Microbiology of Non-Tunnelled Catheter-Related Infections.

INTRODUCTION: Aerobic bacterial infections often complicate vascular access in patients receiving haemodialysis, leading to Catheter-Related Blood Stream Infections (CRBSI). Various studies report Gram - positive bacteria, Staphylococcus aureus (S. aureus) in particular, as the most common aetiologic agent. Studies on microbiological analysis in this subset of population from India are very few. AIM: To examine clinical and bacteriological profiles of haemodialysis patients developing CRBSI, the antibiotic susceptibility of the bacteria isolated from these patients and determine nasal carriage of S. aureus in the study subjects. MATERIALS AND METHODS: Using a prospective observational design 127 patients receiving haemodialysis (84 males; 43 females) from October 2011 to March 2013 were enrolled in this study. At each dialysis session, catheters were examined for any evidence of infection. In case of suspicion for infection, pus swab, blood culture and the catheter tips were sent to microbiology laboratory for site specific investigations. Vancomycin injection was empirically administered to these patients pending culture results. Data obtained was examined for relationship of CRBSI with clinical and socio-demographic risk factors. RESULTS: Out of 127 patients, 19 developed CRBSI, 10 developed exit-site infections and 33 patients were noted to have colonization of their catheters. The most common organisms included S. aureus in 24 (45.2%) catheter tips, followed by Pseudomonas aeruginosa in 9 (17%), Acinetobacter spp. in 5 (9%), Enterobacter spp. in 4 (7.5%) and Klebsiella pneumoniae in 3 (5.6%) catheter tips. Bacteraemia was found in 19 (20.7%) patients and P. aeruginosa was the most commonly isolated organism amongst them (38.8%). Staphylococcal nasal carriage was seen in 60 (69%) patients and 36 (41.4%) of these isolates were methicillin-resistant. Significant factors associated with CRBSI included history of bacteraemia, presence of diabetes mellitus, long duration (>15 days) of catheterization and antibiotic use within three months (p<0.05 for all). CONCLUSION: Although S. aureus was the most common colonizer of non-tunnelled central access catheters among haemodialysis patients, CRBSI was most frequently caused by P. aeruginosa, which may have a bearing on our current antibiotic policy.

Mucormycosis of the transplanted kidney with renal papillary necrosis.

The occurrence of renal allograft mucormycosis is uncommon, but its association with renal papillary necrosis has not been reported. We describe such an association in a patient who survived on peritoneal dialysis after nephrectomy and antifungal therapy.

Predictors of mortality in acute renal failure in a developing country: a prospective study.

Acute renal failure (ARF) occurs in wide range of conditions, making the evaluation of its prognosis a difficult task. Data regarding prognostic factors in ARF in a general population in developing countries are scarce. The objective of the study was to describe predictors of mortality in ARF that are relevant in the developing world. This prospective study was carried out over a one-year period; all hospitalized adults with ARF were included in the study. Predictors of mortality studied included causes of ARF, pre-existing diseases, and severity as well as complications of ARF. Of 33,301 patients admitted during the study period, 294 (0.88%) were either admitted with or developed ARF after hospitalization. Mean age was 43.9 +/- 16.9 (18-86 yrs). Sepsis was the most common cause (63.26%). Pre-existing diseases like cardiovascular disease (CVSD), respiratory system disease (RSD), central nervous system disease (CNSD), hypertension, diabetes mellitus (DM), and malignancy were significantly higher in elderly as compared to younger patients. On univariate analysis sepsis, hypoperfusion as a cause of ARF and hospital-acquired ARF were associated with higher mortality. Pre-existing diseases viz. RSD, CVSD, CNSD, and DM had higher mortality. Among the severity and complications of ARF, oliguria, bleeding and infection during the course of ARF and critical illness were predictors of poor outcome. Age > 60 yrs was associated with significantly higher mortality. However, on multivariate analysis, only critical illness (odds ratio 37.3), age > 60 years (odds ratio of 5.6), and sepsis as cause of ARF (odds ratio of 2.6) were found to be independent predictors of mortality.

Predictors of mortality in elderly patients with acute renal failure in a developing country.

This prospective study was undertaken to systematically analyze the predictors of mortality in the elderly in a developing country. All elderly patients with ARF hospitalized at this tertiary care centre over 1 year were studied. Various predictors analyzed were hospital-acquired ARF, causative factors of ARF, preexisting hypertension and diabetes mellitus, severity of renal failure (initial and peak serum creatinine, need for dialysis), and complications of ARF: infection during the course of illness; serum albumin levels and critical illness defined as presence of two or more organ system failures excluding renal failure. Of 33,301 patients admitted, 4,255 (12.7%) were elderly. Of these 69 (1.6%) had ARF. On analysis of the whole group, both young and elderly, age >60 years had an independent predictor of mortality (odds ratio 5.6, P = 0.001). Forty-two of the 69 (60.9%) elderly ARF patients died. The mortality was significantly increased in those elderly with hospital-acquired ARF (79.2%, P = 0.027), those with sepsis as a cause of ARF (71.2%, P = 0.004), those who required dialysis (72.5%, P = 0.022), those developing an infection during the course of ARF (87.9%, P = 0.000) and in those with a critical illness (90.0%, P = 0.00). On logistic regression analysis of those variables that were significant on univariate analysis, only critical illness (odds ratio 9.97) and infection during course (odds ratio 9.72) were the independent predictors of mortality. To conclude, ARF complicates only 1.6% of hospitalized elderly patients but is associated with a high mortality rate of 61%. Infection during the course of illness and critical illness were the independent predictors of mortality.

Spectrum of renal failure in elderly patients.

This prospective study was undertaken to study the spectrum of renal failure and the outcome in elderly patients. Patients included in the study group were elderly (age>60 years) who either attended outpatient renal clinic and or were hospitalized. Renal failure was classified as acute renal failure (ARF), rapidly progressive renal failure (RPRF) and chronic renal failure (CRF). A total of 4255 elderly patients were seen, of these 236 (5.5%) had renal failure. Mean age was 65.1+/-4.2 years (60-86 years). CRF was the commonest, seen in 137 (58.1%) followed by ARF 69 (29.2%) and RPRF in 30 (12.7%) patients. Diabetic nephropathy was the commonest cause of CRF, seen in 58.4% followed by chronic interstitial nephritis in 9.5% and chronic glomerulonephritis in 8.7% of patients. Of 137 patients 53 (38.7%) presented in end stage renal disease (ESRD). Of these 41 (77.3%) were initiated on maintenance hemodialysis and 12 (22.6%) on continuous ambulatory peritoneal dialysis. Only 15 patients were on dialytic support at the end of 1 year. Sepsis contributed to ARF in 75.4% of cases. Forty of 69 patients (57.9%) needed dialytic support. Forty (57.9%) were critically ill, defined as presence of two or more organ system failures (excluding renal failure). Forty two patients (60.9%) died patients. Acute interstitial nephritis (AIN) was the commonest cause of RPRF seen in 10 (33.3%) patients followed by vasculitis in 7 (23.3%). Myeloma cast nephropathy contributed towards RPRF in 20% of patients. Of 30 patients, 10 (33.3%) reached ESRD at end of 3 months of follow up, 4 (13.3%) died due to sepsis. Only 2 showed complete recovery while 14 (46.6%) had partial improvement. AIN patients had a relatively better outcome.

Safety of kidney biopsy in elderly: a prospective study.

Kidney biopsy plays an important role in the diagnosis and management of several renal diseases. There is a general reluctance to perform kidney biopsy in elderly due to fear of complications. There is no prospective head to head trial comparing complications of percutaneous kidney biopsy in elderly versus young. This prospective study was undertaken to know the frequency and type of biopsy related complications in elderly. Biopsy was performed using a spring loaded automatic 16 G biopsy gun. Post-biopsy, patients were confined to bed rest for 24 h. A record of intraprocedural problems and post-procedural complications was kept. A total of 210 native kidney biopsies were done of which 26 were performed in elderly patients (61-78 years). Co-morbid conditions were present in 17 patients, some having more than one, hypertension (11), diabetes mellitus (5), chronic obstructive airway disease (6), interstitial lung disease (2) and coronary artery disease (2). Mean serum creatinine was 5.6 mg/dl (range 0.8-14.1 mg/dl). Pre-biopsy dialysis was given to 10 patients. Adequate tissue for histopathological diagnosis was seen in 24 out of 26 biopsies. In two elderly patients biopsy had to be abandoned though indicated due to inability to hold the breath because of underlying lung and cardiac disease. Clinico-pathologic discorrelation was seen in eight patients. Incidence of gross hematuria was more in elderly than in young (4/26 vs. 7/184 P<0.01). Hematuria subsided within 1-2 days in three, one had persistent hematuria for 1 week. Other complications viz. gross hematuria with need of blood transfusions or hemodynamic compromise (0/26 vs. 4/184), perinephric hematoma (0/26 vs. 1/184) and need of intervention (0/26 vs. 1/184) were not higher in the elderly. We conclude that the standard precautions kidney biopsy in elderly is a safe procedure.

Section 136 and African/Afro Caribbean minorities

Social, demographic and clinical information was collected retrospectively on all 99 people referred to a South London hospital in 1986 under Section 136 of the Mental Health Act (1983), this being the last complete year before local changes in the procedure for assessment of Section 136 cases were initiated. An over-representation of Afro-Caribbeans was confirmed and thia seemed to be accounted for largely by young men under the age of 30 who with Africans had very high rates of previous Section 136 referral, were more likely to be percieved as threatening, incoherent and disturbed but less clearly diagnosed with a mental illness, and were more likely than the Caucasian sample to be living in stable accommodation. The implications of these results are discussed. (Summary)