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BACKGROUND The optimal choice of initial antibiotic therapy for patients with high-risk febrile neutropenia (FN) in children is unclear and varies by the institution on the basis of local antibiograms and epidemiology of specific pathogens. The authors evaluated the appropriateness of antibiotics for the empiric treatment of FN in pediatric patients with cancer in our institution on the basis of changes in the epidemiology of organisms isolated from blood cultures (BCx). METHODS The authors conducted a retrospective medical record review of pediatric patients who received any oncology care (including patients with cancer and patients who had stem cell transplant) at University of Chicago Medicine Comer Children's Hospitals (March 2009 to December 2016) with a diagnosis of FN who had at least 1 BCx obtained. They reviewed pathogens isolated from BCx and determined whether they were pathogens or contaminants using the Infectious Diseases Society of America (IDSA) guidelines and the team's decision to treat. They investigated the microbiologic spectrum and susceptibility patterns of pathogens causing bacteremia in pediatric FN and whether the empiric therapy chosen may have affected clinical outcomes. RESULTS A total of 667 FN episodes were identified in 268 patients. BCx were negative in 497 (74.5%) and were determined to be contaminants in 27 (4%). In 143 episodes (21.5%), the BCx were positive for a pathogenic species. Polymicrobial bacteremia was identified in 25 episodes; a total of 176 pathogens were isolated. The majority of pathogens (95/176, 54%) were Gram-positive (GP), whereas 64 of 162 (36%) were Gram-negative (GN), 5 were fungal, and 4 were mycobacterial. The most common GP pathogens were viridans group streptococci (VGS) (n=34, 19.3%), coagulase-negative staphylococci (n=25, 14%), and methicillin-susceptible Staphylococcus aureus (n=12, 6.8%). Of aerobic GN bacilli, 15 (8.5%) were AmpC producers and 3 (1.7%) carried extended-spectrum beta-lactamases. There was no increase in the prevalence of multidrug-resistant GN isolates during the study period. Patients with VGS and multidrug-resistant GN bacteremia were more likely to be admitted to the pediatric intensive care unit [odds ratio (OR), 3.24; P=0.017; and OR, 2.8; P=0.07, respectively]. There were trends toward a higher prevalence of GP pathogens causing bacteremia and the emergence of VGS with decreased penicillin sensitivity. The prevalence of bacteremia with VGS was higher in acute myelogenous leukemia and neuroblastoma (OR, 2.3; P

Although there has been an increasing incidence of bacteremia caused by extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae (ESBL-E) across South East Asia, there are sparse data from the Lao PDR, where laboratory capacity for antimicrobial resistance surveillance is limited. We, therefore, retrospectively reviewed bacteremia caused by ESBL-producing Escherichia coli and Klebsiella pneumoniae between 2010 and 2014 at Mahosot Hospital, Vientiane, Lao PDR. Clinical and laboratory data relating to all episodes of ESBL-E bacteremia were reviewed over the 5-year period and compared with non–ESBL-E bacteremia. Blood cultures positive for E. coli or K. pneumoniae were identified retrospectively from laboratory records. Clinical and laboratory data were extracted from research databases and case notes and analyzed using STATA. Between 2010 and 2014, we identified 360 patients with E. coli (n = 249) or K. pneumoniae (n = 111) bacteremia, representing 34.8% of all patients with clinically significant bacteremia. Seventy-two (20%) isolates produced ESBL; E. coli accounted for 15.3% (55/360) and K. pneumoniae for 4.7% (17/360), respectively. The incidence of ESBL-producing E. coli bacteremia rose during the study period. By multiple logistic analysis, reported antibiotic use in the previous week was significantly associated with ESBL positivity (P < 0.001, odds ratio 3.89). Although multiresistant, most ESBL-producing E. coli and K. pneumoniae remained susceptible to meropenem (65/65; 100%) and amikacin (64/65; 98.5%). We demonstrated an alarming increase in the incidence of ESBL-E as a cause of bacteremia in Vientiane during the study period. This has implications for empiric therapy of sepsis in Laos, and ongoing surveillance is essential.

Objective: To describe the causal agents, prevalence of antimicrobial resistance, and risk factors associated with extended spectrum beta-lactamase (ESBL)-producing agents in urinary tract infections (UTIs). Materials and methods: A retrospective study was conducted at a tertiary care hospital in Monterrey, Mexico. Inclusion criteria were patients that clinically presented with a UTI and had a positive urine culture, within the time frame of March to October 2017. The association with ESBL-producing agents was determined through the Χ2 test for categorical variables. Statistical significance was set at a p 50%) to amoxicillin-clavulanate, ciprofloxacin, levofloxacin, fosfomycin, and trimethoprim-sulfamethoxazole and moderate resistance (10-50%) to gentamicin and ceftriaxone. Amikacin, ertapenem, nitrofurantoin, and colistin had the lowest resistance rates (

Coronavirus disease 2019 (COVID-19) arose at a time of great concern about antimicrobial resistance (AMR). No studies have specifically assessed COVID-19–associated superinfections or AMR. Based on limited data from case series, it is reasonable to anticipate that an appreciable minority of patients with severe COVID-19 will develop superinfections, most commonly pneumonia due to nosocomial bacteria and Aspergillus. Microbiology and AMR patterns are likely to reflect institutional ecology. Broad-spectrum antimicrobial use is likely to be widespread among hospitalized patients, both as directed and empiric therapy. Stewardship will have a crucial role in limiting unnecessary antimicrobial use and AMR. Congressional COVID-19 relief bills are considering antimicrobial reimbursement reforms and antimicrobial subscription models, but it is unclear if these will be included in final legislation. Prospective studies on COVID-19 superinfections are needed, data from which can inform rational antimicrobial treatment and stewardship strategies, and models for market reform and sustainable drug development.

The novel corona virus infectious disease, COVID-19, is a pandemic now and is raging through several continents, posing a challenge to health-care systems of all the countries and disrupting lives and livelihoods across the world. The facilities for virus testing are available for only limited numbers in each country and each country excludes a large number of potentially infected subjects because the lab test is done for only certain categories. Nearly 80 % of those infected will therefore go undiagnosed. There is an urgent need therfore to define the clinical syndrome so that practitioners at the primary and secondary levels can make a confident clinical diagnosis and proceed to manage patients early and effectively. Chloroquine and hydroxychloroquine, both antimalarials have shown promise in limited trials in France and China. They are inexpensive, have been around for several decades in the prevention and treatment of malaria, have well-known side-effects and in the short term safe for use . We propose that practitioners make a preliminary clinical diagnosis of the COVID-19 syndrome based on simple clinical criteria and lab tests and proceed to manage patients and protect other family members and contacts by using isolation measures and short regimens of these anti malarial and other medications, anticipating results of more clinical trials.

Background: Carbapenem antibiotics are important therapeutic agents in the health care setting, they are frequently used as an empiric therapy for life-threatening infections as well as infections with multi-drug-resistant gram-negative bacilli. Carbapenemase-producing Carbapenem-Resistant Enterobacteriaceae (CRE) are a significant public health challenge worldwide. The detection of carbapenemases productions in CRE strains is performed by phenotypic and genotypic methods. The phenotypic methods target carbapenemases production but provide no guidance regarding the specific carbapenemases types, while the genotypic diagnosis has the benefit of determining the exact mechanism conferring carbapenems resistance. Aim: Improvement of the antibiotic policy and infection control strategies in Suez Canal University Hospitals in Ismailia; through adequate detection of carbapenem resistance in the hospitals. Methods: All the CRE isolates were tested by the phenotypic methods (mCIM & eCIM) test to detect carbapenemases production, and screened by the conventional PCR for the presence of five carbapenemase genes, namely blaKPC, blaIMI, blaVIM, blaNDM, blaOXA-48 Results: The study showed that (53/155) 34.1% of the Enterobacteriaceae isolates were carbapenems resistant. Carbapenemases activity was detected in (36/53) 67.9% of the examined CRE isolates using mCIM test (20/36)37.8 % showed Metallo-carbapenemases and (16/36) 30.2% showed Serine- carbapenemases by eCIM test. 60.4% (32/53) were sensitive to colistin. While by PCR all the isolates (100%) harbor one or more carbapenemases genes. (51/53) 96.2% were proved to harbor blaOXA-48 gene, (47/53) 88.7% were proved to harbor blaNDM gene, (28/53) 52.8%, were proved to harbor blaVIM,gene, the percentage of blaIMI, blaKPC isolation was (17/53) 32.1%, (4/53)7.5% respectively. Conclusion: High frequencies of carbapenemase genes among CRE isolates.

Erkek infertilitesinde bilinen tüm olası nedenler dikkatlice değerlendirilmeli ve tespit edilirse o neden için hedefe yönelik tedavi seçenekleri uygulanmalıdır. Erkek infertilitesinin hipogonadotropik hipogonadizm, hiperprolaktinemi, genital sistem enfeksiyonları, boşalma bozuklukları, tiroid hormon bozuklukları ve varikosel gibi bilinen nedenleri, hedefe yönelik tedaviler veya cerrahi düzeltmeler ile etkili bir şekilde tedavi edilebilir. Ne yazık ki, bu bilinen nedenler erkek infertilitesinin yaklaşık %20'sini kapsamaktadır ve geri kalanı idiyopatik olarak kalmaktadır. Öte yandan, etiyolojik faktörlerin bulunamadığı, idiyopatik, açıklanamayan erkek infertilitesinin yönetimi hem klinisyen hem de çözüm arayan çiftler için zorlu bir süreçtir. Yardımcı üreme teknolojisi çağında, teorik kavramlara dayanan sınırlı yararları ve düşük bilimsel temeli olan bu konuda hala birkaç tıbbi seçenek mevcuttur, ancak spesifik olmayan tıbbi tedavi, doğal bir hamilelik elde etmek için çoğunlukla endikasyon dışı bir seçenek olarak devam etmektedir. Hipotalamus-hipofiz-gonad aksını kavramak ve hormonların düzenlenmesi bu konuda çok önemlidir. Ampirik tedaviler, yardımcı üreme teknikleriyle yapılacak olan aşırı tedavisinin üstesinden gelme potansiyeline sahiptir, ancak klinisyenler ve çiftler, ampirik terapilerin sınırlamalarının farkında olmalı ve bu yönde danışmanlık almalıdır. Bu derlemede, idiyopatik erkek infertilitesi için spesifik olmayan tıbbi tedavi seçenekleri ele alınmıştır., In male infertility, all possible known causes should be carefully evaluated and if detected, targeted treatment options for the cause should be implemented. The known causes of male infertility such as hypogonadotropic hypogonadism, hyperprolactinemia, genital tract infections, disorders of ejaculation, thyroid hormone disorders and varicocele can be treated efficiently by targeted therapies or surgical corrections. Unfortunately, these known causes cover about 20% of male infertility and the rest remains idiopathic. On the other hand, management of idiopathic, unexplained male infertility, in which no etiological factors can be found, is a challenge for both the clinician and couples seeking solutions. In the era of assisted reproductive technology, few medical options in this regard are still available with limited benefits and low scientific foundation based on theoretical concepts but empirical medical therapy continues as a mostly off-label option for obtaining a natural pregnancy. Comprehending the hypothalamic-pituitary-gonadal axis and the regulation of hormones is crucial in this regard. Empirical therapies have the potential to overcome overtreatment with assisted reproductive technology yet clinicians and couples must be aware of the limitations of empirical therapies and should be counseled in this direction. In this review, non-specific medical treatment options for idiopathic male infertility were covered.

Pneumonia is a leading cause of morbidity. Pneumonia is defined as a lung inflammation of infectious etiology. It can be subcategorized into Community Acquired Pneumonia, Hospital Acquired Pneumonia and Ventilator Acquired Pneumonia. Validated scores including the CRB-65, CURB-65 and PSI can guide decision-making between inpatient and outpatient management of pneumonia. While mild presentations can be managed through empiric treatment alone, more acute cases require identification of the infectious agent, initiation of empiric therapy, and subsequent de-escalation of treatment to the identified pathogen. This article aims to provide a framework for junior trainees to diagnose and manage pneumonia.

Background In the absence of antimicrobial susceptibility data, the institutional antibiogram is a valuable tool to guide clinicians in the empiric treatment of infections. However, there is a misunderstanding on how best to prepare cumulative antimicrobial susceptibility testing reports (CASTRs) to guide empiric therapy (e.g., routine antibiogram) versus monitoring antimicrobial resistance, with the former following guidance from the Clinical Laboratory Standards Institute (CLSI), and the latter from Center for Disease Control and Preventions National Healthcare Safety Network (NHSN). These criteria vary markedly in their exclusion or inclusion of isolates cultured repeatedly from the same patient. Methods We compared rates of non-susceptibility (NS)using annual data from a large teaching healthcare system subset to isolates eligible by either NHSN criteria or CLSI criteria. Results For a panel of the three most prevalent gram-negative pathogens in combination with clinically relevant antimicrobial agents (or priority pathogen-agent combinations, PPACs), we found that the inclusion of duplicate isolates by NHSN criteria yielded higher NS rates than when CLSI criteria (for which duplicate isolates are not included) were applied. Conclusions Patients with duplicate isolates may not be representative of antimicrobial resistance within a population. For this reason, users of CASTR data should carefully consider that the criteria used to generate these reports can impact resulting NS rates, and therefore maintain the distinction between CASTRs created for different purposes.

Hintergrund: Die akute Cholangitis ist ohne ad��quate Therapie mit einer hohen Letalit��t verbunden. Grundpfeiler der Therapie sind die Herstellung der Gallengangsdrainage und die effektive antimikrobiellen Therapie, wobei die Auswahl der empirisch eingesetzten Antibiotika lokale Erreger- und Resistenzdaten ber��cksichtigen sollte. Oft aber liegen diese Daten dem Kliniker nicht vor. Zudem ergibt sich durch die zunehmende Verbreitung resistenter Erreger h��ufig ein Konflikt zwischen sicherer Erregererfassung und dem Bestreben Breitspektrum-Antibiotika sparsam einzusetzen. In dieser Studie wurden Erregerspektrum und Resistenzdaten aus Galle- und Blutproben von Patienten mit akuter Cholangitis analysiert und die Frage untersucht, ob durch Verkn��pfung von mikrobiologischen Daten mit Patientendaten, die Auswahl der empirischen Therapie bei Patienten mit akuter Cholangitis verbessert werden kann. Methodik: Bei der vorliegenden Arbeit handelt es sich um eine retrospektive Beobachtungsstudie. ��ber das mikrobiologische Labor der Charit�� wurden aus 541 konsekutiven Einsendungen von Galle-Asservaten 423 F��lle identifiziert, die gem���� den Kriterien der Revised Tokyo Guidelines von 2013 eine wahrscheinliche oder sichere Cholangitis aufwiesen. Die in den Galle-Asservaten und in assoziierten Blutkulturen gefundenen Erreger wurden hinsichtlich H��ufigkeit und Resistenzprofil ausgewertet. Ferner wurde die Abdeckung der jeweiligen Erreger durch die empirische Therapie analysiert. Durch Korrelation der mikrobiologischen mit Patienten-bezogenen Daten wurden Pr��diktoren f��r Resistenzen identifiziert und aus diesen Kriterien f��r die Auswahl der empirischen Therapie entwickelt. Der Zusammenhang zwischen Patientendaten und mikrobiologischen Daten wurde mittels Chi-Quadrat-Tests und multivariater logistischer Regression untersucht. Ergebnisse: In der Galle waren Enterobacterales und Enterokokken mit jeweils ca. 30% die h��ufigsten Spezies. In den Blutkulturen hingegen dominierten Enterobacterales (56%) vor Enterokokken (21%). Die Abdeckung durch die empirische Therapie war in Galle und Blut gleicherma��en unzureichend (51% und 69%). Bei den Enterobacterales fanden sich im ungefilterten Patientenkollektiv Resistenzraten f��r Fluorchinolone, Cephalosporine und Acylureidopenicilline von jeweils > 20%. Lediglich f��r Carbapeneme zeigten die Erreger eine niedrige Resistenzrate von < 2%. Mittels multivariater Analyse konnten einfach zu erhebende Patientenfaktoren identifiziert werden, bei deren Vorliegen auch eine Carbapenem-freie Therapie eine sehr gute Abdeckung der Erreger gew��hrleistete. Schlussfolgerung: Beim ungefilterten Patientenkollektiv erscheinen Carbapeneme als die einzige sichere Option f��r eine ausreichende Abdeckung durch die empirische Therapie. Durch die Analyse der Assoziation von Patientendaten mit mikrobiologischen Daten und zeigte sich jedoch, dass bei Patienten mit ambulant erworbener Cholangitis, die keine vorbestehende Drainage der Gallenwege aufweisen und keiner intensivmedizinischen Behandlung bed��rfen, mit einer Acylureidopenicillin/Betalaktamaseinhibitor-Kombination (Piperacillin/Tazobactam) eine sehr gute antimikrobielle Abdeckung erreicht werden kann., Background: Without adequate therapy, acute cholangitis is associated with high mortality. Establishment of biliary drainage and effective antimicrobial therapy are the cornerstones of therapy. The selection of empiric antibiotic therapy should take into account local microbial spectra and resistance data. However, often these data are not available. Furthermore, due to the increasing prevalence of multiresistant pathogens, there is a conflict between the need of pathogen coverage and the desire to use broad-spectrum antibiotics sparingly. In this study, the spectrum and resistancies of pathogens isolated from bile and blood samples of patients with acute cholangitis were analyzed. Based on these analyses, we investigated the question whether linking patient data with microbiological data can improve the selection of empirical therapy in patients with acute cholangitis. Methods: The present work is a retrospective observational study. 423 cases with probable or definite cholangitis according to the criteria of the 2013 Revised Tokyo Guidelines were identified from 541 consecutive bile assay submitted to the microbiological laboratory of the Charit��. The biliary specimens and associated blood cultures were evaluated for pathogen frequencies and resistance profiles, and coverage of each pathogen by empiric therapy was analyzed. Predictors of resistance were identified by correlating patient-related data with microbiological data, and criteria for the selection of empirical therapy were developed. The association between patient data and microbiological data was examined using the chi-square test and multivariate logistic regression. Results: In bile, enterobacterales and enterococci dominated, each accounting for approximately 30% of pathogens. In blood cultures Enterobacterales (56%) dominated over Enterococci (21%). Coverage by empiric therapy was equally inadequate in bile and blood (51% and 69%). Among the enterobacterales, high resistance rates of > 20% for fluoroquinolones, cephalosporins, and acylureidopenicillins, respectively, were found in the unfiltered patient population. In these patients, only for carbapenems the pathogens showed a low resistance rate of < 2%. However, by use of easily ascertainable patient factors, we identified a subgroup of patients, in which carbapenem-free therapy also leads to very good coverage of the pathogens. Conclusion: In the unfiltered patient population, carbapenems appear to be the only safe option for adequate coverage by empiric therapy. By analyzing the linkage of patient data with microbiological, we found that good antimicrobial coverage can be achieved using piperacillin/tazobactam in patients with community-acquired cholangitis without preexisting drainage of the biliary tract and who do not require intensive medical care.

Physicians in training and noninfectious disease clinicians can play a vital role in increasing awareness of sexual health issues, early disease recognition and diagnosis, and optimizing management of sexually transmitted infections (STIs). A practical approach to STIs requires knowledge of the main clinical syndromes in men and women, including urethritis, vaginitis, cervicitis, pelvic inflammatory disease (PID), epididymitis, and genital ulcer disease—and their associated pathogens. Newer point-of-care tests and nucleic acid amplification tests have significantly improved detection methods for STIs compared with culture methods for infections including gonorrhea, chlamydia, trichomonas, and genital herpes. Testing from multiple sites with multiple specimens (e.g., pharyngeal, urine, urethral, vaginal, cervical, and rectal) based on history of exposure or risk also increases the likelihood of detecting subclinical infections. However, diagnosis of syphilis continues to rely heavily on serologic assays, including nontreponemal and treponemal antibody tests, and monitoring after therapy is important to ensure appropriate response to treatment. Although empiric therapy is recommended for STI syndromes to prevent sequelae and transmission, targeted therapy based on diagnostic testing is best for persons who are asymptomatic, are likely to return for treatment as needed, and/or are not at high risk for complications (e.g., pregnant women, persons infected with human immunodeficiency virus). In addition to appropriate therapy, prevention methods such as vaccinations for human papillomavirus, condom use, and partner evaluation and treatment remain key components of STI management.

BACKGROUND Eradication of Helicobacter pylori infection is challenging. We aimed to determine the optimal first-line H. pylori treatments at global and regional levels. METHODS We searched Embase, PubMed, Cochrane CENTRAL, Web of Science, Scopus, WHO ICTRP, ClinicalTrials.gov, and ISRCTN registry, for randomized controlled trials published during 2011-2020. Utilizing a network meta-analysis in a Bayesian framework, success rates of 23 regimens were compared. The effect size was standardized risk ratio (RR) with 95% credible interval (CrI). Pooled eradication rate (ER) with 95% CrI was also reported for top combinations. The reference regimen was 7-day clarithromycin-based triple therapy. RESULTS This review identified 121 trials comprising 34,759 participants. Globally, 14-day levofloxacin-based sequential therapy was the most efficient (RR: 1.43; 95% CrI, 1.26-1.59) with low certainty of evidence, followed by modified bismuth-containing quadruple therapy (proton pump inhibitor+bismuth compounds+clarithromycin+amoxicillin) for 10 days (RR: 1.35; 95% CrI, 1.22-1.48) and 14 days (RR: 1.27; 95% CrI, 1.12-1.42), and 14-day hybrid therapy (RR: 1.27; 95% CrI, 1.19-1.36). The corresponding ERs were 98.7% (95% CrI, 86.9-100.0), 93.2% (95% CrI, 84.2-100.0), 87.6% (95% CrI, 82.1-93.8), and 87.6% (95% CrI, 77.3-98.0), respectively. Continentally, the most effective combinations were: 10-day clarithromycin-based sequential therapy [(RR: 1.21; 95% CrI, 1.02-1.42), (ER: 89.5%, 95% CrI, 75.5-100.0)] for Africa, 14-day levofloxacin-based sequential therapy [(RR: 1.41; 95%CrI, 1.27-1.58), (ER: 98.7%, 95% CrI, 88.9-100.0)] for Asia, and 14-day clarithromycin-based triple therapy [(RR: 1.58; 95% CrI, 1.25-2.04), (ER: 94.8%; 95% CrI, 75.0-100.0)] for Europe. For Northern America, no sufficient data were found for network meta-analysis. In South America, none of the combinations were superior to the reference regimen. CONCLUSION Although results of this network meta-analysis revealed optimal combinations for empiric therapy, the treatment preference would be based on the local pattern of antibacterial resistance, when the necessary information exists.

ObjectivesEvaluation of the extent and appropriateness of antimicrobial use is a cornerstone of antibiotic stewardship programs, but it is time-consuming. Documentation of the indication at the moment of prescription might be more time-efficient. We investigated the real-life feasibility of mandatory documentation of the indication for all hospital antibiotic prescriptions for quality evaluation purposes.MethodsA mandatory prescription-indication format was implemented in the Electronic Medical Record (EMR) of three hospitals using EPIC or ChipSoft HIX software. We evaluated the retrieved data of all antibiotics (J01) prescribed as empiric therapy in adult patients with respiratory tract infections (RTI) or urinary tract infections (UTI), from January through December 2017 in Hospital A, June through October 2019 in Hospital B and May 2019 through June 2020 in Hospital C. Endpoints were the accuracy of the data, defined as agreement between selected indication for the prescription and the documented indication in the EMR, as assessed by manually screening a representative sample of eligible patient records in the EMR of the three hospitals, and appropriateness of the prescriptions, defined as the prescriptions being in accordance with the national guidelines.ResultsThe datasets of hospitals A, B and C contained 9588, 338 and 5816 empiric antibiotic prescriptions indicated for RTI or UTI, respectively. The selected indication was in accordance with the documented indication in 96.7% (error rate: 10/300), 78.2% (error rate: 53/243), and 86.9% (error rate: 39/298), respectively. A considerable variation in guideline adherence was seen between the hospitals for severe community acquired pneumonia (adherence rate ranged from 35.4 to 53.0%), complicated UTI (40.0–67.1%) and cystitis (5.6–45.3%).ConclusionsAfter local validation of the datasets to verify and optimize accuracy of the data, mandatory documentation of the indication for antibiotics enables a reliable and time-efficient method for systematic registration of the extent and appropriateness of empiric antimicrobial use, which might enable benchmarking both in-hospital and between hospitals.

Myelopathy can present acutely or more insidiously and has a broad differential diagnosis. In addition to the clinical history and neurologic examination, diagnostic testing, including MRI and cerebrospinal fluid analysis, as well as thorough review of patient comorbidities, risk factors, and potential toxic exposures, can help neurohospitalists distinguish between various causes and potentially start appropriate empiric therapy while awaiting definitive testing. This article focuses on how imaging can help in determining the most likely cause of myelopathy and highlights a range of causes, including compressive, vascular, metabolic and toxic, infectious, autoimmune, neoplastic, and paraneoplastic causes of spinal cord dysfunction.

Plasma cell cheilitis (PCC) is an uncommon condition characterized by mature plasma cell infiltration of the dermis of the mucosal lip. The condition often presents as a red-brown patch or plaque on the lower lip in older individuals that can progress to erosions and edema. Diagnosis can be delayed because clinical findings are nonspecific and can mimic neoplastic, infectious, and inflammatory conditions. We describe a patient with PCC who presented to our institution via teledermatology. Findings were equivocal on 2 early biopsies until the presentation evolved to dramatic ulceration and necrosis, which prompted a third biopsy that was diagnostic for PCC. Empiric therapy with a class I topical corticosteroid was successful.

Infected deep vein thrombophlebitis (i-DVT) in people who inject drugs (PWID) is a clinically challenging but poorly characterised disease. We undertook a retrospective observational study of 70 PWID presenting acutely with i-DVT to improve the clinical and microbiological characterisation of this disease. i-DVT was frequently associated with bacteraemia (59.1% patients with blood cultures obtained), groin abscesses (in 34.3%; of which 54.2% required surgical drainage), and septic pulmonary emboli (38.6%) requiring anticoagulation. Network analysis identified a cluster of patients presenting with respiratory symptoms but lacking typical DVT symptoms, more likely to have septic pulmonary emboli. A microbiologic diagnosis was frequently achieved (70%). Causative pathogens were predominantly gram-positive (S. aureus and streptococci, especially anginosus group), whereas gram-negative pathogens were identified very infrequently (in 6.1% of microbiological diagnoses). This suggests routine empiric therapy against gram-negative bacteria, though commonly administered, is not required. High rates of clinical cure (88.6%) were observed despite the complex nature of infections and independently of the highly variable intravenous and total antimicrobial durations received. There exists a rationale to devise pragmatic approaches to implement novel individualised treatment plans utilising oral antimicrobial therapy for i-DVT. Despite frequent healthcare interactions, opportunities to address HCV treatment and opioid substitution therapy were frequently missed during these acute admissions.

This chapter concentrates on neonatal infections, which are classified according to time and mode of onset in three categories: prenatal, perinata (early onset), and nursery-acquired (late onset). It explains that infections that begin within the first month of life are considered neonatal, but many intensive care units for neonates provide continuing care for infants several months of age with complex problems that are the result of prematurity and complications of neonatal disorders. It also mentions neonatal nursery-associated infections that may occur in infants up to a year or more of age. The chapter analyzes bacterial infections that set in substantially before birth that usually result in a stillbirth due to rapidly dividing high-grade pathogens. It also looks at the difficulty in distinguishing infections that are acquired shortly prior to birth from those acquired as a result of contact with maternal vaginal, fecal, or skin flora during delivery.

Prosthetic joint infections (PJIs) remain a major complication of arthroplasty, most of which are caused by Staphylococcus aureus and gram-negative bacteria. Unfortunately, cultures are false negative in upward of 7 percent of patients with suspected PJIs, and commonly in infections caused by rare rapidly growing mycobacterium (RGM) species. Guidelines recommend 6 months of antimycobacterial therapy for bone diseases caused by RGM, with empiric therapy consists of an oral macrolide (clarithromycin or azithromycin) plus tobramycin and imipenem-cilastatin. Definitive treatment of PJI due to RGM should be guided by antimicrobial susceptibility, however, most microbiology laboratories are unable to differentiate between M. chelonae and M. abscessus. Furthermore, treatment of M. chelonae PJI is challenging due to multidrug resistance and the dearth of oral antibiotics for therapy. This case report investigates a patient with PJI caused by M. chelonae and M. abscessus. The initial treatment with imipenem-cilastatin was complicated by drug induced seizures, further limiting therapy options.

Objectives Timely empiric antimicrobial therapy is associated with improved outcomes in pediatric sepsis, but minimal data exist to guide empiric therapy. We sought to describe the prevalence of four pathogens that are not part of routine empiric coverage (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, Clostridium difficile, and fungal infections) in pediatric sepsis patients in a contemporary nationally representative sample. Design This was a retrospective cohort study using administrative data. Setting We used the Nationwide Readmissions Database from 2014, which is a nationally representative dataset that contains data from nearly half of all discharges from nonfederal hospitals in the United States. Patients Discharges of patients who were less than 19 years old at discharge and were not neonatal with a discharge diagnosis of sepsis. Interventions None. Measurements and main results Of the 19,113 pediatric admissions with sepsis (6,300 [33%] previously healthy and 12,813 [67%] with a chronic disease), 31% received mechanical ventilation, 19% had shock, and 588 (3.1%) died during their hospitalization. Among all admissions, 8,204 (42.9%) had a bacterial or fungal pathogen identified. S. aureus was the most common pathogen identified in previously healthy patients (n = 593, 9.4%) and those with any chronic disease (n = 1,430, 11.1%). Methicillin-resistant S. aureus, P. aeruginosa, C. difficile, and fungal infections all had high prevalence in specific chronic diseases associated with frequent contact with the healthcare system, early surgery, indwelling devices, or immunosuppression. Conclusions In this nationally representative administrative database, the most common identified pathogen was S. aureus in previously healthy and chronically ill children. In addition, a high proportion of children with sepsis and select chronic diseases had infections with methicillin-resistant S. aureus, fungal infections, Pseudomonas infections, and C. difficile. Clinicians caring for pediatric patients should consider coverage of these organisms when administering empiric antimicrobials for sepsis.

To evaluate how previous antimicrobial resistance, prior prescription data, and patient place of residence (ZIP code) can guide empirical therapy for uncomplicated urinary tract infections (UTI). Guidelines recommend empirical antimicrobial selection for women with symptoms of uncomplicated UTIs, most commonly trimethoprim-sulfamethoxazole (SXT), nitrofurantoin (NIT), or ciprofloxacin (CIP). Previous antimicrobial resistance and prior prescription data are potential predictors of resistance in subsequent urine cultures for UTIs. Also, there is evidence of geographic clustering of antimicrobial resistance for UTIs.Retrospective data from women (age ≥18) with an assigned diagnosis of UTI, submitting urine cultures as outpatients (2011-2018), were gathered. Univariate analyses and multivariable regression models were used to determine odds ratios for predicting resistance to SXT, NIT, and CIP on the 2011-2017 data. Antimicrobial choice algorithms were created using 2011-2017 results and tested on 2018 data.In the training cohort, 9455 women had diagnoses of uncomplicated UTIs and positive urine cultures. Prevalence of resistance for SXT, NIT, and CIP was 19.4%, 12.1%, and 10.3%, respectively. A urine culture with previous resistance, prior antimicrobial prescription within 2 years and ZIP code were the strongest predictors of a subsequent resistant culture. An algorithm based on these data had a success rate of 92.2%, compared to provider's choice (87.5%, P.001) or best theoretical outcomes with guidelines (90.0%, P = .048).Previous resistance, prior prescriptions, and patient ZIP code are predictors of subsequent resistance in patients with uncomplicated UTIs. Algorithms using these data can outperform real-world outcomes and guidelines.

Respiratory tract infections are the most common diseases that are associated with social burden for the patient. Western Rajasthan has cases of Cystic fibrosis due to migrant population. The dry and dusty environment has led to prevalence of silicosis and COPD. As per IDSA (2018) guidelines, patients attending Out-Patient Department do not need microbiological investigations for lower respiratory tract infections (LRTI) except for influenza and tuberculosis. Aims: This study was conducted to identify the bacterial aetiology of LRTI among patients who attended AIIMS, Jodhpur, and to ascertain the current scenario of bacterial susceptibility in respiratory tract infections in order to optimize empiric therapy in Hospitals ad community. Methods and Material: In total, 1,775 lower respiratory tract samples were received in Bacteriology Section of Microbiology Department (January 2017 to December 2018). Bartlett's criteria were stringently used to assess quality of specimen. Semiquantitative cultures were done for tracheal aspirate and bronchoalveolar lavage samples. Following culture, the isolated organisms were identified and antimicrobial sensitivity was performed according to CLSI. Results: Total 769 bacterial pathogens were isolated from 1,775 samples collected from cases of VAP, HAP, CAP, COPD, and cystic fibrosis. Pseudomonas species was the commonest isolate (31%), followed by Klebsiella pneumonia (21.3%), Acinetobacter species (17.5%), Escherichia coli (15.4%), and Staphylococcus aureus (5%). Others include Group A β-hemolytic Streptococcus, Burkholderia cepacia complex, Stenotrophomonas maltophilia, and Nocardia. Gram-negative organisms showed increased resistance to routinely used antibiotics. Gram-positive organisms showed 100% susceptibility to vancomycin, linezolid, and clindamycin. Conclusions: Cotrimoxazole, βL-βLIs, aminoglycosides, and all second-line antibiotics tested were effective for treatment of RTIs.

Introduction: Escherichia coli (E. coli) is a very common uro-pathogen and pathogen of bloodstream infections (BSI) in Jamaica. The aim of this study was to examine this organism’s prevalence, determine co-infection rates and assess antibiotic resistance patterns. Methodology: In the absence of automated systems, data on all E. coli isolates identified at the University Hospital of the West Indies in Kingston, Jamaica during the first six months of 2008 and 2012 was collected and sorted. Data were analyzed using IBM SPSS Statistics version 20 for Windows. Results: A total of 1188 isolates (1072 from urine and 116 from blood) was analyzed. Patients with E. coli BSI were older than those with E. coli urinary tract infections (UTI) (55.3 years vs 42.4 years, p < 0.05) and both had a female predominance. Sensitivity profiles in 2012 for E. coli in blood and urine were highest for the carbapenems, Amikacin and Nitrofurantoin and lowest for the fluoroquinolones and Trimethoprim-sulfamethoxazole. Based on antimicrobial susceptibility patterns, Nitrofurantoin was identified as an appropriate choice for empiric therapy for UTI. Ten antibiotics were noted in this study to have developed statistically significant antibiotic resistance. Patients with E. coli BSI had a co-infection E. coli UTI rate of 39%. Conclusions: Resistance patterns change drastically in a few years making frequent antimicrobial susceptibility profiling necessary. Further studies would be beneficial in guiding management of these patients.

This quasi-experimental study compared the appropriate prescribing of antibiotics in the emergency department over a 3-month period before and after implementation of an empiric therapy guide (ETG). Overall appropriateness of antibiotic prescribing per Infectious Diseases Society of America (IDSA) guidelines increased significantly by 20.5% after implementation of the ETG (P

Background Prompt initiation of empiric therapy is common practice in case of suspected meningitis or encephalitis. However, in children the most common pathogens are viruses that usually do not require and are not covered by the applied anti-infective treatment. Novel multiplex PCR (mPCR) panels provide rapid on-site diagnostic testing for a variety of pathogens. This study compared empiric antibiotic and acyclovir usage before and after the introduction of an on-site FilmArray Meningitis/Encephalitis Panel (FA ME Panel). Methods We retrospectively compared data for empiric antibiotic and acyclovir usage between pediatric patients with suspected central nervous system (CNS) infection receiving mPCR testing and a matched historical control group. Patients were matched by age and suspected CNS infection. We included all patients for whom empiric antibiotics and/or acyclovir were prescribed. Results Each study group consisted of 46 patients with 29 (63.0%) infants and 17 (37.0%) older children. A viral pathogen was diagnosed in 5/46 (10.9%) patients in the control group (all enteroviruses) and in 14/46 (30.4%) patients in the mPCR group (enterovirus n = 9; human herpesvirus 6 (HHV-6) n = 5), (p = 0.038)). Length of Therapy (LoT) and Days of Therapy (DoT) for antibiotics were significantly lower for infants (4.0 vs. 3.0, p = 0.038 and 8.0 vs. 6.0, p = 0.015, respectively). Acyclovir therapy was significantly shorter for both, infants and older children (3.0 vs. 1.0 day, p Conclusion The findings of our study suggest that the introduction of a FA ME Panel into clinical routine procedures is associated with a significantly reduced LoT and DoT of empiric anti-infective treatment in children with suspected meningoencephalitis. The largest effect was observed in infants.

BACKGROUND Antimicrobial stewardship interventions to curtail the use of third-generation cephalosporins and antipseudomonal penicillins for the treatment of complicated appendicitis in children are challenging given the tendency to treat complicated disease with broad-spectrum antimicrobials. Reasons for this are unclear, but there is a paucity of contemporary microbiologic data associated with the child presenting with either acute perforated or gangrenous appendicitis. This study aimed to justify the appropriateness of an empiric regimen consisting of ampicillin, tobramycin/gentamicin plus metronidazole and to analyze duration of postoperative therapy. METHODS We conducted a retrospective cohort study from February 1, 2017, to October 31, 2018, in children who underwent appendectomy or interventional radiologic drainage for primary complicated appendicitis. The primary outcome was the proportion of patients who had a pathogen isolated from peritoneal fluid culture that was not susceptible to the recommended empiric therapy. The secondary outcomes were the total duration of antimicrobial therapy and the proportion of patients with a postoperative infectious complication within 30 days after intervention. RESULTS Of 425 children with primary acute appendicitis, 158 (37%) had complicated appendicitis at presentation. Culture was performed in 53 (40%) of the 133 who underwent a surgical or interventional radiologic intervention. The group with peritoneal cultures was more likely to present with longer symptom duration before admission [3 (interquartile range, 2-5) vs 2 (interquartile range, 1-2) days; P < 0.001] and with purulent peritonitis [47% (25/53) vs 13% (10/80); P < 0.001]. The most common pathogens isolated were anaerobes (81%), Escherichia coli (74%) and Streptococcus anginosus group (62%). Only 4% of isolated bacteria were resistant to empiric therapy. Postoperative infectious complications were documented in 23 (17%) patients and were not associated with the presence of a resistant pathogen or the choice of antimicrobial agents but with more severe disease and higher C-reactive protein values (303 vs 83 mg/L; P=0.03) at presentation. CONCLUSIONS In a cohort of previously healthy children presenting with complicated appendicitis requiring surgical drainage, the most common bacteria from peritoneal cultures continue to be S. anginosus, aminoglycoside-susceptible Gram-negative bacilli and anaerobes. In an attempt to reduce extended-spectrum cephalosporin use, these data were useful in supporting the use of metronidazole with ampicillin and an aminoglycoside, rather than third-generation cephalosporins.

Clostridioides difficile infection (CDI) is a common complication in the hematopoietic stem cell transplantation (HSCT) and hematologic malignancy (HM) population. CDI is associated with increased hospital length of stay, health care and societal costs, morbidity, and mortality. Identifying strategies for secondary prevention of CDI is of extreme importance in the HSCT/HM population. In this study, our primary objective was to evaluate the effectiveness and safety of an oral vancomycin prophylaxis (OVP) protocol for secondary prevention of CDI in a retrospective cohort of adult autologous/allogeneic HSCT recipients and patients with HM who did not undergo HSCT with a first CDI episode treated with concomitant broad-spectrum antibiotics (BSA). Patients were diagnosed and treated for CDI as inpatients and/or outpatients and were divided into 2 groups based on a preprotocol versus postprotocol analysis: the OVP group, comprising patients who received planned monotherapy with oral vancomycin 125 mg every 6 hours for 14 days for a first episode of CDI and subsequently received OVP posttreatment and a no OVP (NOVP) group, comprising patients who received planned monotherapy with oral vancomycin 125 mg every 6 hours for 14 days for a first episode of CDI and subsequently did not receive OVP posttreatment. OVP was defined as vancomycin 125 mg every 12 hours for up to 7 days after BSA discontinuation. The primary endpoint was recurrent CDI (rCDI), defined as symptoms of loose stools/diarrhea with high clinical suspicion for CDI prompting empiric therapy within 60 days of completion of treatment/prophylaxis for the first CDI episode. The incidence of vancomycin-resistant enterococcal (VRE) infection and 60-day mortality were also compared between the 2 groups. Multivariate logistic regression was created from associated variables to identify independent associations with rCDI. A total of 50 patients were included, 21 in the OVP group (42%) and 29 in the NOVP group (58%). The mean patient age was 58 years, and the cohort was 60% male and 86% Caucasian. HSCT was performed in 60% of the patients, and 76% of CDI cases were diagnosed during hospitalization. The rate of rCDI was significantly lower in the OVP group compared with the NOVP group (5% [1 of 21] versus 35% [10 of 29]; P= .016), with no subsequent increase in VRE infection rate (14% [3 of 21] versus 10% [3 of 29]; P = .686). By multivariable logistic regression, rCDI was inversely associated with OVP (odds ratio [OR], .14; 95% confidence interval [CI], .007 to .994; P = .049) and directly associated with outpatient CDI diagnosis (OR, 8.72; 95% CI, 1.816 to 49.158; P = .007). No between-group differences were found in 60-day mortality (10% [2 of 21] for OVP versus 7% [2 of 29] for NOVP; P > 0.999). OVP appears to be safe and effective for secondary prevention of CDI in the HSCT/HM population. Prospective trials are needed to validate the effectiveness of OVP in this vulnerable population to prevent rCDI.

Staphylococcus aureus (S. aureus), including methicillin-resistant S. aureus (MRSA), is an important aetiological cause of community-acquired pneumonia (CAP) and associated with significant morbidity and mortality. Empiric therapy for CAP frequently consists of β-lactam monotherapy or β-lactam/macrolide combination therapy. However, such agents are often ineffective against S. aureus and do not reflect the emergence and increasing prevalence of MRSA in the community setting. Ceftaroline fosamil is a fifth-generation parenteral cephalosporin with broad-spectrum activity against Gram-positive pathogens – such as S. aureus (including MRSA), Streptococcus pneumoniae and Streptococcus pyogenes – and typical Gram-negative pathogens, including Haemophilus influenzae and Moraxella catarrhalis. The approval of ceftaroline fosamil in the United States and Europe for the treatment of adults with moderate-to-severe CAP was based on two phase 3 trials (FOCUS 1 and 2), which demonstrated that ceftaroline fosamil was non-inferior to ceftriaxone, a standard empiric treatment for CAP, while exhibiting a comparable safety profile. Although head-to-head trials of ceftaroline fosamil versus comparators against MRSA CAP are lacking, the effectiveness of ceftaroline fosamil in subpopulations of patients not covered by phase 3 trials (e.g. those with MRSA CAP or severe renal impairment) has been demonstrated in the Clinical Assessment Program and Teflaro Utilization Registry (CAPTURE) study. As ineffective empiric therapy is associated with adverse outcomes, including mortality and increased costs, ceftaroline fosamil, with its extended spectrum of activity, is an attractive alternative to standard antibiotic CAP regimens.

Background: Complicated urinary tract infection (cUTI) is often associated with drug-resistant pathogens and requires therapy with broad-spectrum antibiotics. Choice of empiric therapy should be based on an evaluation of clinical efficacy and medical costs. We used a cost-utility model to compare the empiric use of a new antibiotic, ceftolozane/tazobactam with piperacillin/tazobactam in patients with cUTI. Methods: The analysis was conducted using a decision tree and patient-level simulation approach. Patients in the model received empiric antibiotic treatment with ceftolozane/tazobactam or piperacillin/tazobactam. Outcomes included mortality, medical costs and quality-adjusted life years (QALYs). Parameters related to pathogen distribution, length of hospital stay and medical costs, were estimated based on a cohort of patients with cUTI admitted during July 1st, 2015 to August 31st, 2016 to the National Taiwan University Hospital, a teaching hospital in Taiwan. Isolates used for the patient-level simulation to determine susceptibility to either drug were taken from the Study for Monitoring Antimicrobial Resistance Trend database. Results: The analysis was performed on a simulation of 1000 patients. Empiric use of ceftolozane/tazobactam leads to higher total medical costs (USD 4199.01 per patient versus USD 3594.76, respectively) but also more discounted QALYs (4.80 versus 4.78, respectively). The additional cost per discounted QALY gained associated with empiric ceftolozane/tazobactam was 32,521.08 USD (956,282 NTD). Conclusions: Our results suggest that empiric use of ceftolozane/tazobactam for the treatment of cUTI could be a cost-effective choice in Taiwan. Keywords: Complicated urinary tract infection, Ceftolozane/tazobactam, Piperacillin/tazobactam, Cost-effectiveness analysis, Cost-utility analysis

AIM Early-onset neonatal sepsis (EOS) may lead to significant morbidity and mortality, yet the recommended antimicrobials have not changed for many years. We aimed to optimise EOS treatment by examining EOS pathogens, resistance rates and resistance risk factors. METHODS A retrospective, nationwide cohort study analysing 2010-2015 EOS data in Israel. RESULTS The 21 participating centres constitute 92% of the total birth cohort (around 180 000 live births/year). Of 549 EOS neonates (0.57/1000 live births), 306 (56%) and 243 (44%) were full-term and preterm, respectively (0.35 vs. 2.94 per/1000 live births). Gram-negative pathogens predominated, especially in preterms. Escherichia coli and Streptococcus agalactiae were most common pathogens (0.2 and 0.19 per 1000 live births, respectively). In 277 Gram-negatives, 16%, 14%, 8% and 3% were gentamicin-resistant, extended-spectrum beta-lactamase (ESBL)-positive, gentamicin-resistant and ESBL-positive, and amikacin-resistant, respectively; preterms had higher resistance rates. No risk factors for antimicrobial resistance were identified. Mortality was reported in 21% of Gram-negative EOS versus 7% of Gram-positive EOS [OR 3.4 (95% CI 1.8-6.2), p

Background: Many treatment options are available for pulmonary arterial hypertension (PAH), but specific recommendations for long-term treatment are unavailable. We compared prognosis in PAH patients receiving goal-oriented, sequential combination therapy evaluated using cardiopulmonary exercise testing (CPX) parameters or conventional empiric therapy. Methods and Results: The Goal-Oriented Therapy Evaluated by Cardiopulmonary Exercise Testing for Pulmonary Arterial Hypertension (GOOD EYE) study was a multicenter, retrospective/prospective study in which a total of 129 patients with newly diagnosed PAH were enrolled (goal-oriented sequential combination therapy, n=42; conventional empiric therapy, n=87). Patients in the goal-oriented therapy group received sequential combination therapy, the efficacy of which was regularly evaluated using CPX parameters. Patients in the conventional empiric therapy group received conventional empiric therapy. The primary endpoint was cardiovascular death. In the goal-oriented therapy group, plasma brain natriuretic peptide, mean pulmonary arterial pressure, pulmonary vascular resistance, and 6-min walk test were significantly improved at 12 months compared with baseline. Survival in the goal-oriented therapy group at 1, 2, and 3 years (97.6%, 95.2%, and 86.0%, respectively) tended to be higher than that in the conventional empiric therapy group (P=0.082). Conclusions: Goal-oriented sequential combination therapy evaluated using CPX parameters may be associated with a favorable prognosis compared with conventional empiric therapy in patients with newly diagnosed PAH.

The leading cause of autoimmune encephalitis is N-methyl-D-aspartate receptor (NMDAR) encephalitis. Symptoms can present as prominent behavioral abnormalities prompting inaccurate psychiatric diagnoses. Psychiatric features such as bizarre behavior, agitation, anxiety, delusions, and hallucinations are well noted in the current literature, but a manifestation of foreign accent syndrome has, to our knowledge, never been reported in cases of encephalitis. Once diagnosed, initiation of therapy can result in effective treatment. Here, we present a case of a 32-year-old female with new onset seizures and marked behavioral changes, such as speaking in a foreign accent, who was empirically treated for NMDAR encephalitis due to strong clinical suspicion, showed no improvement with first line therapy with IVIG and IV steroids, and finally had rapid resolution of symptoms with the early initiation of second line therapy of rituximab. In a young female presenting with nonspecific behavioral changes, NMDAR encephalitis should be on the differential and, although CSF antibodies are definitively diagnostic, there should be a low threshold to start empiric therapy and escalate to second line treatment.

Helicobacter pylori infection is an infectious disease. Given the alarmingly high antibiotic resistance in H. pylori, gastroenterologists should change the empiric H. pylori treatment paradigm to an antimicrobial susceptibility testing-guided precision treatment. Antimicrobial stewardship programs for H. pylori should be implemented locally, regionally, and nationally to monitor the antibiotic resistance pattern.

In the ED, patients are treated empirically for suspected gonorrhea and/or chlamydia (GC). Limited studies have evaluated the treatment of sexually transmitted diseases (STDs) in conjunction with predictor variables. This study will allow providers to better identify patients with potential GC to streamline antibiotic treatment.The primary objective was to determine the incidence of positive assay in patients that underwent GC screening. The secondary objectives included the proportion of patients assayed that received empiric therapy and the predictive value of risk factors to identify positive assays.This retrospective cohort study included adult patients who presented to the health-system EDs and underwent GC screening. Subjects were excluded if they were victims of sexual assault, left AMA or eloped.A total of 490 assayed patients were included, of which 84 (17%) were found to be positive for GC assay. Of the 278 patients treated empirically, 74% had a negative assay. Of the entire sample (n = 490), risk factors found to predict a positive assay (p 0.05) included male, women25 years of age, concomitant bacterial vaginosis, pelvic inflammatory disease or trichomonas, penile discharge, inconsistent condom use, previous/coexisting STDs, and uninsured.Compared to previous reports, this study found a higher incidence of positive GC assays for patients with suspected infection. This is the first study to evaluate GC testing in both men and women in the ED, and risk factors not previously reported by the CDC were identified.