Pregnancy Outcomes in Women with Sickle Cell Disease in Ireland: A Retrospective Review

Background: Sickle cell disease (SCD) is one of the most common single gene disorders worldwide and is characterised by significant morbidity and early mortality.[1] Pregnancy in SCD is associated with an increased risk of maternal and foetal complications.[2,3] The 2011 RCOG and the 2021 BSH guidelines[5,6] on the management of pregnancy in SCD have provided the basis for best practice care in the UK over the past decade and is the guidance which we follow in Ireland. To date, there is no published data on outcomes for pregnant women with SCD in Ireland. The number of Irish patients with SCD has risen over the past 20 years. Without a national database, the exact prevalence is not known but currently there are at least 600 adults and children with SCD in Ireland, whose population is just over 5 million.[4] Aims: Our study assesses outcomes of pregnant patients with SCD from 2015 to 2022. Our aims were to: * Assess adherence to current guidelines * Assess pregnancy outcomes and maternal complications * Assess transfusion rates amongst our patient cohort. Method(s): This is a retrospective cohort study. We do not have a directly matched cohort, but have compared our findings to published data on Irish pregnancy outcomes from the Irish Maternity Indicator System National Report and have correlated our findings with studies of women with SCD who were managed in UK centres.[8,9,10] Results: We reviewed outcomes of 29 pregnancies in 19 women over a 7-year period. The median age was 29 (range 20-41) and the predominant maternal sickle genotype was HbSS (65.5%). Before conception, 55.2% of cases had pre-existing complications of SCD, including acute chest syndrome (ACS), pulmonary hypertension (PHTN) and prior stroke. In accordance with current guidelines, 100% of women (n=29) were prescribed folic acid, penicillin, and aspirin prophylaxis. 51.7% (n=15) of women had documented maternal complications during pregnancy, including ACS (34%), vaso-occlusive crisis (34%), gestational diabetes (10%), VTE (3%) and UTI (3%). Two women (7%) developed Covid-19 pneumonitis despite vaccination. There was one case of maternal bacteraemia (3%). 65.5% of cases (n=19) required blood transfusion during pregnancy. One woman was already on a blood transfusion programme for disease modification prior to pregnancy. In 6 cases (20.6%), a transfusion programme was commenced during pregnancy due to prior pregnancy complications or intrauterine growth restriction. During pregnancy, 27.6% (n=8) of women required emergency red cell exchange for ACS. Prior studies have suggested that between 30% and 70% of pregnant women with SCD require at least one blood transfusion during pregnancy.[8,9,10] By comparison, only 2.6% of the Irish general obstetric population required transfusion during pregnancy.[7] 20.6% (n=6) of births were preterm at <37 weeks' gestation. There was one live preterm birth (3%) at <34 weeks and one intrauterine death (3%) at 23 weeks' gestation. Similar to UK data[9], 31% of women required critical care stay (n=9) during pregnancy, in comparison with 1.44% nationwide in 2020.[7] Conclusion(s): It is well established that pregnancy in SCD is high risk, and despite adherence to current guidelines, we have shown very high rates of critical care admission, significant transfusion requirement and hospital admissions. Our findings are comparable to published UK outcomes and they further support the need for a comprehensive specialist care setting for this patient cohort.

We should be learning as much from failure as success

'You do not know what you will find, you may set out to find one thing and end up discovering something entirely different'-Alexander Fleming As the pace at which medicine is advancing continues to accelerate, haematologists will increasingly find themselves practising unfamiliar medicine and using novel treatments. Whilst most scientific breakthroughs hopefully lead to an overall improvement in quality of life and prognosis, it is imperative that enough attention is paid to the shortcomings of new treatments and adverse events. The recent COVID-19 pandemic is a stark reminder of the cyclical nature of history and the need for healthcare professionals to utilise lessons learnt by our predecessors. Fleming and the discovery of penicillin highlights how mistakes in practice can sometimes lead to unexpected but useful revelations. The use of thalidomide as a treatment for hyperemesis gravidarum in the 1960s devastatingly lead to birth defects in thousands of people. Today, the repurposing of thalidomide, through lateral thinking and further study, has contributed to significant improvements in the prognosis of patients with Multiple Myeloma.1 Mortality following allogenic stem cell transplant continues to decrease overtime as knowledge surrounding complications and how to manage these improves, despite the fact that patients receiving stem cell transplants are becoming increasingly complex.2 These examples from history demonstrate the merit in studying adverse events and undesired outcomes. National reviews of patient health records indicate that errors currently occur in 10% of hospital admissions.3 With new treatments and more complex patients this will likely increase. It is estimated that voluntary reporting by healthcare professionals of such events only occurs 70% of the time.3 History should be used to guide essential changes in attitudes towards error reporting and help to create an ethos where 'failings' are more willingly recognised as a tool to guide improvement and innovation.

Clostridium Difficillae Infection in Post-Covid Patients

Intro: The ongoing pandemic caused by the SARS-CoV-2 virus has brought many new insights into medicine. During the first months of the pandemic, when there were no comprehensive guidelines for precise antimicrobial therapy, empirical overuse of broad-spectrum antibiotics was observed. Which resulted in the development of clostidium infection in certain cases. In our report, we address 83 cases of clostridial colitis in post-covid patients from 3/2020 to 3/2021 and their specific therapy. Method(s): Retrospective analysis of risk factors for clostridial infection and therapy of clostridial colitis. Finding(s): In the period 3/2020-3/2021, 9617 patients were diagnosed with SARS-CoV-2 virus infection in our hospital, of which 1247 were hospitalized. In 83 cases, clostridial colitis occurred during or after the covid infection had resolved. Mortality in this group was 17%, which corresponds to 14 patients. Previous empirical administered antiobiotics in COVID-19 infection contributed to the development of clostridial colitis in case of 22 patients (27%) by clarithromycin, in 14 pacients (17%) by penicillins and by 3rd generation cephalosporins in 9 patients (11%). The average duration of therapy with broad-spectrum antibiotics was 15.63 days (+-8.99). Other risk factors we observed are: PPI use (25%), active malignant disease (10%), previous glucocorticoid therapy (22%). Vancomycin was used in clostridial infection therapy in 47% (39), metronidazole in 31% (25) and fidaxonicin in 7% (6). In the group, we observed recurrence of clostridium difficile infection in 14% of patients and FMT was performed in 6 patients. Conclusion(s): This study shows a higher percentage of clostridial infection in cases of long-term therapy with broad-spectrum antibiotics. It also points to the effect of specific antimicrobial therapy for infection caused by the bacterium Clostridium difficile and the possibility of using fecal bacteriotherapy.Copyright © 2023

Syphilis: "The Great Imitator" Presenting as Acute Hepatitis

Introduction: Syphilis is a multi-systemic disease caused by spirochete Treponema pallidum. Very rarely, it can affect the liver and cause hepatitis. Since most cases of hepatitis are caused by viral illnesses, syphilitic hepatitis can be missed. Here, we present a case of syphilitic hepatitis in a 35-year-old male. Case Description/Methods: Patient was a 35-year-old male who presented to the hospital for jaundice and mild intermittent right upper quadrant abdominal pain. His medical history was only significant for alcohol abuse. His last drink was 4 weeks ago. He was sexually active with men. On exam, hepatomegaly, mild tenderness in the right upper quadrant, jaundice, and fine macular rash on both hands and feet were noted. Lab tests revealed an ALT of 965 U/L, AST of 404 U/L, ALP of 1056 U/L, total bilirubin of 9.5 mg/dL, direct bilirubin of 6.5 mg/dL, INR of 0.96, and albumin of 2.0 g/dL. Right upper quadrant ultrasound showed an enlarged liver but was negative for gallstones and hepatic vein thrombosis. MRI of the abdomen showed periportal edema consistent with hepatitis without any gallstones, masses, or common bile duct dilation. HIV viral load and Hepatitis C viral RNA were undetectable. Hepatitis A & B serologies were indicative of prior immunization. Hepatitis E serology and SARS-CoV-2 PCR were negative. Ferritin level was 177 ng/mL. Alpha-1-antitrypsin levels and ceruloplasmin levels were normal. Anti-Smooth muscle antibody titers were slightly elevated at 1:80 (Normal < 1:20). Anti-Mitochondrial antibody levels were also slightly elevated at 47.9 units (Normal < 25 units). RPR titer was 1:32 and fluorescent treponemal antibody test was reactive which confirmed the diagnosis of syphilis. Liver biopsy was then performed which showed presence of mixed inflammatory cells without any granulomas which is consistent with other cases of syphilitic hepatitis. Immunohistochemical stain was negative for treponemes. Patient was treated with penicillin and did have Jarisch-Herxheimer reaction. ALT, AST, ALP, and total bilirubin down trended after treatment. Repeat tests drawn exactly 1 month post treatment showed normal levels of ALT, AST, ALP, and total bilirubin (Figure). Discussion(s): Liver damage can occur in syphilis and can easily be missed because of the non-specific nature of presenting symptoms. In our patient, the fine macular rash on both hands and feet along with history of sexual activity with men prompted us to test for syphilis which ultimately led to diagnosis and treatment in a timely manner. (Figure Presented).

Consumption of systemic antibiotics in the Russian Federation in 2017-2021.

Objective. To assess level and the structure of systemic antibiotic consumption in Russia over the period 2017 to 2021. Materials and methods. Data were collected and analysed in compliance with the standard protocol of the World Health Organization Regional Office for Europe by the means of ATC/DDD methodology for J01 group - antibacterials for systemic use. Consumption was calculated for outpatients and inpatients separately as a number of DDDs per 1000 inhabitants per day (DID) for the main classes of antibiotics and the agents with the highest or the most diverse consumption levels for the given period of time, and was based on the data of wholesale purchases and public tenders. Results. Antibiotic consumption in Russia in 2017, 2018, 2019, 2020, and 2021 was 16.6 DID, 14.3 DID, 14.8 DID, 19 DID, and 15.7 DID respectively. Penicillins, macrolides and lincosamides, and quinolones had the highest levels of consumption in outpatients. Prominent increase in outpatient consumption of antibacterials in 2020 was related to three agents: azithromycin, levofloxacin and ceftriaxone. Cephalosporins (mainly III-V generations), quinolones and penicillins had the highest levels of consumption in inpatients. Hospital consumption of meropenem, tigecycline, and vancomycin increased and amikacin and ciprofloxacin decreased over the duration of the study. Conclusions. Levels of systemic antibiotic consumption in Russia for the period 2017 to 2019 were relatively low and consistent with the average means for European Union and European Economic Area countries. The steep increase in consumption in 2020 was probably due to the wide use of antibiotics for the management of COVID-19 patients. The results of the study can be of value for the development of targeted national antibiotic stewardship programs and awareness campaigns as well as for the analysis of trends of emergence and spread of antibiotic resistance.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

Clinico-Epidemiological Profile of Cutaneous Adverse Drug Reactions at Rural Tertiary Care Centre

Background: Cutaneous adverse drug reactions (CADRs), also known as toxidermia, are skin manifestations resulting from systemic drug administration and it constituted 10%-30% among all reported adverse drug reactions (ADRs). These reactions range from mild morbilliform drug rash to much more severe reactions. Material(s) and Method(s): A retrospective observational study was conducted at dermatology outpatient department of rural based tertiary care center for a duration of 03 years from August 2019 to July 2022, a total of 211 patients who had been clinically diagnosed or were suspected to have drug reactions were studied. Result(s): In this observation there was male preponderance (59.72%) and majority of patients were in their 3rd and 4th decade (40.28%) with maculopapular drug rash (33.17%) being most common clinical profile of CADRs, followed by urticaria (23.70%). Less frequently seen CADRs were acneiform eruptions (21), hair Loss (9), photodermatitis (9), generalised pruritus (7), erythroderma (2), pityriasis rosea (2), Stevens Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN) (4), lichenoid drug eruptions (3), Vasculitis (1) and pustular drug eruption (1). The most common group of drugs causing CADRs were antibiotics (40.28%), followed by NSAIDs (28.43%). Conclusion(s): Cutaneous Adverse Drug Reactions (CADRs) are price we pay for the benefits of modern drug therapy;knowledge of these reactions is important for treating physician as prompt recognition and treatment can prove lifesaving.Copyright © 2022 Academic Medicine and Pharmacy

Identification of Multi Drug Resistant Bacteria from Drinking Water Samples - A Microbial Survey

Antimicrobial resistance may result from rising resistance patterns of commercially available antibiotics, which is one of the most serious threats to global health and should not be overlooked while the world is focused on the COVID-19 disaster. Waterborne resistant bacteria have been shown to be capable of spreading to people in a lot of circumstances, particularly crowded places in urban living environment with heavy human behavior, such as drinking in public systems and swimming pools. Four hundred drinking water samples were collected from different zones in district Lahore, Pakistan. Multidrug resistance bacterial strains of waterborne pathogens have been isolated and characterized on the basis of colony characteristics, microscopic visuality and biochemical tests. The outcomes of this project revealed that Staphylococcus aureus was (26%), Escheria coli was (45%), Salmonella typhi (15%), Shigella dysenteriae (10%) and Enterococcus faecalis (4%) in district Lahore, Pakistan. These multidrug resistance bacteria showed high resistant patterns against amoxicillin, penicillin, streptomycin, tetracycline, erythromycin, gentamycin, amikacin whereas susceptible for chloramphenicol, cefixime, ofloxacin and ciprofloxacin. The prevalence of associated risk factors such as polluted drinking water (32%), children<5year age (22%), adults >45year age (18%), excessive use of antibiotics (8%), health status of individual (5%), smoking habits (6%), and emotional variables (6%) were observed in this research. These investigations have demonstrated infectious bacterial contamination in surface and groundwater, which caused significant bowel syndrome.Copyright © 2022 Indian Veterinary Assocaition. All rights reserved.

Macrophage membrane-biomimetic adhesive polycaprolactone nanocamptothecin for improving cancer-targeting efficiency and impairing metastasis

The recent remarkable success and safety of mRNA lipid nanoparticle technology for producing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines has stimulated intensive efforts to expand nanoparticle strategies to treat various diseases. Numerous synthetic nanoparticles have been developed for pharmaceutical delivery and cancer treatment. However, only a limited number of nanotherapies have enter clinical trials or are clinically approved. Systemically administered nanotherapies are likely to be sequestered by host mononuclear phagocyte system (MPS), resulting in suboptimal pharmacokinetics and insufficient drug concentrations in tumors. Bioinspired drug-delivery formulations have emerged as an alternative approach to evade the MPS and show potential to improve drug therapeutic efficacy. Here we developed a biodegradable polymer-conjugated camptothecin prodrug encapsulated in the plasma membrane of lipopolysaccharide-stimulated macrophages. Polymer conjugation revived the parent camptothecin agent (e.g., 7-ethyl-10-hydroxy-camptothecin), enabling lipid nanoparticle encapsulation. Furthermore, macrophage membrane cloaking transformed the nonadhesive lipid nanoparticles into bioadhesive nanocamptothecin, increasing the cellular uptake and tumor-tropic effects of this biomimetic therapy. When tested in a preclinical murine model of breast cancer, macrophage-camouflaged nanocamptothecin exhibited a higher level of tumor accumulation than uncoated nanoparticles. Furthermore, intravenous administration of the therapy effectively suppressed tumor growth and the metastatic burden without causing systematic toxicity. Our study describes a combinatorial strategy that uses polymeric prodrug design and cell membrane cloaking to achieve therapeutics with high efficacy and low toxicity. This approach might also be generally applicable to formulate other therapeutic candidates that are not compatible or miscible with biomimetic delivery carriers. © 2022 The Authors

Massive empyema due to Lactococcus garvieae

Introduction Lactococcus garvieae, a zoonotic pathogen, may rarely infect humans through the consumption of fish. Documented manifestations of L. garvieae infection in humans include infective endocarditis, prosthetic joint infections, liver abscesses, peritoneal dialysis-associated peritonitis, osteomyelitis, meningitis, infective spondylodiscitis, acalculous cholecystitis, and urinary tract infection. Case report An 87-year-old female was hospitalized for coffee-ground emesis secondary to acute gastritis after eating cooked fish. One week after her discharge, she developed new-onset confusion and was returned to the hospital. Chest computed tomography revealed total consolidation of the left lung and a multiloculated left pleural effusion. The patient required intubation and direct admission to the intensive care unit. Pleural fluid and blood cultures grew L. garvieae, which was susceptible to ceftriaxone, penicillin, and vancomycin. Despite intensive antibiotic therapy and supportive care for thirteen days, the patient remained in irreversibl e shock, and the family opted for comfort care. Conclusions Heretofore unreported, this case demonstrates that L. garvieae can cause bronchopneumonia and empyema. Copyright © GERMS 2022.

Not all shortness of breath and throat pain is COVID

Case Report: A previously, healthy 18-year-old female presents to a Pediatric Emergency Medicine Department with shortness of breath, fever, and worsening throat and abdominal pain for 3 days. She had a sick contact, a teacher that tested positive for COVID-19 2 weeks prior to presentation. She denies runny/stuffy nose, cough, loss of taste/smell, or rashes/lesions. She denies any significant past medical history including allergies, as well as any history of smoking or any illicit drug use. Upon arrival to the ED, the patient was noted to be tachycardic, hypotensive and febrile. There were no desaturations. Initial physical examination revealed a generally uncomfortable female that was alert and oriented, with noted tenderness over the right anterior neck region, diffuse cervical lymphadenopathy, and painful neck range of motion. Her pharynx was noted to be erythematous without exudates or any unilateral tonsillar swelling. In the ED patient received IV fluid resuscitation and was started on norepinephrine drip, broad spectrum antibiotics. Initial lab workup revealed an anion gap metabolic acidosis, likely secondary to uremia or lactic acidosis from poor perfusion in setting of sepsis and hypovolemia. BUN and creatinine were elevated, likely due to an acute kidney injury (AKI) secondary to hypovolemia. The patient was also found to have an elevated LDH, fibrinogen, and mild elevation of AST. D-Dimer was elevated at 29 000. Covid PCR, Rapid Strep, and respiratory PCR panel were negative. Her chest X-ray (CXR) was negative and ECG showed sinus tachycardia. Given the patient's history of throat and neck pain with shortness of breath, in the setting of a septic picture, a CT scan of neck, chest, abdomen was ordered prior to transferring the patient to the PICU. CT scan of the chest revealed small patches of consolidation with ground glass opacities in the right lung apex, as well as an nearly occlusive, acute thrombosis of the anterior right facial vein. The patient's initial blood cultures grew gram negative bacilli which later were revealed to be Fusobacterium necrophorum. These findings are consistent with Lemierre's syndrome. The patient was treated in the PICU on vasopressors, heparin anticoagulation, and antibiotics for 6 days and discharged with a course of Augmentin. Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein. First described by Andre Lemierre in 1936, it begins as a bacterial pharyngitis, generally developing into a peritonsillar abscess or other deep space neck infection with progressive erosion into the internal jugular vein. Diagnostic criteria for Lemierre's syndrome includes radiographically evidence of thrombophlebitis of the internal vein and positive blood cultures. CT and MRI can help make the diagnosis, but are not always required. Treatment is prompt intravenous antibiotics with beta-lactamase penicillins, metronidazole, clindamycin, and third generation cephalosporins. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

Community-acquired Methicillin-resistant Staphylococcus aureus Pneumonia and Parapneumonic Effusion in a Male Patient with Diabetes: A Case Report

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a primary health concern. They are commonly differentiated as hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, based on their epidemiology, susceptibility findings, and molecular typing patterns. Therefore, appropriate contact precautions and isolation measures should be implemented. CA-MRSA mostly causes skin and soft-tissue infections, but the probability and incidence of it causing sepsis and invasive infections have increased dramatically in recent years. In this study, we report a case of CA-MRSA pneumonia with pan-pneumonic effusion in a 59-year-old male diabetic patient with preexisting comorbidities such as diabetic ketoacidosis and non-ST elevated myocardial infarction. The early reporting of the organism's identity and its antimicrobial susceptibility, as well as timely initiation of antibiotic therapy, aided in the successful management and cure of the patient.

THE CAT IS OUT OF THE BAG: PASTEURELLA BACTEREMIA AND PNEUMONIA CAUSING SEPTIC SHOCK IN AN IMMUNOCOMPETENT PATIENT

SESSION TITLE: Atypical Cases of Sepsis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pasteurella multocida is a Gram-negative coccobacillus that causes infections after animal bites or scratches. It typically manifests as cellulitis but severe infections are possible though rare. We present a case of an immunocompetent man with COVID-19 who developed septic shock due to P. multocida bacteremia and pneumonia with no evidence of wound infection. CASE PRESENTATION: A 59-year-old Hispanic man with a history of anxiety and HLD presented with 10 days of nausea, vomiting, chills, and nonproductive cough. He was initially afebrile, on room air but tachycardic. His physical exam was unremarkable. Labs revealed WBC 10x10*3/uL, procal 3.3 ng/mL, negative lactic acid, and positive COVID-19. CT chest showed a right upper lobe consolidation with bilateral patchy infiltrates. He was admitted for sepsis secondary to COVID and superimposed bacterial pneumonia. Ceftriaxone, azithromycin, remdesivir, and dexamethasone were started. Overnight, the patient desaturated to low 80s and required HFNC FiO2 65%. In the morning, FiO2 increased to 80%. ICU was called and upon their assessment, the patient was febrile, tachycardic, tachypneic, hypotensive, and saturating 87-88% on HFNC FiO2 70%. Labs showed WBC 3.1 with left shift, Cr 1.7 mg/dL, lactic acid 5 mmol/L, and procalcitonin >100. He was intubated given persistent hypoxia and increased work of breathing. Antibiotics were broadened to vancomycin, pip/tazo, and azithromycin. The patient acutely decompensated after intubation, requiring multiple high-dose pressor support. Prelim blood cultures grew Gram-negative bacteria so antibiotics were broadened to meropenem. TTE was negative for endocarditis. Pressors were eventually weaned and the patient was extubated. Blood cultures grew P. multocida in 4/4 bottles so meropenem was narrowed to penicillin. His family reported that he was living at a friend's house with cats around but was unaware of any bites or scratches and he had no history of splenectomy. No portal of entry was noted upon careful skin examination. The patient continued to improve clinically with procal that rapidly downtrended. He was eventually discharged home. DISCUSSION: The mortality for severe P. multocida presentations is about 25-30%. Severe cases are generally reported in elderly, immunocompromised, or young immunosuppressed patients. We report what is to our knowledge, the first case of a severe P. multocida infection in an immunocompetent middle-aged man in the background of a COVID-19 infection. It is unclear the degree of COVID contribution and if his bacteremia preceded the pneumonia. His morbidity was primarily driven by the P. multocida bacteremia and pneumonia given the localized right upper lobe consolidation, elevated procal that rapidly decreased with antibiotics, and quick improvement and extubation. CONCLUSIONS: P. multocida infection should be considered in any patient with septic shock and exposure to animals. Reference #1: Blain H, George M, Jeandel C. Exposure to domestic cats or dogs: risk factor for Pasteurella multocida pneumonia in older people? Journal of the American Geriatrics Society. 1998;46(10):1329-1330. Reference #2: Tseng HK, Su SC, Liu CP, Lee CM. Pasteurella multocida bacteremia due to non-bite animal exposure in cirrhotic patients: report of two cases. Journal of microbiology, immunology, and infection= Wei mian yu gan ran za zhi. 2001;34(4):293-296. Reference #3: Kofteridis DP, Christofaki M, Mantadakis E, et al. Bacteremic community-acquired pneumonia due to Pasteurella multocida. International Journal of Infectious Diseases. 2009;13(3):e81-e83. doi:10.1016/j.ijid.2008.06.023 DISCLOSURES: No relevant relationships by Joanne Lin No relevant relationships by Harjeet Singh No relevant relationships by Jose Vempilly No relevant relationships by Joshua Wilkinson

A BLOODY MASQUERADE: A CURIOUS CASE OF HEMOPTYSIS

SESSION TITLE: Variety in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Actinomyces is a Gram-positive anaerobic and micro aerophilic filamentous bacillus that normally colonize the human mouth and digestive and urogenital tracts. They most commonly cause cervical and abdominopelvic infections and rarely pulmonary actinomycosis. CASE PRESENTATION: 67-year-old female with past medical history of recurrent DVT with IVC filter placement, non- ischemic cardiomyopathy, atrial fibrillation, 40 pack year history, recent COVID19 infection, lung nodules & COPD presented with complaint of coughing up blood associated with chest pain for the past 2 days. She had a low-grade fever with stable vitals with preliminary labs showing she was anemic and had reactive leukocytosis. She was recommended to hold oral anticoagulation and follow-up outpatient during when her symptoms worsened. On admission she was started on tranexamic acid nebulization for hemostasis and underwent CTA chest which showed no evidence for pulmonary embolism but commented on a right lower lobe perihilar 12.5 mm mass which has increased in size compared to previous scans. Patient underwent bronchoscopy which showed generalized edema of the tracheobronchial tree with bleeding from superior segment of the right lower lobe bronchus with no visualization of mass. PET scan showed hyper-metabolic lung mass with concerns for malignancy. CT guided biopsy of nodule was done and was not staining for malignant cells, acid fast bacilli with no fungal or bacterial growth. Blood cultures and Karius Digital cultures were also negative. She began expectorating blood clots despite being on treatment and cardiothoracic surgery was consulted. A partial lobectomy with lysis of adhesions of the right lower lobe was done. Specimen sent to pathology showed no evidence for malignancy but instead elicited a contained pulmonary abscess containing filamentous bacteria with parenchymal inflammation with areas of chronic hemorrhagic fibrosing pleuritis and hilar thrombi. She was diagnosed with pulmonary actinomycosis and started on IV 24,000,000 IU penicillin. She underwent a panoramic dental x-ray which was read as suboptimal dentition with multiple missing teeth and did not identify a source. Patient symptoms resolved post lobectomy and since discharged on long course of antibiotics. She continued to have no more episodes of hemoptysis. DISCUSSION: Hemoptysis as a symptom of pulmonary actinomycosis is a rather rare presentation. Actinomycosis causes cavities, nodules, and pleural effusions. It is commonly mistaken for chronic suppurative lung disease and sometimes malignancy. Isolation and identification occur only a minority of cases with a high culture failure rate due to previous antibiotic therapy, inadequate incubation time or culture conditions. CONCLUSIONS: Due to it's variable presentation pulmonary actinomyces has a large overlap with other diseases but must be considered in the differential of unexplained hemoptysis. Reference #1: Hemoptysis secondary to actinomycosis: A rare presentation. PMID: 24778485 PMCID: PMC3999682 DOI: 10.4103/0970-2113.129864 DISCLOSURES: No relevant relationships by Victoria Famuyide No relevant relationships by rukhsaar khanam

STUDYING THE ETIOLOGY OF COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN TREATED IN THE HOSPITAL

The study determined the etiological structure and sensitivity to antibacterial agents of pathogens of uncomplicated and complicated forms of pneumonia in children treated in a multidisciplinary hospital. According to the study, that timely bacteriological diagnosis in the treatment of pneumonia in childhood with an adequate selection of effective antibacterial agents helps reduce hospitalizations and the development of complicated forms of pneumonia.

The Agency for Health care Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use: Antibiotic Stewardship Implementation in 63United States Pediatric Practices During the COVID-19 Pandemic

Purpose/Objectives: The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship principles into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing among participating pediatric primary and urgent care ambulatory practices during the COVID-19 pandemic. Design/Methods: The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) establish antibiotic stewardship programs, (b) address attitudes and culture that pose challenges to judicious antibiotic prescribing, and (c) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Monthly data on total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing were collected from all participating practices during the pre-intervention period (September 2019-November 2019) and during the Safety Program (December 2019-November 2020). Data from the beginning to the end of the Safety Program were compared using linear mixed models to account for random effects of participating sites and repeated measurements of outcomes within practices over time. Results: The 63 participating pediatric practices included 23 general pediatric clinics (37%) and 40 pediatric urgent care clinics (63%). 60 practices submitted complete data for analysis, including 1,040,810 visits. Visits/practice-month declined March-April 2020 but exceeded baseline by Safety Program end (Figure 1). Total antibiotic prescribing declined by 16 prescriptions/100 visits (95% CI: -18 to -14) from November 2019 and November 2020. ARI visits/practice-month similarly declined March-June 2020 after widespread recognition of the COVID-19 epidemic, and remained below baseline by Safety Program end (Figure 2). ARIrelated antibiotic prescriptions decreased by 16 prescriptions/100 ARI visits (95% CI: -20 to -12) from November 2019 to November 2020. Among antibiotic classes, the greatest change was in penicillins. Prescriptions for penicillins was reduced by 11 prescriptions/100 ARI visits (95% CI: -14 to -8). Conclusion/Discussion: During the COVID-19 pandemic, while visit rates gradually normalized, a national ambulatory Antibiotic Stewardship program was associated with declines in overall and ARI-related antibiotic prescribing.

TIGECYCLINE INDUCED ACUTE PANCREATITIS: A RARE CASE PRESENTATION

CASE: An 81-year-old female with multiple co-morbidities including recent covid-19, presented to the emergency room with shortness of breath. On arrival, she was febrile with a temperature of 101F, pulse 100 beats/min, respiratory rate 14, blood pressure 196/163 and saturating at 75% on 10 L non-rebreather mask. Initial blood work showed WBC 10.9, lactic acid 1.7, BUN/creatinine 27/1.7 (consistent with her baseline), ABG showed pH 7.37, PCO2 49, PO2 88, HCO3 27.9. Chest x-ray demonstrated volume loss in the left hemithorax, airspace disease in the left mid lung and lung base. Due to suspicion for superimposed bacterial pneumonia and positive blood cultures for staphylococcus haemolyticus, she was started on vancomycin and azithromycin. Choice of antibiotics was challenging as she was allergic to penicillin and cephalosporins. During hospitalization, her kidney function deteriorated, vancomycin was substituted with tigecycline on day 3. Day 5 of treatment, she developed multiple episodes of vomiting with epigastric pain, lipase was 4523. Acute pancreatitis was diagnosed with tigecycline presumed to be the inciting agent in the absence of other risk factors such as gall stones, chronic alcohol use, elevated triglycerides, previous known episodes of pancreatitis or any other causative medications. Tigecycline was switched back to vancomycin and she received aggressive IV fluid hydration which also improved her kidney function. Within 48 hours, the patient had improved oxygen saturation, resolution of her abdominal pain, and good oral intake marking significant overall clinical progress. She was discharged on home oxygen and few more days of IV vancomycin for bacteremia. IMPACT/DISCUSSION: Tigecycline is a broad-spectrum glycylcycline antimicrobial agent belonging to the tetracycline class of antibiotics. Tetracyclines have been associated with acute pancreatitis in literature, and concerns about tigecycline-induced acute pancreatitis have been raised over the past decade in post marketing surveys, we described one such case above. Using the Naranjo Adverse Drug reaction probability scale, a score of 6 was achieved, indicating that the patient's pancreatitis was probably related to tigecycline. CONCLUSION: We recommend physicians monitor patients for signs and symptoms of pancreatitis including abdominal pain after initiating treatment with tigecycline. There should be a low threshold for ordering lipase levels and abdominal CT imaging where indicated. If the patient has symptoms concerning for acute pancreatitis, consider stopping tigecycline and switching to a different class of antibiotics immediately.

Clostridium perfringens Spores in Urology Hospital

Background: Clostridium spp. spores are resistant to many factors, including alcohol-based disinfectants. The presence of clostridial spores in a hospital environment may lead to infection outbreaks among patients and health care workers. Objective: This study is aimed to detect clostridial spores in the aurology hospital using C diff Banana Broth™ and assess the antibiotic sensitivity and toxinotypes of isolates. Methods: After diagnosing COVID-19 in medical staff and closing an 86-bed urology hospital in 2020 for H2O2 fogging, 58 swabs from the hospital environment were inoculated to C diff Banana Broth™, incubated at 37°C for 14 days, checked daily, and positive broths were sub-cultured anaerobically for 48 h at 37°C. After identification, multiplex PCR (mPCR) was performed for Clostridium perfringens, C. difficile toxin genes, and minimum inhibitory concentration (MIC) determination. Results: In this study, 16 out of 58 (~ 28%) strains of Clostridium spp. were cultured: 11-C. perfringens, 2-C. baratii, and 1 each of C. paraputrificum, C. difficile, and C. clostridioforme. 11 C. perfringens were positive for the cpa, 7-the cpb2, 2 – cpiA, and 1 – cpb toxin genes. All isolates were sensitive to metronidazole, vancomycin, moxifloxacin, penicillin/tazobactam, and rifampicin. Two out of the 11 C. perfringens strains were resistant to erythromycin and clindamycin. Conclusions: Regardless of the performed H2O2 fogging, antibiotic-resistant, toxigenic strains of C. perfringens (69%) obtained from the urology hospital environment were cultured using C diff Banana Broth™, indicating the need to develop the necessary sanitary and epidemiological procedures in this hospital.

Impact of COVID-19 Pandemic on Antimicrobial Resistance Pattern;Transition from Resistivity to Susceptibility

Objective: The study aimed to assess the antibiotic resistance pattern before and after the pandemic to provide the physicians with general guidance for antibiotic prescribing. Material and Methods: The yearly antibiograms of different tertiary care hospitals were extracted from Pakistan Antimicrobial Resistance (AMR) Network. The data timeline observed was from January 2016 to December 2020. The data were scrutinized to the most common organism studied with the most recurring antimicrobial used. Results: Among the Gram-positive organisms, increased resistivity against penicillin was observed against both the organism, while a good susceptibility was observed against vancomycin. Among the Gram-negative organisms, the highest resistance was observed in Ceftriaxone, Ciprofloxacin, and Cotrimoxazole. Staphylococcus aureus and Escherichia coli are the most prevalent organisms in tertiary care hospitals. Conclusion: While satisfactory susceptibility was observed in Amikacin and Piperacillin/Tazobactam. The post-pandemic era resulted in a decrease in AMR due to significant changes in antibiotic prescribing patterns. This report may guide future antibiotic prescribing.

RESISTANCE FACTORS OF KLEBSIELLA PNEUMONIAE BACTERIA DURING COVID-19 PANDEMIC

Multidrug-resistant K. pneumoniae bacterial strains producing extended range of beta-lactamases or carbapenemases are of serious clinical concern. The aim of the study was to determine the resistance factors of K. pneumoniae strains isolated from the lower respiratory tract of patients diagnosed with community-acquired pneumonia during the COVID-19 pandemic. Materials and methods. The study of resistance to antimicrobial drugs included 138 strains of K. pneumoniae isolated from the sputum of patients treated in infectious diseases monohospitals in the city of Tyumen and the Tyumen region within the period from May 2020 to June 2021. Among the strains examined, 51.4% of them were isolated from SARS-CoV-2 positive patients. The presence of resistance genes was determined by PCR in 71 strains of K. pneumoniae (34 strains from COVID-19-positive and 37 strains from COVID-19-negative patients). Identification of isolated bacterial strains was carried out according to the protein spectra by using a desktop time-of-flight mass spectrometer with matrix laser desorption MALDI-TOF MS (Bruker, Germany). The belonging of the strains to the hypermucoid phenotype was determined using the string test. Sensitivity to antimicrobial drugs was assessed in the disk diffusion method on Muller-Hinton medium. The sensitivity of culture strains to bacteriophage preparations was determined by the drop method (spot-test). In the study, we used “Polyvalent Sextaphage Pyobacteriophage” and “Purified Polyvalent Klebsiella Bacteriophage”, JSC NPO Microgen, Russia. Detection of resistance genes to beta-lactam antibiotics by real-time PCR was carried out using the BakRezista kit (OOO DNA-technology, Russia). The results of the study evidence that K. pneumoniae bacteria isolated from COVID-19-positive and COVID-19-negative patients diagnosed with community-acquired pneumonia displayed a high resistance to antimicrobial drugs and commercial phage-containing drugs. Resistance of K. pneumoniae strains was recorded from 50% (to aminoglycosides and carbapenems) to 90% (to inhibitor-protected penicillins). Sensitivity to bacteriophages was noted on average in no more than 20% of strains. It is important to emphasize that strains isolated from COVID-19-positive patients more often showed a hypermucoid phenotype, suggesting a high bacterial virulence, and also showed greater resistance to all groups of antibacterial drugs examined in the study, which is confirmed by the presence of resistance genes of the ESBL group and carbapenemase. The results of the study suggest that the high level of resistance of K. pneumoniae strains isolated from COVID-19-positive patients is associated with immunosuppression provoked by the SARS-CoV-2 virus, which contributes to their colonization by more virulent strains.