Prolonged Antibiotic Treatment Research Articles

Total Laparoscopic Resection of Hilar Cholangiocarcinoma Type 3b: Applying a Parachute Technique for Hepaticojejunostomy

BackgroundLaparoscopic liver resection for perihilar cholangiocarcinoma (pCCA) is still in its infancy. The biliary-enteric reconstruction represents one of the most delicate parts of this minimally invasive procedure.MethodsIn this study, a 78-year old woman with perihilar cholangiocarcinoma (pCCA) type 3b underwent a hepaticojejunostomy performed by a parachute technique.ResultsThe operation, performed totally by minimally invasive resections, was completed in 386 min, with a blood loss of less than 400 ml and no transfusion requirements. Two intraluminal stents were placed during the hepaticojenunostomy for splinting of the biliary-enteric anastomosis. The patient required prolonged antibiotic treatment for postoperative cholangitis and finally was discharged on postoperative day 15. The histopathologic grading displayed a G 2–3 adenocarcinoma, pT3 pN0, M0, L1, V1, pN1, UICC IIIc R0, and the patient was referred to adjuvant chemotherapy.ConclusionResections of pCCAs, performed totally by minimally invasive techniques, may be feasible and safe for a selected group of patients. With this approach, a running-suture hepaticojejunostomy using the parachute technique represents a worthwhile strategy for biliary-enteric reconstruction.

Salmonella sp. as the Cause of Periprosthetic Joint Infection of the Hip: Report of a Rare Case and Review of Past 10-year Literatures

BACKGROUND: Periprosthetic joint infection (PJI) due to Salmonella sp. is rare. It is sometimes difficult to treat and need prolonged antibiotic treatment.
 CASE REPORT: We reported a case of PJI of the hip in a 67-year-old female who received prior left total hip arthroplasty. Two-stage revision surgery with antibiotic-loaded cement spacer had been performed to the patient and successfully control the infection.
 CONCLUSION: Although literature review showed that there has been no consensus for the treatment of Salmonella PJI, a two-stage revision procedure has been more commonly performed to control the infection by previous authors and might be the safest way to control Salmonella PJI recently.

A Retrospective Analysis of Microbiologic Profile of Foot Infections in Patients With Diabetic End-Stage Renal Disease.

Individuals with diabetes and end-stage renal disease (ESRD) are at increased risk of foot ulceration and lower extremity amputation. Although risk factors and microbiologic analysis of diabetic foot infections (DFIs) have been extensively studied, there are limited data available for this characteristic group. Clinical, demographic, laboratory, microbiological data, and foot examination information were collected retrospectively regarding 94 patients with ESRD who were referred for DFI between 2006 and 2016 to hyperbaric oxygen therapy. In 6 of 94 patients with ESRD (mean age 60 years; 65 males [69.1%], 29 women [30.8%]; 91 undergoing hemodialysis [96.8%], one peritoneal dialysis [1%], two [2%] recent renal transplants), the lesions were bilateral; therefore, the evaluations were made over 100 DFIs. The most common pathogens isolated in deep wound cultures were Staphylococcus aureus and Pseudomonas aeruginosa, respectively, contributing to 27 (21.2%) and 16 (12.5%) of all 127 isolates. When the distribution of the isolates according to different Wagner grades were analyzed, it was found that the proportion of Gramnegative isolates increased statistically significantly with the ascending Wagner grade (P = .004). DFIs indicate a serious complication associated with a high risk of amputation, prolonged antibiotic treatment, increased hospital and procedure demands, and the cost of health care, on patients with ESRD. The familiarization of causative pathogens underlying DFIs can aid the clinicians in the choice of appropriate empirical antibiotic treatment. This study emphasizes the need for greater attention to risk factors and the microbiologic profile of DFIs in this characteristic group.

Quorum Sensing and Toxin Production in Staphylococcus aureus Osteomyelitis: Pathogenesis and Paradox.

Staphylococcus aureus is a Gram-positive pathogen capable of infecting nearly every vertebrate organ. Among these tissues, invasive infection of bone (osteomyelitis) is particularly common and induces high morbidity. Treatment of osteomyelitis is notoriously difficult and often requires debridement of diseased bone in conjunction with prolonged antibiotic treatment to resolve infection. During osteomyelitis, S. aureus forms characteristic multicellular microcolonies in distinct niches within bone. Virulence and metabolic responses within these multicellular microcolonies are coordinated, in part, by quorum sensing via the accessory gene regulator (agr) locus, which allows staphylococcal populations to produce toxins and adapt in response to bacterial density. During osteomyelitis, the Agr system significantly contributes to dysregulation of skeletal homeostasis and disease severity but may also paradoxically inhibit persistence in the host. Moreover, the Agr system is subject to complex crosstalk with other S. aureus regulatory systems, including SaeRS and SrrAB, which can significantly impact the progression of osteomyelitis. The objective of this review is to highlight Agr regulation, its implications on toxin production, factors that affect Agr activation, and the potential paradoxical influences of Agr regulation on disease progression during osteomyelitis.

When the Cough Does Not Improve: A Review on Protracted Bacterial Bronchitis in Children.

Chronic cough is defined as a daily cough that persists longer than 4 weeks. Protracted bacterial bronchitis (PBB) is a common cause of chronic wet cough in preschool children with no symptoms or signs of other specific causes, and resolution usually follows a 2-week course of an appropriate oral antibiotic. The diagnosis is mainly clinical; generally, no instrumental examinations are necessary. The most common bacteria found in the bronchoalveolar lavage (BAL) of subjects with PBB include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Nowadays, there is no certain evidence of the role of viruses in PBB pathogenesis even though different types of viruses have been detected in BAL from children with PBB. Airway malacia is commonly found in children with PBB; conversely, there is no correlation with any type of immunodeficiency. Amoxicillin-clavulanate acid is the most commonly used antibiotic, as first-line, prolonged therapy (longer than 2 weeks) is sometimes required to cough resolution. When the wet cough does not improve despite prolonged antibiotic treatment, an underlying disease should be considered. Moreover, there are several hypotheses of a link between PBB and bronchiectasis, as recent evidences show that recurrent PBB (>3 episodes/years) and the presence of H. influenzae infection in the lower airways seem to be significant risk factors to develop bronchiectasis. This underlines the importance of a close follow-up among children with PBB and the need to consider chest computerized tomography (CT) in patients with risk factors for bronchiectasis. In this brief review, we summarize the main clinical and pathogenetic findings of PBB, a disease that may be related to a relevant morbidity and decreased quality of life during the pediatric age.

Abscess of the clivus in an adolescent with complicated acute rhinosinusitis: a case report

BackgroundComplications of acute sinusitis affecting multiple sites are very uncommon, and generally develop for a delayed diagnosis of the primary infection, with possible severe and life-threatening evolution. Patients can have variable presentations according to the site and extent of the infection. Multiple forms generally include the coexistence of orbital manifestations and intracranial infections. We here present a case with unusual multiple sites locations (i.e.: intraorbital intraconic abscess, sigmoid sinus thrombosis, preclival abscess, multiple splanchnocranium osteomyelitic processes).Case presentationA 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis. Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess, left sphenoidal sinusitis, transverse and sigmoid sinus thrombosis. Ophthalmologic evaluation documented a right optic nerve sufferance. Endoscopic and superior right trans-palpebral surgical decompression was performed, and the abscess was drained. Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius. Subsequent prolonged antibiotic and anti-thrombotic treatments were started. In the following two-weeks the sinusal and ophthalmologic clinical conditions improved, whereas the patients complained of mild to moderate cervical pain and suffered from intermittent pyrexia. Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx, associated with mandible osteomyelitis, occipital condyles and anterior part of the temporal bone hyper intensity. Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage. Complete clinical and radiological recovery was achieved after 45 days of medical treatment.ConclusionsMultiple sites complicated rhinosinusitis is uncommon, and its management is challenging. A proper history and thorough clinical examination along with a radiological evaluation are key factors in the final diagnosis of patients with complicated multiple sites acute rhinosinusitis. A quick multidisciplinary approach is always necessary to avoid unwanted life-threatening complications.

International Survey on Determinants of Antibiotic Duration and Discontinuation in Pediatric Critically Ill Patients.

We hypothesized that antibiotic use in PICUs is based on criteria not always supported by evidence. We aimed to describe determinants of empiric antibiotic use in PICUs in eight different countries. Cross-sectional survey. PICUs in Canada, the United States, France, Italy, Saudi Arabia, Japan, Thailand, and Brazil. Pediatric intensivists. None. We used literature review and focus groups to develop the survey and its clinical scenarios (pneumonia, septic shock, meningitis, and intra-abdominal infections) in which cultures were unreliable due to antibiotic pretreatment. Data analyses included descriptive statistics and linear regression with bootstrapped SEs. Overall response rate was 39% (482/1,251), with individual country response rates ranging from 25% to 76%. Respondents in all countries prolonged antibiotic duration based on patient characteristics, disease severity, pathogens, and radiologic findings (from a median increase of 1.8 d [95% CI, 0.5-4.0 d] to 9.5 d [95% CI, 8.5-10.5 d]). Younger age, severe disease, and ventilator-associated pneumonia prolonged antibiotic treatment duration despite a lack of evidence for such practices. No variables were reported to shorten treatment duration for all countries. Importantly, more than 39% of respondents would use greater than or equal to 7 days of antibiotics for patients with a positive viral polymerase chain reaction test in all scenarios, except in France for pneumonia (29%), septic shock (13%), and meningitis (6%). The use of elevated levels of inflammatory markers to prolong antibiotic treatment duration varied among different countries. Antibiotic-related decisions are complex and may be influenced by cultural and contextual factors. Evidence-based criteria are necessary to guide antibiotic duration and ensure the rational use of antibiotics in PICUs.

Antibiotic Administration Prior to Central Venous Catheter Removal in Neonates

Background: Central venous catheter infection and sepsis are significant causes of morbidity and mortality in neonatal intensive care unit patients. This complication may result in a significant cost burden, prolonged antibiotic treatment, and increased length of stay. Objectives: The objective of this study was to determine the difference in post-catheter removal clinical sepsis (PCRCS) in neonatal intensive care unit patients who received antibiotics prior to central venous catheter removal when compared to those who did not. Methods: This was a retrospective cohort study of 200 critically ill neonates comparing those who received one-time doses of vancomycin and cefazolin prior to central venous catheter removal to those who did not. Results: There was no statistically significant association between antibiotic treatment and PCRCS when the analysis was controlled for gender, time the catheter was in place, birth weight, gestational age, or type of central catheter (OR 1.19; 95% CI: 0.18-8.00; P = .8558). No statistical difference was seen in adverse renal outcomes or total antibiotic treatment received for the treatment of PCRCS. Conclusions: Administration of one-time doses of vancomycin and cefazolin did not reduce the incidence of PCRCS when administered to critically ill neonates prior to umbilical venous catheter or peripherally inserted central catheter removal.

Rates and determinants of antibiotics and probiotics prescription to children in Asia-Pacific countries.

Antibiotic therapy may have important side effects. Guidelines recommend the administration of specific probiotics to reduce the risk of antibiotic-associated diarrhoea (AAD). The rates and determinants of antibiotics and co-prescription of probiotics in children remain poorly known in Asia-Pacific countries, which are very heterogenous in terms of economic development, health care organization and health policies. A survey among general practitioners (GPs) and paediatricians was performed in seven countries of the Asia-Pacific area (Australia, Japan, Indonesia, India, China, Singapore, and South Korea). Physicians completed an online questionnaire that explored their current habits and the determinants for prescribing antibiotics and probiotics. For the 731 physicians who completed the questionnaire (390 paediatricians and 341 GPs), 37% of all consultations for a child led to the prescription of antibiotics (ranging from 17% in Australia to 47% in India). A large majority of physicians (84%) agreed that antibiotics disrupted gut microbiota and considered probiotics an effective intervention to prevent AAD (68%). However, only 33% co-prescribed probiotics with antibiotics (ranging from 13% in Japan to 60% in South Korea). The main reasons for prescribing probiotics were previous episodes of AAD (61%), presence of diarrhoea (55%), prolonged antibiotic treatment (54%) or amoxicillin-clavulanic acid therapy (54%). Although current local guidelines recommend the use of selected probiotics in children receiving antibiotics in Asia-Pacific area, the rates of antibiotics and probiotics prescription significantly vary among countries and are deeply affected by country-related cultural and organisational issues.

Salmonella Sp. as the Cause of Periprosthetic Joint Infection of the Hip: Report of a Rare Case and Literature Review

Periprosthetic joint infection of the hip due to Salmonella sp. is rare. It is sometimes difficult to treat and needed a prolonged antibiotic treatment. We reported a case of periprosthetic joint infection of the hip in a 67 years old female who received prior left total hip arthroplasty. Two-stage revision surgery with antibiotic-loaded cement spacer has been performed to the patient and successfully control the infection. Review of the literatures also has been done. Salmonella Sp. has to be considered as one of differential etiology in the case of infected arthroplasty especially in an immunosuppressed patient. It showed still there has been no consensus in the treatment of choice for this particular case.

High-Content Screening, a Reliable System for Coxiella burnetii Isolation from Clinical Samples.

Q fever, caused by Coxiella burnetii, is a worldwide zoonotic disease that may cause severe forms in humans and requires a specific and prolonged antibiotic treatment. Although current serological and molecular detection tools allow a reliable diagnosis of the disease, culture of C. burnetii strains is mandatory to assess their susceptibility to antibiotics and sequence their genome in order to optimize patient management and epidemiological studies. However, cultivating this fastidious microorganism is difficult and restricted to reference centers, as it requires biosafety level 3 laboratories and relies on cell culture performed by experienced technicians. In addition, the culture yield is low, which results in a small number of isolates being available. In this work, we developed a novel high-content screening (HCS) isolation strategy based on optimized high-throughput cell culture and automated microscopic detection of infected cells with specifically designed algorithms targeting cytopathic effects. This method was more efficient than the shell vial assay, at the level of time dependency, when applied to both frozen specimens (7 isolates recovered by HCS only, sensitivity 91% versus 78% for shell vial) and fresh samples (1 additional isolate using HCS, sensitivity 7% versus 5% for shell vial), for which most strains were recovered more rapidly with the new technique. In addition, detecting positive cultures by an automated microscope reduced the need for expertise and saved 24% of technician working time. Application of HCS to antibiotic susceptibility testing of 12 strains demonstrated that it was as efficient as the standard procedure that combines shell vial culture and quantitative PCR.

Correction: Prevalence and Characterization of Oxacillin Susceptible mecA-Positive Clinical Isolates of Staphylococcus aureus Causing Bovine Mastitis in India.

[This corrects the article DOI: 10.1371/journal.pone.0162256.].

Managing and preventing exacerbation of bronchiectasis.

Pulmonary exacerbations are key events in the natural history of bronchiectasis given their impact on quality of life, prognosis, and their contribution to healthcare costs. Preventing and managing exacerbations is a priority for clinicians and in this review, we discuss measures that should be utilized to achieve this aim. Experts have proposed a focus on phenotyping and endotyping the bronchiectasis population to overcome the heterogeneity of this condition. Recent large studies of inhaled antibiotics and smaller studies of macrolides, which included exacerbation measures as their primary outcomes, have drawn further attention to this issue. Exacerbations are currently treated with prolonged antibiotic treatment (10-14 days). Prevention of exacerbations requires a multidisciplinary approach which includes optimising airway clearance and treating underlying conditions. Patients who continue to experience exacerbations despite these measures may be offered chronic macrolide therapy or additional therapies based on identified treatable traits.

Treatment of Chronic Left Ventricular Assist Device Infection with Local Application of Bacteriophages

Left ventricular assist device (LVAD)associated infections represent a major complication during long-term support. Additionally, during prolonged antibiotic treatment, antimicrobial resistance and adverse effects may occur. Therefore, alternative anti-bacterial approaches should be evaluated. We report about the successful treatment of two patients with chronic recurrent LVAD pump-associated infections after local application of bacteriophages as adjunct to standard surgical and antimicrobial treatment. No side effects occurred. At the follow up visits six/nine months later the surgical sites showed no signs of infection. Our experience justifies further investigation into the indication and the therapeutic success of bacteriophages in LVAD-associated infections.

Calidad de prescripción de la antibioterapia prolongada en pediatría. Impacto de las intervenciones programas PROA

Introductionthe duration adequacy of antibiotic regimens is one of the key points of Antimicrobial Stewardship Programs (ASP) given the relationship between the risk of resistance and days of exposure to antimicrobials. Methodsmonitoring activities of intravenous antibiotics longer than 7 days at Hospital Infantil Vall d’Hebron, Barcelona, by reviewing data over a 34-weeks period from weekly cross-sectional analysis, followed by recommendations to prescribers to adapt their use. Resultsa total of 81 patients with 146 prolonged intravenous antibiotic treatments (78.8% of prescriptions were adequate) were reviewed. A total of 190 revisions were performed. 36 interventions on inappropriate prescriptions were carried out (52.7% of adherence to recommendation). Nineteen treatments were optimized (14 suspended, 5 de-escalated) reducing their duration by 8.75%. Conclusionsactive intervention of ASP group is an effective tool to improve antibiotic optimization, reducing unnecessarily prolonged treatments, mainly on these areas with a greater range of improvement.

Hyperbaric oxygen treatment: A complementary treatment modality of Modic changes?

Modic changes (MCs) have attracted great interest in recent years. The complex process of MC development and progression seems to involve interplay between mechanical, infective, inflammatory, and degenerative processes that cannot be clearly differentiated. Based on signal intensity on T1- and T2-weighted MRI scans, MCs can be divided three types: Type 1, Type 2, and Type 3. Predominantly Type 1 MCs are commonly associated with chronic low back pain that is unresponsive to classic treatment options. Infection with low-virulent anaerobic microorganisms, most commonly Propionibacterium acnes, has been implicated in MC development following a disc herniation when a tear enables bacteria to enter the disc. Recent studies in patients with chronic low back pain following a lumbar disc herniation associated with Type 1 MCs have reported promising results following prolonged systemic antibiotic treatment with amoxicillin-clavulanate. Hyperbaric oxygen therapy, as primary or adjuvant treatment in association combination with systemic antibiotics or anti-inflammatory therapy, could offer important advantages in treating patients with suspected low-virulent disc infections due to anaerobic microorganisms associated with Type 1 MCs. We believe that hyperbaric oxygenation could contribute to faster resolution of Type 1 MCs and associated pain through multiple effects—including direct antimicrobial effects through formation of reactive oxygen species (ROS), altering the favorable low oxygen tension milieu such that it becomes unfavorable for bacterial growth and survival, and anti-biofilm effects. Additionally, hyperbaric oxygenation could contribute to faster pain resolution via direct and indirect anti-inflammatory effects. As an adjuvant treatment administered in combination with systemic antibiotics, HBOT could increase the sensitivity of Propionibacterium acnes to antimicrobial drugs under hyperoxic conditions, resulting in faster MC resolution. Overall, the faster infection resolution, diminished bacterial load, and anti-inflammatory effects due to reduced cytokine expression and levels of infectious by-products could lead to faster pain resolution following HBOT, and a significant improvement of quality of life in these patients.

Diagnosing diabetic foot osteomyelitis.

Bone involvement during an infection of the diabetic foot represents a serious complication associated with a high risk of amputation, prolonged antibiotic treatment and hospitalization. Diabetic foot osteomyelitis (DFOs) require a multidisciplinary approach given the usual complexity of these situations. DFO should be suspected in most cases especially in the most severe forms of soft tissue diabetic foot infections (DFIs) where the prevalence of bone infection may be up to 60%. Suspicion is based on clinical signs in particular a positive probe-to-bone (PTB) test, elevated inflammatory biomarkers especially erythrocyte sedimentation rate and abnormal imaging assessment using plain X-ray as a first-line choice. The combination of PTB test with plain X-ray has proven effective in the diagnosis of DFO. The confirmation (definite) diagnosis of DFO is based on the results of a bone sample examination obtained by either surgical or percutaneous biopsy. Sophisticated imaging examinations such as Magnetic Resonance Imaging (MRI) and nuclear imaging techniques are useful where doubt persists after first-line imaging assessment. These techniques may also help localize the bone infection site and increase the diagnostic performance of percutaneous bone biopsy. The quality of the microbiological documentation of DFO is likely to improve the adequacy of the antimicrobial therapy especially when medical (ie, no surgical resection of the infected bone tissues) is considered. The use of new (molecular) techniques for the identification of the bone pathogens have not yet proven superiority on classic cultural techniques for the management of such patients.

Middle cerebral artery infarction following common carotid compression due to a multiloculated parapharyngeal abscess

Deep neck space infections (DNSIs) include retropharyngeal and parapharyngeal abscesses. We report a rare complication of left-sided middle cerebral artery infarction precipitated by left common carotid artery compression secondary to a multiloculated parapharyngeal abscess. A 59-year-old woman with poorly controlled diabetes was admitted following a loss of consciousness. Examination demonstrated unilateral right-sided hemiparesis and computed tomography (CT) of the brain revealed an acute left-sided frontoparietal infarct. The patient had been complaining of a fever, left-sided ear redness and pain six days prior. Unfortunately, despite antibiotics in the community, her ear pain worsened to involve her left jaw. Closer examination revealed a swelling in her left submandibular region and a CT of her neck was performed, revealing a multiloculated left parapharyngeal abscess with evidence of left common carotid compression. A naso-pharyngo-laryngoscopy (NPLS) was performed to confirm the presence of an abscess. Owing to the size and complex location of the abscess, management via a prolonged antibiotic treatment was opted for over surgical intervention. After completion there was improvement in medical state and resolution on repeat NPLS. Vascular-related complications are rare following DNSI. Carotid artery compression has been reported, although current literature suggests it to be a benign phenomenon. Our case is the first reported instance of a parapharyngeal abscess with severe neurological complications, reminding physicians that such complications following a DNSI remain possible. Although rare, in the event of a cerebrovascular accident and sepsis, DNSI remains a possible cause to be considered.

1089. Implementation of a Febrile Neutropenia Management Algorithm on Antibiotic Use and Outcomes: An Interrupted Time Series Analysis

BackgroundFebrile neutropenia (FN) is a common complication of cancer therapy and often necessitates prolonged antibiotic treatment. Antibiotic de-escalation can be challenging given tenuous clinical status. Furthermore, a microbiological or clinical etiology is identified in a minority of FN patients. In 2016 we implemented several evidence-based strategies to guide antibiotic use in high-risk FN patients including specifying vancomycin use indications, minimizing carbapenem escalation in stable patients with ongoing fevers, and defining antibiotic durations regardless of neutrophil count. The study objective was to characterize and evaluate our experience implementing these strategies on antibiotic use and clinical outcomes.MethodsInterrupted time series analysis of all admissions to the Malignant Hematology service at the University of California, San Francisco between June 2014 and December 2018. The primary outcome was monthly days of therapy (DOT) per 1,000 patient-days of broad-spectrum IV antibiotics (aztreonam, cefepime, piperacillin–tazobactam, meropenem, and vancomycin). Secondary outcomes included DOT/1,000 patient-days for each IV antibiotic, incidence rates of bloodstream infections (BSI) and C. difficile infections (CDI), and in-hospital all-cause mortality. A segmented regression analysis was conducted to evaluate the impact of the FN management algorithm implementation on antibiotic use and clinical outcomes. Summary statistics and time series scatter plots were used to visualize the trends and outliers.Results2319 unique patients with 6,788 encounters were included. The median (IQR) age was 59 (46–68) years and 60% were male. Regression results and time series plots are shown in Table 1 and Figures 1–3.ConclusionImplementation of an evidence-based FN management algorithm led to decreased vancomycin and meropenem use without a statistically significant impact on overall antibiotic use, CDI rates, or mortality.While BSI rates fluctuated in the 2 months post-implementation, rates returned to baseline thereafter. A multidisciplinary effort facilitated successful implementation of this stewardship project. This collaboration remains essential to addressing future antimicrobial management strategies in this population. Disclosures All authors: No reported disclosures.

NECROTIZING PNEUMONIA CAUSED BY ACINETOBACTER IIWOFI IN A PREVIOUSLY HEALTHY CHILD

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: With the extensive immunization campaign, the occurrence of Necrotizing Pneumonia has become less through the years. Early recognition and timely intervention of Pneumonia has contributed to the progressive decline in its incidence. Several factors exist causing reemergence of this uncommon complication. CASE PRESENTATION: This is a case of a 2-year-old female with massive pleural effusion of the left lung, presenting as 3-week productive cough, fever and tachypnea. She had respiratory distress, chest lagging on the left, retractions, decreased fremitus and breath sounds, and dullness with crackles on the left mid to base lung. Chest ultrasound and CT scan showed massive pleural effusion with consolidation on the left lung and atelectasis on the right upper lung. Chest tube drain was exudative, culture, KOH and AFB were negative. Cytology testing was consistent with abscess and negative for malignant cells. Blood culture and PPD skin test were negative. Cefotaxime, Clindamycin, Azithromycin, Vancomycin and Piperacillin- Tazobactam were given, but no response and chest CT scan showed necrosis of the parenchyma. Broncheoalveolar lavage was done revealing heavy growth of Acinetobacter iiwofi and Linezolid and Ciprofloxacin were given with noted clinical improvement and was discharged. DISCUSSION: Necrotizing Pneumonia entails necrosis and liquefaction of consolidated lung tissue. Chest xray has poor sensitivity in cavitary lesion, hence CT scan is the standard of imaging. Risk factors in one study revealed children less than 5 years old, absence of existing medical comorbidity, immature polymorphs in peripheral blood smear, CRP >12 mg/dL, and thrombocytopenia, are associated with pneumonia complications. Prolonged antibiotic treatment has been the cornerstone of therapy in necrotizing pneumonia. The patient was initially given Ceftriaxone and Vancomycin with poor response, due to Vancomycin’s poor parenchymal penetration. Linezolid produced better outcome since it inhibits protein synthesis and toxin production. Surgical approach was considered, but with clinical improvement, medical treatment was continued. Follow up with subsequent chest imaging showed gradual improvement, which confirmed the adequacy of the antibiotic given. CONCLUSIONS: Despite rigorous efforts of the government to provide adequate vaccine coverage, increasing occurrence of necrotizing pneumonia are reported. Increasing awareness among healthcare practitioners for early recognition and timely referral to subspecialist should be emphasized. Necrotizing pneumonia is one of the conditions where medical treatment, over surgical approach, offers the greater advantage. With appropriate antibiotic treatment, the prognosis of necrotizing pneumonia is full recovery. Reference #1: 1. Masters B, Isles A, Grimwood K. Necrotizing pneumonia: an emerging problem in children?. NPJ Open Access [Internet]. 2017 July 25 [cited 2018 Oct 1]; 9:11. Available from: https://pneumonia.biomedcentral.com/articles/10.1186/s41479-017-0035-0 DOI 10.1186/s41479-017-0035-0 Reference #2: 2. Erlichman I, Breuer O, Shoseyov D, Cohen-Cymbreknoh M, Koplewitz B, Aver-buch D, et al. Complicated community acquired pneumonia in childhood: Dif-ferent types, clinical course, and outcome. Pediatric Pulmonology [Internet]. 2017 Feb [cited 2018 Oct 1]; 52:2. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/ppul.23523 DOI.org/10.1002/ppul.23523 Reference #3: 3. Treatment Guidelines for the Complicated Pneumonia: Parapneumonic Effu-sions, Empyema, Necrotizing Pneumonia, And Pulmonary abscess. Children’s National Medical Center [Internet]. Washington; 2008 Sept 1 [cited 2018 Oct 1]; 13p. Available from: http://www.nccpeds.com/rotations/wrPICU/Algorithms/ Linked%20complicated%20pneumonia%20guidelines%20final.pdf DISCLOSURES: No relevant relationships by shanta carleen magalit, source=Web Response