Prolonged Antimicrobial Treatment Research Articles

1331. Reducing Inpatient Antimicrobial Treatment Duration for Febrile Infants through Implementation of Rapid Diagnostic Testing and Clinical Risk Definition

BackgroundThe management approach to febrile infants remain challenging. Despite new advances in rapid diagnostic testing, febrile infants with a viral infection could receive prolonged antimicrobial treatment due to concerns for co-existing serious bacterial infection (SBI). We sought to decrease the duration of antibiotic treatment in febrile infants less than 8 weeks of age hospitalized on inpatient infectious disease service following sepsis evaluation, who have enterovirus, parechovirus, or respiratory viruses detected, from average 30 hours to 24 hours and sustain for six months.Figure 1. Antibiotic Treatment Duration of Infants Underfoing Evaluation for Sepsis Figure 2. Length of Stay in Infants Underfoing Sepsis Evaluation MethodsA new management guideline that defined “low-risk” infants, as well as inclusion and exclusion criteria, was created to monitor the accurate duration of parenteral treatment and length of hospitalization. Respiratory viruses were detected by a multiplex PCR assay. We created a QlikSense App for further clinical characterization of patients and follow-up. This management guideline was adapted as a quality improvement division initiative. Control charts were used to assess the impact of the interventions.Figure 3. Readmissions in Infants Underfoing Sepsis Evaluation ResultsThe management guideline was developed and implemented by pediatric infectious disease faculty. Febrile infants < 8 weeks of age were included if they had both documented viral infections and sepsis evaluation. 178 infants were admitted with fevers in 2018 and 148 infants were admitted in 2019. The mean inpatient antibiotic treatment duration decreased from 27.7 hours in 2018 to 24.9 hours in 2019 (P > 0.05) (Figure 1). There was no significant difference in length of hospitalization or 30-day readmission rates (Figure 2 and 3). There was no reported readmission for SBI.ConclusionAntibiotic treatment could be discontinued in clinically stable infants with a documented viral infection after 24 hours of negative blood, CSF, and urine bacterial culture incubation so as not to receive unnecessary prolonged inpatient treatment that may increase side effects. In addition to possible decreased treatment side effects our protocol led to decreased patient care costs with no documented changes in readmission rates.Disclosures Octavio Ramilo, MD, Bill & Melinda Gates Foundation (Grant/Research Support)Janssen (Grant/Research Support, Advisor or Review Panel member)Medimmune (Grant/Research Support)Merck (Advisor or Review Panel member)NIH/NIAID (Grant/Research Support)Pfizer (Consultant, Advisor or Review Panel member)Sanofi/Medimmune (Consultant, Advisor or Review Panel member)

Two Cases of the Emerging Candida auris in a university hospital from Saudi Arabia

Candida auris is an opportunistic multidrug-resistant pathogen that was first isolated in 2009 and has since been reported from about 30 countries. In Saudi Arabia, only four cases of C. auris have previously been reported; here, we report two new cases of this infection. Both patients were polymorbid and had long hospitalization periods with recurrent intensive care unit (ICU) admissions. The findings of the tissue/blood cultures and antimicrobial therapy protocols are explained in the case report. Urine culture in both cases was positive for C. auris, and the colonies grew well at 42°C. The fungal isolates were confirmed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. The first patient was treated with the recommended dose of caspofungin, but he passed away. The second patient was also planned to be treated with caspofungin, but he passed away before the treatment could be initiated. The present cases further corroborate signs of a growing number of reports of C. auris in patients with high-risk factors, such as hospitalization in ICU, multiple chronic conditions and prolonged antimicrobial treatment exposure. It also highlights the need for hospitals to further improve their infection control practices to prevent nosocomial infections such as C. auris.

Adjunctive Use of Phage Sb-1 in Antibiotics Enhances Inhibitory Biofilm Growth Activity versus Rifampin-Resistant Staphylococcus aureus Strains.

Effective antimicrobials are crucial for managing Staphylococcus aureus implant-associated bone infections (IABIs), particularly for infections due to rifampin-resistant S. aureus (RRSA). Failure to remove the implant results in persistent infection; thus, prolonged suppressive antibiotic therapy may be a reasonable alternative. However, a high incidence of adverse events can necessitate the discontinuation of therapy. In this scenario, commercial Staphylococcal bacteriophage Sb-1 combined with antibiotics is an option, showing a promising synergistic activity to facilitate the treatment of biofilm infections. Therefore, we evaluated the efficacy of the inhibitory activity of five antibiotics (doxycycline, levofloxacin, clindamycin, linezolid, and rifampin) alone or combined with phage Sb-1 (106 PFU/mL) in a simultaneous and staggered manner, to combat five clinical RRSA strains and the laboratory strain MRSA ATCC 43300 in 72 h by isothermal microcalorimetry. The synergistic effects were observed when phage Sb-1 (106 PFU/mL) combined with antibiotics had at least 2 log-reduction lower concentrations, represented by a fractional biofilm inhibitory concentration (FBIC) of <0.25. Among the antibiotics that we tested, the synergistic effect of all six strains was achieved in phage/doxycycline and phage/linezolid combinations in a staggered manner, whereas a distinctly noticeable improvement in inhibitory activity was observed in the phage/doxycycline combination with a low concentration of doxycycline. Moreover, phage/levofloxacin and phage/clindamycin combinations also showed a synergistic inhibitory effect against five strains and four strains, respectively. Interestingly, the synergistic inhibitory activity was also observed in the doxycycline-resistant and levofloxacin-resistant profile strains. However, no inhibitory activity was observed for all of the combinations in a simultaneous manner, as well as for the phage/rifampin combination in a staggered manner. These results have implications for alternative, combined, and prolonged suppressive antimicrobial treatment approaches.

Dalbavancin for the Treatment of Complicated Gram-Positive Skin and Soft Tissue Infections

New antimicrobial agents have been developed to treat infections caused by methicillin-resistant Staphylococcus aureus and other multidrug-resistant pathogens. Dalbavancin is a novel semisynthetic lipoglycopeptide antibiotic, particularly active against methicillin-resistant Staphylococcus aureus. Due to its unique pharmacological characteristics and longer half-life, it can be administered once-weekly or every 15 days and in outpatient setting. Currently, it is indicated for complicated skin and soft tissue infections, but accumulating evidence points to its off-label efficacy in osteomyelitis and endocarditis. Further experience is still needed to increase our knowledge on the role of dalbavancin in a wider range of Gram-positive infections requiring prolonged antimicrobial treatment.

Decreasing the Duration of Discharge Antibiotic Treatment Following Inpatient Skin and Soft Tissue Abscess Drainage.

Skin and soft tissue abscesses do not require prolonged systemic antimicrobial treatment following drainage. We aimed to decrease the duration of discharge antibiotic treatment to less than 5 days following inpatient incision and drainage of uncomplicated abscesses. A new treatment protocol that defined uncomplicated abscesses, as well as inclusion and exclusion criteria, was created to monitor the accurate duration of prescribed therapy at discharge. We implemented a treatment algorithm that takes into account the epidemiologic changes in microbial etiologies and the presence of systemic findings for patients after surgical incision and drainage. We used control charts to assess the impact of the interventions. Four hundred and eighteen patients were discharged following abscess drainage from our inpatient infectious diseases unit in 2016. The patients were 3 months to 21 years of age. Only 72 (17%) patients had prescribed discharge antibiotic treatment courses that were less than 5 days [range 0-31 days, median 8 days (IQR 6, 9)], and the average prescribed course at discharge was 8.6 days. During the study period, we significantly decreased the average duration of discharge antibiotics to 7.3 days in all patients (P = 0.0016, 95% CI: -2.1036 to -0.4964, difference of means -1.3). The discharge treatment duration of patients with uncomplicated abscess was shorter at 4.7 days [range 0-9 days, median 5 days, (IQR 3, 5)]. Prescription compliance to less than 5 days treatment course at discharge increased from the baseline of 17% to 42% overall. Standardizing definitions of uncomplicated skin and soft tissue abscesses was critical to the success of this project. In addition to possible improved treatment adherence and decreased side effects, our protocol led to decreased patient care costs with no documented changes in readmission rates.

IS256-Mediated Overexpression of the WalKR Two-Component System Regulon Contributes to Reduced Vancomycin Susceptibility in a Staphylococcus aureus Clinical Isolate.

Vancomycin (VAN)-intermediate-resistant Staphylococcus aureus (VISA) is continually isolated globally, with a systematic review suggesting a prevalence of 2% in all blood culture samples. Most VISA strains exhibit common characteristics, such as a thickened cell wall, reduced autolysis, and attenuated virulence. Here, based on multi-omics approaches, we have characterized clinical VISA isolates obtained through prolonged antimicrobial treatment in a single patient. All VISA isolates were isogenic, based on multi-locus sequence typing (MLST) ST5, SCCmec type II (2A), and spa type t17639. Core-genome single nucleotide variations (SNVs) found among thirteen isolates during the patient’s hospitalization, indicated clonality, but not notable genetic features of the VISA phenotype. We determined the complete genome sequence of VAN-susceptible strain KG-03 (minimum inhibitory concentration [MIC] 0.5 μg/mL) and two VISA strains, KG-18 and KG-22 (MIC 8.0 and 4.0 μg/mL, respectively). Comparative genome analysis showed remarkable strain-specific IS256 insertions. RNA-Seq transcriptome analysis revealed IS256-mediated overexpression of the walKR two-component system in VISA KG-18, possibly leading to modulation of cell wall integrity (lytM and sceD) and surface charge (mprF and dltABCD). In addition, secretome analysis indicated that cell wall-anchored proteins (Protein A, SasG, and SdrD) were significantly decreased. KG-18 and KG-22 exhibit thickened cell wall, and are relatively resistant to lysostaphin, which cleaves a staphylococcus-unique pentaglycine chain in the peptidoglycan. We conclude that KG-18 achieved reduced susceptibility to VAN by IS256-mediated WalKR overexpression, leading to a markedly thickened cell wall for trapping free VAN molecules with redundant D-Ala-D-Ala targets. In addition, a positively charged surface with lysyl-phosphatidylglycerol and depolarization of wall teichoic acid could contribute to inhibiting cationic daptomycin and VAN antimicrobial activity. Comparative omics approaches in this study strongly suggest that fully complete and annotated genome sequences will be indispensable for characterizing overall VISA phenotype.

Prosthetic joint infections: clinical management, diagnosis, and treatment.

Prosthetic joint infections (PJIs) represent one of the most disastrous complications in prosthetic surgery, requiring long hospitalization, prolonged antimicrobial treatment and repeated surgical interventions. No gold standard test to formulate diagnosis exist. A combination of high index of suspicion, physical examination, microbiological and biohumoral investigations is required. Therapeutical approach should be based on a multidisciplinary team. In our center, a two-stage approach is preferred. As regards the choice of the empirical antibiotic backbone, individual risk factors for multiple-drug resistant (MDR) pathogens should be considered. Several studies enhance the possibility to shorten the length of antibiotic couses. Some interesting improvements have been made in the setting of PJIs management. As regards diagnosis, novel biomarkers and nuclear imaging are acquiring more importance. Molecular biology techniques also offer the possibility to formulate rapid microbiological identification. The pattern of PJIs is evolving towards higher rates of MDR causes. During the last decade, a number of new antibiotic molecules with activity against MDRs have been approved. Some of them are also available either in oral formulation or as long-acting compounds, offering the opportunity for early patient's discharge, with expected healthcare costs saving. Management of PJIs still represents a major threat for clinicians. Improvements in surgical techniques and antibiotic pipeline promise to revolutionize the approach in next years. Despite data from our experience confirm the efficacy of shorter antibiotic courses and the value of new molecules, randomized clinical trials are lacking. More data are needed in order to modify the routine clinical practice.

Clinical experience with dalbavancin for the treatment of deep sternal wound infection.

Deep sternal wound infection (DSWI) is a complication of major heart surgery with high morbidity as well as prolonged antimicrobial treatment and hospital length of stay (LoS). Dalbavancin is a new lipoglycopeptide antibiotic active against Gram-positive micro-organisms, including methicillin-resistant Staphylococcus aureus (MRSA), with a long half-life. This small case series assessed the feasibility of dalbavancin for the treatment of DSWI. This was retrospective, observational, cohort study of patients treated with dalbavancin for DSWI over a 2-year period (March 2016 to April 2018) in two cardiac surgery departments in Italy. All patients with DSWI underwent surgical accurate debridement. Dalbavancin was administered during the hospital stay or in an outpatient facility. Among 15 patients enrolled in the study, MRSA was isolated in 7 (47%), methicillin-resistant Staphylococcus epidermidis in 6 (40%) and other coagulase-negative staphylococci in 2 (13%). Dalbavancin was administered by two infusions in 9 patients (60%), whereas 5 patients (33%) received a median of four doses. Fourteen patients received a first dose of 1000mg followed by 500mg, whereas one patient received two doses of 1500mg each. All patients were defined as clinically cured. The median hospital LoS was 13 days (interquartile range, 8-18 days). At 6 months after discharge, 14 patients (93%) showed no relapse of DSWI, whereas 1 patient recurred with a diagnosis of DSWI caused by another pathogen (Candida sp.). Dalbavancin may be an alternative option for DSWI caused by Gram-positive bacteria when first-line treatments are contraindicated or as salvage treatment.

Antimicrobial activity of dalbavancin tested against Gram-positive organisms isolated from patients with infective endocarditis in US and European medical centres.

The management of endocarditis requires aggressive and prolonged antimicrobial treatment. We evaluated the in vitro activity of dalbavancin against bacteria from patients with infective endocarditis. A total of 626 Gram-positive organisms were collected from patients with a diagnosis of bacterial endocarditis in the USA (n = 222) and Europe (n = 404) from 2007 to 2017 via the SENTRY Antimicrobial Surveillance Program and were tested for susceptibility to dalbavancin and comparators by broth microdilution. The most common organisms were Staphylococcus aureus (48.4%), Enterococcus faecalis (19.6%) and viridans group streptococci (VGS; 12.5%). Dalbavancin and daptomycin showed complete activity (100.0% susceptibility per CLSI criteria) against S. aureus, but dalbavancin MIC values were 4- to 8-fold lower. Vancomycin, linezolid and teicoplanin were also active against all S. aureus when CLSI criteria were applied. Ceftaroline was active against all MSSA (MIC90 0.25 mg/L) and 78.4% of MRSA isolates at ≤1 mg/L. All E. faecalis isolates were susceptible to ampicillin, daptomycin and linezolid, whereas 97.6% of isolates were susceptible to dalbavancin (MIC90 0.06 mg/L) and 96.7% were susceptible to vancomycin (MIC90 2 mg/L). All VGS and CoNS isolates were susceptible to dalbavancin, daptomycin, vancomycin and linezolid. Against Enterococcus faecium, 65.7% of isolates were inhibited by ≤0.25 mg/L dalbavancin and 62.9% were vancomycin susceptible. Dalbavancin exhibited potent in vitro activity against a large collection of Gram-positive isolates recovered from patients with endocarditis in US and European medical centres. These results support further investigations to determine the role of dalbavancin in the treatment of infective endocarditis.

A case series of actinomycosis from a single tertiary care center in Saudi Arabia.

Actinomycosis is an uncommon but curable chronic infection caused by Actinomyces spp. The cervicofacial region is the most susceptible to infection; however, other sites may also become infected. Data on the current prevalence of this rare disease in Riyadh, Saudi Arabia is lacking. We herein report a case series of four patients with actinomycosis from a single tertiary care center in Riyadh, Saudi Arabia.Three patients presented to us with slowly progressing actinomycosis and one patient developed an acute abdomen, secondary to viscus perforation. Two of the patients had cervicofacial disease, including hard palate actinomycosis. Tissue cultures were sent for three patients; however, tests for actinomycosis were negative. Subsequently, the diagnosis was made through histopathological examination. Therapy involved a combination of surgical resection and debridement and prolonged antimicrobial treatment tailored to each patient.The cases reported in this series highlight the difficulty in diagnosing actinomycosis. For most patients, the diagnosis was delayed or accidentally discovered on histopathological examination. We conclude that increased awareness among physicians is needed for early diagnosis and treatment of actinomycosis.

1081. Antimicrobial Activity of Dalbavancin Tested Against Gram-Positive Organisms Isolated From Patients With Infective Endocarditis in United States and European Medical Centers

BackgroundThe management of endocarditis requires aggressive and prolonged antimicrobial treatment. Dalbavancin (DALBA) has demonstrated potent in vitro activity against Gram-positive (GP) organisms commonly responsible for endocarditis and is being evaluated for treatment of complicated bacteremia and infective endocarditis.MethodsA total of 626 GP organisms were collected from patients with a diagnosis of bacterial endocarditis in the United States (n = 222) and Europe (n = 404) from 2007 to 2017 via the SENTRY Antimicrobial Surveillance Program and were tested for susceptibility (S) against DALBA and comparators by CLSI broth microdilution.ResultsThe most common organisms were S. aureus (48.4%), E. faecalis (EF; 19.6%), and viridans group streptococci (VGS; 12.5%). DALBA and daptomycin (DAPTO) showed complete activity (100.0%S) against S. aureus, but DALBA MICs were 4- to 8-fold lower (table). Linezolid (LZD) and teicoplanin were also active against all SA; whereas vancomycin (VAN) and trimethoprim–sulfamethoxazole were active against 99.7% of isolates. Ceftaroline (CPT) exhibited potent activity against methicillin-susceptible S. aureus (MSSA; MIC90, 0.25 mg/L; 100.0%S) and inhibited 78.4% of methicillin-resistant S. aureus (MRSA) isolates at ≤1 mg/L. All EF isolates were S to ampicillin, DAPTO, and LZD, whereas 97.6% (120/123) of isolates were S to DALBA (MIC90, 0.06 mg/L) and 96.7%S to VAN (MIC90, 2 mg/L). Against EF, DALBA MIC values were 16- to 32-fold lower than DAPTO and VAN. All VGS and coagulase-negative staphylococcal (CoNS) isolates were S to DALBA, DAPTO, VAN, and LZD, and the highest CPT MICs were 0.5 mg/L for VGS and 4 mg/L for CoNS (93.5% inhibited at ≤1 mg/L). Against E. faecium (EFM), 65.7% of isolates were inhibited at ≤0.25 mg/L of DALBA and 62.9% were VAN-S. All EFM were S to DAPTO and LNZ. β-Hemolytic streptococci (BHS) was S to most antimicrobial agents, and only 66.7% of S. pneumoniae (SPN) isolates were PEN-S at ≤0.06 mg/L.ConclusionDALBA exhibited potent in vitro activity against a large collection of GP isolates recovered from patients with endocarditis in the United States and Europe medical centers. These results support further investigations to determine the role of DALBA in the treatment of infective endocarditis. Disclosures H. S. Sader, Allergan: Research Contractor, Research support. R. E. Mendes, Allergan: Research Contractor, Research support. M. A. Pfaller, Allergan: Research Contractor, Research support. R. K. Flamm, Allergan: Research Contractor, Research support.

264. Simple and Feasible NICU Antimicrobial Stewardship Program in a Japanese Community Hospital

BackgroundAntimicrobial stewardship programs (ASP) have been implemented in many hospitals, including NICU departments. Although tertiary hospitals have successfully introduced ASPs by antimicrobial stewardship teams, lots of community hospitals without pediatric infectious disease specialists have difficulty implementing ASP. We present a successful implementation of simple and feasible NICU antimicrobial stewardship program in a Japanese community hospital.MethodsWe developed a protocol of antimicrobial treatment in the NICU department of Nara Prefecture General Medical Center, Nara, Japan and have implemented it from September 2017. The protocol consists of antimicrobial treatment criteria (criteria for starting antimicrobials for neonates with suspected early-onset infection, criteria of prolonged antimicrobial treatment for more than 48 hours and duration of treatment), weekend report of blood culture result from microbiology department and stopping ordering antimicrobials beforehand for the next day. We compared days of therapy (DOT) during the post-implementation period (September 2017 to March 2018) with that of the pre-implementation period (March 2013 to August 2017).ResultsDuring the pre- and post-ASP implementations, 913 and 92 patients were admitted to NICU. Mean DOT/1,000 patient-days were 217.9 and 56.6 in pre- and post-ASP implementations (P < 0.001) with 74.0% reduction of antimicrobial prescriptions. Mortality rates were 0.4% and 0.0% (P = 0.54), and 4.6% and 5.3% of patients had sepsis (P = 0.76), respectively. Weekend reports of blood culture result were performed in six patients and shortened their length of antimicrobial treatment during the post-ASP implementation period.ConclusionThis ASP program was easily implemented in a NICU department of a community hospital and significantly reduced antimicrobial prescription. This kind of simple protocol may be successfully scaled-up in resource limited community hospitals without any pediatric infectious disease specialists or antimicrobial stewardship teams.Disclosures All authors: No reported disclosures.

Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report

BackgroundNon-Tuberculous Mycobacterial–pulmonary disease (NTM-PD) is increasing in incidence and prevalence. Mycobacterium abscessus (M.abscessus) is a rapid growing multi-resistant NTM associated with severe NTM-PD requiring prolonged antibiotic therapy. Complications of therapy are common but reports on direct complications of active NTM-PD are rare. Vasculitis has been described as a rare complication of NTM-PD, most often in individuals with inherited immune defects. This case is the first to describe an ANCA positive vasculitide (Microscopic Polyangiitis) secondary to M.abscessus pulmonary disease.Case presentationA 70 year old female with bronchiectasis underwent a clinical decline associated with the growth of M.abscessus and was diagnosed with NTM-PD. Before treatment could be initiated she developed small joint arthralgia and a glove and stocking axonal loss sensorimotor neuropathy. Positive Perinuclear Anti-Neutrophil Cytoplasmic Antibodies (P-ANCA) and Myeloperoxidase-ANCA (MPO-ANCA) titres led to a diagnosis of microscopic polyangiitis. Further investigation revealed reduced interferon-gamma production but no other significant immune dysfunction.Dual treatment with immunosuppressive therapy (Corticosteroids/Cyclophosphamide) for vasculitis and antimicrobial therapy for M.abscessus NTM-PD was initiated. Clinical stability was difficult to achieve with reductions in immunosuppression triggering vasculitic flares. One flare led to retinal vein occlusion with impending visual loss requiring escalation in immunosuppression to Rituximab infusions. An increase in immunosuppression led to a deterioration in NTM-PD necessitating alterations to antibiotic regimes. Adverse effects including alopecia and Achilles tendonitis have further limited antibiotic choices resulting in a strategy of pulsed intra-venous therapy to stabilise NTM-PD.ConclusionsThis is the first reported case of an ANCA positive vasculitis secondary to M.abscessus pulmonary disease. This rare but important complication had a significant impact on the patient adding to the complexity of an already significant disease and treatment burden. The potential role of reduced interferon-gamma production in this case highlights the importance of investigating immune function in those with mycobacterial infection and the intricate relationship between mycobacterial infection and immune dysfunction. Immune dysfunction caused by genetic defects or immunosuppressive therapy is a known risk factor for NTM-PD. Balancing immunosuppressive therapy with prolonged antimicrobial treatment is challenging and likely to become more common as the number of individuals being treated with biologics and immunosuppressive agents increases.

Osteoarticular Implant Infections by Candida spp., experience at an elderly adults’ center

Background: Osteoarticular implant (OI) infections by Candida spp are a rare entity with high morbidity. The objective of this work is to describe the clinical and microbiological characteristics of OI Candida infections at an elderly adult center. Methods & Materials: We retrospectively studied patients with Candida spp isolation in osteoarticular surgical samples between January 2012 - September 2017. Only patients with the presence of compatible parameters of prosthetic infection were included: signs of inflammation, fistula, pain, functional impotence, elevation of sedimentation rate and C- reactive protein. We analyzed demographic, microbiological, therapeutic and evolutionary variables. Results: Five cases were identified, female, the median age 75 years (range 70-84). The indication of OI in 4 patients was osteoarthrosis (3 gonarthrosis and 1 coxarthrosis) and in 1 knee fracture. Comorbidities: arterial hypertension (n: 5), diabetes (n: 1). The 5 cases presented late chronic OI infection, with isolation of positive cocci and long term antibiotic treatment. An average of 3.6 surgical toilettes were performed, prior to the isolation of Candida spp. The most frequent manifestation of the fungal infection was pain (60%), dislocation (20%), fistula (20%). The isolated species were Candida albicans (2), Candida spp (2), Candida parapsilosis (1); three patients had simultaneous bacterial coinfection. In 3 patients, OI exchange was performed, retention of the OI in one and in another amputation. Treatment with echinocandins was started for 30 days in all cases. Four patients continued with prolonged oral treatment with fluconazole, 1 patient died of cause not related to the infectious event. Conclusion: In this study Candida infections in OI was observed in patients with a history of late chronic osteoarticular infection due to positive cocci, who received prolonged antimicrobial treatment and required multiple surgical interventions. Is important to consider that slime-producing germs such as Staphylococcus spp and Candida spp have a high rate of therapeutic failure, conditioning the quality of life of the elderly.

Syndrome of Inappropriate Antidiuretic Hormone Secretion Complicating Systemic Nocardiosis in a Renal Transplant Recipient: A Case Report

BackgroundInfection by Nocardia species is an uncommon cause of severe clinical syndromes, particularly in immunocompromised patients, and solid-organ transplantation is the most common underlying condition. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been described thus far in lung and stem cell transplants with systemic nocardiosis. Case ReportWe report the first case of SIADH in a female elderly renal transplant recipient diagnosed with systemic nocardiosis 2 years after transplantation. The SIADH was managed appropriately, and her immunosuppressive regimen remained unchanged but was adjusted at a lower level. The systemic Nocardia infection was successfully treated with intravenous administration of trimethoprim-sulfamethoxazole and imipenem for 2 weeks followed by oral trimethoprim-sulfamethoxazole for a total of 12 months. ConclusionsThe SIADH syndrome is a recognizable complication of Nocardia infection in renal transplant recipients. Prompt identification along with proper management and prolonged antimicrobial treatment are essential to improve patients' outcome.

Under the Sea

Traumatic abrasions on human extremities as a result of direct contact with sea, lake, river, or aquarium animals or from traumatic injuries sustained in seawater may develop into solitary or linear granulomatous lesions. One of the more common microbial etiologies for such infections is Mycobacterium marinum. An astute pediatrician, family physician, or nurse practitioner should have a high index of suspicion and obtain specific cultures to support the growth of Mycobacterium species. Mycobacterium marinum infections will not respond to antibiotics typically chosen to treat simple skin and soft tissue infections. Rather, M. marinum infections are best treated by prolonged antimicrobial treatment regimens for 3 to 6 months and, in some cases, may require polypharmacologic therapy. We present the case of a 6-year-old girl who suffered a traumatic abrasion on her right ankle in seawater. For 10 days, the skin infection morphed from cellulitis, papules, pustules, and eventually into sporotrichoid linear granuloma. After several failed antibiotic trials, M. marinum was eventually identified from the depth of her lesions. The patient improved after a 3-month course of clarithromycin. This case report is the first to include pictures demonstrating the clinical progression and resolution of M. marinum infection.

Prosthetic joint infection caused by Granulicatella adiacens: a case series and review of literature

BackgroundBone and joint infection involving Granulicatella adiacens is rare, and mainly involved in cases of bacteremia and infectious endocarditis. Here we report three cases of prosthetic joint infection involving G. adiacens that were successfully treated with surgery and prolonged antimicrobial treatment. We also review the two cases of prosthetic joint infection involving G. adiacens that are reported in the literature.Case presentationNot all five cases of prosthetic joint infection caused by G. adiacens were associated with bacteremia or infectious endocarditis. Dental care before the onset of infection was observed in two cases. The median time delay between arthroplasty implantation and the onset of infection was of 4 years (ranging between 2 and 10 years). One of our cases was identified with 16srRNA gene sequencing, one case with MALDI-TOF mass spectrometry, and one case with both techniques. Two literature cases were diagnosed by 16srRNA gene sequencing. All five cases were cured after surgery including a two-stage prosthesis exchange in three cases, a one-stage prosthesis exchange in one case, and debridement, antibiotics, irrigation, and retention of the prosthesis in one case, and prolonged antimicrobial treatment.ConclusionProsthetic joint infection involving G. adiacens is probably often dismissed due to difficult culture or misdiagnosis, in particular in the cases of polymicrobial infection. Debridement, antibiotics, irrigation, and retention of the prosthesis associated with prolonged antimicrobial treatment (≥ 8 weeks) should be considered as a treatment strategy for prosthetic joint infection involving G. adiacens.

Infant Colonization With Methicillin-Resistant Staphylococcus aureus or Vancomycin-Resistant Enterococci Preceding Neonatal Intensive Care Unit Discharge.

Rates of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) were determined for 1320 infants within 7 days of neonatal intensive care unit discharge. Overall, 4% and 1% of the infants were colonized with MRSA or VRE, respectively. Predictors identified in fixed-effects models were surgery during hospitalization (for MRSA colonization) and prolonged antimicrobial treatment (for VRE colonization).

Antibiotic Resistance of Bacteria Involved in Urinary Infections in Brazil: A Cross-Sectional and Retrospective Study.

Empirical and prolonged antimicrobial treatment of urinary tract infections caused by Escherichia coli is associated with the emergence of bacterial resistance, and not all countries have strict policies against the indiscriminate use of drugs in order to prevent resistance. This cross-sectional and retrospective study (2010–2015) aimed to evaluate the sensitivity and resistance of patient-derived E. coli to different drugs broadly used to treat urinary infections in Brazil: ampicillin + sulbactam, cephalothin, ciprofloxacin, norfloxacin, and nitrofurantoin. We obtained 1654 E. coli samples from ambulatory patients with disease symptoms of the urinary tract from a Brazilian public hospital. While all antibiotics were effective in killing E. coli to a large degree, nitrofurantoin was the most effective, with fewer samples exhibiting antibiotic resistance. We assessed the costs of generic and brand name versions of each antibiotic. Nitrofurantoin, the most effective antibiotic, was the cheapest, followed by the fluoroquinolones (ciprofloxacin and norfloxacin), ampicillin + sulbactam and, lastly, cephalothin. Finally, assessment of antibiotic resistance to fluoroquinolones over the study period and extrapolation of the data led to the conclusion that these antibiotics could no longer be effective against E. coli-based urinary infections in approximately 20 years if their indiscriminate use in empirical treatment continues.

The association of medication-related osteonecrosis of the jaw with Actinomyces spp. infection.

Medication-related osteonecrosis of the jaw (MRONJ) represents a complication of bisphosphonate treatment that responds poorly to standard treatment. In a retrospective cohort study we investigated a possible role of Actinomyces spp. in the pathogenesis of MRONJ. Deep biopsies of necrotic bone were collected during surgical treatment of MRONJ and evaluated by histology and microbiology for the presence of Actinomyces spp. Microbiological, demographic and clinicpathological data were analyzed for risk of Actinomyces-associated MRONJ. Between 2005 and 2014, 111 patients suffering from histologically-confirmed MRONJ were identified. Actinomyces spp. were detected in 99 cases (89%) by histology and in six further patients by microbiological culture. A diverse microbial flora was found in all specimens without association with Actinomyces spp. Demographic and clinicopathological characteristics did not separate significantly Actinomyces-positive from Actinomyces-negative cases. Our observations confirm previous reports of a high prevalence of Actinomyces spp. in MRONJ in the single largest cohort available up to now. The high prevalence of Actinomyces spp. and the lack of clinicopathological risk factors underline the prominent role of Actinomyces spp. in MRONJ and may change the current understanding of MRONJ. Established prolonged antimicrobial treatment regimens against Actinomyces spp. infection could therefore be a mainstay of future MRONJ management.