Use Of Empiric Antibiotic Therapy Research Articles

Ceftazidime-Cefazolin Empiric Therapy for Pediatric Gradenigo Syndrome.

Gradenigo Syndrome (GS), a rare complication of petrous apicitis secondary to acute otitis media, is characterized by (an often incomplete) triad of otorrhea, abducens nerve palsy, and facial pain along the trigeminal nerve distribution. There are several causative pathogens of petrous apicitis, including Streptococcus and Staphylococcus species, while Pseudomonas aeruginosa is the most common. However, the case report literature often describes antibiotic management of GS with antibiotics that do not cover Pseudomonas, potentially predisposing to further intracranial complications or mortality. The purpose of this work was to describe a case of pediatric Gradenigo Syndrome, successfully treated with sufficiently broad-spectrum antibiotics. This is case report. A previously healthy 5-year-old boy with a history of swimming presented with esotropia and acute otitis media. Initial symptoms included otorrhea, otalgia, and pruritis, which were refractory to ciprofloxacin-dexamethasone drops. He subsequently developed a right sixth nerve palsy, suggestive of Gradenigo Syndrome, and neuroimaging showed evidence of petrous apicitis, clival osteomyelitis, and internal carotid artery stenosis. The causative organism was not elucidated to laboratory error. Given this uncertainty, he was successfully treated with empiric intravenous ceftazidime and cefazolin. After 16 weeks, he recovered fully without the need for surgery. In the setting of delayed or absent culture results with suspicion of skull-base infection, our case supports the use of empiric antibiotic therapy with sufficient coverage of all common pathogens including Streptococcus/Staphylococcus and Pseudomonas aeruginosa species, the latter of which is often not adequately covered by antibiotic regimens described in the literature.

Bacterial profile and antimicrobial susceptibility patterns of common neonatal sepsis pathogens in Gulf Cooperation Council countries: A systematic review and meta-analysis.

Neonatal sepsis (NS) is a major healthcare burden in Gulf Cooperation Council (GCC) countries, with a prevalence higher than the global average. Microbial drug resistance has major implications for mortality and morbidity from NS. To synthesize data regarding the patterns of causative bacteria of NS in the GCC and their antimicrobial susceptibility profiles. Following the exploration of four electronic databases, i.e., EBSCOhost, ProQuest, PubMed/MEDLINE, and ScienceDirect, eligible studies were identified (i.e., published between 2013 and 2023 and reported bacterial profile and/or antimicrobial susceptibility patterns). The outcomes included the pooled prevalence of bacteria and their susceptibility patterns. Proportion meta-analysis was performed for each outcome of interest. Fifteen studies were eligible (total positive cases = 2,473). Coagulase-negative Staphylococci (CoNS) (28.1%) were the most common gram-positive causative pathogen, followed by group B Streptococcus (GBS) (16.2%) and Staphylococcus aureus (9.9%); for gram-negative, Escherichia coli (12.7%) and Klebsiella species (11.4%) were most common. The susceptibility rates of these bacteria to first-line antibiotics were high; gram-positive bacteria had the highest susceptibility to ampicillin (72.8-98%), and gram-negative bacteria was most susceptible to amikacin (94.6-98%). Additionally, both gram-positive (67-77%) and negative (87-93%) bacteria exhibited high susceptibility to gentamicin. The most common pathogens among NS patients were gram-positive. The pathogens, irrespective of stain test, were susceptible to the current antibiotic therapy. We recommend the judicious use of empirical antibiotic therapy to prevent the growing risk of antimicrobial resistance.

Antibiotic susceptibility pattern among children admitted to a hospital in Nigeria: A retrospective study.

The impact of antimicrobial resistance on children living in resource-limited countries has been underreported, despite its established global threat. This retrospective study aimed to describe the trend of antibiotic susceptibility in the paediatric age group. Sensitivity test report data consisting of 300 paediatric patients aged 18 hours to 192 months were retrieved from the microbiology laboratory records at a state-owned children's hospital in Nigeria over a period of 4 months starting from December 2021 to March 2022. Five genera (Escherichia coli, Klebsiella spp., Pseudomonas spp., Staphylococcus aureus and Streptococcus spp.) were cultured as recommended by the Clinical Laboratory Standard Institute, using the Kirby Bauer disc diffusion method. Antimicrobial susceptibility testing was carried out on isolates using 15 different antibiotics. Staphylococcus aureus was the most frequent pathogen isolated 32.1% (50/156) and Pseudomonas spp. was the least frequent pathogen isolated 7.1% (11/156) in all samples. The isolates with the highest rate of resistance to the tested antibiotics were S. aureus 32.1% (50/156), E. coli 28.2% (44/156) and Klebsiella spp. 20.5% (32/156). Isolates in all age groups were more resistant to ampicillin, amoxicillin + clavulanic acid, cefuroxime and cefepime. Antibiotic resistance is high, especially the younger Nigerian children. Strict antibiotic protocols should be adhered to especially in the use of empirical antibiotic therapy in hospitals. Our study reveals a higher trend of antibiotic resistance, especially in younger children. It further shows that the pathogens are most resistant to the most available empirical antibiotics in Nigeria.

ANTIBIOTIC THERAPY IN POST-EXTRACT PATIENTS

Abstract Introduction With the increase in complications associated with the implantation of pacemakers and defibrillators, the number of patients who undergo transvenous extraction of leads following infection has increased. Often, in pacemaker-dependent patients there is the problem of having to carry out an early reimplantation after extraction. This study aims to evaluate the incidence of reinfection in post-extracted patients treated with antibiotic therapy and reimplanted with a second device. Methodology To demonstrate the reduction in infection recurrences, a follow-up was carried out on all patients extracted in our center, differentiating between patients reimplanted with a second device who underwent targeted antibiotic therapy before and after surgery and patients reimplanted without targeted pre-extraction antibiotic coverage due to the failure to identify a specific germ. Results 184 device extraction procedures performed due to infection in our center were considered. In 100 patients the need arose to reimplant a second device at the same time as the extraction procedure. Among these patients, 33, in whom the germ of the infection was known, were treated with pre- and post-procedure antibiotic therapy, while in 24 patients no pre-extraction antibiotic therapy was carried out as they did not have a targeted antibiotic and in waiting for a positive blood culture. 4 patients, however, were treated with empirical therapy, which was then updated post-extraction following the results of the analysis of the extracted material. Subsequently, a follow-up was carried out to evaluate any recurrence of infections and it emerged that: a recurrence of infection occurred in 6% of patients treated with targeted antibiotics pre- and post-extraction and in 4% of patients treated with antibiotics only post-extraction -extraction. Among the 4 patients treated with empiric antibiotic therapy, 1 had a recurrent infection. Conclusions From this study it was possible to demonstrate that targeted antibiotic therapy also made it possible to limit infections in the short and long term even in patients who, not having positive blood cultures before the extraction procedure, underwent the therapy only following the results obtained by the extracted material, without the use of empirical antibiotic therapy.

Fear of missing organisms (FOMO): Diabetic foot and osteomyelitis management opportunities

Background: Hospitalizations for diabetic foot infections and lower-extremity osteomyelitis are common. Use of empiric antibiotic therapy for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa is also common. Guidelines recommend antibiotic therapy based on severity of illness, risk factors for MRSA and P. aeruginosa, and local prevalence. We evaluated the concordance between empiric antibiotic therapy and both culture results and definitive antibiotic therapy with a focus on MRSA and P. aeruginosa. We also evaluated how well MRSA and pseudomonal risk factors were predictive of culture results with these organisms. Methods: We conducted a cohort study of all patients admitted to our hospital system in 2021 with a diagnosis of a diabetic foot infection or lower-extremity osteomyelitis. Patients were included if they had an International Classification of Disease, Tenth Revision (ICD-10) diagnosis code of M86, E10.621, E11.621, or E08.621. Patients were excluded if antibiotics were for another indication or if they were aged <18 years. In patients with multiple hospitalizations only the first hospitalization was included. Empiric antibiotic therapy included antibiotics started by the admitting team. Definitive antibiotic therapy included the final antibiotic course either completed during admission or prescribed at the time of discharge. MRSA risk factors included prior positive culture with MRSA within the last year, hospitalization with IV antibiotics within 90 days, intravenous drug use, or hemodialysis. Pseudomonal risk factors included prior positive culture with P. aeruginosa within the last year or hospitalization with IV antibiotics within 90 days. Results: In 2021, 260 unique patients were admitted with suspected diabetic foot infections or lower-extremity osteomyelitis. 68 patients had >1 admission. Empiric anti-MRSA and antipseudomonal therapy was administered to 224 (86%) and 214 (82%) patients, respectively. Definitive anti-MRSA and antipseudomonal therapy was administered to 76 (30%) and 51 (20%) patients, respectively. Of the 195 patients who had wound cultures, 29 (15%) and 18 (9%) had positive cultures for MRSA and P. aeruginosa respectively (Fig.). The negative predictive value of MRSA risk factors for predicting a negative culture with MRSA was 91%. The negative predictive value of pseudomonal risk factors for predicting a negative culture with P. aeruginosa was 95%. Conclusions: Our data suggest an opportunity for substantial reductions in empiric anti-MRSA and antipseudomonal therapy for diabetic foot infection and lower-extremity osteomyelitis. The absence of MRSA and pseudomonal risk factors was reasonably good at predicting the absence of a positive culture with these organisms.Disclosure: None

Pharmacist-Led Antimicrobial Stewardship and Antibiotic Use in Hospitalized Patients With COVID-19.

During the COVID-19 pandemic, a significant increase in the use of empiric antibiotic therapy has been observed especially in patients hospitalized with COVID-19. Improving antibiotic prescribing is one of the main goals of the antimicrobial stewardship program (ASP). The ASP pharmacists have a scope of practice that authorizes changes in anti-infective therapy. We aimed to describe antibiotic prescribing in patients hospitalized with COVID-19 at Veterans Affairs Southern Nevada Healthcare System with a pharmacist-led ASP and to determine the prevalence of bacterial coinfection in this patient population. We performed a retrospective chart review of patients admitted to the facility from November 1, 2020, to January 31, 2021. A total of 199 patients were admitted to the hospital for laboratory-confirmed COVID-19 infection during the study period and 61 patients (31%) received ≥ 1 antibiotic on hospital admission and 138 (69%) did not receive antibiotics. Forty-seven patients (77%) had antibiotics discontinued by the ASP team within 72 hours of admission. Of the 199 admitted, 6 (3%) had microbiologically confirmed bacterial coinfection. Pseudomonas aeruginosa was the most common organism (3 sputum cultures) followed by Klebsiella oxytoca (2 sputum cultures). Sixteen patients (8%) developed a nosocomial infection during their hospital stay. Up to 31% of patients hospitalized for COVID-19 infection received empiric antibiotic treatment for concern of bacterial coinfection. Pharmacist-led ASP led to early discontinuation of antibiotics in many patients. A thorough clinical workup to determine the risk of bacterial coinfection in patients with COVID-19 is important before starting empiric antibiotic therapy. It is essential to continue promoting the ASP during the COVID-19 pandemic to ensure responsible antibiotic use and prevent antimicrobial resistance.

Antimicrobial Resistance Rates and Risk Factors for Extended-Spectrum Beta-Lactamase-Producing Escherichia coli-Associated Urinary Tract Infections in Older Outpatients in East Anatolia from 2011 - 2019

Background: Community-acquired urinary tract infection is among the most common infections in older adults. Regardless of age, the most frequently detected causative microorganism is Escherichia coli. In parallel with the increase in antibiotic use, the frequency of community-acquired extended-spectrum beta-lactamase-producing E. coli (ESBL-E. coli) has reached critical levels. The use of empirical antibiotic therapy is determined by assessing patient-based risk factors. Therefore, knowing the risk factors and the frequency of antimicrobial resistance can guide the treatment to shape the treatment. Objectives: This study aimed to determine the risks and resistance frequencies to guide the empirical treatment selection for ESBL-E. coli-associated urinary tract infection (UTI) in elderly patients. Methods: This study is a retrospective cohort study. It was carried out between 2011 - 2019. Escherichia coli growth of ≥ 105 colony-forming units (cfu)/mL in urine culture was included in 815 patients aged 65 and over who applied to outpatient clinics. Results: Two hundred and sixty (31.9%) of the patients had ESBL-E. coli. In ESBL-E. coli, antimicrobial resistance rates were highest (100%) for penicillins + β-lactamase inhibitors. The lowest resistance rates were determined for carbapenems, aminoglycosides, phosphonic acid, and nitrofurantoins. Risk factors for ESBL-producing bacteria were determined. These were the presence of benign prostatic hypertrophy, antibiotic use in the last three months, history of UTI in the last year, urinary catheter uses in the last year, male gender, and hospitalization in the last year (P < 0.05). The only independent risk factor was a history of UTI in the last year, which increased the risk of ESBL by 2.8 times. Conclusions: Carbapenems can be chosen as parenteral options, and phosphonic acids and nitrofurantoin as oral options for empirical antibiotic treatment, especially in patients with a history of UTI in the past year.

Performance of the early-onset-sepsis calculator in Israeli newborns

Riskin et al report a 2-year single-center prospective surveillance of performance of the early-onset-sepsis (EOS) calculator in Israeli infants born at 34 weeks' gestational age with one or more peripartum risk factors for EOS. The impact of use of the calculator in Israel compared with use in the US where it was invented and validated is of special interest because currently there is no recommendation for screening or intrapartum antibiotic prophylaxis (IAP) for group B Streptococcus (GBS) in Israel. The EOS calculator performed in Israeli infants with peripartum risk factor(s) similarly to its performance in this cohort of US infants and was associated with the expected decrease in laboratory testing and use of empiric antibiotics. However, during this surveillance period, GBS was the most common cause of EOS at this Israeli center, where GBS cases primarily were in infants without peripartum risk factors and who were asymptomatic at birth (which also was the case in the US prior to universal screening and IAP). It should be noted that approximately one-half of GBS EOS in the US currently occur in infants whose mothers' screening during pregnancy was negative. The bottom line is that although sepsis calculators appropriately applied can provide a level of confidence that permits providers to forego laboratory testing and excessive use of empiric antibiotic therapy, the critical element of optimal care of the neonate throughout the first day of life is repeated, templated clinical examinations with protocols in place for rapid response should abnormalities arise. Article page 71 ▸ Evaluation of Implementation of Early-Onset Sepsis Calculator in Newborns in IsraelThe Journal of PediatricsVol. 234PreviewTo evaluate the recommendations based on the early-onset sepsis (EOS) calculator in the first 2 years of its implementation in Israel. Full-Text PDF

Reducing the use of empiric antibiotic therapy in COVID-19 on hospital admission

BackgroundEmpiric antibiotics for community acquired bacterial pneumonia (CABP) are often prescribed to patients with COVID-19, despite a low reported incidence of co-infections. Stewardship interventions targeted at facilitating appropriate antibiotic prescribing for CABP among COVID-19 patients are needed. We developed a guideline for antibiotic initiation and discontinuation for CABP in COVID-19 patients. The purpose of this study was to assess the impact of this intervention on the duration of empiric CABP antibiotic therapy among patients with COVID-19.MethodsThis was a single-center, retrospective, quasi-experimental study of adult patients admitted between 3/1/2020 to 4/25/2020 with COVID-19 pneumonia, who were initiated on empiric CABP antibiotics. Patients were excluded if they were initiated on antibiotics > 48 h following admission or if another source of infection was identified. The primary outcome was the duration of antibiotic therapy (DOT) prior to the guideline (March 1 to March27, 2020) and after guideline implementation (March 28 to April 25, 2020). We also evaluated the clinical outcomes (mortality, readmissions, length of stay) among those initiated on empiric CABP antibiotics.ResultsA total of 506 patients with COVID-19 were evaluated, 102 pre-intervention and 404 post-intervention. Prior to the intervention, 74.5% (n = 76) of patients with COVID-19 received empiric antibiotics compared to only 42% of patients post-intervention (n = 170), p < 0.001. The median DOT in the post-intervention group was 1.3 days shorter (p < 0.001) than the pre-intervention group, and antibiotics directed at atypical bacteria DOT was reduced by 2.8 days (p < 0.001). More patients in the post-intervention group were initiated on antibiotics based on criteria consistent with our guideline (68% versus 87%, p = 0.001). There were no differences between groups in terms of clinical outcomes.ConclusionFollowing the implementation of a guideline outlining recommendations for initiating and discontinuing antibiotics for CABP among COVID-19 inpatients, we observed a reduction in antibiotic prescribing and DOT. The guideline also resulted in a significant increase in the rate of guideline-congruent empiric antibiotic initiation.

A Comparative Analysis of Antibiotic Usage in Diabetic Foot Infections Against Healing Time

The study aimed to analyze bacterial flora in diabetic foot infection, empiric and targeted antibiotic therapy, and factors influencing wound healing duration. The study we undertook a review analysis of data in 118 cases of diabetic foot among 98 patients who reported to the Wound Care Clinic in Warsaw, Poland between 01/2014 and 12/2018. Collected data included sociodemographic data, wounds information, used treatment, results of the microbiological examination, and empiric and targeted antibiotic therapy. For purposes of identifying the empirical and targeted antibiotic compatibility, the patients were divided into subgroups: ETA+ (compatibility of empiric-targeted antibiotic), ETA- (non-compatibility of empiric-targeted antibiotic), NEA (no empiric antibiotic), and NTA (no targeted antibiotic). The study group consisted of men, N = 71 (72.4%) and women, N = 27 (27.6%). Twenty patients (20.4%) were diagnosed as obese according to the body mass index classification. Staphylococcus aureus and Enterococcus faecalis were identified in most cases [N = 53 (24.4%), and N = 41 (18.9%), respectively]. Sixteen patients (13.6%) received gentamycin locally. Amoxicillin with clavulanic acid, clindamycin, and levofloxacin were the most frequently used antibiotics as empiric therapy; meanwhile, in targeted therapy, amoxicillin with clavulanic acid and levofloxacin were most frequently used. Empiric and targeted antibiotic therapies were compatible in 65 (55.1%) cases. The duration of healing did not differ between selected subgroups, and was longer in obese patients (p = .001). Other variables did not influence the healing time. The use of empiric antibiotic therapy before targeted therapy and the topical use of gentamycin did not reduce the healing time of diabetic foot infection. The healing time of diabetic foot infection was longer in obese patients than in nonobese patients.

Antibiotic stewardship for early-onset sepsis

Antibiotics are administered to the vast majority of preterm newborns and to a substantial proportion of term infants in the hours after birth due to risk for early-onset sepsis. The approaches taken to determine which newborns should be evaluated for early-onset sepsis, and what type and duration of antibiotics are administered, are important elements of neonatal antibiotic stewardship. The use of multivariate prediction models for sepsis risk assessment among infants born ≥35 weeks' gestation can safely reduce the use of empiric antibiotic therapy. Approaches incorporating serial physical examination may also contribute to decreasing empiric antibiotic exposure among such infants. Among infants born <35 weeks' gestation, delivery characteristics can be used to identify preterm infants at low enough risk of early infection that empiric therapies are not required. Data informing the epidemiology, microbiology and antibiotic susceptibility patterns of early-onset sepsis pathogens can be used to optimize antibiotic choice for empiric and targeted antibiotic therapy to ensure that effective therapies are administered, while decreasing the risks associated with broad-spectrum antibiotic exposure. Optimal use of blood culture and time to positivity data can also contribute to decreasing the risks associated with prolonged antibiotic administration in the face of sterile cultures.

1516. Early-Onset Neonatal Sepsis Due to Haemophilus influenzae

Background Haemophilus influenzae causes serious invasive disease across all ages, but has not been widely described in neonatal early-onset sepsis (EOS). EOS, likely caused by organisms acquired from the mother, can lead to significant morbidity and mortality, particularly for preterm infants. There are reports of increasing ampicillin resistance in H. influenzae. We describe a case series of EOS due to H. influenzae at our institution.MethodsNeonatal H. influenzae EOS was identified based on positive sterile site cultures at <72 hours of life in infants hospitalized at an Intermountain Healthcare (IHC) facility from 2007–2017. Demographics, clinical and microbiologic data were obtained through an IRB-approved electronic chart and microbiology review.ResultsTwelve neonates with H. influenzae EOS were identified over 11 years. Nine were preterm (<37 weeks); five were extremely preterm (<28 weeks). Eight had low birth weight (<2,500 g); five had very low birth weight (<1,500 g). Most (66%) mothers were primigravida; median maternal age was 24.5 years. Only four (33%) mothers had prolonged rupture of membranes (>24 hours). All infants had signs and symptoms of sepsis within 24 hours of birth. The majority (10/12) had a blood culture positive for H. influenzae from the time of delivery. Two infants had negative delivery blood cultures but a H. influenzae-positive placental culture. No infant had > 1 day of bacteremia. One H. influenzae isolate was serotype b, one serotype c and one non-typeable, but most isolates (9/12) were not serotyped. Only one isolate produced a β-lactamase. All infants were empirically started on ampicillin and gentamicin at delivery. Nine infants underwent lumbar puncture, two were suggestive of meningitis but cultures were negative. Five infants developed interventricular hemorrhage and six required vasoactive medications. No infant died.Conclusion H. influenzae is an infrequent but important cause of neonatal EOS. H. influenzae EOS occurred in infants with known risk factors, including prolonged rupture of membranes, prematurity, and low birth weight. Recognition of H. influenzae as a potential pathogen in EOS has implications for the use of empiric antibiotic therapy particularly ampicillin, in septic neonates.Disclosures All authors: No reported disclosures.

Optimizing use of empirical antibiotics in late preterm neonates at risk of early-onset sepsis

Background: In sick neonates, we are posed to treat suspected or proven infection. However, the vast majority of newborn babies who are given antibiotics do not have any infection. Objective: The objective of this study was to optimize the use of empirical antibiotic therapy in late preterms who are asymptomatic with maternal risk and symptomatic neonates without maternal risk for early-onset sepsis (EOS) and to estimate the rate of risk increase in onset of symptoms in neonates exposed to maternal risk factor for EOS. Methods: In this descriptive study, late preterm neonates (34+0–36+6 weeks) who are asymptomatic at birth with and without maternal risk factor for EOS at birth were subjected to clinical assessment of sensorium, temperature, oxygenation status, perfusion, and skin color, starting after 1 h of initial stabilization till discharge from hospital. Sepsis screen (C-reactive protein and absolute neutrophil count) was obtained at 24 h and 48 h of age from these asymptomatic late preterms. Results: A total of 135 late preterm neonates (34+0–36+6 weeks) recruited during the study period were included for analysis. The presence of maternal risk factor for EOS has shown no statistical significance in relation to the presence of symptoms at birth odds ratio 0.66, 95% confident interval (0.24–1.8) p=0.42. Conclusion: In our study, as maternal risk factor for sepsis has shown no statistical significance in relation to the presence of symptoms at birth, antibiotic use can be restricted to only those babies who have clinical worsening over 24–48 h of observation and/or along with supportive evidence of positive sepsis screen and/or blood culture, irrespective of the presence or absence of maternal risk for EOS.

Prescription of Antibiotics for Adults with Acute Infectious Diarrhea in Korea: A Population-based Study.

BackgroundAcute infectious diarrhea (AID) is a commonly observed condition globally. Several studies recommend against the use of empiric antibiotic therapy for AID, except in some cases of travelers' diarrhea. However, many physicians prescribe antimicrobial agents for AID. We aimed to determine the rate of antibiotic use and the associated prescription patterns among adults with AID.Materials and MethodsThis population-based, retrospective epidemiological study was performed using Korean National Health Insurance claims data from 2016 to 2017. The study population comprised adults (age ≥18 years) who had visited clinics with AID-related complaints. Exclusion criteria were the presence of Crohn's disease, ulcerative colitis, irritable bowel syndrome, and other non-infectious forms of colitis. Patients who underwent surgery during admission were also excluded.ResultsThe study population comprised 1,613,057 adult patients with AID (767,606 [47.6%] men). Young patients (age 18 – 39 years) accounted for 870,239 (54.0%) of the study population. Overall, 752,536 (46.7%) cases received antibiotic prescriptions. The rate of antibiotic administration tended to be higher among elderly patients (age ≥65 years) than among younger patients (49.5% vs. 46.4%, P <0.001). The antibiotics most frequently prescribed in both monotherapy and combination regimens were fluoroquinolones (29.8%), rifaximin (26.8%), second-generation cephalosporins (9.2%), third-generation cephalosporins (7.3%), trimethoprim/sulfamethoxazole (5.5%), and β-lactam/β-lactamase inhibitors (5.3%). Patients who visited tertiary care hospitals had lower rates of antibiotic therapy (n = 14,131, 41.8%) than did those visiting private clinics (n = 532,951, 47.1%). In total, 56,275 (62.3%) admitted patients received antibiotic therapy, whereas outpatients had lower rates of antibiotic prescription (n = 694,204, 46.0%).ConclusionThis study revealed differences between the antibiotics used to treat AID in Korea and those recommended by the guidelines for AID treatment. Multifaceted efforts are necessary to strengthen physicians' adherence to published guidelines.

329. Impact of the Biofire® Film Array (FA) Meningitis Encephalitis (ME) Panel in Colombia

BackgroundCentral nervous system (CNS) infections are associated with significant adverse clinical outcomes. Approximately 50% of all CNS infections are idiopathic. The impact of the Biofire® FAME in Colombia is unknown.MethodsA retrospective study of all adults with CNS infections in one tertiary hospital in Colombia. The cohort was divided into two time periods: before and after the implementation of the Biofire® FAME panel in May 2016. Etiologies, management decisions, and outcomes were compared between both groups. Data analysis was done with Stata® version 14.ResultsA total of 76 patients were enrolled. The majority of the patients (72.4%) were male with a median age of 40.9 years. The most common comorbidity was Human immunodeficiency virus (HIV) infection (47.4%); 54% were admitted to the intensive care unit (ICU) and 29% died. Out of the 76 patients, 33 and 43 were enrolled in the pre- and post-Biofire FAME testing periods, respectively. A diagnosis was made more commonly in the post-Biofire time period (13/33;39% vs. 27/43;63%, P < 0.05). The etiologies in the pre-Biofire group were Cryptococcus neoformans (6); bacterial meningitis (5) and tuberculosis (1) and varicella zoster (1); and the etiologies in the post-Biofire group were Cryptococcus neoformans (7), cytomegalovirus (CMV) (4); bacterial meningitis (4), tuberculosis (3), syphilis (3), ADEM (3), CNS vasculitis (1), and neurocysticercosis (1). The Biofire FAME panel was positive in 14 patients: C. neoformans (6), CMV (3), S. pneumoniae (2), Herpes simplex virus type 2 (2), H. influenzae (1) and N. meningitidis (1). In 12 out of those 14 patient (85%), a change in therapy occurred due to the FAME results (5 started therapy, four stopped therapy and threehad a change in therapy). Furthermore, patients in the post-Biofire FAME period had a reduction in the empirical use of vancomycin, meropenem and cefepime (P < 0.05). The Biofire FAME panel missed identifying one patient with Cryptococcus neoformans and one with CMV.ConclusionThe introduction of the Biofire FAME panel in a hospital with high HIV prevalence in Colombia has increased the yield of pathogens identified and have reduced the use of empirical antibiotic therapy. The Biofire FAME failed to identify one case of Cryptococcus neoformans and one due to CMV.Disclosures R. Hasbun, Biofire: Speaker’s Bureau, Speaker honorariumBiomeriaux: Consultant, Consulting fee.

The Overuse of Empiric Antibiotic Treatment for Enterocolitis Diagnosed by Abdominal CT (OVERACCT)

Introduction: The current ACG guidelines for the management of acute diarrhea discourage the use of empiric antibiotic therapy, unless justified by the clinical presentation, including duration of symptoms, recent traveling, fever or bloody diarrhea. Computed tomography (CT) is a widespread and easily accessible imaging tool for the investigation of abdominal symptoms. However, the incidental finding of nonspecific bowel wall thickening, often results in a radiological diagnosis of enterocolitis, irrespective of the symptoms, with subsequent inappropriate use of antibiotic therapy. Methods: A retrospective, observational, IRB approved study was conducted at an inner-city hospital from July 2015 to July 2017. A total of 184 subjects who experienced gastrointestinal symptoms such as abdominal pain, nausea, vomiting, or diarrhea were identified by the enterocolitis ICD diagnosis code. Patients with comorbidities such as AIDS, cancer, or immunocompromised were excluded from the analysis. Of the remaining subjects, 121 underwent abdominal CT to rule out acute abdominal conditions. Chart review included medical history, recent travel, inflammatory markers and stool studies. Clinical outcomes comprised symptoms resolution, length of hospital stay and final GI diagnosis. Chi-square test was used for data analysis. Results: Among 184 patients identified, 116 (63%) were women with a mean age of 46 ± 26 years. The majority of patients (66%) presented with acute diarrhea, lasting less than 72 hours, without a history of recent travel. A radiological diagnosis of enterocolitis was reached with abdominal CT in 80 patients, of which 71% received antibiotic treatment. There was a significant correlation between positive CT findings and antibiotic use (p=0.005). Surprisingly, 61% of patient with the radiological findings received antibiotic treatment despite the absence of diarrhea (p=0.006). Antibiotic treatment did not impact the clinical outcomes (p=ns). Almost 65% of the patients required only supportive treatment based on ACG guidelines. Conclusion: Patients with CT findings suggestive of enterocolitis were more likely to receive antibiotic therapy, irrespective of the presence or absence of diarrhea. This study highlights the widespread antibiotic misuse for the treatment of enterocolitis based on imaging modalities without adequate clinical correlation. Unwarranted radiological testing and antibiotic therapy were identified in 65% of this cohort, while their clinical outcomes remained unchanged.167_A Figure 1 No Caption available.167_B Figure 2. χ2 Calculations. Two way contingency table.167_C Figure 3. χ2 Calculations. Two way contingency table.

Evaluation of Viral (HHV6, Adenovirus, HSV1, Enterovirus) and Bacterial Infection in Children with Febrile Convulsion by Serum PCR and Blood Culture Mofid Children’s Hospital , 2016 - 2017

Background: Febrile seizures (FS) are common in young children. Viral infections that result in high fever are frequent etiologic agents that lead to febrile seizures. Human Herpesvirus 6 (HHV6), Influenza virus, adenovirus, and enterovirus have been named as the most common viruses causing high fevers in young children. Although bacterial infections have rarely been found as causative agents, many children with febrile seizures are treated with empiric antibiotics. Objectives: To determine the epidemiology of the viral (HHV6, Adenovirus, HSV1, Enterovirus) and bacterial infection in children presenting with febrile seizures. Methods: In a descriptive study, data was collected from 93 children, 3 months to 5 years of age, hospitalized with febrile seizures between September 2016 and April 2017. Relevant information was documented on a previously designed questionnaire. Blood samples were collected for culture, Serum 16S rRNA for bacteria, and PCR assay for 4 viruses (HHV6, adenovirus, enterovirus and HSV), in addition to routine investigations. Results: Of the 93 patients, serum PCR results were negative for 73 patients (78.49%) and 15 (16.13%) were positive for viruses (11 for HHV6 and 4 for Adenovirus). Serum 16S rRNA for bacteria was detected in 5 cases and blood culture was positive in 4 cases. Conclusions: Findings of this study indicate a significant prevalence of viruses and a very low rate of bacterial infection in children with febrile seizures, thus, negating the use of empirical antibiotic therapy.

Multidrug resistant Proteus mirabilis and Escherichia coli causing fulminant necrotising fasciitis: a case report

BackgroundNecrotizing fasciitis is a rare soft tissue infection characterized by rapid progressive necrosis with relative sparing of underlying muscles. This case is reported to highlight the emergence of multidrug resistant microbes in recent days which limits the use of empiric antibiotic therapy and necessitates early cultures and sensitivity enabling targeted antibiotic therapy. Factors that lead to antimicrobial resistance especially in sub-Saharan Africa have also been discussed.Case presentationWe report the case of a 52-year-old black man who was referred to our centre for the management of cellulitis and suppurating ulcers of the right leg which had progressed to a wet gangrene. Following physical examination and work-up, a diagnosis of fulminant necrotizing fasciitis of the right leg caused by multidrug resistant Proteus mirabilis and Escherichia coli was made. Despite the broad-spectrum empiric antibiotic therapy and aggressive multiple surgical debridement, necrosis progressed leading to an above-knee amputation.ConclusionNecrotizing fasciitis is a surgical emergency that requires prompt diagnosis and aggressive surgical debridement in order to reduce morbidity and mortality. The emergence of multidrug resistant organisms in recent days have limited the use of empiric antibiotic therapy, necessitating early culture and sensitivity and the use of susceptibility-guided antibiotic therapy. Timely action to control the use of antibiotics in sub-Saharan Africa will reduce multidrug resistance and delay the arrival of post-antibiotics era.

Antibiotic resistance pattern in intensive care unit of a tertiary care teaching hospital

Background: Antimicrobials are a major class of drugs prescribed in Intensive Care Unit (ICU). Widespread use of empirical antibiotic therapy has facilitated the emergence of drug resistance, since empirical therapy is very often initiated at the outset, even before culture and sensitivity reports are available. The problem of drug resistance is on a rise, therefore, this study was planned to assess the drug resistance and sensitivity patterns of the blood isolates recovered from ICU.Methods: An observational- prospective study was conducted in the Tertiary care teaching hospital over a period of twelve months to assess antibiotic resistance and sensitivity pattern. A total of 104 consecutive patients receiving antibiotics in the ICU and having blood cultures with significant growth were included in the study. Blood sample was collected and after obtaining a culture growth, the identification and antimicrobial sensitivity testing was done.Results: Blood stream infection by Gram-negative bacteria (50.96%) was more common than Gram-positive bacteria (49.04%). Coagulase negative Staphylococci (CoNS) was the predominant single blood culture isolate (35.58%). Klebsiella pneumoniae (13.46%), Escherichia coli (12.50%), Acinetobacter baumannii complex (7.69%) were commonly isolated gram negative organisms. Gram positive isolates were resistant to beta lactams in maximum patients whereas Tigecycline, Linezolid, Daptomycin, Vancomycin, Nitrofurantoin and Teicoplanin were sensitive against them. Common gram negative isolates were sensitive to Colistin and Tigecycline but resistant to most of the antibiotics.Conclusions: A preponderance of gram negative bacteria over gram positive bacteria was noted with a higher degree of resistance to most of the first line antimicrobial agents.

MP23-08 LACK OF UNIFORMITY AMONG UNITED STATES GUIDELINES FOR DIAGNOSIS & MANAGEMENT OF ACUTE, UNCOMPLICATED CYSTITIS

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder II1 Apr 2018MP23-08 LACK OF UNIFORMITY AMONG UNITED STATES GUIDELINES FOR DIAGNOSIS & MANAGEMENT OF ACUTE, UNCOMPLICATED CYSTITIS Lauren N. Wood, Andrew R. Medendorp, Melissa Markowitz, Shlomo Raz, David A. Haake, and Ja-Hong Kim Lauren N. WoodLauren N. Wood More articles by this author , Andrew R. MedendorpAndrew R. Medendorp More articles by this author , Melissa MarkowitzMelissa Markowitz More articles by this author , Shlomo RazShlomo Raz More articles by this author , David A. HaakeDavid A. Haake More articles by this author , and Ja-Hong KimJa-Hong Kim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.740AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Acute, uncomplicated urinary tract infection (UTI) remains one of the most common bacterial infections seen in inpatient and outpatient clinical settings in the United States. Since uncomplicated UTI is treated in a variety of different settings, guidelines from professional medical societies are expected to be well aligned. Our aim was to compare guidelines for diagnosis and treatment of acute, uncomplicated UTI from medical specialties in the U.S. and confirm uniformity. METHODS The most up to date published guidelines within the fields of family medicine, obstetrics & gynecology, internal medicine, female pelvic medicine & reconstructive surgery, and infectious diseases in the U.S. were reviewed. RESULTS All guidelines recommended the use of symptoms and urine dipstick only to diagnose uncomplicated UTI. Some societies did not recommend urine dipstick in cases of recurrent UTI or for patients with classic UTI symptoms with no underlying conditions or competing diagnoses. None recommend the use of urine culture to confirm diagnosis. All guidelines endorsed nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as first-line agents. Discrepancies existed in the classification of fluoroquinolone and beta-lactam antimicrobials, with most guidelines describing them as second-line, while others considered them first or third-line agents. Amoxicillin and ampicillin, antibiotic agents with high resistance rates in the U.S., were described as important to avoid only by some U.S. guidelines. None mentioned the FDA black box warning for Cipro. (Table available for presentation). CONCLUSIONS Comparison of guidelines from various specialties revealed important differences in the approach to the treatment of acute, uncomplicated UTI. This lack of uniformity is likely to contribute to the varying clinical management of patients with UTI, emphasizing the need for more consistent guidelines that may improve physician adherence. With few exceptions, urine culture with sensitivity was not recommended for the diagnosis or treatment of UTI by any of the guidelines reviewed. However, the widespread use of empiric antibiotic therapy for UTI can contribute to growing antibacterial resistance pattern in the U.S. and impede efforts for antibiotic stewardship. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e284 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Lauren N. Wood More articles by this author Andrew R. Medendorp More articles by this author Melissa Markowitz More articles by this author Shlomo Raz More articles by this author David A. Haake More articles by this author Ja-Hong Kim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...