Risk factors for unfavorable outcome and impact of early post-transplant infection in solid organ recipients with COVID-19: A prospective multicenter cohort study

The aim was to analyze the characteristics and predictors of unfavorable outcomes in solid organ transplant recipients (SOTRs) with COVID-19. We conducted a prospective observational cohort study of 210 consecutive SOTRs hospitalized with COVID-19 in 12 Spanish centers from 21 February to 6 May 2020. Data pertaining to demographics, chronic underlying diseases, transplantation features, clinical, therapeutics, and complications were collected. The primary endpoint was a composite of intensive care unit (ICU) admission and/or death. Logistic regression analyses were performed to identify the factors associated with these unfavorable outcomes. Males accounted for 148 (70.5%) patients, the median age was 63 years, and 189 (90.0%) patients had pneumonia. Common symptoms were fever, cough, gastrointestinal disturbances, and dyspnea. The most used antiviral or host-targeted therapies included hydroxychloroquine 193/200 (96.5%), lopinavir/ritonavir 91/200 (45.5%), and tocilizumab 49/200 (24.5%). Thirty-seven (17.6%) patients required ICU admission, 12 (5.7%) suffered graft dysfunction, and 45 (21.4%) died. A shorter interval between transplantation and COVID-19 diagnosis had a negative impact on clinical prognosis. Four baseline features were identified as independent predictors of intensive care need or death: advanced age, high respiratory rate, lymphopenia, and elevated level of lactate dehydrogenase. In summary, this study presents comprehensive information on characteristics and complications of COVID-19 in hospitalized SOTRs and provides indicators available upon hospital admission for the identification of SOTRs at risk of critical disease or death, underlining the need for stringent preventative measures in the early post-transplant period.

Effect of Influenza Vaccination Inducing Antibody Mediated Rejection in Solid Organ Transplant Recipients

Introduction

Our goal was to study whether influenza vaccination induced antibody mediated rejection in a large cohort of solid organ transplant recipients (SOTR).

Methods

Serum anti-Human Leukocyte Antigen (HLA) antibodies were determined using class I and class II antibody-coated latex beads (FlowPRA^TM Screening Test) by flow cytometry. Anti-HLA antibody specificity was determined using the single-antigen bead flow cytometry (SAFC) assay and assignation of donor specific antibodies (DSA) was performed by virtual-crossmatch.

Results

We studied a cohort of 490 SOTR that received an influenza vaccination from 2009 to 2013: 110 (22.4%) received the pandemic adjuvanted vaccine, 59 (12%) within the first 6 months post-transplantation, 185 (37.7%) more than 6 months after transplantation and 136 (27.7%) received two vaccination doses. Overall, no differences of anti-HLA antibodies were found after immunization in patients that received the adjuvanted vaccine, within the first 6 months post-transplantation, or based on the type of organ transplanted. However, the second immunization dose increased the percentage of patients positive for anti-HLA class I significantly compared with patients with one dose (14.6% vs. 3.8%; P = 0.003). Patients with pre-existing antibodies before vaccination (15.7% for anti-HLA class I and 15.9% for class II) did not increase reactivity after immunization. A group of 75 (14.4%) patients developed de novo anti-HLA antibodies, however, only 5 (1.02%) of them were DSA, and none experienced allograft rejection. Only two (0.4%) patients were diagnosed with graft rejection with favorable outcomes and neither of them developed DSA.

Conclusion

Our results suggest that influenza vaccination is not associated with graft rejection in this cohort of SOTR.

Factors associated with the development of septic shock in patients with candidemia: a post hoc analysis from two prospective cohorts

BACKGROUND

Almost one third of the patients with candidemia develop septic shock. The understanding why some patients do and others do not develop septic shock is very limited. The objective of this study was to identify variables associated with septic shock development in a large population of patients with candidemia.

METHODS

A post hoc analysis was performed on two prospective, multicenter cohort of patients with candidemia from 12 hospitals in Spain and Italy. All episodes occurring from September 2016 to February 2018 were analyzed to assess variables associated with septic shock development defined according to The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3).

RESULTS

Of 317 candidemic patients, 99 (31.2%) presented septic shock attributable to candidemia. Multivariate logistic regression analysis identifies the following factors associated with septic shock development: age > 50 years (OR 2.57, 95% CI 1.03-6.41, p = 0.04), abdominal source of the infection (OR 2.18, 95% CI 1.04-4.55, p = 0.04), and admission to a general ward at the time of candidemia onset (OR 0.21, 95% CI, 0.12-0.44, p = 0.001). Septic shock development was independently associated with a greater risk of 30-day mortality (OR 2.14, 95% CI 1.08-4.24, p = 0.02).

CONCLUSIONS

Age and abdominal source of the infection are the most important factors significantly associated with the development of septic shock in patients with candidemia. Our findings suggest that host factors and source of the infection may be more important for development of septic shock than intrinsic virulence factors of organisms.

An evidence-based bundle improves the quality of care and outcomes of patients with candidaemia

Background

Candidaemia is a leading cause of bloodstream infections in hospitalized patients all over the world. It remains associated with high mortality.

Objectives

To assess the impact of implementing an evidence-based package of measures (bundle) on the quality of care and outcomes of candidaemia.

Methods

A systematic review of the literature was performed to identify measures related to better outcomes in candidaemia. Eight quality-of-care indicators (QCIs) were identified and a set of written recommendations (early treatment, echinocandins in septic shock, source control, follow-up blood culture, ophthalmoscopy, echocardiography, de-escalation, length of treatment) was prospectively implemented. The study was performed in 11 tertiary hospitals in Spain. A quasi-experimental design before and during bundle implementation (September 2016 to February 2018) was used. For the pre-intervention period, data from the prospective national surveillance were used (May 2010 to April 2011).

Results

A total of 385 and 263 episodes were included in the pre-intervention and intervention groups, respectively. Adherence to all QCIs improved in the intervention group. The intervention group had a decrease in early (OR 0.46; 95% CI 0.23–0.89; P = 0.022) and overall (OR 0.61; 95% CI 0.4–0.94; P = 0.023) mortality after controlling for potential confounders.

Conclusions

Implementing a structured, evidence-based intervention bundle significantly improved patient care and early and overall mortality in patients with candidaemia. Institutions should embrace this objective strategy and use the bundle as a means to measure high-quality medical care of patients.

Detection of cytomegalovirus drug resistance mutations in solid organ transplant recipients with suspected resistance

BACKGROUND

Current guidelines recommend that treatment of resistant cytomegalovirus (CMV) in solid organ transplant (SOT) recipients must be based on genotypic analysis. However, this recommendation is not systematically followed.

OBJECTIVES

To assess the presence of mutations associated with CMV resistance in SOT recipients with suspected resistance, their associated risk factors and the clinical impact of resistance.

STUDY DESIGN

Using Sanger sequencing we prospectively assessed the presence of resistance mutations in a nation-wide prospective study between September 2013-August 2015.

RESULTS

Of 39 patients studied, 9 (23%) showed resistance mutations. All had one mutation in the UL 97 gene and two also had one mutation in the UL54 gene. Resistance mutations were more frequent in lung transplant recipients (44% p=0.0068) and in patients receiving prophylaxis ≥6 months (57% vs. 17%, p=0.0180). The mean time between transplantation and suspicion of resistance was longer in patients with mutations (239 vs. 100days, respectively, p=0.0046) as was the median treatment duration before suspicion (45 vs. 16days, p=0.0081). There were no significant differences according to the treatment strategies or the mean CMV load at the time of suspicion. Of note, resistance-associated mutations appeared in one patient during CMV prophylaxis and also in a seropositive organ recipient. Incomplete suppression of CMV was more frequent in patients with confirmed resistance.

CONCLUSIONS

Our study confirms the need to assess CMV resistance mutations in any patient with criteria of suspected clinical resistance. Early confirmation of the presence of resistance mutations is essential to optimize the management of these patients.

Caspofungin versus fluconazole as prophylaxis of invasive fungal infection in high-risk liver transplantation recipients: A propensity score analysis

Targeted prophylaxis has proven to be an efficient strategy in liver transplantation recipients (LTRs). The aim of this study was to compare the effectiveness and safety of caspofungin with that of fluconazole in high-risk (HR) LTRs. Caspofungin and fluconazole were compared in a multicenter, retrospective, cohort study in HR-LTRs in Spain. Outcomes were assessed at 180 days after transplantation. A propensity score approach was applied. During the study period (2005-2012), we analyzed 195 HR-LTRs from 9 hospitals. By type of prophylaxis, 97 patients received caspofungin and 98 received fluconazole. Of a total of 17 (8.7%) global invasive fungal infections (IFIs), breakthrough IFIs accounted for 11 (5.6%) and invasive aspergillosis (IA) accounted for 6 (3.1%). By univariate analysis, no differences were observed in the prevention of global IFIs. However, caspofungin was associated with a significant reduction in the rate of breakthrough IFIs (2.1% versus 9.2%, P = 0.04). In patients requiring dialysis (n = 62), caspofungin significantly reduced the frequency of breakthrough IFIs (P = 0.03). The propensity score analysis confirmed a significant reduction in the frequency of IA in patients receiving caspofungin (absolute risk reduction, 0.06; 95% confidence interval [CI], 0.001-0.11; P = 0.044). Linear regression analysis revealed a significant decrease in blood alanine aminotransferase levels and a significant increase in bilirubin levels after administration of caspofungin. Caspofungin and fluconazole have similar efficacy for the prevention of global IFIs in HR-LTRs in this observational, multicenter cohort study. However, caspofungin was associated with a significant reduction of breakthrough IFIs and, after adjusting for confounders, caspofungin was associated with a lower rate of IA. This benefit is probably more favorable in patients on dialysis. Caspofungin is safe in HR-LTRs, although bilirubin levels may be increased.

Management of urinary tract infection in solid organ transplant recipients: Consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

BACKGROUND

Urinary tract infections (UTIs) are one of the most common infections in solid organ transplant (SOT) recipients.

METHODS

Experienced SOT researchers and clinicians have developed and implemented this consensus document in support of the optimal management of these patients. A systematic review was conducted, and evidence levels based on the available literature are given for each recommendation. This article was written in accordance with international recommendations on consensus statements and the recommendations of the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

RESULTS

Recommendations are provided on the management of asymptomatic bacteriuria, and prophylaxis and treatment of UTI in SOT recipients. The diagnostic-therapeutic management of recurrent UTI and the role of infection in kidney graft rejection or dysfunction are reviewed. Finally, recommendations on antimicrobials and immunosuppressant interactions are also included.

CONCLUSIONS

The latest scientific information on UTI in SOT is incorporated in this consensus document.

Executive summary. Management of urinary tract infection in solid organ transplant recipients: Consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

Urinary tract infections (UTI) are one of the most common infections in solid organ transplant (SOT) recipients. A systematic review was performed to assess the management of UTI in SOT recipients. Recommendations are provided on the management of asymptomatic bacteriuria, and prophylaxis and treatment of UTI in SOT recipients. The diagnostic-therapeutic management of recurrent UTI and the role of infection in kidney graft rejection or dysfunction are reviewed. Finally, recommendations on antimicrobials and immunosuppressant interactions are also included.

Executive summary. Management of influenza infection in solid-organ transplant recipients: consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

Solid organ transplant (SOT) recipients are at greater risk than the general population for complications and mortality from influenza infection. We have conducted a systematic review to assess the management and prevention of influenza infection in SOT recipients. Recommendations are provided about the procurement of organs from donors with influenza infection. We highlight the importance of the possibility of influenza infection in any SOT recipient presenting upper or lower respiratory symptoms, including pneumonia. The importance of early antiviral treatment of SOT recipients with suspected or confirmed influenza infection and the necessity of annual influenza vaccination are emphasized. The microbiological techniques for diagnosis of influenza infection are reviewed. Guidelines for the use of antiviral prophylaxis are provided. Recommendations for household contacts of SOT recipients with influenza infection and health care workers are also included. Antiviral dose adjustment guidelines are presented for cases of impaired renal function and for pediatric populations.

Management of influenza infection in solid-organ transplant recipients: consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

BACKGROUND

Solid organ transplant (SOT) recipients are at greater risk than the general population for complications and mortality from influenza infection.

METHODS

Researchers and clinicians with experience in SOT infections have developed this consensus document in collaboration with several Spanish scientific societies and study networks related to transplant management. We conducted a systematic review to assess the management and prevention of influenza infection in SOT recipients. Evidence levels based on the available literature are given for each recommendation. This article was written in accordance with international recommendations on consensus statements and the recommendations of the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

RESULTS

Recommendations are provided on the procurement of organs from donors with suspected or confirmed influenza infection. We highlight the importance of the possibility of influenza infection in any SOT recipient presenting upper or lower respiratory symptoms, including pneumonia. The importance of early antiviral treatment of SOT recipients with suspected or confirmed influenza infection and the necessity of annual influenza vaccination are emphasized. The microbiological techniques for diagnosis of influenza infection are reviewed. Guidelines for the use of antiviral prophylaxis in inpatients and outpatients are provided. Recommendations for household contacts of SOT recipients with influenza infection and health care workers in close contact with transplant patients are also included. Finally antiviral dose adjustment guidelines are presented for cases of impaired renal function and for pediatric populations.

CONCLUSIONS

The latest scientific information available regarding influenza infection in the context of SOT is incorporated into this document.

[Consensus document on vaccination against influenza in health care workers]

Health care workers (HCW) are included each year among risk groups for vaccination against influenza. However, vaccination coverage among this group in our country is very low, not exceeding 25%. Convinced that one of the best tools to increase this coverage among professionals in our country are the scientific evidence, 19 scientific societies and associations professionals bringing together health professionals more directly related to influenza as an health problem, and the General Nursing Council, met to discuss and develop this consensus document in order to inform HCW about the appropriateness of their vaccination against influenza and the benefits that flow from it for themselves, for their patients and for the rest of the population. This recommendation is based on 3 pillars: argument of necessity, ethics and exemplary.

Bacterial urinary tract infection after solid organ transplantation in the RESITRA cohort

BACKGROUND

Urinary tract infection (UTI) is the most common infection in renal transplant patients, but it is necessary to determine the risk factors for bacterial UTI in recipients of other solid organ transplants (SOTs), as well as changes in etiology, clinical presentation, and prognosis.

METHODS

In total, 4388 SOT recipients were monitored in 16 transplant centers belonging to the Spanish Network for Research on Infection in Transplantation (RESITRA). The frequency and characteristics of bacterial UTI in transplant patients were obtained prospectively from the cohort (September 2003 to February 2005).

RESULTS

A total of 192 patients (4.4%) presented 249 episodes of bacterial UTI (0.23 episodes per 1000 transplantation days); 156 patients were kidney or kidney-pancreas transplant recipients, and 36 patients were liver, heart, and lung transplant recipients. The highest frequency was observed in renal transplants (7.3%). High frequency of cystitis versus pyelonephritis without related mortality was observed in both groups. The most frequent etiology was Escherichia coli (57.8%), with 25.7% producing extended-spectrum β-lactamase (ESBL). In all transplants but renal, most cases occurred in the first month after transplantation. Cases were uniformly distributed during the first 6 months after transplantation in renal recipients. Age (odds ratio [OR] per decade 1.1, 95% confidence interval [CI] 1.02-1.17), female gender (OR 1.74, 95% CI 1.42-2.13), and the need for immediate post-transplant dialysis (OR 1.63, 95% CI 1.29-2.05) were independent variables associated with bacterial UTI in renal and kidney-pancreas recipients. The independent risk factors identified in non-renal transplants were age (OR per decade 1.79, 95% CI 1.09-3.48), female gender (OR 1.7, 95% CI 1.43-2.49), and diabetes (OR 1.02, 95% CI 1.001-1.040).

CONCLUSIONS

UTI was frequent in renal transplants, but also not unusual in non-renal transplants. Because E. coli continues to be the most frequent etiology, the emergence of ESBL-producing strains has been identified as a new problem. In both populations, most cases were cystitis without related mortality. Although the first month after transplantation was a risk period in all transplants, cases were uniformly distributed during the first 6 months in renal transplants. Age and female gender were identified as risk factors for UTI in both populations. Other particular risk factors were the need for immediate post-transplant dialysis in renal transplants and diabetes in non-renal transplants.

Community-acquired pneumonia in immunocompromised older patients: incidence, causative organisms and outcome

The number of elderly patients in the community with immunosuppressive conditions has increased progressively over recent decades. We sought to determine the incidence, causative organisms and outcome of community-acquired pneumonia (CAP) occurring in immunocompromised older patients. We prospectively compared cases of CAP in immunocompromised and non-immunocompromised patients admitted to five public hospitals in three Spanish regions. Of 320 cases studied, 115 (36%) occurred in immunocompromised patients, including: solid or hematological malignancy (97), corticosteroids or other immunosuppressive drugs (44), solid organ or stem cell transplant (five), and other conditions (eight). The etiology was established in 44% of immunocompromised patients vs. 32% of non-immunocompromised patients (p 0.03). Streptococcus pneumoniae was the most common causative organism in both groups (29% vs. 21%; p 0.08), followed by Legionella pneumophila (3% vs. 6%; p 0.01). Gram-negative bacilli were more frequent among immunocompromised patients (5% vs. 0.5%; p <0.01), particularly Pseudomonas aeruginosa (3% vs. 0%; p 0.04). Nocardiosis was only observed in immunocompromised patients (two cases). Bacteremia occurred similarly in the two groups. No significant differences were found with respect to ICU admission (8%, in both groups) or the length of stay (12.5 vs. 10.4 days). The early (<48 h) (3.5 vs. 0.5%; p 0.04) and overall case-fatality rates (12% vs. 3%; p <0.01) were higher in immunocompromised patients. In conclusion, a substantial number of older patients hospitalized for CAP are immunocompromised. Although relatively uncommon, CAP due to gram-negative bacilli, including P. aeruginosa, is more frequent among these patients. CAP occurring in immunocompromised patients causes significant morbidity and mortality.

Severe, non-bacteremic infections in ICU patients

The present article is an update of the literature on various types of infections in ICU patients: ventilator-associated pneumonia, community-acquired pneumonia, the impact of the increasing vancomycin MIC in Staphylococcus aureus in the treatment of infections caused by this microorganism and the usefulness of biomarkers in identifying or ruling out septic complications in ICU patients. A multidisciplinary group of Spanish physicians with an interest in infections in critically-ill patients selected the most important recently published papers produced in the field. One of the members of the group discussed the content of each of the selected papers, with a critical appraisal by other members of the panel.

[Guidelines for the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). 2011 Update]

The guidelines on the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) are presented. These recommendations are focused on four clinical categories: oncology-haematology patients, solid organ transplant recipients, patients admitted to intensive care units, and children. An extensive review is made of therapeutical advances and scientific evidence in these settings. These guidelines have been prepared according the SEIMC consensus rules by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. Specific recommendations on the prevention of fungal infections in these patients are included.

Bloodstream infections among transplant recipients: results of a nationwide surveillance in Spain

Bloodstream infections (BSIs) are a major cause of morbidity and mortality in transplant recipients. The aim of this study is to describe the incidence, microbiology and outcomes of BSIs in transplant recipients in Spain. The Spanish Network for Research on Infection in Transplantation (RESITRA) is formed by 16 centers with transplant program in Spain. The incidence and characteristics of BSIs in transplant patients were obtained prospectively from the cohort. We included 3926 transplant recipients (2935 solid organ and 991 hematopoietic stem cell transplants). Overall, 730 episodes of BSIs were recorded with an incidence rate ranging from 3 episodes per 10 000 transplant days in kidney recipients to 44 episodes per 10 000 transplant days in allogeneic hematopoietic stem cell transplantation (HSCT). The most frequent sources were intravascular catheters and the most frequent microorganisms isolated were coagulase-negative staphylococci. Crude mortality of BSIs was 7.8%, being highest in liver recipients (16%). Multidrug resistant nonfermentative gram-negative BSIs had significantly worse prognosis than those caused by their susceptible counterparts (p = 0.015), but no differences were found between resistant and susceptible gram-negative enteric bacilli, S. aureus or Candida spp. BSIs are still a major concern in transplant recipients. The increasing isolations of multiresistant microorganisms represent a challenge for the next years.

Contribution of a Pleural Antigen Assay (Binax NOW) to the Diagnosis of Pneumococcal Pneumonia

STUDY OBJECTIVES

To determine whether the detection of pneumococcal antigen in pleural fluid augments conventional microbiological methods used for the etiologic diagnosis of pneumonia.

METHODS

In this retrospective study, a rapid immunochromatographic test (ICT) [NOW Streptococcus pneumoniae assay; Binax; Scarborough, ME] was performed on pleural fluid samples from 34 patients with pneumonia due to S pneumoniae, 89 patients with effusions of nonpneumococcal origin, and 17 patients with pneumonia of unknown etiology. Data on blood cultures, pleural fluid cultures, and urinary antigen tests were recorded.

RESULTS

The ICT test result was positive in 24 of 34 patients (70.6%) with pneumococcal pneumonia and negative in 83 of 89 patients (93.3%) without pneumococcal pneumonia. The sensitivity of the pleural ICT test was higher than that obtained for blood (37.5%) and pleural fluid cultures (32.3%), but lower than the detection of pneumococcal antigen in urine samples (82.1%). However, three patients with pneumococcal pneumonia and a negative ICT urine test result had a positive pleural fluid antigen detection result test. Previous antibiotic exposure did not influence pneumococcal antigen detection in either pleural fluid or urine specimens. Six additional patients with empyema due to anaerobes (three patients), Streptococcus viridans (two patients), and Enterococcus faecalis (one patient) had false-positive pleural ICT test results. Finally, the ICT assay finding was also positive in 5 of 17 patients (29.4%) with pneumonia without a definite microbiological cause.

CONCLUSIONS

The ICT test performed on pleural fluid samples augments the standard diagnostic methods of blood and pleural fluid cultures, even in the case of prior antibiotic therapy, and enhances the ICT urinary antigen assay.

Clinical experience in the management of community-acquired pneumonia: lessons from the use of fluoroquinolones

Community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality worldwide. The treatment of CAP has been complicated by several factors, including the expanding spectrum of causative organisms and the rising prevalence of antibiotic resistance among respiratory pathogens. Initial antimicrobial treatment for patients with CAP is usually selected empirically and should provide appropriate coverage against the most common causative organisms, including resistant strains. Respiratory fluoroquinolones, such as levofloxacin, are the only antimicrobials that are highly active against the pathogens most frequently implicated in CAP, including macrolide-resistant and penicillin-resistant pneumococci, Haemophilus influenzae, Legionella spp., and atypical agents. This paper reviews recent studies involving adult patients with CAP that suggest that levofloxacin, as compared with other conventional antibiotic treatments, may be associated with better clinical outcomes.

Prognostic factors influencing mortality in cancer patients with neutropenia and bacteremia

The purpose of this study was to identify risk factors for mortality in neutropenic patients with cancer and bacteremia. A consecutive sample of 438 neutropenic patients (granulocyte count <0.5 x 10(9)/l) with cancer and bacteremia was studied to identify the clinical characteristics associated with mortality at the onset of bacteremia. The mean age of the subjects was 48 years (range, 15-87 years). Most cases of bacteremia (77%) were hospital-acquired and occurred in patients with acute leukemia (48%). Gram-positive organisms caused 233 (53%) episodes of bacteremia, gram-negative organisms caused 151 (34%) episodes, and 48 (11%) episodes were polymicrobial. The overall mortality within 30 days of the onset of bacteremia was 24.4%. The variables found to be independently associated with increased mortality using logistic regression techniques were as follows: shock at the onset of bacteremia (OR, 10; 95% CI, 4.2-23.8), pneumonia (OR,4.4; 95% CI, 1.9-10), uncontrolled cancer (OR,4.3; 95% CI, 1.5-12.7), and absence of prophylaxis with norfloxacin (OR,2.4; 95% CI, 1.3-4.5). The prognostic factors ascertained in this study may help to identify those patients at higher risk of death. Medical intervention addressing some of these factors may improve the outcome of bacteremia in neutropenic patients with cancer.

Fatal myofascial necrosis due to imipenem-resistant Aeromonas hydrophila

We report the case of a fatal myofascial necrosis caused by an imipenem-resistant Aeromonas hydrophila in a patient with a history of aplastic anemia. He presented with fever and left thigh tenderness. The CT scan was consistent with cellulitis and, after cultures were obtained, empirical treatment with imipenem and amikacin was started. Two days later, necrotic bullae appeared on his thigh, and cultures showed Aeromonas hydrophila which was imipenem-resistant. Although surgical debridement was performed and ciprofloxacin was initiated, the patient died.

Prospective study of 288 episodes of bacteremia in neutropenic cancer patients in a single institution

Trends in causative organisms and sources of infection were studied in a series of 288 episodes of bacteremia in neutropenic cancer patients observed in a single institution from 1986 to 1993. The incidence of bacteremia increased significantly from 20 episodes per 1000 admissions in 1986 to 50 episodes per 1000 admissions in 1993 (p = 0.00001). Over the study period, a continuous increment in gram-positive bacteremia, which reached 81% of episodes in 1993 (p = 0.000001), was observed. Conversely, the incidence of gram-negative bacteremia remained stable. Coagulase-negative staphylococci and viridans group streptococci were the most commonly isolated pathogens. Bacteremia caused by coagulase-negative staphylococci increased from 3 episodes per 1000 admissions to 19 episodes per 1000 admissions (p = 0.0001), and viridans group streptococci bacteremia increased from 0 episodes per 1000 admissions to 19 episodes per 1000 admissions (p = 0.000001). The upward trend in gram-positive bacteremia appeared to be related to a significant increase in both intravascular catheters (p = 0.003) and oral mucositis (p = 0.003) as sources of infection. Specific strategies to prevent chemotherapy-induced mucositis and catheter-related bacteremia merit further investigations.

Bacteremia due to viridans streptococci that are highly resistant to penicillin: increase among neutropenic patients with cancer

We prospectively studied 260 episodes of bacteremia that occurred over a 6-year period in neutropenic patients with cancer. Twenty-three episodes were caused by viridans streptococci. Thirteen (57%) of these strains were penicillin-resistant (MICs of penicillin ranged from 0.25 micrograms/mL to 8 micrograms/mL). Ten of the 13 penicillin-resistant strains (77%) were highly resistant to penicillin (MIC, > or = 4 micrograms/mL). Rates of bacteremia due to highly penicillin-resistant viridans streptococci increased significantly from zero episodes per 1,000 admissions in 1987 to 17 episodes per 1,000 admissions in 1992 (P = .003). In a comparison between penicillin-resistant and penicillin-susceptible viridans streptococci bacteremia, the administration of beta-lactam antibiotics during the previous 2 weeks was the only factor significantly associated with penicillin-resistant cases: 9 (69%) of 13 patients with penicillin-resistant bacteremia had received beta-lactams vs. 2 (20%) of 10 patients with penicillin-susceptible bacteremia (P = .036). These findings may have significant clinical implications in the choice of both antimicrobial prophylaxis and empirical antibiotic regimens.

Emergence of quinolone-resistant Escherichia coli bacteremia in neutropenic patients with cancer who have received prophylactic norfloxacin

Between January 1988 and December 1992, 35 episodes of Escherichia coli bacteremia were identified in a series of 230 cases of bacteremia in neutropenic patients with cancer. Thirteen episodes (37%) were due to quinolone-resistant strains. Minimal inhibitory concentrations of norfloxacin ranged from 16 micrograms/mL to 128 micrograms/mL, and those of ciprofloxacin from 8 micrograms/mL to 64 micrograms/mL. The incidence of bacteremia due to quinolone-resistant E. coli increased from zero episodes per 1,000 hospital admissions in 1988 to four episodes per 1,000 admissions in 1992 (P = .018). To identify risk factors for quinolone-resistant E. coli bacteremia, we compared episodes of quinolone-resistant and quinolone-susceptible E. coli bacteremia. Among the variables analyzed, prophylaxis with norfloxacin was the only factor significantly associated with the development of quinolone-resistant E. coli bacteremia; 13 of 13 patients with bacteremia due to resistant strains received norfloxacin, whereas only one (5%) of 22 patients with bacteremia due to susceptible strains did (P < .001). According to our data, neutropenic patients with cancer who receive fluoroquinolone prophylaxis may be at risk of developing E. coli bacteremia due to quinolone-resistant strains.

[Mechanical ventilation-associated pneumonia and the prevention of stress ulcer. A randomized clinical trial of antacids and ranitidine versus sucralfate]

BACKGROUND

To study two groups of patients intubated with different prophylaxis of stress gastric ulcer in a prospective randomized trial. The differential effect on gastric pH, gastric colonization and the incidence of pneumonia associated to mechanical ventilation (PMV) were analyzed.

METHODS

A prospective randomized study was carried out in two groups of patients: 1) prophylaxis with antacids and H2 blockers (AA+H2) and 2) prophylaxis with sucralfate. Intubated patients without initial respiratory infection were included in the protocol. Periodically gastric aspirations were collected measuring gastric pH and performing semi-quantitative cultures. When pneumonia was suspected bronchial brushing was carried out with telescoped catheter (BBTC) and quantitative culture.

RESULTS

Fifty-one patients were studied (n = 51), distributed into 25 in the AA+H2 group and 26 in the sucralfate group. In the first group mean pH was higher (5.3 +/- 1.7) than in the sucralfate group (3.2 +/- 2.1) (p = 0.006). Nosocomial pneumonia (NP) was suspected on 25 occasions: 20 patients were positive for NP, 11 in the AA+H2 group and nine in the sucralfate group with no significant differences being observed. S. aureus, S. pneumoniae and H. influenzae (n = 14) were the etiology of predominant PMV. The global mortality of the group was of 22%.

CONCLUSIONS

The prophylaxis of stress ulcers in intubated patients treated with antacids and ranitidine provoked higher gastric pH and an increase in gastric colonization in comparison to that observed with sucralfate. No significant differences were observed in the frequency of pneumonia by PMV diagnosed by BBTC.

[Splenic abscesses caused by Mycobacterium tuberculosis in AIDS]

BACKGROUND

Up to 70% of the patients with tuberculosis and HIV infection develop extrapulmonary disease. Abdominal participation is generally of the lymph node type with splenic tuberculosis being rare.

METHODS

Two cases of splenic tuberculosis from a series of 557 patients diagnosed with AIDS in a general hospital from March 1984 to March 1993 are described.

RESULTS

Splenic tuberculosis was the first manifestation of AIDS in these 2 patients. On pulmonary gammagraphy with gallium-67 both cases presented peripheral polyadenopathies and enhancement of hiliary and paratracheal lymph nodes. Abdominal ultrasound scan and computerized tomography revealed multiple hypoechogenic and hypodense splenic lesions, respectively, in the 2 cases. Diagnosis was made following isolation of Mycobacterium tuberculosis in blood cultures. Rapid response to tuberculostatic drugs was shown in one patient while the second responded favorably on the addition of glucocorticoids.

CONCLUSIONS

The homogenicity of the clinical-radiological picture of the 2 cases herein presented and those previously described in the literature allows the initiation of empiric anti-tuberculous treatment. A treatment schedule with glucocorticoids may be effective in patients presenting slow response to tuberculostatic treatment, thus avoiding therapeutic splenectomy.

Gram-negative bacillary cellulitis in patients with hepatic cirrhosis

Eight episodes of gram-negative bacillary cellulitis in seven patients with hepatic cirrhosis are reported. The patients comprised five women and two men (mean age 59.6 years). The diagnosis was based on a positive culture of specimens obtained by needle aspiration from cutaneous lesions. All patients had grade C cirrhosis according to Pugh's classification. Cellulitis involved the lower extremities in all cases. Five patients developed bullous lesions, three ulcers, two abscesses and two extensive cutaneous necrosis. A single bacterial species was found in seven cases. Organisms isolated were Klebsiella pneumoniae (3 cases), Escherichia coli (2 cases), Pseudomonas aeruginosa (2 cases), Proteus mirabilis (1 case) and Aeromonas hydrophila (1 case). Bacteremia was documented in six cases. Four patients died, death being related to sepsis in three of them. It is concluded that gram-negative bacilli should be considered as possible pathogens in severe infectious cellulitis in patients with advanced cirrhosis. Microbiological study of cutaneous specimens obtained by needle aspiration may be of high diagnostic value in these cases.

[Thoracic actinomycosis]

BACKGROUND

Thoracic actinomycosis is an rare disease in our medium. This fact, together with the variability of its forms of presentation and the difficulty in isolating its etiologic agent, make its diagnosis, particularly difficult.

METHODS

A series of 8 cases diagnosed in the years 1988, 1989 and 1990 in two centers (Hospital de Bellvitge-Prínceps d'Espanya and Hospital de l'Esperança) is described with evaluation of the clinical and analytical data and the therapy applied.

RESULTS

Species were only identified in 3 cases with Actinomyces israelii in two and Actinomyces odontolyticus in the third. The proven association with Mycobacterium tuberculosis, the presence of distant septic metastasis and eosinophilic pleuritis as forms of presentation are of note. Medical treatment was penicillin or derivatives in all the cases except one which was treated with diagnostic/therapeutic segmentectomy.

CONCLUSIONS

It is concluded that when any subacute involvement of the thoracic and/or pleuropulmonary wall specific cultures should be carried out to discard eventual thoracic actinomycosis.

[The Fuenlabrada's study: tobacco as cardiovascular risk factor in children and adolescents]

Smoking habits were studied in 1,274 healthy adolescents of both sexes, aged 10 to 18 years, of Fuenlabrada, Madrid. It was known by personal interview. 30% of the population were smokers. Smoking habits increased with age up to 18 years when 63% of males and 53% of females were smokers. Smoking prevalence was significantly higher among males than in females. Males and females smokers had significantly lower levels of C-HDL and higher levels of C-LDL/C-HDL ratio than non smokers. No differences were observed for anthropometric variables, body mass index, blood pressure, skin-fold thickness, total cholesterol, glucemia and uric acid. The implications of these findings are of concern in light of the apparently protective role of C-HDL in coronary heart disease. These findings provide valuable information to the promotion of antismoking campaigns in adolescent age.

[Rupture of the mitral posteromedial papillary muscle associated with myxomatous mitral valve]

We report a 52 year old man, who without previous thoracic trauma, cardiac diseases or cardiovascular risk factors presented after mild epigastric discomfort acute pulmonary oedema. He did not present clinical, electrocardiographic and biochemical manifestation of acute myocardial infarction. He was hospitalized and 15 days later he was sent to our hospital intubated and with assisted respiration. Haemodynamic studies showed severe acute mitral regurgitation and absence of significant obstructing lesions in the coronaries arteries. He was operated few hours after admission. The surgeon found a dysplasic mitral valve and rupture of a head of the posteromedial papillary muscle. The anatomopathological studies discovered mitral myxoid degeneration and ischemic lesion of the papillary muscle. We review the literature of the exclusive infarction of the papillary muscles and their possible relationships with the mitral prolapse syndrome.