Presumed Sepsis Research Articles

Antibiotic exposure for culture-negative early-onset sepsis in late-preterm and term newborns: an international study.

Early-life antibiotic exposure is disproportionately high compared to the burden of culture-proven early-onset sepsis (CP-EOS). We assessed the contribution of culture-negative cases to the overall antibiotic exposure in the first postnatal week. We conducted a retrospective analysis across eleven countries in Europe, North America, and Australia. All late-preterm and term infants born between 2014 and 2018 who received intravenous antibiotics during the first postnatal week were classified as culture-negative cases treated for ≥5 days (CN ≥ 5d), culture-negative cases treated for <5 days (CN < 5d), or CP-EOS cases. Out of 757,979 infants, 21,703 (2.9%) received intravenous antibiotics. The number of infants classified as CN ≥ 5d, CN < 5d, and CP-EOS was 7996 (37%), 13,330 (61%), and 375 (1.7%). The incidence of CN ≥ 5d, CN < 5d, and CP-EOS was 10.6 (95% CI 10.3-10.8), 17.6 (95% CI 17.3-17.9), and 0.49 (95% CI 0.44-0.54) cases per 1000 livebirths. The median (IQR) number of antibiotic days administered for CN ≥ 5d, CN < 5d, and CP-EOS was 77 (77-78), 53 (52-53), and 5 (5-5) per 1000 livebirths. CN ≥ 5d substantially contributed to the overall antibiotic exposure, and was 21-fold more frequent than CP-EOS. Antimicrobial stewardship programs should focus on shortening antibiotic treatment for culture-negative cases. In a study of 757,979 infants born in high-income countries, we report a presumed culture-negative early-onset sepsis incidence of 10.6/1000 livebirths with an associated antibiotic exposure of 77 antibiotic days per 1000 livebirths. This study sheds light on the major contribution of presumed culture-negative early-onset sepsis to early-life antibiotic exposure. Given the diagnostic uncertainty surrounding culture-negative early-onset sepsis, the low mortality rate, and the disproportionate antibiotic exposure associated with this condition, our study emphasizes the importance of targeting culture-negative early-onset sepsis in antimicrobial stewardship programs.

Antibiotic Management for Early-Onset Sepsis in Neonates With Gestational Ages of ≥ 34 Weeks: The Kaiser Sepsis Calculator Versus the 2010 CDC Guidelines.

The traditional approach to neonatal early-onset sepsis (NEOS) management, involving maternal risk factors and nonspecific neonatal symptoms, usually leads to unnecessary antibiotic use. This study addresses these concerns by evaluating the Kaiser sepsis calculator (KSC) in guiding antibiotic therapy for NEOS, especially in high-incidence facilities (over 4/1,000 live births), by comparing it against the 2010 Centers for Disease Control and Prevention (CDC) guidelines for neonates ≥34 weeks with suspected sepsis, thereby emphasizing its implications for personalized patient care. This is a prospective observational study. All neonates of 34 gestational weeks or more, presenting with either maternal risk factors or sepsis symptoms within 12 hours of birth, were included in the study. The analysis focused on antibiotic recommendations by the 2010 CDC guidelines versus those by the KSC at presumed (0.5/1,000) and actual (16/1,000) sepsis incidence rates. NEOS was identified in 14 cases (14.1%). Compared to the KSC, at an incidence rate of 16 per 1,000, the KSCresulted in a significant 32.3% reduction in antibiotic treatment (74 cases (74.7%) vs. 42 cases (42.4%), respectively; p < 0.001). The calculator advised immediate antibiotic utilization for 13 out of 14 (92.9%) diagnosed cases, suggesting further evaluation for the remaining cases. When a presumed incidence of 0.5/1,000 was applied, the KSC indicated antibiotics less frequently than when using the actual rate of 16/1,000 (p<0.001) with two missed NEOS cases. Using the KSC led to a decrease of 32 cases (32.3%)in unnecessary antibiotic prescriptions compared to adherence to 2010 CDC guidelines. However, setting a presumed incidence below the actual rate risked missing NEOS. The calculator was effective when actual local incidence rates were used, ensuring no missed cases needing antibiotics.

Predictors of mortality among low birth weight neonates after hospital discharge in a low-resource setting: A case study in Uganda.

Most neonatal deaths occur among low birth weight infants. However, in resource-limited settings, these infants are commonly discharged early which further exposes them to mortality. Previous studies on morbidity and mortality among low birth weight infants after early discharge mainly focused on very low birth weight infants, and none described post-discharge neonatal mortality. This study aimed to determine the proportion and predictors of mortality among low birth weight neonates discharged from the Special Care Baby Unit at Mulago National Referral Hospital in Uganda. This was a prospective cohort study of 220 low birth weight neonates discharged from the Special Care Baby Unit at Mulago National Referral Hospital. These were followed up to 28 completed days of life, or death, whichever occurred first. Proportions were used to express mortality. To determine the predictors of mortality, Cox hazards regression was performed. Of the 220 enrolled participants, 216 (98.1%) completed the follow-up. The mean gestational age of study participants was 34 ±3 weeks. The median weight at discharge was 1,650g (IQR: 1,315g -1,922g) and 46.1% were small for gestational age. During follow-up, 14/216 (6.5%) of neonates died. Mortality was highest (7/34, 20.6%) among neonates with discharge weights less than 1,200g. The causes of death included presumed neonatal sepsis (10/14, 71.4%), suspected aspiration pneumonia (2/14, 14.3%), and suspected cot death (2/14, 14.3%). The median time to death after discharge was 11 days (range 3-16 days). The predictors of mortality were a discharge weight of less than 1,200g (adj HR: 23.47, p <0.001), a 5-minute Apgar score of less than 7 (adj HR: 4.25, p = 0.016), and a diagnosis of neonatal sepsis during admission (adj HR: 7.93, p = 0.009). Post-discharge mortality among low birth weight neonates at Mulago National Referral Hospital is high. A discharge weight of less than 1,200g may be considered unsafe among neonates. Caregiver education about neonatal danger signs, and measures to prevent sepsis, aspiration, and cot death should be emphasized before discharge and during follow-up visits.

Impact of Congenital Heart Disease on the Outcomes of Very Low Birth Weight Infants.

This study aimed to investigate the association of congenital heart disease (CHD) with morbidity and mortality of very low birth weight (VLBW) infants. This matched case-control study included VLBW infants born at a single institution between 2001 and 2015. The primary outcome was mortality. Secondary outcomes included necrotizing enterocolitis, bronchopulmonary dysplasia (BPD), sepsis, retinopathy of prematurity, and intraventricular hemorrhage. These outcomes were assessed by comparing VLBW-CHDs with control VLBW infants matched by gestational age within a week, birth weight within 500 g, sex, and birth date within a year using conditional logistic regression. Multivariable logistic regression analyzed differences in outcomes in the VLBW-CHD group between two birth periods (2001-2008 and 2009-2015) to account for changes in practice. In a cohort of 44 CHD infants matched with 88 controls, the mortality rate was 27% in infants with CHD and 1% in controls (p < 0.0001). The VLBW-CHDs had increased BPD; (odds ratio [OR]: 7.70, 95% confidence interval [CI]: 1.96-30.29) and sepsis (OR: 10.59, 95% CI: 2.99-37.57) compared with the control VLBWs. When adjusted for preoperative ventilator use, the VLBW-CHDs still had significantly higher odds of BPD (OR: 6.97, 95% CI: 1.73-28.04). VLBW-CHDs also had significantly higher odds of both presumed and culture-positive sepsis as well as late-onset sepsis than their matched controls. There were no significant differences in outcomes between the two birth periods. VLBW-CHDs showed higher odds of BPD, sepsis, and mortality than VLBW infants without CHD. Future research should focus on the increased mortality and specific complications encountered by VLBW infants with CHD and implement targeted strategies to address these risks. · Incidence of CHD is higher in preterm infants than in term infants but the incidence of their morbidities is not well described.. · VLBW infants with CHD have higher odds of mortality, bronchopulmonary dysplasia, and sepsis.. · Future research is needed to implement targeted preventive responses..

Sepsis mimics among presumed sepsis patients at intensive care admission: a retrospective observational study

BackgroundDiagnosing sepsis remains a challenge because of the lack of gold-standard diagnostics. Since there are no simple, broadly accepted criteria for infection, there is a risk of misclassifying sepsis patients (sepsis mimics) among patients with organ failure. The main objective of this study was to investigate the proportion of non-infected patients (sepsis mimics) in ICU patients with presumed sepsis at intensive care unit (ICU) admission.MethodsAdult patients were screened retrospectively during 3.5 years in four ICUs in Sweden for fulfilment of the sepsis-3 criteria at ICU admission (presumed sepsis). Proxy criteria for suspected infection were sampled blood culture(s) and concomitant antibiotic administration. Culture-negative presumed sepsis patients were screened for infection according to the Linder-Mellhammar Criteria of Infection (LMCI). Sepsis mimics were defined as without probable infection according to the LMCI. Confirmed sepsis was defined as presumed sepsis after the exclusion of sepsis mimics.ResultsIn the ICU presumed sepsis cohort (2664 patients), 25% were considered sepsis mimics. The most common reasons for ICU admission among sepsis mimics were acute heart failure and unspecific respiratory failure. Comparing sepsis mimics and confirmed sepsis showed that confirmed sepsis patients were slightly more severely ill but had similar mortality. C-reactive protein had modest discriminatory power (AUROC 0.71) with confirmed sepsis as the outcome.ConclusionsOne-fourth of a presumed ICU sepsis population identified with the sepsis-3 criteria could be considered sepsis mimics. The high proportion of sepsis mimics has a potential dilutional effect on the presumed sepsis population, which threatens the validity of results from sepsis studies using recommended sepsis criteria.

Use of Electronic Clinical Data to Track Incidence and Mortality for SARS-CoV-2–Associated Sepsis

Efforts to quantify the burden of SARS-CoV-2-associated sepsis have been limited by inconsistent definitions and underrecognition of viral sepsis. To describe the incidence and outcomes of SARS-CoV-2-associated sepsis vs presumed bacterial sepsis using objective electronic clinical criteria. This retrospective cohort study included adults hospitalized at 5 Massachusetts hospitals between March 2020 and November 2022. SARS-CoV-2-associated sepsis was defined as a positive SARS-CoV-2 polymerase chain reaction test and concurrent organ dysfunction (ie, oxygen support above simple nasal cannula, vasopressors, elevated lactate level, rise in creatine or bilirubin level, and/or decline in platelets). Presumed bacterial sepsis was defined by modified US Centers for Disease Control and Prevention adult sepsis event criteria (ie, blood culture order, sustained treatment with antibiotics, and organ dysfunction using identical thresholds as for SARS-CoV-2-associated sepsis). Trends in the quarterly incidence (ie, proportion of hospitalizations) and in-hospital mortality for SARS-CoV-2-associated and presumed bacterial sepsis were assessed using negative binomial and logistic regression models. This study included 431 017 hospital encounters from 261 595 individuals (mean [SD] age 57.9 [19.8] years, 241 131 (55.9%) females, 286 397 [66.5%] from academic hospital site). Of these encounters, 23 276 (5.4%) were from SARS-CoV-2, 6558 (1.5%) had SARS-CoV-2-associated sepsis, and 30 604 patients (7.1%) had presumed bacterial sepsis without SARS-CoV-2 infection. Crude in-hospital mortality for SARS-CoV-2-associated sepsis declined from 490 of 1469 (33.4%) in the first quarter to 67 of 450 (14.9%) in the last (adjusted odds ratio [aOR], 0.88 [95% CI, 0.85-0.90] per quarter). Crude mortality for presumed bacterial sepsis was 4451 of 30 604 patients (14.5%) and stable across quarters (aOR, 1.00 [95% CI, 0.99-1.01]). Medical record reviews of 200 SARS-CoV-2-positive hospitalizations confirmed electronic health record (EHR)-based SARS-CoV-2-associated sepsis criteria performed well relative to sepsis-3 criteria (90.6% [95% CI, 80.7%-96.5%] sensitivity; 91.2% [95% CI, 85.1%-95.4%] specificity). In this retrospective cohort study of hospitalized adults, SARS-CoV-2 accounted for approximately 1 in 6 cases of sepsis during the first 33 months of the COVID-19 pandemic. In-hospital mortality rates for SARS-CoV-2-associated sepsis were high but declined over time and ultimately were similar to presumed bacterial sepsis. These findings highlight the high burden of SARS-CoV-2-associated sepsis and demonstrate the utility of EHR-based algorithms to conduct surveillance for viral and bacterial sepsis.

A rare cause of neonatal feeding intolerance: congenital segmental intestinal dilatation—a case report

BackgroundCongenital segmental intestinal dilatation (CSID) is a rare cause of neonatal bowel obstruction. Patients can present in the early newborn period with feeding intolerance and abdominal distension. Diagnosis is challenging due to its rarity and non-specific clinical and radiological findings in a well neonate. Surgical excision remains the mainstay treatment for this disease.Case presentationWe report a case of a newborn male with congenital segmental ileal dilatation, who presented with abdominal distension and feeding intolerance. He was born preterm at 32 weeks and was treated for presumed sepsis due to a premature rupture of the membrane. The patient developed persistent abdominal distension upon initiation of feedings with large amount of gastric aspirates. Otherwise, there was no delay in the passage of meconium. Serial abdominal radiographs showed persistent focal bowel dilatation on the right side. He was initially diagnosed with small bowel atresia. Ultrasound abdomen and lower gastrointestinal contrasted study showed focal ileal dilatation with no evidence of pneumoperitoneum. Intraoperative findings revealed a segmental ileal dilatation with no evidence of mechanical obstruction. The abnormal dilated bowel was excised and sent for histopathological examination. He recovered well after surgery.ConclusionDiagnosis of CSID can be challenging due to its clinical polymorphism and non-specific radiological findings. CSID should be suspected in neonates with feeding intolerance and focal intestinal dilatation without clinical features of sepsis, peritonitis, or mechanical obstruction. Surgical excision is curative with a good outcome.

Probiotic Use in a Randomized Controlled Trial to Prevent Sepsis and/or Necrotizing Enterocolitis in Low-Birth-Weight Infants

Neonatal sepsis is a major problem throughout the world. Early detection of neonatal sepsis is difficult because the first signs of this disease may be minimal, especially in preterm infants. The clinical signs are similar to those of non-infectious processes. Definitive blood culture results not being immediately available may prove detrimental. As a result, many babies are evaluated and treated for presumed sepsis with parenteral antibiotics while awaiting microbial isolation. This study was undertaken to evaluate the efficacy of probiotics in prevention of Late onset sepsis and or NEC in low-birth-weight babies.

Neonatal Salmonella Meningitis With Subdural Empyema: A Case Report.

To the Editors: Salmonella species can cause a variety of neonatal infections which are most prevalent in sub-Saharan Africa. Salmonella meningitis is associated with long-term neurologic sequelae1 including seizures, hydrocephalus, subdural effusions, empyema, ventriculitis, hemorrhage and abscess.2 The present case describes a neonate with Salmonella meningitis with subdural empyema. A 12-day-old full-term female presented to the emergency department for a 1-day history of fever, decreased feeding, and a shorter, gasp-like breathing pattern. The baby was tachycardic and febrile. Per patient’s mother, both she and the infant’s brother were suffering from diarrhea 3 days before onset of the infant’s symptoms. A full sepsis workup was initiated, including blood, urine and cerebrospinal fluid cultures. The patient was empirically started on intravenous ampicillin and gentamicin pending culture results. Additionally, a respiratory pathogen panel via polymerase chain reaction performed on the same day indicated positive results for coronavirus disease 2019 (COVID-19). The patient was admitted for further management of presumed neonatal sepsis and respiratory monitoring of COVID-19 infection. The patient was subsequently found to have positive blood culture and cerebrospinal fluid gram stain for Gram-negative rods. Speciation and sensitivities later grew Salmonella species with sensitivity to ampicillin and ceftriaxone. Magnetic resonance imaging of the brain was significant for diffuse right leptomeningeal enhancement consistent with meningitis and subdural empyema. No neurosurgical intervention was recommended. Ampicillin and gentamicin were discontinued after 3 days of treatment, and ceftazidime was started for treatment of salmonella meningitis. Ceftriaxone was considered as the standard treatment for invasive Salmonella infection, but was inappropriate due to mildly elevated bilirubin on admission (Table 1) and patient’s age. TABLE 1. - Admission Labs Complete blood count With Differential Day 1 of Admission White blood cell count 6.4 × 103/µL Hemoglobin/hematocrit 12.6/37.3 g/dL Platelets 564 × 103/µL Segmented neutrophils 40% Bands 24% Lymphocytes 26% Monocytes 7% Urinalysis Color Dark yellow Specific gravity 1.021 pH 7.0 Protein 2+ Glucose Trace Ketones Negative Bilirubin Negative Blood Negative Nitrites Negative Urobilinogen 0.2 Leukocyte esterase 2+ Urine microscopy White blood cells >50 Red blood cells 11.1 Squamous epithelial 5.3 Bacteria 40 Casts 3.9 Chemistry Sodium 138 mmol/L Potassium 4.1 mmol/L Chloride 107 mmol/L Bicarbonate 22 mmol/L Blood urea nitrogen/creatinine 8/0.37 mg/dL Glucose 108 mg/dL Total bilirubin 9.6 mg/dL Total protein 6.2 g/dL Albumin 3.1 g/dL Alanine transaminase/aspartate transaminase 18/23 Units/L Alkaline phosphatase 143 Units/L Cerebrospinal fluid Color Cloudy White blood cells 667 cu/mm Red blood cells 42,500 cu/mm Segmented neutrophils 90% Lymphocytes 8% Monocytes 1% Eosinophils 1% Basophils 0% Inflammatory markers C-reactive protein (admission) 3.06 mg/dL C reactive protein (hospital day #2) 25 mg/dL On the third day of admission, a repeat respiratory pathogen panel showed the patient to be COVID-19 negative, and it was concluded that the initial positive test was likely a false positive. Repeat blood cultures drawn on day 4 of admission were negative. On day 8 of admission, a peripherally inserted central catheter line was placed for long-term parenteral antibiotics. On day 10 of admission, ceftazidime was discontinued and switched to ceftriaxone after a repeat complete metabolic panel showed normalized bilirubin levels. Ceftriaxone was selected (in lieu of ampicillin) to minimize peripherally inserted central catheter line access thereby reducing probability of central line–associated bacterial infection. Inflammatory markers and bilirubin were trended closely due to use of ceftriaxone. A 6-week course of treatment was completed with no further complications and improvement of radiologic findings. The patient was discharged with no apparent neurological deficits. Her development was ascertained by phone call and the child continues to develop typically. Previous case reports indicate that third generation cephalosporins are ideal for management of salmonella meningitis due to their bactericidal properties.3,4 This case offers a suggested treatment course of neonates with transition from ceftazidime to ceftriaxone showing satisfactory results in the treatment of neonatal Salmonella sepsis and meningitis complicated by empyema. ACKNOWLEDGMENTS The authors thank the patient and family for their participation in this report.

Patterns of Infections among Extremely Preterm Infants.

Infections remain a leading cause of neonatal death, especially among the extremely preterm infants. To evaluate the incidence, pathogenesis, and in-hospital outcomes associated with sepsis among hospitalized extremely preterm infants born at 24-0/7 to 27-6/7 weeks of gestation, we designed a post hoc analysis of data collected prospectively during the Preterm Epo Neuroprotection (PENUT) Trial, NCT #01378273. We analyzed culture positive infection data, as well as type and duration of antibiotic course and described their association with in-hospital morbidities and mortality. Of 936 included infants, 229 (24%) had at least one positive blood culture during their hospitalization. Early onset sepsis (EOS, ≤3 days after birth) occurred in 6% of the infants, with Coagulase negative Staphylococci (CoNS) and Escherichia Coli the most frequent pathogens. Late onset sepsis (LOS, >day 3) occurred in 20% of the infants. Nearly all infants were treated with antibiotics for presumed sepsis at least once during their hospitalization. The risk of confirmed or presumed EOS was lower with increasing birthweight. Confirmed EOS had no significant association with in-hospital outcomes or death while LOS was associated with increased risk of necrotizing enterocolitis and death. Extremely premature infants with presumed sepsis as compared to culture positive sepsis had lower rates of morbidities. In conclusion, the use of antibiotics for presumed sepsis remains much higher than confirmed infection rates. Ongoing work exploring antibiotic stewardship and presumed, culture-negative sepsis in extremely preterm infants is needed.

Associations Between Neonatal Beta-Lactam Exposure and Adverse Drug Reactions by Age 5 Years

Penicillin and Cephalosporins are commonly used antibiotics for treatment of presumed sepsis in the neonatal period. These beta-lactam drugs are the most frequently implicated drug class to elicit adverse drug reactions (ADR), and we hypothesize that neonatal exposure to them is associated with increased reporting of ADR to them.

Tuberculose perinatal: um diagnóstico a ser considerado

BACKGROUND: Perinatal Tuberculosis (TB) is a rare disease, transmitted during pregnancy or postnatal. Its clinical presentation is similar to congenital infections and neonatal sepsis, thus, remains underestimated and underdiagnosed. CASE PRESENTATION: A 34 week female child, born vaginally, with no prenatal intercurrences. Was admitted in neonatal Intensive Care Unit (ICU) in need of ventilatory support and antibiotic therapy for presumed neonatal sepsis. During the case evolution, a treatment for suspected fungical sepsis was initiated, and after 48h, the newborn showed bilateral otitis media and otomastoiditis. Meanwhile, the newborns mother was hospitalized with miliar TB. Thereby, the newborn was treated for latent TB with Rifampicin, and a lymph node exeresis was made for tuberculosis quick testing (TRM-Ultra) and culture. Since the TRM-Ultra was positive, the treatment was switched to Rifampicin, Isoniazid and Pyrazinamide in order to treat presumed Perinatal TB. The newborn has evolved well and the culture demonstrated Mycobacterium tuberculosis. DISCUSSION: The congenital form of Perinatal TB is transmitted intrauterus by mothers with severe and/or genital TB, while postnatal occurs due to newborns contact with bacilliferous individual after birth. The diagnosis, as the differentiation between the two forms, are hampered by non-specific clinical manifestations. CONCLUSION: This case demonstrates the importance of considering perinatal TB in unspecified symptomatology cases that are not responsive to conventional antibiotic therapy. Despite the uncertainty regarding the time of infection, besides late diagnosis and treatment, the patient obtained a satisfactory clinical outcome.

PSAT034 A Case of Adrenal Crisis in Association With a Febrile Response to the bnt162b2 mRNA COVID-19 (Pfizer) Vaccine Heralding a Diagnosis of Primary Adrenal Insufficiency.

Abstract Background In the face of the COVID-19 pandemic, messenger RNA (mRNA) vaccines were approved for the first time for use in the general population. Vaccination can trigger a febrile flu-like response that is self-limited in healthy individuals. Febrile illness is a classic trigger of acute adrenal insufficiency in patients who are cortisol deficient, but recognizing this clinical scenario is challenging in patients with undiagnosed adrenal insufficiency. Case Presentation A 24-year-old male presented to an acute care community hospital with fatigue, fever, and vomiting 12 hours after receiving the second dose of the BNT162b2 mRNA Covid-19 (Pfizer) vaccine. He was 6 feet tall, and his weight was 175 pounds. He had a temperature of 103 F, a blood pressure of 88/42 mmHg, and a heart rate of 100 bmp on admission. Hypotension persisted despite aggressive fluid resuscitation and broad-spectrum antibiotics. CT of the chest and CT angiogram of the abdomen and Pelvis did not identify an etiology for his presentation. Over a period of hours, he became obtunded, disoriented, and required vasopressor support. He received 100 mg of IV hydrocortisone followed by 50 mg every 6 hours for treatment of presumed sepsis and was transferred to an intensive care unit. Within 24 hours of starting glucocorticoid therapy, he was awake and oriented, defervesced, and became normotensive. This rapid improvement led to suspicion of adrenal insufficiency as an underlying diagnosis. Further questioning revealed a 4-month history of recurrent nausea, vomiting, severe fatigue, to the point where he had trouble climbing a flight of stairs, and a 40-pound unintentional weight loss. He visited an emergency department 3 times over this period and had outpatient evaluations by gastroenterology and cardiology without identifying a cause. Inpatient evaluation revealed a morning Cortisol of 1.4 ug/dL (n 4.8-19.5 ug/dL), aldosterone &amp;lt;3 ng/dL (n &amp;lt;16 ng/dL), and ACTH 1071 pg/mL (n 7.2-63.3 pg/mL) leading to the diagnosis of primary adrenal insufficiency. He was started on physiologic doses of adrenal replacement hormones and discharged home in stable condition 4 days after his admission date. Conclusions A severe post-vaccination reaction should elicit physicians to look for an alternative diagnosis. Autoimmune adrenalitis is the most common cause of primary adrenal insufficiency and is uniquely associated with a long lag to diagnosis. The diagnosis is often made in the setting of an intervening illness or physiologic stressor when a patient's condition acutely deteriorates. Patients with known adrenal insufficiency should be reminded to address post-vaccination febrile reactions with an increase in glucocorticoid doses. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Comparison of Early-Onset Sepsis Risk-Stratification Algorithms in Neonates in a Kenyan Nursery.

Risk stratification algorithms (RSAs) can reduce antibiotic duration (AD) and length of stay (LOS) for early-onset sepsis (EOS). Because of higher EOS and antibiotic resistance rates and limited laboratory capacity, RSA implementation may benefit low- and middle-income countries (LMIC). Our objective was to compare the impact of 4 RSAs on AD and LOS in an LMIC nursery. Neonates <5 days of age admitted for presumed sepsis to a Kenyan referral hospital in 2019 (n = 262) were evaluated by using 4 RSAs, including the current local sepsis protocol ("local RSA"), a simplified local protocol ("simple RSA"), an existing categorical RSA that uses infant clinical examination and maternal risk factors (CE-M RSA) clinical assessment, and the World Health Organization's Integrated Management of Childhood Illness guideline. For each RSA, a neonate was classified as at high, moderate, or low EOS risk. We used к coefficients to evaluate the agreement between RSAs and McNemar's test for the direction of disagreement. We used the Wilcoxon rank test for differences in observed and predicted median AD and LOS. Local and simple RSAs overestimated EOS risk compared with CE-M RSA and the Integrated Management of Childhood Illness guideline. Compared with the observed value, CE-M RSA shortened AD by 2 days and simple RSA lengthened AD by 2 days. LOS was shortened by 4 days by using CE-M RSA and by 2 days by using the local RSA. The local RSA overestimated EOS risk compared with CE-M RSA. If implemented fully, the local RSA may reduce LOS. Future studies will evaluate the prospective use of RSAs in LMICs with other interventions such as observation off antibiotics, biomarkers, and bundled implementation.

Utility of Neonatal Sequential Organ Failure Assessment (nSOFA) Score for Neonatal Mortality Prediction

Aims and Objectives: (a) Utility of neonatal sequential organ failure assessment (SOFA) score for predicting mortality in neonatal sepsis. (b) Determining a cut-off score of neonatal sequential organ failure assessment (nSOFA) score in relation to mortality. Materials and Methods: Prospective pilot study in neonatal intensive care unit (ICU) for 1 year (January-December 2021). Inclusion Criteria: All neonates (inborn and outborn) admitted to neonatal ICU with the diagnosis of presumed or proven sepsis. Exclusion Criteria: Neonates with critical congenital heart disease, congenital malformations, congenital immunodeficiency syndromes, inborn errors of metabolism, and neonates with birth asphyxia. All neonates admitted in neonatal ICU with the diagnosis of presumed or proven sepsis were included in the study. Variables required for nSOFA were assessed along with general demographic like age, gestational age, and so on. The nSOFA score was documented twice, once at the time of admission (initial evaluation) for sepsis and later at 24 h. The final outcome (survivor/nonsurvivor) was recorded. Data was analyzed to see the correlation of nSOFA to outcome and also to see the predictive value of cut-off nSOFA score to outcome. Results: A total of 60 neonates with presumed or proven sepsis (30 each in term and preterm) were admitted, of which 10 (16.7%) were nonsurvivors (6 preterms and 4 term), P value .731. Four deaths were observed in outborn (n = 38) and 6 in inborn (n = 22) babies, P value .149. The mean (±standard deviation [SD]) of age (days) and weight (kg) among survivors was 11.24 (9.47) and 2.23 (0.69) and for nonsurvivors was 11.2 (11.9) and 1.9 (1.1), respectively, P value &gt;.05. There was no statistical significance observed between survivors and nonsurvivors in relation to blood culture positivity, P value .17. Mean (±SD) nSOFA score among survivors at the time of admission (initial evaluation) was 1.96 (1.69) and at 24 h was 1.16 (1.48). Among nonsurvivors mean (±SD), admission (initial evaluation) nSOFA score was 7.6 (2.0) and at 24 h 10 (2) was observed, P value of &lt;.001. The mean (±SD) of nSOFA changes (at the time of admission and at 24 h) for survivors (–)0.8(1.14) and for nonsurvivors 2.4 (1.17) was observed, P value &lt;.001. Outcome in relation to nSOFA score, 90.0% mortality was observed with the score of ≥6 at the time of admission (initial evaluation) and score of ≥5 at 24 h. Based on these cut-off values, receiver operating characteristic curve for mortality prediction was calculated. Area under curve (AUC) for admission (initial) was 0.972 (sensitivity 90%, specificity 98%, positive predictive value 90%, negative predictive value 98, with accuracy of 96.7%). At 24 h, AUC was 0.999 (sensitivity 100%, specificity 98%, positive predictive value 90.9%, negative predictive value 100, with accuracy of 98.3%). Conclusion: nSOFA can predict neonatal mortality due to sepsis. Admission nSOFA score of ≥6 and ≥5 at 24 h correlate well with mortality.

Microbiology Assessments in Critically Ill Patients.

The prevalence of suspected or proven infections in critically ill patients is high, with a substantial attributable risk to in-hospital mortality. Coordinated guidance and interventions to improve the appropriate microbiological assessment for diagnostic and therapeutic decisions are therefore pivotal. Conventional microbiology follows the paradigm of "best practice" of specimen selection and collection, governed by laboratory processing and standard operating procedures, and informed by the latest developments and trends. In this regard, the preanalytical phase of a microbiological diagnosis is crucial since inadequate sampling may result in the incorrect diagnosis and inappropriate management. In addition, the isolation and detection of contaminants interfere with multiple intensive care unit (ICU) processes, which confound the therapeutic approach to critically ill patients. To facilitate bedside enablement, the microbiology laboratory should provide expedited feedback, reporting, and interpretation of results. Compared with conventional microbiology, novel rapid and panel-based diagnostic strategies have the clear advantages of a rapid turnaround time, the detection of many microorganisms including antimicrobial resistant determinants and thus promise substantial improvements in health care. However, robust data on the clinical evaluation of rapid diagnostic tests in presumed sepsis, sepsis and shock are extremely limited and more rigorous intervention studies, focusing on direct benefits for critically ill patients, are pivotal before widespread adoption of their use through the continuum of ICU stay. Advocating the use of these diagnostics without firmly establishing which patients would benefit most, how to interpret the results, and how to treat according to the results obtained, could in fact be counterproductive with regards to diagnostic "best practice" and antimicrobial stewardship. Thus, for the present, they may supplement but not yet supplant conventional microbiological assessments.

A case-control study evaluating the unnecessary use of intravenous broad-spectrum antibiotics in presumed sepsis and septic-shock patients in the emergency department.

Recognition of sepsis frequently occurs in emergency departments. To evaluate the appropriateness of empiric antibiotic use in the setting of suspected sepsis in emergency department, the percentages of bacterial infection and antibiotic-related adverse drug effects were quantified in an emergency department at an academic medical center. We retrospectively reviewed electronic medical records of adults who presented to the emergency department between January 2018 and June 2018 with suspected sepsis (defined as having ≥2 systemic inflammatory response syndrome [SIRS] criteria) and received ≥1 dose of intravenous broad-spectrum antibiotic. In total, 218 patients were included in the final analysis. Moreover, 19.3% of these patients had confirmed bacterial infections; 44.5% had suspected bacterial infections; and 35.9% did not have bacterial infection. Elevated SIRS score (ie, ≥2) and Quick Sequential Organ Failure Assessment (qSOFA) score (ie, ≥2) were not associated with the presence of bacterial infections. We identified 90-day Clostridioides difficile infections in 7 patients and drug-resistant organism infections in 6 patients, regardless of the presence of bacterial infections. A high number of patients received intravenous broad-spectrum antibiotics in the emergency department without confirmed or suspected bacterial infections that were supported by microbiologic cultures, radiographic imaging, or other symptoms of infections. Most patients who were initially admitted to the emergency department with suspected sepsis were discharged home after receiving 1 dose of intravenous antibiotic. Patients who were initially screened using SIRS score and who received broad-spectrum antibiotics in the emergency department were without confirmed or suspected bacterial infection.

Knowledge and perception of Sepsis among Doctors in Karachi Pakistan.

Objectives:To assess knowledge and perception among Pakistani physicians towards sepsis.Methods:This cross-sectional study was conducted in Indus Hospital and Health Networks from September 2020 to March 2021. The International Sepsis Survey questionnaire was adapted, and its link was sent to trainee physicians as well as specialists, and consultants practicing in various hospitals via social media. Knowledge and perception were scored and 50% was considered the cut-off score for adequacy. Data was analyzed using SPSS version 26.Results:Analysis was done on 222 respondents who completed the survey. 37.9% of the participants had adequate knowledge. Knowledge regarding sepsis was significantly associated with specialty, ICU/CCU/HDU, and work experience (P-value <0.0001). More recent trainee physicians and those with more experience in critical care areas demonstrated better knowledge. Over 2/3rd of the respondents strongly agreed that sepsis remains one of the unmet needs in critical care today.Conclusion:A common belief exists that sepsis remains a challenge to treat among doctors. Moreover, there is consensus that it is the most frequently miss diagnosed condition in critical care and a dire need exists for its early diagnosis. Additionally, prompt management of presumed sepsis is imperative to improve outcomes.

A Late-Preterm Infant with Ichthyosis, Pancytopenia, and Recurrent Sepsis.

A Late-Preterm Infant with Ichthyosis, Pancytopenia, and Recurrent Sepsis.

S2445 When Recurring Infections Mask an Atypical Presentation of Inflammatory Bowel Disease

Introduction: Pyoderma gangrenosum (PG) is an uncommon and severe extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD) with head or scalp involvement being exceeding rare. About one-third of presentations can be precipitated by skin trauma or infection, otherwise known as pathergy. These ulcers develop acutely, may not correlate with IBD activity, and can predate IBD diagnosis. Here we present an atypical presentation of PG in the setting of newly-diagnosed IBD. Case description/methods: A 35-year-old male with prior diagnosis of recurrent, diffuse soft tissue infections presented for management of presumed sepsis due to soft tissue infection. Two weeks prior to presentation, patient developed painful and purulent left lower extremity ulcer followed by worsening of facial and scalp ulcerations (Fig A-C). Patient reported prior diagnosis of facial folliculitis 1 year ago triggered by a stressor event that resolved but then had recurrence 3 months prior to this encoutner. Skin biopsy was unremarkable and was managed with IV antibiotics due to suspected infection. CT abdomen and pelvis during that admission showed circumferential sigmoid and rectal wall thickening concerning for colitis, but patient did not pursue further outpatient work up. Since being discharged from prior hospitalization, the patient experienced ongoing melenic stools. Prior to hospital transfer, patient was febrile to 39.4˚C, WBC count of 33k/ul and hemoglobin of 6.1g/dl for which endoscopy was performed showing diffuse erosive gastritis. Wound cultures grew staphylococcal aureus, and he was started on IV antibiotics. Initial concerns for IBD were based on imaging, ulcer concerning for PG, and three-year history of diarrhea elicited after admission. Laboratory work up is summarized in Table 1. Sigmoidoscopy showed cobblestoning with non-bleeding mucosal ulcerations and sigmoid colon biopsies demonstrated severely active colitis (Fig D,E). Skin biopsy was concerning for PG with superimposed infection. Patient was started on steroid therapy with improvement of diarrhea and inflammatory markers. Patient was discharged on oral steroids and planned follow up for initiation of biologic therapy. Discussion: This patient received a new diagnosis of IBD almost solely based on his presenting dermatological findings. This individual initially presented with recurrent skin wounds, however, eliciting further history of recurrent diarrhea, shifted the work up beyond infectious etiologies to earlier diagnosis and treatment of PG and IBD.Table 1.: Laboratory Data Depicting Patient Hospital Course.Figure 1.: Figure A and B: An extensive, necrolytic ulceration with an irregular, violaceous and undermined borders of the left lower extremity Figure C: Diffuse ulcerated lesions of the head and scalp Figure D and E: Endoscopy image of rectosigmoid mucosa with ulcerations, congestion, erythema, granularity and loss of vascularity.