Ángel Asensio

Effect of antibiotic prophylaxis on the risk of surgical site infection in orthotopic liver transplant

Surgical site infections are common bacterial infections in orthotopic liver transplantation. The purpose of this study was to determine the incidence, timing, location, and risk factors, specifically antibiotic prophylaxis, for surgical site infections. A prospective study was performed that included a population of 1222 consecutive patients (73.0% males) who underwent liver transplantation in Spanish hospitals belonging to the Red de Estudio de la Infección en el Trasplante research network. One hundred seven patients developed surgical site infections. The predominant infection sites were incisional wound (53 episodes) and peritonitis (40 episodes). The timing of the organ/space surgical site infections was slightly delayed in comparison with incisional surgical site infections. Enterococcus spp., Escherichia coli, Staphylococcus aureus, and Acinetobacter baumannii were the predominant pathogens. Choledochojejunal or hepaticojejunal reconstruction (odds ratio, 4.2; 95% confidence interval, 1.6–10.7), previous liver or kidney transplant (odds ratio, 2.6; 95% confidence interval, 1.1–6.3), and more than 4 red blood cell units transfused (odds ratio, 2.0; 95% confidence interval, 1.1–3.4) were independently associated with the development of surgical site infections. Biliary reconstruction by choledochojejunostomy or hepaticojejunostomy increases the risk of surgical site infections. Liver Transpl 14:799–805, 2008.

Incisional Surgical Site Infection in Kidney Transplantation

OBJECTIVES Incisional surgical site infections are common bacterial infections in kidney transplantation. The purpose of this study was to determine the incidence, timing, etiology, and risk factors for incisional surgical site infections. METHODS We performed a prospective study that included a population of 1400 consecutive patients (58.4% males) who underwent kidney transplantation in Spanish hospitals pertaining to the RESITRA research network. RESULTS A total of 55 patients developed 63 episodes of incisional surgical site infections. Median time from transplant to incisional surgical site infections was 20 days (range, 2 to 76 days). All infected patients recovered from incisional surgical site infections. The most frequently isolated pathogens were Escherichia coli (31.7%), Pseudomonas aeruginosa (13.3%), Enterococcus faecalis (11.6%), Enterobacter spp. (10%), and coagulase-negative staphylococci (8.3%). Diabetic patients had an increased risk of incisional surgical site infections (7.5%, P = 0.013). We used several different regimens of antimicrobial prophylaxis. None were found to be associated with an increased risk of incisional surgical site infections. The use of sirolimus was associated with an increased risk of incisional surgical site infections (7.4%, P = 0.018). CONCLUSIONS Diabetic patients, and those who received sirolimus-based immunosuppressive regimens, showed an increased risk of developing incisional surgical site infections after kidney transplantation.

Etiología de las infecciones hospitalarias en España (EPINE, 1990-1999)

BACKGROUND: Clinical and demographic characteristics of patients, their interaction with pathogens and antimicrobial therapies are prompting changes in the epidemiology of hospital-acquired infections (HI). The knowledge of the etiology of hospital-acquired infections is valuable for the treatment of infected patients and for the prevention of HI. PATIENTS AND METHOD: We analyzed a series of 10 annual prevalence studies during the period 1990-1999 (EPINE project) in Spanish hospitals. Estimate of prevalence of infection was calculated by means of the percent distribution of every organism regarding overall identified organisms and infections. RESULTS: 40,550 HI were identified among 484,013 patients (HI prevalence = 8.4%; 95% CI, 8.3-8.5%). Gram-positive organism predominated steadily in bloodstream and surgical wound infections, while gram-negative bacilli predominated in respiratory and urinary tract infections. There was an increase in HI infections by Acinetobacter baumannii (from 1.9% in 1990 to 3.6% in 1999; P < 0.001) and Candida albicans (from 2.4 to 3.2%; P < 0.001), as well as an increase in both HI and community-acquired infections by methicillin-resistant Staphylococcus aureus [HI: from 4.7 to 40.2% (P < 0.001); community-acquired: from 2.7 to 15.6% (P < 0.001)]. CONCLUSIONS: We observed some changes in the etiology of infections over the last decade: rates of methicillin-resistant S. aureus hospital-acquired and community-acquired infections increased steadily and their initial rates multiplied by 8 and 6, respectively. Rates of HI caused by yeasts and A. baumannii increased also.

Outcome of Clostridium difficile‐associated disease in solid organ transplant recipients: a prospective and multicentre cohort study

Clostridium difficile‐associated disease (CDAD) is the most common cause of nosocomial diarrhea. Information about CDAD in solid organ transplant (SOT) recipients is scarce. To determine its epidemiology and risk factors, we conducted a cohort study in which 4472 SOT patients were prospectively included in the RESITRA/REIPI (Spanish Research Network for the Study of Infection in Transplantation) database between July 2003 and July 2006. Forty‐two episodes of CDAD were diagnosed in 36 patients. The overall incidence was 0.94%. Median onset of infection was 31.5 days (range 6–741); in half the cases, onset occurred during the first month after transplantation. In 26% of cases, there was no previous antibiotic use. Independent risk factors for CDAD using Cox regression analysis were previous use of first‐ and second‐generation cephalosporins (HR 3.68; 95%CI 1.8–7.52; P < 0.001), ganciclovir prophylactic use (HR 3.09; 95%CI 1.44–6.62; P = 0.004) and corticosteroid use before transplantation (HR 2.95; 95%CI 1.1–7.9; P = 0.031). There were no deaths related to CDAD. In summary, the incidence of CDAD in SOT was low, most cases were diagnosed soon after transplantation and the prognosis was good.

Incisional surgical infection in heart transplantation

Background. Incisional surgical site infections (ISSIs) are common bacterial infections in heart transplantation (HT). The purpose of this study was to determine the incidence, etiology, timing, and risk factors for ISSIs.

Preoperative low molecular weight heparin as venous thromboembolism prophylaxis in patients at risk for prosthetic infection after knee arthroplasty

OBJECTIVE To investigate the effect of preoperative initiation of low molecular weight heparin as prophylaxis for deep venous thrombosis in patients at risk of developing surgical-site infections after knee arthroplasty. DESIGN Case-control study nested in a cohort. The incidence of surgical-site infection in the cohort was calculated. With the use of data extracted from medical histories and after adjustment for other risk factors, the effect of preoperative heparinization on the risk of incisional and prosthetic infection among case-patients and control-patients (1:3 ratio) was assessed. SETTING Orthopedic department in a tertiary-care referral hospital. PATIENTS A cohort of 160 consecutive patients who had received prosthetic knee implants between October 1, 2001, and November 30, 2003. RESULTS Eighteen patients with surgical-site infections were identified, yielding an incidence of incisional and prosthetic infection of 6.9 (95% confidence interval [CI95], 3.5 to 12.0) and 4.4 (CI95, 1.8 to 8.8) cases per 100 patients undergoing surgery, respectively. Surgical-site infection was associated with preoperative use of low molecular weight heparin (odds ratio [OR], 6.2 after adjustment for medical and surgical factors; CI95 1.5 to 23). Prosthetic infection was strongly associated with preoperative use of prophylaxis (OR, undetermined [100% exposure in case-patients vs 35% exposure in control-patients]; P = .002), but incisional surgical-site infection was not. CONCLUSION The use of low molecular weight heparins immediately before knee arthroplasty as prophylaxis for deep venous thrombosis should be questioned because of probable increased risk of prosthetic infection.

Factores pronósticos de mortalidad relacionados con el estado nutricional en ancianos hospitalizados

Fundamento y objetivo: La proporcion de pacientes ancianos ingresados en hospitales de enfermos agudos se ha incrementado progresivamente. Los pacientes con un estado funcional deficiente estan predispuestos a la malnutricion, que afecta negativamente a su pronostico vital. No esta bien establecido si el estado funcional y nutricional son factores independientes relacionados con la mortalidad. El objetivo del estudio fue investigar la relacion entre el estado funcional (indice de Katz) y los parametros nutricionales con la incidencia de mortalidad. Pacientes y metodo: Se ha realizado un estudio prospectivo y observacional de una cohorte de pacientes ingresados en una sala de medicina interna. Se calcularon la prevalencia de malnutricion al ingreso y la incidencia acumulada de mortalidad. Tambien se estudiaron, mediante un analisis multivariante, los factores de riesgo nutricionales y funcionales potencialmente asociados con la mortalidad. Resultados: La prevalencia de malnutricion en los 105 pacientes incluidos en la cohorte fue del 57,1% (intervalo de confianza [IC] del 95%, 47,1-66,8%). La incidencia de mortalidad intrahospitalaria fue del 14,3% (IC del 95%, 8,2-22,5%). Tras el analisis multivariante, los factores pronosticos asociados de forma independiente con la mortalidad intrahospitalaria fueron: un elevado nivel de dependencia funcional (categorias F y G del indice de Katz, odds ratio [OR] = 6,1; IC del 95%, 1,4-26,3), una concentracion baja de transferrina serica (por cada descenso de 1 g/l, OR = 8,3; IC del 95%, 3,4-20,0) y la disminucion del recuento de linfocitos (cada descenso en 0,5 * 109 celulas/l, OR = 2,3; IC del 95%, 1,5-3,5). Conclusiones: La prevalencia de malnutricion y la incidencia de mortalidad son muy elevadas en los ancianos hospitalizados. La concentracion baja de transferrina plasmatica, un bajo recuento linfocitario y un nivel elevado de deterioro funcional estan asociados con un incremento de la mortalidad intrahospitalaria. Considerando la elevada proporcion de pacientes geriatricos en hospitales de enfermos agudos, las estrategias para la identificacion temprana de estos pacientes mediante pruebas sencillas para promover una adecuada nutricion podria disminuir su riesgo de fallecer.

Timing of DVT Prophylaxis and Risk of Postoperative Knee Prosthesis Infection

This multicenter prospective study was performed to determine risk factors for knee prosthesis infection and the effect of timing doses of prophylactic low-molecular-weight heparins (LMWH) related to time of surgery on the risk of knee prosthesis infection. A total of 5496 consecutive patients who underwent total knee arthroplasty from 2005 to 2006 in 13 orthopedic centers were prospectively followed up for 6 months, and the incidence of knee prosthesis infection was recorded. A case control study was nested in the cohort. Case patients were matched to uninfected (control) patients, and the timing of perioperative LMWH was recorded as the main risk factor. Fifty patients developed postoperative knee prosthesis infection during the follow-up period, yielding an incidence of prosthesis infection of 0.91% (95% CI, 0.68%-1.20%). Forty-four patients were matched to 106 controls. Case patients received the first LMWH dose ±12 hours from the start of surgery more frequently than their control counterparts (odds ratio, 1.5; 95% CI, 0.73-3.0). After adjusting by main risk factors, no statistical association was found between close perioperative timing of LMWH and risk of prosthesis infection. Diabetes mellitus (adjusted odds ratio, 3.2; 95% CI, 1.2-8.8) and wound hematoma (adjusted odds ratio, 4.2; 95% CI, 1.1-16.5) were found to be independent risk factors for prosthesis infection.

Factores de riesgo de infección por Clostridium difficile en pacientes hospitalizados.

BACKGROUND AND OBJECTIVES To identify risk factors, and to estimate the crude effects attributable to hospital acquired Clostridium difficile infection (CDI). PATIENTS AND METHODS Case-control study matched by age, gender, and admission date. Patient and healthcare risk factors were evaluated. Hospital stays and mortality were compared. RESULTS Thirty-eight cases and 76 controls were included (mean age 73 years). Cases presented worse Charlson index (P .02), higher pre-infection stay (median 10 vs. 5.5 days) and had received antibiotic treatment more frequently (89.5 vs. 40.7%) than their control counterparts. Albuminemia < 3.5 gr/dL (OR 7.1; 1.4-37), having received cephalosporins (OR 10.1; 1.8-55.1), quinolones (OR 9.4; 1.1-41.1), or proton pump inhibitors (OR 6.6; 1.1-41.1) were associated with an independent higher risk of CDI. Total hospital stay (31 vs. 5.5 days), as well as crude mortality, was higher for cases than for control patients (31.6 vs. 6.6%). CONCLUSIONS Receiving cephalosporins, quinolones and proton pump inhibitors, as well as hyponutrition, increase the risk of CDI. CDI is associated with relevant crude effects on mortality and excess of stay.

Microbiología de las infecciones del sitio quirúrgico en pacientes intervenidos del tracto digestivo

INTRODUCTION Knowledge of the microbiology of surgical infections after abdominal surgery can be of use when prescribing effective empirical antibiotic treatments. METHOD Analysis of surgical infections after abdominal surgery in patients enrolled in the Prevalence of Infections in Spanish Hospitals (EPINE) corresponding to the years 1999-2006. RESULTS During the period of the study, 2,280 patients who were subjected to upper or lower abdominal tract surgery were diagnosed with an infection at the surgical site (SSI). Eight hundred and eighty three patients (37%) had an operation of the upper abdominal tract (gastric, hepatobiliary, and pancreatic surgery) and 1,447 patients (63%) lower abdominal tract surgery (appendectomy and colon surgery). A total of 2,617 bacterial species were isolated in the 2,280 patients included in the analysis. The most frequent microorganisms isolated were, Escherichia coli (28%), Enterococcus spp. (15%), Streptococcus spp. (8%), Pseudomonas aeruginosa (7%), and Staphylococcus aureus (5%, resistant to methicillin 2%). In the surgical infections after upper abdominal tract procedures, there were a higher proportion of isolations of staphylococci, Klebsiella pneumoniae, Enterobacter spp., Acinetobacter spp. and Candida albicans and less Escherichia coli, Bacteroides fragilis and Clostridium spp. CONCLUSION The microbiology of SSI produced after upper abdominal tract surgery did not show any significant differences compared to those of the lower tract. However, more cases of SSI were detected due to staphylococci, Klebsiella pneumoniae, Enterobacter spp., Acinetobacter spp. and Candida albicans and less caused by Escherichia coli, Bacteroides fragilis and Clostridium spp.