Sepsis Workup Research Articles

Comparison of Endogenous Endophthalmitis in Patients with and Without COVID-19 Infection.

Endogenous endophthalmitis (EE) is an ophthalmic emergency that can have severe sight-threatening complications. Prompt diagnosis and aggressive treatment are central to the successful management of EE. In recent years, a significant increase has occurred in the number of cases of EE. Some of these individuals had a COVID-19 infection. The current study compared EE in patients with and without COVID-19 infection. All cases of EE admitted to Khalili Hospital between April 2020 and September 2021 were included in this prospective case-control study. Patients were divided into 2 groups: (i) the case group (EE patients with confirmed COVID-19 infection; n = 7) and (ii) the control group (EE patients without a history or evidence of COVID-19 infection; n = 7). Age, sex, presenting and final visual acuity, systemic diseases and risk factors for EE, anterior segment and fundus findings, hospitalization due to COVID-19, intensive care unit (ICU) admission, systemic steroid therapy, results of the sepsis workup, causative microorganism, types of treatment (pars plana vitrectomy vs. intravitreal or antifungal antibiotics), and follow-up period were recorded. Twenty-four eyes of the 14 patients were included in this study, of which 9 were female. The mean age was 49.57 years. Follow-ups ranged from 1 month to 20 months (mean, 8 months). There were no statistically significant differences in age (P = 0.653), mean follow-up (P = 0.943), gender (P = 0.313), and clinical presentation (P = 0.409) between the case and control groups. Seven patients (50%) had positive intraocular culture results. Two out of 7 patients had a history of COVID-19 infection. The most common causative microorganism was Candida (4 patients [28.57%]; 6 eyes [25%]). No statistically significant differences were observed between the 2 groups in the need for vitrectomy (P = 1.000). The visual outcome between the 2 groups was similar (P = 0.179). The COVID-19 infection does not seem to affect the severity, visual outcomes, improvement rate, or vitrectomy rate of EE. Early diagnosis and management, especially pars plana vitrectomy, can prevent serious complications and save many eyes.

Abstract 15183: From Insult to Injury: A Rare Consequence of Sodium Glucose Cotransporter 2 Inhibitors

Introduction: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection associated with diabetes mellitus (DM), especially in older women. Patients can remain asymptomatic or present with severe sepsis and bacteremia due to E. Coli (58%) or K. pneumonia (21%). Herein, we present a unique case of recurrent life-threatening sepsis due to EPN in a male with Heart failure with reduced ejection fraction (HFrEF) and well controlled DM treated with a sodium-glucose cotransporter two inhibitor (SGLT2i). Case: A 74-year-old man with metabolic syndrome, HFrEF (EF 30%), chronic kidney disease (stage 2) who was started on empagliflozin by his cardiologist four days prior, presented to the emergency department with dizziness and fever for one day. Vitals were notable for temperature of 102.9F and blood pressure of 88/52 mmHg. The physical exam was unremarkable. His WBC was 16,000/dL, and lactate was 2.8. A sepsis workup revealed a urinalysis positive for cystitis along with a CT of the abdomen, which demonstrated evidence of acute right-sided emphysematous pyelonephritis (Fig. 01). Blood culture grew pan sensitive E coli. He was treated with IV Ceftriaxone 2g once daily for 14 days. His previous records unveiled that the patient was initially started on empagliflozin two months ago, followed by admission with EPN within ten days, after which the medication was held until its reintroduction before the current presentation. Conclusion: Emphysematous pyelonephritis as a complication of SGLTI2I use is remarkably under-reported. The median time of onset of disease from SGLT2i initiation is 45 days. The patient experienced his first episode of EPN within ten days and then four days after reintroduction of SGLT2i. This case illustrates the potential for severe UTIs with SGLT2i and the value of a thorough history emphasizing the history of UTIs, especially those with obstructive renal symptoms.

Neonatal sepsis in alloimmune hemolytic disease of the fetus and newborn: A retrospective cohort study of 260 neonates.

Among neonates with hemolytic disease of the fetus and newborn (HDFN), we aimed to describe the frequency of central-line use, indications for insertion, and incidence of confirmed and suspected sepsis, including antibiotic treatment over a 10-year surveillance period. All neonates with HDFN admitted to our neonatal intensive care unit between January 2012 and December 2021 were included in this retrospective, cohort study. Annual proportions of infants with a central-line and central-line-associated bloodstream infection (CLABSI) rates (per 1000 central-line days and per 100 infants) were evaluated. Numbers of confirmed and suspected early- and late-onset sepsis episodes were assessed over the entire study period. Of the 260 included infants, 25 (9.6%) were evaluated for suspected sepsis, with 16 (6.2%) having ≥1 confirmed sepsis episode. A total of 123 central-lines were placed in 98 (37.7%) neonates, with impending exchange transfusion (ET) being the most frequent indication. Of the 34 (34.7%) neonates in whom a central-line was placed due to impending ET, 11 (32.4%) received no ET. Overall CLABSI incidence was 13.58 per 1000 central-line days. Neonates with a central-line had a higher risk for confirmed late-onset infection (RR 1.11, 95% CI: 1.04-1.20) and sepsis work-up (RR 1.10, 95% CI: 1.03-1.17) compared to infants without a central-line. Sepsis incidence among neonates with HDFN remains high, in particular in those with a central-line. Considering the substantial proportion of neonates with a central-line without eventual ET, central-line placement should be delayed until the likelihood of ET is high.

LBODP100 A Rare Case Of Pembrolizumab Induced Graves’ Disease

Abstract Cancer immunotherapies have recently changed the therapeutic armamentarium of anti-cancer treatments, particularly for melanoma and cancers of the kidneys, lungs, and colon. Immune checkpoint inhibitors (ICPis) act on various immune checkpoints. Of them, anti-PD-1 antibodies (such as pembrolizumab) are monoclonal antibodies that act against programmed cell death 1 protein. However, by counteracting the regulators of adaptive immunity, this class of drugs may cause immune-related adverse events that involve multiple organs and endocrine glands, such as the thyroid gland. The symptoms of thyroid dysfunction usually present during the first weeks of ICPis therapy. In the current report, we present a case of a 50-year-old male who presented to the emergency department complaining of fever, chills, nausea, and vomiting for one week. The patient had a history of colon cancer with lymph node metastasis status post tumor resection and colostomy. He began Keytruda® (pembrolizumab) treatment after tumor resection, and the presenting symptoms appeared after receiving the first immunotherapy infusion. His medical history was significant for psoriasis and rheumatoid arthritis. The patient's history was unremarkable for thyroid diseases, and he did not receive thyroid medications with no previous exposure to intravenous contrast media, over-the-counter iodine preparations, or biotin. At the emergency department, the patient had a temperature of 101.4°F, a heart rate of 110 bpm, and blood pressure of 130/70 mm Hg. On examination, tenderness was indicated upon palpating the anterior part of the neck. The patient was treated with intravenous fluids, steroids, beta-blockers, and broad-spectrum antibiotics. A workup for sepsis was requested, and it revealed negative blood culture and urine culture results. His laboratory indices demonstrated a suppressed level of TSH (0. 01 mIU/mL) and elevated Free T4 (3.16 ng/dl). Still, his TSH level reported at the Oncology clinic before Keytruda administration was (0.9 mIU/mL), and Free T4 was (1.7 ng/dl). Thyroid ultrasound revealed a heterogeneous thyroid gland consistent with thyroiditis. Antibody testing showed positive thyroid antithyroglobulin antibodies and elevated thyroid-stimulating antibodies (TSI). A radioactive iodine uptake test was ordered, revealing increased contrast uptake. These findings suggested that the cause of thyroid dysfunction was Graves’ disease. The patient was started on Methimazole 20mg per day and discharged home after scheduling an outpatient follow-up appointment with the endocrinologist. This case is one of the rare cases of thyrotoxicosis attributable to Graves’ disease related to pembrolizumab therapy. To the best of our knowledge, two studies in the literature reported three cases of ICPi-induced thyrotoxicosis with thyroid antibody positivity following anti-PD-1 antibody therapy. Presentation: No date and time listed

RF25 | PMON95 Unique Case of Combined Presentation of Myxedema Coma and Adrenal Crisis in a Patient With Hypopituitarism or Post Sheehan's Syndrome

Abstract Background Patients with hypopituitarism can have a complete or partial deficiency of pituitary hormones. If not treated adequately, it can result in episodes of myxedema coma or adrenal crisis. Our patient was unique with findings of both myxedema coma and adrenal crisis together on initial presentation. Clinical Case A 35-year-old female with a medical history of Sheehan's Syndrome, transient diabetes insipidus and lyme carditis presented to the emergency department with dizziness, lethargy, and generalized weakness for 1 day. EMS found her blood glucose level to be 21. The patient was given oral glucose. In the ED, her blood glucose level was found to be 34. She confessed she had been noncompliant with her medications for a month. She had no other complaints or possible precipitating factors including illness/trauma/stress. On admission, she was found to be hypothermic to 91.3 deg F, bradycardic to 40-50s, and hypotensive (Systolic 80s-90s/diastolic 50s-60s). On physical examination, she was thin and lethargic but oriented. No gross focal neurological deficits were noted. In addition to the initial hypoglycemia, her laboratory findings were significant for a TSH level of 0.52, T3 level of <30, T4 level of <0.5, eosinophilia as well as normal sodium levels. The sepsis workup was negative. Her VBG showed mild respiratory acidosis. For the myxedema coma and adrenal crisis, she was initially given hydrocortisone 100 mg and levothyroxine 200mcg. Her hypoglycemia improved after administration of these medications and intravenous fluids of dextrose-normal saline. The endocrinology service was consulted, and the patient was admitted to the ICU for monitoring. The next day her hypothermia, hypotension resolved and her lethargy, weakness improved. Once she was stabilized in the ICU, she was transferred to the floors. For the myxedema coma, once stable, she was started on oral levothyroxine 100mcg in accordance with weight-based dosing (1.6 mcg/kg daily) on the following day. Her free T4 level improved from 0.48 to 0.56 to 0.72. Her T3 level improved from <30.0 to 42.7. For the adrenal crisis, after the initial dose of IV hydrocortisone 100mg, it was tapered down to IV hydrocortisone 50 mg, then switched to oral prednisone daily. Eosinophilia from admission was mild which resolved later. Additional management of her history of Sheehan's Syndrome, her levels of LH 0.5, FSH 1.2, Estradiol <5, and Prolactin 0.6 were all low, so was advised to follow up with hormone replacement therapy outpatient. Conclusion This is an interesting case presentation of myxedema coma and adrenal crisis in a patient with a history of Sheehan's Syndrome. It is important to consider the unique and similar presentations of both myxedema coma and adrenal crisis such as hypotension, bradycardia, hypothermia, hypoglycemia, and lethargy. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:51 p.m. - 12:56 p.m.

A RARE CASE OF PROTRACTED ANAPHYLAXIS CAUSED BY ACETAMINOPHEN

<h3>Introduction</h3> Acetaminophen is a rare but recognized etiology of anaphylaxis. We present an unusual case of protracted anaphylaxis requiring intensive care unit (ICU) monitoring following intravenous (IV) acetaminophen. <h3>Case Description</h3> A 49-year-old female with a history of ovarian cancer presented to the emergency department with pruritic urticarial rash, fevers, tachycardia, and relative hypotension. A sepsis workup was initiated. Hemodynamics improved with broad-spectrum antibiotics and fluids. Due to symptomatic high-grade fevers, IV acetaminophen was administered. Her rash, tachycardia, and relative hypotension worsened one hour following infusion. Despite resuscitation with diphenhydramine and fluids, she remained tachycardic and febrile, prompting treatment for suspected anaphylaxis with intramuscular epinephrine, corticosteroids, and additional diphenhydramine. Her rash and hemodynamics improved moderately. She was subsequently started on norepinephrine and transferred to the medical ICU, where she had two days of persistent tachycardia and fluctuating urticarial rash responsive to antihistamines. Infectious workup was unrevealing. She later revealed a prior history of urticaria following home oral acetaminophen. Tryptase drawn one hour after decompensation was elevated to 23.8 mcg/L (baseline 3.2 mcg/L). The diagnosis was made of IgE-mediated reaction to acetaminophen causing protracted anaphylaxis. <h3>Discussion</h3> Anaphylaxis secondary to acetaminophen is an uncommon but recognized phenomenon. An initial differential included pseudoallergic reaction, given acetaminophen can be a weak cyclooxygenase-1 inhibitor causing direct mast cell activation and urticaria; however, this does not classically cause hypotension. Overall, this presentation may represent a mixed picture of sepsis of unclear etiology with superimposed IgE-mediated reaction. It is important to recognize anaphylaxis can co-exist with sepsis and manifest with overlapping symptoms.

A RARE CASE OF HAEMOPHILUS INFLUENZAE CELLULITIS LEADING TO BACTEREMIA IN A HEALTHY ADULT

A RARE CASE OF HAEMOPHILUS INFLUENZAE CELLULITIS LEADING TO BACTEREMIA IN A HEALTHY ADULT

Neonatal Early Onset Sepsis (EOS) Calculator plus Universal Serial Physical Examination (SPE): A Prospective Two-Step Implementation of a Neonatal EOS Prevention Protocol for Reduction of Sepsis Workup and Antibiotic Treatment.

Current neonatal early-onset sepsis (EOS) guidelines lack consensus. Recent studies suggest three different options for EOS risk assessment among infants born ≥35 wks gestational age (GA), leading to different behaviors in the sepsis workup and antibiotic administration. A broad disparity in clinical practice is found in Neonatal Units, with a large number of non-infected newborns evaluated and treated for EOS. Broad spectrum antibiotics in early life may induce different short- and long-term adverse effects, longer hospitalization, and early mother-child separation. In this single-center prospective study, a total of 3002 neonates born in three periods between 2016 and 2020 were studied, and three different workup algorithms were compared: the first one was based on the categorical risk assessment; the second one was based on a Serial Physical Examination (SPE) strategy for infants with EOS risk factors; the third one associated an informatic tool (Neonatal EOS calculator) with a universal extension of the SPE strategy. The main objective of this study was to reduce the number of neonatal sepsis workups and the rate of antibiotic administration and favor rooming-in and mother–infant bonding without increasing the risk of sepsis and mortality. The combined strategy of universal SPE with the EOS Calculator showed a significant reduction of laboratory tests (from 33% to 6.6%; p < 0.01) and antibiotic treatments (from 8.5% to 1.4%; p < 0.01) in term and near-term newborns. EOS and mortality did not change significantly during the study period.

Cerebrospinal fluid and plasma procalcitonin for the diagnosis of neonatal bacterial meningitis.

There is a paucity of data on cerebrospinal fluid (CSF) procalcitonin (PCT) to diagnose neonatal meningitis. We evaluated CSF PCT to diagnose bacterial meningitis among neonates with suspected sepsis. Neonates undergoing lumbar puncture (LP) as part of sepsis workup were included. CSF PCT, plasma PCT, CSF:plasma PCT ratio and CSF cytochemistry. Reference Standards: 'Definite meningitis' defined by positive CSF culture and/or gram stain and/or broad-based primer 16S rDNA polymerase chain reaction. 'Definite or probable' meningitis is defined as definite meningitis or abnormal cytochemistry. Of 216 eligible neonates, 18 had 'definite meningitis' and 37 'definite or probable meningitis'. Median (Q1 , Q3 ) CSF PCT level was significantly higher in 'definite meningitis' compared to 'no definite meningitis' (0.429 (0.123, 1.300) vs. 0.181 (0.119, 0.286) ng/mL respectively, P=0.028). Likewise, it was significantly higher in 'definite or probable meningitis' compared to no meningitis (0.245 (0.136, 0.675) vs. 0.170 (0.116, 0.28), P=0.01). The area under the receiver operator characteristics curve of CSF PCT level for definite meningitis was 0.656 and for 'definite or probable meningitis' 0.635. Paired comparisons of area under the receiver operator characteristics curve of CSF PCT with the other index tests showed no significant differences. Based on a priori cut-off of 0.2ng/mL, CSF PCT level had a sensitivity (95% confidence interval) of 67% (50, 80), specificity 58% (54, 61), LR+ 1.6 (1.1, 2.0) and LR- 0.6 (0.3, 0.9). Higher values of CSF PCT are associated with neonatal bacterial meningitis. However, the diagnostic performance of CSF PCT is modest and not significantly different from standard tests.

Blood-culture ordering practices in patients with a central line at an academic medical center–Iowa, 2020

Background: The IDSA has a clinical definition for catheter-related bloodstream infection (CRBSI) that requires ≥1 set of blood cultures from the catheter and ≥1 set from a peripheral vein. However, because blood cultures obtained from a central line may represent contamination rather than true infection, many institutions discourage blood cultures from central lines. We describe blood culture ordering practices in patients with a central line. Methods: The University of Iowa Hospitals &amp; Clinics is an academic medical center with 860 hospital beds. We retrospectively collected data for blood cultures obtained from adult patients (aged ≥18 years) in the emergency department or an inpatient unit during 2020. We focused on the first blood cultures obtained during each admission because they are usually obtained before antibiotic initiation and are the most important opportunity to diagnose bacteremia. We classified blood-culture orders as follows: CRBSI workup, non-CRBSI sepsis workup, or incomplete workup. We defined CRBSI workup as ≥1 blood culture from a central line and ≥1 peripheral blood culture (IDSA guidelines). We defined non-CRBSI sepsis workup as ≥2 peripheral blood cultures without cultures from a central line because providers might have suspected secondary bacteremia rather than CRBSI. We defined incomplete workup as any order that did not meet the CRBSI or non-CRBSI sepsis workup. This occurred when only 1 peripheral culture was obtained or when ≥1 central-line culture was obtained without peripheral cultures. Results: We included 1,150 patient admissions with 4,071 blood cultures. In total, 349 patient admissions with blood culture orders (30.4%) met CRBSI workup. 62.8% were deemed non-CRBSI sepsis workup, and 6.9% were deemed an incomplete workup. Stratified by location, ICUs had the highest percentage of orders with incomplete workups (8.8%), followed by wards (7.2%) and the emergency department (5.1%). In total, 204 patient admissions had ≥1 positive blood culture (17.7%). The most frequently isolated organisms were Staphylococcus epidermidis (n = 33, 16.2%), Staphylococcus aureus (n = 16, 7.8%), and Escherichia coli (n = 15, 7.4%) Conclusions: Analysis of blood culture data allowed us to identify units at our institute that were underperforming in terms of ordering the necessary blood cultures to diagnose CRBSI. Being familiar with CRBSI guidelines as well as decreasing inappropriate ordering will help lead to early and proper diagnosis of CRBSI which can reduce its morbidity, mortality, and cost.Funding: NoneDisclosures: None

Management of fever in infants and children in the emergency setting and during home discharge: recommendations from an Italian panel.

In infants and children, fever is very common in the emergency setting. The overall aim of the present publication was to overview guidance and provide an algorithm for use in the emergency setting as well as recommendations to inform parents for home care. To obtain consensus, a core steering committee drafted a management algorithm and general consensus was obtained by remote voting among experts. A number of common messages are found in current guidelines: management of fever depends on age, antipyretics are indicated only for discomfort; paracetamol or ibuprofen can be recommended; physical methods for lowering temperature are discouraged. A consensus algorithm is presented in which infants <28 days are considered separately, while those >28 days and <90 days are divided into those ill or well appearing. All infants <28 days with fever ≥37.5 °C should undergo complete work-up for sepsis, strongly considered to receive empirical antibiotics ± acyclovir, and be hospitalized. All infants (between 28 and 90 days) ill appearing should undergo diagnostic work-up for sepsis, receive empirical antibiotics, and be hospitalized. In well appearing infants, diagnostic work-up should be carried out to decide admission to hospital and administration of antibiotics. Specific recommendations are also given for home discharge that can be used to inform parents about the actions to take during home care in the attempt to reinforce existing guidelines. At present, physical examination and laboratory tests, along with best clinical judgement and postdischarge guidance following a defined algorithm, are the foundation of management of febrile children.

Management of early-onset sepsis from a Latin American country: A survey of neonatologists management perspective: Management perspective of early-onset sepsis

AimTo determine the management perspective of early-onset neonatal sepsis among neonatologists from Lima – Perú and to compare it with international society guideline recommendations. Material and MethodsWe collected data from August to December 2018 from 151 neonatologists working in neonatal units in Lima-Perú with an anonymous survey. The survey contained three questions related to the participant's general characteristics and eight questions regarding the management of early-onset sepsis, including the risk factors relating to the initiation of postnatal antibiotics, the management of a low-risk febrile neonate, laboratory cutoff values, indications for a lumbar puncture, and first-line therapy and antibiotic therapy duration in culture-proven and culture-negative sepsis. ResultsThe mean age of the participants was 46.2 ± 8.1 years, with a median duration of clinical practice of 6 years (4.0 – 12.0). Chorioamnionitis (76.2%), maternal fever (62.3%) and prolonged rupture of the membranes (52.3%) were the most common risk factors considered for postnatal antibiotic therapy. Of the participants, 91.4% would not prescribe antibiotic therapy for a low-risk febrile neonate and would, instead, track the fever (82.8%) and do a sepsis workup (65.6%). In addition, 97.4% would do a lumbar puncture in a neonate with seizures and EOS. Only 43.1% would do a lumbar puncture in cases with a positive blood culture. Of the neonatologist, 98% defined leukopenia as a leukocyte count ≤5 × 109/L and 47.7% defined leukocytosis as a count of ≥25 × 109/L. An immature to total neutrophil ratio of ≥0.20 was used by 57.6% of them. Ampicillin/amikacin is the most common first-line drug combination for EOS, followed by ampicillin/gentamicin and ampicillin/cefotaxime. Median duration of antibiotic therapy for Gram-positive and Gram-negative organisms is 7 days (7.0 – 10.0) and 10 days (10.0 – 14.0), respectively. In culture-negative early-onset sepsis, the median antibiotic therapy duration is 7 days (5.0 – 7.0). ConclusionThere are significant differences in the approach to and management of EOS among neonatologists from Lima – Perú. A local standardized protocol would prevent this variability and minimize unnecessary procedures, antibiotic exposure, bacterial resistance, prolonged hospital stay, and mother-newborn separation.

Framework for Considering Abnormal Heart Rate Characteristics and Other Signs of Sepsis in Very Low Birth Weight Infants.

A heart rate characteristics index (HeRO score), incorporating low variability and superimposed decelerations, was developed as a sepsis risk indicator for preterm infants in the neonatal intensive care unit (NICU). A rise in the risk score should prompt consideration of other clinical changes that may be signs of sepsis to decide whether a workup and antibiotics are needed. We aimed to develop a framework to systematically consider signs potentially indicating sepsis in very low birth weight (VLBW) infants. We developed easy-recall acronyms for 10 signs of sepsis in VLBW infants. Over 12 months in a level IV NICU, neonatology fellows completed a brief survey after each shift to document changes prompting sepsis workups. We analyzed associations between survey data, hourly heart rate characteristic data, and the diagnosis of the workup, grouped as culture-positive sepsis (CXSEP, positive blood or urine culture), clinical sepsis (CLINSEP, negative cultures treated with antibiotics ≥5 days), or sepsis ruled out (SRO, negative cultures and <3 days antibiotics). We analyzed 93 sepsis workups in 48 VLBW infants (35 CXSEP, 20 CLINSEP, and 38 SRO). The most frequently cited changes prompting the workups were heart rate patterns and respiratory deterioration, which were common in all three categories. Low blood pressure and poor perfusion were uncommonly cited but were more likely to be associated with CXSEP than the other signs. A rise in the HeRO score ≥1 from 0 to 12 hours before compared with 12to 72 hours prior the blood culture occurred in 31% of workups diagnosed as CXSEP, 16% CLINSEP, and 31% SRO. The HeRO score can alert clinicians to VLBW infants at high or increasing risk of a sepsis-like illness, but heart rate characteristic patterns are highly variable in individual babies. The easy-recall NeoSEP-10 framework can assist clinicians in considering other clinical changes when making decisions about sepsis workups and the duration of antibiotics. · Abnormal heart rate characteristics can indicate sepsis or other pathologies in preterm infants.. · We developed a simple bedside tool to consider clinical signs potentially associated with sepsis.. · Considering vital sign trends together with clinical changes is a key to right-timing antibiotics..

Thrombocytopenia in an Apparently Healthy Neonate: An Unusual Report of Postnatally Acquired Dengue Infection

Dengue is one of the commonest viral infections affecting general population in endemic zones every year. However, dengue is usually not reported in newborn period as it is widely believed that infants are protected from serious viral infections in the first 6 months of life by presence of maternal antibodies. Here, a unique case of an apparently healthy newborn with dengue fever is reported where transmission of the infection occurred postnatally. A 10-day-old male child, born to a primigravida mother with normal antenatal history, presented with complaints of fever for four days along with full body macular rash. Examination findings revealed red coloured, pin-point macular rash while rest of general and systemic examination were unremarkable. Routine Sepsis work-up was negative except presence of thrombocytopenia. Keeping in mind the endemicity and season of dengue, NS1 antigen of the baby was tested by a rapid antigen test which was positive, which was further confirmed by IgM ELISA for dengue. However, the mother was asymptomatic and platelet count as well as NS1 antigen and IgM, IgG ELISA for dengue of the mother was negative.

Neonatal Fever in the COVID-19 Pandemic: Odds of a Serious Bacterial Infection.

ObjectivesA sepsis workup is recommended in young infants 56 days or younger with fever to rule out a serious bacterial infection (SBI). Given the reduction in non–severe acute respiratory syndrome - coronavirus 2 viral infections observed in multiple studies during the coronavirus diseases 2019 (COVID-19) pandemic, we sought to determine if the reduction in viral infections led to a change in the incidence of SBI in this vulnerable patient population.MethodsWe performed a multicenter, retrospective study of infants 56 days or younger presenting with fever to emergency departments of 6 community hospitals. We compared the incidence of SBIs, viral meningitis, and viral bronchiolitis during March 2020 to February 2021 (pandemic year) with the same calendar months in the 2 preceding years (prepandemic years).ResultsFrom March 2018 to February 2021, 543 febrile infants presented to the emergency departments, 95 during the pandemic year (March 2020 to February 2021) compared with 231 and 217 in the prepandemic years (March 2018 to February 2019 and March 2019 to February 2020, respectively).During the pandemic year, 28.4% of infants (27 of 95) were diagnosed with an SBI compared with 11.7% and 6.9% (P < 0.001) in the prepandemic years (27 of 231 and 15 of 217, respectively). Five patients were diagnosed with bacterial meningitis over the 3-year period, 4 of them during the pandemic year (4 of 95 [4.2%]). Positivity for viral cerebrospinal fluid polymerase chain reaction during the pandemic year was 6.4% (3 of 47) compared with 20.8% (25 of 120) and 20.4% (23 of 113) in prepandemic years (P = 0.070). During the pandemic year, 2.1% (2 of 95) febrile young infants were admitted with a comorbid diagnosis of bronchiolitis compared with 4.3% and 6.0% in the prepandemic years (P = 0.310).ConclusionsThe COVID-19 pandemic led to an increase in the incidence of SBIs in febrile infants 56 days or younger, likely a result of reduction in non–severe acute respiratory syndrome - coronavirus 2 viral infections. Greater vigilance is thus warranted in the evaluation of febrile infants during the COVID-19 pandemic.

Proportion of urinary tract infection in neonatal sepsis

Background: Urinary tract infection (UTI) in neonates might be associated with bacteremia and congenital anomalies of the kidney and urinary tract (CAKUT), that in complicated situations can lead to renal parenchymal scarring and chronic kidney disease. Aim: To determine occurrence of UTI in neonatal sepsis. Methods: This cross sectional study was conducted on 500 term, extramural hospitalized neonates, suspected to have infection underwent, a detailed history, physical examination and a comprehensive sepsis workup. The diagnosis of neonatal UTI was based, on positive urine culture, obtained by suprapubic aspiration (SPA). Results: Out of 500 neonates included in our study (324 boys and 176 girls), blood culture was positive in 84 (36.5%) neonates in early-onset sepsis group (n=230), while in late-onset sepsis group (n=270) blood culture was positive in130 (48.1%), p-value < 0.05. In both early-onset sepsis (EOS) and late-onset sepsis (LOS) groups, blood culture was found to be positive in a greater proportion of male (41.3%) than female (29.3%) patients, p-value <0.05. The most common organism isolated from blood and urine culture was Klebsiella, followed by E-coli. Urine culture was positive in 34 (6.8%) patients, among whom 29 (85%) culture-positive cases were from the LOS group, a p-value of <0.05. Conclusions: UTI is not uncommon among the hospitalized neonates, and UTI evaluation among septic neonates can prove beneficial for the prevention of long-term sequelae of neonatal UTI.

Neonatal sepsis in Sana\u2019a city, Yemen: a predominance of Burkholderia cepacia

BackgroundNeonatal sepsis is a global concern with increasing morbidity and mortality. The burden of neonatal sepsis is highest in developing countries, especially in those lacking proper surveillance systems. The causative pathogens and their drug-resistance levels vary between countries with emergence of multidrug resistance organisms. Thus, accurate records on the recent trends of organisms causing neonatal sepsis will provide vital information for appropriate intervention. We aimed to investigate neonatal sepsis, identify its associated factors and causative pathogens and to assess the antibiotic susceptibility patterns in Sana’a city, Yemen.MethodsA cross-sectional study was conducted on neonates admitted to intensive care units of six hospitals in Sana’a city, Yemen, in the period from January 15, to March 30, 2020. Natal and prenatal medical data were collected using well-structured questionnaire. Neonates were subjected to sepsis work-up including blood culture, complete blood count and C-reactive protein. Organisms were identified by Gram staining and analyzed by the VITEK II system for bacterial bio-typing and antibiotic susceptibility testing.FindingsOf the 199-neonates with suspected neonatal sepsis, 154 (77.38%) had culture-proven sepsis. Early-onset neonatal sepsis (EOS) was higher (50.25%; 100/199) than late-onset neonatal sepsis (LOS) (27.13%; 54/199). Multivariable analysis identified vaginal delivery as an independent risk factor for neonatal sepsis p = 0.005. Majority of isolated bacteria (74.39%) were gram-negative with Burkholderia cepacia (39%) and Klebsiella oxytoca (13%) being the most common pathogens of EOS and LOS. The most common gram-positive pathogens were Staphylococcus haemolyticus (9.1%) and Staphylococcus epidermidis (7.1%). B. cepacia showed multidrug resistance except for cefepime. All Klebsiella species isolates (100%) and most Pantoea species (93%) were ESBL and carbapenemase positive. All Escherichia coli and Acinetobacter baumannii isolates were ESBL positive. A significant number of gram-positive bacteria showed resistance to vancomycin.ConclusionThe study findings show a high proportion of neonatal sepsis among neonates admitted to hospitals in Sana’a city with antibiotic-resistant B. cepacia being the single most common pathogen causing EOS and LOS. Findings also emphasize the emerging threat of multidrug-resistant bacteria in neonatal units and will help develop evidence-based management of neonatal sepsis in Yemen.

Left Main Coronary Artery to Superior Vena Cava Fistula Unmasked by Endarteritis

Coronary artery fistulas are rare vascular malformations that can present with a broad range of symptoms. We present a case of a left main coronary artery to superior vena cava fistula that was discovered during a work-up for sepsis. A multidisciplinary approach is crucial for successful management of these vascular malformations. (Level of Difficulty: Beginner.)

Peripheral Blood Smear Can Be a Reliable and Inexpensive Alternative to Blood Culture in Early Diagnosis of Neonatal Sepsis

Background: Neonatal sepsis is one of the major causes of morbidity and mortality in newborns, more so in the developing countries. Objectives: The aim of this article is to study the role of peripheral smear, to evaluate the usefulness of white blood cell (WBC) parameters, and to establish the sensitivity and specificity of each parameter for early diagnosis of neonatal septicemia. Materials and Methods: The prospective study is of 150 neonates admitted and fulfilling the inclusion criteria, over the period of June 2019 to December 2020, and tests were performed at the Department of Pathology in a tertiary medical college and hospital. Peripheral blood sample was obtained by venipuncture and the sepsis work-up included routine blood counts and blood culture. Total leucocytes counts were counted on an automated hematology analyzer. Leishman-stained peripheral blood smears were used for the study. Results: Based on the clinical findings and laboratory data, neonates were classified into three categories: sepsis (n = 70), probable infection (n = 50), and no infection (n = 30). The blood culture reports of confirmed sepsis cases reveal the commonest organism as Escherichia coli, followed by Klebsiella, Pseudomonas, and beta-hemolytic streptococci. Abnormal I:T ratio (≥0.2) shows highest sensitivity (90%) and specificity (95%). Conclusion: The peripheral smear study is found to be very useful in the early diagnosis of neonatal septicemia as it can be performed even in a small laboratory without any special equipment and within a short period of time. Among WBC parameters, the I:T ratio shows highest sensitivity and specificity.

Plasma metagenomic sequencing to detect and quantify bacterial DNA in ICU patients suspected of sepsis: A proof-of-principle study.

Timely recognition of sepsis and identification of pathogens can improve outcomes in critical care patients but microbial cultures have low accuracy and long turnaround times. In this proof-of-principle study, we describe metagenomic sequencing and analysis of nonhuman DNA in plasma. We hypothesized that quantitative analysis of bacterial DNA (bDNA) levels in plasma can enable detection and monitoring of pathogens. We enrolled 30 patients suspected of sepsis in the surgical trauma intensive care unit and collected plasma samples at the time of diagnostic workup for sepsis (baseline), and 7 days and 14 days later. We performed metagenomic sequencing of plasma DNA and used computational classification of sequencing reads to detect and quantify total and pathogen-specific bDNA fraction. To improve assay sensitivity, we developed an enrichment method for bDNA based on size selection for shorter fragment lengths. Differences in bDNA fractions between samples were evaluated using t test and linear mixed-effects model, following log transformation. We analyzed 72 plasma samples from 30 patients. Twenty-seven samples (37.5%) were collected at the time of infection. Median total bDNA fraction was 1.6 times higher in these samples compared with samples with no infection (0.011% and 0.0068%, respectively, p < 0.001). In 17 patients who had active infection at enrollment and at least one follow-up sample collected, total bDNA fractions were higher at baseline compared with the next sample (p < 0.001). Following enrichment, bDNA fractions increased in paired samples by a mean of 16.9-fold. Of 17 samples collected at the time when bacterial pathogens were identified, we detected pathogen-specific DNA in 13 plasma samples (76.5%). Bacterial DNA levels in plasma are elevated in critically ill patients with active infection. Pathogen-specific DNA is detectable in plasma, particularly after enrichment using selection for shorter fragments. Serial changes in bDNA levels may be informative of treatment response. Epidemiologic/Prognostic, Level V.