scholarly journals Infected deep vein thrombophlebitis in people who inject drugs: missed opportunities and potential for alternative antimicrobial approaches

Infection ◽  
2021 ◽  
Author(s):  
Hugh McCaughan ◽  
Clark D. Russell ◽  
Dáire T. O’Shea
Keyword(s):  
People Who Inject Drugs ◽  
Empiric Therapy ◽  
Complex Nature ◽  
Pulmonary Emboli ◽  
Opioid Substitution Therapy ◽  
Missed Opportunities ◽  
Gram Negative ◽  
Treatment Plans ◽  
Deep Vein ◽  
Microbiologic Diagnosis

AbstractInfected deep vein thrombophlebitis (i-DVT) in people who inject drugs (PWID) is a clinically challenging but poorly characterised disease. We undertook a retrospective observational study of 70 PWID presenting acutely with i-DVT to improve the clinical and microbiological characterisation of this disease. i-DVT was frequently associated with bacteraemia (59.1% patients with blood cultures obtained), groin abscesses (in 34.3%; of which 54.2% required surgical drainage), and septic pulmonary emboli (38.6%) requiring anticoagulation. Network analysis identified a cluster of patients presenting with respiratory symptoms but lacking typical DVT symptoms, more likely to have septic pulmonary emboli. A microbiologic diagnosis was frequently achieved (70%). Causative pathogens were predominantly gram-positive (S. aureus and streptococci, especially anginosus group), whereas gram-negative pathogens were identified very infrequently (in 6.1% of microbiological diagnoses). This suggests routine empiric therapy against gram-negative bacteria, though commonly administered, is not required. High rates of clinical cure (88.6%) were observed despite the complex nature of infections and independently of the highly variable intravenous and total antimicrobial durations received. There exists a rationale to devise pragmatic approaches to implement novel individualised treatment plans utilising oral antimicrobial therapy for i-DVT. Despite frequent healthcare interactions, opportunities to address HCV treatment and opioid substitution therapy were frequently missed during these acute admissions.

#43: Monotherapy Experience in Pediatric Patients with High-risk Febrile Neutropenia

2021 ◽  
Vol 10 (Supplement_1) ◽  
pp. S19-S19
Author(s):  
Valentina Gutiérrez ◽  
Ximena Claverie
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Fungal Infections ◽  
Clinical Signs ◽  
Empiric Therapy ◽  
Fourth Generation ◽  
Gram Negative Bacteria ◽  
Gram Negative ◽  
Third Line ◽  
Clinical Worsening

Abstract Background Fever during neutropenia is a common occurrence in children with cancer. In a systematic review of RCTs of pediatric febrile neutropenia, compared monotherapy with aminoglycoside-containing combination therapy found no significant differences in failure rates, infection-related mortality, or overall mortality. The updated pediatric-specific guidelines recommend initiation of empirical antibiotic monotherapy using an antipseudomonal β-lactam, a fourth-generation cephalosporin, or a carbapenem for pediatric high-risk febrile neutropenia. However, local epidemiology and resistance patterns should be evaluated regularly. Our local hospital epidemiology does not have Pseudomonas aeruginosa isolates, therefore, we used ceftriaxone as monotherapy in patients with high-risk febrile neutropenia without other risk factors. The goal of our investigation is to describe the experience of using third-generation cephalosporins in these patients. Methods Descriptive study of high-risk febrile neutropenia episodes in patients admitted to the Pediatric Oncology Unit of Hospital Dr. Sótero del Río, Santiago, Chile. We included patients ≤15 years from June 2016 until November 2019. Results We found a total of 133 high-risk febrile neutropenia episodes corresponding to 50 patients, 78% were leukemia and 22% were solid tumor patients. Of the 133 episodes, 92 (69%) had clinical signs at admission, mostly respiratory in 46 (50%) of the cases, 18 (29%) had mucositis and 13 (14%) had diarrhea. Of 133 episodes, 41 (31%) did not have any source at clinical examination. Eighty-six (65%) cases started ceftriaxone at admission, 28 (33%) maintained ceftriaxone for 7 days of treatment with good clinical response. Of this group 58 (67%) patients changed treatment: 32 (37%) cases started second-line antibiotics for clinical worsening, 19 (22%) cases required second- and third-line antibiotics for persistent fever and clinical worsening, and 7 (8%) received third-line antibiotics from the start for past microbiological history. Sixteen (12%) cases of total evolved with sepsis requiring intensive care unit management. We had 30 (23%) episodes with positive blood culture, 11 (37%) due to gram-positive bacteria, 16 (53%) gram-negative bacteria, and 3 (10%) cases of fungal infections. Of the gram-negative bacteria, 7 (44%) were ESBL producers, without P. aeruginosa isolates. One case died (0.7%) for refractory sepsis due to gram-negative bacteria. Conclusion Although we did not have P. aeruginosa isolates, due to the spread of ESBL strains, monotherapy with ceftriaxone is not a good option as initial therapy for high-risk febrile neutropenia patients. The empiric therapy has to be evaluated regularly and should always be based on local epidemiology.

scholarly journals 890. Incidence and Microbiology of Surgical Site Infection (SSI) after Breast Surgery

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S479-S479
Author(s):  
Farah Tanveer ◽  
Dima Youssef ◽  
Mamta Youssef ◽  
Susanna Szpunar ◽  
Michelle Flood
Keyword(s):  
Surgical Site Infection ◽  
Breast Surgery ◽  
Tissue Expander ◽  
Empiric Therapy ◽  
Site Infection ◽  
Gram Positive ◽  
Historical Cohort ◽  
Gram Negative ◽  
Tissue Expanders ◽  
Student’S T

Abstract Background Surgical site infection (SSI) after breast surgery is much more common than expected after a clean surgical procedure. Although breast SSIs are primarily Gram-positive; recent literature shows an increase in Gram-negative infections. We assessed the risk factors and microbiology of SSI following breast surgery at our institution. Methods We conducted a historical cohort study of all (³ 18 y) females who had surgery from 1/1/2014-3/31/2019 and subsequent SSI within 90 days of the procedure. Two controls, matched for surgery type, were selected per case. Data were collected on demographic and clinical characteristics, surgery type, microbiology and antibiotics. Data were analyzed using the χ 2 test, Student’s t-test and multivariable logistic regression with a forward likelihood ratio algorithm. Results After excluding patients with limited data, we reviewed 284 charts: 95 of 132 cases and 189 controls. The 90-day incidence of SSI was 3.5 % (132/3755). Cases were younger than controls: 53.9 ± 12.4 years vs. 58.3± 13.7 years, respectively, p=0.02. Controls had more comorbidities: 1.8 ± 1.3 vs. 1.4 ± 0.7,respectively, p=0.001. Tissue expanders were placed in 65 (70%) cases versus 11 (5.8%) controls (p < 0.0001). After controlling for age, BMI, comorbidities and post-operative antibiotics, only tissue expanders were associated with infection (OR=35.1, p< 0.0001, 95% CI: 16.6, 74.0). Microbiological data were available for 84 cases. Gram-positive organisms accounted for 45 (53.6%) infections and Gram-negative organisms accounted for 39 (46.4%) infections. Over 72% of African Americans (p= 0.014), 76.5% of patients with diabetes (p=0.005) and 57.1 % with tissue expanders (p= 0.02) had Gram-negative infections. The table shows the multivariable predictors of Gram-negative infection. Tissue expander removal was required in 61.5% of patients with Gram-negative infections compared to 39% with Gram-positive infections. Predictors of Gram-negative SSI after breast surgery Conclusion Patients with tissue expanders had a higher incidence of SSI after breast surgery; removal was often required in Gram-negative infections. Diabetes and post-operative antibiotics were significant predictors of Gram-negative infection. Knowledge of local epidemiology is a key factor in deciding empiric therapy for SSI. Disclosures All Authors: No reported disclosures

scholarly journals Association between Cancer and Anatomical Site of Venous Thromboembolic Disease

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 6-6
Author(s):  
David A Froehling ◽  
Damon E. Houghton ◽  
Waldemar E. Wysokinski ◽  
Robert D. McBane ◽  
Danielle Vlazny ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Upper Extremity ◽  
Renal Vein ◽  
The Body ◽  
Published Data ◽  
Anatomical Site ◽  
Pulmonary Emboli ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
Active Cancer

Background:There is limited published data on the association between malignancy and the location of venous thromboembolism (VTE) in the body. Aims:Assess the location of VTE in the body in patients with active cancer and compare these results in patients without malignancy. Methods:Consecutive patients enrolled in the Mayo Clinic VTE Registry between March 1, 2013 and November 30, 2019 for acute VTE were followed prospectively. Anatomical site of thrombosis and malignancy status were recorded. Patient outcomes were assessed in person, by mailed questionnaire, or by a scripted phone interview. Active cancer was defined as treatment for malignancy within the last six months or not yet in remission. Results:During the study period there were 2,798 patients with acute VTE (1256 with and 1542 without active cancer). Pulmonary emboli were more common in patients with active cancer compared to patients without cancer (49.5% vs. 39.7%, p<0.001). Upper extremity deep vein thrombosis (11.4 % vs. 7.7%, p<0.001), renal vein thrombi (1.4% vs. 0.2%, p<0.001) and splanchnic vein thrombi (9.3% vs. 6.0%, p=0.001) were all more common in patients with active cancer compared to patients without cancer. Conclusion:Compared to those without malignancy, patients with active cancer were more likely to have pulmonary emboli, upper extremity deep vein thrombosis, renal vein thrombi, and splanchnic vein thrombi. Disclosures No relevant conflicts of interest to declare.

Incidence and predictors of Gram-negative bacilli in hospitalized people who inject drugs with injection drug use-attributable infections

2021 ◽  
Author(s):  
Megan C. Kelly ◽  
Samantha D. Yeager ◽  
Mahmoud A. Shorman ◽  
Laurence R. Wright ◽  
Michael P. Veve
Keyword(s):  
Drug Use ◽  
Injection Drug Use ◽  
People Who Inject Drugs ◽  
Bloodstream Infections ◽  
Antibiotic Use ◽  
Injection Drug ◽  
Gram Positive ◽  
Gram Negative ◽  
Multivariable Regression ◽  
Infection Types

Objective: Quantify incidence and determine predictors of Gram-negative bacilli (GNB) in people who inject drugs (PWID) with injection-drug use (IDU)-related infections. Design: Retrospective cohort of hospitalized PWID from 1/2017-12/2019. Methods: Inclusion criteria: age ≥18 years, active IDU, treated IDU-attributable infection, organism growth from microbiology cultures. Infection types: infective endocarditis (IE), acute bacterial skin/skin structure infection (ABSSSI), osteoarticular infection (OAI), other bloodstream infections (BSI). Primary outcome was GNB identification from microbiologic culture; descriptive statistics were used to describe the cohort. Multivariable regression was used to identify variables associated with GNB infection. Results: 230 PWID included; 65 (28%) GNB infections, 165 (72%) Gram-positive infections. The median (IQR) population age was 38 (31-45) years. Most patients were women (56%); 37% had no insurance. Infection types were: IE (41%), ABSSSI (37%), OAI (20%), other BSI (2%). 278 organisms were isolated from 230 patients; most common organisms were methicillin-resistant Staphylococcus aureus (43%), Streptococcus spp. (19%), methicillin-susceptible S. aureus (17%), Serratia marcescens (8%); 10% were mixed GNB and Gram-positive infections. 80% of patients received empiric Pseudomonas aeruginosa coverage; only 7% had P. aeruginosa infections. In multivariable regression, age >50 years (adjOR, 2.9; 95%CI; 1.2-7.2), prior hospitalization within 90-days (adjOR, 2.2; 95%CI; 1.2-4.3), and OAI (adjOR, 3.2; 95%CI; 1.5-6.6) were associated with GNB infection. Conclusions: GNB in PWID with IDU-attributed infections were more frequently observed in recently hospitalized, older patients with OAI. The majority of patients received empiric anti-pseudomonal antibiotic coverage, but P. aeruginosa was infrequent. PWID are a potential population to target improved empiric antibiotic use.

scholarly journals 2143. Attempting to Add Clarity to “Indeterminates” on a Deployed Rapid Diagnostic with Antimicrobial Stewardship Program (ASP) Intervention

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S726-S726
Author(s):  
Heather L Cox ◽  
April E Attai ◽  
Allison M Stilwell ◽  
Kasi B Vegesana ◽  
Frankie Brewster ◽  
...  
Keyword(s):  
Pasteurella Multocida ◽  
Diagnostic Testing ◽  
Bloodstream Infections ◽  
Empiric Therapy ◽  
Central Line ◽  
Blood Cultures ◽  
University Hospital ◽  
Salmonella Spp ◽  
Gram Negative ◽  
Stewardship Program

Abstract Background Rapid diagnostic testing paired with ASP intervention optimizes therapy and improves outcomes but few data guide ASP response in the absence of organism identification (ID). We describe the microbiology for organisms unidentified by Accelerate Pheno™ Gram-negative platform (AXDX) in order to inform ASP-provider team communication (PTC). Methods Consecutive, non-duplicate inpatient blood cultures with Gram-negative bacilli (GNB) following AXDX implementation at a single university hospital between April 2018 and March 2019 were included. Standard of care (SOC) ID and susceptibility followed AXDX. Clinical Microbiology emailed AXDX results to the ASP in real time; results were released into the EMR paired with telephone PTC or withheld after ASP review. Bloodstream Infections (BSIs) and patient outcomes for organisms labeled no/indeterminate ID by the AXDX were characterized. Results AXDX was performed on 351 blood cultures. Among 52 (15%) labeled no/indeterminate ID, SOC methods revealed: Enterobacteriaceae (40%; 9 monomicrobial with AXDX targets), anaerobes (21%), non-lactose fermenters (NLFs) other than Pseudomonas aeruginosa (21%), and fastidious GNB (10%). Frequent organisms without AXDX targets included: Raoultella planticola (4); Bacteroides fragilis, Cupriavidus spp., Haemophilus spp., Prevotella spp., Providencia spp., non-aeruginosa Pseudomonas spp., Salmonella spp. (3 each); Pasteurella multocida, Stenotrophomonas maltophilia (2 each). BSI sources were most commonly intra-abdominal (21%), central line-associated (17%), or unknown (17%). CLABSIs were associated with immune suppression and/or substance abuse in all but 1 case. BSIs without active empiric therapy included: NDM-producing Providencia stuartii SSSI; OXA-48-producing R. planticola intraabdominal infection (IAI); Pandoraea spp. CLABSI after liver transplant; enteric fever; B. fragilis, Leptotrichia wadei, and S. maltophilia, each of unknown source. In-hospital mortality occurred in 4 of these cases. Conclusion When AXDX yields no/indeterminate ID, ASP chart review for possible anaerobic/IAI, unique environmental exposures, and travel history may assist in guiding empiric therapy. GNB with AXDX targets are not excluded. Disclosures All authors: No reported disclosures.

Optimizing empiric therapy for Gram-negative bloodstream infections in children

2018 ◽  
Vol 99 (2) ◽  
pp. 145-147 ◽  
Author(s):  
Y. Chao ◽  
C. Reuter ◽  
L.K. Kociolek ◽  
R. Patel ◽  
X. Zheng ◽  
...  
Keyword(s):  
Bloodstream Infections ◽  
Empiric Therapy ◽  
Gram Negative

scholarly journals 2207. Narrowing Antibiotic Spectrum of Activity for Trauma-Associated Pneumonia Through the Use of a Disease-Specific Antibiogram

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S752-S752
Author(s):  
Michelle Ting ◽  
John Radosevich ◽  
Jordan Weinberg ◽  
Michael D Nailor
Keyword(s):  
Hospital Admission ◽  
Critically Ill ◽  
Drug Users ◽  
Illicit Drug ◽  
Retrospective Chart Review ◽  
Empiric Therapy ◽  
Empiric Antibiotic Therapy ◽  
Trauma Patients ◽  
Gram Negative ◽  
Culture Negative

Abstract Background Organism susceptibilities for trauma-associated pneumonia (TAP) differ from those in other groups of patients, including the critically ill. The purpose of this study was to identify common organisms and their susceptibilities in the respiratory isolates of trauma patients diagnosed with pneumonia within the first 7 days of hospital admission, and to create a disease-state antibiogram specific to TAP to guide empiric antibiotic therapy in this patient population. Methods This study was an IRB-approved, retrospective chart review of adult trauma patients with pneumonia admitted between September 1, 2015 and August 31, 2018 were evaluated. Patients included were diagnosed with and treated for pneumonia, with respiratory cultures drawn within the first 7 days of admission; both culture-positive and culture-negative patients were included. Subgroup antibiograms were made for a diagnosis made on days 1–3, 4–5, and 6–7. Results There were 131 patients included with a median age of 45; 85% were male, and 31% were illicit drug users. The majority of patients (63%) had ventilator-associated pneumonia, and most respiratory samples (77%) were obtained via bronchiolar lavage. Cultures were positive in 109 patients and negative in 22. There were 144 total isolates; 54% were Gram-negative bacteria. The most common Gram-negative pathogens were Haemophilus influenzae (16%) and Klebsiella pneumoniae (15%). The most common Gram-positive pathogen was Staphylococcus aureus; 9% of all patients grew methicillin-resistant S. aureus. With culture-negative patients counted as susceptible, ceftriaxone monotherapy and ceftriaxone + vancomycin susceptibility were 85% and 94% of patients, respectively. Susceptibilities to cefazolin, ampicillin/sulbactam, cefepime, piperacillin/tazobactam, and levofloxacin were 49%, 69%, 91%, 90%, and 92%, respectively. Illicit drug use and day of pneumonia diagnosis did not appreciably affect antibiotic susceptibilities. Conclusion For TAP diagnosed within the first 7 days of hospital admission, ceftriaxone monotherapy is adequate as empiric therapy, including in ventilated patients. The addition of vancomycin can be considered in patients with MRSA risk factors or who are critically ill. Disclosures All authors: No reported disclosures.

scholarly journals INCREASED RESISTANCE TO INFECTION AND ACCOMPANYING ALTERATION IN PROPERDIN LEVELS FOLLOWING ADMINISTRATION OF BACTERIAL LIPOPOLYSACCHARIDES

1956 ◽  
Vol 104 (3) ◽  
pp. 383-409 ◽  
Author(s):  
Maurice Landy ◽  
Louis Pillemer
Keyword(s):  
Defense Mechanisms ◽  
Bacterial Species ◽  
Complex Nature ◽  
Gram Negative ◽  
Resistance To Infection ◽  
Bacterial Lipopolysaccharides ◽  
Gram Negative Organisms ◽  
Incomplete Picture ◽  
Time Of Administration

It has been shown that injection of lipopolysaccharides, derived from a variety of Gram-negative bacterial species, evokes in mice a rapidly developing rise in resistance to infection with Gram-negative pathogens. This is accompanied by an elevation in properdin titer, at times to levels 2 to 3 times the normal. The rate, magnitude, and duration of these responses are dependent on many factors, the most important of which are the quantity and timing of the lipopolysaccharide administered. The increased resistance to infection evoked in mice by lipopolysaccharides was effective against infections produced by endotoxin-bearing organisms-bacterial species highly susceptible in vitro to the bactericidal action of the properdin system. Properdin titers of mice prior to infection provide an incomplete picture of the subsequent reaction of the host to the infective agent. Following infection with Gram-negative organisms, properdin levels accurately reflect the bacteriologic course and outcome of the infection. Thus, in control animals, properdin titers progressively declined and the animals died, while in mice appropriately treated with lipopolysaccharide, properdin levels were either maintained in the normal range or increased, depending on the dose and time of administration of lipopolysaccharide; this was always accompanied by successful management of the infection. The complex nature of the alterations produced in the host by lipopolysaccharides is stressed. It is pointed out that the increase in the ability of the host to cope with Gram-negative infections may be the result of stimulation of other defense mechanisms, in addition to the properdin system.

scholarly journals Does ‘heparin-induced thrombocytopenia’ hit our minds?

2016 ◽  
Vol 03 (03) ◽  
pp. 245-248
Author(s):  
Arun Thangavel ◽  
Shalvi Mahajan ◽  
Amarjyoti Hazarika
Keyword(s):  
Deep Vein Thrombosis ◽  
Side Effects ◽  
Pulmonary Emboli ◽  
Heparin Induced Thrombocytopenia ◽  
Vein Thrombosis ◽  
Prophylactic Dose ◽  
Patients At Risk ◽  
Newer Anticoagulants ◽  
Deep Vein ◽  
Heparin Prophylaxis

AbstractUnfractionated heparin is a widely used drug to prevent deep vein thrombosis and pulmonary emboli in patients at risk. With the advent of newer anticoagulants having lesser side effects, its use has diminished but not out of service. Here, we report a case of deep venous thrombosis, in a patient on prophylactic dose of heparin, which was later found to be a manifestation of heparin-induced thrombocytopenia (HIT). Thrombosis in the presence of heparin prophylaxis should be considered as HIT rather than a failure of anticoagulation.

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