Epidemiological differences between sepsis syndrome with bacteremia and culture-negative sepsis

OBJECTIVE

To explore the association of putative disease markers and potential risk factors with the nosocomial sepsis syndrome.

DESIGN

Prospective case-control study matched for gender, age, and length of preinfection hospital stay.

SETTING

1,200-bed tertiary-care center in Spain.

PATIENTS

Cases were selected using the sepsis syndrome criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference and were divided into three groups: sepsis with bacteremia (109 cases), sepsis with positive culture other than blood (122 cases), and sepsis with negative culture (115 cases without documented infection but with sepsis syndrome, clinically suspected infection, and empirical antibiotic treatment). Controls were randomly selected from the daily list of inpatients. Data were collected prospectively. Crude and multiple-risk-factor-adjusted odds ratios and their 95% confidence intervals were computed using conditional logistic regression analysis.

RESULTS

Presence of coma in the 48 hours before sepsis, intensive care unit (ICU) stay, and decreased serum albumin levels at admission were common epidemiological markers identified for the three groups of cases. Having a central venous catheter was the main healthcare-related risk factor for bacteremia. ICU stay and nasogastric tube were the main risk factors for sepsis with positive culture other than blood. Coma within 48 hours before sepsis and the need of intensive care were the only two markers identified for culture-negative sepsis.

CONCLUSION

Culture-negative sepsis does not behave like culture-positive sepsis, and this may imply that implementation of preventive measures to decrease the risk of bacteremia may not decrease the risk of sepsis syndrome.

Prognostic factors for pneumococcal bacteremia in a university hospital

The records of adult patients with pneumococcal bacteremia who were seen over an 8-year-period at an 1,100-bed university teaching hospital were reviewed in order to revise the clinical and laboratory findings and to identify the risk factors associated with mortality. A total of 156 patients were studied, 101 men and 55 women. The mean age of the patients was 65 years. Eighty-seven percent of the patients had community-acquired bacteremia and 13% had nosocomial pneumococcal bacteremia. The overall mortality was 33.9% and the related mortality was 20.5%. The following factors were associated with an increased risk of adverse outcome in the univariate analysis: mechanical ventilation (risk ratio [RR]=3.40; 95% confidence interval [95% CI]=1.44-8.05), administration of parenteral nutrition (RR=3.40; 95% CI =1.44-8.05), and the presence of an intravenous catheter (RR=2.33; 95% CI=1.27-4.24). In the multivariate analysis, the independent prognostic factors for mortality were as follows: development of clinical complications during the episode of bacteremia, rapidly fatal illness, advanced age and administration of parenteral nutrition. The results suggest that the overall mortality due to pneumococcal bacteremia continues to be high. Four independent risk factors associated with increased mortality were identified. Prevention and immunization with polyvalent pneumococcal polysaccharide vaccine should be practiced more widely.

Osteomyelitis caused by Staphylococcus schleiferi and evidence of misidentification of this Staphylococcus species by an automated bacterial identification system

We report a case of sternal osteomyelitis due to Staphylococcus schleiferi in a patient who underwent thoracic surgery. This constitutes the first documented case of osteomyelitis caused by this Staphylococcus species. We also relate our experience in the utilization of commercially available MicroScan panels for the identification of this microorganism.

Analysis of risk factors for nosocomial sepsis in surgical patients

BACKGROUND

This study aimed to identify patients at high risk for developing sepsis following surgery according to criteria determined by the American College of Chest Physicians and the Society of Critical Care Medicine Consensus Conference on sepsis.

METHODS

A prospective case-control study was performed in surgical patients in a tertiary care centre over 1 year. Patients were identified by a daily prospective surveillance. Controls were selected randomly from the daily list of surgical inpatients. Data were collected prospectively. Crude and adjusted odds ratios (ORs) and their 95 per cent confidence intervals were computed using logistic regression analysis.

RESULTS

During follow-up, 99 cases and 99 controls were identified. The main risk factors for sepsis found in the multivariate analysis were coma within 48 h before sepsis (OR 13.5, 95 per cent confidence interval 3.6-50.8), low serum albumin level at admission (OR 15.8, 5.4-46.4), two or more intrinsic co-morbidities (OR 11.8, 2.8-49.4) and parenteral nutrition (OR 5.1, 1.5-17.1). Emergency surgery (OR 3.0, 1.4-6.4), abdominal surgery (OR 2.6, 1.0-6.8) and number of surgical interventions (OR 2.5, 1. 1-6.1) were the variables related to surgery that significantly increased the risk of sepsis. Both the study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance indices showed a statistically significant trend with sepsis.

CONCLUSION

Patient-related factors appear to represent the greatest risk for developing postoperative nosocomial sepsis, rather than factors associated with the surgery.

Talc granulomatosis. A differential diagnosis of interstitial lung disease in HIV patients

Consumers of adulterated drugs may present with talc-induced interstitial lung disease. A transbronchial biopsy specimen showing granulomas with intracellular talc crystals is necessary to confirm this diagnosis. In patients infected with HIV, such a condition can be indistinguishable at first glance from opportunistic infections or other pulmonary diseases. A case is presented of a seropositive patient whose chest radiographs showed a diffuse interstitial pattern.

Evaluation of the Duke criteria in 93 episodes of prosthetic valve endocarditis: could sensitivity be improved?

BACKGROUND

Since publication of the Duke criteria for diagnosing endocarditis, several articles have confirmed their sensitivity when native and prosthetic valves are considered together.

OBJECTIVES

To compare the differences between the older von Reyn criteria and the Duke criteria in prosthetic valve endocarditis only, and to determine if the latter's sensitivity could be improved by adding 2 minor criteria: new-onset heart failure and presence of conduction disturbances.

METHODS

We retrospectively evaluated 93 episodes of prosthetic valve endocarditis from January 1986 to January 1998 in a teaching hospital, and then analyzed the 76 surgically confirmed episodes to compare the differences between the von Reyn and Duke diagnostic criteria.

RESULTS

The von Reyn criteria rejected the diagnosis in 16 of the confirmed episodes, compared with 1 diagnosis missed by the Duke criteria and 1 missed using our suggested modifications. Definite diagnosis (Duke) was established in 60 episodes, compared with a diagnosis of probable (von Reyn) in 36 episodes (P<.001). Our modifications improved the sensitivity of the Duke criteria, diagnosing 70 episodes as definite (P = .02).

CONCLUSIONS

As was the case with native valve endocarditis, the Duke criteria proved to be more sensitive than the von Reyn criteria in prosthetic valve endocarditis. The addition of 2 minor criteria (new-onset heart failure and presence of conduction disturbances) could improve the diagnostic sensitivity of the Duke criteria.

[Clinico-epidemiologic manifestations of progressive multifocal leukoencephalopathy in patients with acquired immunodeficiency syndrome (AIDS)]

BASIS

Severely immunosuppressed patients, including those with AIDS in advanced stage, can suffer opportunistic infections, between them PML. The purpose of this study is to determine epidemiological, clinical and neuroradiological parameters of HIV infected patients diagnosed of PML.

METHOD

Retrospective review of clinical histories and clinical as well as radiological characteristics, of seven patients diagnosed of AIDS and PML in the Infectious Diseases Unit of our center between January 1990 and December 1997.

RESULTS

Seven patients out of 1093 HIV infected patients were diagnosed of PML (0.76%). All of them were male, intravenous drug users, with a mean age of 32.1 years. Five patients were diagnosed before 1994. In four cases PML was the first opportunistic infection. The mean survival time was 119 +/- 82.2 days (27-231 days). At the moment of diagnosis four patients (57.1%) showed cerebellar symptoms, three (42.8%) sensory deficits and two (28.5%) cognitive dysfunction. There were multiple neurological symptoms in five cases. The mean CD4 cell count was 63.4 cells/mm3. None of the patients showed other concomitant opportunistic infections neither disturbances of cerebrospinal fluid (CSF). CT and NMR showed typical lesions in frontal lobe and cerebellum in four patients. Other affected areas were occipital and parietal lobe, basal ganglia and brain stem. The diagnosis of PML was established by clinical and neuroradiological criteria in six patients and by autopsy in one patient.

CONCLUSIONS

The diagnosis of PML in HIV infected patients can be made by clinical and neuroradiological criteria. In the last years, and probably due to the new antiretroviral agents, it has been observed a decrease of the PML incidence in these patients. Nevertheless its prognosis is still dreadful and at present there is no specific curative treatment.

Xanthogranulomatous cholecystitis: clinical, sonographic, and CT findings in 26 patients

OBJECTIVE

The purpose of our study was to evaluate the sonographic and CT features of xanthogranulomatous cholecystitis, correlating the pathologic and surgical findings.

MATERIALS AND METHODS

Xanthogranulomatous cholecystitis was pathologically diagnosed in 26 patients from January 1996 to August 1998. The patients were 15 women and 11 men with a mean age of 63 years. All patients had preoperative sonography and nine also underwent CT In five patients, sonography was performed on the surgical specimen. Clinical indications for imaging included cholecystitis (14 patients), biliary colic (six patients), stone-induced pancreatitis (three patients), tumor (two patients), and gallstone ileus (one patient).

RESULTS

The most characteristic sonographic finding, confirmed by sonographic study of the surgical specimens, was the presence of hypoechoic nodules or bands in the gallbladder wall, which were seen in 35% of the patients. Cholelithiasis and a thickened gallbladder wall were frequent findings. The most characteristic (specific) CT finding was a hypodense band in the gallbladder wall, seen in 33% of the patients. Two of twelve patients who underwent laparoscopic cholecystectomy required conversion to open surgery.

CONCLUSION

Although the preoperative imaging diagnosis of xanthoganulomatous cholecystitis is difficult, the presence of hypoechoic nodules or bands in the gallbladder wall on sonography or of a hypodense band around the gallbladder on CT, is highly suggestive of this disease.

Thrice-weekly sulfadiazine-pyrimethamine for maintenance therapy of toxoplasmic encephalitis in HIV-infected patients. Spanish Toxoplasmosis Study Group

An open, randomised, multicentre trial was conducted to evaluate the efficacy of thrice-weekly versus daily therapy with sulfadiazine-pyrimethamine in the prevention of relapses of toxoplasmic encephalitis in HIV-infected patients. Between February 1994 and July 1997, 124 patients with HIV infection were enrolled after resolution of the first acute episode of toxoplasmic encephalitis treated with sulfadiazine-pyrimethamine. Patients were randomly assigned to receive either a daily regimen consisting of sulfadiazine (1 g) twice a day plus 25 mg pyrimethamine and 15 mg folinic acid daily (n = 58), or a thrice-weekly regimen consisting of the same doses of sulfadiazine and folinic acid plus 50 mg pyrimethamine (n = 66). After a median follow-up period of 11 months (range 1-39 months), no differences were found in the incidence of toxoplasmic encephalitis relapses between the groups, there being 14.9 episodes per 100 patient-years (95% CI: 2.8-20.2) in the daily-regimen group versus 14.1 episodes (95% CI: 2.3-17.2) in the intermittent-regimen group. The estimated cumulative percentages of relapse at 12 months were 17% and 19%, respectively (P = 0.91). In a Cox multivariate analysis, not taking antiretroviral therapy was the only variable independently associated with relapse (adjusted risk ratio: 4.08; 95%CI: 1.32-12.66). Baseline CD4+ cell counts, prior AIDS, mental status, sequelae and allocated maintenance therapy regimen were not independent predictors of relapse. No differences were observed in the survival rate (P = 0.42), or in the incidence of severe adverse effects (P = 0.79). The efficacy of the thrice-weekly regimen was similar to that of the daily regimen in the prevention of relapses of toxoplasmic encephalitis. Administration of antiretroviral therapy was the only factor associated with a lower incidence of relapse.

Laparoscopic cholecystectomy: analysis of risk factors for predicting conversion to open cholecystectomy

AIM

to assess the usefulness of different clinical and ultrasound parameters to identify patients at high risk of conversion from laparoscopic to open cholecystectomy.

METHODS

we retrospectively reviewed the clinical records and preoperative ultrasonographic images of 80 patients who underwent laparoscopic cholecystectomy.

RESULTS

eight clinical and nine ultrasound parameters were assessed. Our statistical analysis showed that ultrasound imaging indicated two risk factors for conversion from laparoscopic to open cholecystectomy: a scleroatrophic gallbladder and dilation of the intrahepatic biliary ducts. A gallbladder wall thicker than 6 mm was also considered a risk factor, although this difference was not statistically significant.

CONCLUSIONS

our results suggest that preoperative ultrasonography is useful in selecting patients who are highly likely to require conversion from laparoscopic to open surgery.

Endocarditis due to Acinetobacter lwoffi on native mitral valve

Endocarditis due to Acinetobacter is a rare pathology with high mortality, reported mainly in hospitalized patients with predisposing risk factors. This is the second case of endocarditis due to Acinetobacter reported in our country in the last 10 years.

[Domiciliary intravenous antibiotic therapy]

BACKGROUND

To assess the efficiency and safety of intravenous antibiotic therapy (IAT) when performed through the traditional simple infusion system by gravity in the home setting.

PATIENTS AND METHODS

The clinical records of patients undergoing intravenous antibiotic therapy through the traditional gravitational infusion system in the home care unit over a five year period were reviewed retrospectively.

RESULTS

120 patients were treated (44 F/76 M), with a mean age of 48 years (44-52). 67% of the total had chronic diseases. Infections were most commonly found in bones and joints (38%), followed by the skin and soft tissues. A wide variety of antibiotics was used, 61% as monotherapy. 76% of them were given intermittently. 161 intravenous catheters were used, 53% of which were central catheters with peripheral insertion, 27% inserted centrally and 20% peripheral catheters. The overall incidence of phlebitis was 18% without associated bacteremia. 91% of our patients evolved well, 6% had to become in-patients, none of them due to problems with the infusion system or by their own petition. The intravenous treatment lasted a mean of 17 days at home and 25 days at both home and hospital, which represents a decrease of 2,040 hospital stays.

CONCLUSIONS

The traditional gravitational system of infusion is an effective and safe method for intravenous antibiotic administration at home. For these therapies to be successful, suitable patients must be selected and continuous attention is required. This treatment at home satisfies the patient and permits hospital stays to be reduced, thus improving the use of hospital resources.

Suppurative mediastinitis after open-heart surgery: a case-control study covering a seven-year period in Santander, Spain

Suppurative mediastinitis developed in 34 (0.9%) of 3,645 patients who underwent median sternotomy at the Hospital Marqués de Valdecilla in Santander, Spain, from 1985 through 1991. These cases were analyzed in a case-control study designed to identify risk factors for poststernotomy mediastinitis. The significant risk factors were (1) preoperative factors: heavy cigarette smoking and history of endocarditis; (2) intraoperative factors: emergency surgery, prolonged duration of surgery, prolonged bypass pump time, ventricular failure, and tearing of the aortic or femoral artery; and (3) postoperative factors: reoperation, prolonged mechanical ventilation, prolonged stay in the intensive-care unit, and tracheostomy. All patients had abnormal sternal wounds (i.e., signs of wound infection or serous discharge). Twelve patients were bacteremic. Thirty-eight organisms were recovered from 31 patients with mediastinitis; 23 of the isolates were gram-positive and 15 were gram-negative. The infections were treated with extensive debridement and appropriate antibiotics. Mortality was 35%. Chronic sternal osteomyelitis was documented in two cases.

Renal failure due to sulphadiazine in AIDS patients with cerebral toxoplasmosis

Cerebral toxoplasmosis is optimally treated with the combination of high doses of sulphadiazine and pyrimethamine. We described two patients with AIDS treated for cerebral toxoplasmosis who developed renal failure due to sulphadiazine-induced crystalluria. Symptoms and renal failure were rapidly reversed with urine alkalinization and hydration. A careful monitoring and adequate hydration of patients with AIDS treated with high doses of sulphadiazine appears mandatory to avoid this complication.

[An analysis of 100 consecutive tuberculosis cases in HIV-infected patients in a hospital in Cantabria]

In our setting, patients infected by human immunodeficiency virus (HIV) show a high rate of tuberculosis infections which manifestations depend on the level of immunodeficiency reached.

METHOD

Clinical, radiological and evolutive characteristics are discussed of 100 diagnosed tuberculosis in seropositive patients during a time span of 52 months, relating them to the number of CD4 detected.

RESULTS

Tuberculosis pulmonary forms (65%) were more frequent than extra-pulmonary ones (35%) even in the advanced phases of the disease due to HIV, even tough the latter tend to cluster in patients with less than 200 CD1/mm. An unspecific febrile syndrome, normal results on simple radiological exploration and the difficulty to obtain diagnostic samples are facts which often delay the diagnosis.

CONCLUSION

Even tough the extra-pulmonary forms are more frequent in the last stages of the disease due to HIV, in our setting there is still a high incidence of pulmonary forms in all stages.

Treatment of cerebral aspergillosis after liver transplantation

We report the treatment of cerebral aspergillosis with amphotericin B, flucytosine, surgery, and liposomal amphotericin B (L-AmB) after a liver transplant. The patient died 2 months after cessation of antifungal therapy, as a consequence of multiple-system organ failure. The only relevant postmortem finding in the brain was a small, encapsulated abscess containing hyphae. This case indicates that L-AmB is an effective alternative drug for cerebral aspergillosis.

Contribution of monocytes to the decreased lymphoproliferative response to phytohemagglutinin in patients with lung cancer

Patients with lung cancer (LC) have a reduced T-cell proliferative response to phytohemagglutinin (PHA) compared with that of healthy individuals. This decreased response is a result of an inhibitory effect exerted by the monocytes as evidenced by: (1) a restoration to normal levels of the response to PHA when the peripheral blood mononuclear cells were depleted of adherent cells (AD) and (2) a dose-dependent inhibition of the response to PHA when the nonadherent cell population was co-cultured with increasing numbers of autologous AD cells. The addition of indomethacin to the cultures resulted in only a partial restoration of the response to PHA. Monocyte production of interleukin-1 from patients with LC in response to lipopolysaccharide was normal. These findings support the hypothesis that the AD cell population plays a major role in the low T-cell proliferative response to PHA in patients with LC. This suppressor effect is partially mediated by the prostaglandins released by the monocytes.

B cell infiltration of the thymic medulla in New Zealand black, New Zealand white, and (New Zealand black x New Zealand white)F1 mice. Effect of total lymphoid irradiation

Thymuses from female (New Zealand black x New Zealand white)F1 [( NZB x NZW]F1), New Zealand black, and New Zealand white mice of different ages were examined by immunohistochemical and flow cytometric analysis. Two-and-a-half-month-old (NZB x NZW)F1 mice showed infiltration of the thymus with B cells, and by 6-8 months of age, showed a disruption of the entire medullary area. More than 80% of the thymic B cells had the phenotypic characteristics of conventional B cells (IgM+, IgD+, Ly-1-). Total lymphoid irradiation induced a marked depletion of medullary B cells and a restoration of the thymic architecture.