Mean Duration Of Antibiotic Therapy Research Articles

Revision Surgery for Shoulder Infection after Arthroscopic Rotator Cuff Repair: Functional Outcomes and Eradication Rate-A Systematic Review.

The outcomes after arthroscopic rotator cuff repair (RCR) have been reported to be successful. The incidence of deep infections (defined as an infection involving any part of the anatomy other than the skin and subcutaneous tissue) after surgery ranges between 0.03% and 3.4%. This systematic review aims to investigate the outcomes of revision surgery for infection following arthroscopic RCR. Clinical outcomes and eradication rates among patients treated with different surgical and antibiotic therapies are analyzed. A total of five studies were eligible for systematic review. A total of 146 patients were treated and evaluated, of whom 71 (48%) and 75 (52%) underwent arthroscopic and open surgery to manage the infection, respectively. The most common causative bacterium was Cutibacterium acnes (50.4%). Two studies reported the pre-and postoperative ASES score and Constant-Murley score (CMS), and a statistically significant improvement was found after surgery (p < 0.001 for both). Eradication was observed in a total of 138 patients (94.5%); no difference was found between arthroscopic and open revision surgery (92.8% and 96%, respectively, p = 0.90). The frequency-weighted mean duration of the intravenous antibiotic therapy was 6.6 ± 5.4 days, while the overall mean duration of antibiotic therapy, considering intravenous and oral administration, was 43.5 ± 40 days. Patients with infection following arthroscopic RCR undergoing revision surgery experienced a high rate of eradication. A significant improvement in shoulder functionality and less residual pain can be expected.

Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study.

Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.

What is the agreement between principles and practice of antibiotic stewardship in the management of diabetic foot infection: an in-hospital quality control study.

Introduction: Standardization of diagnostic and treatment concepts in diabetes-related foot infection (DFI) is challenging. In 2019, specific recommendations regarding diagnostic principles and antibiotic therapy (ABT) for DFI, including the one for osteomyelitis (DFO), were introduced in our institution. In this study, we assessed the adherence to these in-house guidelines 2 years after their implementation. Methods: Adult patients with DFI with and without DFO who underwent surgical intervention between 2019 and 2021 were included. Patients' charts were retrospectively reviewed. Accordance to recommendations regarding biopsy sampling, labeling, requesting microbiological and histopathological examinations, and treatment duration were assessed. Results: A total of 80 patients with 117 hospital episodes and 163 surgical interventions were included; 84.6 % required an amputation. Patients with HbA1c levels of % more often required a revision during the same hospitalization than those with HbA1c levels of % (29.4 % vs.12.1 %, respectively, ). Specimens were obtained in 71.8 % of operations and sent for histological examination in 63.2 %. The mean duration of ABT was 9 (interquartile range (IQR) 5-15) d in macroscopically surgically cured episodes and 40.5 (IQR 15-42) d in cases with resection margins in non-healthy bone ( ). Treatment duration results were similar when using histological results: 13 (IQR 8-42) d for healthy bone vs.29 (IQR 13-42) d for resection margins consistent with osteomyelitis ( ). Conclusion: The adherence to recommendations in terms of biopsy sampling was good, moderate for histopathological analysis and poor for labeling the anatomic location. Adherence to recommendations for ABT duration was good, but further shortening of treatment duration for surgically cured cases is necessary.

1272. Teaching the ABCs of ASB in a 60-minute educational intervention. A quality improvement project.

Abstract Background Asymptomatic bacteriuria (ASB) refers to the presence of bacteria in the urine of individuals that do not present with symptoms of urinary tract infection (UTI). Treatment for ASB is not recommended in most cases. [1] Previous studies have shown that provider education on proper antibiotic use has been effective in mitigating the ongoing wave of antimicrobial-resistant organisms across hospitals in the United States.[2] We aimed to decrease the proportion of cases classified as having asymptomatic bacteria by 20% in four months after the intervention using a small group discussion and a presentation. Methods We evaluated the rates of inappropriate antimicrobial prescribing for asymptomatic bacteriuria (ASB) for 4 months before educational intervention and 4 months after. Data was extracted from the electronic medical record (Cerner®), imported into REDCap®, and with standardized manual chart review. Data analysis was completed using STATA® 17 &amp; 18. Results The mean duration of antibiotic therapy was 7.9 days in the pre-intervention group and 6.1 days in the post-intervention group. See Table 1 for more details on demographics. Following the intervention, the rate of inappropriate use of antimicrobial therapy in ASB was reduced by 29.8% (p-value 0.035). The mean duration of antibiotic therapy decreased by almost 2 days in the post-intervention group. Conclusion This quality improvement project suggests that focused interventions of short interactive educational sessions in small groups may reduce the inappropriate use of antibiotics in ASB by almost 30%. The mean duration in days of antibiotic treatment decreased from 7.9 days to 6.1 days in the pre and post-intervention groups (p-value 0.060). Of note the total number of cases with providers selecting UTI as an indication was also lower in the post-intervention group and although we can’t determine causality, it provided evidence of a lower number of cases, providers initially classified as UTI between the pre and post-intervention period from 33 to 19. Further research may include incorporating small groups and interprofessional educational interventions to help implement good antimicrobial stewardship in inpatient care facilities. [4,5,6] Disclosures All Authors: No reported disclosures

Pleural drainage vs video-assisted thoracoscopic debridement in children affected by pleural empyema

BackgroundBoth thoracic drainage and video-assisted thoracic surgery (VATS) are available treatment for pleural empyema in pediatric patients.Materials and methodsThis retrospective multicenter study includes pediatric patients affected by pleural empyema treated from 2004 to 2021 at two Italian centers. Patients were divided in G1 (traditional approach) and G2 (VATS). Demographic and recovery data, laboratory tests, imaging, surgical findings, post-operative management and follow-up were analyzed.Results70 patients with a mean age of 4.8 years were included; 12 (17.1%) in G1 and 58 (82.9%) in G2. Median surgical time was 45 min in G1, 90 in G2 (p < 0.05). Mean duration of thoracic drainage was 7.3 days in G1, 6.2 in G2 (p > 0.05). Patients became afebrile after a mean of 6.4 days G1, 3.9 in G2 (p < 0.05). Mean duration of antibiotic therapy was 27.8 days in G1, 25 in G2 (p < 0.05). Mean duration of postoperative hospital stay was 16 days in G1, 12.1 in G2 (p < 0.05). There were 4 cases (33.3%) of postoperative complications in G1, 17 (29.3%) in G2 (p > 0.05). 2 (16.7%) patients of G1 needed a redosurgery with VATS, 1 (1.7%) in G2.ConclusionsVATS is an effective and safe procedure in treatment of Pleural Empyema in children: it is associated to reduction of chest tube drainage, duration of fever, hospital stay, time of antibiotic therapy and recurrence rate.

Upfront appendectomy vs interval appendectomy in acute appendicitis with mass formation in pediatric age group: Little difference in major outcome

Aim: The aim of this study is to compare Conservative treatment followed by Interval Appendicectomy, versus Emergency Appendicectomy for the management of appendicular masses in children. Methods: Retrospective review of all appendicectomy performed in Tallaght university hospital, in Paediatric Surgery Department between January 2013 and June 2016. We included 397 procedures of Appendicectomy, among those, 16% (n=64) were diagnosed as appendicular masses. Cases were classified into two groups. Group I included those who were managed conservatively and then underwent Interval Appendicectomy after 6 to 8 weeks, (n=20) 31.3%. Group II included those who were managed with Emergency Appendicectomy, (n=44) 68.8%. The outcomes in the two groups were compared based on three parameters; the duration of hospital stay, the duration of Intravenous Antibiotics and post-operative morbidities. Results: We found that the median duration of hospitalization in group I was significantly longer than in group II (10 days vs 5 days, P&lt;0.0001). The mean duration of antibiotic therapy in group I was also significantly longer than in group II (10.4±3.17 days) vs (5.19±2.53 days), P&lt;0.0001). Nevertheless, the overall complication rate in Group I was similar to that of group II (38.1% vs 25.6%, P=0.304). Conclusion: No major difference in outcomes between the conservative and emergency operative approaches in managing appendicular mass in children. However, operative management is more cost-effective with less duration of hospital stay, as compared to the conservative approach.

Antibiotic Therapy for Pulmonary Exacerbations in Cystic Fibrosis-A Single-Centre Prospective Observational Study.

People with cystic fibrosis experience bronchopulmonary exacerbations, leading to lung damage, lung function decline, increased mortality, and a poor health-related quality of life. To date, there are still open questions regarding the rationale for antibiotic use and the optimal duration of antibiotic therapy. This prospective single-center study (DRKS00012924) analyzes exacerbation treatment over 28 days in 96 pediatric and adult people with cystic fibrosis who started oral and/or intravenous antibiotic therapy in an inpatient or outpatient setting after clinician diagnosis of bronchopulmonary exacerbation. Biomarkers of exacerbation were examined in terms of their ability to predict response to treatment and the need for antibiotic therapy. The mean duration of antibiotic therapy was 14 days. Inpatient treatment was associated with a poorer health status, but no significant difference was found in the modified Fuchs exacerbation score between inpatients and outpatients. A significant increase of in-hospital FEV1, home spirometry FEV1, and body-mass index and a significant decrease of the modified Fuchs symptom score, C-reactive protein, and 8 out of the 12 domain scores of the revised cystic fibrosis questionnaire were demonstrated after 28 days. However, a trend towards a FEV1 decline in the inpatient group on day 28 could be demonstrated, while FEV1 was maintained in the outpatient group. Correlation analyses of changes between baseline and day 28 show a strong positive correlation between home spirometry and in-hospital FEV1, strong negative correlations between FEV1 and the modified Fuchs exacerbation score and between FEV1 and C-reactive protein, and a moderately negative correlation between FEV1 and the three domains of the revised cystic fibrosis questionnaire. Responders and non-responders to antibiotic therapy were defined in terms of FEV1 improvement after therapy. A higher baseline C-reactive protein, a greater decrease in C-reactive protein, a higher baseline modified Fuchs exacerbation score, and a greater decrease in the score after 28 days could be found in the responder group, while other baseline and follow-up parameters like FEV1 showed no significant differences. Our data show that the modified Fuchs exacerbation score is applicable in a clinical setting and can detect acute exacerbations regardless of health status. Home spirometry is a useful tool for outpatient exacerbation management. A change in C-reactive protein and a modified Fuchs score change are suitable follow-up markers of exacerbation due to their strong correlation with FEV1. Further studies are needed to assess which patients would benefit from a longer duration of antibiotic therapy. C-reactive protein at exacerbation onset and C-reactive protein decline during and after therapy better predict antibiotic therapy success than FEV1 at therapy onset, while the modified Fuchs score indicates exacerbation regardless of the need for antibiotic therapy, suggesting that antibiotic therapy is only part of exacerbation management.

Comparison of Short-Term Versus Long-Term Antibiotic Therapy Among Severe Cases of Pneumonia: A Prospective Observational Study Among Children.

Introduction Pneumonia continues to be the leading cause of morbidity and mortality in children younger than five years. The World Health Organization (WHO)recommends intravenous antibiotics for five days for severe pneumonia. However, the optimum duration of parenteral antibiotic therapy for pneumonia is not practicable and feasible in poor and resource-constrained settings like India. Given thecurrent Indian scenario wherein childhood pneumonia is extremely prevalent, we attempted to undertake this study to compare theduration of antibiotic therapy in severe cases of community-acquired pneumonia (CAP). Methods A prospective observational study was carried out on 225 cases of severe and very severe CAP patients at a tertiary care center. The study group included children between two months to five years of age. The participants were subjected to antibiotic therapy (parenteral) plus supportive care. The selection of antibiotics was empirical and according to the WHO acute respiratory infection control program. Hematological parameters including blood hemoglobin, C-reactive protein, erythrocyte sedimentation rate (ESR), and total leukocyte count, and radiological evaluation were performed on all the participants. Cases were followed up for the duration of clinical response. Results Out of the 225 cases, 25 patients did not respond to antibiotics and were categorized as the treatment failure group. Of the remaining 200 cases, 104 (52%) showed clinical response within three days (3.0±0.016), and 96 showed a response in four to seven days (4.4±0.064). The mean duration of antibiotic therapy among short-course versus long-course treatment wasstatistically significant (p<0.0001). The majority of patients developed leukocytosis, neutrophilia, and elevated ESR. Conclusion Short-course parenteral antibiotics therapy was equally effective as long-coursetherapy in severe pneumonia. However, very severe pneumonia patients required a longer course of parenteral antibiotics therapy.Very severe pneumonia was significantly associated with high mortality and treatment failure.

Clinical features and treatment outcomes of pulmonary actinomycosis.

Pulmonary actinomycosis is a rare and chronic infectious disease that mimics malignancy and is frequently misdiagnosed. There are few reports that address the clinical characteristics of pulmonary actinomycosis. The objective of this research is to evaluate the clinical features, radiological findings, diagnostic approaches and treatment outcomes of pulmonary actinomycosis. Thirty-seven patients with pulmonary actinomycosis histopathologically diagnosed from 2009 to 2021 were analyzed retrospectively. The mean age at presentation was 53.7 (±13.3) years. Frequent symptoms were cough and hemoptysis. The median diagnosis time from the first symptoms was 60 days (interquartile range 18-195). Pulmonary comorbidity was found in 59.5% of cases. The most common thorax computed tomography finding was mass or nodule. The low-attenuation center within the mass or consolidation was observed in 40% of the lesions. The median maximal standardized uptake value of lesions on positron emission tomography (PET) was 6.5 (interquartile range 2.7-10.3). In the majority of cases (97.3%), the diagnosis of pulmonary actinomycosis was not suspected at admission, and 56.8% of patients were misdiagnosed with lung cancer. The mean duration of antibiotic therapy was 9.4 days (range 3-22) with intravenous antibiotics and 64.7 days (range 5-270) with oral antibiotics. Four patients died due to concomitant comorbidities. Eight cases were lost to follow-up. All other cases were fully cured. Pulmonary actinomycosis mimics other diseases, often lung cancer. Clinicians should consider the diagnosis of actinomycosis when they detect a mass or consolidation, especially with a low-attenuation center. PET/CT appears not to be useful for differential diagnosis. A shorter course of antibiotic therapy than traditionally recommended appears to be sufficient.

Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): A Pilot Randomized Clinical Trial.

Rationale: Pleural effusion commonly complicates community-acquired pneumonia and is associated with intense pleural inflammation. Whether antiinflammatory treatment with corticosteroids improves outcomes is unknown. Objectives: To assess the effects of corticosteroids in an adult population with pneumonia-related pleural effusion. Methods: The STOPPE (Steroid Therapy and Outcome of Parapneumonic Pleural Effusions) trial was a pilot, multicenter, double-blinded, placebo-controlled, randomized trial involving six Australian centers. Patients with community-acquired pneumonia and pleural effusion were randomized (2:1) to intravenous dexamethasone (4 mg twice daily for 48 h) or placebo and followed for 30 days. Given the diverse effects of corticosteroids, a comprehensive range of clinical, serological, and imaging outcomes were assessed in this pilot trial (ACTRN12618000947202). Measurements and Main Results: Eighty patients were randomized (one withdrawn before treatment) and received dexamethasone (n = 51) or placebo (n = 28). This pilot trial found no preliminary evidence of benefits of dexamethasone in improving time to sustained (>12 h) normalization of vital signs (temperature, oxygen saturations, blood pressure, heart, and respiratory rates): median, 41.0 (95% confidence interval, 32.3-54.5) versus 27.8 (15.4-49.5) hours in the placebo arm (hazard ratio, 0.729 [95% confidence interval, 0.453-1.173]; P = 0.193). Similarly, no differences in C-reactive protein or leukocyte counts were observed, except for a higher leukocyte count in the dexamethasone group at Day 3. Pleural drainage procedures were performed in 49.0% of dexamethasone-treated and 42.9% of placebo-treated patients (P = 0.60). Radiographic pleural opacification decreased over time with no consistent intergroup differences. Mean duration of antibiotic therapy (22.4 [SD, 15.4] vs. 20.4 [SD, 13.8] d) and median hospitalization (6.0 [interquartile range, 5.0-10.0] vs. 5.5 [interquartile range, 5.0-8.0] d) were similar between the dexamethasone and placebo groups. Serious adverse events occurred in 25.5% of dexamethasone-treated and 21.4% of placebo-treated patients. Transient hyperglycemia more commonly affected the dexamethasone group (15.6% vs. 7.1%). Conclusions: Systemic corticosteroids showed no preliminary benefits in adults with parapneumonic effusions. Clinical trial registered with www.anzctr.org.au (ACTRN12618000947202).

303. Evaluation of Antimicrobial Utilization and the Incidence of Bacterial Pneumonia Co-infection in Non-ICU COVID-19 Patients at an Urban Academic Medical Center

BackgroundThe management of COVID-19 poses diagnostic challenges with regard to concomitant bacterial pneumonia. This may result in unnecessary antibiotic therapy. This analysis described the experience of an urban academic medical center’s management of non-ICU patients diagnosed with COVID-19 during the initial months of the pandemic and assessed the rate of concomitant bacterial pneumonia in this population.MethodsThis retrospective analysis evaluated patients 18 years and older admitted to Thomas Jefferson University Hospital (TJUH) between March 1, 2020 and July 31, 2020 who had a positive COVID-19 test, were symptomatic, and received at least one dose of antibiotics. Antibiotic therapy was considered appropriate if there was objective evidence of bacterial pneumonia. Per the TJUH COVID-19 guidelines, objective diagnostic criteria assessed included the following: MRSA nasopharyngeal swab, urine Legionella pneumophilia or Streptococcus pneumoniae antigen test, respiratory pathogen panel, and sputum culture. If patients did not have evidence of bacterial pneumonia, the threshold for appropriate discontinuation of antibiotics was 48 hours.Results50 patients were included in the final analysis. Upon admission, 7 (14%) patients had clear chest radiographs, and 9 (25%) of the 36 patients with a procalcitonin drawn had a level ≥ 0.25, indicating a potential bacterial infection. 15 (30%) patients were known to be COVID-19 positive prior to being administered antibiotics. Additionally, 22 (44%) patients had an infectious diseases service consult during their admission. 25 (50%) patients were continued on antibiotics > 48 hours. The mean duration of antibiotic therapy in the entire population was 3.4 days (82 hours). The monthly average duration of antibiotic therapy trended downward as the pandemic progressed. The most common empiric antibiotic regimen was ceftriaxone and azithromycin, received by 28 (56%) patients. Only 2 (4%) patients were diagnosed with bacterial pneumonia.ConclusionIn a sample of 50 COVID patients the overall rate of concomitant bacterial pneumonia was 4%. Given this finding, it is vital to remain judicious with the use of antibiotics and to employ the assistance of antimicrobial stewardship colleagues when managing patients diagnosed with COVID-19.Disclosures Claudine El-Beyrouty, PharmD, BCPS, Astellas (Advisor or Review Panel member)Shionogi (Advisor or Review Panel member)

Clinical and Radiological Features Predicting Intervertebral Autofusion after Successful Antibiotic Therapy in Pyogenic Vertebral Osteomyelitis

Background: Pyogenic vertebral osteomyelitis (PVO) is a bacterial infection involving the intervertebral disc, vertebral body, and paravertebral soft tissues. Damaged intervertebral structure is a major cause of persistent back pain even after successful antibiotic therapy, which can be improved by achieving autofusion or via additional surgical fixation. In this study, we analyzed the clinical and radiological features predicting intervertebral autofusion after successful antibiotic therapy in lumbar PVO. Methods: This study was retrospectively conducted with 32 patients (20 men and 12 women) diagnosed with lumbar PVO that was completely cured with no recurrences after antibiotic therapy. They were divided into two groups with (group A, n = 18) and without (group B, n = 14) intervertebral autofusion at six-month follow-up. Differences in back pain, blood inflammatory markers, and radiological features of PVO on simultaneous 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (18F-FDG-PET/MRI) of the intervertebral structure between the two groups were analyzed. Results: The mean duration of antibiotic therapy was 41.44 ± 14.21 (21–89) days. Group A showed a statistically higher erythrocyte sedimentation ratio (ESR; 59.28 ± 32.33 vs. 33.93 ± 18.76 mm/h, p = 0.014; normal range of ESR < 25), maximum standardized 18F-FDG uptake (SUVmax; 5.56 ± 1.86 vs. 3.98 ± 1.40, p = 0.013), and sustained extensive edematous changes on T2-weighted fat saturation (T2FS) MRI (p = 0.015) immediately after successful antibiotic therapy. However, no significant differences were observed in back pain, C-reactive protein, or the distribution of 18F-FDG uptake/contrast enhancement on 18F-FDG-PET/MRI (p > 0.05). Conclusions: Higher ESR and SUVmax of the intervertebral structure and sustained extensive edematous change on T2FS MRI immediately after successful antibiotic therapy are related with subsequent intervertebral autofusion, which should be carefully considered when assessing therapeutic response in PVO.

Treatment of Granulomatous Mastitis: Is There a Role for Antibiotics?

To perform a retrospective review of the clinical characteristics, microbiological data, and clinical outcomes in patients with granulomatous mastitis (GM) who were treated at our institution with a unique strategy of prolonged antibiotic therapy as the primary treatment modality. A retrospective case series was performed on patients (n = 42) with GM seen at the breast specialty clinic of our institution between the years 2004 and 2014. Patients were primarily treated with lipophilic antibiotics, and steroids and surgery were reserved for refractory cases. Bacteria were identified in 34 samples from 22/42 patients (52.3%). Diphtheroids (presumptive Corynebacterium spp.) were most commonly identified, followed by Corynebacterium spp. and Propionibacterium acnes (now Cutibacterium acnes). Antibiotics were our preferred first-line medical therapy and were used in 33/36 (91.7%) patients. The mean duration of antibiotic therapy was 7.0±4.5 months. Clarithromycin was our antibiotic of choice and was the initial antibiotic used in 15 of the 33 patients (45.5%) treated with antibiotics. Eleven patients required adjunctive therapy with prednisone. The mean duration of steroid therapy was 4.3±2.5 months. Surgery for therapeutic purposes included incision and drainage in seven patients, fine needle aspiration in eight patients, and excision of the fistulous tract in one patient. No patients had large-volume excisions. The average time from the first breast clinic visit to clinical resolution was 8.0±4.6 months. GM may be the result of a bacterial process that induces a unique form of inflammatory response. Clinicians should consider special requests to microbiology laboratories to attempt to isolate Corynebacterium spp. in the evaluation of samples sent to the laboratory for analysis. An extended course of a lipophilic antibiotic is a largely unexplored but potentially effective treatment option with low associated morbidity. More research is needed in this area.

Duration of antibiotic treatment using procalcitonin-guided treatment algorithms in older patients: a patient-level meta-analysis from randomized controlled trials.

BackgroundOlder patients have a less pronounced immune response to infection, which may also influence infection biomarkers. There is currently insufficient data regarding clinical effects of procalcitonin (PCT) to guide antibiotic treatment in older patients.Objective and designWe performed an individual patient data meta-analysis to investigate the association of age on effects of PCT-guided antibiotic stewardship regarding antibiotic use and outcome.Subjects and methodsWe had access to 9,421 individual infection patients from 28 randomized controlled trials comparing PCT-guided antibiotic therapy (intervention group) or standard care. We stratified patients according to age in four groups (<75 years [n = 7,079], 75–80 years [n = 1,034], 81–85 years [n = 803] and >85 years [n = 505]). The primary endpoint was the duration of antibiotic treatment and the secondary endpoints were 30-day mortality and length of stay.ResultsCompared to control patients, mean duration of antibiotic therapy in PCT-guided patients was significantly reduced by 24, 22, 26 and 24% in the four age groups corresponding to adjusted differences in antibiotic days of −1.99 (95% confidence interval [CI] −2.36 to −1.62), −1.98 (95% CI −2.94 to −1.02), −2.20 (95% CI −3.15 to −1.25) and − 2.10 (95% CI −3.29 to −0.91) with no differences among age groups. There was no increase in the risk for mortality in any of the age groups. Effects were similar in subgroups by infection type, blood culture result and clinical setting (P interaction >0.05).ConclusionsThis large individual patient data meta-analysis confirms that, similar to younger patients, PCT-guided antibiotic treatment in older patients is associated with significantly reduced antibiotic exposures and no increase in mortality.

Serum Procalcitonin as a Biomarker to Determine the Duration of Antibiotic Therapy in Adult Patients with Sepsis and Septic Shock in Intensive Care Units: A Prospective Study.

BackgroundProcalcitonin, a biomarker to adjudge the duration of antibiotic therapy in patients with sepsis.Materials and methodsA prospective, randomized, controlled, interventional, single-center study was conducted in a mixed adult intensive care unit (ICU). In a nonblinded study, 90 adult patients admitted to the ICU with sepsis and septic shock were randomized into group P (group procalcitonin) and group C (group control). The duration of antibiotic therapy was decided based on serum procalcitonin levels for patients in group P versus standard treatment protocols in group C. A procalcitonin value of <0.01 ng/mL or a subsequent decline of >80% from the baseline was cutoff and chosen to stop the antibiotic therapy. The primary aim was to compare the duration of antibiotic therapy (in days) in the two groups. The secondary objective was to compare and assess the length of ICU stay, reinfection, secondary infection rate, readmission rate, and mortality among the groups.ResultsThe mean duration of antibiotic therapy was significantly lesser in patients in group P (4.98 ± 2.56 vs 7.73 ± 3.06 days, p < 0.001). Patients in group C spent more days in ICU (8.80 ± 3.35 vs 5.98 ± 2.73 days, p < 0.001). The secondary infection rate was significantly higher in group C (26.7% vs 4.4%, p = 0.014). Readmission and mortality rates were comparable between the groups.ConclusionSerum procalcitonin-based algorithm in critically ill patients with sepsis could lead to a reduction in the duration of antibiotic therapy, ICU stay, and associated morbidities like secondary infection rates. It further promotes antibiotic stewardship without any adverse effects on the patient's outcome.How to cite this articleVishalashi SMG, Gupta P, Verma PK. Serum Procalcitonin as a Biomarker to Determine the Duration of Antibiotic Therapy in Adult Patients with Sepsis and Septic Shock in Intensive Care Units: A Prospective Study. Indian J Crit Care Med 2021;25(5):507–511.

68. Impact of a Pharmacy-Driven Antimicrobial Time-out on Duration of Therapy in Community-Acquired Pneumonia

BackgroundCommunity-Acquired Pneumonia (CAP) is associated with substantial antibiotic use and potential for overprescribing. Previous studies have demonstrated a reduction in antimicrobial exposure following implementation of provider-driven antimicrobial time-outs (ATOs). ATOs prompt assessment of appropriateness of therapy, clinical response, and duration of therapy. In January 2018, OSF Healthcare System implemented a 48-hour pharmacy-driven ATO in the electronic health record. The purpose of this study was to determine if the implementation of the ATO decreased the duration of antibiotic therapy for CAP at a community hospital.MethodsThis was a retrospective chart review of adults hospitalized with CAP at OSF Saint Anthony Medical Center between May 2016 - October 2017 (pre-implementation; PRE) and April 2018 - September 2019 (post-implementation; POST). The primary outcome was total duration of antibiotic therapy between hospitalization and discharge prescriptions. Secondary outcomes included hospital length of stay (LOS), duration of IV therapy, and rates of treatment failure, relapse, and antibiotic-associated adverse events.ResultsA total of 808 patient charts were reviewed with 155 patients meeting inclusion criteria in both study groups. The mean duration of antibiotic therapy was reduced by 2.14 days (PRE 10.51 days vs. POST 8.37 days; P< 0.001). Duration of IV therapy (3.86% vs. 3.21%; P< 0.001) and 30-day emergency department visit rate (16.13% vs. 3.23%; P< 0.001) were also significantly reduced. Differences in LOS (4.60 days vs. 4.45 days; P=0.279) and 30-day readmission rate (9.03% vs. 4.52%; P=0.114) did not meet statistical significance. Antibiotic-associated diarrhea (28.39% vs. 17.42%; P=0.022) and acute kidney injury (17.42% vs. 6.45%; P=0.003) were significantly reduced while C. difficile infection (2.58% vs. 0.65%; P=0.371) and treatment failure (3.22% vs. 1.94%; P=0.723) only trended downward.ConclusionImplementation of the pharmacy-driven ATO was associated with reduced duration of antibiotic therapy in patients hospitalized with CAP, though total durations still exceeded evidence-based recommendations. The ATO maintained the efficacy of treatment and reduced treatment-associated adverse effects, such as diarrhea and AKI.Disclosures All Authors: No reported disclosures

Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis

BackgroundAlthough perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis. MethodsThis is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared. ResultsForty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively. ConclusionsProvider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.

Acute osteomyelitis of the distal fibula in children: Treatment options and long-term follow-up

IntroductionAcute osteomyelitis of the distal fibula is a rare disease in children and is characterized by special features compared with other sites. The objective of this study was to report the functional outcome at long-term follow-up. MethodsWe reviewed retrospectively, between January 2000 and December 2010, all cases of acute osteomyelitis of the distal fibula. Epidemiological and bacteriological data as well as therapy and outcome factors were analyzed. At the last follow-up, functional outcome was studied based on ankle motion, growth disturbance, and radiological sequelae. ResultsSeven cases of acute osteomyelitis of the distal fibula were found. The mean age was patients was 7.71 years and the sex ratio was 2.5. The portal of entry of the pathogen was a skin injury in 57% of cases. Staphylococcusaureus was identified in 71% of cases. The mean duration of antibiotic therapy was 33.2 days. At a mean of 12.85 years of follow-up, no growth disturbance was found. The mean plantar and dorsal flexion was 41° and 27.7°, respectively. The mean postoperative American Orthopedics Foot and Ankle score (AOFAS) was 96.71 points. ConclusionAcute osteomyelitis of the distal fibula in children is scarce and rarely reported in the literature. It occurs more often in boys at an average age of 7 years. Local symptoms are usually more obvious than general symptoms. Surgical debridement of the subperiosteal abscess without bone trepanation seems to lead to a satisfactory outcome. Level of evidenceLevel IV – case series. IRBSahloul Hospital Human Research Ethics Committee.

Role of procalcitonin in diagnosis of neonatal sepsis and procalcitonin guided duration of antibiotic therapy

Background: Neonatal sepsis is one of the important causes of neonatal morbidity and mortality particularly in the developing countries. Accurate and quick diagnosis is difficult because clinical presentation is non-specific, bacterial cultures are time-consuming and other laboratory tests lack sensitivity and specificity. Procalcitonin (PCT) is often reported to be more superior to C-reactive protein (CRP), being more sensitive and specific, starts to rise earlier and returns to normal concentration more rapidly than CRP.Methods: It is a hospital based prospective observational study. Blood samples were obtained and analyzed for blood culture, septic screen including serum CRP and PCT. Neonates were categorized into proven sepsis (n=39), probable sepsis (n=21) and clinical sepsis (n=40) groups on the basis of laboratory findings and risk factors. Data was analyzed by using standard statistical tests using SPSS 16.Results: Out of 100 cases, elevated PCT level &gt;0.5 ng/dl was detected in 75 and &gt;2 ng/dl was detected in 51 whereas CRP was positive only in 61 cases. Among the 39 culture positive cases, elevated serum PCT level was noticed in 39 (100%) cases whereas CRP level was noticed in 30 (76.9%) cases. Mean PCT levels were significantly high according to infection severity (P&lt;0.01). Procalcitonin (sensitivity 87.2%, specificity 72.13%, positive predictive value 66.7% and negative predictive value 89.8% and with p value of &lt;0.001) is more superior than CRP to predict sepsis in neonate. The mean duration of antibiotic therapy was 12.46±4.62 days in definite sepsis, 4.53±1.78 days in probable sepsis group and in clinical sepsis group 3.75±1.33 days by serial PCT measurement.Conclusions: Serum PCT levels &gt;2 ng/dl has got a better sensitivity and NPV, which help us not only in the early diagnosis but also in the prognosis and duration of antibiotic therapy.

Short duration of post-amputation antibiotic therapy in diabetic foot patients with total resection of osteomyelitis

BackgroundShort duration of post-amputation antibiotic therapy (2–5 days) is recommended in patients with diabetic foot osteomyelitis after total resection of infected bone tissue. ObjectiveTo evaluate the long-term effectiveness of short-duration post-amputation antibiotic therapy in diabetic patients with total resection of osteomyelitis assessed by sterile bone bacteriological samples obtained from the resection margin. MethodsThe endpoint was the absence of osteomyelitis relapse at 6 months, defined as recurrence of osteomyelitis with the need for surgical revision and/or new bone antibiotic therapy. ResultsAmong 15 patients included, 12 (80%) were cured without recurrence of osteomyelitis at 6 months, with a mean duration of antibiotic therapy of 8.3±5.9 days post surgery. This result is comparable to literature data, while all of them reported longer duration of antibiotic therapy and/or shorter follow-up. ConclusionShort duration of post-amputation antibiotic therapy in diabetic patients with sterile bacteriological samples obtained from resection margin seems effective.