Nutritional Therapy in Liver Transplantation

Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation.

Secular Trends of Candidemia in a Large Tertiary-Care Hospital From 1988 to 2000: Emergence ofCandida parapsilosis

Objective:

To analyze the secular trends of candidemia in a large tertiary-care hospital to determine the overall incidence, as well as the incidence by ward and by species, and to detect the occurrence of outbreaks.

Design:

Retrospective descriptive analysis. Secular trends were calculated using the Mantel-Haenszel test.

Setting:

A large tertiary-care referral center in Spain with a pediatric intensive care unit (ICU) to which more than 500 children with congenital cardiac disease are admitted annually.

Patients:

All patients with candidemia occurring from 1988 to 2000 were included. Cases were identified from laboratory records of blood cultures.

Results:

There were 331 episodes of candidemia. The overall incidence of nosocomial candidemia was 0.6 episode per 1,000 admissions and remained stable throughout the study period (P= .925). The species most frequently isolated wasCandida albicans, but the incidence ofC. parapsilosiscandidemia increased (P= .035). In the pediatric ICU, the incidence ofC. parapsilosiswas 5.6 episodes per 1,000 admissions and it was the predominant species. Outbreaks occurred occasionally in the pediatric ICU, suggesting nosocomial transmission.

Conclusions:

During this 13-year period, the incidence of candidemia remained stable in this hospital, butC. parapsilosisincreased in frequency. Occasional outbreaks of candidemia suggested nosocomial transmission ofCandidaspecies (Infect Control Hosp Epidemiol2005;26:548-552).

Candida guilliermondii fungemia in hospitalized patients epidemiologically linked to a patient care attendant

We investigated an outbreak of Candida guilliermondii fungemia with a fatality rate of 54% that occurred during a 19-month period among patients hospitalized in a tertiary care hospital. The hiring of an external care attendant during hospitalization was epidemiologically linked to case patients (100% vs 3% of the controls, P < .001). Subsequent investigation of the outbreak and disclosure of the findings were associated with an end to the epidemic.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Candida isolated from vaginal mucosa of mothers and oral mucosa of neonates: occurrence and biotypes concordance

BACKGROUND

The common occurrence of Candida spp. on the vaginal mucosa of pregnant women suggests this as the source of neonatal candidiasis.

METHODS

This study investigated the occurrence of yeasts on the vaginal mucosa of 100 mothers at the time of birth, and on the oral mucosa of their respective neonates, all full-term, on the 1st, 3rd, and 9th days after birth by vaginal (72 cases) and cesarean (28 cases) routes. In each case where concordance at the level of species was found between the isolate from the mother and that from the neonate, tests were made to check for concordance between the genotypic and phenotypic profiles (susceptibility to killer toxins, serotyping, proteinase and phospholipase production, and susceptibility to antifungal agents).

RESULTS

For the vaginal-route group, yeasts were recovered from the vaginal mucosa of 47.2% of the mothers and from 25% of the neonates. For the cesarean-route group, these rates were 46.4% and 3.6%, respectively. Species found most frequently in the samples from the mothers and the neonates were, respectively C. albicans and C. guilliermondii. For the vaginal-route group, the rate of mother/neonate concordance at the level of species was 23.5% and no cases of concordance for the cesarean births. Of these cases with species concordance, there was concordance between the genotypic and phenotypic profiles in 6% (2 cases).

CONCLUSION

The vaginal mucosa was not the main route of transmission of the Candida species to the neonate, because there was concordance between the genotypic and phenotypic profiles in only 6% (2 cases).

Hospital-acquired infections related to contaminated substances

Drug-related outbreaks are frequently reported from various medical departments. A systematic review was performed to describe characteristics of these outbreaks and to determine the most frequent occasions in which contamination of substances for patient care take place. Articles were assessed by a search of the outbreak database, a search of PubMed, and hand search of reference lists from relevant articles. Articles published before 1990 were excluded. Data on affected patients, hospital-acquired infections, substances, pathogens and graded information about the location of the contamination incidence were extracted. A total of 2250 patients in 128 articles were included, mostly from intensive care units or haematological departments. Septicaemia was the most frequent hospital-acquired infection. Most often articles report contamination of blood products and heparin-sodium chloride solutions. The most frequent pathogens were hepatitis A virus, Yersinia enterocolitica, and Serratia spp. for blood products and Burkholderia cepacia and Enterobacter spp. for substances other than blood products. Mortality was highest if red blood cells or total parenteral nutrition formulas were contaminated. In 64 of the outbreaks multi-dose vials had been used against the manufacturers' recommendations. Thus, drug-related outbreaks are likely to occur particularly when basic hygiene measures are disobeyed. A large proportion of drug-related nosocomial infections could have been prevented, for example, by avoiding the use of multi-dose vials.

An outbreak of candidemia due to Candida tropicalis in a neonatal intensive care unit

An outbreak of candidemia due to Candida tropicalis involving 16 neonates (gestational age 28-36 weeks) is reported. All infants had received hyperalimentation and at least one course of antibiotics. The commonest clinical manifestations included episodes of acute respiratory distress and lack of response to antibacterial antibiotic therapy. Candida tropicalis was recovered from blood in all the 16 infants and urine cultures were positive in 14 infants. Environmental sampling yielded C. tropicalis from one each of the blankets and mattresses used for neonates. Four of five urinary tract isolates and both environmental isolates genotyped by arbitrarily primed-PCR with several random primers were shown to belong to the same genotype.

Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use

Candida is an important nosocomial pathogen. This study was undertaken to provide information on the rate of candidaemia, to define the risks for candidaemia and to describe and account for the epidemiology of candidaemia at our institution between 1992 and 1999. The overall rate was 0.052 per 1000 patient days and 0.27 per 1000 discharges. The major risks for candidaemia were colonization at a non-sterile site (OR 3.85, 95%CI 1.80-9.09), total parenteral nutrition (TPN) in the absence of neutropenia (OR 11.8, 95%CI 4.5-35.4, P<0.001) and neutropenia in the absence of TPN (OR 3.7, 95%CI 1.8-7.7, P<0.001). There was no change in the overall incidence of candidaemia but there was a steady decline in the rate of C. albicans with a corresponding rise in the incidence of non- C. albicans species. C. krusei was highly associated with fluconazole exposure (chi(2)=20.78, P<0.001). There was no evidence of spread of C. krusei using random amplification of polymorphic DNA, suggesting the appearance of this organism was due to the selection pressure exerted by fluconazole.

Nosocomial Candida albicans acquisition in a geriatric unit: epidemiology and evidence for person-to-person transmission

This prospective study, which included 69 patients over a two-month period, was conducted to evaluate the incidence of community-acquired carriage and hospital-acquired yeasts in elderly patients hospitalized in a short stay care unit. Furthermore, possible person-to-person transmission was investigated by means of genotyping the Candida albicans isolates obtained from samples (throat swabs, urine and stools) systematically taken from the patients at different times during the hospitalization and from healthcare workers (throat swabs and handwashes) in the middle of the observation period. This study showed a high prevalence rate of 64% for community-acquired yeast carriage and a 40% incidence rate for hospital- acquired yeasts. Mycological analysis of the samples from the healthcare workers revealed eight of them to be colonized in the oral cavity. In addition, pulsed field gel electrophoresis and mitochondrial DNA analysis of the C. albicans isolates demonstrated person-to-person transmission. This study suggests that regular mycological sampling should be done as hospitalized elderly patients are frequently colonized by yeasts. Likewise, oropharyngeal swabs from healthcare workers may be helpful in this setting.

Elucidating the origins of nosocomial infections with Candida albicans by DNA fingerprinting with the complex probe Ca3

Computer-assisted DNA fingerprinting with the complex probe Ca3 has been used to analyze the relatedness of isolates collected from individuals with nosocomial bloodstream infections (BSIs) and hospital care workers (HCWs) in the surgical and neonatal intensive care units (ICUs) of four hospitals. The results demonstrate that for the majority of patients (90%), isolates collected from commensal sites before and after collection of a BSI isolate were highly similar or identical to the BSI isolate. In addition, the average similarity coefficient for BSI isolates was similar to that for unrelated control isolates. However, the cluster characteristics of BSI isolates in dendrograms generated for each hospital compared to those of unrelated control isolates in a dendrogram demonstrated a higher degree of clustering of the former. In addition, a higher degree of clustering was observed in mixed dendrograms for HCV isolates and BSI isolates for each of the four test hospitals. In most cases, HCW isolates from an ICU were collected after the related BSI isolate, but in a few cases, the reverse was true. Although the results demonstrate that single, dominant endemic strains are not responsible for nosocomial BSIs in neonatal ICUs and surgical ICUs, they suggest that multiple endemic strains may be responsible for a significant number of cases. The results also suggest that cross-contamination occurs between patients and HCWs and between HCWs in the same ICU and in different ICUs. The temporal sequence of isolation also suggests that in the majority of cases HCWs are contaminated by isolates from colonized patients, but in a significant minority, the reverse is true. The results of this study provide the framework for a strategy for more definitive testing of the origins of Candida albicans strains responsible for nosocomial infections.

Multilocus enzyme electrophoresis analysis of Candida albicans isolates from three intensive care units. An epidemiological study

To evaluate the mechanism and risk factor associated with the nosocomial acquisition of Candida albicans, a 3-month prospective study was conducted on non-neutropenic patients in three distinct intensive care units in distinct hospitals. A total of 43 samples from 19 patients has been typed by multilocus enzyme electrophoresis (MEE). Samples (24) from the deep pharynx of hospital staff members were also cultured and typed. Thirteen of the 19 enzyme loci studied were polymorphic. The 52 electrophoretic types were assigned to 67 isolates, each type was represented by one to five isolates; this proved the great diversity of the isolates. It appeared that most patients were colonized or infected with different C. albicans strains. This study pointed out a possible cross-infection between patients and hospital staff and between healthy members of the hospital staff, and also showed the successive stages of infection by different electrophoretic types. Intubation and respiratory equipment as surgery intervention were possible sources of observed infections.

Restriction fragment analysis of a Candida tropicalis outbreak of sternal wound infections

An apparent single-source outbreak of Candida tropicalis sternal wound infections in eight patients was investigated by utilizing DNA restriction fragment analysis (RFA) with HindIII and BstNI. All eight outbreak isolates appeared to be identical and were easily differentiated from control isolates by DNA RFA. Compared with an arbitrarily selected reference outbreak isolate, greater than or equal to 95% of the bands in the restriction digests identified by a computerized image analysis system from each of the outbreak isolates were identical versus 13 to 53% of the bands in any of the nine control isolates. Outbreak strains were significantly more likely to match the reference outbreak isolate than were controls (P less than 0.0001). The RFA was greatly facilitated by the use of computerized image analysis and confirmed the epidemiologic link between a scrub nurse and the infected patients.