Prolonged Intravenous Antibiotic Research Articles

Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study.

Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs. The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults. The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery. Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery. The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.

95. What To Do With Prolonged Bacteremia in Staphylococcus aureus Osteoarticular Infection? A Retrospective Analysis at Two Children's Hospitals

Abstract Background Staphylococcus aureus is the most frequent cause of osteoarticular infection (OAI, including hematogenous osteomyelitis and septic arthritis) in children and is commonly associated with bacteremia. Current guidelines suggest that persistent bacteremia may warrant more aggressive treatment, however, data supporting this are limited. We retrospectively evaluated the management and outcomes of children with S. aureus OAI with respect to bacteremia duration. Methods Cases were identified through prospective S. aureus surveillance studies at Texas Children’s and St. Louis Children’s Hospitals. Children < 18 years old with OAI secondary to S. aureus from 2011-2021 were eligible. Prolonged bacteremia was defined a priori as the upper quartile of duration. Orthopedic complications included pathologic fractures, avascular necrosis, angular deformity and chronic osteomyelitis. Results Overall, 532 cases were identified of which 343 (64.5%) had ≥1 positive blood culture; 61 developed orthopedic complications (11.4%, Figure 1). The median duration of bacteremia in the cohort was 1 day (IQR: 1-3 days). Patients with prolonged (≥ 3 days) and non-prolonged bacteremia were similar in terms of demographics. Children with prolonged bacteremia had a longer duration of fever in hospital (median 6 vs. 3 days, p< 0.001), more often had MRSA, pyomyositis and venous thromboses and were less often transitioned to oral therapy (Figure 2). Duration of bacteremia also influenced discharge antibiotic choice (Figure 3). Within the subset of patients with prolonged bacteremia, those who were transitioned to oral therapy had similar outcomes to those treated with prolonged intravenous antibiotics; such patients received a median of 11.5 days (IQR: 6-23) of IV therapy prior to discharge (median 7 days [IQR: 4-20] after last positive blood culture). Conclusion Prolonged bacteremia in the setting of S. aureus OAI greatly impacts management and should prompt evaluation for other foci of infection. However, our data show that a subset of children with S. aureus OAI and prolonged bacteremia can be safely transitioned to oral antibiotics after a period of IV therapy. Additional work is needed to delineate optimal management of OAI with prolonged bacteremia. Disclosures Jonathon C. McNeil, MD, Allergan: Grant/Research Support|Nabriva Therapeutics: Grant/Research Support Kristina G. Hulten, PhD, Pfizer: Grant/Research Support Sheldon L. Kaplan, MD, MeMed: Grant/Research Support|Pfizer: Grant/Research Support|Pfizer: Honoraria

2399. Changing Demographics of Infective Endocarditis in South Carolina: An Ecological Study

Abstract Background The opioid epidemic in America is likely changing the demographics of patients with infective endocarditis (IE). Traditionally, IE is attributed to older patients and those with prosthetic heart valves or cardiac devices. Rising rates of opioid use (OU), usually via injection, has resulted in younger patients being diagnosed with IE, which raises treatment challenges. Methods This retrospective ecological study analyzed hospitalization records from the South Carolina Revenues and Fiscal Affairs Office (SC RFA) from 2016-2021. ICD-10 codes for the diagnosis of IE yielded 7,175 hospitalizations with 5,066 unique patients. Cases of IE with concurrent OU were identified. Rurality of hospital county, hospital teaching status, hospital bed size, length of stay, total costs, discharge status, and distance to hospital zip were reviewed. Data was analyzed by year and age group (18-34, 35-49, 50-64,65-79, and 80+). Poisson regression was used to examine change in trends. Results From 2016-2021, inpatient stays related to IE showed no significant trend for age groups 35 years and older (p > 0.19), while showing a significant positive trend in the 18-to-34 age group (p = 0.04). Of the 7,175 IE hospitalizations, 977 (13.6%) had a concurrent diagnosis of OU. The percentage of patients with concurrent IE and OU diagnosis increased from 7% to 17% of patients/year. The rate of inpatient stays related to concurrent IE and OU increased from 3.8 to 11.1 (p = 0.01) and 2.5 to 8.7 per 100,000 of SC population (p = 0.01), for the 18–34 year-old and 35-49 year old groups, respectively, while not significantly changing in patients 50 years and older over the study period (p = 0.57). Rate Per 100,000 SC Population of Inpatient Stays Related to IE and OU by Age Group Conclusion There are few epidemiologic studies of IE since the 2015 Infectious Diseases Society of America treatment guidelines, though significant concern about the juxtaposition of the opioid epidemic with diseases like IE. There are major changes in the demographics of IE patients. This study supports the need for updated guidelines to specifically address IE in the setting of OU, particularly in younger patients. This includes possible disparities in treatment due to lack of access to ID physicians in rural communities and challenges in providing prolonged intravenous antibiotic therapy. Disclosures Julie Ann Justo, PharmD, MS, FIDSA, BCPS, Gilead Sciences: Advisor/Consultant|Shionogi: Advisor/Consultant|Vaxart: Stocks/Bonds

STAPHYLOCOCCAL OSTEOARTICULAR INFECTIONS ASSOCIATED WITH BLOOD STREAM INFECTIONS IN CHILDREN: IS PROLONGED IV ANTIBIOTIC THERAPY ALWAYS INDICATED?

Staphylococcus aureus osteo-articular infections (OAI) are frequently accompanied by blood stream infections (BSI) diagnosed by positive blood culture (BC). Microbiological protocols in adults advise prolonged intravenous antibiotics and repeat BC 48-hourly in the presence of a BSI, however evidence to support the systematic employment of these guidelines in paediatric patients is lacking. We aimed to determine whether there was an increased incidence of orthopaedic and systemic complications in patients with s aureus BSI, and whether a shorter duration of intravenous antibiotics was associated with the development of complications.Following ethical approval, the departmental surgical database was searched for patients that underwent surgery for acute OAI over a 5-year period. Patients with no sample taken for BC were excluded, as were those with other or no organisms identified from any site. Demographic and clinical data were captured, including duration of IV antibiotics and development of complications. Statistical significance was set at p<0.05.Following exclusions, 44 patients with a median age of 85 months remained to be analysed. Thirty patients (68%) had a positive BC. A positive BC was associated with a higher rate of systemic complications (p=0.026) but not orthopaedic complications (p=0.159). Patients who had developed any complication had a significantly longer duration of IV antibiotic treatment compared to those without complications (p<0.001). The presenting CRP levels were significantly higher in patients that developed complications (p=0.004).Patients with staphylococcal BSI in association with an OAI are at increased risk of developing systemic complications. In our cohort, a shorter duration of antibiotic use was not associated with the development of complications, which does not support the systematic use of long courses of IV antibiotics in s aureus BSI. Further research will be required to determine the ideal protocol for these patients.

Relai oral de l'antibiothérapie dans les endocardites infectieuses : un pas à franchir?

Infective endocarditis (IE) are severe conditions requiring prolonged intravenous antibiotics. Those antibiotics regimens are recommended since long ago but nowadays several antibiotics have a great bioavailability and there is more clinical evidence of the reliability of an oral step-down antibiotic therapy. We found several observational studies and two clinical trials evaluating the efficacy of an oral step-down antibiotic therapy vs prolonged intravenous course for IE. These studies showed no significant difference between oral or intravenous therapy and generally with less adverse event. The oral step-down therapy for infective endocarditis, after few days of intravenous initiation, seems to be an acceptable alternative treatment. New European recommendation coming in 2023 for IE, should officialize the place of oral step-down regimen as more clinical trials are underway to confirm the efficiency of these oral regimens.

Tuberculosis remains a leading contributor to morbidity due to serious infections in Indian patients of SLE.

Infections are a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). We assessed the incidence and risk factors for major infections in SLE in India. A retrospective review of a cohort of 1354 patients of adult SLE (ACR 1997 criteria) seen between 2000 and 2021 at a single center was conducted. Serious infections (need for hospitalisation, prolonged intravenous antibiotics, disability, or death) were recorded. Cox regression was used to determine factors associated with serious infection and the effects of serious infection on survival and damage. Among the 1354 patients (1258 females, mean age of 30.3years, follow-up of 7127.89 person-years), there were 439 serious infections in 339 patients (61.6 per 1000 person-years follow-up). Bacterial infections (N = 226) were the most common infection followed by mycobacterial infections (n = 81), viral (n = 35), and then invasive fungal infections (N = 13). Mycobacterium tuberculosis was the single most common microbiologically confirmed organism with incidence of 1136.4/100,000 person-years with 72.8% of them being extrapulmonary. Infection free survival at 1year and 5years was 82.9% and 73.8%. There were 119 deaths with infection attributable mortality in 65 (54.6%). On multivariable Cox regression analysis, higher baseline activity (HR 1.02, 1.01-1.05), gastrointestinal involvement (HR 2.75, 1.65-4.69), current steroid dose (HR 1.65, 1.55-1.76), and average cumulative steroid dose per year (HR 1.007, 1.005-1.009) were associated with serious infection and higher albumin (HR 0.65, 0.56-0.76) was protective. Serious infections led to greater damage accrual (median SLICC damage index of 1 vs. 0) and mortality (HR was 18.2, 32.7 and 81.6 for the first, second, and third infections). Serious infections remain a major cause of mortality and damage accrual in SLE and higher disease activity, gastrointestinal involvement, hypoalbuminemia, current steroid dose, and cumulative steroid dose are the risk factors for it.

Treatment of intractable cholangitis in children with biliary atresia: Impact on outcome.

To evaluate the response and outcome with prolonged intravenous antibiotics including home-based intravenous antibiotics in children with intractable cholangitis (IC) after Kasai portoenterostomy (KPE) for biliary atresia (BA). A retrospective review of treatment and outcome of children with IC post KPE (no resolution after fourweeks of antibiotics) was donebetween 2014 and 2020. A protocol-based antibiotic regimen was used based on sensitivity and hospital antibiogram. Children afebrile for more than threedays were discharged on home intravenous antibiotics (HIVA). Twenty children with IC were managed with prolonged antibiotic regimen, including HIVA. All patients were initially listed for liver transplantation (LT) with indication being IC (n = 20) with portal hypertension (n = 12). Seven patients had bile lakes of which four underwent percutaneous transhepatic biliary drainage. Bile culture grew Klebsiella in four and Escherichia coli and Pseudomonas one each. There were eight children with IC who had positive blood culture with most of these organisms being gram-negative (Escherichia coli: 5, Klebsiella pneumoniae: 2, Enterococcus: 1). Median duration of antibiotics was 58days (interquartile range [IQR] 56-84). Median follow-up period post cholangitis was threeyears (IQR 2-4). Following treatment, 14 patients were successfully delisted from LT waitlist and are presently jaundice-free. Two of the five patients undergoing LT died of sepsis. One patient died awaiting LT. Timely and aggressive step-up antibiotic regimen may successfully treat IC and prevent/delay LT. HIVA provides a cost-effective and comfortable environment for a child which might improve compliance with intravenous antibiotics.

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.

長期間の抗菌薬経静脈投与を要した頭蓋底骨髄炎例

Skull-base osteomyelitis occurs as a result of spread of inflammatory disease around the temporal bone into the adjacent skull base, and carries a poor prognosis. Occasionally, patients present with paralysis of the lower cranial nerves, which further worsens the survival. Prolonged intravenous antibiotic therapy for six to eight weeks is needed for treatment. Herein, we present a case of skull-base osteomyelitis caused by Pseudomonas aeruginosa that developed in a 78-year-old male patient with diabetic nephropathy who was under maintenance hemodialysis. He presented to our hospital with the complaints of earache and otorrhea on the left side. Exploratory tympanotomy revealed pus and granulation tissue filling the tympanic cavity and mastoid, and destruction of the tympanic portion of the temporal bone; based on the findings and results of pus culture, we made the diagnosis of skull-base osteomyelitis caused by Pseudomonas aeruginosa. While the osteomyelitis was gradually improving with intravenous meropenem, the patient desired early discharge from the hospital. Therefore, the intravenous antibiotic therapy was switched earlier than intended to oral antimicrobial therapy, which led to progression of the disease, and the patient presented with lower cranial nerve palsies three months after his discharge. He was initiated again on intravenous meropenem. While the osteomyelitis improved gradually with the intravenous antimicrobial therapy for two months, the levels of inflammatory markers, such as the serum c-reactive protein, increased again soon after discontinuation of the intravenous antibiotic therapy. Therefore, we decided to continue the patient on intravenous meropenem every other day administered at the outpatient clinic after dialysis. The treatment was continued for four months after discharge, and the improvement was maintained. We reaffirmed the importance of long-term intravenous antibiotic therapy to treat skull-base osteomyelitis. Intravenous antibiotic administration every other day at the outpatient clinic after dialysis could be a useful treatment strategy to treat skull-base osteomyelitis in patients under maintenance hemodialysis.

Short Course of Oral Antibiotic Treatment After Two-Stage Exchange Arthroplasty Appears to Decrease Early Reinfection

BackgroundRecent evidence has suggested a benefit to extended postoperative prophylactic oral antibiotics after two-stage exchange arthroplasty for treatment of periprosthetic joint infections. We sought to determine reinfection rates with and without a short course of oral antibiotics after two-stage exchange procedures. MethodsA retrospective review identified patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection of the hip or knee. Patients were excluded if they failed a prior two-stage exchange, had positive cultures at reimplantation, prolonged intravenous antibiotics postoperatively, and/or life-long suppression. This resulted in 444 reimplantations (210 hips and 234 knees). Patients were divided into three cohorts based on the duration of oral antibiotics after reimplantation: no antibiotics (102), ≤2 weeks (266), or >2 weeks (76). The primary endpoint was reinfection within 1 year of reimplantation. ResultsWithin 1 year of reimplantation, there were 34 reinfections. In the no-antibiotic, ≤ 2-week, and >2-week cohorts the reinfection rates were 14.1, 7.0, and 6.4%, respectively. Multivariate Cox regression showed a reduced reinfection rate in the ≤2-week cohort relative to no antibiotics (hazard ratio [HR]: 0.38, P = .01). While the smaller cohort with >2 weeks of antibiotics did not significantly reduce the reinfection rate (HR: 0.41, P = .12), when combined with the ≤2-week cohort, use of oral antibiotics had an overall reduction of the reinfection rate (HR: 0.39, P = .01). ConclusionsThese data support the hypothesis that a short course of oral antibiotics after reimplantation decreases the 1-year reinfection rate. Future randomized studies should seek to examine the efficacy of different durations of oral antibiotics to reduce reinfection. Level of EvidencePrognostic Level IV.

Successful management of a rare case of endogenous endophthalmitis from soft tissue (gluteal) abscess

Endophthalmitis, an ophthalmic emergency carries poor visual prognosis without prompt diagnosis and treatment. Endophthalmitis is often exogenous and rarely endogenous. In this report, we describe a rare case of bacterial endogenous endophthalmitis in an immunocompetent 51-year-old patient due to methicillin-resistant staphylococcus aureus septicemia from a gluteal abscess. Ultrasonography confirmed endogenous endophthalmitis. The patient was treated with immediate intravitreal antibiotic injections, prolonged intravenous antibiotics in association with pars plana vitrectomy, retinal detachment repair and vitreous debris removal. Successful treatment was confirmed with negative blood cultures and a clear vitreous on b-scan ultrasound and fundus photography with improvement of his visual acuity. This case highlights the importance of consideration of rare infectious foci as etiology and prompts treatment for successful resolution of endogenous endophthalmitis.

What’s New in Hip Replacement

What’s New in Hip Replacement

Excellent Outcomes With the Selective Use of Oral Antibiotic Therapy for Bone and Joint Infections: A Single-Center Experience.

Background and objectiveRecent studies have challenged the notion that prolonged intravenous (IV) antibiotics are preferable to oral antibiotics for treating musculoskeletal infections. Our institution’s orthopedic surgery and orthopedic infectious disease (ID) groups have established consensus criteria for the use of oral antibiotics in musculoskeletal infections. In this study, we examine one-year and two-year outcomes of the selective use of oral antibiotics for musculoskeletal infections in a real-world setting.MethodsWe conducted a single-center retrospective analysis of adults seen in our orthopedic ID clinic over a six-month period for the first episode of surgically managed osteomyelitis, native joint septic arthritis (NJSA), prosthetic joint infection (PJI), or other musculoskeletal hardware infection with an established microbiologic etiology who received surgical interventions and >2 weeks of antimicrobial treatment. Patients were evaluated for treatment failure at one year and two years following their index surgery, which we defined as death, unplanned surgery, or the initiation of chronic antibiotic suppression.ResultsOne-year treatment failure rates were 0/23 (0%) in patients who switched to oral therapy versus 6/17 (35%) in patients who remained on IV treatment. Two-year treatment failure rates were 0/23 (0%) in patients who switched to oral therapy versus 8/17 (47%) in patients who remained on IV treatment.ConclusionsOur consensus criteria for the switch to oral antibiotics for musculoskeletal infections identified patients who went on to have excellent outcomes at one year and two years, suggesting that these criteria can effectively identify patients at low risk for treatment failure. Collaboration between ID specialists and orthopedic surgeons to select antimicrobial regimens can avoid significant burdens, costs, and complications associated with prolonged IV therapy.

Abstract No. 586 Utilization of outpatient parenteral antibiotic therapy in persons who inject drugs: a meta-analysis

People who inject drugs (PWID) are commonly at risk of infections requiring prolonged intravenous antibiotics via either peripherally inserted catheters (PICC) or tunneled catheters. These patients are usually excluded from outpatient parenteral antibiotic therapy (OPAT), a strategy that would allow them to leave the hospital. Exclusion from OPAT is based on a fear of line tampering and continued drug usage through the line. This premise is not based on evidence. There are currently no established guidelines on the treatment of PWID requiring prolonged antibiotics. Our aim is to present a meta-analysis of the existing literature on the management strategies for PWID with serious infections.

Intravascular large B-cell lymphoma associated with sudden stridor arising from thyroid mucormycosis and concomitant bacterial infection

Dear Editor, Mucormycosis is a life-threatening fungal infection that mainly affects immunocompromised patients. It typically has low prevalence, but fatality rate is as high as 50%. We present a patient with intravascular lymphoma with secondary bacterial infection and invasive mucormycosis involving the thyroid gland, who experienced good outcomes following surgical decompression and prolonged intravenous antibiotics.

28. The Paradox of an Integrated MAT OPAT Program

BackgroundPatients with substance use disorders (SUD), specifically opioid use disorder (OUD) and injection drug use (IDU) utilize healthcare resources for prolonged inpatient treatment of serious infections stemming from their addictions. For a variety of reasons, physicians treating these patients refuse to send these patients home to receive outpatient parenteral antimicrobial therapy (OPAT), and instead keep the patient in the hospital for several weeks or longer to complete treatment for the injection-related infections. Patients who do not have history of IDU are sent home with a PICC line to receive OPAT once they are no longer acutely ill and therefore no longer meet criteria to remain inpatient, which is the established standard of care. Patients with OUD and IDU are not allowed the same standard of care, and furthermore do not receive adequate, if any, therapy for their primary problem and reason for their serious infection – the addiction.Flow chart of the MAT-OPAT process MethodsMedication-assisted treatment (MAT) with buprenorphine-naloxone has been approved for treating adults with opioid use disorder as part of a comprehensive treatment program that also includes counseling and behavioral therapy. Until now in our healthcare system there has been no comprehensive and integrated program to safely discharge patients with OUD and IDU to receive OPAT via a PICC line, while simultaneously treating their addiction. We describe the implementation of a MAT-OPAT program. Please refer to the chart included.ResultsWe present a successful case of a 36-year-old male with a history of endocarditis associated with IV drug use and the intervention of the Healthcare System to link the patient to appropriate Infectious disease, behavioral health and medication adherence treatment for opioid abuse. The patient completed the IV antibiotic therapy and remained enrolled in the behavioral health program with a successful outcome.ConclusionMAT-OPAT implementation in large healthcare system with continuous outpatient support that includes Infectious Disease services, behavioral health and drug abuse rehabilitation therapy can be a successful strategy to minimize readmisión, cost and complications in patients with history of IV drug use and infections that require prolonged intravenous antibiotic therapy.Disclosures All Authors: No reported disclosures

Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients.Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed.Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE.Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.

Deep Wound Infection in Pediatrics after Open Cardiac Surgery

Abstract Surgical site infection (SSI) is a serious complication requiring prolonged hospitalization, intravenous antibiotics, wound care and dressings resulting in increased cost and resistant bacteria. In pediatric cardiac surgery, Median sternotomy is the most frequently used incision for the correction of congenital anomalies. Sternal wound infections (SWIs) are well described complications of cardiac surgery and can occur in 3% to 8% of children. Furthermore, the mortality rate can increase 2-fold after SSIs. Also, SSIs are associated with an increased length of hospital stay, readmissions, and higher health care expenditures. Mediastinitis is a retrosternal wound infection frequently associated with a macroscopically sternal osteomyelitis. Mediastinitis is uncomfortable for patients, is poorly accepted by parents, leads to a prolonged hospital stay repeated surgery and prolonged antibiotic therapy. Mediastinitis are costly for patients, providers, and health-care institutions. In A recent survey among congenital heart programs, the incidence of mediastinitis has been reported to occur in 0.2–1.4%. Gram-positive cocci are the most common pathogen. Gram negative organisms are increasingly recognized, especially in neonates, and are related to delayed sternal closure. Fungal organisms are not infrequently found. Mediastinitis generally presents 2–3 weeks after cardiac surgery. Child often appear irritable, tired, and febrile. The incision is erythematous and painful. Wound separation and purulent drainage from the incision are frequent. Some but not all will also have sternal instability or dehiscence. Associated bacteremia is not uncommon, present in up to 40% of patients. Postoperative mediastinitis is a life-threatening infection and increase health expenditure. Young age, malnutrition, hypothermia, hyperglycemia, longer duration of surgery, long time of delayed sternal closure, postoperative low cardiac output and long ICU stay were a risk factor of mediastinitis. Stick to1999 CDC's Guideline for prevention of surgical site infection and their update in 2017 especially proper timing of antibiotic prophylaxis and post-operative blood glucose management is important in prevention of these life-threatening complication. procalcitonin can be useful biologic marker of infection. Management of mediastinitis consist of debridement and culture-based antibiotics. Primary closure over mediastinal drain or high vacuum drain gave good result, less time consuming, more economic and more cosmetic. Vacuum assisted closure gave excellent result, but more time consuming, less economic and delayed closure is necessary. Larger studies are needed to compare both techniques in effectiveness and coast benefit.

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.

National Trends of Acute Osteomyelitis and Peripherally Inserted Central Catheters in Children.

Although a growing body of evidence suggests that early transition to oral antimicrobial therapy is equally efficacious to prolonged intravenous antibiotics for treatment of acute pediatric osteomyelitis, little is known about the pediatric trends in peripherally inserted central catheter (PICC) placements. Using a national database, we examined incidence rates of pediatric hospitalizations for acute osteomyelitis in the United States from 2007 through 2016, as well as the trends in PICC placement, length of stay (LOS), and cost associated with these hospitalizations. This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 through 2016. Patients ≤18 years of age with acute osteomyelitis were identified by using appropriate diagnostic codes. Outcomes measured included PICC placement rate, LOS, and inflation-adjusted hospitalization costs. Weighted analysis was reported, and a hierarchical regression model was used to analyze predictors. The annual incidence of acute osteomyelitis increased from 1.0 to 1.8 per 100 000 children from 2007 to 08 to 2015 to 16 (P < .0001), whereas PICC placement rates decreased from 58.8% to 5.9% (P < .0001). Overall, changes in LOS and inflation-adjusted hospital costs were not statistically significant. PICC placements and sepsis were important predictors of increased LOS and hospital costs. Although PICC placement rates for acute osteomyelitis significantly decreased in the face of increased incidence of acute osteomyelitis in children, LOS and hospital costs for all hospitalizations remained stable. However, patients receiving PICC placements had longer LOS. Further studies are needed to explore the long-term outcomes of reduced PICC use.