Total Antibiotic Duration Research Articles

Clinical Outcomes of Foot Infections in Patients Without Diabetes

The aim of this study was to report clinical outcomes of moderate and severe foot infections in patients without diabetes. Medical records of 88 nondiabetic patients with foot infections treated at a safety net hospital were retrospectively reviewed. Patients were grouped by the presence of soft-tissue infection (STI) or osteomyelitis (OM). The diagnosis of OM was determined by positive bone culture or histopathology. STIs were defined by negative bone biopsy or negative imaging with magnetic resonance imaging or computed tomography/dual-modality radiolabeled white blood cell single-photon emission computed tomography. Patient outcomes were recorded ≤1 year after admission. Eighty-eight nondiabetic patients admitted to our institution for moderate or severe foot infections were included, 45 OM and 43 STI. No differences were noted in patient characteristics except that OM patients had a higher prevalence of neuropathy (66.7% versus 39.5%, p = .02). OM patients required surgery more often (97.8% versus 67.4%, p < .01), a greater number of surgeries (2.0 ± 1.2 versus 1.4 ± 1.3, p = .02), and more amputations (75.6% versus 11.6%, p < .01) than STI patients. OM patients had a higher proportion of wounds that healed (82.2% versus 62.8%, p = .04). There were no significant differences in reinfection (35.6% versus 25.6%, p = .36), foot-related readmission to hospital (35.6% versus 23.3%, p = .25), or total duration of antibiotics (13.9 ± 10.2 versus 13.5 ± 12.9, p = .87) between OM and STI patients. In conclusion, OM patients required more surgeries and amputations than patients with STIs; however, they had similar rates of reinfection and readmission within a year after the index hospitalization.

Fusobacterium nucleatum brain and liver abscesses following sigmoid diverticulum perforation in an immunocompetent patient

We report a case of disseminated Fusobacterium nucleatum likely secondary to an undiagnosed perforated sigmoid diverticulum. A 50-year old male, (past history of COPD, schizophrenia and diverticulosis) presented with fever, seizures and progressive leg weakness over 4 days. Examination revealed left leg weakness and hepatomegaly. CT-brain showed bilateral supra-tentorial lesions with sulcal effacement; MRI findings were consistent with abscesses. Initial management included burr-hole drainage of 2 intra-cranial lesions and treatment with ceftriaxone and metronidazole. The patient defervesced post-operatively. Blood cultures (day 1) and cerebral pus (day 3) grew Fusobacterium nucleatum after 5 days. HIV Ab/Ag negative. Subsequent imaging excluded endocarditis, intra-cardiac shunting and jugular vein thrombosis. CT revealed pulmonary emboli, liver abscess (68x46x42 mm, inaccessible to drainage) and localised sigmoid perforation. Later, the patient admitted to a 5-day period of severe self-limiting abdominal pain 2-weeks prior to admission, probably relating to sigmoid perforation. The patient required further neurosurgical drainage (day 10) due to fluctuating consciousness; intra-operative samples were culture negative. Neurological improvement occurred during 4 weeks treatment. Total antibiotic duration will be determined by follow-up imaging. Fusobacterium spp.are fastidious Gram-negative rods. Microscopy can differentiate the main pathogenic species showing tapered ends (F. nucleatum) or pleomorphic rods (F. necrophorum). Malignancy, diabetes and immunosuppression/HIV are associated, but none are present here. Presentations include abscesses, bacteraemia, thrombophlebitis, osteomyelitis and endocarditis. This case highlights the need for early sampling, careful history regarding source, covering at least 2-4 weeks preceding presentation, and demonstrates paradoxical deterioration after antibiotics and drainage, likely due to post-treatment inflammatory reaction.

Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation.

Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5-10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.

Antibiotic Duration and Outcome Complications for Surgical Site Infection Prevention in Traumatic Mandible Fracture

BackgroundThe appropriate duration of antibiotic therapy for surgical site infection (SSI) prevention in traumatic mandibular fracture repair is unknown, and practices vary significantly. The objective of this study was to characterize antibiotic duration and outcomes after surgical repair of traumatic mandibular fracture. MethodsA single-center, retrospective analysis of all adult patients who underwent surgical fixation of a mandible fracture between January 2014 and December 2016 was performed. Operative service was categorized between otolaryngology (ear, nose, and throat surgery), plastic and reconstructive surgery, and oral and maxillofacial services. Primary outcomes were SSI and operative complications (including osteomyelitis, nonunion, malocclusion, and hardware infections). Differences in antibiotic prescription pattern were analyzed using analysis of variance test and Pearson chi-squared test. ResultsA total of 75 patients were included in the study with 33 (44.0%), 26 (34.7%), and 16 (21.3%) managed by plastic and reconstructive surgery, ear, nose, and throat surgery, and oral and maxillofacial services, respectively. Median age was 30.0 y. Median injury severity score was 4.0. There was no significant difference in hospital length of stay (P = 0.44), intensive care unit length of stay (P = 0.53), or postoperative complications (P = 0.15). None of our patients developed an SSI or postantibiotics complications. Although the total inpatient duration of antibiotics was not significantly different among services (P = 0.37), there were significant differences in outpatient duration of antibiotics (P = 0.007) and total duration of antibiotics (P = 0.003). ConclusionsDuration of antibiotics is not associated with postoperative SSI or antibiotics-related complications. The wide variation in prescribing practices and lack of any clear benefit for prolonged antibiotics provides an opportunity to explore the benefits of a standardized short course of antibiotics. Level of evidenceTherapeutic study, III.

1486. Evaluation of the Impact of Homelessness on Presentation and Outcomes of Gram-Negative Sepsis

BackgroundLow socioeconomic status has been shown to contribute to an increase in mortality and intensive care unit (ICU) admission in patients with sepsis. The role of homelessness on outcomes of gram-negative sepsis is currently unknown. The primary objective was to evaluate the impact of homelessness on presentation and outcomes compared with low socio-economic status patients with housing.MethodsSingle-center, retrospective cohort study of hospitalized adults with Enterobacteriaceae infections between 2015 and 2017. Medical charts were reviewed for pertinent data. Patients were grouped as homeless (H) vs. non-homeless (NH) and compared for patient characteristics, clinical presentation, and course. Primary outcome was 30-day mortality. Secondary outcomes were 30-day re-admission and hospital length of stay (LOS).Results198 patients were included; 68 in H group vs. 130 in NH group. H group were younger (mean 51 years vs. 57 years, P = 0.01), more likely to be male (71% vs. 37%, P < 0.01) and non-Hispanic White (57% vs. 21%, P < 0.01). Two groups had similar comorbidities, except H group had more liver dysfunction (16% vs. 7%, P = 0.05); however, less heart failure (7% vs. 18%, P = 0.03). H group had a more severe presentation with higher rate of ICU admission (57% vs. 41%, P = 0.04) although initial SOFA score (median 6 vs. 4, P = 0.14) and need for vasopressors (16% vs. 18%, P = 0.19) were similar. Urinary tract infection (37% vs. 45%, P = 0.36) and bacteremia (38% vs. 42%, P = 0.76) were the most common sources. Total antibiotic duration was similar (median 7d, P = 0.61); H group received more empirical vancomycin (16% vs. 7%, P = 0.05) and fluoroquinolones as definitive therapy (13% vs. 8%, P = 0.05). 30d mortality was similar (13% vs. 8%, P = 0.21); however, H group had significantly prolonged LOS by 4d (median 9 days vs. 5 days, P < 0.01) and higher 30 days re-admission (41% vs. 18%, P < 0.01).ConclusionWithin a medically underserved population, homeless patients with gram-negative sepsis were younger and had more liver disease compared with patients with housing. As this group had increased utilization of healthcare resources including need for ICU-level care, prolonged LOS, and 30-day re-admission, additional targeted interventions to prevent and optimally treat Enterobacteriaceae infections in homeless patients may be needed.Disclosures All authors: No reported disclosures.

1149. Reducing Piperacillin/Tazobactam Use in Children with Acute Perforated Appendicitis

BackgroundChildren with perforated appendicitis have more frequent complications compared with nonperforated appendicitis. Existing data suggest broad-spectrum antibiotics are not superior to narrow-spectrum antibiotics for this condition. In an effort to safely decrease broad-spectrum antibiotic use at our hospital, we evaluated the impact of an antimicrobial stewardship program (ASP) intervention on the use of piperacillin/tazobactam (PT) and clinical outcomes in children with perforated appendicitis.MethodsSingle-center, retrospective cohort study of children ≤ 18 years with perforated appendicitis who underwent primary appendectomy. Children with primary nonoperative management or interval appendectomy were excluded. Prior to the intervention, children at our hospital routinely received PT for perforated appendicitis. An electronic health record (EHR)-integrated guideline that recommended ceftriaxone and metronidazole for perforated appendicitis was released on July 1, 2017 (Figure 1). We compared PT utilization, measured in days of therapy (DOT) per 1,000 patient-days, and clinical outcomes before and after the intervention.ResultsA total of 74 children with perforated appendicitis were identified: 23 during the pre-intervention period (June 1, 2016 to June 30, 2017) and 51 post-intervention (July 1, 2017 to September 30, 2018). Thirty-three patients (45%) were female and the median age was 8 years (IQR: 5–11.75 years). Post-intervention rate of guideline compliance was 84%. PT use decreased from 556 DOT per 1000 patient-days to 131 DOT per 1000 patient-days; incidence rate ratio of 0.24 (95% CI: 0.16–0.35), post-intervention vs. pre-intervention. There was no statistically significant difference in duration of intravenous antibiotics, total antibiotic duration, postoperative length of stay (LOS), total LOS, ED visits/readmission, or surgical site infection (SSI) between pre- and post-intervention periods (Table 1).ConclusionAn EHR-integrated ASP intervention targeting children with perforated appendicitis resulted in decreased broad-spectrum antibiotic use with no statistically significant difference in clinical outcomes. Larger, multicenter trials are needed to confirm our findings. Disclosures All authors: No reported disclosures.

1427. Treatment of Children with Acute Hematogenous Osteomyelitis and Staphylococcus aureus Bacteremia: Impact of Severity of Illness on Antimicrobial Therapy

BackgroundThere is limited evidence-based guidance for the treatment of children with acute hematogenous osteomyelitis (AHO) and concurrent Staphylococcus aureus bacteremia (SAB). Current guidelines emphasize the need for parenteral antibiotics in the setting of SAB, but optimal duration of parenteral therapy in this setting remains unclear. We examined the utility of a Severity of Illness (SOI) score to provide guidance for antimicrobial use in this setting.MethodsWe retrospectively studied children with AHO from 2009–2017, employing a clinical practice algorithm and previously validated SOI to assess the incidence and treatment implications of SAB in AHO. Data collected included demographics, antimicrobial therapy, and response to treatment. Cohorts were categorized according to SOI as follows: mild (0–3); moderate (4–7); and severe (8–10), and compared utilizing one-way ANOVA and Kruskal–Wallis tests for continuous variables, and chi-square test for categorical data.ResultsAmong 466 children diagnosed with AHO, 274 (58.5%) were culture positive for Staphylococcus aureus, with SAB noted in 209 (44.8%) individuals. Among children with SAB, 72, 81, and 56 children had SOI scores classified as mild, moderate, and severe, respectively. There were 41 of 72 (57.7%) children with mild illness who were managed with clindamycin alone, clindamycin followed by β-lactam, or β-lactam alone, compared with 36 of 81 (44.4%) with moderate illness, and 3 of 56 (5.4%) with severe illness. Median parenteral antibiotic durations per SOI cohort were 4.7 days, 10.4 days, and 24.7 days, respectively. Greater SOI was associated with longer hospitalization, prolonged bacteremia, more surgeries, increased vancomycin use, greater number of antibiotic combinations, and longer total duration of antibiotics.ConclusionTreatment of AHO with SAB should be tailored to the severity of illness in the affected child. A “one size fits all” approach may expose children to unnecessarily prolonged parenteral antibiotic courses, as well as suboptimal and potentially toxic regimens. Our study demonstrates the utility of an SOI to help guide antibiotic decisions in the setting of AHO with SAB. Additional studies are needed to further delineate optimal parenteral antibiotic durations in AHO with SAB. Disclosures All authors: No reported disclosures.

474. Battling Addiction: Impact of Intravenous Drug Use on Invasive Skin and Soft Tissue Management

BackgroundAlthough skin and soft-tissue infections (SSTIs) remain a common cause of hospitalization for intravenous drug users (IVDU), little has been done to identify whether there should be differences in the SSTI management of IVDU vs. nonusers. The objective of this study was to evaluate the impact of documented intravenous drug abuse on the overall management of invasive SSTIs in hospitalized patients.MethodsThis retrospective cohort study randomly selected 100 IVDU and 100 nonusers (controls) hospitalized for an SSTI over 18 months in a community teaching hospital. Patients eligible for inclusion were 18–60 years old and treated with IV inpatient antibiotics for at least 48 hours. Pregnant women, transfers from an outside hospital, and diabetic foot infections were excluded. The primary endpoint was hospital length of stay (LOS). Secondary endpoints included: percentage prescribed empiric combination antibiotic therapy, percentage prescribed an anti-pseudomonal agent, inpatient and total antibiotic duration of therapy (DOT), 30-day readmission rates, and 30-day emergency department (ED) visit rates.ResultsThe study population was predominantly male (66%), Caucasian (72%), and had a mean age of 40 years old (18–59). IVDU were more likely to have complications (18% vs. 6%) and polymicrobial infections (19% vs. 2%), Mean hospital length of stay was 9.0 days for IVDU compared with 4.8 days for controls (P < 0.001). There was no difference in empiric combination therapy (48% vs. 37%; P = 0.115) or empiric exposure to an anti-pseudomonal agent (38% vs. 30%; P = 0.232). Mean duration of inpatient antibiotic DOT was longer in IVDU (7.5 days vs. 4.3 days; P < 0.001), but total antibiotic DOT was similar between groups (16.0 days vs. 13.8 days; P = 0.141). Thirty-day ED visits were higher for IVDU (16% vs. 5%; P = 0.009); however, there was no difference in 30-day readmission (14% vs. 16%; P = 0.692).ConclusionDocumented IV drug abuse resulted in a significant increase in the length of stay in hospitalized adults with SSTIs requiring IV antibiotics. Exposure to combination therapy and anti-pseudomonal agents did not differ between the groups as would be expected. In the future stewardship initiatives are needed to increase adherence to SSTI guideline recommendations for empiric therapy.Disclosures All authors: No reported disclosures.

Exposure to placental insufficiency alters postnatal growth trajectory in extremely low birth weight infants.

Growth in the immediate postnatal period for extremely low birth weight (ELBW, birth weight < 1000 g) infants is an important topic in neonatal medicine. The goal is to ensure adequate postnatal growth and to minimize complications resulting from suboptimal growth. Past efforts have focused on postnatal nutrition as well as on minimizing comorbidities. It has not been systematically assessed whether antenatal factors play a role in postnatal growth. In this report, we conducted a retrospective study on 91 maternal-neonatal pairs. We prospectively collected maternal and neonatal demographic data, neonatal nutrition in the first 7 days of life and after enteral nutrition is fully established, comorbidity data, as well as weight data from birth to 50 weeks corrected gestational age. We developed a linear mixed-effects model to examine the role of placental insufficiency, as defined by fetal Doppler studies, in postnatal weight z-score trajectory over time in the ELBW population. We relied on Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) for model selection. Interestingly, the selected model included a quadratic term of time and a placental insufficiency-by-time interaction term. In a covariate analysis, AIC and BIC both favored a model that included calories intake in the first 7 days of life and the total duration of antibiotics as fixed-effects, but not their interaction terms with time. Overall, we demonstrated for the first time that placental insufficiency, an antenatal factor, is a major determinant of postnatal weight trajectory in the ELBW population. Prospective studies are warranted to confirm our findings.

Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis

BackgroundVariation exists for postoperative antibiotics in children with complicated appendicitis. We investigated the impact of white blood count (WBC) at discharge on oral antibiotic therapy, abscess rate, and readmission rate. Material/MethodsWe conducted a two year review of children with complicated appendicitis. In the pre-protocol group, total antibiotic therapy was ten days (IV and oral) and home oral antibiotics at discharge. In the post-protocol group, children with leukocytosis were prescribed oral antibiotics to complete seven days of total antibiotic therapy and children without leukocytosis were not prescribed oral home antibiotics. ResultsThere was no difference between mean hospital days after operation (3.52 vs. 3.24, p = 0.5111), means days of inpatient intravenous antibiotics (3.13 vs. 2.58, p = 0.5438), post-operative abscess rates (20.7% vs. 19.6%, p = 0.9975), or readmission rate (13.4% vs. 12.4%, p = 1.000).The post-protocol group had a shorter average total antibiotic duration (4.24 vs. 9.52 days, p < 0.001) and were more likely to be discharged without oral antibiotics (71.1% vs 8.5%, p < 0.001). DiscussionLimiting home antibiotics at discharge to children with leukocytosis significantly decreases home antibiotic use.

Oral fosfomycin versus ciprofloxacin in women with E.coli febrile urinary tract infection, a double-blind placebo-controlled randomized controlled non-inferiority trial (FORECAST)

BackgroundFebrile Urinary Tract Infection (FUTI) is frequently treated initially with intravenous antibiotics, followed by oral antibiotics guided by clinical response and bacterial susceptibility patterns. Due to increasing infection rates with multiresistant Enterobacteriaceae, antibiotic options for stepdown treatment decline and patients more frequently require continued intravenous antibiotic treatment for FUTI. Fosfomycin is an antibiotic with high bactericidal activity against Escherichia coli and current resistance rates are low in most countries. Oral Fosfomycin-Trometamol 3000 mg (FT) reaches appropriate antibiotic concentrations in urine and blood and is considered safe. As such, it is a potential alternative for stepdown treatment.MethodsThe FORECAST study (Fosfomycin Randomized controlled trial for E.coli urinary tract infections as Alternative Stepdown Treatment) is a randomized, double-blind, double-dummy, non-inferiority trial in which 240 patients will be randomly allocated to a stepdown treatment with FT or ciprofloxacin (standard of care) for FUTI, caused by Escherichia coli with in vitro susceptibility to both antibiotics. The study population consists of consenting female patients (≥18 years) with community acquired E. coli FUTI. After intravenous antibiotic treatment during at least 48 (but less than 120) hours, and if eligibility criteria for iv-oral switch are met, patients receive either FT (3 g every 24 h) or ciprofloxacin (500 mg every 12 h) for a total antibiotic duration of 10 days. The primary endpoint is clinical cure (resolution of symptoms) 6–10 days post-treatment. Secondary endpoints are microbiological cure 6–10 days post-treatment, clinical cure, mortality, ICU admittance, relapse, reinfection, readmission, additional antibiotic use for UTI, early study discontinuation, adverse events, days of hospitalization and days of absenteeism within 30–35 days post-treatment. The sample size is based on achieving non-inferiority on the primary endpoint, applying a non-inferiority margin of 10%, a two-sided p-value of < 0.05 and a power of 80%.DiscussionThe study aims to demonstrate non-inferiority of oral fosfomycin, compared to oral ciprofloxacin, in the stepdown treatment of E. coli FUTI.Trial registrationRegistered at the Nederlands trial register (Dutch trial register) on 4-10-2017. Trial registration number: NTR6449. Secondary ID (national authority): NL60186.041.17.

Impact of Penicillin Allergy on Time to First Dose of Antimicrobial Therapy and Clinical Outcomes

PurposeThe objective of this study was to evaluate the impact of a listed penicillin allergy on the time to first dose of antibiotic in a Veterans Affairs hospital. Additional clinical outcomes of patients with penicillin allergies were compared with those of patients without a penicillin allergy. MethodsA retrospective chart review of veterans admitted through the emergency department with a diagnosis of pneumonia, urinary tract infection, bacteremia, and sepsis from January 2006 to December 2015 was conducted. The primary outcome was time to first dose of antibiotic treatment, defined as the time from when the patient presented to the emergency department to the medication administration time. Secondary outcomes included total antibiotic therapy duration and treatment outcomes, including mortality, length of stay, and 30-day readmission rate. FindingsA total of 403 patients were included in the final analysis; 57 patients (14.1%) had a listed penicillin allergy. The average age of the population was 75 years and 99% of the population was male. The mean time to first dose of antibiotic treatment for patients with a penicillin allergy was prolonged compared with those without a penicillin allergy (236.1 vs 186.6 minutes; P = 0.03), resulting in an approximately 50-minute delay. Penicillin-allergic patients were more likely to receive a carbapenem or fluoroquinolone antibiotic (P < 0.0001). ImplicationsPatients with a penicillin allergy had a prolonged time to first dose of antibiotic therapy. No significant differences were found in total antibiotic duration, length of stay, or 30-day readmission rate. The small sample size, older population, and single-center nature of this study may limit the generalizability of the present findings to other populations.

Acute dental infections managed in an outpatient parenteral antibiotic program setting: prospective analysis and public health implications

BackgroundThe number of Acute Dental Infections (ADI) presenting for emergency department (ED) care are steadily increasing. Outpatient Parenteral Antibiotic Therapy (OPAT) programs are increasingly utilized as an alternative cost-effective approach to the management of serious infectious diseases but their role in the management of severe ADI is not established. This study aims to address this knowledge gap through evaluation of ADI referrals to a regional OPAT program in a large Canadian center.MethodsAll adult ED and OPAT program ADI referrals from four acute care adult hospitals in Calgary, Alberta, were quantified using ICD diagnosis codes in a regional reporting system. Citywide OPAT program referrals were prospectively enrolled over a five-month period from February to June 2014. Participants completed a questionnaire and OPAT medical records were reviewed upon completion of care.ResultsOf 704 adults presenting to acute care facilities with dental infections during the study period 343 (49%) were referred to OPAT for ADI treatment and 110 were included in the study. Participant mean age was 44 years, 55% were women, and a majority of participants had dental insurance (65%), had seen a dentist in the past six months (65%) and reported prior dental infections (77%), 36% reporting the current ADI as a recurrence. Median length of parenteral antibiotic therapy was 3 days, average total course of antibiotics was 15-days, with a cumulative 1326 antibiotic days over the study period. There was no difference in total duration of antibiotics between broad and narrow spectrum regimes. Conservative cost estimate of OPAT care was $120,096, a cost savings of $597,434 (83%) compared with hospitalization.ConclusionsADI represent a common preventable cause of recurrent morbidity. Although OPAT programs may offer short-term cost savings compared with hospitalization, risks associated with extended antibiotic exposures and delayed definitive dental management must also be gauged.

Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients.

BackgroundSkin and soft tissue infections (SSTIs) are a leading cause for hospitalizations in the United States. Few studies have addressed the appropriateness of antibiotic therapy in the management of SSTIs without complicating factors. We aimed to determine the appropriateness of antibiotic treatment duration for hospitalized adult patients with uncomplicated SSTIs.MethodsThis was a retrospective analysis performed at two academic medical centers in Pittsburgh, Pennsylvania on patients aged 18 years and older with primary ICD-9 code for SSTIs admitted August 1st, 2014–March 31st, 2015. The primary outcome was the appropriateness of antibiotic treatment duration for uncomplicated SSTIs. Secondary objectives included the appropriateness of antibiotic agent spectrum, duration of inpatient length of stay (LOS), utilization of blood cultures and advanced imaging modalities, and re-hospitalization for SSTI within 30 days of discharge from the index admission.ResultsA total of 163 episodes were included in the cohort. The mean duration of total antibiotic therapy was 12.6 days. Appropriate duration was defined as receipt of total antibiotic duration of less than 10 days and occurred in 20.2% of patients. Twenty eight percent of patients received antibiotics for greater than 14 days. Seventy three (44.8%) patients received greater than 24 h of inappropriate extended spectrum gram-negative coverage; 65 (39.9%) received anaerobic coverage.ConclusionsIn the majority of patients, treatment duration was excessive. Inappropriate broad spectrum antibiotic selection was utilized with regularity for SSTIs without complicating factors. The management of uncomplicated SSTIs represents a significant opportunity for antimicrobial stewardship.

The Use of C-reactive Protein as a Guide for Transitioning to Oral Antibiotics in Pediatric Osteoarticular Infections.

In the treatment of pediatric osteoarticular infections, early transition to oral antibiotics is desirable to shorten hospital stays and complications of prolonged intravenous therapy. C-reactive protein (CRP) is an acute phase reactant with a short half-life and is utilized at our institution to monitor progress and determine the transition to oral antibiotics. We hypothesized that patients can be safely transitioned from parenteral antibiotics to oral antibiotics when patients improve clinically and CRP halves over a period of 4 days. A retrospective review was conducted of all pediatric patients between the ages of 1 month and 18 years admitted and treated for acute bacterial osteomyelitis and/or septic arthritis at the authors' institution. We recorded all relevant data, inpatient progress, and outpatient follow-up. Thirty-seven patients fulfilled the selection criteria and were reviewed for this study. Patients were an average of 8.37±4.91 years old. Surgery was performed in 33 patients (89.2%). The average duration of intravenous antibiotics was 11.00±5.61 days and the average duration of oral antibiotics was 28.76±8.69 days, with an average total duration of antibiotics of 39.16±9.08 days. The average peak CRP was 156.91±97.81 mg/L and the average CRP at discharge was 24.94±22.36 mg/L. Thirty-four patients (91.89%) experienced a 50% decline in CRP over 4 days. Of these patients, only 1 (2.94%) went on develop complications in the follow-up period. The average hospitalization period was 11.50±6.55 days. The average duration of follow-up was 7.83±6.56 months. We found that the combination of clinical improvement and a specific reduction of 50% in CRP levels over 4 days, or 5 CRP half lives, could be used to determine when to transition children with osteoarticular infections from parenteral to oral therapy. Complicated outcomes were associated with negative cultures, longer hospitalizations, and persistently elevated CRP levels.

De-Escalation of Antibiotics Does Not Increase Mortality in Critically Ill Surgical Patients.

Overuse of broad-spectrum antibiotics results in microbial resistance and financially is a healthcare burden. Antibiotic de-escalation refers to starting treatment of a presumed infection with broad-spectrum antibiotics and narrowing drug spectrum based on culture sensitivities. A study was designed to evaluate antibiotic de-escalation at a tertiary care center. We hypothesized that antibiotic de-escalation would not be associated with increased patient mortality rates or worsening of the primary infection. All infections treated in a single, tertiary care Surgical ICU between August 2009 and December 2011 were reviewed. Antibiotic treatment was classified by skilled reviewers as being either de-escalated or not. Outcomes were evaluated. Univariate statistics were performed (Fisher exact test, Chi-square for categorical data; student t-test for continuous variables). Multivariable logistic regression was completed. A total of 2,658 infections were identified. De-escalation was identified for 995 infections and non-deescalation occurred in 1,663. Patients were similar in age (de-escalated 55 ± 16 y vs. 56 ± 16, p = 0.1) and gender (de-escalated 60% males vs. 58%, p = 0.4). There were substantially greater APACHE II scores in non-deescalated patients (15 ± 8 vs. 14 ± 8, p = 0.03). A greater mortality rate among patients with infections treated without de-escalation was observed compared with those treated with de-escalation (9% vs. 6%, p = 0.002). Total antibiotic duration was substantially longer in the de-escalated group (15 ± 13 d vs. 13 ± 13, p = 0.0001). Multivariable analysis found that de-escalation decreased mortality rates (OR = 0.69; 95%CI, 0.49-0.97; p = 0.04) and high APACHE II score independently increased mortality rates (OR = 1.2; 95%CI, 1.1-1.2; p = 0.0001). Other parameters included were age and infection site. Antibiotic de-escalation was not associated with increased mortality rates, but the duration of antibiotic use was longer in this group. Greater mortality rates were observed in the non-deescalated group, but this likely owes at least in part to their relatively greater severity of disease classification (APACHE II). Further investigation will help evaluate whether antibiotic de-escalation will improve the quality of patient care.

Antibiotic utilization based on primary treatment of pediatric empyema

BackgroundChemical fibrinolysis has been shown to be as effective as surgical debridement for the treatment of pediatric empyema. However, no studies effectively evaluate antibiotic treatment. We evaluated antibiotic utilization among different treatments of pediatric empyema. MethodsThis is a retrospective review of 169 empyema patients who underwent chemical and/or mechanical fibrinolysis at a dedicated children's hospital from 2005–2013. Data points included duration of therapy, cultures, presence of necrosis or abscess, and adverse drug reactions. Immunocompromised patients and those with additional foci of infection were excluded. ResultsTwenty-seven patients underwent video-assisted thoracoscopic surgery (VATS), 123 had chemical fibrinolysis via tube thoracostomy with tissue plasminogen activator (tPA), and 19 had tPA followed by VATS. The mean (±standard deviation) duration of total antibiotic therapy was 25.7 ± 6.5 d; following a 24 h afebrile period of 19.4 ± 6.3 d. Patients who had tPA had a significantly shorter duration of parenteral antibiotic therapy when compared with primary VATS (9.2 ± 3.6 d versus 11.6 ± 5.5 d, P = 0.04) and VATS following tPA (9.2 ± 3.6 d versus 14.3 ± 8.1 d, P < 0.01). Patients with necrosis or abscess (n = 26) had an increased total duration of antibiotics (29.3 ± 5.7 d versus 25.1 ± 6.4 d, P < 0.01). Seventy patients (41%) had an adverse reaction related to antibiotic use. ConclusionsPatients with empyema currently receive a protracted variable course of antibiotic therapy influenced by primary treatment and the presence of necrosis or abscess. With a high incidence of adverse reactions, a standardized protocol with truncated treatment duration should be considered.

Empyema thoracis in children: A short term outcome study

This study prospectively evaluates clinical course of pyogenic empyema thoracis in 25 children (2 mo to 12 y) treated with injectable antibiotics and chest tube drainage, and followed for 6 weeks. The median (range) age at presentation was 3 y (4 mo to 11 y). The pleural fluid culture was positive in 24% of patients. Staphylococcus aureus was the most commonly isolated organism. The median (range) duration of injectable antibiotics was 14(14-52) d; median duration of total antibiotics (injectable and oral) was 4 weeks. The median (range) duration of chest tube insertion and hospital stay was 8(5-45) and 14(14-56) days, respectively. All patients were discharged without any surgical intervention besides chest tube drainage. At discharge, pleural thickening was present in 84% and crowding of ribs was seen in 60% of the subjects on radiological examination. All these patients were asymptomatic at discharge. Chest deformity was present in 20% of the patients at 6-weeks follow up. Antibiotics and chest tube drainage is an effective method of treating pyogenic empyema thoracis in children in resource-poor settings.

Horner’s Syndrome in a Child With Otitis Media: An Unusual Complication

Figure 1. Fat-saturated, contrast-enhanced T1 magnetic resonance image of the base of the skull. Avid contrast enhancement of the left petrous apex (arrow) is consistent with apicitis, along with thickening and enhancement of the left petrous internal carotid artery wall (black arrow). A pulsation artifact is present. A 7-year-old, previously healthy girl presented to her family physician with a 1-day history of rhinorrhea and mucoid discharge from the left ear. She was diagnosed with otitis externa and received topical antibiotics. The child was brought to the emergency department of our hospital on day 3 of her illness with a unilateral earache and discharge from the ear. Her temperature at presentation was 37.9 C. She was subsequently afebrile, and her blood pressure was normal. Examination of her ears presented evidence of inflammation of the left eardrum. No postauricular redness or swelling, no mastoid tenderness, and no protrusion of the ear were evident. She manifested ptosis of the left eye and a constricted left pupil. The drooping of her left eye had been observed by her parents on day 2 of her illness, 1 day before presentation at the hospital. Neurologic (including the cranial nerves) and general physical examinations were otherwise unremarkable. She was diagnosed with partial left Horner’s syndrome, secondary to acute otitis media. An otorrhea culture was positive for Streptococcus pyogenes (group A streptococci). She received oral amoxicillin and clavulanic acid (Augmentin; GlaxoSmithKline, Middlesex, UK) for 2 weeks. No previous history of otitis media was reported. Neuroimaging was requested. The child underwent a magnetic resonance imaging scan, followed by a computed axial tomography scan, 2 weeks after her initial presentation. Imaging revealed enhancing soft tissue material within the opacified mastoid air cell complex, middle ear cleft, and petrous apex surrounding the carotid canal on the left side, suggestive of complicated otitis media with mastoiditis, petrous apicitis, and secondary carotid involvement (Figs 1 and 2). Clinically, the partial Horner’s syndrome was unchanged, and the otorrhea had subsided. In view of the neuroimaging results, she received intravenous antibiotics for 14 days, i.e., cefotaxime for 1 week, changed because of mild thrombophlebitis to cefepime and vancomycin for the second week. A further 4-week course of oral cephalexin was prescribed (total duration of antibiotics, 8 weeks, consisting of 2 weeks oral, 2 weeks intravenous, and 4 weeks oral). A repeated magnetic resonance imaging scan 6 weeks later demonstrated a reduction in inflammatory activity in the left petrous temporal bone and a resolution of the narrowing of her

A Clinical Analysis of Shoulder and Hip Joint Infections in Children

Septic arthritis of the shoulder is a rare infection in healthy children. This infection requires prompt surgical drainage and antibiotic treatment. A delay in surgical intervention can result in damage to the articular surface of the glenohumeral joint, adjacent osteomyelitis, and possible growth disturbance. The clinical course of septic arthritis of the shoulder was compared with that of septic arthritis of the hip, a more common disease in children. We identified 9 children with infections of the glenohumeral joint who presented to our pediatric hospital between 2001 and 2007. The average age at presentation was 7 years (range: 7 mo to 12 y). These patients were compared with 14 selected patients treated for septic arthritis of the hip (mean age 7 y, range: 1 to 12 y). Surgical drainage was performed by open arthrotomy in each case. A retrospective review and analysis of the medical records, laboratory tests, and radiographs of these patients were performed. Children with shoulder infections differed significantly (P<0.05) from patients with hip infections with regard to temperature, white blood cell count, and erythrocyte sedimentation rate at the time of admission. The average time from the onset of symptoms to presentation was notably longer in the shoulder group compared with the hip group (P=0.012). Adjacent osteomyelitis was found in 67% of the shoulders and 36% of the hips (P=0.214). Children suffering from septic arthritis of the shoulder showed higher rates of repeat surgical drainage (P=0.056) and extended hospitalizations (P=0.028). The total duration of antibiotics was longer in the shoulder group (P=0.059). Septic arthritis of the shoulder in the pediatric population often has a delayed presentation with a more complicated disease course than an infection of the hip. Children with shoulder infections require a longer duration of treatment and may experience a higher likelihood of skeletal complications. Level III, retrospective comparative study.