Outpatient Antibiotic Therapy Research Articles

The Evolving Epidemiology of Infective Endocarditis: An Observational Study from Western India

Background: Over the last few decades, the epidemiology and the management of infective endocarditis (IE) is undergoing significant evolution and advancements respectively. Many studies from the developed world and some from India have brought this to light. Objective: To study demography, risk factors, microbiological spectrum, clinical profile, management, and outcome of IE in a tertiary care setup in western India. Materials and Methods: This is a retrospective observational study of 90 patients diagnosed with definite as well as possible IE and admitted to the intensive care units (ICU) and wards in our institute from April 2015 to May 2022. Demographics, signs and symptoms, laboratory results, echocardiography, radiological findings, treatment, and outcomes were studied. Results: 73 (81.1%) were definite and 17 (18.9%) were possible cases of IE. 93.3% cases were community-acquired, 6.7% were hospital acquired. Mean age of the patients was 43.3 + or - 18.8 years. Male: female ratio was 4.3:1. 62.2% had an underlying cardiac illness, with congenital heart disease (CHD) being the most common (18.9%) followed by rheumatic heart disease (RHD) (16.5%). Fever, weight loss, dyspnea, and cough were the common presenting symptoms. 69 (76.7 %) patients had native valve IE, 13 (14.4%) had prosthetic valve IE, 6 (6.7%) had vegetations on the endothelium without involvement of the valves, 2 (2.2%) patients had vegetations on the prosthetic material used for repair of congenital heart defects. About 48% of patients had a history of prior receipt of antibiotics. Blood cultures were positive in 48 (53.3%) patients. Most common valve infected was the mitral valve (MV) and the most common organisms isolated were the viridans group of streptococci (VGS), with penicillin (Pn) MIC <0.5 mcg/ml of all but one isolate. Transesophageal echocardiography (TEE), done in 17 patients, improved the pick-up of abnormal echo findings from 83.3% to 91.1%. Ceftriaxone was the most common antibiotic used. Surgery was done in 22 (24.4%) patients. 67 (74.4%) patients were cured, 14 (15.6%) patients died and 9 (10%) patients were lost to follow-up. Conclusion: The increasing age of patients, absence of any underlying cardiac ailment, the importance of TEE in patients with high suspicion of IE, and the trend towards early surgery were the important aspects highlighted with respect to the changes happening in the field of IE. Almost all the strains of VGS, the most common isolated organisms, retained their sensitivity to Pn and ceftriaxone, making the treatment possible with once-a-day dosing of ceftriaxone monotherapy, highlighting the utilization of outpatient antibiotic therapy (OPAT).

Successful conservative management of advanced pyogenic sternoclavicular joint arthritis with osteomyelitis and pulmonary infiltration: a case report

BackgroundSternoclavicular joint arthritis is a rare condition that poses considerable diagnostic and therapeutic challenges, leading to severe complications and a high mortality rate. Although surgical interventions are often considered necessary for advanced cases, some reports have suggested that conservative management with antibiotic therapy can be effective in certain cases. However, to our knowledge, there are no reports of successful conservative treatment in cases exhibiting aggressive spread. This report highlights a case of advanced sternoclavicular joint arthritis with bone destruction and pulmonary infiltration, successfully treated conservatively with outpatient antibiotic therapy.Case presentationA 58-year-old Japanese male presented with a 1-month history of left-sided shoulder pain. Contrast-enhanced computed tomography showed abscess formation and clavicular bone destruction, with infiltrative shadows suggesting lung involvement. The diagnosis of sternoclavicular joint arthritis was made, and outpatient oral antibiotic therapy was initiated. The patient exhibited a marked reduction in inflammatory marker levels and symptoms, and antibiotic therapy was discontinued after 3 weeks, with no recurrence observed at a 4-month follow-up.ConclusionsThis case highlights that conservative management with antibiotics can be effective for treating advanced sternoclavicular joint arthritis, emphasizing the need for individualized management and further research into non-surgical treatment options.

Are Nurses Aware of Their Contribution to the Antibiotic Stewardship Programme? A Mixed-Method Study from Qatar.

The antibiotic stewardship programme (ASP) is a new concept initiated by WHO, but nurses are not yet ready to adopt the program. The training and empowerment of nurses are the best strategies for enhancing their knowledge and engagement in ASP. This mixed-method study was used to assess perceived roles and barriers of nurses' involvement in ASP. An online survey was conducted among 420 clinical nurses to identify their role, and 23 individual interviews were performed among nurses and infection control practitioners to explore the barriers and recommendations to overcome the identified barriers. The majority of the nurses agreed with the sixteen identified roles in ASP, of which 'antibiotic dosing and de-escalation' (82.61%), 'IV to PO conversion of antibiotic, outpatient antibiotic therapy' (85.23%), and 'outpatient management, long-term care, readmission' of the patients (81.19%) had the lowest agreement from the participants. The major themes generated through the qualitative interviews were a lack of knowledge about ASP, poor communication between multidisciplinary teams, lack of opportunity and multidisciplinary engagement, lack of formal education and training about ASP, lack of ASP competency and defined roles in policy, role conflict or power/position, availability of resources, and lack of protected time. Nurses play an integral role in the successful implementation of antibiotic stewardship programs. The empowerment of nurses will help them to adopt the unique role in ASP. Nurses can significantly contribute to antibiotic stewardship efforts and improve patient outcomes through addressing these challenges.

1152 Soft Tissue Infections of the Hand – Reducing Inpatient Cost and Duration of Stay in a London Plastic Surgery Department

Abstract Introduction Soft tissue infections of the upper limb referred to plastic surgery units often require hospital admission for intravenous antibiotics, irrespective of surgical intervention. Aim We explored approaches to reducing the cost and duration of inpatient admission for antibiotic treatment for soft tissue infections. Method We sampled data over a two-month period in 2023 to explore the number, type, and severity of soft tissue infections of the upper limb seen in London Plastic Surgery department. Results 35 patients with soft tissue infections of the upper limb were included. We found no correlation between age; white cell counts or c-reactive protein levels on day of presentation with duration of inpatient stay. Our studies showed that 78% of patients were discharged within 72 hours of admission or procedure, with a greater number of inpatient bed-days for patients receiving intravenous antibiotics without surgery, compared to patients receiving antibiotics and discharge within 3 days of receiving surgical intervention (36 days vs 25 days). 84% of patients were not located within post-codes accessible to existing outpatient antibiotic therapy (OPAT) services. By extending outpatient antibiotic cover for these patients, we projected a total 568 bed-day saving through 202 bed days annual avoidable inpatient bed-stay savings (3+ days, non-OPAT post-codes) and 366 bed days for additional annual avoidable short inpatient bed-stay savings (≤3 days admission, all post-codes), with projected annual cost savings of £319,558. Conclusions Our study projects a possible reduction in inpatient cost and duration of stay through extended OPAT cover in patients requiring intravenous antibiotics for soft-tissue infections of the upper limb.

Increasing incidence of mastoidectomies in children : Result of reduced antibiotic therapy or late COVID-19 sequela?

An increasing number of pediatric patients with mastoiditis and aconsequent increase in mastoidectomy rates was noted in 2022 and 2023. This study aimed to analyze the increase in the number of children presenting with mastoiditis and subsequent mastoidectomy, to assess correlations with prior antibiotic treatment or COVID-19 infection, and to provide an overview of involved pathogens, treatment, and disease course. Aretrospective analysis of all patients with mastoidectomy since 2012 was conducted. Data collected comprised type and duration symptoms, prior antibiotic therapy, diagnostic tests and disease course, causal pathogens, length of hospitalization, and complications. Ahighly significant increase in mastoidectomies in children could be demonstrated from 2022. Neither the pathogens involved nor the course of disease or complications showed differences. An increase in the number of patients with prior outpatient antibiotic therapy could be shown. About ahalf of the patients becoming ill after fall 2022 had apositive history of COVID. Hyperplasia of adenoid tissue was afar less frequent causal mechanism than in the years before COVID. No clear correlation with reduced outpatient antibiotic therapy could be found. Whether there exists an association with prior COVID infection cannot be judged at this time, due to the high number of asymptomatic and therefore unknown COVID infections.

Risk factors for severe community-acquired pneumonia in infants and preschool children

Introduction. The relevance of studying community-acquired pneumonia in children is associated with its high prevalence, despite timely prevention and effective approaches to the treatment of respiratory diseases. Factors influencing the severity of pneumonia are diverse and include comorbid pathology, early age of the child, the state of the immune system, etc.Objective. To identify and rank risk factors for severe community-acquired pneumonia in infants and preschool children.Materials and methods. This article presents the results of a retrospective analysis of 291 medical histories of children from 3 months to 7 years with community-acquired pneumonia. 83 children had severe CAP, of which 63 patients were hospitalized in the ICU.Results and discussion. The average age of a patient with community-acquired pneumonia was 33 months. Children from families with two or more children fell ill more often. On average, children were hospitalized for 4–5 days of illness. Concomitant diseases in children with CAP were quite common and often complicated the course of pneumonia. According to the results of our study, more than 70% of children were not vaccinated against pneumococcus, Haemophilus influenzae and influenza. We established significant linear relationships between the presence of bronchial obstruction and complications of CAP such as respiratory failure and transfer to the ICU (odds ratio (OR) 7.1; Cramer coefficient 0.40; relationship 0.005). It was shown that patients who received outpatient antibiotic therapy were less likely to require transfer to the ICU.Conclusion. Risk factors for severe community-acquired pneumonia and hospitalization in the ICU were: male gender, age under 2 years, lack of vaccination against pneumococcus, Haemophilus influenzae and influenza, combination of bronchial obstruction with CAP, presence of ENT pathology, lack of antibacterial therapy during prehospital stage, as well as the presence of a serious condition already upon admission.

Dosing and Exposure of Vancomycin With Continuous Infusion: A Retrospective Study.

Vancomycin continuous infusion (CI) has suggested benefits over intermittent infusion: reduced nephrotoxicity, higher target attainment, and simpler therapeutic drug monitoring (TDM). Empiric dosing regimens range from 30-60 mg/kg/day and it is unclear which regimen results in optimal exposure. This study evaluates whether a dosing regimen of 45 mg/kg/day after a 20 mg/kg loading dose for patients with estimated glomerular filtration rate (eGFR) ≥ 50 mL/min results in adequate exposure. We retrospectively analyzed plasma concentrations from patients treated with vancomycin CI as routine clinical care between February and October 2021. Patients under 18 years old, with renal replacement therapy, reduced creatinine clearance (Chronic Kidney Disease Epidemiology Collaboration < 50 mL min/1.73 m2) or outpatient antibiotic therapy were excluded. Dose, renal function, and blood draw procedures were assessed for each measured vancomycin sample. Initially, 121 samples were included. Subsequently, 7 samples, 6 of which with concentrations ≥ 40 mg/L, were verified to be incorrectly drawn and excluded. With doses of 40-50 mg/kg/day concentrations ranged from 18.4-61.0 mg/L. Only 25% were within the target window of 17-25 mg/L and 15% were ≥ 40 mg/L. Supratherapeutic concentrations were observed in 89% of samples from patients dosed 40-60 mg/kg/day with eGFR 50-80 mL/min. Concluding, an empiric dosing regimen of 45 mg/kg results in too high vancomycin exposure and thus we recommend lower doses and differentiation according to renal function. Additionally, when measuring concentrations over 40 mg/L incorrect sampling must be excluded before dose adjustment and the large variability in exposure between patients, warrants the need for swift TDM.

Trueperella pyogenes endocarditis in a Swiss farmer: a case report and review of the literature

BackgroundTrueperella pyogenes (T. pyogenes) is a bacterium that colonizes the skin and mucosal surfaces of various domestic and wild animals. It rarely leads to infections in humans, with only a few descriptions available in the literature.Case presentationA 71-year-old Swiss farmer with a history of recurring basal cell carcinoma and metastasized pancreatic neuroendocrine tumor presented with signs of sepsis after a three-day history of general weakness, malaise and fever. Clinical and echocardiographic findings, as well as persistent bacteremia were consistent with mitral valve endocarditis caused by T. pyogenes. The patient’s condition gradually improved under antibiotic treatment with piperacillin/tazobactam (empiric therapy of sepsis), and later penicillin G based on resistance testing. He was discharged after 13 days and continued outpatient antibiotic therapy with ceftriaxone, resulting in a total antibiotic treatment duration of six weeks. This is the first literature review of T. pyogenes endocarditis in humans. Among nine cases of T. pyogenes endocarditis, three patients had documented contact with farm animals and five had an underlying condition that compromised the immune system. While antibiotic resistance of T. pyogenes is an emerging concern, susceptibility to beta-lactam antibiotics seems to persist. The mortality of T. pyogenes endocarditis described in the literature was high, with 66% of patients not surviving the disease.ConclusionsT. pyogenes is a rare causative organism of infectious endocarditis in humans and descriptions are mainly restricted to case reports. In our review of the literature, we found that both an impaired immune system and contact with farm animals might be risk factors. Growth of T. pyogenes in blood cultures is unlikely to be missed during routine analysis, as it shows marked beta-hemolysis on blood agar culture plates, which generally leads to further characterization of the bacteria. Susceptibility to penicillin, ceftriaxone, and macrolides seems to be retained and the reported mortality in the few patients with T. pyogenes endocarditis is high.

Pulmonary and central nervous system nocardiosis: Alcoholism as an immunocompromising factor

Nocardiosis is a disease with worldwide distribution. It is usually found in tropical areas and mainly affects immunocompromised patients, however, there are also cases where its infection has been reported in immunocompetent patients. This pathology is caused by bacteria known as Nocardia spp., which are gram-positive microorganisms and environmental saprophytes, and although exposure to Nocardia spp. is almost universal, only a small fraction of exposed people develops the disease. We present the case of a 47-year-old man, with no evidence of immunosuppression, from a rural area of Boyacá, who was admitted due to intense and intermittent headache accompanied by paresthesia and, finally, a decrease in consciousness. A brain magnetic resonance was performed and evidenced a fronto-temporo- occipital space-occupying lesion in the cortico-subcortical region with a compressive effect and displacement of the ventricular system cavities. It was suspected at first a neoplastic lesion or a brain abscess. The lesion was surgically resected, and its culture showed Nocardia africana/nova. In later studies a possible primary pulmonary focus was evidenced. Alcoholism was the only risk factor documented. The patient completed 6 weeks of hospital antibiotic treatment with favorable clinical and radiological evolution and was discharged with a 1-year plan of outpatient antibiotic therapy. Although Nocardia spp. mainly affects immunocompromised patients, evidence shows that this microorganism can also be a threat to individuals without traditional immunosuppression risk factors.

Antibiotic associated diarrhea in outpatient pediatric antibiotic therapy

BackgroundAntibiotic-associated diarrhea is one of the most frequent side effects of antimicrobial therapy. We assessed the epidemiological data of antibiotic-associated diarrhea in pediatric patients in our region.MethodsThe prospective multi-center study included pediatric patients who were initiated an oral antibiotic course in outpatient clinics and followed in a well-established surveillance system. This follow-up system constituded inclusion of patient by the primary physician, supply of family follow-up charts to the family, passing the demographics and clinical information of patient to the Primary Investigator Centre, and a close telephone follow-up of patients for a period of eight weeks by the Primary Investigator Centre.ResultsA result of 758 cases were recruited in the analysis which had a frequency of 10.4% antibiotic-associated diarrhea. Among the cases treated with amoxicillin-clavulanate 10.4%, and cephalosporins 14.4% presented with antibiotic-associated diarrhea. In the analysis of antibiotic-associated diarrhea occurrence according to different geographical regions of Turkey, antibiotic-associated diarrhea episodes differed significantly (p = 0.014), particularly higher in The Eastern Anatolia and Southeastern Anatolia. Though most commonly encountered with cephalosporin use, antibiotic-associated diarrhea is not a frequent side effect.ConclusionThis study on pediatric antibiotic-associated diarrhea displayed epidemiological data and the differences geographically in our region.

1753. Impact of a Pharmacist-Driven Home Hospital Antimicrobial Stewardship Program Pilot within a Large Community Health System

Abstract Background Home Hospital (HH) is a unique and rapidly expanding care model that allows patients to receive medical therapy and monitoring through telehealth communication and nursing visits, and there are currently no published studies evaluating antimicrobial stewardship interventions in the HH setting. The goal of this study is to evaluate the impact of a pharmacist-driven antimicrobial stewardship pilot for the HH program. Methods This was a pre-post quasi-experimental study of adult patients enrolled in HH program between January through March in 2021 (control cohort) and in 2022 (intervention cohort), who received antibiotics (oral/intravenous) during their HH admission. Patients on long-term prophylactic antimicrobials, antifungals, external antimicrobials, or mycobacterial treatment were excluded. The antimicrobial stewardship pharmacist performed prospective audit and feedback and provided recommendations to clinicians through the electronic medical record. The primary endpoint was antibiotic use (days of therapy per 1000 patient-days). Secondary endpoints included broad-spectrum antibiotic usage; appropriateness of antibiotic indication, dosing, and duration; compliance with the institution’s outpatient antibiotic reference guide or outpatient intravenous antibiotic therapy (OPAT) monitoring; treatment failure; antibiotic-associated adverse effects; and cost of antibiotic therapy. Results The study included 73 and 127 patients in the control and intervention group, respectively (Figure 1). On average, the pharmacist reviewed 8 eligible patients/day. Interventions were generally well received by HH providers (Figure 2). There was no significant difference in the primary outcome. More inappropriate antibiotic indication was identified in the intervention group (46 [36%] vs. 15 [19%], p=0.01), associated with post-surgical infection prophylaxis after orthopedic procedures (Figure 3). Other secondary outcomes did not vary significantly between the groups. Figure 1:Study inclusion flowchartFigure 2:Intervention breakdownFigure 3:Infection types Conclusion The pilot allows for better understanding of outpatient and HH antibiotic prescribing practices to provide targeted interventions, and suggests the need for additional antimicrobial stewardship involvement to optimize antibiotic therapy in this novel care setting. Disclosures Elizabeth B. Hirsch, PharmD, FCCP, FIDSA, Melinta: Advisor/Consultant|MeMed: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support.

Social Risk Screening Changes Medical Decision-Making in a Complex Outpatient Pediatric Antibiotic Therapy Program.

Complex outpatient antibiotic therapy (COpAT) programs facilitate the treatment of serious infections at home, shorten inpatient stays, and improve patient satisfaction when compared to inpatient care [1]. However, COpAT delivery can be complicated by antibiotic side effects and vascular access problems, the management of which can become particularly difficult when attempted in the context of high social risk in the home and community [2]. The use of standardized social risk screening for optimizing infectious disease (ID) discharge plans is largely unexplored. We tested the feasibility and implementation of a novel social risk screening tool for COpAT and described alterations in care plans generated based on social risk information. A COpAT social risk screening tool was created by adapting publicly available social determinants of health screening toolkits [3, 4] to focus on social risks previously identified as prevalent in our patient population and relevant to our COpAT delivery system [5, 6] (Figure 1). From March to October 2019, the COpAT physician assistant assessed social risks for 29 of 40 (73%) consecutively eligible parents/caregivers. Results of social risk screening and COpAT modifications were documented in the patient’s EMR as a progress note. To assess changes made as a result of screening, we retrospectively compared the original COpAT plan by the inpatient consulting ID team to the final COpAT plan. We tabulated changes in COpAT plans using six predefined, a priori categories of change: (1) antibiotic use; (2) caregiver education; (3) COpAT follow-up plans; (4) social work referral; (5) new inpatient consultation; and (6) hospital length of stay. The study was deemed quality improvement and IRB oversight was waived.

AN UNUSUAL COMPLICATION OF ACUTE APPENDICITIS

AN UNUSUAL COMPLICATION OF ACUTE APPENDICITIS

Drivers of Prolonged Outpatient Antibiotic Therapy for Urinary Tract Infections and Community-Acquired Pneumonia.

Variability exists in treatment duration for community-acquired pneumonia (CAP) and urinary tract infection (UTI) in children and may be associated with non-clinical factors. A retrospective study was conducted of patients treated for outpatient CAP and UTI in a children's hospital network from 2016 to 2019. Multivariable logistic regression was performed to identify predictors of long antibiotic duration (≥10 days). Hospitalization within 30 days was determined. Overall, 2124 prescriptions for CAP and 1116 prescriptions for UTI were included. Prescriptions were ≥10 days in 59.9% and 47.6% for CAP and UTI, respectively. Long durations were more common in the emergency department (ED) than in clinics for UTI's (P = .0082), and more common in convenient care for CAP (P = .045). In UTI's, Asian and Hispanic patients received shorter durations than white patients. Younger children had greater odds of long duration for both diagnoses. Medicaid insurance was associated with long therapy for UTI (OR: 1.660, P = .0042) and CAP (OR: 1.426, P = .0169). Residents and fellows were less likely to give long durations than attending physicians (P < .0001). APNs were more likely to administer long therapies in CAP (P = .0062). Subsequent hospitalizations were uncommon for UTI (n = 10) and CAP (n = 20). Younger age, Medicaid insurance, ED, and convenient care visits were associated with a long duration of therapy. Residents and fellows were less likely to give long durations.

The management of tubo-ovarian abscess - A retrospective analysis of a centre offering outpatient intravenous antibiotic therapy

Background Tubo-ovarian abscess (TOA) carries long-term sequale in women of reproductive age. Consensus of the optimal treatment of tubo-ovarian abscess remains lacking. The aims of this study are to identify risk factors predicting the need for early drainage and compare clinical outcomes of current management practices of TOA. Methods From 2015 to 2019, a retrospective cohort study of 92 women admitted to a tertiary centre for gynaecological surgery was performed. Patients with diagnosed TOA were classified into two groups: treatment with antibiotics only, and those receiving additional drainage. Primary outcomes included length of hospital stay (LoS), length of antibiotic treatment (LoA) and need for re-intervention. Results In this study, 52 women (56.5%) were successfully treated with first line intravenous antibiotics; 40 (43.5%) received surgical drainage. Significant predictors for successful medical treatment only include age &lt; 35 (OR: 0.89, 95% CI: 0.82-0.97) and abscess size &lt; 6cm (OR: 0.17, 95% CI: 0.04-0.64), using multivariate analysis. Pyrexia ≥ 38°C predicted a need for drainage (OR: 3.82, 95% CI: 1.01-8.12). Patients who received additional drainage had significantly longer LoA, LoS and higher rates of re-intervention. Within this group, drainage within 72 hours of admission resulted in a trend towards shorter LoA and LoS than drainage after 72 hours, albeit not statistically significant. Conclusions Parameters include age &gt; 35 years, pyrexia ≥ 38°C and a TOA size &gt; 6cm may independently predict the need for drainage of TOA. Early identification of these patients is imperative for timely surgical intervention to avoid prolonged hospitalisation, antibiotic usage, and patient morbidity. More work is required to identify whether early drainage may reduce length of hospital stay and antibiotic treatment, including identifying certain patient groups who most likely to benefit from outpatient antibiotic intravenous therapy.

Pediatric Benign Neutropenia: Assessing Practice Preferences in Canada.

Pediatric benign neutropenia is a self-limited condition with a benign clinical course. An approach to this condition is not well-defined in the literature. Our objective was to use a case-based survey to elucidate trends in the diagnosis and management of benign neutropenia among pediatric hematology/oncology practitioners in Canada. We received 46 completed surveys (response rate 66%). At initial presentation with fever and neutropenia, 67% of respondents recommended partial septic workup but 11% recommended no investigations. Nearly 70% recommended admission for empiric intravenous antibiotics, while 24% would discharge home without antibiotics. In a patient with fever and known neutropenia, respondents were more likely to pursue outpatient antibiotic therapy. For investigation of chronic neutropenia, most respondents (60%) do not use antineutrophil antibody testing. Common indications for bone marrow biopsy were severe infection, prolonged neutropenia, or before initiating granulocyte colony stimulating factor. Indications for granulocyte colony stimulating factor were based on severity and frequency of infection. Most respondents (84%) would not recommend antibiotic prophylaxis. Results demonstrate the considerable variability in management of benign neutropenia among pediatric hematology/oncology practitioners in Canada and highlight the need for prospective studies to establish diagnostic criteria for benign neutropenia and evaluate management of fever in this population.

Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children

Childhood community-acquired pneumonia (CAP) is usually treated with 10 days of antibiotics. Shorter courses may be effective with fewer adverse effects and decreased potential for antibiotic resistance. To compare a short (5-day) vs standard (10-day) antibiotic treatment strategy for CAP in young children. Randomized double-blind placebo-controlled clinical trial in outpatient clinic, urgent care, or emergency settings in 8 US cities. A total of 380 healthy children aged 6 to 71 months with nonsevere CAP demonstrating early clinical improvement were enrolled from December 2, 2016, to December 16, 2019. Data were analyzed from January to September 2020. On day 6 of their originally prescribed therapy, participants were randomized 1:1 to receive 5 days of matching placebo or 5 additional days of the same antibiotic. The primary end point was the end-of-treatment response adjusted for duration of antibiotic risk (RADAR), a composite end point that ranks each child's clinical response, resolution of symptoms, and antibiotic-associated adverse effects in an ordinal desirability of outcome ranking (DOOR). Within each DOOR rank, participants were further ranked by the number of antibiotic days, assuming that shorter antibiotic durations were more desirable. Using RADAR, the probability of a more desirable outcome was estimated for the short- vs standard-course strategy. In a subset of children, throat swabs were collected between study days 19 and 25 to quantify antibiotic resistance genes in oropharyngeal flora. A total of 380 children (189 randomized to short course and 191 randomized to standard course) made up the study population. The mean (SD) age was 35.7 (17.2) months, and 194 participants (51%) were male. Of the included children, 8 were Asian, 99 were Black or African American, 234 were White, 32 were multiracial, and 7 were of unknown or unreported race; 33 were Hispanic or Latino, 344 were not Hispanic or Latino, and 3 were of unknown or unreported ethnicity. There were no differences between strategies in the DOOR or its individual components. Fewer than 10% of children in either strategy had an inadequate clinical response. The short-course strategy had a 69% (95% CI, 63-75) probability of a more desirable RADAR outcome compared with the standard-course strategy. A total of 171 children were included in the resistome analysis. The median (range) number of antibiotic resistance genes per prokaryotic cell (RGPC) was significantly lower in the short-course strategy compared with the standard-course strategy for total RGPC (1.17 [0.35-2.43] vs 1.33 [0.46-11.08]; P = .01) and β-lactamase RGPC (0.55 [0.18-1.24] vs 0.60 [0.21-2.45]; P = .03). In this study, among children responding to initial treatment for outpatient CAP, a 5-day antibiotic strategy was superior to a 10-day strategy. The shortened approach resulted in similar clinical response and antibiotic-associated adverse effects, while reducing antibiotic exposure and resistance. ClinicalTrials.gov Identifier: NCT02891915.

Management of Acute Uncomplicated Diverticulitis: Inpatient or Outpatient.

Diverticular disease is a highly frequent condition and affects 50% of the population in the 9th decade in Western society. Acute diverticulitis is the most prevalent complication. The patients who are clinically stable and tolerate fluid should be hospitalized if fluid intake tolerance worsens, fever occurs, or pain increases. Bowel rest, intravenous fluid therapy, and empiric antibiotic therapy are the traditional treatments for patients admitted to the hospital. This retrospective study aimed to determine the parameters that will affect the outpatient or inpatient treatment of patients diagnosed with uncomplicated acute diverticulitis. Patients who presented to the emergency department with abdominal pain between January 2018 and December 2020 and were diagnosed with uncomplicated diverticulitis (modified Hinchey 1a) on computed tomography (CT) taken after intravenous contrast material shoot up were included in the study. Patient records were recorded retrospectively in the Excel file. After being seen in the emergency department, a comparison was performed between the inpatient group (Group 1) and the outpatient follow-up group (Group 2). The study comprised 172 patients with acute uncomplicated diverticulitis (modified Hinchey 1a). While 110 (64.0%) patients were followed up and treated as inpatients (Group 1), 62 (36.0%) patients were followed up as outpatients (Group 2). There was no statistically significant difference between the two groups in terms of patients readmitted to the hospital in the first 30 days after discharge (both for outpatient follow-up in the emergency department and after treatment in the inpatient group). In this retrospective study, in which we evaluated the hospitalization criteria in uncomplicated Modified Hinchey 1a patients, it was found that patients can be safely treated as an outpatient if they have poor physical examination findings. Although there was no difference between the two groups in terms of hospital readmission after discharge and it was thought that follow-up of patients with Modified Hinchey 1a diverticulitis with outpatient oral antibiotic therapy might be reliable, prospective studies with larger numbers of patients are needed.

Outpatient Antibiotic Prescription Rates and Mastoiditis in Children and Adolescents, Saarland, 2014-2019

Infections of the respiratory tract are the main indication for outpatient antibiotic therapy in children and adolescents. In recent years the antibiotic prescription rate (APR) in the pediatric population has decreased significantly. The aim of the retrospective mastoiditis audit in the PaedineSaar network is to investigate the incidence of inpatient acute mastoiditis (AM) in Saarland (2014-2019) regarding to the decreasing APRs in children, as well as to gather data of the clinical course of AM. All inpatient AM cases 2014-2019 were analyzed retrospectively from 6 hospitals for pediatrics and/or otorhinolaryngology in Saarland and Trier. Children and adolescents aged 0-17 years and residing in Saarland were included in the study. 2014-2019 53 inpatient treated AM cases have been recorded. During the study period there was no significant increase of AM incidence (mean incidence 2014-2019: 6.1/100,000). 34% (18/53) of the patients received prehospital antibiotic treatment (main indication: acute otitis media (AOM) 15/18, 83%). At least one complication occurred in 30% of the patients (16/53). There was a slight trend to more complications in children without oral antibiotic treatment before admission (14/35 (40%) vs. 2/18 (11%) p=0.056). The incidence of AM leading to inpatient treatment in children in Saarland did not increase 2014-2019 despite a significant and sustained decline in the outpatient APRs. The results of this audit should be used for the development of a more standardized approach concerning the diagnostics and treatment of children with AM.

Risk Factors Associated With Nephrotoxicity During Outpatient Intravenous Vancomycin Administration.

Background: Many studies have described an association between intravenous vancomycin and nephrotoxicity; however, the majority have evaluated incidence and risk factors among hospitalized patients. Outpatient administration of intravenous antibiotics is a growing practice and presents its own set of unique challenges. Objective: The aim of this study was to identify risk factors for vancomycin-associated nephrotoxicity in the outpatient setting. Methods: A case-control study of patients who received intravenous vancomycin through an Outpatient Parenteral Antimicrobial Therapy (OPAT) program was conducted. Patients were identified who developed an acute kidney injury (AKI) during treatment. The primary outcome was the incidence of AKI during treatment. Results: A total of 37 out of 130 patients (28.5%) met the criteria for AKI. AKI was more likely to occur in patients with a longer duration of therapy, higher maximum trough concentration, co-administration of a fluoroquinolone or metronidazole, and those who received another potentially nephrotoxic medication. Co-administration of a fluoroquinolone (OR = 5.96, P = 0.009, [CI: 1.59, 24.38]), any nephrotoxic medication (OR = 11.17, P < 0.001, [CI 3.14, 51.23]), and a higher maximum vancomycin trough (OR = 1.29, P < 0.001, [CI 1.17, 1.44]) were all indicative of a higher odds of an AKI. Conclusion: In this cohort, vancomycin-associated nephrotoxicity was common during outpatient intravenous antibiotic therapy. Co-administration of a fluoroquinolone, any nephrotoxic medication, and a higher maximum vancomycin trough were associated with AKI development. Further study is needed to determine how this impacts long-term clinical outcomes and what measures can be taken to reduce nephrotoxicity risk.