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Empyema necessitans (EN) is a rare phenomenon that refers to an insidious extension of the empyema through parietal pleura and subsequent dissection into subcutaneous tissue of the chest wall. A 29-year-old man presented to the hospital with fever and chills a few days after an inadvertent needle stick while injecting heroin. His left forearm was warm with an area of fluctuance. He underwent incision and drainage of the left forearm abscess with fluid submitted for Gram stain and culture. His condition rapidly deteriorated due to sepsis, and he required transfer to the intensive care unit. A new 4 × 3 cm area over the left pectoralis muscle had become increasingly indurated, fluctuant, and erythematous. CT of the chest demonstrated extensive cavitary lung lesions and a large loculated left-sided pleural effusion with extension through the chest wall. TEE revealed a 3 cm complex lesion on the superior septal leaflet of the tricuspid valve. The patient underwent incision and drainage of the pectoralis major EN with placement of a drain. Blood and sputum cultures grew methicillin-susceptible Staphylococcus aureus (MSSA) at which time antibiotic therapy was tailored to oxacillin. Our case highlights a rare occurrence of EN due to MSSA in a patient with intravenous drug use (IDU) and underscores the importance of prompt diagnosis and treatment.

Abstract High patient volume in fellowship programs can affect learning, wellness, and patient outcomes. Training programs must find ways to mitigate high consultation volume to protect the learning environment. This survey describes average new consults and average censuses for infectious diseases training programs and strategies implemented to mitigate high volume. High patient volumes in training programs can impact learning, wellness, and patient outcomes. Mitigating high volume is imperative to protect the learning environment. This nationwide survey describes the average workload for infectious diseases fellows and mitigation strategies implemented by programs.

Background Extensively drug-resistant (XDR) P. aeruginosa (PA), defined as resistant to ≥ 1 agents in all classes of antibiotics except two classes, limits therapeutic options to more toxic agents such as aminoglycosides (AMG) and polymyxins. Majority of the XDR PA isolated in two of our teaching hospitals were found to be susceptible to ceftolozane–tazobactam (CT) in addition to AMG and polymyxins. Our study aims to compare treatment outcomes with traditional antibiotics vs. CT in patients with XDR PA pneumonia. Methods This is a retrospective case–control study of patients admitted to two local hospitals from 2013 to 2018. Patients were screened by discharge diagnosis for pneumonia. We included patients over 18 years with XDR PA in sputum cultures susceptible to ≤ 2 classes of antibiotics. Statistical analyses included ANOVA, T-test, Fisher exact and Chi-square tests. Results Among the 48 patients with XDR PA pneumonia, 33 patients met inclusion criteria. Their mean age was 62 years (SD ±16), 30% were female, and 18% were immunocompromised. Similarly, 85% of patients had underlying lung disease and 55% had a tracheostomy tube. Majority of these patients were either nursing home residents (55%) or hospitalized (46%) within past 3 months. Septic shock associated with XDR PA pneumonia was found in 30% of patients, and 73% required mechanical ventilation during treatment. Nineteen patients received an aminoglycoside (AMG group), 1 colistin, 9 CT (CT group), and 4 received CT plus an AMG. The average time to clinical improvement was 3.5 (±2.2) days for AMG group and 2.2 (±1.7) days for CT group (P = 0.3). Compared with CT group, AMG group had significantly longer mean duration of hospital stay (19 ± 13 vs. 32.4 ± 17 days, P < 0.05). All patients who had clinical failure to improve requiring change in antibiotics (2 patients) or who died after withdrawal of care (3 patients) were in AMG group. Clinical relapse within 30 days occurred equally in both groups (4 AMG, 2 CT, P > 0.05). Six patients who developed acute kidney injury received either an AMG (5) or colistin (1). Conclusion Based on our observation, CT is a safe and effective treatment for XDR PA pneumonia. Compared with CT, patients who received AMG had longer hospital stays and sustained more nephrotoxicity. Disclosures All authors: No reported disclosures.

Background Telavancin (TLV) is a lipoglycopeptide antibacterial active against a wide range of Gram-positive organisms, including methicillin-susceptible and methicillin-resistant Staphylococcus aureus. New onset or worsening renal impairment was observed in phase 3 clinical trials. This analysis was conducted to better understand changes in renal function from real-world experience during prolonged TLV therapy. Methods Data from the Telavancin Observational Use Registry (TOUR™)—a multicenter chart review to characterize types of infection, pathogens, and outcomes of patients treated with TLV in clinical practice—were used to characterize a subset of patients with prolonged TLV therapy duration defined as treatment >21 days. Patient demographics, pathogens, outcomes, and adverse events (AEs) were analyzed. Clinical outcomes were determined by investigator assessment. Creatinine clearance (CrCl) was estimated by Cockcroft-Gault for all patients with serum creatinine measurements at baseline and end of TLV therapy. CrCl values were grouped as ≤30, >30–50, >50–80, and >80 mL/minute; categorical changes from baseline were classified and compared. Results A total of 308/1063 patients were treated with TLV for >21 days. At baseline, patients had a median CrCl of 113.4 mL/minute. Median TLV dose was 750 mg (range 254–1,500 mg) or 8.3 mg/kg (range 2.2–15.0 mg/kg); and median treatment duration was 38 days (range 22–185 days). The 2 most commonly treated infection types were bone and joint infections (55.2%) and complicated skin and skin structure infections (25.6%). A total of 121 (39.3%) patients had methicillin-resistant S. aureus. TLV was used as second-line or greater therapy in 235 (76%) patients, and the majority of patients (65.6%; n = 202) were treated as outpatients prior to starting TLV. Of the 308, 134 reported baseline and end of TLV therapy CrCl. CrCl was unchanged in the majority of patients (68.7%; n = 92), 9 (6.7%) improved, and CrCl decreased in 33 (24.6%) patients. A total of 25 (8.1%) patients reported renal AEs. Conclusion In the subset of patients with baseline and end of TLV therapy CrCl, renal function was unchanged in the majority of patients with prolonged TLV therapy >21 days. Disclosures A. Hassoun, Theravance Biopharma, US: Speaker’s Bureau, Speaker honorarium. M. Lacy, Theravance Biopharma, US: Employee and Shareholder, Salary. C. Barnes, Theravance Biopharma, US: Employee and Shareholder, Salary. B. Castaneda-Ruiz, Theravance Biopharma, US: Employee and Shareholder, Salary.

Abstract The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area. Infectious Diseases (ID) Training Program Directors have observed an increase in clinical volume and acuity. Specific goals and strategies to manage the volume and acuity while preserving quality education in both the inpatient and ambulatory settings are described