It is rare for acalculous cholecystitis to present with symptoms outside the abdomen; hence, making its diagnosis can be a challenge. We report a case of a 77-year-old male, with a relevant past medical history of left knee arthroplasty two years prior, who presented with left knee pain and swelling. Cultures from the arthrocentesis grew Clostridium perfringens, which led to a search for the source of infection. The right upper quadrant (RUQ) ultrasound (US) showed an enlarged gallbladder filled with sludge, but no cholelithiasis or secondary ultrasound findings were present to suggest acute cholecystitis. A computed tomography (CT) scan showed a distended gallbladder with diffuse gallbladder wall thickening and no stone but with suspicion for acalculous cholecystitis. A subsequent hepatobiliary (HIDA) scan confirmed the diagnosis of acalculous cholecystitis. Subsequently, the patient had a biliary drain placed. Bile cultures grew gram-positive rods consistent with Clostridium perfringens, confirming the source. With regards to the septic prosthetic joint, the patient underwent irrigation and debridement with polyethylene exchange without replacement of the prosthesis. The patient was also treated with six weeks of intravenous (IV) ertapenem (1 gram daily) and 12 months of moxifloxacin (400 mg daily). He had a cholecystectomy later and his symptoms were completely resolved.

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BackgroundEvidence surrounding outcomes with the North American pulsed-field gel electrophoresis type 1 (NAP1) Clostridium difficile (CDI) strain remains conflicting. We compared risk factors, severity of illness, and mortality of patients infected with NAP1 strain compared with patients with non-NAP1 strains in our multihospital health system.MethodsThis is a retrospective case–control analysis of patients admitted to one of five hospitals (one academic and four community hospitals) and diagnosed with CDI from April 2014 through July 2017. CDI definition included three or more stools per day with positive stool sample polymerase chain reaction (PCR) testing for C. difficile.ResultsA total of 490 patients met inclusion, of which 155 had the NAP1 strain and 335 patients were infected with non-NAP1 strains. More patients with NAP1 were older, female, had CHF, and presented from a healthcare facility as opposed to from the community (all P < 0.05). No difference in 90-day antibiotic class use was found. NAP1 patients had increased ICU admission (12.3 vs. 6.0%, P = 0.016), a shorter length of stay (10.8 vs. 13.4 days, P = 0.037), abnormal CT findings (P < 0.023), and trend toward more ID consults (P = 0.067). Per IDSA classification, 61.9% in the NAP1 CDI group had severe CDI as opposed to 49.6% in the non-NAP1 study group. (P ≤ 0.038). There was no observed difference in inpatient mortality (7.7 vs. 5.7%, P = 0.381).ConclusionCDI caused by NAP1 strain did result in increased severity but did not result in increased mortality compared with CDI caused by non-NAP1 strains. Evidence continues to mount that while the NAP1 strain may affect severity, its effect on mortality remains in question.Disclosures All authors: No reported disclosures.