Clinical and Laboratory Findings of Nosocomial Sepsis in Extremely Low Birth Weight Infants According to Causative Organisms

Background: nosocomial sepsis remains a significant source of morbidity and mortality in extremely low birth weight (ELBW) infants. Early and accurate diagnosis is very important, but it is difficult due to the similarities in clinical manifestation between the causative microorganisms. We tried to identify the differences between causative microorganisms in clinical and laboratory findings and to help choose antibiotics, when sepsis was suspected in ELBW infants. Methods: a retrospective study was conducted on preterm infants, born at less than 28 weeks of gestation, with a birth weight of less than 1000 g between January 2009 and December 2019. Clinical and laboratory findings of suspected sepsis, after the first 72 h of life, were assessed. We classified them into four groups according to blood culture results (gram positive, gram negative, fungal, and negative culture groups) and compared them. Results: a total of 158 patients were included after using the exclusion criteria, with 45 (29%) in the gram positive group, 35 (22%) in the gram negative group, 27 (17%) in the fungal group, and 51 (32%) in the negative culture group. There were no significant differences in mean gestational age, birth weight, and neonatal morbidities, except for the age of onset, which was earlier in the fungal group than other groups. White blood cell (WBC) counts were the highest in the gram negative group and the lowest in the fungal group. The mean platelet counts were the lowest in the fungal group. C-reactive protein (CRP) levels were the highest in the gram negative group, while glucose was the highest in the fungal group. Conclusions: in conclusion, we showed that there are some differences in laboratory findings, according to causative microorganisms in the nosocomial sepsis of ELBW infants. Increased WBC and CRP were associated with gram negative infection, while decreased platelet and glucose level were associated with fungal infection. These data may be helpful for choosing empirical antibiotics when sepsis is suspected.

Nosocomial sepsis and drug susceptibility pattern among patients admitted to adult intensive care unit of Ayder Comprehensive Specialized Hospital, Northern Ethiopia

Objective Developing nosocomial sepsis within intensive care unit (ICU) is associated with increased mortality, morbidity, and length of hospital stay. But information is scarce regarding nosocomial sepsis in intensive care units of Northern Ethiopia. Hence, this study aims to determine the incidence of nosocomial sepsis, associated factors, bacteriological profile, drug susceptibility pattern, and outcome among patients admitted to the adult ICU of Ayder Comprehensive Specialized Hospital (ACSH), which is the largest tertiary hospital in Northern Ethiopia. Method Facility-based longitudinal study was conducted by following 278 patients who were admitted for more than 48 h to adult ICU of ACSH, from October 2016 to October 2017. Data were collected from charts, electronic medical records, and microbiology registration book using a checklist. The collected data were subjected to descriptive statistics and multivariable logistic regression using SPSS version 25. Statistical significance was declared at p < 0.05. Result Of all the patients, 60 (21.6%) of them acquired nosocomial sepsis. The risk of mortality was about two times higher among adult ICU patients who acquired nosocomial sepsis (RR = 2.2; 95% CI of RR = 1.3–3.5; p = 0.003). The odds of acquiring nosocomial sepsis among those who were on a mechanical ventilator (MV) and stayed more than a week were 5.7 and 9.3 times higher, respectively, than their corresponding counterparts. Among 48 isolates, Klebsiella was the most common pathogen. The isolates had a broad antibiotic resistance pattern for cephalosporins, penicillins, and methicillin. Conclusion The incidence of nosocomial sepsis in the adult ICU patients of ACSH was higher when compared to the incidence reported from some African and Asian countries. Mortality was higher among patients who acquired nosocomial sepsis. Use of MV and longer length of ICU stay were the significant predictors of nosocomial sepsis. The isolates were resistant to several antibiotics. Therefore, strict application of infection prevention strategies and appropriate use of antibiotics is so crucial. As well, priority should be given to patients who develop nosocomial sepsis in ICU.

#21: Risk Factors and Clinical Characteristics of Stenotrophomonas Maltophilia Infections in Neonates & Children from Day 1 to 21-Year Old Between the Years 2008 to 2020

Background Stenotrophomonas maltophilia is a ubiquitous organism associated with opportunistic infections. In the immunocompromised host, increasing prevalence and severity of illness is observed, particularly opportunistic bloodstream infections and pneumonia syndromes. S. maltophilia is intrinsically resistant to most currently available broad-spectrum antibiotics, including carbapenems and beta-lactams. This intrinsic resistance is due to the presence of chromosomally expressed beta-lactamases, L1 (a metallo-carbapenemase), and L2 (an extended-spectrum beta-lactamases), which together can hydrolyze nearly all betalactam antibiotics including carbapenems. In vitro activity is observed with tetracyclines and fluoroquinolones, but resistance can be rapidly induced mainly due to efflux pumps. Trimethoprim/sulfamethoxazole (TMP-SMX) generally is considered the treatment of choice for S. maltophilia infection, although consideration of S. maltophilia in treatment guidelines is sparse. Additionally, a recent study suggests that S. maltophilia susceptibility to TMP-SMX may be decreasing globally, due in part to acquired antibiotic resistance. Though historically identified as a cause of nosocomial infections, communityonset infections increasingly are being reported. From 1996 to 2016, S. maltophilia was commonly isolated from patients hospitalized with pneumonia and bloodstream infection (BSI), and the incidence of S. maltophilia infection is increasing Methods A retrospective analysis of characteristics and outcomes in patients with S. maltophilia–positive cultures were conducted using the Healthbridge EHR. Study Population This retrospective matched case control study was carried out in neonates with S. maltophilia infections at UHB DOWNSTATE MEDICAL CENTER NICU and Pediatric Department between 2008 and 2020. To identify the case patients, we reviewed the admission and medical records of patients and records from the Microbiology Department in the study period. Control patients were selected from the patients who admitted for at least 72 hours and had pneumonia and/or nosocomial sepsis caused by pathogens other than S. maltophilia. To determine the risk factors for S. maltophilia infections among 35 case patients were compared with 35 control patients. Medical charts of all infants with positive cultures for S. maltophilia and control cases were reviewed for birth weight; gestational age; delivery type; postnatal age at hospitalization; prolonged rupture of membranes; invasive procedures (mechanical ventilation, intubation, urinary catheter, umbilical catheter); duration of mechanical ventilation (day); exposure to antimicrobial agents (aminoglycosides, carbapenems, cephalosporins, penicillins); administration of total parenteral nutrition (TPN); duration of TPN; histamine 2 (H2) blockers; exposure to steroids; cholestasis; elevated liver enzymes; death; sepsis-related death; and duration of hospitalization. All the risk factors for infection were calculated before the onset of infection in both groups. Results in progress Conclusions:

Serial measurement of pancreatic stone protein for the early detection of sepsis in intensive care unit patients: a prospective multicentric study

Background The early recognition and management of sepsis improves outcomes. Biomarkers may help in identifying earlier sub-clinical signs of sepsis. We explored the potential of serial measurements of C-reactive protein (CRP), procalcitonin (PCT) and pancreatic stone protein (PSP) for the early recognition of sepsis in patients hospitalized in the intensive care unit (ICU). Methods This was a multicentric international prospective observational clinical study conducted in 14 ICUs in France, Switzerland, Italy, and the United Kingdom. Adult ICU patients at risk of nosocomial sepsis were included. A biomarker-blinded adjudication committee identified sepsis events and the days on which they began. The association of clinical sepsis diagnoses with the trajectories of PSP, CRP, and PCT in the 3 days preceding these diagnoses of sepsis were tested for markers of early sepsis detection. The performance of the biomarkers in sepsis diagnosis was assessed by receiver operating characteristic (ROC) analysis. Results Of the 243 patients included, 53 developed nosocomial sepsis after a median of 6 days (interquartile range, 3–8 days). Clinical sepsis diagnosis was associated with an increase in biomarkers value over the 3 days preceding this diagnosis [PSP (p = 0.003), PCT (p = 0.025) and CRP (p = 0.009)]. PSP started to increase 5 days before the clinical diagnosis of sepsis, PCT 3 and CRP 2 days, respectively. The area under the ROC curve at the time of clinical sepsis was similar for all markers (PSP, 0.75; CRP, 0.77; PCT, 0.75). Conclusions While the diagnostic accuracy of PSP, CRP and PCT for sepsis were similar in this cohort, serial PSP measurement demonstrated an increase of this marker the days preceding the onset of signs necessary to clinical diagnose sepsis. This observation justifies further evaluation of the potential clinical benefit of serial PSP measurement in the management of critically ill patients developing nosocomial sepsis. Trial registration The study has been registered at ClinicalTrials.gov (no. NCT03474809), on March 16, 2018. https://www.clinicaltrials.gov/ct2/show/NCT03474809?term=NCT03474809&draw=2&rank=1.

A “resistance calculator”: Simple stewardship intervention for refining empiric practices of antimicrobials in acute-care hospitals

Objective: In the era of widespread resistance, there are 2 time points at which most empiric prescription errors occur among hospitalized adults: (1) upon admission (UA) when treating patients at risk of multidrug-resistant organisms (MDROs) and (2) during hospitalization, when treating patients at risk of extensively drug-resistant organisms (XDROs). These errors adversely influence patient outcomes and the hospital’s ecology. Design and setting: Retrospective cohort study, Shamir Medical Center, Israel, 2016. Patients: Adult patients (aged >18 years) hospitalized with sepsis. Methods: Logistic regressions were used to develop predictive models for (1) MDRO UA and (2) nosocomial XDRO. Their performances on the derivation data sets, and on 7 other validation data sets, were assessed using the area under the receiver operating characteristic curve (ROC AUC). Results: In total, 4,114 patients were included: 2,472 patients with sepsis UA and 1,642 with nosocomial sepsis. The MDRO UA score included 10 parameters, and with a cutoff of ≥22 points, it had an ROC AUC of 0.85. The nosocomial XDRO score included 7 parameters, and with a cutoff of ≥36 points, it had an ROC AUC of 0.87. The range of ROC AUCs for the validation data sets was 0.7–0.88 for the MDRO UA score and was 0.66–0.75 for nosocomial XDRO score. We created a free web calculator (https://assafharofe.azurewebsites.net). Conclusions: A simple electronic calculator could aid with empiric prescription during an encounter with a septic patient. Future implementation studies are needed to evaluate its utility in improving patient outcomes and in reducing overall resistances.

Nosocomial sepsis and drug susceptibility pattern among patients admitted to adult intensive care unit of Ayder Comprehensive Specialized Hospital, Northern Ethiopia

Objective: Developing nosocomial sepsis within intensive care unit (ICU) is associated with increased mortality, morbidity, and length of hospital stay. But information is scarce regarding nosocomial sepsis in Northern Ethiopia. Hence, this study aims to determine the prevalence of nosocomial sepsis, associated factors, bacteriological profile, drug susceptibility pattern, and outcome among patients admitted to the adult intensive care unit of Ayder Comprehensive Specialized Hospital (ACSH).Method: Facility-based cross-sectional study was conducted by reviewing the medical records of 278 patients admitted for more than 48 hours to adult ICU of ACSH from October 2016 to October 2017. Data were collected from charts, electronic medical records, and microbiology laboratory data registration book using a checklist. The collected data were subjected to descriptive statistics and multivariable logistic regression using SPSS 25. Statistical significance was declared at p<0.05.Result: Of all the patients, 60(21.6%) of them acquired nosocomial sepsis. The risk of mortality was about two times higher among those who acquired nosocomial sepsis (RR=2.2; 95% CI of RR=1.3-3.5; p=0.003). The odds of acquiring nosocomial sepsis among those who were on a mechanical ventilator (MV) and stayed more than a week was 5.7 and 9.3 times higher respectively than their corresponding counterparts. Among 48 isolates, Klebsiella was the commonest. The isolated organisms had a broad antibiotic resistance pattern for cephalosporin, penicillin, and methicillin.Conclusion: Mortality due to nosocomial sepsis in adult ICU was higher. Use of MV and longer length of in-hospital stay were significant risk factors for nosocomial sepsis. The isolated organisms were resistant to several antibiotics. Therefore, strict application of infection prevention strategies and appropriate use of antibiotics is so crucial.

Serial Measurement of Pancreatic Stone Protein for the Early Detection of Sepsis in Intensive Care Unit Patients: A Prospective Multicentric Study

BackgroundThe early recognition and management of sepsis improves outcomes. Biomarkers may help in identifying earlier sub-clinical signs of sepsis. We explored the potential of serial measurements of C-reactive protein (CRP), procalcitonin (PCT) and pancreatic stone protein (PSP) for the early recognition of sepsis in patients hospitalized in the intensive care unit (ICU).MethodsThis was a multicentric international prospective observational clinical study conducted in 14 ICUs in France, Switzerland, Italy, and the United Kingdom. Adult ICU patients at risk of nosocomial sepsis were included. A biomarker-blinded adjudication committee identified sepsis events and the days on which they began. The associations of clinical sepsis diagnoses with the trajectories of PSP, CRP, and PCT in the 3 days preceding these diagnoses of sepsis were tested for markers of early sepsis detection. The performance of the biomarkers in sepsis diagnosis was assessed by receiver operating characteristic (ROC) analysis.ResultsOf the 243 patients included, 53 developed nosocomial sepsis after a median of 6 days (interquartile range, 3–8 days). The association of clinical sepsis diagnosis with an increase in a biomarker value in the 3 days preceding this diagnosis was stronger for PSP (p = 0.003) than for PCT (p = 0.025) and CRP (p = 0.009). The area under the ROC curve at the time of clinical sepsis was similar for all markers (PSP, 0.75; CRP, 0.77; PCT, 0.75).ConclusionsWhile the diagnostic accuracy for sepsis of PSP, CRP and PCT were similar in this cohort, serial PSP measurement demonstrated an increase of this marker the days preceding the onset of signs necessary for a clinical diagnosis the sepsis. This observation justifies further evaluation of the potential clinical benefit of serial PSP measurement in the management of critically ill patients developing nosocomial sepsis.Trial registrationThe study has been registered at ClinicalTrials.gov (no. NCT03474809), on March 16, 2018.https://www.clinicaltrials.gov/ct2/show/NCT03474809?term=NCT03474809&draw=2&rank=1

Disseminated Tuberculosis Presenting as Gastric Outlet Obstruction

A 12-year-old female had a three-year history of fever, non-bilious vomiting and abdominal pain. Upper gastrointestinal series showed a filling defect at the duodenum. Esophagogastroduodenoscopy exhibited circumferentialmass extending from the duodenal bulb to the 2nd part of the duodenum which on histology disclosed chronicgranulomatous inflammation. Chest X-ray suggested miliary tuberculosis; endotracheal tube aspirate was PCRpositive for Mycobacterium tuberculosis. Patient was diagnosed as disseminated tuberculosis of the duodenumand lungs. Quadruple anti-tuberculosis medication was started but patient succumbed to nosocomial sepsis.

94. Clinical Correlates of Cdc’s Hospital-onset Adult Sepsis Event Surveillance Definition and Association with Reportable Healthcare-associated Infections

Background Hospital-onset (HO) sepsis is associated with substantial mortality but is not tracked or reported by most hospitals. CDC’s Adult Sepsis Event (ASE) definition may facilitate standardized surveillance but little is known about the clinical correlates of HO-ASEs and their association with currently reportable healthcare-associated infections (HAIs). Methods In this retrospective study of all adult patients admitted to an academic medical center between June 2015–2018, we assessed the overlap between HO-ASEs and HAIs reported to the National Healthcare Safety Network (NHSN) and reviewed a random subset of 110 HO-ASE cases to determine their clinical correlates. Results The cohort included 168,249 hospitalized patients, including 2,139 (1.3%) with HO-ASE and 2,133 (1.3%) with NHSN HAIs. Amongst the 2,139 HO-ASE patients, 480 (22.4%) had ≥1 HAI: 8.1% VAE, 6.2% CLABSI, 6.1% C.difficile, 3.1% CAUTI, 1.3% MRSA bacteremia, and 0.8% SSI. HO-ASE was associated with higher in-hospital mortality rates than HAIs (28.6% vs 14.6%, p&lt; 0.001). HO-ASE associated mortality was high even when NHSN-reportable HAIs were absent (26.5%) whereas NHSN-reportable HAI mortality was relatively low when HO-ASE was absent (8.4%). Amongst the 110 reviewed HO-ASE cases, 102 (93%) were possible or confirmed infections, most commonly pneumonia (39%, of which 35% were ventilator-associated), non-C.difficile intra-abdominal infections (15%), febrile neutropenia (14%), urinary tract infection (7%, of which 88% were catheter-associated), and skin/soft tissue infection (7%). Most (86%) infections flagged by HO-ASEs were acquired in the hospital rather than the community. The most common non-infectious events flagged by HO-ASE were pulmonary edema and periprocedural blood loss associated with blood cultures and empiric antibiotics. Conclusion CDC’s hospital-onset ASE definition accurately identifies patients with nosocomial sepsis who have very high mortality rates and are generally not captured by currently reportable HAI metrics. Routine hospital-onset ASE surveillance could provide a broader window into serious nosocomial infections, identify new targets for prevention, and further improve outcomes for hospitalized patients. Disclosures All Authors: No reported disclosures

The Spanish National Network “Grupo Castrillo”: 22 Years of Nationwide Neonatal Infection Surveillance

Objective This study aimed to describe the epidemiology of vertically transmitted sepsis (VS) and nosocomial sepsis (NOS) in very low birth weight (VLBW) neonates (birth weight ≤ 1,500 g) over the past 22 years in Spain. Study Design This is a retrospective analysis of prospectively collected VS and NOS in neonates from 1996 to 2018 in the 44 neonatal units integrated in the Spanish Neonatal Network Grupo Castrillo. Results A total of 2,676 episodes of VS were recorded in 2,196,129 live births (LBs; 1.2/1,000 LBs) over the study period (1996–2018). The incidence declined from 2.4 to 1 to 1.2/1,000 LBs (p < 0.0001). Of the 2,676 episodes, 95.7% were early onset (≤72 hours) and 4.3% cases late onset VS. Group B streptococcus (GBS) (33.1%) and E. coli (29.3%) were the most frequently isolated pathogen. The GBS incidence declined significantly from 1.25 to 0.21/1,000 LBs (p < 0.0001). E. coli incidence showed a significant increase trend in VLBW infants (p < 0.05). The global mortality per 1000 LBs decreased from 0.21 to 0.13/1,000. A total of 7,036 episodes of NOS involving 5,493 VLBW infants were registered over 20,935 neonatal admissions (NAs) in the study period (2006–2018). The incidence was 26.2 per 100 NAs. The median postnatal age at onset was 13 days (interquartile range [IQR]: 9–23 days). Around 80% of cases occurred in infants with a central line in place. Gram positive (GP) bacteria accounted for 66.2% with Staphylococcus epidermidis as the most frequently isolated pathogen, gram negative (GN) bacteria entailed 27.4%, and fungi 6.2%. Klebsiella sp. was the most common GN isolated and Candida albicans the most prevalent fungus. The overall mortality was 8.3%. Conclusion The causative pathogen of neonatal sepsis may change over time and between countries, therefore a national surveillance network based on a consensus definition could be essential to provide accurate information. Key Points