Long-term Antibiotic Research Articles

304. Comparison of Short and Long Courses of Antibiotics in Patients with Prosthetic Joint Infection: A Systemic Review and Meta-analysis

BackgroundCurrent guidelines for treatment of prosthetic joint infection (PJI) suggest a combination of intravenous (IV) antibiotics for 2–6 weeks and oral antibiotics for 3–6 months. However, recent studies did not find significant benefits from prolonged use of antibiotics for patients with PJI. We conducted a systemic review and meta-analysis to assess the outcomes of short- and long-term antibiotics in patients with PJI.MethodsWe designed three queries to retrieve literature of PJI from PubMed and Embase databases until December 2017. Each query comprised medical subject headings, title/abstract keywords, and exclusion terms. Two reviewers independently screened literature for three rounds and disagreements were resolved by a third reviewer. Quality of a cohort study and that of a randomized control trial (RCT) were assessed by Newcastle-Ottawa Quality Assessment Form and a modified Jadad scale respectively.ResultsA total of 3,309 studies were retrieved, and nine observation studies and one RCT were included for final analysis (Figure 1). Nine of the 10 studies investigated total hip arthroplasty and/or total knee arthropathy, while one study further included shoulder, elbow, and ankle arthroplasty. Five studies focused on patients receiving debridement and implant retention (DAIR) procedure, three studies on staged exchange arthroplasty (SEA), and two studies on mixed procedures. Eight of the 10 studies were graded as good or fair quality. All of the 10 studies found equivalent outcomes in patients prescribed with short- and long-term antibiotics, regardless of IV or oral form of antibiotics. The aggregate odds ratio (OR) in our meta-analysis was 1.04 (95% CI, 0.70, 1.55), showing no significant difference in outcomes between short-term and long-term antibiotics (Figure 2).ConclusionOur meta-analysis demonstrated that patients prescribed with short-term antibiotics for PJI had similar outcomes when compared with those prescribed with long-term antibiotics. Disclosures All authors: No reported disclosures.

296. Outcomes From a Novel Transition-of-Care OPAT Service Targeting Orthopedic Device-Related Infections

BackgroundIn 2015, a transition-of-care outpatient parenteral antibiotic therapy service (TOC-OPAT) was established at the Montefiore Medical Center in the Bronx, NY for patients requiring long-term antibiotics. Utilizing an OPAT bundle with direct communication between specialists, significant reductions in 30-day readmissions were observed. Montefiore is a regional referral center for orthopedic device-related infections (ODRIs). Here, we evaluate outcomes in TOC-OPAT patients with ORDIs. We hypothesize that a majority achieve infection cure within 6-months.MethodsWe assessed infectious diseases (ID) outcomes in a cohort of TOC-OPAT patients with ODRIs between July 2015 and October 2017. The primary outcome was cure at 6 months defined as (1) infection eradication after initial management, (2) no further surgical or antimicrobial intervention for index infection, and (3) no infection-related mortality. Microbiologic cure for prosthetic joint infection (PJI) was defined as negative joint aspiration cultures prior to revision arthroplasty.ResultsWe reviewed data from 110 infection episodes with 107 unique patients; 2 patients were excluded (deceased from unrelated causes). The average age of patients was 61.5 (demographics shown in Figure 1). There were 80 distinct episodes of PJI (knee, hip, shoulder) and 28 of other ORDI (spine and trauma-related). Of 108 episodes, 91 (84%) were cured by combined surgical and ID management. Patients lost to follow-up (n = 4) were considered non-cured. Microbiologic spectrum of infections is shown in Figure 2. Of 27/80 fluid aspirations prior to revision arthroplasty, four (13%) were positive. Only two patients developed C. difficile infection during the study period (1.8%). Most patients achieved a 50% decline in both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at the end of treatment course (Figure 3). Chronic antibiotic suppression was utilized in 14 (13%) patients, five for chronic active infection and nine for history of multiple prior infections.ConclusionWe observed a high rate of cure in patients managed by a direct orthopedic-ID TOC OPAT service at 6 months. We plan to compare outcomes to a similar cohort of patients predating this multidisciplinary service in future studies. Disclosures All authors: No reported disclosures.

ALternatives To prophylactic Antibiotics for the treatment of Recurrent urinary tract infection in women (ALTAR): study protocol for a multicentre, pragmatic, patient-randomised, non-inferiority trial

BackgroundAt least half of all adult women will experience infective cystitis (urinary tract infection: UTI) at least once in their life and many suffer from repeated episodes. Recurrent urinary tract infection (rUTI) in adult women is usually treated with long-term, low-dose antibiotics and current national and international guidelines recommend this as the ‘gold standard’ preventative treatment. Although they are reasonably effective, long-term antibiotics can result in bacteria becoming resistant not only to the prescribed antibiotic but to other antimicrobial agents. The problem of antimicrobial resistance is recognised as a global threat and the recent drive for antibiotic stewardship has emphasised the need for careful consideration prior to prescribing antibiotics. This has led clinicians and patients alike to explore potential non-antibiotic options for recurrent UTI prevention.Design /methodsThis is a multicentre, pragmatic, patient-randomised, non-inferiority trial comparing a non-antibiotic preventative treatment for rUTI in women, methenamine hippurate, against the current standard of daily low-dose antibiotics. Women who require preventative treatment for rUTI are the target population. This group is comprised of those with a diagnosis of rUTI, defined as three episodes in 1 year or two episodes in 6 months, and those with a single severe infection requiring hospitalisation. Participants will be recruited from secondary care urology / urogynaecology departments in the UK following referral with rUTI. Participants will be followed up during a 12-month period of treatment and in the subsequent 6 months following completion of the prophylactic medication. Outcomes will be assessed from patient recorded symptoms, quality of life questionnaires and microbiological examination of urine and perineal swabs. The primary outcome is the incidence of symptomatic antibiotic-treated UTI self-reported by participants during the 12-month period of preventative treatment. Health economic outcomes will also be assessed to define the cost-effectiveness of both treatments. A qualitative study will be conducted in the first 8 months of the trial to explore with participants/non-participants’ and recruiting clinicians’ views on trial processes and identify potential barriers to recruitment, reasons for participating and non-participation and for dropping out of the study.DiscussionThe study was commissioned and funded by the National Institute for Health Research (NIHR) and approved under the Medicines and Healthcare products Regulatory Agency (MHRA) notification scheme as a ‘Type A’ study.Trial registrationInternational Standard Randomised Controlled Trial Number (ISRCTN), registry number: ISRCTN70219762. Registered on 31 May 2016.

Retro-rectus placement of bio-absorbable mesh improves patient outcomes.

There is little consensus on the ideal anatomical placement of bio-absorbable mesh. We hypothesized that retro-rectus placement of bio-absorbable mesh would significantly reduce recurrence rates when compared to intraperitoneal mesh placement. A retrospective review was conducted of patients who underwent open complex ventral hernia repair using bio-absorbable mesh (Bio-A, Gore, Flagstaff, AZ). Patient demographics and Centers for Disease Control wound type were collected. A total of 81 patients were included. Seventy-four (91.4%) of these hernia repairs had mesh in the retro-rectus position, while 7 (8.6%) had intraperitoneal mesh placement. Patient demographics, including preoperative comorbidities, did not differ between groups. The retro-rectus group trended to have larger hernia defects (156.2cm2) compared to the intraperitoneal group (63.9cm2) (p = 0.058). Overall complications (e.g., dehiscence, wound drainage, cellulitis, sepsis) were also similar in both groups of patients. Recurrence rates in the retro-rectus and intraperitoneal group were 8.1% and 42.9%, respectively (p = 0.005). When evaluating only patients with CDC class 1 wounds, the recurrence rate in the retro-rectus group was 8.2% and the intraperitoneal group was 50% (p = 0.02). Overall, the average patient follow-up was 22months and did not differ between groups. Both the retro-rectus and intraperitoneal groups indicated a significant (p < 0.05) improvement in quality of life from baseline. No long-term (> 7days) antibiotics were used and no mesh implants were removed during the study. Patients who underwent open complex ventral hernia repairs with bio-absorbable mesh in the retro-rectus position experienced lower overall complication rates than those with intraperitoneal mesh placement. Despite a larger hernia defect in the retro-rectus group, recurrence rates were significantly reduced with retro-rectus placement of mesh compared to intraperitoneal placement. In addition, recurrence rates using bio-absorbable mesh in clean wounds are comparable to previously published recurrence rates with permanent mesh.

Transforaminal Interbody Debridement and Fusion to Manage Postdiscectomy Discitis in Lumbar Spine

Traditionally, nonoperative management with long-term antibiotics and bed rest has been recommended as first-line treatment for most patients with postoperative discitis. A recent trend in treatment under a limited range of indications has been to perform surgical débridement followed by long-term administration of antibiotics. This descriptive study investigated whether transforaminal lumbar interbody débridement and fusion (TLIDF) combined with intravenous antibiotics is appropriate to manage postdiscectomy discitis. This study retrospectively analyzed demographic data, laboratory data, and radiography and magnetic resonance imaging of 10 patients with postoperative discitis who underwent surgical TLIDF followed by antibiotic treatment. Preoperative and postoperative spine sagittal alignment, visual analog scale scores, and Kirkaldy-Willis criteria for functional outcomes were evaluated. An infection clearance rate of 100% was ultimately achieved for the patients who underwent TLIDF with short posterior instrumentation. TLIDF yielded better outcomes than traditional conservative treatment in terms of spine alignment correction, functional outcomes, and quality of life. Based on previously reported data and the findings of this study, we suggest that surgical intervention should be used in certain cases, as it can achieve better outcomes than conservative treatment. We recommend a novel single posterior approach with TLIDF and posterior pedicle screw instrumentation for management of postdiscectomy discitis.

Pseudomonas aeruginosa displays a dormancy phenotype during long-term survival in water.

Pseudomonas aeruginosa is capable of long-term survival in water, which may serve as a reservoir for infection. Although viable cell counts of PAO1 incubated in water remain stable throughout 8 weeks, LIVE/DEAD staining indicated a high proportion of cells stained with propidium iodide (PI). The proportion of PI-stained cells increased by 4 weeks, then decreased again by 8 weeks, suggesting an adaptive response. This was also evident in an observed shift in cell morphology from a rod to a coccoid shape after 8 weeks. Fluorescence-activated cell sorting (FACS) was used to recover PI-stained cells, which were plated and shown to be viable, indicating that PI-stained cells were membrane-compromised but still cultivable. PAO1 mid-log cells in water were labeled with the dsDNA-binding dye PicoGreen to monitor viability as well as DNA integrity, which demonstrated that the population remains viable and transitions towards increased dsDNA staining. Metabolic activity was found to decrease significantly in water by 4 weeks. The PAO1 outer membrane became less permeable and more resistant to polymyxin B damage in water, and the profile of total membrane lipids changed over time. Among the ~1400 transcriptional lux fusions, gene expression in water revealed that the majority of genes were repressed, but subsets of genes were induced at particular time points. In summary, these results indicate that P. aeruginosa is dormant in water and this adaptation involves a complex pattern of gene regulation and changes to the cell to promote long-term survival and antibiotic tolerance. The approach of P. aeruginosa incubated in water may be useful to study antibiotic tolerance and the mechanisms of dormancy and survival in nutrient limiting conditions.

Appropriate duration of post-surgical intravenous antibiotic therapy for pyogenic spondylodiscitis

BackgroundMost guidelines recommend 6 to 12 weeks of parenteral antibiotic treatment for pyogenic spondylodiscitis. When surgical debridement is adequately performed, further intravenous antibiotic treatment duration can be reduced than that of conservative treatment alone theoretically. However, the appropriate duration of post-surgical parenteral antibiotic treatment is still unknown. This study aimed to identify the risk factors of recurrence and evaluate the appropriate duration after surgical intervention.MethodsThis 3-year retrospective review included 102 consecutive patients who were diagnosed with pyogenic spondylodiscitis and underwent surgical intervention. Recurrence was defined as recurrent signs and symptoms and the need for another unplanned parenteral antibiotic treatment or operation within one year. This study included two major portions. First, independent risk factors for recurrence were identified by multivariable analysis, using the database of demographic information, pre-operative clinical signs and symptoms, underlying illness, radiographic findings, laboratory tests, intraoperative culture results, and treatment. Patients with any one of the risk factors were considered high-risk; those with no risk factors were considered low-risk. Recurrence rates after short-term (≤3 weeks) and long-term (> 3 weeks) parenteral antibiotic treatment were compared between the groups.ResultsPositive blood culture and paraspinal abscesses were identified as independent risk factors of recurrence. Accordingly, 59 (57.8%) patients were classified as low-risk and 43 (42.2%) as high-risk. Among the high-risk patients, a significantly higher recurrence rate occurred with short-term than with long-term antibiotic therapy (56.2% vs. 22.2%, p = 0.027). For the low-risk patients, there was no significant difference between short-term and long-term antibiotic therapy (16.0% vs. 20.6%, p = 0.461).ConclusionsThe appropriate duration of parenteral antibiotic treatment in patients with pyogenic spondylodiscitis after surgical intervention could be guided by the risk factors. The duration of postoperative intravenous antibiotic therapy could be reduced to 3 weeks for patients without positive blood culture or abscess formation.

Long-term antibiotic therapy is just as effective as amputation for foot osteomyelitis in diabetics without peripheral arterial disease

Long-term antibiotic therapy is just as effective as amputation for foot osteomyelitis in diabetics without peripheral arterial disease

PS01.025: CONSEQUENCES OF MUCOSAL PERFORATION FROM LAPAROSCOPIC HELLER MYOTOMY: A SYSTEMATIC REVIEW

Abstract Background Mucosal perforation is a common complication of Laparoscopic Heller Myotomy (LHM) for achalasia. Perforations discovered intra-operatively are usually treated with laparoscopic suturing. Perforations not identified at the time of operation generally present with sepsis and a leak. We aimed to document every reported case of mucosal perforation in the literature following this procedure and define the prognostic significance of this complication. Methods A systematic literature search was performed using the PubMed database with the key-phrases ‘achalasia’ and ‘laparoscopy’ or ‘laparoscopic’. All English-language case series and trials were included that reported at least one mucosal perforation from 1997 to 2017. Two researchers appraised the literature for inclusion. For centers with multiple publications, the largest series was chosen for inclusion. Results Of 901 articles retrieved, 100 studies were included after duplicates were excluded. 672 mucosal perforations were reported in 8705 LHM procedures (7.7%, range 0.5–30%). 635 perforations were identified intra-operatively. 609 (96%) were repaired with laparoscopic suturing with or without fundoplication and no clinical sequelae. 22 (3.5%) were converted to open procedures. No deaths or long-term morbidity was reported in procedures where perforations were identified intra-operatively. There were 37 definitive missed mucosal perforations that were identified post-operatively. 3 patients died. For those that survived, 22 returned to theatre, 2 were treated with radiological drainage and 10 were managed conservatively with long-term antibiotics. Due to differences in reporting nomenclature and definitions, the actual rate of missed mucosal perforations may be higher. Conclusion Mucosal perforation during LHM is rarely of prognostic significance if it is repaired with laparoscopic suturing at the time. Mucosal perforations identified post-operatively can result in re-operation, sepsis, prolonged hospital stay and death. Care should be taken to ensure any mucosal perforation is detected and repaired intra-operatively. Disclosure All authors have declared no conflicts of interest.

Predictors of Peripherally Inserted Central Catheter Occlusion in the Outpatient Parenteral Antimicrobial Therapy Setting.

In this retrospective study of 285 patients receiving outpatient parenteral antibiotic therapy (OPAT), the duration of antibiotic, use of double-lumen catheters, and receipt of penicillin G and cloxacillin appeared to increase the risk of peripherally inserted central catheter (PICC) occlusion. Physicians should consider these factors when prescribing long-term antibiotic therapy. Further studies are needed to evaluate methods to reduce PICC occlusion, particularly when double-lumen PICCs are necessary and when cloxacillin or penicillin G are the preferred treatment.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome in two young children: the importance of an early diagnosis

BackgroundDrug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious life-treating condition characterized by skin eruption, fever, haematologic abnormalities, and multi-organ involvement that can be fatal if unrecognized, especially in patients with liver failure. Diagnosis may be difficult because it is rarely described in children and can mimic many different conditions.Case presentationWe report two cases of DRESS syndrome due to prolonged antibiotic treatment in young children in whom recovery occurred following different therapeutic approaches. A previously healthy 5-year-old boy had been receiving intravenous vancomycin for right wrist and left elbow osteomyelitis and developed DRESS syndrome on day 30. The patient achieved a complete resolution of all symptoms with pulse methylprednisolone followed by oral prednisone. A 4-year-old girl with cystic fibrosis, pancreatic insufficiency, chronic pulmonary colonization by Gram-positive bacteria admitted for pulmonary exacerbation was treated with intravenous piperacillin-tazobactam and tobramycin. After 14 days of treatment, she developed DRESS syndrome: antibiotic treatment was therefore stopped, and without any further therapy, a progressive resolution of the patient’s clinical features was observed within 7 days, while the normalization of laboratory abnormalities was achieved at 14 days.ConclusionsOur cases highlight that paediatricians should be aware of the clinical presentations of and therapeutic approaches for DRESS syndrome, especially in children receiving long-term antibiotic treatment. The removal of the offending drug is crucial and may be the only life-saving measure. In more aggressive cases, corticosteroid or other immunosuppressive drugs should be considered to achieve the best outcome.

Subdural empyema in children.

Subdural empyema denotes the collection of purulent material in the subdural spaceand is commonly seen in infants and older children. In infants, the most common cause is bacterialmeningitis. In older children, sinusitis and otitis media are usually the source for subdural empyema. Theclinical symptomatology is varied and has a wide range including prolonged or recurrent fever, seizures,meningeal irritation, and raised intracranial pressure. It can mimic as well as complicate meningitis and aheightened clinical awareness is therefore paramount. The clinical profile, etiopathogenesis, imaging features and management of subdural empyema in children is discussed and the relevant literature is reviewed. Subdural empyema is a neurosurgical emergency and rapid recognition and treatment canavoid life-threatening complications. In most cases, surgical decompression through burr hole or craniotomyis warranted. Near complete evacuation of the purulent material and appropriate long-term intravenous antibiotics are necessary for a gratifying outcome.

An Ultrasound Guided Technique of Central Venous Catheterization versus Anatomical Landmark Guided Technique in Medical Intensive Care Patients

Background: Central venous catheterization (CVC) is an important procedure in the practice of emergency medicine. Insertion of CVC is amongst the most frequently performed invasive procedures in ICU. In severely ill and long-stay patients, inserted CVCs enable relatively safe and painless application of parenteral nutrition, long-term antibiotics, chemotherapy, intravenous fluids, and blood components and are also used for repetitive blood sampling. Furthermore, CVCs are used for invasive hemodynamic monitoring, hemodialysis, plasmapheresis and in case of shortage of a peripheral access. With the increasing availability of bedside ultrasound, emergency physicians have begun to incorporate this new technology to reduce error and improve patient care. Objective: To compare the outcome of an ultrasound guided technique versus an anatomical landmark guided technique for central venous catheterization. Patients and methods: The present study was performed on one hundred patients of both sexes; the study was conducted at El-Hussein University Hospital. They were scheduled for insertion of central venous line for various purposes. The patients were assigned into two groups each group formed of fifty patients (n=50). Group (A): Anatomical guided technique for insertion of CVC, Group (B): Ultrasound guided technique for insertion of CVC. Patients with local infection, known vascular abnormalities, untreated coagulopathy (INR more than 1.5, platelets less than 50000/mm3) and age less than 16 years old were excluded from the study. Results: A total of 100 patients were included. The outcome of each group was recorded regarding success rate, number of attempts and access time in seconds. The use of ultrasound guided central venous catheterization has better outcome and higher-safety in comparison to anatomical landmark-based technique. Ultrasound guidance elevated significantly the success rate of central venous catheterization than anatomical landmark-based technique. In addition, the access time was reduced in a significant trend by using ultrasound guidance. In the same manner the average number of attempts needed for accessing the vein was limited significantly when Ultrasound guidance was applied. The incidence of hematoma formation, arterial puncture and malposition was reduced in a significant trend by using ultrasound guidance in comparison to landmark-based techniques. When comparing ultrasound guidance to anatomical landmark-based guidance we found that all mechanical complications were significantly lower when central venous catheterization was carried out by means of ultrasound guidance. Conclusion: Ultrasound examination of the region of interest offers some additional information compared to clinical examination as Position of the vessel, Patency of the vessel, Size of the vessel and Stenosis or hematoma. The implementation of ultrasound guidance improves success and reduces complication rate during central venous catheterization.

Life-long antimicrobial therapy: where is the evidence?

The decision to prescribe long-term or 'life-long' antibiotics in patients requires careful consideration by the treating clinician. While several guidelines exist to help assist in this decision, the long-term consequences are yet to be well studied. In this review, we aim to provide a summary of the available evidence for patient populations where long-term antibiotic therapy is currently recommended in clinical practice. We will also discuss the pitfalls of this approach, including medication adverse effects, economic cost and any possible contribution to the emerging epidemic of microbial resistance.

Continuous versus intermittent antibiotics for bronchiectasis.

Bronchiectasis is a chronic airway disease characterised by a destructive cycle of recurrent airway infection, inflammation and tissue damage. Antibiotics are a main treatment for bronchiectasis. The aim of continuous therapy with prophylactic antibiotics is to suppress bacterial load, but bacteria may become resistant to the antibiotic, leading to a loss of effectiveness. On the other hand, intermittent prophylactic antibiotics, given over a predefined duration and interval, may reduce antibiotic selection pressure and reduce or prevent the development of resistance. This systematic review aimed to evaluate the current evidence for studies comparing continuous versus intermittent administration of antibiotic treatment in bronchiectasis in terms of clinical efficacy, the emergence of resistance and serious adverse events. To evaluate the effectiveness of continuous versus intermittent antibiotics in the treatment of adults and children with bronchiectasis, using the primary outcomes of exacerbations, antibiotic resistance and serious adverse events. On 1 August 2017 and 4 May 2018 we searched the Cochrane Airways Review Group Specialised Register (CAGR), CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and AMED. On 25 September 2017 and 4 May 2018 we also searched www.clinicaltrials.gov, the World Health Organization (WHO) trials portal, conference proceedings and the reference lists of existing systematic reviews. We planned to include randomised controlled trials (RCTs) of adults or children with bronchiectasis that compared continuous versus intermittent administration of long-term prophylactic antibiotics of at least three months' duration. We considered eligible studies reported as full-text articles, as abstracts only and unpublished data. Two review authors independently screened the search results and full-text reports. We identified 268 unique records. Of these we retrieved and examined 126 full-text reports, representing 114 studies, but none of these studies met our inclusion criteria. No randomised controlled trials have compared the effectiveness and risks of continuous antibiotic therapy versus intermittent antibiotic therapy for bronchiectasis. High-quality clinical trials are needed to establish which of these interventions is more effective for reducing the frequency and duration of exacerbations, antibiotic resistance and the occurrence of serious adverse events.

The Rationale and Evidence for Use of Inhaled Antibiotics to Control Pseudomonas aeruginosa Infection in Non-cystic Fibrosis Bronchiectasis.

Non-cystic fibrosis bronchiectasis (NCFBE) is a chronic inflammatory lung disease characterized by irreversible dilation of the bronchi, symptoms of persistent cough and expectoration, and recurrent infective exacerbations. The prevalence of NCFBE is on the increase in the United States and Europe, but no licensed therapies are currently available for its treatment. Although there are many similarities between NCFBE and cystic fibrosis (CF) in terms of respiratory symptoms, airway microbiology, and disease progression, there are key differences, for example, in response to treatment, suggesting differences in pathogenesis. This review discusses possible reasons underlying differences in response to inhaled antibiotics in people with CF and NCFBE. Pseudomonas aeruginosa infections are associated with the most severe forms of bronchiectasis. Suboptimal levels of antibiotics in the lung increase the mutation frequency of P. aeruginosa and lead to the development of mucoid strains characterized by formation of a protective polysaccharide biofilm. Mucoid strains of P. aeruginosa are associated with a chronic infection stage, requiring long-term antibiotic therapy. Inhaled antibiotics provide targeted delivery to the lung with minimal systemic toxicity and adverse events compared with oral/intravenous routes of administration, and they could be alternative treatment options to help address some of the treatment challenges in the management of severe cases of NCFBE. This review provides an overview of completed and ongoing trials that evaluated inhaled antibiotic therapy for NCFBE. Recently, several investigators conducted phase 3 randomized controlled trials with inhaled aztreonam and ciprofloxacin in patients with NCFBE. While the aztreonam trial results were not associated with significant clinical benefit in NCFBE, initial results reported from the inhaled ciprofloxacin (dry powder for inhalation and liposome-encapsulated/dual-release formulations) trials hold promise. A more targeted approach could identify specific populations of NCFBE patients who benefit from inhaled antibiotics.

Antibiotic Prophylaxis in Children with Urinary Tract Infection

Antibiotic prophylaxis is prescribed to prevent recurrent urinary tract infections (UTIs) in children, but this practice is being questioned with attention to efficacy and potential harm of long-term antibiotics. Prophylaxis for children with vesicoureteral reflux remains controversial and providers should consider factors that contribute to risk of recurrent UTI such as age, sex, circumcision status, reflux grade, and bladder and bowel dysfunction. Further complicating our understanding of the impact of prophylaxis is evidence that adherence is poor. Antibiotic resistance is a growing problem that is exacerbated by prophylaxis. Some children have a reduced rate of recurrent UTIs when treated with prophylaxis, though which subset of those at risk who will benefit remains unclear. Given this uncertainty, current guidelines allow physicians to individualize care. Reduction of recurrent UTIs must be balanced with the harm of prophylaxis, including the development of antibiotic resistance.

Repair of Thoracic and Thoracoabdominal Mycotic Aneurysms and Infected Aortic Grafts Using Allograft

Mycotic aneurysm of the thoracic or thoracoabdominal aorta and infection of thoracic or thoracoabdominal aortic grafts are challenging problems with high mortality. In situ reconstruction with cryopreserved allograft (CPA) avoids placement of prosthetic material in an infected field and avoids suppressive antibiotics or autologous tissue coverage. Fifty consecutive patients with infection of a thoracic or thoracoabdominal aortic graft or mycotic aneurysm underwent resection and replacement with CPA from 2006 to 2016. Intravenous antibiotics were continued postoperatively for 6 weeks. Long-term suppressive antibiotics were uncommonly used (8 patients). Follow-up imaging occurred at 6, 18, and 42 months postoperatively. Initial follow-up was 93% complete. Men comprised 64% of the cohort. The mean age was 63 ± 14 years. The procedures performed included reoperations in 37 patients; replacement of the aortic root, ascending aorta, or transverse arch in 19; replacement of the descending or thoracoabdominal aorta in 27; and extensive replacement of the ascending, arch, and descending or thoracoabdominal aorta in 4. Intraoperative cultures revealed most commonly Staphylococcus (24%), Enterococcus (12%), Candida (6%), and gram-negative rods (14%). Operative mortality was 8%, stroke was 4%, paralysis was 2%, hemodialysis was 6%, and respiratory failure requiring tracheostomy was 6%. Early reoperation for pseudoaneurysm of the CPA was necessary in 4 patients. One-, 2-, and 5-year survival was 84%, 76%, and 64%, respectively. Radical resection and in situ reconstruction with CPA avoids placing prosthetic material in an infected field and provides good early and midterm outcomes. However, early postoperative imaging is necessary given the risk of pseudoaneurysm formation.

Dose, duration, and cost: opportunities to improve use of long-term oral antibiotics for people with rosacea

Background: Systemic antibiotics are often used to treat rosacea and tetracyclines are the most common antibiotic prescribed; however, there is ambiguity among clinical guideline suggestions. Importantly, there is an increasing call to all clinicians to curtail antibiotic use.Objective: To investigate the utilization and cost of long-term oral antibiotic use for the treatment of rosacea, including ocular rosacea.Methods: This was a retrospective cohort study of MarketScan® Commercial Claims and Encounters database, from January 1, 2005 through December 31, 2014. Claim data were used to determine the duration and costs of antibiotic treatment among adults with rosacea.Results: The sample included 72,411 patients. The mean (SD) duration of long-term antibiotic treatment was 87.68 (145.99) days and for patients with ocular rosacea was slightly longer, 108.34 (176.74) days [p < .0001]. The majority of antibiotic courses were shorter than 3 months (80.04%) for the entire sample and the subset with ocular rosacea (53.64% [p = .007]).Limitations: Patient adherence is uncertain and database lacks information on rosacea severity and clinical outcomes.Conclusions: The majority of oral antibiotic course durations follow guidelines. Costs of antibiotic therapy were lower for shorter courses and those utilizing generic medications; the cost-effectiveness of these modifications has not been investigated.

Severe acute malnutrition.

Advances in our understanding of the treatment of severe acute malnutrition (SAM) in a resource-limited environment are needed to improve outcome. Ready-to-use therapeutic foods (RUTFs) made from local products and with reduced milk content lower costs and may be effective in older children. None of the therapeutic foods used to treat severely malnourished children correct long chain polyunsaturated fatty acid deficiencies.Routine short-term antibiotic (amoxicillin) treatment, in the context of adequate healthcare supervision, does not improve the recovery rate. Long-term antibiotic (cotrimoxazole) treatment also does not provide significant benefit to non-HIV-infected children.Increased pathogenic bacteria have been found in the intestinal microbiome of malnourished children and candidate organisms for use as probiotics have been identified. There is, however, no evidence to support the routine use of probiotics in these children. Although exocrine pancreatic function is reduced in malnourished children, routine pancreatic enzyme supplementation does not lead to accelerated recovery. Alternative RUTF may provide a cheaper and more acceptable alternative to standard RUTF in the near future. Further research is needed to understand the implications of fatty acid deficiencies and dysbiosis that occur in malnourished children. Routine antibiotic administration in the appropriate setting is unnecessary.