Prolonged Course Of Antibiotics Research Articles

Impact of NICE clinical guidelines for prevention and treatment of neonatal infections on antibiotic use in very preterm infants in England and Wales: an interrupted time series analysis

ObjectiveTo assess the impact of publication of UK National Institute for Health and Care Excellence (NICE) guidelines on the prevention and treatment of early-onset infections (EOIs) in neonates (clinical guideline...

Recurrent ventilator-associated pneumonia in severe Covid-19 ARDS patients requiring ECMO support

ObjectiveTo describe ventilator-associated pneumonia (VAP) recurrence in COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support, and to evaluate the impact of antimicrobial treatment duration of the first VAP episode on VAP recurrence.MethodsAdult patients with COVID-19 severe pneumonia on ECMO admitted between March 2020 and January 2022 were retrospectively included. Primary outcome was incidence of VAP recurrence, and secondary outcome was the impact of duration of antimicrobial treatment on VAP recurrence.ResultsAmong the 252 included patients, 226 (90%) developed a first VAP. Sixteen had lung abscess and were excluded, leaving 210 patients. VAP recurrence occurred in 172 patients (82%), with a median (IQR) time from first VAP to recurrence of 10 (7–13) days. Pseudomonas aeruginosa and Enterobacteriaceae were respectively responsible for 28% and 52% of first VAP, and 51% and 62% of first recurrence episodes. Among the 210 patients with a first VAP, 158 (75%) received a short course of antibiotics [< 8 days, median (IQR) duration 6 (5–7) days] and 52 (25%) received a prolonged course of antibiotics [≥ 8 days, median (IQR) duration 9 (8–10) days]. Estimated cumulative incidence of VAP recurrence, taking into account death and extubation as competing risks, was not different in patients with short– and prolonged–antimicrobial treatment.ConclusionsIn patients with severe Covid-19–ARDS requiring ECMO support, VAP recurrence occurs frequently, with Enterobacteriaceae and Pseudomonas aeruginosa as predominant causative microorganisms. An antimicrobial treatment of ≥ 8 days for the treatment of first VAP episode did not reduce the risk of VAP recurrence, as compared to shorter duration.

Delayed Infection After Cervical Disc Arthroplasty: A Case Report and Review of the Literature.

Case report and literature review. To report the relatively rare complication of delayed infection after cervical disc arthroplasty (CDA). Delayed infection of the M6 device has been a rarely reported complication, with all cases described outside of the United States. The reliability of positive intraoperative cultures remains an ongoing debate. Cases were reviewed, and findings were summarized. A literature review was performed and discussed, with special consideration to current reports of delayed M6 infection, etiology, and utility of intraoperative cultures. We present a case of delayed infection 6 years after primary 1-level CDA with the M6 device. At revision surgery, gross purulence was encountered. Intraoperative cultures finalized with Staphylococcus epidermidis and Cutibacterium acnes. The patient was revised with removal of the M6 and conversion to anterior cervical discectomy and fusion. A prolonged course of intravenous antibiotics was followed by an oral course for suppression. At the final follow-up, the patient's preoperative symptoms had resolved. Delayed infection after CDA is a rare complication, with ongoing debate regarding the reliability of positive cultures. We describe an infected M6 and demonstrate the utility of implant removal, conversion to anterior cervical discectomy and fusion, and long-term antibiotics as definitive treatment. Level V-case report and literature review.

"Give Me Five": The Case for 5 Days of Antibiotics as the Default Duration for Acute Respiratory Tract Infections.

Acute respiratory tract infections (ARTIs) account for most antibiotic prescriptions in pediatrics. Although US guidelines continue to recommend ≥10 days antibiotics for common ARTIs, evidence suggests that 5-day courses can be safe and effective. Academic imprinting seems to play a major role in the continued use of prolonged antibiotic durations. In this report, we discuss the evidence supporting short antibiotic courses for group A streptococcal pharyngitis, acute otitis media, and acute bacterial rhinosinusitis. We discuss the basis for prolonged antibiotic course recommendations and recent literature investigating shorter courses. Prescribers in the US should overcome academic imprinting and follow international trends to reduce antibiotic durations for common ARTIs, where 5 days is a safe and efficacious course when antibiotics are prescribed.

Diabetic Osteomyelitis: Oral versus Intravenous Antibiotics at a Single Level 1 Academic Medical Trauma Center

Residual osteomyelitis is a frequent problem following surgical intervention for diabetic foot infection. The Infectious Disease Society of America guidelines recommend a prolonged course of antibiotics for treatment of residual osteomyelitis. Recent literature suggests oral antibiotic therapy is not inferior to IV therapy. The primary aim of this study was to evaluate treatment success in 128 patients receiving oral versus IV antibiotics for residual osteomyelitis in the diabetic foot after amputation at a Level 1 academic medical trauma center. Treatment success was defined as completion of at least 4 weeks of antibiotic therapy, complete surgical wound healing, and no residual infection requiring further debridement or amputation within 1 year of the initial surgery. Patients with peripheral arterial disease were excluded. A retrospective chart review was performed, and we found no statistically significant difference in treatment success between these two groups (p = .2766). The median time to healing for oral antibiotic treatment was 3.17 months compared to 4.06 months for IV treatment (p = .1045). Furthermore, there was no significant difference in group demographics or comorbidities, aside from more patients in the IV group having coronary artery disease (p = .0416). The type of closure and whether the infection was single or polymicrobial were also not associated with a difference in outcomes between the two treatment arms. The results of the present study suggest oral antibiotics for treatment of residual osteomyelitis are not inferior to IV therapy and may be more efficacious for certain patients regarding cost and ease of administration.

Pasteurella multocida: An Uncommon Cause of Infective Endocarditis Affecting a Homograft Conduit in a Child

Background: Disseminated septicemia and endocarditis are extremely rare complications of Pasteurella infection and are mainly seen in patients with associated major comorbidities. Clinical Description: A 13-year-old boy, who had undergone surgery for congenital heart disease in early childhood, presented with prolonged fever, gross hematuria, and oliguria. The child was found to be conscious and febrile, with tachycardia, pallor, and edema. There was a systolic murmur in the left upper sternal border with hepatosplenomegaly. Management and Outcome: Routine investigations revealed anemia, low serum albumin, and progressively worsening renal functions, with urinalysis showing significant proteinuria and red cells. Serial blood cultures showed growth of Pasteurella multocida. Echocardiography showed vegetation in conduit (homograft) connecting the right ventricle with the pulmonary artery. Despite intravenous antibiotics, the clinical condition did not improve, so the conduit was removed surgically, following which the child recovered. Conclusion: This case creates awareness regarding infective endocarditis in a child being caused by a rare organism P. multocida, involving a surgically created conduit. The case also highlights the importance of timely surgical removal of the source combined with a prolonged course of antibiotics in a successful recovery.

Variables associated with antibiotic treatment tolerance in patients with Mycobacterium avium complex pulmonary disease

BackgroundTreatment of Mycobacterium avium complex pulmonary disease (MAC-PD) involves prolonged courses of multiple antibiotics that are variably tolerated and commonly cause adverse drug reactions (ADR). The purpose of this retrospective, single-center study was to identify demographic and disease-related variables associated with significant ADRs among patients treated with antibiotics against MAC-PD.MethodsWe reviewed all patients treated with antibiotic therapy for MAC-PD at a single center from 2000 to 2021. Patients were included if they met diagnostic criteria for MAC-PD, were prescribed targeted antibiotic therapy for any length of time and had their treatment course documented in their health record. We compared patients who completed antibiotics as originally prescribed (tolerant) with those whose antibiotic treatment course was modified or terminated secondary to an ADR (intolerant).ResultsOver the study period, 235 patients were prescribed antibiotic treatment with their clinical course documented in our center’s electronic health record, and 246 treatment courses were analyzed. One hundred forty-three (57%) tolerated therapy versus 108 (43%) experienced ADRs. Among the 108 intolerant courses, 67 (63%) required treatment modification and 49 (46%) required premature treatment termination. Treatment intolerance was associated more frequently with smear positive sputum cultures (34% vs. 20%, p = 0.009), a higher Charlson Comorbidity Index (CCI) (4 vs. 6, p = 0.007), and existing liver disease (7% vs. 1%, p = 0.03). There was no between-group difference in BMI (21 vs. 22), fibrocavitary disease (24 vs. 19%), or macrolide sensitivity (94 vs. 80%). The use of daily therapy was not associated with intolerance (77 vs. 79%). Intolerant patients were more likely to be culture positive after 6 months of treatment (44 vs. 25%).ConclusionsPatients prescribed antibiotic therapy for MAC-PD are more likely to experience ADRs if they have smear positive sputum cultures at diagnosis, a higher CCI, or existing liver disease. Our study’s rate of early treatment cessation due to ADR’s was similar to that of other studies (20%) but is the first of its kind to evaluate patient and disease factors associated with ADR’s. A systematic approach to classifying and addressing ADRs for patients undergoing treatment for MAC-PD is an area for further investigation.

Dalbavancin Sequential Therapy for Gram-Positive Bloodstream Infection: A Multicenter Observational Study.

Long-acting lipoglycopeptides such as dalbavancin may have utility in patients with Gram-positive bloodstream infections (BSI), particularly in those with barriers to discharge or who require prolonged parenteral antibiotic courses. A retrospective cohort study was performed to provide further multicenter real-world evidence on dalbavancin use as a sequential therapy for Gram-positive BSI. One hundred fifteen patients received dalbavancin with Gram-positive BSI, defined as any positive blood culture or diagnosed with infective endocarditis, from 13 centers geographically spread across the United States between July 2015 and July 2021. Patients had a mean (SD) age of 48.5 (17.5) years, the majority were male (54%), with many who injected drugs (40%). The most common infection sources (non-exclusive) were primary BSI (89%), skin and soft tissue infection (SSTI) (25%), infective endocarditis (19%), and bone and joint infection (17%). Staphylococcus aureus accounted for 72% of index cultures, coagulase-negative Staphylococcus accounted for 18%, and Streptococcus species in 16%. Dalbavancin started a median (Q1-Q3) of 10 (6-19) days after index culture collection. The most common regimen administered was dalbavancin 1500mg as one dose for 50% of cases. The primary outcome of composite clinical failure occurred at 12.2%, with 90-day mortality at 7.0% and 90-day BSI recurrence at 3.5%. Dalbavancin may serve as a useful tool in facilitating hospital discharge in patients with Gram-positive BSI. Randomized controlled trials are anticipated to validate dalbavancin as a surrogate to current treatment standards.

Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study.

This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

A Review of the Clinical Utilization of Oral Antibacterial Therapy in the Treatment of Bone Infections in Adults.

Chronic osteomyelitis in adults is managed with prolonged courses of intravenous antibiotics in conjunction with surgical debridement of necrotic bone. Over the past 40 years, there has been no paradigm shift in this approach, as randomized controlled trials of this standard of care compared to alternatives such as prolonged oral antibiotics are scarce. However, there have been many small trials, case reports, and review papers evaluating the effectiveness of oral treatment for chronic osteomyelitis. The oral route for infections requiring prolonged treatment is intuitively and practically more favorable due to several advantages, the most important of which is the avoidance of long-term IV antimicrobial therapy with its complications, inconvenience, and cost. In this paper, we review the literature evaluating oral antibiotic therapy in the management of chronic bone infections since 1975. The majority of osteomyelitis infections are caused by Staphylococcus aureus, hence we focus on its treatment using oral antibiotics; however, we also emphasize subpopulations of patients with diabetes, implanted hardware, and with less common bacterial organisms. The primary objective of this review is to promulgate clinical recommendations on the use of oral antibiotics in bone infections in the context of initial therapy, transition from intravenous therapy, and the role of chronic suppression. The secondary objective is to summarize current knowledge of the specific oral antimicrobial agents that are commonly utilized, together with a synopsis of the available literature pertaining to their pharmacokinetic/pharmacodynamic properties and duration of therapy in bone infection.

Transperineal drainage of prostate abscesses: A minimally invasive, low-risk management strategy that yields satisfactory results.

In this narrative review, we aim to present two cases of transperineal drainage of prostate abscesses with a good clinical outcome. Furthermore, we reviewed the literature on this treatment approach and aim to propose a minimally invasive protocol for managing this rare condition. Our patients are 33- and 61-year-old males who both underwent uncomplicated transperineal drainage of prostate abscess with the use of a Precision Point device with rapid clinical improvement and complete resolution of the abscess within the follow-up period. We used PubMed to conduct a literature search and included and evaluated 16 relevant case reports and case series in which the authors utilized transperineal drainage techniques for prostatic abscesses. Our first patient was young and very unwell with sepsis and a pulmonary embolism. He had a complex abscess extending through the prostate to the left pelvic side wall. Trans-gluteal drainage of the pelvic side-wall collection was required in addition to transperineal drainage of the prostate abscess. After drainage and a prolonged course of antibiotics, he achieved resolution of the abscess by 7weeks with ejaculatory function intact. Our second patient who was very keen on the preservation of ejaculatory function had multiple small abscesses and underwent transperineal drainage. He had significant interval improvement of his abscess burden at the 4-week follow-up and complete resolution at the 6-month follow-up. The total number of cases in the literature on our review is 22, with considerable variability in how the authors managed the prostate abscesses that underwent transperineal drainage, including variability in their follow-up time frame, choice of imaging modality, duration of antibiotic treatment, drain placement, and use of irrigation solutions (including antibiotics) into the abscess cavity. Furthermore, the sizes of the prostate abscesses were not consistently reported. Given the small sample size and variability in management from different authors, it was not possible to draw any statistical analysis. Transperineal prostate abscess drainage combined with prolonged antibiotic therapy provides a less invasive alternative to treating prostate abscesses for those who which to preserve ejaculatory function and avoid the other adverse events of transurethral de-roofing. In itself, it can achieve complete resolution of abscess. It provides the benefit of drainage under real-time imaging; for percutaneous drain placement; prevents urethral injury; retrograde ejaculation; and can be done under local anaesthetic which is preferable for the unstable patient. The utility of the procedure may be limited by the complexity of the abscess or whether it has extended beyond the prostate. The patient should always be informed that further drainage via percutaneous methods or transurethral methods may be necessary if their clinical condition does not improve. We recommend this procedure be offered as an alternative to transurethral methods in younger patients and those who would like to preserve ejaculatory function. Furthermore, we highly encourage a prolonged course of antibiotic therapy and interval follow-up with clinical review of symptoms and imaging to confirm resolution.

2280. Surveillance of Life-Long Antibiotics (SOLLA) 2: Patients on Life-Long Antibiotics in an Australian Healthcare Network

Abstract Background There is a range of conditions for which long-term antibiotics are prescribed, most of which lack high quality evidence. Apart from promoting antimicrobial resistance, long-term antibiotics also impact the individual patient, disrupting the normal microbiome, and increasing the risk of infection with multi-resistant organisms (MROs). Previous work conducted at Monash Health, in Victoria, Australia, in 2014 noted great heterogeneity in both indications for prolonged antibiotic courses and the antimicrobial agents used. Methods The current study aimed to reassess prescribing trends within the same health network, across two time periods in 2019 and 2021. Outpatient prescriptions were extracted from the Monash Health pharmaceutical database at two time points, from 1st January 2019 – 30th June 2019, and 1st January 2021 – 30th June 2021. Results From 4,704 outpatient prescriptions, 929 patients were identified as being on either one or more antibiotics for an intended duration of ≥ 12 months. There were a total 536 (57.7%) males and 393 females (42.3%), with a mean age of 58.20 years. Sixty-eight patients died between the two follow-up periods. Data was separated into 3 groups: primary prophylaxis in the setting of immunosuppression (n = 687), secondary prophylaxis for infections deemed incurable (n = 78), and “Other” (n = 164). Six hundred and four patients (88%) on primary prophylaxis were for Pneumocystis jirovecii pneumonia, and 83 (12%) post splenectomy. Trimethoprim/sulfamethoxazole was predominantly prescribed for PJP prophylaxis (n = 583), followed by dapsone (n = 21). Prosthetic joint infections made up 57 (73%) of those on suppressive antibiotics for infections deemed incurable. An array of antibiotics was utilised to treat them, as seen in Figure 1. The “Other” category included those on antibiotics for difficult to treat infections, such as mycobacterial infections (n = 43), chronic airways disease (n = 38), spontaneous bacterial peritonitis (n = 23) and recurrent urinary tract infections (n = 12). Data on comorbidities, hospitalisations and MROs between groups can be viewed in Table 1. Conclusion Further research is needed. Prospective data examining long-term patient outcomes, and patterns of prescribing across different health networks would be of benefit. Disclosures Jillian Lau, MBBS, FRACP, Gilead: Advisor/Consultant|Gilead: Grant/Research Support|MSD: Grant/Research Support|Viiv Healthcare: Advisor/Consultant Ian Woolley, MBBS, FRACP, DTM&amp;H, MD, Gilead: Educational support, investigator for Gilead supported trial|MSD: educational support, participation in a clinical trial|Pfizer: Educational support|ViiV: Educational Programs, Advisory Board member, ViiV sponsored trials

2764. Experience with dalbavancin in a pediatric hospital

Abstract Background Due to its long half-life allowing for once-weekly dosing, dalbavancin has become an appealing option for the treatment of infections that require prolonged antibiotic courses. While studies have shown non-inferiority of dalbavancin compared to conventional antibiotic regimens, there is limited information regarding its use in the pediatric population. We describe the experience with dalbavancin use in a large pediatric hospital. Methods Children and young adults who were seen at Cincinnati Children’s Hospital between the period of July 1st, 2019 and December 31st, 2022 and received antibiotic therapy with Dalbavancin were included in this study. We reviewed the patient’s demographic data, laboratory findings including microbiologic data, clinical course, response to treatment and outcomes. Treatment failure was defined as no response or worsening after initial improvement. Clinical response was also evaluated at day 90 after end of therapy. Results We identified 26 children and young adults who received dalbavancin between July 1st 2019 and December 31st 2022 (Table 1). Ages ranged between 6 months and 22 years. Most common indication was osteomyelitis. Side effects were rare and included flushing and transient vision loss, which was later diagnosed as ocular migraine. Seven patients (26.9%) had treatment failure at 90 days, including 33.3% and 18.2% of patients with and without comorbidities, respectively. Ages of patients with treatment failure ranged from 6 months to 20 years. Five of them showed initial improvement during the first week after therapy but required an antibiotic switch due to worsening. Time to failure from first dose of dalbavancin ranged from 10 to 35 days. Of all 7 patients who failed therapy, four had no recovered organisms, two had MRSA and one had MSSA. One patient with no initial recovered organism grew Pseudomonas aeruginosa on a repeat culture. Characteristics of patients who received dalbavancin between July 1st, 2019 and December 31st,2022 Conclusion While our population was small, a high treatment failure rate was seen when using dalbavancin, particularly in patients with comorbidities. More data is needed to evaluate its performance in the pediatric population and clinicians should be thoughtful about deciding who is a good candidate for dalbavancin therapy. Disclosures All Authors: No reported disclosures

680. Comparison of Extended Duration Vancomycin Regimens for Clostridioides difficile Infection in Patients on Prolonged Antibiotic Courses

Abstract Background Antibiotic exposure is a primary risk factor for Clostridioides difficile infection (CDI) and recurrence. We compared CDI recurrence in patients who received extended oral vancomycin (poV) after diagnosis of CDI, at a dose of q12-24h compared to q6h, while on concomitant systemic antibiotic therapy. Methods Retrospective study of adult patients admitted 2/2020-9/2022 to NewYork-Presbyterian Hospital, diagnosed with CDI, and received at least 14 days poV including initial CDI therapy, and at least 2 days of extension with concomitant systemic antibiotics with no interruptions. Patients were grouped based on vancomycin extended dosing to either q6h or q12-24h. Patients were excluded if CDI regimen included vancomycin pulse/taper or fidaxomicin, &amp;gt;1 day interruption between final day of CDI treatment and extended dosing, and incomplete resolution of CDI at day 14. The primary outcome of recurrent CDI at 90 days was compared between the two groups via chi-squared test. Predictors of CDI recurrence were assessed using a logistic regression model. Results 110 patients were included:77 received q6h and 33 received q12-24h extended poV. Median age was 63 years (IQR 55,74), 51% were hospital onset-CDI, and the median total duration of poV was 25 days (IQR 19,38 days). The only significant differences between q6h and q12-24h groups were total days of vancomycin (22 vs. 37 days; p&amp;lt; 0.001) and patients with previous CDI episodes (7% vs 24%; p=0.02). Recurrence at 90 days was similar between q6h and q12-24h groups (13.2% and 6.3% respectively; p=0.505). On multivariable analysis, while controlling for severe and fulminant CDI and patients with inflammatory bowel disease, poV regimen of q12h-24h did not impact recurrence (OR 0.428, 95% CI 0.08-2.21). Conclusion No significant differences were seen in CDI recurrence between extended poV q6h compared to q12-24h. For patients who require extended poV dosing beyond an initial treatment course, q12h-24h dosing may be an option with improved patient convenience and reduced drug cost. The long-term impact of this reduced dosing frequency remains to be determined. Disclosures All Authors: No reported disclosures

2438. Positive Cerebrospinal Fluid Cultures from Intraventricular Reservoirs for CLN2 Patients: One Institution's Experience

Abstract Background Enzyme replacement therapy (ERT) with cerliponase alfa (Brineura) has been shown to slow progression of milestone deterioration in Neuronal Ceroid Lipofuscinosis Type 2 (CLN2), an inherited neurodegenerative lysosomal storage disorder. Brineura must be administered intraventricularly every 2 weeks, necessitating the placement of ventricular reservoirs and requiring frequent access. Traditionally, positive cerebrospinal fluid (CSF) cultures are managed with device replacement and antibiotic treatment. We sought to establish which circumstances might allow for careful observation without device removal. In this study, we report our single-institution experience with clinical outcomes of positive CSF cultures in 16 CLN2 patients over 6 years. Methods We retrospectively reviewed a cohort of 16 patients with CLN2 disease who had ventricular reservoirs placed for ERT administration. At each ERT infusion, CSF was collected by sterile technique and cultured by both thioglycolate broth and agar plate. Epidemiologic and microbiologic data, symptomatology, total antibiotic days, removal and replacement of ventricular reservoir, hospital length of stay, and mortality were analyzed for each patient. Results In our cohort, 11 of 16 patients (69%) had at least one positive CSF culture (Fig 1). Of the 11 with positive cultures, only 3 had their device removed and replaced for a positive culture with concurrent antibiotic treatment at our center, and 2 patients subsequently have been treated with prophylactic antibiotics at infusions (Fig 2). Out of 1401 total CSF cultures, 64 (4.56%) were positive. The most common organism grown was Cutibacterium acnes, which typically grew in only broth culture (82%), suggesting low bacterial burden (Fig 3). The other 7 patients with positive cultures remained asymptomatic with no intervention required. Conclusion At our institution, we have found that in asymptomatic patients with frequently accessed ventricular reservoirs, positive CSF culture with low virulence skin flora was common, and rarely required intervention. This strategy reduced the risks of invasive surgery, prolonged antibiotic courses, and missed infusions. In the future, routine screening cultures in asymptomatic patients can be avoided. Disclosures Raymond Wang, MD, Biomarin Pharmaceutical: Advisor/Consultant|Biomarin Pharmaceutical: Grant/Research Support|Biomarin Pharmaceutical: equity interest Antonio C. Arrieta, MD, FIDSA, FPIDS, Astellas Pharma Global Development, Inc.: Advisor/Consultant|Astellas Pharma Global Development, Inc.: Grant/Research Support|Astellas Pharma Global Development, Inc.: Honoraria|Cumberland Pharmaceutical: Grant/Research Support|IDbyDNA: Advisor/Consultant|IDbyDNA: Grant/Research Support|Melinta: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Nabriva: Grant/Research Support|Paratek Pharmaceuticals: Grant/Research Support|Pfizer, Inc: Advisor/Consultant|Pfizer, Inc: Grant/Research Support|Roche/Genentech: Grant/Research Support|The Medicine Company: Grant/Research Support

Abstract 16833: Native Pulmonary Valve Infective Endocarditis in the Absence of Typical Risk Factors

Introduction: Isolated Pulmonary valve endocarditis (PVE) is a rare subset of right sided endocarditis associated with high mortality. We describe a case of PVE without typical risk factors. Case: A 53-year-old male with a history of controlled type 2 diabetes, coronary artery disease and recent minor trauma to the foot presented with 1 week of intermittent fevers, night sweats, and decreased appetite. Vital signs revealed a temperature of 103°F. Exam was significant for a grade II diastolic murmur best heard on the left sternal border and a healed wound on the left 5th metatarsal. Blood cultures taken grew Methicillin-Resistant Staphylococcus Aureus. A trans-thoracic echocardiogram revealed an echo dense material on the pulmonary valve measuring 1.0 x 0.3 cm. Differential diagnosis included endocarditis, pulmonary fibroelastoma, thrombus, or a cardiac tumor. A trans-esophageal echocardiogram later obtained revealed an echogenic lesion on the pulmonic valve measuring 2.1 x 1.2 cm with severe pulmonic insufficiency. An echodensity adherent to the right ventricular wall was also visualized. Tricuspid valve appeared normal. Due to persistent bacteremia despite appropriate antimicrobial coverage and significant valvular insufficiency, a decision was made to proceed with cardiac surgery. Patient received debridement to both pulmonary valve and right ventricular vegetations and underwent pulmonary valve replacement. Intraoperative pathology was consistent with endocarditis. The nidus for infection was attributed to the patient’s recent traumatic wound. The patient was discharged home with 6 weeks of daptomycin therapy. Conclusion: Right sided endocarditis involving the pulmonic valve is rare but can occur in individuals without an obvious predisposing cardiac structural abnormality. In our case, the patient developed severe valvular insufficiency therefore was successfully treated with surgical intervention and a prolonged course of antibiotics.

Abstract 18958: Management of Patients With Suspected Left-Sided Prosthetic Valve Endocarditis According to Myocardial FDG-PET CT Results

Introduction: Accurate diagnosis of prosthetic valve endocarditis (PVE) is challenging because echocardiography (Echo) can be limited by artifact from prosthetic material. Myocardial FDG-PET (PET) can improve diagnostic accuracy; however, little is known about its effect on patient management. Research Question: Does PET affect management of patients with suspected left-sided PVE? Methods: A retrospective, single-center study was conducted on all admitted patients with a history of aortic valve replacement (AVR) or mitral valve replacement (MVR) or repair who underwent a myocardial PET for suspected endocarditis between April 2016 to December 2022. PET was defined as positive, negative, or indeterminate based on signal intensity/pattern at valve prosthesis. For this analysis, patients with indeterminate results were included with negative results, resulting in four groups PET+, PET-, Echo+ and Echo-. Patients were followed up to twelve months. Data were obtained from chart review and supplemented with national death index data. Results: Of a total of 146 included patients, 68% had a surgical AVR, 14% had a transcatheter AVR and 21% had an MVR. Median age was 63 years and 30% of patients were female. Most patients had positive blood cultures on admission (66%). The Echo+/PET+ group had a high rate of definite PVE (95%). PVE was rejected in 58% of those in the Echo-/PET- group. PET+ patients were more likely to undergo surgery in both the Echo- (24% for PET+ vs. 12% for PET-) and Echo+ (62% for PET+ vs. 20% for PET-) groups. High rates of prolonged antibiotic courses (73%) were seen across all groups; PET- groups had lower rates of prolonged antibiotics. Conclusions: Although most patients with suspected PVE underwent initial conservative management, PET+ patients had higher rates of surgical management. Negative PET results may help to identify patients with suspected PVE that may not require prolonged antibiotics.

Liver Abscesses Due to Fusobacterium nucleatum: A Case Series

Abstract Fusobacteriae are anaerobic gram-negative bacilli, classically involved in the development of septic thrombophlebitis of the internal jugular vein in Lemierre syndrome. The goal of this study is to describe the various presentations, treatment course, and outcomes of patients with Fusobacterium liver abscess(es) and review available literature on this topic. We retrospectively reviewed our microbiologic database for positive cultures of Fusobacteriae species in a tertiary care hospital from July 2018 through November 2022 and identified 5 cases of liver abscess that involved Fusobacterium nucleatum species. Patients presented with a syndrome of fever and chills, abdominal pain, and nausea and vomiting. Laboratory investigations revealed leukocytosis and transaminitis, and imaging revealed liver abscess(es). The identification of the F. nucleatum bacteria involved invasive aspiration of the abscess in all but one case, where it was identified on blood cultures. One patient had a florid picture of sepsis and acute respiratory distress syndrome. All patients responded well with intravenous antibiotics and were discharged home to complete a prolonged course until radiographic resolution. In 3 patients, history and imaging were suggestive of possible sources that may have hematogenously spread to the liver, with history of recent appendectomy in 1 patient, possible appendicitis on computed tomography of the abdomen in another patient, and recent dental manipulation in the third patient. In conclusion, Fusobacteriae should be included in the differential diagnosis of liver abscess, especially in the setting of recent appendicitis or dental disease. Effective treatment includes surgical drainage when feasible and prolonged course of antibiotics with goal of radiologic resolution.

Evaluating antibiotic therapy for ventilator-associated pneumonia caused by gram-negative bacilli

IntroductionVentilator-associated pneumonias (VAPs) are a complication of mechanical ventilation in the intensive care unit (ICU) that increase length of stay, morbidity, and mortality. While identifying and treating infections early is paramount to improving patient outcomes, more and more data demonstrate limited courses of antibiotics improve outcomes. Prolonged (10–14 day) courses of antibiotics have remained the standard of care for pneumonia due to gram-negative bacilli (GNR). We aimed to review our GNR VAPs to assess risk factors for recurrent GNR infections. MethodsWe reviewed trauma patients who developed VAP from 02/2019 through 05/2022. Demographics, injury characteristics, and outcomes were reviewed with a focus on pneumonia details including the cultured pathogen(s), antibiotic(s) used, treatment duration, and presence of recurrent infections. We then compared single episode VAPs to multiple episode VAPs among patients infected by GNRs. ResultsEleven of the fifty trauma patients admitted to the ICU suffered a VAP caused by a GNR. Of these eleven patients, six experienced a recurrent infection, four of which were caused by Pseudomonas aeruginosa and two of which were caused by Enterobacter aerogenes. Among the patients who received ten days of antibiotic treatment, half suffered a recurrence. Although, there was no difference in the microbiology or antibiotic duration between the recurrences and single episodes. ConclusionDespite prolonged use of antibiotics, we found that the risk of recurrent or persistent infections was high among patients with VAP due to GNB. Further study is needed to determine optimal treatment to minimize the risk of these recurrences. Key messageVentilator-associated pneumonia due to gram-negative bacilli is a rare but high morbidity complication in intensive care units. Despite prolonged duration of therapy, these infections still appear to account for many recurrent infections and further study into optimal therapy is warranted.

Case Report: Tropical sprue, diagnostic challenges of an old but unrecognized disease

Tropical sprue (TS) is a post-infective disease of the small bowel characterized by a malabsorption syndrome affecting tropics inhabitants and visitors. Diagnosis of TS remain challenging since it can be confused with common diarrheal diseases, especially in non-endemic areas. We report a Tunisian case of latent TS. A 58-year-old male with a history of chronic watery diarrhea, was admitted to the intensive care unit for confusion which was related to dehydration[J1] . Despite the neurological improvement after hydro-electrolytic resuscitation and acid-base disorders correction, the patient continued to have three to five loose stools daily. A nutritional assessment showed a malabsorption syndrome: iron, Vitamin B12 and folate deficiencies; normochromic normocytic anemia and hypoalbuminemia. Gastrointestinal endoscopy showed duodenal villous atrophy and biopsy confirmed subtotal villous atrophy with increased intraepithelial lymphocytosis and a thickened hyalinized [J2] sub-epithelial basal lamina. Celiac disease was evoked, however the patient did not improve on a gluten-free diet and the celiac serology was negative. On re-interviewing, we discovered that the patient had spent two months in India three years prior. Given the travel history, clinico-biological and histological data TS was highly considered and a good response to a five-month antibiotic course combined to nutritional supplementation supported this diagnosis. Clinico-biological, endoscopic and histological findings were overlapping between TS and other malabsorption diseases, explaining diagnosis difficulties. TS should be systematically discussed in tropics visitors presenting with chronic diarrhea. Improvement after micronutrient and vitamin deficiencies replacement combined to a prolonged antibiotic course supports the diagnosis of TS. [J