Abscess Size Research Articles

The Effects of NLR on the Diagnosis and Pharmacological Management of Brain Abscesses

Aim: The present study aims to examine the effectiveness of the neutrophil-to-lymphocyte ratio in the treatment and diagnosis of patients with brain abscesses. Method: In this retrospective study, radiological, neurological, and surgical data obtained from the medical records of healthy volunteers (n = 10) who presented to the hospital for check-ups and patients with brain abscesses who were treated (n = 10) were evaluated statistically. Alpha significance value was accepted as <0.05. Results: Comparisons between groups revealed that the erythrocyte sedimentation rate, C-reactive protein, leukocyte, and neutrophil values were statistically significant (P <0.05) while lymphocyte value was not statistically significant (P >0.05). The preoperative neutrophil-to-lymphocyte ratio in cases diagnosed with brain abscesses showed statistical significance compared to that in the healthy volunteers (P <0.05) and the neutrophil-to-lymphocyte ratio increased 3.31-fold in the study group compared to the healthy volunteers. Conclusion: A strong positive strong relationship between the neutrophil-to-lymphocyte ratio and abscess size (r = 0.662; P = 0.037) was observed. An increased neutrophil-to-lymphocyte ratio may serve as an early warning signal of brain abscesses. Keywords: Antibiotic treatment; brain abscess; low-cost diagnosis method; magnetic resonance image; neutrophil-to-lymphocyte ratio.

Recurrent appendicitis following successful drainage of appendicular abscess in adult without interval appendectomy during COVID-19. Prospective cohort study

BackgroundCOVID-19 infection is a global pandemic that affected routine health services and made patients fear to consult for medical health problems, even acute abdominal pain. Subsequently, the incidence of complicated appendicitis increased during the Covid-19 pandemic. This study aimed to evaluate recurrent appendicitis after successful drainage of appendicular abscess during COVID-19. Material and methodsA prospective cohort study conducted in the surgical emergency units of our Universities' Hospitals between March 15, 2020 to August 15, 2020 including patients who were admitted with the diagnosis of an appendicular abscess and who underwent open or radiological drainage. Main outcomes included incidence, severity, and risk factors of recurrent appendicitis in patients without interval appendectomy. ResultsA total of 316 patients were included for analysis. The mean age of the patients was 37 years (SD ± 13). About two-thirds of patients were males (60.1%). More than one-third (39.6%) had co-morbidities; type 2 diabetes mellitus (T2DM) (22.5%) and hypertension (17.1%) were the most frequent. Approximately one quarter (25.6%) had confirmed COVID 19 infection. About one-third of the patients (30.4%) had recurrent appendicitis. More than half of them (56.3%) showed recurrence after three months, and 43.8% of patients showed recurrence in the first three months. The most frequent grade was grade I (63.5%). Most patients (77.1%) underwent open surgery. Age, T2DM, hypertension, COVID-19 infection and abscess size >3 cm were significantly risking predictors for recurrent appendicitis. ConclusionsInterval appendectomy is suggested to prevent 56.3% of recurrent appendicitis that occurs after 3 months. We recommend performing interval appendectomy in older age, people with diabetes, COVID-19 infected, and abscesses more than 3 cm in diameter. Research questionIs interval appendectomy preventing a high incidence of recurrent appendicitis after successful drainage of appendicular abscess during COVID-19 pandemic?

ArfX2 GTPase Regulates Trafficking From the Trans-Golgi to Lysosomes and Is Necessary for Liver Abscess Formation in the Protozoan Parasite Entamoeba histolytica.

Entamoeba histolytica is the causative agent of amoebic dysentery and liver abscess in humans. The parasitic lifestyle and the virulence of the protist require elaborate biological processes, including vesicular traffic and stress management against a variety of reactive oxygen and nitrogen species produced by the host immune response. Although the mechanisms for intracellular traffic of representative virulence factors have been investigated at molecular levels, it remains poorly understood whether and how intracellular traffic is involved in the defense against reactive oxygen and nitrogen species. Here, we demonstrate that EhArfX2, one of the Arf family of GTPases known to be involved in the regulation of vesicular traffic, was identified by comparative transcriptomic analysis of two isogenic strains: an animal-passaged highly virulent HM-1:IMSS Cl6 and in vitro maintained attenuated avirulent strain. EhArfX2 was identified as one of the most highly upregulated genes in the highly virulent strain. EhArfX2 was localized to small vesicle-like structures and largely colocalized with the marker for the trans-Golgi network SNARE, EhYkt6, but neither with the endoplasmic reticulum (ER)-resident chaperon, EhBip, nor the cis-Golgi SNARE, EhSed5, and Golgi-luminal galactosyl transferase, EhGalT. Expression of the dominant-active mutant form of EhArfX2 caused an increase in the number of lysosomes, while expression of the dominant-negative mutant led to a defect in lysosome formation and cysteine protease transport to lysosomes. Expression of the dominant-negative mutant in the virulent E. histolytica strain caused a reduction of the size of liver abscesses in a hamster model. This defect in liver abscess formation was likely at least partially attributed to reduced resistance to nitrosative, but not oxidative stress in vitro. These results showed that the EhArfX2-mediated traffic is necessary for the nitrosative stress response and virulence in the host.

From the Editor’s Desk...

From the Editor’s Desk...

Pediatric brain abscess - etiology, management challenges and outcome in Lagos Nigeria.

Background: Brain abscess in children is a neurosurgical emergency with potentially catastrophic outcome despite the advances made in neuroimaging techniques and antibiotic therapy. Symptoms are nonspecific and may vary with the child’s age, location, size, numbers and stage of abscess, and the primary source of infection. Treatment is usually with broad-spectrum antibiotics in combination and surgical evacuation in most cases or antibiotics alone in selected cases with clear-cut indications. This study was to document clinical characteristics, etiological factors, and spectrum of bacteriologic agents responsible for pediatric brain abscess in an African city, the challenges and management outcome over the study period.Methods: This was a retrospective study over an 11-year period involving 89 children who presented with brain abscess. Information of interest was extracted from the medical records of each participant. The results from data analysis were presented in charts and tables.Results: Eighty-nine children aged 0.85–15.7 years (median age of 6.4 years) met the inclusion criteria. The male-to-female ratio was 1.8:1. Headache (80%), fever (78%), and hemiparesis (78%) were the most common symptoms. Brain imaging deployed was CT scan in 56 (63%), MRI in 9 (10%), and transfontanel ultrasound scan in 24 (27%) children. Seventy-one (80%) children had antibiotics with surgical evacuation while 18 (20%) children received only antibiotics. In 19 (27%) children, the culture of the abscess was negative. In 53 (75%) children, Gram-positive aerobic organisms were isolated. A total of 75 patients (84%) had a favorable outcome.Conclusion: Pediatric brain abscess still poses significant public health challenge, especially in resource-limited regions. Successful management of brain abscess requires high index of suspicion for early diagnosis, referral, and intervention.

EP.TU.70The Conservative Management of Perforated Diverticulitis Based on Abscess Size and Presence of Distant Air

Abstract Aims To determine the effectiveness of conservative management in perforated diverticulitis (PD) in a single District Hospital based on the size of the abscess and the presence of distant air (DA). Methods Data on 112 Patients who were admitted between 2013-2018 with PD was collected retrospectively. CT scan reports were used to document the size of abscess and presence of DA. Failed conservative management with antibiotics (ABx) was defined as the need for another therapeutic option after 48 hours of admission or readmission within 90 days. Results Overall, 40 patients (36%) needed operative management, 12 patients (11%) required washout, 6 patients (5%) underwent radiological drainage and 8 patients (7%) were offered best supportive care. In total, 46 patients (41%) were successfully managed with ABx only. ABx were tried on 45 patients who had <4cm abscess and no DA. This was successful in 30 of them (66%). However, 6 out of 17 patients (35%) with >4cm abscess and no DA were treated with ABx only. Despite presence of DA, 8 out of 17 (47%) cases with <4cm abscess were successfully treated with Abx only. Only 2 patients out of 19 (10%) with >4cm and DA were successfully treated with ABx only. Conclusion Abscess size and presence of DA in PD should be considered in predicting the outcome of the management. Even in presence of DA, nearly half of patients with small abscesses (<4cm) diverticular abscesses were successfully managed conservatively. The majority of patients with larger abscesses with DA failed ABx treatment.

Predicting the Need for a Surgical Intervention in the Management of a Tubo-Ovarian Abscess

<h3>Study Objective</h3> To analyze the inpatient management of tubo-ovarian abscess (TOA) and identify factors associated with the need for a surgical intervention. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Community Hospitals with an Academic Affiliation. <h3>Patients or Participants</h3> Women who were managed inpatient with the diagnosis of a TOA between 2014-20 (N=77). <h3>Interventions</h3> TOA managed by intravenous (IV) antibiotics is effective in approximately 70% of patients. For those who fail IV antibiotics, drainage of the abscess is recommended, whether achieved by interventional radiologic means or surgery. We report on the management of TOA in patients who presented to our hospital system. Patients with TOA were identified by International Classification of Disease code N70.93. A confirmation of the diagnosis was made by chart review. Pertinent demographic, medical history, and clinical findings (i.e., abscess size, leukocytosis, fever and treatment) were abstracted from the medical record. <h3>Measurements and Main Results</h3> Descriptive statistics were used to characterize the cohort of patients. The mean age was 41.2 years (S.D. ± 11.12) and mean body mass index was 30.4 kg/m² (S.D. ±10.34). 43% of patients failed IV antibiotics and needed additional therapy. When analyzing data for factors associated with the need for additional therapy, we found that size (>5 cm) was a significant risk with odds ratio (95%CI) 9.423 (1.968- 45.116). When comparing findings amongst co-morbidities, race and ethnicity we found that there was a correlation between size and intervention but no statistical significance. <h3>Conclusion</h3> In our cohort, women with TOA greater than 5 cm were more likely to fail medical management. However, this association did not persist when controlling for other demographic and clinical factors. A larger recruited cohort may reveal a significance of size and the need for intervention. Consideration should be made for early consultation with a minimally invasive gynecologist or interventional radiologist to manage the TOA when there is an increased likelihood of failing medical management.

Clinical Predictors of Failed Medical Treatment in Patients with Tubo-Ovarian Abscess

<h3>Study Objective</h3> To estimate the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) and assess the external validity of a clinical risk score. <h3>Design</h3> External validation study. The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. <h3>Setting</h3> Safety-net teaching hospital system in Houston, Texas. <h3>Patients or Participants</h3> 169 consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with IV antibiotics; others required a drainage procedure. <h3>Interventions</h3> Predictors of failed conservative treatment were captured. The previously published predictors by Fouks et al, included age>36, WBC ≥ 16000), abscess diameter (≥ 7 cm) and bilateral abscesses. A clinical risk score was calculated for each patient and correlated with the risk of failed medical treatment. A multivariate logistic regression using the patient characteristics was created, in addition to the prediction model using the risk score. Then the calibration, discrimination and accuracy of the model were evaluated to perform the external validation analysis. <h3>Measurements and Main Results</h3> Among 169 eligible patients, 50.2% were successfully treated with IV antibiotics and 49.8% needed drainage via minimally invasive or traditional surgery. Patients undergoing the intervention were more likely to be older, diabetic, to present with elevated white blood cell count, have fever and a large abscess size on univariate analysis. Large abscess size was found to be the strongest independent predictor for intervention in our cohort. The AUC curve for the adjusted model was 0.77 (0.71-0.84), indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. <h3>Conclusion</h3> Our results provide external validation to a simple clinical risk score predicting failed medical treatment in patients with TOA. Large abscess size was found to be the strongest independent predictor for intervention.

MANAGEMENT OF PULMONARY ABSCESS: FIBRINOLYTICS AND DRAINAGE?

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Empyema is defined as the presence of purulent material in the pleural space. Lung abscesses are characterized by necrosis of the lung parenchyma, often leading to an isolated cavity. They are usually identified by imaging. Here we present a case of a difficult case of a pulmonary abscess which was initially mistaken for an empyema. CASE PRESENTATION: Case Presentation:A 48-year-old female with no known past medical history, originally from India, but had been living in Europe and then Texas for the last ten years, who had an uncomplicated tooth extraction eight months prior, now presenting with the 3-month onset of symptoms including 10lb weight loss, intermittent fevers, night sweats, and productive cough with yellow foul-smelling sputum. VS: T 98.9, P 89, BP 97/61, RR 18, SpO2 98% on room air. Physical exam was significant for rales in the RLL posteriorly. The metabolic panel was unrevealing. Blood counts showed WBC 6.4, Hgb 7.7. HIV negative. CT chest was obtained (Fig.1), which demonstrated an RLL 9cm lesion with signs of necrosis but notably no air-fluid levels and 'Tree in Bud' opacities on the RUL. She was started on empiric coverage for gram-negative and anaerobic bacteria. She underwent IR-guided pigtail chest tube placement with drainage of 450 cc of purulent material. Fluid studies were exudative with 61K WBC, 93%N. Sputum AFB x 3 and fungal cultures were negative. Chest tube output was minimal for two days. On POCUS, a small collection was seen. One dose of Dornase 5mg was given through a chest tube with no increased output. Repeat CT chest was performed (Fig.2), which demonstrated the decreased size of the pulmonary abscess. She remained afebrile, without leukocytosis. Cardiothoracic surgery was consulted; deemed no plan for surgery. The chest tube was removed, and she was then discharged on PO Amoxicillin/Clavulanic acid for four weeks. Cultures from the lesion grew fusobacterium nucleatum, streptococcus pneumoniae, and klebsiella oxytoca. She was seen in pulmonary clinic, asymptomatic, with imaging demonstrating complete resolution of the abscess. DISCUSSION: The distinction between lung abscess and empyema is vital, as they portend to different clinical outcomes, and their management is different(1). The distinction can be made using imaging, mainly CT. Empyema's are treated with direct chest tube drainage and intrapleural fibrinoytics, whereas lung abscess are treated with antibiotics. In large collections or when medical management fails, drainage or surgery may be necessary, though there are limited prospective data on drainage(2). The role of fibrinolytic in the management of pulmonary abscess are not known, with only case reports offering guidance(3). CONCLUSIONS: The role and safety of fibrinolytic therapy in pulmonary abscess needs to be evaluated and potential surgery may be avoided in select cases. REFERENCE #1: Yu, Hyeon., Management of Pleural Effusion, Empyema, and Lung Abscess, Semin Intervent Radiol 2011;28:75–86 REFERENCE #2: Wali SO. An update on the drainage of pyogenic lung abscesses. Ann Thorac Med. 2012;7(1):3-7. doi:10.4103/1817-1737.91552 REFERENCE #3: Barthwal MS, Tyagi R, Kishore K. Fibrinolytics in loculated abscess cavities - A report of two cases. Lung India. 2016;33(4):417-419. doi:10.4103/0970-2113.184876 DISCLOSURES: No relevant relationships by Juan Deleija, source=Web Response No relevant relationships by Dharani Kumari Narendra, source=Web Response

POSSIBLE ZOONOTIC TRANSMISSION OF UNKNOWN MICROBIAL PATHOGEN IN A LUNG TRANSPLANT RECIPIENT: A CASE REPORT

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: Lung transplant recipients are at an increased risk for microbial infection, which may at times be difficult to isolate or properly identify, even with repeat transbronchial biopsies (1). CASE PRESENTATION: We reviewed the unique, potential route of transmission and infectious disease course of an enigmatic microbial pathogen that was challenging to identify and associated with an abscess of the lung allograft in a 59-year-old bilateral lung re-transplant recipient. Interestingly, the patient reported having multiple pets at home, including dogs, lizards, cows, horses, and chickens residing on her property, which may have been a source of infection. DISCUSSION: This lung re-transplant recipient presented to our advanced lung disease center at 9-years post-transplant with complaints of sudden fever and chills alongside a 2-week history of productive cough with yellow-tinged sputum. Maintenance immunosuppression consisted of tacrolimus, sirolimus, and prednisone. The patient denied unintentional weight loss, night sweats, or known tuberculosis contacts or exposures;COVID-19 testing was negative in the interim. On thoracic imaging (Figure A), a right upper lobe cavitary lesion was identified. Bronchoscopy was negative for microorganismal growth. She was treated empirically with meropenem, isoniazid, and amikacin. The fever resolved, but the patient reported continued malaise over the next several weeks. Repeated bronchoscopies failed to identify any microorganisms. After six weeks of antibiotic therapy, the size of the lung abscess decreased (Figure B), but all cultures and transbronchial biopsies had failed to determine the infectious origin. The only note regarding her history prior to presentation was that she performed mouth-to-mouth resuscitation on her pet dog who unexpectantly collapsed. It is surmised that this event served as the basis for an oral transmission of a microbial pathogen. CONCLUSIONS: Lung abscesses are generally an early complication in the post-lung transplant period, yet our patient seemingly developed an abscess from an unknown microbial infection at 9-years post-transplant, potentially from a zoonotic source. Although infrequently observed, lung transplant recipients (and other immunosuppressed groups) may be at risk for severe harm or prolonged infection due to direct zoonosis. REFERENCE #1: Pahlman LI, Manoharan L, Aspelund AS. Divergent airway microbiomes in lung transplant recipients with or without pulmonary infection. Respir Res. 2021 Apr 23;22(1):118. doi: 10.1186/s12931-021-01724-w. PMID: 33892717. DISCLOSURES: No relevant relationships by Ashwini Arjuna, source=Web Response No relevant relationships by David Bowman, source=Web Response No relevant relationships by Michael Olson, source=Web Response No relevant relationships by Ali Saeed, source=Web Response

Surgical Outcome of Brain Abscess after Single Burrhole Aspiration Technique in Terms of Glasgow Outcome Scale

Objectives: This case-series was aimed to determine the surgical outcome of brain abscess after a single burr hole aspiration technique in terms of the Glasgow outcome scale (GOS).&#x0D; Material &amp; Methods: 100 cases were taken in the study with brain abscess. The favourable outcome included those patients with postoperative GOS of 4 or 5, at discharge and one month postoperatively whereas unfavourable outcome included patients with postoperative GOS of less than 4, at discharge and one month postoperatively.&#x0D; Results: Of the 100 patients included, there were 72 (72%) males and 28 (28%) females. The overall mean diameter of the abscess was 6.01 cm ± 1.90. Mean GOS was 2.95 ± 0.86 while mean GOS 3.79 ± 1.18. In this study 75% (n=75) patients presented with a GCS of 12 or less. Among these patients, 2 patients presented with a GCS of 5, 6 patients with a GCS of 7, 9 with GCS 8, 11 with GCS 9, 18 with GCS 10, 15 with GCS 11 and 14 patients presented with a GCS of 12. A favourable outcome was observed in 73 (73%) patients (GOS = 4 and 5), while 27 (27%) were in the unfavourable outcome group.&#x0D; Conclusion: Although most of the patients present with a good neurological state, those who present with lower GCS are particularly prone to the poor postoperative outcome and higher mortality. The size of the brain abscess is also an important predictor of the postoperative outcome. The overall outcome for brain abscess aspiration was good.

HIF-1α modulates sex-specific Th17/Treg responses during hepatic amoebiasis

An invasive form of intestinal Entamoeba (E.) histolytica infection, which causes amoebic liver abscess, is more common in men than in women. Immunopathological mechanisms are responsible for the more severe outcome in males. Here, we used a mouse model of hepatic amoebiasis to investigate the contribution of hepatic hypoxia-inducible factor (HIF)-1α to T helper 17 (Th17)/regulatory T cell (Treg) responses in the context of the sex-specific outcome of liver damage. C57BL/6J mice were infected intrahepatically with E.histolytica trophozoites. HIF-1α expression was determined by qPCR, flow cytometry and immunohistochemistry. Tregs and Th17 cells were analysed by immunohistochemistry and flow cytometry. Finally, male and female hepatocyte-specific Hif1α knockout mice were generated, and the effect of HIF-1α on abscess development, the cytokine milieu, and Th17/Treg differentiation was examined. E.histolytica infection increased hepatic HIF-1α levels, along with the elevated frequencies of hepatic Th17 and Treg cells. While the Th17 cell population was larger in male mice, Tregs characterised by increased expression of Foxp3 in female mice. Male mice displayed increased IL-6 expression, contributing to immunopathology; this increase in IL-6 expression declined upon deletion of hepatic HIF-1α. In both sexes, hepatic deletion of HIF-1α reduced the Th17 cell frequency; however, the percentage of Tregs was reduced in female mice only. Hepatic HIF-1α modulates the sex-specific outcome of murine E.histolytica infection. Our results suggest that in male mice, Th17 cells can be modulated by hepatic HIF-1α via IL-6, indicating marked involvement in the immunopathology underlying abscess development. Strong expression of Foxp3 by hepatic Tregs from female mice suggests a potent immunosuppressive function, leading to initiation of liver regeneration. Infection with the parasite Entamoeba histolytica activates immunopathological mechanisms in male mice, which lead to liver abscesses that are larger than those in female mice. In the absence of the protein HIF-1α in hepatocytes, abscess formation is reduced; moreover, the sex difference in abscess size is abolished. These results suggest that HIF-1α modulates the immune response involved in the induction of immunopathology, resulting in differential disease susceptibility in males and females.

Enzymatically releasable polyethylene glycol – host defense peptide conjugates with improved activity and biocompatibility

Host defense peptides (HDPs) have been the subject of great interest for the treatment of multidrug-resistant bacterial infections due to their multimodal activity and low induction of resistance. However, aggregation, toxicity, and short biological half-life have limited their applicability for clinical treatment. Many methods have been explored to alleviate these issues, such as polymer (e.g., polyethylene glycol (PEG)) conjugation, but these are often accompanied by reductions in the activity of the HDP. Here, we detail the design of a novel PEG-HDP conjugate incorporating an enzymatic cleavage sequence targeting matrix metalloproteinases (MMPs) that accumulate at sites of inflammation and infection. Addition of the cleavage sequence onto either the N- or the C-terminal region of the parent peptide (peptide 73, a derivative of the HDP aurein 2.2) was explored to determine the location for optimal antimicrobial activity following MMP cleavage; furthermore, the susceptibility of the peptide to MMP cleavage after conjugation to 2 kDa or 5 kDa PEG was examined. The top candidate, L73, utilized an N-terminal cleavage site that was subsequently conjugated to a 2 kDa PEG polymer. Both L73 and the conjugate exhibited no antimicrobial activity in vitro until cleaved by purified MMP, which liberated a peptide fragment with 16- or 63-fold improved activity, respectively, corresponding to a minimum inhibitory concentration (MIC) of 8 μg/mL, comparable to that of peptide 73 (4 μg/mL). Furthermore, PEG conjugation improved the blood compatibility and reduced the aggregation tendency of the HDP in vitro, indicating enhanced biocompatibility. When administered as a single subcutaneous dose (~3.6 mg, or a peptide concentration of 142 mg/kg) in a mouse abscess model of high-density methicillin-resistant Staphylococcus aureus (MRSA) infection, the conjugate displayed strong activity, reducing abscess size and bacterial load by 73.3% and 58-fold, respectively. This activity was completely lost when the cleavage site was rendered resistant to MMPs by the substitution of two d-amino acids, supporting the hypothesis that antimicrobial activity was dependent on cleavage by MMPs, which were shown here to increasingly accumulate at the abscess site up to 18 h post infection. Finally, the conjugate displayed biocompatibility in vivo, with no identifiable toxicity or aggregation.

Is There an Impact of the Duration of Antibiotic Therapy on the Outcome of Nonsurgical Treatment of Complicated Diverticulitis?

Patients treated nonsurgically for complicated diverticulitis are managed by antibiotics. However, there are no recommendations concerning their duration. We aimed to determine the impact of the duration of antibiotic therapy on the risk of failure of nonsurgical treatment of complicated acute diverticulitis. This was a single-center retrospective study of patients with computer tomography (CT)-diagnosed complicated diverticulitis between January 2015 and April 2020. Treatment failure was defined as early recurrence and/or a persistent abscess by control CT. In total, 148 patients fulfilled the inclusion criteria [87 men (58.8%), mean age 55±15 y]. The diverticulitis was classified as Hinchey I in 41.9%, Hinchey II in 9.5%, and pericolic free air in 48.6% of cases. The median abscess size was 2.9±1.7 cm. The median duration of antibiotic treatment was 10±4.2 days. The median follow-up was 64±60 months. The rate of failure was 12.8%. In univariate analysis, treatment >10 days (P=0.015) and an abscess >3 cm (P=0.032) were associated with a risk of treatment failure. In multivariate analysis, only the diameter of the abscess remained associated with a risk of failure (odds ratio: 1.6, 95% confidence interval: 1.09-2.4, P=0.01). This study suggests that there is no need to extend the duration of antibiotic treatment beyond 10 days in nonsurgically treated complicated acute diverticulitis.

Oral Delivery of Novel Recombinant Lactobacillus Elicit High Protection against Staphylococcus aureus Pulmonary and Skin Infections.

Staphylococcus aureus is a leading cause of nosocomial and community-associated infection worldwide; however, there is no licensed vaccine available. S. aureus initiates infection via the mucosa; therefore, a mucosal vaccine is likely to be a promising approach against S. aureus infection. Lactobacilli, a non-pathogenic bacterium, has gained increasing interest as a mucosal delivery vehicle. Hence, we attempted to develop an oral S. aureus vaccine based on lactobacilli to cushion the stress of drug resistance and vaccine needs. In this study, we designed, constructed, and evaluated recombinant Lactobacillus strains synthesizing S. aureus nontoxic mutated α-hemolysins (HlaH35L). The results from animal clinical trials showed that recombinant Lactobacillus can persist for at least 72 h and can stably express heterologous protein in vivo. Recombinant L. plantarum WXD234 (pNZ8148-Hla) could induce robust mucosal immunity in the GALT, as evidenced by a significant increase in IgA and IL-17 production and the strong proliferation of T-lymphocytes derived from Peyer’s patches. WXD234 (pNZ8148-Hla) conferred up to 83% protection against S. aureus pulmonary infection and significantly reduced the abscess size in a S. aureus skin infection model. Of particular interest is the sharp reduction of the protective effect offered by WXD234 (pNZ8148-Hla) vaccination in γδ T cell-deficient or IL-17-deficient mice. In conclusion, for the first time, genetically engineered Lactobacillus WXD234 (pNZ8148-Hla) as an oral vaccine induced superior mucosal immunity, which was associated with high protection against pulmonary and skin infections caused by S. aureus. Taken together, our findings suggest the great potential for a delivery system based on lactobacilli and provide experimental data for the development of mucosal vaccines for S. aureus.

Factors associated with high rates of recurrence of amebic liver abscess (ALA) in north India

Recurrence of amebic liver abscess (ALA), once considered unusual, is increasingly being reported, despite proper management. Realizing the endemicity of ALA in the study setup, this 2-year follow-up study was conducted to investigate the recurrent cases and study the associated factors. A total of 101 confirmed cases of ALA were followed up for a period of 2 years. Recurrent cases were studied for associated bacterial flora, presence of resistance genes (nim), level of matrix metalloproteinase 3 and MMP-9, and genotypes of Entamoeba histolytica and statistically compared with the nonrecurrent cases as controls. Recurrence rates of 8.9% (nine patients) were detected. The presence of Prevotella along with an increased level of MMP-9 in abscess fluid and large size of abscesses (11 × 10.8 cm) was found to be significantly associated with recurrence in ALA. Among the nine cases, the presence of nimE gene was detected in two (22.2%) patients. The genotyping of E. histolytica strains showed that in seven (77.7%) cases, the genotype of E. histolytica was the same in the primary and recurrent samples. This study reports a high rate of recurrence in the cases of ALA, hinting toward the gradual development of clinical resistance toward the commonly used drug. The presence of nim gene and Prevotella in abscess fluid along with increased MMP-9 levels and large abscess size could be important predictors of recurrent ALA.

Management of lactating breast abscesses by ultrasound-guided needle aspiration and continuation of breastfeeding: A pilot study

IntroductionNeedle aspiration of breast abscesses during lactation are currently recommended as an alternative to surgery only for moderate forms. In case of breast abscess, many patients stop breastfeeding on the advice of a health professional. We reviewed our experience of treatment of lactating breast abscesses by ultrasound-guided aspiration and suggest an algorithm of their management. We also analyzed the continuation of breastfeeding of these patients after advices from trained teams. Materiel and methodsWe conducted a retrospective study from April 2016 to April 2017, including 28 patients referred for a breast abscess during lactation at the Duroc Breast Imaging Center. A management by ultrasound-guided aspiration was proposed to each patient. We collected data about the breastfeeding between October 2018 and January 2019. ResultsA single aspiration was sufficient in 64.3% of cases. The delay between the occurrence of the abscess and the indication for drainage was significantly higher for patients who have needed finally surgical drainage (p = 0,0031). There were no difference of size of abscesses between patients receiving needle aspiration alone and those who have undergone surgery (p = 0,97). All patients who had been managed by needle aspiration continued breastfeeding after the treatment and 40% of the patients were still breastfeeding at 6 months. ConclusionThe management of lactating breast abscess by ultrasound-guided needle aspiration is an effective alternative to surgery. It appears to be effective regardless of the size of the abscess and is compatible with the continuation of breastfeeding. Our study has indeed shown that if they are well advised, the majority of patients continue breastfeeding so that it is essential that health professionals be better trained regarding the management of breastfeeding complications.

A Man With Testicular Pain

An 86-year-old male with a history of diabetes presented to the emergency department (ED) with left testicular pain for 2 days. Physical examination demonstrated an uncircumcised male with a normal testicular lie, left testicle enlargement, erythema, and tenderness to palpation. The patient was afebrile, with a WBC count of 9,000 cells/uL, and urinalysis revealed leukocytes. ED point-of-care ultrasonography was obtained (Figures 1 and 2).Figure 2Sonographic image of the left testicle in the sagittal plane obtained with a high frequency linear transducer demonstrated a hypoechoic structure (arrow) with increased surrounding vascular flow demonstrating inflammatory changes (star) within the testicle. Scrotal wall thickening was seen (asterisk).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Testicular abscess. Testicular abscess on ultrasonography is typically spherical or elliptical, with a focal area of mixed echogenicity due to necrotic cellular debris.1Gaillard F. Testicular abscess: radiology reference article.https://radiopaedia.org/articles/testicular-abscess?lang=usDate accessed: December 12, 2020Google Scholar,2O’Rourke K. Kibbee N. Stubbs A. Ultrasound for the evaluation of skin and soft tissue infections.Mo Med. 2015; 112: 202-205PubMed Google Scholar Testicular abscess may also demonstrate enlargement of the affected testicle and a reactive hydrocele. Testicular abscess is rare and typically results from untreated or severe epididymo-orchitis. In sexually active patients, common pathogens include Neisseria gonorrhea and Chlamydia trachomatis. However, those who are not sexually active can have other gram-negative and gram-positive organisms.1Gaillard F. Testicular abscess: radiology reference article.https://radiopaedia.org/articles/testicular-abscess?lang=usDate accessed: December 12, 2020Google Scholar,3Mevorach R.A. Lerner R.M. Dvoretsky P.M. et al.Testicular abscess: diagnosis by ultrasonography.J Urol. 1986; 136: 1213-1216Crossref PubMed Google Scholar,4Hackett B. Sletten Z. Bridwell R.E. Testicular abscess and ischemia secondary to epididymo-orchitis.Cureus. 2020; 12e8991PubMed Google Scholar Typically, patients will report testicular pain, swelling, and fever. The differential diagnosis includes testicular torsion, epididyomo-orchitis, epididymal abscess, testicular cancer, and testicular trauma. Ultrasound is the initial imaging modality needed to differentiate testicular abscess from other similarly presenting diagnoses. Treatment depends on the size of the testicular abscess and clinical parameters. Minor cases (those in patients who have normal WBC counts, are afebrile, are able to urinate, and do not have signs of necrotizing fasciitis) can be treated with antibiotics, while more severe cases may require surgical debridement or orchiectomy. ED treatment includes initiation of antibiotic therapy and urology consultation.

Surveillance of urachal abscess in the Kyushu-Okinawa area of Japan.

To report a multicenter experience with the management of urachal abscess treatment in Japan. This was a retrospective study of 263 cases of urachal abscess managed at 12 university hospitals in the Kyushu-Okinawa region over a 10-year period. Age, sex, abscess size, clinical symptoms, type of urachal remnants, and treatment were collected and analyzed. The average age was 29.8±18.1years, with males accounting for approximately two-thirds of the study population. The average abscess size was 1.7cm (range 0-11cm). The most common presenting symptom was umbilical secretion (66%), followed by abdominal pain (46%). A total of 127 patients (48.3%) were treated with antibiotics alone, whereas 136 patients (51.7%) received surgical treatment. The surgical approach was laparotomy in 75 patients (61.0%) and laparoscopic surgery in 48 patients (39.0%). Regarding the type of urachal remnant, the urachus sinus (180 patients) accounted for 68.4% of the total. To our knowledge, this study represents the first report on urachal abscess treatment in Japan. Our data show that the clinical symptoms might vary depending on the type of urachus remnant. It should be noted that gross hematuria, a characteristic symptom of urachal cancer, is rare in patients with urachal abscess.

PEP27-2, a Potent Antimicrobial Cell-Penetrating Peptide, Reduces Skin Abscess Formation during Staphylococcus aureus Infections in Mouse When Used in Combination with Antibiotics.

PEP27, a 27-amino acid (aa) peptide secreted by Streptococcus pneumoniae, is an autolytic peptide that functions as a major virulence factor. To develop a clinically applicable antimicrobial peptide (AMP), we designed PEP27 analogs with Trp substitutions to enhance its antimicrobial activity compared to that of PEP27. Particularly, PEP27-2 showed strong antimicrobial activity against a wide variety of bacteria, including multidrug-resistant (MDR) bacteria. It was found that the antimicrobial activity of PEP27-2 was increased by substituting Trp for the aa at the middle position of PEP27. We found that PEP27-2 acts as an effective cell-penetrating peptide in bacterial and mammalian cells. Here, we proved that subcutaneous infection with MDR Staphylococcus aureus induced skin lesions such as skeletal muscle damage, deep inflammation, and necrosis of the overlaying dermis in mice. Combination treatment with antibiotics revealed synergistic effects, remarkably reducing abscess size and improving the bacteria removal rate from the infection site. Moreover, PEP27-2-antibiotic combination treatment reduced inflammation, lowering levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), IL-6, inducible NO synthase (iNOS), and cyclooxygenase (COX-2) in skin abscess tissue. The results suggest that the PEP27-2 peptide is a promising therapeutic option for combating MDR bacterial strains by enhancing antibiotic penetration and protecting against MDR bacteria.