High Risk Of Infectious Complications Research Articles

Splenectomy revisited in 2011: Impact on hematologic toxicities while performing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Splenectomy revisited in 2011: Impact on hematologic toxicities while performing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

The impact of invasive fungal diseases on survival after lung transplantation

Recipients of lung transplants are at high risk of infectious complications. We investigated the epidemiology of infections after lung transplantation and determined their impact on survival. We retrospectively reviewed the medical records of patients who underwent lung transplantation at Mayo Clinic (Rochester) during 1990-2005. Survival analyses were performed using Kaplan-Meier estimation and Cox proportional hazard modeling. Sixty-nine lung transplants were performed during the 16-yr study period. The mean (+/-SD) patient age was 50.5 +/- 9.7 yr; 45% were male. During the mean (+/-SD) follow-up period of 1188 (+/-1288) d, the cumulative percentage of patients with infections were: bacteria (52%), cytomegalovirus (CMV) (49%), other viruses (32%), fungi (19%), mycobacteria (7%), and Pneumocystis jiroveci (1%). The median survival time after lung transplantation was 5.02 yr. Kaplan-Meier estimation of one-, three-, and five-yr survival was 80%, 61%, and 50%, respectively. Overall, 37 (54%) patients died due to graft rejection and failure (35%), invasive fungal diseases (16%), post-transplant lymphoproliferative disorder and other malignancies (14%), cardiovascular diseases (5%), CMV disease (3%), bacterial infection (3%), or other causes (24%). Survival analysis using Kaplan-Meier estimation showed that invasive fungal disease (Aspergillus sp., n = 9, Candida sp., n = 2, Alternaria sp., n = 1, Rhizopus sp., n = 1, and/or Mucor sp., n = 1) was significantly associated with mortality (p = 0.0104). After adjusting for age and graft rejection, invasive fungal disease remains a significant predictor of mortality (p = 0.0262). Invasive fungal disease is significantly associated with all-cause mortality after lung transplantation. An aggressive antifungal preventive strategy may lead to improved survival after lung transplantation.

Complications of Central Venous Catheters During Pregnancy and Postpartum

There are numerous indications for the use of central venous catheters. The rate of catheter complications in the general medical and surgical population is estimated to be 15% to 20%. The extent of risk depends on a large number of factors including the study type, anatomic site, population, technique, operator experience, catheter care, and catheter days. Few studies have investigated the risk of catheter complications in pregnancy and postpartum. The true incidence and the magnitude of the risk among women in this population are unclear. The aim of this retrospective case series was to determine the incidence of complications with central venous catheters in an obstetric population and investigate possible risk factors. The participants were 85 pregnant or postpartum women who had been admitted for obstetric care at a tertiary care teaching hospital between 2000 and 2006. A total of 97 central line placements occurred in 85 patients. Individual patient records were analyzed for duration of catheter placement and all subsequent admissions to obtain patient demographic characteristics, indication for placement, and maternal complications. The catheters were placed antepartum in 76% of the women at a gestational age of 24.7 ± 10.7 weeks. The indications for catheter placement included failed peripheral intravenous access (n = 59, 61%), need for long-term intravenous access (n = 33, 34%), need for hemodynamic monitoring (n = 4, 4%), and patient comfort (n = 1, 1%). Catheter complications occurred in 25% (24/97) of the line placements; 12 of the 24 (50%) were culture-proven line infections. Other catheter complications included mechanical line failure (17%, 4/24), presumed line infection (8%, 2/24), superficial and deep venous thrombosis (8%, 2/24), tissue hematoma (8%, 2/24), cardiac arrhythmia (4%, 1/24), and patient discomfort (4%, 1/24). The investigators conclude from these findings that the high risk of infectious complications should be considered before using central venous catheters in pregnant patients.

Relationship between C-reactive protein and early activation of leukocytes indicated by leukocyte antisedimentation rate (LAR) in patients with acute cerebrovascular events

The purpose of this study was to determine the relationship between high-sensitive C-reactive protein (hsCRP) and leukocyte antisedimentation rate (LAR) as a specific test to detect early activation of leukocytes providing the first line of defence against infections in ischemic stroke. In 49 patients with acute ischemic events and 61 healthy subjects (HS), we examined LAR, astroglia specific S100B indicating the extent of brain tissue damage and hsCRP within 6 hours, as well as 24 and 72 hours after onset of symptoms. Serum levels of hsCRP on admission was significantly higher in patients with acute ischemic stroke (AIS) compared to HS and were higher in patients with recurrent to first ever ischemic stroke. Increased basal levels of hsCRP also correlated with severity of stroke and extent of infarct reflected by S100B levels in sera, but did not correlate with post-stroke infections. However, a higher rate of infection was observed among patients, in whom hsCRP was elevated at 72 hours but LAR did not increase. Therefore, such late elevation of hsCRP may indicate pre-clinical infections due to deficient leukocyte activation. Simple tests like LAR and hsCRP may help in predicting outcome and high risk of infectious complications.

Influenza A H1N1 Virus Infection in Two Hematopoietic Stem Cell Transplant Recipients.

Abstract 1169Poster Board I-191In April 2009, a novel swine-origin influenza A (H1N1) virus (S-OIV) was identified in Mexico. Since then, several cases have been reported, with subsequent cases observed in many other countries. Clinical presentation may range from mild symptomatic patients to cases of severe clinical presentation and death due to pneumonia and respiratory failure. Definition of high risk groups are thought to be similar to those defined for seasonal influenza, including young children and elderly patients, pregnant women and patients with chronic medical conditions, especially immunocompromised hosts. Hematopoietic stem cell transplant (HSCT) recipients are at high risk for infectious complications, including severe viral infections. To our knowledge, there are no reported cases of S-OIV infection in HSCT recipients to date. The clinical features and the possible consequences of this novel influenza virus in this setting remain unknown. We describe two HSCT recipients with confirmed influenza H1N1 virus infection and a benign clinical course after oseltamivir treatment. The first case is a 12 year-old male patient with diagnosis of acute myelogenous leukemia in second complete remission who underwent an unrelated umbilical cord blood transplant with two 4/6 HLA-mismatched cord blood units. Graft-versus-host disease (GVHD) prophylaxis consisted of the association of cyclosporine and mycophenolate mofetil. Additionally, he was also being treated for an invasive aspergillosis with oral voriconazole. On day+3 after transplant, he developed fever, rhinorrhea, and dry cough. A nasal wash and a nasal swab were positive for influenza A by direct immune fluorescence and for influenza A H1N1 by real-time polymerase chain reaction (RT-PCR). Computed tomography of the nasal sinus and thorax were unremarkable. Oseltamivir therapy (75 mg po twice daily for 10 days) was initiated the same day with progressive improvement of symptoms. Oseltamivir was well tolerated and there was no interference with serum levels of cyclosporine. The second case is a 30 year-old female patient with gray zone non-Hodgkin lymphoma in relapse after autologous stem cell transplant that underwent an HLA-matched related HSCT in September 2008. She relapsed 6 months after the transplant. Cyclosporine was withdrawn. Ten days later, she developed fever rhinorrhea, and myalgia. Influenza A H1N1 was confirmed by RT-PCR of a nasal wash specimen. Treatment with a 5-day course of oseltamivir (75 mg po twice daily) was initiated and the patient had a favorable clinical course, with no complications. These two cases of confirmed influenza H1N1 virus infection in HSCT recipients with a benign clinical course highlight the need for a better understanding of the clinical course and management of this novel viral agent in severely immunocompromised hosts. Disclosures:No relevant conflicts of interest to declare.

Infections in Pediatric Patients With Hematologic Malignancies

Despite significant advances in supportive care, infection remains second only to malignancy as a cause of death in pediatric oncology patients, and infection accounts for a large fraction of treatment-related costs. Multiple risk factors contribute to infection-related morbidity, chief among them the immunosuppressive effects of leukemia itself and of cytotoxic chemotherapy, prolonged hospitalization and antibiotic use, and loss of barrier integrity associated with mucositis and the need for indwelling central access. While viruses are the most common causes of infection, bacteria are responsible for most life-threatening complications. Gram-negative bacilli are a concern for all patients undergoing treatment, while a subset of gram-positive organisms, particularly viridans streptococci, become significant pathogens in children receiving profoundly immunosuppressive therapy. Invasive fungal infections are also a serious risk for morbidity and mortality in this population. Availability of new antimicrobial agents has made it possible to treat infectious complications more effectively, but their availability is also leading to an increased prevalence of highly resistant pathogens. Future work in pediatric oncology will need to include measures to reduce the immunosuppressive effects of anti-cancer therapy, provide targeted treatment for infections, and better identify groups of patients at high risk for infectious complications, who may benefit from antimicrobial prophylaxis or more aggressive empirical therapy.

CSF3R mutations in paediatric acute myeloid leukaemia

<i>CSF3R</i> mutations in paediatric acute myeloid leukaemia

Immune function and leukocyte sequestration under the influence of parenteral lipid emulsions in healthy humans: a placebo-controlled crossover study

Background: It remains unclear whether immune modulation by lipids contributes to the high risk of infectious complications that is associated with the use of parenteral nutrition. Although mixed long- and medium-chain triacylglycerol (LCT-MCT)–containing emulsions, but not pure LCT emulsions, activate neutrophils and impair crucial leukocyte functions in vitro, in vivo studies have failed to corroborate these findings.Objectives: The present investigation was conducted to evaluate the effects of LCT and LCT-MCT on immune function in healthy humans and to assess whether the lack of in vivo effects results from sampling errors due to extravascular sequestration of activated neutrophils.Design: Saline, LCT-MCT, and LCT emulsions were administered intravenously for 4.5 h to 12 healthy volunteers in a randomized crossover design. Plasma triacylglycerol concentrations were clamped at a clinically relevant concentration of 3–5 mmol/L. Leukocyte population counts and neutrophil activation were assessed before and after infusion. Leukocyte sequestration was evaluated by monitoring the distribution of Technetium-99m–labeled autologous leukocytes during infusions.Results: Whereas LCT exerted no greater effects than did saline, LCT-MCT significantly decreased lymphocyte counts. However, no evidence for neutrophil activation was found with either lipid. Moreover, the clearance of radiolabeled leukocytes from the liver, spleen, and lungs was not altered by any lipid, which suggested that lipid emulsions do not induce leukocyte sequestration.Conclusions: Short-term infusion of LCT-MCT (but not LCT) to healthy humans modulates leukocyte population counts but, in clear contrast with the in vitro situation, does not induce neutrophil activation. These disparate findings cannot be explained by MCT-induced leukocyte sequestration.

Two-hit rat model of short bowel syndrome and sepsis: independent of total parenteral nutrition, short bowel syndrome is proinflammatory and injurious to the liver

Introduction Infants with short bowel syndrome (SBS) are at a high risk for infectious complications and liver failure. We hypothesized that SBS, independent of total parenteral nutrition, is a proinflammatory state that is magnified by sepsis. Methods Sprague-Dawley rats were divided into 2 groups: sham laparotomy (SH, n = 10) or 75% small bowel resection (n = 10). After 14 days, each group underwent a second sham laparotomy (SH/SH and SBS/SH) or cecal ligation and puncture, followed 16 hours later by cecal excision and peritoneal washout (SH/sepsis and SBS/sepsis). Animals were killed 56 hours later. Results The SBS rats had higher serum levels of interleukin (IL) 6 vs SH (355 ± 99 vs 104 ± 71 pg/mL, P < .05). Liver injury scores were higher in SBS/sepsis compared with SBS/SH animals (3.7 ± 0.7 vs 1.9 ± 0.3, P < .05). Hepatic messenger RNA levels of IL-6 (12.8-fold change [FC]) and tumor necrosis factor α (5.65 FC) were elevated in SBS vs SH rats; and IL-6 (114 FC), tumor necrosis factor α (3.87 FC), and Toll-like receptor 4 (7.65 FC) were increased in SBS/sepsis compared with SH/sepsis animals. Conclusion Our results suggest that SBS, independent of total parenteral nutrition, is a proinflammatory state and that sepsis induces an exaggerated proinflammatory cytokine response that may play an important role in liver damage and may be mediated by Toll-like receptor 4.

Prophylactic human granulocyte colony-stimulating factor after induction therapy in pediatric acute myeloid leukemia

AbstractChildren with acute myelogenous leukemia (AML) have a high risk of infectious complications that might be reduced by prophylactic granulocyte colony-stimulating factor (G-CSF). However, G-CSF could induce AML blast proliferation. The prospective randomized trial AML-BFM 98 investigated the impact of G-CSF on hematopoetic recovery and infectious complications (primary endpoints) and on outcome (secondary endpoint) in children (aged 0-18 years) with de novo AML. Patients with more than 5% blasts in day-15 bone marrow or with FAB M3 were not included. Between 1998 and 2003, 161 children with AML were randomized to receive G-CSF after inductions 1 and 2, whereas 156 patients were assigned to the control group. Time of neutropenia after inductions 1 and 2 was significantly shorter in the G-CSF group (23 vs 18 days and 16 vs 11 days; P = .02 and = .001, respectively). G-CSF did not decrease the incidence of febrile neutropenia (72 and 36 patients vs 78 and 37 patients, respectively), microbiologically documented infections (27 and 25 patients vs 36 and 19 patients, respectively) and infection-associated mortality (5 vs 2 patients). Both groups had similar 5-year event-free survival (EFS; 59% ± 4% vs 58% ± 4%). Since G-CSF does not influence the risk of infectious complications or outcome in children undergoing therapy for AML, one cannot advocate the routine use of G-CSF in this patient group.

Transrectal ultrasound-guided prostate biopsy: is antibiotic prophylaxis necessary?

The aim of this study was to assess infectious complications in transrectal ultrasound-guided prostate biopsy (TRUSPB), comparing two groups of patients: one group with antibiotic prophylaxis and the other without prophylaxis. A total of 1,018 TRUSPBs were performed from April 1996 to July 2003. No antibiotic prophylaxis was given in the first 614; the remaining 404 procedures were performed under antibiotic prophylaxis. Biopsy complications were assessed at outpatient urologist visits after the procedure in the 212 first biopsies and by telephone interview in the remaining 806. A total of 78 infectious complications were found. Major infectious complications (n=41) were septic shock (n=3), sepsis (n=3), Fournier gangrene (n=1), urinary tract infection (n=2), and fever requiring hospital admission (n=32). Minor infectious complications were fever that did not require admission (n=29), prostatitis (n=6), and epididymitis (n=2). Infectious complications occurred in 63 of 614 (10.3%) procedures without antibiotic prophylaxis and in 15 of 404 (3.7%) of those with antibiotic prophylaxis (P=0.0001). Of the 41 major infectious complications, 31 (75.6%) occurred in procedures without antibiotic prophylaxis (n=583) versus ten (24.4%) in those with prophylaxis (n=394) (P=0.0410). In conclusion, transrectal ultrasound-guided biopsy of the prostate has a statistically significant higher risk of infectious complications when performed without antibiotic prophylaxis.

Nephrektomie bei akuter unkomplizierter Pyelonephritis

Which complications can develop from uncomplicated pyelonephritis that may require nephrectomy? From January 1999 to June 2003 we carried out nephrectomy in ten cases due to abscess formation after acute, uncomplicated pyelonephritis. The medical files were evaluated retrospectively. Nine women and one man were involved. The mean age was 36.2 years. Leading symptoms: flank pain, fever and chills. The mean symptom duration before admission was 14.6 days. Urinary tract infections were caused by Escherichia coli (six), E. coli and Enterococcus (once) and Klebsiella pneumoniae (once). Two cultures were sterile. Indications for nephrectomy were urosepsis (7 cases), anuria (once), increasing abscess formation under antibiotic therapy (once), drastic deterioration of general condition (once). Uncomplicated pyelonephritis is easy to treat under outpatient conditions with adequate oral antibiotic therapy. Close control must be ensured and clear recovery of symptoms should occur within 48 h. In the case of long duration of symptoms (>6-7 days) or lack of improvement of symptoms under calculated therapy in the first 2 days, inpatient therapy should be initiated because of the high risk of infectious complications. According to our experience, the following patient group is especially at risk: female, symptom duration of at least approximately 1 week, pre-treatment and transfer from another departments.

Mycophenolate mofetil for the treatment of acute and chronic GVHD is effective and well tolerated but induces a high risk of infectious complications: a series of 21 BM or PBSC transplant patients.

The use of mycophenolate mofetil (MMF) for prophylaxis of aGVHD and/or for treatment of acute or chronic GVHD is increasing. However, the benefit of MMF as an alternative to commonly used immunosuppressive agents still needs to be assessed. We ran a retrospective study on 21 consecutive patients (median age, 36 years; range, 20-63) with aGVHD or extensive cGVHD following related (17) or unrelated (4) matched donor SCT (BM, 16; PBSC, 5) who received MMF (2 g/day) because of intolerance to or failure of CsA-containing combinations. Four of the six patients with aGVHD responded, and the response rate was 69% in cGVHD patients. We observed neither significant differences in terms of response rate for skin, liver and bowel nor dissociated response in cases of multiple organ involvement (67% of the patients). Response was the same for lichenoid and sclerodermatous skin cGVHD subtypes. No adverse effects, except diarrhea (three patients), were observed. However, 22 opportunistic or serious viral or bacterial infections occurred in 10 patients. Analysis of trough plasma levels showed a trend for a higher mean MPA concentration in patients responding to MMF. Our study highlights the high risk of infectious complications induced by the administration of MMF, an otherwise efficient and well-tolerated treatment for GVHD.

Risk of Neutropenic Fever and Early Infectious Complications after Autologous Peripheral Blood Stem Cell Transplantation for Malignant Diseases

Autologous peripheral blood stem cell transplantation (auto-PBSCT) has facilitated high-dose chemotherapy for the treatment of various types of malignancy, but the factors affecting the treatment outcome have not been well defined. We evaluated patients who underwent auto-PBSCT (46 patients with hematological malignancies and 39 with solid tumors) to elucidate the risks of background factors, including age, in association with infectious complications. In contrast to former reports, faster engraftment did not influence the incidence of documented infection or neutropenic fever, whereas high age (age > or = 50 years old) and delayed platelet recovery (> or = 18 days) were demonstrated to be positively involved. The odds ratio (OR) for documented infection in elderly patients was 4.94 (95% confidence interval, 1.22-15.8). Another risk factor of infection was the HD-ICE regimen (ifosfamide, carboplatin, etoposide) given to patients with solid tumors (OR, 8.00; 95% confidence interval, 1.61-39.7). In conclusion, we found that elderly patients and patients on the HD-ICE regimen have a higher risk of infectious complications even after auto-PBSCT. Although the clinical indications for auto-PBSCT can be extended to elderly patients, thorough precautions should be taken against infectious complications during the pre-engraftment phase.

Are Femoral Broviac Catheters Effective and Safe?: A Prospective Comparison of Femoral and Jugular Venous Broviac Catheters in Newborn Infants

Patients with femoral venous catheters are commonly believed to be at higher risk of infectious complications as compared to patients with jugular catheters. Although reports have suggested that femoral venous Broviac catheters (Davol; Cranston, RI) are safe, no comparisons with jugular catheters were presented. Thus, we compared our efficacy and complications of femoral and jugular venous Broviac catheters in newborns. We prospectively recorded demographic data, cannulation requirements, duration of catheter use, and complications. Special-care nursery. Newborns. Insertion of tunneled single-lumen Broviac catheters into vessels of the femoral triangle or the internal jugular, external jugular, or facial veins by surgical cutdown. Sixty infants had 2,503 catheter-days with 111 catheters. Twenty-six infants had 47 femoral catheters, and 34 infants had 64 jugular catheters. All insertion attempts were successful. The median durations of catheter use were 24.0 days and 17.0 days for femoral and jugular catheters, respectively (p = 0.021). Group characteristics, insertion variables, incidences of complications, and deaths were not significantly different between groups. We conclude that compared to jugular catheters, femoral venous Broviac catheters are an effective means to vascular access, with similar incidences of complications in newborn infants.

Preliminary Results of a Survey of the Use of Antimicrobial Agents as Prophylaxis in Orthopedic Surgery

An epidemiological survey of the use of antimicrobial prophylaxis in Italian hospitals was carried out under the auspices of the Journal of Chemotherapy. Out of 500 Italian orthopedic centers queried, 225 agreed to participate in this study. A total of 136,321 surgical procedures were reported in the 166 centers reporting complete answers on type of surgery. They comprised hip and knee prosthesis (13.9%), spine surgery (4%), hip endoprosthesis (5.2%), osteosynthesis (26.9%), arthroscopy (24.4%), and others (25.5%). Perioperative antimicrobial prophylaxis was used in 75% of operations (ranging from 57.1% to 99.4% in arthroscopy and joint prosthesis, respectively). Short term (<24 h) antimicrobial prophylaxis was performed in 38.4% of the 206 centers answering this question correctly. 61.1% of centers employed single agent prophylaxis and 70.8% of these prescriptions were betalactam antibiotics. Bacteriological analysis revealed Gram-positive isolates in 73.3% of cases. Methicillin resistance was present in 45% of 915 tested strains. Out of 4221 patients with high risk of infectious complications (joint prosthesis surgery) given antimicrobial prophylaxis in 46 centers, the percentage of surgical wound infections was overall 2.1%, while that of non-surgical wound infections was 3.6%. The total infection rate was decreased by about half in association with long-term (>24 h) as compared to short-term (<24 h) antibiotic treatment (3.7% vs 7.6%, respectively), and with use of antibiotic drug combinations vs single antibiotic drugs (3.9 vs 6.6%, respectively). The incidence of surgical-site infection was not decreased by extending the chemoprophylaxis for more than the first 24 h after surgery, while it was reduced from 2.5 to 1.4% by use of combination antibiotic therapy.

Efficacy of a Benzalkonium Chloride-Impregnated Central Venous Catheter to Prevent Catheter-Associated Infection in Cancer Patients

Background: This study was performed to determine the efficacy of a benzalkonium chloride-impregnated central venous catheter (CVC) in preventing catheter-related infection in patients suffering from malignant diseases and undergoing chemotherapy. Methods: A randomized, prospective clinical trial was carried out to compare the incidence of catheter-related colonization and catheter-related bacteremia using an antiseptic-impregnated CVC (n = 25) with that using a standard triple-lumen CVC (n = 25). Results: All patients were treated with intensive chemotherapy for acute leukemia (n = 28), lymphoma (n = 17) or solid tumors (n = 5). Both study groups presented with similar data in regards to age, insertion site, duration of catheterization and neutropenia period during catheterization, demonstrating a comparable risk for catheter-related colonization. Suspicion of infection led to explantation in 14 versus 15 cases. Catheter-related colonization was proven in 4 cases (16%) and catheter-related bacteremia was observed only once (4%) in both groups. Statistical testing showed no significant differences between the study and control group. Conclusions: The rate of catheter-related colonization was lower than suspected in this high-risk patient group. The use of benzalkonium chloride-impregnated CVC failed to decrease the incidence of catheter-related colonization and bacteremia in patients with a high risk of infectious complications.

Predictors of infectious complications after burn injuries in children.

Infections are the major life-threatening complication of burn injury and occur with the greatest frequency in children. Knowledge of their occurrence and management, however, is extrapolated from studies in adults. We performed a prospective study of infectious complications in burned children. To delineate epidemiology, risk factors and microbiology of infections in burned children where burn care and surgical interventions are optimal. Children hospitalized for burns were entered into prospective study. Characteristics of the burn injury were assessed, and active surveillance for infections was performed. Seventy patients were entered [mean age, 42 months; mean total body surface area (TBSA), burn 15%]. Twenty-seven percent of patients developed 39 infections: 13 involved the burn wound (burn wound sepsis, 6; graft loss, 5; and cellulitis, 2); 13 were catheter-associated septicemia; 13 involved other sites (i.e. pneumonia, 4; urinary tract infection, 3; bacteremia, 2; endocarditis, 1; myocardial abscess, 1; toxin-mediated syndrome, 1; and otitis media, 1). Twenty-three infections were caused by a single organism, 9 infections by more than 1 organism and in 7 infections defined by CDC criteria no organism was recovered. Organisms causing infection were: Staphylococcus aureus, 19; Candida albicans, 4; Pseudomonas aeruginosa, 4; coagulase-negative Staphylococcus, 4; Enterococcus sp., 3; Escherichia coli, 1; Klebsiella oxytoca, 1; Serratia marcescens, 1; Streptococcus pneumoniae, 1; Streptococcus pyogenes, 1; Aspergillus fumigatus, 1; and Candida parapsilosis, 1. Burn mechanism (flame and inhalation), extent (TBSA >30%) and depth (full thickness) were risk factors for infection; young age and site of burn were not. The most common infections occurring in burn children are burn wound infections and catheter-associated septicemia. Characteristics of burn injury predict risk of infection. Children with flame and inhalation injury, TBSA burned >30% and full thickness burns are at high risk of infectious complications.

Profilassi Antimicrobica della Infezione Chirurgica in Ortopedia. Risultati della Indagine Epidemiologica Promossa per l’Italia dal Journal of Chemotherapy

SummaryAn epidemiological survey of the use of antimicrobial prophylaxis in Italian hospitals was carried out under the auspices of the Journal of Chemotherapy. Out of 500 Italian orthopedic centers requested, 225 have participated in this study. A total of 136,321 surgical procedures were reported in the 166 centers reporting complete answers on type of surgery. They comprised hip and knee prosthesis (13.9%), spine surgery (4%), hip endoprosthesis (5.2%), osteosynthesis (26.9%), arthroscopy (24.4%), and others (25.5%). Perioperative antimicrobial prophylaxis was used in 75% of operations (ranging from 57.1% to 99.4% in arthroscopy and joint prosthesis, respectively). Short term (<24 h) antimicrobial prophylaxis was performed in 38.4% of the 206 Centers answering this question correctly. 61.1% of Centers employed single agent prophylaxis. 70.8% of these prescriptions were betalactam antibiotics. Bacteriological analysis of the wound in 86 Centers (total number of isolates 2013) revealed the presence of Gram-positive isolates in 73.7% of cases. Methicillin resistance was expressed in 45% of 915 tested strains. Out of 4221 patients with high risk of infectious complications (joint prosthesis surgery) given antimicrobial prophylaxis in 46 Centers, the percentage of surgical wound infections was overall 2.1%, while that of non-surgical wound infections was 3.6%. A decrease in the total infection rate by about half was associated with long-term (>24 h) as compared to short-term (<24h) antibiotic treatment (3.7 vs 7.6%, respectively), and with the use of antibiotic drug combinations vs single antibiotic drugs (3.9 vs 6.6%, respectively). The incidence of surgicalsite infection is not decreased by extending the chemoprophylaxis for more than the first 24 h after surgery, while it is reduced from 2.5 to 1.4% by use of combination antibiotic therapy.

Outcome and complications of temporary haemodialysis catheters.

The use of temporary haemodialysis catheters is often complicated by mechanical or infectious complications. Risk factors for these complications and optimal management to reduce their incidence are largely unknown. We conducted a prospective study of 105 haemodialysis catheters (79 subclavian, 26 jugular) inserted in 52 patients in order to identify patient outcomes and to analyse the effect of patient and catheter factors on the incidence of infectious complications by multivariate analysis. Fifty-nine per cent of catheters were removed for a suspected complication. Catheter-related bacteraemia (CRB) was diagnosed in 17 catheters (16%), giving a bacteraemia rate of 6.5 episodes per 1000 catheter days. Subgroup analysis revealed a higher risk of CRB with the use of the internal jugular compared with the subclavian site (hazard ratio 3.97, P=0.02). Age, diabetes or catheter exchange over a guidewire did not alter the risk of CRB. The cumulative risk of developing CRB increased in a linear fashion as the period of catheterization increased. Exit-site infection was the cause for removal in eight catheters (8%). Although the number of exit-site infections was small, the risk of exit-site infection was increased in diabetic patients (hazard ratio 10, P=0.03) and the jugular position (hazard ratio 6.5, P=0.01) but not by age or catheter exchange over a guidewire. Staphylococcus aureus and coagulase-negative staphylococcus accounted for all proven episodes of CRB. Exit-site infection was associated with a mixture of Gram-positive and Gram-negative organisms. Temporary haemodialysis catheters have a high failure rate associated with a significant rate of complications. Use of the internal jugular site is associated with a significantly higher risk of infectious complications and methods to reduce this risk should be considered if this site is used.