C. perfringens Blood Stream Infection due to Nontransmural Ischemia of the Esophagus, Stomach, and Left Colon: Case Report

We report the case of a 74-year-old female with abdominal pain, tarry stools, and tachycardia. Previous history included diabetes mellitus with micro- and macroangiopathy. Imaging revealed portal gas, left sided colitis, and emphysematous gastritis, besides severe atherosclerosis with subtotal celiac trunk occlusion and moderate stenosis of the inferior mesenteric artery. Upper endoscopy revealed findings consistent with focal necrotizing gastritis at the greater curvature and acute esophageal necrosis. Blood cultures immediately grew Clostridium perfringens. The patient was treated with broad spectrum antibiotics and was discharged after 21 days in the hospital. This case demonstrates the rare coincident occurrence of nontransmural ischemia of the left colon, the esophagus, and the stomach as a result of low-flow circulatory compromise, which then precipitated C. perfringens associated emphysematous gastritis and blood stream infection.

No need for surgery? Patterns and outcomes of blunt abdominal trauma

Introduction

The management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM).

Materials and methods

Analysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury.

Results

Patients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001).

Conclusion

NOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.

Treatment of necrotizing pancreatitis: redefining the role of surgery

BACKGROUND

Early surgical intervention in necrotizing pancreatitis (NP) is associated with high mortality. Guidelines recommend fine needle aspiration (FNA) in patients with NP and signs of sepsis. Because infection of necrosis is considered an indication for surgery, operations are often performed early. We changed treatment toward a conservative approach with FNA in selected cases only, thereby reducing the rate of necrosectomy.

METHODS

Retrospectively analyzed patients, all operated on for FNA-proven infection of pancreatic necrosis (n = 20, group 1) were compared to patients subjected to conservative treatment (n = 24, group 2) who were followed prospectively.

RESULTS

Prognostic scores did not differ between the two groups, indicating comparable severity: the Acute Physiology and Chronic Health Evaluation (APACHE II) score was 19.8 ± 1.7 versus 16 ± 2.2; the Sequential Organ Failure Assessment (SOFA) score was 8.7 ± 1.4 versus 6.9 ± 1.0, the C-reactive protein (CRP) level on day 3 was 243 ± 21 versus 291 ± 21, and the CTSI (CT severity index) was 7.8 ± 0.5 versus 7.9 ± 0.4 (p = ns). Ten patients in group 2 underwent operation because of severe extrapancreatic complications. Mortality differed significantly (45% in group 1 vs. 8.3% in group 2; p = 0.01).

CONCLUSIONS

A highly conservative approach avoiding open necrosectomy in NP results in significantly lower mortality than previous serial FNA and consecutive indication for surgery in case of proven infection. Open surgery in NP should be reserved for concomitant intra-abdominal complications.

Extracorporeal cell therapy of septic shock patients with donor granulocytes: a pilot study

Introduction

Neutrophil granulocytes are the first defense line in bacterial infections. However, granulocytes are also responsible for severe local tissue impairment. In order to use donor granulocytes, but at the same time to avoid local side effects, we developed an extracorporeal immune support system. This first-in-man study investigated whether an extracorporeal plasma treatment with a granulocyte bioreactor is tolerable in patients with septic shock. A further intention was to find suitable efficacy end-points for subsequent controlled trials.

Methods

The trial was conducted as a prospective uncontrolled clinical phase I/II study with 28-day follow-up at three university hospital intensive care units. Ten consecutive patients (five men, five women, mean age 60.3 ± 13.9 standard deviation (SD) years) with septic shock with mean ICU entrance scores of Acute Physiology and Chronic Health Evaluation (APACHE) II of 29.9 ± 7.2 and of Simplified Acute Physiology Score (SAPS) II of 66.2 ± 19.5 were treated twice within 72 hours for a mean of 342 ± 64 minutes/treatment with an extracorporeal bioreactor containing 1.41 ± 0.43 × 10E10 granulocytes from healthy donors. On average, 9.8 ± 2.3 liters separated plasma were treated by the therapeutic donor cells. Patients were followed up for 28 days.

Results

Tolerance and technical safety during treatment, single organ functions pre/post treatment, and hospital survival were monitored. The extracorporeal treatments were well tolerated. During the treatments, the bacterial endotoxin concentration showed significant reduction. Furthermore, noradrenaline dosage could be significantly reduced while mean arterial pressure was stable. Also, C-reactive protein, procalcitonin, and human leukocyte antigen DR (HLA-DR) showed significant improvement. Four patients died in the hospital on days 6, 9, 18 and 40. Six patients could be discharged.

Conclusions

The extracorporeal treatment with donor granulocytes appeared to be well tolerated and showed promising efficacy results, encouraging further studies.

Trial registration

ClinicalTrials.gov Identifier: NCT00818597

[The role of intensive care medicine in early postoperative complications. Is surgical expertise in danger?]

Intensive care medicine is the backbone of surgery. We describe a profile of parameters which has to be repeatedly evaluated to allow early detection of postoperative complications. Complex surgical diseases are analyzed to underscore that only a surgeon experienced in intensive care medicine is able to interpret abnormalities in correlation with the intra-operative findings resulting in appropriate decisions with respect to diagnostic measures and reintervention. An increasing lack of motivation compromises the necessary training of young surgeons. Work hour limits already prolong education in the operative core competence thus making residents decline a necessary extension of ICU training beyond the compulsory 6 months. Identification of young surgeons with intensive care medicine is further hampered by the establishment of interdisciplinary operative ICUs excluding surgeons from the leadership. Our current survey of 38 university departments of general and gastro-intestinal surgery in Germany shows that a cooperative ICU steering structure of anesthesiologists and surgeons exists in only 19%. The imminent deficit of training in surgical intensive care medicine can only be counteracted by equal leadership structures.

Evaluation of a fully automated procalcitonin chemiluminescence immunoassay

We evaluated a new fully automated microparticle immunoassay for procalcitonin (LIAISON BRAHMS PCT) in comparison with a previously established manual chemiluminescence assay from the same manufacturer (LUMItest PCT, BRAHMS AG). Procalcitonin (PCT) is an early and rather specific marker of systemic bacterial infection. In addition, the efficacy of antibiotic therapy can be monitored by sequential analysis of PCT values. This is why rapid and accurate determinations of PCT are urgently required by intensive care units. The aim of this study was to evaluate in a clinical set-up a new fully automated rapid PCT test. Analytical results are compared with results obtained by a previously introduced quantitative manual test. Intra-assay coefficients of variation (CV) were found in the range of 0.94 to 7.1% at concentrations between 0.46 and 97.2 microg/l. Over a time period of 27 days the inter-assay CV was found below 4.0% at concentrations of 1.93 and 14.29 microg/l and 9.9% at 0.40 microg/l. The functional sensitivity at a CV level of 20% was determined as 0.2 microg/l. Linearity could be demonstrated in a concentration range from 0 to 445 microg/l. When serum and plasma with EDTA, citrate or heparin anti-coagulation were analyzed in parallel, no systematic bias was found. A method comparison by regression analysis showed PCT values determined by both tests in very good agreement (r = 0.99). PCT concentrations in apparently healthy subjects (n =101) were below 0.58 microg/l in line with previously published results. Patients with sepsis (n = 43) or with infectious adult respiratory distress syndrome (ARDS) (n = 28) showed median values of 22.2 and 18.9 microg/l, respectively. In a clinical set-up the LIAISON Brahms PCT assay provided rapid and accurate PCT results supporting the early detection of severe sepsis, the differentiation between systemic bacterial infection and other inflammatory diseases, and the monitoring of antibiotic therapy in septic patients. The results of the new LIAISON BRAHMS PCT assay show an excellent concordance with the LUMItest PCT. The clinical information derived from the measurements is well comparable to the results obtained with the LUMItest PCT, too.

[Fungemia after oral treatment with Saccharomyces boulardii in a patient with multiple comorbidities]

HISTORY AND CLINICAL FINDINGS

A 48-year-old diabetic with multiple co-morbidities presented with generalized micro- and macroangiopathy including peripheral artery disease stage IV with necroses in several digits of both feet. He was admitted to the department of surgery for the insertion of femoropopliteal bypasses.

INVESTIGATIONS

Infectious parameters were elevated (CRP 66.1 mg/l, sedimentation rate 90/96), accompanied by anemia (Hb 7.1 mmol/l), leukocytosis (14.8 Gpt/l) and thrombocytosis (514 Gpt/l). Body temperature was normal (36.8 degrees C). With insulin treatment the patient became nearly normoglycemic (HbA1c 6.8 %).

TREATMENT AND FOLLOW UP

After receiving different broad-spectrum antibiotics over seven weeks the patient developed Clostridium difficile toxin-positive diarrhea that resolved after administration of oral metronidazole and Saccharomyces boulardii (Perenterol ((R))). Three days after bypass insertion, both legs had to be amputated due to infection and beginning sepsis. The condition of the patient improved. However, eight days after bypass-insertion the patient developed a toxic megacolon and sepsis. Blood cultures yielded the growth of Saccharomyces cerevisae. Despite of intensive care treatment the patient died five days later from to multi-organ failure.

CONCLUSION

S. boulardii (synonym: S. cerevisiae) is considered an non-pathogenic probiotic yeast, and live yeast cells are used for supportive therapy of diarrhea. The present case and a review of the literature demonstrate that fungemia and sepsis are rare complications of the administration of S. boulardii in immunocompromised patients. For this reason the therapeutic usage of probiotics should be carefully considered regarding its risk-benefit potential.

Pharmacokinetics of piperacillin-tazobactam in anuric intensive care patients during continuous venovenous hemodialysis

The pharmacokinetics of piperacillin-tazobactam were investigated in eight anuric intensive care patients treated by continuous venovenous hemodialysis (CVVHD). The elimination half-life of piperacillin was 4.3 +/- 1.2 h, and that of tazobactam was 5.6 +/- 1.3 h. The contribution of CVVHD to the overall elimination was relevant (>25%) for both drugs.