Positive Bacterial Blood Culture Research Articles

The utility of procalcitonin in febrile neutropenia.

12040 Background: The utility of procalcitonin (PCT) in febrile neutropenia (FN) in oncology patients on active therapy has not been well validated. FN constitutes a critical oncologic emergency, often characterized by subtle manifestations of infection, and timely diagnosis and treatment is vital. Although a potential harbinger of dangerous infection, FN can also occur without an identifiable infection, in which case hospitalization and antibiotics may be unnecessary. PCT, an amino acid, is elevated specifically during bacterial infections in the non-cancer population and correlates with infection severity. Clinicians employ PCT levels as a diagnostic adjunct, discerning bacterial from viral infections and analyzing PCT changes to guide treatment decisions. We examined oncology patients presenting with FN to correlate PCT levels and trends with confirmed infections. Methods: We identified patients with neutropenic fever, cancer, and a PCT result seen at our institution from 12/1/2017-12/1/2022. Patients were determined to have a confirmed infection if they had a positive bacterial blood culture. Demographics and clinical characteristics were compared between infection status and induction chemotherapy or transplant status using a Wilcoxon Rank Sum test for continuous variables and a Chi-Square or Fisher’s Exact test for categorical variables. Baseline (at time of initial FN) and highest PCT levels were compared by patient and disease characteristics and proven infection using Wilcoxon Rank Sum test. Logistic regression was used to determine the association of log-transformed PCT (baseline and highest) with proven infection (yes/no) while adjusting for covariates. All tests were two-tailed with p< 0.05 considered statistically significant. Results: Of 365 patients, 61 (16.7%) had an identified infection. Median baseline and peak PCT of 1.26 and 1.51 ng/mL, respectively, were significantly greater for these patients as compared to those with negative cultures at 0.54 and 0.65 ng/mL, respectively (P= 0.01 and <0.01). For every unit increase in the log transformed baseline PCT, the odds of having a proven infection increased by 23%. There were no significant differences in patient or clinical characteristics between those with and without infection. Of those admitted for induction chemotherapy and transplant who developed FN, PCT at time of initial fever was higher at 0.97 vs 0.56 ng/mL (p=0.02). Interestingly, median baseline and median peak PCT differed between gender with females 0.51 and males 0.72 ng/mL (p=0.02) at baseline, and 0.63 vs 0.83 ng/mL (p=0.04), respectively, at peak. Conclusions: PCT levels in cancer patients with FN are significantly associated with culture positive infection. This data can help guide treatment and de-escalation of antibiotics in cancer patients admitted with FN. Further evaluation should be taken to determine how to best use PCT to determine the need for admission and antibiotic prescription.

Predictive Factors of Cloxacillin Susceptibility in Primary Bacterial Spinal Infection.

Prognostic study. The objective of this study is to identify predictive factors for cloxacillin susceptibility in spinal infections. A retrospective analysis was conducted using data from January 1, 1997, to December 31, 2021. The study included patients presenting with back pain and either a positive bacterial culture from the spine or radiological evidence of spinal infection (spondylodiscitis and/or epidural abscess) along with positive bacterial blood culture. Among 171 patients (127 males, 44 females), 53.2% had Staphylococcus isolates, with 40.4% showing cloxacillin resistance. Lower globulin levels (<33.5g/L), recent hospitalization within 90days, and residence in an old age home predicted gram-positive bacteria with cloxacillin resistance and gram-negative bacteria as causative organisms (P<.05). The 30-day and 1-year all-cause mortality rates were 0% and 8.2%, respectively. Higher red cell distribution width (RDW >16.1%) and Charlson comorbidity index (CCI) scores predicted 1-year all-cause mortality (P<.05). Intensive care unit admission was required for 9.9% of patients. This study identified predictive factors for spinal infection by gram-positive bacteria with cloxacillin resistance and gram-negative bacteria. Patients with lower globulin levels (<33.5g/L), recent hospitalization within 90days, or residency in an old age home upon admission should avoid standalone cloxacillin therapy and consider antibiotics with gram-negative coverage. Higher RDW (>16.1%) and CCI scores were associated with increased 1-year all-cause mortality. These findings contribute to treatment decision-making and improving patient outcomes in spinal infections.

The current spectrum of infections in cancer patients with chemotherapy related neutropenia

Background: New cancer treatments have improved patient survival but also bring side effects like weakened immunity and higher infection risk. The present study aimed to assess the pattern of blood stream infections and antimicrobial resistance in blood isolates of neutropenic patients. Material and Methods: This Cross-sectional, observational study was conducted at Department of Oncology, Jinnah Postgraduate Medical Centre, Karachi, Pakistan between August 2019 to August 2020. Malignant patients who underwent chemotherapy and presented with fever, neutropenia, and positive bacterial blood culture were enrolled in the study. Patients with a recent history of blood transfusion were excluded. The spectrum of bacterial infections and the antimicrobial resistance patterns of causative organisms isolated from blood were studied. The CLSI standard antimicrobial panel was used for each microorganism. Findings were presented in tabular form. Results: During the study period 95 organisms were isolated from the blood cultures. Strains of E. Coli, Klebsiella, Pseudomonas, S. Aureus, S. Pneumoniae, were found in 27 (28.4%), 18 (18.9%), 13 (13.7%), 17 (17.9%), and 2 (2.1%) patients, respectively. 44.0% of E. coli, 68.8% of Klebsiella, and 38.5% of Pseudomonas were resistant to tazobactam. 92.6% of E. coli, 88.2% of Klebsiella, 100% of Pseudomonas were resistant to Co-amoxiclav. 52.9% of Staph aureus were resistant to methicillin. 23 (92.0%) strains of E. coli, 15 (83.3%) strains of Klebsiella, 6 (46.2%) strains of Pseudomonas, and 11 (68.8%) of Staph aureus were resistant to ciprofloxacin. Conclusion: Resistance to the majority of the commonly used antimicrobial drugs was noted. Continuous antimicrobial resistance surveillance of the everchanging spectrum of causative organisms and their characterization is very important to treat the bloodstream infections (BSI) in cancer patients with chemotherapy induced neutropenia. Keywords: Neutropenia Infection, Fever, Antimicrobial resistance, Chemotherapy.

Intestinal Bacteremia After Liver Transplantation is a Risk Factor for Recurrence of Primary Sclerosing Cholangitis.

Primary sclerosing cholangitis (PSC) is a chronic progressive pathological process, related to inflammatory bowel disease and subsequent bacterial translocation. Liver transplantation (LT) is the only curative therapy, but outcomes are compromised by recurrence of PSC (rPSC). The aim of the study was to investigate a potential link between intestinal bacteremia, fucosyltransferase-2 (FUT2), and rPSC after LT. LT recipients with PSC (n = 81) or without PSC (n = 271) were analyzed for clinical outcomes and positive bacterial blood cultures. A link between bacteremia and the genetic variant of the FUT2 gene was investigated. The incidence of inflammatory bowel disease was significantly higher in PSC recipients but not associated with rPSC. Bacteremia occurred in 31% of PSC recipients. The incidence of rPSC was 37% and was significantly more common in patients with intestinal bacteremia versus no bacteremia (82% versus 30%; P = 0.003). The nonsecretor polymorphism of the FUT2 gene was identified as a genetic risk factor for both intestinal bacteremia and rPSC. Combined FUT2 genotype and intestinal bacteremia in recipients resulted in the highest risk for rPSC (hazard ratio, 15.3; P < 0.001). Thus, in this article, we showed that bacterial translocation is associated with rPSC after LT and related to the FUT2 nonsecretor status.

Short-course empiric antibiotic therapy for possible early-onset sepsis in the NICU.

On 2/2019, the Neonatal Antimicrobial Stewardship Program at Nationwide Children's Hospital recommended reducing empirical antibiotic therapy for early-onset sepsis (EOS) from 48 to 24 hours with a TIME-OUT. We describe our experience with this guideline and assess its safety. Retrospective review of newborns evaluated for possible EOS at 6 NICUs from 12/2018-7/2019. Safety endpoints were re-initiation of antibiotics within 7 days after discontinuation of the initial course, positive bacterial blood or cerebrospinal fluid culture in the 7 days after antibiotic discontinuation, and overall and sepsis-related mortality. Among 414 newborns evaluated for EOS, 196 (47%) received a 24 hour rule-out sepsis antibiotic course while 218 (53%) were managed with a 48 hour course. The 24-hour rule-out group were less likely to have antibiotics re-initiated and did not differ in the other predefined safety endpoints. Antibiotic therapy for suspected EOS may be discontinued safely within 24 hours.

886. Positive Bacterial Blood Cultures and Time to Positivity in Children: Should Empiric Antibiotics be Reconsidered Sooner?

Abstract Background Evaluation for bacterial bloodstream infections (BSIs) is often associated with prescribing empiric antibiotics while awaiting blood culture results, typically 48 hours. We examined characteristics associated with positive cultures treated as BSI vs contaminant in children and BSIs associated with prolonged (≥ 24 hours) time-to-positivity (TTP). Methods In a retrospective study of children (≤ 21 years) at our pediatric healthcare system, we abstracted demographic, clinical, and blood culture data from the electronic medical record for all initial positive bacterial blood cultures from March 2021 to February 2022. We excluded fungi and cultures collected within 14 days of a previous positive. TTP was calculated from time/date of collection to Gram stain report. Host status was categorized as previously healthy, immunocompromised (IC), and chronic condition/s. A BSI was defined as a positive culture treated for ≥ 3 days. BSI cultures were categorized as Gram-positive definite (GPD) pathogens, other Gram-positive (OGP), Gram-negative (GN), or polymicrobial (PM). Characteristics associated with prolonged TTP for BSIs were identified using mixed-effects logistic regression. Results There were 816 positive cultures identified in 697 children, with 582 (71%) treated as BSIs and 536 of those (92%) positive in &amp;lt; 36 hours. Positive cultures drawn with adequate blood volume, in the setting of fever, severe neutropenia, and from IC children were significantly more likely to be treated as BSIs (all p&amp;lt; 0.05, Table 1). The most common BSI was a GN pathogen (34.2%, Figure 1). Characteristics associated with prolonged TTP were absence of fever and cultures drawn peripherally. Early TTP (&amp;lt; 24 hours) was associated with cultures drawn outpatient and growth of high likelihood pathogenic organisms (GPD, GN, PM) compared to OGP (all p&amp;lt; 0.05). On multivariate analysis, cultures drawn peripherally remained associated with prolonged TTP (p&amp;lt; 0.01), while GPD, GN, and PM cultures remained associated with early TTP (p&amp;lt; 0.01, Table 2). Conclusion We found that 92% of clinically significant BSIs in children were identified by 36 hours with BSIs with pathogenic organisms (GPD, GN, PM) associated with TTP &amp;lt; 24 hours. Reassessment of the need for antibiotics after 24–36 hours should be considered. Disclosures Pratik A. Patel, MD, Cardinal Health, Inc: Advisor/Consultant.

Sensitivity and Specificity of Toxic Granules in WBC and Immature to Total Neutrophil Ratio in Diagnosis of Neonatal Sepsis

Background: Septicemia is the commonest cause of neonatal mortality and severe morbidity. Positive bacterial blood culture result confirms clinically suspected sepsis but it is too late to start antibiotic. We need a easy, reliable and cost effective test to diagnose sepsis in time.&#x0D; Objective: To see the relation of toxic granule and immature neutrophil with neonatal sepsis.&#x0D; Material &amp; Methods: This hospital based, cross-sectional study was conducted on 152 neonate with suspected sepsis admitted in Dhaka Shishu Hospital during January 2013 to April 2014. After enrollment all studied neonate were investigated with complete blood cell count, CRP and Blood culture before starting treatment with antibiotic. Raised immature to total neutrophil ratio &gt;0.2 and toxic granules in neutrophil were correlated with positive blood culture test using x2 test.&#x0D; Result: Out of 152 studied neonate 61.89% were male, 41.94% premature, 48.85% low weight. Blood culture result was found positive in 7.24% neonate. Leukopenia (WBC&lt;5000/mm3), Neutropenia (Neutrophil &lt;1750/mm3), Immature to total neutrophil ratio (I:T) &gt;0.2 and toxic granules were present significantly in sepsis. The sensitivity and specificity of toxic granules to diagnose neonatal sepsis was correspondingly 91.67% and 75% &amp; that of I: T&gt;0.2 were 90.91% and 66.67%.&#x0D; Conclusion: Toxic granules and Immature to total neutrophil ratio (I: T) &gt;0.2 can be considered as useful tools in the diagnosis of neonatal sepsis to start antibiotic earlier, especially where there is limited modern investigation facilities.&#x0D; BANGLADESH J CHILD HEALTH 2021; VOL 45 (3) : 141-146

Multi Bacterial Infection in Immunocompromised Patient

Infection is a major cause of morbidity and mortality in immunocompromised cancer patients due to chemotherapy, radiotherapy, or anti-inflammatory therapy. Approximately 0.9%-39% of cancer patients with febrile non neutropenia has bacteremia and about 7.3% of cancer patients hospitalized have positive bacterial blood cultures. Multi-bacterial infection with Multi Drug Resistant (MDR) in immunocompromised cancer patients complicates therapy and is often fatal. A 6 years old boy diagnosed with left orbital tumor intracranial infiltration. Physical examination: lump in the left eye ± 8 x 10 cm, solid, reddish in color, there was a wound on the left eye ± 12 x 10 cm; Temperature 390C. Hematology examination Hb 10.3 g / dL; PLT 156 x103 / uL; WBC 28.92 x103 / uL. Blood culture results: Methicillin Resistant Staphylococcus aureus (MRSA) resistant to Gentamicin, Amoxicillin Clavulanic Acid, Ampicillin, Penicillin G, Oxacillin and Enterococcus faecium resistant to Gentamicin, Ampicillin, Cotrimoxazole, Trimetoprim, Erythromycin, and Clindamycin. Results of pus culture from the left eye wound was Staphylococcus intermedius resistant to Gentamicin, Amoxicillin Clavulanic Acid, Ampicillin, Penicillin G, Oxacillin, Chloramphenicol, Ciprofloxacin. Based on the results of blood and pus culture, all bacterial isolates included multidrug-resistant organisms (MDRO). Multidrug resistant organisms are microorganisms, especially bacteria that are resistant to at least 1 antibiotic of three or more categories. Cancer patients are susceptible to infection with multi-drug resistant bacteria because of their decreased immune system, especially after undergoing chemotherapy. Appropriate antibiotic treatment determines patient morbidity and mortality. Infection due to multi-bacteria accompanied by multi-drug resistance in immunocompromised patients is a condition that has to be treated immediately since the onset of the disease to reduce morbidity and mortality.

Alarming Antibiotic Resistance in Pediatric Oncology Patients: A Three-Year Prospective Cohort Study from Oman.

BackgroundBloodstream infections (BSI) are severe and challenging oncological complications, with a consequent high morbidity and mortality in the immunocompromised. We reviewed the profile and susceptibility of bacteria associated with infections in children under 13 years of age receiving chemotherapy.MethodsProspective cohort study of pediatric oncology patients was conducted between January 2015 and October 2017 at the Royal Hospital in Oman. Patient demographics, clinical data, laboratory parameters, microbial etiology and susceptibility, and outcomes were retrieved and analyzed.ResultsA total of 74 episodes of positive bacterial blood cultures were detected in 38 oncology patients (positive blood culture rate of 51%). Fifty-seven percent were positive for gram-negative organisms with Klebsiella (21%) being the most common gram-negative organism cultured, and the most common gram-positive organism was Staphylococcus (coagulase negative Staphylococcus (CONs) and S. Aureus) (30%). The majority of patients had gastrointestinal complaints (74%), and almost half (51%) had prolonged periods of neutropenia (>7 days). One third of gram-negative organisms were resistant to four or more antibiotics with a major resistance of 31% to piperacillin-tazobactam. Of the gram-positive organisms, 38% were resistant to at least four antibiotics and 30% were pan-resistant (except for vancomycin).ConclusionThe gram-negative organisms were dominant in BSIs with Klebsiella being the most common culprit. Bacteremia was prevalent, however, high resistance to first-line antibiotics was documented amongst gram-negative isolates, demanding strategies to ensure our patients’ safety.

349. Diagnostic Testing and Antibiotic Utilization in Patients with COVID-19

BackgroundPatients with COVID-19 receive high rates of antibiotic therapy, despite viral origin of infection. Reports of bacterial coinfection range from 3.5 to 8% in the early phase of infection. This study aimed to evaluate the relationship between diagnostic tests and antibiotic utilization in patients admitted with COVID-19 at the University of Maryland Medical Center to better inform future prescribing practices.MethodsRetrospective cohort study of adult patients with a positive SARS-CoV-2 PCR on admission from March 2020 through June 2020. Associations between diagnostic tests employed and antibiotic initiation and duration were explored using bivariate analysis (SPSS®). ResultsBaseline characteristics of 224 included patients are reported in Table 1. Excluding SARS-CoV-2 PCRs, most frequently performed diagnostic tests included blood cultures (65.6%), MRSA nasal surveillance (45.1%), respiratory cultures (36.2%), respiratory viral panel (RVP) (33.0%), and Legionella (28.6%) and pneumococcal (26.3%) urine antigens. Positivity of RVP, Legionella, pneumococcus, blood, and respiratory tests were low (1.3%, 0.4%, 0.9%, 1.8%, and 6.7%, respectively). A total of 62% of patients were initiated on antibacterial therapy with a median cumulative antibiotic duration of 77.9 hours (IQR 41.4, 111.8). History of chronic respiratory disease (76% vs. 58.6%; P=0.025), any degree of oxygen requirement on admission (72% vs. 42.6%; P=0.006), and performance of blood cultures (70.7% vs. 46.8%, P< 0.0001) were associated with antibiotic initiation. Positive bacterial diagnostic respiratory culture (median duration 72.8h [IQR 46.7, 96.6] vs. 97.3h [IQR 79.8, 194.1]; P=0.027) and positive blood culture (median duration 80.1h [IQR 42.1, 111.7] vs. 97.5h [IQR 71.8, 164.8]; P=0.046) were associated with longer antibiotic duration. Patients who did not have respiratory cultures performed had similar antibiotic durations as those with negative respiratory cultures.Table 1. Baseline Characteristics ConclusionDespite low coinfection rates, negative diagnostic tests did not result in shorter empiric antibacterial duration. These findings highlight the ongoing need for both diagnostic and antimicrobial stewardship in COVID-19. Disclosures Emily Heil, PharmD, MS, BCIDP, Nothing to disclose Kimberly C. Claeys, PharmD, GenMark (Speaker’s Bureau)

Serum amyloid A as an aid in diagnosing sepsis in equine neonates.

Sepsis is a significant cause of morbidity and mortality in neonatal foals, especially during the first 7days of life. Diagnosing sepsis in neonatal foals can be challenging because initial clinical signs are often ambiguous and non-specific. To determine if the major acute phase protein serum amyloid A (SAA) as measured by a point-of-care SAA testing device can be used as an evidence-based biomarker of sepsis. Retrospective cohort. Clinical diagnosis of sepsis based on positive bacterial blood culture or a positive sepsis score was obtained and compared to SAA values in a population of neonatal foals on a breeding farm and referral hospital during four consecutive foaling seasons. A rapid, point-of-care blood test was used to measure SAA concentrations in neonatal foals <36hours old that were clinically diagnosed as healthy, sick non-septic or septic. The septic foals (n=35) had a median SAA concentration (114µg/mL) that was significantly greater (P<.05) than that for foals in the sick non-septic (n=117, 1.5µg/mL) and healthy (n=245, 0µg/mL) groups. At a diagnostic threshold of 100µg/mL, the SAA test had a sensitivity of 52.9% (95% CI 36.5-68.9), specificity of 97.5% (95% CI 95.0-99.0), positive predictive value of 75.0% (95% CI 56.2-87.5), negative predictive value of 93.7% (95% CI 91.2-95.5), and a test accuracy of 92.1% (95% CI 88.2-95.0). The results of this study indicate that SAA is a useful aid in the diagnosis of sepsis in the neonatal foal.

Hospital survival outcomes in acute respiratory distress syndrome patients receiving veno‐venous extracorporeal membrane oxygenation for longer than 28 days: A retrospective study

AbstractThe successful use of prolonged (ie, &gt;28 days) veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) is being increasingly reported. However, limited data are available on its outcomes. This study investigated the outcomes of acute respiratory distress syndrome (ARDS) patients on prolonged ECMO support. We retrospectively evaluated 57 patients requiring V‐V ECMO for ARDS between 2015 and 2020. The patients were divided into two groups according to ECMO duration: (a) ≤28 days group (n = 43, 75%) or (b) &gt;28 days (n = 14, 25%) group. Clinical characteristics, complications, and outcomes between these two groups were statistically compared. There were no significant differences in demographics, comorbidity, ARDS etiology, and severity scores between the two groups. However, the mechanical ventilation period before ECMO initiation was significantly longer in the &gt;28 days group than in the ≤28 days group (10.5 days vs. 1 day; P &lt; .05). The incidence of positive bacterial blood culture results during ECMO was significantly higher in the &gt;28 days group than in the ≤28 days group (43% vs. 9%; P &lt; .05). Additionally, the hospital survival rate was significantly lower in the &gt;28 days group than in the ≤28 days ECMO group (21% vs. 60%; P &lt; .05). Prolonged ECMO was associated with worse hospital survival outcomes. Early initiation of ECMO along with meticulous care and appropriate treatment against infection during ECMO could improve the hospital survival of ARDS patients on prolonged ECMO support.

Clinical and Microbiological Outcomes of Ceftazidime-Avibactam Treatment in Adults with Gram-Negative Bacteremia: A Subset Analysis from the Phase 3 Clinical Trial Program.

IntroductionThis exploratory analysis assessed efficacy and safety outcomes in patients with Gram-negative bacteremia treated with ceftazidime-avibactam or comparator across five phase 3, randomized, controlled, multi-center trials in adults with complicated intra-abdominal infection (cIAI), complicated urinary tract infection (cUTI)/pyelonephritis, hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP).MethodsIn each trial, RECLAIM and RECLAIM 3 (cIAI; NCT01499290/NCT01726023), REPRISE (cIAI/cUTI; NCT01644643), RECAPTURE (cUTI; NCT01595438/NCT01599806), and REPROVE (HAP/VAP; NCT01808092), patients were randomized 1:1 to intravenous ceftazidime-avibactam (plus metronidazole for those with cIAI) or comparators (carbapenems in > 97% patients) for 5–21 days. Efficacy assessments included clinical and microbiological responses at the test-of-cure visit in the pooled Gram-negative extended microbiologically evaluable (GNeME) population (bacteremia subset). Safety outcomes were summarized for patients with positive bacterial blood culture(s) at baseline who received ≥ 1 dose of study treatment.ResultsThe overall safety population included 4050 patients (ceftazidime-avibactam, n = 2024; comparator, n = 2026). The GNeME population (bacteremia subset) comprised 101 patients (ceftazidime-avibactam, n = 54; comparator, n = 47). Clinical cure rates (all indications combined) were 47/54 (87.0%) for ceftazidime-avibactam and 39/47 (83.0%) for comparators; favorable microbiological response rates were 43/54 (79.6%) and 32/47 (68.1%), respectively. Clinical and microbiological responses in the bacteremia subset were generally similar to those in the overall set. The pattern of adverse events in patients with bacteremia was similar between treatment groups and was consistent with the known safety profile of ceftazidime-avibactam.ConclusionThis analysis provides supportive evidence of the efficacy and safety of ceftazidime-avibactam in patients with Gram-negative bacteremia associated with cIAI, cUTI/pyelonephritis, or HAP/VAP.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00506-7.

Incidence and Predictors of Adverse Respiratory Events during Induction Therapy in Children with Acute Myeloid Leukemia

Background: Mortality in pediatric acute myeloid leukemia (AML) has plateaued between 30-40%, with 5-15% of these deaths occurring during initial induction. While pulmonary complications contribute to the early morbidity and mortality in pediatric AML, our knowledge of the incidence, risk factors, and patterns of respiratory adverse events (AEs) is lacking. Hypothesized risk factors for respiratory AEs during induction include hyperleukocytosis, fluid overload, coagulopathy, and infection. Our objective was to characterize the incidence, categories, and risk factors of respiratory AEs in de novo pediatric AML patients during induction chemotherapy.Methods: We conducted a single institution retrospective longitudinal study from presentation to Day 42 or initiation of the next chemotherapy cycle in de novo pediatric AML patients (age 0-21 years) presenting between January 1, 2001 and December 31, 2016. Patients were identified through the institutional cancer registry. Exclusion criteria included: relapsed AML, induction at another institution, and failure to treat with conventional protocols. Outcomes of interest included development of an NCI CTCAE (v4.0) grade 2-5 respiratory AE or death from another cause. Data was abstracted in regards to demographic and disease characteristics at presentation. Supportive care measures included fluid status, with fluid overload defined as a ≥ 10% increase from body weight at presentation or the use of ≥ 3 doses of furosemide during the follow up period. Respiratory AE was attributed to infection in cases with a positive bacterial or fungal blood culture, respiratory viral panel, endotracheal tube aspirate, or a chest imaging report explicitly suggesting a pulmonary infectious process. A single rater assigned the most specific, best fitting CTCAE category and grade for each incident event at its maximal severity. Time to event distribution curves were created and descriptive statistics using two-sample T-test, Chi square test for independence, or Fisher's exact test as appropriate were calculated (SAS v X, Cary, NC).Results: To date we have reviewed the induction course on 63 of 245 eligible patients with de novo AML. Median age at diagnosis was 8.0 years (range, 0-21 years), 58.7% were female (n = 37), and 42.9% non-Hispanic White (n = 28). During the follow up period, 3 patients died (4.8% induction death at days 5, 25, 73). The deaths at days 25 and 73 were due to pulmonary fungal infection and the death at day 5 from an intracranial bleed. During the first 42 days, 52.4% (n = 33) patients experienced 34 discrete respiratory AEs: CTCAE grade 2 in 2.9% (n = 1), grade 3 in 64.7% (n = 22), grade 4 in 26.5% (n = 9) and grade 5 in 5.9% (n = 2). Among the respiratory AEs, 44.1% required BiPAP/CPAP (n = 4) or mechanical ventilation (n = 11). As shown in Table 1, those with and without respiratory AEs differed significantly in regards to median age at diagnosis (p = .003), coagulopathy at diagnosis (PT (p = .019), D-dimer (p = .012)), and fluid overload status (p < .0001). Those with respiratory AEs did not differ by sex (p = .08), development of infection (p = .65), or WBC at diagnosis (p = .08). A bimodal distribution of time to event was (Figure 1) with 67.7% (n = 23) of AEs occurring between presentation and day 7 and classified as “early.” As seen in Table 2, there were statistically significant differences between the early and late AE groups for WBC at diagnosis (p = .007), PT at diagnosis (p = .012), and fluid overload (p = .026). While a larger proportion of the late AEs experienced infection (45.5% vs 30.4%), this did not significantly differ from the early AEs (p = .39).Conclusion: We note a high incidence of grade 2-5 respiratory AEs in pediatric patients during AML initial induction [52.4%]. Fluid overload appears to be a significant factor in early AEs. Documented infection occurred in a higher proportion of late AE cases, although this did not reach statistical significance. Future analyses will examine the role of cytogenetic factors and morphology. Pulmonology and oncology raters will independently characterize and validate the category of each respiratory AE (e.g. atelectasis, pulmonary edema, pulmonary leukostasis, pneumonia) through a standardized process for the full eligible cohort. Identifying modifiable risk factors will enable design of supportive care interventions to decrease the risk of respiratory AEs and their associated morbidities during induction. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Polymicrobial Pseudomonas Plus Candida Parapsilosis Endocarditis in an Injection Drug User: Considerations for Diagnosis and Management

Fungal endocarditis (FE) is a potentially lethal condition and its diagnosis can be challenging due to the low yield from blood cultures. FE should be suspected in patients with associated risk factors despite the identification of positive bacterial blood cultures. The common risk factors for FE discussed in the literature are total parenteral nutrition, immune suppression, prior antimicrobial therapy, intravenous drug addiction, and cardiac surgery. In this report, we discuss a patient who had positive blood cultures for Pseudomonas but was found to have Candida parapsilosis on valve culture. Physicians need to maintain a high index of suspicion for co-infective endocarditis in this patient population.

Serum Levels of Markers of Endothelial Activation Are Not Associated with a Positive Blood Culture in Surinamese Children with Suspected Severe Infection.

Systemic serum levels of markers of endothelial activation are associated with infection. We hypothesize that levels of markers of endothelial activation are associated with the presence of a positive blood culture as a manifestation of a systemic infection in children with a suspected severe infection in Suriname. In this prospective observational cohort study, children between 1 month and 18 years of age suspected of severe infection as assessed by the threating physician, and in whom laboratory testing and blood culturing was performed before start of intravenous antibiotic treatment, were recruited at the emergency department of the Academic Hospital Paramaribo, Suriname. Serum was collected at blood culturing and after 48-72 h of admission. Serum was stored for measurement of levels of Angiopoietin (Ang)-1, Ang-2, soluble (s)P-selectin, sE-selectin, vascular cell adhesion molecule-1, intercellular adhesion molecule-1 and platelet and endothelial cell adhesion molecule-1. Fifty-one children were included of whom 10 had a positive blood culture. Baseline characteristics were similar between children with and without a positive blood culture. No significant differences in serum levels of the Angiopoietins or soluble cellular adhesion molecules between groups were observed at start of antibiotic treatment nor after 48-72 h. The data from this study indicate that in children with severe infection, serum levels of markers of endothelial cell activation are not associated with a positive blood culture. Thus, having a positive bacterial blood culture may not be the only factor driving endothelial activation in this patient population.

Older age, longer procedures and tandem endoscopic-ultrasound as risk factors for post-endoscopic retrograde cholangiopancreatography bacteremia.

BACKGROUNDClinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bacteremia (PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended only when an ERCP is unlikely to achieve complete biliary drainage. However, the current recommendations may not cover all potential risk factors for PEB.AIMTo identify novel risk factors for PEB and evaluate appropriateness of antibiotic prophylaxis.METHODSA retrospective study of 1082 ERCP procedures performed between January 2012 - December 2013 in a single tertiary medical center. Data collection included: Demographic and clinical characteristics such as pre and post procedure antibiotic treatment and bacterial blood cultures. Exclusion criteria were: (1) Age < 18 years; (2) Positive bacterial blood culture before ERCP; (3) Scheduled antibiotic treatment prior to ERCP; (4) Hospitalization longer than 14 d before ERCP; and (5) missing critical data. Stepwise Logistic Regression analysis and Decision Tree algorithms were used for prediction modeling of PEB.RESULTSA total of 626 ERCPs performed in 434 patients were included. Mean age 66.49 ± 15.4 years and 46.5% were males. PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 139/626 (22.2%) cases but was indicated according to the guidelines only in 44/626 (7%) cases. In all the PEB cases, prophylaxis was deemed not indicated. A stepwise logistic regression [receiver operating characteristic (ROC), 0.766], identified 3 variables as independent risk factors for PEB: Age at ERCP ≥ 75 years (OR, 3.780, 95%CI: 1.519-9.408, P = 0.004); Tandem EUS/ERCP with fine needle aspiration (FNA) (OR, 14.528, 95%CI: 3.571-59.095, P < 0.001); ERCP duration longer than 60 min (OR, 5.396, 95%CI: 1.86-15.656, P = 0.002). In a decision tree model (ROC, 0.778) the probability for PEB without any risk factors was 1% regardless of prophylaxis administration. CONCLUSIONThe prevalence of PEB in our study is similar to previous reports, despite the fact that antibiotic prophylaxis was administrated more readily than recommended. ERCP duration longer than 60 min, tandem EUS-ERCP with FNA and age above 75 years are significant risk factors for PEB. These factors should be further evaluated as indications for prophylactic antibiotic treatment before ERCP.

Association Between Culture-Negative Versus Culture-Positive Sepsis and Outcomes of Patients Admitted to the Pediatric Intensive Care Unit

BackgroundSepsis remains a major cause of death, with high mortality and morbidity rates in children. The cause of mortality may be associated with several factors, including differences in cultures and the type of organism. This study was aimed at evaluating the characteristics and outcomes of negative bacterial blood culture compared to those of positive bacterial blood culture in children with severe sepsis/septic shock.MethodsA retrospective cohort study was conducted at a pediatric intensive care unit (PICU) of a tertiary care medical center. All pediatric patients, from newborn to 14 years of age, admitted between April 2015 and January 2018 were included in the study if they fulfilled the criteria for severe sepsis/septic shock.ResultsOf the 209 patients, 30 (14.3%) had a positive bacterial blood culture whereas 179 (86.6%) had a negative bacterial blood culture. Mortality was more in positive bacterial blood culture 13 (43%) vs 35 (20%) in negative bacterial blood culture (P = 0.004). Respiratory tract infections were extremely common, present in 108 of 179 (60%) patients, and tended to result in a negative culture. The rate of organ dysfunction was higher in the positive bacterial blood culture group at admission (P = 0.01). However, the results did not reveal a significant finding related to multiorgan dysfunction syndrome (MODS) progression over three days of PICU admission (P = 0.06).ConclusionThe negative bacterial blood culture constitutes a substantial proportion of pediatric patients with severe sepsis/septic shock. Furthermore, these pediatric patients have a lower mortality rate compared to positive bacterial blood cultures. The culture-negative sepsis group also had less organ dysfunction.

Pattern of bacterial profile and antibiotic susceptibility among neonatal sepsis cases at Cairo University Children Hospital.

ObjectivesNeonatal sepsis is the third leading contributor to mortality and morbidity. Emanating resistance to antibiotics in neonatal intensive care units (NICUs) is considered a major burden. In this study, we aimed to investigate the bacterial prevalence and antibiotic profile among patients admitted with sepsis in the NICU of Cairo University Children Hospital.MethodsNeonates with suspected sepsis were evaluated for bacterial sepsis in their blood cultures. The neonates with positive bacterial blood culture were included in this study, whereas neonates with negative culture were excluded. Positive samples were sub-cultured on blood, MacConkey, and chocolate agar plates. Organisms were identified by Gram staining and biochemical reactions. Antibiotic susceptibility was assessed by the Kirby–Bauer disc diffusion method.ResultsSeventy blood cultures (31.7%) were bacteria-positive: 45.3% for Klebsiella, 22.7% for coagulase-negative staphylococci (CoNS), and for Acinetobacter (10.7%), methicillin-resistant Staphylococcus aureus (MRSA) (9.3%), Pseudomonas (5.3%), Enterobacter (4%), and streptococci (2.7%). High resistance to all cephalosporins, B-lactamase combinations, penicillin, carbapenems, and aminoglycosides was observed. All Gram-negative Enterobacteria showed the highest sensitivity to levofloxacin, whereas Pseudomonas and Acinetobacter were highly sensitive to polymyxin B. Gram-positive samples were sensitive to vancomycin and linezolid. Streptococci were slightly sensitive to vancomycin and highly sensitive to macrolides and cefotaxime.ConclusionsIn our study, Klebsiella and CoNS were the most common isolates in neonatal sepsis. The levels of multidrug-resistant strains were alarmingly high. This finding negatively affected the outcomes, prompting the need for a strict guideline for antibiotics use.

Detection of some Microorganisms in Patients with Pericarditis by Immunofluresent Assay in Hilla City / Iraq

In this study, (17) pericardial effusion specimens and blood samples were obtained from hospitalized patients diagnosedwith pericardial effusion at Marjan Teaching Hospital, AL-Sader Teaching Hospital and Ibn-AL-Biatar Cardiovascular Center with age range between (2-77) years old from both sexes, 6(35.30%) male and 11(64.70%) of them were female. The period of collection were extended from July (2018) to January (2019). A total of (17) samples from hospitalized patients with pericardial effusion were included in this study, only 9(52.9%) patients with positive bacterial blood culture media, 7(77.8%) from female and 2(22.2%) from male, and 10(58.8%) patients with positive bacterial pericardial effusion, 7(70%) female and 3(30%) male. In the positive culture group, from 10(58.8%) cases, death occurred in 2(20%) patients, and in the negative culture group, from 7(41.2%) cases, death occurred in 2(38.5%) patients. The sera and pericardium effusion of patients in showed anti-IgM to M. pneumoniae, M. pneumophilia, L. pneumophilia, C. pneumophilia, RSV, Adenovirus, Influenza A virus, and Influenza B virus antibodies. The results showed 7/17(41.2%) positive cases of pericarditis attributed to M. pneumoniae. In (17) patients with acute pericarditis admitted found 2/17(11.8%) positive cases detected by IFA in patients with L. pneumophilia. IFA revealed that 1/17(5.9%) of positive cases for the assay positive for Chlamydophila pneumoniae. Recent study revealed that the IFA detect 2/17 (11.8%) of cases positive for Adenovirus. Depending on IFA recent study identified 2/17(11.8%) cases with RSV associated with another etiological agents and present a case of Influenza A virus infection 1/17(5.9%). Our results showed a case with pericardial effusion positive for Influenza B virus 1/17(5.9%) associated with presence of RSV and L. pneumophilia in patient with intestinal cancer with negative results of bacterial culture media for both pericardial effusion and blood.