[Utility of topical vancomycin application in the prevention of surgical site infection of the lumbosacral spine]

INTRODUCTION

surgical site infections (SSI) remain a significant cause of morbidity and mortality and one of the most representative causes of nosocomial infections. The use of intrawound vancomycin in lumbar spine surgery is a potential prophylactic measure against SSI; however, evidence regarding its efficacy is contradictory. Our study was designed to research if intrawound vancomycin significantly prevents SSI in lumbar spine surgery.

MATERIAL AND METHODS

this is a randomized, double-blinded, controlled clinical trial; 233 patients who underwent lumbar spine surgery, were randomly assigned to a group in which intrawound vancomycin was instilled in the incision before closure (109), or to a control group (114). The main outcome is the presence of SSI; we determined its prevalence and searched for difference between groups for association between SSI and independent variables.

RESULTS

global SSI prevalence was 1.8%, in the experimental group was 0.9%, in the control group was 2.6%. There was no significant difference between these values, p = 0.622. The relative risk of SSI in the experimental group was 0.35 (95% CI 0.037-3.30), that of the control group was 2.87 (95% CI 0.30-27.16). The number needed to treat is 58.3. We did not find a significant association between the independent variables studied and the appearance of SSI.

CONCLUSIONS

we did not find a significant difference in the prevalence of SSI between groups nor a significant association between SSI and independent variables.

Opportunistic pulmonary infections in solid organ transplant recipients

BACKGROUND

Opportunistic pulmonary infections (OPI) represent common life-threatening complications after solid organ transplantation. Our objective was to describe pulmonary infections caused by opportunistic pathogens in solid-organ transplant patients.

METHODS

We analyzed all adult solid organ recipients (liver, heart, kidney, and pancreas) between July 2003 and June 2010, reporting all episodes of pulmonary opportunistic infection.

RESULTS

During the study period, 1656 solid organ transplants were performed and 188 opportunistic infections were diagnosed in 163 patients (incidence 10%). In 40 cases, the site of infection was the lung (21%) with 57.5% occurring between the first and sixth month posttransplantation. The most frequently isolated microorganism was Aspergillus spp (n = 25, 63%), followed by Pneumocystis jirovecii (n = 6 cs, 15%). Twenty-five patients with an opportunistic pulmonary infections died during the follow-up including, 16 related to the infection (40%). The causative organism responsible for the highest mortality was Aspergillus spp (n = 12; 48%). Twenty-one patients with an opportunistic nonrespiratory infection died, five of them related to it (4%). Opportunistic pulmonary infection was associated with an increased mortality rate (P < .001). There was a trend toward a higher mortality among patients who developed OPI during the first 6 months after transplantation.

CONCLUSIONS

Opportunistic pulmonary infections after solid organ transplantation are not infrequent. The period of risk for developing this infectious complications goes beyond the first 6 months posttransplantation. Mortality due to these infections was high in comparison to that of opportunistic nonrespiratory infections. It is important to keep a high index of suspicion for infectious complications during all posttransplant periods, as this is the first step toward a rapid diagnosis and adequate treatment.

Influence of cytomegalovirus disease in outcome of solid organ transplant patients

INTRODUCTION

Despite recent advances in prevention and treatment, cytomegalovirus (CMV) is still a major complication in transplant patients. This study sought to analyze the incidence of CMV disease and its impact on patient and graft survival.

METHODS

Between June 2003 and December 2009, we included all kidney, liver, heart, and double transplant patients who underwent solid organ transplantation. They had 1-year posttransplant follow-up.

RESULTS

Among the 1427 patients who received kidney (n = 661), liver (n = 494), heart (n = 89), or double (n = 183) transplants, 103 (7.2%) displayed CMV disease. The incidence by type of transplant was: heart (n = 17, 19%), liver (n = 35, 7%), kidney (n = 41, 6.2%), or double transplant (n = 10, 5.5%; P < .001). In 59% of cases, the infection developed during the first 3 months after transplantation. CMV infections ranged from viral syndrome (n = 47, 45%) to tissue-invasive disease (n = 56, 55%), including 38% with gastrointestinal involvement. Relapsing episodes occurred in 12 patients (11%). Discordant donor/recipient CMV serology was present in 151 patients (donor positive/receptor negative), including 34 (22.5%) who developed primary CMV disease (P < .001). Coinfections mostly bacterial, were diagnosed in 38% of patients. An acute rejection episode was present in 31% of patients with CMV disease compared to 20% without this complication (P = .017). Crude mortality was significantly higher among patients with CMV disease (n = 18 patients [18%] vs 92 patients [7%]; P < .001).

CONCLUSION

Our data confirmed that CMV disease was associated with worse transplant outcomes, with higher incidences of acute rejection episodes and mortality.

Epidemiology and risk factors for late infection in solid organ transplant recipients

BACKGROUND

Information concerning the risk factors and outcome of late infection (LI) after solid organ transplantation (SOT) still remains scarce.

METHODS

We prospectively analyzed all patients undergoing SOT from July 2003 to March 2008, who survived the first 6 months after surgery and with a minimum 1-year follow-up. Risk factors associated with the development of bacterial and cytomegalovirus (CMV) LI and survival were identified.

RESULTS

Overall, 942 SOT recipients (491 kidney, 280 liver, 65 heart, and 106 double transplants) were included. During the study period 147 patients (15.6%) developed 276 episodes of LI (incidence rate, 0.43 per 1000 transplantation-days). Bacteria were the most prevalent etiology (88.0%). Primary sources of infection included urinary tract (36.9%), intra-abdominal (16.7%), and sepsis without source (13.4%). Independent risk factors for late bacterial infection were: age (hazard ratio [HR] [per year] 1.0; 95% confidence interval [CI]: 1.0-1,0), female gender (HR 1.7; 95%CI: 1.1-2.6), anti-hepatitis C virus (HCV) positive serostatus (HR 1.8; 95%CI: 1.1-3.0), chronic allograft dysfunction (HR 3.2; 95%CI: 1.7-6.1), early CMV disease (HR 2.2; 95%CI 1.2-4.1), and early bacterial infection (HR 2.5; 95%CI 1.6-3.8). The occurrence of chronic allograft dysfunction was an independent risk factor for late CMV disease (HR 6.5; 95%CI: 1.7-24.6), whereas immunosuppression based on mammalian target of rapamycin inhibitors protected against the development of late CMV disease (HR 0.3; 95%CI: 0.1-1.0). Cox model selected anti-HCV positive serostatus (adjusted HR [aHR] 2.67; 95%CI: 1.27-5.59), age (aHR [per year] 1.06; 95%CI: 1.02-1.10), and the occurrence of LI (aHR 9.12; 95%CI: 3.90-21.33) as independent factors for mortality.

CONCLUSIONS

LI did not constitute an uncommon complication in our cohort, and patients at risk may benefit from close clinical monitoring.

Klebsiella pneumoniae infection in solid organ transplant recipients: epidemiology and antibiotic resistance

BACKGROUND

Klebsiella pneumoniae is a well recognized source of nosocomial infection in solid-organ transplant (SOT) recipients. It is also the most common species capable of producing extended-spectrum β-lactamases (ESBL). Its treatment can therefore be a challenge owing to antibiotic resistance.

METHODS

Prospective study of all transplant recipients from July 2003 to December 2007 at our center. Klebsiellla pneumoniae infectious events were recorded.

RESULTS

A total of 1,057 patients were enrolled, 509 (48%) renal, 360 (34%) liver, 78 (7%) heart, and 110 (10%) double transplants. We diagnosed 116 episodes of K. pneumoniae infection in 92 patients during the study period, of which 62 were ESBL-producing strains (53%). Thirty-four episodes had bacteremia (29%), 15 of which were caused by ESBL-producing strains. There were no strains of K. pneumoniae producing carbapanemase (KPC). Forty-seven percent of the episodes occurred during the first month after transplantation. The incidence of infection by type of transplant was: renal 11%, liver 7%, cardiac 5%, and double transplant 6% (P=.075). The major sites of infection were urinary tract 72%, surgical wound 5%, intraabdominal 6%, catheter 5%, lung 1%, bloodstream 1%, and others 2%. ESBL-producing K. pneumoniae strains were more common in renal transplant patients (P=.035) and in those who required posttransplant dialysis (P=.022). There were 4 deaths in the first 30 days after the isolation of K. pneumoniae, and 3 of these cases were infections caused by ESBL-producing strains.

CONCLUSIONS

There was a high incidence of ESBL-producing K. pneumoniae infections in SOT recipients and renal transplant recipients, and those who required dialysis were more likely to develop infection by this strain. No KPC-producing organisms were found in our series. The existence of such a high level of resistance is a well recognized hospital threat, and appropriate policies and interventions should be addressed in high-risk patients.

Epidemiology of pneumonia in kidney transplantation

BACKGROUND

Pneumonia remains an important cause of morbidity among solid organ transplant recipients.

METHODS

We prospectively evaluated all renal transplant patients at our center from July 2003 to December 2008 who had pneumonia that required hospitalization. We gathered data regarding underlying diseases as well as pretransplant, transplant, and posttransplant characteristics. Pneumonia defined according to the Centers for Disease Control and Prevention criteria was classified depending on its origin as community acquired or nosocomial. In all patients, microbiologic samples of respiratory secretions and blood were collected at the physician's discretion. The indication to perform a fiberoptic bronchoscopy was the presence of multiple, bilateral, or diffuse pulmonary infiltrates or the absence of a clinical or radiologic response after 3 days of antimicrobial therapy.

RESULTS

Among 610 kidney transplant recipients, we diagnosed 60 episodes of pneumonia in 54 patients (8.8%), of which 23 had a nosocomial origin (38%) and 37 community acquired (62%). Bacterial infection was the most frequent etiology (44%), followed by fungal in 4 (7%) and viral in 2 (3.5%). The most commonly isolated microorganism in nosocomial pneumonia was Pseudomonas aeruginosa (26%, among which 50% was multidrug resistant). In 34% there was no microbiologic isolation. The most common pathogen among community-acquired pneumonias was Strepococcus pneumoniae (11%). In 54% of cases there was no microbiologic confirmation of disease. The overall accuracy of bronchoalveolar lavage was 72%. A total of 21 patients with pneumonia (35%) were admitted to the intensive care unit; of these, 14 had a nosocomial origin (60%) and 9 (15%) died due to the infection (8 [88%] of whom had nosocomial pneumonia; P=.001).

CONCLUSIONS

Our data confirmed that nosocomial pulmonary infections are associated with considerable morbidity and mortality in renal transplant recipients. The performance of invasive procedures is useful for the diagnosis of pneumonia.