Empirical Therapy Research Articles

Pragmatic randomised trial assessing the impact of peer comparison and therapeutic recommendations, including repetition, on antibiotic prescribing patterns of family physicians across British Columbia for uncomplicated lower urinary tract infections

ObjectiveTo evaluate the impact of a personalised audit and feedback prescribing report (AF) and brief educational summary (ES) on empiric treatment of uncomplicated lower urinary tract infections (UTIs) by family...

Assessment of community-acquired urinary tract infections treatment in the emergency department: a retrospective study.

Urinary tract infection (UTI) is one of the most common medical complaints in the emergency department (ED). The aim of this study was to assess the real indication of an initial broad-spectrum treatment administered in the ED for hospitalized patients with a diagnosis of community-acquired UTI (CAUTI). This is a monocentric observational retrospective study conducted in the ED of one of the largest tertiary care centers in Lebanon, on a two-year period, including adult patients admitted to the hospital for a CAUTI. The primary outcome was to evaluate the need of downgrading empirical antibiotherapy started in the ED. Secondary outcomes included a description of CAUTIs characteristics: prevalence and risk factors for (extended spectrum beta lactamases) ESBL-related infection, complicated and uncomplicated UTIs, empirical and targeted treatment, and finally the rate of adherence to local guidelines. The most isolated strains on urine cultures were gram negative bacilli (GNB) with 29.1% producing ESBL; 69.4% of patients received an ESBL-targeting empirical treatment in the ED, in agreement with local guidelines, 46% of which needed a downgrade. Amikacin adjunction was only indicated in 42.8% of the cases. Patients who received antibiotics in the last 6 months had a 2.36 times higher risk of developing an ESBL-related infection. This study showed a high adherence rate to local recommendations suggesting the use of empirical ESBL-targeting antibiotherapy even in uncomplicated UTIs. However, the frequent need of de-escalation highlights the importance of establishing an efficient multi-drug resistant (MDR) bacteria surveillance system in the community in order to elaborate a stewardship program with more solid local guidelines.

Suppurative Granulomatous Osteomyelitis with Microcystic Changes Due to Mycobacterium chelonae- abscessus Complex

Abstract Introduction/Objective Mycobacterium chelonae and Mycobacterium abscessus are rapidly growing non-tuberculous mycobacterium found in soil and water, and represent rare causes of skin and soft tissue infection. Treatment typically involves an extended course of antimicrobial therapy and occasionally surgical debridement. Previous reports have described a distinctive pattern of suppurative granulomatous inflammation with microcystic changes in skin biopsies; however, the morphologic changes of M. chelonae-abscessus complex as a cause of osteomyelitis have not been well-documented in the literature. Methods/Case Report We searched our database from 2013 to 2024 for bone samples diagnosed as granulomatous inflammation in which M. chelonae or M. abscessus were identified on concurrent microbiology studies. Patient demographics, risk factors for infection, and treatment data were collected. Results (if a Case Study enter NA) Three patients with culture- or PCR-confirmed M. chelonae (2) or M. abscessus (1) were identified. All infections involved bones of the distal extremities. Patients were 57 years and older with risk factors for infection that included: diabetes (1), intravenous drug use (1), and long-term immunosuppressive therapy (1). All patients presented with osteomyelitis refractory to antibiotic therapy for which bone biopsy, bone resection, or amputation was performed. All cases showed suppurative granulomatous inflammation with microcystic changes. Cystic spaces were markedly enriched for acid-fast bacilli on Fite and/or Ziehl-Neelsen stains. In two patients, the antimicrobial regimen was changed as a result of the pathologic findings and microbiologic testing that provided additional information about speciation and susceptibilities. Conclusion Suppurative granulomatous inflammation has a broad differential that includes blastomycosis, sporotrichosis, cat scratch disease, non-tuberculous mycobacterial infection, and granulomatosis with polyangiitis, for which there are substantial treatment differences. When this pattern of microcystic suppurative granulomatous inflammation is encountered, it is important to perform special stains for acid-fast bacilli, particularly when seen in distal extremity lesions from patients with infections that are refractory to empiric antibiotic therapy.

Bacterial Profile in Urine Culture and Amikacin Sensitivity and Emergence of Carbapenem-Resistant Pathogens in Tertiary Medical College Hospital, Bangladesh

Background: Urinary tract infection (UTI) is one of the most common encounters both in the outpatient department and inpatient department. It is important to know the bacteriological etiology according to urine culture and to know the antibiotic sensitivity. Objective: Our study was carried out to observe the urine culture and sensitivity pattern to commonly used injectable antibiotics such as amikacin and to look for the emergence of carbapenem-resistant uropathogens.Materials and methods: A total of 150 patients of UTI being culture-positive were isolated and identified by random selection. Samples were collected throughout January 2022 to March 2022. Standard microbiological techniques were used to identify the bacteria and test for susceptibility to various antibiotics. Data were entered into MS Office Excel 2016 for analysis and visualization.Results: The most common urine culture positive was E. coli, 108 (72%) followed by Pseudomonas sp., 16 (11%) and staphylococcus saprophyticus, 15 (10%). The rest of 7% urine culture was positive were other bacterial species. Around 90% of the total cultured E. coli was sensitive to amikacin. Staphylococcus saprophyticus 8 cases (53%), E. coli 15 cases (14%) and Pseudomonas sp. single cases (6%) were resistant to carbapenem. Resistance to vancomycin was common among most of the pathogens, with 88 cases (81%) of E. coli and 12 cases (75%) of Pseudomonas sp. being resistant. In contrast, Staphylococcus saprophyticus had a higher sensitivity to vancomycin, with only 3 cases (20%) being resistant and 12 cases (80%) being sensitive.Conclusion: The study focused on the commonest uropathogens causing UTI and antibiotic resistance in urine isolates may be useful guidelines for clinicians initiating empirical antibiotic therapy as well as help in the formulation of antibiotic therapy strategy. KYAMC Journal Volume: 15, No: 01, April 2024: 16-19.

Clinical Utility of a Multiplex PCR Panel (BioFire Joint Infection®) in the Adjustment of Empiric Antimicrobial Therapy: Experience in Pediatric Osteoarticular Infections.

This study aims to evaluate the impact of the PCR multiplex panel (BioFire JI®) on the diagnosis and management of pediatric osteoarticular infections. This retrospective study analyzed data from pediatric patients diagnosed with osteoarticular infections between January 2023 and April 2024. The effectiveness of the PCR multiplex panel in identifying pathogens was compared with traditional culture methods. In total, 50 patients were identified (66.6% male, 74% under 3 years of age). They were diagnosed as follows: septic arthritis in 46%, osteomyelitis in 26%, and septic osteoarthritis in 22%. An identifiable agent was isolated by conventional culture in 22 cases (44%). Kingella kingae was the predominant pathogen identified, accounting for 50% of cases (11/22), followed by Staphylococcus aureus (9/22). The BioFire JI® Panel PCR demonstrated a sensitivity of 93%, with a specificity of 63% when evaluated against synovial fluid culture as the reference standard. The panel identified seven additional pathogens not detected by conventional culture methods: 2/9 MSSA (22%), 1/1 S. pyogenes (100%), and 4/11 K. kingae (37%), increasing the yield by 14%. The rapid identification of pathogens facilitated timely and targeted therapeutic interventions. The PCR multiplex panel (BioFire JI®) improved the diagnosis of pediatric osteoarticular infections.

Spinal subdural empyema in an immunocompetent patient: illustrative case.

Spinal subdural empyemas are a rare presentation of rapid neurological decline, progressing from radiculopathy to complete paralysis and sensory loss. Although pathogenic mechanisms have been hypothesized, their occurrence in this population of patients remains unclear. The authors present the third documented case of an isolated spinal subdural empyema of unclear etiology in an immunocompetent patient with no established risk factors. Successful treatment requires prompt clinical suspicion, radiological diagnosis, and surgical evacuation along with empirical antibiotic treatment. Radiological clarification of the subdural versus the epidural location of the empyema is difficult, while intraoperative durotomy for exploration risks subdural dissemination. In these cases, intraoperative ultrasonography would be a useful adjunct and decision aid. https://thejns.org/doi/10.3171/CASE24464.

Microbiology of periprosthetic infections following implant-based breast reconstruction surgery: a multicentric retrospective study.

Implant-based breast reconstruction (IBR) is the predominant breast reconstruction technique post-mastectomy, with bacterial infections being a significant complication affecting patient recovery and quality of life. The following study aimed to determine the microbiological features of the causative agents responsible for breast implant infections, with more attention paid to the comparative analysis of Gram-positive and Gram-negative bacteria and their presentation. We conducted a retrospective analysis of 214 patients who presented with periprosthetic infection and underwent implant removal following implant-based breast reconstruction at Humanitas Research Hospital and Istituto Europeo di Oncologia between January 2018 and March 2024. The study revealed that Gram-positive bacteria were more prevalent, with Staphylococcus species, particularly Staphylococcus aureus, being the most isolated pathogen in both institutions (∼39.96%). In contrast, Gram-negative bacteria were less frequent, with a higher proportion of these pathogens being multi-resistant strains. A significant difference was observed (p = 0.007), indicating that individuals with normal BMI have a higher prevalence of Gram-positive infections (88.46%), whereas obese and overweight patients had higher proportions of Gram-negative infections (23.53% and 28.89%, respectively). In addition, smoking status was also significantly associated with pathogen distribution (p = 0.032), with active and past smokers being related to higher percentages of polymicrobial infections. Furthermore, positive prophylactic MSSA/MRSA swabs were significantly more associated with Staphylococcus aureus infections compared to those with negative results (p = <0.001). Gram-positive bacteria, especially Staphylococcus species, dominate the microbiological landscape of implant-based breast reconstruction (IBR) infections. Our findings provide insights into this critical issue, facilitating a more precise choice of empiric antibiotic treatment and prevention strategies. This analysis underscores the necessity for prophylactic protocols and therapeutic approaches tailored to the predominant bacterial groups. Further research is needed to explore long-term trends and resistance mechanisms to improve patient management.

Fungal Malignant Otitis Externa: A Systematic Review.

Malignant otitis externa (MOE) is a rare but serious condition primarily caused byPseudomonas aeruginosa. Fungi, particularly in immunocompromised individuals, can also be a contributing factor. A systematic review was conducted, following PRISMA guidelines, to evaluate the literature on fungal malignant otitis externa (FMOE), focusing on its etiology, patient demographics, clinical presentation, and treatment. Out of 464 articles identified, 10 were analyzed in detail, involving 197 patients with a mean age of 65.9 years. Of the total patients, 143 were male (72.6%), 52 were female (26.4%), and the gender of the remaining two was not specified. One hundred and fifty-five patients (78.7%) had underlying immunosuppressive conditions such as diabetes mellitus, chronic kidney failure, corticosteroid use, chemotherapy, and AIDS. Fungal cultures were positive in 107 cases (54.3%), withCandidaandAspergillusspecies being present in nearly equal proportions. There were no significant differences between fungal and non-fungal MOE in terms of clinical presentation and diagnostic methods. Conservative treatment was used in 179 patients (90.8%), with 172 of them (87.3%) receiving antifungals. Itraconazole and voriconazolewere the most common antifungals, while amphotericin B was less frequently used due to side effects. In some cases, antifungals were combined with antibiotics. Surgical interventions were performed in 35 patients (17.8%), and hyperbaric oxygen therapy was used in 34 of them (17.3%). Eight patients with FMOE died, and the mortality rate was 4%. Late diagnosis, cranial nerve involvement, and inadequate treatment may contribute to higher mortality. Given the potential underdiagnosis of FMOE, early incorporation of antifungal medications into empirical treatment protocols could improve outcomes for patients with a poor prognosis.

Empirical antibiotic therapy for sepsis: save the anaerobic microbiota.

Antibiotics are fundamental in sepsis management; however, the optimal empirical treatment remains debated. Despite anaerobes rarely being the causative pathogen of sepsis, antibiotics targeting them are frequently used, which might lead to unintended consequences. Multiple studies have shown that depletion of commensal anaerobic gut microbes by anti-anaerobic antibiotics influences systemic immunity and is associated with increased mortality in patients with sepsis. However, this knowledge has not yet been translated into clinical practice. When considering empirical coverage of anaerobic pathogens in sepsis, most physicians advocate for a better-safe-than-sorry approach. In this Viewpoint, we argue that anti-anaerobic antibiotics could often result in being sorry rather than safe. We provide an overview of the limited necessity of anaerobic coverage and the potential detrimental effects of anaerobic depletion in sepsis. We aim to raise anaerobic awareness to reduce the unnecessary use of anti-anaerobic antibiotics in empirical sepsis treatment and improve patient outcomes.

Evaluation of an intervention to decrease length of stay in children with low-risk febrile neutropenia

Abstract Background Febrile neutropenia is one of the most common serious complications of myelosuppressive chemotherapy. For this reason, pediatric oncology patients with FN have traditionally been admitted to the hospital and started on empiric intravenous antibiotics. However, not all FN patients are at high risk of developing subsequent complications, and a low-risk group exists that could safely be discharged early. Methods A retrospective study of 194 FN episodes presenting in pediatric oncology patients at St. Jude Children’s Research Hospital. Outcomes of FN episodes were studied and compared before and after early discharge guidelines for low-risk febrile neutropenic (LRFN) were implemented at St. Jude on May 6, 2020. Results Total length of hospital stay was similar in the pre- and post-intervention groups (median 4 [IQR 3,6] vs. 4 [IQR 3,7] days, P = 0.443). Differences in adverse outcomes were insignificant between the pre- and post-intervention cohorts, with only two ICU admissions after the first 24 hours inpatient in the post-intervention group, one new positive blood culture (&amp;gt; 24 hours – 14 days of admission) in each group, and 36.2% versus 21% new fever after resolution of initial fever in pre- and post-intervention cohorts respectively. Cumulative antibiotic use between the pre- and post-intervention groups was statistically insignificant (median 13.5 [IQR 22.8,8] vs. 14 [IQR 22,9] days, P = 0.537), whereas Levofloxacin use was significantly longer in the post-intervention cohort versus the pre-intervention cohort (median 0 [IQR 0,4] vs. 0 [IQR 0,0] days, P = &amp;lt;0.001). Conclusion The implementation of guidelines for early discharge of LRFN patients showed no reduction in hospital stay. Understanding the optimal strategy for effectiveness of guideline implementation is crucial to improve quality and efficiency of care.

Procalcitonin Level Monitoring in Antibiotic De-Escalation and Stewardship Program for Patients with Cancer and Febrile Neutropenia

Objective: Serial procalcitonin (PCT) monitoring has been adopted to supplement clinical judgement and help guide antibiotic therapy as part of antimicrobial stewardship programs. PCT levels peak 24 to 48 h after infection onset and decline with infection resolution. We explored the role of PCT as an infection biomarker for guiding antibiotic therapy in cancer patients hospitalized for febrile neutropenia. Design: Prospective randomized study. Methods: Patients were enrolled between October 2021 and August 2023 and received empiric intravenous broad-spectrum antibiotics (IVBSA) for at least 48 h. PCT was measured at baseline and 48–72 h after IVBSA initiation. PCT drop 48–72 h after IVBSA initiation was defined as a reduction of 30% from baseline or a PCT level &lt; 0.25 ng/mL. De-escalation was defined as a switch from IVBSA to oral or simplified once-daily IV therapy. Results: Of the 89 patients with available PCT levels, 53 (60%) had a PCT drop, most of whom (79%) underwent IVBSA de-escalation. Compared with patients without a PCT drop, patients with a PCT drop had a higher de-escalation rate at 72 h (71% vs. 45%; p = 0.003) and a shorter median antibiotic duration (55 h vs. 98 h; p = 0.004). Patients with bacteremia had a significantly higher median PCT level than those without bacteremia (2.35 ng/mL vs. 0.370 ng/mL, p = 0.013). Conclusions: In patients with cancer and febrile neutropenia, a PCT drop was associated with earlier therapy de-escalation and shorter antibiotic duration. PCT monitoring may be useful in antimicrobial stewardship initiatives in this patient population. Clinical trials identifier: NCT04983901.

Invasive fungal disease in patients with cancer in a tertiary care pediatric hospital

Abstract Background In the last two decades, the raise in invasive fungal diseases (IFD) has been associated with increased morbidity and mortality in immunosuppressed hosts. Its incidence varies between 2 to 21% and depends on the host´s underlying disease, the intensity of immunosuppressive treatment and the presence of comorbidities. The aim of this study is to describe the epidemiological, clinical and microbiological characteristics of IFD in patients with hematology-oncology disease. Methods Retrospective, descriptive study. Patients under 18 years of age with acute leukemias, lymphomas and solid tumors with a diagnosis of proven IFD (according to EORTC-MSG 2019 criteria) were included during the period from January 2020 to November 2023 in a tertiary care pediatric hospital. Results During the study period, 304 patients were under follow-up. 14 episodes of proven IFD were identified in 13 patients.The median age was 120 months. Male sex predominated (69.2%). The recognized factors associated were neutropenia (69.2%), use of corticosteroids in the last 3 months (61.5%) and use of previous antibiotics (92.3%). The most common underlying disease was Acute Lymphoblastic Leukemia (ALL) in 11 cases (78.5%), of which 3 were in relapse. The 21.4% of the episodes occurred in solid tumors (1 osteosarcoma of the tibia, 1 abdominal germ cell tumor, 1 neuroblastoma). Patients receiving primary prophylaxis for filamentous fungi were 3/14 (21.4%), according to the European Conference on Infections in Leukemia (ECIL-8). All received voriconazole. The fungal isolates identified were: 1 Rhizopus spp. (eye biopsy, paranasal sinuses) 1 Penicillum spp. (lung biopsy), 1 Exserohilum rostratum (skin biopsy), 1 Trichophyton asahii (blood cultures), 1 Purpuracillum lilacinus (skin biopsy), 1 Aspergillus fumigatus (Bronchoalveolar lavage, BAL),: 3 Candida parapsilosis (blood cultures), 1 Candida tropicalis (blood cultures), 1 Candida spp (blood cultures), 1 Malassezia (BAL). The patients with invasive molds infections were six, all of them with pathological chest tomography. Galactomannans (GM) were positive in 66% (4/6). BAL with positive GM was performed in 2 of them. The primary focus were: cutaneous (3/6), pulmonary (2/6) and orbital-rhinosinusal (1/6). Regarding IFD due to yeast fungi: all Candida infections were associated with central venous catheters fungemia. Malassezia infection presented with pulmonary involvement. Fungal co-infection was observed in 1 patient with documentation of Aspergillus fumigatus in BAL and Candida tropicalis in blood and urine cultures. Empirical antifungal therapy was liposomal amphotericin in 76.9 % of the patients. Two patients died (15.4%) at 30 days of follow-up. Conclusion Early diagnosis and timely antifungal therapy represent the main strategies to increase the survival of patients with IFD. Antifungal prophylaxis is postulated as an effective prevention measure and its indication should be defined according to the patient’s characteristics and the incidence of IFD at the treating center. We consider that patients with suspected IFD and clinical focus should undergo the corresponding tissue biopsy for culture, histological evaluation, and molecular biology, to direct the appropriate treatment. Candida species represent the most frequent isolates, however, Aspergillus and Rhizopus infections are associated with higher morbidity and mortality.

Outcomes of severe lower respiratory tract infection in Mexican children with cancer

Abstract Background Lower respiratory tract infections (LRTI) are a very serious complication in children with cancer, with high morbidity and mortality, due to viral infections, followed by bacterial and fungal organisms. These patients with cancer are undergoing chemotherapy that damages their mucosal barrier and respiratory epithelium, and course with profound or severe neutropenia. Thus, they are high-risk to develop severe respiratory infections acquired from the community. However, the clinical characteristics, etiological agents, finding on computed tomography (CT) and outcomes of the LRTI in immunocompromised patients are not well known, these are necessary in order to start adequate management including empirical antimicrobial therapy and supplementary oxygen therapy. Methods Children with cancer who were attended in the pediatric emergency room due to fever (&amp;gt;38°C) and presence of respiratory symptoms such as increased breath rate, cough, O2Sat &amp;lt;93%, and needed to supplementary oxygen were included. To analyze the cases of children with cancer and LRTI we documented the data regarding to clinical presentation, detection of respiratory virus and findings in the CT. Data such age, sex, oncological diagnosis, absolute neutrophil count. The detection of nucleic acid of respiratory virus was performed by qPCR, whereas the identification galactomannan in serum was done for fungal diagnosis, and clinical presentation was initial used for diagnosis of bacterial LRTI. The findings on TC were included to integrate all the LRTI etiological diagnosis. The outcomes recorded were to need supplementary oxygen therapy (nasal cannula, high-flow nasal cannula or mechanical ventilation), ICU admission, and mortality on the follow for all patient included in the study. A descriptive statistical analysis was performed to estimate frequency of the etiological agents, outcomes, and mortality rate. Results A total of 10 children with cancer and severe LRTI were followed up, 60% female sex, age 5.5 years (range, 1-16 &amp;lt;); 80% had acute leukemias and 20% lymphoma. Seven (70%) children were diagnosed with bacterial LRTI, whereas two (20%) and one (10%) were viral LRTI-diagnosed. The finding in the CT were the follow: bilateral patchy consolidation and ill-defined small nodules for viral infection, centrilobular nodules and bronchial wall thickening for bacterial infection and scattered nodules or patchy focus for fungal infection. In respect to clinical presentation 90% had fever, 100% had cough, and 100% had O2Sat &amp;lt;93%. Of these patients 60% were presented with profound and 20% with severe neutropenia (p&amp;lt;0.05); 30% had required high-flow oxygen and 10% mechanical ventilation; and three (30%) patients required care in ICU. The mortality rate for severe LRTI was 30%. Conclusion Children with cancer and profound or severe neutropenia are in high-risk to develop severe LRTI and they have high mortality. The finding on the CT can help to start on adequate management for LRTI in immunosuppressed pediatric patients.

Bacteremias in Hemato-Oncological Pediatric Patients: Clinical and Microbiological Characteristics

Abstract Background In haemato-oncologic patients bacteremia is frequent increasing mortality rates, therefore surveillance and close follow up is essential to optimize treatment. The use of invasive devices used frequently in this population increases the incidence of infections by gram-positive microorganisms (currently gram-negative bacilli have been added). Therefore, we propose the characterization the microorganisms to identify the epidemiologic conditions, and the areas of improvement to establish improvement care strategies for this population. Methods We conducted a retrospective study at the haemato-oncologic diseases service at the National Medical Center “20 de Noviembre”. Prevalence of bacteremia in pediatric patients with cancer and neutropenia in Mexican population, which ranges from 8% to 36%, assuming that our results could be similar to higher percentage, employing a proportion formula with a study population of 65 patients. Results It was demonstrated in our population studied that in all cases of bacteremia, patients were in depth neutropenia at diagnosis. The most prevalence phase of chemotherapy was Induction phase (69.2%), with Total XV ST Jude protocol. The clinical data revealed the following frequencies in 100% of the patients: Fever (92%), Tachycardia (72%), Shivering and piloerection (65%), Elevated acute-phase reactants PCT (51%), CPR (32%), and Tachypnea (28%). Cases of Central Line-associated Bloodstream Infection (CLABSI) was reported in 86.2%, affecting individuals with vascular devices. The predominant microbiological isolate in our patients was Escherichia coli ESBL (31%), followed by Klebsiella pneumoniae (18%), and Pseudomonas aeruginosa (13.8%), Staphylococcus epidermidis (11%). Other bacteria were identified at even lower frequencies, such as Stenotrophomonas maltophilia (5%), Klebsiella oxytoca (5%), Staphylococcus aureus (3%), Serratia marcescens (3%), Enterococcus faecalis (3%), and Enterobacter cloacae (3%). The least observed in our population was the identification of Acinetobacter baumannii (2%). The different outcomes recorded in our sample were highly consistent, with a resolution rate of infection in 97% of cases and 3% of cases resulting in death attributable to bacteremia (Table 1). Conclusion The low mortality found in this study may be due to the early initiation of empirical antibiotic treatment in “golden hour”, a protocol carried out in our Center, as well as the identification of severity scales.

Clinical and epidemiological characterization of infections in pediatric hemato-oncology patients with febrile neutropenia in the North of Mexico

Abstract Background Neutropenic fever is the most common complication in patients undergoing chemotherapy, where the choice of empirical antibiotic treatment should be based on the probable focus of infection, the predominant causative microorganisms, and the sensitivity of those organisms to antibiotics, which varies between each hospital and region. Over time, the spectrum of isolated microorganisms in different clinical syndromes of patients presenting during their infectious episode has changed. Our objective is to describe the prevalence of infectious etiology in pediatric patients with neutropenic fever, as well as the clinical characteristics of patients with documented infection. Methods The study design is ambispective, observational, and descriptive of a cohort type. Patients between 0 and 18 years old from the pediatric department of the “Dr. José E. González” University Hospital will be included from May 2019 to June 2023, with hematological-oncological disease during their febrile neutropenia infectious process with a complete medical record. Results A total of 326 episodes of febrile neutropenia were included, of which 15% had microbiological isolation (49 patients). The etiological classification during the events was as follows: bacteria 81%, viruses 14%, and fungi 4%. Five different infection sites were identified. Among these, bacteremia were the most frequent site of infection (10%), followed by gastrointestinal infections (2.4%), respiratory infections (1.5%), skin and soft tissue infections (1.2%), and lastly, urinary tract infections (1%). A total of 45 microorganisms were isolated from different infection sites. Among these, gram-negative bacteria (28 isolates, 62%) were more common and outnumbered gram-positive bacteria (14 isolates, 31%). Among gram-negatives, Escherichia coli (42%) was the most common isolate, followed by Pseudomonas aeruginosa (17%), and Klebsiella pneumoniae (14%). Among gram-positives, Streptococcus mitis (28%), Coagulase-negative Staphylococcus (21%), and Rothia mucilaginosa (14%) were identified. Conclusion Febrile neutropenia at the Hospital Universitario primarily affects 6-year-old males with ALL. The microbiological characterization suggests the intentional search for gram-negative bacteremia, allowing us to direct timely and targeted antibiotic therapy to influence clinical prognosis. It is worthwhile to continue the research line that allows us to identify susceptibility and resistance profiles to address these patients more effectively.

Use of T2Bacteria Panel in Pediatric Hematopoietic Stem Cell Transplant Patients: A Single Center Experience

Abstract Background Bloodstream infection is a common complication following hematopoietic cell transplant (HCT), occurring in 10-40% of patients (1,2). Rapid identification of causative bacteria is imperative to provide proper empiric therapy and ensure optimal patient outcomes. The T2Bacteria Panel detects five bacterial pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli) using T2 magnetic resonance (T2MR, T2Biosystems, Lexington MA, USA) directly from blood specimens. Previous studies have reported per-patient sensitivity, specificity, and negative predictive value (NPV) of 84-90%, 85.9-90%, and 99.7%, respectively, as well as 100% positive agreement and 98.4% negative agreement when compared to blood culture (3-5). To date, there have been no studies on the use of this test in pediatric HCT recipients. Methods We reviewed all pediatric HCT patients at St. Jude Children’s Research Hospital who had a T2Bacteria Panel performed for fever and suspected infection between January 2019 and September 2022. A total of 706 T2Bacteria Panel results and concurrent blood culture results from 251 unique patients were analyzed to determine assay performance for detection of the 5 targeted pathogens. Results T2Bacteria PCR and blood culture showed concordant results in 97% of cases. Overall, our study revealed 65% positive percent agreement with blood culture and 95% negative percent agreement for bacteremia caused by any of the target pathogens. PPV, NPV, sensitivity and specificity for each organism detected by the panel, and the panel overall, are presented in Table 1. Positive predictive value ranged from 28-73%. Negative predictive value was high for all organisms (98-100%). Sensitivity was highest for Pseudomonas aeruginosa (88%), and lowest for Escherichia coli (44%). Specificity was high for all organisms (97-99%). Conclusion In pediatric HSCT patients, the T2Bacteria Panel was most useful for rapidly ruling out the presence of target pathogens, with high negative percent agreement, NPV, and specificity. Positive percent agreement was lower than noted in previous studies. Positive predictive value and sensitivity varied per pathogen.

Malaria and dengue fever in febrile children entering healthcare facilities in Mwanza, Tanzania.

Plasmodium spp. infections and cases of malaria are a long-standing public health problem for children living in middle- and low-income countries. Dengue virus causes an emerging under-recognized disease burden. A cross sectional study was conducted between March 2020 and December 2021 to determine the status of malaria and dengue fever, and the associated factors in children living in Mwanza, Tanzania. Clinical features were recorded; blood samples were analyzed using dengue NS1 rapid diagnostics test (NS1-RDT), malaria rapid diagnostic test (MRDT) and PCR and microscopy for malaria parasites. Descriptive analysis was based on infection status; odds ratio and confidence interval were used to determine the factors associated with dengue fever and malaria. The prevalence of malaria in the 436 children included in the final analysis was 15.6%, 8.5%, and 12.1% as determined by MRDT, blood smear examination and PCR, respectively. The prevalence of dengue fever determined by the NS1-RDT was 7.8%. Body rash, muscle and joint/bone pain were associated with a positive rapid dengue test result. Retro-orbital pain characterized Plasmodium spp. and dengue virus co-infections. Clinical signs and symptoms could not readily differentiate between malaria and dengue fever patients or patients co-infected with both causative agents underscoring the urgent need for the accurate laboratory diagnostics. Additional large-scale studies are required to assess the epidemiological burden of acute febrile illness in developing countries and to produce data that will guide empirical treatment.

Predictors of Methicillin-resistant Staphylococcus aureus infection in children with acute osteomyelitis

BackgroundThis study aims to identify risk factors associated with Methicillin-resistant Staphylococcus aureus (MRSA) infection in children diagnosed with acute osteomyelitis (AO) and to elucidate the laboratory characteristics of these MRSA-infected children to enhance early targeted therapeutic interventions.MethodsWe conducted a retrospective analysis involving 123 children with acute osteomyelitis treated at our hospital. Upon admission, we measured white blood cell (WBC) counts, C-reactive protein (CRP) levels, erythrocyte sedimentation rates (ESR), and platelet counts. Patients were categorized into two groups: the non-MRSA group (n = 73) and the MRSA group (n = 50), with values assigned as follows (non-MRSA group = 0, MRSA group = 1).ResultsThe MRSA group had a significantly higher average age compared to the non-MRSA group (P < 0.05). Notably, the incidence of suppurative arthritis was significantly lower in the MRSA group (P < 0.05). At the time of admission, CRP levels in the MRSA group were markedly elevated compared to those in the non-MRSA group (P < 0.01). After three days of empirical therapy, both WBC and CRP levels remained significantly higher in the MRSA group compared to the non-MRSA group (P < 0.05).ConclusionsIn children newly admitted with acute osteomyelitis, a CRP level exceeding 73.23 µg/mL may indicate a high likelihood of MRSA infection. For children with AO who have been hospitalized for three days on empirical therapy, the presence of WBC > 10.95 × 10^9/L, CRP > 49.56 µg/mL, age > 3.5 years, and the absence of suppurative arthritis suggests a heightened risk of MRSA infection.

Intravenous Anakinra for Treating Macrophage Activation Syndrome in Adult-Onset Still's Disease.

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disease characterized by fever, rash, arthritis, and multi-organ involvement. Macrophage activation syndrome (MAS), a serious complication of AOSD, poses significant diagnostic and therapeutic challenges. A 32-year-old male was diagnosed with AOSD in 2020 after being hospitalized for a fever of unknown origin and elevated liver enzymes. The patient was initially treated with corticosteroids and methotrexate but subsequently discontinued both treatment and follow-up. In September 2023, he presented with fever, sore throat, and elevated inflammatory markers. After screening for infections, methylprednisolone (MP) treatment was initiated because of AOSD activation. The following day, the patient was admitted to the intensive care unit due to an altered state of consciousness. Brain magnetic resonance imaging revealed brainstem involvement. Empirical treatments were initiated, including intravenous MP, and immunoglobulin therapy. Due to suspected macrophage activation syndrome (MAS), anakinra (ANA) infusion was initiated. Significant improvement was observed after the ANA infusion. This case highlights the complex management of severe AOSD complications, emphasizing the role of early recognition, aggressive therapy, and multidisciplinary care in improving outcomes. Macrophage activation syndrome (MAS) is a serious complication of adult-onset Still's disease characterized by systemic inflammation. Early recognition and prompt initiation of treatment are crucial due to the high mortality rate associated with MAS, especially when neurologic symptoms are present.Clinicians should not delay treatment pending confirmatory diagnostic tests when MAS is suspected, as early intervention can significantly impact patient outcomes.Anakinra, an interleukin-1 inhibitor, is typically administered subcutaneously but has shown promise when administered intravenously, particularly in severe cases of MAS.

Prevalence, Species Distribution and Resistance of Candidemia in Pediatric and Adult Patients in a Northeast Italy University Hospital.

Candidemia and invasive candidiasis (IC) are causes of morbidity and mortality in healthcare settings, with notable differences between children and adults. Understanding the species distribution and antimicrobial susceptibility profiles of clinical isolates can guide empiric therapy in patients at risk of IC. This study investigated the incidence and antifungal susceptibility patterns of yeasts involved in IC in pediatric and adult patients from 2019 to 2023. The average incidence of IC was 0.715 per 1000 patients, increasing over the study period; infants had the highest incidence rates. Over half of the IC episodes occurred in intensive care units (ICUs). Non-albicans Candida (NAC) species represented the most frequently isolated species in adults and children (55.96% and 50.0%, respectively), with the prevalence of C. parapsilosis (26.45% and 14.7%, respectively), N. glabratus (14.97% and 8.82%, respectively) and C. tropicalis (4.36% and 2.94%, respectively). C. lusitaniae was identified in 14.7% of pediatric IC cases. In NAC species, antifungal resistance has also increased over the five years of the study: 69.12% were resistant to azoles and 7.35% were resistant to micafungin. Resistance was higher in pediatric patients. Our study highlights differences in IC characteristics between pediatric and adult populations and emphasizes the importance of targeted antifungal stewardship in ICU patients with NAC invasive infections.