Adequate Antibiotic Therapy Research Articles

Effective use of the endoscopic vacuum system in the comprehensive treatment of a patient with a defect in the abdominal segment of the esophagus after gastrectomy

In oncosurgery esophago-intestinal anastomotic leak as well as defects of the abdominal segment of the esophagus are serious complications associated with prolonged hospital stay and increased mortality rate. A choice of management tactics for each patient is individual. Treatment of esophageal anastomotic leak without separation provides the best result by reducing the time of rehabilitation, improving the quality of life and reducing mortality. Conservative treatment requires an adequate drainage when conducting enteral feeding and adequate antibiotic therapy. The indications for separation of the anastomosis include a large defect size, necrosis of the graft uncontrolled purulent-septic complications and a failure of conservative therapy. In recent decades a number of methods for endoscopic treatment of anastomotic leaks in the gastrointestinal tract have been elaborated, including the use of adhesive agents, self-expanding stents, clipping, and endoscopic vacuum system. These methods have several advantages over surgical and conservative management. Despite the accumulated experience, at present there is no single systemic approach to the use of endoscopic methods for closure of defects of anastomosis as well as defects of the abdominal segment of the esophagus. This is mainly due to a relatively small number of publications. One of the promising methods for endoscopic treatment of anastomotic leak is currently the Endoscopic Vacuum System (EndoVAC therapy). The article provides the clinical case of a patient with stomach cancer who was given transperitoneal gastrectomy with D2-lymphadenectomy which was complicated by a defect in the abdominal segment of the esophagus with peritonitis. To treat those complications relaparotomy, sanitation and drainage of the abdominal cavity was performed. In order to achieve closure of the fistula more quickly the vacuum system was used resulting in a marked decrease in fluid exudation, which in turn contributed to closure of the fistula.

КОМПЛЕКСНАЯ ПРОГРАММА СНИЖЕНИЯ РИСКОВ ПЕРИНАТАЛЬНЫХ ОСЛОЖНЕНИЙ У БЕРЕМЕННЫХ С ПИЕЛОНЕФРИТОМ

В результате исследования 533 историй родов было определено, что ОР преждевременных родов при пиелонефрите составляет 2,26 (95% доверительный интервал (ДИ) 1,18-4,32), дистресса плода – ОР 2,82 (ДИ 1,38-5,78), рождения маловесного новорожденного – ОР 2,48 (ДИ 0,8-8,9), рождения новорожденного с низким массо-ростовым коэффициентом – ОР 1,94 (ДИ 1,19-3,17).Была разработана комплексная программа ведения беременных с пиелонефритом, по которой было проведено 276 беременных. Она включала в себя определение антител к липополисахаридам – эндотоксинам грамотрицательных бактерий, С3а компонента комплемента, С-реактивного белка и прокальцитонина, адекватную антибиотикотерапию в сочетании с озонотерапией с энтеросорбцией, оценку динамики регресса воспалительного процесса в почках по уровню С-реактивного белка и оценку риска развития перинатальных осложнений. При подозрении на внутриутробную инфекцию, малом весе при рождении рекомендовано определение в крови пуповины маркеров воспаления, С3а компонента комплемента, С-реактивного белка, прокальцитонина. Риск преждевременных родов при ведении беременных по предложенной нами программе снижается в 2,17 раза (ДИ 1,13-4,14), дистресса плода – в 2,25 раза (ДИ 1,15-4,41), рождения маловесного новорожденного – в 3,06 раза (ДИ 1,31-7,15).

Clinical Approach to Individualization of Antimicrobial Therapy Based on Pharmacokinetic/Pharmacodynamic Analysis and Therapeutic Drug Monitoring

The use of a drug administration plan and therapeutic drug monitoring (TDM) based on pharmacokinetic-pharmacodynamic (PK-PD) analysis is important for the effective use of antimicrobial agents to treat infections. We focused on the use of beta-lactam agents, anti-methicillin-resistant Staphylococcus aureus (MRSA) agents, and an antifungal agent as antimicrobial agents and examined their efficacy in patients under special clinical conditions from the viewpoint of safety and TDM. Our PK-PD analysis of the use of an administration plan to set an optimum serum level for beta-lactam agents or anti-MRSA drugs for the treatment of pneumonia, acute renal failure during continuous hemodialysis filtration, febrile neutropenia, or malignant tumors confirmed the necessity of managing the optimal serum level. PK-PD analysis was also useful for TDM of voriconazole and intubation administration in long-term use from the viewpoint of preventing the onset of side effects. PK-PD analysis appears to be a useful tool in antibiotic therapy and TDM for developing a pharmacokinetic "individual difference" for "individualization therapy" under special clinical conditions. PK-PD analysis utilizes the restrictive information that is obtained by a clinic to the maximum and allows coordination with the mission of hospital pharmacists to provide adequate antibiotic therapy.

IMMUNOMODULATION, IMMUNOSTIMULATION AND EXTRACORPOREAL BLOOD PURIFICATION IN SEPSIS: POTENTIALLY BENEFICIAL TECHNIQUES IN CARDIAC SURGERY

Sepsis is a potentially life-threatening state caused by an infection and an inadequate, dysregulated host immune response. Focusing on cardiac surgery, the prevalence of sepsis is low, after procedures situated between 0.39% and 2.5%. Nevertheless, the current life-expectancy of septic patients are poor, mortality varying from 65% to 79%.Pathophysiology and immunopathology of sepsis is still unclear. Actually we consider sepsis as a dynamic process with two different sides. Both immune hyperactivity and immune suppression are presented during the progression. Although immunomodulation is not a fresh idea in the treatment of sepsis. Currently the diagnosis of sepsis is based on clinical signs. The biomarkers and molecular diagnostic tools are insufficient.The actual concept of immunopathophysiology in sepsis is based on the idea of a dynamic parallel immune response, both pro- and antiinflammatory processes are presented from the beginning. Equilibrium may be the key in the immune response of sepsis. Immune system tries to maintain the homeostatic environment during sepsis via pro- and antiinflammatory processes. In case of an unbalanced, dysregulated and radical (in both directions) response mortality become frightfully high. Infectional source control, adequate antibiotic therapy and organ support are the three corner stones in the treatment of sepsis since the definition of sepsis born.In our review we would like to add a detailed overview on two promising modalities of immunomodulation: (1) extracorporeal blood purification; (2) immunostimulation.The purposeof present article is to give an up-to-date, comprehensive review on the utilization of extracorporeal blood purification techniques and immunostimulation in septic patient after cardiac surgery.

PECULIARITIES OF TYPHOID FEVER CLINICAL COURSE AT THE PRESENT TIME

Typhoid fever is staying actual problem in Russia and in other countries of the world, as the growth of S. Typhi antibiotic resistance and changes of the clinical picture of the disease makes difficult the modern diagnosis and administration of adequate antibiotic therapy. On the example of clinical histories of patients’ diseases who were hospitalized in the 2nd Moscow Infection Clinical Hospital we demonstrate the peculiarities of typhoid fever clinical picture.

Enhanced Performance of Next-Generation Sequencing Diagnostics Compared With Standard of Care Microbiological Diagnostics in Patients Suffering From Septic Shock.

Culture-based diagnostics represent the standard of care in septic patients, but are highly insensitive and in many cases unspecific. We recently demonstrated the general feasibility of next-generation sequencing-based diagnostics using free circulating nucleic acids (cell-free DNA) in plasma samples of septic patients. Within the presented investigation, higher performance of next-generation sequencing-based diagnostics was validated by comparison to matched blood cultures. A secondary analysis of a prospective, observational, single-center study. Surgical ICU of a university hospital and research laboratory. Fifty patients with septic shock, 20 uninfected patients with elective surgery as control cohort. None. From 256 plasma samples of 48 septic patients at up to seven consecutive time points within the 28-day observation period, cell-free DNA was isolated and analyzed by next-generation sequencing and relevance scoring. In parallel, results from culture-based diagnostics (e.g., blood culture) were obtained. Plausibility of blood culture and next-generation sequencing results as well as adequacy of antibiotic therapy was evaluated by an independent expert panel. In contrast to blood culture with a positivity rate of 33% at sepsis onset, the positivity rate for next-generation sequencing-based pathogen identification was 72%. Over the whole study period, blood culture positivity was 11%, and next-generation sequencing positivity was 71%. Ninety-six percent of positive next-generation sequencing results for acute sepsis time points were plausible and would have led to a change to a more adequate therapy in 53% of cases as assessed by the expert evaluation. Our results show that next-generation sequencing-based analyses of bloodstream infections provide a valuable diagnostic platform for the identification of clinically relevant pathogens with higher sensitivity and specificity than blood culture, indicating that patients might benefit from a more appropriate therapy based on next-generation sequencing-based diagnosis.

Etiological structure and antibiotic resistance of the nosocomial strains of microorganisms in the department of anaesthesiology and resuscitation

Due to the formation and wide spread of strains of microorganisms that are multiresistant to modern antimicrobial drugs, the problem of healthcare associated infections (HAIs) is relevant for all healthcare organizations. Most often HAIs are related to intravascular catheter use, mechanical ventilation, bladder catheterization, surgery and enteral feeding. Knowledge of the etiological structure of the nosocomial strains of microorganisms, regular microbiological monitoring, monitoring of antibiotic resistance are necessary to control HAIs and timely implementation of sanitary and anti-epidemic measures. The purpose of the study is to analysis of the etiological structure and determination of antibiotic resistance of the nosocomial strains isolated from patients and environmental objects in the Department of anesthesiology and resuscitation № 1 of City Clinical Hospital № 7. Materials and methods . We used conventional microbiological methods for isolating a pure culture of the pathogen with determining the sensitivity to antibiotics by the diffusimetric method (Kirby-Bauer), including the presence methicillin resistance of staphylococcal strains and extended-spectrum β-lactamases. Results and conclusion . Multiresistant strains of Acinetobacter baumannii, Proteus mirabilis and Klebsiella pneumonia were isolated in the department of anesthesiology and resuscitation. It will allow to conduct adequate antibiotic therapy, and as a result, reduce the incidence of complications, the risk of death and substantial economic losses.

Microbial spectrum and rational antibacterial therapy in treatment of infected forms of necrotic pancreatitis

The most significant areas of scientific and practical research in urgent pancreatology of the last decade are the study of the course of necrotic pancreatitis with the evaluation of the effectiveness of antibiotic therapy at different stages of the disease according to microbiological studies, nosocomial infection and the development of sepsis.
 Purposw of the study. To study the effectiveness of antibacterial therapy in complex treatment of infected forms of necrotizing pancreatitis, depending on the species composition of the infection, the severity of the pathology and the development of sepsis.
 Materials and methods. The study included 48 patients with infected forms of necrotic pancreatitis over the past two years undergoing treatment at the Department of Anesthesiology and Intensive Care of Zaporizhzhia 3rd City Clinical Hospital in 2017–2018.
 Results. Research of the species composition of microorganisms showed that there is predominant gram-negative flora in pancreatogenic infection such as: Pseudomonas aeruginosa – 26,3%, Acinetobacter spp. – 21,1%, the Enterobacteriaceae family: Klebsiella pneumoniae – 10,5% and Escherichia coli – 15,8%. The detected spectrum of microorganisms gives an idea of the main pathogens characteristic of infected forms of necrotizing pancreatitis. Antibiotic sensibility analysis showed that high activity against pathogens was observed in meropenem, taygecycline and tobramycin. In 21% of patients, resistant strains of Ps. Aeruginosa were detected, but in 3 patients there was a positive dynamics in the use of detoxication therapy with inclusion of extracorporal methods (discrete plasmapheresis) in combination with two-component antibiotic therapy (meropenem + linezolid).
 Conclusion. The analysis of treatment of patients with infected necrotizing pancreatitis and its complication sonthebasis of continuous monitoring of bacterial flora with the provision of adequate antibiotic therapy, prevention of nosocominal infectionand a modern strategy for the use of surgical interventions, especiallynoninvasive, contributes to the reduction of sepsis and, as a result, reduction in mortality and severe postoperative complications.

Modern approaches to the treatment of postpartum purulent-septic diseases

The cohort prospective comparative study showed improvement of the management of patients with various forms of purulentseptic diseases (PSD). The study included 276 women with PSD admitted to the gynecological hospital from January 1, 2014 to December 31, 2016. The patients were divided into two cohorts depending on the clinical course, management, and outcomes, which corresponded to the clinical forms of PSD: uncomplicated and complicated. The parameters that were evaluated in patients in both groups included complaints, pregnancy course and childbirth, duration of manifestations of the disease, the clinical picture, laboratory parameters. The study resulted in the development of an algorithm for management of patients with PSD including lavage of the site of infection, adequate antibiotic therapy depending on the type of pathogen, infusion and anticoagulant therapy, and treatment of vaginitis. The developed algorithm for management of patients with various forms of postpartum PSD allowed all 276 (100%) participants to preserve reproductive function and avoid early postoperative complications.

Validation of a diagnostic score model for the prediction of Legionella pneumophila pneumonia

BackgroundCommunity-acquired pneumonia (CAP) due to Legionella has a high mortality rate in patients who do not receive adequate antibiotic therapy. In a previous study, we developed a simple Legionella Score to distinguish patients with Legionella and non-Legionella pneumonia based on clinical information at diagnosis. In the present study, we validated this Legionella Score for the presumptive diagnosis of Legionella CAP. MethodsThis validation cohort included 109 patients with Legionella CAP and 683 patients with non-Legionella CAP. The Legionella Score includes six parameters by assigning one point for each of the following items: being male, absence of cough, dyspnea, C-reactive protein (CRP) ≥ 18 mg/dL, lactate dehydrogenase (LDH) ≥ 260 U/L, and sodium < 134 mmol/L. ResultsWhen the Legionella CAP and non-Legionella CAP were compared by univariate analysis, most of the evaluated symptoms and laboratory test results differed substantially. The six parameters that were used for the Legionella Score also indicated clear differences between the Legionella and non-Legionella CAP. All Legionella patients had a score of 2 points or higher. The median Legionella Scores were 4 in the Legionella CAP cases and 2 in the non-Legionella CAP cases. A receiver operating characteristics curve showed that the area under the curve was 0.93. The proposed best cutoff, total score ≥3, had sensitivity of 93% and specificity of 75%. ConclusionOur Legionella Score was shown to have good diagnostic ability with a positive likelihood of 3.7 and a negative likelihood of 0.10.

The association of adequate empirical treatment and time to recovery from bacteraemic urinary tract infections: a retrospective cohort study

Our objective was to evaluate whether patients with bacteraemic urinary tract infection (UTI) who receive inadequate empirical therapy have worse outcomes than those with adequate therapy. This was a retrospective cohort study of patients with bacteraemic UTI. The exposure variable was adequate versus inadequate empirical antibiotic therapy (AEAT versus IEAT) within 24 h of culture collection. Primary endpoint was time to cure. The primary analysis used propensity score models with inverse probability of treatment weights. A secondary Cox proportional hazards modelling approach was used to test the robustness of this finding, and to evaluate other patient and pathogen predictors of time to cure. Of 469 patients with bacteraemic UTI, 368 (78.5%) received AEAT. There was no significant difference in mortality between those receiving AEAT and those receiving IEAT (adjusted OR 0.86, 95%CI 0.47–1.58). Receipt of AEAT had no association with time to cure (HR 0.93, 95%CI 0.73–1.19, p 0.55) or time to normalization of individual clinical variables. Cox proportional hazards modelling revealed that longer time to cure was associated with liver disease (HR 0.25, 95%CI 0.08–0.76, p 0.015), prior stroke (HR 0.73, 95%CI 0.54–0.99, p 0.044), empirical receipt of piperacillin–tazobactam (HR 0.77, 95%CI 0.59–0.99, p 0.044), qSOFA score >1 (HR 0.68, 95%CI 0.55–0.84, p < 0.001), and hospital-onset UTI (HR 0.53, 95%CI 0.39–0.71, p < 0.001). In conclusion, we found no association between AEAT and time to cure for patients with bacteraemic UTI. It may be appropriate to accept a higher risk threshold when choosing empirical antibiotic regimens, even in centres with high rates of resistant uropathogens.

Financial burden of ventilator associated pneumonia among patients in intensive care unit: Kosovo case study

Background and objective: Ventilator-associated pneumonia (VAP) is a predominant type of healthcareassociated infection (HAI) in intensive care units (ICU), associated with increased length of stay(LOS), mortality rates, and costs. We aimed to assess the financial burden of VAP in terms of direct medical costs incurred by the patients treated in ICU. Methods: A local surveillance dataset was used to perform the assessment of direct medical costs incurred by the patients while being treated for VAP in the ICU at University Clinical Centre of Kosovo (UCCK). Results: Overall, incidence rate of HAIs in the ICU at UCCK was 62.1% with VAP dominating the infection account (73.2%). The LOS in ICU ranged from 2–44 days with a median time of six days, while the distribution between VAP affected and unaffected patients ranged between 13.5 and 5.4 days, respectively. The mean cost to patients with VAP is estimated as €647±487, which is significantly higher than in patients without VAP (€227±174). Conclusion: An immediate action is required to introduce better VAP prevention and control measures in the ICU. Evidence-based practices confirm that compliance to hand-hygiene practices, ICU staff education, introduction of regular surveillance, and adequate antibiotic therapy can significantly decrease VAP incidence, save lives, decrease LOS, and reduce costs.

Nocardia paucivorans cerebellar abscess: Surgical and pharmacotherapy

Background:Nocardia species are ubiquitous in nature and mainly cause pulmonary disease in humans; however, they can also infect the central nervous system and skin. The management of cerebellar nocardiosis is troublesome and requires multiple considerations of the severity of the underlying systemic disease, difficulties in identifying the bacterium, and frequent delay in initiating adequate therapy.Case Description:We report a 52-year-old diabetic female patient with Nocardia paucivorans cerebellar abscesses. Brain magnetic resonance imaging (MRI) revealed innumerable small ring-enhancing lesions of posterior fossa. In this report, we present a case of primary single cerebellar abscesses due to N. paucivorans. Early diagnosis and surgical interventions were significant for the patient. The diagnosis was confirmed by DNA sequencing and the organism was susceptible to trimethoprim–sulfamethoxazole (TMP/SMX). The patient was successfully treated with drugs and surgical excision.Conclusion:According to the literature, surgical excision or aspiration of cerebellar abscess seems to provide favorable outcomes. In our experience, a successful outcome was achieved with subtotal resection and prolonged adequate antibiotic therapy.

Criteria for the morphological diagnosis of sepsis

80 cases of lethal outcomes with a clinical diagnosis of sepsis were analyzed. In 31 of them, the pathologoanatomical diagnosis was confirmed - histologically, the internal organs showed metastatic purulent foci. This criterion for the morphological diagnosis of sepsis corresponded to the modern definition of sepsis as a pyogenic bacterial infection with hematogenous generalization and the absence of a specific pathogen. When re-examining archival micropreparations, special attention was paid to finding inconspicuous small metastatic septic foci in the myocardium, kidneys, and brain (mini foci). Their detection required careful searches with a high magnification of the microscope due to fading with adequate antibiotic therapy with therapeutic pathomorphosis. To confirm suppurative inflammation in metastatic septic foci, neutrophilic granulocytes were identified by immunohistochemistry with an expression of CD15. Most often, mini-foci were found in the myocardium, less often in the brain. The presence of morphological signs of microcirculation disorders in all 80 observations was also recorded: leukostasis, «sludge-phenomenon», diapedesis haemorrhages, convolutions in the lumen of the vessels. In the group where sepsis was confirmed, leukostasis, sludge-phenomenon and diapedesis haemorrhages were more common. Comparison of the number of signs of microcirculation disorders in sepsis, confirmed histologically, with violations in the clinical diagnosis of «sepsis», not confirmed pathologically, was made. The obtained ratio made it possible to consider the pronounced and widespread microcirculatory disorders as objective microscopic criteria that require the study of additional sections for the detection of metastatic pustules for reliable diagnosis of sepsis. At the same time, it is possible to detect single mini-foci, indicating the presence of sepsis.

Acute Tibial osteomyelitis caused by intraosseous access during initial resuscitation: a case report and literature review

BackgroundIntra-osseous (IO) access is recommended in cases of pre-hospital emergency or resuscitation when intravascular (IV) route is difficult or impossible. Despite recent improvement in IO devices and increasing indications, it remains rarely used in practice. Various complications have been reported but are uncommon.Case presentationWe report a case of massive acute tibial osteomyelitis in an adult male three months after an IO catheter insertion for emergency drug infusion. We review the literature on association between IO access and acute osteomyelitis in children and adults.ConclusionsEmergency-care givers and radiologists should be informed about this infrequent complication in order to make early diagnosis and initiate adequate antibiotic therapy.

STAPHYLOCOCCUS AUREUS: PATHOGENICITY, ANTIMICROBIAL RESISTANCE AND CLINICAL IMPLICATIONS

Objective: To conduct a reflection about the pathogenicity, antimicrobial resistance, and clinical implications of the infections caused by Staphylococcus aureus . Method: Reflexive analysis, supported by theoretical references about the pathogenicity, antimicrobial resistance, and clinical implications of the staphylococcal infections. Results: The pathogenesis of S. aureus infections is complex and depends on the host characteristics, expression of virulence factors and ability to develop resistance to antimicrobials. Methicillin-resistant S. aureus (MRSA) is related to an advancement of healthcare- and community-acquired infections, being vancomycin the primary therapeutic option. Infections caused by S. aureus with reduced vancomycin susceptibility (hVISA/VISA) have been associated with treatment failures and increased mortality. Conclusion: With the evolution of S. aureus to MRSA, hVISA and VISA, the treatment of staphylococcal infections has become a major challenge for the medical clinic, and an adequate and early antibiotic therapy is essential for decreasing morbidity and mortality rates related to this microorganism.

Delay in antibiotic therapy results in fatal disease outcome in murine pneumococcal pneumonia

BackgroundCommunity-acquired pneumonia (CAP) remains a major cause of death worldwide. Mechanisms underlying the detrimental outcome despite adequate antibiotic therapy and comorbidity management are still not fully understood.MethodsTo model timely versus delayed antibiotic therapy in patients, mice with pneumococcal pneumonia received ampicillin twice a day starting early (24 h) or late (48 h) after infection. Clinical readouts and local and systemic inflammatory mediators after early and late antibiotic intervention were examined.ResultsEarly antibiotic intervention rescued mice, limited clinical symptoms and restored fitness, whereas delayed therapy resulted in high mortality rates. Recruitment of innate immune cells remained unaffected by antibiotic therapy. However, both early and late antibiotic intervention dampened local levels of inflammatory mediators in the alveolar spaces. Early treatment protected from barrier breakdown, and reduced levels of vascular endothelial growth factor (VEGF) and perivascular and alveolar edema formation. In contrast, at 48 h post infection, increased pulmonary leakage was apparent and not reversed by late antibiotic treatment. Concurrently, levels of VEGF remained high and no beneficial effect on edema formation was evident despite therapy. Moreover, early but not late treatment protected mice from a vast systemic inflammatory response.ConclusionsOur data show that only early antibiotic therapy, administered prior to breakdown of the alveolar–capillary barrier and systemic inflammation, led to restored fitness and rescued mice from fatal streptococcal pneumonia. The findings highlight the importance of identifying CAP patients prior to lung barrier failure and systemic inflammation and of handling CAP as a medical emergency.

Are tracheal surveillance cultures useful in the intensive care unit?

Endotracheal aspirate (ETA) surveillance cultures have been used to predict the microorganisms responsible for ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients for 3 decades. However, although more than a dozen studies have been performed, the usefulness and the safety of this strategy are still debated. Tracheobronchial bacterial colonization often precedes the occurrence of VAP, and it has been postulated that the microbes present in the tracheal secretions a few days before VAP might be the same as those retrieved in the lower respiratory tract. A large number of studies, with heterogeneous designs and variable results, have questioned the possibility of predicting, by regular ETA cultures after the 48th hour of mechanical ventilation (MV), the microbiology of VAP and therefore of determining the adequate antibiotic therapy to limit the over-prescription of broad spectrum molecules when following guidelines. Although it has shown some promising results, the strategy has not achieved unanimity because of some discordant data. The aim of this review is to provide an updated overview of the literature available in the field and to attempt to determine the strengths and weaknesses of antibiotic stewardship based on ETA surveillance cultures in VAP, particularly in the global context of drug resistant microorganism emergence and the crucial necessity of broad spectrum molecule preservation.

Sepsis bei Kindern – alles anders?

Background: A child with sepsis represents a great challenge for all healthcare workers involved in the rescue services and the emergency room, especially those not regularly confronted by pediatric emergencies. Method: Narrative review focused on diagnosis, epidemiology and management of neonatal and pediatric sepsis in the emergency department. Articles published in English or German within the last 5 years were eligible. Presentation of age-specific case vignettes and tables including clinical signs, risk factors, and management in the first hour during transport and in the emergency department. Results: The highest incidence of bacterial sepsis in children is reported within the first few years of life. Clinical signs, site of infection and management of sepsis are age specific. The most frequently reported organ dysfunctions in pediatric sepsis are respiratory dysfunction and circulatory depression but arterial hypotension is a late sign of circulatory insufficiency. Vasoconstriction with a cold periphery and tachycardia is typical in infants but the recognition is often not simple. Immediate administration of 20 ml/kg body weight of balanced crystalloid fluid is mandatory in a state of shock. Diagnosis of sepsis remains challenging, yet outcomes are directly related to time to recognition and treatment. Initially, laboratory markers may be normal or slightly abnormal and are thus not sufficiently predictive to rule out sepsis. Early empiric antibiotic treatment is mandatory for every clinically suspected case of pediatric sepsis. Every child with suspected sepsis has to be admitted to a children’s hospital as soon as possible. Conclusion: The early recognition of signs of sepsis, the prompt initiation of fluid replacement and an adequate antibiotic therapy remain the most important factors to improve the prognosis of pediatric sepsis.

Bacteremia in solid organ transplant recipients: Incidence, etiology, risk factors and evolution. A multicenter study

Background: Solid-organ transplantation (SOT) has become the preferred approach to treat end-stage organ disease. While preventive strategies have reduced the risk for classical opportunistic infections, bacterial -particularly bloodstream infections (BSI)- remain the most frequent short-term complications in SOT recipients and potentially life threatening. Our objective was to analyze the epidemiology, microbiological characteristics and risk factors associated with morbidity and mortality of BSI in SOT during the first 90 days after transplantation. Methods & Materials: Prospective, observational, multicenter study. Through a single data collection record, all BSI in SOT during the first 90 days post-transplantation were enrolled between May 2016 and September 2017. Results: We documented 104 episodes of BSI in: kidney (67%), liver (13%), heart (8%) and other (12%) transplant recipients. Thymoglobulin plus corticoids was the most common induction immunosuppression (43%) in kidney transplant, while tacrolimus, steroids and micofenolic acid was for maintenance (68.5%). 34% of the patients were colonized by multi-drug resistant organisms (MDRO) 12 months prior to BSI, 29% had a previous infection by these MDRO, and 71% received antibiotics 90 days prior to transplantation. Of the 104 BSIs, 92.3% were of nosocomial acquisition and 20 patients (19.2%) had more than one BSI. Secondary bacteremias accounted for 85% of the episodes, being urinary (56.7%) and surgical site infection (12.5%) the most frequent foci. Gram-negative bacilli (GNB) caused 83% of the BSI, with Klebsiella pneumoniae registered as the most common agent (33%). 60% of the specimens were MDRO, being extended spectrum b-lactamase (ESBL) the most frequent mechanisms (59.7%), followed by carbapenemase production (15%). There was no significant difference in clinical symptoms, signs and severity (measured by Pitt and APACHE II scores) between patients infected by MDRO and non-MDRO. An adequate empiric antibiotic therapy was registered in 80% of non-MDRO BSI, and 73% in MDRO BSI (p = 0.67) There was no difference in 30-day overall mortality between both groups (24% vs 21%, p = 0.68) Conclusion: It is essential to know the epidemiology of BSI and the mechanisms of resistance of the MOs in order to improve prophylaxis and empirical therapies, to finally reduce the impact of these infections in mortality.