Microarray patches for managing infections at a global scale.

Since the first patent for micro array patches (MAPs) was filed in the 1970s, research on utilising MAPs as a drug delivery system has progressed significantly, evidenced by the transition from the simple 'poke and patch' of solid MAPs to the development of bio responsive systems such as hydrogel-forming and dissolving MAPs. In addition to the extensive research on MAPs for improving transdermal drug delivery, there is a growing interest in using these devices to manage infectious diseases. This is due to the minimally invasive nature of this drug delivery platform which enable patients to self-administer therapeutics without the aid of healthcare professionals. This review aims to provide a critical analysis on the potential utility of MAPs in managing infectious diseases which are still endemic at a global scale. The range of diseases covered in this review include tuberculosis, skin infections, malaria, methicillin-resistant Staphylococcus aureus infections and Covid-19. These diseases exert a considerable socioeconomic burden at a global scale with their impact magnified in low- and middle-income countries (LMICs). Due to the painless and minimally invasive nature of MAPs application, this technology also provides an efficient solution not only for the delivery of therapeutics but also for the administration of vaccine and prophylactic agents that could be used in preventing the spread and outbreak of emerging infections. Furthermore, the ability of MAPs to sample and collect dermal interstitial fluid that is rich in disease-related biomarkers could also open the avenue for MAPs to be utilised as a minimally invasive biosensor for the diagnosis of infectious diseases. The efficacy of MAPs along with the current limitations of such strategies to prevent and treat these infections will be discussed. Lastly, the clinical and translational hurdles associated with MAP technologies will also be critically discussed.

Early infection risk in patients with systemic lupus erythematosus treated with rituximab or belimumab from the British Isles Lupus Assessment Group Biologics Register (BILAG-BR): a prospective longitudinal study

Background: Patients with systemic lupus erythematosus (SLE) are at an increased risk of infection relative to the general population. We aimed to describe the frequency and risk factors for serious infections in patients with moderate-to-severe SLE treated with rituximab, belimumab, and standard of care therapies in a large national observational cohort. Method(s): The British Isles Lupus Assessment Group Biologics Register (BILAG-BR) is a UK-based prospective register of patients with SLE. Patients were recruited by their treating physician as part of their scheduled care from 64 centres across the UK by use of a standardised case report form. Inclusion criteria for the BILAG-BR included age older than 5 years, ability to provide informed consent, a diagnosis of SLE, and starting a new biological therapy within the last 12 months or a new standard of care drug within the last month. The primary outcome for this study was the rate of serious infections within the first 12 months of therapy. Serious infections were defined as those requiring intravenous antibiotic treatment, hospital admission, or resulting in morbidity or death. Infection and mortality data were collected from study centres and further mortality data were collected from the UK Office for National Statistics. The relationship between serious infection and drug type was analysed using a multiple-failure Cox proportional hazards model. Finding(s): Between July 1, 2010, and Feb 23, 2021, 1383 individuals were recruited to the BILAG-BR. 335 patients were excluded from this analysis. The remaining 1048 participants contributed 1002.7 person-years of follow-up and included 746 (71%) participants on rituximab, 119 (11%) participants on belimumab, and 183 (17%) participants on standard of care. The median age of the cohort was 39 years (IQR 30-50), 942 (90%) of 1048 patients were women and 106 (10%) were men. Of the patients with available ethnicity data, 514 (56%) of 911 were White, 169 (19%) were Asian, 161 (18%) were Black, and 67 (7%) were of multiple-mixed or other ethnic backgrounds. 118 serious infections occurred in 76 individuals during the 12-month study period, which included 92 serious infections in 58 individuals on rituximab, eight serious infections in five individuals receiving belimumab, and 18 serious infections in 13 individuals on standard of care. The overall crude incidence rate of serious infection was 117.7 (95% CI 98.3-141.0) per 1000 person-years. Compared with standard of care, the serious infection risk was similar in the rituximab (adjusted hazard ratio [HR] 1.68 [0.60-4.68]) and belimumab groups (1.01 [0.21-4.80]). Across the whole cohort in multivariate analysis, serious infection risk was associated with prednisolone dose (>10 mg;2.38 [95%CI 1.47-3.84]), hypogammaglobulinaemia (<6 g/L;2.16 [1.38-3.37]), and multimorbidity (1.45 [1.17-1.80]). Additional concomitant immunosuppressive use appeared to be associated with a reduced risk (0.60 [0.41-0.90]). We found no significant safety signals regarding atypical infections. Six infection-related deaths occurred at a median of 121 days (IQR 60-151) days from cohort entry. Interpretation(s): In patients with moderate-to-severe SLE, rituximab, belimumab, and standard immunosuppressive therapy have similar serious infection risks. Key risk factors for serious infections included multimorbidity, hypogammaglobulinaemia, and increased glucocorticoid doses. When considering the risk of serious infection, we propose that immunosupppressives, rituximab, and belimumab should be prioritised as mainstay therapies to optimise SLE management and support proactive minimisation of glucocorticoid use. Funding(s): None.Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Clinical profile of hospitalized spanish patients allergic to antibiotics

Background: Only between 1% and 10% of patients labelled of penicillin allergy are allergic. The negative events associated with this condition include risk of antimicrobial treatment failure, antimicrobial resistance, side-effects from use of a broader spectrum antibiotic, and increased healthcare costs. Our objective was to know the clinical profile of hospitalized allergic patients to estimate the future need for an allergy study. Method(s): We collected data from 15 Spanish hospitals about hospitalized patients labelled as allergic to antibiotics in February 2020 and October 2020 (one-month sample) outside the peak of the Covid-19 pandemic. Result(s): 620 patients were collected, 59% women. Mean age 70.6 years (3-103). 416 patients were labelled as allergic to beta-lactams (105 aminopenicillins, 18 cephalosporins, 4 carbapenems). 41 to aminoglycosides, 26 to macrolides, 55 to quinolones and 4 to glycopeptides. The causes of hospitalization were: Respiratory infection 221 (35.6%), abdominal infection 95 (15.3%), orthopaedic surgery 58 (9.4%), urine infections 57 (9.2%), skin infections 51 (8.2%), gynaecological/ obstetric pathology 21 (3.4%) Only 163 patients (26%) had previously received a clinical allergy work-up. 70 confirmed allergy to antibiotics, however the rest 93 (74%) were not delabelled. Patients received alone or combined alternative antibiotics: 79 glycopeptides, 49 aminoglycosides, 28 macrolides, 254 quinolones, 205 beta-lactams (102 cephalosporins, 41 carbapenems and 57 aminopenicillins). 74 patients (12%) would need an immediate allergic study in order to receive first-line antibiotic, but it was only really done in 38 (6.1%). The studied antibiotics were: 15 carbapenems, 10 ceftriaxone, and others not specified. Of the 416 patients labeled as allergic to beta-lactams, 150 (36%) received beta-lactam antibiotics despite the warning in their clinical reports. Conclusion(s): Allergy to beta-lactams remains the most frequent diagnosis of allergy to antibiotics and implies treatment with second-line antibiotics. Respiratory, trauma, digestive and urinary infections are the main causes of the use of antibiotics in hospitalized patients. The underlying diseases could be a risk factor for antibiotic requirements. Some patients received beta-Lactams despite the alert with a potential risk of an allergic reaction and legal implications. The promptly allergological study would imply an improvement in the use of more specific antibiotics with a good level of security.

Epidemiological characteristics and disease spectrum analysis of outpatients in the dermatology department of a hospital in Wuhan during the COVID-19 epidemic.

Objective: To investigate epidemiological characteristics of outpatients and disease spectrum in the dermatology department during the COVID-19 epidemic Methods: A retrospective comparison of outpatient visits, gender, age and disease types in the dermatology department of Wuhan No.1 Hospital was performed between COVID-19 epidemic period (from 23th January 2020 to 15th April 2020) and the same period in 2019. Enumeration data were analyzed by Pearson's chi-square test. Result(s): During the COVID-19 epidemic, the number of outpatient visits to the dermatology department of the hospital decreased markedly, and the average daily number of outpatient visits (236 visits/day) was only 8.81% of that during the same period in 2019 (2 678 visits/day) ;the ratio of male to female patients was reversed from 1:1.37 in 2019 to 1.16:1 in 2020;the proportions of patients aged 0-6, 7-12, 13-17 and 18-45 years significantly decreased compared with those in 2019 (all P < 0.001), and the proportions of patients aged 46-69 and > 69 years significantly increased (both P < 0.001). During the COVID-19 epidemic, there were 171 types of skin diseases in the dermatology outpatient department, and the number of disease categories decreased compared with that during the same period in 2019 (442 types) ;the number of patient visits for allergic skin diseases, erythematous papulosquamous skin diseases, viral infectious skin diseases and bacterial infectious skin diseases significantly increased compared with that during the same period in 2019 (all P < 0.001), while the number of patient visits for sebaceous and sweat gland disorders, pigmented skin diseases and physical skin diseases significantly decreased (all P < 0.001). Conclusion(s): Compared with the same period in 2019, the number of outpatient visits, patient sex ratio, age distribution and disease types in the dermatology department have undergone marked changes during the COVID-19 epidemic, and this study provides a reference for healthcare workers in dermatology department to respond to various epidemics and natural disasters in the future.Copyright © 2021 by the Chinese Medical Association.

An Early Detection Of NIPAH Infectious Disease Based On Integrated Medical Features For Human Using Ensemble RBM Techniques

Background: The importance of early diagnosis of a hazardous illness cannot be overstated. The transmission rate is extremely high, especially in the current pandemic condition. The ability to predict epidemics will aid public health in reducing mortality and morbidity. Machine Learning (ML) approaches are used in the construction of an effective disease prognosis model. Furthermore, only if the model learns good associated features from the data is it possible to generate a speedy outcome. As a result, selecting features is also necessary before beginning the forecasting process. Objective(s): However, because of the virus's dynamic structure, it's difficult to predict Nipah disease and/or zoonotic infection. Furthermore, there is no clinical treatment for Nipah. The major goal of this research is to develop a prognostic model for early diagnosis of Nipah disease using a combination of several clinical factors such as symptoms, disease incubation information, and routine blood test results confirmed by a lab technician.Proposed System: The healthcare application and data are more complex to handle than other ML applications since various clinical features are assessed throughout disease manifestation. As a result, selecting the most relevant variables is critical when designing a prognosis model for any viral disease. To deal with clinical features from a vast number of features, we proposed a Restricted Boltzmann Machine (RBM) method in this research. Additionally, we employed a hybrid ensemble learning method to predict if the patient was infected with NiV after choosing features using the RBM. Data Collection: The proposed system is being implemented using the NiV infection dataset that erupted in Kozhikode, Kerala in 2018 and 2019. Result(s): The developed stacking-based ensemble Meta classifier was successfully implemented using the python programming language, and its performance was evaluated using a variety of metrics includingaccuracy, precision, recall, f1-score, log loss, AUROC and MCC. Our proposed Stacking Ensemble Meta Classifier (SEMC) model achieved an accuracy rate of 88.3% with a log loss of 0.36. Model precision, recall, f1-score, AUROC, and MCC value were 92.5%, 89.2%, 90.9%, 92.1%, and 0.74 respectively. In addition, we calculated the gravitational pull of each feature using the SHAP approach and discovered that altered sensorium, fever, headache, and cough were the most critical clinical indicators that distinguished NiVD infection from our dataset. Therefore, this classification may assist the pathologist in diagnosing NiVD with symptoms before performing the RT-PCR medical test. Conclusion(s): Using our proposed SEMC technique, we developed a prognostic model for the diagnosis of Nipah in humans. The proposed technique's discriminatory efficiency exhibited good NiVD diagnosis efficacy. We anticipate that this model will aid medics in determining a prognosis more quickly during future epidemics. However, to achieve maximum accuracy, the model requires more unique samples.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Two-week wait skin cancer referrals to a paediatric dermatology clinic: a service evaluation

Skin cancer in children is rare. Data from the USA indicate that paediatric melanoma accounts for approximately 1% of melanomas and up to 5% of all childhood cancers, and its incidence is declining. Paediatric nonmelanoma skin cancer (NMSC) is also rare and often associated with genetic conditions or iatrogenic risk factors such as prolonged immunosuppression. In the UK, suspected cancers are referred from primary care via the '2-week wait' (2WW) pathway. National Institute for Health and Care Excellence guidance (NG12) provides criteria to guide recognition and referral, aimed at improving cancer outcomes through early detection and diagnosis. Melanoma and squamous cell carcinoma are diagnosed in approximately 6% of all 2WW skin cancer referrals;however, the vast majority of these are in adults. We evaluated all urgent paediatric dermatology referrals made via the 2WW skin cancer pathway over a 21- month period (August 2019-May 2021). In total, 172 referrals were made. Fifty-two per cent were female and mean age at time of referral was 10 years (range 2 months-17 years). The mean wait time from referral to clinical review was 9.9 days (range 1-28). Skin biopsy was arranged in 27 (15.6%) patients;nine (33.3%) of these biopsies were completed by paediatric dermatologists and 18 (66.6%) were referred to plastic surgery. There were no confirmed cases of skin cancer. Referrals were deemed inappropriate in 22% of cases. Of these, 15 (41%) were misdirected referrals and the remainder included nonlesional dermatology, including cutaneous infections (24%) and inflammatory conditions (22%). The histological diagnoses are outlined in the Table. As 2WW referrals rise, services must plan efficient and cost-effective pathways for the provision of care. Referral rates for any suspected cancer are disproportionately high in young people, including for melanoma. Signs of a 'changing mole' are less sensitive in a paediatric cohort where melanoma is more likely to present as an amelanotic or nodular lesion. Over a 21-month period, we did not identify a paediatric skin cancer among patients referred on a 2WW pathway. The service burden related to 'stopping the clock' and patient tracking is considerable and has not been formally costed. As we attempt recovery following the COVID-19 pandemic, we plan to introduce greater use of teledermatology triage to address this issue. (Table Presented).

An effective classification of Skin Disease using Deep Learning Techniques

According to WHO, Skin Infection is very common but sometimes very serious and affects a large no population all over the world. Monkeypox, Chickenpox, and Measles are the major infectious disease that causes skin infection all over the world. It has been obverse that the cases of Monkeypox have drastically increased as an effect of Covid 19. This infection has spread easily and exponentially that cause serious health issues in many underdeveloped and developing countries. Some time it has been observed that people are not able to properly classify the type of skin infection well in time, which can be a main reason of serious health issues. So, it became important to propose an effective classification of Skin Disease. In this paper the authors have proposed an effective classification of Skin Disease using Deep Learning Techniques. This approach will help in classification of chicken pox, measles, and monkeypox through skin images. The authors have utilized Monkeypox Skin Images Dataset (MSID) dataset to apply the proposed approach. The Loss, Accuracy, Precision, Recall, AUC, and F1 Score parameters have been used to analyze the performance of proposed approaches. The best algorithms with maximum accuracy and other parameters are Xception, EfficientNetV2L, and EfficientNetV2M, and CNN, VGG16, and VGG19 are the least favored algorithms for this research. © 2023 IEEE.

Joint Distraction Using An Intended Device For Knee Osteoarthritis: A Prospective Two-Year Follow-Up

Purpose: Knee distraction (KD) treatment for young (<65) patients with end-stage knee osteoarthritis (OA) has previously been shown to successfully postpone a knee arthroplasty for years by reducing pain, improving function, and inducing joint tissue repair. During KD treatment, the tibia and femur are separated ~5 mm for ~6 weeks using an external fixation device. The studies performed thus far have used proof-of-concept medical devices intended for other applications than KD. Recently, the first device specifically designed and intended for KD treatment has been developed. The purpose of the current study was to evaluate the clinical efficacy of this intended device. Method(s): In 5 hospitals, 65 patients with end-stage knee OA, in general practice considered for arthroplasty or high tibial osteotomy, were offered KD treatment by their orthopedic surgeon. Inclusion criteria were judged by the orthopedic surgeon and included age <=65 years, BMI <35 kg/m2 with weight <=110 kg, sufficient knee stability and physical condition, KL grade >=2, malalignment <=10 degrees, no history of inflammatory or septic arthritis. KD was performed according to a standardized protocol. Before and 1 and 2 years after treatment, standardized knee radiographs were performed and patients filled out WOMAC (for pain and function, 0-100, primary clinical outcome) and SF-36 (for quality of life, 0-100, secondary outcome) questionnaires. From the radiographs, minimum joint space width (JSW, mm, primary structural outcome) was measured by one experienced observer and KL grade at baseline was determined. Use of self-reported pain medication (paracetamol, opioids, NSAIDs) and intra-articular injections were registered as well, as were adverse events. Changes over 2 years were evaluated for statistical significance with paired t-tests for continuous variables and McNemar's tests for categorical variables. For the primary clinical outcome (WOMAC), clinical significance was evaluated as well, on group level defined as an increase of >=15 points and on individual level using OARSI-OMERACT response criteria. The influence of adverse effects on 2-year changes in primary outcomes was analyzed with independent t-tests. Result(s): Of the 65 treated patients (age: 53.3+/-6.7;BMI: 28.0+/-3.2;sex: 38 (55%) male;KL grade 0/1/2/3/4: 0 (0%) / 7 (11%) / 26 (40%) / 23 (36%) / 9 (14%)), 50 patients completed 2 years follow-up: 6 patients received partial or total arthroplasty (of which 3 in the 1st year) and 8 patients were lost to follow-up in the 2nd year (primarily due to COVID restrictions). The total WOMAC score (Figure 1A/B) showed a statistically and clinically significant improvement over 1 (+28.4 points;p<0.001) and 2 (+26.2 points;p<0.001) years, as did all the subscales (all p<0.001). After 1 year 72% of patients were OARSI-OMERACT responders, while after 2 years this was 51%. The minimum JSW (Figure 1C/D) significantly improved over 1 (+0.5 mm;p<0.001) and 2 (+0.4 mm;p=0.015) years as well. The physical component scale of the SF36 (Figure 2A/B) showed statistically significant improvement over 1 (+10.5 points;p<0.001) and 2 (+9.8;p<0.001) years, while the mental component scale (Figure 2C/D) did not (both p>0.26). The most common adverse event (Table 1) was pin tract skin infections, experienced by 46 (71%) of patients. In most cases (36;78% of cases) they could be treated with oral antibiotics, while in 3 of the cases (5% of treated patients) hospitalization and/or intravenous antibiotics were needed. Also, 8 (12%) of patients experienced device related complications. Experiencing pin tract infections or device complications did not significantly influence 2-year changes in primary outcomes in these patients (both p>0.05). Before treatment, 39 (60%) of patients used pain medication (Table 2), most often paracetamol (20;31%) or NSAIDs (16;25%). Around half used them daily. After treatment, significantly less patients used pain medication (p<0.001), with 35% at 1 year and 36% at 2 years. In total 12 (18%) patients had received an intra-arti ular injection before KD treatment, of whom 5 (8%) steroids and 3 (5%) hyaluronic acid. Both in the 1st and 2nd year after treatment, 1 patient (2%) received an injection. Conclusion(s): Patients treated with the first device intended for KD treatment showed significant clinical and structural improvement after 1 and 2 years. Importantly, the effect was clinically relevant, as a majority of patients were clinical responders and pain medication use decreased. Long-term evaluation will show whether arthroplasty can be postponed successfully as well. [Formula presented] [Formula presented] [Formula presented] [Formula presented]Copyright © 2023

The Impact of Earthquakes on Public Health: A Narrative Review of Infectious Diseases in the Post-Disaster Period Aiming to Disaster Risk Reduction.

Earthquakes are among the most impressive natural phenomena with very high potential to set off a chain of effects that significantly affects public health through casualties and injuries. Related disasters are attributed not only to the strong ground motion and coseismic phenomena but also to secondary effects, comprising mainly landslides and tsunamis, among others. All these can create harsh conditions favorable for the emergence of infectious diseases that are capable of causing additional human and economic losses and disruption of the emergency and recovery process. The present study comprises an extensive narrative review of the existing literature on the earthquake-triggered infectious diseases recorded worldwide, along with their symptoms, causative pathogens, associated risk factors, most vulnerable population groups, and prevention strategies. Respiratory, gastrointestinal, and vector-borne diseases, as well as wound and skin infections, are mainly recorded among the earthquake-affected population. Measures for effectively preventing earthquake-triggered infectious diseases are also proposed. One of the widely proposed measures is the establishment of a proper disease surveillance system in order to immediately and effectively identify the pre- and post-disaster occurrence of infectious diseases. This approach significantly contributes to disease trends monitoring, validation of early warning, and support of the emergency response and recovery actions.

Emerging and reemerging viral infections in globe with special emphasis in India - A review

It has long been recognized that pathogens, such as viruses, parasites, and other microorganisms, emerge and change over time. Viruses are powerful infectious agents that have co-evolved with humans and are responsible for several serious illnesses in people. There is no herd immunity for most humans, making emerging viruses, particularly the RNA viruses, more dangerous. The high mistake rate of the polymerases that copy the RNA viruses' genomes gives them the ability to adapt to the quickly changing local and global environments. Through mutation (as in the case of Dengue viruses), reassortment (as in the case of influenza viruses), and recombination, they can evolve at a rapid rate (polioviruses). The influenza A viruses (such as H1N1 and H5N1), which have caused numerous outbreaks, epidemics, and pandemics around the world, are the finest example of viruses emerging and reemerging. The complex host-pathogen ecology and the co-evolution of microbes with their hosts are linked to the emergence and reemergence of novel diseases. Human viral illness emergence and reemergence is an ongoing problem that affects a nation's social and economic growth.

Cardiac Magnetic Resonance Imaging for the Diagnosis of Infective Endocarditis in the COVID-19 Era

In the COVID-19 pandemic, to minimize aerosol-generating procedures, cardiac magnetic resonance imaging (CMR) was utilized at our institution as an alternative to transesophageal echocardiography (TEE) for diagnosing infective endocarditis (IE). This retrospective study evaluated the clinical utility of CMR for detecting IE among 14 patients growing typical microorganisms on blood cultures or meeting modified Duke Criteria. Seven cases were treated for IE. In 2 cases, CMR results were notable for possible leaflet vegetations and were clinically meaningful in guiding antibiotic therapy, obtaining further imaging, and/or pursuing surgical intervention. In 2 cases, vegetations were missed on CMR but detected on TEE. In 3 cases, CMR was non-diagnostic, but patients were treated empirically. There was no difference in antibiotic duration or outcomes over 1 year. CMR demonstrated mixed results in diagnosing valvular vegetations and guiding clinical decision-making. Further prospective controlled trials of CMR Vs TEE are warranted. © 2022 Elsevier Inc.

Newly Developed Microneedles Can Dissolve in The Skin to Deliver Drugs

Microneedles were first created for medication delivery many decades ago, but serious study on them did not commence until the mid-1990s. Microneedles, skin creams, and transdermal patches are the most extensive treatments for the transdermal administration of medications. Due to the stratum corneum layer of the skin, which acts as a barrier for the particles, multiple particles can appear at the site of action, limiting the effectiveness of the vast majority of supportive specialists. Microneedles are a further type of drug delivery device that aids in working on the transport of pharmaceuticals through this course and overcoming the numerous challenges associated with conventional nuances. The essential rule comprises interruption of the skin layer, so creating micron-sized routes that lead the drug plainly to the epidermis or higher dermis region, from which it can enter the central course straight without encountering a restriction. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

SHEWANELLA SEPTIC SHOCK COMPLICATING COVID-19 SURVIVORSHIP FOLLOWING EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) RECOVERY

SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Shewanella are gram-negative bacteria that inhabit salt and brackish watery environments, rarely causing skin and soft tissue infections. We report a case of septic shock, bacteremia, and empyema due to Shewanella in a COVID-ARDS survivor who previously received ECMO. CASE PRESENTATION: A 67-year-old man with a medical history of hypertension, diabetes, recent COVID-ARDS illness complicated with STEMI, leading to a VT/VF arrest requiring 21-days of VV-ECMO support presented three weeks after discharge due to worsening oxygen needs. The patient was hypotensive, febrile, tachycardic, tachypneic, with SatO2 92% on HFNC> 50%FIO2. Labs showed leukocytosis, lactic acidosis, and acute kidney injury. Chest x-ray showed a loculated left pleural effusion. Broad spectrum antibiotics were started. Blood cultures grew Shewanella species in aerobic and anaerobic bottles. A CT of the chest is shown (Figure 1). Thoracentesis was performed with findings consistent with empyema (Table 1). The empyema was managed with pigtail catheters and TPAse-DNAse. Pleural fluid cultures had no growth. The patient improved and was discharged on 6-week course of IV ceftazidime. DISCUSSION: Shewanella is a rare cause of skin and soft tissue infections, following traumatic injuries in association with exposure to salt or brackish water. It has also been associated with pneumonia, in the setting of near drownings, in both fresh and saltwater. Individuals with underlying liver disease and immunocompromising conditions are at the highest risk of contracting the pathogen and manifesting illness. Shewanella algae and putrefaciens may manifest as deep ulcers with hemorrhagic bullae, bacteremia, endocarditis, and meningitis (1). In addition, biliary tract infections and peritonitis can occur (2). Our patient had no epidemiologic risk factors for Shewanella infection. Although nosocomial transmission is possible, we are not aware of any previous reports of such exposure in association with this infection. Given negative pleural fluid culture with positive blood culture, we hypothesize our patient's empyema is due to Shewanella given no other apparent infectious etiology. Studies have shown that approximately 40% of pleural infection are culture negative. It is possible that antibiotic therapy started before fluid collection lowered the diagnostic yield of thoracentesis. The prevalence of bloodstream infections during ECMO ranges from 3 to 18%, with coagulase-negative staphylococcus as the most frequent cause, followed by Candida spp., Pseudomonas aeruginosa, Enterobacteriaceae, Staphylococcus aureus and Enterococcus spp. (3) with no known reports of Shewanella per the ELSO registry. CONCLUSIONS: This case may confer possible healthcare-related acquirement of Shewanella. Our case adds awareness to clinicians about potential routes of inoculation, predisposing factors, and the wide clinical manifestations of Shewanellosis. Reference #1: Weiss TJ, Barranco-Trabi JJ, Brown A, Oommen TT, Mank V, Ryan C. Case Report: Shewanella Algae Pneumonia and Bacteremia in an Elderly Male Living at a Long-Term Care Facility. Am J Trop Med Hyg. 2021;106(1):60-61. Published 2021 Nov 15. doi:10.4269/ajtmh.21-0614 Reference #2: Savini V, Marrollo R, Nigro R, Fazii P. Chapter 6-Skin and Soft Tissue Infections Following Marine Injuries. In: The Microbiology of Skin, Soft Tissue, Bone and Joint Infections. Vol 2.;2017:93-103. Reference #3: S. Biffi et al. / International Journal of Antimicrobial Agents 50 (2017) 9–16 DISCLOSURES: No relevant relationships by Akram Alkrekshi No relevant relationships by Robert Kalayjian No relevant relationships by Ismini Kourouni No relevant relationships by Srinivasa Potla No relevant relationships by Zahra Zia

INFECTIONS IN KIDNEY TRANSPLANT RECIPIENTS :SINGLE CENTER EXPERIENCE FROM TERTIARY CARE CENTER IN SOUTH INDIA

Introduction: Infections occurring in the post transplant period are the major cause of morbidity and mortality in renal transplant recipients. Early infections (within the first month) are more likely to be due to nosocomially acquired pathogens, surgical issues, and donor-derived infections. Opportunistic pathogens occur after 6 months, reflects the greater impact of immunosuppressive therapies. Late infections may be secondary to opportunistic pathogens or conventional ones. Methods: It is a retrospective observational study.All hospitalised patients with infections were included between November 2019 to march 2022 excluding covid 19 infections.Infections were categorised based on time line of infection into less than one month, 1-6 months and more than 6 months and sub categorised based on type of organisms and source of infection.All baseline characteristics, labs, microbiological including serology, PCR and cultures, radiological findings and histopathological findings were noted.Complications including graft dysfunction and need for various supports such as O2, ionotropes, ventilator and dialysis and treatment details and in hospital patient outcomes were analysed using descriptive statistics. Results: 53 patients admitted with infection in the given period were included in the study.Among them 88.67% were males and 11.33% females. In the study population 66.03 % underwent live related renal transplant and 33.97% underwent deceased donor transplantation. Mean age of the study population was 35.2 years. There were 118 events of infection identified during the study period.UTI was the most common post-transplant infection and occurred in 36.44 % of total events. There were 13 events of post-transplant infection in the first month. Most common infection in early post-transplant period was UTI, 53.84 % of events of UTI occurred followed by pneumonia in 23.07% of total events. E coli was isolated in 57.14 % of events There were 48 events of infections in the period of 1- 6 months.UTI was the most common infection (37.5 % of total events ) and E coli was the most common organism isolated(44.44 %). Pneumonia was the second commonly occurred event in 18.75 % of total events and Klebsiella was the most common isolated ( 55.56 % ).CMV disease was identified in 10.41% events, 40 % had tissue invasive CMV, 60% presented with cytopenia. There were 57 events of infections after 6 months, UTI was the most common infection(31.57% events) and E coli was the most common organism (44.00%).Pneumonia occurred in 19.29% followed by skin and soft tissue infection (13.94 %)herpes zoster ( 8.75% ) gastroenteritis(7.01%), BKVN (5.26%),oral candidiasis (3.50%)CMV disease (3.50%), tuberculosis(3.5%), meningitis (1.75%) and dengue(1.75%). 95.76% of infectious event was associated allograft dysfunction and 22.64 % of the study population had PTDM. In 15.25 % of events, patients had septic shock at presentation.Amongst them 44.44% had urosepsis, 33.33% had pneumonia, 22.22% had acute gastroenteritis. 18.86 % expired during hospital stay,amongst them 60 % had pneumonia and 30% had urosepsis and 10% had acute gastroenteritis. [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: Patients who undergo renal transplantation are subjected to immunosuppression which increase the burden of infections in the post-transplant period.Early and accurate diagnosis is the key to prevent morbidity and mortality of renal transplant recipients No conflict of interest

Decreasing Ordering and Obtaining of Lowvalue Blood Cultures in a Large Community Children's Hospital

Blood cultures are often an important part of evaluation of febrile illnesses in children. There exists a plethora of evidence suggesting routinely obtaining blood cultures in certain clinical situations, namely uncomplicated pneumonia (CAP), urinary tract infection (UTI), skin and soft tissue infection (SSTI), and viral illnesses (URI), is low-value and adds little to the management plan, while increasing risk of repeat visits, prolonged hospital stay, prolonged antibiotic course, and other unnecessary testing due to false-positive results.We sought to implement a guideline for obtaining blood cultures in the pediatric emergency department and pediatric hospital medicine floor with the goal of decreasing the obtainment of low-value blood cultures by at least 50% over a 6-month period. Baseline data was collected from July 2019 to June 2020, which included the number of blood cultures obtained in the pediatric ED and floor, result of blood cultures with organism identification (if positive), and associated visit diagnoses, particularly CAP, UTI, SSTI, and URI. An evidencebased guideline identifying patients/diagnoses with indications for obtaining a blood culture in addition to those in which it is considered low-value was created and distributed to the pediatric ED and PHM providers. Data was reviewed in the postimplementation period from July 2020 to December 2020 on a monthly basis. Results were shared with provider groups monthly and individual providers as needed. Balancing measures of re-visit/-admission and admission to a higher level of care was also tracked. A total of 830 blood cultures were obtained during the baseline period, with 230 (27.4%) of those deemed low-value. Following implementation of the guideline, a total of 320 blood cultures were obtained, with 29 (9.1%) of these deemed low-value, a percentage decrease of 67% from the baseline state. Observed balancing measures were unchanged Implementation of a guideline identifying clinical diagnoses in which routine obtainment of blood cultures is low-value led to a sustained decrease in this practice, which may positively impact other clinical variables outlined above. Interpretation of changes in individual diagnosis groups was limited by seasonality as well as COVID-19 pandemic-related decreases in patient volumes from the baseline period. Further work involving targeted order sets for these diagnoses to aid sustainability of change and increased standardization of this and other aspects of care is ongoing.

Using Individual Clinician Feedback as Key Driver for Multiple Quality Improvement Initiatives at Large Pediatric Urgent Care Network

Purpose/Objectives: Quality improvement (QI) project implementation can be complex and effective interventions can be elusive, especially at large organizations with varied clinician practice. Our institution's large group of physicians and nurse practitioners work within a seven-site pediatric urgent care network in central Ohio. With several simultaneous QI projects we found trends showing varied compliance amongst clinicians that were present across initiatives. Prior studies have shown mixed results for individual clinician feedback as a primary intervention for quality improvement;we hypothesized that it would serve as a key driver in achieving and maintaining our project goals. Design/Methods: In September of 2020 we began emailing monthly individual physician feedback for four QI projects: acute otitis media (AOM) treatment duration, skin and soft tissue infection (SSTI) treatment duration, RSV viral testing rate and viral panel testing rate. The email contained objectives for each project, gave individual performance in relation to goal, and showed ranking compared to peers. Clinician feedback was not punitive, and clinicians' rank was not shared with the larger group. The audits were reviewed for accuracy and populated monthly by QI analyst and physician QI lead. Additionally, group compliance shown as a percentage was presented bimonthly at clinician conferences. Using statistical process control charts, we were able to track progress for all projects concurrently. Results: When scorecards began, AOM and SSTI projects had already improved from baseline while RSV and viral panel testing projects were new. After scorecard initiation, the AOM project had a second baseline shift from 67% to 85% while the SSTI project was sustained at 85% and edged towards 90% (Figure 1). For our respiratory projects, the COVID 19 pandemic had diverging effects. The RSV season abruptly ended and testing dropped precipitously at our institution. As a steady increase in the prevalence of RSV returns, with the scorecard, we have not yet seen an increase in testing and are at less than 1 test per 1000 respiratory visits compared to the pre-pandemic 16 per 1000 respiratory visits (Figure 2). Conversely, for the more comprehensive viral panel testing, we saw a significant increase above the baseline with the pandemic, from 10 per 1000 respiratory visits up to 23 per 1000 respiratory visits. After initiation of the scorecard, we achieved the pre-pandemic goal of 5 per 1000 respiratory visits (Figure 2). Conclusion/Discussion: Our scorecard approach was able to show that getting consistent, reliable, and relevant clinician direct feedback can meaningfully improve clinical practice across varied QI initiatives at different stages of development and with different objectives.

ATYPICAL PRESENTATION OF LEGIONNAIRES DISEASE WITH DIVERTICULITIS IN IMMUNOSUPPRESSED PATIENT

CASE: A 69-year-old male smoker with stage 3b prostate cancer managed with abiraterone and prednisone, prior severe COVID-19 pneumonia requiring mechanical ventilation, and history of perforated sigmoid diverticulitis presented with 3 days of anorexia, watery diarrhea, and left lower abdominal pain. Two weeks earlier he developed a mild dry cough without fever, dyspnea, or chest pain. There were no sick contacts or recent travel. He was afebrile, and initial routine chemistries and a complete blood count were unremarkable. An abdomino-pelvic CT revealed acute diverticulitis of the distal descending and sigmoid colon. A consolidation at the right lung base was also incidentally noted. Follow up imaging confirmed a multifocal pneumonia on chest Xray. Legionella antigen was detected in the urine. Metronidazole and levofloxacin were initiated with clinical improvement and the patient was discharged home to complete a 10-day course of antibiotics IMPACT/DISCUSSION: Legionella bacteria are gram negative organisms found widespread in soil and bodies of water including lakes, streams, and artificial reservoirs. Transmission is via inhalation of aerosols and a high innoculum is typically needed to cause infection. Host risk factors for infection include older age, impaired cellular immunity, smoking, male sex, and medical co-morbidities such as diabetes mellitus, renal, lung and cardiovascular disease. The two most commonly known syndromes associated with Legionella infection are Legionnaire's disease, a pneumonia occurring typically in the late summer or early autumn months (as in our patient), and Pontiac fever, an acute self- limited febrile illness. The mortality rate for hospitalized Legionnaire's is up to 10%. Extra-pulmonary manifestations are rare and can include skin and soft tissue infections, septic arthritis, endocarditis, myocarditis, peritonitis, pyelonephritis, meningitis, brain abscesses, and surgical site infections. The diagnosis of extra-pulmonary disease requires detection of Legionella at the affected site by culture or polymerase chain reaction. In the absence of a known local Legionella outbreak, our patient's age, sex, smoking status, and underlying immune suppression most likely increased his risk for this sporadic infection. We postulate that the acute diarrhea associated with Legionnaire's disease may have triggered inflammation of his diverticula or the acute diverticulitis was an extra-pulmonary manifestation. To our knowledge, we are the first to report a case of Legionnaire's disease presenting as acute diverticulitis. CONCLUSION: Legionnaire's is a typical disease with many atypical and extra-pulmonary presentations. We present a case of Legionnaire's disease masquerading as acute diverticulitis and urge timely consideration and testing for Legionella in at-risk patients presenting with predominantly GI symptoms and subtle or no respiratory complaints, as it can be life-saving.

Community Acquired Methicillin-Resistant Staphylococcus Aureus Pneumonia in a Previously Healthy 12-Year-Old Male

Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) was better recognized to be a nosocomial pathogen found mainly in intensive care units and occurring especially in elderly persons. However, rare but potentially fatal cases of community-acquired MRSA infection have emerged. Risk factors such as infection of the skin or soft tissues, influenza virus infection, history of recent hospital admissions, or immunocompromised status were identified. The prevalence of MRSA in children especially those without risk factors is extremely low. Case: This is a case of a previously healthy 12-year-old male who presented with acute onset of high-grade fever and exertional dyspnea. Upon admission, the patient was in respiratory distress and hypotensive. The patient was managed as a case of severe sepsis with the following considerations: COVID-19 infection, severe pneumonia, tuberculosis, and malignancy. Although the clinical presentation and imaging findings were suggestive of pulmonary tuberculosis infection, sputum and blood culture were positive for MRSA. The patient required admission to the intensive care unit and underwent close tube thoracotomy insertion and tube pericardiostomy due to the rapid spread of infection. The patient was also treated for pulmonary tuberculosis. Thus, anti-tuberculosis medications were added to Vancomycin, with noted improvement thereafter. Discussion: This case highlights the importance of prompt and accurate diagnosis of MRSA pneumonia leading to optimal patient outcome. With this, the rapid institution of appropriate antibiotics is crucial. However, clinical diagnosis is frequently difficult resulting in to delay of diagnosis.