Sepsis Workup Research Articles

Leukocytosis and thrombocytosis after splenectomy: expected finding, infection, or something else: a case report

BackgroundLeukocytosis and thrombocytosis often follow splenectomy in blunt trauma patients, complicating the postoperative identification of infection. While the platelet count to white blood cell ratio provides diagnostic assistance to discern between expected laboratory alterations and infection, diagnoses such as leukemia are often overlooked.Case presentationA 53-year-old Hispanic male presented with abdominal pain, nausea, tachycardia, and focal peritonitis 4 days after being assaulted and struck multiple times in the abdomen. Initial white blood cell count was 38.4 × 109/L, platelet count was 691 × 109/L, and lipase was 55 U/L. Computed tomography abdomen/pelvis demonstrated a hematoma encasing the distal pancreas and abutting the stomach and colon. Emergent laparotomy revealed a nearly transected pancreas and devascularized colon, necessitating a distal pancreatectomy, splenectomy, and colonic resection with primary anastomosis. Postoperatively, he had a persistently elevated leukocytosis, thrombocytosis, segmented neutrophils, eosinophilia, and basophilia (peak at 70, 2293, 64, 1.1, and 1.2 × 109/L, respectively). Despite sepsis workup, including repeat computed tomography, no source was identified. Hematology/oncology was consulted for concern for hematologic etiology, with genetic testing and bone marrow biopsy performed. The diagnosis of breakpoint cluster–Abelson gene-positive chronic myeloid leukemia was made based on genetic tests, including polymerase chain reaction and fluorescence in situ hybridization analysis, which confirmed the presence of the Philadelphia chromosome. Bone marrow biopsy suggested a chronic phase. The patient was treated with hydroxyurea and transitioned to imatinib.ConclusionsThrombocytosis following splenectomy is a common complication and a plate count to white blood cell count ratio < 20 indicates infectious etiology. A significantly elevated white blood cell count (> 50 × 109/L) and thrombocytosis (> 2000 × 109/L) may suggest something more ominous, including chronic myeloid leukemia , particularly when elevated granulocyte counts are present. Chronic myeloid leukemia workup includes peripheral smear, bone marrow aspiration, and determination of Philadelphia chromosome. Post-splenectomy vaccines are still indicated within 14 days; however, the timing of immunization with cancer treatment must be considered. Tyrosine kinase inhibitors are the first-line therapy and benefits of pretreatment with hydroxyurea for cytoreduction remain under investigation. Additionally, tyrosine kinase inhibitors have been associated with gastrointestinal perforation and impaired wound healing, necessitating heightened attention in patients with a new bowel anastomosis.

Evaluation of the Efficacy and Safety of the Neonatal Sepsis Risk Calculator in a Tertiary Referral Center in Lebanon

Abstract Objective Early onset sepsis (EOS) is a significant cause of morbidity and mortality in the newborn period. This has led to overinvestigation and antibiotic overuse, which remains a concern in EOS management. Sepsis risk calculator (SRC), a tool validated in American and European populations, aids physicians in sepsis risk stratification and has been shown to decrease antibiotics overuse for EOS. The aim of the study was to evaluate the efficacy and safety of the SRC in a tertiary referral center in Lebanon. Methods This was a single-center retrospective cohort study, conducted at a tertiary medical center in Beirut, Lebanon, that included infants born at more than 34 weeks' gestational age between January 1, 2017 and January 1, 2019. Data was collected on risk factors for neonatal sepsis and the clinical management performed on each newborn. The SRC was used to calculate a sepsis risk score for each patient. Comparison between actual management performed and SRC recommendation was measured. Results We reviewed 3,085 charts, out of which 257 charts were excluded. Patients were stratified into two groups: high sepsis risk and low sepsis risk. Out of the 2,828 patients included, 81 infants (2.9%) had high risk of sepsis, out of which 2 patients had positive blood cultures. There were no patients with a low SRC score who had positive blood cultures. There were no patients who were supposed to receive antibiotics per the SRC recommendation who did not undergo workup for sepsis. Implementing SRC would have prevented antibiotics administration in 42 (1.5%) patients. Conclusion SRC was adequately capable of detecting neonates with sepsis without missing actual cases of EOS, providing initial support for its safety in the population studied. Implementing the SRC would result in reduced usage of antibiotics, laboratory tests, and admissions to the neonatal intensive care unit.

Stop in Time: How to Reduce Unnecessary Antibiotics in Newborns with Late-Onset Sepsis in Neonatal Intensive Care.

The fear of missing sepsis episodes in neonates frequently leads to indiscriminate use of antibiotics, and prescription program optimization is suggested for reducing this inappropriate usage. While different authors have studied how to reduce antibiotic overprescription in the case of early onset sepsis episodes, with different approaches being available, less is known about late-onset sepsis episodes. Biomarkers (such as C-reactive protein, procalcitonin, interleukin-6 and 8, and presepsin) can play a crucial role in the prompt diagnosis of late-onset sepsis, but their role in antimicrobial stewardship should be further studied, given that different factors can influence their levels and newborns can be subjected to prolonged therapy if their levels are expected to return to zero. To date, procalcitonin has the best evidence of performance in this sense, as extrapolated from research on early onset cases, but more studies and protocols for biomarker-guided antibiotic stewardship are needed. Blood cultures (BCs) are considered the gold standard for the diagnosis of sepsis: positive BC rates in neonatal sepsis workups have been reported as low, implying that the majority of treated neonates may receive unneeded drugs. New identification methods can increase the accuracy of BCs and guide antibiotic de-escalation. To date, after 36-48 h, if BCs are negative and the baby is clinically stable, antibiotics should be stopped. In this narrative review, we provide a summary of current knowledge on the optimum approach to reduce antibiotic pressure in late-onset sepsis in neonates.

The footprint of SARS-COV-2 infection in neonatal late sepsis

BackgroundPredicting and finding the viral agents responsible for neonatal late-sepsis has always been challenging.MethodIn this cross-sectional study, which has been done from September 2020 to December 2022, 145 hospitalized neonates suspected to late-onset sepsis alongside routine sepsis workup, were also evaluated for severe acute respiratory syndrome-coronavirus-2 (SARS-COV-2) infection, by nasopharyngeal real-time polymerase chain reaction (RT-PCR) or serological tests.Result145 neonates including 81 girls and 64 boys with a mean age of 12.3 ± 5.9 days and an average hospitalization stay of 23.1 ± 15.4 days were enrolled in the study. While 76.6% of them had negative bacterial culture, 63 patients (43.4%) showed evidence of SARS-COV-2 infection in RT-PCR or serology tests. None of the underlying factors including gender, age, and laboratory investigation had a significant relationship with SARS-COV-2 infection. Similarly, the outcomes of death and length of hospitalization were not different between the two groups with positive and negative SARS-COV-2 RT-PCR (P < 0.05). There was only a significant relationship between radiological changes including reticulonodular pattern, consolidation, pleural effusion, and different types of infiltrations and SARS-COV2 infection.ConclusionConsidering the widespread of coronavirus disease 2019 (COVID-19) in newborns, it seems logical to investigate the SARS-COV-2 infection in late-sepsis.

Late onset neonatal sepsis: Can plasma gelsolin be a promising diagnostic marker?

Plasma gelsolin (pGSN) correlates with clinical improvement in septic patients. We aimed to investigate pGSN levels as a diagnostic and prognostic marker of neonatal late-onset-sepsis (LOS). A case-control study was done on 184 neonates (92 with LOS and 92 controls). All participants were subjected to detailed history taking, full clinical evaluation, sepsis workup, and pGSN enzyme-linked immunosorbent-assay measurement. We detected significantly lower pGSN level among cases compared to controls (90.63 ± 20.64 vs 451.83 ± 209.59). It was significantly related to the severity of sepsis and mortality, with significantly lower values among cases with septic shock and multiorgan failure and non-survivors. Follow-up pGSN significantly increased after sepsis improvement in survivors compared to admission values. pGSN might be a reliable diagnostic and prognostic marker for LOS.

1626. Group B Streptococcus detection rate and clindamycin resistance among reproductive-age women and early-onset sepsis in neonates in Korea from 2003 to 2022

Abstract Background Group B Streptococcus (GBS) is the leading cause of early-onset sepsis (EOS) in neonates and intrapartum penicillin prophylaxis is recommended for pregnant women with GBS colonization to prevent vertical transmission. For pregnant women with penicillin allergy, clindamycin is recommended. In this study, we retrospectively examined the GBS detection rate and clindamycin resistance rate among Korean women of reproductive age and EOS in neonates in the last 20 years from a single center. Methods From 2003 to 2022, microbiologic studies on genital/rectal swab pairs from females of reproductive age (15-49 years) were reviewed. Among the total number of tests, the number of GBS positive results were extracted and GBS detection rates per year were calculated. Multiple tests from the same person within a year were counted as once. Among the GBS isolates, the clindamycin resistance rate was calculated. The total study period was divided into two periods (period 1 for 2003-2012 and period 2 for 2013-2022) by 10 years and GBS detection rates and clindamycin resistance rates were compared (Chi-square test). EOS caused by GBS in neonates was investigated among all neonates who received sepsis work-up within 3 days after birth. Results For the past 20 years, a total of 14,571 women were tested 16,879 times and GBS was isolated in 1,054 tests (6.2%). GBS detection rate increased from 1.7% (101/6,066) in period 1 to 8.8% (953/10,813) in period 2 (p&amp;lt; 0.001, OR 5.708, 95% CI 4.638-7.025). Among the GBS isolates, clindamycin resistance rates were 29.7% (30/101) in period 1 and 41.1% (392/953) in period 2 (p=0.026, OR 1.654, 95% CI 1.059-2.583). In a separate database, among 9,280 neonates who underwent blood culture or CSF culture studies within 3 days after birth, 9 patients were diagnosed with EOS by GBS and 4 patients died within 30 days. Conclusion Close monitoring is needed on the epidemiology of increasing GBS detection rate and clindamycin resistance rate in GBS isolates from Korean women of reproductive age. Disclosures All Authors: No reported disclosures

Abstract 16403: Toxoplasma Cardiomyopathy in a 36 Year HIV Positive Female

Introduction: Cardiac involvement of toxoplasmosis is extremely rare and can present as myocarditis, pericardial effusion, constrictive pericarditis, arrhythmias or heart failure. While acquired primary infection is severe in immunocompetent, it can be life-threatening among immunodeficient patients. Case: 36 Yr female with PMHx of HIV non-compliant with HAART, Toxoplasma infection in 2019 presented with weakness, dry cough &amp; substernal chest pain x 1-week, sharp type, increasing with lying flat. On presentation vitals were unremarkable. ECG showed diffuse T wave inversions. Troponins elevated at 5000s. MRI brain revealed multiple scattered bilateral cortical and cerebellar enhancing lesion suggestive of toxoplasmosis. Serology was positive for toxoplasmosis. Viral respiratory panel &amp; Sepsis work-up was negative. TTE on admission showed mild pericardial effusion and EF of 50-55%. Follow up TTE (day 7) revealed an EF of 25-30% with mild pericardial effusion pointing towards a toxoplasma induced myopericarditis leading to cardiomyopathy. TEE ruled out possibility of Endocarditis. Discussion: Patient was initiated on anti-toxoplasma therapy with pyrimethamine and sulfadiazine after toxoplasma cardiomyopathy was considered. After initial cardiopulmonary decompensation patient was intubated and needed pressor support. Over the course of next 2 weeks her condition improved with anti-toxoplasma therapy and was extubated. Conclusion: Toxoplasma myopericarditis is rare and a serious presentation among both immunocompetent and immunodeficient patients. Early intervention and diagnosis of Toxoplasma myopericarditis could prevent the progression of cardiomyopathy and improve overall prognosis.

The cost-effectiveness and value of C-reactive protein in the diagnosis and management of neonatal late-onset sepsis in resource-limited settings

Background. Although C-reactive protein (CRP) is used as a biomarker, its value in resource-limited settings for diagnosis andmanagement of late-onset sepsis in neonates has not been reported previously.Objective. To evaluate the value of CRP as a biomarker in identifying late-onset sepsis in symptomatic infants.Method. We performed a retrospective study to evaluate the value of CRP as a biomarker in identifying late-onset sepsis in symptomatic infants. Infants were classified into three groups (blood culture-proven sepsis (n=72), clinical sepsis (n=38) and no sepsis (n=114)). Infants underwent sepsis work-up consisting of complete blood count (CBC), blood culture, urine and cerebrospinal fluid (CSF) culture including CRP measurements.Results. The overall sensitivity and specificity of CRP levels &gt;10 μg/mL was 94.5% and 91.2%, respectively, for the diagnosis of late-onset sepsis. Positive predictive value was 91.2% and negative predictive value was 92.8%. Total white blood cell (WBC) counts had poorsensitivity and specificity compared with CRP. The cost for CRP testing was only 2.5% of the total cost for sepsis work-up in neonates.Conclusion. Our study indicates that CRP has excellent sensitivity and specificity in the diagnosis of late-onset sepsis. In low- and middle-income countries, CRP testing perhaps offers more value compared with W14BC counts

Effect of sepsis protocol in inpatient departments triggered by Ramathibodi Early Warning Score (REWS) on treatment processes

Background: Sepsis needs to be more focused on the effect of patient management at the ward level. We aimed to evaluate the effect of implementing the sepsis protocol triggered by the Ramathibodi Early Warning Score (REWS) on treatment processes in inpatients with new-onset sepsis. Methods: We conducted a prospective observational study among adult medical patients admitted to the general wards. A 25-month pre-protocol period was assigned as a control, and a 14-month protocol period was allocated to a protocol group. An inpatient sepsis protocol comprised a nurse-initiated sepsis protocol with REWS ≥2 plus suspected infection, prompt antibiotic, lactate measurement, and fluid resuscitation. Primary outcomes were the achievement of sepsis treatment processes, including the resuscitation and management bundle, namely: 1) the percentage of patients who were taken for the initial laboratory workup for sepsis, especially lactate and blood culture taking before antibiotics; 2) the percentage of patients who received appropriate antibiotics; 3) the percentage of patients who received optimal fluid resuscitation and management; 4) the percentage of patients who performed inferior vena cava ultrasound; 5) the percentage of patients who received steroid and vasopressor drugs; 6) "time-to-antibiotic," the duration from diagnosis of sepsis to receiving antibiotic treatment; 7) "time-to-optimal intravenous fluid management;" 8) "time-to-transfer to ICU. Results: 282 patients were evaluated (141 pre-implementation, 141 post-implementation); 94.7% of patients with sepsis had REWS ≥2. More patients in the protocol period had a lactate measurement and fluid management (89 [63.1%] vs. 44 patients [31.2%], p&lt;0.001 and (50 [35.4%] vs. 22 patients [15.6%], p&lt;0.001, respectively). More patients in the protocol period received antibiotics within 1 hour than in the pre-protocol period (80 [56.7%] vs. 53 patients [37.6%], p=0.001). The time to antibiotic treatment (mean, SD) in the protocol period was shorter than that in the pre-protocol period (81.7 [77.86] vs. 138.22 [145.17], p=0.007). The length of the intensive care unit (ICU) stay was shorter in the protocol period (8 d [3, 16.5] vs. 10 d [5, 20.5], p=0.011). The two groups did not differ in in-hospital mortality, length of hospital stay, or time-to-transfer to the ICU. Conclusions: Implementing an in-hospital sepsis protocol was associated with significant improvement in sepsis treatment processes, namely lactate measurement, starting antibiotic treatment within 1 hour, fluid management, and a shorter length of ICU stay.

Congenital neuroblastoma presenting as profound neonatal metabolic acidosis with systemic hypertension: Case report.

Clinical collapse in the newborn most often occurs secondary to sepsis, delivery complications, congenital cardiac defects, or inborn errors of metabolism. We report on a neonate with respiratory, cardiac, and hepatic failure, with disproportionate metabolic acidosis and systemic hypertension, found to be caused by a congenital neuroblastoma. A term infant presented to our Level IV NICU via emergent transport at 12 hours of life with clinical and laboratory findings consistent with respiratory, cardiac, and hepatic failure. Typical workup for sepsis and cardiac etiology was unrevealing. The infant was noted to have systemic hypertension despite prolonged capillary refill. A profound metabolic acidosis led the primary team to pursue a genetics consult. In the course of the workup for disorders of metabolism, a urine organic acids panel revealed an elevated HVA (homovanillic acid) and VMA (vanillylmandelic acid), the metabolites of the neurotransmitters epinephrine, norepinephrine and dopamine. Subsequent abdominal ultrasound and chest/abdomen CT revealed a large heterogeneous mass with internal vascular flow and scattered calcifications arising from the medial limb of the left adrenal gland, consistent with neuroblastoma. Although rare, neuroblastomas can present clinically in the perinatal period in a manner requiring immediate life-saving intervention. Providers should consider the diagnosis in the setting of a newborn with a sepsis-like syndrome or profound metabolic acidosis presenting along with systemic hypertension without clear underlying etiology.

C5 (Clinical Case) Coccobacillary Meningitis and Septic Embolic Infarcts in an Ex-Preterm Infant: An Unexpected Pathogen

Abstract Introduction/Background Pasteurella multocida causes life-threatening zoonotic invasive infections in immunocompromised individuals and those at extremes of age (neonates and elderly). Bacteremia, meningitis, and endocarditis are serious complications that are associated with up to 25-30% mortality. Case Description A 7-week-old ex-34-week preterm female infant presented with a one-day history of fever, irritability, and poor feeding without exposure to sick contacts. Household contacts included a constantly drooling Shi Tzu dog. Examination revealed an irritable, febrile infant with a bulging fontanelle and scant purulent eye discharge. No focal neurological deficits, skin rashes or murmurs were appreciated. Empiric antibiotics were initiated following a full work-up for sepsis. Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis with 7608 x106L nucleated cells (95% neutrophils), protein 7360 mg/L, glucose &amp;lt;0.2 mmol/L and gram-negative coccobacilli. Blood and CSF cultures grew Pasteurella multocida, prompting a switch to crystalline penicillin. An echogenic mitral valvular mass was identified in the absence of underlying cardiac defects. Head imaging confirmed ventriculitis with multiple small infarcts. No sequelae of abscess, hydrocephalus or hearing loss were demonstrated after the completion of 6 weeks of penicillin therapy. Discussion Haemophilus influenzae, serotype b, is the typical cause of coccobacillary meningitis in a 7-week-old infant. In addition to non-b serotypes, non-typeable species which cause conjunctivitis may also cause invasive disease in young infants. The resultant growth of P. multocida from cultures was, therefore, unexpected, particularly given there were no preceding animal bites or scratches. In vulnerable hosts, this pathogen can be transmitted across skin or mucous membranes after close animal contact, such as licking and sniffing. The constant drooling and spraying of saliva from the pet dog, a flat-faced breed known to have stenotic nares and chronic nasal secretions, likely provided an opportunity for mucosal contamination. This infant’s young age, prematurity, and exposure to a flat-faced dog placed her at high risk for Pasteurellosis, which manifested as complicated meningitis and endocarditis. Conclusion Pasteurella infections most often arise as local infections following an animal bite or scratch, are rare but important causes of life-threatening severe coccobacillary invasive infection, even without preceding trauma, in young infants. Families of at-risk individuals who own pets should have adequate education about zoonotic infections that address risk factors, including animal breed and behaviour, presenting features and preventive strategies to reduce the potential for serious morbidity and even mortality.

The combination of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio improves accuracy of neonatal sepsis diagnosis

Background Neonatal sepsis remains a challenging issue, due to sophisticated and time consuming tests needed to confirm a diagnosis.&#x0D; Objective To assess the applicability of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) as diagnostic markers in neonatal sepsis.&#x0D; Methods This cross-sectional study was conducted in the Neonatology Ward of Kandou General Hospital, Manado, North Sulawesi. Neonates with suspected sepsis were included by consecutive sampling. We measured NLR and PLR form hematology profiles and differential count. Diagnosis of neonatal sepsis was based on positive blood cultures. A receiver operating characteristic (ROC) curve analysis was done to assess the NLR and PLR cut-off points. Chi-square test was used to analyze the diagnostic value of NLR and PLR.&#x0D; Results A total of 176 full term neonates with suspected sepsis were included in the study. Of these, 84 (47.7%) subjects were confirmed with neonatal sepsis and 92 (52.3%) were non-sepsis. The mean NLRs were 5.9 (95%CI 2.0 to 13.6) in the sepsis group and 1.6 (95%CI 0.2 to 3.2) in the non-sepsis group. A NLR of 3.0 was determined as the predictive cut-off value of neonatal sepsis (sensitivity 94%, speci?city 97.8%, and area under the ROC curve 0.995). NLR can effects on neonatal sepsis diagnosis by 61% . The mean PLRs were 79.9 (95%CI 44.0 to 155.8) in the sepsis group and 44.0 (95%CI 9.7 to 91.8) in the non-sepsis group. A PLR of 60.4 was determined as the predictive cut-off value of neonatal sepsis (sensitivity 86.9%, speci?city 87%, area under ROC curve 0.928). PLR can effects on neonatal sepsis diagnosis by 47.5%. When NLR and PLR were combined, they can improve accuracy of neonatal sepsis diagnosis about 72.2%.&#x0D; Conclusion Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) can be used in combination as adjunct diagnostic tests for neonatal sepsis workups.

PCT testing in sepsis protocols

Septicemia is a prominent disease with a mortality rate of over 20%, making it one of the most expensive illnesses for hospitals in the United States. Many cells throughout the body release procalcitonin (PCT) in response to severe bacterial infection. This literature review attempts to assess PCT testing as a potential addition to sepsis protocols and to identify recommendations when implementing PCT testing into sepsis workups. The incorporation of PCT testing could significantly reduce the financial burden, antibiotic usage, and mortality rates in sepsis cases.

Neonatal Salmonella Meningitis With Subdural Empyema: A Case Report.

To the Editors: Salmonella species can cause a variety of neonatal infections which are most prevalent in sub-Saharan Africa. Salmonella meningitis is associated with long-term neurologic sequelae1 including seizures, hydrocephalus, subdural effusions, empyema, ventriculitis, hemorrhage and abscess.2 The present case describes a neonate with Salmonella meningitis with subdural empyema. A 12-day-old full-term female presented to the emergency department for a 1-day history of fever, decreased feeding, and a shorter, gasp-like breathing pattern. The baby was tachycardic and febrile. Per patient’s mother, both she and the infant’s brother were suffering from diarrhea 3 days before onset of the infant’s symptoms. A full sepsis workup was initiated, including blood, urine and cerebrospinal fluid cultures. The patient was empirically started on intravenous ampicillin and gentamicin pending culture results. Additionally, a respiratory pathogen panel via polymerase chain reaction performed on the same day indicated positive results for coronavirus disease 2019 (COVID-19). The patient was admitted for further management of presumed neonatal sepsis and respiratory monitoring of COVID-19 infection. The patient was subsequently found to have positive blood culture and cerebrospinal fluid gram stain for Gram-negative rods. Speciation and sensitivities later grew Salmonella species with sensitivity to ampicillin and ceftriaxone. Magnetic resonance imaging of the brain was significant for diffuse right leptomeningeal enhancement consistent with meningitis and subdural empyema. No neurosurgical intervention was recommended. Ampicillin and gentamicin were discontinued after 3 days of treatment, and ceftazidime was started for treatment of salmonella meningitis. Ceftriaxone was considered as the standard treatment for invasive Salmonella infection, but was inappropriate due to mildly elevated bilirubin on admission (Table 1) and patient’s age. TABLE 1. - Admission Labs Complete blood count With Differential Day 1 of Admission White blood cell count 6.4 × 103/µL Hemoglobin/hematocrit 12.6/37.3 g/dL Platelets 564 × 103/µL Segmented neutrophils 40% Bands 24% Lymphocytes 26% Monocytes 7% Urinalysis Color Dark yellow Specific gravity 1.021 pH 7.0 Protein 2+ Glucose Trace Ketones Negative Bilirubin Negative Blood Negative Nitrites Negative Urobilinogen 0.2 Leukocyte esterase 2+ Urine microscopy White blood cells >50 Red blood cells 11.1 Squamous epithelial 5.3 Bacteria 40 Casts 3.9 Chemistry Sodium 138 mmol/L Potassium 4.1 mmol/L Chloride 107 mmol/L Bicarbonate 22 mmol/L Blood urea nitrogen/creatinine 8/0.37 mg/dL Glucose 108 mg/dL Total bilirubin 9.6 mg/dL Total protein 6.2 g/dL Albumin 3.1 g/dL Alanine transaminase/aspartate transaminase 18/23 Units/L Alkaline phosphatase 143 Units/L Cerebrospinal fluid Color Cloudy White blood cells 667 cu/mm Red blood cells 42,500 cu/mm Segmented neutrophils 90% Lymphocytes 8% Monocytes 1% Eosinophils 1% Basophils 0% Inflammatory markers C-reactive protein (admission) 3.06 mg/dL C reactive protein (hospital day #2) 25 mg/dL On the third day of admission, a repeat respiratory pathogen panel showed the patient to be COVID-19 negative, and it was concluded that the initial positive test was likely a false positive. Repeat blood cultures drawn on day 4 of admission were negative. On day 8 of admission, a peripherally inserted central catheter line was placed for long-term parenteral antibiotics. On day 10 of admission, ceftazidime was discontinued and switched to ceftriaxone after a repeat complete metabolic panel showed normalized bilirubin levels. Ceftriaxone was selected (in lieu of ampicillin) to minimize peripherally inserted central catheter line access thereby reducing probability of central line–associated bacterial infection. Inflammatory markers and bilirubin were trended closely due to use of ceftriaxone. A 6-week course of treatment was completed with no further complications and improvement of radiologic findings. The patient was discharged with no apparent neurological deficits. Her development was ascertained by phone call and the child continues to develop typically. Previous case reports indicate that third generation cephalosporins are ideal for management of salmonella meningitis due to their bactericidal properties.3,4 This case offers a suggested treatment course of neonates with transition from ceftazidime to ceftriaxone showing satisfactory results in the treatment of neonatal Salmonella sepsis and meningitis complicated by empyema. ACKNOWLEDGMENTS The authors thank the patient and family for their participation in this report.

Early Blood Pressure Changes in Neonatal Sepsis and the Risk of Mortality.

To compare blood pressures (BP) between neonates with culture-proven sepsis and clinical sepsis in the first 120h of sepsis onset and to examine association between BP and in-hospital mortality. In this cohort study, consecutively enrolled neonates with 'culture-proven' sepsis [growth in blood/ cerebrospinal fluid (CSF) within 48h] and clinical sepsis (sepsis workup negative, cultures sterile) were analyzed. Their BP was recorded every 3-hourly for initial 120h and averaged in 20 time-epochs of 6h each (0-6h to 115-120h). BP Z-scores were compared between neonates with culture-proven vs. clinical sepsis and survivors vs. non-survivors. Two hundred twenty eight neonates (102-culture-proven and 126-clinical sepsis) were enrolled. Both groups had comparable BP Z-scores except significantly lower diastolic BP (DBP) and mean BP (MBP) in 0-6 and 13-18 time-epochs in culture-proven sepsis group. Fifty-four neonates (24%) died during their hospital stay. BP Z-scores in the initial 54h of sepsis were independently associated with mortality [systolic BP (SBP) Z-scores in first 54h, DBP Z-scores in first 24h, and MBP Z-scores in first 24h] after adjusting for gestational age, birth weight, cesarean delivery, and 5-min Apgar score. On receiver operating characteristic curves, SBP Z-scores showed better discriminative ability than DBP and MBP to identify non-survivors. Neonates with culture-proven and clinical sepsis had comparable BP Z-scores except low DBP and MBP in the initial few hours in culture-proven sepsis. BP in initial 54h of sepsis was significantly associated with in-hospital mortality. SBP discriminated non-survivors better than DBP and MBP.

The impact of trimester of COVID-19 infection on pregnancy outcomes after recovery.

Many physiological adaptations occur during pregnancy. It is not currently known how timing of COVID-19 infection impacts pregnancy. We hypothesize that maternal and neonatal outcomes are different if COVID-19 infection occurs in different trimesters of pregnancy. This retrospective cohort study was conducted from 3/2020 to 6/2022. Pregnant patients with a positive COVID-19 infection more than 10days before delivery (COVID-recovered) were identified and grouped by trimester of infection. Demographics and maternal, obstetric, and neonatal outcomes were analyzed. ANOVA, Wilcoxon rank-sum test, Pearson's chi-squared test, and Fisher's exact test were used to compare continuous and categorical data. A total of 298 COVID-recovered pregnant patients were identified. Of those, 48 (16 %) were infected in the 1st trimester, 123 (41 %) in the 2nd, and 127 (43 %) in the 3rd. There were no significant demographic differences between the study groups. Vaccination status was similar. Hospital admission rate and the need for oxygen therapy while infected were significantly higher in patients with 2nd or 3rd trimester infection (18 % & 20 % vs. 2 % and 13 % & 14 % vs. 0 %, respectively). Rates of preterm birth (PTB) and extreme PTB were higher in the 1st trimester infection group. Infants born to mothers infected in the 2nd trimester had more neonatal sepsis workups (22 % vs. 12 % & 7 %). Other outcomes were similar between groups. First trimester COVID-recovered patients were more likely to have a preterm birth despite having lower rates of hospital admission and oxygen supplementation while infected than patients who recovered from a 2nd or 3rd trimester infection.

Abstract #1411391: An Untoward Case of Diabetic Ketoacidosis and Hypertriglyceridemia Pancreatitis in a Young Type 2 Diabetes Patient

In the US, every year, there are around 60 cases of Diabetic ketoacidosis (DKA) admissions seen per 10,000 admissions and out of which the mortality rate is only 0.38%. The enigmatic triangle of diabetic ketoacidosis (DKA) with concurrent hypertriglyceridemia-induced acute pancreatitis is an uncommon phenomenon. This rare combined presentation can lead to detrimental outcomes in diabetes mellitus (DM) patients. The patient is a 21-year-old male with a previous history of prediabetes who presents to the ED with complaints of epigastric abdominal pain, nausea, and non-bloody vomiting for two days. In the ED, afebrile, tachycardic, and tachypneic saturating well on room air. His blood pressure was stable. His vitals, physical examination findings were normal. On admission, patient was dehydrated with hemoglobin 19.7, WBC count 25k, BUN 37, creatinine 1.83. Blood glucose 833. His hemoglobin A1c 12.4, positive ketones in serum and urine, anion gap 32, bicarbonate 8, pH of 7.16. TSH 0.64. His levels of lipase 13k and triglycerides 1428. Sepsis workup was negative for any source of infection. Fluid resuscitation to up to 5 liters of fluids was given, was started on an insulin drip. The patient was transferred to ICU and was still tachycardic in the 180s, so adenosine, metoprolol, and diltiazem were given. It improved to the 150s. An hour later, he was more confused and was intubated for airway protection. Around 30 minutes later, he went into cardiac arrest and achieved ROSC. He was then on maximum vasopressor support and eventually had two more cardiac arrests and passed away. Even though the management for both DKA and hyperlipidemia pancreatitis may be similar with insulin administration, when they present together, it can be catastrophic and lead to systemic complications like SIRS, pancreatic necrosis, abdominal compartment syndrome, and even death. This is an example of how this combination led to severe outcomes cascading over the hospital course, which led to the mortality of a young type 2 DM patient.

The Effect of Trimester of COVID-19 Infection on Pregnancy Outcomes After Recovery [ID: 1365996

INTRODUCTION: Many physiological, immune, and respiratory adaptations occur during pregnancy. Data have emerged that COVID-19 infection affects placental function, raising concerns about obstetric morbidity. It is not currently known how timing of COVID-19 infection affects pregnancy. We hypothesize that maternal and neonatal outcomes are different if COVID-19 infection occurs in different trimesters of pregnancy. METHODS: This IRB-approved retrospective cohort study was conducted at a single center from March 2020 to June 2022. Pregnant patients with a positive COVID-19 infection more than 10 days before delivery (COVID-recovered) were identified and grouped by trimester of infection. Demographics and maternal infection, obstetric, and neonatal outcomes were collected. Wilcoxon rank-sum and Fisher’s exact tests were used to compare continuous and categorical data, respectively. To account for multiple comparisons, a significant P value was set at .01. RESULTS: Two hundred ninety-eight COVID-recovered pregnant patients were identified. Of those, 48 (16%) were infected in the first trimester, 123 (41%) in the second trimester, and 127 (43%) in the third trimester. There were no significant demographic differences between the study groups. Vaccination status was similar. Hospital admission rate and the need for oxygen therapy while infected were significantly higher in patients with second- or third-trimester infection (18% and 20% versus 2% and 13% and 14% versus 0%, respectively). Rates of preterm birth (PTB) less than 37 weeks (33% versus 19% and 12%, P=.006) and extreme PTB (19% versus 5%, P&lt;.001) were higher in the first-trimester infection group. Infants born to mothers infected in the second trimester had more neonatal sepsis workups (22% versus 12% and 7%, P=.008). Other maternal, obstetric, and neonatal outcomes were similar between groups. CONCLUSION: First-trimester COVID-recovered patients were more likely to have preterm birth despite having lower rates of hospital admission and oxygen supplementation while infected than patients who recovered from a second- or third-trimester infection.

Surgical management of a large mycotic aneurysm of the distal popliteal artery.

The patient presented with right calf pain, swelling and fevers following a percutaneous coronary intervention for unstable angina two weeks prior via ipsilateral groin access. Physical exam revealed a diffusely swollen, painful lower extremity. Ankle brachial indices were normal. Blood cultures grew methicillin-sensitive Staphylococcus aureus and ultrasound demonstrated a sub-centimeter distal popliteal artery aneurysm with inflammation and calf deep vein thromboses (DVT). Transesophageal echocardiography and sepsis workup revealed no etiologic source.

Time from symptom onset may influence C-reactive protein utility in the diagnosis of bacterial infections in the NICU

BackgroundTaking into account the timing of C-reactive protein (CRP) testing may improve the performance of the test in diagnosing bacterial infections in the neonatal intensive care unit (NICU). We aimed to examine the yield of CRP, relative to time from symptoms onset.MethodsEnrolled were all NICU patients, for whom CRP was obtained as part of a sepsis workup. The time of symptoms onset and of blood draw was recorded. Patients were classified into bacterial and non-bacterial groups according to the National Healthcare Safety Network (NHSN) guidelines. The performance of CRP, CRP velocity, and CRP obtained before or after 6 hours from symptoms onset, was evaluated by receiver-operating characteristic (ROC) curve. Test characteristics were calculated using formulas based on Bayes’ theorem.ResultsOf 129 infants enrolled in the study, 21(16%) had a bacterial infection. A single CRP test and CRP velocity performed similarly in diagnosing bacterial infection, with area under ROC curve of 0.75 (95%CI: 0.61–0.89) and 0.77 (95% CI:0.66–0.88), respectively. The optimal cut-off value for a CRP test obtained <= 6 hours from symptoms onset was 1 mg/dL, whereas the optimal cut-off > 6 hours was 1.5 mg/dL. Using the optimal cut-off values increased the pre-test probability of 16%, to a post-test probability of 35–38%. For infants whose birth weight was < 1000 g, CRP performed poorly.ConclusionsThe optimal CRP cut-off used in the diagnosis of bacterial infections in NICU patients varies by the time from symptom onset. A “negative” CRP may support a clinical decision to stop empiric antimicrobial therapy, for infants whose blood cultures remain sterile.