The Impact of Culturing the Organ Preservation Fluid on Solid Organ Transplantation: A Prospective Multicenter Cohort Study

Background

We analyzed the prevalence, etiology, and risk factors of culture-positive preservation fluid and their impact on the management of solid organ transplant recipients.

Methods

From July 2015 to March 2017, 622 episodes of adult solid organ transplants at 7 university hospitals in Spain were prospectively included in the study.

Results

The prevalence of culture-positive preservation fluid was 62.5% (389/622). Nevertheless, in only 25.2% (98/389) of the cases were the isolates considered "high risk" for pathogenicity. After applying a multivariate regression analysis, advanced donor age was the main associated factor for having culture-positive preservation fluid for high-risk microorganisms. Preemptive antibiotic therapy was given to 19.8% (77/389) of the cases. The incidence rate of preservation fluid-related infection was 1.3% (5 recipients); none of these patients had received preemptive therapy. Solid organ transplant (SOT) recipients with high-risk culture-positive preservation fluid receiving preemptive antibiotic therapy presented both a lower cumulative incidence of infection and a lower rate of acute rejection and graft loss compared with those who did not have high-risk culture-positive preservation fluid. After adjusting for age, sex, type of transplant, and prior graft rejection, preemptive antibiotic therapy remained a significant protective factor for 90-day infection.

Conclusions

The routine culture of preservation fluid may be considered a tool that provides information about the contamination of the transplanted organ. Preemptive therapy for SOT recipients with high-risk culture-positive preservation fluid may be useful to avoid preservation fluid-related infections and improve the outcomes of infection, graft loss, and graft rejection in transplant patients.

Are hip hemiarthroplasty and total hip arthroplasty infections different entities? The importance of hip fractures

Hip hemiarthroplasty (HHA) and total hip arthroplasty (THA) infections are usually considered as one entity; however, they may show important differences. We analyze these differences, as well as predictors of treatment failure (TF) and poor functional status among patients with prosthetic hip infections (PHIs). A multicenter cohort study of consecutive patients with PHIs was performed. The main outcome variable was TF after the first surgical treatment performed to treat the infection. Multivariate analysis was used to identify predictors of TF. A total of 127 patients with PHI were included (43 HHA, 84 THA). Patients with HHA infections were more frequently women (88% vs. 54%; p < 0.001), had comorbidities (86% vs. 67%, p = 0.02), and were older (median age 79 vs. 65 years, p < 0.001), and the reason for arthroplasty was more frequently a fracture (100% vs. 18%, p < 0.001). Failure of initial treatment and crude mortality were more frequent among HHA patients (44% vs. 23%, p = 0.01 and 28% vs. 7%, p = 0.001, respectively). However, HHA was not associated with TF in the multivariate analysis when hip fracture was considered; thus, variables independently associated with TF were hip fracture, inadequate surgical management, prosthesis retention, and higher C-reactive protein level. Failure of the first surgical treatment was associated with poorer functional status. HHA and THA infections showed significant differences in epidemiology, clinical features, and outcome. Although patients with HHA infections had a higher risk of TF, this was related to the reason for hip implant: a hip fracture. Success of the initial management of infection is a predictor of better clinical and functional outcome.

Epidemiology and clinical features of community-acquired, healthcare-associated and nosocomial bloodstream infections in tertiary-care and community hospitals

Classification of bloodstream infections (BSIs) as community-acquired (CA), healthcare-associated (HCA) and hospital-acquired (HA) has been proposed. The epidemiology and clinical features of BSI according to that classification in tertiary-care (TH) and community (CH) hospitals were investigated in a prospective cohort of 821 BSI episodes from 15 hospitals (ten TH and five CH hospitals) in Andalucía, Spain. Eighteen percent were CA, 24% were HCA and 58% were HA. The incidence of CA and HCA BSI was higher in CH than in TH (CA: 3.9 episodes per 1000 admissions vs. 2.2, p <0.01; HCA: 5.0 vs. 2.9, p <0.01), whereas the incidence of HA BSI was lower (7.7 vs. 8.7, p <0.01). In CA and HCA BSI, the respiratory tract was more frequently the source in CH than in TH (CA: 30% vs. 15%; HCA: 20% vs. 9%, p ≤0.03). In HCA BSI, chronic renal insufficiency and tunnelled catheters were less frequent in CH than in TH (11% vs. 26% and 7% vs. 19%, p ≤0.03), although chronic ulcers were more frequent (22% vs. 8%, p 0.008). BSIs as a result of methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa were very rare in CA episodes, although extended-spectrum b-lactamase-producing Escherichia coli (ESBLEC) caused a similar proportion of all BSIs in CA, HCA and HA episodes. Multivariate analysis revealed no significant difference in mortality rates in CH and TH. HCA infections should be considered as a separate class of BSI in both TH and CH, although differences between hospitals must be considered. CA BSIs were not caused by multidrug-resistant pathogens, except for ESBLEC.

Impact of Acute Hepatitis A Virus (HAV) Infection on HIV Viral Load in HIV-Infected Patients and Influence of HIV Infection on Acute HAV Infection

Purpose: To assess the effect of hepatitis A virus (HAV) infection on HIV viral load (VL) and the influence of HIV on the clinical expression of HAV infection. Methods: Single-center study of 23 HIV-positive patients and 41 HIV-negative patients diagnosed with acute HAV infection during 2008-2009. The impact of HAV on HIV VL was defined as an increase of >0.5 log10 during the event, or a detectable VL for those previously suppressed patients. Results: The impact of acute HAV on VL was observed in 37.5% patients. HIV-negative patients were younger (27 vs 34 years, P < .0001), and serum transaminases levels normalized earlier than in the HIV-positive patients (121 vs 178 days, P < .05). Conclusions: Acute HAV infection may have an impact on HIV VL. The interactions between the 2 viruses may not only prolong the HAV viremia, with a potential increase in the transmission of infection, but the impact on HIV may increase the risk of HIV transmission. Studies with higher sample size are needed to confirm our results.

Usefulness of sputum culture for diagnosis of bacterial pneumonia in HIV-infected patients

The use of sputum culture in immunocompetent patients with community-acquired pneumonia is controversial. The usefulness of this technique in HIV-infected patients has not been evaluated. A prospective, observational, multicenter, hospital-based study of bacterial community-acquired pneumonia was carried out to analyze the value of sputum culture in HIV-infected patients. Only good-quality sputum samples were cultured. Altogether, 355 cases of bacterial community-acquired pneumonia were included. An etiological diagnosis was obtained in 190 (53.5%) cases. Sputum was cultured in 313 (88.1%) cases, being diagnostic in 108 (34.5%). The microorganism identified in sputum culture was the same as that identified in sterile samples in 26 of 27 (96.3%) cases in which both cultures were diagnostic. The microbiologic findings in sputum and bronchoscopic cultures were concordant in seven of eight (87.5%) cases in which both were positive. These results suggest that sputum culture is a useful technique, given its availability and ease of performance and its good correlation with culture of sterile samples.

Community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients: validation of severity criteria. The Grupo Andaluz para el Estudio de las Enfermedades Infecciosas

Severity criteria for community-acquired pneumonia (CAP) have always excluded patients with human immunodeficiency virus (HIV) infection. A 1-yr, multicenter, prospective observational study of HIV-infected patients with bacterial CAP was done to validate the criteria used in the American Thoracic Society (ATS) guidelines for CAP, and to determine the prognosis-associated factors in the HIV-infected population with bacterial CAP. Overall, 355 cases were included, with an attributable mortality of 9.3%. Patients who met the ATS criteria had a longer hospital stay (p = 0.01), longer duration of fever (p < 0.001), and higher attributable mortality (13.1% versus 3.5%, p = 0.02) than those who did not. Three factors were independently related to mortality: CD4(+) cell count < 100/microl, radiologic progression of disease, and shock. Pleural effusion, cavities, and/or multilobar infiltrates at admission were independently associated with radiologic progression. A prognostic rule based on the five criteria of shock, CD4(+) cell count < 100/microl, pleural effusion, cavities, and multilobar infiltrates had a high negative predictive value for mortality (97.1%). The attributable mortality for severe pneumonia was 11.3%, as compared with 1.3% for nonsevere disease (p = 0.008). The ATS severity criteria are valid in HIV-infected patients with bacterial CAP. Our study provides the basis for identification of patients who may require hospitalization determined by clinical judgment and the five clinical criteria of shock, a CD4(+) cell count < 100/microl, pleural effusion, cavities, and multilobar involvement. These prognostic factors should be validated in independent cohort studies.

Haemophilus influenzae pneumonia in human immunodeficiency virus-infected patients. The Grupo Andaluz para el Estudio de las Enfermedades Infecciosas

Although Haemophilus influenzae is a common etiologic agent of pneumonia in patients infected with human immunodeficiency virus (HIV), the characteristics of this pneumonia have not been adequately assessed. We have prospectively studied features of H. influenzae pneumonia in 26 consecutive HIV-infected inpatients. Most of these patients were severely immunosuppressed; 73.1% had a CD4+ cell count <100/microL. A subacute clinical presentation was observed in 27% of the patients and was associated with a higher degree of immunosuppression (P=.04). Bilateral lung infiltrates were noted radiographically in 57.7% of the cases. The mortality attributable to H. influenzae pneumonia was 11.5%. Thus, pneumonia caused by H. influenzae affects mainly patients with advanced HIV disease, and since its clinical and radiological features may be diverse, this etiology should be considered when pneumonia occurs in patients with advanced HIV infection. The mortality rate associated with H. influenzae pneumonia is not higher than that occurring in the general population.