Length Of Antibiotic Treatment Research Articles

Intravenous cefuroxime as a first-line treatment for women hospitalized for pyelonephritis

Abstract Background Empirical treatment of pyelonephritis in the emergency ward includes broad-spectrum antibiotics. Such a strategy favours broad-spectrum antibiotic overuse. Local antibiotic stewardship teams can propose local recommendations to adapt empirical antibiotic treatment devoted to spare precious molecules that remain active on MDR bacteria, such as fluoroquinolones or other broad-spectrum antibiotics. Objectives We aimed to evaluate the incidence of urinary tract infection recurrence within 3 months after hospital discharge following empirical antibiotic therapy with cefuroxime in women with pyelonephritis in the emergency room. Patients and methods We conducted a retrospective, single-centre study. We identified 109 women treated for pyelonephritis, 95 with cefuroxime at any time, and 14 with only other antibiotics, and divided them into subgroups based on antibiotic switch to other molecules. We compared the incidence of urinary tract infection recurrence in the subgroups. Results In the group of patients treated with cefuroxime only, we identified five cases of recurrence (9.4%) in a total of 53 patients, but only 1 (1.9%) case of recurrence associated with the same uropathogen. No significant difference in clinical outcome, length of antibiotic treatment, or urinary tract infection recurrence was observed between the subgroups. Conclusions Our study supports that a strategy elaborated by an antibiotic stewardship team based on local ecology and aimed at proposing the narrowest-spectrum antibiotic upon treatment initiation in the emergency room is safe.

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

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

953. Implementation Outcomes in an Antibiotic Stewardship Program (Kicking CAUTI) in Four Veterans Hospitals Correlated with Clinical Outcomes

Abstract Background One of the major barriers to scale up of antibiotic stewardship interventions is the difficulty of engaging already overtaxed personnel. As part of a multisite antibiotic stewardship project to decrease antibiotics treatment of asymptomatic bacteriuria, we explored how to measure local implementation efforts, and what dose of the intervention was necessary to improve clinical outcomes. Methods The intervention was implemented in 4 different sites from February 2019 through May 2020. We chose 3 measures of implementation: the number of intervention delivery sessions (adoption), total number of health care professionals reached (penetration), and minutes spent in delivery of the intervention (adoption). Local site champions kept activity logs. Antibiotic prescriptions were included if ordered within one calendar day prior or two days after a urine culture was ordered on the same patient. Correlation between implementation measures and clinical outcomes (number of urine cultures ordered, days of antibiotic treatment (DOT), and length of antibiotic treatment (LOT)) was calculated using the mixed linear models method. Results Overall, the minutes spent in delivery ranged from 2567 minutes at the most engaged site to 679 in the least engaged site (Figure 1). The number of healthcare professionals reached ranged from 798 to 433, and the number of sessions delivered ranged from 240 to 45. Minutes spent in delivery was inversely correlated with two of our three clinical metrics, DOT (R -0.3, P=0.04) and LOT (R -0.3, P=0.02); minutes spent and urine cultures were not significantly correlated (Table 1). We did not find a significant relationship between the number of intervention delivery sessions or total number of health care professionals reached and any of the clinical outcomes. Figure 1Total Minutes Spent in Delivery of the Intervention Across Four Intervention Sites Table 1 Correlation Coefficients (with p-values) Comparing Implementation Outcomes with Clinical Outcomes (bolded results are statistically significant) Conclusion We found a significant inverse correlation between the number of minutes a local site champion spent delivering the antibiotic stewardship intervention and antibiotic use, both DOT and LOT. In other words, more time spent delivering the intervention locally was associated with a decrease in antibiotics ordered. Our implementation metric (adoption) is scalable and readily adaptable to large antibiotic stewardship dissemination projects. Disclosures Larissa Grigoryan, MD, PhD, Rebiotix Inc: Grant/Research Support Barbara Trautner, MD, PhD, Genetech: Advisor/Consultant.

Infections et cytopénies… impact sur et de l’immunothérapie

Febrile neutropenia consists of a major complication of lung cancer chemotherapy. The frequent association of COPD with lung cancer supports the hospital management of such event. Frequency and potential severity of bacterial infections support the use of an early probabilistic antibiotic therapy. Its choice relies on the knowledge of local bacterial epidemiology and of the local profile of bacterial resistances to antibiotics, the presence of patient severity criteria or risk factors for a severe infection. The time to apyrexia and aplasia exit determines the eventual adaptations and length of antibiotic treatment. Antibiotic prophylaxis is not recommended anymore for prevention of febrile neutropenia. Primary prophylaxis with hematopoietic growth factors is recommended, according to the type of chemotherapy, to age, and the presence of progressive tumor disease.The occurrence of immune checkpoint-induced neutropenia is rare but often severe. Antibiotic prescription in the 60 days flanking the initiation of immunotherapy was evidenced to impair the efficacy such immunotherapy due to its effect on gut microbiota.1877-1203/© 2022 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Differences in isolated bacteria between perforated and non-perforated appendicitis: an analysis of 680 consecutive appendicectomies in a single institution.

Escherichia coli and Bacteroides species are the most frequently detected species in ascites in perforated appendicitis and are generally sensitive to non-empiric cephalosporins like cefazolin or cefmetazole. However, monotherapy with such antibiotics is mostly insufficient for perforated appendicitis. To investigate this issue, this study aimed to compare bacterial floras in ascites culture between perforated and non-perforated appendicitis. Ascites culture results in perforated and non-perforated appendicitis cases were analyzed using a departmental database. The duration of symptoms before surgery, pre-surgical white blood cell count, C-reactive protein value, postsurgical length of stay, length of antibiotic treatment, and the rate of using second-line antibiotics or complications were also compared. A total of 608 and 72 cases of non-perforated and perforated appendicitis were included. Escherichia coli and Bacteroides species were the dominant bacteria in both conditions. However, the total proportions of Pseudomonas aeruginosa, Streptococcus anginosus group, and Enterococcus group were significantly higher in perforated appendicitis than in non-perforated appendicitis. Pseudomonas aeruginosa, Streptococcus anginosus group, and Enterococcus group have better susceptibility to penicillin-based empiric antibiotics than cephalosporins. The abundance of these bacteria might explain why non-empiric cephalosporins are not effective in perforated appendicitis and the superiority of penicillin-based empiric antibiotics.

Pancreatic stone protein point-of-care testing can reduce healthcare expenditure in sepsis

BackgroundSepsis is a life-threatening organ dysfunction in response to infection. Early recognition and rapid treatment are critical to patient outcomes and cost savings, but sepsis is difficult to diagnose because of its non-specific symptoms. Biomarkers such as pancreatic stone protein (PSP) offer rapid results with greater sensitivity and specificity than standard laboratory tests.MethodsThis study developed a decision tree model to compare a rapid PSP test to standard of care in the emergency department (ED) and intensive care unit (ICU) to diagnose patients with suspected sepsis. Key model parameters included length of hospital and ICU stay, readmission due to infection, cost of sepsis testing, length of antibiotic treatment, antibiotic resistance, and clostridium difficile infections. Model inputs were determined by review of sepsis literature.ResultsThe rapid PSP test was found to reduce costs by $1688 per patient in the ED and $3315 per patient in the ICU compared to standard of care. Cost reductions were primarily driven by the specificity of PSP in the ED and the sensitivity of PSP in the ICU.ConclusionsThe results of the model indicate that PSP testing is cost saving compared to standard of care in diagnosis of sepsis. The abundance of sepsis cases in the ED and ICU make these findings important in the clinical field and further support the potential of sensitive and specific markers of sepsis to not only improve patient outcomes but also reduce healthcare expenditures.

Negative pressure wound therapy promotes healing and reduced pain in patients with acute suppurative mastitis

BackgroundThe purpose of this study was to compare the outcomes of vacuum sealing drainage (VSD) and conventional incision and drainage (I&D) for treating acute suppurative mastitis.MethodsHospital medical records were searched for patients 20–50 years of age who were diagnosed with acute suppurative mastitis from January 2014 to December 2018, and treated with traditional I&D or VSD. Patients were divided into those treated with VSD and I&D, and outcomes including pain, healing time, length of hospital stay, and length of antibiotic course were compared between the groups. Pain was evaluated with a numeric rating scale from 0 (no pain) to 10 (most severe pain). Subgroup analysis of lactating women was also performed.ResultsThere were 110 women who received traditional I&D, and 105 women that received VSD included. The 2 groups were similar with respect to age (31.1 ± 4.8 vs. 29.9 ± 4.4, p = 0.058), and disease characteristics. The median pain score of women who received VSD (5 [IQR 5–6]) was significantly less than that of women who received I&D (8 [IQR 7–8]) (p < 0.001). The time for healing was significantly less in women who received VSD (40 days [IQR 30–45 days]) compared to I&D (60 days [IQR 45–70 days]) (p < 0.001). The length of hospital say and the length of antibiotic treatment were similar between the 2 groups. Results were similar for lactating women.ConclusionsVSD is effective for treating acute suppurative mastitis with reduced pain and shortening healing time.

The management of tubo-ovarian abscess - A retrospective analysis of a centre offering outpatient intravenous antibiotic therapy

Background Tubo-ovarian abscess (TOA) carries long-term sequale in women of reproductive age. Consensus of the optimal treatment of tubo-ovarian abscess remains lacking. The aims of this study are to identify risk factors predicting the need for early drainage and compare clinical outcomes of current management practices of TOA. Methods From 2015 to 2019, a retrospective cohort study of 92 women admitted to a tertiary centre for gynaecological surgery was performed. Patients with diagnosed TOA were classified into two groups: treatment with antibiotics only, and those receiving additional drainage. Primary outcomes included length of hospital stay (LoS), length of antibiotic treatment (LoA) and need for re-intervention. Results In this study, 52 women (56.5%) were successfully treated with first line intravenous antibiotics; 40 (43.5%) received surgical drainage. Significant predictors for successful medical treatment only include age &lt; 35 (OR: 0.89, 95% CI: 0.82-0.97) and abscess size &lt; 6cm (OR: 0.17, 95% CI: 0.04-0.64), using multivariate analysis. Pyrexia ≥ 38°C predicted a need for drainage (OR: 3.82, 95% CI: 1.01-8.12). Patients who received additional drainage had significantly longer LoA, LoS and higher rates of re-intervention. Within this group, drainage within 72 hours of admission resulted in a trend towards shorter LoA and LoS than drainage after 72 hours, albeit not statistically significant. Conclusions Parameters include age &gt; 35 years, pyrexia ≥ 38°C and a TOA size &gt; 6cm may independently predict the need for drainage of TOA. Early identification of these patients is imperative for timely surgical intervention to avoid prolonged hospitalisation, antibiotic usage, and patient morbidity. More work is required to identify whether early drainage may reduce length of hospital stay and antibiotic treatment, including identifying certain patient groups who most likely to benefit from outpatient antibiotic intravenous therapy.

Efficacy of antibiotic short course for bloodstream infections in acute myeloid leukemia patients with febrile neutropenia: A retrospective comparative study

ObjectivesThere is no specific recommendation about antimicrobial treatment length for documented infections in chemotherapy induced febrile neutropenia (FN). Practices have changed along time in our center regarding length of antibiotic treatment. The aim of this study was to compare long versus short antibiotic course for bloodstream infection (BSI) treatment in acute myeloid leukemia (AML) patients during FN. MethodsThis monocentric retrospective comparative study included all consecutive BSI episodes among AML patients with FN for 3 years (2017–2019). Episodes were classified regarding the length of antibiotic treatment, considered as short course if the treatment lasted ≤ 7 days, except for nonfermenting bacteria and Staphylococcus aureus or lugdunensis for which the threshold was ≤ 10 days and ≤ 14 days, respectively. The primary outcome was the number of BSI relapses in both groups within 30 days of antibiotic discontinuation. ResultsAmong 71 AML patients, 104 BSI episodes were included; 48 (46%) received short course treatment. Only 8 (7.6%) BSI episodes relapsed within 30 days of antibiotic discontinuation, 5 having received short course treatment. No association was found between risk of relapse and short course of antibiotic treatment (p = 0.37). The only risk factor significantly associated with BSI relapse was neutropenia duration (p = 0.005). ConclusionAntibiotic short course seemed as effective as prolonged treatment for BSI in AML patients during FN, with very few relapses at day 30. These encouraging findings should be confirmed through prospective studies.

Composite Criteria for Non‐Operative Management of Acute Non‐Complicated Appendicitis Result in Low Failure Rates

The aim of this study is to investigate the outcomes of conservative management of non-complicated acute appendicitis (AA) using our unique institutional protocol, and to compare between these and the outcomes of operative management. Patients admitted to our institution between March 2016 and October 2019 with non-complicated AA were grouped according to their initial management: non-operative versus surgical. Our unique protocol for non-operative management includes: pain< 3days; afebrile upon admission; non-gravid; WBC<15,000 (× 109/L); CRP< 5mg/dl; appendix diameter < 1cm; no appendicolith on imaging; no prior episode of AA; no history of Inflammatory Bowel Disease; no evidence of peritonitis on physical examination. The primary outcome measured was failure of non-surgical management during the index admission. Secondary outcomes included recurrence rate, readmissions, complications, length of antibiotic treatment and length of stay (LOS). A total of 695 patients were included, 436 in the operative group and 259 in the non-surgical treatment group. The mean follow-up time was 1004.9 ± 205.7days. Patients initially treated conservatively rarely required surgery during their index admission (6.9%). Recurrence rate was 19.1% after a mean follow up of 33.4months. The overall failure rate of conservative management was documented in 20.8% of the patients. The complication rate was higher in those treated with upfront surgery (1.6% vs. 0.4%, p < 0.001). The overall LOS was not statistically different between the groups. Our composite protocol for non-surgical management of non-complicated AA results in a low failure rate. A well calculated patient treatment allocation in non-complicated AA can advocate for wide-spread use of the conservative approach.

Risk factors and clinical outcomes associated with blood culture contamination.

To determine patient-specific risk factors and clinical outcomes associated with contaminated blood cultures. A single-center, retrospective case-control risk factor and clinical outcome analysis performed on inpatients with blood cultures collected in the emergency department, 2014-2018. Patients with contaminated blood cultures (cases) were compared to patients with negative blood cultures (controls). A 509-bed tertiary-care university hospital. Risk factors independently associated with blood-culture contamination were determined using multivariable logistic regression. The impacts of contamination on clinical outcomes were assessed using linear regression, logistic regression, and generalized linear model with γ log link. Of 13,782 blood cultures, 1,504 (10.9%) true positives were excluded, leaving 1,012 (7.3%) cases and 11,266 (81.7%) controls. The following factors were independently associated with blood-culture contamination: increasing age (adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 1.01-1.01), black race (aOR, 1.32; 95% CI, 1.15-1.51), increased body mass index (BMI; aOR, 1.01; 95% CI, 1.00-1.02), chronic obstructive pulmonary disease (aOR, 1.16; 95% CI, 1.02-1.33), paralysis (aOR 1.64; 95% CI, 1.26-2.14) and sepsis plus shock (aOR, 1.26; 95% CI, 1.07-1.49). After controlling for age, race, BMI, and sepsis, blood-culture contamination increased length of stay (LOS; β = 1.24 ± 0.24; P < .0001), length of antibiotic treatment (LOT; β = 1.01 ± 0.20; P < .001), hospital charges (β = 0.22 ± 0.03; P < .0001), acute kidney injury (AKI; aOR, 1.60; 95% CI, 1.40-1.83), echocardiogram orders (aOR, 1.51; 95% CI, 1.30-1.75) and in-hospital mortality (aOR, 1.69; 95% CI, 1.31-2.16). These unique risk factors identify high-risk individuals for blood-culture contamination. After controlling for confounders, contamination significantly increased LOS, LOT, hospital charges, AKI, echocardiograms, and in-hospital mortality.

Term newborns at risk for early-onset neonatal sepsis: Clinical surveillance versus systematic paraclinical test

IntroductionEarly-onset neonatal sepsis is a rare but potentially lethal infection that is very often suspected in daily practice. Previous national guidelines recommended the use of systematic paraclinical tests for healthy term newborns with suspected infection. These guidelines were updated in 2017 by the French Health Authority (Haute Autorité de santé), and promote initial clinical monitoring taking into account the infectious risk level for term and near-term born infants. ObjectivesTo assess the impact of the new recommendations on antibiotic therapy prescription and invasive tests, and on the outcomes of infants born from 36weeks’ gestation. Materials and methodsThis study compared the management and the outcome of neonates born from 36weeks’ gestation at the level III University Hospital of Nancy, according to their infectious risk level during two periods, before and after the update of national recommendations: from July 1 to December 31, 2017, versus July 1 to December 31, 2018. Data were retrospectively collected from the infants’ files. This study compared the number and length of antibiotic treatment and the number of invasive tests, the number of documented infections, the number and length of hospitalization, and mortality between the two periods. ResultsDuring the first period, among 1248 eligible newborns, 643 presented an infectious risk factor, versus 1152 newborns with 343 having an infectious risk factor during the second period. Antibiotic treatment was initiated for 18 newborns during the first period (1.4%) and for nine during the second (0.8%) (P=0.13). The mean (SD) duration of the antibiotic treatment was longer in the first than in the second period: 6.3±2days vs. 3.1±2.3days (P=0.003). There was no death related to neonatal infection. A total of 1052 blood samples were collected during the first period versus 51 during the second (P<0.01). There was no documented infection. In the first period, there were 18 newborns (1.4%) hospitalized for suspected infection versus nine (0.8%) in the second period (P=0.13). The duration of hospitalization was 5.7±1.7days in the first period versus 5.2±3days in the second (P=0.33). ConclusionIn this study, the application of the new guidelines enabled a reduction of antibiotic exposure and a reduction of invasive tests without additional risk.

Factors affecting outcome in the treatment of streptococcal periprosthetic joint infections: results from a single-centre retrospective cohort study

PurposeTo report and analyse factors affecting the outcome of streptococcal periprosthetic joint infections (PJIs).MethodsA retrospective analysis of consecutive streptococcal PJIs was performed. Musculoskeletal Infection Society 2013 criteria were used. Outcome was compared with a prospective PJI cohort from the same institution.ResultsThe most common isolated streptococcal species was Streptococcus dysgalactiae (9/22, 41%) among 22 patients included. Surgical treatment consisted of DAIR (debridement, antibiotics, irrigation and retention) in 12 (55%), one-stage revision arthroplasty in one (4%), two-stage revision arthroplasty in eight (37%) and implant removal in one (4%) patient. An infection free-outcome was achieved in 15 cases (68%), whilst seven (32%) patients failed initial revision and relapsed with the same pathogen, from which six were treated with DAIR and one with one-stage revision arthroplasty. No failures were observed in patients who received a two-stage revision. Failure rates did not differ in the cases treated with rifampin (1/5) from those without 6/17 (p = 0.55). There was no correlation between the length of antibiotic treatment and relapse (p = 0.723). In all failures, a persistent distant infection focus was identified at the time of relapse. Compared with our prospective PJI cohort, relapse rates were significantly higher 32% vs 12% (p < 0.05).ConclusionNo correlation with the use of rifampin or length of antibiotic treatment was found. No failures were observed in patients who received a two-stage revision, which may be the surgical treatment of choice. A distant persisting infection focus could be the reason for PJI relapse with recurrent hematogenous seeding in the joint.

In mares with placentitis does the duration of antibiotic treatment affect foal outcome?

PICO question&#x0D; In mares with placentitis does treatment with long-term antibiotics result in improved foal viability when compared to repeated short courses of 7 to 10 days?&#x0D; &#x0D; Clinical bottom line&#x0D; Category of research question&#x0D; Treatment&#x0D; The number and type of study designs reviewed&#x0D; The literature search identified six publications that included length of antibiotic treatment and foetal outcome. The publications consisted of four non-randomised non-blinded controlled trials and two randomised non-blinded controlled trials&#x0D; Strength of evidence&#x0D; Collectively there was weak evidence to support either an intermittent or continuous antibiotic protocol in the treatment of placentitis in mares&#x0D; Outcomes reported&#x0D; The literature involved experimental induction of ascending placentitis with foal survival or viability as the outcome&#x0D; Conclusion&#x0D; Further research is required into the diagnosis of placentitis, length of treatment and choice of antibiotic/s to penetrate the uterus in a diseased state&#x0D; &#x0D; How to apply this evidence in practice&#x0D; The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.&#x0D; Knowledge Summaries are a resource to help reinforce or inform decision-making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.&#x0D; &#x0D;

Nosocomial Infections in Gastrointestinal Cancer Patients: Bacterial Profile, Antibiotic Resistance Pattern, and Prognostic Factors.

BackgroundCancers of the gastrointestinal (GI) tract and its associated excretory glands are one of the most common causes of cancer-related death worldwide, and these patients are more likely to developing nosocomial infections due to immunodeficiency.ObjectiveTo explore the bacterial profile, antibiotic resistance pattern, and prognostic factors of nosocomial infections in hospitalized GI cancer patients.MethodsAll electronic medical records of nosocomial infection episodes in hospitalized GI cancer patients were retrospectively reviewed. In-hospital mortality was used to evaluate the prognosis of patients. Mann–Whitney test, Chi-square test, and binary logistic regression analysis were used to identify potential risk factors for in-hospital mortality. P-values <0.05 were considered statistically significant.ResultsA total of 428 GI cancer patients developed nosocomial infections during hospitalization. Respiratory tract infections (44.2%), bloodstream infections (BSIs) (11.7%), and abdominal cavity infections (11.4%) were the most common infection sites. The predominant causative pathogens were extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (13.6%), ESBL-negative E. coli (11.9%), and Klebsiella pneumoniae (10.0%). Multidrug-resistant (MDR) strains were detected in 27.6% of isolates. Antimicrobial susceptibility analysis showed that the isolated Gram-negative bacteria (GNB) exhibited high sensitivity to amikacin, meropenem, imipenem, and piperacillin/tazobactam, while the isolated Gram-positive bacteria exhibited high sensitivity to tigecycline, linezolid, and vancomycin. The overall in-hospital mortality of all patients was 11.2% in the study. Multivariate analysis showed that ECOG performance status ≥two scores, length of antibiotic treatment <9.0 days, existence of septic shock, and hypoproteinemia were independent risk factors for in-hospital mortality.ConclusionThe burden of nosocomial infections in GI cancer patients is considerably high, with GNB being predominantly isolated causative pathogens. Surveillance on serum albumin level, adequate antibiotic treatment, early identification, and prompt treatment of septic shock could benefit the prognosis.

Procalcitonin-guided protocol decreased the antibiotic use in paediatric patients with severe bronchiolitis.

Our aim was to determine the effectiveness and safety of a procalcitonin-guided protocol to decrease antibiotic use in infants with severe bronchiolitis. This prospective, observational study was conducted at the Hospital Sant Joan de Déu from 2010 to 2017. Patients under the age of one were included if they were diagnosed with bronchiolitis, had a suspected bacterial infection and were admitted to the paediatric intensive care unit. A procalcitonin-guided protocol was established in 2014, and two cohorts were compared before and after implementation: 340 in 2010-2014 and 366 in 2015-2017. We recruited 706 patients (58.6% male) with a median age of 47days and an interquartile range of 25.0-100.2. The rate for antibiotic use was 79.9%, and this differed before and after implementation (88.2% vs 72.1%, P=.003). Antibiotic stewardship and withdrawal decisions were higher after implementation (22.3% vs 36.4%, P=.005). The length of antibiotic treatment was also different between the two periods (8.65±4.8days vs 5.05±3.18days, P=.023). No adverse outcomes were observed due to the implementation of the protocol. The implementation of a procalcitonin-guided protocol seems to lead to a safe and general decrease in antibiotic use in paediatric patients with severe bronchiolitis.

Common Variants in the Glycerol Kinase Gene Reduce Tuberculosis Drug Efficacy.

Despite the administration of multiple drugs that are highly effective in vitro, tuberculosis (TB) treatment requires prolonged drug administration and is confounded by the emergence of drug-resistant strains. To understand the mechanisms that limit antibiotic efficacy, we performed a comprehensive genetic study to identify Mycobacterium tuberculosis genes that alter the rate of bacterial clearance in drug-treated mice. Several functionally distinct bacterial genes were found to alter bacterial clearance, and prominent among these was the glpK gene that encodes the glycerol-3-kinase enzyme that is necessary for glycerol catabolism. Growth on glycerol generally increased the sensitivity of M. tuberculosis to antibiotics in vitro, and glpK-deficient bacteria persisted during antibiotic treatment in vivo, particularly during exposure to pyrazinamide-containing regimens. Frameshift mutations in a hypervariable homopolymeric region of the glpK gene were found to be a specific marker of multidrug resistance in clinical M. tuberculosis isolates, and these loss-of-function alleles were also enriched in extensively drug-resistant clones. These data indicate that frequently observed variation in the glpK coding sequence produces a drug-tolerant phenotype that can reduce antibiotic efficacy and may contribute to the evolution of resistance.IMPORTANCE TB control is limited in part by the length of antibiotic treatment needed to prevent recurrent disease. To probe mechanisms underlying survival under antibiotic pressure, we performed a genetic screen for M. tuberculosis mutants with altered susceptibility to treatment using the mouse model of TB. We identified multiple genes involved in a range of functions which alter sensitivity to antibiotics. In particular, we found glycerol catabolism mutants were less susceptible to treatment and that common variation in a homopolymeric region in the glpK gene was associated with drug resistance in clinical isolates. These studies indicate that reversible high-frequency variation in carbon metabolic pathways can produce phenotypically drug-tolerant clones and have a role in the development of resistance.

Knee Infection After Anterior Cruciate Ligament Reconstruction

Knee infection is a challenging scenario. One way to classify the infection would be as spontaneous or post-surgery, the latter having a particular relevance given the presence of synthetic materials such as screws or prostheses surrounding the joint. Open surgery has a higher rate of infection than arthroscopic procedures. Periprosthetic infection is a complication that follows arthroplasty, with an incidence that varies between 0.4% and 2.0%, while arthroscopic procedures have an incidence varying between 0.001% and 1.100%. Anterior cruciate ligament (ACL) reconstruction complication rate is low, with septic arthritis one of the most frequently seen. Early diagnosis of complications is vital to improve functional outcome. In these cases, knee pain, decreased range of motion, fever, and high C-reactive protein levels should alert any physician, and infection must not be ruled out. This article presents a case of infection after ACL reconstruction and discusses risk factors, treatment choice, antibiotic treatment length, and functional outcomes, proposing a guide for the treatment. The clinical case presented is a chronic infection due to Staphylococcus aureus that resulted in extensive cartilage damage and graft loosening; delayed diagnosis was an essential modifiable risk factor in this case. Treatment success is defined as the eradication of the infection without the need to remove the ACL graft. Risk factors for a worse outcome after ACL reconstruction infection are allograft compared to autograft and S. aureus or polymicrobial infection compared to coagulase-negative staphylococcus infection. Functional outcome is compromised by infection; however, if early diagnosis and treatment are performed, good functional results and a return to sports activities can be expected.

Epidemiology of Ventilator-Associated Pneumonia, microbiological diagnostics and the length of antimicrobial treatment in the Polish Intensive Care Units in the years 2013-2015

BackgroundVentilator-associated pneumonia (VAP) is a common nosocomial infection in intensive care units (ICUs). The objective of this study was to describe the epidemiology and microbiology of VAP in Polish ICUs from 2013 to 2015, as well as to understand how these depended on the diagnostic methods used to identify VAP pathogens and the clinical strategy for VAP treatment.MethodsThis observational study was carried out in seven Polish adult ICUs. VAP surveillance was based on the European Healthcare-associated Infections Surveillance Network recommendations and was defined as pneumonia occurring more than 48 h after receiving mechanical ventilation, with symptom onset 3 days or more after the hospital stay. Depending on the microbiological diagnostic method, VAP cases were classified as PNEU-1 (positive quantitative culture from minimally contaminated lower respiratory tract specimen such as broncho-alveolar lavage, protected brush or distal protected aspirate) or other VAP cases.ResultsThe incidence of VAP was 8.0% and the incidence density: 12.3/1000 ventilator days. Microbiological diagnosis was made using PNEU-1 in 80 cases (39%); over the study duration, the proportion of cases diagnosed with PNEU-1 increased from 14 to 60% (p < 0.001). The predominant etiologic agents causing VAP were Enterobacteriaceae (32.6%) and non-fermenting Gram-negative bacteria (27.6%). The causative microbe varied significantly depending on the diagnostic method: in cases diagnosed using PNEU-1, Staphylococcus aureus (21.3%) and Klebsiella pneumoniae (12.5%) were the dominant organisms, whereas in other VAP cases, Acinetobacter baumannii (23.8%) was commonly observed. The length of antibiotic treatment in cases diagnosed with PNEU-1 was shorter than for other VAP cases (7.2 vs. 9.1 days, p < 0.005), as was the duration of hospitalization (49 vs. 51.8 days, p < 0.001). Antibiotic resistance was a particular concern for A.baumannii isolates, which were highly resistance to imipenem (70.6%) and meropenem or doripenem (52.9%). K. pneumoniae isolates demonstrated resistance to ampicillin (90.3%), ceftazidime (71.0%) and third-generation cephalosporins (74.2%).ConclusionA change over time was observed in the microbiological diagnostic methods used for patients with VAP. A. baumannii was observed mainly in VAP cases diagnosed using substandard methods (non-PNEU-1). The duration of treatment for VAP patients diagnosed properly using PNEU-1 was shorter.

Quality of life and clinical-radiological long-term results after implant-associated infections in patients with ankle fracture: a retrospective matched-pair study

BackgroundAnkle fractures are frequently occurring injuries. Despite the relatively simple operative technique, patients often suffer from postoperative complications. Little is known about postoperative treatment of implant-associated infections of the ankle. Therefore, this study shows and evaluates a treatment algorithm in long- and short-term outcomes compared to infection-free patients.MethodsData from patients of over 20 years of a level 1 trauma center and university hospital was retrospectively analyzed including age, gender, comorbidities, smoking status, fracture classification, number of revisions, length of in-patient stay due to fracture and infection, and results of microbiological specimen with the length of antibiotic treatment. Moreover, present long-term outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, the Ankle Osteoarthritis Score, and the Short Form 36 score and compared to a matched-pair infection-free patient cohort.ResultsForty-four patients could be retrospectively evaluated (51% male, 49% women, mean age 46 ± 17 years). Most of the cases were Weber B fractures (38%) following an in-patient stay from 51 ± 4.3 days after primary treatment and 77 ± 10.0 days after secondary treatment in our hospital. Microbiological specimen showed in 77% Staphylococcus aureus with following intravenous antibiotic treatment for 13.9 ± 3.1 days in mean. Common comorbidities/risk factors were cardiovascular disease (28%), smoking (15%), and diabetes (18%). Cure of infection and clinical and radiographic osseous consolidation could be documented for all cases.Patients with implant-associated infections had significantly more risk factors than infection-free patients (1.1/0.33; p = .02 per patient). The matched-pair group showed significantly better long-term outcome in mean regarding the Ankle Osteoarthritis Score (2.0 ± 1.2/13.9 ± 4.7) and AOFAS hindfoot score (96.7 ± 1.9/87.3 ± 3.4).ConclusionImmediate revision surgery with aggressive debridement, microbiological diagnostics, antibiotic therapy, and use of a drain until osseous consolidation is reached with following removal of the implant in patients with implant-associated infections after ankle fracture and open reduction internal fixation lead to cure of infection and fair long-term outcome in all cases. Special care must be taken of risk factors like diabetes and smoking.Trial registration24/2008BO2