Persistent Positive Cultures Research Articles

Long-term Outcomes of Adjunctive Lung Resection for Nontuberculous Mycobacteria Pulmonary Disease.

Adjunctive lung resection is recommended for select patients with nontuberculous mycobacteria (NTM) pulmonary disease (PD). However, data are limited on long-term recurrence rates in patients infected with major pathogens, including Mycobacterium avium complex (MAC) and Mycobacterium abscessus (MABC). In this prospective observational study, we retrospectively analyzed data from 125 patients with MAC-PD (n = 90) or MABC-PD (n = 35) who underwent adjunctive lung resection. We evaluated microbiological response, postoperative complications, recurrence, and all-cause mortality over a median 80-month follow-up. Persistent culture positivity (64%) was the most common indication for surgery, followed by hemoptysis, recurrent pneumonia, or radiologic deterioration. Postoperative complications occurred in 18 (14%) patients, with no surgery-related deaths. Treatment outcomes did not significantly differ between the MAC- and MABC-PD groups. Cure with culture conversion was achieved in 112 (90%) patients. Recurrence occurred in 37 (33%) of 112 patients, of which 18 (49%) cases were attributed to reinfection by different NTM species or subspecies. The MAC group had higher recurrence rates than the MABC group (Kaplan-Meier curve, log-rank test, P = .043) and was significantly associated with recurrence in the multivariable analysis (adjusted hazard ratio, 2.71; 95% CI, 1.23-5.99). However, mortality was higher in the MABC-PD group than the MAC-PD group (7/35 vs 4/90, P = .006). Adjunctive lung resection with antibiotics helps to reduce bacterial burden and manage symptoms in patients with NTM-PD. However, it does not prevent recurrence, which is mostly caused by reinfection.

Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever.

Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.

Evaluation of Recurrence Rates of Pseudomonas Pneumonia in Mechanically Ventilated ICU Patients Receiving ≤7 Versus &gt;7 Days of Antibiotic Therapy

Background Pseudomonas aeruginosa (PA) is commonly implicated in ventilator-associated pneumonia (VAP). Consensus guidelines for VAP recommend a 7-day course of appropriate antibiotics. However, recent studies have shown higher recurrence rates of PA pneumonia with shorter courses of antibiotics. This study was designed to compare PA pneumonia recurrence rates in patients who received appropriate antibiotics for ≤7 days vs &gt;7 days. Methods A retrospective, single-center, observational cohort study of adults diagnosed with PA-VAP between January 2017 and May 2022 was conducted. Patients were divided into a &gt;7-day cohort or a ≤7-day cohort based on duration of appropriate antibiotics. The primary outcome was the recurrence rate of PA pneumonia. Results A total of 106 patients were included, 59 in the &gt;7-day cohort and 47 in the ≤7-day cohort. The median (interquartile range) duration of appropriate antipseudomonal therapy was 12 days (8–18 days) in the &gt;7-day cohort and 7 days (6–7 days) in the ≤7-day cohort. Pseudomonas aeruginosa recurrence was observed in 15 (25.4%) patients in the &gt;7-day cohort and 20 (42.6%) patients in the ≤7-day cohort (P = 0.059). Over 33% of patients in the &gt;7-day cohort had persistently positive PA cultures after at least 7 days of appropriate antibiotic therapy. Conclusion Extending duration of antipseudomonal antibiotics beyond 7 days did not significantly reduce the recurrence of PA pneumonia. However, the lower rate of recurrence in the &gt;7-day group and high rate of persistent positive cultures may be clinically significant, suggesting a role for extended treatment. Further prospective studies are needed to determine the optimal duration of therapy for PA-VAP.

Microbiological persistence in patients with Mycobacterium abscessus complex lung disease: The prevalence, predictors, and the impact on progression

ObjectivesPersistent growth of Mycobacterium abscessus complex (MABC) in the respiratory system is not uncommon and may indicate continuous infection of MABC lung disease (MABC-LD), but its prevalence, risk factors, and clinical impact have not been investigated. MethodsThe present study was conducted in two medical centers in northern Taiwan. We enrolled patients with MABC-LD and investigated the prevalence and predictors of persistent culture positivity (MABC-PP). Furthermore, we analyzed the association between MABC-PP and radiographic or clinical progression. ResultsAmong 189 patients with MABC-LD, 58 were in the MABC-PP group. Independent predictors for MABC-PP included an increasing radiographic score and highest acid-fast stain (AFS) of strong positivity (3-4+) at initial diagnosis (compared with negative AFS). MABC-PP and highest AFS were independently associated with MABC-LD progression by the multivariable analysis model. The adjusted hazard ratio increased to 3.56 when the two independent factors existed. ConclusionsMABC-PP accounted for 30.7% and was predicted by initial AFS grade and radiographic score. Patients with MABC-PP, and highest AFS grade might have disease progression.

Risk factors for microbiological persistence after 6 months of treatment for Mycobacterium intracellulare and its impact on the drug-resistance profile.

Patients with Mycobacterium intracellulare pulmonary disease are more likely to experience poor treatment outcomes if they have been observed with microbiological persistence after 6 months of treatment. This study aims to identify the risk factors for microbiological persistence and describe the changes in the minimum inhibitory concentration (MIC) during antimycobacterial treatment. This retrospective case-control study enrolled patients diagnosed with M. intracellulare pulmonary disease between April 2017 and September 2021 at Shanghai Pulmonary Hospital. Patients with positive cultures after 6 months of treatment (positive group) were matched by age and sex in a 1:1 ratio to patients with negative conversion (negative group). Totally, 46 pairs of patients were analyzed. Risk factors for microbiological persistence at month 6 were smoking, previous tuberculosis treatment, chronic lung diseases, a positive baseline acid-fast bacilli smear, and adverse drug reactions; the risk was reduced by a regimen containing ethambutol, ≥3 effective drugs, and a higher pre-treatment absolute lymphocyte count. Regarding the drug-resistance profile, the negative group had a higher proportion of susceptibility to clarithromycin (100.0% vs 84.8%, P = 0.012). Most isolates were susceptible or intermediate to amikacin in both groups (93.5% and 84.8%, respectively). Nine patients (16.4%, 9/55) had a change in the drug-resistance profile, including four who changed from clarithromycin susceptible to clarithromycin resistant, and the other three reversed. Two pairs of isolates had a change in resistance to amikacin. In conclusion, risk factors for microbiological persistence were identified, and the change in MIC values during antimycobacterial treatment indicated the need for monitoring to enable timely adjustment of the regimen.IMPORTANCENontuberculous mycobacteria pulmonary disease (NTM-PD) has been recognized as an important public health issue because of its increasing incidence globally, low cure rate, and high recurrence rate. NTM-PD has innate resistance to many first-line anti-tuberculous drugs, which limits the treatment options. Mycobacterium intracellulare is reportedly the most important pathogenic NTM and accounts for the highest proportion of NTM-PD in China. A previous study suggested that poor microbiological response after 6 months of treatment is predictive of treatment failure. The present study investigated the risk factors associated with persistent positive sputum cultures by treatment month 6 in patients with M. intracellulare pulmonary disease and the variation in minimum inhibitory concentration patterns in clinical settings. This information might help to identify patients at higher risk of treatment failure and enable the timely provision of necessary interventions.

Time to sputum conversion in patients with pulmonary tuberculosis: A score to estimate the infectious period

IntroductionPatients with pulmonary tuberculosis (PTB) disease and positive sputum cultures are the main source of infection. Culture conversion time is inconsistent and defining the length of respiratory isolation is challenging. The objective of this study is to develop a score to predict the length of isolation period. MethodsA retrospective study was carried out to evaluated risk factors associated with persistent positive sputum cultures after 4 weeks of treatment in 229 patients with PTB. A multivariable logistic regression model was used to determinate predictors for positive culture and a scoring system was created based on the coefficients of the final model. ResultsSputum culture was persistently positive in 40.6%. Fever at consultation (1.87, 95% CI:1.02–3.41), smoking (2.44, 95% CI:1.36–4.37), >2 affected lung lobes (1.95, 95% CI:1.08–3.54), and neutrophil-to-lymphocyte ratio > 3.5 (2.22, 95% CI:1.24–3.99), were significantly associated with delayed culture conversion. Therefore, we assembled a severity score that achieved an area under the curve of 0.71 (95% CI:0.64–0.78). ConclusionsIn patients with smear positive PTB, a score with clinical, radiological and analytical parameters can be used as a supplemental tool to assist clinical decisions in isolation period.

Drug resistance profile of Mycobacterium kansasii clinical isolates before and after 2-month empirical antimycobacterial treatment

ObjectivesMycobacterium kansasii pulmonary disease is frequently misdiagnosed and treated as tuberculosis, especially in countries with high tuberculosis burden. This study aimed to investigate the drug resistance profile of M.kansasii in patients with M.kansasii pulmonary disease in Shanghai and to determine the variations in drug resistance after 2 months of antimycobacterial treatment. MethodsAll patients with a diagnosis of M.kansasii pulmonary disease from 2017 to 2019 in Shanghai were retrospectively analysed. Whole-genome sequencing was performed, and the minimum inhibitory concentration (MIC) to antimycobacterial drugs was measured using the broth microdilution method. ResultsIn total, 191 patients had a diagnosis of M.kansasii pulmonary disease. Of them, 24.1% (46/191) had persistent positive culture after 2 months of antimycobacterial treatment. Whole-genome sequencing revealed that the 46 paired isolates had a difference of <17 single nucleotide polymorphisms, thus excluding the possibility of exogenous reinfection. More than 90% of the baseline isolates were sensitive to rifampin, clarithromycin, moxifloxacin, or amikacin, whereas a high resistance to ethambutol (118/191, 61.8%) and 4 μg/mL of isoniazid (32/191, 16.8%) were observed. Two isolates presented high resistance to rifamycin (i.e. a rifampin MIC of >8 μg/mL and a rifabutin MIC of 8 μg/mL) both containing the rpoB mutation (S454L). The increase of MIC to rifampin, ethambutol, and/or isoniazid was identified in 50.0% (23/46) of the patients. DiscussionA high prevalence of innate resistance to ethambutol and isoniazid was observed among circulating M.kansasii clinical strains in Shanghai. The increase in drug resistance under empirical antimycobacterial treatment highlighted the urgency of definitive species identification before initiating treatment.

CLINICAL CHARACTERISTICS OF PATIENTS TREATED WITH ANTIMYCOBACTERIALS VS NO ANTIMYCOBACTERIALS IN NONCAVITARY MYCOBACTERIUM AVIUM COMPLEX PULMONARY DISEASE

CLINICAL CHARACTERISTICS OF PATIENTS TREATED WITH ANTIMYCOBACTERIALS VS NO ANTIMYCOBACTERIALS IN NONCAVITARY MYCOBACTERIUM AVIUM COMPLEX PULMONARY DISEASE

Treatment outcome of continuation of intravenous amikacin for Mycobacterium abscessus pulmonary disease with a persistent culture positivity after the treatment initiation

IntroductionWhether prolonged intravenous amikacin treatment would lead to better treatment results in patients with Mycobacterium abscessus subspecies abscessus (M. abscessus) pulmonary disease (PD) is unknown. We investigated the efficacy of continued amikacin treatment for the microbiological outcome of M. abscessus PD patients with persistent culture positivity after treatment initiation. MethodsWe retrospectively evaluated 62 patients with M. abscessus PD who were treated with intravenous amikacin and beta-lactams along with a macrolide-based regimen at 3 tertiary referral centers in South Korea. The intravenous antibiotic treatment duration was determined by the attending physician. ResultsThe median treatment durations with amikacin and beta-lactam in the 62 patients were 25.1 and 8.2 weeks, respectively. The overall microbiological cure rate was 29.0%. Among the 62 patients, 44 showed persistent culture positivity at 8 weeks after treatment with an amikacin-containing multidrug regimen. The median parenteral amikacin treatment duration after 8 weeks in these patients was 18.0 weeks. The conditional probability of microbiological cure with continuation of the amikacin-containing regimen in these patients was 18.2% (95% confidence interval 8.2–32.7). Additionally, the conditional probability of microbiological cure in the 34 patients with persistent culture positivity at 12 weeks was 8.8% (95% confidence interval 1.9–23.7). After 16 weeks, the conditional probability of microbiological cure decreased further, reaching 0% at 28 weeks after treatment initiation. ConclusionThe continuation of intravenous amikacin therapy was usually not followed by culture conversion in M. abscessus PD patients with persistent sputum culture positivity after treatment initiation.

Risk factors and outcomes of deep tissue Candida invasion in neonates with invasive candidiasis.

Deep tissue Candida invasion represents a special entity among neonates with invasive candidiasis. We aimed to explore the risk factors and clinical outcomes for deep tissue Candida invasion among neonates with invasive candidiasis. A retrospective data review of neonates admitted to NICU of Madinah maternity and children hospital, KSA from January 2012 to December 2019 was done. Data were analysed between infants with or without deep tissue candidiasis among infants with invasive candidiasis. Invasive candidiasis was defined as positive blood or catheter collected urine culture for Candida. Deep tissue Candida invasion was defined as an infection of the central nervous system, eyes, heart, skeletal system, lungs, liver or kidneys. A total of 14 (11%) out of 130 neonates with invasive candidiasis had deep tissue Candida invasion. Persistent positive blood culture for Candida [OR 15.2, 95% CI (2.0-114), p=.01], prematurity [OR 7.6, 95% CI (1.04-56.4), p=.04] and prolonged antibiotic duration [OR 1.3, 95% CI (1.02-1.6), p=.03] are independent risk factors for deep tissue Candida invasion. Deep tissue Candida invasion was associated with significantly higher rates of cerebral palsy, hydrocephalus, heart failure and longer length of hospital stay compared to infants without deep tissue invasion. Persistent Candida growth in blood cultures, prematurity and long-term antibiotic use are significant risk factors for deep tissue Candida invasion. Deep tissue Candida invasion is associated with prolonged hospital stay and higher neonatal morbidity.

Outcomes of adjunctive surgery for nontuberculous mycobacterial pulmonary disease

BackgroundOwing to the unsatisfactory results of antibiotic treatment alone, surgical resection is currently considered as adjunctive therapy in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD). However, reports regarding the outcomes of surgery vary considerably by institution. Here, we investigated the surgical outcomes and risk factors associated with unfavorable outcomes after surgery.Methods We analyzed patients with NTM-PD who underwent pulmonary resection at Seoul National University Hospital between January 1, 2006, and December 31, 2020, and assessed the types of surgical procedures, complications, and long-term outcomes. Multivariate logistic regression analysis was used to identify the risk factors associated with treatment refractoriness or recurrence after surgery.ResultsAmong 67 patients who underwent surgery during the study period, the most common indication for surgery was persistent culture positivity despite rigorous medical treatment (80.6%), followed by longstanding cavitary lesions or radiographic aggravation (10.4%) and massive hemoptysis (4.5%). Among 53 patients with positive mycobacterial cultures at the time of surgery, 38 (71.7%) achieved initial negative culture conversion, 9 (17.0%) of whom experienced recurrence. Nine (13.4%) patients experienced postoperative complications, which were managed without lasting morbidity and mortality. Female sex (adjusted odds ratio [aOR] 6.63; 95% confidence interval [CI] 1.04–42.4; P = .046), preoperative positive mycobacterial culture (aOR 5.87; 95 %CI 1.04–33.08; P = .045), and residual lesions (aOR 6.86; 95 %CI 1.49–31.56; P = .013) were associated with refractoriness or recurrence.ConclusionsPulmonary resection is a reasonable treatment modality for patients with refractory NTM-PD or major complications such as massive hemoptysis. The potential risk factors associated with unfavorable outcomes included female sex, preoperative positive mycobacterial culture, and residual lesions after surgery.

Abdominal Neuroblastoma and Early Onset Acinetobacter Septicemia in a Newborn

Background: Neonatal sepsis is a leading cause of mortality and morbidity in the first month of life. The underlying risk factors for early-onset infection (in the first 3 days of life) are prematurity, low birth weight, maternal history of infection, difficult delivery, male gender, twin pregnancy, and congenital malformations. Acinetobacter is a nosocomial infection and rarely caused the early-onset-sepsis and meningitis. The most common neonatal tumor is neuroblastoma; however, it is not defined as a risk factor for early-onset sepsis. Case report: A 13-day-old newborn female was referred to our hospital due to ventriculitis, persistent meningitis, and an abdominal mass. She was a term neonate delivered by cesarean section from a mother with a nearly normal pregnancy with no complications, such as chorioamnionitis, prolonged rupture of membrane, urinary tract infection, preeclampsia, and diabetes. A fetal abdominal mass was detected on the left kidney in prenatal sonography. The patient was admitted to the Neonatal Intensive Care Unit in the first minutes of life because of respiratory distress and cyanosis. Subsequently, mechanical ventilation, endotracheal surfactant instillation, and antibiotic therapy were prescribed. Due to the deterioration of the general condition, fever, seizure, and hematuria on the third day, sepsis workup and changing the antibiotics were performed. Blood culture and cerebrospinal fluid (CSF) were positive for Acinetobacter baumannii. Persistent positive CSF culture led to the diagnosis of ventriculitis which was confirmed by brain computed tomography scan (CTS) and ventricular tap. The condition of the patient got better after intraventricular amikacin injection in addition to intravenous colistin and piperacillin. Postnatal sonography and CTS confirmed the abdominal neuroblastoma. Chemotherapy was initiated after the complete treatment of sepsis, meningitis, and ventriculitis. This case report presents a term and female neonate with early-onset neonatal sepsis and meningitis, caused by an unusual microorganism, and a prenatal history of abdominal neuroblastoma. Conclusion: By this case report, the clinicians are suggested to consider the Acinetobacter baumannii as the cause of fulminant sepsis and meningitis in a term neonate with no underlying risk factors for infection.  Keywords

1607. Dual Therapy with Aztreonam &amp; Ceftazidime/Avibactam Against Multi-Drug Resistant Stenotrophomonas maltophilia on Tricuspid Valve Endocarditis

BackgroundAntimicrobial resistance in Stenotrophomonas maltophilia is one of the most complex among Gram-negatives. Presence of regulating non-specific antimicrobial class efflux pumps and chromosomal encoded L1 metallo-betalactamase (Ambler Class B) and L2 betalactamase (Ambler Class A) are responsible for few clinically active antimicrobials and pan-drug resistant strains.MethodsA 38 year old male with a history of IV drug use, chronic hepatitis C, and recent MSSA endocarditis was admitted with sepsis. Workup revealed tricuspid valve endocarditis with pulmonary septic emboli due to S. maltophilia. Initial antibiotics were levofloxacin (LVX), metronidazole, and piperacillin-tazobactam (TZP) followed by LVX and minocycline (MIN). He had valve replacement on day 6. Repeat blood cultures and valve tissue culture revealed pan-resistant S. maltophilia (resistant: ceftazidime (CAZ), LVX, MIN, TMP/SMX, chloramphenicol; intermediate: MIN; eravacycline MIC 8 μg/mL; tigecycline MIC 16 μg/mL). Microbiology Department was consulted for additional antimicrobial options. In vitro testing for aztreonam (ATM) with ceftazidime/avibactam (CZA) was recommended.ResultsSynergy testing between ATM and CZA was performed by positioning ATM strip over the area where CZA had been previously been placed and removed after 10 minutes of incubation. The interception of the growth with the ATM strip was read. In presence of avibactam, ATM MIC was 4 μg/mL, 6 two-fold dilutions lower than ATM without CZA. MIC for ATM (256 μg/mL), CAZ (256 μg/mL) and CZA (32 μg/mL) were tested individually. ATM with CZA was recommended as a salvage treatment based on in vitro result. Patient completed 6 weeks of ATM with CZA along with MIN. He achieved microbiologic clearance and clinical recovery from infection. At the end of treatment, he experienced episodes of refractory ascites. With complex comorbidities, patient was not a transplant candidate and transitioned to hospice two weeks later.ConclusionAlthough the surgical excision was key, treatment with ATM and CZA provided effective antimicrobial treatment in the setting of persistent positive blood culture. ATM with CZA should be considered for cases of pan-drug resistant S. maltophilia with limited treatment options.Disclosures All Authors: No reported disclosures

1468. Culture Conversion and Mortality in Patients With Mycobacterium abscessus (MAB) Lung Disease: A Systematic Literature Review

BackgroundPrognosis for patients with MAB lung disease is poor. We sought to examine the potential association between culture conversion and outcomes (progression, mortality) in patients with MAB lung disease.MethodsEnglish-language MAB lung disease studies with ≥ 10 patients and reporting mortality and/or microbiological outcomes were identified from Embase, PubMed, relevant congress abstracts, and the Cochrane Library (data cutoff, September 24, 2019) using the National Institute for Health and Clinical Excellence guidance for systematic literature reviews. Two independent reviewers screened 1,551 indexed records; relevant extracted data are expressed as population-weighted means.ResultsMean all-cause mortality across 17 studies (N=1,291) was 12.1% (range, 3%–33%); mortality attributable to MAB lung disease was 7.6% (range, 0%–27%; N=526, 9 studies). Culture conversion across 44 studies (N=2,237) was 46.7% (range, 0%–98.6%), with higher rates reported for M. massiliense subspecies (76.9%; N=507,15 studies) than M. abscessus subspecies (35.8%; N=834,18 studies). No direct comparisons were made between mortality and culture conversion; in the 13 studies (N=1,202) that reported both outcomes there was a moderate correlation between increased rate of culture conversion and decreased MAB-attributable mortality (R2=0.60). The most common definition of progression (21 studies) was radiographic worsening supported by persistent symptoms and/or positive cultures. Across 8 studies (N=415) 57.8% patients had improvement while 35.2% progressed with treatment. A broad variance in treatment regimen and duration (range, 32 days to > 3 years) was observed. Limitations include a small number of studies, and inconsistency in methods and outcomes definitions.ConclusionIn this systematic literature review, available data suggest that culture conversion was achieved in less than half of patients and was lower in patients with M. abscessus compared with M. massiliense. One third of patients had disease progression despite treatment. Some data suggest lower MAB-attributed mortality outcomes in studies with higher culture conversion rates, more evidence is needed to demonstrate a survival benefit associated with culture conversion.DisclosuresKevin L Winthrop, MD, MPH, Insmed Incorporated (Consultant, Grant/Research Support) Kevin C Mange, MD, MSCE, Insmed Incorporated (Employee) Zhanna Jumadilova, MD, Insmed Incorporated (Employee) Kristan B Cline, PhD, Insmed Incorporated (Employee) Patrick A Flume, MD, Insmed Incorporated (Grant/Research Support, Scientific Research Study Investigator, Advisor or Review Panel member)

The Prognostic Value of Persistent Culture Positivity in Fungal Keratitis in the Mycotic Antimicrobial Localized Injection Trial

To evaluate the utility of repeat cultures at days 3 and 7 after starting antifungal medications for predicting outcomes in fungal keratitis. Prespecified secondary analysis of the randomized clinical Mycotic Antimicrobial Localized Injection trial. Patients presenting to Aravind Eye Hospital, Pondicherry, India, with fungal keratitis and visual acuity worse than 20/70 received topical natamycin and were randomized to either receive intrastromal injection of voriconazole or topical therapy alone. All subjects received corneal cultures at date of presentation, day 3, and day 7. Outcome measures included 3-week and 3-month visual acuity and scar size, corneal perforation, and/or the need for therapeutic penetrating keratoplasty (TPK). Visual acuity and scar size were analyzed with multiple linear regression controlling for baseline measures. Survival analysis was used to analyze the risk of corneal perforation and/or need for TPK. Of the 70 study subjects with fungal keratitis, 25 of 69 (36%) remained culture positive at day 3, and 20 of 62 (32%) were culture positive at day 7. Culture positivity at day 3 conferred a hazard ratio of 2.8 for requiring TPK (P= .03) but was not a statistically significant predictor of perforation, scar size, or final visual acuity. Culture positivity at day 7 had a hazard ratio of 3.5 for requiring TPK (P= .003). Those with positive cultures at day 7 had on average 3 logMAR lines worse visual acuity at 3months (95% confidence interval 0.9 to 5.2 logMAR lines, P= .006) and 1.1mm larger scar size at 3months after controlling for baseline measures (95% confidence interval 0.1 to 2.2mm; P= .03). While not as predictive as day 7 cultures, culture positivity at day 3 after starting treatment is a significant predictor of the need for TPK in patients with moderate-to-severe filamentous fungal keratitis. This has applications for risk stratification, and may facilitate earlier consideration of TPK in high-risk patients.

Failed Reverse Shoulder Arthroplasty and Recommendations for Revision.

The most common complications warranting revision consideration in reverse shoulder arthroplasty (RSA) include instability and its associated causes: infection, periprosthetic fracture, and glenoid baseplate loosening. Management of complications can be challenging and the nuances of treatment are still being elucidated. The focus of this paper is to review the treatment of the failed RSA and discuss evidence-based recommendations for revision. The most common complications requiring revision RSA are instability and infection. The causes for instability can be subdivided into three main subcategories: loss of compression, loss of containment, and impingement. Loss of compression is further broken down into 6 subcategories revolving around abnormal prosthesis positioning, undersized prostheses, or intrinsic soft-tissue tension loss leading to instability. Periprosthetic infection can also lead to instability, yet the most appropriate management for infected RSA remains controversial. Restoring stability by maximizing deltoid and soft tissue tension while avoiding impingement revolves around three basic methods: (1) lateralizing and/or upsizing the glenosphere to an inferior position on the glenoid, (2) use of a more constrained polyethylene insert, and (3) distalizing the humerus by increasing the polyethylene thickness and/or the thickness of the humeral tray. Management of periprosthetic joint infection can be performed in one-stage, two-stage, or "three-stage" procedures all showing good outcomes with two-stage procedures being the most commonly performed. However, persistent positive culture with propriobacterium acnes can occur in up to 25% of cases. In order to limit the associated morbidity from failed revision reverse shoulder arthroplasty, continued research on best management of associated complications is warranted.

Delftia acidovorans pseudo outbreak in portable reverse osmosis machines: Interventions to ensure safe and cost-effective hemodialysis

Reverse osmosis (RO), a major advance in hemodialysis (HD) safety, effectively clears most water organisms. Delftia acidovorans is an environmental water-borne pathogen that is rarely reported to cause human infections. We report a pseudo outbreak caused by colonization of RO machines with D acidovorans with no reported human infections and interventions to improve HD safety. Repeated positive RO product water cultures triggered our hospital to initiate an investigation, RO machines were examined for mechanical integrity by biomedical engineers. Cultures of product water as well as RO parts were done. Testing for bacterial relatedness after identification was performed. An investigation was conducted in a systematic fashion to determine the cause and the extent of the problem. Upon formal review of policies and procedures, there were minor deficiencies. Rectifying these deviations from policies did not stop the repeated positive water cultures. A 7-step investigation and correction was successfully conducted. City water testing with filtration and concentration methods was positive for D acidovorans. Major renovation of the HD unit with replacement of all RO machines and a 2-step water filtration resulted in elimination of the pseudo outbreak. City water was the source of biofilm formation of D acidovorans in RO machines that was not possible to eradicate. Application of incoming water filters was an effective preventive strategy. Replacement of RO machines after 4 failed disinfection attempts is the most cost-effective strategy as well for persistent positive water cultures. The HD remains RO water culture negative 2 years after changes.

Sitafloxacin-Containing Regimen for the Treatment of Refractory Mycobacterium avium Complex Lung Disease.

BackgroundSitafloxacin (STFX) exhibits potent activity against Mycobacterium avium complex (MAC) in both in vitro and in vivo experiments. However, limited data are available for the clinical efficacy and adverse effects of STFX and the susceptibility of refractory MAC lung disease (MAC-LD) to the drug. Therefore, this study was aimed at evaluating the clinical efficacy and safety of an STFX-containing regimen for the treatment of refractory MAC-LD.MethodsWe retrospectively evaluated treatment outcomes of 31 patients with refractory MAC-LD, who received an STFX-containing regimen for ≥4 weeks between January 2010 and July 2017. Refractory MAC-LD was defined as persistent positive sputum cultures for >6 months of macrolide-based standard therapy.ResultsClarithromycin resistance (minimum inhibitory concentration [MIC] ≥32 μg/mL) was identified in 15 patients (48%). Twelve months after receiving the STFX-containing regimen, 26% and 19% of patients showed symptomatic and radiological responses, respectively. Although STFX-associated adverse effects were noted in 9 patients, their severity was grade 1 (National Cancer Institute Common Terminology Criteria); only 1 patient discontinued STFX because of suspected gastrointestinal disturbance. Negative sputum culture conversion was achieved in 7 patients (23%). Both univariate and multivariate logistic regression analyses revealed that surgery, low STFX MIC (≤1 μg/mL), and macrolide resistance were significant predictors of negative sputum culture conversion.ConclusionsOur results demonstrate that STFX may be effective in one-fourth of patients with refractory MAC-LD. Prospective larger studies that include the analyses of MAC are needed to determine the clinical efficacy of STFX against refractory MAC-LD.

Ocular Surface Microbial Flora in Patients with Chronic Limbal Stem Cell Deficiency Undergoing Cultivated Oral Mucosal Epithelial Transplantation.

PURPOSE:The purpose of this study is to analyze the ocular surface microbial flora in patients with chronic limbal stem cell deficiency (LSCD) due to Stevens–Johnson Syndrome (SJS) and ocular chemical injury undergoing cultivated oral mucosal epithelial transplantation (COMET).METHODS:Patients of SJS and chemical injury who had bilateral total LSCD planned for COMET were studied. Conjunctival swab was taken before surgery. Parameters evaluated were organism cultured, sensitivity pattern, frequency of positive culture, and clinical impact on management strategy.RESULTS:Thirteen patients were included in which nine were males and four females. All patients had positive conjunctival swab culture. Most common organism isolated was Staphylococcus epidermidis, followed by Staphylococcus aureus and Pseudomonas aeruginosa. The staphylococcal species isolated were sensitive to all the conventional antibiotics while Pseudomonas cultured showed resistance to cefuroxime, ceftriaxone, and ceftazidime. Repeat conjunctival swab sent after a week of topical antibiotic therapy yielded positive culture of the same organism twice in 25% (3/12), thrice in 58.3% (7/12), and four times in 16.6% (2/12) of the patients. One patient had a polymicrobial flora with positive yield of S. aureus (thrice), S. epidermidis (twice), and P. aeruginosa (twice) in consecutive conjunctival swab culture in the absence of clinical infection. Two patients with persistent positive cultures had to undergo repeat oral mucosal harvesting as the transplantation of the cultivated explants had to be deferred.CONCLUSION:Ocular surface in LSCD patients yielded pathogenic organisms on culture. Poor ocular surface with absent tear film could be the contributing factors. It is important to perform the conjunctival swab culture before COMET surgery.

Treatment outcomes for multidrug-resistant tuberculosis in Eastern Taiwan.

Objectives:The objective of this study is to evaluate the treatment outcomes of patients with multidrug-resistant tuberculosis (MDR-TB) under special programmatic management in Eastern Taiwan over the past 10 years.Materials and Methods:All newly diagnosed MDR-TB patients and MDR-TB patients enrolled previously with persistent positive cultures were included in this study, from May 2007 to April 2017, in Eastern Taiwan. A panel of pulmonologists designed the initial MDR-TB regimens. Subsequently, regimens were adjusted according to drug susceptibility test results for second-line drugs. Mobile teams were organized for treatment support, and several measures were adapted to safeguard effective treatment support.Results:A total of 178 patients with bacteriological confirmed pulmonary MDR-TB were identified, of whom 167 had treatment outcomes when the study was conducted. Of these 167 patients, 120 (71.9%) were cured, 11 (6.5%) completed therapy (78.4% had successful treatment), 25 (15.0%) died, 9 (5.4%) had treatment failure, none were transferred out, and 2 (1.2%) were lost to follow-up. Surgery was performed on 8 (4.8%).Conclusions:This is an analysis of the treatment outcomes after adopting the Directly Observed Treatment, Short-course Plus program to treat MDR-TB patients in Eastern Taiwan. We had a low proportion of loss-to-follow-up, resulting in a high treatment success rate. This program serves as an effective model in providing quality care to patients with MDR-TB.