Duration Of Parenteral Antibiotics Research Articles

Diagnostic and antibiotic use practices among COVID-19 and non-COVID-19 patients in the Indonesian National Referral Hospital.

Little is known about diagnostic and antibiotic use practices in low and middle-income countries (LMICs) before and during COVID-19 pandemic. This information is crucial for monitoring and evaluation of diagnostic and antimicrobial stewardships in healthcare facilities. We linked and analyzed routine databases of hospital admission, microbiology laboratory and drug dispensing of Indonesian National Referral Hospital from 2019 to 2020. Patients were classified as COVID-19 cases if their SARS-CoV-2 RT-PCR result were positive. Blood culture (BC) practices and time to discontinuation of parenteral antibiotics among inpatients who received a parenteral antibiotic for at least four consecutive days were used to assess diagnostic and antibiotic use practices, respectively. Fine and Grey subdistribution hazard model was used. Of 1,311 COVID-19 and 58,917 non-COVID-19 inpatients, 333 (25.4%) and 18,837 (32.0%) received a parenteral antibiotic for at least four consecutive days. Proportion of patients having BC taken within ±1 calendar day of parenteral antibiotics being started was higher in COVID-19 than in non-COVID-19 patients (21.0% [70/333] vs. 18.7% [3,529/18,837]; p<0.001). Cumulative incidence of having a BC taken within 28 days was higher in COVID-19 than in non-COVID-19 patients (44.7% [149/333] vs. 33.2% [6,254/18,837]; adjusted subdistribution-hazard ratio [aSHR] 1.71, 95% confidence interval [CI] 1.47-1.99, p<0.001). The median time to discontinuation of parenteral antibiotics was longer in COVID-19 than in non-COVID-19 patients (13 days vs. 8 days; aSHR 0.73, 95%Cl 0.65-0.83, p<0.001). Routine electronic data could be used to inform diagnostic and antibiotic use practices in LMICs. In Indonesia, the proportion of timely blood culture is low in both COVID-19 and non-COVID-19 patients, and duration of parenteral antibiotics is longer in COVID-19 patients. Improving diagnostic and antimicrobial stewardship is critically needed.

Short duration of parenteral antibiotics in infants with urinary tract infections.

Current guidelines by the Canadian Paediatric Society on treating urinary tract infections (UTIs) exclude infants ≤ 60 days old. There is considerable practice variability in this age group, especially around the optimal duration of parenteral antibiotics. The study aimed to assess local practice patterns, and the safety of a short course (≤3 days) of parenteral antibiotics in young infants. In this retrospective cohort study, 95 infants (≤60 days) with confirmed UTIs were identified at British Columbia Children's Hospital. Patients receiving short (≤3 days) and long (>3 days) duration of parenteral antibiotics were compared. Outcomes of interest included urinary tract infection recurrence within 30 days, hospital length of stay (LOS), representation, and readmission. Twenty infants (21%) received a short course of parenteral antibiotics. These infants were older (median 47 days versus 28 days) and non-bacteremic. Urinary tract infection recurrence was identified in 8 patients (8%), of which 7 were treated with a long duration (P = 1.0). Patients treated with a short duration had a significantly shorter LOS, with a mean difference of 4.21 days [95% CI: 3.37 to 5.05] (P < 0.001). All five (5%) bacteremic patients were treated exclusively with parenteral antibiotics. In a Canadian setting, a short course of parenteral antibiotics is safe in young, non-bacteremic infants with UTIs. Despite substantial evidence, local practice patterns suggest a tendency towards prescription of long courses, providing an opportunity for quality improvement.

Role of fluoroquinolone prophylaxis in allogeneic hematopoietic cell transplantation in regions with a high prevalence of fluoroquinolone resistance.

The role of fluoroquinolone (FQ) prophylaxis in preventing gram-negative bacilli (GNB) bacteremia, graft-versus-host disease (GVHD), and overall survival (OS) after allogeneic hematopoietic cell transplantation (allo-HCT) is debatable and may differ in settings with low and high prevalences of FQ resistance. In this study, we aimed to answer this question in regions with high FQ resistance. This single-center retrospective study included all consecutive allo-HCT recipients aged ≥12 years from 2012 to 2021. Allo-HCT recipients until 2016 were administered FQ prophylaxis (levofloxacin). After 2016, the institutional protocol was modified to no antibiotic prophylaxis. Data were retrieved from patient records for disease and transplant characteristics, the incidence of GNB bacteremia, duration of parenteral antibiotics, hospitalization duration, acute GVHD, and OS. A total of 135 allo-HCT recipients (43 in the FQ-prophylaxis cohort and 92 in the no-antibiotic prophylaxis cohort) were analyzed in this study. The two cohorts were matched for age (median, 26 vs. 24.5 years; p = 0.8). The no-antibiotic prophylaxis cohort had a higher proportion of malignant diagnoses (80% vs. 58%, p = 0.01), haploidentical transplants (46% vs. 14%, p = 0.004), and posttransplant cyclophosphamide exposure (46% vs. 14%, p = 0.003) than did the FQ cohort. Despite this, the incidence of GNB bacteremia was not significantly different between the two cohorts (37% vs. 34%, p = 0.6). There were no differences in parenteral antibiotic use or hospitalization duration, as well as the incidence of acute GVHD (53% vs. 53%, p = 0.3). The 1-year OS was similar between the two cohorts (66% vs. 67%, p = 0.6). This study shows that FQ prophylaxis did not affect the incidence of GNB bacteremia, parenteral antibiotic use, hospitalization duration, acute GVHD, and OS post-allo-HCT.

Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis.

Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting. Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure). Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB. SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.

111. Duration of Antibiotic Therapy after Debridement and Implant Retention in Patients with Periprosthetic Joint Infections

BackgroundDebridement, antibiotics, and implant retention (DAIR) is appropriate for select acute postoperative and hematogenous periprosthetic joint infections (PJIs). However, the optimal duration of antimicrobial therapy in patients treated with DAIR has not been defined. Therefore, we aimed to identify the ideal duration of parenteral and oral antibiotics after DAIR. MethodsWe performed a retrospective study of patients >18 years of age with hip or knee PJI managed with DAIR between January 1, 2008, and December 31, 2018, at Mayo Clinic. PJI was defined using criteria adapted from the International Consensus Meeting on PJI. The outcome was defined as either PJI recurrence or unplanned reoperation due to infection. Joint-stratified Cox proportional hazards regression models with time-dependent covariates were used to assess nonlinear effects of antibiotic duration. Hazard ratios were computed based on prespecified time points for comparison, whereas p-values represented the overall effect across the entire range of durations.ResultsThere were 247 unique episodes of PJI in 237 patients during the study period. Parenteral antibiotics were given in 99.2% of cases (n=245). This was followed by chronic oral antibiotic suppression in 92.2% (n=226) with a median duration of 2.2 years (1.0-4.1).DAIR failed in 65 cases over a median follow-up of 4.4 years, with a 5-year cumulative incidence of 28.1%. After adjustment for risk factors, there was no significant association between duration of parenteral antibiotics and treatment failure (p=0.203), with no difference between four versus six weeks (HR 1.11; 95% CI 0.71-1.75) (Figure 1). However, both use and longer duration of oral antibiotic therapy was associated with a lower risk of failure (p=0.006). To account for the possibility that this association was driven by results during early follow-up, conditional analyses at one- and two-year follow-up were performed. Both showed a significantly lower risk for a longer duration of antibiotics (Figure 2). Figure 1. Time-Dependent Analysis of Parenteral Antibiotic Duration Figure 2. Time-Dependent Analysis of Oral Antibiotic Suppression Duration ConclusionAfter DAIR, efficacy from four weeks of parenteral antibiotics was no different from six weeks when followed by chronic oral antibiotic suppression. Our results could not establish an optimal duration but suggested that continuing suppression portends a lower risk of failure of DAIR. Disclosures Elie Berbari, MD, Uptodate.com (Other Financial or Material Support, Honorary unrelated to this work) Matthew P. Abdel, MD, Stryker and AAOS Board of Directors (Board Member, Other Financial or Material Support, Royalties) Aaron J. Tande, MD, UpToDate.com (Other Financial or Material Support, Honoraria for medical writing)

Treatment of UTIs in Infants

Urinary tract infections (UTIs) are the most common bacterial infections in infants <2 months of age. However, there are no clear guidelines on the appropriate duration of antibiotics in this age group. In this living systematic review, we compared different durations of parenteral antibiotics (≤3 vs >3 days) in neonates and young infants (<2 months) with UTIs. The secondary objective was to compare different durations of total antibiotic courses (≤10 vs >10 days). MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Google Scholar, and gray literature, up to March 2, 2021. Citations were screened in triplicate by using a crowdsourcing methodology, to identify randomized controlled trials and observational studies. Data were extracted by 2 crowd members and verified by an expert investigator. Outcomes were pooled via random-effects models. A total of 10 334 citations were screened, and 12 eligible studies were identified. A total of 59 of 3480 (1.7% [95% confidence interval (CI): 1.3% to 2.2%]) infants had a UTI recurrence within 30 days after short parenteral treatment (≤3 days), and 47 of 1971 (2.4% [95% CI: 1.8% to 3.2%]) after longer courses. The pooled adjusted odds ratio for UTI recurrence with a short versus long duration of parenteral antibiotics was 1.02 (95% CI: 0.64 to 1.61; P = .95; n = 5451). A total of 5 studies assessed the risk of recurrence on the basis of the total duration of antibiotics (≤10 vs >10 days) with no significant differences (pooled odds ratio: 1.29 [95% CI: 0.45 to 3.66; P = .63; n = 491). On the basis of retrospective studies and Grading of Recommendations, Assessment, Development, and Evaluation level low evidence, short and long duration of parenteral antibiotics were associated with a similar risk of UTI recurrence in infants <2 months.

Outcomes of Gas-Forming Pyogenic Liver Abscess (PLA) Are Comparable to Non-Gas-Forming PLA in the Era of Multimodal Care: A Propensity Score Matched Study

Gas-forming pyogenic liver abscess (GFPLA) occurs in 7-24% of all pyogenic liver abscess (PLA) and has been traditionally associated with high mortality. Studies suggest that use of a proactive approach of prompt resuscitation, parenteral antibiotics, percutaneous drainage and a dedicated multidisciplinary team may improve clinical outcomes. Hence, we aim to investigate if the clinical outcomes of PLA are determined by gas formation. This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes, presence of septic shock, haemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Demographics, clinical profile and perioperative data were compared. 213 patients had PLA: 41(19.2%) patients had GFPLA and 172(80.8%) patients had non-GFPLA. 1:2 PSM resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Clinical profile and microbiology are shown in Table 1. Median duration of parenteral antibiotics was significantly lower in the GFPLA group (9.5 days vs 14 days, p=0.044), but median total duration of antibiotics use was comparable (GFPLA 39 days vs non-GFPLA 37 days, p=0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs 15, p=0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36(72.2%) vs 47/72(65.3%) respectively, p=0.467) and in-hospital all-cause mortality (4/36(11.1%) vs 7/72(9.7%), p=0.822). Outcomes of GFPLA are comparable to non-GFPLA in the era of multimodal care.Table 1Clinical profile and microbiology of patients with gas-forming pyogenic liver abscess (GFPLA) and non-GFPLA before and after matchingOverall cohort (n=213)Matched cohort (n=108)GFPLA (n=41)Non-GFPLA (n=172)p-valueSMD (standardised mean difference)GFPLA (n=36)Non-GFPLA (n=72)p-valueSMDAge (interquartile range)61 (53 - 69)62 (51 - 74)0.7870.01061.5 (52.3 - 68.8)62.5 (53.3 - 73.8)0.6460.047Gender, male (%)27 (65.9)104 (60.5)0.524-24 (66.7)45 (62.5)0.671-Diabetes mellitus, yes (%)18 (43.9)56 (32.6)0.1700.23313 (36.1)24 (33.3)0.7740.058Pus culture, yes (%)21 (70)61 (66.3)0.7080.30717 (65.4)37 (78.7)0.2140.083Klebsiella pneumoniae (%)17 (81)51 (82.3)13 (76.5)33 (89.2)Clostridium perfringes (%)1 (4.8)1 (1.6)1 (5.9)1 (2.7)Others (%)3 (14.3)9 (14.8)3 (17.6)3 (8.1)Size of largest abscess (cm)6.6 (4.9 - 8.3)5.4 (3.6 - 7.0)0.0050.4886.3 (4.5 - 7.5)6.1 (5.0 - 7.6)0.6690.131 Open table in a new tab

277. Comparison of Oral Beta-Lactams and Fluoroquinolones for Step-Down in Uncomplicated Enterobacterales Blood Stream Infections

BackgroundBloodstream infections (BSI) with Enterobacterales (formerly Enterobacteriaceae) group organisms are a frequently encountered complication, often stemming from urinary tract infections. Recent studies have demonstrated similar outcomes among patients transitioned to oral antibiotics compared to those managed solely with parenteral routes; however, most transitions utilize highly bioavailable agents such as fluoroquinolones (FQ). With limited comparative evidence on oral b-lactams (OBL) and mounting concerns over FQ safety and resistance, we sought to compare outcomes of FQ vs. OBL for Enterobacterales BSI step-down.MethodsSingle-center, retrospective cohort of adults at University of Colorado Hospital from 2015–2017 with uncomplicated Enterobacterales BSI who stepped down to OBL or FQ after initial parenteral therapy. Exclusions were: pregnant or incarcerated, causative organism identified as Salmonella spp., Enterobacter spp., Citrobacter freundii, Serratia spp. and/or Klebsiella aerogenes, parenteral antibiotic duration ≥ 5 days, death before day 5, total antibiotic duration < 5 days or > 21 days. Primary outcome was clinical failure, a composite of any of the following within 30-days of antibiotic completion: death, recurrence or antibiotic change for presumed failure, or readmission for original infection.ResultsOverall, 74 patients were included (n=36 OBL, n=38 FQ). Baseline characteristics were not different between groups, with overall mean age (SD) 60 (17) years and 62% female. E. coli was most commonly identified (65%), with 70% originating from the urinary tract. ICU admission was present in 18%, and median (IQR) Pitt Bacteremia Score was 2 (1–3). Treatment failure occurred in 25% OBL vs. 24% FQ recipients, p=0.55. No deaths were identified in either group within 30-days, and adverse events were rarely reported in either group. Multivariable analysis identified presence of nephrostomy tubes (OR 8.1; 95% CI: 1.1–61) but not OBL (OR 1.5; 95% CI: 0.3–7.2) as associated with clinical failure.ConclusionIn a cohort of uncomplicated Enterobacterales BSIs there does not appear to be a difference in clinical failure associated with OBLs compared to FQs. Additional studies with a larger cohort, or prospective trials are needed to confirm these findings.Disclosures matthew miller, PharmD, Allergan (Speaker’s Bureau)Tetraphase (Speaker’s Bureau)

Antimicrobial therapy and assessing therapeutic response in culture-negative pyogenic vertebral osteomyelitis: a retrospective comparative study with culture-positive pyogenic vertebral osteomyelitis

BackgroundThere are still controversies regarding the treatment and outcomes in culture-negative pyogenic vertebral osteomyelitis (PVO). The purpose of this study is to investigate the antimicrobial therapy, assessment of therapeutic response, and outcome of culture-negative PVO compared to culture-positive PVO.MethodsA retrospective study was performed with non-surgical lumbar PVO patients. The patients were divided into two groups based on the causative bacterial identification (CN group with culture-negative PVO and CP group with culture-positive PVO). The clinical features, use of antibiotics, laboratory data, and outcomes were compared between the two groups.ResultsSeventy-three patients with 41 (56.2%) of the CN group and 32 (43.8%) of the CP group were enrolled. The CN group showed a shorter duration of parenteral antibiotics (45.88 ± 16.14 vs. 57.31 ± 24.39, p = 0.019) but a tendency of prolonged duration of total (parenteral + oral) antibiotics (101.17 ± 52.84 vs. 84.19 ± 50.29 days, p = 0.168). When parenteral antibiotics were discontinued or switched to oral antibiotics, the mean erythrocyte segmentation rate (ESR, normal range: < 25 mm/h), C-reactive protein (CRP, normal range: < 0.5 mg/dL) level, and visual analog scale (VAS) score of back pain were 42.86 ± 24.05 mm/h, 0.91 ± 1.18 mg/dL, and 4.05 ± 1.07, respectively, with no significant differences between the two groups. The recurrence rates of CN and CP groups were 7.3% (3/41) and 6.3% (2/32), respectively (p = 1.000). The presence of epidural abscess was the most significant factor for the identification of causative bacteria (p = 0.002), and there was no significant relationship between the use of empirical antibiotics before tissue culture and the causative bacterial identification (p = 0.194).ConclusionsThe CN group required a shorter duration of parenteral antibiotics than the CP group. Discontinuation of parenteral antibiotics or changing the administration route can be considered based on the values of ESR, CRP, and VAS score of back pain. The presence of epidural abscess was the most significant factor for the identification of causative bacteria.

Urinary Tract Infection in Young Infants: Practice Patterns in Evaluation and Treatment.

No clear guidelines exist for the management of infants ≤60 days old with urinary tract infection (UTI), although this condition represents a significant percentage of serious bacterial infection in this age group. We examined patterns of UTI management in infants ≤60 days at a tertiary care children's hospital and hypothesized that younger infants would be hospitalized longer. We reviewed electronic health records of infants age ≤60 days with diagnostic codes of UTI or fever hospitalized from January 2013 to January 2017 with urine culture obtained and UTI diagnosis documented. Outcomes were duration of parenteral antibiotic therapy, length of stay (LOS), and hospital readmission. One hundred ninety-three infants met criteria. Median age at admission was 37 days (interquartile range [IQR]: 22-48). Median duration of parenteral antibiotics was 59 hours (IQR 43-114) and median LOS was 71 hours (IQR 57 127). Infants age ≤28 days, with fever duration ≥24 hours, irritability or lethargy on initial examination, and bacteremia received longer parenteral therapy and had longer LOS. In multivariate analysis, age, irritability or lethargy, and presence of bacteremia remained independently related to parenteral therapy duration and LOS. In young infants with UTI, patients aged ≤28 days had longer duration of IV antibiotic therapy and LOS, independent of other clinical characteristics of their illness. The duration of parenteral therapy and LOS was relatively short, although significant variability still existed.

Management of Febrile Urinary Tract Infection With or Without Bacteraemia in Children: A French Case-Control Retrospective Study.

Background: Febrile urinary tract infections (FUTIs) are common among children, and are associated with a bacteraemia between 4 and 7% of cases. No data is available concerning the management of children with a bacteraemic FUTI.Objectives: To compare the antibiotic treatment (parenteral and total duration) among children with bacteraemic and non-bacteraemic FUTIs, and the mean hospital length of stay (LOS); to describe clinical, microbiological and imaging features of children with bacteraemic and non-bacteraemic FUTIs and observed management modifications when the blood culture was positive.Methods: A retrospective case-control study between 2009 and 2015 at Robert Debré's Pediatric Emergency Department (Paris, France). Children with a bacteraemic FUTI were included and matched for age and sex with two children with a non-bacteraemic FUTI.Results: We included 50 children with a bacteraemic FUTI matched to 100 children with a non-bacterameic FUTI. The mean duration of parenteral antibiotics was longer for bacteraemic children (6.7 vs. 4.0 days, p < 0.001) but this difference was only significant in children > 28 days-old. The mean total duration of antibiotic was similar (11.3 vs. 11.6 days, p = 0.61). The mean LOS was longer for bacteraemic children (5.1 vs. 2.0 days, p < 0.001) but this difference was only significant in children > 28 days-old. A positive blood culture changed the management in 66% of patients. Clinical features at presentation were comparable. Bacteraemic patients had a higher procalcitonin (p = 0.006) and C-reactive protein (p = 0.01), lower mean lymphocyte count (p < 0.001).Conclusions: A bacteraemic FUTI in children induced a longer duration of parenteral antibiotic treatment, a longer hospitalization in children > 28 days-old, and a modification of management for 66% of patients.

Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections.

To determine the association between parenteral antibiotic duration and outcomes in infants ≤60 days old with bacteremic urinary tract infection (UTI). This multicenter retrospective cohort study included infants ≤60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as ≤7 days, and long-course parenteral antibiotic duration was defined as >7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay). Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non-Escherichia coli organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6). Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.

An End in Sight: Shorter Duration of Parenteral Antibiotics in Neonates.

* Abbreviations: GBS — : Group B Streptococcus UTI — : urinary tract infection Prescribing the appropriate duration of antibiotic therapy is at the top of mind for the Centers for Disease Control and Prevention, hospital systems, and individual providers alike because it has a resounding impact on antimicrobial resistance.1 In this month’s issue of Pediatrics , Desai et al2 have taken on the duration of parenteral antibiotics for infants ≤60 days old with bacteremic urinary tract infection (UTI). This is a critical piece of a complicated puzzle that not only includes minimum duration of parenteral antibiotic treatment but also involves bioavailability of antimicrobial agents in infants and total treatment duration, which includes parenteral and oral antibiotic therapy. They have written a methodologically sound multicenter study and propose that a short course of parenteral antibiotics is no less effective than a long course in infants ≤60 days old with bacteremic UTIs. This study uniquely affords granularity with respect to the patient population, including a physician’s documented clinical assessment providing information such as temperature, ill appearance, or presence of a known genitourinary condition, which allowed for ascertainment of critical clinical information that influenced management decisions. Ultimately, … Address correspondence to Hillary L. Copp, MD, MS, Department of Pediatric Urology, University of California, San Francisco, Mission Hall Global Health Sciences Building, 550 16th St, 6th Floor, Box 1695, San Francisco, CA 94143. E-mail: hillary.copp{at}ucsf.edu

Bacteraemic urinary tract infection: management and outcomes in young infants

ObjectivesTo determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI).DesignMulticentre retrospective cohort study.SettingEleven healthcare...

Long‐Term Outcome of Patients with Acute Cholecystitis Receiving Antibiotic Treatment: A Retrospective Cohort Study

Few studies have followed patients who received antibiotic treatment for acute cholecystitis (AC). The present retrospective study investigated recurrence rates of AC and analyzed factors associated with recurrence after antibiotic treatment in adult AC patients. We analyzed patients treated with antibiotics for AC between October 1, 2004, and November 30, 2010. A Cox proportional hazards model was used to identify factors associated with early recurrence. Generalized additive models were applied to detect the nonlinear effects of continuous covariates. The study included 226 patients (mean age: 62.2 years; 144 men [63.7 %]). The average duration of parenteral antibiotics was 8.0 days. Second-generation cephalosporins were administered to 199 patients (88.1 %). The Kaplan-Meier plot indicated that recurrences were more frequent within 100 days of AC; these were defined as early recurrences. The recurrence rate was 13.7 % (31/226) at a median follow-up of 308.5 days (early recurrences: 19/226 [8.4 %]). The duration of parenteral antibiotic use significantly correlated with early recurrence (hazard ratio: 0.83; 95 % confidence interval, 0.73-0.95; p = 0.005). Generalized additive models revealed that patients using parenteral antibiotics longer than 8 days were less likely to suffer from early recurrence. The rate of recurrence of AC in patients who received antibiotics alone was low. The recurrence rate was higher within 100 days of AC. Because of the inherent limitations of a retrospective study, further research is needed to identify factors associated with early recurrence.

Feasibility of early discharge strategies for neutropenic fever: outcomes of a Victorian organisational readiness assessment and pilot

Although Australian consensus guidelines support the use of ambulatory care strategies for management of adult patients with low-risk neutropenic fever (NF), few centres have successfully implemented viable programmes. To study the feasibility of an early discharge programme for adult patients with low-risk NF and assess organisational factors likely to influence successful implementation across participating Victorian hospitals. Four hospitals participated in an organisational readiness assessment preceding selection of a pilot site for programme implementation. Prospective baseline auditing of current practice (i.e. inpatient care until resolution of NF) across three hospitals preceded programme implementation and evaluation. Barriers and facilitators to successful implementation were identified. One hundred and seventeen NF episodes were evaluated during audit phases. The frequency of low-risk NF presentations eligible for early discharge was low (less than two episodes per week). The programme reduced median (interquartile range) duration of parenteral antibiotics and length of stay for eligible patients (n = 11) from 4 (4, 5) days at baseline to 1 (1, 2) day during pilot (P = 0.02) and 4.5 (4, 5) days (baseline) to 2 (1, 3) days (pilot) (P = 0.02) respectively. The proportion of ineligible patients stepped down to oral antibiotics was improved from 38% (baseline) to 67% (pilot). No patients failed ambulatory care requiring readmission into hospital. The ambulatory care strategy for management of NF proposed by Australian consensus guidelines has been successfully piloted at a single Victorian centre. Organisational readiness tools can be used to identify potential barriers to the implementation of evidence based practices in patients with NF.

Impact of in‐hospital enteroviral polymerase chain reaction testing on the clinical management of children with meningitis

Enteroviral meningitis is a common cause of meningitis in children which requires only supportive care. To evaluate the impact of implementing an in-hospital enteroviral polymerase chain reaction (EVPCR) testing protocol on the clinical management of children with meningitis. Retrospective cohort study. Children <19 years old with meningitis. EVPCR testing differed by time period: send-out testing protocol from July 1, 2006-June 23, 2008 (pre-period) versus in-house testing protocol from June 24, 2008-June 30, 2010 (post-period). Test turnaround time, test utilization, length of stay, and duration of parenteral antibiotics. Of the 441 study patients, 216 (49%) presented during the post-period. Median age was 2.9 months (interquartile range, 1.5-96 months). Test turnaround time decreased with the in-house test (53 hours pre vs 13 hours post, P < 0.001), and test utilization increased (28% pre vs 62% post, P < 0.001). Among children with a positive EVPCR test, both length of stay (44 hours pre vs 28 hours post, P = 0.005) and duration of parenteral antibiotics (48 hours pre vs 36 hours post, P = 0.04) decreased in the post-period. No change in either of these outcomes was observed in children with meningitis and a negative EVPCR test. In-house EVPCR testing reduced test turnaround time, increased test utilization, and reduced both length of stay and duration of parenteral antibiotics for children with a positive result. Clinicians caring for children with meningitis should have access to in-hospital EVPCR testing.

Culture-negative Osteoarticular Infections in the Era of Community-associated Methicillin-resistant Staphylococcus aureus

This study examined the characteristics of culture-negative osteoarticular infections (OAIs) during the emergence of methicillin-resistant Staphylococcus aureus. Culture-negative OAIs were mild compared with culture-positive infections, especially those caused by methicillin-resistant Staphylococcus aureus. Despite no increase in severity during the study period, the duration of parenteral antibiotics for children with culture-negative OAIs more than tripled in 2004-2008 compared with 2002-2003.

Success of Short-Course Parenteral AntibioticTherapy for Acute Osteomyelitis of Childhood

The outcome of acute osteomyelitis treated with sequential therapy consisting of a short course of parenteral antibiotics, followed by oral antibiotics, was studied. To be considered acute osteomyelitis, related symptoms must have been present for less than 2 weeks before diagnosis. Short-course parenteral antibiotics (therapy for 7 days or less) and then oral antibiotics were used to treat 29 patients (median age, 6.3 years). Pathogens were identified from blood cultures and bone aspirates. Staphylococcus aureus was isolated in 59%. Median duration of parenteral antibiotics and oral antibiotics was 4 days (range, 0-7 days) and 28 days (range, 14-42 days), respectively. Median duration of combined (parenteral and oral) therapy was 32 days (range, 20-49 days). No failures or complications were noted at the 6-month follow-up, which was available for 27 patients. Short-course parenteral antibiotic therapy followed by oral therapy appears to be effective for treatment of acute, uncomplicated osteomyelitis.

Meta-Analysis of Randomized Controlled Trials of Prophylactic Granulocyte Colony-Stimulating Factor and Granulocyte-Macrophage Colony-Stimulating Factor After Autologous and Allogeneic Stem Cell Transplantation

The primary objective of our meta-analysis was to determine whether prophylactic hematopoietic colony-stimulating factors (CSFs) after hematopoietic autologous and allogeneic stem-cell transplantation (SCT) reduced documented infections. Our secondary objectives were to determine whether prophylactic CSFs affected other outcomes including parenteral antibiotic therapy duration, infection-related mortality, graft-versus-host disease (GVHD), or treatment-related mortality. We included studies if there was random assignment between CSFs and placebo/no therapy and CSFs were given after SCT and before recovery of neutrophils. From 3,778 reviewed study articles, 34 were included based on predefined inclusion criteria. All analyses were conducted using a random effects model. CSFs reduced the risk of documented infections (relative risk [RR] 0.87; 95% CI, 0.76 to 1.00; P = .05) and duration of parenteral antibiotics (weighted mean difference, -1.39 days, 95% CI, -2.56 to -0.22; P = .02) but did not reduce infection-related mortality (RR, 0.76; 95% CI, 0.41 to 1.44; P = .4). CSFs did not increase grade 2 to 4 acute GVHD (RR, 1.03; 95% CI, 0.81 to 1.31; P = .8) or treatment-related mortality (RR, 1.00; 95% CI, 0.78 to 1.29; P = .98). CSFs were associated with a small reduction in the risk of documented infections but did not affect infection or treatment-related mortality.