Tinción de Gram intraoperatoria en bilis para la prevención de complicaciones infecciosas en la duodenopancreatectomía / Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

Introducción Las complicaciones infecciosas presentan un papel destacado en la duodenopancreatectomía. Su incidencia aumenta en casos con drenaje biliar preoperatorio (DBP), por el mayor riesgo de bacterobilia. Se presenta un estudio con el objetivo de valorar un protocolo de antibioterapia guiado por una tinción de gram intraoperatoria de líquido biliar. Métodos Estudio retrospectivo en el que se analiza la incidencia de complicaciones infecciosas entre dos grupos de 25 pacientes, consecutivos en el tiempo, intervenidos de duodenopancreatectomía. En el grupo 1 se administró profilaxis con cefazolina en pacientes sin DBP y antibioterapia durante cinco días con piperacilina-tazobactam en casos con DBP. En el grupo 2 se realizó tinción de gram intraoperatoria de bilis de forma sistemática. Si no se detectaban microorganismos, la antibioterapia se limitaba a profilaxis con cefazolina. Si se apreciaba bacterobilia, se administraba antibioterapia dirigida durante cinco días. Resultados La incidencia de infección órgano-cavitaria fue del 24% en el grupo 1 y del 4% en el 2 (p=0,04) y la incidencia de sepsis fue del 32% en el primer grupo y del 4% en el segundo (p=0,01). No se apreciaron diferencias en el resto de variables de morbimortalidad. Los microorganismos más prevalentes en bilis fueron Enterococcus spp y Klebsiella spp. En cultivos postoperatorios, aunque también fueron los más frecuentes en el grupo 1 (28 y 24%), solo aparecieron en el 4% de los casos del grupo 2 (p<0,05) Conclusión La tinción de gram intraoperatoria de bilis podría ser útil para dirigir la antibioterapia en la duodenopancreatectomía y contribuir a reducir las complicaciones infecciosas (AU)

Introduction Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications. Methods A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days. Results The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively). Conclusion Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications (AU)

Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy.

INTRODUCTION: Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications. METHODS: A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days. RESULTS: The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p < 0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp. and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p < 0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively). CONCLUSION: Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.

Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy. / Tinción de Gram intraoperatoria en bilis para la prevención de complicaciones infecciosas en la duodenopancreatectomía.

INTRODUCTION: Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications. METHODS: A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days. RESULTS: The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively). CONCLUSION: Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.

Eficacia de la tinción de Gram de muestras respiratorias para la predicción de la neumonía asociada al respirador y su utilidad en la selección de la terapéutica antibiótica empírica / Efficacy of the Gram stain in respiratory samples for the prediction of ventilation associated pneumonia and its utility in the selection of the initial empiric antibiotic therapy

Introducción: La neumonía asociada a la ventilación (NAV) es una complicación frecuente de la ventilación mecánica (VM) y se asocia a alta mortalidad. Su adecuado manejo se basa en detección precoz y terapia con antibióticos (ATB) empírica eficaz, siendo esenciales los métodos que permitan predecir la NAV y ayuden a seleccionar los ATB. Objetivo: valorar la eficacia del examen directo por tinción de Gram de muestras obtenidas del tracto respiratorio en la detección de NAV y como ayuda a la selección de ATB. Materiales y Métodos: Se incluyeron prospectivamente 95 episodios de sospecha de NAV en 69 pacientes, considerando sólo los casos sin modificación de los ATB por más de 48 hs o sin ATB. Las muestras fueron obtenidas por medio de Lavado bronquioloalveolar a través de Fibro- broncoscopia (BAL) o minibal por catéter envainado a ciegas (miniBal). La confirmación se efectuó por el análisis bacteriológico cuantitativo (> 10 elevado a la cuarta y > 10³ para el BAL y minibal respectivamente). Se calculó la sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y negativo (VPN) de la técnica de tinción directa de Gram, considerando como referencia el resultado microbiológico del cultivo del BAL o mini-BAL. Se comparó además la concordancia entre el tipo de germen observado en la tinción directa de Gram, bacilo Gram negativo (BGN) o coco Gram positivo (CGP) y el tipo de bacteria aislada en el cultivo. Se analizaron también las variables predictivas específicas o cualitativas, esto es la eficacia del Gram en predecir VAP por CGP o por BGN. Resultados: Se diagnosticó NAV en 52 casos. La S de la tinción de Gram fue de 60%, E: 100%, VPP Positivo: 100%, VPN: 67%. En cuanto a la eficacia para predecir VAP por BGN se observó: S: 52%, E: 100%, VPP: 100%, VPN: 72%. Para CGP: s: 91 %, E: 100%, VPP 100% y VPN: 99%. Conclusión: Si bien un examen bacteriológico directo por tinción de Gram predice presencia de VAP, su VPN es bajo por lo que un directo negativo...

Introduction: Ventilator Associated Pneumonia (VAP) is a frequent complication in mechanically ventilated patients, and is associated with a high mortality. Early diagnosis and appropriate use of empiric antibiotic therapy (ATB) is essential to its treatment. Tests that help to make an early diagnosis and select the initial ATB are useful. Objective: to evaluate the accuracy of the Gram stain examination of respiratory tract samples in the prediction of VAP and its potential role in the selection of empiric ATB. Materials and methods: prospective evaluation of 95 episodes in 69 patients with clinical suspicion of VAP who had not had any changes in the ATB for more than 48 hours or had not been treated with ATB. Samples were taken by bronchoalveolar lavage (BAL) through flexible bronchoscopy or blind mini bronchoalveolar lavage with protected catheter. VAP was confirmed when the quantitative cultures showed =10 to the fourth ufc/ml for BAL and =10³ ufc/ml for mini BAL. A comparison was made between the type of bacteria observed by the direct Gram staining (Gram negative bacteria or Gram positive bacteria) and the type of bacteria isolated by culture. Specific or qualitative predictive variables were analyzed to determine the value of Gram staining to predict a Gram-negative VAP or Gram-positive VAP. Results: VAP was confirmed in 52 cases. The sensitivity of the Gram stain for VAP was 60%, specificity 100%; positive predictive value: 100% and negative predictive value: 67%. The sensitivity of Gram negative bacteria for VAP was: 52%; specificity: 100%; positive predictive value: 100%; negative predictive value: 72%. The sensitivity of Gram positive bacteria for VAP was: 91 %; specificity: 100%; positive predictive value: 100%; negative predictive value: 99%. Conclusions: A positive finding in the Gram staining examination of respiratory tract samples was highly predictive of VAP but a negative result did not mean absence of VAP, because the negative...