Long-term Intravenous Antibiotics Research Articles

Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft

The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection. We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics. The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n=1) and graft-related mortality of 0%. During follow-up (median 13months, range 6-34months), reinfection was 5.2% and primary graft patency 94.7%. The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

Dalbavancin as an alternative to traditional outpatient parenteral antimicrobial therapy for deep gram-positive infections - an observational, retrospective review.

Treatment of invasive gram-positive infections in complex patient populations is challenging. Dalbavancin, approved for skin and soft tissue infections, offers advantages in this setting due to its long half-life and infrequent dosing. However, less is known about the outcomes of off-label dalbavancin for deeper infections. The objective of this study is to examine the feasibility and outcomes of patients with complex gram-positive infections treated with dalbavancin as an alternative to standard outpatient parenteral antimicrobial therapy (OPAT). We conducted a multicenter, retrospective review of adult patients managed within an OPAT program with intravenous dalbavancin for off-label indications. Adult patients were included if they had treatment details and follow-up documented between January 2020 and June 2023. Details of dalbavancin use including indications for prescription were captured. Outcomes of interest included 90-day infection recurrence, prosthesis retention rates, 90-day mortality, and adverse medication events. In all, 61 patients received dalbavancin, mostly as sequential therapy. Twenty-three percent received dalbavancin strictly in the outpatient setting. Dalbavancin was used primarily for hardware (fracture, spine, or joint), native bone or joint, and complicated soft tissue infections. The predominant pathogen was Staphylococcus aureus (61%). Dalbavancin was frequently prescribed as a two-dose 1500 mg regimen (49%) due to persistent infection (23%), difficult line access (30%), difficulty achieving therapeutic vancomycin levels (18%), or substance abuse history (18%). Overall, six patients (10%) had infection recurrence and no patients died during the follow-up period. Three of eight patients with hardware retention had infection recurrence. Adverse effects were minimal and mostly self-limiting. Dalbavancin is an efficacious and safe alternative to standard OPAT, especially in those with barriers to traditional long-term intravenous antibiotics. Improved outcomes may be achieved with hardware removal. Dalbavancin may facilitate early discharge or prevent hospitalizations. Comparative studies of standard OPAT regimens versus dalbavancin are needed.

Tricuspid valve repair and replacement for infective endocarditis.

The online version contains supplementary material available at 10.1007/s12055-023-01650-0.

MYCOTIC ANEURYSM OF INTERNAL ILIAC ARTERY CAUSED BY SALMONELLA SPP. INFECTION: A CASE REPORT

Mycotic aneurysm (MA) is an extremely rare disease caused by secondary infection, one of the most common causes is Salmonella spp. A male patient with type 2 diabetes mellitus presented with edema on the left lower limb, fever, abdominal pain radiating to the back, and was suspicious of Deep Vein Thrombosis (DVT). Laboratory examination showed leukocytosis and elevated inflammatory markers such as C-reactive protein and procalcitonin, with Salmonella spp. detected in the blood culture, and the image of MA with thrombus presented on the run-off CT scan with contrast. The patient was scheduled to undergo Endovascular Aneurysm Repair (EVAR) procedure. However, he suddenly had a cardiac arrest on the sixth day of treatment before surgery, caused by suspected pulmonary embolism with suspected DVT. MA has a high mortality rate (around 40%) with a high risk of aneurysm rupture, however, pulmonary embolism has been reported as a cause of death in MA patients with DVT. In addition to rapid diagnosis, aggressive yet adequate therapy, namely surgery and long-term intravenous antibiotics, is crucial.

Para-spinal abscess presenting with abdominal pain-a case report of 'red herring' symptoms.

Paraspinal abscesses are rare infections affecting the paraspinal muscles and soft tissues. An evolving abscess may pose a threat to the spinal cord via the compressive effect which can manifest as impaired motor or sensory function at the corresponding vertebral level. Paraspinal abscess is often a late diagnosis due to non-specific symptoms at presentation. This results in high morbidity and mortality. We describe the case of a 59-year-old female with a paraspinal abscess presenting with epigastric pain who was initially worked up for a suspected intra-abdominal pathology, however computerised tomography of the chest, abdomen, and pelvis (CTCAP) revealed no abnormality. Later, rising inflammatory markers, accompanied by worsening cervicalgia, prompted a CT of the head, neck and thorax which revealed a soft tissue abscess compressing the thecal sac at cervical levels 1 to 3 (C1-3). This was successfully managed with radiologically guided drainage and long-term intravenous antibiotics. Our patient made a full recovery and a repeat MRI demonstrated resolution of the abscess. We demonstrate that spinal abscess can present with a misleading combination of symptoms and highlight the importance of considering rarer differentials in the face of an evolving clinical picture. Our case also demonstrates that once the correct diagnosis is reached, patients can make an excellent recovery from uncomplicated spinal abscesses.

Management of Epidural and Subgaleal Abscesses in Pediatric Craniosynostosis Surgery

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

長期間の抗菌薬経静脈投与を要した頭蓋底骨髄炎例

Skull-base osteomyelitis occurs as a result of spread of inflammatory disease around the temporal bone into the adjacent skull base, and carries a poor prognosis. Occasionally, patients present with paralysis of the lower cranial nerves, which further worsens the survival. Prolonged intravenous antibiotic therapy for six to eight weeks is needed for treatment. Herein, we present a case of skull-base osteomyelitis caused by Pseudomonas aeruginosa that developed in a 78-year-old male patient with diabetic nephropathy who was under maintenance hemodialysis. He presented to our hospital with the complaints of earache and otorrhea on the left side. Exploratory tympanotomy revealed pus and granulation tissue filling the tympanic cavity and mastoid, and destruction of the tympanic portion of the temporal bone; based on the findings and results of pus culture, we made the diagnosis of skull-base osteomyelitis caused by Pseudomonas aeruginosa. While the osteomyelitis was gradually improving with intravenous meropenem, the patient desired early discharge from the hospital. Therefore, the intravenous antibiotic therapy was switched earlier than intended to oral antimicrobial therapy, which led to progression of the disease, and the patient presented with lower cranial nerve palsies three months after his discharge. He was initiated again on intravenous meropenem. While the osteomyelitis improved gradually with the intravenous antimicrobial therapy for two months, the levels of inflammatory markers, such as the serum c-reactive protein, increased again soon after discontinuation of the intravenous antibiotic therapy. Therefore, we decided to continue the patient on intravenous meropenem every other day administered at the outpatient clinic after dialysis. The treatment was continued for four months after discharge, and the improvement was maintained. We reaffirmed the importance of long-term intravenous antibiotic therapy to treat skull-base osteomyelitis. Intravenous antibiotic administration every other day at the outpatient clinic after dialysis could be a useful treatment strategy to treat skull-base osteomyelitis in patients under maintenance hemodialysis.

Pott's Puffy Tumor: It's not a Tumor but it Can be Lethal (2 Cases Report)

The Pott’s puffy tumor has become an infrequent entity since the advent of antibiotic therapy. It is defined as a subperiosteal abscess arising from frontal bone osteomyelitis. We report two cases of PPT due to intreated frontal sinusitis and confirmed by computed tomography scan. Early surgery associated with long-term intravenous antibiotics is required to obtain a good recovery and prevent life-threatening intracranial complications.

Portal Vein Thrombosis Associated With Fusobacterium nucleatum Bacteremia: A Rare Abdominal Variant of Lemierre’s Syndrome

Lemierre's syndrome is a rare but potentially severe complication of bacterial infections that usually affects previously healthy adolescents and young adults. It commonly presents as septic thrombophlebitis of the internal jugular vein and bacteremia following a recent oropharyngeal infection. The most commonly isolated organisms are Fusobacterium necrophorum, followed by Fusobacterium nucleatum and other anaerobes. Atypical Lemierre's syndrome is characterized by thrombophlebitis at sites distant from the head and neck veins and is far less encountered than typical Lemierre's syndrome. Here, we present a case of an elderly African American female with pylephlebitis, a rare abdominal variant of Lemierre's syndrome with extensive portal vein, splenic vein, and mesenteric vein thrombosis following perforated diverticulitis and resultant F. nucleatum bacteremia. She demonstrated complete recovery following appropriate long-term intravenous antibiotics and anticoagulation. This case calls attention to the re-emergence of the rare manifestation of this forgotten disease and highlights improved outcomes with prompt recognition and early treatment.

Evaluating the Use of Dalbavancin for Off-Label Indications.

(1) Background: Dalbavancin is a long-acting lipoglycopeptide antibiotic approved for skin and soft-tissue infections. Post-marketing experience suggests dalbavancin is being used for off-label indications that normally require long-term intravenous (IV) antibiotics; however, data assessing this off-label usage are limited. The purpose of this study was to evaluate the real-world efficacy, safety, and financial impact of off-label dalbavancin use. (2) Methods: This is a retrospective, observational study conducted within a 4-hospital health system. Adult patients who received dalbavancin from January 2018 to January 2021 for an off-label indication were included. The primary outcome was clinical success at 90 days. Secondary outcomes included safety (nephrotoxicity and hepatotoxicity). A pharmacoeconomic analysis was performed by comparing the cost of dalbavancin to the anticipated cost of patient stay if standard IV therapy was given. (3) Results: Forty-eight patients met study criteria. Indications included osteomyelitis (54%), endocarditis (23%), bacteremia (15%), and prosthetic joint infection (8%). The predominant organism was S. aureus (60%), with 42% caused by methicillin-resistant S. aureus. Overall, 41 (85%) patients achieved clinical success at 90 days, including 85% with osteomyelitis, 82% with endocarditis, and 86% with bacteremia. There were no instances of nephrotoxicity or hepatotoxicity. Estimated cost avoidance per patient was USD 5313 and USD 1683 if traditional IV therapy would have been completed in the hospital and skilled nursing facility, respectively. (4) Conclusion: Dalbavancin was associated with a relatively high success rate for the treatment of off-label indications and may be a cost-effective alternative to traditional IV antibiotic therapy.

Necrotising otitis externa antibiotic therapy complications: Aretrospective cohort analysis.

NOE is a rare but life-threatening condition. Treatment is long-term intravenous antibiotics. However, there is no evidence on the complications of antibiotic treatment in this complex cohort of patients In our study, patients on average are treated with two different antibiotic regimes 63% of these changes in regimen are due to direct adverse effects from treatment including drug intolerance and lack of significant clinical response leading to deterioration and morbid complications Patients requiring multiple antibiotic regimes have a statistically longer duration of treatment. These adverse effects appear to occur more frequently in patients with additional comorbidities. This novel data provides information clinicians can use when initiating treatment for NOE and counsel patients appropriately.

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

AAOMS Stage 2 and Some Stage 3 Medication-Related Osteonecrosis of the Jaws (MRONJ) Can Be Managed Successfully and Predictably in OMFS Private Practice with Surgical Intervention and Long-term Intravenous Antibiotics

Despite published guidelines, the management of medication-related osteonecrosis of the jaws (MRONJ) remains controversial. Most cases that are resistant to straight forward conservative management are usually referred to an academic teaching center or hospital-based practice. This article will attempt to show that these cases can be managed successfully in private practice on an outpatient basis.

612. Empowering Patients with Addiction to Self-Administer Parenteral Antibiotics at Home: A Pilot Project

Abstract Background Nearly 20% of people in the United States use drugs each year. People who use drugs (PWUD) are predisposed to complex infections that require long term intravenous (IV) antibiotics. A frequent clinical quandary in PWUD is safe administration of extended IV antibiotics. Current standard of care is IV antibiotic administration in skilled nursing facilities. In this system, PWUD frequently do not finish antibiotic therapy, resulting in avoidable complications of untreated infections and increased healthcare utilization. We present a pilot study of ten patients with a history of addiction who required long-term IV antibiotics to evaluate the feasibility of self administered outpatient parenteral antibiotic therapy (S-OPAT) for PWUD. Methods Ten patients who had a history of mild addiction and stable housing, social support and transportation were enrolled at Parkland Health and Hospital System to complete S-OPAT. We extracted demographic, drug use, clinical and access to care variables and patients were followed with weekly clinical appointments. Addiction severity was defined using the National Institute of Drug Abuse (NIDA) -Modified ASSIST Score. We completed post-intervention surveys to evaluate the impact of the intervention on provider-patient trust. Results A total of 10 patients were enrolled in S-OPAT (Table 1). The patients were 48 years old on average, all were male and seven were Hispanic. All patients had stimulant use disorder and no patients had commercial insurance. Treated infections were bone/ joint and skin/soft tissue in origin. All patients completed their antibiotic course, nearly all appointments were attended (96%) and there were no 30-day hospital readmissions (Table 2). More than two-third of patients experienced improvement in addiction severity with progress in multiple psychosocial factors including housing instability, social support and legal problems (Figure 1; Table 2). Table 1. Demographic, substance use and clinical variables among people who use drugs enrolled in the pilot project for S-OPAT (N=10). Table 2. Clinical, drug use and psychosocial outcomes among people who use drugs and received S-OPAT (N=10). Addiction severity was defined using the National Institute of Drug Abuse (NIDA) -Modified ASSIST Score. Figure 1. Progression of addiction severity before and after completion of self-administered outpatient parenteral antibiotic therapy pilot among patients with a history of drug use (N=10). Addiction severity was defined using the National Institute of Drug Abuse (NIDA) -Modified ASSIST Score. Conclusion We demonstrate that PWUD can successfully complete S-OPAT with simultaneous improvement in addiction severity and psychosocial factors. We hope to create a framework for the patient-centered administration of extended courses of antibiotics for PWUD and to advocate for the expansion of individualized approaches to extended courses of IV antibiotics for PWUD. Disclosures All Authors: No reported disclosures

Current management of skull base osteomyelitis.

Skull base osteomyelitis (SBO) is a life-threatening condition. Due to an aging and increasingly multimorbid population, clinicians are more often challenged with this disease. Yet, there is no consensus on the optimal diagnostic and follow-up management. This review should aid clinicians in decision-making for their patients. Treatment-resistant otalgia or headache is suspicious of SBO. Pseudomonas aeruginosa remains the most common pathogen but clinicians are challenged with increasing rates of sterile or fungal cultures due to previously applied antibiotics/steroids. No single imaging modality is able to detect the full extent of the disease. Whereas functional nuclear imaging with gallium-67 or methylene diphosphonate-technetium-99m was once advocated, its actual benefit is questionable. Newer modalities such as fluoro-D-glucose-positron emission tomography (PET)/computed tomography, PET/magnetic resonance imaging (MRI), or diffusion-weighted MRI seem to be promising in diagnosis and follow-up. Finding the causative pathogen is of utmost importance followed by long-term intravenous antibiotics until the disease has completely resolved. Surgery plays a minor role in treatment but can be helpful in selected cases. The numerous challenges in SBO render management difficult, but with a clear work-up including regular clinical, laboratory and imaging examinations, outcome can be improved.

Long-term prophylactic intravenous antibiotics after Kasai portoenterostomy for biliary atresia do not reduce the risks of post-operative cholangitis, a retrospective study.

BackgroundPostoperative cholangitis (PC) is the most common and serious complication of biliary atresia (BA) patients post-Kasai portoenterostomy (KPE). The duration of prophylactic intravenous antibiotics (IVA) after KPE varies with no clear consensus. We conducted a retrospective cohort study to explore the effects of IVA duration on preventing post-operative cholangitis and analyze the risk factors for cholangitis and short-term prognosis.MethodsAll patients diagnosed with BA and received KPE in Guangzhou Women and Children’s Hospital in 2018, were included in this study. The patients received prophylactic IVA after KPE. Firstly, the patients were divided into two groups based on the presence or absence of PC (PC and NPC group). The correlation between PC and the IVA duration was analyzed, followed by a comparison of short-term prognosis, outcome, and other risk factors between the groups. Next, the patients were divided based on the median IVA duration of 11 days (long IVA and short IVA group), followed by a comparison of the incidence of PC, short-term prognosis, outcome, and other risk factors between the two groups.ResultsTotally 89 patients were included in this study. Amount them, eleven patients who were lost during follow-up, were excluded from the study. The prophylactic IVA duration of the PC (n=52) and NPC (n=25) groups was 12.6±8.5 and 13.0±4.5 days, respectively (P=0.79). Further, the jaundice clearance rate of the two groups was similar (PC: 31/52, NPC: 13/25, P=0.53). There was no difference in the incidence and frequency of cholangitis between the short (n=42) and long (n=35) IVA groups (27/42, 25/35, P=0.51), and the duration of IVA had no effect on jaundice clearance (24/42, 20/35, P=1.00). The short IVA group had a significantly shorter hospital stay than the long IVA group (16.2±5.1, 25.3±8.3, P=8.95×10−8). Patients undergoing KPE at an older age were at a higher risk of cholangitis (NPC: 60.6±19.7, PC: 72.3±17.8, P=0.01).ConclusionsA long duration of IVA after KPE for BA may not be necessary. Early diagnosed patients had timely surgery had a lower incidence of PC. Our findings may help in promoting the scientific use of antibiotics and reducing the LHS.

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

Preventive effect of prophylactic intravenous antibiotics against cholangitis in biliary atresia: a randomized controlled trial.

Biliary atresia (BA) is a neonatal liver disease and requires Kasai portoenterostomy. Many patients develop postoperative cholangitis, resulting in a poor prognosis. The preventive strategy of antibiotics is empirical and lacks a standard regimen. We aimed to analyze the effect of different durations of prophylactic intravenous antibiotics against post-Kasai cholangitis. A single-center, open-labeled, randomized clinical trial was performed from June 2016 to August 2017. One hundred and eighty BA patients were recruited and randomized into a short-term (n = 90) and a long-term (n = 90) treatment group, and prophylactic intravenous antibiotics were used for 7 versus 14days, respectively. The primary outcome was the overall cholangitis incidence within 6-months post-Kasai portoenterostomy. The secondary outcomes included cholangitis incidence within 1 and 3months post-Kasai portoenterostomy, the onset and average episodes of cholangitis, jaundice clearance rate, native liver survival rate, and adverse events within 6-months post-Kasai portoenterostomy. The cholangitis incidence within 6-months post-Kasai in the short-term group was similar to the long-term group (62% vs. 70%, p = 0.27) with intention-to-treat and pre-protocol analysis. There was no significant difference in jaundice clearance rate or native liver survival rate between the two groups. However, the percentage of early onset (61% vs. 38%, p = 0.02) and average episodes (2.4 ± 0.2 vs. 1.8 ± 0.1 episodes, p = 0.01) of cholangitis were lower in the long-term group. Long-term intravenous antibiotics can be replaced by the short-term regimen in the general protection against post-Kasai cholangitis.

A Case of Atypical Central Skull Base Osteomyelitis with Bilateral Alveolar Bone Destruction

Central skull base osteomyelitis (CSBO) is a rare, fatal condition seen mostly in elderly diabetic or immunocompromised patients; it mainly involves the sphenoid or occipital bones and diagnosis is often delayed. A 72-year-old male with diabetes was referred to our department with severe pain in the maxillary gingiva. Endoscopic biopsy of the pterygoid bone confirmed the presence of mucormycosis combined with Klebsiella pneumoniae infection. Sinus surgery was performed with bilateral alveolar bone sequestrectomy. Long-term intravenous broad-spectrum antibiotic therapy using meropenem and ampicillin/sulbactam and antifungal therapy using amphotericin B (100 mg/day) was administered; an oral antifungal agent, posaconazole (800 mg/day), was also prescribed for 11 weeks. At the 6-month follow-up visit, there were no complications and no progression of the CSBO lesion was observed. Timely diagnosis and multidisciplinary treatment including endoscopic surgery, alveolar bone sequestrectomy, and combined antifungal and antibiotic therapy can reduce mortality and minimize complications associated with CSBO.

Overutilization of Peripherally Inserted Central Venous Catheters in the Hospital Setting

The purpose of this study was to assess the appropriate utilization of peripherally inserted central venous catheter (PICC) placement in patients in an urban hospital setting. We performed a retrospective review of a prospective database created for quality assurance purposes of all patients who had a PICC request placed on Friday afternoon–Sunday between January and June 2019. Data collected included demographic information, pertinent medical history, and procedural details (incidence of PICC placement and the reason for PICC cancellation). The most common reasons for PICC consultation was “long-term intravenous (IV) antibiotics” (51.3%) and “poor IV access” (39.5%). On retrospective chart review, only 51/76 (67%) patients underwent subsequent PICC placement in the days following request placement. Of the 1/3 patients in whom a PICC was not subsequently placed, 64% were deemed nonindicated, and an additional 28% were contraindicated. In these patients, the reason for PICC consultation was most commonly “poor IV access.” There appears to be an overutilization of PICCs in our hospital setting; indications for PICCs should be carefully reviewed as these lines pose a risk of morbidity to patients who may not need them.