Incidence Of Major Infections Research Articles

Incidence and risk factors for major infections in hospitalized children with nephrotic syndrome.

ABSTRACTIntroduction:Children with nephrotic syndrome are at increased risk of infections because of disease status itself and use of various immunosuppressive agents. In majority, infections trigger relapses requiring hospitalization with increased risk of morbidity and mortality. This study aimed to determine the incidence, spectrum, and risk factors for major infections in hospitalized children with nephrotic syndrome.Methods: All consecutive hospitalized children between 1-12 years of age with nephrotic syndrome were enrolled in the study. Children with acute nephritis, secondary nephrotic syndrome as well as those admitted for diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion were excluded.Results:A total of 148 children with 162 admissions were enrolled. Incidence of major infections in hospitalized children with nephrotic syndrome was 43.8%. Peritonitis was the commonest infection (24%), followed by pneumonia (18%), urinary tract infection (15%), and cellulitis (14%), contributing with two thirds of major infections. Streptococcus pneumoniae (n = 9) was the predominant organism isolated in children with peritonitis and pneumonia. On logistic regression analysis, serum albumin < 1.5gm/dL was the only independent risk factor for all infections (OR 2.6; 95% CI, 1.2-6; p = 0.01), especially for peritonitis (OR 29; 95% CI, 3-270; p = 0.003). There were four deaths (2.5%) in our study, all due to sepsis and multiorgan failure.Conclusions:Infection remains an important cause of morbidity and mortality in children with nephrotic syndrome. As Pneumococcus was the most prevalent cause of infection in those children, attention should be paid to the pneumococcal immunization in children with nephrotic syndrome.

Surgical Replacement of Implantable Pulse Generators in Deep Brain Stimulation: Adverse Events and Risk Factors in a Multicenter Cohort

Background: Deep brain stimulation (DBS) is a growing treatment modality, and most DBS systems require replacement of the implantable pulse generator (IPG) every few years. The literature regarding the potential impact of adverse events of IPG replacement on the longevity of DBS treatments is rather scarce. Objective: To investigate the incidence of adverse events, including postoperative infections, associated with IPG replacements in a multicenter cohort. Methods: The medical records of 808 patients from one Australian and five Swedish DBS centers with a total of 1,293 IPG replacements were audited. A logistic regression model was used to ascertain the influence of possible predictors on the incidence of adverse events. Results: The overall incidence of major infections was 2.3% per procedure, 3.7% per patient and 1.7% per replaced IPG. For 28 of 30 patients this resulted in partial or complete DBS system removal. There was an increased risk of infection for males (OR 3.6, p = 0.026), and the risk of infection increased with the number of prior IPG replacements (OR 1.6, p < 0.005). Conclusions: The risk of postoperative infection with DBS IPG replacement increases with the number of previous procedures. There is a need to reduce the frequency of IPG replacements.

Analysis of Major Infection Risk in 706 Patients with Chronic Lymphocytic Leukemia

BackgroundChronic lymphocytic leukemia (CLL) is the most common leukemia in western country. Although the prognosis is improved in the last years, CLL is still an incurable disease and infections are the major cause of morbidity and mortality. Susceptibility to infections in CLL patients can be an intrinsic characteristic of the disease or due to chemo-immunotherapy. Immunoglobulin (Ig) replacement therapy is a safe and effective way to prevent infectious events in CLL patients, but indications to their use are not strictly defined.The aim of this study was to determine risk factors to serious bacterial infections in CLL patients and to identify a clinical phenotype of patients characterized by a high infectious risk, in which Ig replacement therapy (IgRT) is appropriate.MethodsWe retrospectively analyzed clinical and biochemical data of 706 patients, referred to the Hematology and Clinical Immunology Unit of Padua University Hospital since 1982. In this series, we identify patients with at least one episode of major infections (MI), defined as pneumonia, sepsis, meningitis, and endocarditis. We considered only non neutropenic MI.FISH analyses (n=450), CD38 expression (n=529), ZAP70 (n=502), IGHV (n=473), TP53, NOTCH1, BIRC3, SF3B1 (176 genes tested) mutational status, were evaluated before at diagnosis or before starting treatment. Staging and Ig levels were collected at the time of the MI; for patients who didnÕt complain any MI we recorded the last available data. Inferior normal values for IgG, IgA and IgM were 7.0, 0.70 and 0.40g/dL, respectively.Continuous variables were compared by Mann-Whiney test, while categorical variables by Fisher exact test or Chi-square test, when appropriated. Overall survival (OS) was calculated from the date of initial presentation to death for any cause (event) or last known follow-up (censored). Survival analyses were performed by Kaplan-Meier method. Log-rank test was used to compare overall survival curves between groups and Cox regression models to estimate hazard ratios. The proportional hazard assumption was tested in all cox models. p values <0.05 were considered significant and <0.0005 as highly significant. 95% confidential intervals (CI), positive predictive value (PPV) and negative predictive valure (NPV) were also reported.Results69 patients (9.8%) had 89 MI, among these 62 were pneumonia (3 pulmonary aspergillosis), 21 sepsis, 1 meningitides, 1 cerebral abscess, 1 uveitis and 1 endocarditis.We observed a higher risk of MI in subject with at least 2 Ig isotypes deficiencies (Figure 1, Odds Ratio 10.1 (CI 5.78-17.6), p<0.0001); PPV and NPV were 29% and 96%, respectively. By contrast, patients with only 1 Ig deficiency did not show a higher risk of MI.Clinical-biological characteristics between patients with MI (PwI) and without MI (PwoI) were skewed, in particular the formers harbored a high-risk cytogenetic (i.e. del17p and del11q, p<0.0001), unmutated IGHV (homology>98%, p=0.0043), CD38+ (>30%, p=0.0205), were at a more advance stage (Rai III-IV, p<0.0001) and experienced treatment (p<0.0001). No differences were found neither for ZAP70 expression (>20%, p=0.6775), nor TP53, NOTCH1, BIRC3, SF3B1 gene mutations (p=0.9998), nor chemotherapy regiments (p=0.1587).Considering PwI and at least 2 Ig isotypes deficiencies (n=47), 21 patients treated with IgRT showed a reduction of the incidence of MI (0.70 MI/patient/year in the 12 months before IgRT and 0.27 MI/patient/year during replacement therapy).Kaplan-Meier analysis showed that PwI had a shorter OS than PwoI with a median OS of 196 months vs not reached, respectively (Figure 2, p<0.0001). 10-years OS were 64.7% and 83.4% for PwI and PwoI, respectively. In multivariate analysis highly significant variables were history of MI, del17p and U-IGHV. In particular PwI had 2.3 (CI 1.5-3.6, p<0.0001) higher risk of death than PwoI patients.DiscussionIn our work, we described the prognostic role of MI in CLL patients, superimposable to other main prognostic factors. Moreover, we identified the clinical profile of patients at high risk of major infections: low levels of at least 2 Ig isotypes, aggressive disease (U-IGHV, del17p) and previous treatment. We also described the reduction of the incidence of MI in a small cohort of 21 patients after IgRT. Taking advantage from this study, we will investigate safety and usefulness of Ig prophylaxis in a bigger subset of patients. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The effect of immunoglobulin VH gene mutation status and other prognostic factors on the incidence of major infections in patients with chronic lymphocytic leukemia

Infections are a major factor in the clinical course of chronic lymphocytic leukemia (CLL) and account for 30% to 50% of all deaths. The pathogenesis of infections in CLL is related to hypo-gamma-globulinemia, T-cell immune dysfunction, and the immunosuppressive effect of treatment. The authors retrospectively assessed the correlations between new prognostic markers and types of infections encountered, the time taken to develop these infections, and infection-related mortality in 280 unselected patients with CLL. One hundred patients (36%) had at least 1 major infection (median, 2 major infections; range, 1-8 major infections) over a median follow-up of 67 months. Infections were the most common cause of death, accounting for 51% of all fatalities. Older age (P = .007), clinical Stage B or C disease (P < .001), unmutated immunoglobulin (Ig)VH gene status (P < .001), genetic abnormalities (P < .001), positive CD38 status (P < .001), and type of initial therapy were associated with a significantly shorter time to first infection. Equally, patient age (P < .001), disease stage (P < .001), CD38 expression (P < .001), IgVH mutation status (P < .001), and genetic abnormalities (P = .003) had a significant impact on infection-related mortality. Clinical stage at diagnosis, IgVH mutation status, and initial therapy were possible predictors of severe infections in patients with CLL. The current results may help to identify which patients with CLL are at particularly high risk of developing serious infections and, thus, should be considered for Ig or antibiotic prophylaxis.

Indirect Outcomes Associated with Cytomegalovirus (Opportunistic Infections, Hepatitis C Virus Sequelae, and Mortality) in Liver-Transplant Recipients with the Use of Preemptive Therapy for 13 Years

The effect of preemptive therapy on indirect sequelae associated with cytomegalovirus (CMV) in liver-transplant recipients has not been clearly delineated. Thirteen years of outcome with the use of preemptive therapy were assessed in a cohort of 216 consecutive liver-transplant recipients. The incidence of major infections (31% vs. 44.3%), bacterial infections (31% vs. 39.2%), bacteremia (19% vs. 29.1%), or fungal infections (3.4% vs. 7.6%) did not differ significantly for patients with CMV infection who received preemptive therapy compared with those who never developed CMV infection and did not receive antiviral prophylaxis for CMV (P>0.20 for all variables). The rate of opportunistic infections also did not differ when patients were stratified by primary CMV infection, reactivation infection, or no CMV infection. Recurrent hepatitis C virus (HCV) hepatitis occurred in 55.6% of the patients with CMV treated with preemptive therapy and 49.8% of those without CMV infection (P>0.20). The probability of survival at 6 months, 12 months, 2 years, and 3 years was also comparable for the two groups. Liver-transplant recipients with CMV infection, including high-risk R-/D+ patients, when followed using the preemptive therapy approach had no significant difference in meaningful outcomes such as opportunistic superinfections, HCV recurrence rates, rejection, and survival when compared with the patients in whom CMV infection never developed and who did not receive antiviral prophylaxis for CMV.

Use of Subjective Global Assessment to Identify Nutrition-Associated Complications and Death in Geriatric Long-Term Care Facility Residents

Objective: The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition.Methods: Fifty-three consecutive residents who were ≥ 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality.Results: Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05).Conclusions: Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

Antibiotic prophylaxis in cardiac operations

This clinical trial, which was composed of 1,031 adults undergoing cardiac operations, compared the efficacy of a single dose of 1 g of ceftriaxone with a 48-hour regimen consisting of flucloxacillin and gentamicin. There was no significant difference ( p = 0.89) in the overall incidence of major infections: 30 of 515 patients (5.8%; 95% confidence interval, 5.4% to 6.2%) taking ceftriaxone and 29 of 516 patients (5.6%; 95% confidence interval, 5.2% to 6.0%) taking flucloxacillin and gentamicin. Subgroup analyses, with a lower statistical power, failed to show a significant difference between patients who received ceftriaxone and those who received flucloxacillin/ gentamicin: major sternal wound infections arose in 2.7% of the patients taking ceftriaxone versus 1.6% in those on the 48-hour regimen ( p = 0.20) and major limb wound infections arose in 4.2% and 5.4%, respectively ( p = 0.44). Single-dose prophylaxis was associated with fewer intravenous administrations (864 doses versus 9,570 doses) and cost less (A$17,248 versus A$78,510). Although the regimen that included gentamicin was associated with the greatest biochemical impairment of renal function, the overall toxicity for both groups was low. We conclude that a single dose of ceftriaxone provided cost-efficient prophylaxis for adults undergoing cardiac operations when compared with a 43-hour regimen of gentamicin and flucloxacillin. The general principle revealed by our data is that the short-term administration of an appropriate antibiotic regimen represents optimal prophylaxis for patients undergoing cardiac procedures.

A prospective study of bacterial infections in the newborn.

Neonatal bacterial infections were identified in 1675 consecutive liveborns in Pondicherry. Babies weighing less than 2000 gm at birth had higher incidence of major infections as compared to higher birth weight babies. Minor infections like pyoderma and conjunctivitis occurred with equal frequency in both the weight groups. Commonest organism isolated from neonates with minor infection wasStaphylococcus pyogenes. In cases of septicemia predominant organisms isolated wereKlebsiella, Salmonella, E. coli andPseudomonas aerugenosa, in descending order of frequency. Antibiotic sensitivity pattern of all the organisms showed high sensitivity to gentamycin (94.2%), chloramphenicol (70.3%) and kanamycin (67.3%) and poor sensitivity to streptomycin, tetracycline, ampicillin and penicillin.