Intravenous Antibiotic Therapy Research Articles

323. Outpatient Initiation and Successful Completion of Intravenous Antibiotic Therapy at Home for Eligible Patients: A Quality Improvement Project

Abstract Background Outpatient Parenteral Antibiotic Therapy (OPAT) is known to reduce hospital length of stay, readmissions, hospital morbidity, increase patient satisfaction, and reduce costs. Initiating IV antibiotics directly in the outpatient setting requires coordination with a multidisciplinary team and can be a lengthy process. Outpatient initiations can prevent hospitalizations and unnecessary ED visits for eligible patients. This strategy became critical during the COVID-19 pandemic given limited hospital capacity. The aim of this project was to streamline the process of initiating IV antibiotics in the outpatient setting for eligible patients and reduce time-to-initiation to less than seven days in our institution. Methods We mapped the steps for outpatient initiations and identified factors leading to delays. Through a prospective and retrospective chart review, we identified TTI, hospitalizations prevented, diagnosis (figure 1), and 60-day relapse. TTI was represented in an SPC chart, highlighting the variability in days among patients. We created an action plan to improve the processes of obtaining insurance approval, establishing IV access, and a standardized protocol. Return on investment was calculated. Results We coordinated outpatient initiations for 31 patients from Dec 2020 to Mar 2023. TTI varied (4-21 days, median 11 days) (figure 2). There was no difference in TTI of the Dalbavancin group vs non-dalbavancin group (median 10 and 10.5 days, respectively). After implementing a standardized protocol in Dec 2022, three patients were started on IV antibiotics. Although the protocol outlined steps and improved communication, the TTI remained similar (4-23 days, median 10.5 days). Delays were driven by insurance approval. Two patients were started within the goal of seven days. Of 31 outpatient starts, one patient had a 60-day relapse. We calculated savings between $102,000 to $168,000, driven by ED and hospital admission diversion.Figure 1:Common diagnoses for eligible OPAT initiation Pareto chart depicting the number and frequency of diagnoses in which IV antibiotics were initiated from our OPAT clinic. SSTI, skin/soft tissue infection; ODRI, orthopedic device-related infection; UTI, urinary tract infection.Figure 2:Time-to-initiation (TTI) in days Statistical process control (SPC) chart depicting the time-to-initiation in days for each subject started on IV antibiotics from our OPAT clinic. The vertical line indicates the date we implemented our standardized protocol for outpatient initiations. Conclusion Despite not meeting our goal, we made strides in implementing a standardized protocol that streamlines communication to reduce delays in a cost-effective manner while improving patient satisfaction, continuity of care, and resource utilization. This model can help implement more efficient protocols of this kind nationwide. Disclosures Jason Bowling, MD, Eli Lilly: Advisor/Consultant

Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis.

Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis scorewere found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.

Abstract 17647: Potential Candidates for Partial Oral Treatment in Patients With Endocarditis at a US Center

Introduction: In the Danish POET trial, oral step-down antibiotic therapy was non-inferior to intravenous antibiotic therapy (IVAB) in stabilized patients with left-sided infective endocarditis (IE). It is unknown whether oral treatment for IE can be efficacious in the US population. Aim Identify patients with IE who may have been candidates for POET treatment in a US cohort and assess the reduction of IVAB days and differences in characteristics and outcomes compared to participants in the POET trial. Methods: Retrospective study of patients admitted with IE at a US single center in Jan 2021 - July 2022. Possible candidates for POET treatment were patients with left-sided IE and infection with S. aureus , E. faecalis , Streptococcus , or coagulase-negative staph (CoNS), who had reached stabilization of infection or were discharged. Primary outcome was a composite of all-cause mortality, relapse of bacteremia, embolism or unplanned cardiac surgery within 6 months. Results: Of 152 patients with IE, 90 (59%) were possible candidates for POET treatment. Median length of IVAB after stabilization was 33 days (IQR 24-37). Compared to POET-trial patients, POET candidates in the US cohort were younger (64 vs 70 years), more often had diabetes (30% vs 17%), cancer (30% vs 8%), intravenous substance use (8% vs 1%) or pacemakers (18% vs 9%) [Table]. Prevalence of S. aureus (35% vs 22%) and CoNS infections (23% and 6%) was higher; Streptococcus was less common (30% vs 49%). Primary outcome occurred in 25 patients (28%) compared to 42 patients (10%) in the POET-trial (p<0.001). Conclusions: More than half of patients admitted with IE were possible POET candidates, for whom 4 weeks of IVAB may have been converted to oral antibiotics. Candidates in the US cohort had more comorbidities and primary outcome was three times higher than in the POET trial. Prospective studies are needed for verification of POET treatment in higher-risk US IE patients.

Long-term outcomes after responsive neurostimulation for treatment of refractory epilepsy: a single-center experience of 100 cases.

Despite antiepileptic drugs, more than 30% of people with epilepsy continue to have seizures. Patients with such drug-resistant epilepsy (DRE) may undergo invasive treatment such as resection, laser ablation of the epileptogenic focus, or vagus nerve stimulation, but many are not candidates for epilepsy surgery or fail to respond to such interventions. Responsive neurostimulation (RNS) provides a neuromodulatory option. In this study, the authors present a single-center experience with the use of RNS over the last 5 years to provide long-term control of seizures in patients with DRE with at least 1 year of follow-up. The authors performed a retrospective analysis of a prospectively collected single-center database of consecutive DRE patients who underwent RNS system implantation from September 2015 to December 2020. Patients were followed-up postoperatively to evaluate seizure freedom and complications. One hundred patients underwent RNS placement. Seven patients developed infections: 2 responded to intravenous antibiotic therapy, 3 required partial removal and salvaging of the system, and 2 required complete removal of the RNS device. No postoperative tract hemorrhages, strokes, device migrations, or malfunctions were documented in this cohort. The average follow-up period was 26.3 months (range 1-5.2 years). In terms of seizure reduction, 8 patients had 0%-24% improvement, 14 had 25%-49% improvement, 29 experienced 50%-74% improvement, 30 had 75%-99% improvement, and 19 achieved seizure freedom. RNS showed significantly better outcomes over time: patients with more than 3 years of RNS therapy had 1.8 higher odds of achieving 75% or more seizure reduction (95% CI 1.07-3.09, p = 0.02). Also, patients who had undergone resective or ablative surgery prior to RNS implantation had 8.25 higher odds of experiencing 50% or more seizure reduction (95% CI 1.05-65.1, p = 0.04). Responsive neurostimulator implantation achieved 50% or more seizure reduction in approximately 80% of patients. Even in patients who did not achieve seizure freedom, significant improvement in seizure duration, severity, or postictal state was reported in more than 68% of cases. Infection (7%) was the most common complication. Patients with prior resective or ablative procedures and those who had been treated with RNS for more than 3 years achieved better outcomes.

A 20-Year Study of Intracranial Pyogenic Complications of Sinusitis in Children.

Intracranial pyogenic complications of sinusitis in children can lead to serious sequelae. We characterize the clinical, epidemiologic and microbiologic characteristics of children with such complications over a 20-year period. Single-center retrospective chart review. Cases were identified based on International Classification of Diseases diagnostic codes (ICD)-9 and ICD-10 depending on the year and by reviewing all intracranial microbiologic samples. A total of 104 cases of complicated sinusitis were included after review of 1591 charts. Median age was 12 (IQR 9-14); 72 were male (69%). The most frequent complications were epidural empyema (n = 50, 48%), subdural empyema (n = 46, 44%) and Pott's puffy tumor (n = 27, 26%). 52% (n = 54) underwent neurosurgery and 46% (n = 48) underwent otolaryngologic surgery. The predominant pathogen isolated from sterile site specimens was Streptococcus anginosus (n = 40, 63%), but polymicrobial growth was common (n = 24; 38%). The median duration of intravenous antibiotic therapy was 51 days (IQR 42-80). Persistent neurologic sequelae (or death, n = 1) were found in 24% (n = 25) and were associated with the presence of cerebritis and extensive disease on neuroimaging ( P = 0.02 and P = 0.04, respectively). Intracranial complications of sinusitis continue to cause significant morbidity in children. Polymicrobial infections are common, which reinforces the need for broad-spectrum empiric antibiotic therapy and cautious adjustment of the antibiotic regimen based primarily on sterile site cultures. The association of neurologic sequelae with the presence of cerebritis and extensive intracranial involvement on neuroimaging suggest that delayed diagnosis may be a contributor to adverse outcome.

Supine mini percutaneous nephrolithotomy in horseshoe kidney.

The percutaneous nephrolithotomy (PCNL) in Horseshoe kidneys (HSK) is usually performed in the prone position, allowing entry through the upper pole and providing good access to the collecting system. However, in patients with normal kidney anatomy, the supine position is reliable and safe in most cases, but it is unknown whether the supine position is adequate in patients with HSK. The purpose of this study was to describe the results of PCNL in HSK in three different surgical institutions and to evaluate the impact of supine position during surgery, comparing pre-operative and post-operative data, complications, and stone status after surgery. Between 2017 and 2022, a total of 10 patients underwent percutaneous renal surgery for stone disease in HSK. All patients were evaluated pre- and post- operatively with non-contrast CT. we evaluated patients (age and gender), stones characteristics (size, number, side, site and density ), and outcomes. The change in haemoglobin, hematocrit, creatinine and eGFr were assessed between the most recent preoperative period and the first postoperative day. Procedure success was defined as stone-free or presence of ≤4 mm fragments (Clinically Insignificant residual Fragments - CIrF). Complications were registered and classified according to Clavien-dindo Grading System, during the 30 - day postoperative period and Clavien scores ≥ 3 were considered as major complications. Statistical analysis was performed using "r 4.2.1" software, with a 5% significance level. we also compared pre-operative and post-operative data using "wilcoxon signedrank test". No statistical difference was observed between preoperative and post-operative renal function data. At one post operative day CT scan, an overall success rate of 100% was registered. 9/10 patients were completely free from urolithiasis (stone-free rate: 90%), while 1/10 patients had ≤4 mm residual stone fragments (CIrF rate: 10%). No cases of intraoperative complications were registered. Post-operative complications were reported in 1/10 patients. A patient developed urosepsis (defined as SIrS with clinical signs of bacterial infections involving urogenital organs - Clavien-dindo Grade II) after procedure, and was treated with intravenous antibiotic therapy successfully. Conclusions: This study shows that in patients with HSK mini- PCNL in supine position allows to achieve good stone free rate with a very low morbidity. According to our series, the described technique for PCNL in HSK should be an option. Nevertheless these results must be confirmed by further studies.

Using antibiotics wisely.

This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases. There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages. In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven. http://links.lww.com/COID/A50.

Acute mastoiditis in cochlear implanted children: A single-centre experience

BackgroundAcute mastoiditis (AM) is the most common complication of acute otitis media and primarily affects children under the age of two; current data on its prevalence in paediatric patients with cochlear implant (CI) are still scant. Proper management of AM in CI children is crucial in order to avoid the implications (financial and emotional) of an explant.Aim of this paper is to describe the cases of AM occurred among young patients with CI in follow up at our department, also in order to evaluate its prevalence, potential predisposing factors, clinical course and therapeutic strategies. Patients and methodsRetrospective study. Medical records of all paediatric patients with CI, who had at least one year of follow-up, were searched aiming to identify those who developed AM, from January 1st 2002 to January 31st 2022. The following data were collected and analysed: demographic features, implant type and side, interval between CI surgery and AM, treatment, laboratory tests, clinical course, vaccination history, associated diseases. ResultsAM was developed by six (1.3%) of the 439 children with CI (541 implanted ears). In total, 9 episodes (2.05 %) were recorded, as three patients reported two consecutive infections. Average time interval between CI surgery, to the first or only AM diagnosis, was 13.8 months (range 3–30 months). Furthermore, 3/6 of patients had a history of recurrent acute otitis media; 2/6 an autism spectrum disorder, associated to a combined immune deficiency in one case. All patients were hospitalized and promptly treated by intravenous antibiotic therapy; 4/6 also underwent a mastoidectomy. CI was not explanted in any cases of this series. ConclusionsOver a 20-year period, AM rate in CI children was 1.3%, which is consistent with the current literature rates of 1–4.7%. All cases were successfully treated, preserving the integrity of the device. In our experience, the early parenteral antibiotic therapy and, when necessary, surgical treatment were adequate to eradicate the infection.

43 Nursing Home Residents presenting to the Emergency Department; what can multidisciplinary, integrated frailty teams offer?

Abstract Background Comprehensive Geriatric Assessment (CGA) in the Emergency Department (ED) may provide opportunities to improve care of Nursing Home Residents (NHR). The aim was to develop an abbreviated CGA (aCGA) for NHRs presenting to the ED and identify their multidisciplinary care needs. Methods The existing Frailty at the Front Door (FFD) CGA was simplified. Over a three-month period, consecutive patients over the age of 75 years in an age friendly hospital accredited emergency department, were selected by address from iPMS and underwent an aCGA. Age, gender, Clinical Frailty Score (CFS), 4AT, excessive polypharmacy, high risk medications usage, 4QT swallow screen, MST nutrition screen, need for physiotherapy and/or occupational therapy input, use of intravenous (IV) antibiotic therapy and the number of those experiencing their last 1,000 days was entered prospectively onto an Excel database. Data was analysed using descriptive statistics. Results 104 NHR presented to the ED, 59 of which (57%) underwent an ‘a-CGA’. Co-ordinated care was then delivered through the FFD. The mean (SD) age was 85 years (+/−6.5). Male to female ratio was 2:1. The mean CFS was 6.6(+/−0.5) 0.39% (n = 23) were at risk of delirium (4AT ≥ 2), 80% (n = 47) had excessive poly-pharmacy or were prescribed high risk medications, 63% (n = 37) presented with dysphagia, 50% (n = 30) were at risk for malnutrition (MST ≥ 2), 39% (n = 23) required trans-disciplinary assessment of function/mobility, 52% (n = 31) required IV antibiotics and 20% (n = 12) were experiencing their last 1,000 days. Conclusion The aCGA effectively identified frailty syndromes, triggering early input from the ED based interdisciplinary team. A significant number of NHRs were in their last 1,000 days. Administering IV antibiotics in nursing homes with on-site access to the wider multi-disciplinary team would address the needs of many NHRs who currently have no option other than admission to hospital. For those in their last 1,000 days particularly, this would represent a more person-centred approach.

Intravenous versus Partial Oral Antibiotic Therapy in the Treatment of Uncomplicated Bloodstream Infection Due to Streptococcus Species.

This retrospective cohort study examines effectiveness of partial oral antibiotic regimens in uncomplicated bloodstream infections (BSIs) due to Streptococcus species compared to standard intravenous therapy. Adult patients with uncomplicated streptococcal BSIs from April 2016 to June 2020 in seven hospitals in South Carolina, USA, were evaluated. Multivariate Cox proportional hazards regression was used to examine the time to treatment failure within 90 days of a BSI after adjustment for the propensity to receive partial oral therapy. Multivariate linear regression was used to examine the hospital length of stay (HLOS). Among the 222 patients included, 99 received standard intravenous antibiotics and 123 received partial oral therapy. Of the standard intravenous therapy group, 46/99 (46.5%) required outpatient parenteral antibiotic therapy (OPAT). There was no difference in the risk of treatment failure between partial oral and standard intravenous therapy (hazards ratio 0.53, 95% CI 0.18, 1.60; p = 0.25). Partial oral therapy was independently associated with a shorter HLOS after adjustments for the propensity to receive partial oral therapy and other potential confounders (-2.23 days, 95% CI -3.53, -0.94; p < 0.001). Transitioning patients to oral antibiotics may be a reasonable strategy in the management of uncomplicated streptococcal BSIs. Partial oral therapy does not seem to have a higher risk of treatment failure and may spare patients from prolonged hospitalizations and OPAT complications.

Intravenous antibiotic therapy after laparoscopic appendectomy in acute complicated appendicitis: the patient clinical response is the key.

The guidelines about acute complicated appendicitis (ACA) recommend 3-5 days of postoperative intravenous antibiotics (IVA). Nevertheless, the time selected by the surgeon can vary according to patient clinical response, ACA type, and professional experience. Once an adequate clinical response is obtained, the change from IVA to oral antibiotic (OA) could be realized without the waiting time established with satisfactory results. Determine if a short course of IVA and/or switch to oral route is safe based on the patient clinical response. Observational prospective cohort study from a general surgery reference center database since July 2019. 48 patients with ACA intraoperative findings were included. Regarding postoperative antibiotic management, only preoperative IVA: 7 (14.58%), IVA 1-3 days: 1 (20.83%), IVA 1-3 days and change to OA: 21 (43.75%), IVA > 3 days: 6 (12.5%), and only OA: 3 (27.08%). The bivariate analysis did not show statistically significant differences in reconsultation (p = 0.81), rehospitalization (p = 0.44), and surgical site infection (p = 0.56) between the antibiotic scheme based on the postoperative clinical response and the traditional one regarding intra-abdominal collection rate, the hospital stays, and hospitalization costs.

Prevention, diagnosis and treatment of cardiac implantable electronic device infections. Position paper of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)

The number of cardiac implantable electronic device (CIED) implantations has increased over recent years as a result of population growth, increasing life expectancy, adoption of guidelines, and better access to healthcare. Device-related infection is, however, one of the most serious complications of CIED therapy associated with significant morbidity, mortality, and financial healthcare burden. Although many preventive strategies such as administration of intravenous antibiotic therapy before implantation are well recognized, uncertainties still exist about other regimens. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. The key aspect to successful treatment of definite CIED infections is complete removal of all parts of the system and transvenous hardware, including the device and all leads. Thus, transvenous lead extraction has been increasing. Expert consensus statements on how to prevent, diagnose, and treat CIED infections and on lead extraction have been published by the European Heart Rhythm Association in 2020 and 2018, respectively. The aim of this AIAC position paper is to describe the current knowledge on the risks for device-related infections and to assist healthcare professionals in their clinical decision making regarding its prevention, diagnosis, and management by providing the latest update of the most effective strategies.

Transcriptomic identification of genes expressed in invasive S. aureus diabetic foot ulcer infection.

Infection in diabetic foot ulcers (DFUs) is one of the major complications associated with patients with diabetes. Staphylococcus aureus is the most common offending pathogen in patients with infected DFU. Previous studies have suggested the application of species-specific antibodies against S. aureus for diagnosis and monitoring treatment response. Early and accurate identification of the main pathogen is critical for management of DFU infection. Understanding the host immune response against species-specific infection may facilitate diagnosis and may suggest potential intervention options to promote healing infected DFUs. We sought to investigate evolving host transcriptome associated with surgical treatment of S. aureus- infected DFU. This study compared the transcriptome profile of 21 patients with S. aureus- infected DFU who underwent initial foot salvage therapy with irrigation and debridement followed by intravenous antibiotic therapy. Blood samples were collected at the recruitment (0 weeks) and 8 weeks after therapy to isolate peripheral blood mononuclear cells (PBMCs). We analyzed the PBMC expression of transcriptomes at two different time points (0 versus 8 weeks). Subjects were further divided into two groups at 8 weeks: healed (n = 17, 80.95%) versus non-healed (n = 4, 19.05%) based on the wound healing status. DESeq2 differential gene analysis was performed. An increased expression of IGHG1, IGHG2, IGHG3, IGLV3-21, and IGLV6-57 was noted during active infection at 0 weeks compared with that at 8 weeks. Lysine- and arginine-rich histones (HIST1H2AJ, HIST1H2AL, HIST1H2BM, HIST1H3B, and HIST1H3G) were upregulated at the initial phase of active infection at 0 weeks. CD177 and RRM2 were also upregulated at the initial phase of active infection (0 weeks) compared with that at 8 weeks of follow-up. Genes of heat shock protein members (HSPA1A, HSPE1, and HSP90B1) were high in not healed patients compared with that in healed patients 8 weeks after therapy. The outcome of our study suggests that the identification of genes evolution based on a transcriptomic profiling could be a useful tool for diagnosing infection and assessing severity and host immune response to therapies.

#6672 THE DEVELOPMENT OF A COMMUNITY-NEPHROLOGY, MULTI-DISCIPLINARY SERVICE

Abstract Background and Aims The Walsall Together clinical and operational leads constructed a collaborative initiative between nephrology and community services. Driven to provide multi-agency, patient-focused care. The aim of the community nephrology MDT service is to identify and optimally manage individuals with acute nephrological presentations and optimally manage individuals with secondary complications of chronic kidney disease (CKD) at home, while maximally utilising outpatient community services to prevent hospital admissions. Method Nephrology and community teams, including rapid-response, complex-case management, enhanced-care and frailty teams devised a MDT service for individuals with either community-acquired acute kidney injury (AKI) or complications of CKD. The MDT can consist of; a nephrologist, community-CKD nurse, a member from each of the above teams, a community pharmacist and an MDT coordinator. Patients are identified from the MDT attendee's caseload, from the community heart failure and the community geriatrician patient cohort. A weekly MDT meeting is held on Microsoft Teams, this allows for efficient working across a large geographical area. The MDT coordinator is essential for the efficient performance of the community nephrology MDT. They are responsible for: organising meetings, producing minutes, requesting laboratory investigations (including urine album in creatinine ratio), chasing results from clinical investigations and finally ensuring that the actions generated from the MDT are completed. The community pharmacist is an independent prescriber and immediately actions any medication changes. The community teams consist of advanced clinical practitioners or band 7/above nurse prescribers. All clinical staff perform home visits and fully utilise outpatient services including ambulatory-care-unit services for medical assessment, urgent imaging and intravenous electrolyte replacement. The medical-day-case unit services for the administration of blood transfusions. The community outpatient access team services for intravenous iron therapy and antibiotic therapy. Results Currently, the community nephrology MDT is actively managing over 60 patients. This excludes patients who have been successfully managed and discharged from the community MDT service. The multimorbid, patient cohort with recurrent hospital admissions appear to have benefited the most. A reduction and/or cessation is noted, in hospital admissions after the introduction of interventions from the community nephrology MDT. The service allows the nephrology team to easily monitor and manage housebound, individuals with CKD. This reduces the number of admissions related to secondary complications of CKD. Furthermore, by managing acute illness in the community, the service reduces the number of individuals admitted to hospital with community acquired AKI. Finally, in the unfortunate event of terminal, irreversible pathology, the MDT service allows for advanced care planning and referral to community palliative care services. Conclusion The Walsall Together collaboration has demonstrated that utilising a multi-agency approach to managing acute and chronic renal disease, can result in a reduction in hospital admissions. Furthermore, the cooperative multi-speciality approach, has led to improved monitoring and management of housebound individuals with CKD.

Three cases of subcorneal pustular dermatosis with immunohistochemical examinations.

Subcorneal pustular dermatosis, a rare, benign skin disease, is a type of neutrophilic dermatosis. The authors reported three cases of subcorneal pustular dermatosis. In case 1, a 9-year-old girl developed a skin rash with blisters following a mycoplasma infection and had a flare-up due to a common cold. She was successfully treated with a topical corticosteroid. In case 2, a 70-year-old woman who had been treated for rheumatoid arthritis with adalimumab, salazosulfapyridine, and leflunomide developed 3- to 5-mm pustules on her trunk and thighs 4 days after flu vaccination. The rash disappeared with drug withdrawal and treatment with diaminodiphenyl sulfone. In case 3, an 81-year-old man, who was diagnosed with pyoderma gangrenosum at 61 years old, developed multiple small flaccid pustules on his trunk and extremities due to an infection in the arteriovenous shunt area on the forearm. The pustule disappeared with intravenous antibiotic therapy; however, the pustules subsequently flared up along with ulcers typical of pyoderma gangrenosum. He was given oral prednisolone therapy, which was effective for the small pustules and some ulcers. Immunohistochemical examination of the three cases revealed neutrophilic infiltration in the subcorneal layer of the epidermis. The pustules contained neutrophils as well as some CD68+ and a few CD1a+ cells. The epidermis and dermis were more predominantly infiltrated by CD4+ cells than by CD8+ cells. Positive stainings for interleukin 8, interleukin 36γ, and phospho-extracellular signal-regulated kinases 1 and 2 were observed in the upper layers of the epidermis below the pustules. Although the pathogenesis of subcorneal pustular dermatosis has not been clarified, the current results suggest that a variety of inflammatory cells, including those responsible for both innate and acquired immunity, are involved in the accumulation of neutrophils in subcorneal pustular dermatosis.

The Bacterial Profile of Aortic Infectious Endocards: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective endocarditis is defined as infection of a native or prosthetic heart valve, endocardial surface, or cardiac device. The causes and epidemiology, as well as the microbiology of the disease have evolved over the last few decades with the doubling of the average age of patients and an increased prevalence in patients with indwelling cardiac devices. Patients and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at ERRAZI Hospital-Mohammed VI University Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: Over the study period, 46 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. Endocarditis on aortic prosthesis was found in 15%. The valves were rheumatic in 85%. The presumed portal of entry was cutaneous in 45%, oral and ENT in 33%, urinary in 15%, and digestive in 7%. In our series, 21 out of 26 patients presented a biological inflammatory syndrome. At least one or more blood cultures were positive in 38% of cases. Coagulase-negative Staphylococcus was the most common germ in aortic infective endocarditis, found in 40% of positive blood cultures. All the patients in our series had received a combination of broad-spectrum intravenous antibiotic therapy, initially probabilistic, taking into consideration the portal of entry. Adapted after antibiogram results. The evolution during the hospitalization, was marked by an improvement of the clinical state in only 12%, a perioperative death in 38%, and a worsening of the clinical state in 50%, with an average duration of hospitalization of 14 days. In our series, 60% of the patients with positive blood cultures died, whereas there was 75% survival in the group with negative blood cultures. Conclusion: Infective endocarditis is a serious disease because of its high morbidity and mortality. Despite improvements in diagnostic testing, antimicrobial therapy, and surgical intervention, changes in the epidemiology of IE, including the increase in healthcare-associated infections and the virulence of staphylococcus aureus as the causative organism, increase the risk of complications and death in the acute phase of IE. Action must be taken to prevent infective endocarditis, especially in this rheumatically endemic area.

P247 ETI reduces antibiotic treatment days in people with cystic fibrosis – a real-life observation

Since its approval, Elexacaftor/Tezacaftor/Ivacaftor (ETI) has improved lung function and decreased the number of pulmonary exacerbations in people with cystic fibrosis (pwCF). Here, we investigated the influence of ETI on the amount of oral and intravenous (iv) antibiotic therapies in pwCF since the initiation of ETI therapy.

Management of Epidural and Subgaleal Abscesses in Pediatric Craniosynostosis Surgery

Introduction: Epidural/subgaleal abscesses in craniosynostosis surgery are rare but serious complications that may compromise neurological functioning in pediatric craniofacial populations. We evaluated the risk and evolution of management of post-operative subgaleal/epidural abscesses in craniosynostosis patients treated over 20 years by a single surgeon. Methods: Pediatric patients who underwent transcranial procedures for craniosynostosis by a single surgeon from 1997 to 2018 were included. The patients were stratified into groups based on the development of post-op abscess. The primary outcome measure was bone salvage success. Post-op abscesses were drained in the following manner: either open packing with delayed closure or no elevation of the scalp flap, followed by copious irrigation and deep (epidural) drain placement plus long-term intravenous antibiotics. Results: A total of 384 patients underwent 413 cases in this period: 177 sagittal, 85 unicoronal, 49 metopic, 4 lambdoid, and 69 cases of multiple suture synostosis. In this cohort, epidural/subgaleal abscess were found in 6 patients (1.5%) who all had bilateral fronto-orbital advancement ( P = .03). Bone salvage was attempted in all 6 patients with only minor bone resorption seen in 3 of the patients who presented with abscess. Conclusion: This study found that patients undergoing bilateral fronto-orbital advancement were at increased risk of a deep space infections, while those undergoing clavarial vault remodeling with barrel staves alone, were not. We were able to salvage the bone grafts and prevent neurological sequela with surgical washout, placement of drains and intravenous antibiotic therapy.

What's New in Musculoskeletal Infection.

What's New in Musculoskeletal Infection.

Comparison of Oral and Intravenous Definitive Antibiotic Therapy for Beta-Hemolytic Streptococcus Species Bloodstream Infections from Soft Tissue Sources: a Propensity Score-Matched Analysis.

Beta-hemolytic streptococci are common causes of bloodstream infection (BSI). There is emerging data regarding oral antibiotics for BSI but limited for beta-hemolytic streptococcal BSI. We conducted a retrospective study of adults with beta-hemolytic streptococcal BSI from a primary skin/soft tissue source from 2015 to 2020. Patients transitioned to oral antibiotics within 7 days of treatment initiation were compared to those who continued intravenous therapy, after propensity score matching. The primary outcome was 30-day treatment failure (composite of mortality, infection relapse, and hospital readmission). A prespecified 10% noninferiority margin was used for the primary outcome. We identified 66 matched pairs of patients treated with oral and intravenous antibiotics as definitive therapy. Based on an absolute difference in 30-day treatment failure of 13.6% (95% confidence interval 2.4 to 24.8%), the noninferiority of oral therapy was not confirmed (P = 0.741); on the contrary, the superiority of intravenous antibiotics is suggested by this difference. Acute kidney injury occurred in two patients who received intravenous treatment and zero who received oral therapy. No patients experienced deep vein thrombosis or other vascular complications related to treatment. In patients treated for beta-hemolytic streptococcal BSI, those who transitioned to oral antibiotics by day 7 showed higher rates of 30-day treatment failure than propensity-matched patients. This difference may have been driven by underdosing of oral therapy. Further investigation into optimal antibiotic choice, route, and dosing for definitive therapy of BSI is needed.