Prevention and management of infectious complications of percutaneous interventions

Endoscopic approach for biliopancreatic disease after pancreaticoduodenectomy: a 10-year single-center experience

BACKGROUND AND AIM

In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging, and it remains debatable the choice of the optimal endoscopic approach within this context. We aim to show our experience and evaluate the technical and clinical success of endoscopic treatment performed in the setting of adverse events (AE) after pancreaticoduodenectomy (PD).

METHODS

This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Endoscopy Unit. Clinical, instrumental data, and characteristics of endoscopic treatments were collected.

RESULTS

133 patients were included (80 M, mean age = 65 y.o.) with a total of 296 endoscopic procedures (median = 2 procedures/treatment). The indications for ERCP were mainly biliary AE (76 cases, 57.1%). Technical success was obtained in 121 patients of 133 (90.9%). 112 out of 133 (84.2%) obtained clinical success. Nine patients out of 112 (8%) experienced AEs. Clinical success rates were statistically different between patients with biliary or pancreatic disease (93.4% vs 73.6%, p < 0.0001). Septic patients were 38 (28.6%) and showed a worse prognosis than non-septic ones (clinical success: 65.7% vs 91.5%, p = 0.0001). During follow-up, 9 patients (8%), experienced recurrence of the index biliopancreatic disease with a median onset at 20 months (IQR 6-40.1).

CONCLUSION

Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients with AEs after PD is both safe and effective in treating the condition, even in a long-term follow-up.

Predicting Infectious Complications after Percutaneous Thermal Ablation of Liver Malignancies: A 12-year Single-Center Experience

Background Infectious complications after percutaneous thermal ablation are seldom discussed, but better understanding of risk factors and early prediction is critical. Purpose To estimate the incidence of infectious complications after percutaneous thermal ablation of liver malignancies and to develop prediction models. Materials and Methods This single-center retrospective study reviewed the data of 3167 patients who underwent 7545 percutaneous US-guided thermal ablation procedures of liver malignancies between January 2010 and January 2022. All procedures with infectious complications were included as the case group. For each case, one treatment date-matched control subject without infection was randomly selected following a nested case-control design. Independent factors of overall and hepatobiliary infection were investigated with multivariable logistic regression. Results A total of 80 patients (median age, 59 years; IQR, 51-68 years; 64 men, 16 women) developed infectious complications after 80 ablation procedures; the incidence was 1.1% (80 of 7545 procedures). Of those with infection, 18% (14 of 80 patients) were severe, and 10% (eight of 80 patients) died as a result. Independent risk factors for overall infectious complication included prior biliary intervention (odds ratio [OR], 18.6; 95% CI: 4, 86; P < .001), prior transarterial chemoembolization (TACE) (OR, 2.4; 95% CI: 1.0, 5.8; P = .045), and the largest tumor size (OR, 1.9; 95% CI: 1.3, 2.8; P = .002); on this basis, subcapsular location was an additional risk factor of hepatobiliary infection. Prediction models for overall and hepatobiliary infection had an area under the receiver operating characteristics curve (AUC) of 0.77 and 0.82, respectively, both of which showed better AUC compared with the models, including prior biliary intervention alone (AUC = 0.63 and 0.65, respectively; P = .01 and P = .005, respectively). Conclusion Infectious complications after percutaneous thermal ablation of liver malignancies were uncommon but potentially fatal. Independent predictors were prior biliary intervention, prior transarterial chemoembolization, and the largest tumor size. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Ben-Arie and Sosna in this issue.

Knowledge of Medical Imaging Professionals on Healthcare-Associated Infections: A Systematic Review and Meta-Analysis

Healthcare-associated infections (HCAIs) are a significant concern for both healthcare professionals and patients. With recent advances in imaging modalities, there is an increase in patients visiting the radiology department for diagnosis and therapeutic examination. The equipment used for the investigator is contaminated, which may result in HCAIs to the patients and healthcare professionals. Medical imaging professionals (MIPs) should have adequate knowledge to overcome the spread of infection in the radiology department. This systematic review aimed to examine the literature on the knowledge and precaution standard of MIPs on HCIAs. This study was performed with a relative keyword using PRISMA guidelines. The articles were retrieved from 2000 to 2022 using Scopus, PubMed, and ProQuest databases. The NICE public health guidance manual was used to assess the quality of the full-length article. The search yielded 262 articles, of which Scopus published 13 articles, PubMed published 179 articles, and ProQuest published 55 articles. In the present review, out of 262 articles, only 5 fulfilled the criteria that reported MIPs' knowledge of Jordan, Egypt, Sri Lanka, France, and Malawi populations. The present review reported that MIPs have moderate knowledge and precautionary standards regarding HCIAs in the radiology department. However, due to the limited studies published in the literature, the current review limits the application of the outcome in the vast MIPs population. This review recommended further studies to be conducted among the MIPs worldwide to know the actual knowledge and precaution standards regarding HCIAs.

Antibiotics Tubes and Lines

Antibiotic prophylaxis in interventional radiology (IR) is widely used; however, such practice is based on data from the surgical literature. Although published guidelines can help determine the need for prophylactic antibiotic use in the patient undergoing percutaneous procedures, local practice patterns often dictate when such medications are given. In this article, the current state of periprocedural antibiotic use in commonly performed IR procedures (i.e., tube and catheter placements) is presented.

A review on treatments of hepatocellular carcinoma—role of radio wave ablation and possible improvements

Background

Currently, several treatment options are available for liver cancer depending on various factors such as location, size, shape, and liver function. Image fusion is required for the diagnosis, intervention, and follow-up of certain HCCs. Presently, mental fusion is the only way while diagnosing liver lesions by comparing the ultrasound (US) image with the computed tomography (CT) image. Nevertheless, mental fusion is bound to have errors. The objective of this paper is to study the present treatment options for hepatocellular carcinoma and review the present treatment options, list out their potential limitations, and present a possible alternative solution based on the findings to reduce errors and mistargeting.

Methods

This is a systematic review on the present treatment options for hepatocellular carcinoma, especially radio wave ablation.

Results

It is found that computer fusion is the possible alternative to the present mental registration.

Conclusions

Although computer fusion is the best alternative to use radio wave ablation, there have been a few open-ended questions to further explore.

Renal actinomycosis with muscular invasion post-nephrostomy tube placement

Perinephric abscesses are a rare complication of nephrostomy tube placement. There are several aerobic bacteria that are common culprits of abscess formation. Here we describe a novel report of a perinephric abscess due to Actinomyces odontolyticus. We describe the presentation of illness, imaging and clinical findings, and the prolonged treatment course needed for this medically complex patient.

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Actinomyces odontolyticus can cause formation of peri-nephric abscesses.

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Actinomyces odontolyticus can cause extensive muscular invasion into retroperitoneal space.

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Actinomyces ability to colonize urogenital epithelium allows for invasion of damaged epithelium into the peri-renal space.

Healthcare-associated urinary tract infections in urology

The purpose of the present review is to report the incidence and characteristics of healthcare-associated urinary tract infections (HAUTIs) in urology with their microbiological and resistance patterns. Urinary tract infections are the main type of healthcare-associated infection in patients hospitalized in a urology ward. Patients admitted to urology departments report a high prevalence of urinary tract catheterization, up to 75% during the hospitalization period, and up to 20% had a urinary catheter before admission. An endourological surgical procedure is another risk factor for HAUTIs. Other risk factors for HAUTIs are the presence of immunosuppression and previous urinary tract infections.

In urological patients, Enterobacterales are the principal causative agent of HAUTIs, and E. coli is the most frequently isolated microorganism. However, there is also a high rate of microorganisms other than E. coli such as Klebsiella spp. and Enterococcus spp. Non-E. coli microorganisms show a higher prevalence in immunosuppressed patients and those with urinary catheters before admission. High resistance patterns are reported in patients with HAUTIs, and ESBL-producing bacteria are frequently described. Moreover, the isolation of multidrug-resistant microorganisms is more common in immunosuppressed patients, those with previous urinary tract infections, and urinary catheters into the upper urinary tract. Treatment must be tailored according to patient characteristics and patient profiles, bearing in mind the ORENUC classification for risk factors (no risk factors (O), recurrent urinary tract infections risk factors (R), extraurogenital risk factors (E), nephropathic disease (N), urological risk factors (U), permanent urinary catheter and non-resolvable urological risk factors (C)).

Radiation segmentectomy of hepatic metastases with Y-90 glass microspheres

PURPOSE

To evaluate safety and efficacy of radiation segmentectomy (RS) with ⁹⁰Y glass microspheres in patients with limited metastatic liver disease not amenable to resection or percutaneous ablation.

METHODS

Patients with ≤ 3 tumors treated with RS from 6/2015 to 12/2017 were included. Target tumor radiation dose was > 190 Gy based on medical internal radiation dose (MIRD) dosimetry. Tumor response, local tumor progression (LTP), LTP-free survival (LTPFS) and disease progression rate in the treated segment were defined using Choi and RECIST 1.1 criteria. Toxicities were evaluated using modified SIR criteria.

RESULTS

Ten patients with 14 tumors underwent 12 RS. Median tumor size was 3 cm (range 1.4-5.6). Median follow-up was 17.8 months (range 1.6-37.3). Response rates per Choi and RECIST 1.1 criteria were 8/8 (100%) and 4/9 (44%), respectively. Overall LTP rate was 3/14 (21%) during the study period. One-, two- and three-year LTPFS was 83%, 83% and 69%, respectively. Median LTPFS was not reached. Disease progression rate in the treated segment was 6/18 (33%). Median overall survival was 41.5 months (IQR 16.7-41.5). Median delivered tumor radiation dose was 293 Gy (range 163-1303). One major complication was recorded in a patient post-Whipple procedure who suffered anaphylactic reaction to prophylactic cefotetan and liver abscess in RS region 6.5 months post-RS. All patients were alive on last follow-up.

CONCLUSION

RS of ≤ 3 hepatic segments can safely provide a 2-year local tumor control rate of 83% in selected patients with limited metastatic liver disease and limited treatment options. Optimal dosimetry methodology requires further investigation.

Incidence of Cholangitis and Sepsis Associated with Percutaneous Transhepatic Cholangiography in Pediatric Liver Transplant Recipients

Background. Percutaneous transhepatic cholangiography (PTC) is an established treatment in the management of biliary strictures. The aim of our study was to determine the incidence of PTC-related infectious complications in transplanted children, and identify their precise aetiol-ogy. Methods. We retrospectively reviewed all PTC performed from January 2017 to October 2020 in our center. Before the procedure, all patients received antibiotic prophylaxis defined as first line, while second line was used in case of previously microbiological isolation. Cholangitis was defined as fever (>38.5°) and elevated inflammatory markers after PTC, while sepsis included hemodynamic instability in addition to cholangitis. Results. One hundred and fifty-seven PTCs from 50 pediatric recipients were included. The overall incidence of cholangitis and sepsis after PTC was 44.6% (70/157) and 3.2% (5/157), respectively, with no fatal events. Blood cultures yielded positive results in 15/70 cases (21.4%). Enterococcus faecium and Pseudomonas aeruginosa were the most common isolated pathogens. Multidrug-resistant (MDR) pathogens were found in 11/50 patients (22%). Conclusion. PTC is associated with a relatively high rate of post-procedural cholangitis, although with low rate of sepsis and no fatal events. Blood cultures allowed to find a precise aetiology in roughly a quarter of the cases, showing prevalence of Enterococcus faecium and Pseudomonas aeruginosa.

Infection Rates Following Hepatic Embolotherapy in Patients with Prior Biliary Interventions: Comparison of Single-Drug Moxifloxacin and Multidrug Antibiotic Prophylaxis

PURPOSE

To investigate the incidence of infection in patients with prior biliary interventions undergoing hepatic embolotherapy following extended antibiotic prophylaxis using moxifloxacin monotherapy or a multidrug regimen.

MATERIAL AND METHODS

Under an Institutional Review Board-approved protocol, retrospective review of a quality assurance database identified all liver-directed therapies (LDTs) at a tertiary care center between 2010 and 2019 with biliary intervention prior to LDT Records were reviewed for infectious complications within 3 months of chemo- or radioembolization. Patients were categorized based on extended antibiotic prophylaxis regimen: oral moxifloxacin monotherapy or multidrug regimen of levofloxacin and metroniodazole plus preprocedural neomycin and erythromycin. Procedures without at least 2 months of clinical follow-up, hepatic ablation, and procedures without extended antibiotic prophylaxis were excluded Regression analysis was used to analyze multivariate data to detect a difference in infection rate.

RESULTS

Twenty-four chemoembolization and 58 radioembolization procedures were performed on 55 patients with prior biliary interventions. Forty-four used monotherapy and 38 used multidrug regimen. The incidence of infection was 16.7% (4/24) after chemoembolization and 13.8% (8/58) after radioembolization The incidence of infection in patients did not differ between antibiotic prophylaxis regimens (18.2% [8/44] with moxifloxacin monotherapy and 10.5% [4/38] multidrug regimen, P = .3) or between types of biliary interventions (24.1% [7/29] with bilioenteric anastomosis and 23.8% [5/21] biliary stenting, P = .3).

CONCLUSIONS

The types of extended antibiotic prophylaxis (moxifloxacin monotherapy vs multitherapy), prior biliary intervention, and embolotherapy were not found to be associated with differences in the incidence of infectious complications in this population.

Adherence to Antibiotic Prophylaxis for Percutaneous Transhepatic Cholangiography: A Single-Centre Experience

Background

Percutaneous transhepatic cholangiography (PTC) is associated with high rates of sepsis. The aim of the current study was to audit the adherence to trust guidelines on antibiotic prophylaxis in patients undergoing PTC. Secondary aims included the management and outcome of patients with sepsis post-procedure.

Methods

This was a retrospective analysis of 50 consecutive patients who underwent a PTC procedure between January 2016 to January 2017. Collated data included PTC indication, drug allergies, antibiotics given pre-PTC, culture results, and antibiotic sensitivities within one-month post-PTC.

Results

Complete data were available for 41 patients and 61 PTC procedures. The median age was 68 years, and 51% were females. The indication for PTC was malignancy (n=32, 78%), benign conditions (n=1, 2%), and unknown diagnosis at the time of PTC (n=8, 20%). Three cases did not receive antibiotic prophylaxis. Only 27 (44%) PTC procedures received appropriate pre-PTC antibiotics as per guidelines, with no adherence to guidelines in all penicillin-allergic patients. In six patients who were not being treated for sepsis pre-PTC, a newly positive post-PTC blood/drain culture was observed within one month. Organisms grown in the post-PTC cultures were 56% gram-negative, the majority being Escherichia coli. The 30-day mortality rate was 12.2% (5/41).

Conclusions

Poor adherence to recommended antibiotic regimes is a significant contributing factor for sepsis post-PTC. Investigating barriers to guideline implementation, stricter adherence, and peer education are interventions that could improve post-PTC outcomes.

Health Care-Associated Infections and the Radiology Department

Health care-associated infections (HCAIs) are a significant concern for both health care workers (HCWs) and patients. They are a major contributing factor of disease in industrialized countries, and are responsible for significant morbidity, mortality, and a direct annual financial loss of $6-7 billion in North America alone. They are an increasingly challenging health issue due to multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci among others, along with an increasing number of susceptible patients. Over the last three decades, the risk of HCAIs has increased in the radiology department (RD) in part because of an increased number of patients visiting the department and an increase in the utilization of imaging modalities. In this review, we will discuss how patients and staff can be exposed to HCAIs in the RD, including contaminated inanimate surfaces, radiology equipment, and associated medical devices. As the role of medical imaging has extended from primarily diagnosis to include more interventions, the implementation and development of standardized infection minimization protocols and infection control procedures are vital in the RD, particularly in interventional radiology. With globalisation and the rapid movement of people regionally, nationally, and globally, there is greater risk of exposure to contagious diseases such as Ebola, especially if infected patients are undiagnosed when they travel. For effective infection control, advanced training and education of HCWs in the RD is essential. The purpose of this article is to provide an overview of HCAIs as related to activities of the RD. We will discuss the following major topics including the variety of HCAIs commonly encountered, the role of the RD in HCAIs, transmission of infections to patients and HCWs in the RD, standard infection prevention measures, and the management of susceptible/infected patients in the RD. We shall also examine the role of, and the preparedness of, HCWs, including RD technologists and interventional radiologists, who may be exposed to undiagnosed, yet infected patients. We shall conclude with a brief discussion of the role of further research related to HCAIs. Learning Objectives After the completion of this review article, the readers will • Understand the exposure and role of radiology department in health care-associated infections, • Know the causes/modes/transmission of infections in radiology department, • Be conscious of standard disinfection protocols, • Be aware of current and future strategies required for the effective control of health care-associated infection in the radiology department. This is a CME article and provides the equivalent of 2 hours of continuing education that may be applied to your professional development credit system. A 10-question multiple-choice quiz follows this reading. Please note that no formalized credit (category A) is available from CAMRT.

[Percutaneous endoscopic gastrostomy]

Percutaneous endoscopic gastrostomy (PEG) was developed in 1980. Since that time this method has become preferable for long-term enteral nutrition. PEG is an effective and relatively safe procedure for enteral nutrition of patients with impaired enteral feeding. However, complications and mortality are also observed. Indications, contraindications and potential complications of PEG are reviewed in the article.

Infections in Cancer Patients with Solid Tumors: A Review

Solid tumors are much more common than hematologic malignancies. Although severe and prolonged neutropenia is uncommon, several factors increase the risk of infection in patients with solid tumors, and the presence of multiple risk factors in the same patient is not uncommon. These include obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces, and treatment-related factors such as chemotherapy, radiation, diagnostic and/or therapeutic surgical procedures, and the increasing use of medical devices such as various catheters, stents, and prostheses. Common sites of infection include the skin and skin structures (including surgical site infections), the bloodstream (including infections associated with central venous catheters), the lungs, the hepato-biliary and intestinal tracts, and the urinary tract, and include distinct clinical syndromes such as post-obstructive pneumonia, obstructive uropathy, and neutropenic enterocolitis. The epidemiology of most of these infections is changing with resistant organisms [MRSA, Pseudomonas aeruginosa, extended spectrum beta-lactamase (ESBL)-producing organisms] being isolated more often than in the past. Polymicrobial infections now predominate when deep tissue sites are involved. Conservative management of most of these infections (antibiotics, fluid and electrolyte replacement, bowel rest when needed) is generally effective, with surgical intervention being reserved for the drainage of deep abscesses, or to deal with complications such as intestinal obstruction or hemorrhage. Infected prostheses often need to be removed. Reactivation of certain viral infections (HBV, HCV, and occasionally CMV) has become an important issue, and screening, prevention and treatment strategies are being developed. Infection prevention, infection control, and antimicrobial stewardship are important strategies in the overall management of infections in patients with solid tumors. Occasionally, infections mimic solid tumors and cause diagnostic and therapeutic challenges.