Prophylactic Antimicrobial Therapy Research Articles

Antimicrobial Resistance in Bacterial Species Causing Orthopaedic Surgical Site Infections at a National Trauma Center, Kathmandu, Nepal.

Hospital-acquired infections, including surgical site infections (SSIs), pose a concerning challenge because of the growing resistance to multiple drugs, largely influenced by extensive prophylactic antimicrobial therapy. Although SSIs are well documented in advanced hospitals in developed nations, their prevalence and bacterial profiles are inadequately reported in low- and middle-income nations such as Nepal. This retrospective cohort study explored the prevalence of orthopaedic SSIs in relation to bacterial etiology and antimicrobial resistance. We examined the surgical and bacteriological records of patients suffering SSIs (clean or clean-contaminated wounds) within a month of their surgical procedures between January 2020 and June 2022 at the National Trauma Center, Kathmandu, Nepal. The prevalence of orthopaedic SSIs among hospital-visiting patients was 31.2% (448/1,438; 95% CI: 28.8-33.5). There were 341 (76.1%) males and 361 (80.6%) adults with SSIs. Knee/joint infections (n = 141, 31.5%) were predominant. An SSI typically occurs 7 days after surgery. Enterobacterales were dominated by Escherichia coli (n = 54, 40.9%), whereas nonfermenters gram-positive cocci (GPC) were dominated by Pseudomonas aeruginosa (n = 69, 81.2%) and Staphylococcus aureus (n = 216, 93.5%), respectively. Enterobacterales, nonfermenters, and GPC exhibited penicillin resistance at 74.5%, 29.8%, and 65.1%, respectively, whereas cephalosporin resistance was exhibited at 48.3%, 57.1%, and 49.6%; fluoroquinolone resistance at 25.9%, 40.5%, and 25.7%; and aminoglycoside resistance at 21.5%, 43.2%, and 17.3%. One-third of orthopaedic surgeries resulted in SSIs, mainly caused by S. aureus. Fluoroquinolones and aminoglycosides were moderately effective in treating bacterial SSIs, whereas penicillins and cephalosporins were the least effective. Nonfermenters exhibited higher antimicrobial resistance compared with Enterobacterales and GPC.

Antimicrobial prophylaxis is not indicated for horses undergoing general anaesthesia for elective orthopaedic MRI.

Post-anaesthetic fever is a known complication of general anaesthesia, however, its incidence in horses undergoing elective magnetic resonance imaging (MRI) is unknown. To determine the incidence of post-anaesthetic fever in horses undergoing elective orthopaedic MRI and determine whether prophylactic antimicrobial therapy would be associated with a reduction in the incidence of post-anaesthetic fever. We hypothesised that prophylactic antimicrobials would be associated with a reduction in the incidence of post-anaesthetic fever. Retrospective cross-sectional study. This retrospective study included 791 elective orthopaedic MRIs in systemically healthy horses between June 2006 and March 2020 that recovered from general anaesthesia and did not undergo surgery or intensive medical therapy soon after recovery. Potential factors associated with post-anaesthetic fever were evaluated using multivariable logistic regression. Case signalment, travel time, preanaesthetic haematology and fibrinogen abnormalities, use of prophylactic antimicrobials, peri-anaesthetic nonsteroidal anti-inflammatories, anaesthesia time and recovery time were all evaluated for association with post-anaesthetic fever. Of 791 MRI cases, 44 (5.6%) developed a post-anaesthetic fever. Horses that received prophylactic antimicrobials were [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.98-7.46; p ≤ 0.001] more likely to develop a post-anaesthetic fever than those that did not receive antimicrobials. Young horses (1-4 years of age) were (OR 2.8, 95% CI 1.26-6.17; p = 0.01) more likely to develop fever compared with adult horses (≥5 years of age). Limitations of this study pertain to retrospective analysis including nonrandomised case selection and incomplete data records. While fever may indicate infection, the majority of early post-anaesthetic fevers resolved before discharge from the hospital with no identified cause. The use of prophylactic antimicrobials to reduce the risk of post-anaesthetic fever for elective MRI is not supported by this study.

WINTER SPECIALIZED IMMUNOLOGY SCHOOL, “INBORN ERRORS OF IMMUNITY”

On December 15–17, 2022, the Winter Specialized Immunology School, “Inborn Errors of Immunity,” was held in Uzhgorod of Zakarpattia Region with the support of Danylo Halytsky Lviv National Medical University, the International Interdisciplinary Association of Medical Professionals, the All-Ukrainian Association of Pediatric Immunology NGO, and the International European University. This school aims to analyze new approaches to the early diagnosis of primary/congenital disorders of the immune response in the context of the multidisciplinary approach, as well as to discuss the strategy of therapeutic tactics of such patients. The scientific event was held in the case marathon and direct communication formats. At the beginning of the event, a round table was held with the participation of regional experts in pediatric and adult immunology from different parts of Ukraine. More active cooperation with European colleagues and the creation of a national registry of immunodeficient patients with impaired antibody synthesis were noted. More than 20 speeches by clinical immunologists/pediatric immunologists were presented during two days of intensive work. During this school, results of Biopharma activities, a domestic producer of immunoglobulins, and plans for the future were presented in the field of domestic immunology development and diagnosis of patients with inborn errors of immunity. Discussions during the Winter School revealed the need to actively protect persons with congenital disorders of the immune system against infections by means of timely systematic seasonal vaccination, replacement immunoglobulin therapy, prophylactic antimicrobial therapy, and coordinated activities of specialists from various fields to provide immunological aid to patients in war conditions. At the end of the “Inborn Errors of Immunity” Winter School, organizers expressed confidence that most efforts and ideas highlighted during the professional meeting will be successfully implemented.

Analysis of the use of empiric antimicrobial prophylaxis for temporary cardiac devices at a large academic medical center.

Varying rates of access site infections with temporary percutaneous cardiac devices have been reported in the literature. The purpose of this study is to determine the impact of a change in institutional practice in utilizing antimicrobial prophylaxis to prevent access site infections in patients with these devices. This observational, pre-post implementation analysis evaluated the benefit of prophylactic antimicrobial therapy in adult patients with temporary percutaneous cardiac devices admitted to cardiac intensive care units. Patients in the pre-cohort received prophylactic antibiotics for the duration of device insertion. Patients in the post-cohort received a single dose of intravenous antibiotics for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella® 5.5 device placement, and no antimicrobial prophylaxis for all other devices placed. The primary endpoint was the incidence of definitive access site infection. Secondary endpoints included the incidence of Clostridium difficile infection and initiation of broad-spectrum antibiotics. Fifty patients in the pre-cohort and 45 patients in the post-cohort were evaluated. Devices included intra-aortic balloon pumps, VA-ECMO, Impella® CP and Impella® 5.5. The median duration of device insertion was fourdays. No significant difference in the primary outcome was seen between the two groups. A significant reduction in prophylactic antimicrobial utilization and total days of antimicrobial exposure was observed in the post-implementation cohort. Based on the results of our study, the implemented guideline reduces the utilization of antimicrobial prophylaxis in patients with temporary percutaneous cardiac devices and does not result in an increased rate of infections.

Prophylactic Antimicrobial Therapy and Antimicrobial Stewardship in Urologic Surgery

INTRODUCTIONEFFECTIVENESS OF THE ANTIBIOTIC STEWARDSHIP PROGRAMPREOPERATIVE PREPARATIONURETEROSCOPIC LITHOTRIPSYPERCUTANEOUS NEPHROLITHOTRIPSYTRANSURETHRAL RESECTION OF THE PROSTATETRANSURETHRAL RESECTION OF BLADDER TUMORCLEAN PROCEDURESCLEAN‑CONTAMINATED PROCEDURESPROCEDURES INVOLVING INTESTINEPROCEDURES INVOLVING PROSTHETICSVAGINAL SURGERYCONCLUSIONSEFFECTIVENESS OF THE ANTIBIOTIC STEWARDSHIP PROGRAMCONFLICT OF INTERESTFUNDINGReferences

Optimizing transitions of care antimicrobial prescribing at a community teaching hospital.

Antibiotic prescribing at hospital discharge is an important focus for antimicrobial stewardship efforts. This study set out to determine the impact of a pharmacist-led intervention at hospital discharge on appropriate antimicrobial prescribing. This was a pre-/post-study evaluating the impact of a pharmacist-led review on antibiotic prescribing at hospital discharge. Pharmacists evaluated antibiotic prescriptions at discharge for appropriate duration, spectrum of activity, frequency, and strength of dose. Each of these criteria needed to be met for an antibiotic regimen to be considered appropriate. Moses Cone Hospital is a 535-bed community teaching hospital in Greensboro, North Carolina. Patients ≥18 years of age discharged from the hospital with an antibiotic prescription were included. Exclusion criteria included patients discharged against medical advice, discharged to a skilled nursing facility, or prescribed indefinite prophylactic antimicrobial therapy. A review of patients discharged with antibiotics in 2020 was performed. Patients discharged with antibiotic prescriptions from January 2021 to April 2022 were evaluated prior to discharge by pharmacists. The pharmacist made recommendations to providers based on their evaluations. 162 retrospective patients were screened, and 136 patients were screened at discharge from the hospital in the prospective cohort. 76/162 (47%) retrospective patients received appropriate antibiotic therapy at discharge, while 92/136 (68%) of prospective patients received appropriate discharge therapy (p = 0.001). In this study examining the efficacy of stewardship pharmacist intervention at hospital discharge, pharmacist review and recommendations were associated with an increased rate of appropriate antimicrobial prescribing. This study was conducted under the approval of the Institutional Review Board of the Moses H. Cone Health System. The approval protocol number was 1483117-1 and took effect on September 2nd, 2019. As the research was either retrospective in nature or part of the standard of care recommendations, the project was granted expedited review.

Intraoral and maxillofacial abnormalities in patients with autosomal dominant hyper-IgE syndrome.

Autosomal dominant hyper-IgE syndrome (AD-HIES) is an inborn error of immunity (IEI) caused by a dominant-negative mutation in the signal transducer and activator of transcription 3 (STAT 3). This disease is characterized by chronic eczematoid dermatitis, recurrent staphylococcal skin abscesses, pneumonia, pneumatoceles, and extremely high serum IgE levels. Loss-of-function STAT3 mutations may also result in distinct non-immunologic features such as dental, facial, skeletal, and vascular abnormalities, central nervous system malformations and an increased risk for bone fractures. Prophylactic treatment of Candida infections and prophylactic antimicrobial therapy for staphylococcal skin infections and sinopulmonary infections are essential. An awareness of the oral and maxillofacial features of HIES may facilitate early diagnosis with genetic counselling and may improve future patient care. This study describes oral, dental, and maxillofacial manifestations in 14 patients with genetically defined AD-HIES. We also review the literature and propose recommendations for the complex care of patients with this rare primary immunodeficiency.

Prevention of long-term catheter-related bloodstream infection with prophylactic antimicrobial lock solutions: why so little use?

For many years, I have been contacted by clinicians for advice managing adult and pediatric patients who have repeated catheter-related bloodstream infections (CRBSIs) and whose lives depend on long-term central venous access for chemotherapy, hemodialysis, or parenteral nutrition. Despite these repeated infections, these patients did not have the benefit of prophylactic antimicrobial lock therapy. This may be a missed opportunity as there is an abundance of data in the literature to support this preventative measure for such patients, many of whom have limited alternative access sites.

Rate of surgical site and urinary tract infections in dogs after cessation of antibiotics following spinal surgery.

Excessive use of antimicrobials and the increasing occurrence of antimicrobial resistance are major challenges in both human and veterinary medicine. The role of prophylactic antimicrobial therapy in orthopaedic and neurosurgeries in dogs can be questioned. The aim of this study was to evaluate the rate of surgical site infections (SSI) and urinary tract infections (UTI) in dogs after cessation of antibiotics following spinal surgery. Electronic patient records from January 2018 to December 2019 were retrospectively reviewed to identify dogs that underwent spinal surgery (n = 158). Antimicrobial drug use and the presence of SSI and UTI were recorded. Overall, SSI developed in 1.3% of dogs that underwent spinal surgery, while UTI developed in 8.2%. Multidrug-resistant (MDR) bacteria were detected in 5.1% of dogs. The rates of SSI, UTI and MDR did not differ significantly between dogs that received postoperative antimicrobial therapyandthosethatdidnot. The main limitation of this study was its retrospective design. Overall, the SSI rate in this study was low. Cessation of postoperative antimicrobial use in dogs followingspinal surgery did not havea negative effect on either SSI development or the occurrence of UTI.

Infection Control With Topical Antimicrobial Prophylaxis for Mucosal Head and Neck Surgery: A Meta-analysis.

To assess for differences in surgical site infection (SSI) rates and bacterial load after major mucosal head and neck surgery between patients who received topical antimicrobial prophylaxis and those who did not. Ovid Medline, Embase, SCOPUS, Cochrane Library, and ClinicalTrials.gov from inception to May 20, 2021, with cross-referencing of retrieved studies per PRISMA guidelines. Inclusion criteria captured clinical trials, cohort studies, and case-control studies with infectious outcomes of adults who underwent major mucosal head and neck surgery and received perioperative topical antimicrobial therapy to the oral cavity and/or pharynx. Studies of dental procedures were excluded. The primary outcome was SSI rate, and the secondary outcome was bacterial load. Two blinded investigators screened each text. Of 265 unique citations, 9 studies of 470 total patients were included. Topical treatments included numerous antibiotics and antiseptics directly applied over mucosa. Pooled SSI rates of 252 patients in the intervention cohort and 218 in the control cohort were 8% (95% CI, 3%-14%; I 2 = 61.2%) and 29% (95% CI, 16%-43%; I 2 = 79.5%), respectively. A meta-analysis of 7 comparative studies totaling 192 patients receiving topical therapy and 218 control patients revealed a pooled relative risk of 0.44 (95% CI, 0.28-0.68; I 2 = 0.0%) in favor of the treatment group. The studies demonstrated a short-term decrease in bacterial counts after topical antimicrobial prophylaxis. Patients who underwent prophylactic topical antimicrobial therapy had less than half the risk of developing SSI after mucosal head and neck surgery when compared with those who received no topical prophylaxis.

809. Evaluation of Antimicrobial Prophylaxis Prescribing in Post-operative Neurosurgical Procedures

BackgroundDue to lack of relevant clinical data or guidelines, duration of post-operative prophylactic antimicrobial therapy for neurosurgical procedures at the Kaiser Permanente Northern California (KPNC) hospitals has varied among patients and is largely based on the clinical judgment of surgeons. Non-standardized perioperative microbial prophylaxis practice has been associated with excessive antimicrobial therapy, increased risk of drug resistance, institutional cost, and adverse drug effects. This study aims to evaluate differences in prescribing practices of post-operative prophylactic antibiotics among neurosurgeons and to observe the incidence of surgical site infections and adverse drug events caused by antimicrobial prophylaxis that are associated with varying durations of post-procedure prophylaxis.MethodsA retrospective, observational study of health plan members of KPNC who underwent neurosurgical procedures from 01/01/2011 to 12/31/2019. Prophylactic antimicrobial therapy and duration was identified from medication dispensing and administration records. The study analyzed rates of surgical site infection, post-surgical wound drainage, 60-day mortality, and adverse drug events within 60 days of surgery.ResultsThe cohort consisted of 491 patients. 140 received antibiotics for >24 hours and 351 received antibiotics for ≤24 hours. The most common procedures analyzed in our patient population were VP shunt insertion (70.7%) and craniotomy subdural hematoma evacuation (17.9%). There were more surgical site infections in those who received antibiotics >24 hours (4.3% vs 1.4%, p value= 0.05). Univariate logistic regression model showed receiving antibiotics for ≤ 24 hours significantly decreased chance of composite drug event (odds ratio 0.345, 95% CI 0.172-0.691, p value= 0.003).ConclusionThis study demonstrated that antimicrobial prophylaxis for neurosurgical procedures ≤24 hours decreases risk of adverse drug events. The study provides further evidence to support the development of a standardized protocol that recommends short duration of antibiotic prophylaxis for neurosurgical procedures at KPNC.Poster Disclosures All Authors: No reported disclosures

53. Optimizing Transitions of Care Antimicrobial Prescribing at a Community Teaching Hospital

BackgroundAntimicrobial stewardship integral to patient care. Institutions with stewardship decrease antibiotic use, cost, and antibiotic-associated infections. However, few efforts have been formally made to address discharge antimicrobial prescribing, even though many patients started on antibiotic therapy in the hospital are prescribed oral antibiotics to complete their regimens.MethodsThis was an IRB approved, quasi-experimental, pre-post study. Patients were included if they were >18 years and were discharged from the hospital with an oral antibiotic prescription. Patients discharged against medical advice, prescribed indefinite prophylactic antimicrobial therapy for legitimate reasons, or discharged to a skilled nursing facility were excluded. The retrospective group evaluated a random sample of patients discharged in 2/2020. The prospective group included patients discharged between 1/2021 – 6/2021. In the prospective group, a clinical pharmacist assessed the indication for antibiotics and pended discharge antibiotic prescriptions for physician review. Antibiotic choice and duration of therapy were based on local and national guidelines.Patient Screening for Inclusion and Exclusion Breakdown of patients screened, included, and excluded for studyResults86 (53.1%) of 162 retrospective patients from 2/2020 prior to implementation of the program demonstrated were discharged on inappropriate antimicrobial therapy with excessive duration being the principal driver for inappropriateness. In the prospective group of 64 patients, the rate of patients discharged on inappropriate antibiotics decreased to 28.1% (p=0.001). The duration of inappropriate therapy decreased from a mean of 4.6 days to 2.7 days (p=0.001). 45 (70.3%) of 64 prospective pharmacist’s interventions were accepted by providers.Study Outcomes Outcomes including overall appropriate prescribing, appropriate duration, spectrum, frequency, and dose, as well as days of inappropriate therapyConclusionLiterature demonstrates that prospective evaluation of discharge antibiotics by a clinical pharmacist is effective in improving appropriateness of discharge antibiotic prescriptions, optimizing duration of outpatient antibiotics as well as reducing unnecessarily broad-spectrum therapy. The prospective results from this study demonstrate that this innovative approach can improve outpatient oral antibiotic prescribing and provide a framework for other institutions to implement similar programs.Disclosures All Authors: No reported disclosures

Haploidentical Hematopoietic Stem Cell Transplantation With Reduced Intensity Conditioning, T-Cell Replete Grafts and Post-Transplant Cyclophosphamide In Pediatrics

Hematopoietic stem cell transplants (HSCT) may be curative in the treatment of many hematological diseases. However, most patients do not have an HLA- matched sibling donor and an unrelated donor search may be a long process, during which the patients' disease may relapse or progress. Haploidentical transplants with in vitro T-cell depletion have been used in Pediatrics. However, it requires specialized laboratory infra-structure to manipulate the graft, increases the chances of graft failure and relapse. In vivo T-cell depletion can be achieved with the use of post-transplant cyclophosphamide, as reported by the Johns Hopkins and other groups. The results in adults are very promising and comparable to unrelated double cord blood transplants. Children, however, have not been included in any of the reported protocols. Our objective is to report the institutional experience with five consecutive children who received Haploidentical HSCT with reduced intensity conditioning, T-cell replete grafts and post transplant cyclophosphamide. MethodsChildren with clear indication to be treated with HSCT and no HLA-matched related or unrelated donor available were offered compassionate haploidentical transplants. Conditioning comprised cyclophosphamide 14.5 mg/kg/day on days -6 and -5, fludarabine 30 mg/m2/day for five consecutive days starting on day -6, and 2Gy total body irradiation given in a single fraction on day -1. Bone marrow was harvested from donors and infused into recipients on day 0. The target nucleated cell dose was 5 x10(8) mononuclear marrow cells/kg (i.e., peripheral blood count was substracted from the marrow cell count). There was no graft manipulation. GVHD prophylaxis consisted of cyclophosphamide 50 mg/kg IV on days +3 and +4 with 140% Mesna divided on hours 0, 4, 8 and 12 after each dose, Mycophenolate mofetil 15 mg/kg po every 8 hours (maximum 3 g/day) from day +5 to day +35, and tacrolimus from day + 5 to day +180 to keep levels between 5 and 10ng/ml. Prophylactic antimicrobial therapy was started on day +1 and included fluconazole and acyclovir. ResultsFive children with AML and T-ALL (three in CR2; one induction failure and one 4th relapse) were offered haploidentical transplants as the first HSCT. They had a median age of 10 years (4-16) and weight 41 kg (14-67), 2 girls. One graft was a peripheral blood stem cell collection per physician preference. The median total nucleated cell count was 12x10(8)/kg (10-27) with 10x10(6) CD34/kg (5-15). Mucositis was mild in three patients and none of them had sinusoidal obstruction syndrome. All patients engrafted after a median 14 days (13-17) but one of them, in 4th relapse of acute promyelocytic leukemia (APL), rejected the graft. Two of four evaluable patients had mild acute graft versus host disease (GVHD), and one mild chronic GVHD. The patient with APL died of two graft rejections on day+125, one T-ALL relapsed on day+180 and three children are disease-free with excellent clinical status one month to 1.7 years after transplant. We conclude that haploidentical HSCT with post-transplant cyclophosphamide is feasible to treat children without an available matched related or unrelated donor and should be prospectively studied. Disclosures:No relevant conflicts of interest to declare.

ORAL MUCOSITIS – SIGNIFICANT COMPLICATION OF PEDIATRIC PATIENTS UNDERGOING HEMATOPOIETIC STEM CELL TRANSPLANTATION

Introduction. The prognosis of pediatric solid tumors has improved in recent years through the use of multimodal treatment – chemotherapy, local control (surgery and radiotherapy) and hematopoietic stem cell transplantation (HSCT) for high-risk forms. A limiting factor of these transplant procedures is short-term toxicity, oral mucositis (OM) being associated with potential severe evolution. The introduction of tandem stem cell transplant procedures, which increase the intensity of chemotherapy treatment and thus increase the response rate, is associated with increased toxicity. In this study we evaluated the impact of multiple transplant procedures on the severity and evolution of OM. Materials and methods. This retrospective study included 57 pediatric patients diagnosed with solid tumors (neuroblastoma, germ cell tumor, Ewing sarcoma, nephroblastoma) who underwent HSCT in the Pediatric Bone Marrow Transplantation Unit of Fundeni Clinical Institute, between January 2002 and December 2020. Patients were divided into 2 study groups: the first group included patients who had one HSCT procedure (43 patients) and the second group included patients who benefited from multiple HSCT procedures (14 patients). We evaluated the degree and average extent of OM, associated risk factors, duration of analgesic treatment and parenteral nutrition, as well as infectious risk. Conditioning regimens were based on administration of busulfan, thiotepa or ifosfamide. All patients received prophylactic antimicrobial therapy and followed a daily oral care protocol. Results. The 57 patients underwent 73 HSCT procedures for the following diagnoses: 36 neuroblastoma, 6 germinal cell tumor, 12 Ewing sarcoma and 3 Wilms tumor. Patients were diagnosed, staged and treated according to international protocols. The study highlights the influence on the degree of OM: delayed platelet engraftment and increased parenteral nutrition requirements correlated with the number of HSCT procedures per patient. Infectious risk was higher for patients from the second study group. Conclusions. OM treatment remains prevention-centered and identifying effective measures, encouraging modern treatment strategies and developing practical evidence-based guidelines are imperative.

Characterization of Prophylactic Antimicrobial Therapy Practices for Patients With Marine-Associated Injuries in the Emergency Department

Background: Centers for Disease Control and Prevention (CDC) recommendations for the treatment of marine-associated wound infections include empiric coverage for Vibrio species with a combination of a third-generation cephalosporin and doxycycline. These recommendations are based on limited data and it remains unclear if this regimen is also indicated for prophylaxis. Objective: The purpose of this analysis was to assess the antibiotic regimens used in the emergency department (ED) for prophylaxis of marine-associated injuries relative to the CDC recommendations and evaluate any clinical impact. Methods: A retrospective review evaluated adult patients discharged from the ED over a 4-year period with an antibiotic prescription following an injury with marine exposure. Results: 114 patients were included in the analysis. The majority of patients were < 40 years of age with no previous medical history and presented after sustaining a laceration secondary to oyster shells. 97.4% received prophylactic antibiotic therapy that did not match the CDC recommendations, with the majority receiving doxycycline monotherapy (82%). A 1.8% 30-day ED revisit rate was noted with 2 patients returning for therapy failure. No patients were admitted to the hospital within 30 days and no documented adverse effects related to antibiotic therapy were noted. Conclusion: Current prophylactic antibiotic prescribing practices diverge from the current CDC recommendations for the treatment of marine-associated infections, however, an effect secondary to these variations was not observed. Further investigations of prophylaxis against Vibrio infections in low-risk patients is warranted to limit collateral damage and improve antimicrobial stewardship in the ED.

COVID-19 Infection in a 13-year-old Heart Transplant Recipient in Immediate Post Transplant Period - A Case Report

IntroductionExperience regarding course and outcome of Covid-19 infection in heart transplant recipients is limited. Case fatality rate of 25% of covid-19 infection in adult recipients of heart transplant and mild and self-limited disease in young heart transplant patients have been reported in small case series. We describe a case where a 13 year old patient contracted covid-19 infection on 7th post-operative day after undergoing heart transplant and was subsequently discharged from hospital uneventfully.Case ReportA 13 year old boy, with dilated cardiomyopathy underwent orthotopic heart transplant surgery. In the immediate pre-operative period, the real-time polymerase chain reaction (RTPCR) of nasopharyngeal swabs of both the recipient and the brain-dead organ donor were negative for severe acute respiratory syndrome coronavirus type 2 (SARS CoV 2). The intraoperative and immediate postoperative periods were uneventful. The recipient got weaned off from mechanical ventilation on the 1st postoperative day and O2 support was weaned off on 4th postoperative day. He was put on immunosuppressive regimen consisting of mycophenolate mofetil, tacrolimus and prednisone. On 7th postoperative day, he complained of fever, sore throat and dry cough. Nasopharyngeal swab for RTPCR was sent. It reported positive for SARS CoV 2. He was shifted to isolation facility. He maintained more than 94% saturation on pulse oximetry in room air. Immunosuppressive regimen was continued. He was administered 5-day course of remdesivir. Inotropic support was weaned off on 10th postoperative day. On serial bedside echocardiography, the allograft function was found to be normal throughout. He was kept on prophylactic antimicrobial, antifungal and anti-cytomegaloviral therapy and on prophylactic dose of low molecular weight heparin. There was initial rise in neutrophil lymphocyte ratio (17), C reactive protein (58 mg/l), ferritin (871 ng/ml), D-dimer (1904 ng/ml), Troponin T (227 pg/ml) levels, which gradually came down to within normal limits. He was discharged on 38th postoperative day to a home isolation facility as his RTPCR for SARS CoV 2 was still positive, although he remained completely asymptomatic for the last 21 days.SummaryThe course of Covid-19 infection in the immediate post-transplant period of this young heart transplant recipient was largely uneventful.

Prophylaxis for Chagas Disease Reactivation: Is it Necessary?

<h3>Purpose</h3> Chagas disease (CD) is caused by the parasite T cruzi and may reactivate in immunosuppressed transplant recipients. The incidence of CD has increased in Southern California as patients with Chagas cardiomyopathy may progress to require heart transplantation. While there are prophylactic medications for CD, is it not clear whether this prophylaxis prevents CD reactivation. <h3>Methods</h3> We reviewed 13 recipients transplanted between 1999 and 2019 who had CD prior to transplant. These patients had CD serologies checked at 1, 3, 6, 12 months post-transplant. 7 had T cruzi IgG antibodies and were given nifurtimox (n=2) or benznidazole (n=5). The other 6 did not develop antibodies and were not given antimicrobial therapy. Outcomes were compared: symptomatic CD, 1-year survival, freedom from rejection [any-treated (ATR), acute cellular (ACR) and antibody-mediated rejections (AMR)]. <h3>Results</h3> The patients who received antimicrobial therapy had numerically better 1-year survival. There was no difference in 1-year rejection (Table). Of the 7 patients who received antimicrobial therapy, none had CD reactivation while 3 patients in the no-prophylaxis group had CD reactivation. <h3>Conclusion</h3> Heart transplant patients with a history of CD appear to have acceptable outcome when closely monitored and administered antimicrobial therapy when indicated. Administration of prophylactic antimicrobial therapy to all CD, even without IgG antibodies, may be considered.

Acute corneal hydrops of presumed traumatic origin: An uncontrolled case series (three horses)

SummaryThis case series describes acute corneal hydrops in three young horses. Due to similarities in the clinical appearance and progression of the disease with that which is reported in humans and cats with acute corneal hydrops, traumatic Descemet’s membrane rupture was suspected to be the underlying aetiology in these equine cases. The horses presented with acute severe corneal oedema with intrastromal bullae formation and anterior bulging of the corneal contour. Focal posterior corneal changes were also seen in two of three cases. Mild anterior uveitis was also present. Other causes of corneal oedema (e.g. glaucoma) were ruled out based on presentation and clinical examination. Treatment approaches were medical and included various combinations of prophylactic topical antimicrobial therapy in case of secondary corneal ulceration, anti‐inflammatory therapy for uveitis, targeted oedema therapy with topical hypertonic saline and corneal cross‐linking, and placement of a temporary partial tarsorrhaphy for corneal tamponade. The outcome was excellent in all cases, with rapid resolution of the ocular changes. Acute corneal hydrops of presumed traumatic Descemet’s membrane rupture origin should be considered in cases of young horses presenting with acute corneal oedema. However, further studies are warranted to better characterise the disease and to try to confirm the suspected aetiology.

Non-infectious complications in the group of pediatric patients with chronic granulomatous disease

Chronic granulomatous disease (CGD) is a primary immunodeficiency (PID), characterized by a defective production of reactive oxygen species by phagocytes. Infectious diseases are a classic manifestation of this form of PID; however, many patients present with a variety of inflammatory and immune non-infectious complications. We analyzed non-infectious complications in a group of 60 patients with CGD, who were treated in Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology (Moscow, Russia) since 2012 to February 2020. This study is supported by the Independent Ethics Committee and approved by the Academic Council of the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology. Non-infectious manifestations were recorded in 53/60 patients, the most frequent of which were granulomatous complications (81.7% (49/60) of cases) in the following organs - the gastrointestinal tract, lungs, liver and lymph nodes. The median age of granulomas presentation was 3 years, and 45.8% of patients had a combined granulomatous lesion of several organs. Hepatomegaly (40%), splenomegaly (31.7%), dermatitis (21.7%) and chorioretinal lesions (11.3%) were other non-infectious complications. Hematological features outside acute infectious episodes included monocytosis (26.7%), eosinophilia (20%), neutrophilia (13.3%). 96.7% of patients had anemia with a decrease level of serum iron (65%), 31.7% - with signs of hemolysis. Autoimmune manifestations included arthritis, thyroiditis, immune thrombocytopenia or immune neutropenia. Non-infectious complications comprise a significant part of the CGD manifestations and often are the first symptoms of the disease. Awareness of this fact is very important for multidisciplinary approach in treatment of CGD. Delayed diagnosis and immunosuppressive therapy of non-infectious complications without prophylactic antimicrobial therapy can be life-threatening for patients with CGD.

Assessment of Antibiotic Prophylaxis in Surgical Patients and Association Factors at Thu Duc District Hospital, Ho Chi Minh City, Vietnam in 2018.

Surgical antibiotic prophylaxis (SAP) is considered an important interventional tool for antimicrobial resistance. Guideline compliance was poor across different countries and this results in an inappropriate and overuse of antibiotics. The study was cross-sectional, combining qualitative and quantitative. The Research used the MOH’s Antibiotic Preventive Medicine Guidelines as the standard to verify surgical preventive treatment compliance from patient medical records. Research performed on 373 medical records with surgical indications. The study was conducted from January to June 2019. Data were entered using Epidata software and processed by SPSS software version 19.0. Analysis: calculating OR for related factors. The compliance rate of using prophylactic antibiotics was 83.1%. There is a relationship between the type of incision, the length of time surgery, and compliance with surgical prophylactic use of antibiotics (P < .05). Barriers to adherence to prophylactic antimicrobial therapy include: overcrowding patients, health-care workers “broad-spectrum antibiotic use habits, and health-care workers” views on surgical and muscle environment, the material was not completely sterilized.