RESUMEN
Prevalence and clinical impact of viral respiratory tract infections (VRTIs) on community-acquired pneumonia (CAP) has not been well defined so far. The aims of this study were to investigate the prevalence and the clinical impact of VRTIs in patients with CAP. Prospective study involving adult patients consecutively admitted at medical wards for CAP and tested for VRTIs by real-time PCR on pharyngeal swab. Patients' features were evaluated with regard to the presence of VRTI and aetiology of CAP. Clinical failure was a composite endpoint defined by worsening of signs and symptoms requiring escalation of antibiotic treatment or ICU admission or death within 30 days. 91 patients were enrolled, mean age 65.7 ± 10.6 years, 50.5% female. 62 patients (68.2%) had no viral co-infection while in 29 patients (31.8%) a VRTI was detected; influenza virus was the most frequently identified (41.9%). The two groups were similar in terms of baseline features. In presence of a VRTI, pneumonia severity index (PSI) was more frequently higher than 91 and patients had received less frequently pre-admission antibiotic therapy (adjusted OR 2.689, 95% CI 1.017-7.111, p = 0.046; adjusted OR 0.143, 95% CI 0.030-0.670, p = 0.014). Clinical failure and antibiotic therapy duration were similar with regards to the presence of VRTI and the aetiology of CAP. VRTIs can be detected in almost a third of adults with CAP; influenza virus is the most relevant one. VRTI was associated with higher PSI at admission, but it does not affect patients' outcome.
Asunto(s)
Infecciones Comunitarias Adquiridas/microbiología , Neumonía/microbiología , Infecciones del Sistema Respiratorio/virología , Anciano , Coinfección , Infecciones Comunitarias Adquiridas/epidemiología , Femenino , Hospitalización , Humanos , Italia/epidemiología , Masculino , Neumonía/epidemiología , Prevalencia , Estudios Prospectivos , Infecciones del Sistema Respiratorio/epidemiologíaRESUMEN
Visceral artery aneurysms represent a very rare condition. The affected patients usually present as emergency secondary to the sudden rupture of the aneurysm or as an incidental finding on imaging. In this setting, gastric and gastroepiploic aneurysms account for only about 4% of all the splancnic aneurysms. Since ruptured visceral aneurysms present a high mortality, a prompt and adequate (surgical or radiological interventional) treatment is mandatory. Due to the difficulty in achieving an adequate transcatheter access in some cases the emergency laparotomy may represent the only chance for the recover of the affected patients. We report two cases of ruptured left gastroepiploic aneurysms occurred in two young male patients, treated respectively with emergency laparotomy and laparoscopy.
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Aneurisma Roto/complicaciones , Arteria Gastroepiploica/lesiones , Hemorragia/etiología , Enfermedades Raras/complicaciones , Adulto , Aneurisma Roto/cirugía , Urgencias Médicas , Hemorragia/cirugía , Humanos , Laparoscopía , Laparotomía , Masculino , Enfermedades Raras/cirugía , Espacio Retroperitoneal , Rotura Espontánea/etiología , Rotura Espontánea/cirugía , Adulto JovenRESUMEN
BACKGROUND AND AIMS: Recently, the albuminocentric view of diabetic kidney disease (DKD) in type 2 diabetes (T2DM) has been changing. Therefore, the relationship between diabetic retinopathy (DR) and chronic kidney disease (CKD) has to be addressed according to this new clinical presentation of DKD. The aim of this study was to evaluate, in a real-world setting, the correlation DR-DKD in T2DM. METHODS AND RESULTS: A total of 2068 type 2 diabetic patients enrolled in a multicenter cross-sectional study were investigated. Albuminuric subjects were largely prevalent among subjects with DR (p = 0.019). In the whole study population, no difference in albumin excretion rate (AER) was observed between presence/absence of DR; instead, AER was significantly higher among patients with glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 (CKD) (p = 0.009), above all in those with CKD and AER ≥0.03 g/24 h (p = 0.005). Multivariate analysis confirmed that eGFR (O.R. 0.976; 95% C.I.: 0.960-1.028; p < 0.001) and AER (O.R. 1.249; 95% C.I. 1.001-1.619; p = 0.004) were independently associated with DR and HDL-cholesterol (O.R.: 1.042; 95% C.I.: 1.011-1.120; p = 0.014). Additionally, among patients with eGFR <60 mL/min/1.73 m2 and albuminuria, both eGFR and AER significantly varied between those with/without DR (p = 0.012 and p = 0.005, respectively), and this finding was observed among only albuminuric patients. Analogous results were obtained considering DR classification. AER was significantly higher among subjects with either proliferative DR (PDR) or severe nonproliferative DR (NPDR), with regard to mild NPDR (0.498 and 0.938 g/die vs. 0.101 g/die; p < 0.001, respectively). Similar results were obtained in the specular subgroups. CONCLUSION: In T2DM with DKD, the AER seems to be related to the presence of DR. This association is confirmed above all in those with more severe DR.
Asunto(s)
Albuminuria/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Nefropatías Diabéticas/epidemiología , Retinopatía Diabética/epidemiología , Insuficiencia Renal Crónica/epidemiología , Anciano , Albuminuria/diagnóstico , Albuminuria/fisiopatología , Estudios Transversales , Diabetes Mellitus Tipo 2/diagnóstico , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/fisiopatología , Retinopatía Diabética/diagnóstico , Retinopatía Diabética/fisiopatología , Femenino , Tasa de Filtración Glomerular , Humanos , Italia/epidemiología , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Eliminación Renal , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/fisiopatología , Factores de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
Visceral leishmaniasis has been recognized as an opportunistic infection affecting people with cellular-immunity impairment, including hematopoietic cell transplantation (HCT) recipients. We describe the case of a young Italian man with Hodgkin lymphoma, who developed visceral leishmaniasis after multiple lines of chemotherapy and allogenic HCT. Literature review of visceral leishmaniasis in HCT recipients was also performed. Eleven patients (median age 50 years, 9 male) developed visceral leishmaniasis after allogenic (n = 9) and autologous (n = 2) HCT. Most of them presented with fever and pancytopenia. Bone marrow examination was the main diagnostic technique; liposomal amphotericin B was the treatment of choice. Four out of eight patients (for whom data are available) experienced visceral leishmaniasis relapse. Visceral leishmaniasis in HCT recipients is a rare event that should be suspected in patients with persistent fever, pancytopenia and possible exposure to Leishmania spp., remembering that - as well as South-East Asia, East Africa and South America - it is endemic in several European regions.
Asunto(s)
Anticuerpos Antiprotozoarios/inmunología , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Enfermedad de Hodgkin/terapia , Leishmania/inmunología , Leishmaniasis Visceral/parasitología , Infecciones Oportunistas/parasitología , Adulto , Anfotericina B/administración & dosificación , Anfotericina B/uso terapéutico , Anticuerpos Antiprotozoarios/sangre , Antineoplásicos/uso terapéutico , Antiprotozoarios/administración & dosificación , Antiprotozoarios/uso terapéutico , Examen de la Médula Ósea , Resultado Fatal , Femenino , Enfermedad de Hodgkin/tratamiento farmacológico , Humanos , Leishmania/genética , Leishmania/aislamiento & purificación , Leishmaniasis Visceral/sangre , Leishmaniasis Visceral/diagnóstico , Leishmaniasis Visceral/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Infecciones Oportunistas/sangre , Infecciones Oportunistas/diagnóstico , Infecciones Oportunistas/tratamiento farmacológico , RecurrenciaRESUMEN
INTRODUCTION: the purpose of this retrospective multicenter study was to assess whether the risk of developing bloodstream infections (BSI) due to carbapenem-resistant Klebsiella pneumoniae (CRKP) in colonized patients is influenced by the occurrence of BSI due to other pathogens. METHODS: from January 2012 to March 2014, all patients with at least one rectal swab positive for CRKP and at least 30 days of previous hospital stay were included in the study. The primary outcome measure was CRKP BSI, defined as a time-to-event endpoint. The role of potential predictors was evaluated through univariable and multivariable Cox regression analyses, considering previous BSI as a time-dependent variable. RESULTS: during the study period, 353 patients met the inclusion criteria. Thirty-seven developed a CRKP BSI (11%). A higher incidence of CRKP BSI was observed in presence rather than in absence of previous BSI. In the final multivariable model of risk factors for CRKP BSI, multisite colonization (hazard ratio [HR] 13.73, 95% confidence intervals [CI] 3.29-57.32, p < 0.001), ICU stay (HR 3.14, 95% CI 1.19-8.31, p = 0.021), and previous BSI (p = 0.026, with the overall effect being mainly due to Enterococcus spp. BSI vs absence of BSI, HR 6.62, 95% CI 2.11-20.79) were associated with the development of CRKP BSI, while an inverse association was observed for age (HR 0.98, 95% CI 0.95-1.00, p = 0.027). CONCLUSIONS: previous BSI due to other pathogens were associated with an increased risk of CRKP BSI that was independent of other factors in colonized patients with prolonged hospital exposure.
Asunto(s)
Antibacterianos/farmacología , Bacteriemia/microbiología , Carbapenémicos/farmacología , Infecciones por Klebsiella/microbiología , Klebsiella pneumoniae/efectos de los fármacos , Resistencia betalactámica , Anciano , Bacteriemia/epidemiología , Femenino , Humanos , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
The aim of this study was to evaluate the sensitivity and the levels of 1,3-ß-d-glucan (BDG) among patients with candidaemia due to different Candida species. Retrospective study of all patients who had a single-species candidaemia and BDG testing performed within 48 h from the onset of candidaemia during 2009-2015 was performed. Factors influencing the sensitivity of BDG, including the presence of a central venous catheter, antifungal therapy and Candida species, were analysed in univariate and multivariate models. In all, 107 patients with the following Candida distribution were included: 46 (43%) Candida albicans, 37 (35%) Candida parapsilosis, and 24 (22%) other species. BDG sensitivity and levels were the highest in C. albicans candidaemia and lowest for C. parapsilosis (respectively, 72% and 410 pg/mL for C. albicans, 41% and 39 pg/mL for C. parapsilosis, and 63% and 149 pg/mL for other species; p 0.015 and p 0.003). In multivariate analysis, Candida species (parapsilosis versus others) was the only factor influencing the sensitivity of BDG (OR 0.3, 95% CI 0.1-0.7, p 0.006). The sensitivity of BDG in candidaemia seems highly dependent on the fungal species, with the lowest being for C. parapsilosis.
Asunto(s)
Candida/aislamiento & purificación , Candidemia/diagnóstico , Candidemia/microbiología , Pruebas Diagnósticas de Rutina/métodos , Suero/química , beta-Glucanos/sangre , Anciano , Anciano de 80 o más Años , Candida/clasificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proteoglicanos , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
Limited information is available on the incidence of Clostridium difficile infections (CDIs) in Italian hospitals. In this study, we assessed the changes in the incidence of CDI over a 5-year period in a teaching hospital in Liguria, the Italian region with the oldest population. Secondary endpoints were the development of severe CDI and 30-day mortality. The annual incidence of CDI/10000 patient-days significantly increased from 0·54 in 2010 to 3·04 in 2014 (χ 2 for trend, P < 0·001). The median age of patients with CDI was 81 years. As many as 81% and 89% of these patients had comorbid conditions and previous exposure to antibiotics, respectively. In the multivariate analysis of risk factors for severe CDI, previous therapy with histamine 2 blockers and low serum albumin were associated with severe CDI, while diabetes appeared to be protective. In the multivariate model of risk factors for 30-day mortality, high leukocyte count, low serum albumin, and increased serum creatinine were unfavourably associated with outcome. Strict adherence to infection control measures was of utmost importance to counteract the increasing incidence of CDI in our hospital, particularly because of the advanced age of the patients and their very high frequency of chronic conditions and use of antibiotics, which readily predispose them to the development of CDI.
Asunto(s)
Clostridioides difficile/fisiología , Infecciones por Clostridium/epidemiología , Hospitales de Enseñanza , Factores de Edad , Anciano , Anciano de 80 o más Años , Infecciones por Clostridium/microbiología , Infecciones por Clostridium/mortalidad , Femenino , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Incidencia , Italia/epidemiología , Masculino , Análisis Multivariante , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyradiculoneuropathy, usually triggered by an infectious episode, mostly of viral origin. Varicella zoster virus (VZV) is a rare cause of GBS, mainly in the case of latent infection reactivation. We report on three adult patients who developed GBS following chickenpox, after a short period of latency. They were promptly treated with intravenous immunoglobulin, and the first one with plasma exchange additionally. All the patients experienced almost complete clinical recovery. Our experience suggests that primary VZV infection constitutes a GBS triggering event.
Asunto(s)
Varicela/complicaciones , Síndrome de Guillain-Barré/terapia , Inmunoglobulinas Intravenosas/uso terapéutico , Factores Inmunológicos/uso terapéutico , Intercambio Plasmático , Adulto , Femenino , Síndrome de Guillain-Barré/tratamiento farmacológico , Síndrome de Guillain-Barré/etiología , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
The increasing prevalence of colistin resistance (ColR) Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (Kp) is a matter of concern because of its unfavourable impact on mortality of KPC-Kp bloodstream infections (BSI) and the shortage of alternative therapeutic options. A matched case-control-control analysis was conducted. The primary study end point was to assess risk factors for ColR KPC-Kp BSI. The secondary end point was to describe mortality and clinical characteristics of these infections. To assess risk factors for ColR, 142 patients with ColR KPC-Kp BSI were compared to two controls groups: 284 controls without infections caused by KPC-Kp (control group A) and 284 controls with colistin-susceptible (ColS) KPC-Kp BSI (control group B). In the first multivariate analysis (cases vs. group A), previous colistin therapy, previous KPC-Kp colonization, ≥3 previous hospitalizations, Charlson score ≥3 and neutropenia were found to be associated with the development of ColR KPC-Kp BSI. In the second multivariate analysis (cases vs. group B), only previous colistin therapy, previous KPC-Kp colonization and Charlson score ≥3 were associated with ColR. Overall, ColR among KPC-Kp blood isolates increased more than threefold during the 4.5-year study period, and 30-day mortality of ColR KPC-Kp BSI was as high as 51%. Strict rules for the use of colistin are mandatory to staunch the dissemination of ColR in KPC-Kp-endemic hospitals.
Asunto(s)
Bacteriemia/epidemiología , Colistina/uso terapéutico , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/clasificación , Anciano , Bacteriemia/microbiología , Bacteriemia/mortalidad , Estudios de Casos y Controles , Farmacorresistencia Bacteriana Múltiple , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Infecciones por Klebsiella/mortalidad , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
A retrospective study was conducted to assess the role of initial serum (1,3)-ß-d-glucan (BDG) values in predicting mortality in proven candidaemia. The study was conducted in two large teaching hospitals in Italy and Brazil. From January 2009 to June 2014, all patients with proven candidaemia who underwent a BDG test within 96 hours before or after the first positive blood culture were included in the study. The primary end point was 28-day mortality, with the role of initial BDG being assessed by univariate and multivariate analyses. A total of 104 patients met the inclusion criteria. Overall, the crude 28-day mortality was 30% (31/104). In the final multivariate model, an initial BDG of >287 pg/mL (odds ratio (OR) 4.40, 95% confidence interval (CI) 1.56-12.39, p 0.005), haemodialysis (OR 4.33, 95% CI 1.24-15.17, p 0.022) and a Pitt score of ≥ 2 (OR 4.10, 95% CI 1.24-13.54, p 0.021) were significant predictors of 28-day mortality. The >287 pg/mL cutoff predicted 28-day mortality with 65% sensitivity and 70% specificity. Centre of enrolment (p for interaction 0.012), haemodialysis (p for interaction 0.062) and timing of BDG test of more than 24 hours before or after the positive culture (p for interaction 0.143) appeared to interact with BDG's ability to predict mortality. Although not statistically significant, the last two of these interactions might partially explain why BDG's ability to predict mortality was present only in the Italian cohort.
Asunto(s)
Biomarcadores/sangre , Candidemia/diagnóstico , Candidemia/patología , Técnicas de Apoyo para la Decisión , Suero/química , beta-Glucanos/sangre , Adulto , Anciano , Anciano de 80 o más Años , Brasil , Candidemia/mortalidad , Femenino , Hospitales de Enseñanza , Humanos , Italia , Masculino , Persona de Mediana Edad , Pronóstico , Proteoglicanos , Estudios Retrospectivos , Sensibilidad y Especificidad , Análisis de SupervivenciaRESUMEN
BACKGROUND: Concomitant systemic and intracatheter antibiotic therapy is a therapeutic option for catheter-related bloodstream infections (CRBSI) in patient fitted with long-term intravenous central catheters. CRBSI are mainly caused by Gram-positive bacteria. Daptomycin (DPT) is an antibiotic active against Gram-positive bacteria with high bactericidal activity and good biofilm penetration. OBJECTIVE: To study the efficacy of DPT given systemically and as lock therapy in the treatment of CRBSI. MATERIALS AND METHODS: A retrospective review was conducted of adult patients with a long-term central venous catheter (CVC) receiving both systemic intravenous and intracatheter lock therapy for CRBSI. The primary outcome was catheter maintenance, following clinical success and microbiological eradication. RESULTS: Eight patients who had failed previous standard therapy (vancomycin 7, cefazolin 1) were included in the study. In all but one, coagulase-negative staphylococci were repeatedly isolated. The other patient had enterococcal infection. DPT, given intravenously and as lock therapy, was successful in six of eight cases. The mean time to negative blood cultures was 2 days (range 1-6). In two cases neither clinical nor microbiological response was documented and the catheter was removed. DISCUSSION: Systemic and intracatheter therapy with DPT is feasible, carries no toxicity and is apparently effective. DPT might be a suitable therapeutic option in CRBSI to achieve CVC sterilization and preserve the catheter.
Asunto(s)
Antibacterianos , Bacteriemia/tratamiento farmacológico , Infecciones Relacionadas con Catéteres/tratamiento farmacológico , Catéteres Venosos Centrales/efectos adversos , Daptomicina , Administración Intravenosa , Adulto , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Daptomicina/administración & dosificación , Daptomicina/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Ninety-one serum samples from 51 hematology patients with bacteremia infections were tested for (1,3)-ß-d-glucan (BG). Eleven samples (15%) from 7 patients (14%) were positive for BG. Of these 7 patients with positive BG results, 4 (8%) had invasive aspergillosis and 3 (6%) had no invasive fungal disease. Bacteremia was an unlikely cause of the false-positive BG results.
Asunto(s)
Reacciones Falso Positivas , Neoplasias Hematológicas/complicaciones , Aspergilosis Pulmonar Invasiva/diagnóstico , Aspergilosis Pulmonar Invasiva/patología , Suero/química , beta-Glucanos/sangre , Humanos , ProteoglicanosRESUMEN
Knowledge of carbapenem-resistant Klebsiella pneumoniae (CR-KP) colonization is important to prevent nosocomial spread but also to start prompt adequate antibiotic therapy in patients with suspicion of infection. However, few studies have examined the incidence and risk factors for CR-KP bloodstream infection (BSI) among rectal carriers. To identify risk factors for CR-KP BSI among carriers, we performed a multicentre prospective matched case-control study of all adult CR-KP rectal carriers hospitalized in five tertiary teaching hospitals in Italy over a 2-year period. Carriers who developed CR-KP BSI were compared with those who did not develop subsequent BSI. Overall, 143 CR-KP BSIs were compared with 572 controls without a documented infection during their hospitalization. Multivariate analysis revealed that admission to the Intensive Care Unit (ICU) (OR, 1.65; 95% CI, 1.05-2.59; p 0.03), abdominal invasive procedure (OR, 1.87; 95% CI, 1.16-3.04; p 0.01), chemotherapy/radiation therapy (OR, 3.07; 95% CI, 1.78-5.29; p <0.0001), and number of additional colonization sites (OR, 3.37 per site; 95% CI, 2.56-4.43; p <0.0001) were independent risk factors for CR-KP BSI development among CR-KP rectal carriers. A CR-KP BSI risk score ranging from 0 to 28 was developed based on these four independent variables. At a cut-off of ≥2 the model exhibited a sensitivity, specificity, positive predictive value and negative predictive value of 93%, 42%, 29% and 93%, respectively. Colonization at multiple sites with CR-KP was the strongest predictor of BSI development in our large cohort of CR-KP rectal carriers.
Asunto(s)
Antibacterianos/farmacología , Carbapenémicos/farmacología , Portador Sano/epidemiología , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/efectos de los fármacos , Recto/microbiología , Resistencia betalactámica , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Portador Sano/microbiología , Estudios de Casos y Controles , Femenino , Hospitales de Enseñanza , Humanos , Incidencia , Italia/epidemiología , Infecciones por Klebsiella/microbiología , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Centros de Atención Terciaria , Adulto JovenRESUMEN
HBsAg-negative/HBcAb-positive haematopoietic stem cell transplant (HSCT) recipients are at high risk of hepatitis B virus (HBV) reactivation. Allogeneic HSCT recipients from years 2000 to 2010 were evaluated in order to study the impact of being HBsAg-negative/HBcAb-positive in this population. Overall, 137 of 764 patients (18%) were HBsAg-negative/HBcAb-positive before HSCT. Overall survival, non-relapse mortality (NRM), acute and chronic graft-vs.-host disease were similar in HBcAb-positive and HBcAb-negative patients. Reactivation occurred in 14 patients (10%) within a median of 19 months after HSCT (range 9-77). Cause-specific hazard for reactivation was decreased in the case of an HBV-immune/exposed donor (HRadjusted = 0.12; 95% CI, 0.02-0.96; p 0.045) and increased in patients who received rituximab treatment (HRadjusted = 2.91; 95%CI, 0.77-10.97; p 0.11). Competing risk analyses documented a protective role of an HBV-immune/exposed donor (p 0.041) and an increased probability associated with the length of treatment with cyclosporine (p <0.001) and treatment with rituximab (but not with low-dose rituximab prophylaxis, p <0.001 at each landmark point). No differences in overall survival and NRM were found between patients with and without HBV reactivation. The donor's immunity was independently and consistently associated with a decreased risk of HBV reactivation, while rituximab and cyclosporine treatments increased the probability.
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Trasplante de Células Madre Hematopoyéticas/efectos adversos , Antígenos de Superficie de la Hepatitis B/análisis , Virus de la Hepatitis B/fisiología , Activación Viral , Adolescente , Adulto , Anciano , Anticuerpos Monoclonales de Origen Murino/efectos adversos , Niño , Ciclosporina/efectos adversos , Femenino , Enfermedad Injerto contra Huésped/inmunología , Humanos , Inmunosupresores/efectos adversos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Rituximab , Análisis de Supervivencia , Receptores de Trasplantes , Trasplante Homólogo , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Invasive candidiasis (IC) has primarily been studied in intensive care unit (ICU) patients, although, in reality, a vast majority of these infections occur outside of the ICU. The recent publication of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines also deal with the non-ICU population, but many uncertainties remain on the management of IC, particularly in non-critically ill patients. METHODS: The Italian Society of Antimicrobial Therapy, Società Italiana di Terapia Antimicrobica (SITA), produced practical, hospital-wide recommendations on the management of Candida infection in non-immunocompromised patients in the hospital ward. RESULTS AND DISCUSSION: Our focus is on patient stratification in terms of risk factors for IC and of clinical severity, emphasising a high index of suspicion to ensure early diagnosis, early treatment and de-escalation when a patient is clinically stable, in order to optimise resource allocation.
Asunto(s)
Antifúngicos/uso terapéutico , Candidiasis Invasiva/tratamiento farmacológico , Candidiasis Invasiva/diagnóstico , Candidiasis Invasiva/epidemiología , Candidiasis Invasiva/prevención & control , Consenso , Humanos , Italia/epidemiología , Factores de RiesgoRESUMEN
OBJECTIVES: Galactomannan (GM) testing is extremely useful for diagnosing invasive aspergillosis in high-risk patients, but false-positive results have been reported in patients treated with piperacillin/tazobactam. The aims of this study are to test if the recent piperacillin/tazobactam (Tazocin™; Pfizer) preparation still contains GM, and if serum GM positivity in haematopoietic stem cell transplant (HSCT) recipients receiving piperacillin/tazobactam can be attributed to this treatment. PATIENTS AND METHODS: Serum samples obtained from 1 October 2009 to 31 October 2010 from HSCT recipients for GM testing were analysed. The difference in the rate of positive results (defined as GM ≥ 0.5) in patients receiving and not receiving piperacillin/tazobactam was evaluated. Piperacillin/tazobactam vials from randomly selected batches were tested. RESULTS: Of 1606 samples drawn in the absence of piperacillin/tazobactam therapy, 25 (1.6%) tested positive for GM versus 10 of 394 samples (2.5%) drawn while on piperacillin/tazobactam (P = 0.18). The median GM result of samples drawn on piperacillin/tazobactam was slightly higher than that of samples drawn in the absence of piperacillin/tazobactam (0.141 versus 0.122; P < 0.001). All 90 piperacillin/tazobactam vials from 30 randomly selected batches tested negative for GM, with a median GM value of 0.057 (range: 0.011-0.320). CONCLUSIONS: Although some residual GM might still be present in piperacillin/tazobactam, currently available brand piperacillin/tazobactam preparations seem no longer responsible for false-positive GM results.
Asunto(s)
Antibacterianos/administración & dosificación , Aspergilosis/diagnóstico , Reacciones Falso Positivas , Mananos/sangre , Antibacterianos/química , Galactosa/análogos & derivados , Trasplante de Células Madre Hematopoyéticas , Humanos , Ácido Penicilánico/administración & dosificación , Ácido Penicilánico/análogos & derivados , Ácido Penicilánico/química , Piperacilina/administración & dosificación , Piperacilina/química , Combinación Piperacilina y TazobactamRESUMEN
PURPOSE: Bloodstream infections (BSIs) are frequent after allogeneic haematopoietic stem cell transplantation (HSCT). The aim of this study was to identify predictors of mortality after BSI in patients who undergo HSCT. METHODS: Patients who underwent HSCT between 1 January 2004 and 31 January 2008 and developed BSI during the first year post-transplantation were included. Variables influencing overall mortality at 7 and 30 days after BSI were analysed. RESULTS: BSIs developed in 149 patients, within a median of 9 days after undergoing HSCT. Early and late mortality were 15 and 27%, respectively. Of the BSI, 54% were due to Gram-positive microorganisms, 33% were due to Gram-negative microogranisms, 10% were polymicrobial and 3% were fungal. The associated 7-and 30-day mortality was respectively 10 and 24% (Gram positive), 22 and 31% (Gram negative; Pseudomonas aeruginosa mortality 67%, all within 7 days), 13 and 27% (polymicrobial) and 40% (fungal, all within 7 days). Early mortality was higher in relapsed disease at HSCT (25.9%, p = 0.01), but lower in early (i.e. within 20 days of HSCT) BSI (11.7%, p = 0.03) and BSI due to Gram-positive infective agents (10%, p = 0.05). Multivariate analysis confirmed a higher mortality in late BSI [odds ratio (OR) 3.29, p = 0.03] and relapsed disease at HSCT (OR 2.2, p = 0.04). Late mortality was associated with the type of underlying disease (OR 0.44 for diseases other than acute leukaemia, p = 0.05) and its status (OR 6.04 for relapse at HSCT, p = 0.001). Appropriate empirical therapy was associated with lower early and late mortality in single Gram-negative BSI (16 vs. 45% for 7-day mortality, p = 0.09; 21 vs. 64% for 30-day mortality, p = 0.02). CONCLUSIONS: BSIs are frequent during the first year after HSCT and are associated with a high mortality rate. The aetiology influenced early mortality, while the type and phase of the underlying disease played a pivotal role in late mortality. Appropriate empirical therapy is crucial in BSI due to Gram-negative infective agents.
Asunto(s)
Bacteriemia/mortalidad , Coinfección/mortalidad , Fungemia/mortalidad , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Adolescente , Adulto , Anciano , Bacteriemia/epidemiología , Bacteriemia/microbiología , Bacterias/aislamiento & purificación , Estudios de Cohortes , Coinfección/epidemiología , Coinfección/microbiología , Femenino , Fungemia/epidemiología , Fungemia/microbiología , Hongos/aislamiento & purificación , Trasplante de Células Madre Hematopoyéticas/mortalidad , Trasplante de Células Madre Hematopoyéticas/estadística & datos numéricos , Humanos , Italia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Factores de Tiempo , Trasplante Homólogo/efectos adversos , Trasplante Homólogo/mortalidad , Trasplante Homólogo/estadística & datos numéricos , Adulto JovenRESUMEN
The proportion of patients with hematological malignancies (HM) who develop rare invasive fungal infections (IFI) has increased worldwide over the past few decades. Zygomycosis is an opportunistic fungal infection, which begins in the nose and paranasal sinuses due to inhalation of fungal spores. Rhino-cerebral zygomycosis is the most common form of the disease, it typically develops in diabetic or immunocompromised patients and presents as an acute fulminate infection, which is often lethal. We report a case of rhino-cerebral zygomycosis in an allotransplanted patient to emphasize early diagnosis and treatment of this potentially fatal fungal infection. We discuss different risk factors, specific diagnosis procedures and review the current concepts in management of zygomycosis.