etiology. MicroRNAs (miRNAs) do not encode for proteins but regulate gene expression by inhibiting the translation or transcription of their target mRNAs. Recently, it was demonstrated in adult patients that miRNAs are released into the circulation and that the spectrum of circulating miRNAs is altered during various pathologic conditions, such as inflammation, infection, and sepsis. Here, we summarize current findings on the role of circulating miRNAs in the diagnosis and staging of neonatal sepsis. The conclusions point to substantial diagnostic potential, and several miRNAs have been validated independently by different teams, namely miR-16a, miR-16, miR-96-5p, miR-141, miR-181a, and miR-1184.

A Rare Case Report of Pseudomonas oryzihabitans Bacteremia from North India in a Terminally Ill Patient

Pseudomonas oryzihabitans is a gram-negative bacillus usually isolated from cases of bacteremia, CNS infections, catheter associated infections or any device related infections, sinusitis, wound infections, skin infections especially in immunocompromised patients in a hospital settings. Only few cases of bacteremia have been reported due to this rare pathogen. This is a first case report from North India in a terminally ill patient suffering from chronic liver disease. Proper isolation and early initiation of antibiotics as per sensitivity pattern cleared the infection, but later he died due to other complications. The need of automated methods for identification and sensitivity testing limits the reporting of this rare but important pathogen in hospital settings. Detailed research work and studies are needed to better understand this rare pathogen and its clinical manifestations for better outcome.

Excessively Prolonged Early Antibiotic Duration in Very-Low-Birth-Weight Infants: A Multicenter Prospective Cohort Study in a Developing Country.

PurposeSignificant antibiotic overuse due to prolonged antibiotic duration has not draw enough attention in developing countries with high antibiotic consumption. We aimed to describe the current status of prolonged early antibiotic duration in very-low-birth-weight (VLBW) infants in a large regional multicenter cohort in China.Patients and MethodsInstitution-based prospective cohort study was conducted in all VLBW infants admitted to 16 Grade A tertiary hospitals between January 1, 2019 and December 31, 2020. Early antibiotic use was defined as antibiotic initiation within the first 3 days of life. Prolonged early antibiotic course was defined as early antibiotic initiation for more than 7 days in infants with early-onset sepsis (EOS) or more than 3 days in infants with unlikely EOS. Antibiotic use was described as days of therapy (DOT) per 1000 patient days (PD).ResultsAmong 1684 eligible VLBW infants, 1544 (91.7%) infants were prescribed with prolonged early antibiotic course, including 618 infants with EOS and 926 infants with unlikely EOS. The median duration of early antibiotic course was 13 (IQR 8;20) days, with 78.0% of courses >7 days and 43.6% of courses >14 days. Total early antibiotic use was 408.3DOT/1000Pd, of which prolonged antibiotic courses accounted for 98.2% of all antibiotic use days. More than three antibiotics used, escalation antibiotic therapy, antibiotics for special use and the use of third generation cephalosporins and carbapenems were significantly common in prolonged courses compared to short courses in both infants with EOS and unlikely EOS group (P<0.05).ConclusionA large proportion of VLBW infants had excessively prolonged early antibiotic durations in the regional multicenter in China. Timely discontinuation of antibiotics in VLBW infants according to standardized guidelines and limit on the use of third-generation cephalosporins and carbapenems may be key drivers in reducing the antibiotic overuse in developing countries like ours.

Therapeutic Drug Monitoring of Antibiotics in Critically Ill Patients: Current Practice and Future Perspectives With a Focus on Clinical Outcome.

Early initiation of antibiotics is essential for ameliorating infections in critically ill patients. The correct dosage of antibiotics is imperative to ensure their adequate exposure. Critically ill patients have altered pharmacokinetic parameters and are often infected by less susceptible microorganisms. Differences in drug disposition are not considered with standard doses of antibiotics. This can lead to suboptimal antibiotic exposure in critically ill patients. To overcome this problem of suboptimal dosing, therapeutic drug monitoring (TDM) is a strategy commonly used to support individualized dosing of antibiotics. It is routinely used for vancomycin and aminoglycosides in clinical practice. In recent years, it has become apparent that TDM may also be used in other antibiotics. This review summarizes the evidence for TDM of antibiotics in critically ill patients, focuses on clinical outcomes, and summarizes possibilities for optimized TDM in the future. After reviewing the literature, we can conclude that general TDM implementation is advised for glycopeptides and aminoglycosides, as evidence of the relationship between TDM and clinical outcome is present. For antibiotics, such as beta-lactams, fluoroquinolones, and linezolid, it seems rational to perform TDM in specific patient cases. TDM involving other antibiotics is supported by individual cases, specifically to decrease toxicity. When focusing on future possibilities to improve TDM of antibiotics in critically ill patients, implementation of model-informed precision dosing should be investigated because it can potentially streamline the TDM process. The logistics of TDM, such as turnaround time and available equipment, are challenging but may be overcome by rapid bioanalytical techniques or real-time monitoring of drug concentrations through biosensors in the future. Education, clinical information on targets, and clinical outcome studies are other important factors that facilitate TDM implementation.

Impact of antibiotic pretreatment on cultures in children with osteomyelitis and septic arthritis: a retrospective review

BackgroundIn the management of pediatric osteomyelitis or septic arthritis, delay in treatment may affect outcome, while receipt of antibiotics prior to culture may affect culture results. We aimed to determine if pathogen identification decreased in cultures that were pretreated with antibiotics.MethodsWe conducted a retrospective cohort study of 584 hospitalized children between 30 days and 18 years of age admitted to two tertiary children’s hospitals. Logistic regression assessed the effect of antibiotic duration on blood, bone, joint aspirate, and “other” culture positivity.ResultsOverall, 42% of blood cultures, 70% of bone cultures, 39% of joint cultures, and 70% of “other” cultures were positive. Compared with children who did not receive antibiotics prior to culture, there were no significant differences in odds of a positive culture in children whose cultures were pretreated with antibiotics for any of the culture types [OR (95% CI) 0.90 (0.56–1.44) for blood cultures, 0.77 (0.25–2.34) for bone cultures, 0.71 (0.39–1.28) for joint cultures, 1.18 (0.58–2.41) “for other” cultures; all p > 0.05]. Furthermore, the duration (hours) of antibiotics in the pretreated cultures was also not a significant predictor of culture positivity (OR ranged from 0.99–1.00 for all cultures, p > 0.05).ConclusionsCulture positivity was not associated with antibiotic pretreatment in any of the samples, even for longer duration of antibiotics prior to culture, though the small sample size of subgroups is an important limitation. In pediatric patients hospitalized with osteomyelitis and/or septic arthritis, early initiation of antibiotics may not affect culture positivity.

Case report of COVID-19 positive new born with necrotizing enterocolitis (NEC)

COVID-19 caused by SARS-Cov-2 virus has spread rapidly across the world. Children are just as like as adult to become infected with virus but have lesser symptoms and less severity of the disease. Necrotizing enterocolitis is one of the common gastrointestinal emergencies in neonatal intensive care unit. More than 85% of cases of NEC occur among preterm and very low birth weight. Preterm babies are vulnerable to develop NEC because of high incidence of perinatal distress factor, stasis of gut due to autonomic immaturity, poor barrier function of gut or immune defences, lack of feeding with human milk and higher incidence of nosocomial infections. During the current COVID-19 pandemic, no similar finding has been reported in the neonatal population to date. In this review we summarize the case report of two newborns admitted in our NICU who were COVID 19 positive presented to us with symptoms suggestive of necrotizing enterocolitis (NEC) and their outcome based on presence of comorbidity. Our case reports two case of two COVID-19 positive newborns admitted in our NICU with history, examination and investigations suggestive of necrotizing enterocolitis. Early initiation of antibiotics covering bowel flora, bowel rest and resuscitation, similar to our tried and true medical management of NEC, should be considered for initial management to avoid surgical intervention

Epididymo-orchitis in an 18-day-old boy; a rare case report

Epididymo-orchitis is almost an acute inflammatory disease involving the epididymis and testis. Epididymo-orchitis is considered as a rare disease in childhood. We reported an 18-day-old boy with epididymo-orchitis who responded to antibiotic treatment and surgery and finally the patient was discharged in good general condition. It is a rare phenomenon in neonate that should be considered by practitioners. According to our case report, infants of any age are at risk for epididymo-orchitis, and it should always be one of the differential diagnoses in any testicular inflammation, pain, and redness. Early initiation of antibiotics and in some cases surgery can be very helpful in treating this disease.

S3334 No Fluoroscopy, No Problem: Non-Fluoroscopic, Non-Sonographic Biliary Drainage

INTRODUCTION: Acute cholangitis (AC) is classically associated with fever, right upper quadrant pain, and jaundice. Severe AC is a gastrointestinal (GI) emergency that requires urgent intervention. The most common cause of AC is biliary obstruction due to gallstones. The management of severe AC involves early initiation of antibiotics, aggressive resuscitation, and endoscopic retrograde cholangiopancreatography (ERCP). We present a case of severe AC requiring an urgent ERCP that was complicated by fluoroscopy malfunction with successful stent placement. CASE DESCRIPTION/METHODS: A 27-year-old man with a past medical history of autism presented with jaundice and fever. The patient is nonverbal and developed nausea and emesis for 3 days prior to presentation. The patient developed jaundice which prompted medical evaluation. On evaluation, the patient was tachycardic and febrile and was directed to the emergency department (ED). In the ED, abdominal ultrasound showed a CBD measuring 15mm. Initial labs were notable for WBC 21.8k, AST 171, ALT 254, and direct bilirubin >10. The patient was given antibiotics and underwent urgent ERCP. Upon biliary cannulation, pus and bile was released from the papilla. Following cannulation however, the fluoroscopy equipment malfunctioned and was no longer available. Given severe AC and aspiration of pus/bile, one plastic biliary stent was placed under endoscopic guidance. The patient’s labs and vital signs rapidly improved, and he was discharged on oral antibiotics. DISCUSSION: Severe AC requires antibiotics, fluids, and timely ERCP. Although endoscopic ultrasound (EUS) is accurate in diagnosing choledocholithiasis, it is unclear whether EUS-guided biliary drainage is as effective as ERCP. One randomized trial of patients with malignant biliary obstruction showed similar success rates among those undergoing EUS-guided drainage compared to ERCP. Another randomized trial of patients with choledocholithiasis found EUS-guided ERCP without fluoroscopy to be inferior to ERCP with fluoroscopy. In our patient, ERCP with fluoroscopy was unavailable due to a technical malfunction. Although EUS was not attempted, we successfully decompressed the biliary tree with blind stent placement after confirming pus and bile on aspiration. Although ERCP with fluoroscopy is preferred, EUS-guided drainage may be a safe alternative. Biliary decompression without EUS or fluoroscopy may be a viable bedside option in patients too sick for transfer, or in situations where fluoroscopy is unavailable.

Delivery-based criteria for empiric antibiotic administration among preterm infants.

Objective:Determine impact of using delivery criteria to initiate antibiotics among very low birth weight (VLBW) and extremely low birth weight (ELBW) infants.Design:Single site cohort study from 01/01/2009 to 01/31/2020. After 04/2017, infants delivered by Cesarean section, without labor or membrane rupture were categorized as low-risk for early-onset infection and managed without empiric antibiotics. We determined effect of this guideline by pre-post, and interrupted time series analyses.Result:After 04/2017, antibiotic initiation ≤3 days decreased among low-risk VLBW (62% vs. 13%, p<0.001) and low-risk ELBW (88% vs. 21%, p<0.001) infants. In time series analysis, guideline was associated with decreased initiation among low-risk ELBW infants. In contrast, low-risk VLBW infants demonstrated decreased antibiotic initiation throughout study period. Incidence of confirmed infection, death or transfer ≤7 days age was unchanged.Conclusion:Delivery criteria may be used to optimize early antibiotic initiation among preterm infants without short-term increase in adverse outcomes.

Incidence of central venous and Foley’s catheter related bacteraemia, organisms responsible and antibiotic sensitivity pattern: in cardio-thoracic intensive theraputic unit following elective surgery, in a tertiary care hospital of Kolkata, India

Background: Mortality from bacteraemia related to indwelling Central Venous Pressure (CVP) lines could be as high as 12 - 25% and that due to indwelling urinary catheters about 5%, in critically ill patients. Hence, initiation of early and aggressive antibiotic therapy, often even before the culture- sensitivity reports are available is necessary. Objectives of the study was to find out the incidence of bacteraemia related to indwelling CVP catheters &amp;/or Foley’s catheters in post operative patients in Cardio-thoracic Intensive Theraputic Unit (ITU) and to understand the antibiotic sensitivity patterns against the organisms causing such bacteraemiaMethods: 48 hours after their insertion, CVP catheter tips, Foley’s catheter tips and Peripheral blood samples were collected for cultures in 50 patients who underwent elective cardiothoracic surgery, over a period of one year and results were interpreted.Results: Incidence of bacteraemia associated with indwelling CVP catheters was 8% and was caused by both - Gram positive (Staphylococcus aureus, Enterococcus faecium) and Gram negative (Acinetobacter baumanii, Pseudomonas aeruginosa) organisms. Foley’s catheter was not related to such blood stream infection. Vancomycin and Linezolid were effective against the Gram positive organisms; while Piperacillin- Tazobactam, Meropenem, Polymyxin B and Colistin were effective against the Gram negative organisms.Conclusions: Indwelling CVP catheters were associated with blood stream infection in 4 post operative patients in our ITU. An idea about the organisms responsible, as well as their antibiogram may help in early initiation of antibiotics empirically before culture-sensitivity reports are available.

Assessing the impact of introducing a satellite blood culture incubator within a tertiary neonatal unit on length of hospital stay

Timely recognition and treatment of early-onset neonatal sepsis (EONS) reduces mortality and morbidity. The National Institute for Health and Care Excellence (NICE) recommends early initiation of antibiotics in babies with...

Quality Improvement Project to Evaluate Fever Management and Appropriateness of Lab Draws in Hospitalized Sickle Cell Disease Patients in a Tertiary Care University Teaching Hospital

Introduction: Sickle cell disease is the most common inherited blood disorder that affects almost 100,000 people in the U.S. Infection is the most common cause of death in these patients. Early identification and initiation of antibiotics given functional asplenia is the key to appropriate management of hospitalized sickle cell disease patients. Approximately 4-5 billion laboratory studies are ordered every year in hospitals. Unnecessary blood tests lead to frequent blood draws and worsening anemia in this already anemic population as well as contribute towards increasing cost of hospital stay. Total national health expenditures in the U.S. is $3.3 trillion (2016) with percent of national health expenditures for hospital care: 32.4%. Objective: We reviewed inpatient admissions of sickle cell disease patients to assess for appropriate work up and timely antibiotic initiation in case of fever. Additionally, we looked up the number of blood draws as well as number of days labs were drawn during the inpatient stay. Methods: This was a retrospective chart review of all patients with sickle cell disease who were admitted to John Dempsey hospital at University of Connecticut with length of stay of at least 3 days between April 2018 to Feb 2019. Results: 57 inpatient admissions were reviewed. Out of 57 admissions, 14 had fever either at the time of presentation or during the hospital stay. Mean time to first blood culture was 56 minutes with 92% (13/14) drawn within 1 hour of fever. Mean time to first antibiotic was 4.58 hours. Antibiotics were initiated in 7% (1/14) in less than 1 hour and 50% (7/14) within 3 hours. Urine culture was checked 78% and chest X-ray was checked 100% of the time in case of fever. On review of 57 patient admissions, labs were checked every single day of hospital stay in 35% (20/57) and if the day of discharge was excluded in 50% (29/57) of the patients. Overall, the labs were checked 82.33 percent of the days patients were hospitalized. On average, labs were drawn 1.14 times per day on each patient. Conclusion: Our project addresses safety, efficiency and timeliness with identification of areas of improvement in febrile sickle cell disease patients. It also addresses patient-centeredness raising awareness for decreased needle sticks for our sickle cell disease patients. There is continuing need to educate our care providers on how to manage fever in sickle cell disease for appropriate work up and early initiation of antibiotics. Also, we need to be more considerate when ordering labs on our patients especially sickle cell disease patients with baseline anemia. This will lead to decreased number of needle sticks and iatrogenic anemia as well as better healthcare resource utilization. Disclosures No relevant conflicts of interest to declare.

Investigating Antibiotic Exposure and Risk of Severe Acute Graft Versus Host Disease in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Several studies have shown that alteration of the microbiota, particularly in the gastrointestinal tract, can be associated with graft-versus-host disease (GvHD). Patients undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT) usually get exposed to antibiotics (ATB), mainly in the peri-transplant period. Moreover, ATB, specifically those that target anaerobic bacteria, can alter the microbiota in a variety of body organs. This, in turn, renders several organs vulnerable to injury making them more prone to developing diseases such as GvHD. In this study, we evaluate whether the use of ATB, characterized by duration, timing and type, in the peri-transplant period, is associated with an increased incidence of acute GvHD (aGvHD) and aGvHD-related mortality. In this retrospective study, we included 318 consecutive patients who underwent allo-SCT including haploidentical and cord blood transplantation between December 2012 and June 2018 at a single center. ATB exposure was collected and classified into 3 groups according to the date of initiation of ATB: from the start of conditioning to day - 1 of allo-SCT (early ATB exposure), from day 0 to neutrophil engraftment (late ATB exposure) and a third group of patients who did not receive ATB (no ATB exposure). ATB were only initiated if a patient develop fever or show signs of infection. Patients did not receive any prophylactic ATB. Exposure was further categorized as primary or adjunct. Primary exposure included the use of 4 classes of ATB: carbapenems, anti-pseudomonal penicillin, 4thand 5thgeneration cephalosporins and fluoroquinolones. Adjunct ATB comprised other ATB and was further divided into 2 groups according to anaerobic coverage. The median age at transplant was 55 years. The stem cell source was peripheral blood in 85%, bone marrow in 10% and cord blood in 5% of the patients. Ninety-nine percent of the patients received cyclosporine A as GvHD prophylaxis and 80% and 7% of the patients received (along with cyclosporine A), mycophenolate mofetil and methotrexate, respectively. In addition, 35% and 89% of the patients received post-transplant cyclophosphamide and anti-thymocyte globulin, respectively, as GvHD prophylaxis. The median time to neutrophil engraftment was 16 days post-transplant. The median follow-up was 85 months. 93.7% of the patients received ATB in the peri-transplant period with 64.5% of them in the early ATB exposure group, and 29.2% of them in the late ATB exposure group. The 2-year overall survival and progression free survival were 74.3% and 63.6% in patients with early ATB exposure, compared to 79.5% and 70.8% in patients with late ATB exposure (p=0.11 and p=0.07 respectively). The 2-year cumulative incidence of non-relapse mortality was 16.5% in patients with early ATB exposure, compared to 15.1% in patients with late ATB exposure (p=0.63). The 180-days cumulative incidence of grade 2-4 and 3-4 aGvHD were 23.8% and 12.2% in patients with early ATB exposure, compared to 27.2% and 5.4% in patients with late ATB exposure (p=0.64 and p=0.06 respectively). In multivariate analysis, including the most important parameters associated with GvHD (stem cell source and donors, conditioning regimen, sex mismatch and patients age), early ATB initiation was the only parameter associated with a significantly higher risk of severe grade 3-4 aGvHD [HR 0.51 (0.28-0.90); p=0.02]. In conclusion, in the absence of any ATB prophylaxis, early initiation of ATB, before graft infusion,is associated with a significantly higher risk of severe grade 3-4 aGvHD. Weighing risk of morbidity and mortality associated with infections versus later on risk of developing aGvHD is essential. Hence, new strategies should be developed to risk stratify patients with fever and thus to avoid early non necessary ATB exposure especially in those who develop fever during anti-thymocyte globulin infusion. Studies evaluating such strategies will be necessary in the next years. Disclosures Mohty: Jazz Pharmaceuticals: Honoraria, Research Funding. Malard:Astellas: Honoraria; JAZZ pharmaceutical: Honoraria; Sanofi: Honoraria; Keocyte: Honoraria; Janssen: Honoraria; Therakos/Mallinckrodt: Honoraria.