Difference In Incidence Of Infection Research Articles

#1654 Infectious complications after kidney transplantation: a retrospective study

Abstract Background and Aims Infection is a major cause of morbidity among kidney transplant recipients. Allograft rejection is a frequent cause of dysfunction and its treatment increases the risk for both common and opportunistic infections. Nevertheless, its exact impact on infection incidence and further worsening of allograft dysfunction is not fully known. We aimed to characterize the incidence, nature, and severity of infectious complications following kidney transplantation, their association with previous rejection and its impact on allograft function. Method This was a single center retrospective study covering all patients transplanted between July 2021 and June 2023 in a tertiary referral center. Demographic and clinical data were collected from patient records, including donor and patient features, graft function over time and occurrence of either infection or rejection. Logistic regressions were adjusted considering sex, age, blood type and presence of diabetes as independent variables. Results A total of 139 patients were considered, 49 (35.3%) were women and 90 (64.7%) were men. Mean age was 49.6 ± 13.0 years. Median follow-up time was 375 [194-596] days. The main cause of renal disease was diabetes (37 patients, 26.8%) and most patients (113; 81.9%) were on hemodialysis for a median vintage of 3 [2.3] years. Considering the 139 transplants performed, 113 (81.2%) were isolated kidney, 24 (17.4%) were simultaneous kidney-pancreas and 2 (1.4%) were simultaneous kidney-liver transplantation. Eleven (7.9%) were living donor. During follow-up time, in-hospital infection occurred in 34 (24.4%) patients, mostly urinary (13, 38%) and blood stream (11, 32%) infections. These events significantly delayed hospital discharge (15.88 ± 8.52 vs 26.05 ± 14.3 days, p-value=0.001). During the follow up, a total of 107 (77%) patients developed 220 infection episodes leading to 47 hospital admissions. Urinary infections (64, 28.8%) and cytomegalovirus (CMV) viremia (64, 28.8%) were the most common at median follow-up time of 85.5 [40.25-183.75] and 159 [43.25-258.5] days, respectively. Median timing of diagnosis was 400.8 [203-614] days after transplant. They were much more common during the first three months (0.014 vs 0.002 per follow-up day). There were no differences in infection incidence between type of donor (p=0.76), type of allograft (p=0.361), immunosuppression protocol (thymoglobulin or basiliximab, p=0.45), renal replacement therapy or presence of diabetes. Regarding urinary infections, days of urinary catheterization (p=0.905), need for catheter replacement (p=0.092) or presence of residual diuresis (p=0.375) had no impact on infection rates. A positive correlation was found, between the number of infection episodes and creatinine increase over the first year (r=0.386; p<0.000). Allograft rejection was diagnosed and treated through protocol biopsy in 25 (18%) cases. These patients presented 17 confirmed episodes of infection over the three following months. Nine of them (36%) were CMV detectable viremias. Patients with a history of rejection had significantly more infections (1.49 ± 1.22 vs 2.20 ± 1.26, p=0.01), even after adjustment (p=0.006). Conclusion Early infections after kidney transplantation negatively impact hospital length of stay and allograft function. Furthermore, immunosuppressive treatment of allograft rejection carries a higher risk of infection. Further research is needed to clarify the impact of specific subsets of allograft rejection and immunosuppression protocols on the incidence of various types of infectious complications which could impair short-term renal function.

Higher infection risk for JAK inhibitors tofacitinib and baricitinib compared to subcutaneous biological DMARDs.

Rheumatoid arthritis (RA) is usually treated with disease modifying antirheumatic drugs (DMARDs), including biological DMARDs (bDMARDs) and more recently, Janus kinase inhibitors (JAKi). Randomized trials suggest similar infection risks for JAKi and bDMARDs, but real-world data are scarce. From a nationally representative prescription database, adult RA patients starting a new JAKi or bDMARD between August 1st, 2018, and January 31st, 2021, were included. Prescriptions of antibiotic, antiviral or antifungal medication were used as proxy for infections. Infection incidence rates (IR) were compared between JAKi and bDMARDs and infection risks were estimated using multilevel Poisson regression adjusted for follow-up time and potential confounders and stratified for age < 65 and ≥ 65 years. In 14,989 patients, we identified 20,050 treatment episodes with either JAKi or bDMARDs. The infection IR was significantly higher in JAKi (48/100 patient years) compared bDMARDs (35/100 patient years, adjusted incidence rate ratio (IRR) 1.22, 95% CI 1.12-1.33). More herpes zoster infections were seen in JAKi compared to bDMARDs (adjusted IRR 2.65, 95% CI 1.94-3.60). No significant differences in infection IRs were found comparing JAKi baricitinib and tofacitinib. In older patients, infection IRs were higher, but IRRs were similar between age groups. In comparison to bDMARDs, JAKi are associated with a slightly higher infection risk and a higher risk of herpes zoster specifically. In older patients, infection IRs are higher but similar infection risks for JAKi and bDMARDs are observed. No differences in infection risk between tofacitinib and baricitinib were found. Key Points • Compared to bDMARDs, JAKi are associated with a slightly higher infection risk for all ages • An increased risk of herpes zoster in patients who use JAK inhibitors was confirmed • No significant differences in infection incidence were found between tofacitinib and baricitinib.

Surgical Site Infection After Polymethyl Methacrylate Pedicle Screw Augmentation in Osteoporotic Spinal Vertebrae: A Series of 537 Cases.

Retrospective observational study of prospectively collected outcomes. The use of transpedicular screws augmented with polymethyl methacrylate (PMMA) is an alternative for patients with osteoporotic vertebrae. To investigate whether using PMMA-augmented screws in patients undergoing elective instrumented spinal fusion (ISF) is correlated with an increased risk of infection and the long-term survival of these spinal implants after surgical site infection (SSI). We studied 537 consecutive patients who underwent ISF at some point within a 9-year period, involving a total of 2930 PMMA-augmented screws. Patients were classified into groups: (1) those whose infection was cured with irrigation, surgical debridement, and antibiotic treatment; (2) those whose infection was cured by hardware removal or replacement; and (3) those in whom treatment failed. Twenty eight of the 537 patients (5.2%) developed SSI after ISF. An SSI developed after primary surgery in 19 patients (4.6%) and after revision surgery in 9 (7.25%). Eleven patients (39.3%) were infected with gram-positive bacteria, 7 (25%) with gram-negative bacteria, and 10 (35.7%) with multiple pathogens. By 2 years after surgery, infection had been cured in 23 patients (82.15%). Although there were no statistically significant differences in infection incidence between preoperative diagnoses (P = 0.178), the need to remove hardware for infection control was almost 80% lower in patients with degenerative disease. All screws were safely explanted while vertebral integrity was maintained. PMMA was not removed, and no recementing was done for new screws. The success rate for treatment of deep infection after cemented spinal arthrodesis is high. Infection rate findings and the most commonly found pathogens do not differ between cemented and noncemented fusion. It does not appear that the use of PMMA in cementing vertebrae plays a pivotal role in the development of SSIs.

Comparing Outcomes in the Therapeutic and Prophylactic Breast for Bilateral Mastectomy With Implant-Based Breast Reconstruction.

Increasingly patients with unilateral breast cancer elect to undergo bilateral mastectomy with subsequent reconstruction. Studies have aimed to better identify the risks associated with performing mastectomy on the noncancerous breast. Our study aims to identify differences in complications between therapeutic and prophylactic mastectomy in patients undergoing implant-based breast reconstruction. A retrospective analysis of implant-based breast reconstruction from 2015 to 2020 at our institution was completed. Patients with less than 6-month follow-up after final implant placement had reconstruction using autologous flaps, expander or implant rupture, metastatic disease requiring device removal, or death before completion of reconstruction were excluded. McNemar test identified differences in incidence of complications for therapeutic and prophylactic breasts. After analysis of 215 patients, we observed no significant difference in incidence of infection, ischemia, or hematoma between the therapeutic and prophylactic sides. Therapeutic mastectomies had higher odds of seroma formation ( P = 0.03; odds ratio, 3.500; 95% confidence interval, 1.099-14.603). Radiation treatment status was analyzed for patients with seroma; 14% of patients unilateral seroma of the therapeutic side underwent radiation (2 of 14), compared with 25% patients with unilateral seroma of the prophylactic side (1 of 4). For patients undergoing mastectomy with implant-based reconstruction, the therapeutic mastectomy side has an increased risk of seroma formation.

P816 The efficacy of an over the counter multivitamin and mineral supplement to prevent opportunistic infections in patients with inflammatory bowel disease in remission

Abstract Background Patients with inflammatory bowel disease (IBD) treated with immunomodulators or biological therapy are at increased risk of infections. Malnutrition and vitamin or mineral deficiencies are common among patients with IBD. The results of various studies have indicate that vitamin deficiencies might increase the risk of infections. Methods Single-centre, randomized, double-blinded, placebo-controlled clinical trial to compare a multivitamin and mineral supplement (vitamin group) versus identical in appearance placebo (placebo group). Patients with Crohn’s disease or ulcerative colitis using immunomodulators and/or biological therapy without vitamin deficiency were considered for participation in our study. Participants were asked to take a daily multivitamin and mineral supplement or placebo and report the occurrence of infections during a 24 weeks period of follow up. The primary endpoint of this study was the difference in incidence of infection between the two groups measured by a validated questionnaire, the revised version of the ID screen to assess infection13. Randomization was conducted by using computer generated random numbers with an allocation ratio of 1:1 to vitamin supplement or placebo in blocks of 8 and stratified according to type of IBD.Results Between July 2020 and February 2021, 320 patients were randomized. Treatment arms consisted out of 162 and 158 for vitamin and placebo, respectively. Both groups showed similarity in patient characteristics. All patients were included in the intention-to -Treat (ITT), 265 patients in the per protocol (PP) (compliance &amp;gt;80%) analyses. For both groups, 107 patients reported an infection during the 24 weeks follow up period (Unadjusted Odds Ratio: 0.93 (95% confidence interval: 0.56-1.48). In the vitamin group, 32 patients received antibiotics for an infection compared with 21 patients in the placebo group (Unadjusted Odds Ratio: 1.61 (95% confidence interval: 0.88-2.93). 166 patients in the PP analysis reported an infection (Unadjusted Odds Ratio: 0.91 (95% confidence interval: 0.55-1.50), 23 reported a serious infection (Unadjusted Odds Ratio: 2.57 (95% confidence interval: 1.02 -6.46). None of the patients was hospitalized due to serious infection. Conclusion An over the counter multivitamin and mineral supplement did not reduce the risk of infection for patients with IBD in remission with immunomodulators and/or biological therapy.

The infection, cervical and perineal lacerations in relation to postpartum hemorrhage following vaginal delivery induced by Cook balloon catheter.

To identify whether infection, cervical laceration and perineal laceration are associated with postpartum hemorrhage in the setting of vaginal delivery induced by Cook balloon catheter. The retrospective study included 362 women who gave birth vaginally at or beyond 37weeks of gestation with a diagnosis of postpartum hemorrhage between February 2021 to May 2022, of which including 216 women with induction of labor (Cook balloon catheter followed by oxytocin or oxytocin) and 146 women with spontaneous delivery. Risk factors for postpartum hemorrhage were collected and compared. 362 women were divided into three groups, group 1 with spontaneous delivery, group 2 with oxytocin, group 3 with Cook balloon catheter followed by oxytocin. There was no significant difference in incidence of infection within three groups (P > 0.05). The rate of cervical laceration and perineal laceration was significantly higher in group 3 compared with groups 2 and 1 (P < 0.05); Multivariate logistic regression analysis found that compared with group 1, either group 3 or group 2 was associated with increased risks of cervical laceration and perineal laceration (P < 0.05), and compared with group 2, group 3 was not associated with increased risks of cervical laceration and perineal laceration (P > 0.05). Infection, cervical laceration and perineal laceration are identified not to be independent risk factors for postpartum hemorrhage for women undergoing labor with Cook balloon catheter; Cervical laceration and perineal laceration increase the risk of postpartum hemorrhage in women with labor induction.

Psychological Wellbeing and Perceived Fatigue in Competitive Athletes after SARS-CoV-2 Infection 2 Years after Pandemic Start: Practical Indications

The COVID-19 pandemic deeply affected sports and athletes, influencing performance and psychological wellbeing. In order to provide useful guidelines for coaches, a web-based survey was conducted. Three web-based questionnaires were administered during the last phase of the Omicron wave to a total of 204 Italian athletes (age 24.96 ± 9.82): an informative questionnaire to collect sociodemographic data and infection symptoms information, the Fatigue Severity Scale (FSS) and the General Health Questionnaire-12 (GHQ-12). No differences between infection sequels of different variant typologies were found over the long term after the infection. The most frequently declared symptoms included cough (50%), muscular skeletal impairments (48%) fatigue (43%) and fever (43%). Results showed that female athletes have a higher risk of developing post-COVID-19 symptoms, GHQ-12 worse results (p = 0.005) and greater fatigue (p = 0.0002) than males. No significant difference in infection incidence between high- and low-level athletes was found. Endurance athletes showed greater perceived fatigue than anaerobic sports athletes (p = 0.045). Conclusions: These results suggested the need for specific approaches and continuous updating to differentiate training programs for different athletes during the return to play. Medical controls and daily monitoring of athletes of all levels after the infection could be advisable.

Incidence, Description, and Timing of Serious or Opportunistic Infections in Patients with Hairy Cell Leukemia Treated with Purine Nucleoside Analogues

Background: Hairy cell leukemia (HCL) is an uncommon B-cell malignancy characterized by pancytopenia on presentation. While the purine nucleoside analogues (PNAs) cladribine and pentostatin have resulted in long overall survival, infections remain a major cause of mortality. PNAs are known to be immunosuppressive, and in combination with the inherent infection risk of HCL, patients are vulnerable to serious and/or opportunistic infections throughout the disease course. Furthermore, there is prolonged CD4+ lymphopenia post-PNA treatment for 1-3 years. We thus conducted a comprehensive retrospective review at an academic center to (1) describe the incidence and types of infections seen in HCL and (2) determine how treatment with pentostatin versus cladribine may affect infection risk. Methods: We reviewed charts of all HCL patients that were seen at The Ohio State University between January 1 2012 and June 30 2020. Patients with less than 1 year of follow up were excluded. We defined our infections of interest as (1) serious i.e. requiring hospitalization or (2) opportunistic i.e. organisms commonly seen in immunosuppression. These patients’ baseline demographics, disease characteristics, bone marrow biopsies, and treatment histories were abstracted from medical records. Time to infection was calculated from the start of HCL treatment to the onset of infections, treating death without infection as a competing risk. The cumulative incidence of infection was estimated, and the associations with patient characteristics were evaluated using Fine and Gray sub-distribution hazard models accounting for competing risks. Overall survival was calculated from diagnosis to date of death or last contact. Kaplan-Meier method was used to estimate the survival functions and corresponding 95% confidence intervals. Results: Our study included 149 patients with a median follow up time of 6.9 years (range 1.3 - 48.8) and a 10-year estimated overall survival of 99% (95% CI: 93 - 100%). Median age at diagnosis was 51 years (range 22 - 80) and most patients (n = 117, 78.5%) were male. A total of 138 (92.6%) had classical HCL and 11 (7.4%) had variant HCL. There was a total of 70 incidents of infection, with 52 patients (35%) experiencing at least one infection and 18 (12%) with a second infection. Forty-six infections (66%) were serious and 24 (34%) were opportunistic. Most infections were likely to be seen 2 months prior to (n = 10, 14%) or 2 months after (n=14, 20%) initial treatment. The cumulative incidence of infection increased during the 50 days after starting treatment (Figure 1). Based on infection site, clinical presentation, and/or laboratory findings, 36 infections (51%) were classified as bacterial, 14 (20%) were viral, 8 (11%) were fungal, and 1 was concurrent viral and bacterial. Eleven (16%) infections did not have a confirmed organism. Sixty-seven (96%) infection cases had resolved; the outcomes in 2 cases were unknown, and 1 case resulted in death. Organisms were confirmed in 38 cases and are listed in Table 1. We examined baseline factors that could be associated with increased risk of infection, including sex, age at diagnosis, variant histology, total number of HCL treatment courses, prior infection, and a palpable spleen at diagnosis: none of these were associated with increased risk. Using cladribine as a reference, no treatment agents (including newer, non-PNA therapies) were associated with lower or higher infection risk. Examining the PNAs specifically, treatment with pentostatin versus cladribine was not associated with a significant difference in infection incidence (HR 1.12, 95% CI: 0.48 - 2.63). Conclusions: In our large institutional cohort of patients with HCL, a considerable fraction (35%) of patients experienced serious or opportunistic infections. The majority of these were in the 2 months before or after initial treatment. We did not identify any demographic or disease factors associated with infection, although this is limited by the small sample size. Notably, treatment with either cladribine or pentostatin was not associated with a significant difference in infection incidence. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Bacitracin for Injection Recall: Impact on Immediate Breast Implant Surgical Outcomes.

Background Triple-antibiotic irrigation of breast implant pockets is a mainstay of infection prophylaxis in breast reconstruction and augmentation. The recall of bacitracin for injection due to risk of anaphylaxis and nephrotoxicity in January 2020, a staple component of the irrigation solution, has raised concern for worsened postoperative sequelae. This study aimed to investigate pre- and post-recall implant-based breast surgery to analyze the impact of bacitracin in irrigation solutions on infection rates. Methods All implant-based breast reconstruction or augmentation surgeries from January 2019 to February 2021 were retrospectively reviewed. In a regression discontinuity study design, patients were divided into pre- and post-recall groups. Patient demographics, surgical details, and outcomes including infection rates were collected. Differences in complication rates were compared between groups and with surgical and patient factors. Results 254 implants in 143 patients met inclusion criteria for this study, with 172 implants placed before recall and 82 placed after recall. Patients in each cohort did not differ in age, BMI, smoking status, or history of breast radiation or capsular contracture (p > 0.05). All breast pockets were irrigated with antibiotic solution, most commonly bacitracin, cefazolin, gentamycin, and povidone-iodine before recall (116,67.4%) and cefazolin, gentamycin, and povidone-iodine after recall (59,72.0%). There was no difference in incidence of infection (6.4% vs. 8.5%, p=0.551) or cellulitis (3.5% vs. 3.7%, p=0.959) before and after recall. Implant infection was associated with smoking history (p < 0.001) and increased surgical time (p=0.003). Conclusions Despite the recent recall of bacitracin from inclusion in breast pocket irrigation solutions, our study demonstrated no detrimental impact on immediate complication rates. This shift in irrigation protocols calls for additional investigations into optimizing antibiotic combinations in solution, as bacitracin is no longer a viable option, to improve surgical outcomes and long-term benefits.

Abdominal paracentesis drainage improves outcome of acute pancreatitis complicated with intra-abdominal hypertension in early phase

BackgroundIntra-abdominal hypertension (IAH) is an important risk factor for organ dysfunction, and it occurs in the early phase of severe acute pancreatitis (SAP). We have reported a novel step-up approach and shown the benefit of performing abdominal paracentesis drainage (APD) ahead of percutaneous catheter drainage (PCD) when treating Patients with SAP with fluid collections. This study aimed to evaluate the efficacy of APD in Patients with SAP complicated with IAH in the early phase. MethodsIn the present study, 206 AP patients complicated with IAH in the early phase were enrolled in hospital between June 2017 and December 2020. The patients were divided into two groups: 109 underwent APD (APD group) and 97 were managed without APD (non-APD group). We retrospectively compared the outcomes of the APD and non-APD groups for IAH treatment. The parameters including mortality, infection, organ failure, inflammatory factors, indications for further interventions, and drainage-related complications were observed. ResultsThe demographic data and severity scores of the two groups were comparable. The mortality rate was lower in the APD group (3.7%) than in the non-APD group (8.2%). Compared with the non-APD group, the intra-abdominal pressure and laboratory parameters of the APD group decreased more rapidly, and the mean number of failed organs was lower. However, there was no significant difference in incidence of infections between the two groups. ConclusionsApplication of APD is beneficial to AP patients. It significantly attenuated inflammation injury, avoided further interventions, and reduced multiple organ failure.

Potential benefits of immunomodulator use with vedolizumab for maintenance of remission in ulcerative colitis.

Background and AimThis study aimed to determine the efficacy and safety of vedolizumab treatment with or without concomitant immunomodulator use in Japanese patients with moderate‐to‐severe ulcerative colitis.MethodsAmong enrolled patients in a phase 3 study conducted in Japan (clinicaltrials.gov, NCT02039505), data from patients allocated to 300‐mg intravenous vedolizumab for induction and maintenance phases were used for this exploratory analysis. Efficacy endpoints were clinical response, clinical remission, and mucosal healing at week 10 and clinical remission and mucosal healing at week 60, and disease worsening and treatment failure during the maintenance phase.ResultsAt week 10, the differences in clinical response, clinical remission, and mucosal healing rates between the subgroups (those with concomitant immunomodulator use minus those without) were 0.7 (95% confidence interval: −14.3, 15.7), 3.3 (95% confidence interval: −8.5, 15.2), and 1.8 (95% confidence interval: −13.0, 16.5), respectively. At week 60, the differences in clinical remission and mucosal healing between the subgroups with and without concomitant immunomodulator use were 26.1 (95% confidence interval: −3.5, 55.6) and 29.9 (95% confidence interval: 1.4, 58.4), respectively. The proportions of patients without treatment failure at day 330 of the maintenance phase were 90.7% with concomitant immunomodulator use and 73.7% without. No marked differences in incidence of infections were observed between subgroups.ConclusionsThis study suggested the possibility that concomitant immunomodulator use may be beneficial to maintain the clinical efficacy of vedolizumab.

Do We Require to Use Antibacterial Prophylaxis in Hand Trauma? Results of a Randomised Prospective Case-Control Trial

Abstract The proper management of traumatic hand injury is crucial for wound infection prevention. Antibiotics in various forms and conditions are prescribed to avoid this complication, but the effectiveness is unclear. Most forms used are intravenous solutions, topical ointments, and oral tablets. This prospective case-control trial was conducted in a tertiary care hospital. Healthy adult patients with simple, non-bite, surgically treated hand wounds were included. During the surgery, a proper debridement and irrigation with simple saline was consistently performed. Patients were randomly assigned to one of the eight groups. Seven groups received different antibacterial prophylaxis and one received none. At the two-week postoperative follow-up the wound site was assessed and any local infection was documented. Patients were excluded from the trial if they did not comply to treatment recommendations (i.e. commence antibiotics, applied solutions or ointments on the wound). Overall, 240 patients (80.2% male, mean age 38.7 years), 30 in each study group were included. 226 patients returned for the follow-up, and seven patients were excluded from the trial. Wound infection was observed in five patients from different groups. Thus, the rate of wound infection was 2.28%. A Chi-square test revealed no difference in infection incidence between the groups (p &gt; 0.05). In this study, antibiotics did not affect incidence of wound infection after hand trauma. Attention should be paid to proper debridement and irrigation of the wound as these interventions reduce the risk for wound infection and avoid unnecessary usage of antibiotics.

Optimal perioperative antibiotic strategy for kidney stone patients treated with percutaneous nephrolithotomy

ObjectiveTo assess the relevance of urine test (UT), urine culture (UC) and stone culture (SC) for postoperative infections and to investigate the optimal perioperative antibiotic treatment strategy in association with percutaneous nephrolithotomy (PCNL) in patients with renal calculi. Materials and methodsBetween September 2016 and September 2018 1,060 patients treated with PCNL were included in the study. The results of UT, UC and SC were reviewed. The details of perioperatively administered antibiotics and postoperative infections were recorded. ResultsA positive UT was associated with an increased incidence of infection; this was also the case in patients with negative UC (p < 0.05). There was no significant difference in incidence of infection between patients who were given a single dose of antibiotics compared with those given multiple doses when UC was negative, whether UT was positive or negative (all p > 0.05). The incidence of infection was decreased when pre-operative antibiotics were administered according to the sensitivity pattern based on UC (p < 0.05). This outcome was particularly evident when the treatment duration exceeded 7 days (p < 0.05). A positive SC was associated with increased incidence of infection, even if the patient had a negative UC and UT (p < 0.05). The incidence of infection was significantly decreased when antibiotic treatment was administered based on the results of SC (p < 0.05). ConclusionPre-operative prophylaxis with a single-dose antibiotic was sufficient in patients with negative UC, whether UT was positive or negative. Pre-operative treatment with antibiotics according to the bacterial sensitivity pattern should be administered for ≥7 days in patients with positive UC. The postoperative antibiotic treatment strategy should be tailored according to the SC results.

EUS-guided fiducial placement for pancreatobiliary malignancies: safety, infection risk, and use of peri-procedural antibiotics.

Background and study aims Chemoradiation with stereotactic body radiation therapy (SBRT) is increasingly being used for optimal treatment of locally advanced pancreatobiliary cancers. Fiducial markers are used to track these tumors during SBRT. Endoscopic ultrasound (EUS) is the preferred route for fiducial marker placement for ease of access to pancreatobiliary structures and accurate placement. Here we evaluate the safety and infection risk associated with EUS-guided fiducial placement for pancreatobiliary malignancies and use of peri-procedural prophylactic antibiotics. Patients and methods This was a retrospective, single-center study including consecutive patients presenting for EUS-guided fiducial placement in pancreatobiliary region by three expert interventional endoscopists for SBRT from July 2010 to February 2018 at a tertiary care center. Patient demographics, tumor characteristics, EUS technique, fiducials, use of prophylactic antibiotics, adverse events (AEs) and SBRT/Cyberknife administration were reported. Results A total of 355 patients with pancreatobiliary malignancy underwent EUS-guided fiducial placement, of whom 308 patients (86.76 %) successfully underwent SBRT. Of the patients, 304 (85.63 %) received peri-procedural prophylactic antibiotic. Of 355 total patients, 5.9 % (n = 21) were noted to develop AEs (mild to severe) with no significant difference in incidence of infection with or without use of peri-procedural prophylactic antibiotic. Only three patients developed infectious AEs, none of which were definitively related to fiducial placement. Conclusion EUS-guided fiducial placement for pancreatobiliary malignancy is safe and efficacious, and risk of infection is rare, regardless of whether or not peri-procedural antibiotics are used. We favor limiting routine use of peri-procedural antibiotics for patients undergoing EUS-guided fiducial placement in pancreaticobiliary malignancy.

The effectiveness of older insecticide-treated bed nets (ITNs) to prevent malaria infection in an area of moderate pyrethroid resistance: results from a cohort study in Malawi

BackgroundA previous cohort study in Malawi showed that users of new insecticide-treated bed nets (ITNs) were significantly protected against malaria compared to non-users, despite moderate levels of pyrethroid resistance among the primary mosquito vectors. The present study investigated whether ITNs that were 1–2 years old continued to protect users in the same area with moderate pyrethroid resistance.MethodsOne year following a baseline cross-sectional malaria parasitaemia prevalence survey and universal distribution of deltamethrin ITNs (May 2012), a fixed cohort of 1223 children aged 6–59 months was enrolled (April 2013). Children were tested for parasitaemia at monthly scheduled visits and at unscheduled sick visits from May to December 2013 using rapid diagnostic tests. ITN use the prior night and the condition of ITNs (based on presence of holes) was assessed by caregiver self-report. The incidence rate ratio (RR) comparing malaria infection among users and non-users of ITNs was modelled using generalized estimating equations adjusting for potential confounders and accounting for repeated measures on each child. The protective efficacy (PE) of ITN use was calculated as 1 − RR.ResultsIn this cohort, self-reported ITN use remained consistently high (> 95%) over the study period. Although users of ITNs were slightly more protected compared to non-users of ITNs, the difference in incidence of infection was not statistically significant (RR 0.83, 95% confidence interval [CI] 0.54–1.27). Among ITN users, malaria incidence was significantly lower in users of ITNs with no holes (of any size) compared to users of ITNs with ≥ 1 hole (RR 0.82, 95% CI 0.69–0.98).ConclusionsThere was no significant PE of using 1–2 year-old ITNs on the incidence of malaria in children in an area of moderate pyrethroid resistance, but among ITN users, the authors found increased protection by ITNs with no holes compared to ITNs with holes. Given the moderate levels of pyrethroid resistance in the primary malaria vector and recent evidence of added benefits of ITNs with synergists or non-pyrethroid insecticides, next-generation ITNs may be a useful strategy to address pyrethroid resistance and should be further explored in Malawi.

Efficacy and safety of cyclosporine a for patients with steroid-resistant nephrotic syndrome: a meta-analysis

BackgroundThe purpose of this study was to determine efficacy and safety of cyclosporine A (CsA) for patients with steroid-resistant nephrotic syndrome (SRNS).MethodsThe Cochrane Library and PubMed were searched to extract the associated studies on Oct 10, 2018, and the meta-analysis method was used to pool and analyze the applicable investigations included in this study. The P(opulation) I(ntervention) C(omparison) O(utcome) of the study were defined as follows: P: Patients with SRNS; I: treated with CsA, cyclophosphamide (CYC), tacrolimus (TAC) or placebo/not treatment (P/NT); C: CsA vs. placebo/nontreatment (P/NT), CsA vs. CYC, CsA vs. TAC; O: complete remission (CR), total remission (TR; complete or partial remission (PR)), urine erythrocyte number, proteinuria levels, albumin, proteinuria, serum creatinine, and plasma cholesterol, etc. Data were extracted and pooled using RevMan 5.3.ResultsIn the therapeutic regimen of CsA vs. placebo/nontreatment (P/NT), the results indicated that the CsA group had high values of CR, TR, and low values of proteinuria, serum creatinine, and plasma cholesterol when compared with those in the placebo group. In comparing CsA vs. cyclophosphamide (CYC), the results indicated that the CsA group had higher TR than the CYC group. In comparing CsA vs. tacrolimus (TAC), the results revealed insignificant differences in CR, and TR between the CsA and TAC groups. The safety of CsA was also assessed. The incidence of gum hyperplasia in CsA group was higher than that in the P/NT group, with no differences in incidence of infections or hypertension between CsA and P/NT groups. There was no difference in the incidence of hypertension between the CsA and TAC groups.ConclusionsCsA is an effective and safe agent in the therapy of patients with SRNS.

Infection safety of dexamethasone in total hip and total knee arthroplasty: a study of eighteen thousand, eight hundred and seventy two operations.

Dexamethasone has been shown to prevent post-operative nausea and vomiting (PONV) and seems to reduce post-operative pain. Both factors, which can extend the hospital stay, delay rehabilitation, and impact patient satisfaction. Because of the immunosuppressive and glucose-rising effects of dexamethasone, there has been concern of its safety in arthroplasty surgery. The purpose of our study was to examine infection safety of dexamethasone in arthroplasty surgery with enough large study material to reliably detect a possible, even small, difference in infection incidence. A total of 18,872 consecutive primary and revision hip and knee arthroplasties were analyzed with data gathered from clinical information databases and a surgical site infection surveillance database with prospective data collection. Also, emergency operations due to fractures were included except for hip hemiarthroplasties. During the follow-up, 189 (1.0%) prosthetic joint infections (PJIs) occurred: 0.8% after primary arthroplasty and 1.9% after revision arthroplasty. Dexamethasone was used in 2922 (15.5%) operations. The PJI rate in the dexamethasone group was 1.1% (31/2922) and in the non-dexamethasone group 1.0% (161/15950), with no significant difference in the risk of PJI between the two groups (OR 1.052, 95% CI 0.715-1.548, P = 0.773). In our study material, the use of a single 5-10mg dose of dexamethasone did not increase the incidence of post-operative PJI. A low dose of dexamethasone may be safely used to prevent PONV and as part of multimodal analgesia on patients undergoing arthroplasty operation.

Basiliximab as Induction in Kidney Transplantation: Are There any Real-Life Advantages?

Background: Basiliximab is an interleukin-2 receptor antagonist used as induction therapy in kidney transplantation and is believed to reduce acute rejection episode (ARE). Our aims were to compare the impact of basiliximab induction therapy with no induction therapy on incidence of ARE, time requirement for serum creatinine (S.Cr) to normalize after transplantation, initial post-transplant hospital stay, infection in immediate post-transplant period, chronic allograft injury and graft survival at 1 and 3 years.Methods: We retrospectively reviewed the medical records of patients who had undergone living related donor kidney transplantation in a tertiary care hospital of a developing country between July 2004 and June 2014. We selected patients who received calcineurin inhibitors, mycophenolate and prednisolone to classify as no induction therapy (n=50; group 1, receiving prednisolone, mycophenolate and cyclosporine as maintenance therapy) and induction therapy with basiliximab (n=61; group 2, receiving prednisolone, mycophenolate and tacrolimus as maintenance therapy).Results: Among the 111 study subjects, only two had experienced ARE (one from each group, p=0.889). Patients who received basiliximab had a shorter mean hospital stay (11.4±3.3 versus 13.7±5.0 days, p=0.005) and shorter mean duration for normalization of S.Cr (4.7±2.3 versus 7.3±5.6 days, p=0.002) after transplantation. There was no significant difference in incidence of infection in immediate post-transplant period (p=0.134). One year graft survival rate was better in those who received basiliximab (98.2% versus 89.4%, p=0.010) but there was no significant difference at 3 years (79% versus 74%, p=0.549). Overall incidence of chronic allograft injury was less with basiliximab (11.5% versus 36%, p=0.002) induction.Conclusions: Induction therapy with basiliximab was associated with shorter mean hospital stay, early renal function recovery, better 1 year graft survival and less overall incidence of chronic allograft injury. We have encountered minimum ARE to comment on benefit of basiliximab on ARE.Birdem Med J 2017; 7(2): 90-94

Infectious complications in the era of MELD.

Infections are a major cause for morbidity and mortality in liver transplant recipients. So far there has been no study systematically investigating the correlation between the MELD (Model for End-Stage Liver Disease) scoring system and complications caused by infections. The aim of the present retrospective study was to evaluate the impact of the pretransplant MELD score on incidence and mortality of pneumonia and septicemia in liver transplant recipients. The clinical courses of 201 liver transplant recipients between 12/2006 and 3/2009 were recorded and analyzed on the basis of chart review. Patients were stratified into three groups (pretransplant MELD score: group I 6-20, group II ≥ 21-30, group III ≥ 31-40) and compared in terms of incidence of infection and survival. The mean pretransplant MELD score was 22 ± 12. There were 81 patients in group I, 65 patients in group II, and 55 patients in group III. There was no difference in incidence of infections between the MELD groups. However, septicemia-associated mortality was significantly higher in group III. A high MELD score is not associated with higher incidence of infections but it is associated with a significantly higher mortality in the case of septicemia. Prevention of infections is of utmost importance, especially in liver transplant recipients with high MELD scores.

Impact of Providing a Combination Lipid Emulsion Compared With a Standard Soybean Oil Lipid Emulsion in Children Receiving Parenteral Nutrition: A Systematic Review and Meta-Analysis.

Soybean oil lipid emulsion may compromise immune function and promote hepatic damage due to its composition of long-chain fatty acids, phytosterols, high proportion of ω-6 fatty acids, and low α-tocopherol levels. Combination lipid emulsions have been developed using medium-chain triglyceride oil, fish oil, and/or olive oil, which provide adequate essential fatty acids, a smaller concentration of ω-6 fatty acids, and lower levels of phytosterols. The purpose of this systematic review is to determine if combination lipid emulsions have a more favorable impact on bilirubin levels, triglyceride levels, and incidence of infection compared with soybean oil lipid emulsions in children receiving parenteral nutrition. This study comprises a systematic review of published studies. Data were sufficient and homogeneous to conduct a meta-analysis for total bilirubin and infection. Nine studies met the inclusion criteria. Meta-analysis showed that combination lipid emulsion decreased total bilirubin by a mean difference of 2.09 mg/dL (95% confidence interval, -4.42 to 0.24) compared with soybean oil lipid emulsion, although the result was not statistically significant (P = .08). Meta-analysis revealed no statistically significant difference in incidence of infection between the combination lipid emulsion and the soybean oil lipid emulsion groups (P = .846). None of the 4 studies that included triglyceride as an outcome detected a significant difference in triglyceride levels between the combination lipid emulsion and soybean oil lipid emulsion groups. There is inadequate evidence that combination lipid emulsions offer any benefit regarding bilirubin levels, triglyceride levels, or incidence of infection compared with soybean oil lipid emulsions.