Higher Rates Of Bacteremia Research Articles

Prevalence of bacteremia and antimicrobial resistance pattern among patients in South Lebanon

Bacteremia is a leading cause of morbidity and mortality worldwide. Rising prevalence and antimicrobial resistance (AMR) are critical public health issues. This study aims to determine the prevalence of bacteremia and the AMR pattern among patients in South Lebanon. A cross-sectional study analyzed 76 positive blood cultures from Hammoud and Labib Hospitals in South Lebanon between September 2023 and March 2024. The phenotype and antimicrobial susceptibility of gram-positive and gram-negative were determined by using disk diffusion. Genotypically, polymerase chain reaction was used to detect the carbapenemase-resistant Enterobacterales (CRE), extended-spectrum β-lactamases (ESBL), and methicillin-resistant Staphylococcus aureus genes. Out of 76 isolates, 38 (50%) were gram-positive and 38 (50%) were gram-negative. Escherichia coli was the most common among gram-negative (18. 42%), with 10.52% ESBL and 3.94% CRE. Staphylococcus coagulase negative was the most common among gram-positive (40.78%), followed by Staphylococcus aureus (6.57%), with 3.94% methicillin-resistant S. aureus. The prevalent ESBL gene was CTX-M (100%), and for the CRE, NDM (66.66%) was the most common gene. Regarding S. aureus, 66.66% were mecA. The diverse bacteremia isolates and resistance genes in South Lebanon reflect global variability in incidence and resistance profiles. High rates of bacteremia and AMR in South Lebanon underscore the need for effective antibiotic stewardship programs.

Differences in the clinical presentation of necrotizing fasciitis depending on the causative pathogen.

Necrotizing fasciitis is a fatal, soft tissue infection of the skin that requires prompt treatment. Historically, most cases have been attributed to group A beta-hemolytic Streptococcus infection. However, in recent years, other bacteria have been identified as causing necrotizing fasciitis. In the current study, we analyzed cases of necrotizing fasciitis and examined the significant differences in symptoms caused by pathogenic bacteria. We included 79 patients (43 males and 36 females, mean age 65.4 years) diagnosed with necrotizing fasciitis who visited our hospital between April 2004 and July 2023. The patients were classified into five groups based on the identified pathogen: group A beta-hemolytic Streptococcus; group B beta-hemolytic streptococcus; group G beta-hemolytic Streptococcus; mixed infection, including anaerobic bacteria; and Staphylococcus (S) aureus. The clinical characteristics of patients, including treatment duration and laboratory values, were analyzed. Group G beta-hemolytic Streptococcus was more common in older patients (Bonferroni method, p < 0.05). Patients with S. aureus tended to be hyperglycemic (Bonferroni method, p < 0.05), had a higher rate of bacteremia (Fisher's direct probability test, p < 0.05), and had a longer treatment duration than the other examined groups (Bonferroni method, p = 0.0132). Although the five groups did not differ in the mortality rate, overall survival was shorter in the mixed infection group than in the other groups (log-rank test, p < 0.05). The legs were the most common site of infection in the non-mixed infection group; in the mixed infection group, the pubic area was identified as the most common site of infection, accompanied by a poor prognosis. Collectively, these findings suggest that necrotizing fasciitis can be characterized by pathogenic bacteria and that these characteristics may inversely predict the pathogen of origin.

Assessing the clinical utility of abdominal computed tomography in sepsis patients with unknown origin: A retrospective cohort study.

Early identification of the sources of infection in emergency department (ED) patients of sepsis remains challenging. Computed tomography (CT) has the potential to identify sources of infection. This retrospective study aimed to investigate the role of CT in identifying sources of infection in patients with sepsis without obvious infection foci in the ED. A retrospective chart review was conducted on patients with fever and sepsis visiting the ED of Linkou Chang Gung Memorial Hospital between July 1, 2020 and June 30, 2021. Data on patient demographics, vital signs, clinical symptoms, underlying medical conditions, laboratory results, administered interventions, length of hospital stay, and mortality outcomes were collected and analyzed. Of 218 patients included in the study, 139 (63.8%) had positive CT findings. The most common sources of infection detected by CT included liver abscesses, acute pyelonephritis, and cholangitis. Laboratory results showed that patients with positive CT findings had higher white blood cell and absolute neutrophil counts and lower hemoglobin levels. Positive blood culture results were more common in patients with positive CT findings. Additionally, the length of hospital stay was longer in the group with positive CT findings. Multivariate logistic regression analysis revealed that hemoglobin levels and positive blood culture results independently predicted positive CT findings in patients with fever or sepsis without an obvious source of infection. In patients with sepsis with an undetermined infection focus, those presenting with leukocytosis, anemia, and elevated absolute neutrophil counts tended to have positive findings on abdominal CT scans. These patients had high rates of bacteremia and longer lengths of stay. Abdominal CT remains a valuable diagnostic tool for identifying infection sources in carefully selected patients with sepsis of undetermined infection origins.

Neutropenic Sepsis and Challenges to Combat

Neutropenic sepsis (NS) is a common and predictable complication of bone marrow disorders and cytotoxic chemotherapy. After intensive chemotherapy, the incidence of NS is about 70–100% during the neutropenic phase. Patients with neutropenia are vulnerable to invasive infections, which can be rapidly overwhelming, causing septic shock and death. The epidemiology of sepsis in industrialized countries is mainly influenced by the age of the population and the increasing prevalence of comorbidities, such as chronic organ dysfunctions, non-cancer-related immunosuppressive diseases, or cancer itself. Patients with cancer are at more than 10 times higher risk for sepsis than the general population, with some variability according to the cancer types. There is frequent frustration among physicians caring for patients with neutropenic sepsis. Infections are a frequent complication in leukopenic patients, affecting an estimated 24% of patients after chemotherapy for hematologic diseases or solid organ tumors. Bloodstream infections (BSIs) are the most frequent infection in febrile neutropenic, onco-hematological patients, with incidence rates spanning from 10% to 38%. Septic shock is the most severe clinical presentation form of such infections. This is becoming a cause for growing concern due to several factors. Rates of Gram-negative bacilli (GNB) in oncohematological patients are progressively increasing. It is shown that ~50% of bacteremia in cancer patients was caused by GNB, among which almost 14% were MDR GNB. This could impact a greater percentage of patients presenting with septic shock. The widespread emergence and dissemination of multidrug-resistant Gram-negative bacilli, which are a common cause of infection and sepsis in patients with cancer, is of great concern. Several investigators have reported high rates of bacteremia due to extended-spectrum â-lactamase (ESBL)-producing Enterobacterales, MDR Pseudomonas aeruginosa (MDR-PA), and carbapenem-resistant Enterobacterales. Additionally, empirical antibiotic therapy is challenging in the era of emerging multidrug-resistant (MDR) GNB. Indeed, inappropriate empirical antibiotic therapy (IEAT) has been associated with increased mortality in patients with febrile neutropenia and BSI. Neutropenic sepsis is a medical emergency in which broad-spectrum antibiotics must be given without delay. Delaying treatment in neutropenic sepsis may increase the risk of death. â-Lactam/â-lactamase inhibitors (BL/ BLIs) and carbapenems are often considered for the treatment of sepsis when the main suspected pathogens are Gram-negative bacteria, because of their broad spectrum of coverage. Ceftazidime avibactam is a new molecule available against these bugs. It is a novel combination of ceftazidime (thirdgeneration cephalosporin) and avibactam (novel, nonâ- lactam â-lactamase inhibitor) which covers ESBL isolates like E Coli &amp; K. Pneumoniae, MDR Pseudomonas aeruginosa, and CRE. Ceftazidime and avibactam are now playing a crucial role in combating MDR gram-negative infections in sepsis patients. Many international guidelines recommend using early ceftazidime and avibactam in sepsis patients to achieve better outcomes and reduce volatility. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 197-198

Transient increase in atherosclerotic plaque macrophage content following Streptococcus pneumoniae pneumonia in ApoE-deficient mice.

Despite epidemiological associations between community acquired pneumonia (CAP) and myocardial infarction, mechanisms that modify cardiovascular disease during CAP are not well defined. In particular, largely due to a lack of relevant experimental models, the effect of pneumonia on atherosclerotic plaques is unclear. We describe the development of a murine model of the commonest cause of CAP, Streptococcus pneumoniae pneumonia, on a background of established atherosclerosis. We go on to use our model to investigate the effects of pneumococcal pneumonia on atherosclerosis. C57BL/6J and ApoE-/- mice were fed a high fat diet to promote atherosclerotic plaque formation. Mice were then infected with a range of S. pneumoniae serotypes (1, 4 or 14) with the aim of establishing a model to study atherosclerotic plaque evolution after pneumonia and bacteremia. Laser capture microdissection of plaque macrophages enabled transcriptomic analysis. Intratracheal instillation of S. pneumoniae in mice fed a cholate containing diet resulted in low survival rates following infection, suggestive of increased susceptibility to severe infection. Optimization steps resulted in a final model of male ApoE-/- mice fed a Western diet then infected by intranasal instillation of serotype 4 (TIGR4) S. pneumoniae followed by antibiotic administration. This protocol resulted in high rates of bacteremia (88.9%) and survival (88.5%). Pneumonia resulted in increased aortic sinus plaque macrophage content 2 weeks post pneumonia but not at 8 weeks, and no difference in plaque burden or other plaque vulnerability markers were found at either time point. Microarray and qPCR analysis of plaque macrophages identified downregulation of two E3 ubiquitin ligases, Huwe1 and Itch, following pneumonia. Treatment with atorvastatin failed to alter plaque macrophage content or other plaque features. Without antibiotics, ApoE-/- mice fed a high fat diet were highly susceptible to mortality following S. pneumoniae infection. The major infection associated change in plaque morphology was an early increase in plaque macrophages. Our results also hint at a role for the ubiquitin proteasome system in the response to pneumococcal infection in the plaque microenvironment.

Lymphopenia at the time of transplant is associated with short-term mortality after deceased donor liver transplantation

Absolute lymphocyte count (ALC) is considered a surrogate marker for nutritional status and immunocompetence. We investigated the association between ALC and post-liver transplant outcomes in patients who received a deceased donor liver transplant (DDLT). Patients were categorized by ALC at liver transplant: low (<500/μL), mid (500-1000/μL), and high ALC (>1000/μL). Our main analysis used retrospective data (2013-2018) for DDLT recipients from Henry Ford Hospital (United States); the results were further validated using data from the Toronto General Hospital (Canada). Among 449 DDLT recipients, the low ALC group demonstrated higher 180-day mortality than mid and high ALC groups (83.1% vs 95.8% and 97.4%, respectively; low vs mid: P = .001; low vs high: P < .001). A larger proportion of patients with low ALC died of sepsis compared with the combined mid/high groups (9.1% vs 0.8%; P < .001). In multivariable analysis, pretransplant ALC was associated with 180-day mortality (hazard ratio, 0.20; P = .004). Patients with low ALC had higher rates of bacteremia (22.7% vs 8.1%; P < .001) and cytomegaloviremia (15.2% vs 6.8%; P = .03) than patients with mid/high ALC. Low ALC pretransplant through postoperative day 30 was associated with 180-day mortality among patients who received rabbit antithymocyte globulin induction (P = .001). Pretransplant lymphopenia is associated with short-term mortality and a higher incidence of posttransplant infections in DDLT patients.

1253: EFFECT OF PERIPHERALLY INFUSED NOREPINEPHRINE ON REDUCING CENTRAL VENOUS CATHETER UTILIZATION

Introduction: Vasoactive agents like norepinephrine have been historically administered via central venous catheters (CVCs) due to the perceived risk of local tissue injury with peripheral infusion. While infusion-related complications may be reduced with CVC administration, the higher rates of bacteremia, pneumothorax, and air embolism must be weighed, along with delays in administration and achievement of hemodynamic stability. This study is designed to add to the available safety data of peripheral norepinephrine administration while also investigating the direct cost savings associated with CVC avoidance. Methods: This is a retrospective analysis of adult patients who received norepinephrine between January 1 and September 1, 2021. A hospital guideline allows peripheral infusion of norepinephrine via dedicated, 16 – 20 gauge, mid-to-upper arm IV catheters for up to 24 hours. The primary outcome was the need for central venous access in patients initially started on peripherally infused norepinephrine. Safety outcomes included local tissue injury attributed to norepinephrine infusion. Results: Ninety-eight of 124 total patients initially received peripheral norepinephrine infusions, most of which required vasopressors for distributive or mixed shock. Thirty-six patients (37%) avoided the need for central line placement. The median duration of vasopressors was 6 hours [IQR 3.3 – 11.3] at a median maximum rate of 0.08 mcg/kg/min [IQR 0.05 – 0.15]. In the remaining 62 patients who progressed from peripheral to central line placement, the median duration was 15.5 hours [IQR 6 – 38.5] at a median maximum rate of 0.15 mcg/kg/min [IQR 0.06 – 0.25]. Eighty of the 98 patients (82%) who started peripherally infused norepinephrine required therapy for ≤12 hours. No extravasation or local complications were observed regardless of site of infusion. Avoiding progression to a CVC in 37 of every 100 peripheral lines resulted in an estimated direct supply cost savings of $8,900. Conclusions: Initial administration of norepinephrine via a dedicated peripheral IV site was safe and led to a reduction in the need for subsequent CVC access. To minimize cost while achieving timely resuscitation goals and maintaining patient safety, initial peripheral administration should be considered for all patients.

Characteristics and one year outcomes of melioidosis patients in Northeastern Thailand: a prospective, multicenter cohort study

Melioidosis is a neglected tropical infection caused by the environmental saprophyte Burkholderia pseudomallei. We conducted a prospective, observational study at nine hospitals in northeastern Thailand, a hyperendemic melioidosis zone, to define current characteristics of melioidosis patients and quantify outcomes over one year. 2574 individuals hospitalised with culture-confirmed melioidosis were screened and 1352 patients were analysed. The median age was 55 years, 975 (72%) were male, and 951 (70%) had diabetes. 565 (42%) patients presented with lung infection, 1042 (77%) were bacteremic, 442 (33%) received vasopressors/inotropes and 547 (40%) received mechanical ventilation. 1307 (97%) received an intravenous antibiotic against B. pseudomallei. 335/1345 (25%) patients died within one month and 448/1322 (34%) of patients died within one year. Most patients had risk factors for melioidosis, but patients without identified risk factors did not have a reduced risk of death. Of patients discharged alive, most received oral trimethoprim-sulfamethoxazole, which was associated with decreased risk of post-discharge death; 235/970 (24%) were readmitted, and 874/1015 (86%) survived to one year. Recurrent infection was detected in 17/994 patients (2%). Patients with risk factors other than diabetes had increased risk of death and increased risk of hospital readmission. In northeastern Thailand patients with melioidosis experience high rates of bacteremia, organ failure and death. Most patients discharged alive survive one year although all-cause readmission is common. Recurrent disease is rare. Strategies that emphasize prevention, rapid diagnosis and intensification of early clinical management are likely to have greatest impact in this and other resource-restricted regions. US NIH/NIAID U01AI115520.

Risk factors of Bartonella spp. infection and the association between Bartonella spp. and T-lymphocyte subset alteration in asymptomatic retrovirus-infected cats in Bangkok Metropolitan, Thailand

Cats are a reservoir for Bartonella spp. infection in humans. Human bartonellosis causes disseminated inflammation to develop in immunocompromised patients, such as those infected with human immunodeficiency virus. However, the associated risks of Bartonella spp. infection in immunocompromised retroviral-infected cats have been inconclusive. This study aimed to evaluate the associated risks of Bartonella spp. infection with the alteration of T-lymphocyte subsets of retroviral-infected cats. We collected blood samples from 161 client-owned cats at veterinary clinics and hospitals throughout the Bangkok Metropolitan area from 2017 to 2020. The samples underwent hematological biochemical tests, feline retroviral status evaluation, Bartonella spp. polymerase chain reaction assay, immunofluorescence assay, and CD4+ and CD8+ lymphocyte counts. Risk factors associated with Bartonella spp. infection were determined by odds ratio (OR). Hematological and biochemical parameters were compared using independent t-tests. CD4+ and CD8+ lymphocyte counts and the CD4+/CD8+ ratio were compared among groups classified according to their retroviral and Bartonella spp. infection status. The prevalence of Bartonella spp. in our study cohort was 16.1%, and the seroprevalence was 94.9%. Cats aged >1 year were at a higher risk of seropositivity than cats aged <1 year (OR: 4.296, 95% confidence interval: 1.010-18.275). The CD8+ percentage was significantly higher in seropositive cats (p = 0.026). There was a significant reduction in the CD4+/CD8+ ratio between cats negative for both retrovirus and Bartonella spp. infection and cats with concurrent retrovirus and Bartonella spp. infection (p = 0.041). In endemic countries or areas, cat owners must be made aware of the risk of exposure to Bartonella spp. due to the high rate of bacteremia and seroprevalence. Retrovirus-infected cats with concurrent Bartonella spp. infection also showed a significant, inverted CD4+/CD8+ ratio, which may be used as a novel marker in bartonellosis. Similar studies focusing on the different stages of retrovirus infection should be undertaken further to elucidate the effect of retrovirus infection on Bartonella spp. infection.

Krueppel-Like Factor 4 Expression in Phagocytes Regulates Early Inflammatory Response and Disease Severity in Pneumococcal Pneumonia.

The transcription factor Krueppel-like factor (KLF) 4 fosters the pro-inflammatory immune response in macrophages and polymorphonuclear neutrophils (PMNs) when stimulated with Streptococcus pneumoniae, the main causative pathogen of community-acquired pneumonia (CAP). Here, we investigated the impact of KLF4 expression in myeloid cells such as macrophages and PMNs on inflammatory response and disease severity in a pneumococcal pneumonia mouse model and in patients admitted to hospital with CAP. We found that mice with a myeloid-specific knockout of KLF4 mount an insufficient early immune response with reduced levels of pro-inflammatory cytokines and increased levels of the anti-inflammatory cytokine interleukin (IL) 10 in bronchoalveolar lavage fluid and plasma and an impaired bacterial clearance from the lungs 24 hours after infection with S. pneumoniae. This results in higher rates of bacteremia, increased lung tissue damage, more severe symptoms of infection and reduced survival. Higher KLF4 gene expression levels in the peripheral blood of patients with CAP at hospital admission correlate with a favourable clinical presentation (lower sequential organ failure assessment (SOFA) score), lower serum levels of IL-10 at admission, shorter hospital stay and lower mortality or requirement of intensive care unit treatment within 28 days after admission. Thus, KLF4 in myeloid cells such as macrophages and PMNs is an important regulator of the early pro-inflammatory immune response and, therefore, a potentially interesting target for therapeutic interventions in pneumococcal pneumonia.

Risk factors, outcomes and time to detect positive blood culture among cases with acute brucellosis.

Brucellosis causes a disabling human disease and loss of animals' lives. The clinical significance of Brucella bacteremia is still unclear and Brucella identification in blood culture is suboptimal. This was a retrospective study conducted in Medina in Saudi Arabia from August 2016 to May 2019. We included cases with brucellosis symptoms and a positive culture or serological evidence for brucellosis, comparing bacteremic with non-bacteremic brucellosis cases for the rates of complications, infection relapses and brucellosis development. Also, we estimated blood culture positivity rates and the time to detect Brucella in an automatic blood culture instrument. Of the total number of 147 cases, 62 (42%) had a positive blood culture for Brucella, and the blood culture instrument (BACT/ALERT 3D) detected all positive blood cultures within 3 d of incubation. We found higher rates of chronic brucellosis in bacteremia than non-bacteremia cases (OR 7.25, 95% CI 1.41 to 37.23; p=0.018). Patients aged <15 y developed a higher rate of bacteremia than those aged ≥15 yr (OR 11.93 95% CI 1.37 to 103.75; p=0.025). Brucella bacteremia is an independent predictor for the development of chronic infection. Brucella bacteremia cases may need long follow-up periods and a more thorough evaluation to exclude deep-seated infection.

Children with Primary Septic Arthritis Have a Markedly Lower Risk of Adverse Outcomes Than Those with Contiguous Osteomyelitis.

It is widely believed that septic arthritis poses a risk of joint destruction and long-term adverse outcomes for children if not treated emergently. In the present study, children who had primary confirmed septic arthritis were compared with those who had septic arthritis and adjacent osteomyelitis to evaluate differences that affect the relative risk of adverse outcomes. Children who underwent multidisciplinary treatment for septic arthritis with or without contiguous osteomyelitis between 2009 and 2019 were retrospectively studied. Clinical, laboratory, treatment, and outcome data were compared between cohorts of children with primary confirmed septic arthritis and children with septic arthritis and contiguous osteomyelitis. One hundred and thirty-four children had primary confirmed septic arthritis, and 105 children had septic arthritis with contiguous osteomyelitis. Children with osteomyelitis were older (median, 7.4 versus 2.4 years), had higher initial C-reactive protein (median, 15.7 versus 6.4 mg/dL), and had a higher rate of thrombocytopenia (21.0% versus 1.5%). They also had a higher rate of bacteremia (69.5% versus 20.2%) for a longer duration (median, 2.0 versus 1.0 days). Detected pathogens in children with osteomyelitis as compared with those with primary septic arthritis were more likely to be Staphylococcus aureus (77.1% versus 32.1%) and less likely to be Kingella kingae (2.9% versus 32.1%). Children with contiguous osteomyelitis had longer hospitalizations (median, 8.0 versus 4.0 days), a higher rate of intensive care (21.0% versus 1.5%), a higher readmission rate (17.1% versus 5.2%), and a higher complication rate (38.1% versus 0.7%). Primary septic arthritis in children is dissimilar to septic arthritis associated with osteomyelitis. The present study demonstrates that long-term adverse outcomes in children with septic arthritis are likely due to the contiguous osteomyelitis. Children with primary septic arthritis are sufficiently distinguishable from those who have contiguous osteomyelitis to guide decisions for magnetic resonance imaging acquisition, duration of antibiotic therapy, and length of outpatient follow-up in order to recognize and address adverse outcomes. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Primary Septic Arthritis Among Children 6 to 48 Months of Age: Implications for PCR Acquisition and Empiric Antimicrobial Selection.

Primary septic arthritis requires unique evaluation and treatment considerations for children in the 6- to 48-month age range because of the spectrum of identified pathogens and high rate of negative cultures. The purpose of this study is to evaluate primary septic arthritis in this age group in order to differentiate children with infection caused by Kingella kingae from those with other confirmed pathogens and those with no identified pathogen. Preschool children who underwent multidisciplinary evaluation and treatment for septic arthritis between 2009 and 2019 were retrospectively studied. Three cohorts were established for comparison of clinical and laboratory features of primary septic arthritis: (1) confirmed K. kingae, (2) confirmed other pathogen, and (3) presumed (without identified pathogen). Among 139 children with septic arthritis, 40 (29%) were confirmed K. kingae, 29 (21%) other pathogen, and 70 (50%) presumed. Children with Kingella and those with presumed septic arthritis had significantly lower initial C-reactive protein (4.8 and 4.5 vs. 9.3 mg/dL) and fewer febrile hospital days (0.2 and 0.4 vs. 1.3 d) than children with other confirmed pathogens. Children with other pathogens had higher rates of bacteremia (38% vs. 0%) and positive joint fluid cultures (86% vs. 15%) than that of children with Kingella. The rate of polymerase chain reaction (PCR) acquisition was 38 of 40 (95.0%) Kingella cases, 18 of 29 (62.1%) other pathogen cases, and 33 of 70 (47.1%) presumed cases. K. kingae was the most commonly identified pathogen among 6-month to 4-year-old children. The Kingella and other identified pathogens in this study serve to guide empiric antimicrobial recommendations for this age range. Because of similarities between children with septic arthritis because of K. kingae and those with no identified pathogen, it is likely that an unrecognized burden of Kingella resides in culture negative cases, particularly if no PCR is sent. Systematic evaluation, including PCR acquisition, and a high index of suspicion for K. kingae are recommended to thoroughly evaluate septic arthritis in preschool children. Level III-Retrospective cohort comparison.

S3519 Septic Pulmonary Emboli From Pyogenic Liver Abscess After Cholecystectomy

INTRODUCTION: Pyogenic liver abscess(PLA) is potentially fatal with an incidence of about 1 in 45 to 100,000, with significant mortality rate of 6% to 19.6%. Most frequent isolated microorganisms are Escherichia(E) Coli and streptococcus millery group. In the past 2 decades, Klebsiella pneumonia has been reported to be the most common pathogen causing PLA, especially in Asia and the US with higher probability of hematogenous spread and metastatic infection. CASE DESCRIPTION/METHODS: 38 year old female with a history of cholesystectomy, complicated by biliary leak and stenosis in common hepatic duct s/p ERCP with stent placement. Few weeks later, patient developed pyogenic liver abscess growing Klebsiella pneumonia, confirmed by CTAP(CT of abdomen and pelvis) and blood culture. Patient was placed on 1 week course of antibiotics after CT guided aspiration and got discharged. 3 months later, patient presented with flank pain. Ultrasound of the abdomen did not show any signs of abscess. However, blood culture grew K. pneumonia for which patient was given another 1 week course of antibiotics. 1 week later, patient comes back again with chief complaint of abdominal pain, pleuritic chest pain with fever and chills. Repeat CT scan showed hypodensity in the lateral mid right hepatic lobe, suggestive of abscess. CTPA showed peripheral fill defect and nodular changes in right lower lobe in which septic emboli is highly likely. DISCUSSION: As complications of liver abscesses due to high rates of bacteremia, patients can sometimes develop pulmonary septic embolism, caused by clot, fibrin matrix and micro-organisms. Other complications include right sided endocarditis, pelvis thrombophlebitis. The main features on CT scan on septic pulmary emboli is feeding vessel sign(79%), nodules with or without cavitations (79%) and subpleural wedge shaped subpleural opacities (64%). Abdominal imaging raises high suspicion of this condition. CT is more sensitive than ultrasound for liver abscesses (approximately 95 versus 85 percent). Key component of the management is drainage of abscess guided by either CT or ultrasound, ERCP, followed by appropriate duration of the antibiotics. If the location is difficult to be accessed, open surgical drainage, laparoscopic drainage should be indicated. Antibiotics therapy should be continued for two to 4 weeks for complete drainage and 4 to 6 weeks for the incomplete drainage.Figure 1.: Gas forming sub capsular fluid collection in the the right lobe of the liver, suggestive of pyogenic liver abscess.Figure 2.: Abnormal hypo density lateral mid right hepatic lobe, consistent with persistent pyogenic liver abscess.Figure 3.: Feeding vessel sign, distinct branch of pulmonary artery directly leading to a nodule. This is one of the specific findings of septic pulmonary emboli.

Keys to diagnosis and management of spinal epidural abscesses: 9 years of institutional experience

Objective: Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. MethodsAll patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. Results108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management.Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. Conclusions21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

Should Buttonhole Cannulation of Arteriovenous Fistulas Be Used? CON.

Fistulas continue to be promoted as the vascular access of choice due to their lower complication rates as compared with catheters (1,2). However, depending on the fistula cannulation method, the infection risk can compared with that of a catheter. Traditionally, cannulation is an area most physicians tend to ignore; instead, the choice and technique of cannulation is routinely left to nurses. However, given the pain, fear, and anxiety with cannulation that most hemodialysis patients experience (3–⇓5), all health care providers should pay more attention to needling. Furthermore, cannulation and its associated mishaps can lead to fistula complications of infection, and decreased patency. The most common method of cannulation among maintenance hemodialysis patients is the rope ladder technique, which rotates needling sites along the full length of the fistula. The area wall technique, where favored regions are repeatedly needled, is actively discouraged due to progressive weakness in the vessel wall and subsequent aneurysm formation (6). Buttonhole cannulation is more often used in home hemodialysis and it was first introduced as a measure to cannulate a fistula with a limited area for needling (7). Buttonhole involves a constant site of needling that, over time, leads to an epithelized track into which a blunt needle is inserted. Since its first introduction almost 50 years ago by Dr Twardoski and his head nurse (Sister Kumara), buttonhole has continued to garner widespread enthusiasm. Support for its use has been mostly promoted by observational data and poor-quality methodology studies showing beneficial effects on pain and fewer needling complications. Nephrology societies (8,9) (renal.org/guidelines) still recommend buttonhole use as a means to reduce pain and increase longevity. In order to promote a novel cannulation technique over the standard of care, there should be evidence of benefit and a lack of demonstrable …

Utility of Blood Cultures and Empiric Antibiotics in Febrile Pediatric Hemophilia Patients With Central Venous Access Devices.

Children with hemophilia frequently require long-term central venous access devices (CVADs) for regular infusion of factor products. Hemophilia patients are not immunocompromised, but the presence and use of CVADs are associated with infections including bacteremia. Currently, the utility of blood cultures in evaluation of the febrile hemophilia patient with an indwelling CVAD is unknown, nor is optimal empiric antibiotic use. We performed a retrospective cross-sectional study of febrile immunocompetent hemophilia patients with CVADs presenting to a large academic urban pediatric emergency department from 1995 to 2017. We used a natural language processing electronic search, followed by manual chart review to construct the cohort. We analyzed rate of pathogen recovery from cultures of blood in subgroups of hemophilia patients, the pathogen profile, and the reported pathogen susceptibilities to ceftriaxone. Natural language processing electronic search identified 181 visits for fever among hemophilia patients with indwelling CVADs of which 147 cases from 44 unique patients met study criteria. Cultures of blood were positive in 56 (38%) of 147 patients (95% confidence interval, 30%-47%). Seventeen different organisms were isolated (10 pathogens and 7 possible pathogens) with Staphylococcus aureus and coagulase-negative Staphylococcus species as the most common. Thirty-four percent of isolates were reported as susceptible to ceftriaxone. Positive blood cultures were more common in cases involving patients with inhibitors (n = 71) versus those without (n = 76), odds ratio, 7.4 (95% confidence interval, 3.5-15.9). This was observed irrespective of hemophilia type. Febrile immunocompetent hemophilia patients with indwelling CVADs have high rates of bacteremia. Empiric antimicrobial therapy should be targeted to anticipated pathogens and take into consideration local susceptibility patterns for Staphylococcus aureus.

Brain Abscess and Esophageal Dilatation: Where is the Link? - Case Report

Abstract Introduction Caustic substance ingestion is a common cause of esophageal stricture in children. The primary treatment is esophageal dilatation. Although it is known that endoscopic esophageal dilatation is a procedure associated with a high rate of bacteremia, current guidelines do not recommend routine throat swab cultures or antibiotic prophylaxis for the general children population. Case Report We describe a case of a 7-year-old boy presenting with refractory headaches who was diagnosed with cranial abscess after multiple esophageal dilatations due to stenosis caused by caustic soda ingestion. The patient was subjected to neurosurgical intervention and intravenous antibiotic treatment for 6 weeks. Streptococcus viridans culture was positive in purulent abscess content. Conclusion We highlight this condition that, although rare, needs immediate diagnosis and proper treatment. We also recommend routine testing of throat swabs and antibiotics prophylaxis to children undergoing esophageal dilatation.

Clinical- vs. model-based selection of patients suspected of sepsis for direct-from-blood rapid diagnostics in the emergency department: a retrospective study

Selecting high-risk patients may improve the cost-effectiveness of rapid diagnostics. Our objective was to assess whether model-based selection or clinical selection is better for selecting high-risk patients with a high rate of bacteremia and/or DNAemia. This study involved a model-based, retrospective selection of patients from a cohort from which clinicians selected high-risk patients for rapid direct-from-blood diagnostic testing. Patients were included if they were suspected of sepsis and had blood cultures ordered at the emergency department. Patients were selected by the model by adding those with the highest probability of bacteremia until the number of high-risk patients selected by clinicians was reached. The primary outcome was bacteremia rate. Secondary outcomes were DNAemia rate, and 30-day mortality. Data were collected for 1395 blood cultures. Following exclusion, 1142 patients were included in the analysis. In each high-risk group, 220/1142 were selected, where 55 were selected both by clinicians and the model. For the remaining 165 in each group, the model selected for a higher bacteremia rate (74/165, 44.8% vs. 45/165, 27.3%, p = 0.001), and a higher 30-day mortality (49/165, 29.7% vs. 19/165, 11.5%, p = 0.00004) than the clinically selected group. The model outperformed clinicians in selecting patients with a high rate of bacteremia. Using such a model for risk stratification may contribute towards closing the gap in cost between rapid and culture-based diagnostics.

The Yield of Echocardiography in the Diagnosis of Infective Endocarditis in Patients Undergoing Chemotherapy for Acute Myeloid Leukemia

INTRODUCTION:The pathogenesis of infective endocarditis (IE) , a typical biofilm-associated infectious disease frequently caused by commensal or pathogenic bacteria, is mainly attributed to the formation of septic vegetations, which are fibrin-platelet complexes embedded with bacteria on heart valves detected by echocardiography. Patients with acute myeloid leukemia (AML) are prone to neutropenia, immunosuppression and central venous catheters leading to high rates of bacteremia. It has been postulated that despite high rates of bacteremia, patients with AML undergoing intensive chemotherapy are only rarely able to form vegetations due the frequent thrombocytopenia associated with such treatment (McCormick 2002). Here, we sought to determine the rate of echocardiographic detection of IE in patients with AML and chemotherapy induced thrombocytopenia .METHODS:To assess the yield of echocardiography, we conducted a retrospective, single center, analysis of patients with AML who underwent treatment using anthracycline or fludarabine induction and intermediate/high dose cytarabine based consolidation. At all time points, patients with febrile neutropenia were empirically treated with piperacillin/tazobactam ± aminoglycosides and underwent appropriate investigations including blood cultures. Cultures were drawn every 24 to 48 hours with fevers and daily, if positive, till culture clearance. Patients with positive blood cultures for organisms associated with IE underwent an echocardiogram as standard of care.RESULTS:From January 2010 to January 2018, 296 patients underwent curative intent chemotherapy for treatment of acute myeloid leukemia (AML) at the University of Alberta Hospital, Edmonton, Canada. The median age of all patients was 56.7 years (IQR: 44-64) and 40.2% were females. During the induction or consolidation chemotherapy , 53 echocardiogram were done to investigate 53 episodes of bacteremia in 50 patients (16.9%) who had organisms associated with IE (Table 1). Two echocardiograms were done to investigate possible culture negative IE based upon clinical suspicion. Transesophageal echocardiogram were utilized in 19 patients (36%) while transthoracic echocardiogram were done in 34 patients (64%). The median platelets count on the day of the echocardiogram was 23 x109/L (IQR: 14-38). Viridans Group Streptococci and Staphylococcus aureus were the most frequent isolates cultured in the blood in 36% and 16% of cases, respectively. The median duration of bacteremia was 1 day (IQR 1-2). Three (5.6%) patients had echocardiographic findings suggestive of IE based on a positive transesophageal study (n=2) or transthoracic study (n=1). Among these, two were secondary to Enterococcus bacteria and involved the mitral valve and the third was secondary to a non-HACEK gram-negative bacteria leading to tricuspid valve involvement .CONCLUSION:This study is the first to suggest that despite the high prevalence of Viridans Group Streptococci and Staphylococcusaureus in patients with AML undergoing chemotherapy, echocardiographic findings of IE in these patients are rare, with the notable exception of Enterococcal and Non-HACEK gram negative organisms. In contrast, in the general population, Viridans Group Streptococci and Staphylococcus aureus and bacteremia are associated with IE in 20% and 63% %, respectively (Westling 2009, Rasmussen 2011). The low incidence in our cohort may be attributed to impaired fibrin-platelet deposition in these patients with inability to mount a vegetation response, or the early initiation of broad spectrum antibiotics. Given these findings, the value of routine echocardiography should be questioned in patients with AML without other clinical features of IE. DisclosuresSandhu:Bioverativ: Honoraria; Celgene: Honoraria; Novartis: Honoraria; Janssen: Honoraria; Amgen: Honoraria. Brandwein:Pfizer: Consultancy; Celgene: Consultancy; Boehringer Ingelheim: Consultancy, Research Funding; Novartis: Consultancy; Lundbeck: Consultancy.