Cerebral abscess in Down syndrome: a systematic review on treatment and prognosis. Illustrative case.

BACKGROUND: No universal protocol exists for treating cerebral abscesses in Down syndrome. An illustrative case supplemented with a systematic literature review on brain abscesses in Down syndrome is presented, comprising a total of 16 cases. Preoperative infectious disease workups, cardiac examinations including echocardiography, as well as reported surgical and antibiotic treatments were correlated in the reported cohorts. OBSERVATIONS: Overall, 18.8% of cases (n = 3) had no reported cardiac evaluation. The majority of cases were treated surgically (n = 8), with aspiration (n = 3), drainage (n = 2), or other operations (n = 3); 25% (n = 4) were treated with antibiotics only. Strikingly, 25% of cases (n = 4) reported neither surgical nor antibiotic therapy, a significantly higher rate compared to 0%-3% of patients with brain abscess in other reported cohorts. Half of the patients (n = 8) who died either lacked a cardiac evaluation or had existing heart conditions. This mortality rate was about 4 times higher than the rates observed in other studies. LESSONS: Down syndrome patients with cerebral abscess have a high morbidity rate, mainly due to cardiac disease. Therefore, early diagnostic workup, including echocardiography, allows proactive management with an improved outcome. https://thejns.org/doi/10.3171/CASE23394.

Optimising antibacterial utilisation in Argentine intensive care units: a quality improvement collaborative.

BACKGROUND: There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country. METHODS: We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training. RESULTS: We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs. CONCLUSION: Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.

Intravenous antibiotic therapy after laparoscopic appendectomy in acute complicated appendicitis: the patient clinical response is the key.

INTRODUCTION: The guidelines about acute complicated appendicitis (ACA) recommend 3-5 days of postoperative intravenous antibiotics (IVA). Nevertheless, the time selected by the surgeon can vary according to patient clinical response, ACA type, and professional experience. Once an adequate clinical response is obtained, the change from IVA to oral antibiotic (OA) could be realized without the waiting time established with satisfactory results. OBJECTIVE: Determine if a short course of IVA and/or switch to oral route is safe based on the patient clinical response. MATERIALS AND METHODS: Observational prospective cohort study from a general surgery reference center database since July 2019. RESULTS AND CONCLUSION: 48 patients with ACA intraoperative findings were included. Regarding postoperative antibiotic management, only preoperative IVA: 7 (14.58%), IVA 1-3 days: 1 (20.83%), IVA 1-3 days and change to OA: 21 (43.75%), IVA > 3 days: 6 (12.5%), and only OA: 3 (27.08%). The bivariate analysis did not show statistically significant differences in reconsultation (p = 0.81), rehospitalization (p = 0.44), and surgical site infection (p = 0.56) between the antibiotic scheme based on the postoperative clinical response and the traditional one regarding intra-abdominal collection rate, the hospital stays, and hospitalization costs.

INTRODUCTION: Las guías sobre apendicitis aguda complicada (ACA) recomiendan 3-5 días de antibióticos intravenosos (IVA) postoperatorios. No obstante, el tiempo seleccionado por el cirujano puede variar según la respuesta clínica del paciente, tipo de ACA y experiencia profesional. Una vez obtenida una adecuada respuesta clínica, el cambio de IVA a antibiótico oral (OA) podría realizarse sin esperar el tiempo establecido con resultados satisfactorios. OBJETIVO: Determinar si un ciclo corto de IVA y/o el cambio a OA según la respuesta clínica del paciente es seguro. MATERIALES Y MÉTODOS: Estudio observacional de cohorte prospectivo a partir de la base de datos de un centro de referencia en cirugía general desde julio del 2019. RESULTADOS Y CONCLUSIÓN: Se incluyeron 48 pacientes con hallazgos intraoperatorios de ACA. En cuanto al manejo antibiótico postoperatorio, solo IVA preoperatorio: 7 (14.58%), IVA 1-3 días: 1 (20.83%), IVA 1-3 días y cambio OA: 21 (43.75%), IVA > 3 días: 6 (12.5%) y solo OA: 3 (27.08%). El análisis bivariado no mostró diferencias estadísticamente significativas en la reconsulta (p = 0.81), la rehospitalización (p = 0.44) y la infección del sitio operatorio (p = 0.56) entre el esquema de antibióticos basado en la respuesta clínica postoperatoria y el tradicional con respecto a tasa de colección intrabdominal, estancia hospitalaria y costos de hospitalización.

The Real Practice Prescribing Antibiotics in Outpatients: A Failed Control Case Assessed through the Simulated Patient Method.

The first level of medical care provides the largest number of consultations for the most frequent diseases at the community level, including acute pharyngitis (AP), acute diarrhoea (AD) and uncomplicated acute urinary tract infections (UAUTIs). The inappropriate use of antibiotics in these diseases represents a high risk for the generation of antimicrobial resistance (AMR) in bacteria causing community infections. To evaluate the patterns of medical prescription for these diseases in medical offices adjacent to pharmacies, we used an adult simulated patient (SP) method representing the three diseases, AP, AD and UAUTI. Each person played a role in one of the three diseases, with the signs and symptoms described in the national clinical practice guidelines (CPGs). Diagnostic accuracy and therapeutic management were assessed. Information from 280 consultations in the Mexico City area was obtained. For the 101 AP consultations, in 90 cases (89.1%), one or more antibiotics or antivirals were prescribed; for the 127 AD, in 104 cases (81.8%), one or more antiparasitic drugs or intestinal antiseptics were prescribed; for the scenarios involving UAUTIs in adult women, in 51 of 52 cases (98.1%) one antibiotic was prescribed. The antibiotic group with the highest prescription pattern for AP, AD and UAUTIs was aminopenicillins and benzylpenicillins [27/90 (30%)], co-trimoxazole [35/104 (27.6%)] and quinolones [38/51 (73.1%)], respectively. Our findings reveal the highly inappropriate use of antibiotics for AP and AD in a sector of the first level of health care, which could be a widespread phenomenon at the regional and national level and highlights the urgent need to update antibiotic prescriptions for UAUTIs according to local resistance patterns. Supervision of adherence to the CPGs is needed, as well as raising awareness about the rational use of antibiotics and the threat posed by AMR at the first level of care.