Prolonged Intravenous Antibiotic Treatment Research Articles

Endocarditis

Infectious endocarditis (IE) is an inflammatory condition that affects the endocardium, the heart's inner lining, as well as the valves that separate each of the heart's four chambers. Despite a low prevalence and improvements in its management, IE remains associated with a high burden of morbidity and mortality. IE can be associated with reduced quality of life and a high risk of re-infection. It often requires prolonged intravenous antibiotic treatment. The mortality rate is high, with an estimated one-third of patients dying within a year of diagnosis. It is important to have an awareness of the key features of a patient’s history and examination findings that should prompt referral to specialist services.

Antibiotic-resistant profile and the factors affecting the intravenous antibiotic treatment course of generalized Staphylococcal Scalded Skin Syndrome: a retrospective study

BackgroundStaphylococcal Scalded Skin Syndrome (SSSS) is caused by a special type of Staphylococcus aureus (S.aureus) which can produce exfoliative toxins. The generalized SSSS is recommended to be admitted and treated with intravenous antibiotics. However, there were limited reports on whether personal and clinical factors can have impacts on the duration of intravenous antibiotic application for pediatric patients with generalized SSSS.We performed a study to assess the factors affecting intravenous antibiotic treatment course of SSSS patients. Additionally, the positive culture rates of S.aureus in different samples and the antibiotic-resistant profile were investigated.MethodsTwo hundred nineteen patients with generalized SSSS were included. Gender, age, area, season, maximum axillary temperature, white blood cell (WBC) count, C-reactive protein (CRP) level, types of intravenous antibiotics, and types of external antibiotics were recorded as the baseline. Simple linear regression was applied in the univariate analysis to determine the variables with statistical significance and then these variables were further examined in multivariate linear regression model. The positive culture rates of S.aureus in different sample sources were calculated and the drug sensitivity results were statistically compared by pairwise Chi square test.ResultsAccording to the multiple linear regression, older ages (β = − 0.01, p < 0.05) and external application of fusidic acid (β = − 1.57, p < 0.05) were associated with shorter treatment course, elevated leukocytes (β = 0.11, p < 0.001) and CRP level (β = 1.64, p < 0.01) were associated with longer treatment course. The positive culture rates of periorificial swabs, throat swabs, and blood samples were 54.55, 30.77, and 5.97% respectively. The resistant rates of levofloxacin (8.33%), gentamycin (8.33%), tetracycline (25%), oxacillin (8.33%), vancomycin (0%) were significantly lower than the ones of erythromycin (100%), trimethoprim-sulfamethoxazole (TMP/SMX) (83.33%), clindamycin (91.67%), penicillin G(100%) (p < 0.001).ConclusionElevated leukocytes and CRP level indicated prolonged intravenous antibiotic treatment course. Older ages and external application of fusidic acid helped to reduce the treatment course. Compared with blood samples, the culture positive rates of S.aureus in periorificial and throat swabs were higher. Oxacillin and vancomycin resistance was rare and clindamycin resistance was common. Clindamycin monotherapy for SSSS should be avoided.

P1798Assessing attitudes and knowledge of infective endocarditis in adult survivors of congenital heart disease

Abstract Background Adults with congenital heart disease (ACHD) have an increased risk of infective endocarditis (IE), which is associated with significant morbidity and mortality. This risk is further compounded by patient-related factors such as education and awareness of IE. The onus of patient education falls on both patient and physician, and is paramount to successful outcomes. Our study sought to evaluate patients' understanding of the risks, preventative measures and symptoms of IE, and to identify high-risk ACHD patients who would benefit from targeted education. Methods A cross-sectional study was conducted using a pre-tested questionnaire to assess knowledge of and attitudes towards IE. Patients attending the outpatient department of a tertiary referral centre completed the questionnaires independently. Baseline demographics and clinical data were collected from electronic patient records. Results 132 questionnaires were completed (median age 38 years, 50% male). 106 patients (80%) had previous surgical or percutaneous interventions and 7 patients (5%) had suffered with infective endocarditis in the past. 37% were able to accurately define IE. Out of a range of symptoms, most patients chose temperature (47%) and tiredness (39%) as classical symptoms of IE, however none correctly identified all listed symptoms as potential signs of IE. The majority of patients knew tooth abscess (58%) and body piercings (50%) were risk factors for IE. A fifth of patients (20%) were failing to have annual dental check-ups. 22% thought that IE would only require a few days stay as an inpatient and only 20% of patients were aware of the requirement for prolonged antibiotic treatment and the majority (63%) were unaware of the potential need for open heart surgery. 1 in 4 patients could recall having received information regarding IE. A third of patients reported that they would have made lifestyle changes had they known that IE required prolonged intravenous antibiotic treatment and could result in open heart surgery and death. Discussion Our study highlights key issues in the management of ACHD. Moving forward with the continuously growing population of patients we need to focus on the multi-disciplinary approach including specialist clinical nurses and increasing awareness online and through meetings and patient days as well as the importance of transition services as paediatric patients move across to adult specialists. General physcians will also encounter ACHD, therefore it is important to ensure awareness is widespread in the form online platforms and leaflets. We must also acknowledge the impact of guidelines and ensure there is still a significant focus on IE within them. To conclude, despite the significant morbidity and mortality associated with IE in ACHD, patient awareness of symptoms, risk factors and consequences is limited. Promotion of IE awareness is a cost-effective intervention, which can reduce the incidence and complications of IE.

Intracranial complications of pediatric sinusitis: Identifying risk factors associated with prolonged clinical course

ObjectiveIntracranial extension is one of the most serious and morbid complications of pediatric sinusitis. Managing this complication continues to be challenging even after widespread pneumococcal vaccination adoption. We aim to identify risk factors associated with complicated clinical courses, and to assess for altering microbial communities and increased antibiotic resistance. MethodsA retrospective review was conducted of sinus procedures performed at a single institution for acute sinusitis with intracranial extension, and 16 cases were identified. Variables collected included patient demographics, vaccination status, laboratory results, imaging data, antibiotic therapy, sinus and intracranial cultures, perioperative and surgical reports, and hospital course. ResultsThe average patient age was 11.9 years, and 75% were male. The dominant microbial organisms were gram positive in 93.8% (15/16) of cases and 37.5% (6/16) were anaerobic. There were no cases of resistant bacterial growth, and only one case of Streptococcus pneumoniae. Increased antibiotic therapy duration was associated with anaerobic and polymicrobial sinus cultures. A significant increase in length of hospital stay was identified in polymicrobial sinus cultures and frontal sinus involvement. Intracranial abscess re-accumulation was associated with sinus cultures positive for fusobacterium (p = 0.036), polymicrobial infections (p = 0.034), and involvement of brain parenchyma (p = 0.036). Patients with frontal sinus involvement required a greater number of surgical procedures for abscess drainage (p = 0.046). An anaerobic intracranial culture was associated with an increased number of revision craniotomies (p < 0.001). Parenchymal involvement of the infection was associated with an increased number of surgical complications. ConclusionsFrontal sinus involvement, and anaerobic and polymicrobial sinus cultures were predictive of a more severe infection requiring more surgical interventions, prolonged intravenous antibiotic treatment and overall hospital length of stay. Streptococcus pneumoniae was not prevalent in our series, and there seems to be a shift in the microbial profile of this patient subset, compared to previous studies, which can likely be attributed to the adoption of pneumococcal vaccinations. Sinus cultures were more predictive of a complicated clinical course compared to intracranial cultures, suggesting the importance of a thorough sinus debridement and obtaining directed sinus cultures.

Intradural Extension of a Pyogenic Epidural Abscess: A Case Report.

Few cases of spinal epidural abscess involving an extradural abscess with an intradural extension have been reported. A unique complication with extension of pus from the epidural space through multiple perforations into the dura is described. Due to a proximal meningeal inflammatory reaction, which served as a proximal plug, no cerebrospinal fluid leak was encountered. Intradural extension of pus through multiple dural perforations is a rare complication of spinal epidural abscess and a treatment challenge. Early diagnosis enabling prompt surgical decompression, along with subsequent aggressive debridements and prolonged intravenous antibiotic treatment, can lead to a favorable outcome.

Necrotizing Dermatosis of the Arm Following Cubital Tunnel Release: Pyoderma Gangrenosum, the Great Mimic: A Case Report.

We report the case of a fifty-one-year-old woman who underwent an uneventful cubital tunnel release and was admitted five days after surgery with a diagnosis of infection. Despite multiple surgical debridements and prolonged intravenous antibiotic treatment, the wound edges continued to slough and necrose. A delayed diagnosis of postsurgical pyoderma gangrenosum (PG) was made, and corticosteroid and immunosuppressive treatment was administered, with immediate clinical improvement. When apparent postoperative infections fail to improve with debridement and antimicrobial treatment, and when accompanied by a fever and severe local pain, nonspecific histopathological findings, and negative microbiological cultures, postsurgical PG should be considered.

Enterococcal Diskitis

We describe 2 patients diagnosed with enterococcal vertebral spondylodiskitis, leading to the unsuspected diagnosis of endocarditis in one. Because of high-level aminoglycoside resistance, 1 patient received a 6-week course of ampicillin and ceftriaxone, whereas the other received standard ampicillin and gentamicin treatment. Both patients recovered. Review of the literature revealed only 20 previously reported cases with enterococcal diskitis. Of the 20 patients for whom data on sex were available, 14 were men, and 6 were women; the mean age at diagnosis was 67 ± 8 years; all experienced back pain, but only 10 had low-grade fever. Thirteen (59%) of these 22 patients were diagnosed with endocarditis. Only 4 patients underwent diskectomy, and 3 other patients required transcutaneous drainage; all received prolonged intravenous antibiotic treatment, consisting of ampicillin and gentamicin in the majority. Of the 21 patients for whom outcome was available, 17 (81%) recovered, and 4 patients died.

Pristinamycin: old drug, new tricks?

Osteoarticular infections with Gram positive bacteria present an increasing challenge in an era of multidrug-resistant organisms. Prolonged intravenous antibiotic treatment is often required, with associated risks, costs and difficulties with administration; a safe, effective oral option would be ideal for this indication. Pristinamycin, an oral streptogramin antibiotic with bactericidal activity against Gram positive organisms including methicillin-resistant Staphylococcus aureus, has been used for over 50 years in Europe for the treatment of osteoarticular infections. We review the published evidence for the treatment of native bone and prosthesis-related osteoarticular infections with pristinamycin.

DD-001 Stability of piperacillin/tazobactam in elastomeric infusion pumps

BackgroundSeveral departments at Aarhus University Hospital use piperacillin/tazobactam elastomeric pumps, prepared by the Hospital Pharmacy, to give a 24 h continuous infusion to patients who require prolonged intravenous antibiotic treatment....

Neck Abscess and Osteomyelitis Secondary to a Sternoclavicular Septic Arthritis: a Case Report

Neck Abscess and Osteomyelitis Secondary to a Sternoclavicular Septic Arthritis: a Case Report A 64-year old female was referred to our Ear Nose and Throat (ENT) / Head & Neck surgery department due to a progressive, painful swelling on the left side of the neck since 2 weeks. A couple of weeks prior to the painful swelling in the neck she had left shoulder complaints. A contrast enhanced CT scan was made showing an impressive neck abscess, with an estimated volume of 200cc. After clinical examination, intensive surgical exploration and abscess drainage took place. Cultures showed a Staphylococcus aureus, for which prolonged intravenous antibiotic treatment (Augmentin, Clindamycin) followed. Disregulated diabetes mellitus might have been a predisposing factor, but osteomyelitis of the sternoclavicular (SC) joint proved to be the cause of abscess formation.

Elevated Serum Cytokine Levels Using Cytometric Bead Arrays Predict Culture-Positive Infections in Childhood Oncology Patients With Febrile Neutropenia

Neutropenic patients with bacteraemia need prolonged intravenous antibiotic treatment. Using cytometric bead array technology, we show in children with febrile neutropenia that bacteraemia is associated with an elevation of at least 1 of 3 plasma cytokines plus C-reactive protein. The combination of interleukin (IL)-8, IL-6, IL-10, and C-reactive protein values above operator-defined cutoff levels identified 15 of 16 episodes of bacteraemia, making this a potentially useful technique in identifying high-risk patients who should not be discharged early from hospital. Furthermore, low risk of bacteraemia may be predicted by a combination of below threshold cytokines and negative clinical examination.

A case series of children in a UK hospital infected with panton-valentine leucocidin positive Staphylococcus aureus: features of an important emerging infection

AimsTo describe the important clinical features and management of cases of Panton-Valentine Leucocidin (PVL) positive Staphylococcus aureus in children in a UK hospital from 2009 to 2010. To highlight the...

Rhinovirus infection liberates planktonic bacteria from biofilm and increases chemokine responses in cystic fibrosis airway epithelial cells

BackgroundIntermittent viral exacerbations in patients with cystic fibrosis (CF) with chronic Pseudomonas aeruginosa (PA) infection are associated with increased bacterial load. A few clinical studies suggest that rhinoviruses (RV) are...

Chronic Lyme disease

In this issue of The Journal, Johnson and Feder tested the hypothesis proposed by “Lyme literate” advocacy groups that practitioners in the community frequently diagnose and treat patients for chronic Lyme disease—as opposed to those in medical centers who tend to be the individuals who study Lyme disease and write guidelines for management of patients. A survey was sent to a random sample of 33% of primary care physicians in Connecticut, which has the highest density of Lyme disease in the country (and which physicians expectedly would be highly experienced with chronic Lyme disease cases). With almost 40% response rate among eligible study participants, only 2.1% diagnosed and treated patients with chronic Lyme disease. The 2006 Lyme disease guidelines, published on behalf of the Infectious Diseases Society of America, recommended against prolonged intravenous antibiotic treatment for patients with Lyme disease, or thought to have chronic Lyme disease by non-validated testing schemes. The Connecticut Attorney General, Richard Blumenthal, began an anti-trust investigation that included scrutiny of the guidelines, their process and composition, and potential conflicts of interest of the writing body. To end the Attorney's General investigation, which legal fees threatened to bankrupt the Society, the Infectious Diseases Society of America agreed to review the guidelines by an independent Review Panel. On April 22, the Review Panel unanimously agreed that no changes needed to be made to the 2006 guidelines. There is no controversy about the validity of science underpinning these recommendations. There is still, however, in many states, citizens' opinions and politicians' advocacy to propose legislation to make providers who choose to treat patients with prolonged parenteral therapy immune to medical investigation, and to force insurers to pay for such therapy. Similar to families with children with autism, we should feel their desperation and foster research to enlighten the science of their problem, but should not legislate bad medicine. Article page 1025 ▸ Chronic Lyme Disease: A Survey of Connecticut Primary Care PhysiciansThe Journal of PediatricsVol. 157Issue 6PreviewTo determine how frequently Connecticut primary care physicians are diagnosing and treating patients with chronic Lyme disease. Full-Text PDF

A comparative study of bacteremic and non-bacteremic pneumococcal pneumonia

Background Few attempts have been made to compare bacteremic and non-bacteremic pneumococcal pneumonia, mainly because it is difficult to gain agreement on which cases represent non-bacteremic pneumococcal pneumonia. Recently, an immunochromatographic assay for the detection of Streptococcus pneumoniae urinary antigen has been successfully evaluated for the diagnosis of pneumococcal pneumonia. The aim of our study was to examine and compare clinical and radiological features, risk factors, and outcome associated with bacteremic and non-bacteremic groups. Methods A retrospective study (1995–2003) analyzing the clinical records of patients diagnosed with pneumococcal pneumonia in our institution was performed. S. pneumoniae were identified by blood cultures (bacteremic group) and detection of urinary antigen (non-bacteremic group). Results There were 82 patients (57 bacteremic and 25 non-bacteremic). In seven non-bacteremic cases, another etiology was detected, i.e., Legionella ( n = 1) and Chlamydia pneumoniae ( n = 6). Bacteremic patients were significantly younger ( p = < 0.001), more likely to have liver disease ( p = 0.028), current smokers ( p = 0.024), alcohol and intravenous drug abusers ( p = 0.014 and p < 0.001, respectively), and infected with HIV ( p < 0.001). Non-bacteremic patients were more likely to have congestive heart failure ( p = 0.004), chronic obstructive pulmonary disease ( p = 0.033) and to be former smokers ( p = 0.004). Bacteremic cases needed more prolonged intravenous antibiotic treatment (6 days vs. 4.5 days; p = 0.006) than non-bacteremic cases and their length of stay was also longer. Conclusion In our study, smoking was the leading risk factor for pneumococcal pneumonia. However, current smokers have an increased risk of bacteremic forms and former smokers and patients with COPD developed non-bacteremic forms more frequently. Bacteremic patients need more prolonged intravenous antibiotic treatment than non-bacteremic patients.

Necrotizing fasciitis and gangrene associated with topical herbs in an infant

A 4-mo-old Chinese infant developed necrotizing fasciitis and gangrene from a small skin infection on his buttock that was treated with topical herbs. Sequential cultures revealed a number of organisms: Enterococcus species, sensitive to ampicillin, were isolated throughout the course, and coagulasenegative staphylococci replaced gram-negative rods during the later phase of the illness. The infant required prolonged intravenous antibiotic treatment and underwent multiple surgical procedures for debridement and reconstruction. This report serves to alert the public of the importance of avoiding application of unknown topical herbs in children with skin disease. A seemingly small wound, if inappropriately treated, may result in extensive tissue destruction and require extensive surgery.

Liver Abscesses in Children: A Single Center Experience in the Developed World

The aim of this study was to investigate the clinical and radiologic features, predisposing risk factors, and complications of children with pyogenic liver abscess (PLA) referred to a tertiary pediatric hepatology center. We analyzed our database of all children referred to our unit over a 10 year period and performed a case note review of all patients with a radiologically proven PLA. PLA was diagnosed in 15 children (7 boys), 0.5% of all referrals. They presented at a median age of 10 years (range 2 months-15 years). In three children (2 boys), PLA was the first manifestation of chronic granulomatous disease. Among the others, five had radiologic evidence of other intra-abdominal pathology (1 with subsequently proven appendicitis), and four developed portal vein thrombosis with portal hypertension. The commonest isolated pathogen was Staphylococcus aureus. Combined treatment with guided aspiration and prolonged intravenous antibiotics was successful in all patients. PLA is a rare diagnosis in children in the developed world. It may be caused by primary neutrophil disorders even in the absence of a previous history of infection. Co-existent appendicitis, intra-abdominal sepsis, and ascending pylephlebitis must be sought because these children are at risk of developing portal vein obstruction and portal hypertension. Prolonged intravenous antibiotic treatment guided by microbiologic sensitivities is highly effective.

Impact of Mandatory Inpatient Infectious Disease Consultation on Outpatient Parenteral Antibiotic Therapy

Outpatient parenteral antibiotic therapy (OPAT) has had an important impact on infections historically requiring prolonged intravenous antibiotic treatment. Within the past decade, new antibiotics with oral/intravenous bioequivalence, plus recent data on infection management, have increased the potential role of the Infectious Disease (ID) consultant for OPAT. We studied the impact of mandatory ID consultation on the use and outcomes of OPAT in patients initially hospitalized. The study was approved by the Institutional Review Board and the Executive Committee of the Medical Staff of Baystate Medical Center. Patients older than 18 years of age being considered for discharge to home on OPAT were identified, primarily through discharge planning. Formal ID consultation was performed to determine both need for OPAT and a variety of issues regarding antibiotic choice. Thirty-day telephone follow-up determined outcomes. Data regarding demographics, outcomes, and costs were analyzed. Forty-four patients received mandatory ID consultation, 39 (88.6%) of whom had some change in antibiotic recommendations. Seventeen (38.6%) were discharged on oral antibiotics, 1 (2.3%) had antibiotics discontinued, 13 (29.6%) had a change in parenteral antibiotic, 5 (11.4%) had a change in antibiotic dose, and 3 (6.8%) had a change in antibiotic duration. Follow-up demonstrated a single rehospitalization for unrelated issues. The total cost savings were 33,667.00 US dollars, approximately 760.00 US dollars per patient. Charges of consults were approximately 11,970.00 US dollars, still resulting in savings of close to 21,700.00 US dollars, or almost 500.00 US dollars per patient. Mandatory ID consultation resulted in substantial cost savings and excellent outcomes.

The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx.

Stubbing injuries to the great toe can be a cause of occult open fractures and osteomyelitis. Five such patients were identified after conducting a retrospective review of injuries to the hallux between January 1998 and December 1998. The study was conducted to draw attention to the association between this trivial trauma and its possible complications. All five children had open fractures of the distal phalanx of the great toe. Osteomyelitis did not develop in the children whose injuries were recognized early and who were treated with antibiotics. However, three children with delayed diagnoses and treatment developed osteomyelitis. At a mean follow-up of 10 months (range, 9-11) after injury, all five fractures had healed with no active signs of infection. Two of these children experienced a partial growth arrest and two experienced a full growth arrest of the distal phalanx of the great toe, the significance of which is yet unknown. Clinical signs such as bleeding from the eponychium and a laceration proximal to the nail bed should alert physicians to the presence of a possible open fracture. Early detection and treatment of these injuries may reduce or eliminate hospital stays and prolonged intravenous antibiotic treatment for osteomyelitis.

The Stubbed Great Toe: Importance of Early Recognition and Treatment of Open Fractures of the Distal Phalanx

Stubbing injuries to the great toe can be a cause of occult open fractures and osteomyelitis. Five such patients were identified after conducting a retrospective review of injuries to the hallux between January 1998 and December 1998. The study was conducted to draw attention to the association between this trivial trauma and its possible complications. All five children had open fractures of the distal phalanx of the great toe. Osteomyelitis did not develop in the children whose injuries were recognized early and who were treated with antibiotics. However, three children with delayed diagnoses and treatment developed osteomyelitis. At a mean follow-up of 10 months (range, 9–11) after injury, all five fractures had healed with no active signs of infection. Two of these children experienced a partial growth arrest and two experienced a full growth arrest of the distal phalanx of the great toe, the significance of which is yet unknown. Clinical signs such as bleeding from the eponychium and a laceration proximal to the nail bed should alert physicians to the presence of a possible open fracture. Early detection and treatment of these injuries may reduce or eliminate hospital stays and prolonged intravenous antibiotic treatment for osteomyelitis.