Prolonged Course Of Antibiotics Research Articles

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.

Septic Arthritis of the Pubic Symphysis in a 16-Year-Old Male Adolescent: A Case Report.

A 16-year-old male adolescent presented with 4 weeks of right-sided hip pain and fever in the setting of recent groin trauma. He was diagnosed with septic arthritis of the pubic symphysis (SAPS) and was treated nonoperatively with antibiotics. Symptoms recurred, and he underwent surgical drainage of the pubic symphysis followed by a prolonged course of antibiotics. Follow-up at 12 months indicated complete symptom resolution. This is the ninth reported adolescent case of SAPS. Although the presentation and disease course closely resembled those reported in the literature, this is the only case that required surgical intervention after failed nonoperative management.

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

1212 Actinomycosis of the Middle Ear Mimicking Cholesteatoma – a Case Report and Literature Review

Abstract Introduction Actinomycosis, a rare infection of the middle ear, has less than 50 documented cases worldwide. Actinomyces are an anaerobic, filamentous bacterium causing granuloma formation and suppurative infection. Case We present a young male with a nine-month history of unilateral, yellow coloured otorrhoea and hearing loss. Swabs showed no growth, with infection not responding to oral or topical antibiotics. CT temporal bones was consistent with cholesteatoma and ossicular disruption. Surgical exploration revealed a yellow, cystic mass within the middle ear. Cortical mastoidectomy and washout were performed. Histological diagnosis confirmed actinomyces clusters with positive Gram stain. Discussion Actinomyces typically presents as chronic otitis media. It likely reaches the middle ear via the Eustachian tube. It is often misdiagnosed due to culture insensitivity; however clinical suspicion can aid labs in providing an optimum culture environment. Tympanomastoidectomy allows for histopathological diagnosis. Surgical resection should be followed by a prolonged course of antibiotics.

Lung abscess as a complication of Lemierre Syndrome in adolescents: a single center case reports and review of the literature

BackgroundFusobacterium necrophorum is an anaerobic, gram-negative, non-motile, filamentous, non-spore forming bacillus found in the oral cavity, gastrointestinal tract, and female genital tract, responsible of a rare disease named Lemierre Syndrome, characterized by septic thrombophlebitis of the internal jugular vein, which mainly affects previously healthy adolescents and young adults; some risk factors are reported, as smoking or primary viral or bacterial infection leading to the disruption of mucosa. The syndrome originates commonly from an upper respiratory infection such as pharyngotonsillitis, acute otitis media, cervical lymphadenitis, sinusitis, or odontogenic abscess, and may result in multiorgan metastasis, more frequently leading to pulmonary complications, especially lung abscesses.Case presentationWe describe two cases of adolescents with atypical Lemierre Syndrome evaluated in a tertiary care center, one with a confirmed infection by Fusobacterium necrophorum and one with a presumptive diagnosis based on clinical features, who developed lung abscesses needing a prolonged antibiotic course and hospitalization. Of interest, both were user of electronic cigarette, configuring a possible new risk factor. The proper diagnosis of Lemierre Syndrome is often difficult to establish, so a high degree of suspicion is needed, especially in the case of lung abscesses in otherwise healthy adolescents.ConclusionThe current study will contribute to providing insight into Lemierre Syndrome clinical presentation and management in adolescents, promoting awareness for a rare but potentially fatal disease. Moreover, it suggests a possible relationship between Lemierre syndrome and the use of electronic cigarette, that should be investigated by future studies.

Acute kidney injury secondary to obstructive bladder malakoplakia: a case report

BackgroundMalakoplakia is a rare granulomatous inflammatory condition that can affect immunosuppressed patients. The genitourinary system is the most involved organ. We present a case of kidney failure caused by obstructing bladder lesions, clinically suspicious for malignancy and pathologically proven to be malakoplakia.Case presentationA 70-year-old woman presented with acute kidney injury and Escherichia coli (E.coli) bacteremia. Investigation showed bilateral hydronephrosis with thickening of the renal pelvises suggestive of urothelial malignancy. Cystourethroscopy revealed multiple bladder lesions completely obliterating both ureteral orifices. Pathology of the resected lesions confirmed the diagnosis of malakoplakia. Patient was treated with a prolonged antibiotic course over 6 months with recovery of her kidney function.ConclusionMalakoplakia can mimic invasive tumors, and the diagnosis is only attained through histopathology which uniquely demonstrates the pathognomonic Michaelis–Gutmann inclusions inside sheets of histiocytes. Treatment is largely dependent on prolonged antibiotics therapy that must cover the most common isolated pathogen, E.coli.

A rare case of Candida parapsilosis pneumonia in an immunocompetent patient

Introduction: The presence of fungus in an immunocompetent host is usually disregarded as a mere contaminant, as it can be a commensal organism of the skin, gastrointestinal, urogenital, and respiratory tract. Hence, its growth in cultures has to be interpreted within a clinical context. This case illustrates the challenges experienced when diagnosing Candida parapsilosis necrotizing pneumonia, and the importance for considering candida pneumonia as a differential diagnosis for an immunocompetent patient. After a thorough literature review, we would like to present the first case report of C. parapsilosis causing necrotizing pneumonia in an immunocompetent patient. Case Report: We present a case involving a middle-aged smoking male who presented with respiratory and metabolic abnormalities and was found to have necrotizing pneumonia. He was managed for severe sepsis with lactic acidosis, respiratory failure, and severe acute kidney injury (AKI), which improved with broad spectrum antibiotics and fluids. These conditions improved; however, his respiratory distress did not despite a prolonged course of antibiotics. This led to a workup for other causes of necrotizing pneumonia, after which cultures revealed the growth of C. parapsilosis. He was then started on antifungals and subsequently improved. Conclusion: Candida necrotizing pneumonia is a rare disease for an immune-competent individual; however, chronic lung damage in the setting of a smoking history may make individuals more susceptible. This case illustrates the challenges associated when dealing with such a case, and it is the team’s hope that publishing this case will add to awareness. Additionally, this can contribute to improved antibiotic stewardship and earlier diagnosis which will hopefully lead to a shorter hospital stay and improved morbidity and mortality.

Group B Streptococcus infection-induced ovarian vein thrombosis identified during cesarean section: A case report and a literature review.

Ovarian vein thrombosis (OVT) is a rare yet potentially life-threatening condition associated with thromboembolic events. Group B Streptococcus (GBS) is a type of β-hemolytic Gram-positive bacterium known for asymptomatic colonization in the lower genital and gastrointestinal tracts. Here we reported a 35-year-old multiparous woman with gestational diabetes who suffered from placental abruption, stillbirth, OVT, septic shock, and renal failure due to severe GBS infection. A 35-year-old woman with gestational diabetes presented with acute and sustained lower abdominal cramping, vaginal bleeding, and fever at 35 gestational weeks. Based on preoperative ultrasound and intraoperative findings, the patient was diagnosed with placental abruption, intrauterine fetal demise, and right OVT. GBS was cultured from the amniotic fluid obtained during cesarean section. The patient underwent a right adnexectomy during a cesarean section and received intravenous antibiotics. Subsequently, an ultrasound-guided uterine curettage was performed due to recurrent fever. After a prolonged course of intravenous antibiotics for over a month, the patient recovered and was discharged from the hospital. This case underscores the need for early initiation of anticoagulant protocols in cases of OVT, particularly when GBS infection is identified as a predisposing factor. Further research and awareness are warranted to better understand the relationship between GBS infection and OVT and to optimize management strategies in such cases.

P14 Surgical source control and colistin therapy for the management of osteomyelitis due to Pseudomonas aeruginosa with difficult-to-treat resistance

Abstract Patient A 45-year-old man from Lagos, Nigeria, now living in the UK, presented to his local hospital with purulent discharge from his knee. During a road traffic accident in 2019, he had sustained open fractures of his femur and tibia. These required surgical fixation and he underwent four surgeries over a 10-month period in Nigeria. He was reportedly on antibiotics throughout this period. In early 2022, he noticed discharge from the knee and was referred to the Bone Infection Unit in Oxford. On examination, left leg shortening and a sinus on the anterior proximal tibia were noted. Knee flexion was reduced to 30 degrees. He was otherwise systemically well. PET-CT revealed two areas of avidity, supporting the clinical diagnosis of fracture-related infection adjacent to a retained tibial plate. Treatment The patient underwent removal of the tibial plate, excision of infected bone, insertion of local antibiotic carrier (Cerament G with vancomycin added) and a medial gastrocnemius flap with split skin grafting. Five out of five intra-operative samples were culture positive for Pseudomonas aeruginosa, with NDM metallo-β-lactamase detected. This was resistant to ceftazidime, meropenem, piperacillin/tazobactam, gentamicin, tobramycin, amikacin, ciprofloxacin, ceftazidime/avibactam, imipenem/cilastatin/relebactam, ceftolozane/tazobactam and cefiderocol. The organism had an aztreonam MIC of 16 mg/mL and a colistin MIC of 2 mg/mL. The patient also had MRSA isolated from all intra-operative samples. Following multidisciplinary team discussion, he was started on aztreonam 2 g QDS and colistin loading with 9 million IU followed by 4.5 million IU BD for the P. aeruginosa and doxycycline 100 mg BD for the MRSA. After 8 days of therapy, he developed a symmetrical body rash, which was felt to be a delayed hypersensitivity reaction to aztreonam and resolved when aztreonam was stopped. He was subsequently treated with colistin monotherapy for 6 weeks via OPAT. Whilst on this treatment, his renal function was monitored regularly with appropriate dose reductions because of renal impairment. Follow-up at 9 months demonstrates good recovery with no pain or symptom recurrence. Conclusions This case illustrates the challenges of managing fracture-related infections with extensively drug-resistant organisms and the importance of multi-disciplinary input. Drug-resistant infections requiring prolonged courses of antibiotics can be successfully managed using an OPAT service. Finally, this case emphasizes the importance of understanding global patterns of antimicrobial resistance and stewardship to identify cases that are at risk of being infected with drug-resistant bacteria especially where there may be long intervals between establishment of the infection and presentation to healthcare services.

Delays in Lung Cancer Diagnosis: Observations from a Tertiary Care Centre in Kerala, India.

Merin YohannanIntroduction Timely diagnosis of lung cancer is critical because treatment outcomes correspond to the stage of disease. This study identified patient and physician determined reasons for diagnostic delays. Materials and Method s This was an observational cross-sectional study, conducted at a tertiary care institution in South India, for 12 months. From 207 consecutively selected patients, with a presumptive lung cancer diagnosis, 150 were enrolled utilizing a prefixed questionnaire. The time intervals from appreciation of initial respiratory symptoms to a final tissue diagnosis were defined sequentially as approach interval, referral interval, and diagnostic interval and factors causing delay in each interval were identified. Results In a state with 100% literacy, the mean time to approach a doctor was 8 weeks (range: 0-336 days; SD: 7.95) with a delay seen in 52% of the study group. Referring a suspect lung cancer diagnosis to a specialist, took an average of 4.98 weeks (range: 1-26 weeks; SD: 5.64) with referral delays in 47.3% of patients. The mean diagnostic interval was 9.21 days (range: 3-41 days; SD: 7.18) and 16.7% of cases had diagnostic delays in spite of a definite procedure. Conclusion In a tuberculosis endemic location, empirical treatment with anti-tuberculosis therapy and prolonged antibiotic courses without serially monitoring the course of disease are responsible for referral delays. Also, 88.2% of the total females studied, presented late due to family and work pressures, fear of being stigmatized and being on prolonged home remedies. A wider dissemination and awareness on lung cancer are needed especially among females. A low threshold to reinvestigate and an early referral to a pulmonary or lung cancer specialist, when expected clinicoradiological improvement is lacking, in microbiologically negative tuberculosis should be highlighted.

Whipple’s disease presenting as weight gain and constipation in a Chinese woman

BackgroundWhipple’s disease is a chronic infection due to Tropheryma whipplei, commonly reported in the Caucasian but not in the Chinese population.Case presentationA 52-year-old female with good past health, was diagnosed with Whipple’s disease, presenting with constipation, unintentional weight gain, and fleeting polyarthralgia. Investigations prior to admission showed raised CA125 and computed tomography of the abdomen showed multiple retroperitoneal mesenteric lymphadenopathies. Extensive investigations performed on secondary causes of weight gain were unrevealing. Subsequent PET-CT scan revealed generalized lymphadenopathy involving the left deep cervical, supraclavicular, and retroperitoneal mesenteric area. Excisional biopsy of the left supraclavicular lymph node was performed, with histology showing infiltrations of Periodic acid-Schiff positive foamy macrophages. T. whipplei DNA was detected in her serum, saliva, stool, and lymph node by PCR targeting the 16S ribosomal RNA gene. She was started on intravenous ceftriaxone, and then stepped down to oral antibiotics for a total of 44 months. The recurrence of fever after 12 days of ceftriaxone raised the suspicion of Immune Reconstitution Inflammatory Syndrome (IRIS). Serial imaging showed a gradual reduction in the size of retroperitoneal lymphadenopathies. Literature review on Whipple’s disease in the Chinese population identified 13 reports of detectable T. whipplei DNA in clinical specimens. The majority of the cases were pneumonia, followed by culture-negative endocarditis, encephalitis, and skin and soft tissue infection. However, most patients with pneumonia were diagnosed based on next generation sequencing alone, with the resolution of pulmonary infiltrates without adequate duration of antibiotics, suggesting the possibility of colonization instead of infection. The recommendation of long-term doxycycline suppression after treatment may be supported by the slow response of retroperitoneal lymphadenopathies to antibiotics in our patient.ConclusionsUnintentional weight gain and constipation could be atypical presentations of Whipple’s disease. It is a rare disease in the Chinese population despite the advancement of molecular techniques in the diagnosis of infections. A prolonged course of antibiotics may be required due to slow clinical response as documented by serial imaging in our case. The possibility of IRIS should be considered in patients with breakthrough fever during treatment of Whipple’s disease.

Unnecessary hospitalisations and polypharmacy practices in Romania: A health system evaluation for strengthening primary health care.

Children and pregnant women usually have multiple contacts with the health care system. While most conditions can be managed by primary health care (PHC) providers, hospitalisations are nevertheless common and often unjustified. The number of hospitalizations decreased in Romania at the start of the COVID-19 pandemic. While this is likely due to the disruption of health services and public health measures established to limit the spread of COVID-19, it also suggests that a proportion of hospitalisations prior to the pandemic were unnecessary. This healthcare system evaluation in Romania quantified unnecessary and unnecessarily prolonged hospitalisations in children, pregnant women and women hospitalised for delivery, and assessed antibiotic and polypharmacy practices in these groups. We conducted the healthcare system evaluation in 10 hospitals across the country. We extracted data from medical records of patients hospitalized between 2019 and 2020. In each hospital, we randomly selected 40 medical records for each of the following groups: children 2-59 months of age, pregnant women, and women hospitalised for delivery. Clinical data were compared against WHO standards indicating a need for inpatient treatment or antibiotic therapy. Among 209 children and 349 pregnant women, unnecessary hospitalisations accounted for 57.9% and 56.2% of hospitalisations, respectively. Among necessary hospitalisations, a large proportion was unnecessarily prolonged, including 44.4% (n = 32/72) in children, 23.3% (n = 34/146) in pregnant women, and 45.8% (n = 110/240) in women after delivery. The proportion of unnecessary and unnecessarily prolonged hospitalisations did not differ between the pre-pandemic, the lockdown, and the post-lockdown periods. Antibiotics were prescribed to 53.1% (n = 43/81) of children with diarrhoea, while 50.8% (n = 61/120) of women with caesarean section received an unjustified prolonged course of antibiotics. Children and women were commonly prescribed unnecessary medications. Findings of this evaluation should inform evidence-based decisions and actions for strengthening PHC and the healthcare system structure and improving the management of common diseases in mothers, newborns, and children. The evaluation should be repeated periodically to monitor progress.

Retrospective review of antimicrobial use for gastroschisis patients in Kigali, Rwanda: can improved stewardship reduce late inpatient deaths?

We identified frequent late deaths, prolonged antibiotic courses, and regular use of second-line antibiotic agents in this retrospective cohort of Rwandan gastroschisis patients. Future studies are needed to evaluate antimicrobial resistance in pediatric surgical patients in Rwanda. • Global disparities in gastroschisis outcomes are extreme, with <4% mortality in high-income settings and 75-100% mortality in low-income settings. • Antimicrobial surveillance data is sparse across Africa, but existing evidence suggests high levels of resistance to first-line antibiotics in Rwanda. • In-hospital survival for gastroschisis was 23% from 2016-2019 and most deaths occurred late (>48hrs after admission) due to sepsis. • Rwandan gastroschisis patients received prolonged courses of antibiotics and second-line antibiotics were frequently used without culture data, raising concern for antimicrobial resistance.

Successful Management of Malakoplakia in a Patient Combined Variable Immunodeficiency

Malakoplakia is a rare tumor-like inflammatory condition often affecting the urogenital and gastrointestinal tract of immunocompromised individuals. Malakoplakia is posited to be secondary to impaired macrophages with an inability to phagocyte bacteria completely. The resulting inflammation may trigger CVID-associated enteropathy. Treatment is challenging, often requiring prolonged antibiotics, and reducing immunosuppression.Our patient is a 45-year-old female with heterozygous TNFRSF13B c.310T>C common variable immunodeficiency (CVID). She has granulomatous lymphocytic interstitial lung disease (GILD), CVID-enteropathy in remission, immune thrombocytopenia requiring splenectomy, and chronic norovirus shedding. She was on mycophenolate mofetil, immunoglobulin replacement, and trimethoprim/sulfamethoxazole prophylaxis.She presented with two months history of progressive diarrhea, weight loss, and abdominal pain. Stool calprotectin was 131 uG/G. GI pathogen panel was only positive for Norovirus. Endoscopy showed intraepithelial lymphocytosis and villus blunting (seen on previous scopes). Colonoscopy demonstrated rectal polyps, submucosal atypical lymphoid proliferation, abundant histiocytes with Michaelis-Gutman bodies, positive calcium deposits with Von-Kossa stain, consistent with malakoplakia, with no evidence of malignancy.We started ciprofloxacin 500 milligrams twice daily, Vitamin C, oral immunoglobulin, and probiotics. We continued mycophenolate mofetil to avoid GLILD flares. Diarrhea resolved several weeks after starting ciprofloxacin. However, attempts to wean ciprofloxacin led to recurrence of diarrhea. She completed nine months of ciprofloxacin, after which calprotectin normalized, and repeat scopes showed no evidence of malakoplakia; diarrhea did not recur after stopping ciprofloxacin.We highlight a rare CVID GI complication that successfully responded to a prolonged course of antibiotics. Balancing immune suppression with worsening malakoplakia requires vigilant diagnostic and therapeutic decision-making. Malignancy surveillance will be warranted.

Leave No Stone Unturned: A Case of an Actinomyces Rhinolith Presenting With Chronic Cough and Throat Pain.

Actinomycosis infection in the nasal cavity, especially an actinomyces rhinolith, is extremely rare. It should be considered in cases where a heterogenous calcified mass is found within the nasal cavity on endoscopy and radiographically. Treatment includes surgical debridement and a prolonged course of antibiotics, unique from the more typically encountered fungus ball. This case highlights the broad differential for chronic cough and throat pain and the importance of considering sinonasal contributions to throat symptoms.

Dalbavancin as sequential therapy for infective endocarditis due to Gram-positive organisms: a review.

Dalbavancin is a parenteral lipoglycopeptide antibiotic derived from teicoplanin, an analogue of vancomycin. It is mainly used for skin and soft tissue infections. The sustained half-life of approximately 14days makes dalbavancin a novel option for potential use as sequential treatment in infections such as infective endocarditis, which require prolonged antibiotic courses. However, only a few studies have been reported in the literature, and the use of dalbavancin remains limited.This article is a review of the currently available literature using dalbavancin for the treatment of infective endocarditis due to Gram-positive organisms. Almost all patients received dalbavancin as sequential therapy following standard-of-care antibiotics. The overall clinical efficacy of dalbavancin was approximately 90%, and it appeared to be well tolerated.

Prolonged Antibiotic Exposure during Adolescence Dysregulates Liver Metabolism and Promotes Adiposity in Mice

Antibiotic administration during early life has been shown to have lasting effects on the gut microbiota, which have been linked to sustained alterations in liver metabolism and adiposity. Recent investigations have discerned that the gut microbiota continues to develop toward an adult-like profile during adolescence. However, the impact of antibiotic exposure during adolescence on metabolism and adiposity is unclear. Herein, a retrospective analysis of Medicaid claims data was performed, which indicated that tetracycline class antibiotics are commonly prescribed for the systemic treatment of adolescent acne. The purpose of this was to discern the impact of a prolonged tetracycline antibiotic exposure during adolescence on the gut microbiota, liver metabolism, and adiposity. Male C57BL/6T specific pathogen-free mice were administered a tetracycline antibiotic during the pubertal/postpubertal adolescent growth phase. Groups were euthanized at different time points to assess immediate and sustained antibiotic treatment effects. Antibiotic exposure during adolescence caused lasting genera-level shifts in the intestinal bacteriome and persistent dysregulation of metabolic pathways in the liver. Dysregulated hepatic metabolism was linked to sustained disruption of the intestinal farnesoid X receptor-fibroblast growth factor 15 axis, a gut-liver endocrine axis that supports metabolic homeostasis. Antibiotic exposure during adolescence increased subcutaneous, visceral, and marrow adiposity, which intriguingly manifested following antibiotic therapy. This preclinical work highlights that prolonged antibiotic courses for the clinical treatment of adolescent acne may have unintended deleterious effects on liver metabolism and adiposity.