Providing value to patients and providers via a pediatric statewide antibiogram in South Carolina.

Objective: Antimicrobial stewardship has special challenges in particular populations and facilities, including pediatrics. We sought to augment the information available to antimicrobial stewardship programs (ASPs) by created a cumulative statewide antibiogram for neonatal and pediatric populations. Methods: In the Antimicrobial Stewardship Collaborative of South Carolina (ASC-SC), we created statewide antibiograms, including a separate antibiogram accounting for the pediatric and neonatal intensive care unit (NICU) populations. We collated data from the 4 pediatric and 3 NICU facilities in the state to provide a cumulative statewide antibiogram. Results: Methicillin-susceptible Staphylococcus aureus was more prevalent than methicillin-resistant Staphylococcus aureus. Pseudomonas aeruginosa, Citrobacter koserii, and Acinetobacter baumannii were isolated in only 1 NICU. Conclusions: These antibiograms should improve empiric prescribing in both the inpatient and outpatient setting, providing data in some areas that historically do not have pediatric antibiogram to inform prescribing. The antibiogram alone is not sufficient independently to improve prescribing but is one important aspect of stewardship in the pediatric population of South Carolina.

Recurrent ESBL Escherichia coli Urosepsis in a Pediatric Renal Transplant Patient Treated With Antibiotics and Bacteriophage Therapy.

INTRODUCTION: Treating recurrent multidrug resistant (MDR) urosepsis in pediatric transplant recipients can be challenging. Particularly when antibiotics fail to prevent future occurrence and the nidus is seemingly undiscoverable. While there is an increasing amount of data on phage therapy, to our knowledge, there are no published cases involving pediatric renal transplant recipients. Therefore, we present a challenging clinical case in which phage therapy was used in a pediatric renal transplant recipient who developed recurrent MDR urosepsis with an unclear source. CASE PRESENTATION: Our patient was a 17-year-old female who initially developed urosepsis caused by extended-spectrum ß-lactamase (ESBL) Escherichia coli , while being treated with an immunosuppressant regimen because of kidney rejection secondary to poor immunosuppression therapy compliance. She was admitted to our hospital intermittently for 4 months with 4 episodes of urosepsis caused by ESBL E. coli . She received multiple courses of antibiotics (mainly ertapenem) and underwent a fecal material transplant to eradicate her ESBL E. coli colonized gastrointestinal tract. Because of recurrent development of urosepsis after antibiotic treatment, she later underwent treatment with a phage cocktail consisting of 2 isolate-specific phages. After a prolonged antibiotic course and subsequent 3-week intravenous phage treatment, she had no ESBL E. coli in her urinary cultures for 4 years post-treatment. DISCUSSION: This case highlights the challenges of treating recurrent ESBL E. coli infections in a pediatric renal transplant patient and provides evidence that phage therapy may prove useful in such cases.

Evaluation of Time to Resolution of Medical Necrotizing Enterocolitis Using Severity-Guided Management in a Neonatal Intensive Care Unit.

OBJECTIVE: No studies, to our knowledge, have determined the relationship between symptom resolution and timing of antimicrobial discontinuation in necrotizing enterocolitis (NEC). Our study seeks to determine the period to NEC resolution by using severity-guided management, based on surrogate markers used in the diagnosis of NEC. METHODS: This retrospective, observational review included patients in our NICU with NEC from June 1, 2012, to June 1, 2018. Patients were excluded for surgical NEC, a positive blood culture or transfer from an outside institution at the time of NEC, presence of a peritoneal drain, or death prior to NEC resolution. The primary outcome was time to resolution of NEC, measured by return to baseline of surrogate markers used in the diagnosis of NEC. RESULTS: The median times to resolution in days, based on our institution's NEC severity group, were as follows: mild 3 (range, 1-4); moderate 4 (range, 1-17); severe 9 (range, 5-21). No difference in NEC recurrence was found based on antibiotic duration (OR 0.803; 95% CI, 0.142-4.225). CONCLUSIONS: Time to resolution of NEC differs by severity group, suggesting a need for different treatment durations. Recurrence of NEC did not differ between groups, suggesting that shorter antibiotic durations do not lead to an increased incidence of NEC recurrence. Further exploration of the optimal antimicrobial treatment duration for NEC is warranted.

Cefiderocol for the Treatment of Adult and Pediatric Patients With Cystic Fibrosis and Achromobacter xylosoxidans Infections.

Treatment options for Achromobacter xylosoxidans are limited. Eight cystic fibrosis patients with A. xylosoxidans were treated with 12 cefiderocol courses. Pretreatment in vitro resistance was seen in 3 of 8 cases. Clinical response occurred after 11 of 12 treatment courses. However, microbiologic relapse was observed after 11 of 12 treatment courses, notably without emergence of resistance.

Combining bacteriophages with cefiderocol and meropenem/vaborbactam to treat a pan-drug resistant Achromobacter species infection in a pediatric cystic fibrosis patient.

Cystic fibrosis is associated with significant morbidity and early mortality due to recurrent acute and chronic lung infections. The chronic use of multiple antibiotics without pathogen eradication increases the possibility of extensive drug resistance or even pan-drug resistance (PDR). It is imperative that new or alternative treatment options be explored. We present a clinical case of a 10-year-old female cystic fibrosis patient, infected with a PDR Achromobacter spp. She was treated with cefiderocol, meropenem/vaborbactam, and bacteriophage therapy (Ax2CJ45ϕ2) during two separate admissions in an attempt to clear her infection and restore baseline pulmonary function. The Centers for Disease Control and Prevention confirmed antibiotic susceptibilities, which showed resistance to both cefiderocol and meropenem/vaborbactam. However, after using all three agents concomitantly during the second treatment course, our patient's pulmonary function improved dramatically, and the Achromobacter spp. could not be isolated from sputum samples obtained 8 and 16 weeks after completion of therapy. Overall, the treatment regimen consisting of cefiderocol, meropenem/vaborbactam, and bacteriophage was safe and well-tolerated in our patient.

Fatal clindamycin-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a rare, complex, idiosyncratic drug reaction that can be fatal. Systemic symptoms include lymphadenopathy, hepatic failure, and possibly renal failure. The syndrome has been primarily associated with anticonvulsants, whereas antimicrobials are less commonly associated. We describe a 63-year-old woman who initially presented with rash and acute kidney injury secondary to treatment with clindamycin for a methicillin-susceptible Staphylococcus aureus prosthetic hip infection. Her rash progressed to desquamation of over 90% of her body surface area. Her renal function progressively declined during her hospital stay, and continuous renal replacement therapy was started. Peripheral eosinophilia was present, and urine studies were consistent with intrinsic renal failure. The patient also developed pancreatitis, hepatic failure with elevated liver enzyme levels and coagulopathy, respiratory failure necessitating mechanical ventilation, and hypotension. After a 16-day hospitalization, life-sustaining measures were withdrawn, and the patient died. Use of a cutaneous adverse drug reaction scale indicated that clindamycin was the definite cause of this patient's DRESS syndrome. To our knowledge, this is the first case report of fatal clindamycin-induced DRESS syndrome and only the second case report of DRESS attributable to clindamycin therapy. Although commonly linked with anticonvulsants, clinicians should consider the possibility of this reaction with antimicrobials, including clindamycin.