Purulent Drainage Research Articles

NCMP-29. BRAIN LESIONS IN A TEEN WITH NEWLY DIAGNOSED T-CELL ALL AND SARS-COV-2 INFECTION

Abstract T-cell Lymphoblastic Leukemia (T-cell ALL) accounts for up to 15% of all newly diagnosed cases of acute lymphoblastic leukemia in pediatric patients (0-18 years old). Patients are at risk of opportunistic infections during induction therapy with up to 2% developing blood stream infections when their absolute neutrophil count is above 1,500. We report a case of a 15-year-old female with High-Risk T-cell ALL, CNS1 (negative CNS disease), presenting with three days of headaches, photophobia, and non-neutropenic fever. She completed induction chemotherapy one week earlier with vincristine, daunorubicin, calaspargase and a 28-day course of dexamethasone. On physical exam, she had no focal deficits or changes in sensation or strength. CBC was notable for a white blood cell count: 7500, hemoglobin: 8.6, platelets: 328,000 and ANC (Absolute Neutrophil Count): 4700. The patient was also COVID positive on admission. A contrast enhanced MRI brain demonstrated multiple diffusion restricting and peripherally enhancing lesions, concerning for intracranial abscesses. Neurosurgery performed a burr hole craniotomy and aspirated 5 mL of purulent drainage, the culture of which grew Aspergillus fumigatus complex. The patient was started empirically on Voriconazole, in addition to broad spectrum antibiotic coverage pending culture results, due to excellent CNS penetration and proven superiority to amphotericin-based therapy for invasive aspergillosis. Micafungin was added due to CT chest demonstrating nodular infiltrates, suggesting primary pulmonary aspergillosis with CNS dissemination. The patient improved symptomatically without further sequelae. Patients with COVID-19 on prolonged courses of corticosteroids are at higher risk of developing fungal co-infections regardless of neutrophil count. While pulmonary aspergillosis is the most common location of a COVID-19 aspergillus coinfection, there have been documented reports of intracranial micro-abscesses. Contrast-enhanced brain MRI should be obtained in any patient with a recent history of COVID-19 presenting with new neurological symptoms, especially in a patient with a recent history of corticosteroids.

A Rare Presentation of Acute Suppurative Thyroiditis.

A previously healthy 17-year-old female patient initially presented with symptoms of anterior neck pain. After multiple emergency department visits, she was found to have unilateral enlargement of her thyroid gland. Laboratory studies were consistent with hyperthyroidism. Symptoms were initially attributed to subacute thyroiditis, and she was discharged with steroids and propranolol. She presented again 1 week later with complaints of nausea, vomiting, abdominal pain, and shortness of breath. She was readmitted and developed sepsis with multiorgan system infection and Lemierre syndrome. Further imaging revealed acute suppurative thyroiditis as the likely source. Direct laryngoscopy and bronchoscopy revealed ulceration of the anterior esophageal wall, a fistulous tract to the thyroid, and copious purulent drainage. Esophageal biopsies with immunostaining established a diagnosis of herpes simplex virus esophagitis as the likely cause of esophageal perforation, fistula development, and acute suppurative thyroiditis.

First report on the occurrence of psoroptic mange in llamas (Lama glama) of the Andean region.

An outbreak of Psoroptes sp.-caused mange was detected in a llama herd of Larcas, Jujuy province, Argentina. Infested llamas showed alopecia, erythema, hyperpigmentation, hyperkeratosis, and inflammation of the ear pinnae, as well as crusts and serous, serosanguineous, or purulent drainage with unpleasant smell in the external ear canal. Microscopic evaluation of skin scrapings revealed 0.5- to 0.7-mm-long acari identified as Psoroptes sp. based on their morphology. Histology showed a typical allergic reaction with perivascular to periadnexal mixed inflammatory infiltrate. Phylogenetic tree analysis showed that the cytochrome c oxidase subunit I gene sequences analyzed from the sampled acari clustered into a single P. ovis clade including sequences isolated from rabbits and bighorn sheep, with P. natalensis as a sister taxon that infested bighorn sheep from the USA. Phylogenetic analysis of cytochrome b sequences showed three well-supported clades, one of which contained the sequences of the Larcas llamas and US bighorn sheep isolates. This is the first report on P. ovis infestation of llamas raised in their original location. Investigations on mange etiological agents acting on South American camelids and their distribution are necessary to implement control strategies to mitigate the negative impacts of these parasitic infections.

The value of an open biopsy in the diagnosis of periprosthetic joint infection

IntroductionDetermining the presence of bacteria in the shoulder prior to shoulder arthroplasty can be challenging especially in the case of revision arthroplasty. An open biopsy provides an opportunity to obtain tissue samples with minimal patient morbidity. The purpose of this study was to characterize the diagnostic utility of an open shoulder biopsy. MethodsA retrospective cohort study was performed at an academic medical center. All patients that underwent an open shoulder biopsy using a small proximal deltopectoral incision between 2008 and 2021 were included. Demographics, surgical history, culture results, and development of subsequent infection were recorded. Subsequent infection was defined as the development of a sinus tract, purulent drainage, or revision surgery with greater than or equal to two tissues specimens with growth of the same bacterial species. Sensitivity and negative predictive value (NPV) of an open biopsy were calculated based on the development of subsequent infection. As culture positive patients were treated for their infection, positive predictive value and specificity could not be determined. ResultsWe identified 55 patients that underwent 75 open biopsies. Most patients had a shoulder arthroplasty in place at the time of biopsy (69.1%), while 23.6% had an antibiotic spacer, and 7.3% had a native shoulder. Patients with a history of infection were more likely to have a spacer in place at the time of biopsy (65% vs. 0%; P < 0.001). The sensitivity of an open biopsy was 60% and the NPV was 83% among patients with a shoulder arthroplasty with no history of infection to predict infection after revision arthroplasty. The sensitivity was 63% and NPV was 75% among patients with any history of shoulder infection. The sensitivity was 67% and the NPV was 83% among patients with an arthroplasty in place at the time of biopsy independent of prior infection. The sensitivity was 62% and the NPV was 75% among patients with an antibiotic spacer at the time of biopsy. Mean operative time was 32.2±10.5 minutes. DiscussionThis diagnostic utility of an open shoulder biopsy is not influenced by whether there is a history of infection or whether there is currently a spacer or an arthroplasty in place, with a sensitivity between 60% and 67% and a NPV between 75% and 83%.

Should Blood Cultures Be Drawn Through an Indwelling Catheter?

There is no practical way to definitively diagnose a catheter-related bloodstream infection in situ if blood cultures are only obtained percutaneously unless there is the rare occurrence of purulent drainage from a central venous catheter insertion site. That is why the Infectious Diseases Society of America guidelines for diagnosis and management of catheter-related bloodstream infections and Infectious Diseases Society of America guidelines for evaluation of fever in critically ill patients both recommend drawing blood cultures from a central venous catheter and percutaneously if the catheter is a suspected source of infection. However, central venous catheter-drawn blood cultures may be more likely to be positive reflecting catheter hub, connector, or intraluminal colonization, and many hospitals in the United States discourage blood culture collection from catheters in an effort to reduce reporting of central-line associated bloodstream infections to the Centers for Disease Control and Prevention. As such, clinical decisions are made regarding catheter removal or other therapeutic interventions based on incomplete and potentially inaccurate data. We urge clinicians to obtain catheter-drawn blood cultures when the catheter may be the source of suspected infection.

Effectiveness evaluation of antibiotic use in patients with Methicillin-resistant Staphylococcus aureus (MRSA) infection: a review

Methicillin-resistant Staphylococcus aureus (MRSA) is a pathogen that become a public health problem due to its ability to be resistant to more than three classes of antibiotics. Evaluation of the effectiveness of antibiotic use in patients with MRSA is important to optimize antibiotic use and to control antibiotic resistance. This article review attempted to evaluate the effectiveness of antibiotics in patients with MRSA. This review explored the results of previous research from PubMed as a literature source and the PRISMA flow diagram as a protocol for the article selection process. Eight studies reviewed the evaluation of the effectiveness of antibiotic use in MRSA patients with various clinical conditions, such as uncomplicated wound infections, cellulitis and no wound, purulent drainage or abscess, cSSSI infections caused by MRSA, infections caused by MRSA bacteremia and nosocomial infections caused by MRSA. In conclusion, the effectiveness of antibiotics in patients with MRSA infection depends on the clinical condition of each patient. Therefore, the use of antibiotics is adjusted based on the type of infection and the efficacy of the antibiotics. Combination therapy is recommended for MRSA patients considering its life-threatening ability.

Abstract 18489: Double Edged Sword: SGLT-2 Inhibitors in the Immunosuppressed Heart Failure Patient

Introduction: SGLT-2 inhibitors are often prescribed for patients with heart failure, as a part of Goal Directed Medical Therapy. There is a known risk of genitourinary tract infections with utilizing this medication class. We present a case of a patient on chronic immunosuppression therapy on Dapagliflozin who developed a prostate abscess. Case Description: 70-year-old male with history of cardiac sarcoidosis on prednisone and mycophenolate mofetil, non-ischemic cardiomyopathy, and atrial fibrillation who initially presented with suprapubic pain and urinary urgency for two weeks. Urinalysis was positive for glucose greater than 1,000 and urine culture positive for Klebsiella pneumoniae. CT imaging revealed a prostate abscess measuring 4.5 x 4.4 x 5.7cm. Patient underwent CT guided drainage of the prostate abscess with thick, purulent drainage that cultured positive for Klebsiella pneumonia. He was initially started on an 8-day course of Ceftriaxone but transitioned to Trimethoprim-Sulfamethoxazole for 6-weeks at discharge. He was previously prescribed Empagliflozin for heart failure, however, this was discontinued due to expense and was switched to Dapagliflozin four months prior to presentation. Discussion: SGLT-2 inhibitors are commonly prescribed in heart failure patients. We encourage special consideration in patients at increased risk of infection, prior to starting SGLT-2 inhibitors as they may have more complicated manifestations of side effects. In this case, the patient underwent procedural interventions and required long term antibiotic therapy as a consequence of SGLT-2 inhibitor use. Conclusion: Patients who are chronically immunosuppressed are at increased risk for infections, including genitourinary, compared to the general population. While trying to optimize patient's cardiomyopathy, it is imperative to consider their risk for developing complications when initiating SGLT-2 inhibitors in immunocompromised patients.

Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania

IntroductionFracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania. Materials and MethodsPatients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7–10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two “confirmatory” criteria questions for FRI (i.e., open wound and purulent drainage) and three “suggestive” criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator. ResultsThere were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %). ConclusionOur study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.

Abstract 11918: Simultaneous Presentation of Pyogenic Pericarditis, Coronavirus Infection, and Endocarditis: A Challenging Triad in a Single Patient

Background: Pyogenic pericarditis is a rapidly progressive infection with high mortality near 100%. In the present antibiotic age, bacterial pericarditis is an uncommon cause of acute pericarditis. The reported incidence of pyogenic pericarditis is less than 1% of all pericarditis cases. Case: 54 year-old male patient that presented with complaints of generalized weakness, fatigue, and fever. He was diagnosed with Coronavirus 229E by PCR. He was in respiratory distress, and CT chest showed concern for large pericardial effusion. Transthoracic echocardiogram showed large pericardial effusion (Image) without tamponade effect. Patient decompensated overnight and bedside point of care ultrasound overnight showed concern for tamponade effect. Pericardial window was performed and 800 ml thick purulent drainage evacuated. While in the ICU patient underwent transesophageal echocardiogram that showed Small hyper-mobile echo-density on the aortic valve concerning for endocarditis (image). Patient also had Type 1 Bicuspid aortic valve with heavily calcified raphe. Cultures on the pericardial effusion grew methicillin sensitive Staphylococcus Aureus. Patient will need 6 weeks of IV antibiotics and aortic valve replacement. Infectious disease recommended lifelong suppression therapy for MSSA. Decision-making: It is not uncommon for bacterial endocarditis and viruses to cause pericardial effusions. It is uncommon for a patient to have bacterial endocarditis, Coronavirus, and be diagnosed with pyogenic pericardial effusion. Cardiac tamponade is a clinical emergency, and evacuation of pericardial fluid to assist reduce the pressure surrounding the heart is used to treat cardiac tamponade. Conclusion: Here we present a case to our knowledge that has never been described before. This is a case of a patient that had infective endocarditis with confirmed Coronavirus that resulted in a pyogenic pericardial effusion.

Osteomyelitis of the Ischium in a Hemodialysis Dependent Adult – A Rare Case Report

Introduction: Osteomyelitis of the pelvis is rare, and the correct diagnosis may be missed during the early stage when the correct treatment would be most beneficial. Osteomyelitis requires multidisciplinary treatment to cure or control symptoms. Case Presentation: A 71-year-old woman, with end stage renal disease on hemodialysis, presented in emergency department for purulent drainage of a right buttock swelling. A pelvic computer tomography (CT) revealed a collection of the gluteal musculature and an activated chronic osteomyelitis with one osteolytic lesion on right ischiopubic branch. The patient underwent surgical treatment, with need of two interventions. First, she was only submitted to surgical drainage of the abscess. She completed a cycle of antibiotic therapy, with good response. Two months later, she returns with fever and drainage of the surgical wound. A pelvic CT showed an area of bone destruction at right ischium, with an increase in bone sequestration. She underwent a partial orchiectomy and surgical debridement of necrotic tissues. A Klebsiella oxytoca, Proteus mirabilis and multidrug-resistant Staphylococcus epidermidis was isolated. She was on antibiotic therapy for 4 months. Three years later, she remains without new symptoms or signs of active osteomyelitis. Conclusion: Pelvic osteomyelitis represents a diagnostic challenge, because the symptoms and signs vary, depending on the initial site of infection, its duration and the direction of its spread. Osteomyelitis of the ischium is generally diagnosed in the late stage with complications. Treatment of pelvic osteomyelitis is challenging due to the anatomic constraints of the pelvis and the high degree of comorbidity in affected patients. A multidisciplinary approach is often required. This case of a chronic abscess with osteomyelitis of the ischium is rare and was neglected for months because of the absence of constitutional symptoms in a hemodialysis dependent woman.

MYCOBACTERIUM ABSCESSUS SCLERAL BUCKLE INFECTION.

To report the successful management of a rare case of Mycobacterium abscessus scleral buckle infection. Case report. A 63-year-old woman with a history of sarcoid anterior uveitis and macula-off retinal detachment repaired by scleral buckle and pars plana vitrectomy presented with eye pain, redness, and purulent drainage in the left eye. Slit-lamp examination showed superonasal scleral buckle exposure, purulent conjunctival discharge, corneal edema, nongranulomatous keratic precipitates, and anterior chamber cell and flare. The patient underwent urgent scleral buckle removal. Intraoperatively, an area of scleral thinning without perforation underneath the exposed buckle was discovered and covered with a scleral patch graft, and an amniotic membrane graft was used to cover an area of bare sclera with significant conjunctival scarring and retraction. Cultures grew M. abscessus panresistant except to amikacin. After 6 weeks of fortified amikacin drops and a long taper of topical steroid therapy for persistent postoperative anterior uveitis, the patient's symptoms resolved. Mycobacterium is an emerging causative agent of scleral buckle infections. Our report provides insights about the management of such cases.

The hidden star: mastoiditis as a late sequela of retained foreign body in the nose

BackgroundAcute mastoiditis is an intratemporal complication due to acute otitis media (AOM). Common risk factors include young age (often < 24 months), high values of C-reactive protein and previous antibiotic therapy, previous middle ear infection, or history of ear surgery. The main factor of acute mastoiditis is obstruction of the aditus antrum by granulation tissue or mucosa edema, inhibiting purulent drainage from the mastoid. Retained foreign body in the nose is a rare indirect cause of acute mastoiditis. It may be due to mucosal inflammation and accumulation of secretion causing nasal tract or nasopharyngeal infection leading to otitis media and later manifesting as an intratemporal complication.Case presentationWe report a case of acute mastoiditis as a late sequela of retained foreign body in the nose, and we also emphasize the incidental radiological finding of a star-shaped foreign body in the nose, which was a miss during the initial presentation. Further questioning revealed a history of recurrent unilateral blood-stained, foul-smelling nasal discharge, which was left untreated for years, leading to a delayed presentation of acute mastoiditis. After removing the foreign body and broad-spectrum antibiotic administration, complete disease resolution was achieved.ConclusionAlthough rare, retained foreign bodies of the nose must be ruled out in certain cases of mastoiditis. A thorough history with a high index of clinical suspicion is recommended for early diagnosis to prevent complications.

SAT256 Buschke Loewenstein Tumor Presenting With Hypercalcemia

Abstract Disclosure: K. Jones: None. P. Krutilova: None. J.B. McGill: None. Introduction: Humoral hypercalcemia of malignancy is known to be associated with squamous cell carcinomas (SCC), although rarely seen in the setting of skin cancer. We present an interesting case of a young patient with giant condyloma acuminatum complicated by SCC presenting with severe hypercalcemia. Case Description: A 37-year-old man presented with pain and purulent drainage due to bacterial superinfection of genital warts. He had recurrent and locally advanced condylomas, first occurring more than 10 years ago. Skin lesions in the genital and perianal area never resolved and he required multiple surgical interventions including sigmoid colostomy placement due to Fournier gangrene. His laboratory evaluation this admission was notable for an elevated calcium level (13.0 mg/dL [8.5-10.3], albumin 3.4 g/dL [3.5-5.0]), phosphorus 3.9 mg/dL [2.3-4.5], and normal kidney function. He did not have history of hypercalcemia and was not taking any calcium supplements. Hypercalcemia prompted work-up including: PTH 4 pg/mL [15-65], 25-OH vitamin D 36 ng/mL [30-80], unremarkable SPEP/UPEP, TSH 0.91 mcIUnit/mL [0.3-4.2]. Initial differential diagnosis included hypercalcemia due to granulomatous process and increased production of calcitriol vs. PTH-related protein (PTHrP) mediated hypercalcemia. 1,25-OH vitamin D was normal (33 pg/mL [18-64]) and PTHrP was elevated (6.7 pmol/L [&amp;lt;4.2]). The patient subsequently underwent biopsy of groin lesions which demonstrated SCC in situ. PET/CT only demonstrated hypermetabolic changes in the perineum and groins bilaterally. Inguinal lymph node biopsy was negative for malignancy. His hypercalcemia persisted despite administration of IV fluids and he was treated with IV zolendronic acid. Calcium level subsequently normalized (9.1 mg/dL). He underwent extensive excision of the tumor involving the right gracilis muscle, left testicle, portions of the perineum, and penile shaft skin. Discussion: While cases of hypercalcemia in malignancy are common, this is an unusual case of giant condyloma acuminata (GCA) heralding development of SCC by elevated calcium levels. GCA also known as Buschke-Loewenstein tumor is a rare disease with estimated incidence of 0.1% in the general population and a male-to-female ratio of 2.7:1, typically associated with human papilloma virus subtypes 6 and 11. It is a locally aggressive tumor with a potential for destructive growth and malignant transformation (estimated rate up to 56%), very high rate of recurrence after excision (66%), and overall mortality of approximately 20%. Early recognition and treatment of GCA is essential in order to prevent devastating complications. Purzycka-Bohdan D, Nowicki RJ, Herms F, et al. The Pathogenesis of Giant Condyloma Acuminatum (Buschke-Lowenstein Tumor): An Overview. Int J Mol Sci. 2022;23(9):4547. Published 2022 Apr 20. doi:10.3390/ijms23094547 Presentation: Saturday, June 17, 2023

Carrier State of Chronic Granulomatous Disease Presented at Middle Age: A Case Report

Introduction: Chronic granulomatous disease (CGD) is the most common inherited defect of phagocytes. Although most female carriers of X-linked CGD have been considered to be unaffected, they may have similar problems to those of CGD patients. This study suggests that the CGD carrier state might be more complex than it was previously appreciated. Case Presentation: A sixty-year-old woman visited our hospital in June 2021 due to pneumonia and pleural effusion. Chest computed tomography scan revealed left lower lobe pneumonia and mediastinal lymphadenopathies. In July 2021, her symptoms (high-grade fever, chills, and hemoptysis) were initially attributed to a hydatid cyst. Therefore, she underwent a lobectomy, resulting in purulent drainage on the excision site on the skin, refractory to local and systemic treatments. The refractory and recurrent nature of the lesions led to the immunological evaluation, which was completely normal with a 100% nitroblue tetrazolium (NBT) and a dihydrorhodamine (DHR) of 278 (normal &gt; 100). Further DHR123 flow cytometry investigations with multiple stimulants revealed a carrier state of CGD, which was relevant to her history of chronic complications. Conclusions: Adult patients with unusual manifestations suggestive of neutrophil function defects in adulthood should be evaluated for the CGD carrier state. In these cases, NBT alone may miss the diagnosis of CGD. In such cases, DHR testing with multiple stimulants may establish a robust diagnosis.

Delayed Sublingual Edema Following Neonatal Mandibular Distraction Osteogenesis.

The authors aim to report a rare sequela following neonatal mandibular distraction osteogenesis (MDO) involving delayed onset sublingual swelling. They performed a retrospective chart review of 3 patients who presented with delayed onset sublingual edema following neonatal MDO. The 3 patients presented at 2, 4, and 12 months following MDO for micrognathia secondary to Robin sequence with intermittent sublingual swelling associated with sialorrhea and feeding difficulties. There was no associated recent illness, fevers, or purulent drainage. All 3 children underwent magnetic resonance imaging which demonstrated asymmetric sublingual gland edema. The edema was located on the left sublingual gland in 2 children and was bilateral in the third. The symptoms continue to recur 25.5±3.3 months (range, 22.3-28.9) postoperatively and all are being managed conservatively. Chronic delayed onset intermittent sublingual edema is a possible long-term complication following neonatal MDO and further studies should explore the incidence and management of this finding.

The Role of Continuous Positive Airway Pressure Chinstraps in the Development of Neonatal Suppurative Parotitis

Neonatal suppurative parotitis is a rare entity in the neonatal period that typically presents with unilateral parotid swelling, tenderness, erythema, and purulent drainage of Stensen’s duct. We present a 6-week-old male with a history of prematurity who exhibited physical exam findings suspicious for a suppurative parotitis. We propose that the extended use of continuous positive airway pressure chinstraps may be a contributing factor to the development of suppurative parotitis in our neonates. This case accentuates a unique presentation of neonatal suppurative parotitis.

#5521 TENCKHOFF CATHETER EXIT-SITE INFECTION BY ACTINOMYCES ODONTOLYTICUS: A RARE CASE

Abstract Background and Aims Actinomyces odontolyticus is an anaerobic Gram-positive bacteria, which can be found among the commensal flora of the mouth and oropharynx. Diagnosis of infections due to this microorganism can be difficult because of its rarity, indolent course and lack of specific symptoms. Only one case of exit-site infection (ESI) due to Actinomyces odontolyticus in a patient on continuous ambulatory peritoneal dialysis (CAPD) has been reported. This work aims to report a case of ESI due to this rare agent. Method We present a case of Tenckhoff catheter ESI due to Actinomyces odontolyticus in a patient on CAPD. Results Case report: We report the case of a 26-year-old woman with a personal history of dyslipidemia, arterial hypertension and end-stage chronic kidney disease caused by Alport Syndrome in a CAPD program since April 2016. In June 2020, the patient presented an episode of refractory ESI due to methicillin-sensitive Staphylococcus aureus and was submitted to a shaving of the external cuff of the Tenckhoff catheter, with good subsequent evolution. The patient had no complications related to the catheter until April 2021, when she presented purulent drainage through the exit-site associated with erythema of the surrounding area. The consecutive exit-site swabs were negative. She underwent antibiotic therapy with cotrimoxazole for 2 weeks with apparent resolution. However, in May 2021, the patient presents again erythema and purulent drainage and, at that time, a rare agent was isolated in the swab: Actinomyces odontolyticus with resistance to penicillin, amoxicillin, ceftriaxone and cotrimoxazole. Given this isolation, the patient was treated with doxycycline 100mg every 12 hours for 4 weeks. The evolution was favorable with resolution of the infection and absence of recurrence for a 6-month follow-up. At the end of this follow-up time, the patient was transplanted. Conclusion Actinomyces odontolyticus is a bacteria of the commensal flora of the oral cavity and upper gastrointestinal tract, which can acquire pathogenicity in situations of impaired mucosal integrity and in immunosuppressed patients. Infections caused by this agent are rare and represent a diagnostic challenge due to its growth in an anaerobic environment and prolonged isolation time (5 days to 4 weeks). The immunosuppression conferred by chronic kidney disease and the history of external cuff shaving may have propitiated the infection by this rare opportunistic agent in our patient. The ESI presented for the patient in the previous month, which did not have an identified agent, was possibly caused by Actinomyces odontolyticus, but it was not isolated probably due to culture difficulties. The treatment of Actinomyces infections is generally conservative with 2 to 4 weeks of high-dose of intravenous penicillin, followed by 2 to 6 months of oral antibiotic therapy. In case of allergy, regimens with ceftriaxone, doxycycline, clindamycin or carbapenems are recommended. There is no consensus on the duration of treatment, with some authors recommending a minimum of 2 to 6 weeks. The mentioned patient was treated with 4 weeks of doxycycline according to the sensitivity test and the result was favorable, without the need to remove the catheter.

(443) A Randomized Prospective Evaluation of Next-generation Sequencing Versus Traditional Cultures for Clinically Infected Penile Prostheses: Impact of Microbial Identification on Outcomes

Abstract Introduction Traditional culture is the current standard-of-care to determine therapeutic antibiotics for patients suffering from penile prostheses (PP) infections. However, approximately 50% of PPs removed for infection are culture negative. Next-generation sequencing (NGS) of DNA has proven to be beneficial in its thorough analysis of biofilm composition and determination of the relative abundance of specific microbes. In this prospective, multicenter, single-blinded, randomized controlled trial, we hypothesize that the use of NGS will lead to better therapeutic strategies that will result in improved patient outcomes by determining the microbial composition of infected PP. Objective We present our early results from our prospective study that compares outcomes of microbial identification between NGS versus culture for clinically infected PP. Methods Upon institutional review board approval, adult men undergoing treatment for mild to moderate PP infection are enrolled after providing informed consent. Enrollees are randomized to one of two analytic arms – traditional culture or NGS, using Captivate by ClinCapture. Patients with severe infection requiring urgent explantation are excluded. Traditional culture and NGS samples are collected upon clinical presentation prior to initiation of antibiotics. Specimens of infected fluid were collected, stored in sterile packaging, and transported for both traditional culture at the institutional laboratory and NGS testing (MicroGenDX, Lubbock, TX). Patients are started on set empiric antibiotics and randomized to traditional culture or NGS. Patients with a positive culture or NGS result will receive treatment-specific antibiotics, while patients with negative results continue empiric antibiotics for two weeks. For patients randomized to the NGS arm, positive results will undergo central infectious disease (ID) review, and antibiotics initiated based on their recommendations. Patients will follow up within ten days of antibiotic initiation and at six months to complete a safety and compliance questionnaire which assesses symptoms, device function, and patient satisfaction. Results To date, two patients have been enrolled. The first patient was randomized to the culture arm and presented with mild tenderness and drainage around the scrotal pump area for five days but remained afebrile. His culture resulted as Citrobacter koseri. He started empiric treatment with amoxicillin-clavulanate which was changed to ciprofloxacin based on culture results. The second patient was randomized to the NGS arm and presented with four days of bloody and purulent drainage from the scrotal pump area. Although he was afebrile, he had moderate tenderness, swelling, and erythema in his scrotum. NGS identified multiple organisms (data remains blinded). He was started on empiric trimethoprim-sulfamethoxazole but was treated successfully with a course of cefdinir and doxycycline per ID. Both patients had primary implants and did not require device removal. On the post-treatment questionnaire, both patients reported that their devices were working and endorsed high satisfaction rates. Conclusions This is the first prospective, randomized controlled trial comparing the utility and outcomes of NGS and culture for the identification of microbes in clinically infected PP. Currently, recruitment is ongoing. We hope that this trial will demonstrate a clinical benefit of NGS in characterizing distinct microbiomes of infected PP to tailor antimicrobial therapy. Disclosure Yes, this is sponsored by industry/sponsor: MicroGenDX Clarification Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: MicroGenDX

TREATMENT OF DIFFUSE INFLAMMATION IN THE JAW AREA: MULTIPLY 2 CLINICAL CASES LUDWIG’ ANGINA - CASES REPORT

Target: Analyze the factors related to the treatment results of diffuse facial inflammation through 2 cases to draw experience in diagnosis and management attitude. Objects - Methods: 2 patients diagnosed with diffuse inflammation in the jaw area were treated at the Faculty of Facial Surgery and Plastic - 108 Centre Military Hospital on December 2019. Method: Description of a cluster of diseases. Results - Discussion: Diagnosis of diffuse inflammation in the jaw area is based on clinical and imaging diagnosis. Diagnostic imaging methods can use ultrasound, computed tomography, magnetic resonance. Computer tomography is often used because of the rapid duration of the scan, assessment of soft inflammatory lesions, and to assess bone and tooth damage. Computerized tomography image said: (1) edema of the organization, the location, size of purulent foci, the direction of spread of inflammation, the appearance of air bubbles in the organization; (2) degree of tamponade of the airway; (3) condition of inflammation spread to the mediastinum, pleura; (4) the source of the infection can be teeth. Diffuse inflammation in the jaw area progresses rapidly, with a high risk of death. Treatment should be aggressive, comprehensive based on factors: early diagnosis, airway control, adequate purulent drainage enlargement surgery, high-dose antibiotics, cause tooth extraction. Conclude: Diffuse inflammation in the jaw area is an emergency disease, need early diagnosis and surgery, incision to remove the pus satisfactorily at the beginning, Combined with systemic antibiotics, treatment for other associated systemic disorders will bring good results, shorten treatment time, reduce the number of surgeries as well as treatment costs, reduce the risk of death.

Analysis of influencing factors of multiple urethrocutaneous fistula after urethroplasty in children with hypospadias.

The objective of this study was to investigate the influencing factors of multiple urethrocutaneous fistula (UF) after urethroplasty in children with hypospadias. The clinical data of 195 children with UF after urethroplasty treated surgically in the Third Affiliated Hospital of Zhengzhou University from August 2015 to August 2022 were retrospectively analyzed and divided into the single UF group (n = 134) and the multiple UF group (n = 61) according to whether multiple UF occurred after urethroplasty. The possible correlated factors were collected and compared between the two groups, including hypospadias degree, length of formed urethra, time of urethroplasty, pre-urethroplasty weight, age at urethroplasty, urethroplasty style, season of urethroplasty, the first fistula repair method, season of the first fistula repair, diameter of the largest fistula of the first fistula repair, time of the first fistula repair surgery, and other 13 factors. By univariate analysis, statistically significant differences were found between the two groups in age at urethroplasty, length of the formed urethra, method of urinary drainage after urethroplasty, whether or not purulent urethral drainage after first fistula repair was present, the first fistula repair method, and diameter of the largest fistula of the first fistula repair (P < 0.05). After multifactorial analysis, the independent risk factors associated with multiple UF after urethroplasty were determined to be use of a vesicostomy tube as the urinary drainage method after urethroplasty (P < 0.05, OR = 6.574, 95% CI: 2.720-15.891) and the presence of purulent urethral drainage after first fistula repair (P < 0.05, OR = 2.723, 95% CI: 1.214-6.109). A catheter as the drainage method after urethroplasty is an independent protective factor for multiple urethrocutaneous fistula, and the existence of purulent urethral secretions after the first fistula repair is an independent risk factor.