Prophylactic Antimicrobial Agents Research Articles

Antimicrobial agent usage patterns and their role in preventing surgical site infections at a tertiary care teaching hospital: A comprehensive study

Background: Surgical site infections (SSIs) present a formidable challenge in contemporary healthcare, impacting patient well-being and contributing to escalating healthcare costs. The judicious utilization of antimicrobial agents is paramount in effectively combating SSIs. This study, conducted at a Tertiary Care Teaching Hospital in Kerala, seeks to unravel the intricate patterns of antimicrobial agent usage within the General Surgery Department over 10 months. Aims and Objectives: The primary aim is to thoroughly examine antimicrobial agent patterns within the General Surgery Department, focusing specifically on patients undergoing surgical procedures. The study aims to assess the appropriateness of antimicrobial agent usage, encompassing the choice for prophylactic purposes, timing of pre-operative dosing, the occurrence of intraoperative dosing, and the selection appropriateness for post-operative prophylaxis. Materials and Methods: Crafted for robust analysis, the study included 150 cases, implementing specific inclusion and exclusion criteria to ensure data quality. The emphasis was placed on patients undergoing surgical procedures, focusing on prophylactic antimicrobial use. Data collection involved meticulously evaluating appropriateness across critical parameters, including the choice of prophylactic antimicrobial agent, pre-operative dosing timing, intraoperative dosing, and selection appropriateness for post-operative prophylaxis. Results: Analysis of 150 cases provided valuable insights into the age and gender distribution, predominantly within the 41–60 age groups. Prevalent surgical procedures, such as hernia and appendicitis, underscored the necessity for tailored antimicrobial protocols. Cephalosporins emerged as the dominant class, raising concerns about potential overuse and resistance. Pre-exposure prophylactic antibiotics, predominantly cephalosporins, were administered in 88 cases. Post-exposure prophylaxis mirrored this trend, necessitating a critical evaluation of antibiotic selection and duration. Detailed analysis of cephalosporin pre- and post-exposure prophylaxis identified prevalent choices such as Cefotaxime and Cefoperazone + Sulbactam, emphasizing the importance of scrutinizing cephalosporin selection. Conclusion: This study furnishes valuable insights into the appropriateness of antimicrobial agent usage for preventing SSIs, serving as a model for analogous healthcare settings. It underscores the significance of local antibiotic stewardship, guideline adherence, and the ongoing commitment to optimizing prophylactic antimicrobial usage for ensuring patient safety and advancing healthcare quality amidst evolving challenges.

Comparison of Cefazolin and Ceftriaxone as Antimicrobial Prophylaxis in Pancreatoduodenectomy with Preoperative Drainage: Incidence of Surgical Site Infection and Susceptibility of Bacteria in Bile.

The optimal perioperative antimicrobial agent for preventing surgical site infection (SSI) in pancreatoduodenectomy (PD) with preoperative biliary drainage (PBD) remains unclear. We retrospectively reviewed 288 patients who underwent PD after PBD between 2010 and 2020 at our institution. Patients were classified into two groups according to the perioperative antimicrobial agent used (cefazoline [CEZ] group [n = 108] and ceftriaxone [CTRX] group [n = 180]). The incidence of SSI, type of bacteria in intraoperative bile culture (IBC), and antimicrobial susceptibility to prophylactic antimicrobial agents were analyzed. The incidence of incisional SSI was significantly lower in the CTRX group than in the CEZ group (18% vs. 31%, P = 0.021), whereas the incidence of organ/space SSI in the two groups did not differ to a statistically significant extent (35% vs. 44%, P = 0.133). Gram-negative rod (GNR) bacteria in the IBC showed better antimicrobial susceptibility in the CTRX group than in the CEZ group. In multivariate analysis, antimicrobial resistance due to GNR was a significant risk factor for incisional SSI (odds ratio, 3.50; P < 0.001). CTRX had better antimicrobial coverage than CEZ for GNR cultured from intraoperative bile samples. In addition, CTRX provides better antimicrobial prophylaxis than CEZ against superficial SSI in patients with PD after PBD. This study was not a clinical trial and had no registration numbers.

The dawn of repurposing vitamins as potential novel antimicrobial agents: A call for global emergency response amidst AMR crisis.

Amidst, the global pandemic of antimicrobial resistance (AMR), the rate at which AMR increases overwhelms the increased efforts to discover new effective antimicrobials. There is a persistent need for alternative treatment modalities so as to keep up with the pace. AMR is the leading cause of death in the world and its health and economic consequences suggest the urgent need for sustainable interventions. Vitamins have consistently proven to have antimicrobial activity as well as slowing down the AMR rate by influencing the AMR genes even towards extensive multidrug resistant strains. Evidences suggest that the use of some vitamins on their own or in combination with existing antimicrobial agents could be a breakthrough towards combating AMR. This will widen the antimicrobial agents' options in the treatment arena, preserve the antimicrobial agents susceptible to develop resistant so that they can be used in severe infections only, reduce the tension and burden of the AMR crisis significantly and give enough room for development of new antimicrobial agents. Moreover, almost all viral, fungal, parasitic and bacterial resistant strains of concern as listed by World Health Organization have been found to be sensitive to several vitamins either synergistically with other antimicrobials or independently. Considering their widened spectrum of immunomodulatory and antimicrobial effect, some vitamins can further be repositioned as prophylactic antimicrobial agents in clinical situations like in presurgeries prophylaxis so as to avoid unnecessary use of antimicrobials especially antibiotics. Various relevant AMR stakeholders should invest in clinical trials and systematic reviews with available data to enable quick repositioning of some potential vitamins as antimicrobial agents as an emergency rapid response towards AMR Crisis. This includes the preparation of guidelines containing specificity of which vitamin to be used for treatment of which type of infection.

Influence of discontinuation of prophylactic antimicrobial agent for trabeculectomy

BackgroundThere is no unified view of the necessity of prophylactic antimicrobial agents in trabeculectomy. Preoperative prophylactic antimicrobial agent injection and cefazolin sodium (CEZ) for trabeculectomy were discontinued at the Hiroshima University Hospital. In this study, we evaluated whether discontinuation of preoperative administration of CEZ in ophthalmology affects the incidence of postoperative infections.MethodsWe retrospectively investigated patient background, concomitant medications, subconjunctival dexamethasone sodium phosphate (DEX) injection at the end of the surgery, and the incidence of infective endophthalmitis within 6 weeks after surgery in the CEZ and non-CEZ groups. We also performed propensity score matching for background matching. Statistical analysis was performed using the Mann-Whitney U-test and Fisher’s exact test.ResultsThe incidence of postoperative endophthalmitis was not significantly different between 629 and 751 patients in the CEZ and no-CEZ groups, respectively (0 in the CEZ group and 2 in the no-CEZ group, P = 0.504). More patients in the CEZ group were taking diabetes drugs preoperatively (P = 0.028) and fewer patients were receiving subconjunctival DEX at the end of surgery (P < 0.001) than those in the non-CEZ group. Propensity scores were calculated using the risk factors for postoperative infection as covariates, and matching (580 patients in the CEZ group and 580 patients in the non-CEZ group) showed no significant difference in the incidence of postoperative endophthalmitis (P = 0.500).ConclusionsThere was no significant difference in the incidence of endophthalmitis after trabeculectomy between the CEZ and non-CEZ groups, suggesting a decreased need for CEZ injections before trabeculectomy.

Clinical features and outcomes of patients with chronic granulomatous disease in Taiwan.

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency disease characterized by defective neutrophil killing of microbial pathogens and recurrent infections. We aimed to investigate the clinical, genetic features, treatment, and outcomes in patients with CGD. Pediatric patients diagnosed with CGD from a medical center in Taiwan were enrolled from January 1999 to Oct 2021. Nine pediatric patients with CGD were enrolled: six X-linked (XL) CGD with CYBB gene mutations, three autosomal recessive (AR) CGD with two NCF1 and one CYBA gene mutations.The median age of onset and age of diagnosis was 0.92 and 2.64 years, respectively. Patients with XL-CGD had a younger age of onset (4.6 months vs. 1.83 years, P=0.06) and age of diagnosis (1.71 vs. 8.86 years, P=0.024) than AR-CGD patients. The most common sites of infections were skin and soft tissue abscesses. The most common pathogens were Staphylococcus, Serratia, and Salmonella spp. Prophylactic antibiotics, anti-fungal agents, and interferon-gamma (IFN-γ) were given in 9 (100%), 7 (77.8%), and 8(88.9%) patients, respectively. The mean duration of IFN-γ usage was 5.15 years. One male patient with XL-CGD was successfully treated with hematopoietic stem cell transplantation at 2.2 years. The mortality rate was 11.1%, and the estimated overall survival at 20 years was 66.7%. Staphylococcus aureus, Serratia marcescens, and Salmonella infections are important in Taiwanese CGD patients. Patients with XL-CGD have early disease onset. IFN-γ prophylaxis and prophylactic anti-microbial agents might have an effect on alleviating the infection episodes in CGD patients.

Diagnosis and treatment of adult patients with inborn errors of immunity

Primary immunodeficiency diseases (PID) are caused by abnormalities in molecules involved in the immune system, and there are nearly 500 genes associated with PID. The symptoms are not only susceptibile to infectious diseases but also to autoimmune diseases, malignancies, autoinflammatory diseases, and allergies. Thus, these diseases are considered inborn errors of immunity (IEI) rather than PID. IEI is typically thought to occur in childhood because IEI is associated with a genetic variant, but there are also several adult-onset IEIs. The same 10 warning signs used to diagnose IEI in children are used to diagnose the condition in adults as well, who are then given a definitive genetic diagnosis after a 4-step diagnostic process. In addition to prophylactic antimicrobial agents and immunoglobulin replacement therapy, allogeneic hematopoietic cell transplantation (HCT) is performed as a curative therapy in some patients with IEI. However, in adult patients with IEI, HCT may have to be stopped due to complications. Adult patients with IEI need to be promptly assessed for HCT, and HCT must be done before complications increase.

The usefulness of preoperative bile cultures for hepatectomy with biliary reconstruction

BackgroundInfectious complications can cause lethal liver failure after hepatectomy with biliary reconstruction. This study assessed the increased risk for postoperative infectious complications in patients who underwent hepatectomy with biliary reconstruction and explored the possibility of predicting pathogenic microorganisms causing postoperative infectious complications based on preoperative monitoring of bile cultures. MethodsThis study involved 310 patients who received major hepatectomy with or without biliary reconstruction at our institution between January 2010 and December 2019. The relationship between the microorganisms detected through perioperative monitoring of bile culture and those in the postoperative infectious foci was examined. ResultsForty-nine patients underwent major hepatectomy with biliary reconstruction, and 261 received hepatectomy without biliary reconstruction. The multivariate analysis revealed hepatectomy with biliary reconstruction to be associated with an increased risk of postoperative infectious complications (odds ratio: 22.9, 95% confidence interval: 5.2–164.3) compared to hepatectomy without biliary reconstruction. In the patients with biliary reconstruction, the concordance rates between the microorganisms detected in the postoperative infectious foci and those in preoperative bile cultures were as follows: incisional surgical site infection (44.4%), organ/space surgical site infection (52.9%), bacteremia (47.1%), and pneumonia (16.7%); the concordance rates were high, and the risk of infection increased over time. ConclusionsBiliary reconstruction is a significant risk factor for postoperative infectious complications, and preoperative bile cultures may aid in prophylactic and therapeutic antimicrobial agent selection.

RISK FACTORS FOR INFECTIONS AT SURGICAL SITES AND REMOTE REGIONS IN PATIENTS UNDERGOING LAPAROSCOPIC PYELOPLASTY AND EVALUATION OF ANTIMICROBIAL PROPHYLAXIS

(Objectives) We measured the incidences of surgical site infections (SSIs) and remote infections (RIs) in patients undergoing laparoscopic pyeloplasty to treat ureteropelvic junction obstruction, and the effects of prophylactic antimicrobial agents. (Patients and Methods) We compared the incidences of SSI and RI, risk factors for such infections, and differences in the prophylactic antimicrobial protocols in 94 patients who underwent laparoscopic pyeloplasty at our hospital from August 2009 to June 2021. (Results) Two patients experienced SSIs (2.1%) and three had RIs (3.2%). There were no significant differences in the incidence of either infection type in those who complied and did not comply with the prophylactic antimicrobial guidelines. (Conclusions) Laparoscopic pyeloplasty is associated with low incidences of both SSI and RI; prophylactic antimicrobials may not be required. A large multicenter survey is required for continuous evaluation of SSIs and RIs and to accumulate data.

Bringing Eyelid Surgery in Line with International Guidelines Regarding Peri-Operative Antibiotic Agents: A Pilot Study.

Background: International guidelines advise against prophylactic antimicrobial agents for primarily closed surgical incisions, but most oculoplastic surgeons report using chloramphenicol ointment. We evaluated baseline surgical site infection (SSI) rates in patients undergoing eyelid surgery who received prophylactic chloramphenicol ointment post-operatively. Withdrawal of prophylaxis was then prospectively audited to establish whether infection rates changed in a clinically meaningful way. This article reports the early findings. Patients and Methods: A single-center retrospective audit was undertaken; electronic medical records were reviewed for consecutive patients who underwent eyelid surgery with primary incision closure. All patients received post-operative prophylactic chloramphenicol. Those with histopathologic evidence of malignancy were excluded. Patient demographics, surgical details, evidence of post-operative SSI and other complications were recorded. Local policy was changed in accordance with national guidelines; prophylactic chloramphenicol ointment was withheld, and the above information collected prospectively. Our policy excluded skin malignancies, full thickness skin grafts, patients on systemic immunosuppression, and diabetes mellitus because of potential increased infection risk. Results: There were no statistically significant differences between the groups, except seniority of surgeon. Surgical site infection was identified in 14 of 872 eyes (1.6%) receiving post-operative chloramphenicol, and three of 133 eyes (2.25%) without antibiotic agents, which was not statistically significant. Conclusions: Post-operative SSI rates in eyelid surgery are low. Routine use of prophylactic antibiotic agents in primarily closed surgical eyelid incisions does not adhere to international standards and may contribute to antimicrobial resistance. Early results suggest infection rates remain low without prophylactic chloramphenicol; clinicians should consider withdrawing it from routine practice in suitable patients.

Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019.

Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019.

ХАРАКТЕРИСТИКА МИКРОБИОЛОГИЧЕСКИХ ПОКАЗАТЕЛЕЙ ЭФФЕКТИВНОСТИ СПИРТОСОДЕРЖАЩИХ СРЕДСТВ

The purpose of the research was to study the indicators of microbiological efficacy of compositions of ethyl alcohol 72% with brilliant green 0.01-0.001%, crystalline iodine 0.5-0.1%, chlorhexidine bigluconate 0.5-0.01%. Material and methods. The studies were performed on standard test cultures of Escherichia coli ATCC 25922, Staphylococcus aureus ATCC 25923, Pseudomonas aeruginosa ATCC 27853, Proteus mirabilis ATCC 14153, Candida albicans ATCC 10231, as well as on clinical strains of Klebsiella pneumoniae 620, Acinetobacter baumannii 445, isolated from patients of the Vitebsk Regional Clinical Infectious Diseases Hospital, and clinical strains of Klebsiella pneumoniae 1051, Acinetobacter baumannii 886, Staphylococcus aureus 1230, Pseudomonas aeruginosa 1074, isolated from patients of the Vitebsk Regional Clinical Hospital. Results. In the studied alcohol compositions the totalamountofaerobesislessthan 102 CFUper 1 ml, the totalnumber of fungi is less than 10 CFU per 1 ml. Standard and clinical strains of microorganisms are sensitive to compositions of ethyl alcohol 72% with all the studied concentrations of brilliant green, crystalline iodine, chlorhexidine bigluconate, as well as ethyl alcohol 70% and 72% at an exposure of 1 minute in a qualitative suspension test tube method without protein load, in a micromethod on sterile 96-dimple polystyrene plates and in the disk diffusion method. The reduction factor in the quantitative suspension method for all the studied compositions in relation to standard and clinical strains is above 5.0 lg. Conclusions. The results of the study enable to conclude that the developed alcohol compositions have high antimicrobial activity against standard and clinical strains and meet the standard microbiological indicators of the efficacy of disinfectants and antiseptics, and are microbiologically pure and meet the regulatory requirements in terms of microbiological purity. Compositions of ethyl alcohol 72% with brilliant green 0.01%, with crystalline iodine 0.25%, with chlorhexidine bigluconate 0.1% are combined agents with a sufficient synergistic effect and can be recommended as prophylactic antimicrobial agents.

ANTIPSEUDOMONAL ACTIVITY OF METABOLIC COMPLEXES OF L. RHAMNOSUS GG AND S. BOULARDII AGAINST THE POLYRESISTENT PATHOGEN IN IN VITRO AND IN VIVO TESTS.

The aim: Explore the antimicrobial properties of lactobacilli's metabolites and combination of lactobacilli's and saccharomycetes' metabolites with different concentrations (in vitro) and to test the effectiveness of samples with minimum inhibitory concentration on infected polyresistant strain P. aeruginosa skin wounds (in vivo) for the possibility of creating prophylactic antimicrobial agents. Materials and methods: Metabolic complexes (L. rhamnosus GG and S. boulardi) were obtained by culturing lactobacilli or lactobacilli and saccharomycetes in lactobacilli disintegrates. The sensitivity of Pseudomonas aeruginosa PR (in vitro) to them was determined by the microtechnique of serial dilutions in a liquid nutrient medium. In vivo, 0.9 % sodium chloride solution (control) or lactobacillus metabolic complex (experiment, treatment group) was applied to infected skin wounds or, in addition, immediately before the infection, to the wound and then to infected wounds (experiment, prophylactic-treatment group). Results: There was observed the decrease of the infectious process of skin wounds in the prophylactic-treatment group (3.25-3.4 times; p=0.01 related to control samples) compared with the treatment group (2.05-2.25 times; p=0.02) by the wound healing rate (day 5). The healing rate of control wounds (day 11) coincided with the rates of experimental wounds in the prophylactic-treatment group (day 8), indicating that the use of lactobacilli metabolites promotes the acceleration of healing by almost three days. Conclusions: Metabolic complexes of probiotic microorganisms are promising for construction on their new class of antimicrobials for the effective pharmacoprophylaxis and pharmacotherapy.

Comparison of drug susceptibility between Escherichia coli detected in stool cultures of patients undergoing transrectal prostate needle biopsy and Escherichia coli in hospital-wide urine antibiograms

A prostate biopsy is essential for prostate cancer diagnosis. However, infections are one of the biopsy-associated complications, and post-biopsy fever is estimated to occur in approximately 1% of all cases. It may thus be beneficial to perform a rectal swab culture before a transrectal prostate biopsy to confirm the presence of resistant bacteria and select preventive antibacterial agents according to the drug susceptibility results. This study aimed to determine whether there is a difference between the drug susceptibility of bacteria detected in the stool of patients who were scheduled to undergo prostate biopsy and the hospital-wide urine antibiogram. Patients suspected of having prostate cancer who underwent transrectal prostate biopsy via transrectal ultrasonography between August 1, 2016, and June 30, 2020, were included in this study. Stool samples were collected and cultured before biopsy. Overall, 99 patients underwent prostate biopsy, and of these, culture results were available for 81 patients (81.8%). Escherichia coli was detected in 74.0% (60 samples) of the stool culture samples, of which 4 samples were extended-spectrum β-lactamase-producing types. We found greater susceptibility of Escherichia coli to ampicillin, fluoroquinolones, sulfamethoxazole/trimethoprim, and cefixime in the stool culture antibiogram than in the hospital-wide urine antibiogram. We also found a significantly low incidence of ESBL-positive Escherichia coli in the stool culture antibiogram with p-values of 0.009, 0.007, and 0.03 compared to the hospital-wide urine antibiograms for 2017, 2018, and 2019, respectively. Stool culture of prostate cancer patients undergoing biopsy may provide useful information for selecting prophylactic antimicrobial agents.

Predictive and risk factor analysis for bloodstream infection in high-risk hematological patients with febrile neutropenia: post-hoc analysis from a prospective, large-scale clinical study

Bloodstream infection (BSI) is a frequent complication observed in patients with febrile neutropenia (FN). BSI risk factors and incidence vary depending on chemotherapy types and prophylactic antimicrobial agents. We clarified these issues by post-hoc analysis of a prospective clinical trial cohort for severe FN in hematological malignancy. We performed an intention-to-treat analysis of 413 high-risk patients and 1272 blood culture sets. Overall, 356 patients (86.2%) developed FN, and 20.8% had BSI complications. Prophylactic antimicrobials did not prevent complications of FN and BSI, but the incidence of BSIs of Gram-negative (GN) bacteria was lower than in the non-prophylaxis group (23.8% vs. 56.7%). Multinational Association of Supportive Care in Cancer (MASCC) scores < 20 were significantly correlated with the incidence of BSI, whereas MASCC scores > 21 were not (41.7% vs. 17.2%). The only significant risk factors were hypotension and dehydration. axillary temperatures were higher in GN-caused BSIs than in Gram-positive-caused BSIs and in patients with negative blood culture results (38.7°C vs. 38.2°C vs. 38.0°C). The higher the fever, the higher the incidence of BSI and GN bacteremia. MASCC score and axillary temperature are strong predictors of BSI. Non-administration of prophylactic antimicrobials and GN-caused BSI are correlated. UMIN00010411.

Pediatric Ambulatory Central Line-Associated Bloodstream Infections.

Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes. Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors. Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13). Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

CO-INFECTION WITH HISTOPLASMA CAPSULATUM AND PNEUMOCYSTIS JIROVECII IN A PATIENT WITH LIVER CIRRHOSIS: A DIAGNOSTIC DILEMMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Histoplasma capsulatum and Pneumocystis jirovecii pulmonary coinfection are unusual in HIV negative populations. We present the case of a man in respiratory failure with H. capsulatum and P. jirovecii detected in bronchial washings. CASE PRESENTATION: A 64-year-old man with T2DM, moderate COPD, and NASH cirrhosis with pancytopenia presented with 2-month history of progressive hypoxic respiratory failure. CT chest revealed multifocal consolidations with mediastinal lymphadenopathy which progressed despite antimicrobial therapy (Fig. 1). Bronchoalveolar lavage (BAL) was remarkable for 2800 copies/mL of P. jirovecii PCR with beta-D-glucan of 286. BAL specimen also grew H. capsulatum on culture and the FNAC specimen taken from lymph node 7 during the transbronchial biopsy was indicative of fungal elements similar to Histoplasma (Fig. 2A-2C). The patient was started on itraconazole for Histoplasmosis and trimethoprim-sulfamethoxazole with steroids for P. jirovecii pneumonia (PJP). He was tested during the hospitalization and found to be negative for HIV but had CD4 and CD8 counts at 86 and 70 x10E9/L respectively. Due to progression of his disease the patient was transitioned to comfort measures and passed on hospital day 36. DISCUSSION: Histoplasmosis is an endemic mycosis in the Ohio and Mississippi river valleys often resulting in asymptomatic infection [1]. PJP has also been reported as an asymptomatic infection or colonization in immunocompetent hosts [2]. Co-infection with both H. capsulatum and PJP ranges from 0.5-13% in studies on HIV positive patient groups [3,4]. In the sample population studied by Carreto-Binaghi et al, a coinfection rate of 1.5% was noted in the HIV negative group [5]. Irrespective of host immune status, patients with coinfection have a higher mortality rate than with a single infection alone [5], thus warranting treatment for both pathogens. Our patient had a history of chronic lymphopenia which had been attributed to his cirrhosis, with tests showing extremely low CD4 counts. Patients with end stage liver disease are recognized as being relatively immunocompromised when compared to healthy individuals due to coexisting leucopenia, lymphopenia and CD4/CD8 ratio abnormalities [6]. This case raises the question if patients with cirrhosis and lymphopenia should be treated with prophylactic antimicrobial agents based on their CD4 counts. CONCLUSIONS: This case highlights the importance of recognizing and treating co-infection of PJP and Histoplasmosis in non-HIV infected individuals. Additionally, it reminds us that patients with liver disease have important deficiencies in their cellular and humoral immunity which make them more susceptible to unusual opportunistic infections. Reference #1: [1] Goodwin RA, Loyd JE, Des Prez RM. Histoplasmosis in Normal Hosts. Medicine. 1981; 60(4): 231-266. Reference #2: [2] Ponce CA, Gallo M, Bustamante R, et al. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population. Clin Infect Dis. 2010; 50(3):347-353. [3] Baughman RP, Dohn MN, Frame PT. The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients. Am J Med. 1994; 97(6): 515-522. Reference #3: [4] Wheat JL, Slama TG, Zeckel ML. Histoplasmosis in the acquired immune deficiency syndrome. Am J Med. 1985; 78(2): 203-210. [5] Carreto-Binaghi LE, Morales-Villarreal FR, García-de la Torre G, et al. Histoplasma capsulatum and Pneumocystis jirovecii coinfection in hospitalized HIV and non-HIV patients from a tertiary care hospital in Mexico. Int J of Inf Dis. 2019; 86: 65-72. [6] Tuchendler E, Tuchendler PK, Madej G. Immunodeficiency caused by cirrhosis. Clin Exp Hepatol. 2018;4(3):158-164. DISCLOSURES: No relevant relationships by James Dugan, source=Web Response No relevant relationships by Akisha Glasgow, source=Web Response No relevant relationships by Eduarda Grinsztejn, source=Web Response No relevant relationships by Amrita John, source=Web Response

Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients.

Solid organ transplant recipients are at high risk for infections due to the complexity of surgical procedures combined with the impact of immunosuppression. No consensus exists on the role of antibiotics for surgical site infections in solid organ transplant recipients. To assess the benefits and harms of prophylactic antimicrobial agents for preventing surgical site infections in solid organ transplant recipients. The Cochrane Kidney and Transplant Register of Studies was searched up to 21 April 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. All randomised controlled trials (RCTs) and quasi-RCTs in any language assessing prophylactic antibiotics in preventing surgical site infections in solid organ transplant recipients at any time point after transplantation. Two authors independently determined study eligibility, assessed quality, and extracted data. Primary outcomes were surgical site infections and antimicrobial resistance. Other outcomes included urinary tract infections, pneumonias and septicaemia, death (any cause), graft loss, graft rejection, graft function, adverse reactions to antimicrobial agents, and outcomes identified by the Standardised Outcomes of Nephrology Group (SONG), specifically graft health, cardiovascular disease, cancer and life participation. Summary effect estimates were obtained using a random-effects model and results were expressed as risk ratios (RR) and 95% confidence intervals (CI). The quality of the evidence was assessed using the risk of bias and the GRADE approach. We identified eight eligible studies (718 randomised participants). Overall, five studies (248 randomised participants) compared antibiotics versus no antibiotics, and three studies (470 randomised participants) compared extended duration versus short duration antibiotics. Risk of bias was assessed as high for performance bias (eight studies), detection bias (eight studies) and attrition bias (two studies). It is uncertain whether antibiotics reduce the incidence of surgical site infections as the certainty of the evidence has been assessed as very low (RR 0.42, 95% CI 0.21 to 0.85; 5 studies, 226 participants; I2 = 25%). The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). It is uncertain whether extended duration antibiotics reduces the incidence of surgical site infections in either solid organ transplant recipients (RR 1.19, 95% CI 0.58 to 2.48; 2 studies, 302 participants; I2 = 0%) or kidney-only transplant recipients (RR 0.50, 95% CI 0.05 to 5.48; 1 study, 205 participants) as the certainty of the evidence has been assessed as very low. The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). None of the eight included studies evaluated antimicrobial agent adverse reactions, graft health, cardiovascular disease, cancer, life participation, biochemical and haematological parameters, intervention cost, hospitalisation length, or overall hospitalisation costs. Due to methodological limitations, risk of bias and significant heterogeneity, the current evidence for the use of prophylactic perioperative antibiotics in transplantation is of very low quality. Further high quality, adequately powered RCTs would help better inform clinical practice.

Implementing a multidisciplinary care bundle to reduce colon surgical site infections.

PurposeThe aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery.MethodsThe multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014.ResultsOverall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014.ConclusionAfter implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.

Hematopoietic Stem Cell Transplantation for Progressive Combined Immunodeficiency and Lymphoproliferation in Patients With Activated Phosphatidylinositol–3–OH Kinase δ Syndrome Type 1

To examine clinical features, laboratory findings, treatment, and outcomes of patients with activated phosphatidylinositol-OH-3 kinase δ syndrome type 1 (APDS1) and evaluate hematopoietic stem cell transplant (HSCT) as a potential treatment option.This study included 23 patients with confirmed PIK3CD mutations. Nine of these patients underwent HSCT.This was a retrospective study to characterize clinical characteristics, laboratory findings, treatment, and outcomes of patients with APDS1. Patients were identified by patient registry, physician referral, or having been previously reported in literature. Data were obtained by review of medical records and physician questionnaires.Common clinical features of patients with APDS1 included recurrent infections, lymphoproliferation, and enteropathy, with a median age at symptoms onset of 11 years old. The majority (65%) of patients received immunoglobulin replacement, and some additionally had prophylactic antimicrobial agents. Eleven transplantations were performed for recurrent infections or treatment refractory disease among 9 total patients. Fludarabine-based reduced-intensity conditioning regimens were used in all transplants (90–180 mg/m2), and 55% used human leukocyte antigen–mismatched donors. All but 1 patient ultimately achieved engraftment, but 36.4% had initial graft failure and required retransplantation, boosts of peripheral blood stem cells, or growth hormone administration for delayed T lymphocyte recovery. More than 90% of transplanted patients had an adverse complication, most commonly mild graft-versus-host disease. Despite this, most symptoms were improved post-HSCT, and no patients required ongoing immunoglobulin replacement by day 100 post-HSCT. The 30-year overall survival was 86.1%, and event-free survival was 39.6%.HSCT should be considered in patients with APDS1 and recurrent infections and/or treatment refractory lymphoproliferation. Clinical symptoms improved posttransplantation, although adverse complications and graft failure were frequent.Patients with APDS1 are at increased risk for recurrent infections, bronchiectasis, lymphoproliferation, chronic viral infections, and lymphoma. This article highlights the role that HSCT may play in the future management of patients with APDS1. Although not without its own risks, early HSCT can improve clinical symptoms and reduce the lifetime risk for potentially fatal complications in this disease. Investigators in this study closely examine HSCT regimens for APDS1 patients among various international medical centers, which serves as the first critical step toward improving event-free and overall survival for these patients.

Outcome of Repeated Vaccination to Hepatitis B Virus in Patients Failing to Respond to Vaccination Following Allogeneic Hematopoietic Stem Cell Transplantation (HSCT): If at First You Don't Succeed, Try Try Again

Background: Recipient immunity is compromised after HSCT, obligating patients (pts) to take prophylactic antimicrobial and antiviral agents and to be reimmunized to viral and bacterial pathogens. Hepatitis B virus (HBV) infection is a major public health problem, with about 30% of the world population having serological evidence of current or past HBV infection. HBV vaccination post-HSCT is imperative in these pts, as most lose protective HBV surface antibodies (anti-HBs) following conditioning, placing them at high risk for HBV reactivation. Guidelines recommend delaying vaccination (including HBV) for 6-12 months following transplantation to allow for cellular and humoral immune recovery. Even with delaying vaccination, immunosuppression, graft-versus-host disease (GVHD), and delayed immune reconstitution hinder the effectiveness of vaccines. The efficacy of HBV vaccination is not well defined in pts on immunosuppressive therapy (IST) and/or in those with GVHD. Further, little data exists on the efficacy of HBV revaccination in pts failing to respond to the 1st vaccination series. We studied factors impacting the success of vaccination in pts undergoing one to four HBV vaccination series after HSCT. Methods: This single-center, retrospective study evaluated the effectiveness of HBV vaccine in HSCT pts by assessing protective antibody generation after vaccination. Fifty-two pts (25 female, 27 male) who received at least one 3-dose HBV vaccination series post-HSCT and who had evaluable post-vaccine anti-HBs titers were included in the analysis. Pts with negative or indeterminate anti-HBs titers following the first vaccine series were eligible to receive one or more additional series of HBV vaccinations. All pts were treated with cyclophosphamide and fludarabine based conditioning (± anti-thymocyte globulin) and received GVHD prophylaxis with either cyclosporine/tacrolimus with or without mycophenolate mofetil. The vaccine response rate over a series of vaccinations was estimated by Kaplan-Meier methods. The development of response after the first vaccination was correlated with patient baseline and post-HSCT factors including pretransplant HBV titers, vaccination time post-transplant, use of rituximab and IST and absolute lymphocyte count (ALC), CD4, and CD8 cell counts and history of acute or chronic GVHD. Results: The studied cohort included 52 HSCT pts with a median age of 22 years (range 7-62) and a variety of diagnoses (38 aplastic anemia, 6 myelodysplastic syndrome and 8 hematological malignancies). Thirty-five pts underwent HSCT from an HLA-matched donor and 17 pts received a combined haploidentical and umbilical cord blood transplant. The median time to first HBV vaccination was 12 months (8-37) post-HSCT. Following the 1st vaccination series; 19, 4 and 2 pts received a 2nd, 3rd and 4th vaccination series. The estimated cumulative anti-HBs response rates were 51.9%, 82.3%, 91.1% and 100% for the four vaccination series, respectively (Figure). A logistic regression analysis revealed: a) Pts who achieved a response after the initial vaccination series had higher CD4 counts compared to those who failed to mount a response (median CD4 count 450 vs. 300/μL, P= 0.024, Figure); b) Pts without a history of acute GVHD (n=23) were significantly more likely to respond to the 1st vaccination series compared to those with acute GVHD (n=29) (response: 69.6% vs 37.9%, P= 0.029). Other factors included in this analysis were not found to be correlated with the anti-HBs response after the initial vaccination series. Conclusions: Multiple rounds of HBV vaccination may be required before a protective antibody response is achieved. After the first vaccination series, only 51.9% of pts achieved a response, with lower pre-vaccination CD4 counts and a prior history of acute GVHD being negatively associated with vaccine success. Remarkably, with continued vaccination attempts (up to four vaccination series), all evaluable pts ultimately developed a protective anti-HBs response. Figure Disclosures Shalabi: GlaxoSmithKline: Other: Spouse is employed by GSK Pharma.