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Bilateral recurrent periorbital cellulitis is a very rare condition, with only five cases having been reported. Two cases are presented of recurrent bilateral asynchronous eyelid oedema in two paediatric patients. It was associated with respiratory infections, with no systemic disease. The patients had recurrent episodes (three times) since nine months old. They received oral and intravenous antibiotics, with a good response. There were no complications and no surgery was needed.

Management of acute pancreatitis and its complications has rapidly evolved in recent years. The earlier pillars of management that included prolonged bowel rest, empiric intravenous antibiotics, and early surgical intervention for complications such as pancreatic necrosis have become much less common. The latest evidence-based approaches to acute pancreatitis are taking almost a diametrically different path to previous management. The current strategy focuses on early feeding, judicious use of antibiotics, and delayed use of invasive interventions. Even in complex cases, when surgical interventions may be indicated, there is an expressed preference for minimally invasive techniques. We review the changes that have evolved rapidly over the past decade in this common clinical problem.

Objective To evaluate the prognostic accuracy of qSOFA for predicting in-hospital mortality among patients with suspected infection presenting to the ED of a public tertiary hospital in Brazil. Methods We performed a retrospective cohort study of consecutive adult patients (age ≥ 18 years) with suspected infection who presented to an academic tertiary ED in Porto Alegre (Southern Brazil) during an 18-month period. The qSOFA was calculated by using information collected at triage and patients were followed throughout hospitalization for the primary outcome of in-hospital mortality. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios with corresponding 95% CIs were calculated for the qSOFA and qSOFA65. Results A total of 7523 ED visits of patients with suspected infection in which an intravenous antibiotic was administered within 24 h were included, which resulted in 908 in-hospital deaths (12.1%). There were 690 (9.2%) patients whose triage qSOFA was ≥2 points. When such cutoff was used, the sensitivity for in-hospital death was 24.6% (95% CI 21.8 to 27.4%) and the specificity was 92.9% (95% CI 92.3% to 93.5%). The sensitivity increased to 67.4% (95% CI 64.2% to 70.3%) when a cutoff of ≥1 was tested, but the specificity decreased to 55.3% (95% CI 54.1% to 56.5%). Using a cutoff of ≥2, the qSOFA65 had a sensitivity of 51.0% (95% CI 47.7% to 54.3%) and a specificity of 75.7% (95% CI 74.6% to 76.7%). Conclusions The qSOFA score yielded very low sensitivity in predicting in-hospital mortality. Emergency physicians or ED triage nurses in low-to-middle income countries should not be using qSOFA or qSOFA65 as “rule-out” screening tools in the initial evaluation of patients with suspected infection.

Background Mycobacterium abscessus subspecies massiliense is a non-tuberculous mycobacteriosis and was subdivided from Mycobacterium abscessus in 2006. This article is the first report on nasopharyngitis caused by Mycobacterium abscessus subspecies massiliense. Case presentation A 45-year-old woman had an 18-month history of recurrent nasopharyngitis and presented with pain in the throat. Mycobacterial tissue culture and polymerase chain reaction testing revealed the presence of Mycobacterium abscessus subspecies massiliense in the nasopharyngeal tissue. This patient underwent surgery, followed by multiple rounds of chemotherapy with oral and intravenous antibiotic agents for 16 weeks. She has had no recurrence during the 56 weeks since treatment. Conclusion It is difficult to detect the presence of Mycobacterium abscessus subspecies massiliense in a culture from the swabbing sample. The tissue culture from a biopsy specimen is mandatory for the identification of the species. Currently, no definite treatment policy is available and only empirical treatment is applied. This case is an important for the diagnosis and treatment of this bacterial infection on nasopharynx.

In children, spontaneous mediastinitis is a rare, severe and commonly misdiagnosed disease. Although standard of care treatment frequently involves surgery, we report a case of mediastinitis in a five-year-old child, successfully treated with 4 weeks of intravenous antibiotics. Ultrasound imaging was used to monitor patient response to conservative treatment while reducing radiation exposure.

BACKGROUND AND OBJECTIVES: Children with deep neck infections (DNIs) are increasingly being managed nonsurgically with intravenous antibiotics. Our objective was to examine variation in the management of children with DNIs across US children’s hospitals. METHODS: We conducted a retrospective cohort study using the Pediatric Health Information System database. Children ≤12 years of age hospitalized for retropharyngeal or parapharyngeal abscesses from 2010 to 2018 were included. Hospital variation in management modality and imaging use was described. Temporal trends in management modality were assessed by using logistic regression. Medical management alone versus a combination of medical and surgical management was assessed, and the characteristics of children in these 2 groups were compared. The relationship between hospital rates of initial medical management and failed medical management was assessed by using linear regression. RESULTS: Hospitals varied widely in their rates of surgical management from 17% to 70%. The overall rate of surgical management decreased from 42.0% to 33.5% over the study period. Children managed surgically had higher rates of ICU admission (11.5% vs 3.2%; P < .001) and higher hospital charges ($25 241 vs $15 088; P < .001) compared with those managed medically alone. Seventy-three percent of children underwent initial medical management, of whom 17.9% went on to undergo surgery. Hospitals with higher rates of initial medical management had lower rates of failed medical management (β = −.43). CONCLUSIONS: Although rates of surgical management of pediatric DNI are decreasing over time, there remains considerable variation in management across US children’s hospitals. Children managed surgically have higher rates of resource use and costs.

Delayed inflammatory and infectious complications occurred in a 63-year-old woman after receiving AQUAfilling filler injection in the forehead and nasolabial folds. The complications were idiopathic and occurred at different time points at different sites. Her condition improved after the removal of the injected materials and capsule, and administration of intravenous antibiotics. Although injection sites differ, inflammation can occur at any site at different time points. The possibility of inflammation at other injection sites should always be considered during periodic follow-up, even if the filler injection site initially shows no signs of complications.Level of Evidence: Level IV.

Oral versus Intravenous Antibiotics for Endocarditis This interactive feature about the treatment of endocarditis offers a case vignette accompanied by two essays supporting a full 6-week course of...

Aim To examine differences in risk factors, clinical features and outcomes of cellulitis between those 75 + years and those, Highlights • To examine the differences in outcomes of cellulitis in hospitalized patients who are 75 + years and those

AIM: To investigate the efficacy and safety of home-treatment with oral piv-mecillinam or amoxicillin-clavulanate in children with acute pyelonephritis.METHODS: Children aged over 6 months diagnosed with culture confirmed pyelonephritis at Danish Paediatric Departments were home-treated with piv-mecillinam (tablets) or amoxicillin-clavulanate (liquid or tablets). Follow-up was performed by phone (second treatment day) and clinical review of the patients in the hospital (day three).RESULTS: Four hundred eighteen children were included. In total, 333/418 (80%) responded well to the initial oral antibiotic treatment. 85/418 (20%) were changed to another treatment of these 47/418 (11%) to a second-line oral antibiotic and 38/418 (9%) to intravenous antibiotics due to insufficient clinical improvement or bacterial resistance. Bacterial resistance was similar for piv-mecillinam and amoxicillin-clavulanate: 4/74 (5%) versus 33/333 (10%) (p = 0.22). Insufficient clinical improvement, despite no resistance, primarily occurred in children treated with piv-mecillinam: 16/74 (22%) versus 28/344 (8%) (p < 0.001), and predominantly occurred in piv-mecillinam treated children CONCLUSION: A home-treatment regime for pyelonephritis in children >6 months is safe; however, during treatment, clinical re-evaluation is required as in 20% of cases a change in treatment was necessary.

BACKGROUND After surgery for complicated appendicitis (CA), common practice is to treat all patients with a standardised long-course of intravenous antibiotics (IVAB) to reduce the risk of postoperative surgical infections (PSI). The aim of the current study was to evaluate the safety and efficacy of a short-course IVAB after CA in selected patients. METHODS The Department's prospectively collected database identified CA patients treated between2015 and 2019. Baseline and treatment characteristics and postoperative outcomes were analysed. The cut-off between short- and long-course IVAB was 2 days. Outcomes of interest were PSI and 30-day unplanned readmission. RESULTS In total, 226 patients had CA: Ninety-nine CA (43.8%) received short-course IVAB and 127 (56.2%) received long-course. PSI occurred in 6% and 10% of the short-course and long-course patients, respectively (p = 0.34). Length of IVAB after a PSI was comparable to that of patients without PSI (median 3 and 2 days of IVAB respectively; p = 0.28). 30-day unplanned readmission rates were 7% and 6%, respectively (p = 0.99). Length of IVAB for readmitted patients was similar to those who were not readmitted (median 3 days of IVAB in both; p = 0.91). Multivariable analysis showed that the intraoperative findings of the appendix (p = 0.04) was a prognostic predictor for PSI. ASA score (p = 0.02) and surgical approach (p = 0.05) were prognostic predictors for 30-day unplanned readmission. CONCLUSIONS This study shows that when patients respond well, a short-course IVAB can safely be applied after CA without increasing risk of PSI or 30-day unplanned readmission.

An 86-year-old female presented to the Emergency Department (ED) in respiratory distress after choking on a sandwich at home. Her family had noticed that she had had difficulty during and coughing after swallowing for several months. Her initial chest x-ray showed diffuse alveolar infiltrates in both lungs and blood tests showed normal white cells and C-Reactive Protein (CRP). She was started on intravenous antibiotics for presumed aspiration pneumonia and received 15 L of oxygen. However, the infiltration had dramatically improved, both radiologically and clinically, within 24 hours. She was diagnosed with negative pressure pulmonary oedema (NPPE) type 1 and made a rapid recovery. The Speech and Language Team diagnosed an impaired swallow and advised soft or bite-sized suitable foods. We discussed the ongoing risk of aspiration and long-term feeding options with the patient’s family. We agreed on a conservative plan for ‘risk feeding’, given her frailty and co-morbidities, and began discussions on ceilings of care. This case aims to raise awareness of NPPE so that it can be diagnosed, investigated and treated promptly. Although seen most commonly by intensivists and anaesthetists, it is relevant to those on the acute medical take and geriatricians managing patients with swallowing difficulties.

Uncomplicated colonic diverticulitis is common. There is no consensus regarding the most appropriate management. Some authors have reported the efficacy and safety of observational management, and others have argued for a more aggressive approach with oral or intravenous antibiotic treatment.The purpose of this study was to perform an updated meta-analysis of the different management strategies for uncomplicated diverticulitis with 2 separate meta-analyses.MEDLINE, Embase, and Cochrane databases were used.All randomized clinical trials, prospective, and retrospective comparative studies were included.Observational and antibiotics treatment or oral and intravenous antibiotics treatment were included.Successful management (emergency management, recurrence, elective management) was measured.After review of 293 identified records, 11 studies fit inclusion criteria: 7 studies compared observational management and antibiotics treatment (2321 patients), and 4 studies compared oral and intravenous antibiotics treatment (355 patients). There was no significant difference between observational management and antibiotics treatment in terms of emergency surgery (0.7% vs 1.4%; p = 0.1) and recurrence (11% vs 12%; p = 0.3). In this part, considering only randomized trials, elective surgery during the follow-up occurred more frequently in the observational group than the antibiotic group (2.5% vs 0.9%; p = 0.04). The second meta-analysis showed that failure and recurrence rates were similar between oral and intravenous antibiotics treatment (6% vs 7% (p = 0.6) and 8% vs 9% (p = 0.8)).Inclusion of nonrandomized studies, identification of high risks of bias (selection, performance, and detection bias), and presence of heterogeneity between the studies limited this work.Observational management was not statistically different from antibiotic treatment for the primary outcome of needing to undergo surgery. However, in patients being treated by antibiotics, our studies demonstrated that oral administration was similar to intravenous administration and provided lower costs. Although it may be difficult for physicians to do, there is mounting evidence that not treating uncomplicated colonic diverticulitis with antibiotics is a viable treatment alternative.

Background The most common cystic fibrosis (CF)-causing mutation is deltaF508 (F508del), which is present in 28% of CF Spanish patients. While the literature based on real-life studies on CF patients homozygous F508del treated with lumacaftor/ivacaftor is limited, it demonstrates the need for better strategies to prevent related adverse events (AEs) as well as the development of newer drugs. Methods We conducted a multicenter, retrospective, observational study to describe the effects of lumacaftor/ivacaftor treatment in real-life in Spain. 20 CF patients were included, all aged 6 and upwards and presented with ppFEV1 Results The mean age was 26.65 (range of 10–45), while the mean ppFEV1 before the treatment was 32.4% and mean BMI was 19.9 kg/m2. We analysed the changes in ppFEV1 and BMI from baseline during the treatment with lumacaftor/ivacaftor, but no differences were found. However, a moderate association between days of intravenous antibiotic needed and the use of lumacaftor/ivacaftor (p = 0.001) was established. Indeed, under the lumacaftor/ivacaftor, patients required 5.8 days of intravenous antibiotic treatment compared to 14.9 days prior to study. Also, severe pulmonary exacerbations requiring hospitalisation were statistically fewer under lumacaftor/ivacaftor treatment (p = 0.003). Finally, 75% of the sample presented with AEs, which led 35% of the subjects to discontinue the treatment. Conclusions While treatment with lumacaftor/ivacaftor resulted in an improvement in the number of pulmonary severe exacerbations, no improvement in ppFEV1 or BMI was found.

Background Early antibiotics are fundamental to sepsis management. Second-dose antibiotic delays were associated with increased mortality in a recent study. Study objectives include: 1) determine factors associated with delays in second-dose antibiotic administration; 2) evaluate if delays influence clinical outcomes. Methods ED-treated adults (≥18 years; n = 1075) with severe sepsis or septic shock receiving ≥2 doses of intravenous antibiotics were assessed, retrospectively, for second-dose antibiotic delays (dose time > 25% of recommended interval). Predictors of delay and impact on outcomes were determined, controlling for MEDS score, 30 mL/kg fluids and antibiotics within three hours of sepsis onset, lactate, and renal failure, among others. Results In total, 335 (31.2%) patients had delayed second-dose antibiotics. A total of 1864 second-dose antibiotics were included, with 354 (19.0%) delays identified by interval (delayed/total doses): 6-h (36/67) = 53.7%; 8-h (165/544) = 30.3%; 12-h (114/436) = 26.1%; 24-h (21/190) = 8.2%; 48-h (0/16) = 0%. In-hospital mortality in the timely group was 15.5% (shock-17.6%) and 13.7% in the delayed group (shock-16.9%). Increased odds of delay were observed for ED boarding (OR 2.54, 95% 1.81–3.55), shorter dosing intervals (6/8-h- OR 2.99, 95% CI 1.95–4.57; 12-h- OR 2.46, 95% CI 1.72–3.51), receiving 30 mL/kg fluids by three hours (OR 1.42, 95% CI 1.06–1.90), and renal failure (OR 2.57, 95% CI 1.50–4.39). Delays were not associated with increased mortality (OR 0.87, 95% CI 0.58–1.29) or other outcomes. Conclusions Factors associated with delayed second-dose antibiotics include ED boarding, antibiotics requiring more frequent dosing, receiving 30 mL/kg fluid, and renal failure. Delays in second-dose administration were not associated with mortality or other outcomes.

Hospital at home units allow the treatment of moderate and severe infections by administering intravenous antibiotics to patients who would otherwise have to remain hospitalised. Increasing antibiotic resistance adds an element of difficulty to outpatient treatment of infections because multiple daily doses of antimicrobials or combinations of antimicrobials are sometimes required. This manuscript discusses some of the challenges of outpatient management of infections with multidrug- resistant microorganisms and shows the main antibiotic resistances and the outcomes of treatment of these infections in Spanish home hospitalisation units. post-print 107 KB

To explore a new surgical treatment for infection and obstruction of ventriculoperitoneal shunt in hydrocephalus. Two cases of post-operative infection of ventriculoperitoneal shunt were analyzed retrospectively. One case was cryptococcal infection, the other case was Acinetobacter lwoffii. The number of cerebrospinal fluid cells was high, the infection of ventriculoperitoneal shunt was generally complicated with abdominal obstruction, and the hydrocephalus was aggravated again, The authors try to pull out the drainage tube at the end of abdominal cavity for external drainage, combined with intravenous antibiotics, completely control of infection, and then use the original shunt device for intraventricular jugular shunt. The authors explore that this method is simple, safe and effective, and it is an effective and feasible method for the treatment of infection after ventriculoperitoneal shunt.

BackgroundIt is rare that drains cannot be removed after surgery, however, this situation cannot be completely avoided, and is also hard to deal with. The main reason for a tethered drain is inadvertent suture fixation. At present, no effective way was published or widely accepted to locate the tethered drain.MethodsThree cases of orthopedic trauma patients experienced unsuccessful removal of the drain after surgery. The ultrasound was used to locate the sutured site of the drain. Based on the sliding sign and vanishing point which can be detected by the ultrasound, the sutured site of the drain can be clearly identified. Finally, the suture was loosened through a small incision, and the drain was completely removed.ResultsThe surgical procedure was very successful in all patients. The tethered drain was quickly and completely removed through a small incision with locating by ultrasound. Intravenous antibiotics were administered within 24 h after surgery, and no wound or deep infections occurred.ConclusionsUltrasound can be used to locate a tethered drain based on the sliding sign. This method can simplify the release procedure and achieve fast removal of the drain. Furthermore, it will help lower the risk of a retained drain and soft tissue complications.

Following open reduction and internal fixation for a proximal humerus fracture a 71-year-old man re-presented with wound changes consistent with infection and elevated inflammatory markers. No significant improvement was seen with concomitant intravenous antibiotics and multiple debridement procedures. This case was further complicated by soft tissue breakdown at the site of a left thigh haematoma also requiring debridement. Surgical site infections represent the most common cause of morbidity postoperatively. This case highlights the importance of considering a number of differential diagnoses. A diagnosis of pyoderma gangrenosum prompted systemic corticosteroid therapy giving rapid clinical improvement.

Idiopathic orbital inflammation (IOI) is a benign inflammatory disease usually confined to the orbit. Two middle-aged patients with IOI have been reported who could have been misdiagnosed as involutional ptosis. Two patients presented to the clinic with eyelid ptosis. One patient's erythrocyte sedimentation rate was slightly increased; the other patient's immunoglobulin G4 (IgG4), IgG, and thyroid-stimulating hormone results were higher than the upper limits of normal. The computed tomographic images and orbit magnetic resonance imaging tests showed an inflammatory condition around the droopy eyelids. They were both admitted to the hospital with diagnosis of IOI, and intravenous antibiotic and steroid treatment were administered, which improved their symptoms.

BACKGROUND When performing revision shoulder arthroplasty, surgeons do not have access to the results of intraoperative culture specimens and will administer empiric antibiotics to cover for the possibility of deep infection until the culture results are finalized. The purpose of this study was to report the factors associated with the initiation, modification, and adverse events of 2 different postoperative antibiotic protocols in a series of revision shoulder arthroplasties. METHODS In this study, 175 patients undergoing revision shoulder arthroplasty were treated with either a protocol of intravenous (IV) antibiotics if there was a high index of suspicion for infection or a protocol of oral antibiotics if the index of suspicion was low. Antibiotics were withdrawn if cultures were negative and were modified as indicated if the cultures were positive. Antibiotic course, modification, and adverse effects to antibiotic administration were documented. RESULTS On univariate analysis, factors significantly associated with the initiation of IV antibiotics were male sex (p < 0.001), history of infection (p < 0.001), intraoperative humeral loosening (p = 0.003), and membrane formation (p < 0.001). On multivariate analysis, male sex (p = 0.003), history of infection (p = 0.003), and membrane formation (p < 0.001) were found to be independent predictors of the initiation of IV antibiotics. On the basis of preoperative and intraoperative characteristics, surgeons anticipated the culture results in 75% of cases, and modification of antibiotic therapy was required in 25%. The modification from oral to IV antibiotics due to positive culture results was made significantly more often in male patients (p < 0.001). Adverse effects of antibiotic administration occurred in 19% of patients. The rates of complications were significantly lower in the patients treated with oral antibiotics and a shorter course of antibiotics (p < 0.001). CONCLUSIONS Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent and are more common in patients whose initial protocol is IV antibiotics. Further study is needed to balance the effectiveness and risks of post-revision antibiotic treatment given the frequency of antibiotic-related complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Children with complicated appendicitis, osteomyelitis, and complicated pneumonia have historically been treated with postdischarge intravenous antibiotics (PD-IV) using peripherally inserted central catheters (PICCs). Recent studies have shown no advantage and increased complications of PD-IV, compared with oral therapy, and the extent to which use of PD-IV has since changed for these conditions is not known. We used a national children’s hospital database to evaluate trends in PD-IV during 2000-2018 for each of these three conditions. PD-IV decreased from 13% to 2% (risk ratio [RR], 0.15; 95% CI, 0.14-0.16) for complicated appendicitis, 61% to 22% (RR, 0.41; 95% CI, 0.39-0.43) for osteomyelitis, and 29% to 19% (RR, 0.63; 95% CI, 0.58-0.69) for complicated pneumonia. Despite these overall reductions, substantial variation in PD-IV use by hospital remains in 2018.

Outpatient parenteral antimicrobial therapy (OPAT) offers an alternative to inpatient care for delivering intravenous antibiotics in patients' homes or in a day care clinic setting. It was first introduced in North America in the 1970s and has evolved over the years, starting with the adult population and now moving to the paediatric population ( Chapman 2013 ). OPAT has the potential to offer excellent, patient-centred, high-quality care to treat a wide variety of infectious conditions in patients who are medically stable and do not need hospitalisation. For children and young people OPAT has the potential for families to resume their normal lives: returning to work, school and home. Paediatric OPAT (P-OPAT) is being implemented across the UK, with five centres now established. This article reports on the implementation of P-OPAT at Sheffield Children's NHS Foundation Trust (Sheffield Children's) in June 2016, highlighting the challenges and successes.

Outpatient parenteral antibiotic therapy enables patients to receive intravenous antibiotics without having to be an inpatient. Outpatient parenteral antibiotic therapy can be delivered in an outpatient setting or in the patient's own home by a visiting nurse or the patient can be trained to self-administer antibiotic treatment. The advantages and limitations of each of these methods are discussed in this article. Common clinical situations in which outpatient parenteral antibiotic therapy is used are described. The article also considers the advantages of outpatient parenteral antibiotic therapy, how to ensure that care is safe and effective and how to obtain funding to set up a service.

Proximal muscle weakness of the legs is a symptom with a broad differential diagnosis. It is mainly caused by neuromuscular disorders and is often a diagnostic challenge. Here, we present a 73-year-old man with isolated proximal weakness of the legs due to lumbar root involvement on the basis of neuroborreliosis. After treatment with intravenous antibiotics he recovered completely. This is the first described case with isolated proximal muscle weakness of the legs due to neuroborreliosis. Despite the fact neuroborreliosis is a rare cause of proximal muscle weakness of the legs, clinicians should include it in their differential diagnosis, especially since it is a treatable condition.

Summary Objectives No interventions have yet been implemented to improve antibiotic use on Aruba. In the Netherlands, the introduction of an antibiotic checklist resulted in more appropriate antibiotic use in nine hospitals. The aim of this study was to introduce the antibiotic checklist on Aruba, test its effectiveness, and evaluate the possibility of implementing this checklist outside the Netherlands. Methods The antibiotic checklist includes seven quality indicators (QIs) that define appropriate antibiotic use. It applies to adult patients with a suspected bacterial infection, treated with intravenous antibiotics. The primary endpoint was the QI sum score, calculated by the patient's sum of performed checklist-items divided by the total number of QIs that applied to that specific patient. Outcomes before and after the introduction of the checklist were compared. Results The percentage of patients with a QI sum score ≥50% increased significantly during the intervention ( n =173) compared to baseline ( n =150) (odds ratio 3.67, p 0.001). However, performance did not improve on each individual QI. The checklist was used in 63.3% of the eligible patients. Conclusions The introduction of the antibiotic checklist increased appropriate antibiotic use on Aruba. Additional initiatives are necessary for further improvement per QI. These results suggest that the antibiotic checklist could be used internationally.

A 69-year-old woman with orbital cellulitis secondary to odontogenic Streptococcus constellatus was transferred to the authors' institution for surgical management of infection refractory to intravenous antibiotics. She underwent debridement with preservation of the globe, recovering full motility. Visual recovery was limited by optic nerve ischemia. This case supports the importance of urgent surgical drainage in necrotizing orbital infections secondary to odontogenic Streptococcus constellatus.

Omphalitis is a rare infection in our countries. Streptoccus pyogenes is one of the most frequently encountered germs. Complications are rare but include septicemia and necrotizing fasciitis with a high mortality rate. The case reported in this article is that of an 11 days old infant with pyogenic streptococcal omphalitis who developed cellulitis of left food. An intravenous antibiotic treatment allowed complete resolution of the symptoms. The article is the opportunity to review of the risk factors of this affection, its complications and treatments.L’omphalite est une infection rare dans nos pays. Le streptocoque pyogène est un des germes les plus fréquemment rencontrés. Les complications sont rares mais incluent les septicémies et la fasciite nécrosante avec un taux important de mortalité. Le cas rapporté dans cet article est celui d’un nourrisson de 11 jours présentant une omphalite à Streptocoque pyogène ayant développé une cellulite du pied gauche. Un traitement antibiotique intraveineux a permis une résolution complète des symptômes. Cet article est l’occasion d’une revue des facteurs de risques de cette affection, de ses complications et traitements.

A 52-year-old male and 55-year-old female underwent surgical resection of a voluminous symptomatic epiphrenic diverticulum via a right thoracotomy. A formal myotomy of the distal esophagus was not performed. The first patient had an uncomplicated recovery whilst the other patient still suffers from an esophageal-cutaneous fistula and repetitive abscesses, treated by intravenous antibiotics and percutaneous drainage. The authors discuss the indication for resection, surgical techniques and complications.

It is well established that delays in antibiotics increase morbidity and mortality in sepsis.[1][1] Difficult peripheral access is one of several factors that cause delays in initiating treatment.[2][2] Small studies have shown that ultrasound (US) guidance can aid timely insertion of difficult

A 5-year-old boy presented with sudden onset diminution of vision in his left eye for 5 days. Patient also had history of intermittent bleeding from gums since 7 days. There was history of fever 25 days back for which he was treated with intravenous antibiotics at local hospital and fever

Recent estimates of inpatient antibiotic use in the USA suggest that broad-spectrum antibiotic use has increased significantly. The objective of this study was to assess the impact of a selective antibiotic susceptibility reporting intervention on broad-spectrum intravenous (i.v.) antibiotic use in seven hospitals of a health system in New Jersey. This was a retrospective pre- and post-intervention ecological study. Standardised selective antibiotic susceptibility reporting rules were developed and implemented between January 2016 and June 2017. The 8 months before and after each individual hospital's implementation constituted the pre- and post-intervention study periods. The primary outcome was the rate of broad-spectrum i.v. antibiotic use for hospital-onset/multidrug-resistant infections (broad MDR). Secondary outcome measures were the use rates of non-glycopeptide anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) agents, carbapenems, non-carbapenem antipseudomonal β-lactams, third-generation cephalosporins, first/second-generation cephalosporins, fluoroquinolones and narrow-spectrum penicillins. Antibiotic use data were collected as inpatient i.v. antibiotic days of therapy per 1000 patient days (DOT/1000-PD). Interrupted time series analysis with segmented regression was used to compare outcomes. There was no significant change in the use of broad MDR agents (slope change, +0.54 DOT/1000-PD per month, 95% confidence interval -1.78 to 2.87) or other antibiotic classes. Whilst the implementation of selective antibiotic susceptibility reporting across seven hospitals had no impact on overall broad-spectrum i.v. antibiotic use, further study is needed to determine the long-term impact of this intervention.

Comment on: Meta‐analysis of oral antibiotics, Meta-analysis of Oral Antibiotics, in Combination With Preoperative Intravenous Antibiotics and Mechanical Bowel Preparation the Day Before Surgery, Compared With Intravenous Antibiotics and Mechanical Bowel Preparation Alone to Reduce Surgical-Site Infections in Elective Colorectal Surgery ( BJS Open 2018; 2: 185-194)

A 69-year-old immunocompromised man developed mitral valve endocarditis due to Salmonella enterica serotype Mbandaka, contracted from the cereal outbreak. The patient had a history of HLA-matched related hematopoietic stem cell transplant with persistent graft-versus-host disease (GVHD). This case report discusses prior international outbreaks that occurred due to Salmonella enterica subtype Mbandaka, the risks of developing endovascular infections from salmonellosis, and persistent infections that may develop more frequently with S. enterica serotype Mbandaka. The patient received a six-week course of intravenous antibiotics and remains on oral suppressive antibiotics, with his length of therapy to be determined based on his GVHD treatment.

BACKGROUND\ud \ud The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.\ud \ud \ud \ud METHODS\ud \ud We enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points.\ud \ud \ud \ud RESULTS\ud \ud Among the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of −1.4 percentage points (90% confidence interval [CI], −4.9 to 2.2; 95% CI, −5.6 to 2.9), indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% vs. 1.0%).\ud \ud \ud \ud CONCLUSIONS\ud \ud Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927. opens in new tab.)

Source Citation Iversen K, Ihlemann N, Gill SU, et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med. 2018. [Epub ahead of print]. 30152252

Objectives: Patients with suspected Neutropenic sepsis require rapid antibiotic administration, but despite extensive education, only 67% of patients received antibiotics within 60 minutes. Methods: A Neutropenic Sepsis Alert Card was created, as a Patient Specific Directive – this allows nurses to administer antibiotics to specific patients without prior medical review. Results: Since the intervention, 301 patients presented with suspected neutropenic sepsis. 277 patients (92%) received their first dose of intravenous antibiotics within 1 hour of arrival into hospital, compared to 95 out of 143 patients (67%) presenting between January and June of 2014 (p=0.036). Conclusion: The Neutropenic Sepsis Alert Card can significantly improve door to antibiotic needle time for chemotherapy patients with suspected neutropenic sepsis. This intervention is inexpensive and easily replicable in other health care organisations.

Purple urine bag syndrome is a rare clinical entity commonly seen in elderly females with a long-term urinary catheterization. It presents as purple discoloration of the patient's plastic urine bag and tubing. We report the first case of this rare entity from Central Africa. We present the case of an 80-year-old female with purple urine associated with signs of urinary tract infection. Her symptoms resolved after 3 days of intravenous antibiotic treatment and diet modification. Purple urine bag syndrome remains rare, especially in African literature. Awareness of this benign syndrome is necessary for clinicians so as to adequately manage up to and including the associated anxiety.

Background: Infections are a major concern in fixation surgeries. Most of the infections could occur in the first three months after the operation. Case Report: We present a 45-year-old man who known case of achondroplasia who underwent craniospinal fixation and was presented to our clinic with surgical site infection after six years. His instruments were removed, and a halo vest was fixed for the patients. Accordingly, he received intravenous antibiotics, and during nine months’ follow-up, no any significant problems were found. Conclusion: Infection of instruments in spinal surgeries might be presented years after the surgery. Hence, it needs to be considered by surgeons in patients’ follow-ups. [GMJ.2020;9:e1906]

Varicella infection is one of the most common and contagious infection in children and could course with severe complications. We report the case of a 4-year-old patient derived to our hospital for suspicion of suppurative complication in the context of a varicella infection. A computerized tomographic scanning was performed, showing a large retropharyngeal abscess with mediastinitis. Complications of varicella are up to 2% of patients, but this is the first report of a retropharyngeal and mediastinal abscess in this context. In the face of clinical suspicion, early intervention is important through imaging, intravenous antibiotics and surgical drainage in necessary cases.

The National Institute for Health and Care Excellence (NICE) guidelines recommend intravenous antibiotics to be discontinued at 36 hours in asymptomatic, low-risk babies with negative blood cultures and reassuring inflammatory markers.1 Despite this, national practice remains varied. On contacting all 155 neonatal units in England, 91 units reported using a 36-hour blood culture threshold. Fifty-nine (38%) units reported awaiting 48-hour cultures, with 235 972 babies born in these units in 2016–2017.2 A further five units awaited 24-hour cultures (table 1). View this table: Table 1 National variation in time to stop antibiotics in low-risk, asymptomatic babies with reassuring inflammatory markers and negative culture results The barriers to 36-hour culture results may be varied, often involving transport to central laboratories and access to reporting/analysing systems.3 However, stopping antibiotics at 36 hours could …

A previously healthy 22-year-old woman presented with acute, unilateral facial and neck swelling, associated with fever and malaise. She was initially treated with intravenous antibiotics; however, CT imaging showed unilateral, synchronous swelling and inflammation of the parotid and submandibular glands, and a PCR swab from the parotid duct was positive for mumps. She was fully immunised and had no contact in the preceding period with anyone diagnosed with mumps. She responded to supportive management and her symptoms resolved over the course of her admission. Unilateral, synchronous swelling and severe inflammation of both the parotid and submandibular glands in mumps is a very unusual presentation, and not one previously reported in the literature.

Source Citation Scarborough M, Li HK, Rombach I, et al. Oral versus intravenous antibiotics for bone and joint infections: the OVIVA non-inferiority RCT. Health Technol Assess. 2019;23:1-92. 31373271

We report the first case of an association between Leptotrichia trevisanii and an episode of pelvic inflammatory disease (PID) and the second case of the isolation of this infection in the cervical canal. A 45-yr-old woman was admitted to our emergency department with clinical and radiological signs and symptoms compatible with an episode of PID. She was hospitalized for intravenous antibiotic control and treatment and the subsequent surgical drainage of abscesses. Cultures were taken throughout the process, but only cultures from cervical canal exudate were positive, with the growth of L. trevisanii species. It appears important to carry out a complete microbiological screening, not limited to conventional agents, on adequate clinical samples to detect possible infectious agents that may be missed in these cases.

Objective We herein present a case involving a prevertebral abscess complicated by a spinal epidural abscess (SEA) secondary to intradiscal oxygen–ozone chemonucleolysis for treatment of a cervical disc herniation. Methods A 67-year-old woman with a history of intradiscal oxygen–ozone chemonucleolysis developed numbness and weakness in her right upper and bilateral lower extremities followed by urinary retention. Her symptoms did not respond to intravenous antibiotics alone. Magnetic resonance imaging of the cervical region revealed an extensive SEA anterior to the spinal cord, spinal cord myelopathy due to anterior compression by the lesion, and a prevertebral abscess extending from C2 to T1. She underwent surgical drainage and irrigation. Results The patient was successfully treated with surgical drainage and systemic antibiotic therapy without kyphosis. Streptococcus intermedius was detected within the abscess. All clinical symptoms except for the sensory deficit in the left leg were relieved. Conclusions The safety of intradiscal oxygen–ozone therapy requires further assessment. High-dose intravenous antibiotics should be initiated empirically at the earliest possible stage of prevertebral and epidural abscesses. Surgical drainage may be a rational treatment choice for patients with a prevertebral abscess complicated by an SEA and spinal cord myelopathy.

A 37-year-old male complained of pain and swelling of his left hand for 7 days. He was a woodworker and reported that he was using a pneumatic needle gun when the pain began. The patient claimed to have seen a scorpion in the workplace and he believed to have suffered a sting. Initially he sought an emergency room, where hydrocortisone and ketoprofen were administered, and loratadine was prescribed. Because it does not show improvement with seven days of loratadine, he sought the dermatology service. On physical examination, heat, redness and swelling of whole left hand was observed. Dermoscopy with a handheld dermoscope (DermLite II Pro 3Gen) showed a single puncture wound over volar surface of the third left metacarpal. Hand X-ray revealed a foreign body in soft tissue of third left metacarpal. The diagnosis of hand injury from pneumatic needle gun was made. Foreign body was identified and removed. Intravenous antibiotics were administered pre-operatively and oral antibiotics continued post-operatively. Nail gun injuries commonly occur related to improper use by the operator and not following occupational health and safety requirements for operating a nail gun. The amount of energy required to cause serious injury is fairly low: penetration of the skin occurs with projectile velocities of 150 feet per second, whereas bony fractures may occur with projectile velocities of 195 feet per second. Mechanisms of nail gun injury include direct penetration, shrapnel wounds from exploding cartridges and high-pressure injection injuries from the compressed air used to activate the gun. Assessment of a patient with a puncture wound and suspected foreign body begins with a careful history and physical examination.

Eustachian valve infective endocarditis is rare and mostly affects intravenous drug abusers and those with implanted medical devices or indwelling central venous catheters. The most commonly identified organism is Staphylococcus aureus. Treatment includes intravenous antibiotics for approximately 6 weeks. We present a case of Staphylococcus aureus Eustachian valve endocarditis in an individual without traditional risk factors.

We hypothesised that delays in providing non-urgent medication step-downs at weekends to medical management may be associated with increased length of stay.In a novel use of electronic prescribing data, we analysed emergency admissions from a busy acute medical hospital over 52 weeks from November 2014 to October 2015. The main outcomes of interest were switching from intravenous antibiotics to oral antibiotics and stopping nebulised bronchodilators. The rate of switching from intravenous to oral antibiotics was lower on Saturdays and Sundays compared with weekdays, and the rate of stopping nebulised bronchodilators was similarly lower at weekends (p

Sphingomonas paucimobilis, a yellow-pigmented, aerobic, glucose non-fermenting, Gram-negative bacillus, is a rare cause of human infection normally associated with immunocompromised hosts. It has been associated with a few cases of continuous ambulatory peritoneal dialysis (PD) and is notorious for its resistance to the commonly used antibiotics. In half of the cases reported so far, the peritonitis was refractory to treatment, necessitating PD catheter removal. We report a case of Sphingomonas paucimobilis peritonitis in a 50-year-old patient who had been on PD for two years. The patient was successfully treated with intraperitoneal and intravenous antibiotics and the PD catheter was salvaged.