Microbiological Evidence Research Articles

DIAGNOSTIC YIELD OF LUMBAR PUNCTURE IN CRITICALLY ILL MEDICAL ICU PATIENTS WITH ALTERED MENTAL STATUS: A RETROSPECTIVE COHORT STUDY

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: ICU-acquired delirium frequently complicates critical illness with the elderly and those with pre-existing neurocognitive disorders at greatest risk. Primary central nervous system (CNS) diseases frequently present similarly to ICU-acquired delirium. Whether to perform lumbar puncture (LP) in all cases of diagnostic uncertainty remains unknown. Previous retrospective studies of hospitalized patients have shown that nosocomial meningitis is rare. In these cohorts, LP yield depended on indication and timing of the procedure and pretest probability of neurological disease processes. These studies are largely descriptive and are hampered by small sample sizes. The aims of this study were to establish the diagnostic yield of LP among the critically ill and to determine therapeutic efficacy i.e. how often management changed based on LP results. METHODS: This retrospective cohort study examined patients admitted to a medical ICU service from 2012 to 2018 at a tertiary academic center. Patients were included if they had altered mental status (or synonymous term) documented and underwent LP in the medical ICU.We gathered clinical variables including patient demographics, duration of hospitalization and ICU stay prior to LP, and duration of index ICU admission. We also collected patient variables such as immunocompromised status, underlying CNS disorders, and receipt of EEG, vasopressors, sedatives, or antimicrobials. LP-specific variables included indication and cerebral spinal fluid (CSF) analyses.The primary outcome was LP diagnostic yield as defined by CSF pleocytosis, elevated CSF protein, positive cytology, or microbiological evidence of infection. The secondary outcome of interest was the therapeutic efficacy on a Likert scale of 1-5 which was subsequently dichotomized.We performed chi-square analyses for individual variables and multivariable logistic regression of all variables. To assess the reliability of therapeutic efficacy, a second reviewer rated a subset of cases on the same Likert scale. RESULTS: We identified 104 records of patients who met inclusion criteria. While 48% of LPs yielded a "positive result” (50/104), only 16% (17/104) demonstrated abnormal cytology (3 cases) or evidence of CNS infection (14 cases). Moreover, only 13% (14/104) of LPs had therapeutic efficacy.In both chi-square and multivariate logistic regression analyses, we did not identify any variables that were significantly associated with diagnostic yield or therapeutic efficacy of LP. Cohen's kappa was 0.64 for dichotomized ratings of therapeutic efficacy (2 reviewers, 40 charts), indicating modest to strong agreement. CONCLUSIONS: Diagnostic yield and therapeutic efficacy of LP were low among critically ill medical ICU patients and likely cannot be predicted from clinical variables alone. CLINICAL IMPLICATIONS: Physicians must rely on clinical judgement to determine the necessity of LP in medical ICU patients. DISCLOSURES: No relevant relationships by Paul Bergl, source=Web Response No relevant relationships by Rahul Nanchal, source=Web Response No relevant relationships by Meghan Nothem, source=Web Response No relevant relationships by Alan Salazar, source=Web Response No relevant relationships by Shama Sharwani, source=Web Response

Pediatric Inflammatory Multisystem Syndrome Temporally Related With SARS-CoV-2: Immunological Similarities With Acute Rheumatic Fever and Toxic Shock Syndrome.

Several studies demonstrated that COVID-19 in children is a relatively mild disease. However, recently a more serious condition characterized by systemic inflammation with clinical or microbiological evidence of exposure to SARS-CoV-2 has been described. This syndrome is now known as either “Pediatric Inflammatory Multisystem Syndrome temporally related with COVID-19” (PIMS-TS) (1), or Multisystem Inflammatory Syndrome in Children (MIS-C) (2) and is currently considered a rare post-COVID-19 complication which, in a minority of cases, can lead to death. The signs and symptoms of PIMS-TS are largely overlapping with the for Kawasaki disease (KD) and toxic shock syndrome (TSS) and are characterized, by fever, systemic inflammation, abdominal pain and cardiac involvement. In this study, we describe clinical and immunological characteristics shared by PIMS-TS, acute rheumatic fever and TSS, in order to provide hypotheses to direct future clinical and basic research studies.

Microbial utilization of rare earth elements at cold seeps related to aerobic methane oxidation

A major breakthrough in the field of rare earth element (REE) geochemistry has been the recent discovery of their utility to microbial life, as essential metalloenzymes catalyzing the oxidation of methanol to formaldehyde. Lanthanide-dependent bacteria are thought to be ubiquitous in marine and terrestrial environments, but direct field evidence of preferential microbial utilization of REE in natural systems is still lacking. In this study, we report on the REE and trace element composition of the tube of a siboglinid worm collected at a methane seep in the Gulf of Guinea; a tube-dwelling annelid that thrives in deep-sea chemosynthetic ecosystems. High-resolution trace element profiles along the chitin tube indicate marked enrichments of lanthanum (La) and cerium (Ce) in its oxic part, resulting in REE distribution patterns that depart significantly from the ambient seawater signature. Combined with various geochemical and microbiological evidence, this observation provides direct support for an active consumption of light-REE at cold seeps, associated with the aerobic microbial oxidation of methane. To further evaluate this hypothesis, we also re-examine the available set of REE data for modern seep carbonates worldwide. While most carbonate concretions at cold seeps generally display REE distribution patterns very similar to those for reduced pore waters in marine sediments, we find that seafloor carbonate pavements composed of aragonite commonly exhibit pronounced light-REE enrichments, as inferred from high shale-normalized La/Gd ratio (>~0.8), interpreted here as possibly reflecting the signature of lanthanide-dependent methanotrophic activity. This finding opens new perspectives for revisiting REE systematics in ancient seep carbonates and other microbialites throughout the Earth's history. In particular, the geochemical imprint of aerobic methane oxidation could be possibly traced using REE in Archaean stromatolites and other archives of Precambrian seawater chemistry, potentially providing new insights into the oxygenation of early Earth's oceans and associated microbiogeochemical processes.

Next-generation sequencing technology for detecting pulmonary fungal infection in bronchoalveolar lavage fluid of a patient with dermatomyositis: a case report and literature review

BackgroundInvasive fungal pneumonia is a severe infectious disease with high mortality in immunocompromised patients. However, the clinical diagnosis of the pathogen(s) remains difficult since microbiological evidence is difficult to acquire.Case presentationHere, we report a case of pulmonary fungal infection detected by next-generation sequencing (NGS) of bronchoalveolar lavage fluid (BALF) in a 61-year-old male with corticosteroid-treated dermatomyositis. Cytomegalovirus and influenza A virus infections were confirmed by nucleic acid detection and treated with antiviral medicine. The patient had been diagnosed with severe pneumonia and treated with empiric broad-spectrum antibacterial and antifungal drugs before bronchoscopy was performed. The patient responded poorly to those empiric treatments. Three fungi were found by NGS in the BALF, namely, Pneumocystis jirovecii, Aspergillus fumigatus and Rhizopus oryzae. After adjusting the patient’s treatment plan according to the NGS results, he improved significantly.ConclusionsThis case highlights the combined application of NGS and traditional tests in the clinical diagnosis of pulmonary invasive fungal disease. NGS is proposed as an important adjunctive diagnostic approach for identifying uncommon pathogens.

Yogurt enriched to correct intestinal microflora in dysbiosis

The high incidence of dysbiotic disorders, growing threat of new intestinal bacterial pathogens with multidrug resistance and high virulence, and high level of xenobiotic contamination of food products and the environment require the search for alternative non-medicinal products aimed at improving and maintaining health of the intestinal tract. The authors developed a recipe and technology of two-layer yogurt enriched with a prebiotic complex, containing dietary fiber of wheat bran, indigestible food components that promote the growth of normal intestinal microflora (bifidobacteria and lactobacilli), an inactivated yeast culture of Saccharomycescerevisiae (vini), and blueberry and cornelian cherry puree—a source of polyphenolic compounds. The yoghurt culture used in the technology contains freeze-dehydrated strains of probiotic cultures, i.e., Streptococcus thrmophilus, Lactobacillus delbrueckiissp.bulgaricus, Lactobacillus acidophilus, Bifidobacterium lactis, and lactose. The authors studied the effect of the developed yogurt on the intestinal microflora and their ability to prevent and correct dysbiosis. To this end, a model of experimental antibiotic-associated dysbiosis was reproduced using a broad-spectrum antibiotic Gentamicin in white mice. The antibiotic was being injected intraperitoneally for 5 days. After withdrawal of gentamicin, a considerable increase in opportunistic enterobacteria (Enterobacteraerogenes, Enterobactercloacae, and Citrobacterfreundii), Proteussp, and Candidasp. was observed. There was also a decrease in the quantity and quality of Lactobacillussp. E.coli and a decrease in the content of Bifidobacteriumsp. Enriched yogurt in the diet of mice allowed the microbiological evidences of dysbiosis to be eliminated in a short time, prevented clinical symptoms of dysbiosis, i.e., decreased physical activity and poor appetite, stool softening, constipation, flatulence, and worsening the appearance. Thus, the developed enriched yogurt can be used to prevent and correct dysbiotic intestinal disorders.

Tuberculous vasculitic lung mass: Unique presentation of a common disease

Tuberculosis is a common disease but it keeps on surprising with its unique presentations. It has been reported as lung mass but here we are reporting a case of Tuberculosis presented as vasculitic lung mass. A 61 years old female, known case of hypertension and secondary Sjogren syndrome, on treatment, presented with history of mild dyspnea and generalised weakness with incidental finding of Right hilar mass on chest X-ray undergoes a CECT thorax and CT guided biopsy. Histopathology contrary to expectations revealed granulomatous vasculitis with no microbiological evidence of TB, responded to antitubercular treatment and there was almost complete regression of the lesion after 6 weeks of ATT.

Evaluation of Antibiotic Prescription and Utilization amongst Hospitalized Children in a Tertiary Facility in Sokoto, North-Western Nigeria

Background: Antibiotics are the most widely utilized therapeutic agents. Inappropriate use causes increase cost and antibiotic resistance. The World Health Organization recommends assessment of antibiotics use to guide prescribing practices.
 Objective: To describe the pattern of antibiotic usage among paediatric inpatients aged > 1 month to 15 years in a tertiary hospital in Sokoto, Nigeria.
 Methods: Febrile children were recruited prospectively by systematic random sampling from January to October 2018. Socio-demographics, diagnosis, antibiotics administered were obtained from case notes. The WHO indicators of use of antibiotics were employed for evaluation. Data was analysed with SPSS version 23.
 Results: Out of 352 children, 318 (90.3%) received antibiotics; commonest being Ceftriaxone in 155/318 (48.7%), Cefuroxime in 74 (23.2%), and Metronidazole in 29 (9.1%). Average number of antibiotics per patient was 2.3±1.1 with treatment duration of 4.3±1.4days. Antibiotic consumption was 937.2 days of antibiotic therapy/1000 patient days (DOT/PD). Generic name was used in 92.3% while 100% of the drugs were on the essential medicine list. Frequent diagnoses were severe malaria 98/352 (27.8%), respiratory infections 39 (11.1%) and severe malnutrition in 38 (10.8%). Only 6 (1.7%) patients had microbiologic evidence of infection.
 Conclusion: Utilization of antibiotics is higher than recommended. There is need for improved diagnostic facilities to avoid antibiotic overuse and its consequences.
 Keywords: antibiotics, prescription, utilization, children, inpatients, DOT

A case series of non-valvular cardiac aspergillosis in critically ill solid organ transplant and non-transplant patients and systematic review.

Non-valvular cardiac aspergillosis is a rare infection of the pericardium, myocardium or endocardium and is associated with a high mortality. There is a paucity of reports of non-valvular cardiac aspergillosis in critically ill and solid organ transplant (SOT) patients. The majority of cases have been reported in haemato-oncology patients, some of whom have undergone a bone marrow transplant. We describe four cases affected by non-valvular cardiac aspergillosis in the intensive care setting including a systematic review of this extremely rare infection which is associated with high mortality. All four-patients died but presented with varying clinical, radiological and microbiological evidence of the disease. Three patients presented following complications after solid organ transplantation, two in the context of acute liver failure and emergency liver transplant and one several years after a double lung transplant. The last patient presented with necrotising gall stone pancreatitis, multi-organ failure and subsequently a prolonged intensive care unit (ICU) stay. On review of the literature, January 1955 to July 2019, 45 cases were identified, with different risk factors, clinical and radiological manifestations, treatment regimen and outcome. Antemortem diagnosis of cardiac aspergillosis is difficult and rare, with no cases reporting positive blood culture results. Galactomannan serology has poor sensitivity in solid organ transplant patients, further reduced by prophylactic antimicrobial treatment, which is common in the ICU setting especially post-transplant patients. Due to the scarcity of cases, treatment is extrapolated from invasive aspergillosis management, with emphasis on early treatment with combination therapy.

Analytic Study of Spinal Infections: Clinical Picture, Treatment, and Outcomes in King Fahad Military Medical Complex in Dhahran, Saudi Arabia

Objective: To evaluate the prevalence of spinal infection in a hospital located in the eastern region of Saudi Arabia through a retrospective review and to identify the associated etiological agents in terms of clinical picture, treatment, and outcomes. Design: Retrospective cross-sectional study. Setting: Single hospital in Dhahran, Saudi Arabia. Patients: Patients with any type of spinal infection and/or who had undergone neurosurgical intervention for spinal infection between January 2006 and December 2018. Methods: We collected data on all patients with an established diagnosis of spinal infection from January 2006 to December 2018 in the King Fahad Military Medical Complex in Dhahran, Saudi Arabia. A validated and structured checklist was used for data collection. Spinal infection diagnosis was based on the clinical manifestation, microbiological evidence, radiological findings, and antimicrobial therapy response. Results: Seventeen patients were included in this study, and their mean age was 54.93 years. Twelve of the patients were male and four were female. The approximate time from symptom onset to diagnosis was 2 - 6 months. Most of the patients experienced back pain, with lumbosacral spondylitis being the most commonly cited type (61.11%), followed by thoracolumbar spondylodiscitis (25%) and cervical spondylodiscitis (6.25%). The most frequently isolated organism was Mycobacterium tuberculosis (8 patients, 50%), followed by extended-spectrum beta lactamase (ESBL)-producing Escherichia coli (4 patients, 25%), Brucella spp (3 patients, 18.75%), Staphylococcus aureus (1 patient, 6.25%), and Quambalaria cyanescens (1 patient, 6.25%). Totally, in 50% of the patients with thoracolumbar and lumbosacra site involvement, tuberculosis spondylodiscitis was observed, while another 50% of the cases showed complications associated with paravertebral abscess that required surgical drainage. Conclusion: M. tuberculosis was found to be the major cause of infectious spondylodiscitis. Additionally, Quambalaria cyanescens was isolated; this is the second reported case of the organism being isolated and the first associated with spinal infection.

Ventilator-associated Pneumonia: Multidrug Resistant Acinetobacter vs. Extended Spectrum Beta Lactamase-producing Klebsiella.

Ventilator-associated pneumonia (VAP) has been considered as a healthcare-associated infection with high mortality. Acinetobacter baumannii and Klebsiella pneumoniae are the common causes of VAPs around the world. This research was a retrospective observational study in the intensive care unit (ICU) in a tertiary referral collegiate hospital in Tehran between March 2016 and May 2018. Patients who fulfilled VAP due to documented Multidrug Resistant Acinetobacter baumannii (MDR-AB) or Extended Spectrum Beta Lactamase-producing Klebsiella pneumoniae (ESBL-KP) criteria were enrolled. General demographic features, duration of hospital stay, antimicrobial treatment regimens, duration of ICU admission, the period of mechanical ventilation (MV) and 30-day mortality were documented and compared. 210 patients were found with clinical, microbiological and radiological evidence of VAP. In total, 76 patients with MDR-AB and 76 patients with ESBL-KP infections were matched in the final analysis. Duration of hospitalization in the patients with MDR-AB was significantly more than that of patients infected with ESBL-KP (p-value: 0.045). Patients diagnosed with MDR-AB VAP had a 65.8% mortality rate compared to 42.1% in the ESBL-KP infection group (p = 0.003). Results of the present study demonstrated that VAPs caused by MDR-AB may be more hazardous than ESBL-KP VAPs because they could be accompanied by a longer hospitalization course and even a higher mortality.

Comparison of diagnostic accuracy of the GeneXpert Ultra and cell-free nucleic acid assay for tuberculous meningitis: A multicentre prospective study

DesignA prospective multicentre study was conducted to compare the diagnostic accuracy of the GeneXpert MTB/RIF Ultra (Xpert Ultra) and cell-free DNA (cfDNA) assay for tuberculous meningitis (TBM) in China. MethodsA prospective cohort study was conducted among individuals with symptoms suggestive of TBM registered in three TB specialised hospitals in China between June 2018 and January 2019. ResultsOverall, 84 patients suggestive of TBM were included in this analysis between June 2018 and January 2019. Using microbiological evidence as reference, the sensitivity/specificity for the diagnostic tests were Xpert Ultra 93.3%/100%, cfDNA 93.3%/92.6% and mycobacteria growth indicator tube (MGIT) culture 13.3%/100%. In addition, the sensitivity of culture was 6.7% when using clinical diagnosis criteria as the gold standard. Xpert Ultra correctly identified 28 cases as TBM, indicating a sensitivity of 46.7%. Notably, four additional TBM cases were detected by cfDNA compared with Xpert Ultra, yielding an overall sensitivity of 53.3%. Statistical analysis revealed that the sensitivity of Xpert Ultra and cfDNA was significantly higher than that of culture. ConclusionsThe data demonstrate that Xpert Ultra and cfDNA assay showed optimal sensitivity compared with MGIT culture. In addition, there was no significant correlation between bacterial load and TBM severity in the participants.

Long Noncoding RNA and Predictive Model To Improve Diagnosis of Clinically Diagnosed Pulmonary Tuberculosis.

Clinically diagnosed pulmonary tuberculosis (PTB) patients lack microbiological evidence of Mycobacterium tuberculosis, and misdiagnosis or delayed diagnosis often occurs as a consequence. We investigated the potential of long noncoding RNAs (lncRNAs) and corresponding predictive models to diagnose these patients. We enrolled 1,764 subjects, including clinically diagnosed PTB patients, microbiologically confirmed PTB cases, non-TB disease controls, and healthy controls, in three cohorts (screening, selection, and validation). Candidate lncRNAs differentially expressed in blood samples of the PTB and healthy control groups were identified by microarray and reverse transcription-quantitative PCR (qRT-PCR) in the screening cohort. Logistic regression models were developed using lncRNAs and/or electronic health records (EHRs) from clinically diagnosed PTB patients and non-TB disease controls in the selection cohort. These models were evaluated by area under the concentration-time curve (AUC) and decision curve analyses, and the optimal model was presented as a Web-based nomogram, which was evaluated in the validation cohort. Three differentially expressed lncRNAs (ENST00000497872, n333737, and n335265) were identified. The optimal model (i.e., nomogram) incorporated these three lncRNAs and six EHRs (age, hemoglobin, weight loss, low-grade fever, calcification detected by computed tomography [CT calcification], and interferon gamma release assay for tuberculosis [TB-IGRA]). The nomogram showed an AUC of 0.89, a sensitivity of 0.86, and a specificity of 0.82 in differentiating clinically diagnosed PTB cases from non-TB disease controls of the validation cohort, which demonstrated better discrimination and clinical net benefit than the EHR model. The nomogram also had a discriminative power (AUC, 0.90; sensitivity, 0.85; specificity, 0.81) in identifying microbiologically confirmed PTB patients. lncRNAs and the user-friendly nomogram could facilitate the early identification of PTB cases among suspected patients with negative M. tuberculosis microbiological evidence.

Outcomes of HIV-positive patients with non-tuberculous mycobacteria positive culture who received anti-tuberculous treatment in Botswana: Implications of using diagnostic algorithms without non-tuberculous mycobacteria.

BackgroundPatients with non-tuberculous mycobacteria (NTM) or Mycobacterium tuberculosis (MTB) pulmonary disease may have similar clinical presentation. The potential for misdiagnosis and inappropriate treatment exists in settings with limited testing capacity for Xpert® MTB/RIF (Xpert), phenotypic culture and NTM speciation. We describe treatment outcomes among people living with HIV (PLHIV) who received anti-tuberculosis treatment and were found to have NTM or MTB positive sputum cultures.MethodsPLHIV attending one of the 22 participating HIV clinics, who screened positive for ≥1 tuberculosis (TB) symptoms (cough, fever, night sweats, or weight loss) were asked to submit sputa for culture and speciation from August 2012 to November 2014. The national intensified TB case finding algorithms were followed: initially symptomatic patients were evaluated by testing sputum samples using a smear (smear-based TB diagnostic algorithm) and, after GeneXpert instruments were installed, by testing with Xpert (Xpert-based TB diagnostic algorithm). Within the study period, TB diagnostic algorithms used for MTB did not include screening, diagnosis, and management of NTM. Despite MTB negative culture, some symptomatic patients, including those with NTM positive culture, received empirical anti-TB treatment at the discretion of treating clinicians. Per the World Health Organization treatment outcomes classification: died, treatment failure or loss-to-follow-up were classified as unfavorable (unsuccessful) outcome; cured and treatment completed were classified as favorable (successful) outcome. Empiric treatment was defined as initiating treatment without or before receiving a test result indicating MTB. We compare treatment outcomes and characteristics among patients with NTM or MTB positive culture who received anti-TB treatment.ResultsAmong 314 PLHIV, who were found co-infected with TB, 146 cases had microbiological evidence; and for 131/146 MTB positive cultures were reported. One-hundred fifty-two of the 314 were clinically diagnosed with TB and treated empirically. Among those empirically treated for TB, 36/152 had culture results positive for NTM, and another 43/152 had culture results positive for MTB, reported after patients received empirical anti-TB treatment. Overall, MTB positive culture results were reported for 174 (131 plus 43) patients. Treatment outcomes were available for 32/36 NTM and 139/174 MTB; unfavorable outcomes were 12.5% and 8.7% for NTM and MTB, respectively, p = 0.514, respectively. For 34/36 tested NTM patients, all Xpert results indicated ‘no MTB’. Among patients who initially received empiric anti-TB treatment and ultimately were found to have MTB positive culture, the unfavorable outcome was 11.8% (4/34), compared to 12.5% (4/32) of patients with NTM positive culture, Fisher’s exact test p = 1.00.ConclusionsWhile the higher unfavorable outcome was non statistically significant, the impact of inappropriate treatment among NTM patients should not be overlooked. Our findings suggest that Xpert has the potential to rapidly rule-out NTM and avoid sub-optimal treatment; further research is needed to evaluate such potential.

Clinical spectrum, etiology and outcome of infectious disease emergencies in adult diabetic patients in northern India

Background and aimsThe patients with diabetes mellitus (DM) have an increased incidence of both common and unusual infections. Despite an increasing prevalence of DM in India, local data on the epidemiology and clinical spectrum of associated infections are lacking. We aimed to investigate the spectrum, etiology, and outcome of infectious disorders in adult patients with DM admitted in a medical emergency. MethodsA single-center retrospective observational study conducted between January 2018 to June 2019 in a tertiary care hospital in north India. Based on clinical presentation, radiological features, and microbiological or pathological evidence, 152 diabetic patients aged 12 years and above were diagnosed with the infectious syndrome. ResultsUrinary tract infection was the most prevalent infectious syndrome (32.2%), followed by pneumonia and empyema (26.3%), skin and soft tissue infections (6.6%), sepsis of unknown primary source (6.6%), pulmonary tuberculosis (4.6%), rhinocerebral infections (4.6%), infectious diarrhea (3.9%), and viral encephalitis (2.6%). The majority of the infections were community-acquired (94.7%). 80.3% of study cases had type 2 DM. The common presenting symptoms were fever (46.1%), dyspnea (27.6%), and altered sensorium (25.7%). Shock and diabetic ketoacidosis were frequent, and each was seen in 27.6% of cases. The mortality rate was 27.6% and was higher with sepsis of unrecognized source (50.0%) and lung infections (30.0%). The presence of shock was the independent predictor of mortality on a multivariant analysis (p-value 0.000). ConclusionsUrinary tract and lung infections remain common in DM. Establishing a microbiological etiology and identification of the source are necessary steps to reduce mortality.

A randomized trial evaluating virus-specific effects of a combination probiotic in children with acute gastroenteritis

Gastroenteritis accounts for nearly 500,000 deaths in children younger than 5 years annually. Although probiotics have been touted as having the potential to expedite diarrhea resolution, recent clinical trials question their effectiveness. A potential explanation is a shift in pathogens following the introduction of a rotavirus vaccine. Here, we report the results of a multi-center, double-blind trial of 816 children with acute gastroenteritis who completed follow-up and provided multiple stool specimens. Participants were randomized to receive a probiotic containing Lactobacillus rhamnosus and Lactobacillushelveticus or placebo. We report no virus-specific beneficial effects attributable to the probiotic, either in reducing clinical symptoms or viral nucleic acid clearance from stool specimens collected up to 28 days following enrollment. We provide pathophysiological and microbiologic evidence to support the clinical findings and conclude that our data do not support routine probiotic administration to children with acute gastroenteritis, regardless of the infecting virus.

Diagnostic uncertainty and urinary tract infection in the emergency department: a cohort study from a UK hospital

BackgroundSuspected urinary tract infection (UTI) syndromes are a common reason for empirical antibiotics to be prescribed in the Emergency Department (ED), but differentiating UTI from other conditions with a similar presentation is challenging. We investigated how often an ED diagnosis of UTI is confirmed clinically/microbiologically, and described conditions which present as UTI syndromes.MethodsObservational study using electronic health records from patients who attended the ED with suspected UTI and had a urine sample submitted for culture. We compared the ED diagnosis to diagnosis at discharge from hospital (ICD-10 codes), and estimated the proportion of cases with clinical/microbiological evidence of UTI.ResultsTwo hundred eighty nine patients had an ED diagnosis of UTI syndrome comprising: lower UTI (191), pyelonephritis (56) and urosepsis (42). In patients admitted to hospital with an ED diagnosis of lower UTI, pyelonephritis or urosepsis, clinical/microbiological evidence of UTI was lacking in 61/103, 33/54 and 31/42 cases respectively. The ED diagnosis was concordant with the main reason for admission in less than 40% of patients with UTI syndromes, and antibiotics were stopped within 72 h in 37/161 patients.ConclusionsClinical/microbiological evidence of UTI was lacking in 60–70% of patients, suggesting scope to revise empirical prescribing decisions for UTI syndromes in light of microbial culture and clinical progression.

Effects of preoperative dental examination and oral hygiene instruction on surgical site infection after hepatectomy: a retrospective study.

This study retrospectively investigated relationships among risk factors and post-hepatectomy surgical site infection (SSI) and other complications in patients who underwent hepatectomy for hepatocellular carcinoma (HCC). We included 334 patients who underwent hepatectomies for liver cancers between January 2011 and December 2015 in this study. We evaluated risk factors for SSI and other post-hepatectomy complication, including demographic factors, preoperative factors, and preoperative intervention including oral management, perioperative factors, and length of hospital stay, with univariate and multivariate analyses. The oral management intervention included self-care instructions, extraction of infected teeth, removal of dental plaques and calculus (scaling), professional mechanical teeth cleaning, removal of tongue coating, and cleaning of dentures. SSI was defined in accordance with the guideline issued by the Centers for Disease Control and Prevention; it included purulent discharge from any incision or organ space within 30days postoperatively, with or without microbiological evidence. Complications of grade II or greater, according to the Clavien-Dindo classification, were regarded as postoperative complications. We found bacterial infection of ascites (Odds ratio (OR) = 13.72), lack of preoperative oral management intervention (OR = 10.17), and severe liver fibrosis (OR = 2.76) to be associated with SSI and severe liver fibrosis (OR = 2.28), hypoalbuminemia (OR = 2.02), blood transfusion (OR = 1.86), and longer operation time (OR = 1.80) to be associated with postoperative complications. Preoperative oral management may reduce the risk of SSI in patients with HCC who undergo hepatectomy.

Gram-negative endophthalmitis: A prospective study examining the microbiology, clinical associations and visual outcomes following infection.

This is the largest Gram-negative endophthalmitis specific series and provides important evidence to guide management. Endophthalmitis is a sight-threatening emergency. Gram-negative infections are associated with poorer visual outcomes; however, there is limited literature pertaining to this uncommon condition. Prospective case series. All patients presenting with endophthalmitis to a tertiary institution over a 20-year period. Data were collected prospectively and entered into a registry. Patients with microbiological evidence of Gram-negative infection were included in the analysis. Final visual acuity (VA), precipitating events, causative organisms, antibiotic sensitivity profiles and risk factors for poor visual outcomes were reported. One hundred Gram-negative organisms were isolated in 97 eyes. Final VA was worse than 6/60 in 65 (67.0%) eyes at follow-up and 29 (29.9%) eyes were eviscerated or enucleated. Microbial keratitis (26.8%, n = 26) and Pseudomonas aeruginosa (34.0%, n = 34) were the most common precipitating event and causative organism, respectively. Eight (8.0%) isolates were third-generation cephalosporin resistant; of which, 7 (88.0%) were sensitive to ciprofloxacin. Preceding microbial keratitis (OR = 13.16, P = .015) or P. aeruginosa infections (OR = 3.40, P = .045) were strongly associated with poorer visual outcomes (worse than 6/60). Visual outcomes following Gram-negative endophthalmitis are extremely poor, with almost 30% of patients being eviscerated or enucleated. A majority of ceftazidime resistant organisms are sensitive to ciprofloxacin, providing evidence to support the empirical use of quinolones. Clinicians should be mindful that infections secondary to P. aeruginosa or microbial keratitis carry a particularly poor prognosis.

MON-638 The WBC Differential in Relation to DKA Severity

BACKGROUND: Diabetic ketoacidosis (DKA) is well-known to be associated with increased levels of inflammatory markers including cytokines. Interestingly, an elevated white blood count (WBC) has been associated with a higher prevalence of acute and chronic diabetes metabolic complications, including DKA, and micro- and macrovascular complications (Tong et al., 2004; Xu et al., 2013). However, very few studies have looked at the relationship between WBC differential and the severity of DKA. For instance, a study looking at platelet-to-lymphocyte ratio found it to be a significant predictor of mortality in DKA patients admitted to the intensive care unit (Liu et al., 2016). Aim: The goal of the present study is to investigate the relationship between the WBC differential and the severity of DKA. Method: This study was conducted at Dalhousie University-affiliated hospitals in Nova Scotia, Canada. Ethics approval was obtained. The medical records of 646 emergency visits for 338 patients between November 2015 to December 2018 with a provisional diagnosis of DKA were retrospectively reviewed. 84 records were excluded due to non-anion gap metabolic acidosis, and 66 were excluded due to radiological or microbiological evidence of infection (positive urine, stool or blood cultures, pneumonia, etc.). Only the first set of blood investigations were analyzed to avoid post-treatment changes in blood composition. WBC differential (neutrophils, basophils, eosinophils, immature granulocyte, lymphocytes, metamyelocytes, monocytes, and myelocytes) and severity of DKA based on pH value (mild: 7.25–7.30, moderate: 7.24-7.00, and severe: <7.00) were analyzed. Result: A total of 496 visits for 277 patients were analyzed, with about 1:1.2 male-to-female ratio and median age of 36.5 years (range 18–90 years), with no significant differences in sex or age in relation to the severity of DKA (P-value= 0.68 and 0.16, respectively). Leukocytosis (WBC >11 x10(9)/L) was seen in 65% (n=314). 32% (n=158) had mild DKA, while 56% (n=273) and 1% (n=57) had moderate and severe DKA, respectively.With increased severity of DKA, higher WBC count and hemoglobin levels were observed (P-value= 0.002 and 0.037, respectively). This is not unexpected due to hemoconcentration. However, monocytes, immature granulocytes, and basophils (percentage unit of the total WBC) increased with the severity of DKA (P-value: 0.004, <0.001, and <0.001, respectively). On the other hand, lymphocytes displayed an inverse relationship to DKA severity (P-value: 0.015). In contrast, eosinophils & neutrophils had no significant correlation to the DKA severity (P-value= 0.96, and 0.44, respectively). Conclusion: The WBC differential (namely, monocytes, immature granulocytes, basophils, & lymphocytes) is associated with the severity of DKA. We propose that the WBC differential be further studied as a prognostic indicator in patients with DKA.

Ceftolozane/Tazobactam for Treatment of Severe ESBL-Producing Enterobacterales Infections: A Multicenter Nationwide Clinical Experience (CEFTABUSE II Study).

BackgroundFew data are reported in the literature about the outcome of patients with severe extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) infections treated with ceftolozane/tazobactam (C/T), in empiric or definitive therapy.MethodsA multicenter retrospective study was performed in Italy (June 2016–June 2019). Successful clinical outcome was defined as complete resolution of clinical signs/symptoms related to ESBL-E infection and lack of microbiological evidence of infection. The primary end point was to identify predictors of clinical failure of C/T therapy.ResultsC/T treatment was documented in 153 patients: pneumonia was the most common diagnosis (n = 46, 30%), followed by 34 cases of complicated urinary tract infections (22.2%). Septic shock was observed in 42 (27.5%) patients. C/T was used as empiric therapy in 46 (30%) patients and as monotherapy in 127 (83%) patients. Favorable clinical outcome was observed in 128 (83.7%) patients; 25 patients were considered to have failed C/T therapy. Overall, 30-day mortality was reported for 15 (9.8%) patients. At multivariate analysis, Charlson comorbidity index >4 (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9–3.5; P = .02), septic shock (OR, 6.2; 95% CI, 3.8–7.9; P < .001), and continuous renal replacement therapy (OR, 3.1; 95% CI, 1.9–5.3; P = .001) were independently associated with clinical failure, whereas empiric therapy displaying in vitro activity (OR, 0.12; 95% CI, 0.01–0.34; P < .001) and adequate source control of infection (OR, 0.42; 95% CI, 0.14–0.55; P < .001) were associated with clinical success.ConclusionsData show that C/T could be a valid option in empiric and/or targeted therapy in patients with severe infections caused by ESBL-producing Enterobacterales. Clinicians should be aware of the risk of clinical failure with standard-dose C/T therapy in septic patients receiving CRRT.