Initiation Of Appropriate Antibiotics Research Articles

Can flow cytometric measurements of reactive oxygen species levels determine minimal inhibitory concentrations and antibiotic susceptibility testing for Acinetobacter baumannii?

Current antimicrobial susceptibility testing (AST) requires 16-24 hours, delaying initiation of appropriate antibiotics. Hence, there is a need for rapid AST. This study aims to develop and evaluate the feasibility of a rapid flow cytometric AST assay to determine minimum inhibitory concentration (MIC) for carbapenem-resistant Acinetobacter baumannii (CRAB). Antibiotic exposure causes increased intracellular reactive oxygen species (ROS) in bacteria. We hypothesized that ROS can be used as a marker to determine MIC. We assessed three CRAB clinical isolates across fifteen antibiotics at various concentrations in a customized 96-well microtiter plate. The antibiotics assessed include amikacin, beta-lactams (ampicillin/sulbactam, aztreonam, cefepime, ceftolozane/tazobactam, doripenem, imipenem, meropenem, and piperacillin/tazobactam), levofloxacin, polymyxin B, rifampicin, trimethoprim/sulfamethoxazole, and tetracyclines (tigecycline and minocycline). These clinical CRAB isolates were assessed for ROS after antibiotic treatment. Increased ROS levels indicated by increased RedoxSensorTM Green (RSG) fluorescence intensity was assessed using flow cytometry (FCM). MIC was set as the lowest antibiotic concentration that gives a ≥1.5-fold increase in mode RSG fluorescence intensity (MICRSG). Accuracy of MICRSG was determined by comparing against microtiter broth dilution method performed under CLSI guidelines. ROS was deemed accurate in determining the MICs for β-lactams (83.3% accuracy) and trimethoprim/sulfamethoxazole (100% accuracy). In contrast, ROS is less accurate in determining MICs for levofloxacin (33.3% accuracy), rifampicin (0% accuracy), amikacin (33.3% accuracy), and tetracyclines (33.3% accuracy). Collectively, this study described an FCM-AST assay to determine antibiotic susceptibility of CRAB isolates within 5 hours, reducing turnaround time up to 19 hours.

NECROTIZING FACICIT AFTER HEMOROIDECTOMY

Necrotizing fasciitis (NF); is a progressive soft tissue infection involving the lower extremities and perianal region, extending from the skin to the fascia. Although it is frequently seen in the elderly, it can be seen in all age groups with concomitant diseases, previous surgery history, and immune system disorders. NF, which develops as a result of rapid tissue invasion, can cause serious morbidity and mortality if early diagnosis and early surgical debridement are not performed. Therefore, NF should be suspected if pain, fever, and septic markers are disproportionate to the lesion in the clinic. The most important step in the treatment of NF is early surgical debridement and initiation of appropriate antibiotics. In addition to these treatments, various wound care treatments can also be applied. We tried to explain the process from diagnosis to discharge in a patient who developed NF after hemorrhoidectomy in terms of treatment management.

Elizabethkingia meningoseptica Outbreak in NICU: An Observational Study on a Debilitating Neuroinfection in Neonates

Background: Elizabethkingia meningoseptica is an emerging nosocomial pathogen implicated in neonatal sepsis with high mortality and morbidities. However, there is very limited data regarding the characteristics as well as outcomes following this infection, particularly in developing countries. Methods: We conducted a retrospective observational study of all infants with culture-positive Elizabethkingia sepsis as part of an outbreak, to study their clinical and epidemiological characteristics, as well as their antimicrobial susceptibility patterns, using a structured proforma from the neonatal intensive care unit database. Analysis was done using descriptive statistics and predictors of mortality and hydrocephalus were also identified. Results: Of the 21 neonates enrolled, 9 (42.9%) were male, with a mean gestational age and birth weight of 31.7 ± 3.4 weeks and 1320 ± 364 g, respectively. The median (interquartile range) age of onset of illness was 7 (5–12) days. The overall mortality rate was 23.8%, and among survivors, 50% had neurologic complications requiring intervention. Vancomycin and ciprofloxacin were the most used antibiotics for treatment in our series, with a median duration of 26 (17–38) days. On univariate analysis, shock at presentation was significantly associated with increased mortality (P = 0.04) while, seizures (P = 0.04) and elevated cerebrospinal fluid protein levels (P = 0 .01) at onset of illness predicted progressive hydrocephalus in surviving neonates. Conclusion: E. meningoseptica sepsis is associated with high morbidity and mortality. Early diagnosis and prompt initiation of appropriate antibiotics are critical for improving survival and neurodevelopmental outcomes. Though isolation of the organism by environmental surveillance is always not possible, with proper infection control measures, the infection can be controlled.

Antimicrobial Sensitivity Pattern of Causative Agents of Urinary Tract Infection in Children Between 1 to 15 Years

Background: The presence of actively multiplying organisms in the urinary tract implies urinary tract infection. Although it is infrequently associated with mortality, it is still an important cause of morbidity in the pediatric age group. Prompt diagnosis and early initiation of appropriate antibiotics in children reduce the morbidities associated with urinary tract infection. The objective of the study was to find out the causative agents of urinary tract infections and their antibiotic sensitivity pattern in pediatric patients.
 Methods: This was a cross-sectional study conducted in the department of pediatrics over a period of 12 months and 80 patients fulfilled the inclusion criteria. The modes of presentation, laboratory investigation reports which included urine routine microscopy, bacterial isolates with colony count from the urine culture, and antibiotic sensitivity pattern were documented. Descriptive statistics were used for analysis of data.
 Result: Escherichia coli was the most common organism isolated (55.9%). Most of them were sensitive to amikacin.The highest degree of resistance was noticed with ampicillin.
 Conclusion: Aminoglycosides like amikacin can be considered as first-line drugs in urinary tract infection. 
 Keywords: antibiotics, children, urinary tract infections.

Acute encephalitis syndrome with the cause hidden in plain sight – A case series

Acute encephalitis syndrome (AES) is one of the important life-threatening presentations in children with a case fatality rate of 12.6%. The most common etiology in India is viral encephalitis. However, one of the emerging yet treatable causes is scrub typhus, which is endemic in many parts of India including Tamil Nadu and Puducherry. It is a vector borne disease which has myriad presentations, one among those being AES. This is a case series of four such cases noted over the first 6 months of 2022. All the patients presented with symptoms of fever and alteration of sensorium without any seizures. Examination revealed generalized lymphadenopathy, hepatosplenomegaly, and abnormal central nervous system findings. A thorough examination revealed the classical eschar in all the cases. Based on the examination findings, oral doxycycline was started in all the patients along with supportive treatment while awaiting results, which later revealed to be scrub ELISA positive. After 48 h, due to inadequate defervescence and improvement in sensorium, IV azithromycin was added in two patients and oral doxycycline was changed to injectable in other two patients. All of them recovered without any complications or sequelae. Early identification and initiation of appropriate antibiotics are essential for a positive outcome. In endemic areas, children with AES should be thoroughly examined for signs of scrub typhus including eschar. In our patients, parenteral doxycycline or azithromycin was found to be more effective than oral doxycycline in resolution of fever and neurological abnormalities. If AES is suspected to be due to scrub typhus, parenteral therapy may be preferred over oral.

Effect of a tailored sepsis treatment protocol on patient outcomes in the Tikur Anbessa Specialized Hospital, Ethiopia: results of an interrupted time series analysis

BackgroundDespite improvement, sepsis mortality rates remain high, with an estimated 11 million sepsis-related deaths globally in 2017 (Rudd et. al, Lancet 395:200-211, 2020). Low- and middle-income countries (LMICs) are estimated to account for 85% of global sepsis mortality; however, evidence for improved sepsis mortality in LMICs is lacking. We aimed to improve sepsis care and outcomes through development and evaluation of a sepsis treatment protocol tailored to the Tikur Anbessa Specialized Hospital Emergency Department, Ethiopia, context.MethodsWe employed a mixed methods design, including an interrupted times series study, pre-post knowledge testing, and process evaluation. The primary outcome was the proportion of patients receiving appropriate sepsis care (blood culture collection before antibiotics and initiation of appropriate antibiotics within 1 h of assessment). Secondary outcomes included time to antibiotic administration, 72-h sepsis mortality, and 90-day all-cause mortality. Due to poor documentation, we were unable to assess our primary outcome and time to antibiotic administration. We used segmented regression with outcomes as binomial proportions to assess the impact of the intervention on mortality. Pre-post knowledge test scores were analyzed using the Student’s t-test to compare group means for percentage of scenarios with correct diagnosis.ResultsA total of 113 and 300 patients were enrolled in the pre-implementation and post-implementation phases respectively. While age and gender were similar across the phases, a higher proportion (31 vs. 57%) of patients had malignancies in the post-implementation phase. We found a significant change in trend between the phases, with a trend for increasing odds of survival in the pre-implementation phase (OR 1.24, 95% CI 0.98–1.56), and a shift down, with odds of survival virtually flat (OR 0.95, 95% CI. 0.88–1.03) in the post-implementation phases for 72-h mortality, and trends for survival pre- and post-implementation are virtually flat for 90-day mortality. We found no significant difference in pre-post knowledge test scores, with interpretation limited by response rate. Implementation quality was negatively impacted by resource challenges.ConclusionWe found no improvement in sepsis outcomes, with a trend for increasing odds of survival lost post-implementation and no significant change in knowledge pre- and post-implementation. Variable availability of resources was the principal barrier to implementation.Trial registrationOpen Science Framework osf.io/ju4ga. Registered June 28, 2017

Pseudomonas oryzihabitans corneal ulcer

We report clinical features, culture-sensitivity profile and outcomes of infectious keratitis caused by Pseudomonas oryzihabitans. A 70 year-old male presented with acute pain, redness and diminution of vision in left eye since 6 days. Clinically, was diagnosed as infectious keratitis and microbiology revealed gram-negative bacilli. Culture showed Pseudomonas oryzihabitans growth. Initiation of appropriate antibiotics with steroids led to the resolution of keratitis. Pseudomonas oryzihabitans causes fulminant keratitis with rapid deep stromal involvement. However, timely intervention with appropriate topical anti-bacterials with steroids may lead to successful outcomes.

Association of methicillin resistance with mortality of hospital-acquired Staphylococcus aureus bacteremia.

ObjectiveMethicillin-resistant (MR) Staphylococcus aureus bacteremia (SAB) is associated with higher mortality rates than methicillin-susceptible (MS) SAB. This study assessed potential predictors of mortality and evaluated the association of methicillin resistance with mortality in patients with SAB.MethodsWe conducted a retrospective cohort study in patients with hospital-acquired SAB, from 2009 to 2018. Clinical features of patients with MR-SAB were compared with those of patients with MS-SAB and predictors of 30-day mortality were determined using Cox regression analysis.ResultsAmong 162 patients, 56.8% had MR-SAB. Overall 30-day mortality was 19.1%; MR-SAB had higher mortality (25.0%) than MS-SAB (11.4%). Univariate analysis highlighted long-term hospitalization, prior antibiotics use, and delayed initiation of appropriate antibiotics as risk factors. Cox regression analysis showed that respiratory tract source, Pitt bacteremia score, Charlson comorbidity index, and appropriate antibiotic therapy within 24 hours were independently and significantly associated with 30-day mortality outcome.ConclusionsMethicillin resistance was not an independent risk factor for mortality in patients with SAB. Early, appropriate antibiotic treatment is an important prognostic factor.

Bolus Versus Prolonged Infusion of Broad-Spectrum Beta-Lactams for Patients with Hematologic Malignancies and High Risk Febrile Neutropenia - a Single Center Prospective Unblinded Randomized Trial

▪Background: Neutropenic fever is a life-threatening condition which is common in patients with hematologic malignancies, and prompt initiation of appropriate antibiotics is of great importance.Empirical treatment includes monotherapy with a beta-lactam containing anti-pseudomonal activity. Theoretically, time-dependent antibiotics are most active when administered as a continuous infusion, but evidence is lacking in cases of febrile neutropenia. This study examines the optimal dosing regimen (bolus infusion vs. prolonged 4 hour-infusion) for high risk patients undergoing hematopoietic cell transplantation or patients with acute leukemia and febrile neutropenia.Methods: This was a single center, prospective, unblinded randomized study, of 123 hospitalized hematologic patients enrolled between July 2015 and March 2017. The primary outcome was a successful response to treatment, defined as the combination of- defervescence at 96 hours after initiation of broad spectrum beta-lactams (pipracillin/tazobactam or ceftazidime) or before, sterile cultures after 72-96 hours, and no requirement of additional aminoglycoside therapy after 48 hours. Secondary outcomes included breakthrough fever or additional infection after 5 days from initiation of treatment, death within 30 days of study enrollment, duration of hospitalization, duration of neutropenia, occurrence of renal failure (doubling of serum creatinine levels) within 5 days, and requirement for noradrenaline due to hypotension. Patients were randomized using a computerized random number program and allocation was concealed by sequentially numbered sealed and opaque envelopes. All patients signed informed consent and the study was approved by the Tel Aviv Medical Center Institutional Review Board.Results: 123 patients were randomized to bolus infusion (n=63) and prolonged infusion (n=60). Febrile neutropenia occurred in 87% of the patients, and these patients were eligible for the intention-to-treat analysis (ITT). 73% of the patients were given at least one dose of antibiotic according to the allocation arm and were eligible for the per-protocol analysis, Figure. The patients' baseline characteristics were well-balanced between the 2 groups, Table 1. In the ITT analysis (Table 2), there was a higher success rate in patients allocated to the prolonged infusion arm, compared to those allocated to the bolus infusion arm (76% vs. 55%, p= .03). This was also true for the subgroups of patients with microbiologically documented infections (MDI) - (55.6% vs. 7.7%, p=.013) and blood stream infections, (BSI) - (67% vs. 8.3%, p=.009). Similarly, in the per-protocol analysis, the success rate was higher in patients allocated to the prolonged infusion arm who had MDI (62.5% vs. 12.5%, p=.039) or BSI (80% vs. 14.3%, p=.023). There was no difference in the secondary endpoint outcomes between the 2 groups. 30-day death rate was similarly low in both groups. Prolonged beta-lactam infusion was associated with significantly higher treatment success in a logistic regression model that included either BSI (odds ratio of 2.4, 95% CI 0.97-6.1, p=.058) or MDI (OR 2.8, 95% CI 1.1-7.4, p=.032) .Conclusions: This is the first randomized study showing superior treatment outcomes in patients with high-risk febrile neutropenia treated with prolonged versus bolus beta-lactam infusion. Optimization of beta-lactam dosing is a widely available and cost-effective strategy to improve treatment outcomes in patients with high risk febrile neutropenia. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Re-thinking treatment strategies for febrile neutropenia in paediatric oncology population: the perspective from a developing country

BackgroundThis study was conducted to evaluate the microbiological profile of bacterial isolates in febrile neutropenia in a pediatric oncology unit, thereby, reviewing the use of restricted antibiotics and need for aggressive medical treatment accordingly.MethodsA prospective observational study was conducted in a paediatric haemat-oncology division of a tertiary care teaching hospital in southern India from September 2014 to August 2016. One hundred and thirty children with febrile neutropenia were enrolled in the study. Blood cultures were performed using automated system. Cultures from other sites were obtained if needed, based on the clinical profile. Standard antibiotic susceptibility testing was done. Statistical analysis was done using SPSS.ResultsOne hundred and thirty children were enrolled for the study. Two hundred and fifty episodes of febrile neutropenia were studied. Three hundred and eighty four cultures were sent and 92 (24%) cultures were positive. There were 48 (52.2%) Gram negative isolates followed by 33 (35.8%) Gram positive isolates, six (6.5%) fungal isolates and five (5.5%) poly-microbial cultures. Lactose fermenting Gram negative bacilli (20 isolates, 31.5%) were the most frequently isolated in the Gram negative group, with Escherichia coli being the most common organism (19 isolates, 20.6%). Amongst the Gram positive coagulase negative staphylococcus was the most common (twenty seven isolates, 29%). Escherichia coli and Non lactose fermenting gram negative bacteria (NFGNB) had only 36, 25% sensitivity to ceftazidime, respectively. Most Gram negative bacilli were found to have better sensitivity to amikacin (mean: 57%). There was a higher prevalence of extended spectrum beta lactamase producing organisms. Pan drug resistance, Extreme drug resistance and Multi drug resistance was found in three, twenty and thirteen Gram negative isolates respectively.Escherichia coli and Klebsiella were often drug resistant. Significantly higher mortality was associated with Gram negative isolates (eight deaths out of the thirteen deaths, 61.5%).ConclusionsOur results show the importance of surveillance, monitoring resistance frequencies and identifying risk factors specific to each region. Given that significant mortality is attributed to drug resistant Gram negative bacilli, early initiation of appropriate antibiotics to cover for drug resistance is required while formulating empirical antibiotic policies for febrile neutropenia in the oncology units in the developing world.

Antibiotic Response to Pediatric Scrub Typhus in South India: Is Clinical Failure to Azithromycin to be Worried?

Scrub typhus is typically associated with a rapid defervescence and clinical improvement within 48 h of initiation of appropriate antibiotics. But increasing reports of resistance to anti-rickettsial medications in scrub typhus are being reported in the literature. This is a retrospective observational study of children up to the age of 14 years admitted between July 2017 and March 2020, to a private medical college hospital in southern part of India. The aim of this study was to compare the clinical response to antibiotic therapy with doxycycline and azithromycin in pediatric scrub typhus infection. One hundred thirty-eight children with scrub typhus infection were included for analysis. The median fever control time (h) was 12 (IQR = 6-29) and 24 (IQR = 10-52) with doxycycline and azithromycin respectively (p < 0.001*). Rapid fever control within 48 h was observed in 92% with doxycycline and in 74% with azithromycin (p < 0.001*). The clinical failure rate (defined by the necessity to change the antibiotics due to: (i) worsening of symptoms and signs of scrub typhus despite 48 h of antibiotics or (ii) persistence of fever and other symptoms of scrub typhus beyond 72 h), was significantly less with doxycycline (1%) compared with azithromycin (9.6%). There has been a significant delayed clinical response to azithromycin in the treatment of scrub typhus in India, when compared to doxycycline. Hence it is preferable to use doxycycline as the first line of antibiotic for undifferentiated fever in scrub typhus endemic areas. This retrospective study aims to compare the clinical response to doxycycline or azithromycin in the treatment of scrub typhus infection in children. The median fever control time, clinical failure rate and the proportion of children with rapid defervescence of fever within 48 h were significantly superior with doxycycline as compared to azithromycin. The findings of this study and those of similar studies in India represent a spectrum of delayed clinical response of Orientia tsutsugamushi to azithromycin as compared to doxycycline in this region.

Group A Streptococcal Infections in Children.

Invasive group A streptococcal disease (iGAS) can have varied clinical presentations in children, are responsible for prolonged hospital stays and can cause mortality and long-term morbidity in children. Over the last decade, there has been an increase in the incidence of iGAS infections in the UK and worldwide. This has renewed the focus on early diagnosis, management and prevention of this disease. The aim of this study was to review the varied clinical presentations and management of children with iGAS infections. We reviewed the data of children admitted to our tertiary Children's Hospital who had positive isolation of Group A Streptococcus( GAS) from sterile site cultures over the last 8 years. We reviewed their clinical presentations and management including treatment given (antibiotics and duration), outcome and follow up. A total of 57 children had iGAS during the study period. The incidence of iGAS was 6-7 cases per year during the study period, except for 2015 when we had 11 cases. The mean length of stay of children admitted with iGAS was 11 days (range 2- 35 days). 21.1% children were admitted to intensive care during their hospital stay. Fever was the most common presenting symptom. Pneumonia with or without empyema was the most common Diagnosis. Initial antibiotic management was varied with ceftriaxone the most commonly used antibiotic in 30% of the cases. 50% of children had their antimicrobial therapy optimised to IV benzylpenicillin after the confirmed isolation of GAS. 7 Children were re-admitted for further treatment and needed a further course of antibiotics. 4 children (7%) died due to iGAS infection. Our study highlighted the varied symptomatology and management practices in children with iGAS and showed that early diagnosis and prompt initiation of appropriate antibiotics for iGAS can help in the resolution of symptoms and good outcomes.

Perinatal outcome in women with bacterial sepsis: A cross-sectional study from West China.

Maternal bacterial sepsis during pregnancy and the postpartum period is a common cause of maternal mortality and fetal morbidity and mortality. This study was performed to analyze perinatal prognosis and related factors of maternal bacterial sepsis in west China.We conducted a cross-sectional study of pregnant women with bacterial sepsis who were admitted into a tertiary care center in western China between 2011and 2015. Data from these cases were collected and analyzed.Eighty six women were identified with bacterial sepsis in our hospital, and the incidence of maternal bacterial sepsis was 1.7 per 1000 maternities, the incidence of septic shock was 1.8 per 10,000 maternities, and 1 maternal death occurred. Among the 86 pregnant women with bacterial sepsis, genital tract infection was the most common source of infection (41/86, 47.7%). The most common bacteria in the Gram-positive bacteria group was Listeria monocytogenes and in the Gram-negative bacteria group was Escherichia coli. The premature delivery rate (65.7%) was substantially higher in the Gram-negative bacteria group (P = .011), and the miscarriage rate (31.3%) was higher in the Gram-positive bacteria group (P = .042). The fetal/neonatal mortality rate was 20% (21/105) and higher in the Gram-positive bacteria group (P = .008), and the infant mortality rate in 1 year was 7.1% (6/84).Bacterial sepsis remains an alarming cause of both maternal and fetal morbidity and mortality, and infant mortality. Key treatment involves a multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women with sepsis and early initiation of appropriate antibiotics according to the type of bacterial infection. The effect of maternal sepsis on long-term fetal outcome should be investigated.

181. Antimicrobial Susceptibility Trends and Risk Factors for Antibiotic Resistance in Pseudomonas aeruginosa Bacteremia: A 10-Year Experience at a Korean Tertiary Hospital

BackgroundBacteremia due to Pseudomonas aeruginosa is associated with high mortality and inappropriate initial antimicrobial therapy leads to worse outcomes. We aimed to analyze clinical characteristics of P. aeruginosa bacteremia and risk factors for antibiotic resistance and investigate their antimicrobial susceptibility trends.MethodsWe retrospectively reviewed the medical records of patients with P. aeruginosa bacteremia admitted to a tertiary hospital between January 2009 and March 2019.ResultsA total of 242 patients were identified and the median age was 70 years [interquartile range (IQR) 57.6–75.4]. Hepatobiliary tract (28.5%) was most common primary site of infection, followed by respiratory tract (20.2%) and urinary tract (15.7%). Out of 197 (81.4%) patients treated with susceptible antibiotics and the median duration of active antibiotic therapy was 10 days (IQR 4–15.5). The percentages of susceptible P. aeruginosa to amikacin, aztreonam, cefepime, ceftazidime, ciprofloxacin, colistin, gentamicin, imipenem, meropenem, piperacillin–tazobactam, and ticarcillin-clavulanate were 90.1%, 57.9%, 77.3%, 74.8%, 74.4%, 99.2%, 91.3%, 76.0%, 76.0%, 69.4%, and 51.2%. There were 24.8% carbapenem-resistant P. aeruginosa (CRPA), 36.4% multidrug-resistant P. aeruginosa (MDRPA), and 15.3% extensively drug-resistant P. aeruginosa (XDRPA). Susceptible P. aeruginosa to gentamycin and ticarcillin-clavulanate were significantly decreased in 2014–2019 than that in 2009–2013 (both; P < 0.001). Resistance rates to carbapenems and fluoroquinolones tended to increase over time. CRPA, MDRPA, and XDRPA were significantly associated with delayed active therapy (>48 h) (all; P < 0.001). Independent risk factors for CRPA were urinary tract infection (adjusted odds ratio [aOR], 3.4; 95% confidence interval [CI], 1.5–7.8), underlying hematologic malignancy (aOR, 3.0; 95% CI, 1.1–8.3) and cerebrovascular accident (aOR, 2.6; 95% CI, 1.1–5.9), hospital-acquired infection (aOR, 2.5; 95% CI, 1.0–6.1), and co-colonization with multidrug-resistant organisms (aOR, 2.2; 95% CI, 1.1–4.4).ConclusionThe identification of risk factors for antibiotic resistance and analysis of antibiotics susceptibility are useful for early initiation of appropriate antibiotics in patients with P. aeruginosa bacteremia.Disclosures All authors: No reported disclosures.

2177. The Impact of the BioFire® FilmArray® Gastrointestinal Syndromic Panel on the Management of Infectious Gastroenteritis due to Diarrheagenic E. coli Strains in a Large Community Hospital

BackgroundPCR-based rapid diagnostic tests (RDTs) provide rapid and accurate infectious gastroenteritis (IGE) etiologies within hours. However, there are limited data evaluating the impact of these panels on the appropriate management for diarrheagenic E. coli strains (DECS). This study evaluated the impact of the BioFire® FilmArray® GI panel on the appropriate antimicrobial management of DECS.MethodsA retrospective analysis was conducted at a large community hospital in San Antonio, TX. Patients with a positive infectious diarrhea diagnostic panel (IDDP) for DECS from October 1, 2016 through September 30, 2018 and admitted for ≥48 hours were included. Patients were excluded if they had a positive IDDP for multiple DECS. An algorithm based on all available literature was used to classify appropriate management of DECS, which included patients having prolonged diarrhea (≥7 days), immunocompromised hosts (ICHs), or the presence of systemic symptoms. Antimicrobial therapy changes based on IDDP results, presence of an ID consult, and incidence of hemolytic uremic syndrome (HUS) were evaluated.ResultsA total of 374 patients were included for analysis. Overall, the IDDP did not lead to a change of therapy in 290 cases. However, the IDDP resulted in 84 antimicrobial changes including initiation of appropriate antibiotics (n = 48) and de-escalation/discontinuation (n = 22), primarily in special populations, such as ICHs. The IDDP results led to appropriate therapy optimization in 63%, 17%, 16%, and 9% of enteroinvasive E. coli (EIEC), enteroaggregative E. coli (EAEC), enteropathogenic E. coli (EPEC), and enterotoxigenic E. coli (ETEC) cases, respectively. In contrast, 81% of Shiga toxin-producing E. coli (STEC) cases were inappropriately managed with antibiotics, and 33% developed HUS. Only 14% of all DECS cases generated an ID consult.ConclusionOf note, this study found that the IDDP did not lead to a change in the management of most pathotypes. However, it was associated with positive changes in the management of DECS in specific patients, particularly ICHs. RDTs assist providers in the timely identification and treatment of IGE pathogens, but both antimicrobial and diagnostic stewardship remain critical for the optimal management of DECS.Disclosures All authors: No reported disclosures.

Haemophilus Influenzae Causing Lactational Mastitis and Sepsis During the Second Trimester of Pregnancy [23K

INTRODUCTION: Lactational mastitis is a common complaint in the post-partum period, most frequently occurring within the first three months after initiating breastfeeding. Mastitis is most often caused by Staphylococcus aureus, Streptococcus species, and Escherichia coli, typically managed in the outpatient setting with oral antibiotics. Rarely, mastitis can lead to severe infections requiring hospitalization. METHODS: Our patient is a 23 year-old G3P2002, breastfeeding female at 15-weeks' gestation, who presented to the emergency department with breast tenderness, erythema, hypotension, and tachycardia. Emergency room evaluation excluded common sources of infection and her clinical picture was consistent with mastitis. A breast ultrasound ruled out an abscess. She was admitted to the intensive care unit with sepsis and started Vancomycin and Zosyn with aggressive fluid management. The patient's breast milk culture was positive for Haemophilus influenza. Her clinical picture improved with treatment and she was discharged from the hospital after three days. Consent was obtained from the patient to write this case report. CONCLUSION: Herein, we present the first reported case of mastitis caused by H. Influenza. Our patient also developed mastitis while currently in her early second trimester of pregnancy, something not commonly seen. Early identification of sepsis and initiation of appropriate antibiotics were necessary for a positive outcome. Rapid recognition of sepsis, early initiation of broad-spectrum antibiotics, and aggressive fluid management are critical for survival of women with complications of this typically minor condition.

Microbial profile of neonatal sepsis and antibiotic resistance from a tertiary care hospital in South India

Microbial profile of neonatal sepsis and antibiotic resistance from a tertiary care hospital in South India - IJMR- Print ISSN No: - 2394-546X Online ISSN No:- 2394-5478 Article DOI No:- 10.18231/2394-5478.2019.0012, Indian Journal of Microbiology Research-Indian J Microbiol Res

1797. Combining Rapid Diagnostics With Pharmacy Resident-Led Antimicrobial Stewardship to Optimize Outcomes for Bacteremia With Methicillin-Resistant S. aureus (MRSA-B), Methicillin-Susceptible S. aureus (MSSA-B), and Coagulase-Negative Staphylococcus (CoNS) at Yale New Haven Hospital (YNHH)

BackgroundGiven the severity of S. aureus bacteremia, prompt initiation of appropriate antibiotics is key. YNHH implemented the Cepheid® Xpert MRSA/SA PCR in an effort to decrease the time needed to identify MRSA-B, MSSA-B, and CoNS. The impact of rapid diagnostics has been limited without stewardship or infectious disease involvement. Our unique notification algorithm utilized our on-call pharmacy residents to allow for 24/7 coverage. The primary objective was time to optimal antibiotic therapy (OAT) before and after implementation of the PCR and algorithm. Secondary outcomes included time to blood culture clearance (BCC), acceptance rate of pharmacist interventions, days of vancomycin therapy avoided, and 30-day mortality.MethodsA retrospective cohort study was conducted in adult inpatients with blood cultures positive for Gram positive cocci in clusters. The pre-implementation, control group (CG) included patients from April 2017 to October 2017 and the post-implementation, intervention group (IG) was from October 2017 to April 2018. Patients <18 years and polymicrobial bacteremia were excluded. Data collected in addition to primary and secondary outcomes included baseline demographics, allergies and empiric antibiotics. OAT included vancomycin for MRSA-B or MSSA-B with severe β-lactam allergy; nafcillin or cefazolin for MSSA-B; and discontinuation of vancomycin for CoNS deemed a contaminant.ResultsOf the 544 patients reviewed, 434 met inclusion criteria: 182 in the CG and 252 in the IG with similar baseline characteristics. Mean time to OAT decreased from 10 hours in the CG to 5 hours in the IG (P = 0.006). Time to BCC in the CG and IG cohorts decreased from 100 to 43 hours (P = 0.0001). One day of vancomycin was avoided in patients with MSSA-B and 2 days with CoNS. 30-day mortality decreased from 18% (n = 32) in the CG vs. 6% (n = 15) in the IG (P = 0.0001). Finally, 95% (n = 153/161) of pharmacist interventions were accepted.ConclusionUtilizing the on-call pharmacy resident for notification of rapid diagnostic results for S. aureus bacteremia, we saw a significant decrease in time to OAT, BCC, and 30-day mortality. Our study demonstrates that in the setting of limited stewardship resources, additional members of the healthcare team can be used to optimize antibiotics in conjunction with rapid diagnostics.Disclosures All authors: No reported disclosures.

17. A study of rapid bedside diagnosis of spontaneous bacterial peritonitis using leukocyte esterase test strips

Background and Aims: Spontaneous Bacterial Peritonitis (SBP) is a potentially life threatening complication of liver cirrhosis with ascites. The diagnosis of SBP is based on diagnostic paracentesis. The prevalence of SBP in outpatients is 1.5–3.5% and 10% in hospitalized patients. The in hospital mortality is also very high (30–50%). Timely diagnosis of SBP has positive therapeutic implications. The urgent leukocyte count of AF is warranted for the initiation of appropriate antibiotics. The use of strips has been tested for the diagnosis of bacterial meningitis, pleural infection, synovial infection and peritoneal infection. For diagnosis of SBP, use of a reagent strip may be an useful approach. In various studies it has shown high sensitivity, between 85% and 100%, and high specificity between 98% and 100%. Methods: Patients were enrolled from March 2017 to September 2017 in the study. The study was conducted at the Department of Gastroenterology, Lokmanya Tilak Medical College & General Hospital, Sion, Mumbai. Patients either referred or presented by themselves were included. Results: At cut off of 2+; sensitivity to diagnose SBP was 100%; specificity being 94%; PPV being 57% and NPV being 94%. Similarly at the cut off level of 3+; sensitivity decreased down to 76%; specificity increased to 100%; PPV of 100% and NPV of 93.75%. Overall accuracy at 2+ and 3+ was respectively 94.5% and 93.75%. Conclusions: For diagnosis of SBP, the use of a reagent strip may be a useful approach. The authors have none to declare.

Successful resolution of hyperammonemia following hematopoietic cell transplantation with directed treatment of Ureaplasma parvum infection

Hyperammonemia following hematopoietic cell transplantation (HCT) has been characterized as idiopathic and is associated with a very high mortality. A causal relationship between Ureaplasma infection and hyperammonemia in immunocompromised lung transplant recipients has recently been described. We document the first case of hyperammonemia following HCT associated with Ureaplasma parvum. The initiation of appropriate antibiotics resulted in rapid resolution of hyperammonemic encephalopathy and eradication of the implicating organism.