Oral Ciprofloxacin Research Articles

Salmonella Aortitis Related to Rheumatoid Arthritis

Abstract A 65-year-old woman with a history of rheumatoid arthritis on immunosuppression with methotrexate and etanercept presented with abdominal pain, fever, and diarrhea. Symptoms initially improved with a short course of oral ciprofloxacin but soon recurred. Computed tomography imaging of the abdomen was concerning for intramural abscess, aortitis, and a 3.8-cm aneurysm. She was initiated on broad-spectrum antibiotics and underwent emergent endovascular repair and graft. Blood and intraoperative cultures remained negative. After completing 6 weeks of broad-spectrum antibiotics, she had recurrence of symptoms, with blood cultures showing Salmonella species, requiring explant of hardware and a surgical bypass. She had several subsequent morbidities, including iatrogenic chylous leak, and Clostridium difficile colitis, and ultimately died. A high degree of suspicion is needed for a timely diagnosis of infectious aortitis in patients with compatible findings. Despite optimal therapy, infectious aortitis continues to have significant morbidity and mortality.

A rare case of periprosthetic Trueperella bernardiae following a total hip arthroplasty and antimicrobial stewardship

Trueperella bernardiae is a rare, anaerobic Gram-positive bacillus. Very few published clinical reports1 of Trueperella infections, eludes its true incidence and pathogenicity. We share a case of a 70-year-old woman with recurrent peri-prosthetic joint infection (PJI) following a total hip arthroplasty. A month after hip replacement, she presented with PJI, which was treated with extensive debridement and oral Ciprofloxacin in community for ESBL Enterobacteriaceae from peri-prosthetic samples. Five months later, she represented with peri-prosthetic collection which grew Trueperella bernardiae, during stage 1 hip revision. This was treated in hospital with six-weeks intravenous (IV) benzyl penicillin. A month after the second stage revision, she presents with hip re-collection that grew ciprofloxacin resistant Escherichia coli. She was managed in community with a 6-week IV carbapenem. However, 12 months later she developed a psoas abscess and subsequently elected for cessation of active management, leading to her demise. This report emphasises on the emergence of antimicrobial resistance2 Enterobacteriaceae due to constant antibiotic pressure, possibly causing a prosthetic joint infection by a rare Trueperella bernardiae, which was treated effectively by a narrow spectrum penicillin. This case report calls the need for antimicrobial stewardship3 while elucidating the existence of rare pathogens. 1.Loïez C, Tavani F, Wallet F, et al. An unusual case of prosthetic joint infection due to Arcanobacterium bernardiae. J Med Microbiol 2009; 58: 842–3.2.Serwecińska L. Antimicrobials and antibiotic-resistant bacteria: a risk to the environment and to public health. Water 2020; 12: 3313.3.McKenzie D, Rawlins M, Del Mar C. Antimicrobial stewardship: what’s it all about? Aust Prescr 2013; 36: 116–20.

Population pharmacokinetics of intravenous and oral ciprofloxacin in children to optimize dosing regimens.

This study aimed to characterize pharmacokinetics of intravenous and oral ciprofloxacin in children to optimize dosing scheme. Children treated with ciprofloxacin were included. Pharmacokinetics were described using non-linear mixed-effect modelling and validated with an external dataset. Monte Carlo simulations investigated dosing regimens to achieve a target AUC0-24h/MIC ratio ≥ 125. A total of 189 children (492 concentrations) were included. A two-compartment model with first-order absorption and elimination best described the data. An allometric model was used to describe bodyweight (BW) influence, and effects of estimated glomerular filtration rate (eGFR) and age were significant on ciprofloxacin clearance. The recommended IV dose of 10mg/kg q8h, not exceeding 400mg q8h, would achieve AUC0-24h to successfully treat bacteria with MICs ≤ 0.25 (e.g. Salmonella, Escherichia coli, Proteus, Haemophilus, Enterobacter, and Klebsiella). A dose increase to 600mg q8h in children > 40kg and to 15mg/kg q8h (max 400mg q8h, max 600mg q8h if augmented renal clearance, i.e., eGFR > 200mL/min/1.73 m2) in children < 40kg would be needed for the strains with highest MIC (16% of Pseudomonas aeruginosa and 47% of Staphylococcus aureus). The oral recommended dose of 20mg/kg q12h (not exceeding 750mg) would cover bacteria with MICs ≤ 0.125 but may be insufficient for bacteria with higher MIC and a dose increase according bodyweight and eGFR would be needed. These doses should be prospectively confirmed, and a therapeutic drug monitoring could be used to refine them individually.

Mycotic Pseudoaneurysm of the Ascending Aorta after Heart Transplantation

Introduction Mycotic pseudoaneurysm of the ascending aorta is a potentially fatal complication after heart transplantation (HTx). Pseudomonas (P.) aeruginosa as a pathogen is mainly seen in immunosuppressed patients. Possible symptoms are malaise, chest or thoracic back pain, dyspnea, dysphagia or fever. Occasionally asymptomatic cases are also reported. There is often a previous mediastinitis or other infection in the patient history. In our patient a P. aeruginosa pseudoaneurysm developed after HTx without any alarm symptoms. Case Report The 67-year-old male patient treated with hypertension, diabetes mellitus and chronic renal failure attended a regular visit five months after HTx. He was asymptomatic except of an unexplainable weight loss. Lab test showed a moderate C-reactive protein level elevation over the course of two months (4-7-24-57 mg/L), therefore further examinations were prepared to identify the source of infection. Transthoracic echocardiography, chest X-ray, abdominal ultrasound and urine culture revealed no abnormalities. Chest computed tomography (CT) however showed a significant (90 mm) saccular dilatation of the tubular portion of ascending aorta. No obvious concomitant infection was reported. An urgent surgical intervention was indicated. A pseudoaneurysm was identified intraoperatively starting at the aortic anastomotic suture line, it was successfully resected and the sinotubular junction was reconstructed with a vascular prosthesis. Cultures of the resected specimen grew P. aeruginosa while all blood cultures taken pre- and postoperatively remained negative. Histological examinations verified aortitis. The patient received 3 weeks of intravenous treatment with ceftazidim followed by long-term oral ciprofloxacin. 19 day postoperative CT revealed no sign of recurrent graft infection. 4 months after the operation the patient was asymptomatic with controlled blood pressure and normal inflammatory markers. Summary This case demonstrates the importance of considering a mycotic pseudoaneurysm of the aorta in the etiology of unexplainable inflammation following HTx. P. aeruginosa can be a causative organism which may indicate a long-term antibiotic therapy. It is important to check regularly the physical status, blood pressure, aortic diameters and inflammatory markers of the patient, as well as the potential side effects of antibiotic treatment.

Disseminated Mycobacterium Fortuitum Infection in Bilateral Lung Transplant Recipient

Introduction Lower respiratory tract secretions from lung transplant recipients are known on rare occasions to yield a low inoculum of non-tuberculous mycobacteria. However, despite the intense systemic immunosuppression required in these recipients, disseminated mycobacterial disease has rarely been reported. Case Report A 66-year-old male with history of right total knee arthroplasty in 2007 and bilateral lung transplant in 2019 (cytomegalovirus [CMV] donor seropositive/recipient negative) was admitted with two days of fevers, chills, and dyspnea. Immunosuppression therapy included basilixumab induction and maintenance immunosuppression with mycophenolate mofetil, tacrolimus, and prednisone. A CT chest demonstrated patchy opacities in the left lung allograft and right middle lobe with a moderate partially loculated left pleural effusion. A bronchoscopy with bronchoalveolar lavage (BAL) was performed and cultures demonstrated Veillonella parvula, anaerobic gram negative bacilli, and M. fortuitum. Two months earlier, BAL cultures had demonstarted M. fortuitum, but treatment had been deferred at that time as recipient was asymptomatic. Now, with rapid improvement on cephalosporin therapy, treatment for M. fortuitum was again not pursued. The recipient was readmitted one month later with left knee pain, fever, and diarrhea, and was diagnosed with hemarthrosis and CMV colitis. Four weeks later the recipient experienced right knee pain and when joint aspiration demonstrated M. fortuitum he underwent two stage revision at which time intraoperative cultures again yielded M. fortuitum. Following this surgery the recipient then was found to have a chest wall abscess, which when incised also yielded M. fortuitum. Treatment with imipenem and ciprofloxacin for six weeks was initiated, with transition to oral ciprofloxacin for one year. Summary This case illustrates the potential for M. fortuitum pulmonary infections to result in disseminated disease in lung transplant recipients. While rarely reported in the literature, non-tuberculous mycobacterium infections have been associated with bronchiolitis obliterans syndrome and mortality in lung transplant recipients. Dissemination of M. fortuitum is uncommon and prompt recognition is crucial for appropriate source control and antibiotic therapy initiation.

Topical ciprofloxacin as treatment for rhinoscleroma in a series of 23 patients.

There is no current consensus on treatment of rhinoscleroma, with no treatment shown to achieve reliable long-term cure of the disease. Oral ciprofloxacin for three months is currently one of the most favored options for treatment of rhinoscleroma. In a series of 23 patients, Topical ciprofloxacin was investigated as a novel option for treatment of rhinoscleroma and was found to be effective in treating the disease in all patients after 12-24 weeks. However, 5 cases of recurrence were encountered between 12-18 months after end of treatment. Topical treatment with ciprofloxacin in cases of rhinoscleroma limited to the nose may be preferable to systemic treatment, with similar efficacy and lower risk of side effects.

Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography-guided prostate biopsy.

To evaluate the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections following transrectal ultrasonography-guided prostate biopsy. In this prospective interventional study, patients aged between 40 and 70years with clinical indications for transrectal ultrasonography-guided prostate biopsy were enrolled. Consecutive patients who received intraprostatic injection of amikacin coupled with oral ciprofloxacin were compared with historical controls receiving only prophylactic oral fluoroquinolones prior to biopsy. Patients were followed for 7days after biopsy for signs and symptoms of infection. A total of 210 patients were included in this study (mean age 65.7±7.8years). Among patients without intraprostatic injection, nine (8.6%) developed infectious complications (lower urinary tract infection in seven patients, and prostatitis in two), which led to hospitalization in six patients (5.7%). None of the patients who received intraprostatic antibiotic injection developed infectious complications. The difference in the incidence of post-transrectal ultrasonography-guided biopsy infections between the two groups was statistically significant (P=0.003). Local intraprostatic antibiotic injection during transrectal ultrasonography-guided prostate biopsy adjuvant to oral fluoroquinolones can significantly reduce the rate of post-biopsy infectious complications.

Systemic antibiotics for chronic suppurative otitis media.

Systemic antibiotics for chronic suppurative otitis media.

Активность тобрамицина в отношении штаммов Pseudomonas aeruginosa, выделенных у пациентов с муковисцидозом

Study Objective: To determine in vitro activity of Tobramycin for Pseudomonas aeruginosa spp. isolated in children with cystic fibrosis (CF); to retrospectively study the efficiency dynamics of inhalative Tobramycin in management of bronchopulmonary process exacerbation in children with CF aged 9 years old (2009–2018). Study Design: retrospective analysis. Materials and Methods. The study included 173 children with cystic fibrosis aged 3 to 17 years old; the median age in the general group was 11 [8; 15] years. Subjects were divided into two comparison groups, depending on various 14-day combined antipseudomonal therapy: 42 children were treated with Cefepime 150 mg/kg + Amikacin 20 mg/kg IV drop infusion; 48 subjects — with Meropenem 100 mg/kg + Amikacin 20 mg/kg IV drop infusion; 83 patients — with Ceftazidime 200 mg/kg IV + Tobramycin (Bramitob) 300 mg twice daily, inhalation + Ciprofloxacin per os 30–40 mg/kg. Study Results. After the two-week therapy of 83 children with Tobramycin inhalations plus oral Ciprofloxacin and Ceftazidime IV, 123 (82%) out of 150 pathogenic P. aeruginosa and Staphylococcus aureus spp. were eliminated (p &lt; 0.001 when compared to bacteriologic test results of pre-therapy bronchial mucus). Comparison groups demonstrated statistically significantly lower number of such subjects: in Cefepime + Amikacin group, 32 (43.8%) out of 73 pathogenic P. aeruginosa and S. aureus spp. were eliminated; whereas in Meropenem + Amikacin group, only 28 (35.4%) pathogens were eliminated out of 79 species. Upon admission in 2013, 50 followed up children underwent antimicrobial therapy with inhalative Tobramycin using the same regimen as in 2009; the P. aeruginosa elimination was the same: 11 (18%) out of 61 pathogenic species remained viable, 50 (82%) species were eliminated, as demonstrated by control sputum. The difference between the number of P. aeruginosa and S. aureus colonies before and after therapy was statistically significant (p &lt; 0.001). Practically the same result after the use of inhalative Tobramycin was observed in 2018: 14 (70%) out 20 children with P. aeruginosa spp. had their control sputum samples sanitised (p &lt; 0.001). Conclusion. Despite a 20-year history of using in patients with cystic fibrosis, inhalative Tobramycin is still clinically efficient and potent for isolated P. aeruginosa as a component of primary eradication and management of chronic Pseudomonal lung infections. Keywords: cystic fibrosis, Pseudomonas aeruginosa, inhalative Tobramycin.

1232. Efficacy and Safety of Intravenous Sulopenem Followed by Oral Sulopenem etzadroxil/Probenecid Versus Intravenous Ertapenem Followed by Oral Ciprofloxacin or Amoxicillin-clavulanate in the Treatment of Complicated Urinary Tract Infections (cUTI): Results from the SURE-2 Trial

BackgroundSulopenem is a broad-spectrum IV and oral penem antibiotic being developed for the treatment of infections caused by multidrug-resistant bacteria to allow for earlier discharge of hospitalized patients.Methods1,395 hospitalized adults with pyuria, bacteriuria, and clinical signs and symptoms of cUTI were randomized to sulopenem IV once daily for 5 days followed by a bilayer tablet of sulopenem-etzadroxil and probenecid bid or ertapenem IV once daily for 5 days followed by either oral ciprofloxacin or amoxicillin-clavulanate bid, depending on susceptibility of the baseline uropathogen. The primary endpoint was overall (clinical and microbiologic) response at Day 21 [Test of Cure (TOC)] in the micro-MITT population.ResultsThe sulopenem and ertapenem treatment arms were well-balanced at baseline.The difference in overall response was driven by a difference in asymptomatic bacteriuria occurring between the end of treatment (EOT) and TOC in the subgroup of patients with a ciprofloxacin susceptible uropathogen at baseline who received ertapenem IV followed by oral ciprofloxacin. No difference in overall response was identified at EOT [86.7% vs 88.9%, sulopenem and ertapenem, respectively; difference, 95% CI: -2.2% (-6.5, 2.2)].19% of patients remained on ertapenem IV as the baseline pathogen was both resistant to quinolones and ESBL positive; overall response for patients with these resistant pathogens on IV sulopenem who stepped down to oral sulopenem was higher [64/80 vs 55/84 on sulopenem IV/oral and ertapenem IV, respectively; difference, 95% CI: 14.5% (0.8, 27.8)].Treatment emergent adverse events (all, 14.8% vs 16.1%; related, 6.0% vs 9.2%) and serious adverse events (2.0% vs 0.9%) were similar for patients on sulopenem and ertapenem, respectively.Overall Response at Test of Cure, micro-MITT Population ConclusionSulopenem followed by oral sulopenem-etzadroxil probenecid was not non-inferior to ertapenem followed by oral step-down therapy for the treatment of cUTI driven by a lower rate of asymptomatic bacteriuria in patients receiving oral ciprofloxacin. Sulopenem, both IV and oral, was well-tolerated; its oral formulation allowed patients with baseline pathogens resistant to both quinolones and β-lactams an opportunity to successfully step down from IV therapy.DisclosuresMichael W. Dunne, MD, Iterum Therapeutics (Employee, Shareholder) Steven I. Aronin, MD, Iterum Therapeutics (Employee, Shareholder)

CLINICAL EFFECTIVENESS OF AZITHROMYCIN VERSUS CIPROFLOXACIN IN THE TREATMENT OF UNCOMPLICATED ENTERIC FEVER IN CHILDREN;

ABSTRACT&#x0D; Objective: To compare the clinical effectiveness of oral azithromycin with oral ciprofloxacin in the treatment of uncomplicated enteric fever in children.&#x0D; Material and Methods: A randomized controlled trial was carried out in the Pediatric department of Khyber Teaching Hospital for which a sample size of 282 patients was determined using WHO calculator with 5% level of significance and 80% power of test (Two sided). Non-probability consecutive sampling technique was used for selection of children age 6 to 18 years and either gender. They were divided into two groups (141 in each) where Group A was treated with oral azithromycin while Group B with ciprofloxacin for 7 days. Clinical effectiveness was determined when the patient remained afebrile for more than 48 hours without antipyretics.&#x0D; Results: In group A, 128 children (90.78%) while in Group B, 105 (74.46%) children become clinically cure.&#x0D; Conclusion: Oral Azithromycin is more effective than oral Ciprofloxacin in the treatment of typhoid fever in children.

LB-1. Efficacy and Safety of Oral Sulopenem Etzadroxil/Probenecid Versus Oral Ciprofloxacin in the Treatment of Uncomplicated Urinary Tract Infections (uUTI) in Adult Women: Results from the SURE-1 Trial

BackgroundSulopenem is a broad-spectrum IV and oral penem antibiotic being developed for the treatment of infections caused by multidrug-resistant bacteria.Overall and Clinical Success in Patients with an Uncomplicated UTI at Test of Cure (TOC) and End of Treatment (EOT) Methods1,671 adult women with pyuria, bacteriuria, and signs and symptoms of uUTI were randomized to sulopenem etzadroxil/probenecid bid for 5 days or ciprofloxacin bid for 3 days. Two independent primary analyses, each with a separate alpha assigned, were incorporated into the design of the study with the primary endpoint being overall success (combined clinical and microbiologic success) at the Test of Cure (TOC) visit. In the micro-MITTR population (patients with baseline pathogen resistant to ciprofloxacin), sulopenem was compared for superiority over ciprofloxacin; in the micro-MITTS population (patients with baseline pathogen susceptible to ciprofloxacin), the two agents were compared for non-inferiority. Using a pre-specified hierarchical testing procedure (Westfall 2001), the primary efficacy endpoint was then to be further tested if either superiority or non-inferiority was declared in the MITTR or MITTS populations, respectively.ResultsIn the micro-MITTR population, sulopenem demonstrated superiority to ciprofloxacin (p < 0.001). In the micro-MITTS population, sulopenem was not non-inferior to ciprofloxacin for the primary endpoint, driven primarily by the higher rate of asymptomatic bacteriuria post treatment in patients on sulopenem. In the combined analysis of all randomized patients with an organism identified at baseline (MITTR+MITTS), sulopenem was non-inferior to ciprofloxacin.Treatment emergent adverse events occurred more frequently in sulopenem patients (all, 24.8% vs 13.9%; related, 17.0% vs 6.2%), accounted for by a higher incidence of self-limited diarrhea (12.4% vs 2.5%). Serious adverse events were similar on each regimen.ConclusionSulopenem was superior to ciprofloxacin for the treatment of adult women with uUTI due to quinolone non-susceptible pathogens. Sulopenem was not non-inferior in the treatment of quinolone susceptible pathogens, driven by a lower rate of asymptomatic bacteriuria in patients receiving ciprofloxacin, but was non-inferior in the combined population of patients.Disclosures Michael W. Dunne, MD, Iterum Therapeutics (Employee, Shareholder) Anita F. Das, PhD, Iterum Therapeutics (Consultant) Michael Zelasky, BS, Iterum Therapeutics (Employee) Karthik Akinapelli, BS, Iterum Therapeutics (Employee) Steven I. Aronin, MD, Iterum Therapeutics (Employee)

Poor prognostic factors in post-traumatic endophthalmitis following open globe injury.

To demonstrate prognostic factors for poor visual outcome in patients with post-traumatic endophthalmitis (PTE) following open globe injury. A retrospective study was conducted on 66 patients (66 eyes) with PTE following open globe injury from 2005 to 2015. Potential factors accounting for good and poor visual outcome were statistically analyzed by Chi-square test and Logistic regression model. In 66 cases, 39 cases (59%) had a poor visual outcome. Univariate and multivariate Logistic regression analysis identified retained intraocular foreign body (IOFB) as the only factor significantly associated with poor visual outcome [adjusted odds ratio, 4.62; 95% confidence interval (1.04-20.53); P=0.04]. The most common causative agents were gram-positive organisms (83%), of which Bacillus cereus (33%), was the most common pathogen. All cases received intravitreal antibiotic injections. Oral ciprofloxacin was the most used systemic antibiotic (33%). Pars plana vitrectomy was performed in 83% (55/66) of cases. At 6mo follow-up, mean BCVA was 1.74±0.72 logMAR units. In patients with PTE following open globe injury, the only predictor of poor visual outcome is the presence of IOFB. Bacillus cereus is the most isolated microorganism.

The overly attached bacteria

Background: Chromobacterium violaceum is a Gram negative bacillus which is a common inhabitant of soil and water in tropical and subtropical regions. Infections involving humans are rare; only about 150 cases were reported worldwide up till 2004. Interestingly, the first case of human infection was reported in Malaysia back in 1927. Case Description: A 65 y old gentleman was electively admitted for (CABG) surgery. Post procedure, he developed temperature spikes and blood culture grew Chromobacterium violaceum. Subsequently, serial blood cultures persistently yielded the same organism despite being on various antibiotics. Transthoracic Echocardiography, Ultrasound Abdomen as well as CT Thorax, Abdomen and Pelvis to look for possible foci of infection or disseminated abscesses yielded negative results. Eventually patient was able to achieve bacteremic clearance after 1 m from the 1st positive blood culture. This was achieved after total 25 d of IV Ceftazidime, 48 d of IV Ciprofloxacin and Oral Bactrim for 61 d. Patient was discharged with further doses of Oral Bactrim and Oral Ciprofloxacin completing total 3 m. He was reviewed in clinic post discharge and remained well. Discussion: Chromobacterium violaceum are usually found in soil or water. Therefore, the reason our patient was able to acquire infection was unknown since he was already admitted for almost 1 m prior to first positive blood culture. Previous studies reported common predisposing factors were immunocompromised state, chronic granulomatous disease, steroid therapy, and diabetes among others, in which the patient did not fulfil. Another issue was with regards to antimicrobial agent of choice as well as duration of treatement. Considering that Chromobacterium infections are rare, there are very limited data and evidence on treatment regimes. There is no definite breakpoint for antibiotic susceptibility interpretation for Chromobacterium violaceum according to 2018 Clinical and Laboratory Standards Institute (CLSI) guidelines. The sensitivity results provided are based on non-lactose fermenter Gram negative bacillus breakpoints. Furthermore, the sensitivity testing was done in vitro; which does not directly translate to in vivo activity and response. Conclusion: Infections with Chromobacterium violaceum has been increasingly reported worldwide. Further studies and research into this organsism are required to improve patient management in the coming future.

Pseudomonas aeruginosa Implant-Associated Bone and Joint Infections: Experience in a Regional Reference Center in France.

Background: P. aeruginosa implant-associated bone and joint infections (BJI) is considered to be one of the most difficult to treat BJI. The data focusing specifically on this pathogen are sparse, and it seems difficult to extrapolate the results obtained with Enterobacteriaceae.Methods: We performed a retrospective observation study of all P. aeruginosa implant-associated BJI diagnosed at our institution from 2011 to 2018. We defined failure as any type of relapse, including persistence of the same P. aeruginosa, superinfection by another organism(s) or any other cause of relapse such as the need for a subsequent surgery. Nonparametric statistical methods were used to compare the study groups and Kaplan-Meier curves and multivariate Cox analysis and were used to detect determinants associated with treatment failure.Results: A total of 90 patients (62% men, median age 60 years IQR 47–72) including 30 (33%) prosthetic-joint infections and 60 (66%) other implant-associated BJIs were studied. Most of them were acute (62%). During the prolonged follow-up, (median 20 months; IQR 9–37), 23 patients (26%) experienced treatment failure. Optimal surgical treatment (DAIR for acute forms, explantation, 1-stage or 2-stage exchange for others) was significantly associated with a higher success rate in the univariate analysis (p = 0.003). Sixty-four (71%) patients received effective initial treatment against P. aeruginosa administered and 81 of them (90%) did for at least 3 weeks: both these parameters correlated with a higher success rate. In the multivariate Cox-analysis optimal surgical treatment, IV effective treatment of at least 3 weeks and treatment with ciprofloxacin for at least 3 months proved to be independently associated to a better outcome in patients with P. aeruginosa implant-associated BJI.Conclusion: P. aeruginosa implant-associated BJI is one of the most difficult-to-treat BJI, with a strong impact on the prognosis of the surgical strategy. An effective initial IV antibiotic treatment for at least 3 weeks seems to be required, followed by oral ciprofloxacin for a total duration of 3 months.

Recurrent Achilles tendinitis after ophthalmic ofloxacin use

A 67-year-old woman developed recurrent fluoroquinolone-induced Achilles tendinitis after using topical ofloxacin for delayed sequential bilateral cataract surgeries, 2 weeks apart. Within days of the first surgery, she noted onset of left foot pain. Clinical examination and magnetic resonance imaging ultimately confirmed recurrence of left Achilles tendinitis. Her first episode of Achilles tendinitis occurred 13 years prior, after oral ciprofloxacin use for acute appendicitis. To our knowledge, this is the second report of topical ophthalmic-induced fluoroquinolone tendinopathy.

S1820 Diverticulitis in the Time of COVID-19: Acute Diverticulitis Complicated by Colo-Colonic Fistula

INTRODUCTION: Colo-colonic fistula is a rare complication of diverticulitis. We present a case of acute diverticulitis with delayed presentation due to COVID 19, complicated by diverticular abscess and colo-colonic fistula in the setting of delayed treatment with oral antibiotics. CASE DESCRIPTION/METHODS: An 82 year old male presented with a 3 week history of diffuse abdominal pain, fever, nausea, anorexia and 12 lbs weight loss. He reported narrow stools without hematochezia. There were no other symptoms or prior episodes. Diverticulosis was present on his colonoscopy 5 years earlier. On examination his abdomen was mildly tender throughout without guarding or rebound. Stool was guaiac negative. Lab work revealed WBC of 19 K/uL, and a microcytic anemia with Hb 10.6 g/dL. Computed tomography (CT) revealed sigmoid diverticulitis with extraluminal air loculations and a 3 cm pericolonic abscess. Because of the Coronavirus pandemic, the patient requested outpatient therapy and was started on oral Ciprofloxacin and Metronidazole. He was followed weekly via telehealth with improvement in symptoms except for mild intermittent abdominal pain. Follow up CT revealed fistulization of the previously noted abscess to distal sigmoid colon, producing an inverted U-shaped fistulous tract from proximal to distal sigmoid. Labs revealed resolving leukocytosis and stable anemia. He completed 4 weeks of oral antibiotics and declined surgery. DISCUSSION: The Coronavirus pandemic has overt direct health consequences, as well as secondary and tertiary consequences. Our patient presented, after a 3 week interval without treatment, with localized sepsis and a 3 cm abscess. This would normally be treated with parenteral antibiotics and possibly percutaneous drainage or surgical intervention. Due to concerns regarding Coronavirus exposure in the hospital, he opted for treatment with oral antibiotics alone after a delayed presentation. Consequently, the abscess decompressed into a distal segment of sigmoid colon, producing a colo-colonic fistula. Colo-colonic fistulae are a rare complication of diverticulitis compared to colo-vesical, colo-vaginal, colo-enteric and colo-cutaneous types. Literature on colo-colonic fistulae is sparse in the past 50 years, perhaps because antibiotic therapy is often begun at the onset of symptoms. This case demonstrates an uncommon complication of a common condition which may not have occurred if not for the Coronavirus pandemic.Figure 1.: Sagittal CT showing U shaped fistula of sigmoid colon.

A Randomized Controlled Trial of Novel Treatment for Hemorrhagic Radiation Proctitis.

Background:Various methods have been used for treatment of hemorrhagic radiation proctitis (HRP) with variable results. Currently, the preferred treatment is formalin application or endoscopic therapy with argon plasma coagulation. Recently, a novel therapy with colonic water irrigation and oral antibiotics showed promising results and more effective compared to 4% formalin application for HRP. The study objective is to compare the effect of water irrigation and oral antibiotics versus 4% formalin application in improving per rectal bleeding due to HRP and related symptoms such as diarrhoea, tenesmus, stool frequency, stool urgency and endoscopic findings. Methods:We conducted a study on 34 patients with HRP and randomly assigned the patients to two treatment arm groups (n=17). The formalin group underwent 4% formalin dab and another session 4 weeks later. The irrigation group self-administered daily rectal irrigation at home for 8 weeks and consumed oral metronidazole and ciprofloxacin during the first one week. We measured the patients’ symptoms and endoscopic findings before and after total of 8 weeks of treatment in both groups. Results:Our study showed that HRP patients had reduced per rectal bleeding (p = 0.003) in formalin group, whereas irrigation group showed reduced diarrhoea (p=0.018) and tenesmus (p=0.024) symptoms. The comparison between the two treatment arms showed that irrigation technique was better than formalin technique for tenesmus (p=0.043) symptom only. Conclusion:This novel treatment showed benefit in treating HRP. It could be a new treatment option which is safe and conveniently self-administered at home or used as a combination with other therapies to improve the treatment outcome for HRP.

S1402 An Unusual Cause of Biliary Stricture: Surgical Clip Migration After Orthotopic Liver Transplantation

INTRODUCTION: Surgical clip migration into the biliary tree is a well-known phenomenon after cholecystectomy but is rarely reported after other procedures. We report an unusual complication after orthotopic liver transplantation (OLT) in which a biliary stricture was caused by surgical clip migration into the bile duct. This was determined after cholangioscopic examination was required to examine an anastomotic stricture that could not be traversed with traditional wire and catheter techniques. CASE DESCRIPTION/METHODS: Our patient is a 29-year-old man with an initial OLT for decompensated primary sclerosing cholangitis complicated by antibody-mediated rejection who received another OLT seven months later. Fifteen months after his second transplant, his liver markers were elevated in a cholestatic pattern: ALT 99 (normal 0-50 U/L), AST 71 (0-50 U/L), alkaline phosphatase 553 (40-130 U/L), and a total bilirubin peaking at 2.2 mg/dL (0.3-1 mg/dL). Ultrasound revealed patent hepatic vasculature and a new finding of echogenic foci throughout the right hepatic lobe concerning for pneumobilia versus surgical material. He started oral ciprofloxacin and metronidazole for possible cholangitis and underwent ERCP. During the procedure, cholangiogram demonstrated a narrowing at his CBD anastomosis (Figure 1). Multiple attempts were made to traverse the stricture without success. Spyglass cholangioscopy identified a surgical clip within the stricture lumen with sludge and stone debris seen through the narrow lumen of stricture at the proximal end of the stricture (Figure 2). Repeat wire cannulation under cholangioscopy was unsuccessful and the procedure was stopped given concern that further attempts could risk complications. His labs trended down after instrumentation and he did not require percutaneous transhepatic drainage. We are planning for repeat ERCP pending his clinical course. DISCUSSION: Surgical clip migration into the biliary tree is rarely documented after OLT. Our literature review yielded one case report by Alsulaiman et al in 20061. However, as cholangioscopy is used more often for assessing complex, difficult-to-traverse anastomotic strictures in OLT patients, this may become a more commonly reported phenomenon. Alsulaiman, R., Barkun, J., & Barkun, A. (2006). Surgical clip migration into the common bile duct after orthotopic liver transplantation. Gastrointestinal Endoscopy, 64(5), 833-834.Figure 1.: Marked stricture at biliary anastomosis with only a small amount of contrast partly opacifying the duct proximal to the stricture. Multiple clips are seen at the anastomosis.Figure 2.: A clip is seen within the narrow caliber lumen of the recipient–donor biliary anastomosis. Guidewire seen attempting to traverse the stricture behind the clip.

Intravenous versus oral antibiotics for eradication of Pseudomonas aeruginosa in cystic fibrosis (TORPEDO-CF): a randomised controlled trial

SummaryBackgroundChronic pulmonary infection with Pseudomonas aeruginosa is one of the most important causes of mortality and morbidity in cystic fibrosis. If antibiotics are commenced promptly, infection can be eradicated. The aim of the trial was to compare the effectiveness and safety of intravenous ceftazidime and tobramycin versus oral ciprofloxacin in the eradication of P aeruginosa.MethodsWe did a multicentre, parallel group, open-label, randomised controlled trial in 72 cystic fibrosis centres (70 in the UK and two in Italy). Eligible participants were older than 28 days with an isolate of P aeruginosa (either the first ever isolate or a new isolate after at least 1 year free of infection). Participants were excluded if the P aeruginosa was resistant to, or they had a contraindication to, one or more of the trial antibiotics; if they were already receiving P aeruginosa suppressive therapy; if they had received any P aeruginosa eradication therapy within the previous 9 months; or if they were pregnant or breastfeeding. We used web-based randomisation to assign patients to 14 days intravenous ceftazidime and tobramycin or 12 weeks oral ciprofloxacin. Both were combined with 12 weeks inhaled colistimethate sodium. Randomisation lists were generated by a statistician, who had no involvement in the trial, using a computer-generated list. Randomisation was stratified by centre and because of the nature of the interventions, blinding was not possible. Our primary outcome was eradication of P aeruginosa at 3 months and remaining free of infection to 15 months. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who received at least one dose of study drug. TORPEDO-CF was registered on the ISRCTN register, ISRCTN02734162, and EudraCT, 2009-012575-10.FindingsBetween Oct 5, 2010, and Jan 27, 2017, 286 patients were randomly assigned to treatment: 137 to intravenous antibiotics and 149 to oral antibiotics. 55 (44%) of 125 participants in the intravenous group and 68 (52%) of 130 participants in the oral group achieved the primary outcome. Participants randomly assigned to the intravenous group were less likely to achieve the primary outcome, although the difference between groups was not statistically significant (relative risk 0·84, 95% CI 0·65–1·09; p=0·18). 11 serious adverse events occurred in ten (8%) of 126 participants in the intravenous antibiotics group and 17 serious adverse events in 12 (8%) of 146 participants in the oral antibiotics group.InterpretationCompared with oral therapy, intravenous antibiotics did not achieve sustained eradication of P aeruginosa in a greater proportion of patients with cystic fibrosis and was more expensive. Although there were fewer hospitalisations in the intravenous group than the oral group during follow-up, this confers no advantage over oral treatment because intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P aeruginosa in cystic fibrosis.FundingNational Institute for Health Research Health Technology Assessment Programme.