Skin Soft Tissue Infections Research Articles

Anthraquinone/Activated Carbon Electrochemical Sensor and its Application in Ofloxacin Analysis

AbstractOfloxacin (OFL) has antibacterial and anti‐inflammatory effects on respiratory tract infection, skin soft tissue infection and urogenital tract infection caused by sensitive bacteria. In this study, an electrochemical sensor on account of glassy carbon electrode (GCE) and anthraquinone (AQ)/Vulcan XC‐72 (C) composite was prosperity prepared for the determination of ofloxacin (OFL) drug. The morphology and structure of C/20%AQ composites were characterized by SEM. The electrochemical behavior of OFL on the C/20%AQ/GCE sensor was tested using differential pulse voltammetry (DPV) and cyclic voltammetry (CV). The consequences indicate that the linear response of the sensor to OFL at pH 6.5 in 0.2 M phosphate buffer solution (PBS) was in the scope of 0.1–550.0 μM (R2=0.998) with the limit of detection of 0.01 μM. The prepared C/20%AQ/GCE sensor exhibited good anti‐interference ability and repeatability against OFL. The sensor presents a sensitive, simple and low cost OFL detection method, and has been successfully applied to real samples.

Antimicrobial Stewardship: A Game Changer in the Fight against Carbapenem-Resistant Enterobacteriaceae (CRE) among Children with Cancer

Abstract Background Carbapenem-resistant Enterobacteriaceae (CRE) is an emerging threat among pediatric cancer patients, with a high mortality rate. A previous study in our center reported that 254 patients with CRE BSI were diagnosed from (2013-2018) with mortality from CRE BSI being 30%. Previous colonization was reported in 35% of those patients. Time to start adequate antibiotics is an independent prognostic factor for patients with CRE BSI, (48%) of patients started active treatment after 48h from culture and associated with higher mortality when compared to patients who started treatment earlier. Our recommendations include antimicrobial stewardship for early detection through routine screening and timely adequate therapy that may impact the outcome for such high-risk patient groups. Methods This prospective study included all pediatric cancer patients with (CRE) bloodstream infections (BSI) at a children’s cancer hospital in Egypt (2020–2022) with adopting antimicrobial stewardship program goals by (1) applying routine screening by rectal swab for high-risk patients and starting active treatment for patients colonized by CRE. (2) Introduction of PCR-based method (Cepheid XpertCarba-R assay) is developed for detecting carbapenemase genes with the availability of results within one hour which can allow for rapid time to start active treatment in less than 48h. Results One hundred and fifty pediatric cancer patients with CRE BSI were identified; 83% had hematological malignancies, and 17% had solid tumors. Acute myeloid leukemia was the most common hematological malignancy (47%). The main clinical features for acquiring CRE-BSI were prolonged neutropenia > 7 days (62%), previous Carbapenem exposure (82%), Quinilone prophylaxis (44%), central venous catheter use (40%), previous colonization with a resistant pathogen (35%) and ICU admission within 90 days (18%). E. coli was the most common isolated pathogen (65%), followed by Klebsiella pneumoniae (31%). Documented site of infection was reported with pneumonia in (32%), typhlitis in 15% skin soft tissue infection (57%), CNS infection (18%), and urinary tract infection in (10%). Time to start active antibiotics in less than 48h was reported in 89% with clinical cure reported in 71% and microbiological clearance was reported in in less than 7 days in 70% of patients. The need for ICU admission as sepsis related to CRE was reported in 29/150 (19%). The Gentopyic profile for CRE in our study reported that class B (69%) with NDM reported in 98/150 (65%) and VIM 6/150 (4%) was the most common carbanamases followed by Oxa-48 in 89/150(59%) of patients while KPC enzyme reported only in 6/150(4%). Day 30 mortality was reported in 23/150(15%). Upon multivariate analysis, patients with Klebsiella pneumoniae BSI, NDM genotype carbapenemases, CRE with aminoglycosides resistance or associated with pneumonia, and CRE patients who developed septic shock with the need for ICU admission were predictors of poor outcome. Conclusion CRE-BSI is a major threat among pediatric cancer patients in limited-resource countries and is considered a barrier against better outcomes. Antimicrobial stewardship through routine screening for colonization detection and Rapid diagnosis by using gene expert with rapid time to start adequate active antibiotics treatment is associated with improvement of outcome and decreasing mortality. Table 1: Comparison between retrospective study and prospective study (after adopting antimicrobial stewardship goals)

Glucose transporter 1 is essential for the resolution of methicillin-resistant S. aureus skin and soft tissue infections

Skin/soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) pose a major healthcare burden. Distinct inflammatory and resolution phases comprise the host immune response to SSTIs. Resolution is a myeloid PPARγ-dependent anti-inflammatory phase that is essential for the clearance of MRSA. However, the signals activating PPARγ to induce resolution remain unknown. Here, we demonstrate that myeloid glucose transporter 1 (GLUT-1) is essential for the onset of resolution. MRSA-challenged macrophages are unsuccessful in generating an oxidative burst or immune radicals in the absence of GLUT-1 due to a reduction in the cellular NADPH pool. This translates invivo as a significant reduction in lipid peroxidation products required for the activation of PPARγ in MRSA-infected mice lacking myeloid GLUT-1. Chemical induction of PPARγ during infection circumvents this GLUT-1 requirement and improves resolution. Thus, GLUT-1-dependent oxidative burst is essential for the activation of PPARγ and subsequent resolution of SSTIs.

Repurposing antibiotic resistance surveillance data to support treatment of recurrent infections in a remote setting

In northern Australia, a region with limited access to healthcare and a substantial population living remotely, antibiotic resistance adds to the complexity of treating infections. Focussing on Escherichia coli urinary tract infections (UTIs) and Staphylococcus aureus skin & soft tissue infections (SSTIs) captured by a northern Australian antibiotic resistance surveillance system, we used logistic regression to investigate predictors of a subsequent resistant isolate during the same infection episode. We also investigated predictors of recurrent infection. Our analysis included 98,651 E. coli isolates and 121,755 S. aureus isolates from 70,851 patients between January 2007 and June 2020. Following an initially susceptible E. coli UTI, subsequent recovery of a cefazolin (8%) or ampicillin (13%) -resistant isolate during the same infection episode was more common than a ceftriaxone-resistant isolate (2%). For an initially susceptible S. aureus SSTI, subsequent recovery of a methicillin-resistant isolate (8%) was more common than a trimethoprim-sulfamethoxazole-resistant isolate (2%). For UTIs and SSTIs, prior infection with a resistant pathogen was a strong predictor of both recurrent infection and resistance in future infection episodes. This multi-centre study demonstrates an association between antibiotic resistance and an increased likelihood of recurrent infection. Particularly in remote areas, a patient’s past antibiograms should guide current treatment choices since recurrent infection will most likely be at least as resistant as previous infection episodes. Using population-level surveillance data in this way can also help clinicians decide if they should switch antibiotics for patients with ongoing symptoms, while waiting for diagnostic results.

Transferosomes stabilized hydrogel incorporated rhodomyrtone-rich extract from Rhodomyrtus tomentosa leaf fortified with phosphatidylcholine for the management of skin and soft-tissue infections.

Rhodomyrtus tomentosa leaf (RT)-incorporated transferosomes were developed with lecithin and cholesterol blends with edge activators at different ratios. RT-transferosomes were characterized and employed in transferosomal gel formulations for the management of skin and soft-tissue infections. The optimized formulation entrapped up to 81.90 ± 0.31% of RT with spherical vesicles (405.3 ± 2.0nm), polydispersity index value of 0.16 ± 0.08, and zeta potential of -61.62 ± 0.86mV. Total phenolic and flavonoid contents of RT-transferosomes were 15.65 ± 0.04μg GAE/g extract and 43.13 ± 0.91μg QE/g extract, respectively. RT-transferosomes demonstrated minimum inhibitory and minimum bactericidal concentrations at 8-256 and 64-1024μg/mL, respectively. Free radical scavenging assay showed RT-transferosomes with high scavenging activity against DPPH and ABTS radicals. Moreover, RT-transferosomes demonstrated moderate activity against mushroom tyrosinase, with IC50 values of 245.32 ± 1.32μg/mL. The biocompatibility results against L929 fibroblast and Vero cells demonstrated IC50 at 7.05 ± 0.17 and 4.73 ± 0.13μg/mL, respectively. In addition, nitric oxide production significantly decreased by 6.78-88.25% following the treatment with 31.2-500ng/mL RT-transferosomes (p < 0.001). Furthermore, the freeze-thaw stability study displayed no significant change in stability in the sedimentation and pH of gel fortified with RT-transferosomes. The results suggested that RT-transferosome formulation can be effectively employed as natural biomedicines for scar prevention and the management of skin soft-tissue infections.

Community-associated methicillin-resistant Staphylococcus aureus infection of diabetic foot ulcers in an eastern diabetic foot center in a tertiary hospital in China: a retrospective study

BackgroundDiabetic foot concerns are a major public health problem. Methicillin-resistant Staphylococcus aureus (MRSA) plays a significant role in diabetic foot ulcers. Community-associated MRSA has become notorious for skin and skin soft tissue infections over the last two decades. This study investigated MRSA infection in diabetic foot patients at a tertiary hospital, focusing on the epidemiology and characteristics of community-associated MRSA.MethodsA total of 149 patients with diabetic foot infection whose culture results indicated Staphylococcus aureus as the source were selected. Epidemiological investigations, clinical characteristics, laboratory index records, antibiotic susceptibility analysis, and clinical outcome tracking were performed in all cases. Based on oxacillin resistance using the Vitek Compact 2 system, cases were divided into methicillin-sensitive Staphylococcus aureus and MRSA groups. Subgroup analysis of the MRSA group was performed in accordance with the Centers for Disease Control definition: community-associated MRSA and hospital-associated MRSA.ResultsThe MRSA group (n = 41, 27.5%) had a longer duration of ulcers and hospital stay and higher hospitalization costs than the methicillin-sensitive Staphylococcus aureus group (n = 108, 72.5%). According to the classification criteria of Infectious Diseases Society of America, the severity of infection in the community-associated MRSA group was higher than that in the hospital-associated MRSA group. The analysis of antimicrobial susceptibility of 41 MRSA isolates showed that the resistance rates to erythromycin, clindamycin, quinolone, gentamicin, tetracycline, and rifampicin were 78.0%, 68.3%, 31.7%, 17.1%, 9.8%, and 2.4%, respectively. All the MRSA strains were sensitive to linezolid, tigecycline, and vancomycin. The resistance rates to quinolones and gentamycin in the community-associated MRSA group (both 0%) were lower than those in the hospital-associated MRSA group.ConclusionEmergence of MRSA in diabetic foot ulcer was associated with a prolonged wound duration and increased consumption of medical resources. Community-associated MRSA strains predominated among MRSA isolates from diabetic foot wounds and caused more severe infections.

Complicated and suppurative skin soft tissue infections: our four-year cases

Skin and soft tissue infections (SSTIs) are common community and hospital-acquired infections and rarely result in severe morbidity and mortality. It is not always possible to obtain cultures and isolate the causative agent in these patients, primarily treated with empirical antibiotics. In this retrospective cross-sectional study, 57 patients with complicated SSTI followed between 2018 and 2022 with purulent and necrotizing characteristics or growth in blood cultures were included. Thirty-eight patients (66.7%) were male, and 39 (68.4) had diabetes. In 43 (75.5%) patients, the infection was in the lower extremity and gluteal region. Gram-positive agents were detected in 35 patients (61.4%), Gram-negative agents were found in 13 patients (22.8%), and Gram-positive and Gram-negative mixed growth was detected in 1 patient (1.8%), and no causative agent could be produced in 8 (14%) patients. Of the 21 Staphylococcus aureus produced, 4 (19%) were methicillin-resistant (MRSA). Growth was detected in blood cultures in three patients (5.3%), and all were streptococcal bacteria. It was observed that 31 patients (54.4%) required hospitalization for treatment, and 29 (50.8%) required surgical intervention such as drainage, aspiration, debridement, or amputation. Three patients (5.3%) died, and four (7%) underwent amputation. There was no significant difference between diabetic and non-diabetic patients regarding factors and mortality–morbidity. In the logistic regression analysis, none of the variables of gender, type of causative agent, presence of diabetes, and site of infection significantly affected severe morbidity and mortality. Since it was detected at a low rate in our cases, it can be said that MRSA and P.aeruginosa do not need to be considered in every patient for the initial empirical treatment, Gram-negative rods can be taken into account, especially in diabetics, and broad-spectrum and combined antibiotics are not needed in the vast majority of patients. Microbiological follow-up and sensitivity studies at regional and global scales will need to continue to guide empirical treatments in SSTIs.

Detection of the international lineage ST71 of methicillin-resistant Staphylococcus pseudintermedius in two cities in Rio de Janeiro State.

Staphylococcus pseudintermedius is the main coagulase-positive staphylococci associated with canine skin/soft tissue infections (SSTI), otitis externa, and surgical site infections. The international spread of an epidemic and multiresistant lineage of methicillin-resistant Staphylococcus pseudintermedius (MRSP), the so-called European clone-displaying sequence type (ST) 71-requires attention. The first isolation of an MRSP ST71 isolate in South America was reported in Rio de Janeiro city, in 2010; however, a limited number of canine isolates were analyzed. Thus, to have a better panel of the MRSP spread in this city, we were stimulated to continue this study and search for the presence of MRSP in 282 colonized or infected dogs in the city of Rio de Janeiro. Among the MRSP isolates collected (N = 17; 6.1%), the pulsed-field gel electrophoresis (PFGE) patterns were similar to those of European clone. All 17 isolates were classified as ST71 by multilocus sequence typing (MLST). In order to assess whether isolates of MRSP ST71 may have also spread to the Rio de Janeiro state countryside, we collected samples from 124 infected dogs in the city of Campos dos Goytacazes (232km away from Rio de Janeiro city). Our data showed the presence of ST71 lineage in one isolate among three MRSP detected. S. pseudintermedius was isolated from 40.6% of the clinical samples (N = 165/406). A relatively high incidence of methicillin resistance, detected by a PCR-based method, was found in 12.1% of the S. pseudintermedius recovered from animals (N = 20/165). The resistance profile of these isolates was similar to that described for the international ST71 strains whose genomes are publicly available in the GenBank. The prospect of ST71 isolates being resistant to virtually all antimicrobials used in veterinary medicine is alarming and should be considered a central issue considering that MRSP ST71 spreads over large geographic distances and its transmission from animals to humans.

Optimizing Antibiotic Treatment of Skin Infections in Pediatric Emergency and Urgent Care Centers.

The objective was to optimize antibiotic choice and duration for uncomplicated skin/soft tissue infections (SSTIs) discharged from pediatric emergency departments (EDs) and urgent cares (UCs). Pediatric patients aged 0 to 18 years discharged from 3 pediatric EDs and 8 UCs with a diagnosis of uncomplicated SSTIs were included. Optimal treatment was defined as 5 days of cephalexin for nonpurulent SSTIs and 7 days of clindamycin or trimethoprim/sulfamethoxazole for purulent SSTIs. Exclusion criteria included erysipelas, folliculitis, felon, impetigo, lymphangitis, paronychia, perianal abscess, phlegmon, preseptal or orbital cellulitis, and cephalosporin allergy. Baseline data were collected from January 2018 to June 2019. Quality improvement (QI) interventions began July 2019 with a revised SSTI guideline, discharge order set, and maintenance of certification (MOC) QI project. MOC participants received 3 education sessions, monthly group feedback, and individual scorecards. Balancing measures included return visits within 10 days requiring escalation of care. Data were monitored through March 2021. In total, 9306 SSTIs were included. The MOC QI project included 50 ED and UC physicians (27% of eligible physicians). For purulent SSTI, optimal antibiotic choice, plus duration, increased from a baseline median of 28% to 64%. For nonpurulent SSTI, optimal antibiotic choice, plus duration, increased from a median of 2% to 43%. MOC participants had greater improvement than non-MOC providers (P < .010). Return visits did not significantly change pre- to postintervention, remaining <2%. We improved optimal choice and reduced duration of antibiotic treatment of outpatient SSTIs. MOC participation was associated with greater improvement and was sustained after the intervention period.

Efficacy and Safety of Iclaprim for the Treatment of Skin Structures and Soft Tissue Infections: A Methodological Framework.

Background: Skin and soft tissue infections (SSTIs) are among the most common infections worldwide. They manifest in a variety of forms, such as erysipelas, cellulitis, and necrotizing fasciitis. Antibiotics are the significant method for clinical treatment of SSTIs. This study reported a methodology framework to determine the efficacy and safety of iclaprim in treatment of SSTIs. Methods: We will search the PubMed, EMbase, CNKI, WanFang Data, VIP, and ClinicalTrials.gov from their inception to June 2022 for randomized controlled trials and cohort studies on iclaprim with SSTIs. Two authors will independently screen the eligible studies, assess the quality of the included papers, and extract the required information. Randomized controlled trials will be assessed using the Cochrane risk-of-bias tool. The Newcastle–Ottawa Scale will be used to evaluate observational studies. The quality of the evidence will be evaluated using the Grading of Recommendations Assessment Development and Evaluation system. RevMan 5.3 will be used for the data synthesis and quantitative analysis. Results and Discussions: This study will provide the clinicians with more high-quality evidence to choose iclaprim for patients with SSTIs. Ethics and Dissemination: This systematic review and meta-analysis will be based on published data, so ethical approval is not necessary. The results of this meta-analysis will be published in a peer-reviewed journal.

ADD It Up: An Evaluation of Antibiotic Duration at Hospital Discharge at a Community Hospital.

BackgroundAccording to the Centers for Disease Control and Prevention, patients admitted to the hospital are commonly discharged on antibiotic therapy with prolonged courses of therapy, which contributes to excessive antibiotic exposure and adverse events. The purpose of this study was to evaluate total antibiotic duration of therapy at hospital discharge at Indiana University Health Arnett, White Memorial, and Frankfort hospitals.MethodsA multicenter, retrospective electronic health record review was conducted from 1 January to 30 June 2019. Patients were included if they were at least 18 years of age, began antibiotic therapy while admitted, and continued antibiotic therapy at hospital discharge for 1 of the following indications: skin/soft tissue infection (SSTI), urinary tract infection (UTI), community-acquired pneumonia (CAP), or acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The number of days of therapy (DOT) of each inpatient and outpatient antibiotic prescribed was collected to calculate the total DOT, which was utilized to determine the appropriateness of the duration of therapy.ResultsOf the 547 patients included, 233 patients (42.6%) had CAP, 120 (21.9%) had UTI, 101 (18.5%) had SSTI, and 93 (17%) had AECOPD. The median duration of antibiotic therapy across all indications was 9 days (interquartile range [IQR], 7–11). Median duration for CAP was 9 days (IQR, 7–10), AECOPD was 7 days (IQR, 5–9), UTI was 8 days (IQR, 6–10), and SSTI was 12 days (IQR, 10–14).ConclusionsExcess antimicrobial duration at hospital discharge represents an unmet need of antimicrobial stewardship programs.

Reasons for hospitalization and factors of mortality in patients with Parkinson's disease in the Philippines.

Aim: We aimed to determine the reasons for hospitalizations and factors of mortality of Filipino Parkinson's disease (PD) patients in a tertiary hospital. Methods: We conducted a retrospective review of medical records of PD patients admitted to our institution between 2016 and 2018. Demographic and clinical data were analyzed. Results: We included 166 PD patients. The most common cause of admission was infectious (pneumonia, urinary tract, and skin-soft tissue infections) (n=65, 39.2%). The most common cause of mortality was sepsis (n=9, 5.4%). Renal comorbidity was a significant factor of mortality (OR: 3.67, 95% CI: 1.11-12.12; p=0.033). Conclusion: Interventions designed to reduce the risk of complications in PD patients should be prioritized to potentially decrease the probability of eventual hospitalization.

Adding Another Piece to the Puzzle of Why NTM Infections Are Relatively Uncommon despite Their Ubiquitous Nature

Since nontuberculous mycobacteria (NTM) are pervasive in the environment and NTM infections are relatively uncommon, underlying hereditary or acquired host susceptibility factors should be sought for in most NTM-infected patients. To facilitate identification of underlying risk factors, it is useful to classify NTM disease into skin-soft tissue infections, isolated NTM lung disease, and extrapulmonary visceral/disseminated disease because the latter two categories have unique sets of underlying host risk factors. Nakajima and coworkers (M. Nakajima, M. Matsuyama, M. Kawaguchi, T. Kiwamoto, et al., mBio 12:e01947-20, 2021, https://doi.org/10.1128/mBio.01947-20) in a recent issue of mBio found that Nrf2 (nuclear factor erythroid 2-related factor 2), a transcription factor that is induced by oxidative stress but induces antioxidant molecules, provides protection against an NTM infection in a murine model. While they showed that Nrf2 induction of Nramp-1 enhanced phagosome-lysosome fusion, we discuss other potential mechanisms by which oxidative stress predisposes to and Nrf2 protects against NTM infections.

Mono vs. combo regimens with novel beta-lactam/beta-lactamase inhibitor combinations for the treatment of infections due to carbapenemase-producing Enterobacterales: insights from the literature.

Ceftazidime-avibactam (CZA), meropenem-vaborbactam (MVB) and imipenem-relebactam (I-R) are combinations of old ß-lactams with novel non-ß-lactam ß-lactamase inhibitors (BLBLIs) able to inhibit some carbapenemases, such as the KPC-type, thus are becoming the standard for difficult-to-treat carbapenemase-producing Enterobacterales (CPE); a practical question is whether these novel BLBLIs should be used as monotherapy or as part of a combination regimen with other antibiotics, and if so, with which ones, to reduce the emergence of resistant strains and to optimize their efficacy. In this short review, we assessed clinical outcomes in patients with CPE-infections treated with the novel BLBLIs as mono- or combo-regimens, and laboratory studies on the synergistic effects with other antimicrobials. Available evidence on combination therapy is scarce and mainly limited to retrospective studies involving 630 patients treated with CZA: aminoglycosides were used in 39.6% of 336 patientstreated with combo-regimens, followed by polymyxin B/colistin (24.4%), tigecycline (24.1%), carbapenems (13.4%) and fosfomycin (5.4%). Aminoglycosides could be useful in case of bloodstream and severe urinary infections. Pneumonia is a risk factor for CZA-resistance emergence: fosfomycin, due to favorable lung pharmacokinetics/pharmacodynamics, could represent an interesting partner; fosfomycin could be added alsofor osteomyelitis. Tigecycline could be preferred for intrabdominal and skin-soft tissue infections. Due to nephrotoxicity and lack of in vitro synergy, the association CZA/colistin seems not optimal. MVB and I-R were mostly used as monotherapies. Currently, there is no definitive evidence whether combinations are more effective than monotherapies; further studies are warranted, and to date only personal opinions can be provided.

1421. Assessing Serious Infections Common in Persons Who Inject Drugs in the United States and Tennessee

BackgroundThe opioid crisis is a public health emergency in the United States (US) and Tennessee (TN), and injection drug use predisposes users to a variety of serious infections. We therefore examined infection rates among persons who inject drugs (PWID) from 2001-2014 in the US and TN.MethodsWe conducted an ecological study using publicly available data including discharge diagnosis codes: the Healthcare Cost and Utilization Project (HCUP). We identified all persons from 2001-2014 with ICD-9 codes for bacterial infections common among PWID: endocarditis (IE), osteomyelitis (OM), septic arthritis (SpA), and skin/soft tissue infections (SSTI). We calculated rates of substance use and infection among all hospital discharges. Spearman’s rank correlation quantified the relationship between infection and reported hepatitis C seropositivity (HCV), Substance Abuse (SA) and opioid use disorder (OUD) rates. Poisson regression yielded incidence rate ratios (IRR) and 95% confidence intervals [-], and restricted cubic splines were fit to assess annual trends flexibly.ResultsUnadjusted rates of both substance use and infection among those discharged from hospitals were higher in the US overall than in TN from 2001-2014 (p< 0.05) (Figure 2,3). Overall infections, HCV (IRR=1.14 [1.12-1.17]), SSTI, OM, and SpA increased annually in the US; overall infections, HCV (IRR=1.14 [1.10-1.15]), and SSTI increased in TN. OUD (IRR=0.96 [0.94-0.98]) and IE (IRR=0.97 [0.97-0.98]) decreased in the US (Table 1). In the US, there were strong positive correlations between any other infection and HCV (ρ=0.87), IE and OUD (ρ=0.7), SSTI and HCV (ρ=0.9), OM and HCV (ρ=0.69), and SpA and HCV (ρ=0.68); IE was negatively correlated with HCV (ρ=-0.84). In TN, overall infections (ρ=0.68), and specifically SSTI (ρ=0.62), were correlated with HCV (Figure 1).Table 1 Figure 1 Figure 2 ConclusionSerious infections common in PWID are increasing in TN and the US; they correlate with HCV rates, which have risen significantly in hospitalized patients. Interestingly, opioid use disorder incidence from discharge data declined from 2001-2014 for both TN and the US, which may be due to coding lapses or shifts in type of opioid use with no well-known billing code. However, we must continue monitoring and mitigating both substance use and its sequelae.Disclosures All Authors: No reported disclosures

89. A Collaborative &amp; Novel Antimicrobial Stewardship Initiative– Mandatory Approval of Peripherally Inserted Central Venous Catheters

BackgroundCentral line-associated bloodstream infections result in thousands of deaths and billions of dollars annually. At the Augusta University Medical Center (AUMC), it was identified that ~50% of peripherally inserted central venous catheters (PICCs) that were placed for intravenous (IV) antibiotic administration were unnecessary. A novel initiative was implemented, which required antimicrobial stewardship/infectious diseases approval for PICC insertions if the indication was for IV antibiotic administration only. The objective of this study was to determine the impact of this initiative.MethodsA retrospective observational study was conducted at the AUMC. All adult patients with a PICC line insertion order for IV antibiotic administration, between December 2017 and May 2019 were included. The vascular access team would forward requests for PICC insertions to the antimicrobial stewardship pharmacist. The pharmacist would approve/disapprove the PICC or recommend an infectious diseases consult. The variables collected were: infection types, infectious diseases consultation, reason for PICC denial and 30-day PICC-related complications.ResultsA total of 215 requests for PICC insertion (for IV antibiotics) were placed. Of these, 54% of the requests were denied, while 46% were approved. The reasons for PICC denial included: midline catheter preferred (47%), switched to oral antibiotics (33%), further work-up required (10%), or no antibiotics needed (7%). The types of infections treated were: bone and joint infections (28%), urinary tract infections (13%), intra-abdominal infections (12%), endocarditis/endovascular infections (11%), skin soft tissue infections (9%), pneumonia (7%), catheter-related bloodstream infections (6%), central nervous system infections (6%), bacteremia (4%) and others (4%).The infectious diseases consult team was involved in the care of 79% of the patients. Of those that received a PICC line, only 5% experienced any PICC-related complications. The overall cost savings for PICCs that were denied was ~ $294,000.ConclusionMandatory antimicrobial stewardship/infectious diseases approval for PICC insertion can decrease healthcare cost and reduce the number of unnecessary PICC lines placed.Disclosures All Authors: No reported disclosures

An Emerging Infection: Streptococcal Toxic Shock-Like Syndrome Caused By Group B Streptococcus (GBS), Streptococcus Agalactiae

Abstract Introduction/Objective Streptococcus agalactiae, Group B Streptococcus (GBS), is a major cause of neonatal sepsis and infections in pregnant women. However, incidence of invasive GBS infections has more than doubled in the last two decades with highest risk in adults 65 years or older. Other risk factors are diabetes, malignancy, and immunocompromised state. Bacteremia and skin soft tissue infections are the most common invasive infections in nonpregnant adults. Rarely GBS infection has a fulminating pyrogenic exotoxin-mediated course characterized by acute onset, multiorgan failure, shock, and sometimes death, referred to as toxic shock-like syndrome. Methods A 77-year-old hypertensive female with uncontrolled type 2 diabetes mellitus and a history of bilateral foot ulcers presented to the hospital in probable septic shock. Clinical diagnosis of necrotizing fasciitis was made and she underwent bilateral lower limb amputations. Results Grossly soft tissue appeared gray. Microscopically fascia was necrotic without neutrophils present and Gram stain revealed sheets of Gram positive cocci. These findings reflected histopathologic Stage III necrotizing fasciitis, which is associated with 47% mortality. Autopsy showed a similar histology of Stage III necrotizing fasciitis involving the surgical stump. Erythema and desquamation of the upper limbs bilaterally and multi-organ failure met the clinical picture of Streptococcal Toxic Shock Syndrome (STSS) and fulfilled the criteria for TSS due to Group A Streptococcus (GAS), defined by The Working Group on Severe Streptococcal Infections. Conclusion Group B Streptococcal Toxic Shock-Like Syndrome may have a similar outcome to STSS caused by GAS and other pathogens and, in limited studies, mortality has been 30% or greater.

A National Aged Care Infection and Antimicrobial Use Survey: A Three-Year Report

Background: Australia has ~2,700 aged-care homes and 180 multipurpose services. The annual Aged Care National Antimicrobial Prescribing Survey (AC NAPS), first pilot tested in 2015, is a surveillance tool that can be used in these facilities to monitor infections and antimicrobial use. It assists in identifying priorities for local and national infection control and antimicrobial stewardship interventions. Methods: Nurses or pharmacists collect point prevalence data using standardized data collection forms: (1) A facility form, completed by each participating facility, includes resident-level data fields (eg, number of residents present on the survey day). (2) An infection form is completed for residents with signs and/or symptoms of infection. (3) An antimicrobial form is completed for residents who are prescribed an antimicrobial. Results: Regarding prevalence,for those 31 facilities that participated annually, there was no significant change in either prevalence rate (Table 1). Regarding priority areas for improvement (2018 data only), 64.6% of prescriptions were for residents who did not have signs and/or symptoms of a suspected infection in the week prior to the antimicrobial start date. The most common clinical indications for prescriptions were skin soft-tissue and mucosal infection (18.3%), cystitis (16.0%) and pneumonia (9.4%). Cefalexin (20.3%), clotrimazole (19.0%), and chloramphenicol (7.0%) were the most commonly prescribed antimicrobials. Review or stop dates were not documented for 58.9% of prescriptions. Only 39.2% of antimicrobials were prescribed in the 7 days prior to the survey day; 28.3% were prescribed &gt;6 months prior. Furthermore, 36.3% of all prescriptions were for topical application. In addition, 19.0% of antimicrobials were prescribed for PRN (as needed) administration; most (94.4%) of these were for topical antimicrobials, most commonly clotrimazole (65.4%). Conclusions: The AC NAPS has identified infections and consistent patterns of antimicrobial use that may adversely affect the safety of care for Australian aged-care residents. Interventions are now being developed, implemented, and evaluated to address identified ‘priority areas for improvement.’Funding: NoneDisclosures: None

A multicentric study on clinical characteristics and antibiotic sensitivity in children with methicillin-resistant Staphylococcus aureus infection

Objective: To investigate the clinical characteristics of pediatric methicillin-resistant Staphylococcus aureus (MRSA) infection and the antibiotic sensitivity of the isolates. Methods: The clinical data of children with MRSA infection and antibiotic sensitivity of the isolates from 11 children's hospitals in Infectious Diseases Surveillance of Paediatrics (ISPED) group of China between January 1, 2018 and December 31, 2018 were collected retrospectively. The children's general condition, high-risk factors, antimicrobial therapy and prognosis, differences in clinical disease and laboratory test results between different age groups, and differences of antibiotic sensitivity between community-acquired (CA)-MRSA and hospital-acquired (HA)-MRSA were analyzed. The t test and Wilcoxon rank sum test were used for statistical analysis of the quantitative data and Chi-square test were used for comparison of rates. Results: Among the 452 patients, 264 were males and 188 were females, aged from 2 days to 17 years. There were 233 cases (51.5%) in the ≤1 year old group, 79 cases (17.5%) in the>1-3 years old group, 29 cases (6.4%) in the >3-5 years old group, 65 cases (14.4%) in the >5-10 years old group, and 46 cases (10.2%) in the>10 years old group. The main distributions of onset seasons were 55 cases (12.2%) in December, 47 cases (10.4%) in February, 46 cases (10.2%) in November, 45 cases (10.0%) in January, 40 cases (8.8%) in March. There were 335 cases (74.1%) CA-MRSA and 117 (25.9%) cases HA-MRSA. Among all cases, 174 cases (38.5%) had basic diseases or long-term use of hormone and immunosuppressive drugs. During the period of hospitalization, 209 cases (46.2%) received medical interventions. There were 182 patients (40.3%) had used antibiotics (β-lactams, glycopeptides, macrolides, carbapenems, oxazolones, sulfonamides etc) 3 months before admission. The most common clinical disease was pneumonia (203 cases), followed by skin soft-tissue infection (133 cases), sepsis (92 cases), deep tissue abscess (42 cases), osteomyelitis (40 cases), and septic arthritis (26 cases), suppurative meningitis (10 cases). The proportion of pneumonia in the ≤1 year old group was higher than the >1-3 years old group,>3-5 years old group,>5-10 years old group,>10 years old group (57.5% (134/233) vs. 30.4% (24/79), 31.0% (9/29), 38.5% (25/65), 23.9% (11/46), χ(2)=17.374, 7.293, 7.410, 17.373, all P<0.01) The proportion of skin and soft tissue infections caused by CA-MRSA infection was higher than HA-MRSA (33.4% (112/335) vs. 17.9% (21/117), χ(2)=10.010, P=0.002), and the proportion of pneumonia caused by HA-MRSA infection was higher than CA-MRSA (53.0% (62/117) vs. 42.1% (141/335), χ(2)=4.166, P=0.041). The first white blood cell count of the ≤1 year old group was higher than that children > 1 year old ((15±8)×10(9)/L vs. (13±7)×10(9)/L, t=2.697, P=0.007), while the C-reactive protein of the ≤1 year old group was lower than the 1-3 years old group,>5-10 years old group,>10 years old group (8.00 (0.04-194.00) vs.17.00 (0.50-316.00), 15.20 (0.23-312.00), 21.79(0.13-219.00) mg/L, Z=3.207, 2.044, 2.513, all P<0.05), there were no significant differences in procalcitonin (PCT) between different age groups (all P>0.05). After the treatment, 131 cases were cured, 278 cases were improved, 21 cases were not cured, 12 cases died, and 10 cases were abandoned. The 452 MRSA isolates were all sensitive to vancomycin (100.0%), linezolid (100.0%), 100.0% resistant to penicillin, highly resistant to erythromycin (85.0%, 375/441), clindamycin (67.7%, 294/434), less resistant to sulfonamides (5.9%, 23/391), levofloxacin (4.5%, 19/423), gentamicin (3.2%, 14/438), rifampicin (1.8%, 8/440), minocycline (1.1%, 1/91). The antimicrobial resistance rates were not significantly different between the CA-MRSA and HA-MRSA groups (all P>0.05). Conclusions: The infection of MRSA is mainly found in infants under 3 years old. The prevalent seasons are winter and spring, and MRSA is mainly acquired in the community. The main clinical diseases are pneumonia, skin soft-tissue infection and sepsis. No MRSA isolate is resistant to vancomycin, linezolid. MRSA isolates are generally sensitive to sulfonamides, levofloxacin, gentamicin, rifampicin, minocycline, and were highly resistant to erythromycin and clindamycin. To achieve better prognosis. clinicians should initiate anti-infective treatment for children with MRSA infection according to the clinical characteristics of patients and drug sensitivity of the isolates timely and effectively.

Localization and Accumulation Studies of Daptomycin in Rats Kidney Using Immunohistochemistry

Daptomycin (DAP) has a completely different mechanism of action compared to conventional methicillin-resistant Staphylococcus aureus (MRSA) drugs and is widely used clinically as the first-line drug for the treatment of skin soft tissue infection and sepsis caused by MRSA infection. However, the most serious side effects of DAP include renal dysfunction and rhabdomyolysis. Knowledge of the time sequence of localization of DAP in cells and tissues of animals may help in developing a better understanding of the actual overall pharmacokinetics of DAP. We prepared DAP-specific antibodies by immunizing mice with DAP-GMBS-BSA conjugate. The Anti-DAP antibody was specific for DAP, which enabled us to develop an immunocytochemical method for detecting the uptake of DAP in the rat kidneys. One hour after a single intravenous (i.v.) injection of DAP at 12 mg/kg, immunohistochemical observation showed a strong ring-like positive reaction in the cytoplasm immediately below the microvilli of proximal tubule epithelial cells. The distal tubules and collecting ducts contained DAP-positive and negative cells in the cross section of one tubule. Twenty-four hours after DAP administration, several strong positive reactions of different sizes were observed in the cytoplasm of epithelial cells at the proximal tubule. No staining was detected after 7 days. This study will be a useful tool for analyzing the pharmacokinetics of DAP.