Initiation Of Broad-spectrum Antibiotics Research Articles

Early de-escalation of antibiotic therapy in hospitalized cellular therapy adult patients with febrile neutropenia

Febrile neutropenia (FN) is an oncologic emergency frequently encountered in hematopoietic cell transplant (HCT) and chimeric antigen receptor (CAR) T-cell therapy patients, which requires immediate initiation of broad-spectrum antibiotics. Data regarding antibiotic de-escalation (DE) in neutropenic patients are limited, and guideline recommendations vary. A clinical protocol for antibiotic DE of broad-spectrum agents was implemented if patients were afebrile after 72 hours and had no clinical evidence of infection. The primary endpoint was the difference in the number of antibiotic therapy days between the pre-and post-DE protocol implementation group. Secondary endpoints included rates of subsequent bacteremia during index hospitalization, 30-day mortality, and hospital length of stay. Retrospective chart reviews were conducted to assess outcomes for patients who received allogeneic HCT, autologous HCT, or CAR T-cell therapy under the antibiotic de-escalation protocol (post-DE) compared to those who did not (pre-DE). The pre-DE group underwent HCT/CAR T-cell from February 2018 through September 2018 (n=64), and the post-DE group from February 2019 through September 2019 (n=67). The median duration of antibiotics was significantly lower in the post-DE group (6 days; range 3-60 days) compared to the pre-DE group (8 days; range 3-31 days) (p=0.034). There were no differences in any secondary endpoints. We conclude that antibiotic DE in neutropenic HCT or CAR T-cell therapy patients treated with broad-spectrum antibiotics for at least three days who are afebrile and without documented infection appears to be a safe and effective practice. Adopting it significantly reduces the number of days of antibiotics without compromising patient outcomes.

A comparative analytical study on outcome of secondary peritonitis using Mannheim's peritonitis index in geographically diverse Indian patients.

Secondary peritonitis is caused by infection of the peritoneal cavity due to perforation of the alimentary tract. Mannheim's peritonitis ındex (MPI) is a prognostic scoring system that predicts outcomes in peritonitis. Increasing MPI scores correlate with poor outcomes and mortality. The objective of this study is to evaluate the effectiveness of MPI-based prognosis and its impact on Indian patients with secondary peritonitis. For understanding the effectiveness of the MPI scoring system, a cross-sectional data analysis of published studies on secondary peritonitis from 10 geographical locations in India was performed. The 10-site study results were compared with unpublished in-house study data for individual MPI parameters to analyze any variations of MPI score-based predictions across a diverse Indian population. Patients were divided into risk groups on the basis of MPI scores: <21 mild, MPI= 21-29 moderate, MPI> 29 severe risk. We observed a significant correlation between mortality with age and gender as reported worldwide. Site of perforations were prevalent in the upper alimentary tract with the majority being gastro-duodenal for the Indian population as opposed to distal parts in the western population. Higher lethality in India is often associated with evolution time, organ failure, and sepsis due to delayed presentation and poor management. MPI scoring is effective in predicting risk across geographically diverse Indian populations. The sensitivity and specificity of MPI scores are more reliable and a score >29 specifically recommends aggressive resuscitation & monitoring of patients, initiation of broad-spectrum antibiotics, and intensive care support to reduce mortality and morbidity.

Dynamic Reconstruction of Anal Sphincter with Camera Shutter Style Double-Opposing Gracilis Flaps.

Fournier's gangrene is a life-threatening infection which requires prompt recognition, early surgical debridement of unhealthy tissue, and initiation of broad-spectrum antibiotics. Relook debridement are usually performed until all the devitalized tissue has been removed. Involvement of the anal sphincter may result in significant morbidity such as permanent incontinence. Dynamic reconstruction of the anal sphincter has always been one of the holy grails in the field of pelvic reconstruction. We demonstrate a new method of camera shutter style double-opposing gracilis muscle flaps that allows dynamic sphincteric function without the need for electrostimulation. The bilateral gracilis muscles are inset in a fashion that allows orthograde contraction of the muscle to narrow and collapse the neoanal opening. With biofeedback training, the patient is able to regain dynamic continence and return to function without a stoma. There was also no need for neurotization or microsurgery techniques to restore sphincteric function to the anus. The patient was able to reverse his stoma 14 months after the initial insult and reconstruction with biofeedback training without the use of electrostimulation.

Do prehospital sepsis alerts decrease time to complete CMS sepsis measures?

IntroductionIn an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. MethodsThis study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. ResultsMedian time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61–153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75–189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. ConclusionThis study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.

Analysis of the use of empiric antimicrobial prophylaxis for temporary cardiac devices at a large academic medical center.

Varying rates of access site infections with temporary percutaneous cardiac devices have been reported in the literature. The purpose of this study is to determine the impact of a change in institutional practice in utilizing antimicrobial prophylaxis to prevent access site infections in patients with these devices. This observational, pre-post implementation analysis evaluated the benefit of prophylactic antimicrobial therapy in adult patients with temporary percutaneous cardiac devices admitted to cardiac intensive care units. Patients in the pre-cohort received prophylactic antibiotics for the duration of device insertion. Patients in the post-cohort received a single dose of intravenous antibiotics for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella® 5.5 device placement, and no antimicrobial prophylaxis for all other devices placed. The primary endpoint was the incidence of definitive access site infection. Secondary endpoints included the incidence of Clostridium difficile infection and initiation of broad-spectrum antibiotics. Fifty patients in the pre-cohort and 45 patients in the post-cohort were evaluated. Devices included intra-aortic balloon pumps, VA-ECMO, Impella® CP and Impella® 5.5. The median duration of device insertion was fourdays. No significant difference in the primary outcome was seen between the two groups. A significant reduction in prophylactic antimicrobial utilization and total days of antimicrobial exposure was observed in the post-implementation cohort. Based on the results of our study, the implemented guideline reduces the utilization of antimicrobial prophylaxis in patients with temporary percutaneous cardiac devices and does not result in an increased rate of infections.

Antibiotic practice and stewardship in the management of neutropenic fever: A survey of US institutions

Background: Neutropenic fever management decisions are complex and result in prolonged duration of broad-spectrum antibiotics. Strategies for antibiotic stewardship in this context have been studied, including de-escalation of antibiotics prior to resolution of neutropenia, with unclear implementation. Here, we present the first survey study to describe real-world neutropenic fever management practices in US healthcare institutions, with particular emphasis on de-escalation strategies after initiation of broad-spectrum antibiotics. Methods: Using REDCap, we conducted a survey of US healthcare institutions through the SHEA Research Network (SRN). Questions pertained to antimicrobial prophylaxis and supportive care in the management of oncology patients and neutropenic fever management (including specific antimicrobial choices and clinical scenarios). Hematologic malignancy hospitalization (2020) and bone-marrow transplantation (2016–2020) volumes were obtained from CMS and Health Resources &amp; Services Administration databases, respectively. Results: Overall, 23 complete responses were recorded (response rate, 35.4%). Collectively, these entities account for ~11.0% of hematologic malignancy hospitalizations and 13.3% bone marrow transplantations nationwide. Of 23 facilities, 19 had institutional guidelines for neutropenic fever management and 18 had institutional guidelines for prophylaxis, with similar definitions for neutropenic fever. Firstline treatment universally utilized antipseudomonal broad-spectrum IV antibiotics (20 of 23 use cephalosporin, 3 of 23 use penicillin agent, and no respondents use carbapenem). Fluoroquinolone prophylaxis was common for leukemia induction patients (18 of 23) but was mixed for bone-marrow transplantation (10 of 23). We observed significant heterogeneity in treatment decisions. For stable neutropenic fever patients with no clinical source of infection identified, 13 of 23 respondents continued IV antibiotics until ANC (absolute neutrophil count) recovery. The remainder had criteria for de-escalation back to prophylaxis prior to this (eg, a fever-free period). Respondents were more willing to de-escalate prior to ANC recovery in patients with identified clinical sources (14 of 23 de-escalations in patients with pneumonia) or microbiological sources (15 of 23 de-escalations in patients with bacteremia) after dedicated treatment courses. In free-text responses, several respondents described opportunities for more systemic de-escalation for antimicrobial stewardship in these scenarios. Conclusions: Our results illustrate the real-world management of neutropenic fever in US hospitals, including initiation of therapy, prophylaxis, and treatment duration. We found significant heterogeneity in de-escalation of empiric antibiotics relative to ANC recovery, highlighting a need for more robust evidence for and adoption of this practice.Disclosures: None

Waterhouse-Friderichsen Syndrome with Bilateral Adrenal Hemorrhage Associated with Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia in an Adult Patient with History of Intravenous Drug Use

Patient: Male, 58-year-old Final Diagnosis: MRSA infection • Waterhouse-Friderichsen syndrome Symptoms: Shock • weakness Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Endocrinology and Metabolic • Infectious Diseases Objective: Unusual clinical course Background:Waterhouse-Friderichsen syndrome, also known as acute adrenal insufficiency due to adrenal gland hemorrhage, is an uncommon and frequently fatal condition classically presenting with fever, shock, rash, and coagulopathy. Although most often associated with Meningococcemia, many other etiologies have been implicated, including reports of Staphylococcus aureus infection on autopsy examinations. This report details an adult intravenous drug user with adrenal hemorrhage associated with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.Case Report:A 58-year-old man with a history of intravenous drug use presented to the hospital with weakness. Vitals were initially normal and exam findings were notable for decreased right-sided motor strength. Magnetic resonance imaging (MRI) revealed a cervical epidural abscess with spinal cord compression. Despite initiation of broad-spectrum antibiotics and intravenous fluids, the patient progressed to shock, requiring vasopressor administration, and his blood cultures later grew MRSA. Further imaging of the abdomen/pelvis was completed, revealing bilateral adrenal hemorrhage. Random cortisol at that time was 5.6 µg/dL, confirming a diagnosis of critical illness-related corticosteroid insufficiency in addition to likely septic and spinal shock. The patient was initiated on hydrocortisone with improvement in his hypotension. He was transitioned to prednisone and fludrocortisone in addition to 8 weeks of antibiotics after achieving clinical stability.Conclusions:This report brings to attention the risk of adrenal hemorrhage and acute adrenal insufficiency as a sequela of the relatively common illness of Staphylococcus aureus bacteremia. As symptoms of adrenal insufficiency can overlap with septic shock related to the primary condition, this diagnosis requires a high index of suspicion in the critically ill patient.

Successful medical management of emphysematous cholecystitis in a patient with acute hepatitis: case report

Emphysematous cholecystitis (EC) is a rare, but life-threatening, form of acute cholecystitis caused by a gas-forming organism in the gallbladder. We describe a 37-year-old female who had emphysematous cholecystitis after delivering a stillbirth 3 months ago at 40 weeks gestation. She also tested positive for hepatitis B virus and has been taking herbal remedies. She was successfully managed medically with antibiotics. The patient´s progression was also monitored with liver function test and urinalysis. In resource limited countries, where cholecystectomy may not be readily available, early diagnosis and prompt initiation of broad spectrum antibiotics with close monitoring may help treat and prevent complications.

Fournier Gangrene and Retroperitoneal Abscess Secondary to Perforated Appendicitis: A Case Report

Fournier’s gangrene and retroperitoneal abscess are rare complications of late presentation of perforated acute appendicitis. This case report discusses the case of a 46-year-old male patient who presented with 5 days history of progressive abdominal pain and was admitted to our department as a case of complicated perforated acute appendicitis followed by retroperitoneal abscess formation and Fournier’s Gangrene few days later. The patient had a hospital stay of 53 days, during which he underwent diagnostic laparoscopy and appendectomy, computerized tomography guided percutaneous abscess incision and drainage for the retroperitoneal abscess and multiple scrotal debridement surgeries for the Fournier’s gangrene, in addition to the drain care and intravenous antibiotic course he received. Diabetes mellitus is one of the most common risk factors of Fournier’s gangrene, which was newly detected in our patient six months earlier. Fournier’s gangrene is ten times more common in males than in females, especially in their third and sixth decade of life. It is life-threatening and has unfavorable prognosis that indicates early detection and aggressive surgical and medical intervention with a multidisciplinary approach, including fluid resuscitation, immediate initiation of broad-spectrum antibiotics and aggressive debridement of the necrotic tissue; in addition to the respiratory and hemodynamic support to improve the prognosis and overall outcome and to maximize the chances of survival.

Necrotising Fasciitis: Appearances Can Be Deceptive.

BACKGROUNDNecrotizing fasciitis is a potentially fatal infection of β hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment. METHODSIn a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre.RESULTSThe patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases.CONCLUSIONPain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.

Leclercia adecarboxylata causing necrotising soft tissue infection in an immunocompetent adult

A 72-year-old woman presented with concern for a necrotising soft tissue infection (NSTI) 6 days after a tree branch impaled her left lower extremity while hiking in Hawaii. The wound was irrigated and closed at a local clinic in Hawaii. She completed a 5-day course of clindamycin. She presented to our emergency department 1 day after completion of antibiotics due to worsening erythema and malodorous drainage. Local wound exploration revealed bullae and easy dissection of fascial planes. CT scan revealed complex heterogeneous fluid and inflammatory stranding in the posterior calf. Clinical and radiographic findings raised concern for NSTI prompting initiation of broad spectrum antibiotics and urgent operative debridement. Wound cultures and deep tissues cultures returned positive for pansusceptible Leclercia adecarboxylata She underwent two additional operative debridements and transitioned to negative pressure wound therapy during her hospitalisation. She was discharged home on oral amoxicillin/clavulanate on hospital day 6.

Impact of the Centers for Medicare and Medicaid Services Sepsis Core Measure on Antibiotic Use.

The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti-methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014-September 2015) and after (October 2015-June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.

Perivesicular Abscess Drainage with Lumen-Apposing SelfExpanding Metal Stents

Abdominal and pelvic abscesses can occur due to a number of reasons, the most common being surgery. They are associated with significant morbidity and mortality. The treatment approach for these types of collections is often the initiation of broad-spectrum antibiotics, accompanied by drainage. Multiple diagnostic and therapeutic modalities have been described, including; percutaneous, transvaginal, endoscopic, and surgicaldrainage. Due to the complexity of pelvic anatomy, minimally invasive approaches such as percutaneous drainage are usually difficult. Pelvic abscesses have been historically drained through surgery. Endoscopic ultrasound (EUS)-guided interventions have emerged as an alternative for the management of difficult abdominal and pelvic abscesses. Endoscopic interventions have classically included diagnostic and therapeutic aspiration, utilizing drainage catheters with or without placement of plastic stents. More recently, the use of lumen apposing self-expanding metal stents has become a treatment option for deep pelvic abscesses. Lumen opposing metal stents (LAMS) have a saddle-shaped design with two large-diameter flanges on both ends of the stent to anchor the stent edges within the respective lumens as well asa central waist that allows for communication between the two lumens. LAMS were originally designed for transmural pancreatic fluid collection drainage; however,they have been successfully implemented for numerous other off-label uses, including the drainage of pelvic and abdominal abscesses. We present the case of a 34-year-old womanwho presented with a septated abscess located between the urinary bladder and the rectum, which was successfully and definitively drained with LAMS.

Case Report: Retroperitoneal Abscess After Uncomplicated Spontaneous Vaginal Delivery [19H

INTRODUCTION: Retroperitoneal abscess following an uncomplicated vaginal delivery is uncommon and may be potentially life-threatening. We present a case of a multiparous 36 year old patient who developed a large retroperitoneal abscess following an uncomplicated vaginal delivery, requiring CT-guided fluid drainage and intravenous antibiotics. METHODS: Patient consent was obtained for this case report. Our patient is a 36 year old multiparous female who presented in spontaneous labor. She was febrile to 101.0 and started on empiric antibiotics. She underwent an uncomplicated spontaneous vaginal delivery with intact perineum without anesthesia. She remained afebrile and antibiotics were discontinued. Patient again developed fever to 102.5 prompting consult to infectious disease. Recommendation was made for broad spectrum antibiotics. She presented 3 weeks later with complaint of constipation, abdominal swelling, and pain. A palpable mass was noted, and patient was sent to the emergency department. CT scan showed heterogeneous fluid collection in the retroperitoneal left lower quadrant measuring 14.1 x 6.5 x 13.4 cm. Interventional radiology was consulted and she was taken for CT-guided drainage of fluid collection. Fluid culture resulted as Streptococcus pyogenes. IV antibiotics were adjusted based on culture and continued for 14 days. Follow up imaging demonstrated near-complete resolution of fluid collection. CONCLUSION: Diagnosis of a retroperitoneal abscess requires a high level of suspicion. In this case, we highlight the importance of postnatal follow-up and a low threshold for postpartum imaging. A multidisciplinary approach to treatment is important. Initiation of broad-spectrum antibiotics and drainage of the abscess should be arranged if diagnosis is made.

2688. The Clinical Impact of Early De-escalation of Broad-Spectrum Antibiotics in Acute Myeloid Leukemia Patients with Febrile Neutropenia

BackgroundIn patients with febrile neutropenia (FN) the initiation of broad-spectrum antibiotics (BSA), an anti-pseudomonal agent +/− vancomycin, is recommended by national guidelines. BSA should be continued until absolute neutrophil count (ANC) recovery (ANC > 500 cells/mm3). With increasing antimicrobial resistance, clinicians are reassessing the need to continue BSA until count recovery; new data are emerging that patients may be able to have their BSA de-escalated if stable and afebrile. At our institution, some patients are de-escalated from BSA to a fluoroquinolone before ANC recovery and others are continued on BSA. The purpose of this study was to evaluate the efficacy and safety of early de-escalation compared with the standard of care.MethodsWe retrospectively reviewed acute myeloid leukemia patients receiving induction chemotherapy who developed FN while at Yale New Haven Hospital from March 2013 to August 2018. Patients were excluded if they developed a culture documented infection, received incomplete or multiple induction chemotherapy treatments, or died from underlying disease during hospitalization. The primary outcome was recurrent fever during admission and secondary outcomes included incidence of breakthrough infections (BI), duration of hospital stay, early discharge (discharge before ANC recovery), duration of BSA, and readmission within 7 days of discharge.ResultsA total of 210 patients were evaluated and 91 patients were included (de-escalation, n = 45; BSA, n = 46). Baseline characteristics are noted in Table 1. There was no statistical difference in rate of recurrent fever in patients who were de-escalated from BSA compared with those that were continued (P = 0.05). De-escalated patients had a shorter duration of BSA therapy (P < 0.05), earlier discharge (P = 0.05) and no difference in readmission rates (P = 0.39) (Table 2). There was no difference in rate of BI between both groups and all BI were bacteremias. (Table 3) No patients who experienced a BI died from infection.ConclusionThe results of this study revealed no difference in the primary outcome of recurrent fever between the BSA and de-escalation groups. De-escalation led to a reduced duration of BSA and facilitated earlier discharge without increasing readmission rates and BI. Disclosures All authors: No reported disclosures.

2671 Sparing the Knife: A Case of Emphysematous Gastritis Managed Conservatively

INTRODUCTION: Emphysematous gastritis (EG) is a rare and obscure disease that carries a high mortality rate, whilst posing a diagnostic challenge. EG is caused by gas forming bacteria invading the gastric wall through disruptions in the mucosal barrier. Diagnosis is made with abdominal computed tomography (CT) scan demonstrating gas in the gastric wall. Traditionally EG has been managed surgically with partial gastrectomy, however recent case based studies support the role of conservative medical management in treating this aggressive disease. Here we present a case of non-surgically managed emphysematous gastritis. CASE DESCRIPTION/METHODS: A 28-year-old male with a history of uncontrolled type 1 diabetes mellitus (Hemoglobin A1c: 14.70) presented with a three-day history of diarrhea, melena, and orthostatic dizziness. Earlier that week the patient had been diagnosed with diabetic and initiated on metoclopramide. Despite stopping metoclopramide, the patient's diarrhea continued. Upper and lower endoscopy was performed and was largely unremarkable. The patient was discharged on erythromycin. The patient returned to the ED the following morning after developing severe abdominal pain. The physical examination revealed a soft abdomen with diffuse tenderness to palpation. Abdominal CT scan demonstrated emphysematous gastritis. Treatment was initiated with aztreonam, clindamycin, vancomycin, levofloxacin, and caspofungin. Within twenty-four hours, the patient improved clinically and repeat abdominal CT scan demonstrated significant improvement in gastric wall emphysema. After five days of broad-spectrum antibiotics the patient had complete resolution of abdominal pain. DISCUSSION: EG is a rare condition caused by gastric wall invading bacteria. Recently there has been a drastic shift in the preferred management strategy for this deadly condition that carries a mortality rate as high as 60%. A retrospective review demonstrated that prior to the year 2000 62.5% of patients with EG underwent surgical management, after 2000 this percentage dropped to 22.2%. In deciding on appropriate regimens, it is important to have broad coverage for gram-negatives, anaerobes, and fungi. Despite the lethality of EG, our case contributes to the growing body of literature that suggests that with early diagnosis and initiation of broad spectrum antibiotics, patients can be spared operative management and have successful recovery.

2132 Perivesicular Abscess Drainage With Axios Stent

INTRODUCTION: Pelvic abscesses can occur as sequelae of surgery and are associated with significant morbidity and mortality. The treatment of choice for these abscesses is immediate initiation of broad-spectrum antibiotics and drainage of the collection. We propose that lumen-apposing self-expanding metal stents (LAMS) are a safe treatment option for drainage of pelvic abscesses. LAMS were originally designed for transmural pancreatic fluid collection drainage however have been successfully used for drainage of various extra-luminal fluid collections. CASE DESCRIPTION/METHODS: The patient is an obese 34-year-old female with a PMHx of IDDM, and HTN who had recently underwent ex-lap for a large non-malignant pelvic mass. On POD #5, the patient developed a fever and repeat CT revealed a multiloculated pelvic abscess measuring 5.8 × 4.2 cm. IR was unable to drain the collection in this location between bladder and rectum. Rectal EUS was performed and revealed a septated fluid collection viewed best using 7.5 mHz ultrasound at 10 cm from the anal verge. A 2 cm margin was observed between the abscess and the urinary bladder. A 2 mm margin was seen between the rectal wall and the abscess wall. A 19-gauge non-core needle was used to access the fluid collection which appeared purulent. A 15 mm AXIOS stent was then deployed using the same technique employed with pseudocyst drainage. Drainage was successful. 9 days after placement, the stent was removed using a cold snare. No bleeding resulted from stent pull. The defect was then clipped closed with a 15 mm over the scope clip. The patient tolerated the procedure well, experienced complete resolution of the abscess. DISCUSSION: Manvar et al suggest that EUS-guided LAMS drainage of pelvic abscesses is more efficacious and has a more favorable safety profile when compared to EUS-guided drainage with catheters and plastic stents. It is an efficient and safe alternative for the management of intra-abdominal and pelvic collections. This case demonstrated the novel use of a lumen-apposing self-expanding metal stent for peri-rectal abscess drainage. Although more evidence is needed for its off-label use, we conclude that it should be strongly considered as a viable treatment option if not the initial treatment modality for collections located in the pelvis.

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.

JUST ANOTHER PINPRICK MADE ME SICK

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Fournier’s gangrene is a urological emergency characterized by rapidly progressive fulminant necrotizing infection of the genital, perineal and/or perianal regions.Most case series and observational studies indicate a mortality of 30 to 50 percent without prompt management.It is rare to have gas formation along fascial planes with non-clostridial organisms, however an increasing number of case reports have described a rise in non-clostridial organisms causing gangrene especially in diabetic patients. Emergent surgical debridement followed by aggressive local care and timely initiation of broad spectrum antibiotics remains the backbone of management. CASE PRESENTATION: A 37-year-old man presented with 5-days of worsening left testicular pain, swelling and erythema associated with subjective fevers, chills. He was pricked by a safety-pin in the scrotal area before engaging in sexual activity. He endorses binge drinking over the weekends, but denies tobacco consumption, illicit drug use, any sick contacts or travel outside the country recently. His left scrotum doubled in size with significant surrounding erythema, edema, crepitus and induration, over the course of 24 hours, driving the patient to seek medical attention. Ultrasound of the scrotum revealed extensive soft tissue swelling and gas formation extending to the retroperitoneum via perineum. Imaging revealed extensive gas formation in the perineum, ascending and descending along fascial planes. Subcutaneous emphysema of abdominal wall with mediastinal gas was also noted. Investigation showed WBC count of 22,000 with 12% bands and HIV testing was negative.IV Vancomycin and Ertapenem were administered on presentation followed by emergent debridement of bilateral scrotum, perineum and left inguinal region. Due to the extent of necrosis and gas formation, clindamycin was added for anti-toxin effect. Wound/tissue cultures grew methicillin sensitive staphylococcus aureus, group B streptococcus, group G streptococcus and anaerobic bacteroides. Antibiotics were de-escalated in 48 hours to IV Cefazolin and metronidazole.He has completed his antibiotic course and is currently recovering well. DISCUSSION: Fournier’s gangrene can also be caused due to a synergistic bacterial infection by a combination non-clostridial aerobic and anaerobic organisms. We present a case of traumatic (pinprick induced) rapidly progressive perineal gas gangrene with documented bacterial synergism. It can be hypothesized that the magnitude of gangrene, necrosis and bacterial load was greater because of the bacterial synergism present. CONCLUSIONS: Improved survival can only be achieved by a high index of suspicion leading to prompt diagnosis, early debridement by an experienced surgical team and microbiology guided use of antibiotics. Reference #1: Clinical Features of Non-Clostridial Gas Gangrene and Risk Factors for in-Hospital Mortality. Tokai J Exp Clin Med 40, no. 3 (Sep 20 2015): 124-9. Reference #2: Fatal Morganella morganii bacteremia in a diabetic patient with gas gangrene. Journal of Medical Microbiology(2009), 58: 965-967.Lamerton, A. J. “Fournier's Gangrene: Non-Clostridial Gas Gangrene of the Perineum and Diabetes Mellitus.” J R Soc Med 79, no. 4 (Apr 1986): 212-5. Reference #3: A Case of Fournier's Gangrene. Eplasty 17 (2017): ic25. DISCLOSURES: No relevant relationships by Padmastuti Akella, source=Web Response No relevant relationships by Imola Daniel, source=Web Response No relevant relationships by Himmat Grewal, source=Web Response

Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data.

Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data. We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT). Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32-0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03-1.24). The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.