Intravenous Metronidazole Research Articles

Impact of an enhanced anti-infection prophylaxis strategy for pancreatoduodenectomy: a single centre analysis

Introduction Surgical site infection (SSI) after pancreatoduodenectomy (PD) is a significant concern. Targeted antibiotic prophylaxis (pAP) has been tested to mitigate antibiotic resistance patterns, especially after preoperative bile duct stenting. The aim of this study was to investigate the effect of enhanced anti-infective prophylaxis (EAP) on the incidence of superficial and intraabdominal SSI.MethodsAll patients who underwent PD at a single centre between May 2018 and May 2021 were retrospectively analysed. A control cohort of patients who received pAP with intravenous cefuroxime and metronidazole and routine intraoperative abdominal lavage according to the surgeons’ preferences. Since March 2020, pAP has been changed to piperacillin/tazobactam according to local resistance patterns and combined with routine intraoperative extended abdominal lavage (EIPL). Preoperative selective decontamination of the digestive tract (SDD) has been applied routinely since Jan 2019.ResultsIn total, 163 patients were included. The standard (n = 100) and EAP (n = 63) groups did not significantly differ with regard to pertinent patient and operative characteristics. In the EAP group, the rates of SSI (14% vs. 37%, p = 0.002, total rate: 28%) and urinary tract infection (24% vs. 8%, p = 0.011, total rate 18%) were significantly lower. Other septic complications were not significantly different. In addition, the risk of developing gastrointestinal bleeding and delayed gastric emptying was significantly lower in the EAP group. Multivariate analysis showed that an age > 67 years was a significant risk factor for SSI.ConclusionThe results indicate that enhanced anti-infective prophylaxis may significantly decrease the incidence of SSI in patients after PD.

The role of magnesium sulphate infusion in controlling muscle spasms and rigidity in a child with severe generalised tetanus unresponsive to diazepam in a resource-limited hospital – a case report and literature review

Tetanus is an acute and potentially fatal spastic paralytic disease. This case aims to describe the role of magnesium sulphate infusion in controlling muscle spasms and rigidity in a child with severe generalised tetanus in a resource-limited hospital. A six-year-old unimmunised child with severe tetanus was brought to the emergency unit of the Kalabahi Regional Hospital. The patient was treated with intramuscular human tetanus immunoglobulin, intravenous metronidazole, and ceftriaxone. Diazepam infusion was administered and gradually increased to a dose of 140 mg/day. The patient was unresponsive to diazepam, so intravenous magnesium sulphate was administered at a dose of 100 mg/kg for 30 minutes, followed by an infusion at 40 mg/kg/hour. The patient responded well to the treatment and was discharged from the hospital on day 28. Magnesium sulphate infusion can be an effective adjunctive therapy to control muscle spasms and rigidity in children with severe generalised tetanus.

EP568 - A rare case of necrotizing fasciitis caused by Streptococcus Anginosus and Staphylococcus Lugdunensis

Abstract Necrotizing fasciitis (NF) is a rare soft tissue infection involving the fascial planes, causing rapid and extensive tissue destruction. We present a unique case of NF in a patient with poor glycemic control caused by atypical pathogens. A 66-year-old female with a recent biopsy for a wart-like lesion developed a wound infection, with greenish-black exudate. Initial observations were: temperature: 39.4 degrees, heart rate: 105, GCS: 15/15. Physical examination revealed a grossly filiform lesion below her abdominal apron measuring 7cm in diameter. The patient was empirically treated with IV Co-Amoxiclav. Abnormal biochemistry results are shown below. Microbiological analysis revealed Streptococcus Anginosus, anaerobes and Staphylococcus Lugdunensis. CT abdomen revealed extensive inflammatory changes with gas and fluid collection and enlarged pelvic and inguinal lymph nodes. Two urgent surgical explorations and debridements, with meticulous wound care using negative pressure wound dressings (Prevena) were done. Intravenous Gentamicin, Benzylpenicillin, Clindamycin, Metronidazole and Flucloxacillin were administered for six weeks. The patient's clinical status gradually improved. Streptococcus Anginosus, that is part of the Streptococcus Milleri group and Staphylococcus Lugdunensis, a coagulase-negative Staphylococci (CoNS) are commensal organisms of the oral and gastrointestinal tracts. These organisms possess virulence factors that facilitate tissue invasion and destruction, causing an aggressive course of NF. This case highlights the importance of considering atypical pathogens, especially in patients with predisposing factors such as diabetes and obesity. Early recognition, prompt surgical intervention and a multidisciplinary approach are essential for improving outcomes in these cases.TestResultWhite Blood Cells (WBC)22,200 [WBCs per microliter]Sodium123 [mmol/L]Chloride88 [mmol/L]C-reactive protein (CRP)318 [mg/L]Blood Glucose19.3 [mmol/L]

Amoebic Liver Abscess Multifocal with Bilateral Parapneumonic Effusion: A Case Report

A liver abscess is defined as a pus-filled mass in the liver that can develop from injury to the liver or an intraabdominal infection disseminated from the portal circulation. The majority of these abscesses are categorized into pyogenic or amoebic, although a minority is caused by parasites and fungi. Most amoebic infections are caused by Entamoeba histolytica. Complications of amoebic liver is abscess Pleuropulmonary involvement, which is reported in 20–30% of patients. A male patient, 53 years old, was admitted to Hospital for Upper right abdominal pain, Fever, Cough, Pain in the lower right chest. Chest examination found weakened bronchovesicular breath sounds as high as RIC V, Pleural Friction Rub, wet crackles. Abdominal Examination found supel palpation, liver palpable 2 fingers below the arcus costae and 2 fingers below the process xiphoid, blunt edge, soft consistency, tenderness pain in the dextra hypochondrium. Laboratory report Anti Amoeba : Positive 40,3 unit. The patient was given intravenous metronidazole therapy 3x750 mg for 10 days. Complications of Amoebic Liver Abscess is Pleuropulmonary involvement. Pulmonary and pleural amebiasis is an uncommon disease, usually occurring on the right side of the lung compared to the left side. Pulmonary amoebiasis is a life-threatening, but treatable, condition.

Antimicrobial treatment for human intestinal spirochaetosis: a systematic review

IntroductionThe antimicrobial treatment options for patients with intestinal spirochaetosis (caused by Brachyspira pilosicoli and Brachyspira aalborgi) are not well defined. We aimed to systematically review the literature to explore antimicrobial...

To assess the effectiveness of intravenous metronidazole as an analgesic in post hemorrhoidectomy patients

To assess the effectiveness of intravenous metronidazole as an analgesic in post hemorrhoidectomy patients

Screening for Bacterial Vaginosis Prior to Delivery: A Cost-Effectiveness Study.

The objective of this study was to compare the cost and effectiveness of three strategies for screening and/or treating bacterial vaginosis (BV) during pregnancy prior to delivery: (1) the current standard of care was neither test nor treat for BV (Treat None); (2) test all patients for BV at 36 weeks' gestation; treat if positive (Test Treat); and (3) treat all patients undergoing cesarean delivery with intravenous metronidazole at time of surgery (Treat All Cesarean). Effectiveness was defined as avoidance of postpartum surgical site infection (SSI). A decision analytic cost-effectiveness model was designed from a third-party payer perspective using clinical and cost estimates obtained from the literature, American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2019), 2019 National Vital Statistics, Medicare costs, and wholesale drug costs. Cost estimates were inflated to 2020 U.S. dollars. For this study, effectiveness was defined as avoidance of postpartum SSIs. The base case analysis that is the current standard of care of not routinely testing and treating patients for BV (Treat None) was the most expensive and least effective strategy, with a mean cost of $59.16 and infection rate of 3.71%. Empirically treating all patients for BV without testing (Treat All Cesarean) was the most effective and the least expensive strategy, with a mean cost of $53.50 and an infection rate of 2.75%. Testing all patients for BV and treating those positive for BV (Test Treat) was also relatively inexpensive and effective, with an infection rate of 2.94% and mean cost of $57.05. Compared with Treat None, we would expect the Treat All Cesarean strategy to reduce the infection rate by 26%. These findings suggest that treating pregnant patients with intravenous metronidazole at time of cesarean delivery could be an effective and cost-saving strategy. Testing and treating for BV could also be considered a reasonable strategy, as it has the added benefit of preserving antibiotic stewardship. In no analysis was the standard of care strategy of neither testing nor treating for BV before delivery the preferred strategy. · BV colonization may increase surgical site infection risk after cesarean section.. · Treatment of BV before or during delivery may be cost-saving strategies as treatment could prevent costs associated with infection.. · Further study is needed to best balance the risk of surgical site infection with antibiotic stewardship..

Multiple brain abscess in systemic lupus erythematosus patients

Introduction: Because SLE patients receive immunosuppressive and glucocorticoid medication, they are more susceptible to opportunistic infections. Multiple brain abscesses are an extremely uncommon side effect of systemic lupus erythematosus (SLE). Case description: The purpose of this case study is to raise awareness of the 14-year-old girl who reported experiencing weakness in her limbs. A year ago, she received a diagnosis of systemic lupus erythematosus. Upon physical examination, nervus VII central paresis was discovered; the lower extremities' muscular strength was 3333/2222 and the upper extremities' 3333/2222. A head CT scan revealed findings that were consistent with lupus cerebritis. Multiple ring lesions with extensive edoema were detected by magnetic resonance imaging, raising the possibility of multiple brain abscesses. For six weeks, the patient had intravenous metronidazole and ceftriaxone. The patient was allowed to go home with instructions to keep taking corticosteroids and mycophenolic acid as well as to schedule routine outpatient appointments. This case study aims to raise awareness about the 14-year-old girl who reported experiencing weakness in her limbs. Her condition was identified by specialists as systemic lupus erythematosus a year ago. Upon physical examination, nervus VII central paresis was discovered; the lower extremities' muscular strength was 3333/2222 and the upper extremities' 3333/2222. A head CT scan revealed findings that were consistent with lupus cerebritis. Multiple ring lesions with extensive edoema were detected by magnetic resonance imaging, raising the possibility of multiple brain abscesses. For six weeks, the patient received metronidazole and ceftriaxone intravenously. We sent the patient home with instructions to keep taking mycophenolic acid and corticosteroids and to make routine outpatient appointments. This case study aims to raise awareness about the 14-year-old girl who reported experiencing weakness in her limbs. Her condition was identified by specialists as systemic lupus erythematosus a year ago. Upon physical examination, nervus VII central paresis was discovered; the lower extremities' muscular strength was 3333/2222 and the upper extremities' 3333/2222. A head CT scan revealed findings that were consistent with lupus cerebritis. Multiple ring lesions with extensive edoema were detected by magnetic resonance imaging, raising the possibility of multiple brain abscesses. For six weeks, the patient received metronidazole and ceftriaxone intravenously. We sent the patient home with instructions to keep taking mycophenolic acid and corticosteroids and to make routine outpatient visits. Conclusion: It is critical to being aware that individuals with impaired immune systems should always be suspected of having an opportunistic central nervous system infection when they experience new neurologic symptoms. A brain abscess is a chronic infection of the central nervous system that can arise from a number of risk factors and infection sources. A brain abscess is one of the uncommon side effects of SLE.

Amoebic liver abscess in an adult Nigerian: A case report

Background: Amoebic liver abscess (ALA) is a parasitic infection caused by Entamoeba histolytica. ALA is a significant health concern, particularly in regions with poor sanitation and hygiene practices. Radiological imaging plays a crucial role in the diagnosis and management of ALA. Methods: We present a case report of a 40-year-old male patient with ALA. The patient presented to a radio diagnostic centre in Umuahia with right upper quadrant abdominal pain, fever,diarrhea and weight loss. Radiological evaluation was performed using abdominal ultrasound and contrast-enhanced CT scan. The imaging findings were correlated with clinical presentation and laboratory investigations. Results: The radiological findings revealed a focal hypoechoic lesion in the right hepatic lobe with ill-defined margins and internal echoes suggestive of liquefaction. The contrast-enhanced CT scan confirmed the presence of a well-defined, hypodense lesion with peripheral enhancement and central hypoattenuation. No evidence of biliary ductal dilatation or vascular invasion was observed. Based on the findings, a diagnosis of ALA was made, and the patient was initiated on intravenous metronidazole therapy. Follow-up imaging demonstrated a decrease in abscess size and resolution of internal echoes, indicating a positive response to treatment. Conclusion: Radiological imaging, including ultrasound and CT scan, plays a pivotal role in the diagnosis and management of ALA. The characteristic imaging findings, such as hypoechoic lesions with internal echoes and peripheral enhancement with central hypoattenuation, aid in differentiating ALA from other hepatic lesions. Early diagnosis and prompt initiation of appropriate therapy are crucial for favorable patient outcomes. Radiological follow-up allows monitoring of treatment response and guides further management decisions.

On the use of intravenous metronidazole for severe and complicated Clostridioides difficile infection: a review and meta-analysis.

The European Society of Clinical Microbiology and Infectious Disease (ESCMID) has advised against the use of metronidazole for fulminant Clostridioides difficile (C. difficile) infection (CDI) in their latest guidelines. They suggest using oral vancomycin alone instead. This recommendation is based on a few retrospective studies, which have multiple biases. We evaluated the three studies that led ESCMID to advise against intravenous metronidazole for fulminant CDI and performed a meta-analysis. The meta-analysis revealed a mild (2.7%), not statistically significant (p=0.8) difference in mortality between the two groups. The high heterogeneity (I2= 89%) should also be noted. The decision to add or remove metronidazole should be discussed in the near future. In the meantime, combination therapy could be a cautious treatment for fulminant CDI.

The Prevalence and The Association of Antibiotic Practices with Surgical Site Infection Following Cesarean Section

Background: This study focuses on Cesarean section (CS) procedures and the associated risk of surgical site infections (SSIs). The global CS rate is currently at 21%, higher than the recommended 15%, leading to an increased risk of SSIs. These infections are a significant burden on economies, healthcare systems, patients, and their families, despite being preventable. The research aims to address the issue in Uganda, where the burden of SSIs stands at 15.5%. While previous studies have examined various risk factors, such as age, parity, surgeon expertise, and antiseptic solutions, there is a lack of research on pre- and post-CS antibiotic practices and their connection to SSIs. This study seeks to establish the prevalence of SSIs and evaluate the antibiotic practices before and after CS procedures at Mbale Regional Referral Hospital from January 1, 2020, to December 31, 2022.Methods: The design was retrospective cross-sectional. Consecutively selected 104 patient files that developed SSIs and randomly an equal number of patient files that did not develop SSIs to make up a sample size of 208 files that were reviewed at Mbale regional referral hospital (MRRH) from 1st –January -2020 to 31st -December-2022.Result: The prevalence of surgical site infections (SSIs) was 4.3%. Among the 208 patient files reviewed, 71.2% received antibiotic prophylaxis, with intravenous ceftriaxone being the most common (47.1%). However, only 14.9% received prophylaxis within the recommended 30-60 minutes before incision. Post-cesarean section, 92.8% received intravenous ceftriaxone and metronidazole, and the mean hospital stay was 2.74 days. Factors significantly associated with reduced SSI risk were the timing of antibiotic prophylaxis, administration of intravenous antibiotics post-cesarean, oral antibiotics post-cesarean, duration of hospital stay, and the cadre of the surgeonConclusion: The prevalence of surgical site infections (SSIs) at Mbale Regional Referral Hospital (MRRH) was found to be 4.3%. This study highlighted several factors that were associated with a reduced risk of SSIs in women undergoing Cesarean section (CS), including timely administration of antibiotic prophylaxis within 30-60 minutes before the incision, the use of post-CS intravenous (IV) ceftriaxone and metronidazole, hospital stays of 3 days, oral cefixime upon discharge, and being operated on by a medical officerRecommendation: The study emphasizes the importance of medical professionals following guidelines and acquiring knowledge on appropriate antibiotic use to combat surgical site infections (SSIs) following cesarean sections. Adhering to guidelines and continuous education is crucial in preventing SSIs and addressing antibiotic resistance

RESULTS OF THE ANTIBIOTICS TREATMENT COMBINED WITH LIVER ABSCESS DRAINAGE AT NGUYEN TRI PHUONG HOSPITAL

Background: Percutaneous drainage of liver abscess is the initial treatment of choice for abscesses larger than 5 cm in size and has long been applied in many hospitals in Vietnam. However, there are not many summary reports on both antibiotic treatment and abscess drainage under ultrasound guidance. Subjects and methods: Retrospective study of patients with liver abscess who were treated with antibiotics and drained the abscess under ultrasound guidance at Nguyen Tri Phuong Hospital from January 2017 to March. 12/2022. Results: There were 61 patients included in the study. The first-line antibiotic treatment is Cephalosporin III generation combined with intravenous metronidazole, most are sensitive to third generation Cephalosporins (49.2%), 8.2% are multi-resistant ESBL-secreting bacteria using Carbapenems. The treatment success rate is high (96.7%). The time for the patient to have no fever and no pain in the right lower quadrant is from 1 to 4 days. Most of the interventions were 1 time (90.2%). The average tube retention time was 12 days. Conclusion: Treatment of liver abscess with antibiotics combined with ultrasound-guided drainage is an effective and safe measure. Most of the cases are only intervention 1 time with high success rate.

Cost-effectiveness of selective decontamination of the digestive tract to decrease infectious complications in colorectal cancer surgery: An analysis of the SELECT trial

IntroductionSelective decontamination of the digestive tract (SDD) is effective in reducing infectious complications in elective colorectal cancer (CRC) surgery. However, it is unclear whether SDD is cost-effective compared to standard antibiotic prophylaxis. Material & methodsEconomic evaluation alongside multicenter randomized controlled trial, the SELECT-trial, from a healthcare perspective. Patients included underwent elective surgery for non-metastatic CRC. The intervention group received oral non-absorbable colistin, tobramycin and amphotericin B (SDD) next to standard antibiotic prophylaxis. Both groups received a single shot intravenous cefazolin and metronidazole preoperatively as standard prophylaxis. Occurrence of postoperative infectious complication in the first 30 postoperative days was extracted from medical records, Quality-Adjusted Life-Years (QALYs) based on the ED-5D-3L, and healthcare costs collected from the hospital's financial administration. ResultsOf the 455 patients, 228 were randomly assigned to intervention group and 227 patients to the control group. SDD significantly reduced the number of infectious complications compared to control (difference = −0.13, 95 % CI -0.05 to −0.20). No difference was found for QALYs (difference = 0.002, 95 % CI -0.002 to 0.005). Healthcare costs were statistically significantly lower in the intervention group (difference = −€1258, 95 % CI -2751 to −166). The ICER was −9872 €/infectious complication prevented and −820,380 €/QALY gained. For all willingness-to-pay thresholds, the probability that prophylactic SDD was cost-effective compared to standard prophylactic practice alone was 1.0. ConclusionThe addition of SDD to the standard preoperative intravenous antibiotic prophylaxis is cost-effective compared to standard prophylactic practice from a healthcare perspective and should be considered as the standard of care.

Ziekte van Pott: zeldzaam, maar niet uitgestorven

Pott’s disease: rare but not extinct In a 78-year-old woman with a history of colon diverticulitis, an incidental finding of spondylodiscitis T12-L2 was found on the CT scan to evaluate the diverticulitis. The finding was confirmed on an MRI, showing multifocal involvement of T12-L2 and the intervertebral discs with alongside an intraspinal abscess collection and a psoas abscess. Further investigations (hemocultures and cultures of the abscess) remained negative. Empirical antibiotic therapy was initiated with intravenous ceftriaxone and metronidazole for 6 weeks. The patient was discharged after the antibiotic treatment. One week later, the patient presented at the emergency department due to abnormal liver function values. Because of the multifocal lytic lesions, she received a pedicle screw fixation T11-L2 with a biopsy of L2 at the same time. The biopsy sample showed a positive PCR for Mycobacterium tuberculosis. The patient was diagnosed with tuberculous spondylitis. Multidrug anti-tubercular therapy was initiated with a 4-drug regimen (rifampicine, isoniazide, ethambutol and pyrazinamide).

Fulminant Amebic Enteritis in the Perinatal Period: A Case Report.

Pregnancy is a known risk factor for amebic enteritis, which develops into potentially fatal fulminant amebic enteritis in some cases. We describe a case of a 27-year-old non-immunosuppressed pregnant woman with fulminant amebic enteritis complicated with cytomegalovirus enteritis. She improved with intensive care and intravenous metronidazole and ganciclovir but eventually required subtotal colectomy for intestinal stenosis. It is difficult to diagnose amebic enteritis, especially in a non-endemic area. Amebic enteritis must be considered as a differential diagnosis for refractory diarrhea with bloody stools in women in the perinatal period, even those without immunosuppression.

Antibiotic treatment reduces the intensity of intraamniotic inflammation in pregnancies with idiopathic vaginal bleeding in the second trimester of pregnancy

Idiopathic bleeding in the second trimester of pregnancy complicates <1% of all pregnancies. This pregnancy complication can be caused by alterations in local hemostasis in the decidua due to infection/inflammation in the choriodecidual niche. This condition is associated with intraamniotic inflammatory complications. Antibiotic therapy effectively reduces the intensity of intraamniotic inflammation in certain pregnancy pathologies. However, whether antibiotic administration can reduce the intensity of the intraamniotic inflammatory response or eradicate microorganisms in patients with idiopathic bleeding during the second trimester of pregnancy remains unclear. This study primarily aimed to determine whether antimicrobial agents can reduce the magnitude of intraamniotic inflammation in patients with idiopathic bleeding in the second trimester of pregnancy by assessing the concentration of interleukin-6 in the amniotic fluid before and after 7 days of antibiotic treatment. The secondary aim was to determine whether treatment with a combination of antibiotics altered the microbial load of Ureaplasma species DNA in amniotic fluid. This retrospective cohort study included singleton-gestation patients with idiopathic bleeding between 15+0 and 27+6 weeks who underwent transabdominal amniocentesis at the time of admission. Follow-up amniocentesis was performed in a subset of patients unless abortion or delivery occurred earlier. Concentrations of interleukin-6 were measured in the amniotic fluid samples, and the presence of microbial invasion of the amniotic cavity was assessed using culture and molecular microbiological methods. Intraamniotic inflammation was defined as an interleukin-6 concentration ≥3000 pg/mL in the amniotic fluid samples. A total of 36 patients with idiopathic bleeding in the second trimester of pregnancy were included. All the patients underwent initial amniocentesis. Patients with intraamniotic inflammation (n=25) were treated using a combination of antibiotics consisting of intravenous ceftriaxone, intravenous metronidazole, and peroral clarithromycin. The patients without intraamniotic inflammation (n=11) were treated expectantly. In total, 25 patients delivered 7 days after admission. All patients with intraamniotic inflammation at the initial amniocentesis who delivered after 7 days underwent follow-up amniocentesis. Treatment with antibiotics decreased the interleukin-6 concentration in the amniotic fluid at follow-up amniocentesis compared with that at the initial amniocentesis in patients with intraamniotic inflammation (median [interquartile range]: 3457 pg/mL [2493-13,203] vs 19,812 pg/mL [11,973-34,518]; P=.0001). Amniotic fluid samples with Ureaplasma species DNA had a lower microbial load at the time of follow-up amniocentesis compared with the initial amniocentesis (median [interquartile range]: 1.5×105 copies DNA/mL [1.3×105-1.7×105] vs 8.0×107 copies DNA/mL [6.7×106-1.6×108]; P=.02). Antibiotic therapy was associated with reduced intraamniotic inflammation in patients with idiopathic bleeding in the second trimester complicated by intraamniotic inflammation. Moreover, antibiotic treatment has been associated with a reduction in the microbial load of Ureaplasma species DNA in the amniotic fluid.

Oropharyngeal Mucocele as an Unusual Cause of Recurrent Pneumonia in a Young Infant

Background: Oral mucoceles, though frequently seen as asymptomatic lesions in young adults, very little is known about their existence in infants and the complications arising out of them in this age group. Clinical Description: A 4-month-old infant presented with a history of recurrent episodes of breathing difficulty since 15 days of life, every episode being managed as aspiration pneumonia. The child presented in the fifth such episode with tachypnea tachycardia and chest indrawing. Auscultation revealed bilateral crepitations and chest X-ray showed diffuse haziness in the bilateral chest predominantly in the right middle lobe, rest of the systemic examination being normal. Oral cavity examination showed a bluish globular bulge behind the tongue with surrounding congested mucosa and thick secretions. Management and Outcome: The baby was managed with respiratory support in the form of continuous positive airway pressure, intravenous antibiotics Piperacillin-Tazobactam, amikacin and metronidazole, and anti-reflux measures of oral Domperidone. Flexible laryngoscopy showed a cystic lesion behind the tongue and contrast-enhanced computerized tomography confirmed a hypodense lesion arising from the uvula suggestive of a mucocele. Excision of the oro-pharyngeal cystic lesion was done and the histopathological examination confirmed it to be a mucocele. The baby was gradually weaned off oxygen support and proper breastfeeding was re-established. Conclusion: This case creates awareness regarding the fact that an unsuspected oral mucocele may be the cause of recurrent respiratory symptoms in an infant, thereby reiterating the importance of oral examination even in young infants.

A Rare Cause of Orbital Cellulitis: Eikenella corrodens.

To The Editors: Eikenella corrodens is a small, nonmotile Gram-negative rod and is a member of the ordinary flora of the oral mucosa. Eikenella species can cause a wide variety of head and neck infections, such as sinusitis, preseptal cellulitis and orbital cellulitis in immunocompromised patients as well as in hosts with normal immunity.1,2 In the literature, there are few cases of orbital cellulitis caused by E. corrodens. We herein report 2 cases of orbital cellulitis due to Eikenella spp. as the complication of untreated sinusitis in previously healthy girls. The first case, a previously healthy 15-year-old girl, was admitted to the pediatric emergency department (PED) complaining of new-onset left eyelid swelling, painful eye movements and chemosis. On physical examination, her eye movements were limited and painful. Significant chemosis and ectropion were observed. Laboratory results were notable for leukocytosis (16000 cells/mm3) and increased C-reactive protein (CRP) (176 mg/L) levels. Orbital computed tomography (CT) revealed orbital cellulitis and subperiosteal abscess as a complication of sinusitis in the left orbit (Fig. 1). The treatment was administered as intravenous (IV) cefotaxime (300 mg/kg/day), vancomycin (60 mg/kg/day) and metronidazole (30 mg/kg/day). Orbital decompression and subperiosteal abscess drainage were performed. Abscess culture grew E. corrodens that was susceptible to penicillin (MIC:0.023), cefuroxime (MIC:1.00) and cefotaxime (MIC:0.064). Vancomycin and metronidazole were discontinued on day 3. After 14 days of IV cefotaxime treatment, she was discharged with oral cefuroxime, and the total treatment period was completed in 21 days.FIGURE 1.: The arrow marks show abcess and the stars show sinusitis in both pictures. A: The orbital CT reveal orbital cellulitis of the left eye and ethmoid sinusitis. B: Orbital CT represents the subperiosteal abscess in the medial extraconal area of the left orbita.The second case, a previously healthy 9-year-old girl, presented to the PED with a 4-day history of painful eye movements. On physical examination, eye movements were painful, and there was proptosis in her left eye. In the laboratory, acute phase reactants were normal (CRP:26 mg/L, procalcitonin:<0.06 µg/L) without leukocytosis (WBC:11500 cells/mm3). Orbital CT showed diffuse sinusitis and subperiosteal abscess in the left orbital medial extraconal region (Fig. 1). Treatment was arranged as IV cefotaxime, vancomycin and metronidazole. Orbital decompression and subperiosteal abscess drainage were performed. E. corrodens grew in abscess culture, which was susceptible to ampicillin (MIC:0,064), cefotaxime (MIC:0,16), clindamycin (MIC:0,75) and meropenem (MIC:0,16). Her treatment was continued with IV ampicillin-sulbactam (300 mg/kg/day) for 10 days. She was discharged with amoxicillin/clavulanic acid, and the total treatment was completed in 21 days. Acute sinusitis is a common condition that can cause severe complications due to expanding to the surrounding structures, including the eye and the brain.3 Orbital cellulitis is a rare but important complication of acute sinusitis, as it may result in vision loss.4 Although Streptococcus and Staphylococcus spp. are the most common, other less frequent oral flora members, including anaerobes and facultative anaerobic agents such as E. corrodens, may also cause the same clinical presentations. In routine culture, E. corrodens was challenging to detect due to growth in 72 hours in an atmosphere of 5%–15% CO2, 35–37 °C and 100% humidity.5E. corrodens is usually susceptible to penicillin, second- and third-generation cephalosporins, and carbapenem but is resistant to clindamycin, macrolide, metronidazole and aminoglycoside.2 Antibiotic susceptibility tests are important in terms of guiding for appropriate treatment. In summary, we present 2 previously healthy children who developed orbital cellulitis due to Eikenella corrodens. Early diagnosis, appropriate surgical drainage, and targeted medical treatment due to antibiotic susceptibility will improve the outcomes.

A260 PYOGENIC LIVER ABSCESS FORMATION SIX MONTHS AFTER PERFORATED APPENDICITIS IN AN OTHERWISE HEALTHY CHILD

Abstract Background Pyogenic liver abscesses (PLA) in children are uncommon in the developed world. When they are diagnosed, it is often in patients with hepatobiliary cancers, biliary diseases and liver transplants. PLA post perforated appendicitis has been reported as an aetiology in non-immunocompromised children. Reported cases of PLA’s developing as a late complication of perforated appendicitis are rare. The longest time from appendicitis to PLA diagnosis previously reported was four months. Purpose To report a rare case of liver abscess formation, post ruptured appendicitis, in a previously healthy and review the recent literature relevant to this topic. Method Retrospective chart review through electronic patient records was conducted for our reported case. Literature review of the relevant medical literature was performed. Result(s) Patient is an 11-year-old female with no significant past medical history apart from a perforated appendix requiring laparotomy for washout and 10 days of antibiotics, 6 months prior to presentation. The patient presented to her local emergency room with 6-week history of right flank pain and 10 days of fever. Abdominal ultrasound (US) identified a 3cm x 3cm x 3cm mass in the right lobe of the liver consistent with an abscess which was confirmed with magnetic resonance imaging (MRI). She was transferred to Toronto Hospital for Sick Children for management and investigation. At the Hospital for Sick Children she was started on Intravenous (IV) cefotaxime and metronidazole. After a repeat US on transfer it was determined the liver abscess was not amenable to drainage. Echinococcosis and Entamoeba serology were negative and neutrophil oxidative burst test (NOBT) test was within normal limits. Liver enzymes never exceeded 2x the upper limit of normal and synthetic function remained intact. After 7 days of IV antibiotics the patient’s inflammatory markers had improved and she had remained afebrile, but repeat US and MRI showed little to no change in abscess size. The decision was made for a prolonged course of IV antibiotics. After another two weeks of IV antibiotics her repeat US showed reduction in abscess size by roughly one third, and she was switched to oral antibiotics, after a total of 28 days, for a further four weeks with ongoing improvement. Conclusion(s) A review of the literature identified one nationwide population-based analysis in the United States reporting 4075 cases of PLAs, as well as three single centre reviews, from Iran, Tailand and the United Kingdom, reporting 18, 15 and 38 cases of liver abscesses, respectively. Common underlying aetiologies included primary immunodeficiency’s, liver transplantation, hepatobiliary cancers and non-PLA intra-abdominal infections. Managements included IV antibiotics plus/minus drainage when amenable. No cases of liver failure or death were reported. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Lyme Disease Associated Orbital Myositis: A Rare Cause of Orbital Swelling

A 61-year-old man presented with a 1-day history of right eye pain, right periorbital swelling, and painful diplopia upon right gaze. He was triaged as having Orbital Cellulitis in the emergency room and was given intravenous metronidazole and ceftriaxone. The patient has a medical history of Type 2 diabetes, right subclavian thrombosis, and Lyme disease, for which he was treated with Doxycycline and Rifampicin. He also has colour blindness and a raised immunoglobulin level, as well as a history of soft tissue thickening and acute inflammatory changes in the right periorbital region. Upon examination, the patient's visual acuity was 6/9 in both eyes, and the right eye showed swelling and tenderness at the superior and inferior margins, chemosis, and restriction of left abduction and upgaze. Blood tests showed elevated CRP levels and a positive rheumatoid factor.