Diabetic Foot Osteomyelitis Caused by Francisella Tularensis

Purpose: A rare patient case of a diabetic foot osteomyelitis caused by Francisella tularensis is presented. Summary: A 69-year-old Caucasian female was admitted for the treatment of diabetic foot osteomyelitis. Her past medical history included type II diabetes mellitus, hypertension, chronic kidney disease, coronary artery disease, hypothyroidism, hyperuricemia and thyroidectomy. Empiric antimicrobial therapy consisting of clindamycin 600mg i.v. every 8hrs and impanel/cilastatin 200 mg i.v. every 6hrs hours was initiated immediately after admission. During her hospitalization, a pus sample from the infection site was taken for culture which showed a gram negative microorganism: Francisella tularensis. The strain was resistant to all the antibiotics tested with the exception of ciprofloxacin, ofloxacin, gentamicin, ceftazidime, cefepime, piperacillin/tazobactam and colistin. After culture results, the treatment regimen was changed to piperacillin/tazobactam 4.5g i.v. every 12hrs and ciprofloxacin 400mg i.v. every 12hrs. The patient continued to receive both antibiotics during hospitalization for 9 days with noted clinical improvement. The patient was discharged on piperacillin/tazobactam 4.5g i.v. every 12hrs and oral ciprofloxacin 500mg every 12hrs to complete a total duration of 6 weeks. Conclusion: This is the first reported case of a diabetic foot osteomyelitis caused by Francisella tularensis.

Tattoo-Associated Cutaneous Mycobacterium mageritense Infection: A Case Report and Brief Review of the Literature

There have been increasing reports of tattoo-associated mycobacterial infections in recent years, with a number of outbreaks documented worldwide. This has therefore become a public health concern. Nontuberculous mycobacteria (NTM) are capable of producing skin and soft tissue infections typically via inoculation during surgery, trauma, and cosmetic procedures. We present a case of tattoo-associated cutaneous infection caused by <i>Mycobacterium mageritense</i>, a rare species of rapidly growing NTM. A 25-year-old man developed a rash on his left lower leg 4 weeks after he underwent professional tattooing. A skin swab identified <i>M</i>. <i>mageritense</i> complex. Based on susceptibility testing, a course of oral ciprofloxacin and trimethoprim/sulfamethoxazole was initiated, with significant improvement observed after 5 weeks. We speculate that the mechanism of inoculation was a result of either the artist using nonsterile water to dilute black ink to gray or from use of contaminated prediluted gray ink. The Therapeutic Goods Administration does not have regulatory authority over the sterility of tattoo inks or practices in Australia. Instead, tattoo practices are regulated by local government jurisdictions. Because of the variability seen in clinical presentation and challenges associated with organism identification, a high index of suspicion is required to diagnose mycobacterial infections. Infection caused by NTM should be considered in the differential diagnosis of tattoo-associated dermatological complications, particularly in patients who have chronic lesions, negative bacterial cultures, and fail to respond to standard antibiotic therapy. Mandatory regulations for safe tattoo practices should be considered to prevent outbreaks and ensure public safety.

Pyelonephritis and Bacteremia Caused by Klebsiella variicola following Renal Transplantation

Klebsiella variicola (K. variicola) is a Gram-negative organism genetically similar to Klebsiella pneumoniae (K. pneumoniae) that can cause a variety of diseases in humans. Bacteremia due to K. variicola is associated with a higher mortality rate than bacteremia with K. pneumoniae. Here, we describe a 65-year-old woman who developed pyelonephritis 2 months after receiving a renal transplantation following a longstanding history of end-stage renal disease secondary to polycystic kidney disease. Her creatinine on admission was unchanged from her posttransplant baseline, and an abdominal CT scan showed inflammatory changes around the transplanted kidney that were suggestive of an infection rather than allograft rejection. She was initially treated empirically with meropenem given a history of extended-spectrum beta-lactamase- (ESBL-) producing E. coli bacteriuria. After a day of therapy with meropenem, her therapy was streamlined based on culture results to ceftriaxone. She continued to improve, her kidney function remained stable, and she was prescribed oral ciprofloxacin to complete a 14-day total course of antibiotics. This case is the first reported instance of K. variicola bacteremia associated with pyelonephritis in a renal transplant recipient. Hospitalization with acute pyelonephritis within the first year following kidney transplant is common and is associated with increased risk of graft loss and mortality. However, K. variicola is not a commonly known organism to cause this infection. Despite the risk of allograft failure in this circumstance, this patient was successfully treated with a 14-day course of antibiotic therapy.

Intravenous fosfomycin as salvage therapy for osteomyelitis caused by multidrug-resistant Pseudomonas aeruginosa

Purpose A case of osteomyelitis caused by multidrug-resistant (MDR) Pseudomonas aeruginosa is reported. Summary An 84-year-old Caucasian male with an underlying history of type 2 diabetes, peripheral vascular disease, and coronary artery disease had chronic nonhealing wounds on his right foot. Wound care and a course of intravenous (IV) ertapenem with oral ciprofloxacin were ineffective. His initial wound culture grew Staphylococcus aureus, group G streptococcus and P. aeruginosa; the Pseudomonas was susceptible to multiple agents. The patient eventually required midtarsal amputation and angioplasties to his right leg. Twenty days after the operation, 2 openings were discovered at the surgical site, 1 of which was probed to the bone. He was readmitted 5 weeks after the operation. A repeat wound swab grew MDR P. aeruginosa and Finegoldia magna. The Pseudomonas was susceptible to gentamicin and colistin. The patient had revision of the infected amputation site with the goal of salvaging his right lower limb. The patient developed acute renal failure after 26 days of IV gentamicin, IV ceftriaxone, and oral metronidazole. Additional susceptibility testing was performed to identify alternatives. The bacteria were considered susceptible to IV fosfomycin, the last resort, by our microbiology laboratory. This was combined with ceftolozane/tazobactam followed by meropenem to treat the residual infection. After 2 weeks of IV fosfomycin, the patient’s wound improved and further amputation was avoided. Conclusion Our case demonstrates that IV fosfomycin may provide an effective salvage therapy when combined with β-lactams for the treatment of severe diabetic foot infection or osteomyelitis caused by MDR P. aeruginosa.

CLINICAL EFFECTIVENESS OF AZITHROMYCIN VERSUS CIPROFLOXACIN IN THE TREATMENT OF UNCOMPLICATED ENTERIC FEVER IN CHILDREN;

ABSTRACT Objective: To compare the clinical effectiveness of oral azithromycin with oral ciprofloxacin in the treatment of uncomplicated enteric fever in children. Material and Methods: A randomized controlled trial was carried out in the Pediatric department of Khyber Teaching Hospital for which a sample size of 282 patients was determined using WHO calculator with 5% level of significance and 80% power of test (Two sided). Non-probability consecutive sampling technique was used for selection of children age 6 to 18 years and either gender. They were divided into two groups (141 in each) where Group A was treated with oral azithromycin while Group B with ciprofloxacin for 7 days. Clinical effectiveness was determined when the patient remained afebrile for more than 48 hours without antipyretics. Results: In group A, 128 children (90.78%) while in Group B, 105 (74.46%) children become clinically cure. Conclusion: Oral Azithromycin is more effective than oral Ciprofloxacin in the treatment of typhoid fever in children.

Pseudomonas laryngeal perichondritis: unexpected diagnosis

A 57-year-old male chronic smoker with underlying diabetes mellitus presented with dysphonia associated with cough, dysphagia and reduced effort tolerance of 3 months’ duration. Videoendoscope finding revealed bilateral polypoidal and erythematous true and false vocal fold with small glottic airway. The patient was initially treated as having tuberculous laryngitis and started on antituberculous drug. However, no improvement was observed. CT of the neck showed erosion of thyroid cartilage, which points to laryngeal carcinoma as a differential diagnosis. However, the erosion was more diffuse and appeared systemic in origin. The diagnosis of laryngeal perichondritis was made when the histopathological examination revealed features of inflammation, and the tracheal aspirate isolated Pseudomonas aeruginosa. The patient made a good recovery following treatment with oral ciprofloxacin.

1232. Efficacy and Safety of Intravenous Sulopenem Followed by Oral Sulopenem etzadroxil/Probenecid Versus Intravenous Ertapenem Followed by Oral Ciprofloxacin or Amoxicillin-clavulanate in the Treatment of Complicated Urinary Tract Infections (cUTI): Results from the SURE-2 Trial

Background Sulopenem is a broad-spectrum IV and oral penem antibiotic being developed for the treatment of infections caused by multidrug-resistant bacteria to allow for earlier discharge of hospitalized patients. Methods 1,395 hospitalized adults with pyuria, bacteriuria, and clinical signs and symptoms of cUTI were randomized to sulopenem IV once daily for 5 days followed by a bilayer tablet of sulopenem-etzadroxil and probenecid bid or ertapenem IV once daily for 5 days followed by either oral ciprofloxacin or amoxicillin-clavulanate bid, depending on susceptibility of the baseline uropathogen. The primary endpoint was overall (clinical and microbiologic) response at Day 21 [Test of Cure (TOC)] in the micro-MITT population. Results The sulopenem and ertapenem treatment arms were well-balanced at baseline. The difference in overall response was driven by a difference in asymptomatic bacteriuria occurring between the end of treatment (EOT) and TOC in the subgroup of patients with a ciprofloxacin susceptible uropathogen at baseline who received ertapenem IV followed by oral ciprofloxacin. No difference in overall response was identified at EOT [86.7% vs 88.9%, sulopenem and ertapenem, respectively; difference, 95% CI: -2.2% (-6.5, 2.2)]. 19% of patients remained on ertapenem IV as the baseline pathogen was both resistant to quinolones and ESBL positive; overall response for patients with these resistant pathogens on IV sulopenem who stepped down to oral sulopenem was higher [64/80 vs 55/84 on sulopenem IV/oral and ertapenem IV, respectively; difference, 95% CI: 14.5% (0.8, 27.8)]. Treatment emergent adverse events (all, 14.8% vs 16.1%; related, 6.0% vs 9.2%) and serious adverse events (2.0% vs 0.9%) were similar for patients on sulopenem and ertapenem, respectively. Overall Response at Test of Cure, micro-MITT Population Conclusion Sulopenem followed by oral sulopenem-etzadroxil probenecid was not non-inferior to ertapenem followed by oral step-down therapy for the treatment of cUTI driven by a lower rate of asymptomatic bacteriuria in patients receiving oral ciprofloxacin. Sulopenem, both IV and oral, was well-tolerated; its oral formulation allowed patients with baseline pathogens resistant to both quinolones and β-lactams an opportunity to successfully step down from IV therapy. Disclosures Michael W. Dunne, MD, Iterum Therapeutics (Employee, Shareholder) Steven I. Aronin, MD, Iterum Therapeutics (Employee, Shareholder)

Resistance-Guided Treatment of Gonorrhea: A Prospective Clinical Study

Background Novel treatment strategies to slow the continued emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae are urgently needed. A molecular assay that predicts in vitro ciprofloxacin susceptibility is now available but has not been systematically studied in human infections. Methods Using a genotypic polymerase chain reaction assay to determine the status of the N. gonorrhoeae gyrase subunit A serine 91 codon, we conducted a multisite prospective clinical study of the efficacy of a single oral dose of ciprofloxacin 500 mg in patients with culture-positive gonorrhea. Follow-up specimens for culture were collected to determine microbiological cure 5–10 days post-treatment. Results Of the 106 subjects possessing culture-positive infections with wild-type gyrA serine N. gonorrhoeae genotype, the efficacy of single-dose oral ciprofloxacin treatment in the per-protocol population was 100% (95% 1-sided confidence interval, 97.5–100%). Conclusions Resistance-guided treatment of N. gonorrhoeae infections with single-dose oral ciprofloxacin was highly efficacious. The widespread introduction and scale-up of gyrA serine 91 genotyping in N. gonorrhoeae infections could have substantial medical and public health benefits in settings where the majority of gonococcal infections are ciprofloxacin susceptible. Clinical Trials Registration NCT02961751.