Intravenous Azithromycin Research Articles

399: A CASE OF SEVERE BABESIOSIS REQUIRING EXCHANGE TRANSFUSION

Introduction: Babesiosis is an infection caused by a protozoan that infects human erythrocytes. In the United States, Babesia microti is the most commonly isolated strain transmitted by tick vector (Ixodes scapularis). The severity of infection usually depends on host immune status and Babesia species, ranging from asymptomatic to life-threatening. We describe a case of severe babesiosis requiring exchange transfusion in an elderly but otherwise healthy individual. Description: A previously healthy 90-year-old man presented to the emergency department with a 1-week history of dyspnea and dark-colored urine. Patient reported a tick bite two months prior for which he was empirically treated with doxycycline. On admission, he was afebrile, blood pressure was 130/69 mmHg, heart rate was 84 bpm, and respiratory rate was 22 breaths/min. Physical exam was unremarkable. Labs were notable for serum creatinine 2.70mg/dl, total bilirubin 3.2mg/dl, direct bilirubin 1.6mg/dl, AST 125U/L, ALT 66U/L, hemoglobin 10.1g/dl, and platelets 44k/µL. Peripheral smear showed babesia species without Anaplasma and Ehrlichia, and Lyme serology was negative. Patient was started on intravenous azithromycin and atovaquone and admitted to medical ward. Later that day he became hypotensive with elevated lactate of 3.1mmol/dl. His blood pressure was minimally fluid-responsive. Further labs revealed a haptoglobin < 10, elevated lactate dehydrogenase, and parasitemia of 31.4%. Due to the hypotension with evidence of organ damage, intravascular hemolysis, and high-grade parasitemia, he was transferred to the medical intensive care unit (MICU) for exchange transfusion. In the ICU patient received two rounds of exchange red blood cell transfusion with which parasitemia decreased to 1.4% and hemolysis parameters improved. His blood smear was negative for babesia on hospital day 5 and he was discharged home to complete a 2-week course of azithromycin and atovaquone from the day of negative smear. Discussion: Babesiosis can be life-threatening, especially in elderly, asplenic, and immunocompromised patients. Our case outlines the importance of early institution of exchange transfusion in addition to appropriate antimicrobial therapy in patients with end-organ damage, intra-vascular hemolysis, and high-grade parasitemia for better outcomes.

Prevention and treatment of wound infections after caesarean section

Caesarean section (cS) is one of the most common obstetric operations in the world. About 32 % of all births end by caesarean section. Postpartum infection at the surgical site, wound infection and endometritis are the main causes of long stays in maternity hospitals and are a source of additional costs for the healthcare system. In 2–16 % of cases postpartum endometritis develops. Many risk factors for the development of postpartum infections have been described. These include maternal factors (such as tobacco use, inadequate prenatal care, obesity, corticosteroid use; prematurity, multiple gestation, and uterine scar), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged anhydrous period; prolonged labor , especially a long second period; large incision of the anterior abdominal wall; subcutaneous tissue thickness more than 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; rapid labor; massive blood loss during childbirth). Effective measures to reduce the incidence of obstetric infectious complications include prophylactic use of antibiotics (preoperative preparation with first-generation cephalosporins and intravenous azithromycin), preoperative showering with chlorhexidine instead of iodine, shaving immediately before surgery, vaginal sanitation, removal of the placenta by traction of the umbilical cord, suturing of the subcutane-ous tissue, if the depth of the wound is larger than 2 cm and suturing the skin with sutures instead of using staples. Establishing an evidence-based optimal care algorithm for patients after caesarean section can reduce the incidence of serious infectious complications.

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

AZTEC—azithromycin therapy for prevention of chronic lung disease of prematurity: a statistical analysis plan for clinical outcomes

BackgroundThe AZTEC trial is a multi-centre, randomised, placebo-controlled trial of azithromycin to improve survival without development of chronic lung disease of prematurity (CLD) in preterm infants. The statistical analysis plan for the clinical outcomes of the AZTEC trial is described.Methods and designA double-blind, randomised, placebo-controlled trial of a 10-day course of intravenous azithromycin (20 mg/kg for 3 days; 10 mg/kg for 7 days) administered to preterm infants born at < 30 weeks’ gestational age across UK tertiary neonatal units. Following parental consent, infants are randomly allocated to azithromycin or placebo, with allocated treatment starting within 72 h of birth. The primary outcome is survival without moderate/severe CLD at 36 weeks’ postmenstrual age (PMA). Serial respiratory fluid and stool samples are being collected up to 21 days of life. The target sample size is 796 infants, which is based on detecting a 12% absolute difference in survival without moderate/severe CLD at 36 weeks’ PMA (90% power, two-sided alpha of 0.05) and includes 10% loss to follow-up.ResultsBaseline demographic and clinical characteristics will be summarised by treatment arm and in total. Categorical data will be summarised by numbers and percentages. Continuous data will be summarised by mean, standard deviation, if data are normal, or median, interquartile range, if data are skewed. Tests of statistical significance will not be undertaken for baseline characteristics. The primary analysis, on the intention to treat (ITT) population, will be analysed using multilevel logistic regression, within a multiple imputation framework. Adjusted odds ratios, 95% confidence intervals, and p-values will be presented. For all other analyses, the analysis population will be based on the complete case population, which is a modified ITT population. All analyses will be adjusted for gestational age and treatment arm and account for any clustering by centre and/or multiple births as a random effect.ConclusionWe describe the statistical analysis plan for the AZTEC trial, including the analysis principles, definitions of the key clinical outcomes, methods for primary analysis, pre-specified subgroup analysis, sensitivity analysis, and secondary analysis. The plan has been finalised prior to the completion of recruitment.Trial registrationISRCTN registry ISRCTN11650227. Registered on 31 July 2018.

Scrub Typhus Associated with Guillain-Barré Syndrome (GBS).

Scrub typhus is a vector-borne disease caused byOrientia tsutsugamushi. Clinical manifestations generally occur due to vasculitis and inflammation and can have variable degrees of systemic involvement. Meningoencephalitis and cerebellitis are well-known neurological manifestations of scrub typhus, but the occurrence of Guillain-Barré syndrome is extremely rare. The authors report a 7-y-old boy who developed fever followed by rapidly progressive ascending quadriparesis with areflexia and whose etiological workup revealed positive IgM scrub typhus antibody, as well as, a high OXK titer (1:80). Nerve-conduction studies in all four limbs were suggestive of demyelinating neuropathy. He showed complete recovery after treatment with intravenous immunoglobulin (2g/kg) and azithromycin.

Adjunctive azithromycin prophylaxis protects women from uterine cesarean scar defect: A randomized controlled trial.

Cesarean scar defect (CSD) is a long-term outcome of cesarean section (CS) and associated with numerous gynecological and obstetric problems. Previous studies indicate that infection may be a risk factor for CSD. Adjunctive azithromycin was shown to reduce the risk of postoperative infection in patients undergoing non-elective primary cesarean delivery in labor or after the rupture of membranes compared with standard antibiotic prophylaxis. This study investigated the protective effect of adjunctive azithromycin in combination with single-dose cephalosporin against CSD in women undergoing non-elective cesarean delivery. A randomized, double-blind, controlled clinical trial was conducted in a University hospital in Shanghai, China. A total of 242 women who underwent their first non-elective CS were randomly assigned to receive 1500 mg cefuroxime sodium plus 500 mg intravenous azithromycin (n=121; experimental group) or 1500 mg cefuroxime sodium plus a placebo (n=121; placebo group). The primary outcome was CSD prevalence, as determined by transvaginal ultrasound and saline infusion sonohysterography within 6months of delivery. Secondary outcomes were changes in infectious indicators (eg hypersensitive C-reactive protein and procalcitonin), postoperative morbidity, and use of postoperative antibiotics. We also examined the operative procedure, pathogenic microorganism cultures, and fetal outcomes. Outcomes were compared between groups with the chi-squared test, Fisher's exact test, or Student's t test. Between May 2018 and May 2021, 121 women were randomized to each arm. Because the sonographic follow up was disrupted by the coronavirus disease 2019 pandemic and strict management policies, we merged the follow-up time points (6 weeks and 6months) into a single time period (6 weeks to 6months); 104 and 108 women in the experimental and placebo groups, respectively, completed the first sonographic follow up. CSD was diagnosed by sonography in 34/104 (32.7%) and 50/108 (46.3%) patients in the experimental and placebo groups, respectively (relative risk 0.71, 95% confidence interval 0.50-0.99; p=0.043). Characteristics of CSD and short-term infection outcomes did not differ between groups. A single dose of intravenous 500 mg azithromycin adjunctive to single-dose cefuroxime prophylaxis significantly reduced the incidence of CSD in women undergoing non-elective CS.

101. Impact of an Integrated Tele-Antimicrobial Stewardship Program at a Rural Community Hospital

BackgroundSmall hospitals in the US may lack access to infectious diseases (ID) expertise despite similar rates of antimicrobial use and drug-resistant bacteria as larger hospitals. A tele-antimicrobial stewardship program (TASP) is a force multiplier, expanding access to specialty care, training, and guidance on appropriate resource utilization. Data on the impact of TASPs in community or rural inpatient settings is limited.MethodsWe established a TASP at a 160-bed hospital in Armstrong County, PA (population < 5000) in September 2020. Tele-ID consult services were already being used (Figure 1). A non-local ID pharmacist or ID physician performed prospective audits and provided feedback with 1 local pharmacist on a 30-minute video conference call daily. At TASP implementation, all patients receiving intravenous (IV) fluoroquinolones, metronidazole, and azithromycin were reviewed. Figure 1 shows the additional support following TASP implementation, including addition of ceftriaxone, carbapenems, IV vancomycin, and tocilizumab to daily reviews. A patient monitoring form was developed to track interventions and the local pharmacists were trained in documentation. Table 1 lists other TASP features implemented.Figure 1. TASP Timeline Table 1. TASP Accomplishments ResultsFrom 09/01/2020 to 04/30/2021, 304 stewardship opportunities were identified and 77% of interventions were accepted. Recommending a duration of therapy was accepted most frequently (93.5%) and de-escalation of therapy least frequently (69.6%) (Table 2). Recommending an ID consultation or diagnostic testing was always accepted but only comprised 6.2% of all interventions. Daily calls involved an average of 5 patient reviews. Monthly antimicrobial use declined on average from 673 DOT (days of therapy)/1000 PD (patient days) to 638 DOT/1000 PD (Figure 2). Daily calls were cancelled on 31/166 weekdays (18.7%) due to staffing shortages.Table 2. TASP Interventions (9/2020 - 4/2021) Figure 2. Monthly Antimicrobial Use in Days of Therapy (DOT) per 1000 Patient Days (4/2019 - 5/2021) ConclusionImplementation of TASP in a community hospital resulted in a high percentage of accepted stewardship interventions and lower antimicrobial usage. Success is dependent on robust educational efforts, establishing strong relationships with local providers, and involvement of key stakeholders. Lack of dedicated stewardship time for local pharmacists is a very significant barrier.Disclosures Erin K. McCreary, PharmD, BCPS, BCIDP, AbbVie (Consultant)Cidara (Consultant)Entasis (Consultant)Ferring (Consultant)Infectious Disease Connect, Inc (Other Financial or Material Support, Director of Stewardship Innovation)Merck (Consultant)Shionogi (Consultant)Summit (Consultant) Erin K. McCreary, PharmD, BCPS, BCIDP, AbbVie (Individual(s) Involved: Self): Consultant; Cidara (Individual(s) Involved: Self): Consultant; Entasis (Individual(s) Involved: Self): Consultant; Ferring (Individual(s) Involved: Self): Consultant; Infectious Disease Connect, Inc (Individual(s) Involved: Self): Director of Stewardship Innovation, Other Financial or Material Support; Merck (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant; Summit (Individual(s) Involved: Self): Consultant Tina Khadem, PharmD, Infectious Disease Connect, Inc. (Employee) Nancy Zimmerman, RN, BSN, I’d connect (Employee) John Mellors, MD, Abound Bio, Inc. (Shareholder)Accelevir (Consultant)Co-Crystal Pharma, Inc. (Other Financial or Material Support, Share Options)Gilead Sciences, Inc. (Advisor or Review Panel member, Research Grant or Support)Infectious DIseases Connect (Other Financial or Material Support, Share Options)Janssen (Consultant)Merck (Consultant) Rima Abdel-Massih, MD, Infectious Disease Connect (Employee, Director of Clinical Operations) Rima Abdel-Massih, MD, Infectious Disease Connect (Individual(s) Involved: Self): Chief Medical Officer, Other Financial or Material Support, Other Financial or Material Support, Shareholder J Ryan. Bariola, MD, Infectious Disease Connect (Other Financial or Material Support, salary support)

Delayed hypersensitivity to the Comirnaty coronavirus disease 2019 vaccine presenting with pneumonitis and rash

Delayed hypersensitivity to the Comirnaty coronavirus disease 2019 vaccine presenting with pneumonitis and rash

MYCOPLASMA PNEUMONIAE-INDUCED RHABDOMYOLYSIS AND PERI-MYOCARDITIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Mycoplasma pneumoniae (MP) is a common cause of community acquired pneumonia with an incidence of 1-3 per 1000 cases annually [1]. However, extrapulmonary manifestations of MP in the adult population are rare [3]. The mechanism behind injury is predicted to be caused by bacterial inflammation and vascular occlusion combined with an autoinflammatory response [2]. We present a case of a 21-year-old Hispanic male with rhabdomyolysis and peri-myocarditis caused by MP. CASE PRESENTATION: A 21-year-old Hispanic male with a past medical history of Kawasaki disease presented complaining of constant chest pain for two days. He endorsed subjective fever, dark urine, and myalgias. He had previously visited an urgent care and was prescribed ibuprofen and cyclobenzaprine to no avail. On physical exam, the patient was afebrile and tachypneic. Cardiac exam revealed tachycardia with no rubs, murmurs, or gallops. Lung fields were clear to auscultation bilaterally. Chest pain was not reproducible upon palpation. The abdomen was soft, nondistended, and without organomegaly. Initial labs revealed leukocytosis, transaminitis, elevated d-dimer, elevated troponins, elevated C-reactive protein, and elevated creatinine kinase. Admission chest x-ray was without infiltrates, cardiomegaly, or pneumothorax. Initial electrocardiogram demonstrated ST elevations in inferolateral leads. Emergent cardiac catheterization demonstrated normal coronary anatomy. CTA of the chest was negative for pulmonary embolism and aortic dissection. Original echocardiogram demonstrated normal ejection fraction. Respiratory pathogen panel was positive for MP IgM. Treatment for MP-induced rhabdomyolysis and peri-myocarditis with intravenous fluids and azithromycin was initiated. He experienced a transient systolic heart failure, managed with Bilevel Positive Airway Pressure. The rapid clearance of bacteria with proper antibiotics allowed the stunned myocardium to recuperate within 72 hours. At which point the patient experienced rapid clinical improvement and was discharged home in stable condition. DISCUSSION: The diagnosis of MP is difficult due to its cellular structure, its ability to be missed on routine blood cultures, and its ability to cause extrapulmonary manifestation via autoimmune dysfunction [2]. The case demonstrates a patient with rhabdomyolysis and peri-myocarditis with positive MP IgM. The patient also experienced rapid clinical improvement with clearance of bacteria by antibiotic administration. Thus, we were able to diagnose another rare manifestation of a MP infection causing rhabdomyolysis and peri-myocarditis. CONCLUSIONS: MP is difficult to isolate and has the ability to present with myriad symptomatology. Although MP is difficult to diagnose, it is easily treated. Therefore, MP should be considered in young patients due to its increased incidence in the younger population and unique presentations. REFERENCE #1: Foy, H. M., Kenny, G. E., Cooney, M. K., & Allan, I. D. (1979). Long-Term Epidemiology of Infections with Mycoplasma pneumoniae. Journal of Infectious Diseases, 139(6), 681–687. https://doi.org/10.1093/infdis/139.6.681 REFERENCE #2: Narita, M. (2016). Classification of Extrapulmonary Manifestations Due to Mycoplasma pneumoniae Infection on the Basis of Possible Pathogenesis. Frontiers in Microbiology, 7. https://doi.org/10.3389/fmicb.2016.00023 REFERENCE #3: Khan, F. Y., & Sayed, H. (2012). Rhabdomyolysis associated with Mycoplasma pneumoniae pneumonia. Hong Kong medical journal, 18(3), 247–249. DISCLOSURES: No relevant relationships by Taleb El-Masri, source=Web Response No relevant relationships by Alex Morizio, source=Web Response No relevant relationships by Tram Nguyen, source=Web Response No relevant relationships by Elena Tellez, source=Web Response No relevant relationships by Yaswanraj Yuvaraj, source=Web Response

CHRONIC CAVITARY PULMONARY ASPERGILLOSIS IN A PATIENT WITH IDIOPATHIC PULMONARY FIBROSIS

TOPIC: Diffuse Lung Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Chronic cavitary pulmonary aspergillosis (CCPA) is a rare form of aspergillosis involving patients with structural lung diseases. Here we will describe a case of CCPA in a patient with idiopathic pulmonary fibrosis (IPF), which is rarely reported. CASE PRESENTATION: The patient was a 78-year-old male with a medical history significant for IPF diagnosed 13 years prior, on oral pirfenidone and long-term oxygen therapy, who presented to the hospital for worsening shortness of breath, productive cough, and fatigue of two months duration. The patient was initially hospitalized in another facility for the above symptoms where he received two courses of antibiotics without significant improvement. Chest examination showed bilateral fine inspiratory crackles, worse on the right side. The results of routine blood tests were normal. The nasal swab for the respiratory viral panel was negative. Chest X-ray showed fibrotic lung disease with a superimposed alveolar and interstitial process involving the lung bases and right upper lobe. Computed Tomography (CT) scan of the chest was suggestive of a thick-walled cavitary lesion in the right apex measuring 4.8 x 3.3 cm, enlarged mediastinal and right hilar lymph nodes along with other chronic changes. Three sets of sputum acid-fast bacilli (AFB) smears along with serum Quantiferon TB gold plus test were negative. The patient was empirically started on intravenous (IV) ceftriaxone and azithromycin. Later, blood and sputum cultures were reported negative for bacteriological growth. Interestingly, the sputum cultures were positive for Aspergillus species along with positive serum Aspergillus immunoglobulin (Ig)G level. The patient was diagnosed with CCPA based on the serology, culture results, and radiological findings. IV antibiotics were discontinued and the patient was started on oral posaconazole 300 mg daily resulting in clinical improvement. Currently, the patient is on a 6-month posaconazole regimen. DISCUSSION: Pulmonary aspergillosis is a common opportunistic infection that can present as aspergilloma, allergic bronchopulmonary aspergillosis, CCPA, and invasive pulmonary aspergillosis based on lung changes. Mycobacterium infection and obstructive lung diseases are the most frequent underlying pulmonary diseases that are associated with CCPA. However, IPF with CCPA is rare, and its clinical features and radiological findings lack specificity leading to delays in diagnosis and treatment. Once confirmed, the treatment is straightforward with long-term triazole antifungals. CONCLUSIONS: In a patient with IPF, presenting with rapidly progressing radiologic findings suggestive of pulmonary cavitation, CCPA should be considered in the differential diagnosis. REFERENCE #1: Liu C, Yang J, Lu Z. Idiopathic pulmonary fibrosis with chronic necrotizing pulmonary aspergillosis: a case report. Int J Clin Exp Pathol. 2019 Jul 1;12(7):2653-2656. PMID: 31934094; PMCID:PMC6949565 REFERENCE #2: Graham KG, Nasir A. Chronic Cavitary Pulmonary Aspergillosis: A Case Report and Review of the Literature. Am J Case Rep. 2019 Aug 18;20:1220-1224 doi: 10.12659/AJCR.915893. PMID: 31422416; PMCID: PMC6711266. REFERENCE #3: Sehgal IS, Dhooria S, Muthu V, Prasad KT, Agarwal R. An overview of the available treatments for chronic cavitary pulmonary aspergillosis. Expert Rev Respir Med. 2020 Jul;14(7):715-727. doi: 10.1080/17476348.2020.1750956. Epub 2020 Apr 20. PMID: 32249630. DISCLOSURES: No relevant relationships by Rabab Elmezayen, source=Web Response No relevant relationships by Syed yousaf Shah, source=Web Response

A CASE OF MISTAKEN IDENTITY: PULMONARY BLASTOMYCOSIS DIAGNOSED AS PULMONARY CRYPTOCOCCOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Community acquired pneumonia (CAP) has a wide range of differential diagnosis with high potential for misdiagnosis. We report a case of Blastomycosis in an Appalachian hunter who was misdiagnosed with bacterial and Cryptococcal pneumonia. This case highlights the importance of evaluating CAP etiologies based on patients' epidemiological risks. CASE PRESENTATION: A 32-year-old West Virginian man with a history of recurrent sinusitis, body-mass index of 18, current smoker, and avid hunter presented with dyspnea and dry cough. Initially, at an outside facility 3 weeks prior, chest x-ray showed a left upper lobe consolidation. He was prescribed a 10-day course of levofloxacin and steroid taper, but his symptoms did not improve. Further evaluation with computed tomography (CT) chest showed a 1.6-centimeter necrotic lymph node in the subcarinal area and consolidation in the left upper lobe and lingula. He was admitted and received empiric intravenous vancomycin, piperacillin-tazobactam, and azithromycin. Severe acute respiratory syndrome coronavirus 2 and human immunodeficiency virus tests were negative. Initial pathology read of lingula biopsy was stratified squamous epithelia with enmeshed clusters of cysts with double walls and inclusion bodies suggestive of Cryptococcus neoformans. Antibiotics were discontinued and fluconazole was started, but he developed a fever of 103⁰ Fahrenheit. Then, he was transferred to our hospital for further management. Serum Blastomyces and Histoplasma antigens were positive. Silver staining of the original biopsy specimen showed a thick-walled yeast and broad-based budding forms suggestive of Blastomyces. Fluconazole was changed to itraconazole. The patient improved and resumed daily activities. DISCUSSION: It is important to consider individual patients' risk factors to aid in narrowing the broad differential diagnosis for CAP to minimize morbidity. In this case, the patient was empirically treated for bacterial CAP despite having no improvement after taking levofloxacin, a broad-spectrum antibiotic. Differential diagnoses should include fungal etiology due to the patient's hunting history. Identifying the fungus is important, especially in Blastomycosis since it is often missed, which leads to delay in diagnosis, inappropriate treatment, and disease progression. CAP diagnosis is made with visualization of the fungus due to cross-reactivity in serologic tests. Treatment is specific to the organism. Cryptococci spp. are encapsulated, narrow-based budding yeasts, found in immunocompromised patients, and treated with fluconazole. However, Blastomyces are broad-based budding yeasts, found in areas surrounding the Ohio and Mississippi River valleys, and treated with itraconazole. CONCLUSIONS: It is important to consider individual patients' risk factors to aid in narrowing the broad differential diagnosis for CAP to minimize morbidity. REFERENCE #1: Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev. 2011;24(2):247-280. doi:10.1128/CMR.00053-10 REFERENCE #2: Kanjanapradit K, Kosjerina Z, Tanomkiat W, Keeratichananont W, Panthuwong S. Pulmonary Cryptococcosis Presenting With Lung Mass: Report of 7 Cases and Review of Literature. Clin Med Insights Pathol. 2017;10:1179555717722962. Published 2017 Aug 4. doi:10.1177/1179555717722962 REFERENCE #3: Martynowicz MA, Prakash UB. Pulmonary blastomycosis: an appraisal of diagnostic techniques. Chest. 2002;121(3):768-773. doi:10.1378/chest.121.3.768 DISCLOSURES: No relevant relationships by Allison Lastinger, source=Web Response No relevant relationships by Shu Xian Lee, source=Web Response No relevant relationships by Yusra Shah, source=Web Response

Acute pancreatitis associated with severe acute respiratory syndrome coronavirus-2 infection: a case report and review of the literature

IntroductionWe report a case of Severe acute respiratory syndrome coronavirus-2 infection with acute pancreatitis as the only presenting symptom. To the best of our knowledge, there are few case reports of the same presentation.Case presentationAn otherwise healthy 44-year-old white male from Egypt presented to the hospital with severe epigastric pain and over ten attacks of nonprojectile vomiting (first, gastric content, then bilious). Acute pancreatitis was suspected and confirmed by serum amylase, serum lipase, and computed tomography scan that showed mild diffuse enlargement of the pancreas. The patient did not have any risk factor for acute pancreatitis, and extensive investigations did not reveal a clear etiology. Given a potential occupational exposure, a nasopharyngeal swab for polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 was done, which was positive despite the absence of the typical symptoms of severe acute respiratory syndrome coronavirus 2 such as fever and respiratory symptoms. The patient was managed conservatively. For pancreatitis, he was kept nil per os for 2 days and received intravenous lactated Ringer’s (10 ml per kg per hour), nalbuphine, alpha chymotrypsin, omeprazole, and cyclizine lactate. For severe acute respiratory syndrome coronavirus 2, he received a 5-day course of intravenous azithromycin (500 mg per day). He improved quickly and was discharged by the fifth day. We know that abdominal pain is not a rare symptom of severe acute respiratory syndrome coronavirus 2, and we also know that elevated levels of serum amylase and lipase were reported in severe acute respiratory syndrome coronavirus-2 patients, especially those with severe symptoms. However, the association between severe acute respiratory syndrome coronavirus-2 infection and idiopathic acute pancreatitis is rare and has been reported only a few times.ConclusionWe believe further studies should be conducted to determine the extent of pancreatic involvement in severe acute respiratory syndrome coronavirus-2 patients and the possible causality between severe acute respiratory syndrome coronavirus 2 and acute pancreatitis. We reviewed the literature regarding the association between severe acute respiratory syndrome coronavirus 2 and acute pancreatitis patients. Published data suggest that severe acute respiratory syndrome coronavirus 2 possibly could be a risk factor for acute pancreatitis.

Lyme Borreliosis Associated with Sensorineural Hearing Loss: A Case Report

Background: Lyme borreliosis is a tick-borne infection caused by Borrelia species. It has a geographic distribution that makes it more frequent in certain regions like like North America and Europe. It manifests in a wide range of symptoms but is often under-investigated in patients presenting with sensorineural hearing loss (SNHL). Case Report: In this report, we describe a case presenting with SNHL as a manifestation of neuroborreliosis in a female adult patient suffering from Lyme disease, with multiple metachronous symptoms, including arthritis and seizures. Lyme borreliosis (LB) was clinically diagnosed and supported by positive serologic tests, along with Babesiosis. The patient was treated with intravenous (IV) ceftriaxone and azithromycin, in addition to oral atovaquone. Improvement after 4 weeks of IV ceftriaxone was noted in all aspects, including SNHL and arthritis. Conclusion: LB is a possible, but rare, etiology of hearing impairment. It has been documented that if treatment is initiated early, improvement and even complete recovery are possible. Hence, in a patient presenting with SNHL and a high index of suspicion for LB, assessment for LB is warranted.

Pregnancy latency after preterm premature rupture of membranes: oral versus intravenous antibiotics

Following the destruction of pharmaceutical production facilities in Puerto Rico by Hurricane Maria in September 2017, a shortage of small-volume bags of sterile intravenous fluid for infusion led to a decreased ability to administer intravenous azithromycin and ampicillin efficiently for use in the treatment of patients with preterm premature rupture of membranes. This study aimed to assess pregnancy latency after preterm premature rupture of membranes following treatment with oral-only antibiotics compared with treatment with intravenous antibiotics followed by oral antibiotics. This is a retrospective historic control study comparing women with preterm premature rupture of membranes who were initiated on a 7-day oral-only regimen of azithromycin and amoxicillin (modified regimen) during a 12-month period beginning December 2017 (during which time there was a shortage of small-volume bags of intravenous fluid) to women with preterm premature rupture of membranes who were initiated on a 2-day regimen of intravenous ampicillin and azithromycin followed by 5 days of oral amoxicillin and azithromycin (standard regimen) from December 2016 to December 2018. Women were included in the study if they were diagnosed with preterm premature rupture of membranes at <34 weeks' gestation and were started on latency antibiotics, and women were excluded from the study if they had a contraindication to expectant management, a cerclage, or suspected fetal anomalies. The primary outcome was pregnancy latency, defined as time from the first dose of antibiotics to delivery. The 37 women who received the modified regimen and the 79 women who received the standard regimen had similar baseline characteristics. Mean (standard deviation) gestational age at time of preterm premature rupture of membranes was similar between the modified (30.5 weeks' gestation [±3.1]) and standard regimen groups (30.2 weeks' gestation [±3.2]), and the rate of group B streptococcus rectovaginal colonization was similar for both groups (27% vs 24%; P=.95). Pregnancy latency did not differ in the modified vs standard regimen (mean difference, -0.15 days; 95% confidence interval, -4.87 to 4.58) There was no statistically significant difference in the relative risk of composite maternal infection (relative risk, 0.43; 95% confidence interval, 0.05-3.53) or composite neonatal infection (relative risk, 0.43; 95% confidence interval, 0.05-3.52). Although limited by small sample size, our study suggested that adoption of an oral-only antibiotic regimen for pregnancy latency following preterm premature rupture of membranes is worthy of further study.

Recommendations on off‐label use of intravenous azithromycin in children

Intravenous azithromycin (AZM) has been widely used in children worldwide, but there still remains much concern regarding its off-label use, which urgently needs to be regulated. Therefore, we developed a rapid advice guideline in China to give recommendations of rational use of intravenous AZM in children. This guideline focuses on antimicrobial therapy with intravenous AZM in children. The Delphi research method was used to select questions. A systematic literature review was also conducted. Data were pooled and ranked according to the GRADE system. Recommendations were developed based on expert clinical experience, patients' values and preferences, and evidence availability. After an external review, the recommendations were revised and approved. This guideline included eighteen recommendations that covered four domains: (a) Indications: the treatment of pneumonia caused by atypical but common pathogens, such as Mycoplasma pneumoniae, Chlamydia trachomatis or Chlamydophila pneumoniae and Legionella pneumophila, more typical bacteria as well as the treatment of bronchitis of presumed bacterial aetiologies; (b) Usage and dosage: administration route, infusion concentrations, treatment duration, course of sequential treatment, and dosage stratified by age; (c) Adverse reactions and treatment: the management of gastrointestinal reactions, arrhythmias, pain or phlebitis at the infusion site, and anaphylaxis; and (d) Special population: children with renal or liver dysfunction, congenital heart disease, and obesity. This guideline will hopefully help promote a rational use of intravenous AZM in children worldwide. This guideline has summarised the evidence and has developed recommendations on the use of intravenous AZM in children worldwide. Further attention and well-designed researches should be conducted on the off-label use of intravenous AZM in children.

Septic shock due to Yersinia pseudotuberculosis infection in an adult immunocompetent patient: a case report and literature review

BackgroundYersinia pseudotuberculosis infection can occur in an immunocompromised host. Although rare, bacteremia due to Y. pseudotuberculosis may also occur in immunocompetent hosts. The prognosis and therapeutic strategy, especially for immunocompetent patients with Y. pseudotuberculosis bacteremia, however, remains unknown.Case presentationA 38-year-old Japanese man with a mood disorder presented to our hospital with fever and diarrhea. Chest computed tomography revealed consolidation in the right upper lobe with air bronchograms. He was diagnosed with pneumonia, and treatment with intravenous ceftriaxone and azithromycin was initiated. The ceftriaxone was replaced with doripenem and the azithromycin was discontinued following the detection of Gram-negative rod bacteria in 2 sets of blood culture tests. The isolated Gram-negative rod bacteria were confirmed to be Y. pseudotuberculosis. Thereafter, he developed septic shock. Doripenem was switched to cefmetazole, which was continued for 14 days. He recovered without relapse.ConclusionsWe herein report a case of septic shock due to Y. pseudotuberculosis infection in an adult immunocompetent patient. The appropriate microorganism tests and antibiotic therapy are necessary to treat patients with Y. pseudotuberculosis bacteremia.

Respiratory Distress in an Adolescent Girl.

1. Bobby Kumar, MD* 2. Katie Meyer, DO* 3. Leon Rosenberg, DO* 4. Alyson Trillo, DO* 5. Ashley Van Putten, DO, PGY3* 1. *Salah Foundation Children’s Hospital, Fort Lauderdale, FL A 17-year-old girl with past medical history of iron deficiency anemia and depression presented with 6 days of fever (maximum temperature of 103.6°F), cough, congestion, and mild shortness of breath. Other symptoms included nonbloody, nonbilious emesis, decreased appetite, diarrhea, chest pain, body aches, and abdominal pain. When her shortness of breath worsened, she presented to the emergency department for evaluation. On presentation, she was febrile, with oral temperature of 103.1°F, tachycardia, and in severe respiratory distress with subcostal and supraclavicular retractions, decreased breath sounds on the bases, and significant crackles on the right side. Initial oxygen saturation was 89% on room air, with improvement to 98% on 2 L/min of oxygen via nasal cannula. Chest radiograph shows extensive right-sided infiltrates as well as a focal patchy infiltrate on the left (Fig 1). Figure 1. Anteroposterior (a) and lateral (b) chest radiographs showing extensive right-sided infiltrates with patchy infiltrates on the left. Due to right upper quadrant abdominal pain and persistent diarrhea, an abdominal ultrasound was performed, which was unremarkable. Initial laboratory testing on admission revealed no elevated white blood cell count, mild microcytic anemia (hemoglobin 11.3 g/dL, mean corpuscular volume 60.6), hyponatremia (sodium 125 mmol/L), hypokalemia (potassium 3.3 mmol/L), elevated aspartate aminotransferase (141 units/L) and alanine aminotransferase (57 units/L), elevated γ -glutamyl transferase (52 units/L), prolonged coagulation studies (prothrombin time 17.7 seconds and partial thromboplastin time 30.0 seconds), minimally elevated lipase (200 units/L), positive toxicology for cannabis, elevated C-reactive protein of 36.6 mg/dL, negative urine pregnancy test, urinalysis with 100 mg/dL of protein, and a specific gravity of 1.024. Screening for sexually transmitted infections was negative. The …

Study protocol: azithromycin therapy for chronic lung disease of prematurity (AZTEC) - a randomised, placebo-controlled trial of azithromycin for the prevention of chronic lung disease of prematurity in preterm infants

IntroductionChronic lung disease of prematurity (CLD), also known as bronchopulmonary dysplasia (BPD), is a cause of significant respiratory morbidity in childhood and beyond. Coupled with lung immaturity, infections (especially by...

Use of Azithromycin for the Prevention of Lung Injury in Mechanically Ventilated Preterm Neonates: A Randomized Controlled Trial

Introduction: Macrolides have anti-inflammatory and immunomodulatory properties that give this class of antibiotics a role that differs from its classical use as an antibiotic, which opens new therapeutic possibilities. Objective: The aim of this study was to evaluate the anti-inflammatory effect of azithromycin in preventing mechanical ventilation (MV)-induced lung injury in very-low-birth-weight preterm neonates. Methods: This is a randomized, double-blind, placebo-controlled trial of preterm neonates who received invasive MV within 72 h of birth. Patients were randomized to receive intravenous azithromycin (at a dose of 10/mg/kg/day for 5 days) or placebo (0.9% saline) within 12 h of the start of MV. Two blood samples were collected (before and after intervention) for measurement of interleukins (ILs) and PCR for Ureaplasma. Patients were followed up throughout the hospital stay for the outcomes of death and broncho­pulmonary dysplasia defined as need for oxygen for a period of ≥28 days of life (registered at ClinicalTrials.gov, No. NCT03485703). Results: Forty patients were analyzed in the azithromycin group and 40 in the placebo group. Five days after the last dose, serum IL-2 and IL-8 levels dropped significantly in the azithromycin group. There was a significant reduction in the incidence of death and O₂ dependency at 28 days/death in azithromycin-treated patients regardless of the detection of Ureaplasma in blood. Conclusions: Azithromycin has anti-inflammatory effects, with a decrease in cytokines after 5 days of use and a reduction in death and O₂ dependency at 28 days/death in mechanically ventilated preterm neonates.

Meta-analysis of Xiaoer Xiaoji Zhike Oral Liqud combined with azithromycin in treatment of mycoplasma pneumonia in children

Systematic evaluation of the effectiveness and safety of Xiaoer Xiaoji Zhike Oral Liqud combined with azithromycin in the treatment of mycoplasma pneumonia in children. Clinical literatures were retrieved from PubMed, Cochrane Library, EMbase, VIP, CNKI, SinoMed, WanFang from inception to September 2019. Two reviewers independently screened out the literatures, extracted data and assessed the risk of bias of the included studies. Then, Meta-analysis was performed by RevMan 5.3 software. A total of 17 RCT were included, involving 1 712 patients. In this study, there were two subgroups by the application approach of azithromycin: oral azithromycin subgroup and intravenous azithromycin subgroup. According to Meta-analysis results, in terms of the alleviation of clinical symptoms and signs, such as shortening of antifebrile time, cough disappeared time, rales disappearance time, and lung X-ray infiltrating shadow disappearance time, Xiaoer Xiaoji Zhike Oral Liquid combined with oral azithromycin or intravenous azithromycin were better than single-dose azithromycin; in the aspect of the improvement of the overall effective rate, the two combination subgroups were better than the single-use azithromycin; In terms of the decline of IgM, the combination subgroups were also more efficient than the single-use azithromycin, with statistically significant differences. In terms of the incidence of adverse reactions, there was no significant difference between the two combination subgroups and the single-use azithromycin in children, and no serious adverse reactions were found. In inclusion, Xiaoer Xiaoji Zhike Oral Liquid combined with azithromycin can improve the clinical efficacy in treating pediatric mycoplasma pneumonia, with a high safety. Due to the limited quantity and quality of the included studies, more high-quality studies are needed to verify the above conclusion.