Gram-positive Cocci In Clusters Research Articles

Performance evaluation of machine-assisted interpretation of Gram stains from positive blood cultures.

Manual microscopy of Gram stains from positive blood cultures (PBCs) is crucial for diagnosing bloodstream infections but remains labor intensive, time consuming, and subjective. This study aimed to evaluate a scan and analysis system that combines fully automated digital microscopy with deep convolutional neural networks (CNNs) to assist the interpretation of Gram stains from PBCs for routine laboratory use. The CNN was trained to classify images of Gram stains based on staining and morphology into seven different classes: background/false-positive, Gram-positive cocci in clusters (GPCCL), Gram-positive cocci in pairs (GPCP), Gram-positive cocci in chains (GPCC), rod-shaped bacilli (RSB), yeasts, and polymicrobial specimens. A total of 1,555 Gram-stained slides of PBCs were scanned, pre-classified, and reviewed by medical professionals. The results of assisted Gram stain interpretation were compared to those of manual microscopy and cultural species identification by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). The comparison of assisted Gram stain interpretation and manual microscopy yielded positive/negative percent agreement values of 95.8%/98.0% (GPCCL), 87.6%/99.3% (GPCP/GPCC), 97.4%/97.8% (RSB), 83.3%/99.3% (yeasts), and 87.0%/98.5% (negative/false positive). The assisted Gram stain interpretation, when compared to MALDI-TOF MS species identification, also yielded similar results. During the analytical performance study, assisted interpretation showed excellent reproducibility and repeatability. Any microorganism in PBCs should be detectable at the determined limit of detection of 105 CFU/mL. Although the CNN-based interpretation of Gram stains from PBCs is not yet ready for clinical implementation, it has potential for future integration and advancement.

Prevalence of Staphylococcus aureus on Noncritical Surfaces of the Laboratories of a Medical Laboratory Training Institution

Staphylococcus aureus is a Gram positive bacterium that is frequently encountered on surfaces such as benches and skin. This organism being a normal flora of the skin is usually nonpathogenic but becomes pathogenic when found outside its normal flora where it can cause varying number of infections such as nosocomial infections and sepsis which may even lead to death if left untreated. This research was therefore carried out to determine the prevalence of Staphylococcus aureus on noncritical surface areas including: Furniture, Doors and Windows of the laboratories of Federal College of Medical Laboratory Science & Technology Jos, Nigeria. Samples were processed, examined and analyzed accordingly. It was observed that out of the 120 samples examined, 8 were gram positive cocci in clusters under Gram staining examination Coagulase and catalase tests were positive indicating specific biochemical tests to identify the organisms in the 8 organisms as Stapylococcus aureus showing a prevalence rate of 6.67%. The 17 working Benches examined, 3(2.50%) were positive. Out of 75 Chairs examined, 5(4.17%) were positive. The 18 Windows examined, 10 Doors examined showed no growth for Staphylococcus aureus. Distribution according to laboratory sections showed that, out of the 95 samples in main laboratory, 6(5.00%) were positive. Out of the 14 samples examined in side laboratory one, 2(1.67%) were positive while none 0(0.0%) was positive out of 11 samples examined in side laboratory two. The isolation of Stapylococcus aureus from these locations stresses the urgent need for public enlightenment campaigns by the appropriate authorities to educate the laboratory workers as well as the masses on the etiological agents, the possible risk factors, routes of transmission and health implication of Stapylococcus aureus infection and ways of preventing these bacteria in the Laboratories especially in Federal College of Medical Laboratory Science and Technology Jos Nigeria.

Clinical significance of Nosocomiicoccus ampullae isolated from blood cultures.

Nosocomiicoccus species are infrequently isolated from clinical specimens and their clinical significance has not been evaluated. We retrospectively reviewed five cases in which Nosocomiicoccus ampullae was identified in a single blood culture set during routine culture. All patients were admitted for altered mental status and had several comorbidities. Patients improved without antibiotic therapy directed to N. ampullae or their condition declined due to underlying conditions, and N. ampullae isolation was not considered clinically significant in any case. Matrix-assisted laser desorption/ionization-time of flight mass spectrometry and/or 16S rRNA gene Sanger sequencing allowed genus identification, but whole genome sequencing was required for accurate species identification. All strains were susceptible to penicillin, oxacillin, cefoxitin, tetracycline, doxycycline, daptomycin, minocycline, clindamycin, nitrofurantoin, vancomycin, and linezolid; they showed high-level resistance to trimethoprim-sulfamethoxazole and erythromycin, and inducible resistance to clindamycin, applying Clinical and Laboratory Standards Institute Staphylococcus spp. guidelines with an extended incubation. They frequently carry genes associated with macrolide resistance. In conclusion, N. ampullae appears to have low pathogenicity and most probably represents a contaminant when isolated from a single blood culture set.IMPORTANCENosocomiicoccus species are recently described as members of the Staphylococcaceae family. With their inclusion in commercial matrix-assisted laser desorption/ionization-time of flight mass spectrometry databases, Nosocomiicoccus species can now be identified when Gram-positive cocci in clusters are detected in positive blood cultures. However, their clinical significance is not known, making it difficult for the clinical microbiology laboratory to decide the extent of work-up. Based on our study, Nosocomiicoccus species demonstrate low pathogenicity and opportunistic potential. If isolated from a single blood culture set, limited work-up should be performed to an extent similar to other possible blood culture contaminants.

Implementation of a pharmacy-driven rapid bacteremia response program.

This report describes a comprehensive pharmacy-driven rapid bacteremia response program. This novel program positioned the pharmacy department at a large, community health system to receive and respond to critical microbiologic diagnostic testing results, 24/7/365. The program empowered pharmacists to provide centralized, comprehensive care including assessing blood culture Gram stain results, adjusting antibiotic therapy per protocol, ordering repeat blood cultures, analyzing and interpreting rapid molecular diagnostic test results, placing orders for contact isolation, and communicating antibiotic recommendations to the treatment team. In the first year after program implementation, 2,282 blood culture Gram stains and 2,046 rapid diagnostic test results were called in to the pharmacy department. The program reduced the median time to effective therapy in patients who did not already have active antimicrobial orders from over 10 hours to less than 1 hour. Based on the Gram stain results, antibiotics were started per protocol in 34.2% of patients. Based on the rapid molecular diagnostic test results, adjustments were made to antibiotic regimens in 55.7% of cases after discussion with a provider. Of these adjustments, 39.9% were for escalation of antibiotics and 37.7% were for de-escalation of antibiotics. By expanding the scope of pharmacy practice, barriers to optimizing clinical care were overcome.

Assessment of the Occupational Risk of Tuberculosis & Air Borne Infection Control in High-Risk Hospital Wards and Its Implications on Healthcare Workers in a Tertiary Care Hospital in South India.

Introduction The indoor air in hospitals could play a significant role in the transmission of a wide array of infections, especially in respiratory intensive care units, pulmonary outpatient departments, and other areas. Unprotected coughing and sneezing may facilitate the release of aerosols and contaminate the indoor environment. The majority of infections transmitted through these modes include viral diseases, including tuberculosis (TB), influenza, and measles, among several others. Moreover, the possibility of direct and indirect transmission of microbes by air has been underestimated in hospital settings, especially in developing countries. This studytherefore was carried out to assess the burden of microbes in the air of selected wards in a tertiary care hospital and evaluate the occupational risk of some infections among healthcare workers (HCWs). Methods This study was carried out between September 2019 and February 2021 at a tertiary care teaching hospital in South India. A total of 30 symptomatic healthcare workers (HCWs) were included in the study and were screened for present and past tuberculosis (TB) as well as other lower respiratory tract infections. A tuberculin skin test, chest X-ray, and sputum acid-fast staining were performed on all the HCWs who were negative for other bacterial infections and were symptomatic. The study was conductedin coordination with the pulmonology department. Active monitoring of air was performed by microbiological air sampler in the respiratory intensive care unit (RICU) and other high-risk areas including the pulmonology outpatient department (OPD), the radiology OPD, and the microbiology department. Results Sputum for tuberculousbacteriawas positive in four (16.6%) HCWs. The chest X-ray showed radiological findings suggestive of TB in five (20.8%) HCWs. Three (12.5%) HCWs who were screened for extrapulmonary TBrevealed one (33.3%) was positive for TB of the hip joint. Among the HCWs, eight (33%) returned positive tuberculin tests. Assessment of the hospital air in theRICU revealedthe bacterial count (288 CFU/m3) exceeded the normal limit (≤50 CFU/m3). The COVID-19 isolation ward showed the lowest bacterial count (06 CFU/m3) and no fungi. The predominant bacterial isolates were gram-positive cocci in clusters (Methicillin-sensitive Staphylococcus aureus). After proper disinfection and correction of ventilation techniques, the resampling results noted microbial colonies under normal limits. Conclusion A high burden of TB was noted among the HCWs. The airborne infection control strategies are essential to minimize the risk ofnosocomial infections and occupational TB risk to HCWs. Most microbes are transmitted through the airborne route and therefore it is extremely important to take measures to control the transmission of such pathogens in hospital settings.

ODP475 Developing suppurative thyroiditis

Abstract Suppurative thyroiditis is rare and associated with significant mortality. A high level of suspicion and aggressive management is needed to reduce the risk of serious outcomes. A 67-year-old male with a medical history including diabetes type 2, cognitive impairment, and ESRD presented with decreased appetite and lethargy for a few days. He presented with fever, tachycardia, and hypertension. There was a non-tender fullness around the anterior neck region. Initial laboratory tests revealed leukocytosis to 24K/uL, lactic acid of 5. 0 mmol/L, ESR 100 mm/hr, CRP 419 ng/dl, and blood culture was positive for gram-positive cocci in clusters for which he was started on iv vancomycin and piperacillin/tazobactam. CT scan on admission showed a probable inflammatory process in the neck originating from the thyroid bed, concerning acute thyroiditis and developing abscess/abscesses vs. very atypical presentation of thyroid cancer. Thyroid ultrasound showed diffuse thyroid enlargement with heterogeneous echogenicity. Repeat CT obtained due to apparent thyroid enlargement with erythema and tenderness on examination and fever on day 7 showed extensive heterogeneous thyroid enlargement with ill-defined margins to the adjacent soft tissue structures. A modified barium swallow revealed severe oropharyngeal dysphagia leading to thyroid fine-needle aspiration of both thyroid lobes by interventional radiology and subsequent urgent incision and drainage (I&D) of the right neck and thyroid biopsy under general anesthesia by ENT. I&D showed purulent drainage from the thyroid. Cultures were positive for MRSA. Surgical pathology reported a necrotic muscle and abscess and fragment of thyroid tissue. Thyroid function tests (TFTs) on admission revealed a TSH 0.31 mcIU/ml (reference: 0.30 - 5. 0 mcIU/ml) and a free T4 of 2.21 ng/dl (reference: 0.76- 1.46 ng/dl) and repeat TFTs with a TSH of 0.30 mcIU/mL, free T4 of 1.87 ng/dL, free T3 of 2.15 pg/ml (reference: 2.18- 3.98 pg/ml), consistent with sick euthyroid syndrome. TPO and TSI were negative. Subsequently, the patient's fever resolved, and the neck swelling improved. He continued IV vancomycin for a month. TFTs six weeks later showed an elevated TSH of 13.10 mcIU/ml and normal free T4 of 1. 03 ng/dl. Conclusion MRSA suppurative thyroiditis is rare, and its diagnosis may be delayed due to its indolent course, especially in immunocompromised patients. Therefore, a high index of clinical suspicion is needed for this endocrine emergency in a patient presenting with fever and neck swelling. While an early FNA of the thyroid is likely to aid in diagnosing thyroid infection, TFTs may be variable and not helpful. Presentation: No date and time listed

Late-onset Sepsis in Preterm Neonates is Associated with Higher Risks of Cerebellar Hemorrhage and Lower Motor Scores at Three Years of Age.

ObjectivesTo evaluate the impact of late-onset sepsis (LOS) in preterm infants on brain injury and neurodevelopmental outcomes at 36 months corrected age (CA).MethodsWe retrospectively analyzed the medical records of 203 preterm neonates of 24–32 weeks gestational age who were admitted between January and December 2017 at the neonatal intensive care unit (NICU) of a maternity hospital in Kuwait. The cases were stratified into no sepsis, early-onset sepsis (first onset of sepsis ≤ 72 hours postnatally), and LOS (> 72 hours postnatally). Brain injury was assessed from MRI records. Neurodevelopmental outcomes were evaluated at 36 months CA using Bayley-III scales of infant development.ResultsOut of 203 neonates, 16 had early-onset sepsis with Klebsiella pneumonia and group B streptococcus, and 93 developed LOS with K. pneumonia and gram-positive cocci in clusters. There were no group-wise differences in the prevalence of intraventricular hemorrhage (n = 68) or white matter injury (n = 42). However, higher cerebellar hemorrhage risk (adjusted odds ratio = 4.6 (1.3–18.6; p = 0.030) was observed in LOS group. At 36 months CA, infants in the LOS group were more likely to have lower motor, cognitive, and language composite scores. After adjusting for gestational age, birth weight, cerebellar hemorrhage, and white matter injury, the relationship between LOS and lower motor scores remained significant (adjusted β = –9.5, 95% CI: –16.4 to –2.7; p = 0.007), whereas the association with cognitive and language scores were no longer significant.ConclusionsLOS in preterm neonates significantly raises the risk of cerebellar hemorrhage and lower motor scores by three years of age.

Penile implant infection resulting in Staphylococcus aureus bacteraemia and infective endocarditis

IntroductionPenile implant infections are a possible surgical complication that has historically been most commonly associated with Gram-positive bacteria. Staphylococcus aureus is a Gram-positive bacteria and is the most common cause of endocarditis.Case PresentationA male patient in his 50s with a past medical history of hypertension, diabetes, end-stage renal disease (ESRD) on peritoneal dialysis (PD) and erectile dysfunction with a penile implant placed 6 years prior to the admission date presented with complaints of scrotal pain. The pump for his implant had eroded through his scrotum and was draining pus. Blood cultures returned positive for Gram-positive cocci in clusters in 4/4 bottles, which was eventually identified as methicillin-sensitive Staphylococcus aureus (MSSA). A transthoracic echocardiogram (TTE) was performed due to concern for infective endocarditis (IE) but did not show any valvular abnormalities. Due to high clinical suspicion, a transesophageal echocardiogram (TEE) was performed and revealed a vegetation on the native mitral valve. His penile implant was removed by urology and intraoperative cultures grew MSSA. Surgical valve replacement was not recommended, and the patient was sent home with IV antibiotics for 6 weeks.DiscussionPost-operative site infections are a quite uncommon point of entry for infective endocarditis, with penile implant infections being an even rarer cause. While a TTE is often used initially to attempt to diagnose infective endocarditis, it has lower sensitivity than a TEE. If clinical suspicion for infective endocarditis remains high after negative imaging with TTE, then TEE should be performed for better visualization of the heart valves.

Can the Xpert MRSA/SA BC assay be used as an antimicrobial stewardship tool? A prospective assay validation and descriptive impact assessment study in a South African setting

BackgroundPositive blood cultures showing Gram positive cocci in clusters signifies either Staphylococcus aureus or the less-virulent coagulase-negative staphylococci. Rapid identification and methicillin susceptibility determination with the Xpert MRSA/SA BC assay can improve management of S. aureus bloodstream infection and reduce inappropriate antibiotic use.MethodsWe prospectively evaluated the Xpert MRSA/SA BC assay in comparison with culture, on samples referred to our laboratory in the Western Cape, South Africa. We interviewed attending clinicians upon culture result availability, to assess antibiotic choices and estimate potential impact of the assay.ResultsOf the 231 samples included, there was 100% concordance between the Xpert MRSA/SA BC assay and culture (methicillin-resistant S. aureus 15/15, methicillin-susceptible S. aureus 42/42, coagulase-negative staphylococci 170/170). Time to final result could be reduced by approximately 30 h with the assay. Of the 178 patients with adequate antibiotic history, optimisation of antistaphylococcal therapy could have occurred more than 1 day sooner in 68.9% with S. aureus bloodstream infection (31/45, 95% CI 53.2–81.4%). Six of the 11 patients with methicillin-resistant S. aureus bloodstream infection (54.5%) could have received anti-MRSA cover sooner. Fifty-four days of antibiotic therapy could have been spared, equating to 0.3 days (95% CI, 0.2–0.4) saved per patient, driven by broad-spectrum beta-lactams (32 days, in 18.0% of the cohort).ConclusionThis assay has potential as an antimicrobial stewardship tool; costing and impact on clinical outcome in patients with S. aureus bloodstream infection should be assessed.

Impact of Rapid Identification of Staphylococcus Species in Positive Blood Culture Using GeneXpert Methicillin-Resistant Staphylococcus aureus/ Staphylococcus aureus Blood Culture Assay Combined with Antibiotic Stewardship.

Staphylococcus aureus bacteremia is a life-threatening condition associated with a substantial financial burden on the health care system. The use of the GeneXpert® methicillin-resistant S. aureus (MRSA)/S. aureus blood culture (BC) test for the identification of S. aureus may influence antibiotic stewardship and clinical outcomes. This study assessed the clinical and financial impact of utilizing GeneXpert MRSA/SA in combination with criterion-based testing. The outcomes between October 1, 2018, and June 30, 2019, were evaluated in 65 adult patients who had positive BCs with Gram-positive cocci in clusters. GeneXpert MRSA/SA significantly shortened the time to optimal antimicrobial therapy by 1.7 days (2.5 vs. 44 hr, p < 0.0001). The cost saved because of interventions based on GeneXpert testing results was $4,121. GeneXpert testing has shortened the time to optimal therapy and positively impacted cost, although it had no significant effect on length of hospital stay and mortality rate.

285. Evaluation of the ePlex® Blood Culture Identification (BCID) Panels for Gram-positive/Gram-negative bacteria and yeasts

BackgroundMultiple methods used for blood culture identification create inconsistent to reporting of critical results. Study aim was to evaluate performance characteristics of the ePlex BCID panels compared to current standard of care (SOC) methods used in our lab.MethodsIdentification sensitivity and specificity were assessed across all targets detected by the ePlex as well as time to final identification (from time of bottle positive Gram stain) between ePlex and SOC testing. SOC included Xpert MRSA/SA or latex agglutination for Gram-positive cocci in clusters (GPCC), Vitek MS + Accelerate Pheno for Gram-negative rods (GNRs), serotyping or optochin disk ± Vitek MS for Gram-positive cocci in chains (GPC chains), Vitek MS or Vitek-2 for Gram-positive rods (GPR), and PNA-FISH or Vitek MS for yeasts.Results313 unique prospective blood culture specimens were tested with ePlex BCID panels during a 3-month period (January-March 2020). The positive percent agreement was 100% for GNR (n= 98), S. aureus (n= 42), coagulase-negative staphylococci (n= 38), Group A Streptococcus (n= 3), Group B Streptococcus (n= 5), S. pneumoniae (n= 10), GPR (n= 21), and yeasts (n= 20). There was 1 false negative, (S.mutans) which should have been detected. The negative percent agreement was 100% across all targets except for 1 false positive Corynebacterium spp. In total, 6.7% of blood cultures had an off-panel organism which ePlex did not detect. The median time to final identification was 3 (2 – 4) hrs. for ePlex and calculated for all other SOC methods. Compared to SOC molecular methods, the ePlex reduced time to identification 0.5 h compared to Xpert MRSA/SA, 6.7 h compared to Accelerate Pheno for GNR (but Accelerate Pheno provides susceptibilities), and 3 h compared to PNA-FISH for yeasts (p< 0.05). ePlex compared to non-molecular techniques (MALDI-TOF), SOC for Streptococcus spp. and Enteroococcus spp., the time to final identification was reduced by 24 – 30 hours (p< 0.05).Workflow chart comparison eplex to SOC Time to results eplex vs SOC ConclusionThe ePlex BCID system provided highly accurate identification results for GP and GN bacteria as well as for yeasts. Our evaluation showed that this system significantly reduced time to final identification compared to SOC testing methods.Disclosures Kimberle Chapin, MD, genmark (Scientific Research Study Investigator) Giannoula Tansarli, MD, GenMark (Grant/Research Support)

Black hairy tongue associated with linezolid therapy in a patient with mycobacterial abscesses infection- Report from rural india

Background: Black Hairy tongue consists of a benign condition related to abnormal keratin build-up in filiform papillae, giving them an elongated hair-like appearance. We report a case of a 35 y/m presented who developed black discoloration of tongue while on linezolid therapy. Case Description: A 35 y/m, presented to gastroenterology OPD with chief complaints of on and off chromic discharging sinuses from port site right hypochondrium since past 1 y. Pus swabs taken from discharging site were taken and sent for gram stain, ZN stain and culture. Gram stain showed few pus cells,gram positive cocci in clusters. ZN stain showed few acid fast bacilli. Discussion: Bacterial culture grew MSSA and LJ media showed growth of rapidly growing mycobacteria(RGM) after 6 d of incubation. RGM was further identified by HAINS genotypic assay as Mycobacterium abscesses subspecies abscesses. Antibiotic susceptibility was performed on Middlebrook 7H11 with OADC and isolate was found to be sensitive to amikacin, gentamycin,imipenem and linezolid and resistance to macrolides, fluroquinolones and doxycycline. Diagnosis of MSSA and Mycobacterium abscesses infection was made and patient was started on amikacin and linezolid 600 mg OD. On 16thday of therapy patient developed dark discoloration of dorsum of tongue, teeth and oral mucosa. Other antibiotics, drugs, poor oral hygiene, smoking, and consumption of coffee or other coloured beverages were rule out as risk factors. Patient was switched on to meropenem and aminoglycoside. Discoloration improved after three weeks of discontinuing Linezolid. Conclusion: The diagnosis of BHT primarily relies on a visual intra- oral examination. Described adverse reaction is uncommonly described with prolonged Linezolid therapy.Careful review of known precipitating factors and recent medication changes is also fundamental in the diagnosis of BHT. Overall clinical prognosis of BHT is excellent.

Abstract 16207: An Uncommon Pathogen Causing Endocarditis and Valve Abscess: Aerococcus Sanguinicola

Introduction: Aerococcus Sanguinicola is a rare pathogen associated with urinary tract infections (UTI). Widespread use of MALDI-TOF can better differentiate Aerococcus species and has led to the identification of A. Sanguinicola as a source of endocarditis. Case Presentation: A 55-year-old male with a history of diabetes mellitus and recent cystitis presented to the hospital with confusion, back pain, fever, chills and myalgias. The patient was tachycardic and hypotensive on exam. Leukocyte count was at 16 k/ul with elevated inflammatory markers. Blood cultures were obtained and empiric vancomycin and cefepime were initiated. Transthoracic echocardiogram revealed mild mitral regurgitation. On hospital day 3, gram stain demonstrated gram positive cocci in clusters, and physical exam revealed a new 3/6 holosystolic murmur in the left 6th intercoastal space. Transesophageal echocardiogram demonstrated acute severe mitral regurgitation and multiple large vegetations with abscess on the anterior leaflet (Figure). Gentamycin was added to treat presumed Staphylococcus Aureus endocarditis. Subsequent species identification revealed A. Sanguinicola as the blood-based pathogen. He underwent bioprosthetic mitral valve replacement due to acute heart failure. Anatomic pathology of the valve confirmed A. Sanguinicola infection. He completed a 6-week course of antibiotics. On his follow up visit at 3 months, the patient had recovered. Conclusion: This case demonstrates a severe case of A. Sanguinicola endocarditis requiring urgent valve replacement. A. Sanguinicola is known to generate biofilms, which are activated by plasma which contrasts with S. Aureus, for which A. Sanguinicola can be mistaken. Additionally, known case of A. Sanguinicola infection demonstrate B-lactams sensitivity. While the organism has the potential to form abscesses, we present the first reported case of valvular abscess that was successfully cured with antibiotics and surgery.

GEMELLA MORBILLORUM: A RARE CAUSE OF INFECTIVE ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Gemella morbillorum is a Gram-positive coccus, catalase negative facultative anaerobe that is normal flora in the oropharynx and gastrointestinal and genitourinary tracts. It is a rare pathogen in infective endocarditis, accounting for <1% of cases. CASE PRESENTATION: A 23 year old male presented to the emergency department complaining of a three day history of nocturnal cough producing bloody, yellow sputum. He denied fever, intravenous drug use, significant past medical history or ill contacts. He had immigrated from Guatemala to Colorado eight months before presentation to work as a painter. In the ED, he developed respiratory failure, presumed a result of pneumonia, and rapidly decompensated into cardiogenic and distributive shock. A transthoracic echocardiogram showed a bicuspid aortic valve and large vegetations on the mitral and aortic leaflets, severe mitral and aortic regurgitation with perforated leaflets, findings consistent with infective endocarditis. Blood cultures were positive with Gram positive cocci in clusters. His tenuous condition required urgent cardiothoracic surgery to replace both mitral and aortic valves. G.morbillorum was identified employing matrix-assisted laser desorption/ionization using time-of-flight mass spectroscopy (MALDI-TOF MS). Consequently, he began intravenous gentamicin and ampicillin. The source of infection was identified on dental panorex as a lucency in his left lateral incisor; on subsequent questioning, the patient disclosed a history of dental carie with filling that fell out and was replaced before arriving in the US. His postoperative course was complicated by recurrent pneumothoraces, complete heart block, atrial fibrillation with rapid ventricular response, and cardiac arrest due to torsades de pointe and ventricular fibrillation ultimately requiring pacemaker/defibrillator implantation prior to discharge. The aforementioned antibiotics were completed over his 31-day hospitalization. DISCUSSION: This case highlights pre-disposing factors associated with endocarditis: male sex, a congenital bicuspid aortic valve, and recent dental work. G. morbillorum is not easily identified with traditional microbiologic methods and requires more sophisticated techniques utilizing mass spectroscopy and advanced PCR. Biofilm production and downregulation of Interleukin-12 / Interferon-γ support this organism’s opportunistic pathogenicity. A recent case series from Cleveland Clinic identified this Gemella species in <1% of endocarditis patients in their registry. CONCLUSIONS: G. morbillorum, although normal flora, may become pathogenic and cause endocarditis in patients with underlying risk factors such as valvular abnormalities, intravenous drug use and prosthetic heart valves. Utilization of advanced identification microbiologic technology facilitates identification and consequent treatment with appropriate antibiotics. Reference #1: A.Ramanathan, S.M.Gordon and N.K.Shrestha, Acaseseries of patients with Gemellaendocarditis, Diagnostic Microbiology&Infectious Disease (2020),https://doi.org/10.1016/j.diagmicrobio.2020.115009 Reference #2: Nagy, E., Becker, S., Kostrzewa, M., Barta Noémi, & Urbán Edit. (2012). The value of MALDI-TOF MS for the identificationof clinically relevant anaerobic bacteria in routinelaboratories. Journal of Medical Microbiology, 61(10), 1393–1400. doi: 10.1099/jmm.0.043927-0 Reference #3: Benedetti, M., Rassu, M., Branscombe, M., Sefton, A., & Giampietro,P. (2009). Gemella morbillorum: an underestimated aetiology of central nervous system infection. Journal of Medical Microbiology. 58, 1652-1656. doi:10.1099/jmm.0.013367-0 DISCLOSURES: No relevant relationships by Geoffrey Blossom, source=Web Response No relevant relationships by Lauren Spaeth, source=Web Response

NOT ALL CAVITARY LESIONS WITH AIR FLUID LEVELS ARE LUNG ABSCESSES

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary Pulmonary Hodgkin lymphoma is very rare, less than 100 cases have been reported (1,2) as they comprise less than 0.5 % of lung neoplasias (3,4) and of out of those only 2% are PPHL (5). Diagnosis of this neoplasm is very challenging because it usually presents with nonspecific symptoms and radiological images that can be attributed to other etiologies such as infection. CASE PRESENTATION: 26-year-old male presented to his PCP with dry cough, fevers, chills, night sweats, 20-pound unintentional weight loss, and dyspnea for a month. Outpatient treatment with azithromycin for a presumed pneumonia failed and he was admitted to the hospital. He was found to be febrile (39c) and tachycardic (123 beats/min). Laboratory work up was notable for a WBC 25.9. Chest x-ray showed left upper lobe (LUL) lung abscess and left side effusion. He was started on broad spectrum antibiotics. Sputum gram stain was positive for MRSA. CT of the chest showed extensive cavitary necrotic airspace consolidation of the LUL and lingula with moderate left sided pleural effusion(Fig 1). Pleural fluid analysis was found to be exudative in nature. AFB samples were negative. BAL showed gram positive cocci in clusters, however, culture results were negative. Despite antibiotics, the fever persisted, and the patient underwent a second thoracentesis and CT scan that showed progression of the left sided cavitary lesion(2). Repeat bronchoscopy with transbronchial needle biopsy was negative for malignancy. The patient’s symptoms improved, and he was discharged home on antibiotics. One month later the patient was readmitted due to persistent progressive SOB and weight loss. Broad spectrum antibiotics were initiated and repeat BAL was unrevealing. Ultimately, the patient underwent FNA and multiple biopsies around the rim of the LUL “abscess” revealed classical Nodular Sclerosing Hodgkin lymphoma. The patient underwent one cycle of chemotherapy and his symptoms improved significantly, and he was discharged with outpatient follow up. Unfortunately a few months later he presented with the same symptoms and similar CT findings.(Fig 3) DISCUSSION: Cavitary lesions in the lung have a broad differential (6), it is important to consider different etiologies in a patient with recurrent symptoms and non-resolving radiographic abnormalities. Due to the nonspecific signs, symptoms, laboratorial and radiological findings of primary pulmonary lymphomas the diagnosis is very challenging and usually delayed (7, 8) Such as in our case the patient received multiple empirical broad-spectrum antibiotics for suspected abscess without complete resolution of symptoms and progression of radiographic findings. CONCLUSIONS: Our case highlights the importance of considering other differentials for cavitary lung lesions in the treatment plan especially when confronted with a non-resolving symptoms. Reference #1: Rodriguez J, Tirabosco R, Pizzolitto S, et al. Hodgkin lymphoma presenting with exclusive or preponderant pulmonary involvement: a clinicopathologic study of 5 new cases. Ann Diagnos Path 2006;10:83–8 Reference #2: Primary pulmonary Hodgkin's lymphoma and a review of the literature since 2006 Reference #3: Primary Pulmonary Involvement in Mucosa-associated Lymphoid Tissue Lymphoma DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response No relevant relationships by Victor Zavala, source=Web Response

Performance and impact of a multiplex PCR in ICU patients with ventilator-associated pneumonia or ventilated hospital-acquired pneumonia

BackgroundEarly appropriate antibiotic therapy reduces morbidity and mortality of severe pneumonia. However, the emergence of bacterial resistance requires the earliest use of antibiotics with the narrowest possible spectrum. The Unyvero Hospitalized Pneumonia (HPN, Curetis) test is a multiplex PCR (M-PCR) system detecting 21 bacteria and 19 resistance genes on respiratory samples within 5 h. We assessed the performance and the potential impact of the M-PCR on the antibiotic therapy of ICU patients.MethodsIn this prospective study, we performed a M-PCR on bronchoalveolar lavage (BAL) or plugged telescoping catheter (PTC) samples of patients with ventilated HAP or VAP with Gram-negative bacilli or clustered Gram-positive cocci. This study was conducted in 3 ICUs in a French academic hospital: the medical and infectious diseases ICU, the surgical ICU, and the cardio-surgical ICU. A multidisciplinary expert panel simulated the antibiotic changes they would have made if the M-PCR results had been available.ResultsWe analyzed 95 clinical samples of ventilated HAP or VAP (72 BAL and 23 PTC) from 85 patients (62 males, median age 64 years). The median turnaround time of the M-PCR was 4.6 h (IQR 4.4–5). A total of 90/112 bacteria were detected by the M-PCR system with a global sensitivity of 80% (95% CI, 73–88%) and specificity of 99% (95% CI 99–100). The sensitivity was better for Gram-negative bacteria (90%) than for Gram-positive cocci (62%) (p = 0.005). Moreover, 5/8 extended-spectrum beta-lactamases (CTX-M gene) and 4/4 carbapenemases genes (3 NDM, one oxa-48) were detected. The M-PCR could have led to the earlier initiation of an effective antibiotic in 20/95 patients (21%) and to early de-escalation in 37 patients (39%) but could also have led to one (1%) inadequate antimicrobial therapy. Among 17 empiric antibiotic treatments with carbapenems, 10 could have been de-escalated in the following hours according to the M-PCR results. The M-PCR also led to 2 unexpected diagnosis of severe legionellosis confirmed by culture methods.ConclusionsOur results suggest that the use of a M-PCR system for respiratory samples of patients with VAP and ventilated HAP could improve empirical antimicrobial therapy and reduce the use of broad-spectrum antibiotics.

Etiological evaluation of purulant aspirates on lymph node FNAC

Fine needle aspiration is the mainstay in the diagnosis of Lymphadenopathies. In present study the purulent aspiratesfrom lymph nodes were evaluated for etiological agents to know the distribution pattern of various disease agents.This study was a prospective one covering 100 cases taken from patients attending MBS and NMCH Hospitals under Govt. medical college, Kota. Our study spanned from January to December, 2017.Out of a total of 100 cases incidence of different types of lymphadenopathies were, Tubercular, 55%, Acute suppurative, 27%, Granulomatous Inflammatory, 12% and Metastatic Carcinoma, 6%. Cases of lymphadenopathy showed a wide age range from 1 to 73 years. Male to female ratio was 1:1.04. AFB positivity was seen in 61.8% cases of Tubercular lymphnoditis. Among the 55 cases of tubercular lymphnoditis, 46 (83.6%) cases showed Auramine Rhodamine positivity while only 34 (61.8%) corresponding cases were positive by Ziehl Neelsen stain, demonstrating higher sensitivity of Auramine Rhodamine stain.In present study, commonest cause of Metastasis in lymph nodes was Squamous Cell Carcinoma (33.3%). Other diagnosis were Metastatic Adenocarcinoma, Duct carcinoma breast, Mucoepidermoid carcinoma and poorly differentiated carcinoma. On gram’s staining out of 27 cases of Acute suppurative lymphnoditis, 3 showed positivity for gram positive cocci. Out of 3 cases, 1 case showed gram positive cocci in clusters and 2 cases showed gram positive diplococci. Diplococci were more common in younger population.FNAC is a safe, convenient, rapid and inexpensive first approach procedure, without any complications in evaluation of cases of lymphadenopathy and can be practiced even in peripheral hospitals where histopathological techniques are not available.

A case of recurrent aerococcus urinae infective endocarditis with associated cerebral embolic phenomena

Aerococcus urinae is a gram positive, alpha haemolytic cocci that rarely is associated with urinary tract infections, bacteraemia and infective endocarditis. We describe a case of recurrent aerococcus urinae endocarditis with associated cerebral embolic phenomena. A 76 year old man presented with sudden onset right sided weakness and dysphasia. CT and MRI head imaging showed infarcts in the left pons and cerebellum suspicious of embolic aetiology. He had a background of a prosthetic mitral valve replacement following an episode of culture negative infective endocarditis associated with discitis and a psoas abscess 3 years previously. A 16S rRNA PCR on valve tissue had yielded an aerococcus urinae. The anaerobic bottle of a blood culture taken on his present admission flagged positive at 48 hours but no organisms were seen on gram stain. However, Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI – TOF MS) identified an aerococcus urinae 4 hours later. The same organism was also identified in the aerobic bottle which had flagged positive later the same day with gram positive cocci in clusters. Susceptibility testing revealed a MIC (Minimum Inhibitory Concentration) of 0.032, 1 and 8mg/L for penicillin, vancomycin and gentamicin respectively. A transthoracic echocardiogram confirmed reoccurrence of endocarditis with a 1.5cm lesion on the mitral valve. There was no evidence of other embolic phenomena. The patient was managed medically with initial treatment with intravenous vancomycin and gentamicin followed by benzylpenicillin and gentamicin for 6 weeks. The patient made slow rehabilitative progress and remained debilitated by his right sided hemiparesis.

Diagnostic accuracy and clinical impact of loop-mediated isothermal amplification for rapid detection of Staphylococcus aureus bacteremia: a retrospective observational study.

The aim of this study was to evaluate the diagnostic accuracy and the clinical impact of isothermal loop-mediated amplification (LAMP; eazyplex® MRSA kits) for rapid diagnosis of Staphylococcus aureus bacteremia (SAB) in comparison with conventional blood culture diagnostics. We performed a retrospective, single-center observational study over the period between November 2016 and December 2018 on patients (and blood cultures) with growth of Gram-positive cocci in clusters in their blood cultures. We quantified diagnostic accuracy with sensitivity and specificity for detection of S. aureus, methicillin-resistant S. aureus (MRSA), and the mecA/C resistance genes in 797 blood cultures. The clinical impact was assessed by time to result reporting, time to appropriate treatment, and length of stay in intensive care unit (ICU) in 190 SAB patients. We observed sensitivity and specificity above 90% for S. aureus detection (sensitivity (95% confidence interval (CI)), 99.57% (97.61%, 99.98%); specificity, 99.12% (97.95%, 99.71%)), for MRSA detection (sensitivity, 100% (89.11%, 100.00%); specificity, 99.72% (99.05, 99.96)), and for mecA/C detection (sensitivity, 94.71% (91.85%, 96.78%); specificity, 95.89% (93.58%, 97.54%)). LAMP testing was associated with shorter median time to result reporting (24.0h (first and third quartiles (Q1-Q3), 20.0-27.0h) vs 41.5h (36.0-46.0h); p < 0.001) and different distribution of time to appropriate treatment (2.0days (1.0-3.0) vs 2.0days (2.0-3.0); p = 0.004). No evidence for differences in length-of-stay in ICU was observed. Our analysis suggests for the application of LAMP (i) a high diagnostic accuracy for detection of S. aureus and the mecA/C genes in blood cultures, (ii) an earlier result reporting, and (iii) a shorter time to appropriate treatment.

A Study on the Isolation and Analyzation of Staphylococcus aureus Obtained from Nasal Samples of Female Students (Undergraduates and Graduates) at The Obafemi Awolowo University Campus

One of the predominant bacteria found in the nose is Staphylococcus aureus, and they are found in approximately the same number as on the skin and face. The study was carried out to isolate and analyze Staphylococcus aureus obtained from the nasal cavity of female students (at undergraduate and postgraduate levels) of the Obafemi Awolowo University, Ile-Ife campus, Osun state, Nigeria. Out of 40 samples obtained from the nasal cavity of the female students, a total of 9 isolates were confirmed as Staphylococcus aureus. Based on the biochemical tests, they were all Gram-positive cocci in clusters, catalase positive, coagulase positive and were also DNase positive. Based on these criteria, we concluded that individual should ensure that their nose is kept clean and should practice good hygiene especially in a hospital environment to prevent nosocomial infections due to Staphylococcus aureus.