1306. Early Transition to Oral Antibiotics, Including Fluoroquinolone Therapy, for Streptococcus milleri Empyema Following Video-Assisted Thoracoscopic Surgery

Background Pleural empyema from Streptococcus milleri (SM) is often complex and requires a combination of surgery and intravenous (IV) antibiotics. There is a paucity of data on the efficacy of oral (PO) treatment due to concerns about the development of resistance, particularly to fluoroquinolones (FQ). We report outcomes of postoperative antibiotic treatment for SM empyema over 3 years, including PO therapy. Methods A single-center retrospective chart review was performed of 20 patients treated with video-assisted thoracoscopic surgery (VATS) from October 2015 to March 2018 and SM diagnosed by thoracentesis or operative culture. We reviewed clinical factors, route and duration of antibiotics, complications (empyema recurrence, repeat surgery, 30-day readmission due to empyema), and mortality (30-day and 1-year) Results Of the 20 patients, 12 (60%) received all IV and 8 (40%) transitioned to PO therapy (Table 1). Median age was 60 and 58 in the IV and PO group, respectively. IV treated patients had more comorbidities. Cultures were primarily monomicrobial. Isolates tested were susceptible (S) to penicillin (Table 1), Of 10 tested specimen, all had moxifloxacin MIC < 0.19 μg/mL and 8/8 specimens tested were S to levofloxacin. The average duration of antibiotic therapy in the IV group was 34 days and 32 days in the PO group. There were no complications in the IV group: however, there were 2 deaths (1 patient died from comorbid complications and 1 patient was readmitted and died due to MSSA endocarditis). There were no complications or deaths in patients treated PO. Conclusion Our review suggests that early transition to PO antibiotics may be a viable option for operatively managed empyema caused by SM in certain patients. FQs have been generally avoided due to concerns about the rapid development of resistance that has been shown in-vitro; however, no in-vivo data have been reported regarding this concern. We show excellent outcomes with the use of PO therapy in susceptible isolates, particularly FQs, with no failure or reported resistance in patients with SM empyema treated with VATS. Further study is needed to validate these findings and determine optimal patient characteristics for transition to PO therapy. Disclosures All Authors: No reported disclosures

Sphenoid sinusitis: a rare cause of ischaemic stroke

We present the case of a 61-year-old woman who presented to the accident and emergency department with an ischaemic stroke, on a background of receiving intravenous and oral antibiotics to treat chronic left sphenoid sinusitis. Initially presenting with right-sided weakness and aphasia, a diagnosis of acute ischaemic stroke was made. Antibiotics had been commenced 1 month prior to the ischaemic stroke. Imaging at that time showed changes in keeping with chronic sphenoid sinusitis along with a small dehiscence in the lateral wall of the left sphenoid sinus and thrombosis of the left superior ophthalmic vein. During that admission blood cultures grew Streptococcus constellatus, a member of the Streptococcus milleri group. We discuss the unusual aetiology of this stroke, the emerging evidence associating chronic rhinosinusitis with stroke and the complex multidisciplinary approach required for management in this case.

1563. Variations in the clinical spectrum of the Streptococcus anginosus group: a report of two rare presentations

Background The Streptococcus Anginosus Group (SAG) formerly Streptococcus Milleri Group is a subgroup of viridans streptococci including S. anginosus, intermedius, and constellatus. SAG are microaerophilic digestive tract commensals. They are associated with empyema and deep organ abscesses. We present 2 unusual cases: necrotizing fasciitis and aortic valve endocarditis with aortic root abscess, resulting in septic emboli causing renal infarction. Methods Review of the literature and reported cases of SAG. Results Case1) 48 year-old-male with history of HTN, T2DM, presented with swelling and erythema of the right arm of 2-day evolution. Exam: tender, erythematous indurated right deltoid. Significant labs: WBC 25k/uL and lactate of 2.5. CT of the RUE showed an extensive fluid collection. Vancomycin, levofloxacin and clindamycin were initiated, surgical debridement revealed extensive necrotizing fasciitis Wound cultures grew S. constellatus. Required multiple debridement and prolonged course of penicillin G. Case 2) 53-year-old male with history of COPD, Prior Splenectomy for a large splenic infarct, heterozygous factor V Leiden mutation, HCV infection, cirrhosis, presented with right flank pain, hematuria over 5 days. Labs: WBC 16.8 k/uL, CT abdomen with contrast: right renal infarct. Heparin drip, Vancomycin and Ceftriaxone were initiated. Blood cultures grew S. anginosus. TEE revealed new aortic valve vegetations with severe aortic regurgitation. His condition deteriorated, requiring aortic valve surgery, found to have aortic root abscess requiring aortic root replacement. Necrotizing Fascitis - Soft Tissue Air Post-Surgical Debridement Right Renal Infarct Conclusion SAG infections infections are unique from other S viridans, causing severe deep organ abscesses requiring combined surgical and antibiotic therapy. Isolation in clinical specimens should alert the possibility of severe life threatening infections. Here we highlight 2 unusual manifestations of necrotizing fasciitis and aortic valve endocarditis with aortic root abscess and possible large septic renal embolism. One patient had a splenectomy. We are not sure if this contributed to a severe SAG infection Disclosures All Authors: No reported disclosures

CLINICO-EPIDEMIOLOGICAL PROFILE OF BRAIN ABSCESS- A SINGLE CENTER STUDY

INTRODUCTION: The overall incidence of bacterial brain abscess has remained relatively constant despite improved treatment of underlying systemic infections and development of more effective antibiotics. The systemic antibiotics are generally given for 6-8 weeks. The Choice of surgery varies from stereotactic aspiration /open surgical method including twist drill aspiration, burr hole aspiration with or without drainage, small craniectomy with aspiration and drainage to craniotomy and excision of abscess. The purpose of this article is to share authors’ experience regarding clinico epidemiological profile of brain abscess. MATERIAL AND METHODS: Total 30 patients with brain abscess who presented to the Department of Neurosurgery, PGIMER Dr. RML Hospital Delhi, from November 2016 to April 2018 analyzed for clinical, epidemiological, microbiological profile of brain abscess patients along with modes of treatment and their outcome. RESULTS: Total 30 patients of Brain Abscess were evaluated with males outnumbering females. Predominated symptoms were fever (96.7%), headache (83.3%) and nausea and vomiting (40%). The chronic suppurative otitis media (CSOM) was predominately underlying factor in 18 patients i.e. (60%) and commonest organism isolated was streptococcus pneumonia (66.6%) followed by streptococcus Milleri (33.33%). The length of hospital stay was longer in aspiration group {21.2 days (SD ± 4.1)} compared to excision group {13 days (SD ± 1.1)}. Total 20 (66.7%) patients survived, 2 (6.7%) patients died and 8 (26.7%) were lost to follow up. CONCLUSION: Majority of time there is an underlying factor for brain abscess. The treatment of brain abscess involves both medical and surgical modalities. Third generation cephalosporins and metronidazole are the most commonly used antimicrobial agents in the treatment of brain abscesses. The length of hospital stay in excision group was less as compared to medical group and aspiration group.

A Rare Cause of Hand Infection: Streptococcus Constellatus

Hand infections represent common medical and surgical challenges that endanger delicate structures with severe consequences if not promptly addressed. Early identification and management are essential to achieve optimal outcomes. To the best of our knowledge this is the first reported case caused by Streptococcus constellatus, in which a severe periungueal infection evolved rapidly with septic thrombosis of digital vessels and culminated in amputation. This microorganism belongs to a group of commensal bacteria, Streptococcus milleri, that causes dental, peritonsillar and sinus abscesses. When bacteriemia outbursts, distant abscesses may form or endocarditis may ensue. A missed diagnosis and treatment can induce important morbidities, often delayed by the difficult isolation of the agent in the laboratory and its complex mechanisms of antibacterial resistance. This article focus on the importance of identifying serious hand infections requiring urgent or emergent treatment, since delayed or inadequate identification and management can lead to important and permanent deficits.

Streptococcus intermedius as a leading agent of brain abscess: retrospective analysis of a UK cohort

ABSTRACTBackgroundBrain abscess is an uncommon condition, but carries high mortality. Current treatment guidelines are based on limited data. Surveillance of clinical, radiological and microbiology data is important to inform patient stratification, interventions, and antimicrobial stewardship.MethodsWe undertook a retrospective, observational study of patients with brain abscess, based on hospital coding, in a UK tertiary referral teaching hospital. We reviewed imaging data, laboratory microbiology, and antibiotic prescriptions.ResultsOver a 47 month period, we identified 47 adults with bacterial brain abscess (77% male, median age 47 years). Most of the abscesses were solitary frontal or parietal lesions. A microbiological diagnosis was secured in 39/47 (83%) of cases, among which the majority were of the Streptococcus milleri group (27/39; 69%), with a predominance of Streptococcus intermedius (19/27; 70%). Patients received a median of 6 weeks of intravenous antibiotics (most commonly ceftriaxone), followed by variable oral follow-on regimens. Ten patients (21%) died, up to 146 days after diagnosis. Mortality was significantly associated with increasing age, multiple abscesses, immunosuppression and the presence of an underlying cardiac anomaly.ConclusionOur data suggest that there has been a shift away from staphylococcal brain abscesses, towards S. intermedius as a dominant pathogen. In our setting, empiric current first line therapy with ceftriaxone remains appropriate on microbiological grounds and narrower spectrum therapy may sometimes be justified. Mortality of this condition remains high among patients with comorbidity. Prospective studies are required to inform optimum dose, route and duration of antimicrobial therapy.