The Microbiome and Antimicrobial Stewardship in Surgical Patients.

Abstract The human microbiome plays a critical role in health and disease. The microbiota of the human body undergoes disruptions in critical illness, in part due to alterations in physiology but also as the result of medical interventions, most notably antimicrobial drug administration. These alterations may lead to a significant dysbiosis, with increased risks of multi-drug-resistant organism-based secondary infections, Clostridioides difficile promotion, and other infection-related complications. Antimicrobial stewardship is a process that seeks to optimize antimicrobial drug prescription, with recent evidence emphasizing shorter courses of therapy, earlier transitions from empiric to pathogen-specific regimens, and enhanced diagnostic testing. Through a combination of prudent stewardship and wise use of diagnostic testing, clinicians can improve outcomes, reduce the risk of antimicrobial resistance, and help improve the integrity of the microbiome.

Penile implant infection resulting in Staphylococcus aureus bacteraemia and infective endocarditis.

INTRODUCTION: Penile implant infections are a possible surgical complication that has historically been most commonly associated with Gram-positive bacteria. Staphylococcus aureus is a Gram-positive bacteria and is the most common cause of endocarditis. CASE PRESENTATION: A male patient in his 50s with a past medical history of hypertension, diabetes, end-stage renal disease (ESRD) on peritoneal dialysis (PD) and erectile dysfunction with a penile implant placed 6 years prior to the admission date presented with complaints of scrotal pain. The pump for his implant had eroded through his scrotum and was draining pus. Blood cultures returned positive for Gram-positive cocci in clusters in 4/4 bottles, which was eventually identified as methicillin-sensitive Staphylococcus aureus (MSSA). A transthoracic echocardiogram (TTE) was performed due to concern for infective endocarditis (IE) but did not show any valvular abnormalities. Due to high clinical suspicion, a transesophageal echocardiogram (TEE) was performed and revealed a vegetation on the native mitral valve. His penile implant was removed by urology and intraoperative cultures grew MSSA. Surgical valve replacement was not recommended, and the patient was sent home with IV antibiotics for 6 weeks. DISCUSSION: Post-operative site infections are a quite uncommon point of entry for infective endocarditis, with penile implant infections being an even rarer cause. While a TTE is often used initially to attempt to diagnose infective endocarditis, it has lower sensitivity than a TEE. If clinical suspicion for infective endocarditis remains high after negative imaging with TTE, then TEE should be performed for better visualization of the heart valves.