Negative Blood Cultures Research Articles

The Value of Perinatal Factors, Blood Biomarkers and Microbiological Colonization Screening in Predicting Neonatal Sepsis.

Background: Neonatal sepsis is one of the most important causes of elevated morbidity and mortality rates in neonatal intensive care units worldwide. While the clinical manifestations of neonatal sepsis tend to be nonspecific, its rapid development and life-threatening potential call for reliable markers for early detection. Methods: We conducted a retrospective single-center study including all neonates suspected of having developed neonatal sepsis from 2013 to 2016. Perinatal and clinical characteristics as well as microbiological and laboratory findings were evaluated. Neonatal sepsis was defined as either culture-proven sepsis (positive blood culture) or clinical sepsis (at least one symptom and elevated C-reactive protein (CRP) concentrations within 72 h with negative blood culture). We further differentiated between early-onset (EOS) and late-onset (LOS) sepsis. Results: Microbiological colonization screening by throat and rectal swabs frequently did not detect the organism that subsequently caused the sepsis. Depending on the age of the newborn with sepsis (EOS or LOS), associations between different anamnestic and clinical factors (prenatal or postnatal ones) were found. In particular, the central–peripheral temperature difference showed a strong association with LOS. Laboratory results useful for the early detection of neonatal sepsis included interleukin-6 (IL-6) and CRP concentrations. Conclusions: Elevated IL-6 >100 ng/L was a strong marker for neonatal sepsis. When choosing the antibiotics for treatment, data from microbiological colonization screening should be considered but not solely relied on. Some indicators of infection also depended on postnatal age.

Importance of Lumbar Puncture in Late Onset Sepsis

Neonatal sepsis is the significant reason of neonatal mortality and morbidity and mostly results in extended hospitalization of infants in the neonatal intensive care unit. The sepsis was confirmed by a positive blood culture and a condition is considered clinical sepsis when the blood culture is negative. It is practically not possible to clinically differentiate sepsis from neonatal meningitis. However, a positive CSF for pathogenic bacteria indicates meningitis. Aim: The purpose of this study was to evaluate the frequency of late-onset sepsis in neonates with meningitis and to determine whether CSF analysis and lumbar puncture is mandatory in all cases of late-onset sepsis. Methods: This study was conducted in the Paediatrics department of CMH Abbottabad, and Sharif Medical City Hospital Lahore, and Pathology department of Women Medical and Dental College, Abbottabad for the duration from January 2022 to June 2022 among neonates with late neonatal sepsis. All neonates underwent clinical examination, history, routine tests (blood culture, C-reactive protein, complete blood count) and analysis and culture of cerebrospinal fluid for clinical evaluation of sepsis. Results: All 80 neonates tested positive for clinical sepsis: hematological sepsis was seen in 59 patients and 21 were CSF culture positive for sepsis; 8 (38.9%) of the 21 have positive CSF culture and 13 cases have negative blood culture. The most common clinical symptom was poor suction 70(87.5%), followed by weak moor 61(76.3%), and lethargy 46(57.5%). The Klebsiella spp was common organism seen in 15 children in the blood culture and the most communal organism in the cerebrospinal fluid culture was Staphylococcus aureus in 6 cases. Conclusions: The incidence of neonatal meningitis is high in new-borns with late-onset sepsis. Meningitis in neonates often transpires in the absence of bacteraemia. Therefore, the CSF examination and lumbar puncture are compulsory in all children with late onset sepsis. Keywords: Lumbar puncture, Meningitis, Neonatal sepsis

Combining Complete Blood Count with Differential Count; C-Reactive Protein and Band Neutrophils in Diagnosis of Early onset Neonatal Sepsis

Aim: To assess the diagnostic accuracy of complete blood count with band versus total neutrophil ratio and C-reactive proteins as an efficient analytical procedure for determining early onset sepsis in neonates. Study design: Cross sectional analytical study Place and duration of study: Department of Paediatric Medicine, Abbas Institute of Medical Sciences Muzafarabad, AJ Kashmir from 01-02-2022 to 31-07-2022. Methodology: Fifty patients were enrolled. Coulter counter was used for analyzing leucocytes of the neonates. Thin film-smears were generated by the laboratory scientist for identifying band neutrophils separately from mature neutrophils. C-reactive proteins level <5mg/dl was considered as negative. Thio-glycate-oxide in liquid form was used for 2ml neonatal blood culture analysis mixed in the 20ml medium at 36 degree celsius. Results: There were 28 (56%) males and 22 (44%) females. The mean age of the neonates was 1.6± 0.77 days. The mean weight of the neonates was 2.4±0.51kg with a range of 4-1.2kg. A variance of band versus total neutrophil ratio was significantly higher in cultures which were positive than negative such as 70% vs 25%. There was also significant percentage of C-reactive proteins positive in positive sepsis cultures in comparison to negative blood culture. Conclusion: A combination of complete blood count with differential count, white blood cell analysis with band versus total neutrophil ratio and c-reactive proteins is an efficient early analytical procedure for determining early onset sepsis in neonates as gold standard test blood culture is time taking. Key Words: Complete blood count, C-reactive protein, Total neutrophils ratio, Early onset neonatal sepsis.

Listeria monocytogenes Infection in a 69-year-old Diabetic

Listeria monocytogenes is a gram-positive, rod-shaped facultative anaerobe, often misidentified with Diphtheroids due to sharing similar characteristics. Due to its virulence factor listeriolysin O, it is capable of evading host immune systems and living in extreme environments. This organism often causes listeriosis in pregnant women, newborns, the elderly, or immunocompromised individuals. Therefore, it is crucial to include listeria infection in patients with positive diphtheroids in blood or CSF. We discuss a case of a 69- ear-old Hispanic woman with a history of type 2 diabetes mellitus, hypertension, seizure disorder, and obesity who presented with generalized body aches and fever. Initial blood culture showed diphtheroid on blood culture. In order to distinguish listeria from diphtheroids, longer blood culture inoculation is required. After 48 hours of inoculation, blood culture resulted in L. monocytogenes as the culprit of the patient’ symptoms, contributing to the complex nature of distinguishing between diphtheroid and listeriosis. Therapy was modified to ampicillin at this time. Following antibiotic treatment and negative blood culture, the patient fully recovered from the listeriosis without suspicion of having symptoms of endocarditis and meningitis.

Serial Measurement of Interleukin-6 Enhances Chance to Exclude Early-Onset Sepsis in Very Preterm Infants.

The aim of this retrospective study was to evaluate the reliability of peak interleukin-6 (IL-6) level within 24 hours after delivery as a predictor for early-onset sepsis (EOS) in very preterm neonates. Interleukin-6 was assessed at 2 hours and at 12 to 24 hours after delivery. The highest level was considered a peak value. The definition of EOS was based on positive blood culture and clinical signs of infection or negative blood culture, clinical signs of infection, and C-reactive protein >10 mg/L. Among 445 enrolled infants, 53 developed EOS. A peak IL-6 level of more than 200 ng/L had a sensitivity of 89% and specificity of 77% for the presence of EOS. The negative predictive value was 98%. Receiver operating characteristics curve had area under the curve of 0.92. Peak IL-6 is a reliable marker of systemic inflammatory response and might be useful to exclude EOS within the first 24 hours.

Association of Follow-up Blood Cultures With Mortality in Patients With Gram-Negative Bloodstream Infections

Obtaining follow-up blood cultures (FUBCs) in patients with Staphylococcus aureus bloodstream infection (BSI) is standard practice, although its utility in patients with gram-negative bacterial BSI (GN-BSI) is unclear. To examine whether obtaining FUBCs is associated with decreased mortality (key question [KQ] 1) and whether positive vs negative FUBCs are associated with increased mortality (KQ2). MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and gray literature were searched from inception to March 11, 2022. Two investigators used predefined eligibility criteria to independently screen titles, abstracts, and relevant full texts. Randomized clinical trials or observational studies that matched or statistically adjusted for differences in, at minimum, level of acute illness between patients in the intervention (eg, FUBCs obtained) and control (eg, FUBCs not obtained) groups were included in primary analyses. Articles published in languages other than English were excluded. Data abstraction and quality assessments were performed by one investigator and verified by a second investigator. Risk of bias was assessed with the Newcastle-Ottawa Scale. Effect sizes were pooled using random-effects models. The study followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline. Mortality before hospital discharge or up to 30 days from the index blood culture. From 3495 studies, 15 were included (all nonrandomized). In the 5 studies (n = 4378 patients) that met criteria for the KQ1 primary analysis, obtaining FUBCs was associated with decreased mortality (hazard ratio, 0.56; 95% CI, 0.45-0.71). For KQ2, 2 studies met criteria for the primary analysis (ie, matched or statistically adjusted for differences in patients with positive vs negative FUBCs), so an exploratory meta-analysis of all 9 studies that investigated KQ2 (n = 3243 patients) was performed. Positive FUBCs were associated with increased mortality relative to negative blood cultures (odds ratio, 2.27; 95% CI, 1.54-3.34). Limitations of the literature included a lack of randomized studies and few patient subgroup analyses. In this systematic review and meta-analysis, obtaining FUBCs in patients with GN-BSI was associated with decreased mortality. The benefit of FUBCs may stem from identification of patients with positive FUBCs, which was a poor prognostic marker.

Vasoplegic Syndrome after Cardiac Surgery for Infective Endocarditis.

Purpose: Post-operative vasoplegic syndrome is a dreaded complication in infective endocarditis (IE). Methods and Results: This retrospective study included 166 consecutive patients referred to cardiac surgery for non-shocked IE. Post-operative vasoplegic syndrome was defined as a persistent hypotension (mean blood pressure < 65 mmHg) refractory to fluid loading and cardiac output restoration. Cardiac surgery was performed 7 (5–12) days after the beginning of antibiotic treatment, 4 (1–9) days after negative blood culture and in 72.3% patients with adapted anti-biotherapy. Timing of cardiac surgery was based on ESC guidelines and operating room availability. Most patients required valve replacement (80%) and cardiopulmonary bypass (CPB) duration was 106 (95–184) min. Multivalvular surgery was performed in 43 patients, 32 had tricuspid valve surgery. Post-operative vasoplegic syndrome was reported in 53/166 patients (31.9%, 95% confidence interval of 24.8–39.0%) of the whole population; only 15.1% (n = 8) of vasoplegic patients had a post-operative documented infection (6 positive blood cultures) and no difference was reported between vasoplegic and non-vasoplegic patients for valve culture and the timing of cardiac surgery. Of the 23 (13.8%) in hospital-deaths, 87.0% (n = 20) occurred in the vasoplegic group and the main causes of death were multiorgan failure (n = 17) and neurological complications (n = 3). Variables independently associated with vasoplegic syndrome were CPB duration (1.82 (1.16–2.88) per tertile) and NTproBNP level (2.11 (1.35–3.30) per tertile). Conclusions: Post-operative vasoplegic syndrome is frequent and is the main cause of death after IE cardiac surgery. Our data suggested that the mechanism of vasoplegic syndrome was more related to inflammatory cardiovascular injury rather than the consequence of ongoing bacteremia.

A positive blood culture is associated with a lower haemoglobin increment in hospitalized patients after red blood cell transfusion.

Abundant clinical evidence supports the safety of red blood cell (RBC) concentrates for transfusion irrespective of storage age, but still, less is known about how recipient characteristics may affect post-transfusion RBC recovery and function. Septic patients are frequently transfused. We hypothesized that the recipient environment in patients with septicaemia would blunt the increase in post-transfusion blood haemoglobin (Hb). The main objective was to compare the post-transfusion Hb increment in hospitalized patients with or without a positive blood culture. A retrospective cohort study using data from the Transfusion Research, Utilization, Surveillance, and Tracking database (TRUST) was performed. All adult non-trauma in-patients transfused between 2010 and 2017 with ≥1 RBC unit, and for whom both pre- and post-transfusion complete blood count and pre-transfusion blood culture data were available were included. A general linear model with binary blood culture positivity was fit for continuous Hb increment after transfusion and was adjusted for patient demographic parameters and transfusion-related covariates. Among 210,263 admitted patients, 6252 were transfused: 596 had positive cultures, and 5656 had negative blood cultures. A modelled Hb deficit of 1.50 g/L in blood culture-positive patients was found. All covariates had a significant effect on Hb increment, except for the age of the transfused RBC. Recipient blood culture positivity was associated with a statistically significant but modestly lower post-transfusion Hb increment in hospitalized patients. In isolation, the effect is unlikely to be clinically significant, but it could become so in combination with other recipient characteristics.

Profile of Tumor Necrosis Factor Alpha Levels in Childhood Malignancy with Febrile Neutropenia

Infection is a significant cause of morbidity and mortality in childhood malignancy with Febrile Neutropenia (FN). Tumor Necrosis Factor-Alpha (TNF-α) is involved in host defense against bacterial invasion. However, changes in TNF-α levels with the possibility of bacterial infection confirmed by blood culture are still unclear. The study aimed to evaluate TNF-α levels in childhood malignancy with FN who had blood cultures with a control group. Observational cross-sectional analysis during January-October 2020 at Dr. Soetomo General Academic Hospital, Surabaya. Childhood malignancy with FN episodes as the case group and nonfebrile neutropenia as the control. TNF-α levels examination used plasma with the Enzyme-Linked Immunosorbent Assay (ELISA) sandwich method. Blood culture results were obtained from the patient's medical record. The differences in TNF-α levels in the case groups and control were analyzed by the T-square test for two independent samples or Mann-Whitney U according to the data distribution. There were 18 cases group with 30 FN episodes and 15 controls. There were 8(26.66%) positive and 22(73.33%) negative blood cultures from 30 FN episodes. The mean TNF-α levels in the positive blood culture cases group and control: 14.72±5.77 and 9.78±2.74 pg/mL, and the median (min-max) negative blood cultures: 12.19 (7.01-25.70) pg/mL. There was no significant difference in TNF-α levels in the positive and negative blood culture cases group (p=0.527), but there was a significant difference in the control (p=0.049 and p=0.027). Therefore, TNF-α levels cannot be used as a marker of bacterial infection in the case groups.

Association of Procalcitonin with the Patient's Infection Characteristics and Prognosis after Hematopoietic Stem Cell Transplantation.

Objective To study whether procalcitonin (PCT) is an important indicator of infection with or without agranulocytosis and to reveal whether PCT can distinguish between infected sites and affect prognosis after hematopoietic stem cell transplantation (HSCT). Method In the present study, 682 patients with HSCT were enrolled, and their clinical characteristics were noted. Their blood culture and inflammatory and biochemical indicators were studied. The patients were divided into respective groups according to the degree of agranulocytosis, type of bacterial infection, infected sites, and prognosis. Results The PCT, CRP, and D-dimer levels were significantly improved in patients with positive blood culture results compared to the case for those with negative blood culture results. The PCT level was the highest in the gram-negative group. The levels of PCT and D-dimer were significantly elevated in patients with infection and agranulocytosis after HSCT compared to those in the nonagranulocytosis cohort. Interestingly, no significant difference in the PCT level was observed among any of the eight foci. Lower PCT levels were associated with higher survival in patients with infection after HSCT. Conclusion Among patients that underwent HSCT, PCT levels were significantly elevated in those with infection and agranulocytosis, with the levels being specifically high in the gram-negative group. Moreover, lower PCT levels were associated with higher survival in patients with infection after HSCT.

Infective endocarditis in developing countries: An update.

IntroductionDespite advances in diagnostic and treatment, morbidity and mortality due to infective endocarditis (IE) has not decreased. There is a discrepancy in epidemiology of IE between developed and developing countries. Over the last years, increased early detection and consequently prevalence of rheumatic heart disease (RHD) and congenital heart disease (CHD) which are considered predisposing conditions for IE, is noted. Here, we present a review of literature on IE in developing countries.MethodsWe conducted a systematic literature search of IE studies in developing countries through PubMed and Embase. We have divided the studies into two groups: studies published before 2015 (group 1) and studies ≥ 2015 (group 2). The outcome was defined as a difference in epidemiology, microbiology, treatment, and mortality over time. The Scale for Assessment of Narrative Review Articles guidelines was applied.FindingsIn total, 16 studies were included. The total number of IE cases was 1,098 and 1,505 in groups 1 and 2, respectively. We compared 4/7 cohorts from group 1 (n = 789) with 5/9 cohorts from group 2 (n = 636). Six studies were not included in the comparison because they were interacting between the two cohorts. Males predominated in all studies. Rheumatic heart disease was higher in group 1 than in group 2 (42.3% vs. 30.3%, p < 0.001) while for CHD there was no change (17.6% vs. 16.7%, p = 0.672). Streptococci infections was lower in group 1 than group 2 (26.2% vs. 37.7%, p < 0.001). The proportion of Staphylococcus aureus was 15.3% in group 1 and 23.6% in group 2, p < 0.001. Negative blood culture (NBC) was higher in group 1 than in group 2 (42.2% vs. 34.1%, p = 0.002). Patients in group 1 received more surgery than in group 2 (38.8% vs. 28.8%, p < 0.001). Mortality was similar in the two groups (20.9% vs. 22.3%, p = 0.518).ConclusionThis review shows a scarcity of studies on IE in developing countries. Rheumatic heart disease and congenital heart disease are common predisposing conditions. Other risk factors are prosthetic valves, degenerative valve disease (DVD), intravenous drug use, and human immunodeficiency virus infection. While the proportion of IE cases caused by Streptococcus and Staphylococcus has increased, the number of NBC and patients getting surgery has decreased. Mortality has not changed over time. Timely diagnosis and management of patients with RHD and CHD and comprehensive management of IE are warranted.

Determining Time to Positivity of Blood Cultures in a Neonatal Unit.

Blood cultures are the gold standard for detecting bacteremia. We have studied the time to positivity of blood cultures in our neonatal unit to reduce antibiotic doses in patients with a negative blood culture. Empirical antibiotic treatment of neonatal sepsis could be withdrawn 24 hours after obtaining blood cultures.

Successful management of a rare case of endogenous endophthalmitis from soft tissue (gluteal) abscess

Endophthalmitis, an ophthalmic emergency carries poor visual prognosis without prompt diagnosis and treatment. Endophthalmitis is often exogenous and rarely endogenous. In this report, we describe a rare case of bacterial endogenous endophthalmitis in an immunocompetent 51-year-old patient due to methicillin-resistant staphylococcus aureus septicemia from a gluteal abscess. Ultrasonography confirmed endogenous endophthalmitis. The patient was treated with immediate intravitreal antibiotic injections, prolonged intravenous antibiotics in association with pars plana vitrectomy, retinal detachment repair and vitreous debris removal. Successful treatment was confirmed with negative blood cultures and a clear vitreous on b-scan ultrasound and fundus photography with improvement of his visual acuity. This case highlights the importance of consideration of rare infectious foci as etiology and prompts treatment for successful resolution of endogenous endophthalmitis.

32963 Nivolumab-induced vasculopathy: A novel immunotherapy reaction

Immune checkpoint inhibitor therapy has revolutionized treatment of metastatic melanoma. However, both novel and fatal adverse events continue to be reported. We present a case of a 45-year-old Caucasian woman who developed severe small-vessel vasculopathy on nivolumab therapy for metastatic melanoma. Eight years prior to presentation, she had a resection of a stage IA melanoma. Four months prior to presentation, she developed an axillary mass prompting CT and PET imaging with subsequent axillary node biopsy. Biopsy findings showed poorly differentiated tumor consistent with her primary melanoma and nivolumab therapy was initiated. After her 4th cycle, she presented to the ED with dusky, indurated plaques on her breasts, lower abdomen, proximal legs, and buttocks covering <30% TBSA. Initial punch biopsies showed suppurative dermatitis with hemorrhage and Gram-positive cocci. Eleven days later, these areas evolved into ulcerations with eschars. Repeat incisional biopsies showed extensive epidermal and dermal necrosis with small vessel thrombotic vasculopathy. Laboratory values including factor V Leiden, antiphospholipid antibodies, c-ANCA/p-ANCA, PT/PTT/INR, protein C & S deficiency, cryoglobulins, negative blood cultures, among other tests, excluded hypercoagulable and infectious etiologies. Given the timing of lesions and exclusion of other causes, nivolumab therapy was determined the cause of her vasculopathy and was subsequently held. Apixaban was initiated, resulting in the cessation of new lesions. This case illustrates a vasculopathy mediated by a novel mechanism secondary to immunotherapy. We believe it is essential clinicians are aware of this novel reaction and its management as late recognition could prove fatal for patients.

Culture-negative sepsis after pediatric cardiac surgery: Incidence and outcomes.

Significant proportion of congenital heart surgery (CHS) children exhibit sepsis, but have negative blood culture and defined "culture negative sepsis (CNS)." Retrospective analysis of CNS patients undergoing CHS. 437 consecutive CHS children grouped as controls (antibiotic prophylaxis), CNS, and culture positive sepsis (CPS). Incidences of CNS and CPS were 16% and 7%. Median mechanical ventilation (MV) in hours among CPS, CNS, and control was 116 (45-271), 63 (23-112), and 18 (6-28) (P < 0.001), respectively. Multivariable linear regression identified CPS (median ratio: 3.1 [2.3-4.1], P < 0.001), CNS (median ratio: 5.6 [3.7-8.4], P < 0.001), and weight (kg) (median ratio: 0.98 [0.96-0.99], P = 0.009) as associations of MV. Intensive care unit (ICU) stay (hours) was 192 (120-288) in CNS, 288 (156-444) in CPS, and 72 (48-120) in controls (P < 0.0001). Multivariable linear regression showed CNS (median ratio: 2.4 [2.0-2.9], P< 0.001) CPS (median ratio: 3.3 [2.5-4.4], P < 0.001), and weight (median ratio: 0.98 [0.97-0.99], P ≤ 0.001) prolonging ICU stay. Mortality was 10.7%, 2.9% and 1.2% in CPS, CNS, and control (P = 0.03). Multivariable regression identified CPS an independent predictor of mortality with odds ratio 8.6 (1.7-44.9; P = 0.010). 11.26% patients in CNS and 79.3% in CPS received antibiotics for more than 10 days. Incidence of CNS was 16%; duration of MV and ICU stay and mortality was significantly less in CNS than CPS patients.

Defining the clinical characteristics of Q fever endocarditis: A case-control study in China.

Q fever is a worldwide zoonosis caused by Coxiella burnetii. Atypical presentations of Q fever can cause diagnostic difficulty or be misdiagnosed. Here we compared the clinical and diagnostic features of Q fever endocarditis and endocarditis caused by other bacteria to identify features of Q fever endocarditis that might facilitate early diagnosis. This was a retrospective case-control study of eight cases of Q fever endocarditis diagnosed between 2000 and 2018 at Peking Union Medical College Hospital in China and 24 age- and gender-matched patients diagnosed with bacterial endocarditis over the same period. Clinical and laboratory data were collected and compared between groups. The median time interval between symptoms and diagnosis was significantly longer in the case group than the control group (8.0 months (IQR 7.0-16.0) vs. 4.0 months (IQR 1.0-7.0); p = 0.002). Patients in case group had significantly lower white blood cell counts (5.8 ± 2.4 × 109/L vs. 10.0 ± 3.4 × 109/L; p = 0.003), percentage of neutrophil (62.4 ± 14.7% vs. 79.1 ± 9.2%; p = 0.014), high-sensitivity C-creative protein levels (21.1 mg/L (IQR 18.5-32.8) vs. 45.3 mg/L (IQR 32.9-54.3); p = 0.038), and platelet counts (133 ± 73 vs. 229 ± 65; p = 0.001) but higher levels of rheumatoid factor (104.3 U/L (IQR 99.0-132.8) vs. 10.2 U/L (IQR 6.9-32.5); p = 0.011) than controls. Elevated creatinine (50.0% vs. 12.5%; p = 0.047) and liver enzymes (50.0% vs. 0%; p = 0.002) were more common in cases than controls. Q fever endocarditis was less frequently diagnosed than controls before cardiac surgery (62.5% vs. 100%; p = 0.011), with negative blood cultures in all cases. The diagnosis of Q fever endocarditis can easily be delayed compared to other causes of infectious endocarditis. Patients with chronic fever and new valve dysfunction require careful assessment, especially when presenting with negative blood cultures and high rheumatoid factor levels. Clinical and laboratory evaluation of these patients should include routine serological testing for C. burnetii.

The skip phenomenon in Staphylococcus aureus bacteremia: clinical implications

Serial blood cultures (BCs) are integral in managing Staphylococcus aureus bacteremia (SAB) to determine complication risks and treatment response. Several studies recognized the skip phenomenon (SP)- the occurrence of intermittent negative BCs and recommend obtaining additional BCs to document clearance. We examined patients with SP to determine its clinical significance. Significant differences between those who did and did not manifest the SP included higher rates of injection drug use and community-onset SAB in the SP cohort. Longer SAB duration, high-grade SAB, and complicated bacteremia were more common in the SP group. In unadjusted outcome analyses, association of SP with hospital length of stay was not significant, although a higher risk of in-hospital mortality among SP patients approached significance. Analysis of hospital survivors revealed no significant differences in 90-day relapse or 1-year mortality. Clinical implications of patients with SAB and SP indicate that serial BCs are warranted to document bacterial clearance.

Association between duration of early empiric antibiotics and necrotizing enterocolitis and late-onset sepsis in preterm infants: a multicenter cohort study

The threshold to initiate empiric antibiotics for suspicion of early-onset sepsis (EOS) is low in preterm infants. Antibiotics’ effects on short-term outcomes have recently been debated. We aimed at exploring the extent of early empiric antibiotic exposure (EEAE) in preterm infants and the association between the duration of EEAE with necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) within different EEAE groups. EEAE practice for suspicion of EOS was evaluated in all included infants (gestational age < 30 weeks) born in 9 centers in the Netherlands and Belgium between Oct. 2014 and Jan. 2019. EEAE association with NEC and LOS development was analyzed by multivariate regression. After excluding 56 EOS cases, 1259 infants were included. A total of 1122 infants (89.1%) were exposed to empirical antibiotics for the suspicion of EOS of whom 802 (63.7%) had short (≤ 72 h) and 320 (25.4%) prolonged EEAE (> 72 h). Infants with EEAE ≤ 72 h had a lower incidence of NEC compared to both infants without EEAE (adjusted odds ratio (aOR) 0.39; 95% confidence interval (CI) [0.19–0.80]; p = 0.01) and with prolonged EEAE (> 72 h) (aOR [95%CI]: 0.58 [0.35–0.96]; p = 0.03). With every additional day of EEAE, LOS incidence decreased (aOR [95%CI]: 0.90 [0.85–0.97]; p = 0.003).Conclusion: Almost 90% of preterm infants who have negative blood culture results in the first 72 h of life are exposed to EEAE under suspicion of EOS. One-fourth has prolonged EEAE. Duration of EEAE was differently associated with NEC and LOS incidence. The effects of antibiotics, and potentially induced microbial dysbiosis related to development of NEC and LOS, should further be explored.What is Known:• Preterm infants often receive antibiotics empirically directly after birth for suspicion of early-onset sepsis.• The effects of the duration of early empirical antibiotic exposure on the risk for necrotizing enterocolitis and late-onset sepsis are debated.What is New:• Almost 90% of preterm infants with a gestational age below 30 weeks are exposed to antibiotics empirically after birth despite negative culture results. In a quarter of these culture-negative infants, empirical antibiotics are prolonged.• A short course of empirical antibiotics (≤72h) is associated with decreased odds for necrotizing enterocolitis compared to both prolonged (>72h) or no empirical antibiotics after birth. Furthermore, every additional day of empirical antibiotic exposure is associated with decreased risk for late-onset sepsis in the first month of life.

Cutaneous vesicles in an infant after bone marrow transplantation.

Eight-month-old infant who recently received a matched unrelated donor transplant for malignant infantile osteopetrosis was admitted on T+48 for the evaluation of fevers. Her complete blood count (CBC) on admission showed a neutrophil count of 8940 × 109/L and Hb of 7.1 g/dl. Patient was started on cefepime and vancomycin while awaiting results of blood culture that grew methicillin-susceptible Staphylococcus aureus. She continued treatment with cefepime and had her central line removed. On T+50 parents reported the appearance of a new blistering rash on her hands. Skin examination demonstrated multiple 1–2 mm deep seated noninflammatory vesicles located on the distal digits and metacarpophalangeal joints of both hands and pad of the right thumb (Figure 1). During this admission, our patient's Epstein–Barr virus (EBV) polymerase chain reaction (PCR) test in whole blood became positive and she also had diarrhea that tested positive for norovirus. In an early posttransplant (<100 days) patient, our major concern was acute graft versus host disease (GVHD). Due to the limited distribution of rash and the lack of systemic symptoms, it became less likely. Although GVHD can present as bullous skin lesions, it is associated with severe disease presentation. Second in our list were infectious causes. There are reports of norovirus-related urticaria presenting with generalized erythematous wheals associated with pruritus. Dermatologic manifestations of EBV are reported more commonly in patients with infectious mononucleosis (IM). IM patients more commonly develop a faint erythematous macular rash early in the course or a maculopapular rash associated with the inappropriate use of amoxicillin. There are reports of IM presenting with erythematous papulovesicules, but it is uncommon. Vesicular lesions associated with Herpes simplex 1 or 2 infection are characterized by grouped vesicles on an erythematous base ring. In severely immunocompromised patients with deficient cellular immunity, the risk of extensive mucocutaneous disease and disseminated infection is higher. Transplant patients are at risk of developing herpes simplex virus (HSV) infection due to reactivation. Lastly, sucking blisters are noninflammatory vesicles with thick walls that contain sterile fluid. Lesions are usually located on dorsal areas of fingers, hands or wrists and can be bilateral. The observation of the infant sucking the involve areas helped guiding with the diagnosis. In the absence of lesions in other areas and with lack of systemic symptoms sucking blisters became the most likely diagnosis. No biopsy was performed due to well apearing baby. Fever subsided and antibiotics were stopped after 10 days with negative blood culture. Rash is persistent with a healthy looking infant without other manifestations. Kristen Nagle, PNP; Linda Cabral, PA. The authors declare they have no conflicts of interest. The authors received no specific funding for this work. A written informed consent was obtained from the parents of the patient to publish the case and images in a medical journal.

Left ventricular non-compaction in a juvenile systemic lupus erythematosus girl with Hashimoto’s thyroiditis: Case report and review of the literature

BackgroundLeft ventricular noncompaction (LVNC) is a structural abnormality of the left ventricular myocardium of unknown cause. Cardiovascular system involvement is an important manifestation in juvenile systemic lupus erythematosus (jSLE) and is a leading cause of morbidity and mortality. Aim of the workTo present a case of jSLE with LVNC and Hashimoto's thyroiditis. Case presentationA 15-year-old Tunisian girl with a history of Hashimoto's thyroiditis presented with paroxysmal chest pain, exertional dyspnea, headache, and polyarthralgia and was diagnosed with jSLE. Clinical examination revealed a febrile patient (39 °C). There was no tachypnea, no evidence of right heart failure, no audible murmurs on cardiac auscultation, and no edema of the lower limbs. Laboratory investigations revealed leucopenia (3500/mm3), anemia (10 g/dl), elevated erythrocyte sedimentation rate (ESR)(50 mm\\1sth), C-reactive protein (20 mg/l). Infections were excluded with multiple negative blood cultures and negative anti-streptolysin O antibodies. The antinuclear antibody (ANA) was positive homogenous at 1/10,000 and both anti-native DNA and anti-SSA were positive. The electrocardiogram (ECG) showed sinus tachycardia, the transthoracic echocardiography revealed pericarditis associated with a non-compacted LV and a small pericardial effusion. Thus, a cardiac magnetic resonance imaging (CMRI) was performed confirming LVNC with a hypertrabeculated sub-endocardium. There was no proteinuria, hypocomplementemia or cerebral vasculitis on cerebral magnetic resonance imaging (MRI). The patient received high-dose corticosteroids associated with beta-blocker therapy with a favorable outcome. ConclusionA rare case of LVNC which was accidentally discovered in a patient with jSLE and Hashimoto's thyroiditis is documented. Follow-up is needed for the development possible complications.