Sepsis Of Unknown Origin Research Articles

A Case of Acute Liver Failure Associated with Methimazole in Patient with Underlying Liver Disease

We report a case of methimazole-induced acute hepatic failure, which occurred 4 days after initiation of drug in a 51-year-old man with hyperthyroidism. Liver function was evaluated before taking methimazole, total bilirubin was 14.2 mg/dL. This finding suggested toxic hepatitis d/t herbal medication or unknown liver disease. He was treated with methimazole with increasing doses from 15 to 45 mg/day, he developed liver failure gradually, despite of suspending methimazole. From the time of admission, his liver function test was abnormal and liver cirrhosis was suspected by liver sonography. With aggravated liver function, he died of renal failure, sepsis of unknown origin and respiratory failure. Fulminant hepatitis rarely occurs in methimazole users, and spontaneous recovery is expected. But this case shows that methimazole-induced hepatotoxicity with possible underlying liver disease could increase the risk of poor outcomes. And in case of continued deterioration of liver function, prompt liver transplatation should be considered.

P18.21: Use of amniocentesis and cervical cerclage to achieve successful pregnancy outcome in a case of mid‐trimester sepsis of unknown origin

Amniocentesis with positive culture is the gold standard for diagnosis of chorioamnionitis (Tita, 2010) and in this case was used to justify not starting oxytocin to end the pregnancy. A 21-year-old para 0 + 1 (previous midtrimester loss) with a history of recurrent UTI was admitted at 19 + 3 with lower abdominal and loin pain and 3+ blood on urinalysis. Observations: BP 130/60, P114 bpm, RR 24/min and temperature 38.4C. Blood cultures, MSU and HVS were sent. Pyelonephritis or chorioamnionitis were considered. Amniocentesis was performed; gram stain was negative. Oxytocin was therefore not commenced. Antibiotics were given on microbiology advice. 48 hours later she developed sudden onset of shortness of breath with oxygen saturations of 83% in air. A CTPA showed multifocal pneumonia but no PE. Clarithromycin was commenced. Amniotic fluid culture was negative. The MSU grew E.coli. A 20 + 3 transvaginal scan showed bulging membranes. A rescue suture was placed. Anomaly and all follow up scans were normal. She had a normal vaginal delivery at 38 weeks after suture removal at 37 weeks. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

EMPIRICUS micafungin versus placebo during nosocomial sepsis in Candida multi-colonized ICU patients with multiple organ failures: study protocol for a randomized controlled trial

BackgroundThe potential interest of antifungal treatment of non-immunocompromized patients with sepsis, extra-digestive Candida colonization and multiple organ failure is unknown. It represents three-quarters of antifungals prescribed in Intensive Care Units. It may allow early treatment of invasive fungal infection in the incubation phase but expose patients to unnecessary antifungal treatments with subsequent cost and fungal selection pressure. As early diagnostic tests for invasive candidiasis are still considered to be insufficient, the potential interest in this strategy needs to be demonstrated.MethodsThis prospective multicenter, double blind, randomized-controlled trial is conducted in 23 French Intensive Care Units. All adult patients, mechanically ventilated for more than four days with sepsis of unknown origin and with at least one extradigestive fungal colonization site and multiple organ failure are eligible for randomization. Patients with proven invasive candidiasis are not included. After a complete mycological screening, patients are allocated to receive micafungin 100 mg intravenously once a day or placebo for 14 days. We plan to enroll 260 patients. The main objective is to demonstrate that micafungin increases survival of patients without invasive candidiasis at day 28 as compared to placebo. Other outcomes include day 28 and 90 survival and organ failure evolution. Additionally, pharmacokinetics of micafungin in enrolled patients will be measured and evolution of fungal biomarkers and susceptibility profiles of infecting fungi will also be followed.DiscussionThis study will help to provide guidelines for treating non-immunocompromized patients with fungal colonization multiple organ failure and sepsis of unknown origin.Trial registrationClinicaltrials.gov number NCT01773876

Septische Arthritis als Manifestation einer floriden Endokarditis

Septic arthritis due to endocarditis is a rare and life-threatening disease. Endocarditis occurs with an incidence of 30 patients per 1 million citizens/year. Staphylococcus aureus is one of the most common causative pathogens. Methicillin-resistant Staphylococcus aureus (MRSA) can lead to a severe outcome with a high mortality rate, and embolic complications of the kidney, brain, and spleen are seen in one third of all cases. The diagnosis and treatment of endocarditis is a challenge for all health care providers. We report about a patient who was admitted to our hospital with generalized sepsis of unknown origin.

Streptococcal necrotising myositis of obturator internus and piriformis in a type 2 diabetic patient presenting as sepsis of unknown origin

This report describes a case of necrotising myositis of the obturator internus and piriformis muscles. Necrotising myositis is a rare result of group A streptococcal infection. It is usually fatal and has not been described previously in the obturator internus and piriformis. We describe how, following presentation to an emergency department, rapid diagnosis was arrived at by clinically guided radiological investigation. The report considers the possible aetiology of the condition, the diagnosis and its management, and reviews the relevant literature.

Embolismos sépticos cutáneos tras angioplastia

Invasive vascular procedures have good efficacy and safety profiles and are now widely used for the diagnosis and treatment of many cardiovascular disorders. However, they do have potential complications that can occasionally be life-threatening. We present a new case of infectious pseudoaneurysm following percutaneous transluminal coronary angioplasty and complicated by septic emboli to the skin. It is a rare condition characterized by persistent bacteremia, sepsis of unknown origin, and regional septic emboli. Histopathology of the skin lesions typically reveals gram-positive coccobacilli and septic vasculitis. The condition carries a significant morbidity and mortality, making early diagnosis essential. Both cholesterol and septic emboli should be considered in the differential diagnosis of skin lesions after invasive vascular procedures.

An unusual case of hypercalcaemia

A 54-year-old male Caucasian was admitted to North Manchester General Hospital with a 5-day history of confusion and hallucinations. A history taken from his family revealed a prior 4-week history of decreased appetite and weight loss coupled with episodes of urinary incontinence. Three months before this the patient had been diagnosed with squamous cell carcinoma of the soft palate, confirmed to be locally invasive by computed tomography scan. He had been booked for radical resection of the tumour in the coming week. Past medical history included coeliac disease and hypertension. He was a current heavy smoker and a heavy consumer of alcohol until 1 month ago. He was not taking any regular medications. On examination the patient appeared agitated and confused. He was apyrexial, with a heart rate of 103 beats per minute, blood pressure 128/75 mmHg and low pulse oximetry at 93%. Systemic clinical examination was otherwise unremarkable. Initial blood investigations including full blood count, urea and electrolytes and liver function tests were normal except for raised inflammatory markers and markedly raised corrected calcium of 4.08 mmol/litre. His parathyroid hormone level was 6 ng/litre. Other investigations included a normal mid-stream urine sample, electrocardiogram and chest X-ray; computed tomography of the head and neck did not show any change from a previous scan showing soft palate lesion with local invasion. The differential diagnosis at this point was sepsis of unknown origin, hypercalcaemia secondary to bony metastasis or confusion secondary to hypercalcaemia or infection. He was treated with aggressive intravenous fluids (4 litres in the first 24 hours) and intravenous pamidronate for his hypercalcaemia, intravenous broad spectrum antibiotics for sepsis and lorazepam for his agitation. His confusion persisted despite corrected calcium coming down to 3.27 mmol/litre over the next few days. Subsequently computed tomography of the abdomen, pelvis and thorax was performed which showed diffuse liver metastatic deposits. There was no bony metastasis to account for the hypercalcaemia. A bone scan did not show evidence of any lytic or sclerotic metastases. His inflammatory markers remained high but blood and urine cultures revealed no growth. Tumour markers showed normal carcinoembryonic antigen and alpha-fetoprotein levels. CA19-9 was raised at 841 U/ml (normal range <35 U/ml). He was reviewed by oncology who deemed him unfit for any intervention but suggested liver biopsy to try and get any clues for the primary as oral squamous cell carcinoma was suggested to be unlikely to metastasize to the liver. He started becoming increasingly drowsy and his calcium started to rise again (corrected calcium 5.26 mmol/litre). A further dose of intravenous pamidronate (90 mg course) made little difference to his hypercalcaemia. He continued to deteriorate and eventually died 22 days after admission. His parathyroid hormone-related protein level was high at 13.8 pmol/litre (normal range <1.8 pmol/litre). The post-mortem examination revealed diffuse infiltration of the liver by a tumour which was squamous cell carcinoma on histology. There were no other sites found to have squamous cell carcinoma.

Das akute (chirurgische) Abdomen – Epidemiologie, Diagnostik und allgemeine Prinzipien des Managements

This review comments on epidemiology, diagnosis and general principles of surgical management in patients with acute abdomen. DEFINITION AND EPIDEMIOLOGY: The most common cause of acute abdominal pain is non-specific abdominal pain (24 - 44.3 % of the study populations), followed by acute appendicitis (15.9 - 28.1 %), acute biliary disease (2.9 - 9.7 %) and bowel obstruction or diverticulitits in elderly patients. Acute appendicitis represents the cause of surgical intervention in two-thirds of the children with acute abdomen. A standardised physical examination combined with ultrasonography (US) represents the initial investigation in patients with acute abdominal pain. Due to the risk associated with radiation and due to the costs, a selective use of CT imaging is recommended. The work-flow given in this paper restricts the use of CT imaging to less than 50 % of patients with acute abdominal pain. Diagnostic laparoscopy should be considered in patients without a specific diagnosis after appropriate imaging and as an alternative to active clinical observation which is the current practice in patients with non-specific abdominal pain. Acute small bowel obstruction has previously been considered as a relative contraindication for laparoscopic management, but it has been shown in the meantime that laparoscopic treatment is an elegant tool for the management of simple band small bowel obstruction. Bedside diagnostic laparoscopy is recommended in intensive care unit (ICU) patients with acute abdomen or sepsis of unknown origin, in suspicion of acute cholecystitis, diffuse gut hypoperfusion and mesenteric ischaemia or in refractory lactic acidosis, especially after cardiac surgery. Early administration of analgesia to patients with acute abdominal pain in the emergency department will reduce the patient's discomfort without impairing clinically important diagnostic accuracy and is recommended on the basis of some prospective randomised trials. However, the impact on diagnostic accuracy depends on dosage, kind of application and cause of acute abdominal pain. A practice of judicious provision of analgesia therefore appears safe. There are significant differences between the knowledge of the current literature and the routine practice of providing analgesia as a survey has shown demonstrating that less than 50 % of paediatric emergency physicians and paediatric surgeons are usually willing to provide analgesia before definitive diagnosis.

Hemodynamic instability in septic shock

Septic shock is a common cause of hemodynamic instability. To optimize management, causative mechanisms need to be determined early in the process. Early diagnosis and intervention remain very important aspects in establishing a favourable outcome. Fortunately, early diagnosis can be facilitated with good clinical acumen and aided with bedside echocardiography, as illustrated in the following case. The Research Ethics Committee of the Montreal Heart Institute granted approval for the use of the related echocardiographic images for research and educational purposes. A 30-yr-old woman presented with mild hypotension, high fever, and acute renal failure 3 days after instrumental vaginal delivery. She had experienced mild pharyngeal discomfort and non-hemorrhagic diarrhea for 24 hr on the second puerperal day. She was first diagnosed with sepsis of unknown origin and was given broad-spectrum

Acute Celiac Artery Compression Syndrome After Surgical Correction of Scheuermann Kyphosis

A case of acute celiac artery compression syndrome after spinal fusion in a patient with Scheuermann kyphosis is reported. To describe the unusual complication of acute celiac artery compression after surgical kyphosis correction, to outline diagnostic methods, and to review the pertinent literature. Chronic celiac artery compression syndrome is well described, yet there is only 1 reported case of acute celiac artery compression after surgical correction of kyphosis. There have been no previous reports of this complication leading to foregut ischemic necrosis after correction of Scheuermann kyphosis. Case report and literature review. After an anterior release and posterior spinal fusion for a 106 degrees kyphotic deformity performed under 1 anesthetic, our patient developed a perforated gastric antrum on postoperative day 5, evolving to ischemic necrosis of the stomach, gallbladder, and spleen discovered on postoperative day 7. Abdominal angiography indicated that his celiac artery had been occluded at its origin. After this event, the patient required a prolonged intensive care hospital stay and required a Roux-en-Y gastro-jejeunostomy reconstruction. He is now doing well at 1-year follow-up with independent ambulation and a regular diet. Acute celiac artery compression after surgical kyphosis correction is a rare but potentially serious adverse event. Spinal deformity surgeons and intensivists should be aware of this entity, and should have a high index of suspicion for it if sepsis of unknown origin, an acute abdomen, or elevated liver enzymes are encountered after surgery after correction of a kyphotic deformity.

Hepatic abscess secondary to a rosemary twig migrating from the stomach into the liver

The ingestion of a foreign body that penetrates the gastric wall and migrates to the liver, where it causes an abscess is uncommon. A case of an ingested rosemary twig perforating the gastric antrum, then migrating to the liver, complicated by hepatic abscess and Staphylococcus aureus sepsis is reported. A 59-year-old man without a history of foreign body ingestion was admitted to our hospital because of sepsis and epigastralgia, which had progressively worsened. No foreign body was identified at preoperative imaging, but a rosemary twig was discovered during laparotomy. The liver abscess and sepsis were controlled successfully with surgery and antibiotics. This unusual condition should be kept in mind when dealing with cases of hepatic abscess, or even sepsis of unknown origin. Despite the improvement of non-surgical techniques such as percutaneous drainage and interventional endoscopy, surgery still remains important in the treatment of hepatic abscess caused by an ingested foreign body.

Differences in time to positivity can affect the negative predictive value of blood cultures drawn through a central venous catheter

Sir: We have read with interest the contribution by Tanguy et al. [1] in Intensive Care Medicine reporting a negative predictive value of 98% for culture at 24 h of blood drawn through a catheter. The authors suggested that this could be used to rule out catheter-related infection in patients with central venous catheters (CVC) and sepsis of unknown origin. However, we think that some considerations must be noted in relation to the growth rate of micro-organisms. Clinical studies show variations in times to positivity of blood cultures between pathogens especially between bacteria and Candida spp. [2, 3, 4]. Weinstein et al. [2] observed that in usual clinical practice Enterobacteriaceae are positive in an average

Palliation of Patients with Malignant Gastric Outlet Obstruction with the WallFlex Enteral Stent: A Retrospective Multicentre Study

Introduction: Gastric outlet obstruction can be a late complication of advanced gastric, periampullary and duodenal carcinoma. Palliation of symptoms of obstruction is the primary aim of treatment in these patients. Self-expandable metal stents (SEMS) have emerged as a promising treatment option. The purpose of this study was to investigate the technical and short-term clinical success (30 days) of a new enteral stent made of nitinol (WallFlex, Boston Scientific) in a multicentre patient cohort. Methods: The first 18 European centres having this stent were approached to collect data of every patient treated. Of these centres 15 returned their data. The collected data were: general patients' data, type of tumour, complaints, symptom-score (Gastric-Outlet-Obstruction-Scoring-System: a 4-point scoring system from 0 to 3) before and one week after stent placement, procedure related technical data and complications within 30 days. Descriptive statistics were used and the patients' improvement of GOOSS-score by two points was calculated using the Chi-square test. A GOOSS-score of 2 and 3 was considered a satisfactory quality of diet. Results: Case record forms of 62 patients (35 men, mean age 70 years) were completed. Obstruction was caused by cancer of the stomach in 9, periampullary in 47, duodenal in 1 and metastases in 5. All patients suffered from nausea, vomiting or inability to eat. The median length of the stenosis was 4 cm (1-15 cm). Sixty-six enteral stents (diameter 27/22 mm) were placed: 58 patients required one stent, 4 patients required two stents either because of the position (2) or the length of the stenosis (1) or due to migration (1). Before stent placement 49 patients had no oral intake or were only tolerating liquids (GOOSS-score 0 or 1). The GOOSS-score after one week was obtained from 56 patients (6 patients died): of these 7 were able to tolerate liquids only and 49 patients tolerated soft solids or a low-residue diet (GOOSS-score 2 or 3). A GOOSS-score improved by two points was significant (p = 0.007). Oral intake was possible on average 1 day (0-8 days) after stent placement. Of the 62 patients enrolled the 30 days follow-up has so far been collected in 59. Complications within 30 days occurred in 11 patients: perforation (2), stent migration (2), tumour ingrowth (1), bleeding (1), aspiration pneumonia (3), cholangitis (1), sepsis of unknown origin (1). Conclusion: WallFlex enteral stent placement for the palliative treatment of patients with malignant gastric outlet obstruction was technical successful in 58 out of 62 (94%) and allowed 49 out of 62 (79%) patients to resume a satisfactory quality of diet.

Hyponatremia Impairs Early Posttransplantation Outcome in Patients With Cirrhosis Undergoing Liver Transplantation

Hyponatremia is associated with reduced survival in patients with cirrhosis awaiting liver transplantation. However, it is not known whether hyponatremia also represents a risk factor of poor outcome after transplantation. We aimed to assess the effects of hyponatremia at the time of transplantation on posttransplantation outcome in patients with cirrhosis. Two-hundred forty-one consecutive patients with cirrhosis submitted to liver transplantation during a 4-year period (January 2000-December 2003) were included in the study. The main end point was survival at 3 months after transplantation. Secondary end points were complications within the first month after transplantation. Patients with hyponatremia (serum sodium lower than 130 mEq/L) had a greater incidence of neurologic disorders, renal failure, and infectious complications than patients without hyponatremia (odds ratio; 4.6, 3.4 and 2.7, respectively) within the first month after transplantation. By contrast, hyponatremia was not associated with an increased incidence of severe intra-abdominal bleeding, acute rejection, or vascular and biliary complications. Hyponatremia was an independent predictive factor of early posttransplantation survival. Three-month survival of patients with hyponatremia was 84% compared with 95% of patients without hyponatremia (P < .05). Survival was similar after 3 months. In patients with cirrhosis, the presence of hyponatremia is associated with a high rate of neurologic disorders, infectious complications, and renal failure during the first month after transplantation and reduced 3-month survival. In cirrhosis, hyponatremia should be considered not only a risk factor of death before transplantation but also a risk factor of impaired early posttransplantation outcome.

Epidemiology, risk factors and outcome of nosocomial infections in a Respiratory Intensive Care Unit in North India

To determine the epidemiology, risk factors and outcome of infections in a Respiratory Intensive Care Unit (RICU) of a tertiary care institute in northern India. Prospective, observational clinical study. The study included 201 patients (1285 patient days) admitted to RICU over a period of one-and-a-half years. A total of 77 infections were identified in 67 patients (33.5%). The infections included pneumonia (23%), sepsis of unknown origin (10.5%), bacteremia (7.5%), urinary tract infections (1.5%), catheter related blood stream infections (1%) and Clostridium difficile colitis (1%). The most commonly identified organisms were the Acinetobacter species (34.8%), Pseudomonas aeruginosa (23.9%) and Escherichia coli (15.2%). The median length of stay in patients with and without infection was 13 days (interquartile range, IQR, 28) and 4 days (interquartile range, IQR, 3), respectively (p<0.0001). Multivariate analysis showed the following risk factors for ICU-acquired infection: the admitting diagnosis of infection (odds ratio [OR] 3.3; 95% confidence intervals [CI] 1.06-10.1), length of stay in the RICU (OR, 1.2; 95% confidence intervals [CI] 1.1-1.33); renal failure (OR, 4.7; 95% CI, 1.52-14.41) and institution of parenteral nutrition (OR, 16.9; 95% CI, 1.07-269.03). Multivariate analysis showed the following risk factors for death in ICU: APACHE II scores (OR, 1.06; 95% CI, 1.01-1.11), and endotracheal intubation (OR, 5.07; 95% CI, 1.24-20.65). This study clearly documents a high prevalence rate of infections in the ICU, and the data suggest that occurrence of infections was associated with a prolonged ICU stay but had no significant effect on the final outcome.

PERCUTANEOUS CHOLECYSTOSTOMY IN THE MANAGEMENT OF ACUTE CHOLECYSTITIS

Percutaneous cholecystostomy (PC) has been used in managing acute cholecystitis in the setting of a patient with severe comorbidities where emergency cholecystectomy would carry significant mortality. The present study aims to assess the role, efficacy and complications of PC in acute cholecystitis. Retrospective review of case notes of patients who underwent PC at Box Hill Hospital, Melbourne, Australia between July 1997 and December 2002. Sixteen patients (mean age 75 years; range 50-96) underwent PC. Indications for PC were significant comorbidities (n = 6), failure of conservative treatment (n = 4), bile duct malignancy (n = 2), sepsis of unknown origin (n = 2), patient declined surgery (n = 1) and local perforation (n = 1). Technical success rate was 94%. Clinical response to PC was observed in 15 patients. Overall mortality was 18% (3/16) with one death caused by PC failure. Interval cholecystectomy was performed in seven patients (44%). Percutaneous cholecystostomy is a useful alternative means of treating non-resolving acute cholecystitis in circumstances where emergency surgery is hazardous. It also offers effective palliation in patients not suitable for subsequent surgery.

The use of laparoscopy in abdominal emergencies.

Background: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. Methods: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). Results: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. Conclusions: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

The use of radionuclide-labeled white blood cell scintigraphy and 67gallium scintigraphy in critically ill patients with sepsis

The usual diagnostic approach to patients with sepsis in an intensive care unit (ICU) or coronary care unit is based on clinical, biochemical, microbiologic and pathologic data and on radiologic imaging (radiograph, ultrasound and computed tomography), which are used to determine the most common sites of infection. In many cases, however, the site of infection is difficult to determine. Nuclear medicine provides various noninvasive scintigraphic methods for the imaging of focal sepsis, based on the intravenous administration of a radiotracer that accumulates at the site of infection or inflammation. The combined use of total body scintigraphy with ultrasound and computed tomography is considered a useful tool for the diagnosis of occult sepsis in ICU patients, and allows the targeting of aggressive measures against infections. The aim of this study is to evaluate the diagnostic value of technetium 99 m-white blood cell (99mTc-WBC)-labeled scintigraphy and gallium-67 citrate (67Ga) scintigraphy in the detection of focal sepsis in the ICU. We reviewed seven patients affected by sepsis of unknown origin. After the usual diagnostic approach, five patients were submitted to a total body scan using the 99mTc-WBC and two patients using 67Ga. The patients had complete clinical and instrumental data, but none of the radiological image detected the site of infection. The 99mTc-WBC scan showed typical patterns of increased tracer accumulation in six different sites. Four of these sites were studied histopathologically, confirming the infection: one case of left kidney abscess was associated with concomitant infection of the psoas muscle in the same patient, one frontoparietal osteomyelitis, and one acute cholecystitis. The other two sites corresponded to pulmonary accumulation of the tracer, which was interpreted as pneumonia. Of the two patients who underwent 67Ga scintigraphy, one had decubitus ulcerated infection associated with sacrum and left femoral osteomyelitis, and the other had clinical suspect of pulmonary vasculitis and diffuse pulmonary 67Ga accumulation.

Infectious complications in patients undergoing unrelated donor bone marrow transplantation: experience from a single institution

Objective To analyze the incidence and characteristics of documented infections in patients with hematologic malignancies undergoing unrelated donor bone marrow transplantation (UD-BMT).Methods We studied the occurrence of infections in 22 patients with hematologic malignancies or severe aplastic anemia who underwent UD-BMT from April 1990 to December 2000. The median age was 26 years (range 13-46). Acyclovir-ganciclovir, cotrimoxazole, fluconazole-nystatin and ciprofloxacin were administered for anti-infectious prophylaxis.Results We registered 61 infectious episodes. During the early post-transplant period, there were eight clinically documented infections (CDIs), four cases of fever of unknown origin (FUO), seven cases of bacteremia, two cases of cytomegalovirus (CMV) antigenemia, and one case of CMV disease. In the intermediate period (days 30-100 after BMT), there were nine cases of CMV antigenemia, three bacterial infections, two fungal infections, one case of disseminated toxoplasmosis, and one case of FUO. In the late period (day 100 and later), we documented 13 viral infections, eight bacterial infections, one CDI, and one case of invasive aspergillosis. Infections contributed to death in 10 of 17 patients. Citrobacter bacteremia and sepsis of unknown origin were the main causes of infectious mortality in the early period. Infection was the main cause of death in six of seven patients in the late period.Conclusion A high incidence of life-threatening infections and infection-related mortality was observed. A high rate of CMV infection in the early period, and death caused by multiresistant Gram-negative microorganisms in the late period, were the main findings in this series.

Impact of a rotating empiric antibiotic schedule on infectious mortality in an intensive care unit.

The development of antibiotic-resistant bacteria is associated with significant morbidity and mortality in critically ill patients. We postulated that quarterly rotation of empirical antibiotics could decrease infectious complications from resistant organisms in an intensive care unit (ICU). Prospective cohort study. An ICU at a university medical center. All patients admitted to the general, transplant, or trauma surgery services who developed pneumonia, peritonitis, or sepsis of unknown origin. A 2-yr study consisting of 1 yr of nonprotocol-driven antibiotic use and 1 yr of rotating empirical antibiotic assignment. Over 100 variables were recorded for each infectious episode, including patient characteristics (e.g., Acute Physiology and Chronic Health Evaluation [APACHE] II score, age, comorbidities), infection characteristics (e.g., site, organism), treatment characteristics (e.g., antibiotic, treatment duration) and outcome measures (e.g., mortality, length of stay, antibiotic cost). Of 1456 consecutive admissions to the ICU, 540 episodes of infection were treated. No differences were noted in age, APACHE II score, race, overall antibiotic utilization or duration of therapy between the 2 yrs of study. Outcome analysis revealed significant reductions in the incidence of antibiotic-resistant Gram-positive coccal infections (7.8 infections/100 admissions vs. 14.6 infections/100 admissions, p <.0001), antibiotic-resistant Gram-negative bacillary infections (2.5 infections/100 admissions vs. 7.7 infections/100 admissions, p <.0001), and mortality associated with infection (2.9 deaths/100 admissions vs. 9.6 deaths/100 admissions, p <.0001) during rotation. Logistic regression identified age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06), APACHE II score (OR, 1.06; 95% CI, 1.01-1.13), solid organ transplantation (OR, 9.50; 95% CI, 2.01-52.21), and malignancy (OR, 10.16; 95% CI, 4.11-26.96) as independent predictors of mortality. Antibiotic rotation was an independent predictor of survival (OR 6.27, 95% CI 2.78-14.16). Rotation of empirical antibiotic therapy seems to be a promising method to reduce infectious mortality in an ICU.