[Infections by OXA-48 carbapenemase-producing Enterobacteriaceae in surgical patients: antibiotic consumption and susceptibility patterns]

Objetivos

Analizar la administración de antibióticos, la evolución temporal de sensibilidades y el tratamiento dirigido de las infecciones asociadas a enterobacterias productoras de carbapenemasas (EPC) OXA-48 en un servicio de Cirugía General y Digestivo.

Material y métodos

Estudio observacional retrospectivo, incluyendo pacientes con cultivo positivo de OXA-48 y datos clínicos de infección activa, hospitalizados en un servicio de Cirugía General y Digestivo entre enero 2013 y diciembre 2018.

Resultados

Se incluyeron 65 pacientes, con 66 aislamientos de OXA-48: Klebsiella pneumoniae, 57 (86,5%); Enterobacter cloacae, 5 (7,6%); Escherichia coli, 3 (4,5%); Morganella morganii, 1 (1,5%). La infección intraabdominal fue la más común (n=39, 60%), y el consumo previo de antibióticos fue: piperacilina-tazobactam (48%), meropenem (45%), ciprofloxacino (25,5%), ertapenem (16,5%), imipenem (12%), amikacina (12%), tigeciclina (12%). La evolución temporal (2013/14, 2015/16 y 2017/18) de las sensibilidades (porcentajes) según antibiograma fue: ceftazidima-avibactam X-X-100; amikacina 100-96-84 (p=0,518); tigeciclina 100-92-80 (p=0,437); colistina 100-67-66 (p<0,001); meropenem 37-64-72 (p=0,214); imipenem 51-41-77 (p=0,109); gentamicina 13-19-18 (p=0,879); ertapenem 35-0-0 (p<0,001). El tratamiento dirigido tuvo una mediana de duración de 14 [RIQ 9-20] días, destacando en frecuencia: tigeciclina (57%); meropenem (40,5%); amikacina (37,5%); ceftazidima-avibactam (9%); imipenem (7,5%); colistina (7,5%). La mortalidad global a 30 días fue del 12% (8 individuos). El tratamiento dirigido fue adecuado según antibiograma en el 87,7%, utilizando un régimen de terapia combinada en el 76,9%, régimen que incluyó algún carbapenémico en el 49,2%.

Conclusiones

En Cirugía General y Digestivo destaca la infección intraabdominal asociada a OXA-48, con elevado consumo previo de antibióticos de amplio espectro. El tratamiento dirigido con mayor sensibilidad de cepas productoras de OXA-48 incluye ceftazidima-avibactam, amikacina, tigeciclina, meropenem e imipenem.

Conservative Management of Gallstone Disease in the Elderly Population: Outcomes and Recurrence

BACKGROUND & AIMS

The prevalence of gallstone disease increases with age, being early cholecystectomy the most accepted treatment in the vast majority of patients in order to prevent complications and recurrence. The aim of this study is to determine the recurrence rate and its possible predictors after initial non-operative management.

MATERIALS AND METHODS

We reviewed a consecutive series of patients, older than 65 years, admitted for a gallstone-related disease and treated with a non-operative management between January 2010 and December 2013. We analyzed comorbidities, clinical data, diagnosis, management, recurrence, and its treatment. Median follow-up after the discharge was 2 years. Recurrence was analyzed by a Kaplan-Meier survival curve. Possible recurrence's predictors were analyzed.

RESULTS

The study included 226 patients. Mean age was 80.4 ± 7.2 years, 127 (56%) were female. The main causes of index hospitalization were acute cholecystitis (58%) and biliary pancreatitis (18.1%). After 2 years of follow-up, the recurrence rate was 39.8%; mean time to recurrence was 255.2 ± 42.1 days, 81% of patients recurred within 1 year. Bile duct disease implied a higher recurrence rate than the gallbladder disease group (52% vs 33%, p < 0.001). Subjects with two or more diagnoses during index admission presented higher recurrence rate (32% vs 49%, p < 0.001).

CONCLUSION

More than a third of elderly patients could present a recurrence within 2 years after initial non-operative management. Early cholecystectomy should be considered at index admission in order to prevent recurrence.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

Neuroendocrine tumour arising inside a tailgut cyst

Tailgut cysts are rare benign retrorectal cysts arising from persistent remnants of an embryonic hindgut. Malignant transformation inside this lesion is very uncommon and occurrence of neuroendocrine tumours in this context is extremely rare. We report the case of a 56-year-old woman who underwent surgical excision of a presacral tailgut cyst, which was found incidentally to include a neuroendocrine tumour.