Pulmonary nocardiosis in heart transplant recipients: treatment and outcome.

BACKGROUND: Nocardial infections typically affect patients receiving immunosuppressants, occurring early after surgery in 3% to 40% of heart transplant (HTx) recipients. The emergence of antibiotic resistance and occurrence of disease recurrences in AIDS population has engendered controversy about the treatment for immunodepressed HTx patients. METHODS: We present a retrospective study of the diagnosis, treatment and outcome of 560 HTx recipients between 1984 and 2002. RESULTS: Among the five cases of Nocardia infection (0.9%), three cases developed late after HTx (between 3.1 and 11 years follow-up). All patients had pulmonary disease and one in addition had subcutaneous nodules. Microbiological diagnosis required open lung biopsy in one case. All patients were treated primarily with trimethoprim-sulphamethoxazole, but evidence of resistance to sulfonamides led us to change the antimicrobial combination in two cases. Four patients who received one year of antibiogram-guided therapy showed complete healing without recidivism. Three patients died, all due to non-related causes, at follow-ups between 1 and 5 years. In one case a cutaneous recurrence of disease was attributed to noncompliance. CONCLUSIONS: Nocardiosis in current HTx is less common than previously reported. Its incidence seems to be delayed in time with modern immunosuppressants. Given the high incidence of sulfamide resistance, treatment must be guided by antibiotic sensitivity. We believe that maintenance therapy for a whole year is the appropriate option in order to avoid recidivism in this population.

[Aspergillosis in pulmonary transplantation]. / Aspergilosis en el trasplante pulmonar.

BACKGROUND: Fungal infections are a frequent cause of morbidity an mortality in transplant recipients. Aspergillus spp. is an ubiquitous fungus capable of producing diverse clinical entities with varying severity. OBJECTIVE: To study the incidence and severity of Aspergillus spp. infections in lung transplantation, analysing the different clinical presentations and response to antifungal drugs. METHODS: A review was made of the clinical histories of all patients undergoing lung transplantation who developed positive Aspergillus spp. cultures in our centre between June 1991 and December 1996. RESULTS: Eleven of 49 transplanted patients (22%) developed Aspergillus spp. infections. Four patients presented invasive aspergillosis forms and 7 tracheobronchitis. In spite of antifungal treatment 3 patients (30%) died of invasive aspergillosis as a direct consequence of the infection. Of the 7 patients with tracheobronchitis, 2 were ulcerative and 1 pseudomembranous, all responded to antifungal treatment. Three patients (10.3%) developed Aspergillus spp. infections despite prophylaxis with itraconazole. CONCLUSION: Invasive aspergillosis in the immediate posttransplant period was mortal despite treatment. As opposed, aspergillar tracheobronchitis have been overcome using combined treatments of liposomal or lipidic amphotericin, itraconazole and nebulised amphotericin.

[Septic arthritis caused by Streptococcus pneumoniae]. / Artritis séptica por Streptococcus pneumoniae.

BACKGROUND: Streptococcus pneumoniae is an uncommon agent of infective arthritis. In this report three cases of pneumococcal arthritis are described. METHODS: Retrospective review of synovial fluids processed in our laboratory yielding bacteria. The study period was from January 1991 to December 1995. The clinical records of patients with the clinical and microbiological diagnosis of septic arthritis were reviewed. RESULTS: Twenty-eight out of a total of 43 clinical records had the clinical and microbiological diagnosis of septic arthritis and three (11%) were caused by Streptococcus pneumoniae. The infective source in two of these three cases was probably the respiratory tract, and the most common location was the knee. CONCLUSIONS: In our cases immunosuppression seemed to be the major risk factor involved in the development of pneumococcal arthritis.

[Infections in lung transplantation]. / Infecciones en el trasplante pulmonar.

Lung transplantation has become the therapeutic hope of terminal respiratory patients. Infections are among the main causes of morbidity and mortality in these patients. We therefore analyze infections suffered after lung transplants performed at Clínica Puerta de Hierro over a two-year period. The cases of 14 transplanted patients, 6 bilateral and 8 unilateral, were analyzed. Pre-transplant data available for all included analysis of serum antibodies to several viruses, as well as bacterial and fungal cultures, and Ziehl's sputum test. All received prophylactic antibiotic, antifungal and antiviral treatment according to protocol. The bronchial aspirate of the donor, and recipient specimens of bronchial aspirate, bronchoalveolar lavage and biopsies obtained by bronchoscopy after transplantation were cultured. Bronchoscopies were performed according to protocol, based on clinical picture. Other cultures were obtained as needed. We recorded 27 respiratory infections, among which 4 were pneumonia transmitted by the donor, 3 were tuberculosis, 3 were Aspergillus infections, 5 were cytomegalovirus pneumonitis and one, P. carinii pneumonia. Lung infections have a strong impact on outcome of lung transplant patients. Knowledge of the chronological development of infections made appropriate prophylaxis and early detection possible, such that survival during the first two years after transplantation was approximately 70% in our hospital.

[Pyogenic liver abscess. A descriptive study of 35 cases]. / Absceso hepático piógeno. Estudio descriptivo de 35 casos.

Thirty-five patients with pyogenic hepatic abscess (PHA) attended over 13 years in a general hospital were studied. The aim of the study was to know the usefulness of the performance of opaque enema in patients with cryptogenic PHA and the prognosis of the patients treated with only antibiotics. The most frequent clinical and analytical manifestations were fever and leukocytosis. Other less frequent findings were abdominal pain, hepatomegaly and elevated alkaline phosphatase and aspartate aminotransferase levels. One third of the patients presented radiologic alterations at the base of the right hemithorax. Colon studies in the patients with cryptogenic PHA performed to discard another origin of the abscess demonstrated very low profitability. Abdominal echography showed adequate sensitivity (0.85) in the diagnosis of PHA and allowed percutaneous drainage to be performed in most of the cases. The patients who were treated with only antibiotics presented a significantly worse prognosis than those treated with antibiotics and drainage (p = 0.03). Drainage of the PHA also allowed a decrease in the length of fever duration.

[Bacteremia associated with mycotic aneurysm of the transversal aortic arch and myocarditis caused by Salmonella enteritidis]. / Bacteriemia asociada a aneurisma micótico de arco aórtico transverso y miocarditis por Salmonella enteritidis.

A 60-year-old male with diabetes mellitus had Salmonella enteritidis bacteremia associated with mycotic aneurysm of the transverse aortic arc and myocarditis. Antibiotic therapy with ampicillin and chloramphenicol was ineffective despite the fact that the microorganism was sensitive in vitro to those antimicrobials, and the patient had a progressive clinical deterioration which culminated in death.

Activity of cefotaxime and amikacin against 14,272 gram-negative bacteria from clinical samples in the period 1980 to 1985.

The sensitivity to cefotaxime and amikacin of 14,272 Gram-negative bacilli (Enterobacteriaceae and non-fermenting Gram-negative bacilli) isolated from clinical samples was studied during the period 1980 to 1985. The minimum inhibitory concentration (MIC) was determined by means of diffusion in agar. Strains were considered resistant to cefotaxime and amikacin if the MIC values were greater than 16 mg/L and greater than 8 mg/L, respectively. The MIC90 reached the critical value for cefotaxime in the case of Citrobacter spp., Escherichia coli, Klebsiella spp., Proteus mirabilis, Salmonella spp. and Shigella spp., and for amikacin in the case of Citrobacter spp., Enterobacter spp., E. coli, Klebsiella spp., P. mirabilis, Proteus vulgaris, Salmonella spp. and Serratia spp. Only Shigella spp. were sensitive to cefotaxime but not to amikacin, and only strains of Enterobacter spp. and Serratia spp. were sensitive to amikacin but not to cefotaxime.