Streptococcal Bacteremia Research Articles

Maternal and Infant Mortality in Physicians' Families in 1922.

Maternal and Infant Mortality in Physicians' Families in 1922.

Mycotic Pseudoaneurysm of Dorsalis Pedis Artery

A 76 year old diabetic man presented with a rapidly growing (over two weeks) pulsatile mass on the left foot, with no history of trauma (A, arrow). Duplex ultrasonography revealed a 32 × 17 mm dorsalis pedis artery pseudoaneurysm, the diagnosis confirmed by whole body computed tomography angiography (B, arrow). Blood cultures revealed a non-enterococcal group D streptococcal bacteraemia secondary to periodontitis. Mycotic pseudoaneurysm was suspected. Intravenous amoxicillin followed by oral amoxicillin–clindamycin for a six week total duration were given. Because of the pseudoaneurysm location and risk of ischaemia, surgery was not performed. The pseudoaneurysm was treated successfully by ultrasonographically guided thrombin injection without ultrasound recurrence at one year.Image 1

Social distancing and bacteraemia in the time of COVID‐19

BackgroundSocial distancing was the predominant strategy used to mitigate the spread of Coronavirus disease 2019 (COVID‐19) at the start of the COVID‐19 pandemic.AimsTo study the impact of social distancing on the incidence of bacteraemia. The number of admitted patients with positive blood cultures in April–May 2020 in one tertiary medical centre was compared with the number during the same period in the previous 3 years (April–May 2017–2019).MethodsRetrospective review of all positive blood cultures from January to July in the years 2017–2020.ResultsThere were fewer cases of Streptococcus bacteraemia as well as coagulase‐negative Staphylococcus bacteraemia and other possible contaminated blood cultures in April–May 2020. Compared with the previous 3 years, the incidence of Streptococcus pneumoniae bacteraemia among all bacteraemias was lower in April–May 2020 (5%) than in 2017–2019 (12.0%; 95% confidence interval 10.3–14.1%). In general, fewer cases of bacteraemia caused by oropharynx organisms were observed in April–May 2020; only 6 cases versus 31 (95% confidence interval 10–53) during the same period in 2017–2019. Only one case of S. pneumoniae bacteraemia was observed in April–May 2020 and its percentage among all bacteraemias was lower in April–May 2020 (0.4%) than during the same period in 2017–2019 (3.3%).ConclusionThe incidences of streptococcal bacteraemia and bacteraemia of organisms transmitted through respiratory secretions were lower when there were social distancing restrictions. Adopting measures of social distancing may decrease the morbidity from bacteraemia caused by oropharynx and respiratory bacteria.

Recurrent group B streptococcus bacteremia despite discontinuing contaminated breast milk.

Recurrent group B streptococcus bacteremia despite discontinuing contaminated breast milk.

694. Prediction Tool for Infective Endocarditis in Beta-hemolytic Streptococcal Bacteremia

BackgroundAlthough beta-hemolytic streptococci (BHS) is a rare causative pathogen of infective endocarditis (IE), IE is a serious condition and it is important to predict IE in BHS bacteremia (BHS-IE). The purpose of this study was to develop a predictive score for BHS-IE.MethodsWe conducted a retrospective study comparing the clinical features of BHS-IE and BHS-non infective endocarditis (BHS-nIE) in adult patients with BHS bacteremia at a 520-bed tertiary hospital in Tokyo, Japan from 2004 to 2020. IE was diagnosed according to modified Duke's criteria, and both “Definite” and “Possible” were included. Univariate and multivariable analyses were conducted using logistic regression.ResultsAmong 250 patients with BHS bacteremia, 47 (19%) were diagnosed with BHS-IE. The median (IQR) patient age was 71 (59, 84) years and 121 (68%) were male. The proportions of A, B, C/G groups were 14%, 38.4%, and 47.6%, respectively. Five predictors, either independently associated with BHS-IE or clinically relevant, were used to develop the prediction score: C-reactive protein ≥ 10 mg/dl (2 points); Group B Streptococci (1 point); Auscultation of heart murmur (1 point); Platelet count < 150 /µl (1 point); and Hypotension (systolic blood pressure < 90 mmHg or on vasopressor) (1 point). In a receiver operating characteristic analysis, the area under the curve was 0.74 (95% confidence interval [CI]: 0.66 - 0.82). The cut-point was 2. A score ≥2 had a sensitivity of 87% (95%CI: 0.743 - 0.952), a specificity of 37% (95%CI: 0.308 - 0.445), a positive predictive value of 24%, and a negative predictive value of 93%, respectively.ConclusionWe developed the score to help clinicians rule out IE in BHS bacteremia. Further research is warranted for validation.Disclosures All Authors: No reported disclosures

195. Duration of Therapy for Streptococcal Bacteremia

BackgroundShorter durations have shown similar clinical outcomes as longer durations for uncomplicated (source-controlled) Gram-negative bloodstream infections (BSI). There is limited data on the outcomes of patients with non-pneumococcal streptococcal BSI receiving shorter durations of therapy compared to usual durations. MethodsThis was a retrospective, multicenter study of adults hospitalized between January 2018 and March 2019 with ≥ 1 blood culture positive for Streptococcus spp. Exposed patients were those who received ≤ 10 days of antibiotics (i.e., short course therapy) and unexposed patients were those who received 11-21 days of antibiotics (i.e., prolonged course therapy). Patients were excluded if they had S. pneumoniae BSI, suspected contamination, did not receive or complete therapy, or treated for > 21 days. The primary outcome was a composite of recurrent bacteremia with the same pathogen, hospital readmission, or all-cause mortality, all within 30 days from completing therapy. The odds of achieving the primary outcome was compared between exposed and unexposed patients using multivariable logistic regression analysis. ResultsA total of 176 patients met eligibility criteria. 35 (20%) received a short course (median 8 days) and 141 (80%) received a prolonged course (median 15 days) of antibiotic therapy. Baseline characteristics were similar between short and long course groups. The most common pathogens were viridans group streptococci (22%) and S. agalactiae (23%). The most common BSI source was skin and soft tissue infection (SSTI) (40%). The primary outcome occurred in 26% (9/35) and 23% (33/141) of patients in the short course and prolonged course groups, respectively (p = 0.774). The proportion of patients in the short course and prolonged course groups who experienced recurrent BSI, hospital readmission, or all-cause mortality were also non-significant. After adjusting for receipt of an infectious diseases consult, Pitt bacteremia score, and SSTI source, the adjusted odds of meeting the composite outcome remained unchanged (aOR 1.41, 95% CI 0.55 – 3.61, p = 0.466). Table 1. Cohort Characteristics Table 2. Source/Microbiology Table 3. Outcomes ConclusionApproximately a week of antibiotic therapy may be associated with similar clinical outcomes as longer antibiotics courses in patients with uncomplicated streptococcal BSI. Disclosures Kate Dzintars, PharmD, Nothing to disclose Sara E. Cosgrove, MD, MS, Basilea (Individual(s) Involved: Self): Consultant Pranita Tamma, MD, MHS, Nothing to disclose

A Phase I Clinical Trial Testing the Safety of IL-21-Expanded, Universally Alloreactive Donor-Derived Natural Killer Cells for Relapsed/Refractory Acute Myeloid Leukemia and Myelodysplastic Syndrome

Background: Natural Killer (NK) cells are cytotoxic lymphocytes that are able to exert an anti-tumor effect in an MHC-I independent manner, but are dysfunctional and reduced in number in patients with leukemia. Several studies have shown therapeutic potential for related donor NK cells expanded and/or activated ex vivo when administered to cancer patients, including patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). However, personalized, donor-derived cell therapies require time for donor identification, manufacturing and product release, resulting in patient attrition. As NK alloreactivity and NKG2C expression play critical roles in mediating anti-tumor effects, we identified ‘ideal’ NK cell donors (in partnership with “Be the Match Biotherapies”) for collection. Human leukocyte antigen (HLA) and Killer immunoglobulin receptor (KIR) genotyping were done to screen and select donors. Following this, a sample was collected from donors to expand NK cells under small-scale conditions. If donor NK cells showed robust expansion, they proceeded with apheresis. To ensure these therapeutic cells would be readily-available, we established a third-party NK cell bank through scalable, affordable mass-production with membrane-bound IL-21 feeder cells (FC21), and cryopreserved large numbers of these NK cells for immediate ‘off-the-shelf’ administration to recipients. Here, we report our initial experience in a Phase I trial of these off-the-shelf (OTS) alloreactive NK cells as immunotherapy for patients with relapsed/refractory AML and MDS.Methods: Patients were treated at Dose level 1, to allow infusion at a dose of 1 x 10e7 NK cells/ kg. Each dose level had two cohorts, stratified by age. Patients were enrolled into Cohort 1 (patients <60 yrs. received Fludarabine (Flu) 30 mg/m2/day & Cytarabine 2 g/m2/day on days -6 to -2) and Cohort 2 (patients ≥ 60 yrs. received Flu 30 mg/m2/day (days -5 to -2) & Decitabine 20 mg/m2/day (days -6 to -2). Patients were evaluated to see if they had any donor-directed antibodies. After chemotherapy, NK cells were infused thrice weekly for 6 doses, to be given over a period of 2 weeks (Clinicaltrials.gov: NCT04220684). Persistence of donor NK cells was determined by flow cytometry using haplotype-discriminating anti-HLA antibodies (Figure 1, 2). NK cells were completely HLA-mismatched between donor and recipients.Results: 6 patients (3/cohort) were treated at the first dose level of 1x10 7 NK cells/kg/dose. All 6 patients had relapsed/refractory AML and had received at least two prior lines of treatment. One patient (005) withdrew from the study prior to infusion of NK cells. 6 patients received the first NK cell dose as an inpatient and were discharged to receive the remaining 5 doses as an outpatient. 5 patients tolerated infusion of all 6 doses of NK cells administered over 2 weeks. One patient (006) developed a Cytokine response (CRS) - like syndrome in the context of streptococcus bacteremia and received only one dose of NK cells. Symptoms suggestive of CRS responded fully with steroids and patient was able to successfully wean off steroids and discharged to the outpatient setting. One patient proceeded to allogeneic hematopoietic cell transplant. No infusion-related reactions, neurotoxicity or graft versus host disease was observed. In vivo persistence/expansion NK cells were superior with FLU/CY lymphodepletion (cohort 1).Conclusions: Cryopreserved, third-party donor-derived NK cells are safe and feasible in relapsed/refractory AML patients, and even at this first dose level, completely HLA-mismatched NK cells can persist and expand to high levels in vivo. [Display omitted] DisclosuresVasu: Kiadis, Inc.: Research Funding; Seattle Genetics: Other: travel support; Boehringer Ingelheim: Other: Travel support; Omeros, Inc.: Membership on an entity's Board of Directors or advisory committees. Walker: Newave: Other: clinical trial support; Geron: Other: clinical trial support; Novartis: Other: clinical trial support. Blachly: INNATE: Consultancy, Honoraria; KITE: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; AstraZeneca: Consultancy, Honoraria. de Lima: Incyte: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Miltenyi Biotec: Research Funding. Lee: Kiadis Pharma: Divested equity in a private or publicly-traded company in the past 24 months, Honoraria, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding; Courier Therapeutics: Current holder of individual stocks in a privately-held company.

S292 Diagnostic Yield of Colonoscopy in the Setting of Viridans Streptococcus Bacteremia

S292 Diagnostic Yield of Colonoscopy in the Setting of Viridans Streptococcus Bacteremia

Using Electronic Medical Record Data and Block Group Level Estimates of Poverty to Investigate the Association between Socioeconomic Status and Bloodstream Infection Among Pediatric Patients with Acute Leukemia

IntroductionAdvances in chemotherapy regimens have greatly improved outcomes in acute leukemia (AL) with 5-year survival being 90% in acute lymphoblastic leukemia (ALL) and 60-70% in acute myeloid leukemia (AML). Despite these advances, AL accounts for the greatest proportion of malignancy-related death among children. We and other investigators have shown that this mortality burden, frequently in the context of infectious complications, is greater in racial minority groups. We sought to expand these prior analyses by using automated data extraction from the electronic medical record (EMR) combined with geocoded block group level estimates of poverty to examine the incidence of bloodstream infection during induction in relation to race and socioeconomic status (SES).MethodsA total of 287 ALL (246 B-ALL, 41 T-ALL) and 61 AML patients who started therapy at The Children's Hospital of Philadelphia between 2006 and 2014 were included. Risk group, chemotherapy protocol, course dates, and initial white blood cell (WBC) count were manually abstracted into a REDCap database. Patient age, sex, race, blood culture results, initial absolute neutrophil count (ANC), and residential address were extracted from the EMR with an automated REDCap/EPIC data query tool. Residential addresses were batch-matched to geo-coordinates that linked each patient to a census-derived block group. Figure 1 shows patient residential address mapped onto the percentage of residents below the federal poverty level in each block group. Percent below poverty was dichotomized at greater than the third quartile (13.31%), as a measure of block group SES. Course level bloodstream infection incidence was computed based on positive blood culture results between course start and end dates. Common commensal organisms were only counted as true pathogens if there were two or more positive blood cultures for the same organism in a three day period. Log-binomial regression was used to compute the unadjusted risk ratios (RR) and corresponding 95% confidence intervals (CI) comparing incidence of bloodstream infection during induction by block group SES, race, sex, age, risk classification and presenting WBC and ANC. Due to the small number of T-ALL patients, T-ALL and B-ALL patients were grouped for modeling.ResultsPatient characteristics are shown in Table 1. The cumulative incidence for any bloodstream infection throughout the course of treatment was 82% for AML patients, and 18% and 24% for B-ALL and T-ALL patients, respectively. 52% of AML patients developed viridans group streptococcal bacteremia during the course of therapy, and 6% had fungemia, from organisms in the Candida, Trichosporon, or Fusarium genera. Incidence of any bloodstream infection during first induction was 5.88% for ALL and 16.13% for AML. In ALL patients, age >10 y (RR: 0.35 , 95% CI: 0.08, 1.51) and black race (RR: 0.75, 95% CI: 0.18, 3.18) were associated with a lower bloodstream infection risk during induction, whereas block group with >13.31% below poverty (RR: 1.27, 95% CI: 0.46, 3.47), females (RR: 1.38, 95% CI: 0.55, 3.47), high risk classification (RR: 1.67, 95% CI: 0.66, 4.18), presenting WBC >50,000 (RR: 3.03, 95% CI: 1.22, 7.53) and presenting ANC ≤500 (RR: 1.58, 0.63, 3.99) suggested a higher bloodstream infection risk during induction, though none of these associations achieved statistical significance. Results of similar magnitude and direction were obtained for AML with the exception of presenting ANC ≤500 (RR: 0.84, 95% CI: 0.24, 2.91).ConclusionsThis study demonstrates the feasibility of linking automatically extracted patient demographic and laboratory data with geocoded estimates of block group level covariates to evaluate the association between socioeconomic status and bloodstream infection risk during induction therapy among children with AL. Work is ongoing to expand the study population to other centers, to extend the bloodstream infection susceptibility analyses to other chemotherapy courses, and to evaluate event free and overall survival. This preliminary analysis suggests that race and poverty may have unexpectedly discrepant relationships with health outcomes. These findings suggest the need for larger studies to better parse the independent effects of race and SES, as well as their potential interaction, on incident bloodstream infection in pediatric AL. [Display omitted] DisclosuresFisher:Merck: Research Funding; Pfizer: Research Funding.

Ingested fishbone causing a hepatic abscess.

Question: A 69-year-old male who initially presented with Streptococcus bacteremia was later readmitted with recurrent fevers, chills, and abdominal pain. A contrasted computed tomography (CT) scan of the abdomen and pelvis was obtained. What is the diagnosis and management?

Group A streptococcal bacteraemia at a tertiary hospital in Melbourne: concern of an under-reported risk group in Australia.

Invasive group A streptococcal (iGAS) infections are increasing worldwide with at-risk groups being children, pregnant women and the elderly. In 2017, there was a rise in iGAS cases in Victoria, prompting a Chief Health Officer advisory. To describe the characteristics of patients with GAS bacteraemia admitted to a tertiary hospital. To compare at-risk groups in our population with those identified in the Victorian Government health alert. Retrospective review of patients with GAS bacteraemia admitted between June 2014 and December 2017 at a tertiary hospital in Melbourne, Victoria. Forty-three cases of GAS bacteraemia occurred. Average age was 52 years (range 15-88 years) with 63% male. Average length of stay was 14 days (range 0-72 days) and all-cause mortality occurred in two (5%) cases. Twelve (28%) patients presented with shock, 11 (26%) required intensive care unit admission and 13 (30%) surgical intervention. A history of intravenous drug use was documented in 18 (42%) cases and was commonly complicated by bone or joint involvement or thrombosis. Typing of GAS samples identified 22 different emm-types. GAS bacteraemia resulted in significant morbidity and prolonged hospitalisation. In contrast to the at-risk groups identified in the Victorian Government health advisory, the commonest risk group in this series were people who inject drugs and most commonly middle-aged men. Invasive GAS should be considered if a person who injects drugs presents with acute severe sepsis.

Evaluation of Empiric Vancomycin for Fevers During High-dose Cytarabine Administration.

Cytarabine is a nucleoside analog used in chemotherapy regimens for the treatment of multiple hematologic malignancies. One of the known adverse effects of cytarabine, particularly in patients receiving high-dose cytarabine (HDAC), is drug-induced fever. Multiple studies have demonstrated an increased risk of viridans group streptococcal bacteremia in patients who have received HDAC. For this reason, our institution and several other institutions across the country routinely include vancomycin as empiric coverage for patients who develop fever during HDAC, due to concern for resistance to cephalosporin monotherapy. Patient demographic, diagnosis, treatment, and outcome information was collected by electronic chart review for each HDAC infusion from 2007 to August 2018 at the University of Iowa Stead Family Children's Hospital. If fever was documented during or within 24 hours of HDAC, additional information was collected regarding patient outcome and diagnostic testing. Of 208 HDAC administrations documented, patients developed fevers during the course on 82 occasions (39.4%). A median of 3 blood cultures per febrile period were obtained from time of fever onset during HDAC administration through >24 hours afebrile. One blood culture was positive for an oral flora organism determined by the microbiology lab report to be a likely contaminant. There were no other positive blood cultures in non-neutropenic or neutropenic patients. Fever due to HDAC is relatively common but appears to frequently lack association with bacteremia during the time of HDAC administration. Broad-spectrum empiric antibiotic regimens including vancomycin may be unnecessary for these patients, particularly before they become neutropenic.

Group B Streptococcus bacteremia among non-pregnant adults in Kelantan: Description on clinical presentations, serotypes and virulence genes

Group B Streptococcus bacteremia among non-pregnant adults in Kelantan: Description on clinical presentations, serotypes and virulence genes

Limited Clinical Utility of Follow-up Blood Cultures in Patients With Streptococcal Bacteremia: An Opportunity for Blood Culture Stewardship.

BackgroundThe value of positive follow-up blood cultures (FUBCs) in streptococcal bacteremia has not been well defined. Therefore, we explored the frequency of and risk factors for positive FUBC in a retrospective cohort of patients with streptococcal bacteremia.MethodsAdults ≥18 years of age, admitted with at least 1 positive blood culture for Streptococcus spp between 2013 and 2018 followed by at least 1 FUBC, were potentially eligible. Positive FUBCs were defined as cultures positive for the same streptococcal species drawn >24 hours after the index culture. We excluded patients with polymicrobial bacteremia. We compared the characteristics of patients with and without a positive FUBC.ResultsIn our single-center cohort, we identified 590 patients with streptococcal bacteremia, and 314 patients met inclusion criteria. Ten patients had FUBC with Streptococcus spp (3.2%), 4 (1.3%) had a contaminant identified, and 3 (1.0%) had a new pathogen isolated. Endocarditis (5 of 10 [50.0%] vs 35 of 304 [11.5%]), epidural abscess (2 of 10 [20%] vs 4 of 304 [1.3%]), and discitis or vertebral osteomyelitis (3 of 10 [30.0%] vs 14 of 304 [4.6%]) were associated with positive FUBC. Patients with positive FUBC had a longer median length of stay (12.9 vs 7.1 days, P = .004) and longer duration of antibiotic treatment (14.9 vs 43.2 days, P = .03).ConclusionsFollow-up blood cultures among patients with streptococcal BSI are rarely positive. Clinicians could consider limiting follow-up blood cultures in patients at low risk for deep-seated streptococcal infections, persistent bacteremia, or endovascular infection.

A CASE OF IGG4-RELATED INTERSTITIAL LUNG DISEASE MANIFESTING AS RECURRENT NECROTIZING PNEUMONIA

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: IgG4-related disease is a newly recognized fibroinflammatory disorder characterized by enlargement of one or more organs with classic histopathologic findings of diffuse lymphoplasmacytic infiltration and IgG4+ plasma cells. Presentation relies on the primary organ affected. Pulmonary disease can be especially difficult to characterize, as its course may mimic various lung pathologies. In this case report, we describe a case of IgG4-related interstitial lung disease (ILD) that manifested as recurrent necrotizing pneumonia. CASE PRESENTATION: A 33-year old female with past medical history of recent Group B Streptococcal bacteremia with aortic valve endocarditis was admitted for severe aortic insufficiency, necessitating aortic valve replacement. She developed hypoxic respiratory failure requiring ventilation support and treatment for pneumonia. After discharge, she was soon readmitted for right sided necrotizing pneumonia. Initial bronchoscopy positive for Streptococcus Viridians and Lactobacillus with repeat bronchoscopy after antibiotics showing normal flora. Patient was ultimately readmitted for left sided chest pain and hypoxia. Initial workup showed elevated inflammatory markers and CT chest with right-sided, multifocal pneumonia with cavitations. Microbiology and immunologic studies unremarkable. The patient did not improve on 1 month of antibiotics so underwent a lung biopsy revealing for interstitial fibrosis, inflammatory lymphoplasmacytic infiltrate, and positive IgG4 staining with elevated serum IgG4 levels- diagnostic for IgG4-related ILD. The patient was started on PO prednisone with complete resolution on most recent follow-up 2 months later. DISCUSSION: IgG4-related disease was first recognized in 2003 and is now understood as a spectrum of related diseases. In particular, the prevalence of pulmonary involvement remains uncertain, and neither diagnostic criteria nor treatment have officially been established. Review of previous cases reveals diverse presentations sharing features of other lung pathologies including pneumonias, cancer, and granulomatous diseases. The current report describes IgG4-related ILD manifesting as recurrent necrotizing pneumonia confirmed via characteristic lung pathology and an elevated serum IgG4 level of 235 mg/dL. Treatment relied on previous cases describing good prognosis from corticosteroids; specifically, prednisone 0.6 mg/kg with plans for slow taper. Patient was successfully weaned from oxygen support without further addition of DMARDs. CONCLUSIONS: IgG4-related disease encompasses a spectrum of fibroinflammatory disorders that can affect multiple organ systems, including the lungs. Given the evolving nature of IgG4-related ILD, diagnosis can be especially difficult given the multitude of presentations mimicking other infectious, neoplastic, and inflammatory disease processes. Larger studies could further understanding of this complex disease. Reference #1: Stone, John H., et al. “Mechanisms of Disease: IgG4-Related Disease.” The New England Journal of Medicine, 9 Feb. 2012. Reference #2: Chen, Chiu-Fan et al. “IgG4-related lung disease presenting as interstitial lung disease with bronchiolitis: A case report.” Medicine vol. 96,49 (2017): e9140. doi:10.1097/MD.0000000000009140 Reference #3: Umehara, Hisanori, et al. “Comprehensive diagnostic criteria for IgG4-related disease (IgG4-RD).” Modern Rheumatology, vol. 22, no. 1, 2 Jan. 2014, pp. 21-30. Abstract. DISCLOSURES: no disclosure on file for Duc Ho; No relevant relationships by Larry Jankelowitz, source=Web Response No relevant relationships by Ramier Lehne, source=Web Response

HYPERAMMONEMIA AS A CAUSE OF SEIZURE

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hyperammonemia is a metabolic disturbance characterized by excess ammonia in the blood and a life-threatening condition that can affect patients of any age. It is a dangerous condition that may lead to cerebral edema, brain injury, and death. It is commonly associated with acute or chronic liver failure with or without hepatic encephalopathy, inborn errors of metabolism, upper gastrointestinal bleeding, and non-hepatic causes include chemotherapy, valproic acid, ureterosigmoidostomy, UTIs. Elevations of ammonia in plasma indicate its increased production and/or decreased detoxification. CASE PRESENTATION: An 83-Year-old female with a past medical history of hypertension, gout, chronic kidney disease presenting to emergency with acute motor loss in bilateral lower extremities with a power of 0/5 and areflexia in all lower extremity muscle groups. The initial diagnosis was cord infarct vs compression. Lumbar puncture, blood work, and imaging of the spinal cord were non-significant. She was started on pulse dose steroids for potential cord compression. On Day 3 of hospitalization, she developed streptococcus and enterococcus bacteremia, later developing into septic shock and AKI at which time she became altered and lethargic. She was transferred to ICU for further monitoring. in the ICU she was found to have extremely elevated levels of ammonia, 595µmol/L (normal15 – 63 µmol/L) with worsening septic shock and multi-organ failure, AKI, liver failure and encephalopathy with seizure-like activity and two vasopressor medications requirement. Subsequent ammonia levels trended down after lactulose treatment to 252 and 161 µmol/L. Due to her unstable condition, the patient was not able to tolerate RRT. With poor prognosis and unstable conditions, she expired. DISCUSSION: There is a relatively poor correlation with symptoms based on ammonia level, and severe symptoms generally occur with higher levels of ammonia. Previous studies showed ammonia levels around 500, sustained ammonia levels of 150 to 200 µmol/L greatly increase intraneuronal osmolality and hence the risk for intracranial hypertension and encephalopathy. An absolute ammonia level above which dialysis is needed among adults is not well defined and relies heavily on clinical evaluation. Monitoring ammonia levels, neurologic status, arterial or venous pH, and hemodynamic parameters in hyperammonemia patients will prompt for the acute need for the dialysis. Intermittent and Continuous modalities of renal replacement therapy (RRT) are indicated for hyperammonemia. Dialysis can be discontinued once the mental status is restored to the baseline and ammonia levels are declining or have stabilized. CONCLUSIONS: In the case of unexplained encephalopathy, idiopathic seizures hyperammonemia must be excluded. Early detection and prompt treatment is the key. Early evaluation for RRT as a treatment modality for hyperammonemia, as it is a dialyzable agent. Reference #1: Daughtry, DO JT, Boehm, DO, MSc KM. Transient Hyperammonemia Seen in Post Seizure Activity: A Series of Six Case Reports. SMRJ. 2017;1(2). Reference #2: Clemmesen JO, Larsen FS, Kondrup J, et al. Cerebral herniation in patients with acute liver failure is correlated with arterial ammonia concentration. Hepatology 1999; 29:648. Reference #3: Nakamura K, Yamane K, Shinohara K, et al. Hyperammonemia in an idiopathic epileptic seizures. Am J Emerg Med. 2013;31(10):1486-1489. DOI:10.1016/j.ajem.2013.08.003 DISCLOSURES: Speaker/Speaker's Bureau relationship with pfizer Please note: $1001 - $5000 Added 06/11/2020 by Yizhak Kupfer, source=Web Response, value=Consulting fee No relevant relationships by kiran para, source=Web Response No relevant relationships by Ratnam Santoshi, source=Web Response

S2749 Streptococcus intermedius Liver Abscesses in a Patient Presenting With Fatigue

INTRODUCTION: Streptococcus intermedius is part of the Streptococcus milleri group. It can be found as part of the normal flora of the oropharyngeal cavity and gastrointestinal tract. Although rare, Streptococcus intermedius can cause hematogenous infection in addition to liver abscesses in healthy patients. We describe a case of Streptococcus intermedius liver abscesses and bacteremia in a patient who presented with fatigue. CASE DESCRIPTION/METHODS: A 73 year old male patient with a past medical history of coronary artery disease and hypertension presented to the hospital with progressively worsening weakness and fatigue in addition to generalized abdominal pain. Patient had a previous history of resolved hepatitis C infection. There was no signs of hepatic decompensation or weight loss. On presentation, patient’s vital signs were within normal limits. Physical exam was remarkable for generalized abdominal tenderness. Labs were significant for a WBC of 12.6 × 109/L and INR of 1.4. Liver function tests were significant for an ALT of 50 U/L and a total bilirubin of 3.1 U/L. A CT of the abdomen and pelvis showed nonspecific sigmoid colitis or diverticulitis. Blood cultures were taken. Patient was started on appropriate antibiotics for suspected diverticulitis. Blood cultures were later positive for Streptococcus intermedius. Liver ultrasound showed multiple small hypoechoic lesions in the liver, and signs of hepatic steatosis. MRI of the abdomen was suggestive of multifocal hepatic abscesses. He was treated with IV ceftriaxone for six weeks followed by Augmentin for 2 two weeks. Follow up MRI one month after initial presentation showed decrease in the size of liver abscesses. Complete resolution of abscesses was seen on MRI a month later. DISCUSSION: Although it is uncommon, Streptococcus intermedius is notorious for causing abscesses with reported cases of brain, lung, and liver abscesses in the literature. It is likely that the bacteremia occurred first followed by abscess formation. The source of the bacteremia is unclear though it is most likely from a GI source in the setting of colitis seen on CT scan in this case. Patient is scheduled for colonoscopy to look for malignancy as the nidus for this infection. He will also undergo cardiac echo to rule out endocarditis although rare. There should be high suspicion for liver abscesses in patients with Streptococcus intermedius bacteremia. Timely diagnosis is important as untreated pyogenic liver abscesses can be fatal.

A RARE PRESENTATION OF GROUP C STREPTOCOCCUS ENDOCARDITIS WITH DIFFUSE SEPTIC EMBOLI

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Group C beta-hemolytic Streptococcus (GCS) typically causes skin and soft tissue infections, pharyngitis, and wound infections. However, the incidence of bacteremia from GCS has increased significantly over the past decade1. Most cases of GCS bacteremia and complications including endocarditis, meningitis, and septic arthritis occur in older adults with underlying chronic illnesses2. We present the unusual case of GCS endocarditis with diffuse septic emboli causing multi-organ failure in a young female. CASE PRESENTATION: A 24-year-old female with a history of intravenous drug use was admitted with altered mental status after IV drug use. On presentation, patient was afebrile with no leukocytosis, and examination was significant for tachycardia, extreme agitation, hyperalgesia, and hallucinations. Preliminary workup revealed thrombocytopenia, acute kidney injury, acute liver injury, and troponinemia. Chest radiographs showed cardiomegaly with concern for mild pulmonary edema. Toxicology screen was positive for amphetamines and cannabinoids but negative for opioids. Echocardiogram revealed a 1.9cm x 1.8cm echodensity attached to the basal free wall of the right ventricle near the level of the tricuspid valve. Blood cultures were positive for GCS, meeting 2 major Duke criteria for infective endocarditis. Her clinical course was complicated by septic shock and acute hypoxic respiratory failure requiring intubation. Repeat chest imaging revealed diffuse patchy airspace opacities with superimposed interstitial predominance. Computed tomography of the chest showed a bronchovascular distribution of wedge-shaped consolidative opacities scattered diffusely throughout bilateral lungs. Imaging findings also included hepatosplenomegally and evidence of embolization to the kidneys. She showed clinical improvement with intravenous antibiotics and mechanical ventilation and is under evaluation by cardiothoracic surgery for valve repair and vegetation excision. DISCUSSION: Though GCS bacteremia and endocarditis are typically seen in older adults with comorbidities, this case highlights the rapid progression and clinical sequelae of GCS bacteremia in a young female with IV drug use. Tricuspid valve vegetations are commonly seen in IV drug use-associated endocarditis, however a vegetation in the right ventricle arising from the basal free wall is exceedingly rare. The location of the vegetation likely contributed greatly to the rapid showering of emboli and severity of symptoms in this case. CONCLUSIONS: Though GCS is not an organism frequently associated with IV drug use, it should now be considered given the rising incidence of GCS bacteremia and the severity of disease it may cause1. Reference #1: Lother S, Jassal D, Lagacé-Wiens P, Keynan Y. Emerging Group C and Group G Streptococcal Endocarditis: A Canadian Perspective. Int J Infect Dis 2017; 65: 128-132 Reference #2: Berenguer J, Sampedro I, Cercenado E, et. al. Group-C Beta-Hemolytic Streptococcal Bacteremia. Diagn Microbiol Infect Dis 1992; 15(2): 151-155 DISCLOSURES: No relevant relationships by Gold Adkins, source=Web Response No relevant relationships by Aria Bryan, source=Web Response No relevant relationships by Shine Raju, source=Web Response No relevant relationships by Pallavi Sharma, source=Web Response No relevant relationships by Catalina Teba, source=Web Response

Plasma C3d levels as a diagnostic marker for complete complement factor I deficiency

Plasma C3d levels as a diagnostic marker for complete complement factor I deficiency

Oral antibiotic therapy in people who inject drugs (PWID) with bacteraemia.

Bacterial infections are a major cause of morbidity and mortality in people who inject drugs (PWID). Patients with bacteraemia have a particularly high risk of complications and are usually treated with intravenous antibiotics. Intravenous treatment is challenging in certain PWID because of difficult venous access and a high rate of catheter-associated complications. Therefore, oral treatment alternatives must be considered. This review discusses the potential options for oral antimicrobial treatment of gram-positive and gram-negative bacteraemia in PWID and the evidence for them. Data on oral antibiotic treatment of bacteraemia in PWID is scarce. Whenever possible, a course of intravenous antibiotic treatment should precede the switch to an oral regimen. For Staphylococcus aureus bacteraemia, there is growing evidence that initial intravenous antibiotics can be switched to oral treatment (e.g., a fluoroquinolone and rifampin or linezolid) when the patient is clinically stable and source control has been achieved. However, regimen selection remains challenging due to pharmacokinetic/pharmacodynamic issues, potential toxicity and drug-drug interactions of oral antibiotics. For some streptococcal bacteraemia, oral amoxicillin is probably a reasonable option. The best existing evidence for oral antibiotic treatment is for gram-negative bacteraemia, which, if susceptible, can be treated successfully with oral fluoroquinolones. Oral antibiotic options for fluoroquinolone-resistant gram-negative bacteraemia are very limited, although in selected patients oral trimethoprim-sulfamethoxazole can be considered. In conclusion, treatment of bacteraemia in PWID remains very complex, and an interdisciplinary approach is essential in order to select the best therapy for this vulnerable group of patients.