Intravenous Antibiotic Treatment Research Articles

Therapeutic drug monitoring of elexacaftor, tezacaftor, and ivacaftor before, during, and after pregnancy in women with cystic fibrosis: An observational study

BackgroundElexacaftor/tezacaftor/ivacaftor (ETI) has improved health and increased life expectancy in many patients with cystic fibrosis (pwCF). Family planning issues have become more important since then. Many women decide to remain on modulator therapy during pregnancy despite insufficient evidence-based recommendations for continuing ETI during pregnancy and lactation. MethodsIn this retrospective observational report, we present data on maternal serum concentrations of ETI, assessed via a therapeutic drug monitoring (TDM) program established at our CF center for adults. Blood was taken during routine visits. We retrospectively analyzed the corresponding predicted forced expiratory volume in 1 s (ppFEV1), at five time points before, during, and after pregnancy. ResultsOf seven ETI-exposed pregnancies in six women between February 2021 and September 2023, the intake of ETI resulted in no maternal complications and healthy offspring. The dose was reduced in all women, 71.4 % before and 28.6 % during pregnancy, primarily as a result of side effects and/or increased ETI concentrations. Despite dose reductions, serum concentrations showed a broad distribution, with values below, within, and above the Cmax range according to the pharmacokinetic data in the manufacturer's product characteristics. Pulmonary function largely remained stable without pulmonary exacerbations requiring intravenous antibiotic treatment. ConclusionThis observational report shows the most extensive dataset for ETI concentrations during pregnancy. Individualized dose adjustments could help to resolve adverse side effects while continuing CFTR therapy. Specific populations, such as pregnant women, might benefit from a TDM. However, future research with more pharmacokinetic data from pregnant pwCF is needed.

Investigating Osteomyelitis as a Rare Adverse Effect of Vaccination in the Pediatric Population.

Immunization is a preventive measure of crucial importance. As with any other medication, side effects are a possibility and include the rare occurrence of severe infections, such as osteomyelitis. We report an unusual case of pediatric osteomyelitis following vaccination and provide a review of similar reports submitted to the Vaccine Adverse Event Report System (VAERS), aiming to explore the association between the vaccination procedure and the occurrence of osteomyelitis in childhood. A previously healthy infant, with no history of trauma or infection, presented with hyperpyrexia, swelling, and functional impairment in the left leg and was eventually diagnosed with osteomyelitis of the left femur. An edema was noted at the site of the injection that he received days before for immunization purposes. The infection required surgical drainage and a four-week-long intravenous antibiotic treatment, and the patient was discharged upon showing improved clinical conditions. Forty-seven reports of similar cases submitted to VAERS between 1994 and 2023 were collected, and several cases from the literature, including a case of femoral osteomyelitis in a newborn vaccinated against Hepatitis B, attributed to improper injection technique. Another case was reported in a 15-year-old girl, which aligned with six similar cases of osteomyelitis in adolescents following HPV vaccines collected from VAERS. Despite the small sample number, the findings that in 77% of cases the infection was localized in the vaccinated limb and that symptoms appeared on average 4.3 days (IQR 1.0-5.7 days) post-vaccination suggest a possible link to the injection procedure and highlight the need to adhere to recommendations regarding skin preparation and the selection of the appropriate needle length and injection site.

Impacts of clinical backgrounds and intervention strategies on duration of intravenous antibiotics treatments in patients diagnosed with calculous pyelonephritis: A single-center retrospective study

ObjectivesThere are limited information that need to do appropriate treatment including duration of antibiotic treatments, timing of urinary drainage and pathogenesis of bacteria in calculous pyelonephritis. In the present study, we investigated real-world data on clinical features and succeeded treatment strategies in calculous pyelonephritis cases in our hospital, then, aimed to make predictive model estimating duration of intravenous antibiotics treatment. MethodsParticipants were 163 consecutive patients diagnosed with calculous pyelonephritis who underwent antibiotics treatments between 2017 and 2023 in our in-patients’ clinic. Candidates for explanatory variables that may affect duration of antibiotic treatments were age, gender, body mass index, stone location, stone size, septic status, blood culture, urine drainage, indwelling urethral catheter, diabetes mellitus and steroid intake. ResultsDuration of intravenous antibiotics treatment was 6 days in median (IQR: 4–8 days). Indwelling DJ stent or percutaneous nephrostomy were undergone in 74 (45.4 %) patients. Multiple regression analysis revealed that gender, age, indwelling urethral catheter, septic status and management of urine drainage independently affected essential duration of intravenous antibiotics treatment and regression coefficient estimates of those factors respectively were 0.998, 0.890, 2.487, 1.462, 1.293 with constant of 2.464. ConclusionsOur preliminary multiple regression models for predicting duration of intravenous antibiotics treatment may be useful to judge the timing of changing treatment strategies for patients who would not improve at around estimated intravenous antibiotics treatment periods. If vital signs were stable, it may be acceptable to judge urine drainage from above the urinary stone at around two days after intravenous antibiotic treatments.

Clinical and microbiological characteristics of Eggerthella lenta causing bacteremia

Eggerthella lenta is an obligate anaerobic, Gram-positive bacilli, belonging to the human microbiota of gastrointestinal and female reproductive tracts, oral cavity and prostate gland. In this article, we aim to describe clinical and microbiological characteristics of seven E. lenta strains causing bacteremia. We conducted a descriptive retrospective study including all E. lenta strains causing bacteremia, from February 2019 to August 2023 at the Basurto University Hospital. Seven patients were included in the study with a mean age of 72.7 years. Six patients presented risk factors associated with bacterial infections. All patients were admitted to the hospital because of suspicious of bloodstream infection associated with abdominal symptoms for intravenous antibiotic treatment. Four E. lenta isolates were resistant to penicillin, while all isolates presented high MICs to piperacillin/tazobactam and low MICs to amoxicillin/clavulanic acid. All patients recovered without no complications.

Timely empirical antibiotic therapy against sepsis in a rural Norwegian ambulance service: a prospective cohort study

BackgroundEarly diagnosis and antibiotic therapy in patients with sepsis reduce morbidity and mortality, thus pre-hospital management is likely to affect patient outcomes. Pre-hospital administration may increase the risk of unnecessary use of broad-spectrum antibiotics, but identification of an infectious focus enables more targeted antibiotic therapy. The aim of this study was to investigate how paramedics, with or without the assistance of general practitioners, can administer empiric intravenous antibiotic treatment against sepsis in a timely manner.MethodsCohort study of patients with suspected sepsis that received pre-hospital intravenous antibiotics and were transported to hospital. The setting was mainly rural with long average distance to hospital. Patients received targeted antibiotic treatment after an assessment based on clinical work-up supported by scoring systems. Patients were prospectively included from May 2018 to August 2022. Results are presented as median or absolute values, and chi-square tests were used to compare categorical data.ResultsWe included 328 patients. Median age was 76 years (IQR 64, 83) and 48.5% of patients were female. 30-days all-cause mortality was 10.4%. In cases where a suspected infectious focus was determined, the hospital discharge papers confirmed the pre-hospital diagnosis focus in 195 cases (79.3%). The presence of a general practitioner during the pre-hospital assessment increased the rate of correctly identified infectious focus from 72.6% to 86.1% (p = 0.009). Concordance between pre-hospital identification of a tentative focus and discharge diagnosis was highest for lower respiratory tract (p = 0.02) and urinary tract infections (p = 0.03). Antibiotic treatment was initiated 44 min (median) after arrival of ambulance, and median transportation time to hospital was 69 min. Antibiotic therapy was started 76 min (median) before arrival at hospital.ConclusionsPre-hospital identification of infectious focus in suspected sepsis was feasible, and collaboration with primary care physicians increased level of diagnostic accuracy. This allowed initiation of intravenous focus-directed antibiotics more than one hour before arrival in hospital in a rural setting. The effect of pre-hospital therapy on timing was much stronger than in previous studies from more urban areas.

The Midline Catheter Within the Context of Home Intravenous Antibiotic Treatment.

Home intravenous antibiotic treatment (HIAT) consists of the administration of intravenous antibiotic therapy in the home of the patient. Short peripheral intravenous catheters have long been the first option for antimicrobial therapies. However, these devices are known for their short durability. At present, the midline catheter is one of the median duration devices most commonly used and recommended within the context of HIAT. The objective of this study was to evaluate the occurrence of complications related to midline catheters implanted by a vascular access team in patients undergoing HIAT within the context of home hospitalization. This was a prospective observational study, which consecutively included 77 patients. A total of 92 midline catheters were analyzed. The complications observed were device obstruction (8.7%), infiltration (3.3%), dislodgement (2.2%), and thrombosis (1.1%). Bivariate analysis showed that the pH of the drug and ertapenem administration were associated with catheter obstruction. The authors found a low prevalence of midline catheter-associated complications in patients undergoing HIAT. The use of antireflux needleless connectors should be considered to reduce obstructions. In addition, algorithms that include the variable of type of daily life activity should be developed for deciding the most appropriate catheter for home hospitalized patients receiving HIAT.

Postoperative recovery in peroral versus intravenous antibiotic treatment following laparoscopic appendectomy for complicated appendicitis: a substudy of a cluster randomized cluster crossover non-inferiority study.

Acute appendicitis is the most common cause of abdominal pain requiring surgery, usually managed with laparoscopic appendectomy. In Denmark, the standard postoperative treatment for complicated cases involves intravenous antibiotics. This study compares peroral versus intravenous antibiotics in the context of fast-track surgery and Enhanced Recovery After Surgery (ERAS) protocols. Our objective is to evaluate the impact of peroral versus intravenous antibiotics on patient-reported outcomes following laparoscopic appendectomy for complicated appendicitis. This was a sub-study within a broader Danish cluster-randomized non-inferiority trial conducted at Zealand University Hospital, focusing on adult patients undergoing laparoscopic appendectomy for complicated appendicitis. Participants were randomized into two groups: one receiving a three-day course of peroral antibiotics and the other intravenous antibiotics after surgery. Recovery quality was assessed on the third postoperative day using the Quality of Recovery-15 (QoR-15) questionnaire. The study included 54 patients, 23 in the peroral and 31 in the intravenous groups. The peroral group reported significantly better recovery outcomes, with higher QoR-15 scores (mean difference of 12 points, p < 0.001). They also experienced shorter hospital stays, averaging 47 h less than the intravenous group (p < 0.001). No significant differences between the groups were observed in readmissions or severe postoperative complications. Peroral antibiotic administration after laparoscopic appendectomy for complicated appendicitis significantly improves patient recovery and reduces hospital stay compared to intravenous antibiotics. These results advocate a potential shift towards peroral antibiotic use in postoperative care, aligning with ERAS principles. ClinicalTrials.gov NCT04803422.

A rare case of hemophagocytic lymphohistiocytosis (HLH) secondary to Salmonella infection

HLH (Hemophagocytic lymphohistiocytosis) is a severe hyperinflammatory disease which could be caused by a range of pathogenic organisms, involving Salmonella. This unique case of bacterial-induced HLH tells the story of a 24y/o male who has been admitted to the hospital and is experiencing the severe symptoms of HLH that developed after an enteric fever caused by Salmonella. Despite earlier hospitalization and intravenous antibiotic treatment, he presented with a high temperature, excessive sweating, yellowish staining of urine and eyes, shortness of breath, and significant systemic inflammation. Laboratory studies revealed severe anemia, bicytopenia, and increased markers such as hyperferritinemia and hypertriglyceridemia, resulting in the diagnosis of HLH. The treatment method includes intensive care with intravenous immunoglobulins (IVIG), corticosteroids, and broad-spectrum antibiotics to address both the underlying infection and the inflammatory condition. Despite intense care, his condition was complex and created substantial complications. This instance emphasizes the significance of early detection as well as treatment of HLH, especially when accompanied by bacterial infections, which are not generally thought to produce this strong immunological response. The example emphasizes the requirement to include HLH in the individuals differential diagnosis with severe illness and systemic inflammatory reactions that do not respond to standard treatment. It also emphasizes the necessity of a comprehensive therapeutic approach, customized to the underlying cause and specific clinical presentations of the disease, in improving outcomes in critically sick patients.

Early Oral Step-Down Versus Continued Intravenous Antibiotic Treatment of Complicated Intra-Abdominal Infection.

Background: Complicated intra-abdominal infections (cIAIs) require a combined tactic, of source control and antimicrobial therapy. This study aimed to evaluate the safety and efficacy of oral step-down antimicrobial therapy in cIAIs after initial intravenous (IV) antimicrobial therapy. Methods: This retrospective cohort study included hospitalized adult patients diagnosed with a cIAI who received more than seven days of IV therapy from March 2017 to October 2021. Exclusion criteria included primary/peritoneal dialysis-related peritonitis, necrotizing pancreatitis, fistulizing inflammatory bowel disease, or upper gastrointestinal tract infection. Patients were assigned into two groups: IV-only or oral step-down therapy. The primary outcome was infection recurrence, defined as re-initiation of antimicrobial agents after a treatment-free period of more than or equal to three days. Secondary outcomes included treatment escalation, repeat source control procedure, treatment-related complications, and all-cause mortality. Results: The cohort consisted of 248 patients (199 IV-only and 49 oral step-down). Patients receiving IV-only therapy had a shorter median antimicrobial duration than the oral step-down group (13 vs. 23 d; p <0.0001). Infection recurrence occurred in 26 (13.1%) and 6 (12.2%) patients in the IV-only and oral step-down groups, respectively (p = 0.88). Treatment escalation, repeat source control, and 28-day mortality were similar between groups. Oral step-down therapy resulted in more adverse drug events (10.2% vs. 3.0%; p = 0.04). Discussion: Transition to oral step-down after initial IV therapy had a similar rate of infection recurrence as IV-only therapy but was associated with a longer duration of antimicrobial therapy and an increased rate of adverse drug reactions. Larger randomized non-inferiority studies are needed to confirm this approach.

Clinical characteristics of apical segment lung abscess: a 10-year retrospective study.

Lung abscess in the apical segment of the lung is not rare and is often underestimated in clinical practice. However, the clinical features of apical segment lung abscess (AL) have scarcely been reported. Hence, this study aimed to determine the clinical characteristics of AL and explore moderate therapeutic strategies. This was a retrospective, single-center cohort study. We reviewed the medical records of consecutive patients who were admitted to Shanghai Pulmonary Hospital in Shanghai, China, from January 2009 to December 2018. This study collected information on patients with lung abscess, including demographics, symptoms, clinical findings, and treatment. The statistical methods used were descriptive statistics, Chi-squared test, Fisher's exact test, t-tests, and logistic regression analysis. Of 824 patients, 431 with lung abscess were finally eligible after a review of medical records. The patients were divided into two groups: the AL group (n=68) and the non-apical segment lung abscess (NAL) group (n=363). Compared with patients in the NAL group, those in the AL group had lower rates of chronic obstructive pulmonary disease (COPD) (5.9% vs. 17.4%, P=0.02), diabetes (14.7% vs. 32.2%, P=0.004) and hypoprealbuminemia (10.3% vs. 25.3%, P=0.007). Regarding clinical symptoms, patients in the AL group exhibited lower fever (38.2% vs. 58.4%, P=0.002) and less purulent sputum (32.4% vs. 45.5%, P=0.045). Moreover, regarding radiological features, the AL group had a lower proportion of air-fluid level on chest computed tomography (CT) (7.4% vs. 16.8%, P=0.047). In addition, the study demonstrated that the AL group had a shorter duration of intravenous antibiotic treatment [8 (7-8) vs. 10 (8-12) days, P <0.001]. Surprisingly, the AL group had a high rate of surgical treatment (36.8% vs. 15.4%, P<0.001). In multivariate analysis, surgical treatment occurred more frequently in patients with AL [odds ratio (OR): 2.58, 95% confidence interval (CI): 1.40-4.77, P=0.002], lower in patients who had fever (OR: 0.55, 95% CI: 0.31-0.98, P=0.04), and imaging features of liquefaction necrosis (OR: 0.32, 95% CI: 0.15-0.69, P=0.004). Patients with AL presented with atypical and relatively mild clinical symptoms. However, the rate of surgical treatment was significantly higher. These data should be considered when managing the AL.

Case presentation of urinary tract infection by &lt;i&gt;StenotrophomonaS maltophilia&lt;/i&gt;

Stenotrophomonas maltophilia is an emerging aerobic, non-fermentative, gram-negative multidrug-resistant global opportunistic bacillus. S. maltophilia causes a wide range of infections including respiratory tract infections, blood stream infections and, less commonly, biliary tract infections, skin and soft tissue infections, as well as bone and joint infections. It is increasingly being reported to cause urinary tract infections (UTIs). As for the case report, a 87-year-old male patient visited the Biopathology Laboratory of Nikea Primary Healthcare Center, Piraeus, Greece, for routine examination, being referred by the family doctor (GP). Patient history revealed diabetes mellitus type 2, arterial hypertension, hypercholesterolemia, hypertriglyceridemia, hyperuricemia, chronic obstructive pulmonary disease, diagnosed before 30 years prostate cancer Gleasongrade 6, operated before 15 years, followed by hormone therapy and radiation therapy. Patient history also revealed urinary tract stones with 3 episodes of obstructive pyelonephritis during the last 5 years, followed by hospital admissions and administration of intravenous antibiotic treatment. During the hospital admissions, he had a permanent bladder catheter and received special antimicrobial treatment, for various microorganisms detected in his urine samples, such as Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis and Enterococcus faecalis. Urinary incontinence has been a symptom for 15 years, after the prostate cancer surgery. Moreover, during the last 5 years, the patient faced many difficulties in his daily life because of the urinary incontinence. The situation was managed by bladder catheterisation, which further worsened his condition with recurrent UTIs and new episodes of pyelonephritis with subsequent hospitalization. Urinalysis showed proteinuria, intense pyuria, abundance of micro-organisms and abundance of red blood cells. The urine culture grew monomicrobial Stenotrophomonas maltophilia 105 CFU/ml. The bacterium was identified by the RapID™ REMEL ONE identification system (Thermo Fisher Scientific). Antimicrobial susceptibility testing revealed susceptibility to Trimethoprime/Sulfamethoxazole, Levofloxacin, Ceftriaxone and moderate susceptibility to Ciprofloxacin and Norfloxacin.The patient received treatment with Trimethoprime/Sulfamethoxazole.

Health State Utilities Associated With Treatment Burden in Cystic Fibrosis: A Patient Valuation Study

BACKGROUNDWhile recent advancements in the treatment of cystic fibrosis (CF) have improved survival, reducing high levels of treatment burden remains a priority issue for many people with CF (pwCF). However, economic evaluations of novel interventions may fail to capture their impact on treatment burden due to a lack of suitable outcome measures. This study aimed to estimate health state utilities (HSUs), for changes in treatment burden associated with different CF treatments. RESEARCH QUESTIONWhat value do pwCF place on changes in treatment burden associated with intravenous antibiotic treatment of pulmonary exacerbations, inhaled medicines, and physiotherapy? STUDY DESIGNAND METHODS: Adults attending a specialist CF center were invited to participate in a web-based time trade-off interview. Participants valued their own health, and five health state vignettes describing varying levels of intensity of physiotherapy, inhaled, and IV antibiotic treatment. HSUs for additional instances of each treatment type were estimated using mixed effect linear regression models. RESULTSFifty one people with CF completed the interview (median age, 30 years; range, 19-66); 53% were female; mean FEV(1) % predicted, 65% [SD, 20%]).Mean utility scores for own health were very similar between the EQ-5D index value (0.81, SD 0.20) and the TTO value (0.82, SD 0.20), however limited concordance was observed at the individual level. Adjusted utility decrements associated with treatment burden were -0.037 (SE 0.008) for an additional annual IV antibiotic treatment, -0.029 (SE 0.014) for an additional daily physiotherapy session, and -0.019 (SE 0.013) for an additional daily inhaled medicine. INTERPRETATIONIncreasing treatment burden was associated with decreasing HSU values. The utility decrements associated with treatment burden changes suggest meaningful differences in health-related quality of life (HRQoL) for pwCF. These findings align with existing literature on the impact of treatment burden on HRQoL, and highlight the importance of considering treatment burden in economic evaluations of interventions in CF.

Ceftazidime-Induced Non-Convulsive Status Epilepticus (NCSE) in a Pediatric Patient with Literature Review.

Cephalosporins are a class of antibiotics routinely prescribed for a variety of pediatric infections. Among uncommon adverse effects, cephalosporins can be neurotoxic and epileptogenic, particularly in patients with reduced renal function. Neurotoxic effects are most frequently observed in adults with impaired renal function, and they have rarely been recorded in children. An 11-year-old boy with chronic renal failure experienced non-convulsive status epilepticus two days after initiating intravenous cefazolin and ceftazidime with a pre-diagnosis of peritonitis. The patient's mental condition reverted to baseline within hours after intravenous antibiotic treatment was discontinued and appropriate antiepileptic and anticonvulsive therapy was started. Providers should investigate cephalosporin-induced non-convulsive status epilepticus clinically and electrophysiologically in any child with renal impairment who demonstrates acute changes in mental status or decreased awareness after initiating intravenous cephalosporins.

Implementation of a program for treatment of acute infections in nursing homes without hospital transfer.

Nursing care residents have high hospitalization rates. To address this, we established a unique virtual geriatric unit that has developed a program aimed at providing support to nursing homes. We aimed to evaluate effectiveness of in-house intravenous antibiotic treatment in nursing hospitals after the implementation of the specially designed training program. A cohort study of nursing home residents to evaluate a training program for providers, designed to increase awareness and give practical tools for in-house treatment of acute infections. Data obtained included types of infections, antibiotics used, hospital transfer, and length of treatment. Primary outcomes were in-house recovery, hospitalization and mortality. Univariate analysis and multivariable logistic regression analysis to assess association between different factors and recovery. A total of 890 cases of acute infections were treated with intravenous antibiotics across 10 nursing homes over a total of 4,436 days. Of these cases, 34.8% were aged 90 years or older. Acute pneumonia was the most prevalent infection accounted for 354 cases (40.6%), followed by urinary tract infections (35.7%), and fever of presumed bacterial infection (17.1%). The mean duration of intravenous antibiotic treatment was 5.09 ± 3.86 days. Of the total cases, 800 (91.8%) recovered, 62 (7.1%) required hospitalization and nine (1.0%) resulted in mortality. There was no significant difference observed in recovery rates across different types of infections. Appling a simple yet unique intervention program has led to more "in-house" residents receiving treatment, with positive clinical results. Treating in-house nursing home residents with acute infections resulted in high recovery rates. Special education programs and collaboration between healthcare organizations can improve treatment outcomes and decrease the burden on the healthcare system.

Retrospective study to investigate appropriate duration of antibiotic treatment for uncomplicated Staphylococcus aureus bacteremia in patients with immunodeficiency

BackgroundSince the appropriate antibiotic duration for uncomplicated Staphylococcus aureus (S. aureus) bacteremia (u-SAB) in an immunocompromised state is still unclear, physicians are likely to extend antibiotic therapy from 2 weeks to 4–6 weeks. To examine the appropriate duration of antibiotic therapy for u-SAB, we performed this study. Patients and methodsWe reviewed all patients with u-SAB at our institute seen between January 2020 and August 2023. A total of 51 patients were enrolled, and they were divided into the following two groups by antibiotic duration: longer duration group ≥28 days after blood culture negativity, and shorter duration group. Then, the patients were matched by a propensity score using the covariates of age, sex, qSOFA, and CCI. The primary outcome was to identify the prognosis by duration of antibiotic treatment. ResultsAfter propensity score matching, all-cause 30-day mortality was 0 % in both groups. Hence, there was no significant difference in all-cause 90 days mortality (19.0% vs 9.5%, p = 0.33) or recurrence (9.5%% vs 0%, p = 0.22). Before propensity-score matching, we found that a serum level of CRP 2.0 mg/dL and greater after intravenous antibiotic treatment was one of the poor prognostic factors. The cut-off value of serum CRP level was 2.0 mg/dL with a sensitivity of 82.1% and a specificity of 75.0%. ConclusionWe suggested that 4–6 weeks of antibiotic treatment for immunodeficient u-SAB patients was unnecessary. Moreover, the serum level of CRP after completion of IV antibiotic treatment could be a prognostic marker for u-SAB.

Combination of Antistaphylococcal β-Lactam With Standard Therapy Compared to Standard Therapy Alone for the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia: A Post Hoc Analysis of the CAMERA2 Trial Using a Desirability of Outcome Ranking Approach.

Desirability of outcome ranking (DOOR) is an emerging approach to clinical trial outcome measurement using an ordinal scale to incorporate efficacy and safety endpoints. We applied a previously validated DOOR endpoint to a cohort of CAMERA2 trial participants with methicillin-resistant Staphylococcus aureus bacteremia (MRSAB). Participants were randomly assigned to standard therapy, or to standard therapy plus an antistaphylococcal β-lactam (combination therapy). Each participant was assigned a DOOR category, within which they were further ranked according to their hospital length of stay (LOS) and duration of intravenous antibiotic treatment. We calculated the probability and the generalized odds ratio of participants receiving combination therapy having worse outcomes than those receiving standard therapy. Participants assigned combination therapy had a 54.5% (95% confidence interval [CI], 48.9%-60.1%; P = .11) probability and a 1.2-fold odds (95% CI, .95-1.50; P = .12) of having a worse outcome than participants on standard therapy. When further ranked according to LOS and duration of antibiotic treatment, participants in the combination group had a 55.6% (95% CI, 49.5%-61.7%) and 55.3% (95% CI, 49.2%-61.4%) probability of having a worse outcome than participants in the standard treatment group, respectively. When considering both efficacy and safety, treatment of MRSAB with a combination of standard therapy and a β-lactam likely results in a worse clinical outcome than standard therapy. However, a small benefit of combination therapy cannot be excluded. Most likely the toxicity of combination therapy outweighed any benefit from faster clearance of bacteremia.

Oral versus intravenous antibiotic treatment of moderate-to-severe community-acquired pneumonia: a propensity score matched study

Community-acquired Pneumonia (CAP) guidelines generally recommend to admit patients with moderate-to-severe CAP and start treatment with intravenous antibiotics. This study aims to explore the clinical outcomes of oral antibiotics in patients with moderate-to-severe CAP. We performed a nested cohort study of an observational study including all adult patients presenting to the emergency department of the Haga Teaching Hospital, the Netherlands, between April 2019 and May 2020, who had a blood culture drawn. We conducted propensity score matching with logistic and linear regression analysis to compare patients with moderate-to-severe CAP (Pneumonia Severity Index class III–V) treated with oral antibiotics to patients treated with intravenous antibiotics. Outcomes were 30-day mortality, intensive care unit admission, readmission, length of stay (LOS) and length of antibiotic treatment. Of the original 314 patients, 71 orally treated patients were matched with 102 intravenously treated patients. The mean age was 73 years and 58% were male. We found no significant differences in outcomes between the oral and intravenous group, except for an increased LOS of + 2.6 days (95% confidence interval 1.2–4.0, p value < 0.001) in those treated intravenously. We conclude that oral antibiotics might be a safe and effective treatment for moderate-to-severe CAP for selected patients based on the clinical judgement of the attending physician.

Costs of fracture-related infection: the impact on direct hospital costs and healthcare utilisation

PurposeFracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization.MethodsThis was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies.ResultsIn total, 246 patients were included with a median follow-up of 1 year (IQR 0.6–1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment.ConclusionDirect healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI.

Fournier's Gangrene in 21 Years Old Female: A Case Report

Introduction: Fournier's gangrene, also known as gangrene of the genital region, is an uncommon and rapidly advancing form of necrotizing fasciitis that affects the genitals. The severity and mortality of the disease are dependent upon the overall health status of the patient at the time of diagnosis and the speed at which the infection spreads.&#x0D; Case presentation: An unmarried 21-year-old woman presented with a persistent discharge of abscesses in the perineal area. The patient came in ambulatory and showed no indicators of heart or lung discomfort. A pelvic examination was performed, and the following observations were made: A visual examination revealed swelling in the vulvar area on both sides, along with an open wound within the swelling measuring 3×3 cm. The wound was discharging reddish, thick, and foul-smelling fluid. A glucose level of +4 was observed in the urine, and a random blood sugar test yielded a value of 324 mg/dl. The patient received wound debridement, excision, and electrocauterization of genital warts, blood sugar monitoring with insulin administration, and a 14-day course of antibiotics. The patient's condition improved, and they were discharged after receiving 14 days of intravenous antibiotic treatment.&#x0D; Conclusion: The treatment of Fournier gangrene requires a comprehensive approach that includes intensive systematic management, broad-spectrum antibiotic therapy, and early surgical debridement. This involves removing the necrotic tissues and surgically draining the peritoneum, scrotum, penis, and inguinal regions.

Recurrent Orbital Subperiosteal Abscess in Patient with Nasopharyngeal Carcinoma

Introduction : Subperiosteal abscess (SPA) is a rare finding in cancer patients with orbital cellulitis. Severe complications associated with this condition are permanent visual loss, intracranial extension, and death.&#x0D; Case Illustration : A 38-year-old male with history of nasopharyngeal carcinoma (NPC) came with progressive right eyelid swelling, non-axial proptosis, and visual acuity was NLP. CT scan revealed right SPA associated with frontal sinusitis. NPC staging was T3N2M0. Despite the treatment of intravenous antibiotics and drainage incision of SPA, there was recurrence of right SPA two weeks after procedure and re-staging revealed T4N3M0. A joint operation with otolaryngology department to do debulking of the mass, frontal sinus surgery, and drainage incision was held. Culture resulted in Talaromyces marneffei. Patient was assessed with talaromycosis and given itraconazole for ten weeks. Moreover, patient came again with proptosis seven weeks postoperatively. Re-drainage incision was performed and clinical presentation was improved.&#x0D; Discussion : This case describes rare biological nature of NPC where extensive blockage of paranasal sinuses allows microorganism overgrowth and infection. The anatomical changes and cancer-related immunosuppression contribute to recurrent SPA. Chemotherapy and radiotherapy are ideal treatments for our patient, however, infection must be treated adequately first. Surgical interventionis needed to manage the infection by SPA drainage where antimicrobial has poor penetration into the abscess and debulking of tumor to clear the blockage of drainage pathway.&#x0D; Conclusion : Recurrent orbital SPA could happen in patients with NPC, therefore appropriate medical treatment and timely surgical intervention are essential in managing orbital SPA. Multidisciplinary management is required to optimize patient outcomes.