Start Of Antibiotic Treatment Research Articles

Cat bite injuries to the hand and forearm: the impact of antibiotic treatment on microbiological findings and clinical outcome

IntroductionPatients and physicians often underestimate cat bite injuries. The deep and narrow wound seals quickly and provides an environment for the inoculated saliva and bacteria. Interestingly, the literature reports no bacterial growth in the microbiological workup of wound swaps in up to 43%. The time between bite injury and the first clinical presentation, the start of antibiotic treatment and surgical debridement might affect these findings. Therefore, the current project examines if (1) these factors impact the outcome of microbiological results following cat bite injuries and (2) the detection of bacterial growth leads to higher complication rates, longer hospital stays, longer total treatment time, or higher total treatment costs.Materials and methodsThis single-center retrospective study analyzed data from 102 adult patients. All patients received antibiotic and surgical treatment following a cat bite injury. Microbiological samples were collected during surgery in all cases. The time from the bite incident to the first presentation, beginning of antibiotic administration, and surgical debridement was calculated. Demographic data, complication rate, length of hospital stay, total treatment time, and total treatment costs were recorded. (1) A generalized linear model was fitted using the microbiological outcome as the dependent variable. (2) Two groups (negative or positive microbiological results) were formed and statistically compared.ResultsThe median age was 50 (SD 16), and 72% were female. (1) The time from the bite incident to the first clinical presentation, antibiotic administration, or surgical treatment was not associated with the outcome of the microbiological result. (2) No significant differences were observed between the two groups.ConclusionsOur data do not suggest that early antibiotic administration or delayed surgical treatment affects the outcome of the microbiological workup following cat bite injuries to the hand and forearm. The microbiological outcome did not affect the complication rate, treatment time, and total treatment costs.

Changes in Inflammatory Markers in Patients Treated for Buruli Ulcer and Their Ability to Predict Paradoxical Reactions.

Mycobacterium ulcerans causes Buruli ulcer, the third most frequent mycobacterial disease after tuberculosis and leprosy. Transient clinical deteriorations, known as paradoxical reactions (PRs), occur in some patients during or after antibiotic treatment. We investigated the clinical and biological features of PRs in a prospective cohort of 41 patients with Buruli ulcer from Benin. Neutrophil counts decreased from baseline to day 90, and interleukin 6 (IL-6), granulocyte colony-stimulating factor, and vascular endothelial growth factor were the cytokines displaying a significant monthly decrease relative to baseline. PRs occurred in 10 (24%) patients. The baseline biological and clinical characteristics of the patients presenting with PRs did not differ significantly from those of the other patients. However, the patients with PRs had significantly higher IL-6 and tumor necrosis factor alpha (TNF-α) concentrations on days 30, 60, and 90 after the start of antibiotic treatment. The absence of a decrease in IL-6 and TNF-α levels during treatment should alert clinicians to the possibility of PR onset.

Severe community-acquired Streptococcus pneumoniae bacterial meningitis: clinical and prognostic picture from the intensive care unit

BackgroundSevere community-acquired pneumococcal meningitis is a medical emergency. The aim of the present investigation was to evaluate the epidemiology, management and outcomes of this condition.MethodsThis was a retrospective, observational and multicenter cohort study. Sixteen Spanish intensive care units (ICUs) were included. Demographic, clinical and microbiological variables from patients with Streptococcus pneumoniae meningitis admitted to ICU were evaluated. Clinical response was evaluated at 72 h after antibiotic treatment initiation, and meningitis complications, length of stay and 30-day mortality were also recorded.ResultsIn total, 255 patients were included. Cerebrospinal fluid (CSF) culture was positive in 89.7%; 25.7% were non-susceptible to penicillin, and 5.2% were non-susceptible to ceftriaxone or cefotaxime. The most frequent empiric antibiotic regimen was third-generation cephalosporin (47.5%) plus vancomycin (27.8%) or linezolid (12.9%). A steroid treatment regimen was administered to 88.6% of the patients. Clinical response was achieved in 65.8% of patients after 72 h of antibiotic treatment. Multivariate analysis identified two factors associated with early treatment failure: invasive mechanical ventilation (OR 10.74; 95% CI 3.04–37.95, p < 0.001) and septic shock (OR 1.18; 95% CI 1.03–1.36, p = 0.017). The 30-day mortality rate was 13.7%. Only three factors were independently associated with 30-day mortality: delay in start of antibiotic treatment (OR 18.69; 95% CI 2.13–163.97, p = 0.008), Sepsis-related Organ Failure Assessment (SOFA) score (OR 1.36; 95% CI 1.12–1.66, p = 0.002) and early treatment failure (OR 21.75 (3.40–139.18), p = 0.001). Neurological complications appeared in 124 patients (48.63%).ConclusionsMortality rate in critically ill patients with pneumococcal meningitis is lower than previously reported. Delay in antibiotic treatment following admission is the only amendable factor associated with mortality.

The prevalence of persistent bacteraemia in patients with a non-staphylococcal infective endocarditis, a retrospective cohort study

BackgroundCurrent guidelines on the management of infective endocarditis (IE) recommend follow-up blood cultures (FUBCs) to identify persistent bacteraemia, as this has prognostic value and guides treatment decisions. While persistent bacteraemia frequently occurs in Staphylococcus aureus bacteraemia and IE, its prevalence and impact in non-staphylococcal IE is largely unknown. We determined prevalence and prognostic value of persistent bacteraemia in non-staphylococcal IE. MethodsWe conducted a retrospective analysis of all patients diagnosed with definite non-staphylococcal endocarditis according to the modified Duke Criteria in two university hospital endocarditis registries We determined the prevalence and prognostic value of persistent bacteraemia. ResultsOf the included 159 patients 70 (44%) had prosthetic valve endocarditis (PVE). A median number of two [IQR 1–3] FUBCs were taken during the first week, with 134/159 (84%) having at least one FUBC in the first four days. Seven patients (4,4%) had persistent bacteraemia 48 h after start of antibiotic treatment: 5/70 patients (7.1%) with PVE and 2/89 (2.2%) with native valve endocarditis. Among 97 patients with streptococcal IE, nine patients with HACEK IE and six patients with Cutibacterium IE, no persistent bacteraemia was observed. Enterococcus faecalis was the causative microorganism in five patients with persistent bacteraemia, the other two had non-HACEK Gram-negative endocarditis. ConclusionPersistent bacteraemia in non-staphylococcal endocarditis was rare. It was more frequently observed in PVE and was restricted to more resilient microorganisms such as enterococci and non-HACEK Gram-negative bacteria. Routine collection of FUBCs in patients with streptococcal endocarditis has a low yield and may require re-evaluation.

Diagnostic parameters of cellular tests for Lyme borreliosis in Europe (VICTORY study): a case-control study

Cellular tests for Lyme borreliosis might be able to overcome major shortcomings of serological testing, such as its low sensitivity in early stages of infection. Therefore, we aimed to assess the sensitivity and specificity of three cellular tests. This was a nationwide, prospective, multiple-gate case-control study done in the Netherlands. Patients with physician-confirmed Lyme borreliosis, either early localised or disseminated, were consecutively included as cases at the start of antibiotic treatment. Controls were those without Lyme borreliosis from the general population (healthy controls) and those with potentially cross-reactive conditions (eg, autoimmune disease). We used three cellular tests for Lyme borreliosis (Spirofind Revised, iSpot Lyme, and LTT-MELISA) as index tests, and standard two-tier serological testing (STTT) as a comparator. Clinical data from Lyme borreliosis patients were collected at baseline and at 12 weeks after inclusion, and blood samples were obtained at baseline, 6 weeks, and 12 weeks. Control participants underwent clinical and laboratory assessments at baseline only. Cases comprised 271 patients with Lyme borreliosis (of whom 245 had early-localised Lyme borreliosis and 26 had disseminated disease) and controls comprised 228 participants without Lyme borreliosis from the general population and 41 participants with potentially cross-reactive conditions. Recruitment occurred between May 14, 2018, and March 16, 2020. The specificity of STTT in healthy controls (216 of 228 samples [94·7%, 95% CI 91·5-97·7]) was higher than that of the cellular tests: Spirofind (140 of 171 [81·9%, 76·1-87·2]), iSpot Lyme (32 of 103 [31·1%, 21·5-40·3]) and LTT-MELISA (100 of 190 [52·6%, 44·9-60·3]). Cellular tests had varying sensitivities: Spirofind (88 of 204 [43·1%, 36·4-50·4]), iSpot Lyme (51 of 94 [54·3%, 44·5-63·7]), and LTT-MELISA (66 of 218 [30·3%, 23·8-36·7]). The Spirofind and iSpot Lyme outperformed STTT for sensitivity, but were similar to the C6-ELISA (C6-ELISA: 135 of 270 [50·0%, 44·5-55·5]; STTT: 76 of 270 [28·1%, 23·0-33·6]). The cellular tests for Lyme borreliosis used in this study have a low specificity compared with serological tests, which leads to a high number of false-positive test results. We conclude that these cellular tests are unfit for clinical use at this stage. Netherlands Organization for Health Research and Development, AMC Foundation (Amsterdam UMC), and Ministry of Health of the Netherlands.

Prevalence of persistent symptoms after treatment for lyme borreliosis: A prospective observational cohort study.

SummaryBackgroundConcerns about long-lasting symptoms attributed to Lyme borreliosis (LB) are widespread in the Western world, while such symptoms are highly prevalent in the general population.MethodsIn the largest prospective study to date, adults with physician-confirmed LB were included at the start of antibiotic treatment. Primary outcomes, prevalence of persistent symptoms and symptom severity, were assessed using three-monthly standardised questionnaires during one year. Persistent symptoms were defined as impaired scores for fatigue (CIS, subscale fatigue), cognitive impairment (CFQ) or pain (SF-36, subscale bodily pain) ≥6 months, with onset <6 months. Outcomes were compared with a longitudinal general population and a tick-bite cohort without LB as a reference.FindingsOf 1135 LB patients (94•8% erythema migrans, 5•2% disseminated LB), 1084 fulfilled primary analysis criteria, as well as 1942 population and 1887 tick-bite controls. Overall prevalence of persistent symptoms in LB patients was 27•2% (95%CI, 24•7%-29•7%); 6•0% and 3•9% higher than in population (21•2%, 95%CI, 19•3%-23•1%; p < 0•0001) and tick-bite (23•3%, 95%CI 21•3%-25•3%; p = 0•016) cohorts, respectively. At 12 months, fatigue, cognitive impairment, and pain were significantly more severe in erythema migrans patients than in reference cohorts, while in disseminated LB patients, only pain was more severe.InterpretationIn treated LB patients, persistent symptoms were significantly more prevalent and symptoms were more severe than in individuals without LB, although the background prevalence was substantial. This suggests an association, either direct or indirect, between persistent symptoms and LB in a relatively small subset of patients.FundingZonMw; Dutch Ministry of Health, Welfare and Sport.

Serum Levels of Markers of Endothelial Activation Are Not Associated with a Positive Blood Culture in Surinamese Children with Suspected Severe Infection.

Systemic serum levels of markers of endothelial activation are associated with infection. We hypothesize that levels of markers of endothelial activation are associated with the presence of a positive blood culture as a manifestation of a systemic infection in children with a suspected severe infection in Suriname. In this prospective observational cohort study, children between 1 month and 18 years of age suspected of severe infection as assessed by the threating physician, and in whom laboratory testing and blood culturing was performed before start of intravenous antibiotic treatment, were recruited at the emergency department of the Academic Hospital Paramaribo, Suriname. Serum was collected at blood culturing and after 48-72 h of admission. Serum was stored for measurement of levels of Angiopoietin (Ang)-1, Ang-2, soluble (s)P-selectin, sE-selectin, vascular cell adhesion molecule-1, intercellular adhesion molecule-1 and platelet and endothelial cell adhesion molecule-1. Fifty-one children were included of whom 10 had a positive blood culture. Baseline characteristics were similar between children with and without a positive blood culture. No significant differences in serum levels of the Angiopoietins or soluble cellular adhesion molecules between groups were observed at start of antibiotic treatment nor after 48-72 h. The data from this study indicate that in children with severe infection, serum levels of markers of endothelial cell activation are not associated with a positive blood culture. Thus, having a positive bacterial blood culture may not be the only factor driving endothelial activation in this patient population.

Probiotics use for antibiotic-associated diarrhea: a pragmatic participatory evaluation in nursing homes

BackgroundAntibiotic-associated diarrhea (AAD) occurs in 2–25% of nursing home residents, which may lead to dehydration, malnutrition, severe complications and hospitalizations. Research shows that probiotics can be effective and safe in reducing AAD. However, probiotics are not routinely used in Dutch nursing homes. The objectives of this evaluation were to develop a procedure for the implementation of probiotics to prevent AAD in nursing homes, to evaluate effects on AAD occurrence, and to evaluate the implementation process of probiotics in daily care.MethodsA pragmatic participatory evaluation (PPE) design was chosen, as it seemed a suitable approach for implementation of probiotics, as well as for evaluation of its effectiveness in daily nursing home practice. Probiotics administration was implemented in three nursing homes of the Rivas Zorggroep for residents with somatic and/or psychogeriatric conditions. Ninety-three residents provided data on 167 episodes of antibiotics use, of which 84 episodes that included supplementation with probiotics and 83 episodes with no probiotics supplementation. A multispecies probiotics was administered twice daily upon start of antibiotic treatment, up to 1 week after completing the antibiotics course. The occurrence of AAD was monitored and a process evaluation was conducted to assess facilitators and barriers of probiotics implementation.ResultsThe number of episodes with AAD when using probiotics was significantly lower than when no probiotics was used (20% vs 36%; p = 0,022, Chi-square). No significant differences in the occurrence of AAD were found between the residents taking amoxicillin/clavulanic acid or ciprofloxacin. Reported facilitators for implementation were perceived benefits of probiotics and prescription by medical staff. Reported challenges were probiotics intake by residents and individual decision-making as to which resident would benefit from it.ConclusionSuccessful implementation of probiotics demonstrated the prevention of AAD in nursing home residents.Trial registrationISRCTN 94786163, retrospectively registered on 3 February 2020.

Q-fever - a rare cause for myocarditis

A 33-year old Romanian chef presented with sudden onset of chest pain and chills as well as a significant elevation of myocardial markers and CRP. Coronary angiography showed no signs of relevant atherosclerosis. A myocarditis was assumed and later diagnosed on cardiac MRI. Due to fevers up to 40 °C and occupational history, Q fever was assumed. Serologic findings confirmed the diagnosis. After the start of antibiotic treatment, temperatures remained normal and the patient could be discharged a few days later. Azithromycin was recommended for several weeks to prevent a chronic infection. At the check-up visit one month later the patient appeared to have no signs of chronic heart failure or persistent infection. Myocarditis is a rare manifestation of Q fever, which should not be missed. The diagnostic evaluation with antibody titers is easy. The antibiotic therapy is well tolerated and is a causal treatment that helps to prevent long-term damage.

Cytokines and chemokines in cerebrospinal fluid in relation to diagnosis, clinical presentation and recovery in children being evaluated for Lyme neuroborreliosis

In Lyme neuroborrelios (LNB), the immune response has been in focus, but the association between different cytokines/chemokines and clinical manifestations in LNB patients has not been fully investigated. The aim of this study was to evaluate a large number of cytokines and chemokines in cerebrospinal fluid (CSF) in relation to diagnosis, clinical presentation and recovery in children being evaluated for LNB. Materials and methodsPediatric patients (n = 105) were recruited at seven Swedish pediatric departments during 2010–14. Serum and CSF samples were drawn on admission, before start of antibiotic treatment. Patients diagnosed as Definite LNB or Possible LNB were categorized as LNBtot patients, all LNBtot patients presented with pleocytosis in CSF. Patients diagnosed as Non-LNB or Other diagnosis were categorized as Controlstot, all controlstot presented without pleocytosis in CSF.Multiplex bead array (Luminex) kits were used for analyses of 41 different cytokines/chemokines in CSF (Millipore). ResultsTwenty-eight cytokines/chemokines were detectable in CSF and the levels of 26 of these mediators were significantly higher in LNBtot patients than in Controlstot. In a discriminant analysis, a combination of four cytokines/chemokines (CXCL1, GM-CSF, IL-7 and IL-10) were shown to independently separate relevant patient groups. Furthermore, an IL-10/CXCL1 ratio was created and shown to have an improved diagnostic performance in distinguishing LNBtot vs Non-LNB patients, as compared to CXCL13 in CSF. No immune mediator differed significantly, when comparing LNBtot patients with different clinical presentation on admission or when comparing patients with or without recovery within 2 months of admission. ConclusionA discriminant analysis was shown to be useful to distinguish the independently most important cytokines/chemokines (CXCL1, GM-CSF, IL-7 and IL-10) in CSF, in order to discriminate LNBtot patients from Non-LNB patients. An IL-10/CXCL1 ratio was shown to have a promising diagnostic profile with a better performance than the chemokine CXCL13 in CSF. However, further evaluation is required to address future possible usefulness of these cytokines and chemokines in laboratory diagnostics in LNB, including control groups with neuro-inflammation. No significant associations were found between CSF immune mediator levels and clinical presentation or recovery in pediatric LNB patients.

Markers of endothelial cell activation in suspected late onset neonatal sepsis in Surinamese newborns: a pilot study.

Serum levels of markers of endothelial cell activation are associated with bacteremia and mortality in sepsis in adults, children, and newborns with early onset sepsis. We hypothesize that levels of these markers are associated with these outcomes in hospitalized newborns with suspected late onset neonatal sepsis (LONS). In this prospective cohort study, newborns admitted to the tertiary neonatal care facility of Suriname were included upon clinical suspicion of LONS and before start of antibiotic treatment, between April 1, 2015 and May 31, 2016. Serum concentrations of angiopoietin-1, angiopoietin-2, and soluble isoforms of P-selectin, E-selectin, vascular cell adhesion molecule-1 (sVCAM-1), intercellular adhesion molecule-1 (sICAM-1), platelet and endothelial cell adhesion molecule-1 (sPECAM-1), matrix metalloproteinase-9 (MMP-9), neutrophil elastase, and tissue-inhibitor of metalloproteinases-1 (TIMP-1) were measured. Twenty-thee newborns were included. Baseline characteristics were similar between newborns with and without bacteremia and between non-survivors and survivors. Only soluble E-selectin (sE-selectin) was higher in newborns with bacteremia versus non-bacteremia (P=0.04) and lower in non-survivors (P=0.04). No conclusions could be made for sVCAM-1 due to high serum concentrations. In conclusion, the data from this pilot study indicate that serum levels of markers of endothelial cell activation are poorly associated with bacteremia and mortality.

Validation of cellular tests for Lyme borreliosis (VICTORY) study

BackgroundLyme borreliosis (LB) is a tick-borne disease caused by spirochetes belonging to the Borrelia burgdorferi sensu lato species. Due to a variety of clinical manifestations, diagnosing LB can be challenging, and laboratory work-up is usually required in case of disseminated LB. However, the current standard of diagnostics is serology, which comes with several shortcomings. Antibody formation may be absent in the early phase of the disease, and once IgG-seroconversion has occurred, it can be difficult to distinguish between a past (cured or self-cleared) LB and an active infection. It has been postulated that novel cellular tests for LB may have both higher sensitivity earlier in the course of the disease, and may be able to discriminate between a past and active infection.MethodsVICTORY is a prospective two-gate case-control study. We strive to include 150 patients who meet the European case definitions for either localized or disseminated LB. In addition, we aim to include 225 healthy controls without current LB and 60 controls with potentially cross-reactive conditions. We will perform four different cellular tests in all of these participants, which will allow us to determine sensitivity and specificity. In LB patients, we will repeat cellular tests at 6 weeks and 12 weeks after start of antibiotic treatment to assess the usefulness as ‘test-of-cure’. Furthermore, we will investigate the performance of the different cellular tests in a cohort of patients with persistent symptoms attributed to LB.DiscussionThis article describes the background and design of the VICTORY study protocol. The findings of our study will help to better appreciate the utility of cellular tests in the diagnosis of Lyme borreliosis.Trial registrationNL7732 (Netherlands Trial Register, trialregister.nl).

Prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis: study protocol for an observational, prospective cohort study (LymeProspect)

BackgroundAfter antibiotic treatment of Lyme borreliosis, a subset of patients report persistent symptoms, also referred to as post-treatment Lyme disease syndrome. The reported prevalence of persistent symptoms varies considerably, and its pathophysiology is under debate. The LymeProspect study has been designed to investigate the prevalence, severity, and a wide range of hypotheses on the etiology of persistent symptoms among patients treated for Lyme borreliosis in the Netherlands.MethodsLymeProspect is a prospective, observational cohort study among adults with proven or probable Lyme borreliosis, either erythema migrans or disseminated manifestations, included at the start of antibiotic treatment. During one year of follow-up, participants are subjected to questionnaires every three months and blood is collected repeatedly during the first three months. The primary outcome is the prevalence of persistent symptoms after treatment, assessed by questionnaires online focusing on fatigue (CIS, subscale fatigue severity), pain (SF-36, subscale pain) and neurocognitive dysfunction (CFQ). Potential microbiological, immunological, genetic, epidemiological and cognitive-behavioral determinants for persistent symptoms are secondary outcome measures. Control cohorts include patients with long-lasting symptoms and unconfirmed Lyme disease, population controls, and subjects having reported a tick bite not followed by Lyme borreliosis.DiscussionThis article describes the background and design of the LymeProspect study protocol. This study is characterized by a prospective, explorative and multifaceted design. The results of this study will provide insights into the prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis, and may provide a rationale for preventive and treatment recommendations.Trial registrationNTR4998 (Netherlands Trial Register). Date of registration: 13 February 2015.

Oral versus Intravenous Antibiotics for Bone and Joint Infection

BackgroundThe management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.MethodsWe enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points.ResultsAmong the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of −1.4 percentage points (90% confidence interval [CI], −4.9 to 2.2; 95% CI, −5.6 to 2.9), indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% vs. 1.0%).ConclusionsOral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927.)

Meningoencefalitis por Herpes simplex virus 1 y Streptococcus pneumoniae en Pediatría. Reporte de caso

Introducción: la meningoencefalitis es una infección que compromete meninges y parénquima cerebral. Su expresión clínica varía desde síntomas inespecíficos, hasta signos de irritación meníngea de comienzo agudo y con resultados fatales. La coinfección de bacterias y virus es rara. El inicio del tratamiento antibiótico es empírico; la identificación etiológica por métodos moleculares permite realizar un manejo específico. Objetivo: Describir el caso clínico de una paciente en edad escolar con meningoencefalitis, con compromiso neurológico rápidamente progresivo, y letal, en donde se identificó coinfección entre Herpes simplex virus 1 (HSV1) y Streptococcus pneumoniae serotipo 14 en líquido cefalorraquídeo (LCR). Caso clínico: Paciente femenina de 8 años de edad, sin antecedentes de hospitalizaciones previas, ingresa a urgencias con cefalea, fiebre y emesis de 12 horas de evolución. Presenta deterioro neurológico rápidamente progresivo, con estudio de LCR con características de infección del sistema nervioso central (SNC) e identificación de HSV1 y Streptococcus pneumoniae serotipo 14 por reacción en cadena de polimerasa (PCR) y reacción de Quellung, para lo cual recibió aciclovir, Ceftriaxona, vancomicina. Se identificó hipogamaglobulinemia G, M, linfopenia, complemento C3 disminuido para la edad. La paciente presenta muerte encefálica a las 20 horas de evolución del cuadro clínico, y posteriormente fallece. Conclusiones: la meningoencefalitis puede tener manifestaciones clínicas de inicio súbito, rápidamente progresivas y con desenlaces fatales a pesar de un tratamiento adecuado. En este paciente se identificó la coinfección de HSV1 y Streptococcus pneumoniae serotipo 14 que, en conjunto con las anomalías inmunológicas, pudiesen estar relacionado con su compromiso severo.

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities.

Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities. We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices. Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice. Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities.

The new great imitator – neuropsychiatric symptoms of Lyme disease

IntroductionLyme disease, caused by the spirochete Borrelia burgdorferri as recognized as a possible cause of multisystemic signals and symptoms, including symptomatology of the central as well as the peripheral nervous system.ObjectivesIdentification of neuropsychiatric symptoms associated with Lyme disease.MethodsLiterature review in the light of researched articles published in Pubmed/Medline as well as related bibliography.ResultsSince the identification of the etiology of syphilis in the early twentieth century, mental health professionals consider the fact that serious psychiatric symptoms can be caused by infections of the central nervous system and that early antibiotic treatment can prevent permanent neurological/psychiatric damage. Syphilis was known as “the great imitator” because its multiple manifestations mimic other known diseases. In recent years, a new epidemic, also with multiple manifestations emerged–Lyme disease, also known as the “new great imitator”. Like syphilis, Lyme disease may be associated with neuropsychiatric symptoms, which means that often these cases are initially referred for psychiatric services, before another diagnosis is made. The incorrect assessment of these patients as individuals with functional psychiatric disease can result in a delay in the start of antibiotic treatment and may cause serious neurological and psychiatric damage.ConclusionsAccording to the review, the authors propose that in the evaluation of acute psychiatric disease or atypical chronic disease, with poor therapeutic response, Lyme disease should be considered and ruled out, especially if there is epidemiological context and absence of psychiatric family antecedents.Disclosure of interestThe authors have not supplied their declaration of competing interest.

PD02-06 HEALTHCARE-ASSOCIATED INFECTIONS BY MULTIDRUG-RESISTANT BACTERIA IN A TERTIARY UROLOGY DEPARTMENT

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I1 Apr 2016PD02-06 HEALTHCARE-ASSOCIATED INFECTIONS BY MULTIDRUG-RESISTANT BACTERIA IN A TERTIARY UROLOGY DEPARTMENT Vera Marques, Francisco Rolo, Edgar Tavares Silva, Alexandra Torres, Arnaldo Figueiredo, and Alfredo Mota Vera MarquesVera Marques More articles by this author , Francisco RoloFrancisco Rolo More articles by this author , Edgar Tavares SilvaEdgar Tavares Silva More articles by this author , Alexandra TorresAlexandra Torres More articles by this author , Arnaldo FigueiredoArnaldo Figueiredo More articles by this author , and Alfredo MotaAlfredo Mota More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2080AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Healthcare associated infections are a growing concern, particularly when caused by multidrug-resistant (MDR) bacteria. We intend to evaluate the impact of HAI by MDR bacteria in a tertiary urology department, analyzing the consequences on patient morbidity and mortality and identifying possible areas for improvement in the health care provided. METHODS Of the 2547 patients admitted to our urology department in 2014, we identified 66 patients (2.6%) which had had 80 HAI caused by MDR bacteria in different admissions (31 elective and 49 emergent). All HAI by MDR bacteria were confirmed by culture of biological product taken during the hospital stay. We conducted a retrospective analysis of the following data: general characteristics of patients, type of admission, delay at the start of antibiotic treatment, therapeutic approach used and clinical evolution of the patient. Statistical analysis was performed using the SPSS 21.0 program. RESULTS The average age of the 66 patients (14 female; 52 male) was 71.3 years (32-93). The average duration of the hospitalizations was 23.5 days, about 4 times higher than the global average in our department. The final result of the culture was obtained 4.2 days (2-12) after the collection. Overall, there were 41 infections of the urinary tract, 24 wound infections, 7 pneumonias and 8 other infections. The most common strain was methicillin-resistant Staphylococcus aureus (n=29) and the most used antibiotic was meropenem (n=21). In 47 cases (59%), empirical antibiotic therapy was adjusted to antibiogram, with an average delay of 1 day. In 33 cases (41%), the antibiotic therapy had not been adjusted, in two thirds of these (22 cases) because of clinical improvement with empirical therapy. The mortality associated with HAI caused by MDR bacteria was 26.2% (21 cases). The average age of patients who died (79.5 years) was significantly higher (p<0,001) than the average age of those who survived (67.8 years). The infection occurred later during the hospital stay on those patients who died (9.4 vs. 17.5 days, p=0.001). However, there were no differences in the mean duration of hospital stay between these two groups (26.3 vs. 22.3 days, p=0,26). CONCLUSIONS HAI caused by MDR bacteria are associated with a prolonged hospital stay, about 4 times higher than the average stay. In most cases the antibiotic therapy was adjusted to antibiogram, but empirical therapy proved effective in a significant number of patients. The mortality related to HAI by MDR is high at 26.2%, patient advanced age and late onset during in-hospital stay being risk factors. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e52-e53 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Vera Marques More articles by this author Francisco Rolo More articles by this author Edgar Tavares Silva More articles by this author Alexandra Torres More articles by this author Arnaldo Figueiredo More articles by this author Alfredo Mota More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cardiovascular outcomes associated with use of clarithromycin: population based study

Study question What is the association between clarithromycin use and cardiovascular outcomes?Methods In this population based study the authors compared cardiovascular outcomes in adults aged 18 or more receiving oral...

Vascular complications and surgical interventions after world's largest Q fever outbreak

Since chronic Q fever often develops insidiously, and symptoms are not always recognized at an early stage, complications are often present at the time of diagnosis. We describe complications associated with vascular chronic Q fever as found in the largest cohort of chronic Q fever patients so far. Patients with proven or probable chronic Q fever with a focus of infection in an aortic aneurysm or vascular graft were included in this study, using the Dutch national chronic Q fever database. A total of 122 patients were diagnosed with vascular chronic Q fever between April 2008 and June 2012. The infection affected a vascular graft in 62 patients (50.8%) and an aneurysm in 53 patients (43.7%). Seven patients (5.7%) had a different vascular focus. Thirty-six patients (29.5%) presented with acute complications, and 35 of these patients (97.2%) underwent surgery. Following diagnosis and start of antibiotic treatment, 26 patients (21.3%) presented with a variety of complications requiring surgical treatment during a mean follow-up of 14.1± 9.1months. The overall mortality rate was 23.7%. Among these patients, mortality was associated with chronic Q fever in 18 patients (62.1%). The management of vascular infections with C.burnetii tends to be complicated. Diagnosis is often difficult due to asymptomatic presentation. Patients undergo challenging surgical corrections and long-term antibiotic treatment. Complication rates and mortality are high in this patient cohort.