Antibiotic Therapy for Epididymitis Clarified

We conducted a 3-decade clinical review of prophylaxis for wound infection and postoperative intra-abdominal abscess after open appendectomy for pediatric ruptured appendicitis. We reviewed the charts of patients with ruptured appendicitis who underwent open appendectomy performed by the same pediatric surgeon at the Hospital for Sick Children, Toronto, Canada, between 1969 and 2003, inclusive. We evaluated 3 types of prophylaxis: subcutaneous (SC) antibiotic powder, peritoneal wound drain and intravenous (IV) antibiotics. We divided the sample into 4 treatment groups: peritoneal wound drain alone (group 1); peritoneal wound drain, SC antibiotic powder and IV antibiotics (group 2); SC antibiotic powder and IV antibiotics (group 3); and IV antibiotics alone (group 4). We used the χ(2) test with Bonferroni correction for multiple comparisons. There were 496 patients: 348 (70%) boys and 148 (30%) girls, with a mean age of 7 (range newborn to 17) years. There were 90 (18%) wound infections. Compared with the current standard of practice, IV antibiotics alone (group 4), peritoneal wound drain (group 1) was associated with the lowest number of wound infections (7 [7%], p = 0.023). There were 43 (9%) postoperative intra-abdominal abscesses. Compared with IV antibiotics alone, SC antibiotic powder with IV antibiotics (group 3) was associated with the lowest number of postoperative intra-abdominal abscesses (14 [6%], p = 0.06). Over a 35-year period of open appendectomy for pediatric ruptured appendicitis, wound infection was least frequent in patients who received prophylactic peritoneal wound drain, and postoperative intra-abdominal abscess was least frequent in those who received prophylactic SC antibiotic powder and IV antibiotics.

IV Antibiotic Use during Autologous Hematopoietic Stem Cell Transplantation Is Associated with Inferior Survival in Patients with Multiple Myeloma

BackgroundThis pilot study analyzes decisions of infectious diseases faculty: hospital discharge with oral vs. intravenous antibiotics in the context of an academic OPAT (outpatient parenteral antibiotic therapy) system.MethodsWe created a survey of eight patient scenarios culled from the OPAT records of Tufts Medical Center. Six case scenarios had clinical equipoise, while two control scenarios had a clear indication for discharge with intravenous antibiotics. Infectious diseases attendings affiliated with Tufts Medical Center were surveyed. Respondents were asked preferences for oral vs. intravenous antibiotics for each scenario, their confidence in each decision, and demographics. Providers’ antibiotic scores equaled the sum of responses to the six case scenarios (1 point for intravenous, 0 points for oral). Self-assessments of confidence in each decision were on a scale of 0 to 100% (100% indicating complete confidence).ResultsNine of thirty responded to the survey. All reported US-based training/experience. All indicated preference for intravenous antibiotics in the two control scenarios. The average antibiotic score for all providers was 2.9. Factors trended with choosing oral antibiotics: ≤5 years of experience and >12 weeks of inpatient service per year.AllOPAT Providers, N = 6Non-OPAT Providers, N = 3≤5 Years’ Experience N = 3>5 Years’ Experience, N = 6≤12 Weeks Inpatient, N = 6>12 Weeks Inpatient, N = 3Average antibiotic score2.92.8323.33.32Average confidence level %72727364767174“OPAT providers” = MDs who see OPAT patients as outpatients.ConclusionAlthough in reality all six case scenario patients had been discharged on intravenous antibiotics, respondents chose oral antibiotics almost 50% of the time. This pilot study demonstrates potential for antibiotic stewardship regarding intravenous recommendations.Disclosures All authors: No reported disclosures.

BackgroundThe benefit of intravenous (IV) antibiotics in bronchiectasis has been established,1 and IV antibiotics can be safely delivered in a domicillary setting.2 We report on the experience of obtaining funding...

IntroductionFew studies have addressed the decision-making process of antibiotic therapy (AT) in intensive care unit (ICU) patients.MethodsIn a prospective observational study, all consecutive patients admitted over a one-month period (2004) to 41 French surgical (n = 22) or medical/medico-surgical ICUs (n = 19) in 29 teaching university and 12 non-teaching hospitals were screened daily for AT until ICU discharge. We assessed the modalities of initiating AT, reasons for changes and factors associated with in ICU mortality including a specific analysis of a new AT administered on suspicion of a new infection.ResultsA total of 1,043 patients (61% of the cohort) received antibiotics during their ICU stay. Thirty percent (509) of them received new AT mostly for suspected diagnosis of pneumonia (47%), bacteremia (24%), or intra-abdominal (21%) infections. New AT was prescribed on day shifts (45%) and out-of-hours (55%), mainly by a single senior physician (78%) or by a team decision (17%). This new AT was mainly started at the time of suspicion of infection (71%) and on the results of Gram-stained direct examination (21%). Susceptibility testing was performed in 261 (51%) patients with a new AT. This new AT was judged inappropriate in 58 of these 261 (22%) patients. In ICUs with written protocols for empiric AT (n = 25), new AT prescribed before the availability of culture results (P = 0.003) and out-of-hours (P = 0.04) was more frequently observed than in ICUs without protocols but the appropriateness of AT was not different. In multivariate analysis, the predictive factors of mortality for patients with new AT were absence of protocols for empiric AT (adjusted odds ratio (OR) = 1.64, 95% confidence interval (95%CI): 1.01 to 2.69), age ≥60 (OR = 1.97, 95% CI: 1.19 to 3.26), SAPS II score >38 (OR = 2.78, 95% CI: 1.60 to 4.84), rapidly fatal underlying diseases (OR = 2.91, 95% CI: 1.52 to 5.56), SOFA score ≥6 (OR = 4.48, 95% CI: 2.46 to 8.18).ConclusionsMore than 60% of patients received AT during their ICU stay. Half of them received new AT, frequently initiated out-of-hours. In ICUs with written protocols, empiric AT was initiated more rapidly at the time of suspicion of infection and out-of-hours. These results encourage the establishment of local recommendations for empiric AT.

SummaryBackgroundChronic pulmonary infection with Pseudomonas aeruginosa is one of the most important causes of mortality and morbidity in cystic fibrosis. If antibiotics are commenced promptly, infection can be eradicated. The aim of the trial was to compare the effectiveness and safety of intravenous ceftazidime and tobramycin versus oral ciprofloxacin in the eradication of P aeruginosa.MethodsWe did a multicentre, parallel group, open-label, randomised controlled trial in 72 cystic fibrosis centres (70 in the UK and two in Italy). Eligible participants were older than 28 days with an isolate of P aeruginosa (either the first ever isolate or a new isolate after at least 1 year free of infection). Participants were excluded if the P aeruginosa was resistant to, or they had a contraindication to, one or more of the trial antibiotics; if they were already receiving P aeruginosa suppressive therapy; if they had received any P aeruginosa eradication therapy within the previous 9 months; or if they were pregnant or breastfeeding. We used web-based randomisation to assign patients to 14 days intravenous ceftazidime and tobramycin or 12 weeks oral ciprofloxacin. Both were combined with 12 weeks inhaled colistimethate sodium. Randomisation lists were generated by a statistician, who had no involvement in the trial, using a computer-generated list. Randomisation was stratified by centre and because of the nature of the interventions, blinding was not possible. Our primary outcome was eradication of P aeruginosa at 3 months and remaining free of infection to 15 months. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who received at least one dose of study drug. TORPEDO-CF was registered on the ISRCTN register, ISRCTN02734162, and EudraCT, 2009-012575-10.FindingsBetween Oct 5, 2010, and Jan 27, 2017, 286 patients were randomly assigned to treatment: 137 to intravenous antibiotics and 149 to oral antibiotics. 55 (44%) of 125 participants in the intravenous group and 68 (52%) of 130 participants in the oral group achieved the primary outcome. Participants randomly assigned to the intravenous group were less likely to achieve the primary outcome, although the difference between groups was not statistically significant (relative risk 0·84, 95% CI 0·65–1·09; p=0·18). 11 serious adverse events occurred in ten (8%) of 126 participants in the intravenous antibiotics group and 17 serious adverse events in 12 (8%) of 146 participants in the oral antibiotics group.InterpretationCompared with oral therapy, intravenous antibiotics did not achieve sustained eradication of P aeruginosa in a greater proportion of patients with cystic fibrosis and was more expensive. Although there were fewer hospitalisations in the intravenous group than the oral group during follow-up, this confers no advantage over oral treatment because intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P aeruginosa in cystic fibrosis.FundingNational Institute for Health Research Health Technology Assessment Programme.

Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA. This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein <20 mg/L, and reduction in abscess size. A noninferiority margin of 12% was used. Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, -4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group. Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA. NCT01723150.

Background: Inadequate hand-off communication from hospital to skilled nursing facility (SNF) hinders SNF nurses’ ability to prepare for specific patient needs, including prescriptions for critical medications, such as controlled medications and intravenous (IV) antibiotics, resulting in delayed medication administration. This project aims to improve hand-off communication from hospital to SNF by utilizing a standardized hand-off tool. This project was conducted in an inpatient, 50-bed, post-hospital skilled nursing care unit of a local SNF. The participants included all 32 staff nurses employed by the SNF. Methods: Lewin’s change management theory (CMT) guided this quality improvement (QI) project. Baseline assessment included a one-month chart review of 76 patient charts that was conducted to assess the disparities related to ineffective hand-off and medication delays in the SNF before intervention. The wait time for the availability of prescriptions for controlled medications and IV antibiotics, and delays in medication administration were assessed. Intervention: Multiple randomly selected hospital-to-SNF hand-offs were observed. Semistructured interviews with all staff nurses were conducted using open-ended questions about hand-off structure and process matters. Data gathered from observation and interviews were used to create the standardized hand-off tool used in this project. In-service training on hand-off tool utilization for SNF nurses was conducted. Champions for each shift were cultivated to assist with project implementation. Results: After six weeks of implementation, a chart review of 101 patient charts was conducted to evaluate the effects of the hand-off tool on the wait time on the availability of prescriptions for controlled medications and IV antibiotics, and medication administration. The wait time of prescriptions availability during the hospital-to-SNF transition was decreased by 79% for controlled medications, with an associated 52.9% reduction in late administration, and decreased by 94% for IV antibiotics, with a 77.8% reduction in late administration. Conclusion: The use of standardized hand-off resulted in improved communication during the hospital-to-SNF hand-off and significantly decreased the wait time for the availability of prescriptions for controlled medications and IV antibiotics. Integrating standardized hand-off into the SNF policies can help sustain improved communication, medication management, and patient transition from hospital to SNF.

Use of antibiotic beads to salvage infected breast implants

Are Oral Antibiotics an Effective Alternative to Intravenous Antibiotics in Treatment of Osteomyelitis of the Jaw?

4556 Background: There is growing evidence indicating that gut microbiome content is associated with the effectiveness of immune checkpoint inhibitory (ICI) therapy in various cancer types. Antibiotic therapy (ABT) induces significant changes in gut microbiota; however, the effects of ABT on oncologic outcomes with ICI therapy has only been explored in small, single-institution studies. We aimed to investigate the relationship between ABT on overall survival (OS) and real-world progression free survival (rwPFS) in subjects with advanced renal cell carcinoma (RCC) treated with ICI utilizing a national database. Methods: We queried the nationwide electronic health record (EHR)-derived de-identified FlatIron Health (FIH) database after Institutional Review Board approval was obtained and included a waiver of informed consent to select 1809 subjects who received ICI therapy. Patient characteristics were described and compared between those with known ABT use and without known ABT use (in the 3 months pre/post ICI initiation) using ANOVA and Chi-square tests. rwPFS and OS were calculated from date of initiation of ICI to date of real-world progression/date of death. Three-month landmark Kaplan Meier and log-rank tests were used to compare rwPFS and OS between groups defined by ABT use (any ABT, and ABT in 3 months pre-ICI vs 3 months post-ICI initiation). Cox proportional models were used to investigate the association between rwPFS, OS, and antibiotic use, adjusting for patient characteristics. Results: Patients receiving ABT group were younger (p = 0.007) and more likely female (p = 0.024) but similar in other measured demographic variables. rwPFS (median: 9.03 vs 11.6 months; p = 0.015) and OS (median: 23.7 vs 31.8 months; p = 0.019) were significantly shorter in the with-ABT group than in the without-ABT group. When assessing ABT use 3 months prior to initiation of ICI (vs ABT during/no known ABT use), neither rwPFS (median: 9.53 vs 11.66, p = 0.38) nor OS (median: 23.7 vs 22.6 months; p = 0.38) were significantly different. However, rwPFS (median: 23.5 vs 14.0 months vs not reached; p = 0.004) and OS (median: 36.2 vs 22.5 vs 31.8; p = 0.007) were statistically significantly different when stratifying based on exposure and timing of ABT amongst pre-ICI initiation ABT, post-ICI initiation ABT and no ABT groups, respectively. Multivariable analysis identified as a significant predictor of rwPFS (HR = 0.725, CI = 0.579-0.908; p =.005) and OS (HR = 0.722, CI = 0.573-0.911; p = 0.006). Conclusions: This study identifies a significant negative prognostic association of ABT administration on survival in advanced RCC treated by ICI in the first line setting. These results are consistent with the growing body of evidence suggesting that alterations in gut microbiome secondary to antibiotics appear to blunt efficacy of ICI treatment and emphasize the importance of antibiotic stewardship.

• On the basis of class B evidence and consensus, acute appendicitis in children can often be diagnosed clinically with only selective use of imaging. (13)(14)(15)(16) • On the basis of class B evidence and consensus, ultrasonography is the test of choice when acute appendicitis is suspected but is unclear based on history, physical examination, and laboratory results. (17)(18)(19) • On the basis of class B evidence and consensus, the use of computed tomography scan should be limited to cases of suspected complex appendicitis with abscess or when there is clinical suspicion for acute appendicitis but ultrasonography results are not helpful. (16) • On the basis of class C evidence and consensus, children with possible appendicitis ideally should be treated in medical centers that have skilled sonographic personnel. (21) • On the basis of class B evidence and consensus, simple appendicitis should be treated by appendectomy during normal operating hours. Preoperative treatment with intravenous antibiotics and fluids during the overnight hours halts disease progression and allows for the safest surgery with the benefit of a full and rested staff. (24)(25)(26) • On the basis of class B evidence and consensus, complex appendicitis with a well-defined abscess can be treated nonoperatively initially, with the option of an interval appendectomy after recovery from the acute infection. (29)(30) (31)(32)(33)

In-hospital use of antibiotics in internal medicine: A cross-sectional study before, during and after the COVID-19 pandemic in a COVID-19-free ward

<h3>Introduction</h3> Allergic bronchopulmonary aspergillosis (ABPA) is increasingly prevalent among cystic fibrosis (CF) patients. Atopy, sex, season at diagnosis and cystic fibrosis transmembrane conductance regulator (CFTR) mutation are suggested risk factors for ABPA. Studies indicate that centres using a high amount of intravenous antibiotics have better outcomes, but this has also been linked to the increase in ABPA. The objective of this retrospective case-control study was to assess potential risk factors for ABPA, in particular intravenous antibiotic use. <h3>Methods</h3> Of 150 paediatric patients, 13 fulfilled the CF foundation consensus diagnostic criteria for ABPA. These were compared to 130 patients without evidence of ABPA. Seven patients were excluded from the study as they showed evidence of ABPA but did not fulfil the diagnostic criteria. The intravenous antibiotic data for the ABPA group was compared to 80 patients without ABPA using extended matching by age of diagnosis. The data collected included age, sex, CFTR mutation, atopy (history or family history of diagnosed hay fever, eczema or asthma), and weeks of intravenous antibiotics administered. Season of diagnosis was noted for the ABPA group. <h3>Results</h3> The median duration of use of intravenous antipseudomonal antibiotics in the ABPA group was 38 weeks, compared to 5 weeks in the non-ABPA group (p&lt;0.05). No difference was found in the duration of use of non-antipseudomonal antibiotics (median 12 weeks in ABPA group, 2 weeks in non-ABPA group). The average time since diagnosis of CF was higher in the ABPA group by 3 years (p=0.01). 12/13 (92%) of ABPA patients had a history of atopy compared to 50/105 (47%) of the non-ABPA group (p=0.05). There was no difference in CFTR mutation, sex or season of ABPA diagnosis. <h3>Conclusion</h3> Intravenous antipseudomonal antibiotic use was substantially higher in the ABPA population. This could be a factor in the increase in ABPA, suggesting that tighter microbiological guidance may be useful before initiating antibiotic treatment. However, this could also be that IV use and ABPA are both markers for increased disease severity. Atopy was also significantly higher in the ABPA population. This could potentially be used to highlight those CF patients at risk from this disease.

Short-course antibiotic (SCA) therapy after appendectomy for complicated appendicitis (CA) has gained increasing attention, but its safety and efficacy remain insufficiently supported by meta-analyses. This study aimed to evaluate whether SCA therapy is as safe and effective as conventional long-course antibiotic (LCA) therapy following appendectomy for CA. A comprehensive literature search was conducted to identify randomized controlled trials (RCTs) and observational studies comparing different durations of postoperative antibiotic therapy for CA. Data were analyzed using RevMan 5.3 for meta-analysis, and the GRADE approach was applied to assess the quality of evidence for key outcomes. Four RCTs and nine observational studies involving 3,251 patients were included. The meta-analysis revealed no significant increase in the risk of surgical site infection (SSI) (RR = 1.19, 95% CI: 0.52 to 2.73, P = 0.67, low-quality evidence) or intra-abdominal abscess (IAA) (RR = 1.18, 95% CI: 0.92 to 1.51, P = 0.19, moderate-quality evidence) with less than 3-day SCA therapy compared to LCA therapy. Secondary outcomes showed no significant differences between the two regimens (moderate to very-low quality evidence). However, SCA therapy was associated with a shorter length of hospital stay (low-quality evidence). For patients with CA, less than 3-day SCA therapy does not increase the risk of SSI or IAA. Moreover, reducing the duration of antibiotic use may help minimize unnecessary antibiotic consumption.