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We describe the case of a 14-year-old girl with relapsed pain following adequate treatment of pubic symphysis septic arthritis with adjacent osteomyelitis. Evaluation of her symptoms was challenging, because magnetic resonance imaging (MRI) was not helpful and repeat surgical exploration was not favored. She was treated with a combination of prolonged antimicrobial therapy and local steroid injection. This case highlights the limitations of MRI as a follow-up study for evaluating symptom relapse of acute osteomyelitis.

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We describe the case of a previously healthy 7-month-old male infant with urinary tract infection due to Staphylococcus epidermidis grown from two separate urine cultures. Further evaluation showed severe bilateral vesicoureteral reflux. Physicians should not assume that S. epidermidis is always a contaminant in urine cultures.

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BackgroundCerebrospinal fluid (CSF) pleocytosis, defined here as ≥5 white blood cells (WBC)/high power field (HPF) suggests inflammation of brain parenchyma /meninges or both. However, the absence of pleocytosis does not rule out meningoencephalitis. The frequency with which infectious targets are identified in the absence of CSF pleocytosis is not well known. Traditional diagnostic methods based on culture and single target polymerase chain reaction (PCR) assay were inadequate to answer this question. However, the availability of multiplex (PCR) panels opens up the opportunity.MethodsStarting June of 2016 Akron children’s hospital adopted the Biofire® Meningitis encephalitis panel (MEP). The panel is run routinely on all CSF specimens obtained from patients presenting with a clinical picture consistent with meningoencephalitis irrespective of their CSF biochemistry and cell count Results. We retrospectively collected laboratory data for all the MEP positive patients. The data were filtered based on CSF WBC count, pathogens identified as well as by patient age.ResultsA total of 133 positive results were identified from June 2016 to March 2019. Due to unclear significance, 22 positive Human herpes virus (HHV) 6 results were excluded, One VZV positive result was also excluded (Figure 1). Of the remaining 110 positives, 29% had CSF WBC count < 5/HPF. Parecho and Enterovirus were the most common. Three isolates were positive for Herpes simplex 1 (HSV 1) and one for Herpes simplex 2 (HSV 2). Haemophilus influenzae was detected in one patient (Figure 2).ConclusionOur observations suggest that viral meningoencephalitis may occur frequently in the absence of CSF pleocytosis. Bacterial meningitis seems less likely. Several centers have a policy to restrict multiplex PCR panel testing based on CSF WBC cut-offs, citing increased costs. However, this approach may lead to missed diagnosis. As a direct result of this additional investigations and/or treatment may be pursued leading to increased overall costs as well as exposing the patient to potential harm. Additionally making a diagnosis could lend itself to monitoring outcomes—an area where there is paucity of high-quality data. Disclosures All Authors: No reported Disclosures.

Background Deep neck infections (DNI’s) are uncommon (~45,000 US cases annually) but, potentially serious. Published data regarding bacteriology and antibiotic usage for DNI’s in children is limited. In addition, geographic variation in the incidence of pathogens and their antimicrobial susceptibility limits generalization of treatment guidance. Reviewing our practice at Akron childrens we noted considerable variation in the choice of empiric antibiotics (ampicillin-sulbactam vs piperacillin-tazobactam vs Ceftriaxone and Clindamycin/vancomycin/linezolid). Admission unit (floors vs intensive care) and service (hospitalist vs infectious diseases) were some important determinants that influenced choice of empiric antibiotics. This retrospective study aimed to review local data and come up with standard guidance for empiric therapy. Summary of the predominant bacterial isolates. Methods We reviewed records of 125 patients who underwent surgical drainage of DNI’s from 1/2015 – 12/2019. In addition to demographic data we gathered information on bacterial isolates and their susceptibilities. Chart review was performed for patients with staphylococcus aureus, to look for any unique presenting features. Results Up on reviewing the data- peritonsillar abscesses were common in older children (Median age 11 years). As expected, retropharyngeal and parapharyngeal infections were common in younger ones (&lt; 5 years). Group A streptococcus remained the most common aerobic isolate followed by Hemophilus influenzae/parainfluenzae. MRSA was detected in ~7 % of all cultures (see enclosed table). Notably, none of the MRSA isolates were clindamycin resistant. However, MSSA resistance to clindamycin was about 20%. No clinical characters predicted isolation of S. aureus. Anaerobic infections (polymicrobial) were overwhelmingly common across all abscess types. Conclusion Based on our review, Ampicillin-Sulbactam is a good empiric choice antibiotic for deep neck infections in our institution. Ceftriaxone with clindamycin is another option. Clindamycin monotherapy seems to be inadequate. Staph aureus and especially MRSA, were only isolated in a small percentage of cases. Unless a patient is ill appearing, vancomycin use seems unnecessary. Clinical presentation was not helpful to suspect infection with Staph aureus. Disclosures All Authors: No reported disclosures

Introduction: Cystitis and pyelonephritis are common bacterial infections in infants and children, and initial treatment is usually empirical. Antimicrobial stewardship advocates using narrow-spectrum antibiotics with consideration for local resistance patterns. Narrow-spectrum antibiotic use is critical in addressing the global issue of bacterial antimicrobial resistance, associated with approximately 5 million annual deaths. Methods: The antimicrobial stewardship committee developed a guideline for diagnosing and managing urinary tract infections and distributed it to all primary care providers. A standardized order set provided clinical decision support regarding appropriate first-line antibiotic therapy. A chief complaint of dysuria prompted the use of the order set. Prescription rates for the most common antimicrobials were tracked on a control chart. Results: From March 2018 through March 2020, there were 4,506 antibiotic prescriptions for urinary tract infections. Utilization of the recommended first-line therapy, cephalexin, increased from 27.5% to 74.8%. Over the same period, trimethoprim-sulfamethoxazole, no longer recommended due to high local resistance, decreased from 31.8% to 8.1%. Providers have maintained these prescribing patterns since the conclusion of the project. Conclusion: Using clinical decision support as a standardized order set can sustainably improve the use of first-line antimicrobials for treating pediatric urinary tract infections.