Factors associated with severe sepsis or septic shock in complicated pyelonephritis.

Severe sepsis or septic shock are the main factors influencing the prognosis of acute pyelonephritis (APN). Our aim was to analyze factors associated with the development of severe sepsis or septic shock in a large sample of patients with acute complicated pyelonephritis (ACPN).This prospective observational study comprised 1507 consecutive patients aged 14 years or older who were admitted to a tertiary care hospital because of ACPN between 1997 and 2015. Covariates associated in univariate analysis with severe sepsis or septic shock were then analyzed by multivariate logistic regression.Of the 1507 patients, 423 (28.1%) fulfilled the criteria for severe sepsis or septic shock at the time of admission. Crude and attributable mortality at 30 days were 17.7% and 11.7% in patients with severe sepsis or septic shock versus 1.7% and 0.6% in patients without severe sepsis or septic shock, P < .0001 and P < .0005, respectively. An age > 65 years, urinary instrumentation in the previous 2 weeks, the lack of mictional syndrome or costovertebral tenderness, an ectasia ≥ grade II, and bacteremia were independent risk factors associated with severe sepsis or septic shock.The prevalence of severe sepsis and septic shock in patients with ACPN is high. Some factors associated with severe sepsis are easy to identify in any emergency department. The information provided here could be useful when deciding which patients should be admitted to receive immediate treatment.

Clinical and epidemiological features and prognosis of complicated pyelonephritis: a prospective observational single hospital-based study.

BACKGROUND: Complicated pyelonephritis (cPN), a common cause of hospital admission, is still a poorly-understood entity given the difficulty involved in its correct definition. The aim of this study was to analyze the main epidemiological, clinical, and microbiological characteristics of cPN and its prognosis in a large cohort of patients with cPN. METHODS: We conducted a prospective, observational study including 1325 consecutive patients older than 14 years diagnosed with cPN and admitted to a tertiary university hospital between 1997-2013. After analyzing the main demographic, clinical and microbiological data, covariates found to be associated with attributable mortality in univariate analysis were included in a multivariate logistic regression model. RESULTS: Of the 1325 patients, 689 (52%) were men and 636 (48%) women; median age 63 years, interquartile range [IQR] (46.5-73). Nine hundred and forty patients (70.9%) had functional or structural abnormalities in the urinary tract, 215 (16.2%) were immunocompromised, 152 (11.5%) had undergone a previous urinary tract instrumentation, and 196 (14.8%) had a long-term bladder catheter, nephrostomy tube or ureteral catheter. Urine culture was positive in 813 (67.7%) of the 1251 patients in whom it was done, and in the 1032 patients who had a blood culture, 366 (34%) had bacteraemia. Escherichia coli was the causative agent in 615 episodes (67%), Klebsiella spp in 73 (7.9%) and Proteus ssp in 61 (6.6%). Fourteen point one percent of GNB isolates were ESBL producers. In total, 343 patients (25.9%) developed severe sepsis and 165 (12.5%) septic shock. Crude mortality was 6.5% and attributable mortality was 4.1%. Multivariate analysis showed that an age >75 years (OR 2.77; 95% CI, 1.35-5.68), immunosuppression (OR 3.14; 95% CI, 1.47-6.70), and septic shock (OR 58.49; 95% CI, 26.6-128.5) were independently associated with attributable mortality. CONCLUSIONS: cPN generates a high morbidity and mortality and likely a great consumption of healthcare resources. This study highlights the factors directly associated with mortality, though further studies are needed in the near future aimed at identifying subgroups of low-risk patients susceptible to outpatient management.

Establishing the diagnosis of tuberculous vertebral osteomyelitis.

PURPOSE: The aim of this article has been to analyze the clinical and radiological data suggesting tuberculous vertebral osteomielitis (TVO), and then discuss the steps to be followed to achieve an aetiological diagnosis. METHODS: A thorough literature search was carried out to identify the best clinical and microbiological evidence for a fast and efficient diagnosis of TVO. RESULTS: The clinical and radiological diagnosis of spinal tuberculosis suffers from serious limitations, with a high percentage of cases requiring vertebral biopsy to reach a definitive diagnosis. The increasing incidence of multidrug-resistant tuberculosis has highlighted the insufficiency of the histopathological diagnosis and the need for microbiological diagnosis. Unfortunately, the maximum sensitivity of spinal tuberculosis cultures is 80 %, and traditional methods require 6 to 8 weeks for the isolation, identification and sensitivity study. New culture media and identification methods have improved sensitivity and reduced the time required for the identification. Molecular methods have now been integrated into a single test, with identification of the mycobacterium responsible and its sensitivity to rifampicin. Additionally, multiplex-PCR tests have been developed that allow a rapid differential diagnosis between granulomatous spondylodiscitis. CONCLUSIONS: All patients with subacute inflammatory back or neck pain showing suggestive radiological findings should be studied to rule out TVO. If there is no clear evidence of tuberculosis from another location or indication for surgery, a percutaneous vertebral biopsy should be performed. When TVO is suspected, all spinal or paravertebral tissue samples should be sent simultaneously to pathology and microbiology laboratories for appropriate processing.

Multiplex real-time polymerase chain reaction: a practical approach for rapid diagnosis of tuberculous and brucellar vertebral osteomyelitis.

STUDY DESIGN: Case-control study for assessing a diagnostic test. OBJECTIVE: The aim of this study was to analyze the diagnostic yield of a multiplex real-time polymerase chain reaction (PCR) assay in the differential diagnosis of tuberculous vertebral osteomyelitis (TVO) and brucellar vertebral osteomyelitis (BVO). SUMMARY OF BACKGROUND DATA: Vertebral osteomyelitis (VO) is one of commonest osteoarticular complications of tuberculosis and brucellosis. However, the very similar clinical, radiologic, and histologic characteristics of these entities mean that diagnosis requires etiological confirmation, but conventional microbiologic methods have important limitations. METHODS: Fifteen vertebral samples from patients with TVO or BVO and 9 from pyogenic and nontuberculous mycobacteria VO were studied by multiplex PCR and conventional microbiologic techniques. To identify Brucella DNA, we used a fragment of 207 bp from the conserved region of the gene coding for an immunogenic membrane protein of 31 kDa of B. abortus (BCSP31) and for Mycobacterium tuberculosis complex, a fragment of 164 bp from the intergenic region SenX3-RegX3. RESULTS: The histopathologic findings were inconclusive in 4 of 14 cases (28.6%) with TVO or BVO and cultures were positive in 11 of 15 cases (73.3%). Multiplex PCR correctly identified 14 of the 15 samples from patients with TVO and BVO and was negative in all the control samples. Thus, the overall sensitivity and specificity of the multiplex PCR were 93.3% and 90%, respectively, with an accuracy of 92% (95% CI, 81.4%-100%). CONCLUSION: These results suggest that multiplex real-time PCR is far more sensitive than conventional cultures, and this, together with its speed, makes this technique a very practical approach for the differential diagnosis between TVO and BVO.

Clinical findings, therapeutic approach, and outcome of brucellar vertebral osteomyelitis.

BACKGROUND: Osteoarticular complications are the most common focal complications of brucellosis. Although vertebral osteomyelitis is the most frequent location in adults >30 years of age, little information is available about this serious complication of brucellosis, and great confusion surrounds its prognosis and the most appropriate treatment. METHODS: We undertook a descriptive, retrospective, observational study of 96 patients who received a diagnosis of brucella vertebral osteomyelitis from September 1982 through December 2005 at a tertiary care hospital. All of the patients were treated for 3 months, after which they were followed up monthly for the first 3 months and then at 2-month intervals for the subsequent 6 months. RESULTS: The incidence of vertebral osteomyelitis was 10.4%. The mean diagnostic delay was 12.7 weeks. Inflammatory spinal pain (occurring in 94.8% of patients) and fever (91.7%) were the most relevant clinical characteristics. Eight patients (8.3%) had motor weakness or paralysis. Paravertebral masses, epidural masses, and psoas abscesses were detected in 45.8%, 27.1%, and 10.4% of patients, respectively. Sixty-three patients (65.6%) received medication only, and 33 (34.4%) required surgical therapy in addition to medication. Twenty percent of patients experienced therapeutic failure. Attributable mortality was 2.1%, and severe functional sequelae were apparent in 6.2% of the patients. No significant differences were seen between patients who were treated with doxycycline-streptomycin and those treated with doxycycline-rifampicin. CONCLUSIONS: Vertebral osteomyelitis is a serious complication of brucellosis. It generates a high rate of therapeutic failure and functional sequelae. In the absence of more-powerful controlled studies, the duration of treatment of brucellar vertebral osteomyelitis should be 3 months.