Piperacillin-tazobactam Research Articles

Microbes and antibiotic susceptibility patterns of urinary tract infections in toilet-trained Children at a Tertiary Care Hospital of Sialkot, Pakistan.

Objective: To find out various types of microorganisms causing urinary tract infections and their antibiotic sensitivity patterns among toilet-trained children presenting at a tertiary care hospital of Sialkot District. Study Design: Descriptive study. Setting: Department of Microbiology/Urology, Khawaja Muhammad Safdar Medical College, Sialkot. Period: June to December 2019. Material & Methods: A total of 176 toilet trained children, aged 7 to 15 years, presenting in outpatient department and having culture positive urinary tract infections were enrolled. Demographic information like age, gender and area of residence along with clinical findings, antibiotic sensitivities and resistance patterns were recorded. Mid-stream urine sample was collected from all toilet-trained children and immediately sent to institutional laboratory for urine analysis and urine culture and sensitivities. Results: Out of a total of 176 children, 95 (54.0%) were female and 81 (46.0%) male. Overall mean age was noted to be 10.68+2.42 years while most of the children, 94 (53.4%) were above 10 years of age. Majority of the patients, 98 (55.7%) belonged to rural areas. Eschericia coli were the most common isolate, found among 140 (79.5%) children. Imipenem (98.9%), meropenem (98.9%), piperacillin tazobactam (97.7%), fosfomycin (96.6%), amikacin (95.5%), nitrofurantoin (84.4%), gentamycin (90.9%) and amoxicillin clavulanate (83%) were found to have the highest sensitivities. Conclusion: Eschericia coli were the most common bacterial urinary pathogens in toilet-trained children. Amoxicillin clavulanate, Nitrofurantoin and Fosfomycin available in oral form showed good sensitivity of 83%, 84.4%, and 96.6% respectively) to commonly found microorganisms. It was also noted that resistance to commonly used antibiotics in our region is rising.

Piperacillin-Tazobactam Allergies: An Exception to Usual Penicillin Allergy.

PurposeThe majority of penicillin allergy labels are false, and skin tests (ST) have high negative predictive value (NPV) of up to 90%. Piperacillin-tazobactam (PT) allergy has been suspected to be an exception to this, but existing literature is scarce. We investigate the epidemiology, clinical characteristics, testing outcomes and predictive value of ST in patients referred for suspected PT allergies.MethodsThe records of all patients referred for suspected PT allergy testing and prescription rates of PT in all Hong Kong public hospitals (2015–2019) were analyzed.ResultsThere was an increase in both PT prescriptions and number of newly reported PT allergies between 2015 and 2019. The majority (91.1%) of patients with suspected PT allergy had at least 1 underlying medical co-morbidity or immunosuppressant use leading to increased risk of infections. Thirty-six patients with suspected PT allergy completed ST. Two patients had positive ST, and 32/34 patients with negative ST underwent drug provocation testing (DPT). Nine of these patients were diagnosed with PT allergy based on positive DPT. Overall, 11/34 (32.4%) were diagnosed with PT allergy and the NPV of ST was 71.9%.ConclusionsThere is growing utilization of PT and corresponding cases of suspected allergies. The majority of suspected PT allergies had increased risk for recurrent infections. Unlike other penicillin allergy, there is a high rate of genuine PT allergy (up to 30%) and a poor NPV of ST (up to 70%). DPT remains the gold standard for accurate diagnosis, and all patients with a suspected allergy should undergo thorough allergy workup.

Microbiological Spectrum and Outcomes of Acute Pyelonephritis in North Indian Population.

A wide range of causative organisms can cause acute pyelonephritis (APN). However, in recent times, these pathogens have increasingly become resistant to most of the antibiotics making treatment difficult. This was a prospective observational single-center study with a aim to study the microbiological spectrum, resistance patterns, and clinical outcome of patients with APN conducted in a private tertiary care hospital in India. All adult patients hospitalized in the department of nephrology at our institute with a diagnosis of APN from February 2016 to May 2017 were included. Patients <18 years of age, kidney-transplant recipients, and pregnant patients were excluded. Demographic details, clinical symptoms, signs, and radiological and laboratory data including urine and blood cultures of all patients were recorded. The details of treatment received and outcomes in hospital and after discharge were noted. Patients were followed up three months post discharge. Decision of antibiotic and duration of antibiotics was documented by treating nephrologists. Quantitative data were presented in terms of means and standard deviation. Student's "t" test was used for comparison of quantitative outcome parameters. P <0.05 is considered statistically significant. SPSS software version 23.0 was used for statistical analysis. A total of 89 patients with a mean age of 50.33 ± 13.9 years, of which 61.8% were males and were studied; 82/89 had complicated pyelonephritis. The most common risk factor for APN was diabetes mellitus in 64 (72%). Most common symptom was fever in 80 (90%). A triad of fever, flank pain, and dysuria was present only in 27 (30.33%). Overall, 15 patients (16.8%) had severe pyelonephritis requiring intensive care unit admission. The most common organism isolated was Escherichia coli in 26/49 (53%), followed by Klebsiella pneumoniae in 12 (24.40%). Twenty-two (58%) isolates were extended-spectrum beta lactamase producers. Six (12.20%) were resistant to carbapenems and two (4%) were pan-resistant. All 89 were treated with intravenous antibiotics. Older patients, those with diabetes, with poor glycemic control, and with emphysematous pyelonephritis and patients in whom ESBL organisms were grown had poor outcome. Piperacillin tazobactam, aminopenicillins, cefoperazone sulbactam, and carbapenems (in severe pyelonephritis) can be considered as the empirical antibiotic of choice.

The Evolving Antibiotic Profile of Paediatric Urinary Tract Infections at a Tertiary Hospital in Cape Town

Abstract Background: Urinary tract infection (UTI) is a common problem in infants presenting to hospitals with fever. International data reports that uropathogens and their associated antibiotic susceptibility is evolving. This study describes the organism profile and the respective antibiotic resistance patterns in a paediatric unit at a tertiary hospital in the Western Cape, South Africa. Methods: A retrospective study on urine samples sent to the National Health Laboratory Service from 1 January 2012 to 31 December 2013 was performed. UTI was defined as a single organism growth &gt;105 cfu/ml and leukocytes &gt;1000 cells/ml. The organisms and antibiotic sensitivities were described and stratified into either community, hospital-associated or hospital-acquired infections. Results: Two hundred and eighty-two samples met the study definitions for inclusion in the study. Escherichia coli was cultured most frequently (50.7%) followed by Klebsiella pneumoniae (22.7%) and Proteus mirabilis (4.6%). Extended-spectrum beta-lactamase (ESBL) producing organisms accounted for 26.6% of identified UTI; K. pneumoniae accounted for 54/75 (72%) of those infections. Of ESBL-producing organisms, 6.7% of E. coli were sensitive to piperacillin–tazobactam and 33.3% to amikacin. K. pneumoniae displayed 18.5% and 68.5% sensitivity to piperacillin–tazobactam and amikacin, respectively. E. coli isolates were highly resistant to amoxicillin/ampicillin (90.8%). K. pneumoniae demonstrated high rates of resistance to co-amoxiclavulanate acid (88.7%) and cefotaxime/ceftriaxone (98.2%). Conclusion: The organism population and antibiotic sensitivity profile is evolving in-line with published data. These antibiograms support current hospital policy to treat hospital-associated and acquired infections with piperacillin–tazobactam and amikacin empirically thereby limiting carbapenem drug pressure. Predictors for uropathogen antibiotic resistance require further investigation.

Infective endocarditis caused by Neisseria mucosa on a prosthetic pulmonary valve with false positive serology for Coxiella burnetii – The first described case

We present a case of infective endocarditis (IE) on a prosthetic pulmonary valve in a 36-year-old patient with tetralogy of Fallot (TOF). The patient underwent valve replacement surgery and active antibiotic treatment against Gram-negative cocci (Piperacillin Tazobactam then Ceftriaxone) for a total duration of 42 days with a favourable outcome. The causative agent was Neisseria mucosa which was identified on the infected valve by sequencing of 16S ribosomal RNA. To our knowledge, this is the first described case of a N. mucosa infective endocarditis on a pulmonary valve. Initially, serologies performed in clinical settings by immunofluorescence for Coxiella burnetii antibodies showed a major increase in phase I IgG titers at 1024 (normal values <16) corresponding with the diagnostic criteria for Q fever endocarditis. However, this diagnosis could not be confirmed by the National Reference Center, making it the first reported case of a false positive serology for C. burnetii during an infection due to Neisseria spp.

耳管通気を契機に重症呼吸不全を来した1例(A case of severe respiratory failure triggered by eustachian tube inflation that required life–saving venovenous extracorporeal membrane oxygenation)

要旨耳管通気法は，耳管咽頭口より耳管を通じて鼓室内へ空気を送気し，耳管の通気度や鼓室内の浸出液の評価，また滲出性中耳炎や耳管狭窄症の治療を行う外来処置である。昔より日常的に行われてきた手技であるが，合併症として鼻腔損傷，化膿性中耳炎および鼓膜穿孔のほか，稀に重篤な中枢神経合併症を起こすことが知られ，最近は施行頻度が減少している。今回我々は，耳管通気法後に，合併症と思われる気脳症，空気塞栓症を発症し，さらに重篤な呼吸不全を併発し，救命にVV–ECMOを要した症例を経験したので，文献的な考察とともに報告する。

Microbiological profile and antibiotic sensitivity pattern of post-operative orthopaedic Implant infections in tertiary care hospital

Background: A correct information about most common causative organism and it sensitivity pattern in that clinical setup is essential for designing empirical therapy. Present study has been designed to study the microbiological profile and antibiotic sensitivity pattern of post-operative orthopaedic Implant infections in tertiary care teaching hospital.Material and Method: This prospective observational study. Patients who presented with the signs and symptoms of infections, confirmed by laboratory and other routine investigations, were included in present study. The demography, microbiological data sensitivity to antimicrobial agent of organism was recorded.Result: The most common pathogen isolated was pseudomonas aeruginosa that is 52(43.3 %), followed by staphylococcus aureus that is 50(41.66%). Pseudomonas aeruginosa was sensitive to Piperacillin tazobactam 42(80.7%), Imipenem 40(76.9%), Imipenem+cilastatin 42(80.7%) and Meropenem 43(82.7%). Methicillin resistant staph aureus were sensitive to Cotrimoxazole 6(50%), Clindamycine 9(75%), Vancomycin 11(91.7%) and Linazolid10 (83.4%).Conclusion: Implant of femur was most commonly infected. Staphylococcus Aureus (MSSA) was commonly associated with biofilm formation followed by Staphylococcus Aureus (MRSA). Pseudomonas aeruginosa isolated from implant infections were sensitive to Piperacillin+ tazobactam, Imipenem, Imipenem+cilastatin and Meropenem.

Bacterial Etiology of Neonatal Sepsis, Antibiotic Susceptibility Profile, and Associated Factors at Burdwan Medical College, Burdwan, West Bengal, India

AbstractObjective Neonatal sepsis remains to be a major cause of neonatal mortality and morbidity in developing countries like India. This study was aimed to identify the bacterial isolates and study antimicrobial profile among admitted babies with neonatal sepsis.Methods A cross-sectional retrospective study was conducted in the sick neonatal wards and neonatal intensive care unit of Burdwan Medical College from March 2017 to February 2018. A total of 299 neonates suspected of neonatal sepsis was evaluated. Diagnosis of neonatal sepsis was made through positive blood culture. Positive samples were subcultured on specific media like blood, chocolate agar, nutrient, Muller–Hinton agar, and MacConkey plates, and the organisms were identified by gram staining and biochemical reactions. Antibiotic susceptibility was tested by Kirby–Bauer disc diffusion method.Results Overall, 118 blood cultures out of 299 patients (39.46%) were bacteria-positive. Of these, 31.3% cases had early-onset septicemia (EOS), while 68.6% had late-onset septicemia (LOS). The prevalence of sepsis was higher in males (55.9%), preterm babies (58.47%), and low birth weight neonates (37.29%). The highest bacterial strains isolated were Klebsiella spp. (33.8%) followed by Staphylococcus aureus (25.8%), Escherichia coli (22.8%), coagulase-negative Staphylococcus (12.5%), Pseudomonas spp. (2.5%), Enterococcus spp. (1.6%), Acinetobacter spp. (0.8%), and Burkholderia spp. (0.8%). Resistance is high among the gram-negative bacteria, like Enterobacter and Pseudomonas, for piperacillin–tazobactam and cephalosporins but they are mostly sensitive to meropenem, colistin, and levofloxacin. Gram-positive bacteria, like S. aureus, are mostly resistant to amoxicillin–clavulanic acid but highly sensitive to linezolid, vancomycin, azithromycin, and teicoplanin.Conclusion K. spp. and S. aureus are the most common isolates in our study. The level of resistance among the organisms toward conventional antibiotics like amoxicillin, cephalosporins, and piperacillin–tazobactum is alarmingly high. This warrants formulation of a hospital-specific guideline for antibiotic use and periodic review of the same.

80. Pharmacoeconomic Analysis Comparing the Empiric Utilization of Cefepime Versus Piperacillin/tazobactam

BackgroundIn the hospital setting, cefepime (CFP) and piperacillin/tazobactam (PTZ) are among the most commonly utilized antipseudomonal agents in the empiric treatment of nosocomial and healthcare-associated infections. Institutional preference of CFP or PTZ as the preferred antipseudomonal antibiotic varies. Recent literature suggests each may be associated with increased rates of harmful adverse effects including Clostridiodes difficile infection (CDI) and acute kidney injury (AKI). The objective of this study is to perform a pharmacoeconomic analysis comparing CFP versus PTZ for empiric antibiotic treatment in patients where Pseudomonas aeruginosa is a concern.MethodsWe performed a cost-utility analysis comparing CFP and PTZ for empiric utilization in the hospital setting by creating a decision analytic model from the hospital perspective. Model variables were populated utilizing published clinical and economic data including incidence of AKI and CDI, their associated costs and mortality, and the cost of antibiotic therapy. Secondary and univariate sensitivity analyses tested the impact of model uncertainties and the robustness of our model. A willingness to pay (WTP) threshold of $0 was utilized.ResultsResults of our base-case model predicted that the use of CFP dominated PTZ as empiric utilization was less expensive ($7690 vs. $9331) and associated with a higher quality-adjusted life-years (QALY) (0.9193 vs. 0.9191) compared to the use of PTZ. Several variables had the potential to impact base case results. PTZ became cost-effective at our WTP threshold if CFP nephrotoxicity rates increased to 17.3%, the PTZ nephrotoxicity decreased to 28.5%, or if the cost of nephrotoxicity was less than $17,457. No other model variables, including incidence of CDI, impacted base case results.Sensitivity Analysis on Cefepime Clostridioides difficile Infection Incidence and Piperacillin/tazobactam Nephrotoxicity ConclusionResults of our model showed that CFP dominated PTZ for the empiric treatment of nosocomial infections. The model was sensitive to variation in CFP and PTZ nephrotoxicity rates.Disclosures All Authors: No reported disclosures

1576. Re-Evaluation of cefepime or piperacillin-tazobactam to Decrease Use of Carbapenems in ESBL-Producing Enterobacterales BloodStream Infections (REDUCE-BSI)

BackgroundThe ideal therapy for treatment of bloodstream infections (BSI) due to ESBL-producing organisms is widely debated. Although prior studies have demonstrated efficacy of non-carbapenems (CBPNs) for ESBL infections, results from the MERINO study group found increased mortality associated with piperacillin/tazobactam (PT) when compared with meropenem for treatment of ESBL BSI. The goal of this study was to investigate patient outcomes associated with the use of CBPN-sparing therapies (PT and cefepime (CEF)) for ESBL BSI. The primary outcome was in-hospital mortality between non-CBPN (PT and CEF) and CBPN groups. Secondary outcomes included clinical cure, microbiologic cure, infection recurrence, and development of resistance.MethodsThis was a retrospective observational study of patients admitted to the hospital from May 2016 - May 2019 with a positive blood culture for an ESBL-producing organism. Patients receiving meropenem, ertapenem, PT, or CEF were included. Patients were excluded if < 18 years old, receiving antibiotics for < 24 hours, treated for a polymicrobial BSI, or receiving concomitant antibiotic therapy for another gram-negative (non-ESBL) infection.ResultsOne hundred and fourteen patients were analyzed; 74 (65%) patients received CBPN therapy compared with 40 (35%) patients that received a non-CBPN (CEF N=30, PT N=10). There were no statistically significant differences in baseline characteristics between groups. The overall in-hospital mortality rate was 6% (N=7). Eight percent of patients (N=6) in the CBPN arm died compared to 3% (N=1) of patients in the non-CBPN arm, P = 0.42. No difference in mortality was detected between groups when evaluating subgroups with Pitt bacteremia score ≥4 (N=25), requiring ICU admission (N=50), non-genitourinary source (N=50), or by causative organism (N=76 E. coli; N=38 Klebsiella spp.). There was no difference between groups for secondary outcomes.ConclusionCEF and PT are reasonable options for the treatment of ESBL BSI and did not result in increased mortality or decreased clinical efficacy when compared to CBPNs in this cohort.Disclosures All Authors: No reported disclosures

LB-4. Cefepime-Enmetazobactam Demonstrates Superiority to Piperacillin-Tazobactam in a Subgroup of Patients with Complicated Urinary Tract Infections/Acute Pyelonephritis Caused by Extended Spectrum β-Lactamase-Producing Enterobacterales

BackgroundThere is a critical need for carbapenem-sparing therapies for infections caused by extended spectrum β-lactamase (ESBL)-producing Enterobacterales. Enmetazobactam is a novel ESBL inhibitor combined with the cephalosporin cefepime. Treatment outcomes of cefepime-enmetazobactam (FPE) versus piperacillin-tazobactam (PTZ) were assessed in subgroups of patients with ESBL-producing baseline uropathogens (ESBL-BU) in the ALLIUM phase 3 trial of complicated urinary tract infections (cUTI)/acute pyelonephritis (AP).Methods1034 cUTI/AP patients randomized 1:1 in a double-blind, multicenter trial received either 2 g cefepime/0.5 g enmetazobactam or 4 g piperacillin/0.5 g tazobactam q8h by 2h infusion for 7 to 14 days. Enterobacterales with MICs ≥1 µg/ml to ceftazidime, ceftriaxone, cefepime, meropenem, or FPE were genotyped for β-lactamases. In addition to the primary analysis (by stratified Newcombe) of overall success (combination of clinical cure and microbiological eradication) in the microbiological modified intent to treat population (mMITT) at test-of-cure (TOC), subgroup analyses were performed on patients with ESBL-BU non-resistant to FPE (MIC≤8 µg/ml) and PTZ (MIC≤64 µg/ml) and a subgroup (mMITT+R) that also included the ESBL-BU resistant to either agent (FPE MIC ≥16 µg/ml or PTZ MIC≥128 µg/ml).ResultsIn mMITT, FPE (273/345, 79.1%) demonstrated superiority to PTZ (196/333, 58.9%) at TOC (difference, 21.2%; 95% CI: 14.3, 27.9). The prevalence rate of ESBL-BU was 20.9% (142/678), with 99.3% (141/142) expressing a CTX-M-type (-1, -3, -9, -14, -15, -27, -55, -91, -169) and 3.5% (5/142) co-expressing AmpC (CMY-2/-59). FPE (56/76, 73.7%) demonstrated superiority to PTZ (34/66, 51.5%) in this subgroup at TOC (difference 30.2%; 95% CI: 13.4, 45.1; Table). In mMITT+R, the ESBL-BU prevalence rate was 22.3% (172/771), with 6.4% (11/172) co-expressing AmpC (CMY-2/-4/-59/-99), 4.7% (8/172) co-expressing a metallo-β-lactamase (VIM-1, NDM-1), and 2.3% (4/172) co-expressing OXA-48. Superiority of FPE (67/91, 73.6%) compared to PTZ (41/81, 50.6%) was also observed at TOC despite inclusion of ESBL-BU resistant to either agent (difference 30.0%; 95% CI: 14.9, 43.3).Table ConclusionFPE may represent a new empiric carbapenem-sparing option in settings where ESBL are endemic.Disclosures Adam Belley, PHD, Allecra Therapeutics SAS (Consultant) Philip Barth, MD, Allecra Therapeutics SAS (Consultant) Shikhar Kashyap, n/a, Allecra Therapeutics SAS (Consultant)Allecra Therapeutics SAS (Consultant) Omar Lahlou, PhD, Allecra Therapeutics SAS (Employee) Paola Motta, PhD, Allecra Therapeutics SAS (Employee) Patrick Velicitat, MD, Allecra Therapeutics SAS (Employee)

English

BACKGROUND Acute pyelonephritis (APN) is one of the most severe forms of urinary tract infections (UTI) with a higher incidence among females compared to males. Escherichia coli is the commonest causative organism isolated in 80 % of the cases in Kerala. Risk factors like structural or functional abnormalities of urogenital system, immunosuppression, comorbidities and virulence &amp; resistance of microorganism play vital roles in predicting the prognosis. Our aim was to study the prevalence of various risk factors of acute pyelonephritis in adult patients, the clinical profile, aetiological agents and their sensitivity to antibiotics, and related complications on their usage. METHODS In a cross-sectional observational study, 100 adult patients with acute pyelonephritis admitted in a tertiary teaching hospital in Kerala were studied between January 2016 and January 2017. Detailed history and clinical examination were carried out. Complete haemogram, random blood sugar, renal function test, urine culture and sensitivity, and ultrasonogram of abdomen and pelvis were done. RESULTS The most common age group was 40 - 49 years with a male to female ratio of 2:3. Dysuria was observed in 82 % of patients followed by increased frequency of micturition in 65 % and vomiting in 42 %. Diabetes mellitus was observed in 55 % of patients and recurrent UTI in 44 %. Escherichia coli was found in 66 % of patients followed by Klebsiella in 23 %. Culture showed that 85 % of the bacteria were sensitive to piperacillin-tazobactam. 44 % of the patients did not respond to the empirical antibiotic, and the failure rate was higher among those empirically treated with ciprofloxacin. 41 % of the patients developed acute kidney injury, which necessitated haemodialysis in 23 %. 14 % of the patients developed septic shock and the mortality was 10 %. CONCLUSIONS Certain risk factors such as diabetes, hypertension, chronic kidney disease and indwelling catheters were associated with increased incidence of complications. Hence, in presence of such risk factors appropriate treatment and preventive measures should be initiated promptly. Among the pathogens, 85 % of the organisms were sensitive to piperacillin–tazobactam. Hence, piperacillintazobactam can be recommended as the first line empirical antibiotic. KEYWORDS Acute Pyelonephritis, Urinary Tract Infection, Acute Kidney Injury (AKI), and E. coli

Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections.

The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014–2016) and the three years after (2017–2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin–tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.

Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis

BackgroundAlthough perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis. MethodsThis is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared. ResultsForty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively. ConclusionsProvider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.

Herpes Zoster Duplex Unilateralis as a manifestation of severe lymphopenia in COVID19

To the editor in chief, SARS-CoV2 (severe acute respiratory syndrome coronavirus-2), a novel coronavirus was first reported in December of 2019 from Wuhan, China as an aetiological agent causing a new infectious respiratory disease (coronavirus disease 2019- COVID-19). The main clinical manifestations of COVID-19 are fever, cough, fatigue, dyspnoea and muscle aches. Herpes zoster is characterized by several groups of painful vesicles on an erythematous base with a distribution in a unilateral dermatome involving the skin and/or mucosa. Herpes zoster is caused by varicella zoster virus which remains dormant in the sensory root ganglion contained by the immune system particularly CD lymphocytes (Wollina, 2017). This characteristic presentation is seen in an immunocompetent host. Severe forms of Herpes zoster not respecting the borders of a dermatome have been described. They are (a) Disseminated Herpes zoster that is, lesions extending over three contiguous dermatomes or lesions going outside the original dermatome. (b) Herpes zoster Duplex—here the lesions involve two non-contiguous dermatomes. If the dermatome involved are unilateral then it is known as Herpes Zoster Duplex Unilateralis and if present bilaterally then—Herpes Zoster Duplex Bilateralis (Jung et al., 2000). The non-contiguous variants are rare in both immunocompetent and immunocompromised host and represent a viraemic spread of VZV due to decrease in lymphocyte count and/or function. Classical Dermatomal Herpes Zoster has been described as a marker of subclinical COVID19 infection (Tartari et al., 2020). We are presenting a case of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve (V1) and left Thoracic 10 (T10) dermatome in a patient of COVID19 with severe lymphopenia. A 62-year-old otherwise healthy male presented with highly painful vesicular lesions on an erythematous base involving the left ophthalmic division of trigeminal nerve (Day 6) and left thoracic 10 (T10) (Day 8) dermatome occurring 2 days apart. The vesicles ranged from 0.3 mm to 1 cm in size and had necrotic element at some places. Hutchinson sign was positive. A diagnosis of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve and left Thoracic 10 (T10) dermatome was observed. The patient had fever (101–103°F) with malaise for preceding 5 days of appearance of vesicles. His COVID19 RT PCR test was positive (Day 8), however, evaluation for HIV status, diabetes, any immunosuppressive state and malignancy was negative. HRCT thorax showed multiple ground glass opacities in both the lungs with CT severity score being 18/30. His LDH levels were 229 units/L (normal range 135–225 U/L), D-dimer 3,422.26 (0–500 ng/ml), IL-6 levels 23 (normal range 0–7 pg/ml). Troponin-T levels determined by Card test, serum ferritin levels and liver function tests were normal. Total leucocyte count was 7,100 cells/mm3 (4000–11000 cells/mm3 normal range). However differential eucocyte count showed neutrophilia (90%) and relative lymphopenia (2.2%), whereas the normal range is 20%–40%. The patient was treated according to institutional COVID19 protocol and was given piperacillin tazobactam 4.5 mg thrice a day injection, remdesivir 200 mg slow iv infusion and dexamethasone injection 4 mg once daily , low molecular weight heparin 6 mg twice a day subcutaneously for 5 days. For VZV lesions, oral acyclovir was given at a dose of 800mg five times a day for 10 days after which he recovered with mild post herpetic neuralgia. Herpes Zoster Duplex Unilateralis represents a viraemic spread of VZV, probably due to decreased immune protection. In our patient lymphocyte percentage was 2.2% representing a severe lymphopenia. We tried to look into the possible explanations: In COVID 19 patients, the inflammatory cytokine storm is likely a key factor behind the observed lymphopenia. The serum level of pro-inflammatory cytokines, such as TNF-α and IL-6, have been closely correlated with lymphopenia, while recovered patients show close to normal levels of such cytokines (Mazzoni et al., 2020). Autopsy studies on lymphoid organs collected from several patients who succumbed to the disease revealed massive lymphocyte death, which was attributed to high levels of IL-6 as well as Fas–FasL interactions. Our patient also had high IL 6 levels and clinical features suggestive of cytokine storm. COVID-19 infection can result in exhaustion of T cells. A recent study has found both CD4+ and CD8+ T cells from COVID-19 patients had increased cell surface expression of programmed cell death protein 1 (PD-1) and T cell immunoglobulin and mucin domain 3 (Tim-3), the two markers of T cell exhaustion (Diao et al., 2020). The SARS-CoV-2 can directly infect T cells. This infection can interfere with T cell expansion. A report suggests that some genes involved in T cell activation and function, such as MAP2K7 and SOS1 are downregulated in the T cells of severe COVID-19 patients (Ouyang et al., 2020). All these mechanisms may be an explanation to the relative lymphopenia in our patient with an unusual presentation of Herpes Zoster. Nil. None declared.

Bacteriological profile and antibiotic susceptibility patterns of lower respiratory tract infections in a tertiary care hospital, Central Kerala

Background and Objective: Lower respiratory tract infections (LRTIs) is one of the leading human diseases causing high morbidity and mortality worldwide. The prevalent etiological agents and their antimicrobial resistance patterns differs, both geographically and over time. With emerging resistance of respiratory bacterial pathogens to commonly used antibiotics, it is imperative to study their recent trends for effective management of these cases. Materials and Methods: A retrospective, record based study was conducted on culture and sensitivity reports of lower respiratory samples obtained in the microbiology lab during 1st January 2015- 31st December 2017. The samples were processed by standard methods for isolation and identification followed by antimicrobial sensitivity testing using Kirby Bauer disc diffusion method. Results: 288 (26.34%) of total 1093 samples were positive for bacterial culture. 244 (84.7%) were gram negative bacilli (GNB) and 44 (15.3%) were gram positive cocci. The predominant pathogen isolated was K.pneumoniae (31.1%) followed by P.aeruginosa (30.2%).The overall susceptibility of GNB was highest towards Imipenem followed by Amikacin and Piperacillin tazobactam with resistance rates of 11.5%, 26.2% and 31.6% respectively. Gram positive organisms exhibited highest susceptibility towards Vancomycin and Linezolid. 15.4 % of Staphylococcus aureus were Methicillin resistant (MRSA). Conclusion: Imipenem is the most sensitive antibiotic followed by Amikacin and Piperacillin tazobactam which can be used for empirical therapy for LRTI. The antibiotic therapy should be modified as per the culture and sensitivity report. Regular determinations of the type of bacterial pathogens and updation of antibiogram must be followed in every institution to aid in better patient management by helping the clinician in the judicious use of antibiotics. Keywords: Antibiotic resistance patterns, Lower respiratory tract infections.

Study of the bacteriological profile of neonatal septicemia and associated risk factors

Introduction: Neonatal sepsis is one of the major causes of morbidity and mortality among the newborns in the developing countries. For the effective management of neonatal sepsis, knowledge about causative agent and antibiotic sensitivity pattern play a vital role. Present study was undertaken to analyze the various risk factors of bacterial sepsis, to isolate aerobic bacteria causing neonatal septicemia and to study the antibiogram of bacterial isolates. Material and Methods: Study was done over a period of one year. 198 clinically suspected cases of neonatal septicemia were included in the study. Detailed record of various predisposing neonatal factors were noted in a pro-forma. Blood samples from the neonates were subjected to aerobic blood cultures. The identification of the causative organism was carried out by standard identification tests and antibiotic sensitivity testing was done as per Clinical and Laboratory Standards Institute guidelines. Results: Of 198 neonates studied, predisposing factors for neonatal sepsis were mainly low birth-weight and preterm. Blood cultures were positive in 128(64.64%) cases. Predominant organisms isolated were Staphylococcus aureus (54.7%) and Klebsiella spp. (14.1%). Among Staphylococcus aureus, 43(61.42%) isolates were MRSA and most of them were sensitive only to vancomycin and linezolid. Most of the MSSA were sensitive to cotrimoxazole, clindamycin, ciprofloxacin, vancomycin, linezolid. Most of the Gram negative bacilli were sensitive to imipenem, piperacillin–tazobactam and amikacin. Conclusion: For the effective management of neonatal sepsis continued surveillance is mandatory for each center due to temporal changes in the causative organisms and their antibiotic susceptibility. Keywords: Bacteriological Profile, Neonatal Septicemia, Risk Factors, Antibiogram and Blood Culture.

Emerging trends in the antimicrobial resistance among uropathogens

Emerging trends in the antimicrobial resistance among uropathogens - IJMR- Print ISSN No: - 2394-546X Online ISSN No:- 2394-5478 Article DOI No:- 10.18231/2394-5478.2018.0009, Indian Journal of Microbiology Research-Indian J Microbiol Res

692: Septic Shock From Sore Throat? Presentation of Streptococcus anginosus Shock and Lemierre Syndrome

INTRODUCTION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein caused by oropharyngeal or head and neck infections The main causative organism is Fusobacterium necrophorum but rarely other organisms such as Staphylococcus aureus, E coli, streptococci, staphylococci, Klebsiella etc can cause the syndrome as well Members of the Streptococcus Anginosus group are rare causes of Lemierre syndrome with very few pediatric case reports in the literature METHODS: A previously healthy 15-year-old female presented with four days of fever, throat pain, abdominal pain and persistent vomiting and was admitted with septic shock requiring extensive fluid resuscitation and vasopressor support Initial labs included WBC 15 2 x 10 9/ L, CRP 34 9 mg/dL, ESR 78 mm/Hr Review of systems was negative for tampon use Rapid streptococcus probe test, respiratory viral panel, and SARS CoV-2 tests were all negative Clindamycin was added to empiric coverage with concern for toxic shock syndrome Within 24 hours of hospitalization, she developed ARDS requiring non-invasive positive pressure ventilation She continued to complain of worsening throat pain and headache CT scan of the neck revealed extensive thrombosis of the left internal jugular and initial blood culture grew Streptococcus constellatus, a member of the S Anginosus group Antibiotic coverage was switched to piperacillin-tazobactam to cover anaerobic organisms such as Fusobacterium as well as Streptococcus Anginosis Enoxaparin was started Lupus antibodies were transiently positive secondary to infection Following discharge, she received intravenous ceftriaxone via PICC line and oral metronidazole for 3 weeks and then oral levofloxacin and metronidazole for 2 weeks She was followed up regularly to assure clearance of septic thrombi from internal jugular vein after 6 weeks of antithrombotic therapy RESULTS: Lemierre syndrome should be considered a diagnosis for an adolescent with throat pain presenting with shock

Genomic Analysis of Aeromonas veronii C198, a Novel Mcr-3.41-Harboring Isolate from a Patient with Septicemia in Thailand.

The resistance of Gram-negative bacteria to colistin, mediated by plasmid-borne mcr genes, is an emerging public health concern. The complete genome sequence (4.55 Mb) of a clinical isolate of Aeromonas veronii biovar veronii obtained from a patient with septicemia was determined using short-read and long-read platforms. This isolate (C198) was found to harbor a novel mcr-3 gene, designated mcr-3.41. Isolate C198 revealed adjacent mcr-3.41 and mcr-3-like genes. It contained one chromosome and two plasmids, both of which encoded a RepB replication protein. Other antimicrobial resistance genes, including blacphA3, blaOXA-12, tetA, rsmA, and adeF, were also present. Isolate C198 was resistant to amoxicillin–clavulanate, ampicillin–sulbactam and tetracycline, and showed intermediate resistance to trimethoprim–sulfamethoxazole. The isolate was susceptible to piperacillin–tazobactam, carbapenem, third-generation cephalosporins, fluoroquinolones, chloramphenicol, and aminoglycosides. Putative virulence genes in the C198 genome encoded type II, III, and VI secretion systems; type IV Aeromonas pili; and type I fimbria, flagella, hemagglutinin, aerolysin, and hemolysins. Multilocus sequence typing revealed a novel sequence type (ST), ST720 for C198. Phylogenetic analysis of the single nucleotide polymorphisms in C198 demonstrated that the strain was closely related to A. veronii 17ISAe. The present study provides insights into the genomic characteristics of human A. veronii isolates.