Incorporating patient, nursing and environmental factors into antimicrobial stewardship: effects of simplifying treatment from cefuroxime to ceftriaxone.

AIM: Our antimicrobial guidelines (AGs) were changed in 2021 to recommend once-daily ceftriaxone in place of three-times-daily cefuroxime as preferred cephalosporin. This analysis sought to assess the effects of this on incidence of Clostridioides difficile infection (CDI), third-generation cephalosporin-resistant Enterobacterales (3GCR-E) and resource utilisation. METHOD: Before and after analysis of 30-day CDI and 3GCR-E incidence following receipt of cefuroxime/ceftriaxone pre- and post-AG change. Total nursing time and waste production relating to cefuroxime/ceftriaxone delivery were calculated pre- and post-change. RESULTS: CDI incidence was 0.6% pre- and 1.0% post-change (adjusted odds ratio [aOR] 1.44, p=0.07) and 3GCR-E incidence 3.5% and 3.1% (aOR 0.90, p=0.33). Mean per-quarter estimated nursing administration time decreased from 2,065 to 1,163 hours (902 nurse-hour reduction) and antibiotic-related waste generation from 1,131kg to 748kg (383kg reduction). Overall days of therapy per-quarter of cefuroxime/ceftriaxone were unchanged between periods. CONCLUSION: This simplification of our AG from a three-times-daily to a once-daily antibiotic resulted in considerable savings for our hospital (roughly 1.7 full-time equivalent nurses and over a tonne of waste yearly), with no significant increases in CDI or 3GCR-E. The impact of dosing schedules on non-antibiotic-spectrum factors, such as nursing time and resource usage, is worthy of consideration when designing AGs.

Pharmacodynamic evaluation of ceftriaxone single-dose therapy (0.125-1 g) to eradicate ceftriaxone-susceptible and ceftriaxone-resistant Neisseria gonorrhoeae strains in a hollow fibre infection model for gonorrhoea.

BACKGROUND: Antimicrobial resistance in Neisseria gonorrhoeae is threatening the gonorrhoea treatment, and optimizations of the current ceftriaxone-treatment regimens are crucial. We evaluated the pharmacodynamics of ceftriaxone single-dose therapy (0.125-1 g) against ceftriaxone-susceptible and ceftriaxone-resistant gonococcal strains, based on EUCAST ceftriaxone-resistance breakpoint (MIC > 0.125 mg/L), in our hollow fibre infection model (HFIM) for gonorrhoea. METHODS: Gonococcal strains examined were WHO F (ceftriaxone-susceptible, MIC < 0.002 mg/L), R (ceftriaxone-resistant, MIC = 0.5 mg/L), Z (ceftriaxone-resistant, MIC = 0.5 mg/L) and X (ceftriaxone-resistant, MIC = 2 mg/L). Dose-range HFIM 7 day experiments simulating ceftriaxone 0.125-1 g single-dose intramuscular regimens were conducted. RESULTS: Ceftriaxone 0.125-1 g single-dose treatments rapidly eradicated WHO F (wild-type ceftriaxone MIC). Ceftriaxone 0.5 and 1 g treatments, based on ceftriaxone human plasma pharmacokinetic parameters, eradicated most ceftriaxone-resistant gonococcal strains (WHO R and Z), but ceftriaxone 0.5 g failed to eradicate WHO X (high-level ceftriaxone resistance). When simulating oropharyngeal gonorrhoea, ceftriaxone 0.5 g failed to eradicate all the ceftriaxone-resistant strains, while ceftriaxone 1 g eradicated WHO R and Z (low-level ceftriaxone resistance) but failed to eradicate WHO X (high-level ceftriaxone resistance). No ceftriaxone-resistant mutants were selected using any ceftriaxone treatments. CONCLUSIONS: Ceftriaxone 1 g single-dose intramuscularly cure most of the anogenital and oropharyngeal gonorrhoea cases caused by the currently internationally spreading ceftriaxone-resistant gonococcal strains, which should be further confirmed clinically. A ceftriaxone 1 g dose (±azithromycin 2 g) should be recommended for first-line empiric gonorrhoea treatment. This will buy countries some time until novel antimicrobials are licensed. Using ceftriaxone 1 g gonorrhoea treatment, the EUCAST ceftriaxone-resistance breakpoint is too low.

Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial.

BACKGROUND: Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation. METHODS: PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406. FINDINGS: From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone. INTERPRETATION: In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation. FUNDING: French Ministry of Social Affairs and Health.

Australian Gonococcal Surveillance Programme Annual Report, 2022.

The Australian Gonococcal Surveillance Programme (AGSP) has continuously monitored antimicrobial resistance in Neisseria gonorrhoeae for more than 40 years. In 2022, a total of 8,199 isolates from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. The current treatment recommendation for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2022, of N. gonorrhoeae isolates tested, 0.51% (42/8,199) met the WHO criterion for ceftriaxone decreased susceptibility (DS), defined as a minimum inhibitory concentration value ≥ 0.125 mg/L. Resistance to azithromycin was reported in 3.9% of N. gonorrhoeae isolates, proportionally stable since 2019. There were nine isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) reported in Australia: Queensland (4), New South Wales (3), Victoria (1) and non-remote Western Australia (1). This is the highest number detected annually by the AGSP. In 2022, penicillin resistance was found in 38.8% of gonococcal isolates, and ciprofloxacin resistance in 63.3%, however, there was considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low; in these settings, penicillin continues to be recommended as part of an empiric therapy strategy. In 2022, in remote Northern Territory, one penicillin-resistant isolate was reported; in remote Western Australia, 11.8% of gonococcal isolates (9/76) were penicillin resistant. There were three ciprofloxacin-resistant isolates reported from remote Northern Territory; ciprofloxacin resistance rates remain comparatively low in remote Western Australia (6/76; 7.9%).

Análisis de una guía clínica para el tratamiento y alta precoz en apendicitis aguda complicada / Analysis of a clinical guideline for treatment and early discharge in complicated acute appendicitis

Objetivo: El objetivo de este estudio es evaluar los resultados entérminos de complicaciones infecciosas y estancia hospitalaria de lainstauración de una guía clínica para el tratamiento y alta precoz enpacientes con apendicitis aguda complicada.Material y métodos: Se elaboró una guía para el tratamiento delas apendicitis en función de su grado de severidad. Las complicadas setrataron con ceftriaxona-metronidazol durante 48h, siendo alta si cumplen ciertos criterios clínicos y analíticos. Se realizó un estudio analíticoretrospectivo comparando la incidencia de abscesos intraabdominalespostquirúrgicos (AIA) e infección del sitio quirúrgico (ISQ) en pacientesmenores de 14 años sometidos a la nueva guía (Grupo A), respecto a unacohorte histórica (Grupo B), en la que la pauta de tratamiento era gentamicina-metronidazol 5 días. Además, se realizó un estudio de cohortesprospectivas para evaluar qué antibioterapia (amocilina-clavulánico ocefuroxima-metronidazol) es más eficaz en los pacientes que cumplencriterios de alta precoz. Resultados: Se incluyeron 205 pacientes menores de 14 años en elGrupo A y 109 en el Grupo B. Presentaron AIA un 14,3% en el grupoA, frente al 13,8% en el B (p= 0,83); e ISQ un 1,9% y un 8,25% respectivamente (p= 0,008). Cumplieron criterios de alta precoz el 62,7%de los pacientes del Grupo A. La mediana de estancia disminuyó a de6 a 3 días. Al alta, el 57% recibieron amoxicilina-clavulánico y el 43%cefuroxima-metronidazol, sin hallarse diferencias en términos de ISQ(p= 0,24) ni de AIA (p= 0,12).Conclusiones: El alta precoz disminuye la estancia hospitalariasin aumentar el riesgo de complicaciones infecciosas postquirúrgicas.La amoxicilina-clavulánico es una opción segura para la antibioterapiaoral domiciliaria.(AU)

Objective: The objective of this study was to assess the results of aclinical guideline for the treatment and early discharge of patients withcomplicated acute appendicitis in terms of infectious complicationsand hospital stay. Materials and methods: A guideline for appendicitis treatmentaccording to severity was created. Complicated appendicitis caseswere treated with ceftriaxone-metronidazole for 48h, with dischargebeing approved if certain clinical and blood test criteria were met. Aretrospective analytical study comparing the incidence of postoperative intra-abdominal abscess (IAA) and surgical site infection (SSI) inpatients under 14 years of age to whom the new guideline was applied(Group A) vs. the historical cohort (Group B, treated with gentamicinmetronidazole for 5 days) was carried out. A prospective cohort study toassess which antibiotic therapy (amoxicillin-clavulanic acid or cefuroxime-metronidazole) proved more effective in patients meeting earlydischarge criteria was also conducted.Results: 205 patients under 14 years of age were included in GroupA, whereas 109 patients were included in Group B. IAA was presentin 14.3% of patients from Group A vs. 13.8% from Group B (p=0.83),while SSI was present in 1.9% of patients from Group A vs. 8.25%from Group B (p=0.008). Early discharge criteria were met by 62.7%of patients from Group A. Median hospital stay decreased from 6 to 3days. At discharge, 57% of patients received amoxicillin-clavulanic acid,whereas 43% received cefuroxime-metronidazole, with no differencesbeing found in terms of SSI (p=0.24) or IAA (p=0.12). Conclusions: Early discharge reduces hospital stay without increas-ing the risk of postoperative infectious complications. Amoxicillin-clavulanic acid is a safe option for at-home oral antibiotic therapy.(AU)

Dosificación de ceftriaxona en el paciente crítico hipoproteinémico: un factor más a tener en cuenta / Dosage of ceftriaxone in the critical hypoproteinemic patient: another factor to take into account

Introducción: El objetivo principal del estudio fue evaluar la necesidad de ajuste posológico de ceftriaxona en pacientes críticos hipoproteinémicos. Pacientes y métodos: Estudio observacional y retrospectivo, llevado a cabo en la unidad de cuidados intensivos (UCI) del Hospital General Universitario de Ciudad Real (médico-quirúrgica de 21 camas), en el que se incluyeron pacientes tratados con ceftriaxona en la UCI desde enero de 2014 a diciembre de 2019 y se clasificaron en dos grupos al inicio del tratamiento: pacientes normoproteinémicos (proteínas totales >5,5g/dl) e hipoproteinémicos (proteínas totales ≤5,5g/dl).Variables principales: Edad, sexo, APACHE II, diagnóstico-localización del foco infeccioso, estancia en UCI, dosis de ceftriaxona, pauta posológica, tratamiento antibiótico concomitante, empírico o dirigido, necesidad de cambio de tratamiento, días de antibioterapia y mortalidad. Resultados: Se incluyeron 98 pacientes (44 normoproteinémicos y 54 hipoproteinémicos). No se obtuvieron diferencias estadísticamente significativas entre las características basales de ambos grupos, exceptuando la localización del foco, siendo respiratorio con mayor frecuencia en el grupo de pacientes normoproteinémicos (p=0,044). Se obtuvieron diferencias estadísticamente significativas a favor del grupo de pacientes normoproteinémicos para: estancia en UCI (p=0,001), necesidad de cambio de tratamiento antibiótico (p=0,004), días de antibioterapia (p=0,007) y mortalidad (p=0,046). Conclusión: Los resultados terapéuticos obtenidos en el grupo de pacientes críticos hipoproteinémicos tratados con ceftriaxona ponen en evidencia la necesidad de considerar la hipoproteinemia como un factor que podría condicionar dicho resultado si se emplean las pautas posológicas de tratamiento habituales. (AU)

Introduction: The main objective of the study was to evaluate the need for posologic adjustment of ceftriaxone in critical hypoproteinemic patients. Patients and methods: Observational and retrospective study, carried out in the intensive care unit (ICU) of the General University Hospital of Ciudad Real (21-bed medical-surgical), which included patients treated with ceftriaxone in the ICU from January 2014 to December 2019 and classified into two groups at the beginning of treatment: normoproteinemic (total proteins >5.5 g/dl) and hypoproteinemic (total proteins ≤5.5g/dl) patients.Main variables: Age, sex, APACHE II, diagnosis-location of the infectious site, ICU stay, ceftriaxone dose, dosage regimen, concomitant antibiotic treatment, empirical or targeted antibiotic treatment, need to change treatment, days of antibiotic therapy and mortality. Results: 98 patients were included (44 normoproteinemics and 54 hypoproteinemics).No statistically significant differences were obtained between the basal characteristics of both groups, except for the location of the infectious site, being respiratory more frequently in the group of normoproteinemic patients (p=0.044).Statistically significant differences were obtained in favour of the group of normoproteinemic patients for: stay in ICU (p=0.001), need for change of antibiotic treatment (p=0.004), days of antibiotherapy (p=0.007) and mortality (p=0.046). Conclusion: The therapeutic results obtained in the group of critical hypoproteinemic patients treated with ceftriaxone show the need to consider hypoproteinemia as a factor that could condition such result if the usual treatment dosage guidelines are used.

Neuroprotective Effect of Ceftriaxone on MPTP-Induced Parkinson's Disease Mouse Model by Regulating Inflammation and Intestinal Microbiota.

Parkinson's disease (PD) is a common degenerative disease of the central nervous system. Although some drugs can alleviate the progress of PD, their long-term use will lead to complications, so it is still necessary to find new drugs to delay or cure PD effectively. In view of the difficulty in developing new drugs, it is imperative to discover new functions of existing compounds that could be used to treat PD. In this study, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) was used to induce PD symptoms in a mouse model. Subsequently, these mice were treated with the antibiotic ceftriaxone. Ceftriaxone alleviated the behavioural and neuropathological changes induced by MPTP, downregulated the expression of glial fibrillary acidic protein (GFAP) and ionised calcium-binding adapter molecule 1 (Iba1) as markers of astroglia and microglia, respectively, and reduced the expression of neuroinflammation-related Toll-like receptor 4 (TLR4), myeloid differentiation primary response 88 (MyD88), and phosphorylated nuclear factor kappa-B (p-NF-κB)/NF-κB in the brain of PD mice. In addition, ceftriaxone reduced the abundance of pathogenic bacteria of the genus Proteus and increased the abundance of probiotic Akkermansia. Finally, ceftriaxone treatment increased the expression of the tight junction proteins zona occludens-1(ZO-1) and occludin in the colon, decreased the expression of the inflammation-related proteins TLR4, MyD88, and NF-κB in the colon, and decreased the serum concentration of the proinflammatory cytokines interleukin-1ß (IL-1ß), IL-6, and tumour necrosis factor-α (TNF-α). These results indicate that ceftriaxone had a neuroprotective effect on MPTP-induced PD mice, and its neuroprotective effect could be through regulating inflammation and intestinal microbiota. While we showed that ceftriaxone exerts a neuroprotective effect in an MPTP-induced PD mouse model, our findings are limited to the short-term effects of ceftriaxone. Additional work using transgenic mice is required to determine the long-term effects of ceftriaxone. In addition, the dose and frequency of ceftriaxone use should be evaluated.

Subacute transverse myelitis as a clinical presentation of neurobrucellosis.

Brucella melitensis is the main cause of human brucellosis worldwide and is considered the most virulent and neurotropic species. In Mexico, this species is considered endemic, being reported since the first decade of the 20th century. Here we present a case of subacute transverse myelitis with the isolation and identification of B. melitensis as the causative agent of Neurobrucellosis in a female patient from the coastal state of Guerrero, Mexico.

Clinical Significance of Postoperative Antibiotic Treatment for Positive Islet Cultures After Total Pancreatectomy With Islet Autotransplantation.

OBJECTIVES: Islet cultures are routinely performed in total pancreatectomy with islet autotransplantation (TPIAT), and the need for empiric antibiotic treatment based on culture results is unknown. We evaluated the effect of postoperative antibiotic treatment for positive islet cultures on clinical infection. METHODS: Seventy-nine patients undergoing TPIAT were reviewed. Prophylactic perioperative ceftriaxone and metronidazole were administered, and transplanted islet preparations included ciprofloxacin. Postoperative antibiotics were not routinely given for positive cultures unless a clinical infection was suspected. The primary end point was 30-day infectious complications. RESULTS: Fifty-one patients (65%) had a positive culture. Overall, 39 patients (87%) had organisms susceptible to our perioperative antibiotic regimen. There was no difference in the infectious complication rate between those with positive compared with negative cultures (16% vs 29%, P = 0.17). Patients with a positive culture had similar 30-day postoperative infectious complication rates whether receiving postoperative antibiotics (n = 7) or not (14% vs 16%, P = 0.91). Only 1 patient had a correlation of clinical and islet cultures. CONCLUSIONS: Beyond prophylactic antibiotics, empiric antibiotic treatment for a positive culture is not warranted and provides a rationale for the abandonment of routine cultures in TPIAT.

Case Report: Anaphylactoid Shock Associated with Snakebite Envenoming in Portugal.

Although rare in Portugal, snakebite envenoming entails severe morbidity and mortality. We present the case of a 65-year-old woman bitten on her leg in a northern coastal region in Portugal, on a walk during the COVID-19 pandemic lockdown. Despite first looking for help at the nearest pharmacy, she developed anaphylactoid shock and was promptly driven to a tertiary hospital, where antivenom was administered in a timely manner under close monitoring. Prophylactic antibiotics were started and maintained based on elevated inflammatory markers and signs of wound inflammation. She evolved favorably, with rapid weaning of vasopressors and resolution of end-organ dysfunction. This case highlights the importance of prompt recognition and describes crucial steps in envenomation management in a country where snakebite is infrequent, but potentially fatal.

Gonorrhea vaginitis in a pediatric patient: a case report.

Gonorrhea is all diseases caused by Neisseria gonorrhoeae. Prepubertal child is more susceptible to N. gonorrhoeae infection because the vagina is alkaline and contains no estrogen. Gonorrhea vaginitis is the most common form of gonorrhoea in prepubertal children beyond neonatal period. Transmission in child can be through sexual contact (abuse) or non-sexual contact. Gonorrhea vaginitis in children more often asymptomatic, with clinical manifestation such as mucopurulent discharge, vaginal pruritus and vulval erythema. Supporting examination comprise of gram staining from vaginal discharge, culture and nucleic acid amplification testing (NAAT). Ceftriaxone is drug of choice gonorrhea without complication in children. We report a case of 4 year and 9-month female girl that was diagnosed by history taking and supporting examination from gram staining and polymerase chain reaction (PCR) from vaginal discharge, and then treated with single dose ceftriaxone 125 mg intramuscular that gave clinical improvement.

Campylobacter fetus bacteremia and meningitis in an acute lymphoblastic leukemia patient undergoing maintenance therapy: a case report.

BACKGROUND: Campylobacter fetus is an uncommon Campylobacter species, and its infections mainly cause infective endocarditis, aortic aneurysm, and meningitis rather than enteritis. It is more likely to be detected in blood than Campylobacter jejuni or Campylobacter coli, specifically reported in 53% of patients. In our case, C. fetus was detected in both blood and cerebrospinal fluid (CSF) cultures. CASE PRESENTATION: A 33-year-old woman, who was on maintenance chemotherapy for acute lymphoblastic leukemia (ALL), presented to our clinic with chief complaints of severe headache and nausea. Blood and CSF cultures revealed C. fetus. We administrated meropenem 2 g intravenously (IV) every 8 h for 3 weeks, and she was discharged without neurological sequelae. CONCLUSION: We encountered a case of C. fetus meningitis without gastrointestinal symptoms, neck stiffness or jolt accentuation in a patient with ALL. Undercooked beef was considered the source of C. fetus infection in this case, suggesting that the need for a neutropenic diet and safe food handling be considered.

Ceftriaxone and methicillin-susceptible staphylococcus aureus: a perspective from pharmacokinetics/pharmacodynamics studies.

Introduction: Usage of ceftriaxone-based therapy to treat Methicillin-Susceptible Staphylococcus aureus (MSSA) infections is a controversial issue, from in vitro to clinical studies.Area covered: We conducted a literature review using PubMed of articles with ceftriaxone pharmacokinetics parameters and built a probability of target attainment (PTA) based on PK values from stable conditions (non-critically-ill patients) with goals of fT>55%, fT>75%, and fT>100%. Ceftriaxone's minimal inhibitory concentration from 31 MSSA strains (0.25-64 mg/L) was used to build the cumulative fraction response (CFR). The isolates were clinically relevant from blood, bronchoalveolar lavage, and soft tissue biopsy.Expert opinion: The results from controversies about using ceftriaxone for MSSA infections have been commonly addressed in the literature. However, variables such as (i) pharmacokinetic profile, (ii) pharmacodynamic target, (iii) site of infection, and (iv) MIC distributions may influence divergences. From this pharmacokinetics-pharmacodynamics perspective, ceftriaxone may be a reasonable option for MSSA infections when the MIC50 and MIC90 were 4 mg/L and 8 mg/L. CFR analysis demonstrated that ceftriaxone 1 g q24 h could be used if bacteriostasis is the aim (fT>55%), while 1 g q12h should be used for bactericidal effects (fT>75% or fT>100%). These dosing regimens should be considered in other clinical trials.

The contribution of nano-based strategies in overcoming ceftriaxone resistance: a literature review.

Antimicrobial drug resistance, including resistance to multiple antibiotics, is continuously increasing. According to research findings, many bacteria resistant to other antibiotics were susceptible to ceftriaxone. However, over the last few years, ceftriaxone resistance has become growing and extremely worrisome challenge to the global healthcare system and several strategies have been initiated to contain the spread of antimicrobial drug resistance. Its extended use for therapeutic or preventative measures in humans and farm animals resulted in the development and spread of resistance. Recent advances in nanotechnology also offer novel formulations based on distinct types of nanostructure particles with different sizes and shapes, and flexible antimicrobial properties. For ceftriaxone, several nanostructured formulations through conjugation, intercalation, encapsulation with lipid carrier, and polymeric films have been investigated by different groups with promising results in combating the development of resistance. This review addressed the existing knowledge and practice on the contribution of nano-based delivery approaches in overcoming ceftriaxone resistance. Evidences have been generated from published research articles using major search electronic databases such as PubMed, Medline, Google Scholar, and Science Direct.

Minimum inhibitory concentration (MIC) of Ceftriaxone and Azithromycin for blood culture isolates of Salmonella enterica spp.

INTRODUCTION: Enteric fever caused by Salmonella enterica continues to be a major public health problem worldwide. In the last decade, ceftriaxone and azithromycin have become the drugs of choice for treating enteric fever caused by Nalidixic acid resistant Salmonella (NARS) enterica. This has led to reports of drug resistance to both drugs. Since enteric fever is endemic in India, accurate drug susceptibility surveillance is crucial to ensure empiric management of enteric fever is appropriate. The aim of this study is to evaluate the minimum inhibitory concentration (MIC) of ceftriaxone and azithromycin for blood culture isolates of NARS isolated at our centre. METHODOLOGY: This is a retrospective study conducted in a tertiary care center in Mumbai for blood culture isolates of NARS from 2016 to 2018. Isolates were tested for antimicrobial susceptibility testing (AST) against ceftriaxone and azithromycin using a manual broth microdilution method (BMD). RESULTS: Of 155 blood culture isolates of NARS: S. Typhi (n = 112) and S. Paratyphi A (n = 43) were included in the study. 81.9% (127 / 155) isolates were susceptible, 6.4% (10 / 155) isolates were intermediate while 11.6% (18 / 155) isolates were resistant to ceftriaxone. 100% susceptibility of NARS was observed to azithromycin. CONCLUSIONS: This study documents an alarming increase in resistance to ceftriaxone among NARS in Mumbai while azithromycin continues to be susceptible in vitro. It is essential to know MICs to understand epidemiological trends and choose appropriate treatment regimens for treating enteric fever.

Antibiotic Prophylaxis and Treatment in Early Cardiac Implantable Electronic Devices Infection.

BACKGROUND: Cardiac implantable electronic devices - PM, ICD, and CRTs- are well-proven life-sustaining and the ultimate destination for many heart conditions. Based on scientific evidence, there is a worldwide incremental increase in CIED implantations numbers. OBJECTIVE: Early infection of cardiac implantable electronic devices (CIED)- pacemaker (PM), implantable cardioverter-defibrillator (ICD), and cardiac resynchronization therapy (CRT)- is a growing health challenge. We examined the effectiveness of antibiotic prophylaxis and treatment of early infection of CIED in a single center. METHODS: This is a retrospective, single-center observational study. Data were collected from patients' records from July 2017-July, 2019. All Patients received intravenous ceftriaxone 2gm before incision, Gentamicin 120mg pocket irrigation, and oral Amoxicillin/Clavulanate for 5 days post-implantation. RESULTS: A 639 consecutive CIED implantations - PM (n=474, mean age, 64yr, female=49%), ICD (n=106, mean age 56yr, female=17%) and CRT (n=59, mean age, 54yr, female=20%)- were performed over 3years. The incidence of early infection was 1.9% (12 cases), female=41%. PM=5/474, ICD=5/106, and CRT=2/59. Three out of the 12 patients had total device explant due to pocket abscess; one PM had a generator changed; one ICD who had a pneumothorax, and the third one had reimplantation after ICD lead perforation. Nine cases were managed conservatively using saline dressing and oral Amoxicillin/Clavulanate, 3/9 patients developed a hematoma, 4/9 patients developed purulent suture line infection. None of them had infection recurrence on three months follow up. CONCLUSION: Early infection of CIED is a rare complication with multiple predisposing factors. Our protocol is reassurance and prompt initiation of management protocol to prevent and treat this issue's sequences.

HACEK Infective Endocarditis at a Tertiary Children's Hospital.

HACEK organisms (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella species) are rare causes of endocarditis. HACEK organisms are fastidious and may escape detection by culture techniques, but the use of molecular studies may aid diagnosis. A 10-year review of pediatric HACEK endocarditis cases at Texas Children's Hospital identified 10 patients, with 2 cases recognized by next-generation sequencing, highlighting potential benefits of these assays.