Risk Factors For Late Infection Research Articles

830. Risk factors for late Pneumocystis jirovecii pneumonia in kidney transplant recipients: A Case-Control Study of United States Renal Data System Data

Abstract Background Organ transplant recipients are at increased risk of potentially life-threatening opportunistic infections, including Pneumocystis jirovecii pneumonia (PJP). Given the use of effective prophylaxis, PJP has become less common, especially during the first-year post-transplant. Recent data has shown that the risk of infection has shifted within the first 2 years after discontinuing prophylaxis. We aimed to determine risk factors for late posttransplant PJP using a national database. Methods Using the United States Renal Data System database, we performed a retrospective case-control study of patients who underwent kidney transplant from 1998 through 2019. To evaluate risk factors for late PJP, we performed logistic regression analysis by comparing characteristics between infected patients and their matched uninfected controls. Results We identified 407 cases with PJP and matched to 1628 controls (1:4). 60 (14.7%) of the cases occurred within one year post transplant and 347 (85.3%) patients were diagnosed after one year of transplant. In the late period, the median time between transplant and PJP diagnosis was 68.7 (IQR 28 -134.2) months. Seventy cases (20.1%) occurred between 12 and 24 months. In multivariate analysis (table 1), risk factors for late infection included a higher Elixhauser Comorbidity Index (ECI), history of cytomegalovirus disease, older donor age, use of antilymphocyte agents, history of re-transplant and a longer time of hemodialysis prior to transplant. Of note, in the early period, we found that having a living donor was protective. Multivariate analysis of risk factors for late Pneumocystis jirovecii pneumonia Conclusion Our findings highlight the importance of a timely transplant to mitigate the risk of post-transplant PJP in the late post-transplant period where prophylaxis is not routinely used. These results also raise the consideration of PJP prophylaxis in the late period in patients diagnosed with CMV disease, history of re transplant and recent use of antilymphocyte agents. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun: Grant/Research Support|Cidara: Grant/Research Support|Scynexis: Grant/Research Support

Risk factors associated with development of coinfection in critically Ill patients with COVID-19.

BackgroundAt outset of the coronavirus disease 2019 (COVID-19) pandemic, the significance of bacterial and fungal coinfections in individuals with COVID-19 was unknown. Initial reports indicated that the prevalence of coinfection in the general population was low, but there was uncertainty regarding the risk of coinfection in critically ill patients.MethodsNine hundred critically ill adult patients with COVID-19 infection were enrolled in this observational case-control study. Patients with a coinfection (case) and patients without a coinfection (control) were compared using univariate and multivariable analyses. A subgroup analysis was performed on patients with coinfection, dividing them into early (infection within 7 days) and late (infection after 7 days) infection groups.ResultsTwo hundred and thirty-three patients (25.9%) had a bacterial or fungal coinfection. Vasopressor use (P<0.001) and severity of illness (higher Acute Physiology and Chronic Health Evaluation III score, P=0.009) were risk factors for the development of a coinfection. Patients with coinfection had higher mortality and length of stay. Vasopressor and corticosteroid use and central line and foley catheter placement were risk factors for late infection (>7 days). There were high rates of drug-resistant infections.ConclusionsCritically ill patients with COVID-19 are at risk for both community-acquired and hospital-acquired infections throughout their hospitalization for COVID-19. It is important to consider the development of a coinfection in clinically worsening critically ill patients with COVID-19 and consider the likelihood of drug-resistance when choosing an empiric regimen.

Late infectious complications in hematopoietic cell transplantation survivors: a population-based study

Few studies have compared the incidence of infections occurring ≥2 years after hematopoietic cell transplant (HCT) with other cancer patients and the general population. In this study, ≥2-year HCT survivors who were Washington residents treated from 1992 through 2009 (n = 1792; median age, 46 years; 52% allogeneic; 90% hematologic malignancies) were matched to individuals from the state cancer registry (n = 5455, non-HCT) and driver's license files (n = 16 340; Department of Licensing [DOL]). Based on hospital and death registry codes, incidence rate ratios (IRRs; 95% confidence interval [CI]) of infections by organism type and organ system were estimated using Poisson regression. With 7-year median follow-up, the incidence rate (per 1000 person-years) of all infections was 65.4 for HCT survivors vs 39.6 for the non-HCT group (IRR, 1.6; 95% CI, 1.3-1.9) and 7.2 for DOL (IRR, 10.0; 95% CI, 8.3-12.1). Bacterial and fungal infections were each 70% more common in HCT vs non-HCT cancer survivors (IRR, 1.7; P < .01), whereas the risk for viral infection was lower (IRR, 1.4; P = .07). Among potentially vaccine-preventable organisms, the IRR was 3.0 (95% CI, 2.1-4.3) vs the non-HCT group. Although the incidences of all infections decreased with time, the relative risk in almost all categories remained significantly increased in ≥5-year HCT survivors vs other groups. Risk factors for late infection included history of relapse and for some infections, history of chronic graft-versus-host disease. Providers caring for HCT survivors should maintain vigilance for infections and ensure adherence to antimicrobial prophylaxis and vaccination guidelines.

Response to Weiss HR, Moramarco M: “indication for surgical treatment in patients with adolescent idiopathic scoliosis – a critical appraisal” (Patient Saf. Surg. 2013, 7:17)

Response to Weiss HR, Moramarco M: “indication for surgical treatment in patients with adolescent idiopathic scoliosis – a critical appraisal” (Patient Saf. Surg. 2013, 7:17)

Late Prevertebral Abscess After Anterior Cervical Fusion

We present a unique case of a 54-year-old woman who developed a prevertebral abscess 2 years after anterior cervical fusion in the absence of previously reported risk factors for late infection. The literature relevant to this topic is reviewed. To report a rare complication of a commonly performed surgery. Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. The complication rate is relatively low; the risk of infection is only 0.1% to 1.6%. In the late postoperative setting, more than 6 months, wound infections are very rare and are often associated with an esophageal perforation secondary to hardware migration. We present a rare complication of a deep wound infection in a 54-year-old woman 2 years after an anterior cervical fusion. On serial radiograph imaging after surgery, the surgical level demonstrated progressive fusion. At 2 years, however, the patient presented with acute dysphagia. Computed tomography (CT) of the neck with contrast demonstrated a rim enhancing prevertebral mass, which was treated with wound exploration and debridement. Direct laryngoscopy at the time of surgery did not demonstrate a breach in the esophageal mucosa and inspection of the esophagus during surgery did not reveal a diverticulum, tear, or breach in the esophagus. After surgical exploration and debridement the patient was placed on a 6-week course of antibiotics. Her dysphagia improved significantly after debridement of the prevertebral abscess. Late occurring, deep wound infections are a rare complication of anterior cervical fusion. Dysphagia in the late postoperative setting should be considered carefully and evaluated for esophageal perforation or deep wound infection.

Epidemiology and risk factors for late infection in solid organ transplant recipients

Information concerning the risk factors and outcome of late infection (LI) after solid organ transplantation (SOT) still remains scarce. We prospectively analyzed all patients undergoing SOT from July 2003 to March 2008, who survived the first 6 months after surgery and with a minimum 1-year follow-up. Risk factors associated with the development of bacterial and cytomegalovirus (CMV) LI and survival were identified. Overall, 942 SOT recipients (491 kidney, 280 liver, 65 heart, and 106 double transplants) were included. During the study period 147 patients (15.6%) developed 276 episodes of LI (incidence rate, 0.43 per 1000 transplantation-days). Bacteria were the most prevalent etiology (88.0%). Primary sources of infection included urinary tract (36.9%), intra-abdominal (16.7%), and sepsis without source (13.4%). Independent risk factors for late bacterial infection were: age (hazard ratio [HR] [per year] 1.0; 95% confidence interval [CI]: 1.0-1,0), female gender (HR 1.7; 95%CI: 1.1-2.6), anti-hepatitis C virus (HCV) positive serostatus (HR 1.8; 95%CI: 1.1-3.0), chronic allograft dysfunction (HR 3.2; 95%CI: 1.7-6.1), early CMV disease (HR 2.2; 95%CI 1.2-4.1), and early bacterial infection (HR 2.5; 95%CI 1.6-3.8). The occurrence of chronic allograft dysfunction was an independent risk factor for late CMV disease (HR 6.5; 95%CI: 1.7-24.6), whereas immunosuppression based on mammalian target of rapamycin inhibitors protected against the development of late CMV disease (HR 0.3; 95%CI: 0.1-1.0). Cox model selected anti-HCV positive serostatus (adjusted HR [aHR] 2.67; 95%CI: 1.27-5.59), age (aHR [per year] 1.06; 95%CI: 1.02-1.10), and the occurrence of LI (aHR 9.12; 95%CI: 3.90-21.33) as independent factors for mortality. LI did not constitute an uncommon complication in our cohort, and patients at risk may benefit from close clinical monitoring.

What Are the Risk Factors for Infection in Hemiarthroplasties and Total Hip Arthroplasties?

Late infection is the second most frequent early complication after total hip arthroplasty (THA) and the most frequent after hemiarthroplasty. Known risk factors for infection after THA include posttraumatic osteoarthritis, previous surgery, chronic liver disease, corticoid therapy, and excessive surgical time. However, risk factors for hemiarthroplasty are not clearly established. We therefore determined the preoperative and intraoperative risk factors for late infection (more than 3 months after surgery) in patients with hemiarthroplasties and THAs. We retrospectively compared 47 patients with a hip arthroplasty (23 hemiarthroplasties, 24 total hip arthroplasties) and late infection with 200 randomly-selected patients with primary arthroplasty (100 hemiarthroplasties, 100 total hip arthroplasties) during the same time period of time without any infection during followup. Potential risk factors were identified from medical records. Minimum followup was 12 months (mean, 27 months; range, 12-112 months) for the study group and 18 months (mean, 84 months; range, 18-144 months) for the control group. The following factors were more frequent in late infected hemiarthroplasties: female gender; previous surgery; obesity (body mass index greater than 30 kg/m(2)); glucocorticoid and immunosuppressant treatments; prolonged surgical time; inadequate antibiotic prophylaxis; prolonged wound drainage; hematoma; dislocation; and cutaneous, urinary, and/or abdominal infections. The following were more frequent in infected total hip arthroplasties: posttraumatic osteoarthritis; previous surgery; glucocorticoids; chronic liver disease; alcohol and intravenous drug abuse; prolonged surgical time; prolonged wound drainage; dislocation; subsequent surgery; and cutaneous, urinary, respiratory and abdominal infections. Diabetes did not appear to be a risk factor. Our data suggest there are specific risk factors for infection in hemiarthroplasties. The major risk factors for late infection in hip arthroplasty must be recognized so they can be minimized or controlled if not possible to employ prophylactic measures.

Risk Factors for Late Infections after Allogeneic Hematopoietic Stem Cell Transplantation from a Matched Related Donor

After allogeneic hematopoietic stem cell transplantation (HSCT), early infections represent a major cause of morbidity and mortality but little information has been previously reported on late infections. Late infection incidence and risk factors were retrospectively determined in 196 long-term survivors after HLA matched related HSCT. Patients transplanted for aplastic anemia, chronic myelogenous leukemia (CML), and acute myelogenous leukemia (AML) were included. Median follow-up was 8 years. Thirty patients died beyond the first year, causes of death were relapse (n = 10) and infections (n = 19, associated with graft-versus-host disease [GVHD] in 16 patients). Late severe bacterial (LSB) and fungal infections occurred in 30 and 8 patients, yielding to an 8-year cumulative incidence of 15 (95%CI: 10-20) and 4% (95%CI: 1-6), respectively. The majority of viral infections were hepatitis C (HCV) and VZV (8-year cumulative incidence: 10 (95%CI: 5-14) and 27% (95%CI: 20-34), respectively. Three risk factors for LSB have been identified in multiple Cox analysis: CMV status (positive recipient and negative donor) (hazard ratio [HR]: 2.5, 95%CI: 1.1-5.9, P = .033), irradiation-based conditioning regimen (HR: 3.1, 95%CI: 1.2-7.8, P = .016), and extensive chronic GVHD (cGVHD; HR: 2.9, 95%CI: 1.3-6.9, P = .013). Extensive cGVHD was the only risk factor for non-HCV viral infections in patients transplanted for AML or CML (HR: 2.7, 95%CI: 1.4-5.1, P = .002). After HSCT, patients remain at high risk of infections even late after transplantation, in particular, with the above risk factors, and required a prolonged follow-up.

Risk Factors for Late Infections after Allogeneic Hematopoietic Stem Cell Transplantation from a Matched Related Donor.

After allogeneic hematopoietic stem cell transplantation (HSCT), late infections represent a major cause of morbidity and mortality but little has been previously reported. In a retrospective cohort study, late infections incidence was determined in 196 long-term survivors after matched related HSCT. Only patients transplanted for aplastic anemia, chronic myeloid leukemia (CML) and acute myeloblastic leukemia (AML) were included in this study. Median follow-up was 8 years. Among 30 patients who died beyond the first year, 9 patients died from graft-versus-host disease (GVHD) and 10 from infections. Bacterial late severe infections occurred in 30 patients, yielding an 8-year cumulative incidence of 15%. Late invasive fungal infection occurred in 8 patients corresponding to a cumulative incidence of 3.6%. Most viral infections were hepatitis C and VZV and overall late viral infection incidence was 35%. We identified 3 risk factors for bacterial infections in multiple analysis: CMV status (positive recipient and negative donor), irradiation based conditioning regimen and extensive chronic GVHD within the first year. Extensive chronic GVHD was the only risk factor of non-HCV viral infection in patients transplanted for AML or CML. Thus, late life threatening infections may occur in nearly a fourth of late survivors even after matched related transplantation and are associated not only with chronic GVHD but also with irradiation and to CMV status prior to transplantation.

Late Infection after Cranioplasty

The incidence of late infection after cranioplasty was studied in 130 patients with 133 cranioplasties. The materials used were prefabricated resin in 62 cases, autogenic bone in 38, intraoperatively fashioned resin in 25, and vitallium in eight. Six infections were documented, for an infection rate of 4.5%. In addition to these six cases, we studied eight patients with infections who had undergone cranioplasty elsewhere but had the infected plates removed in our hospitals. Among the 14 cases of infection, the intervals between cranioplasty and plate removal were 3 to 43 months (average, 10.5 months). The eight patients referred from other hospitals had a significantly shorter average interval between external decompression and cranioplasty than did patients who did not develop infection (2.6 versus 6.7 months; p less than 0.005). Systemic signs were mild despite obvious local signs of infection. Of the 11 first infections, nine (82%) were associated with discharge of pus from a fistula; in these cases a galeal suture had become infected apparently through scratching by the patients. In contrast, in the three patients who had had a previous infection, the second infection manifested as subgaleal and epidural empyema or meningitis without a fistula or pus discharge. Nine infections (69%) were due to Staphylococcus. All but two patients required removal of the infected plates. One recovered with conservative therapy and one died of meningitis, giving a mortality rate of 0.8%. No matter how mild the systemic signs, late infection warrants surgical debridement and plate removal. The risk factors for late infection of cranioplasty are discussed.