Anna Maria Azzini

Epidemiology Incidence and Risk Factors for Invasive Candidiasis in High-Risk Patients

Candida spp. are an increasing cause of bloodstream infections, and are associated with high morbidity and mortality in both neutropenic and non-neutropenic critically ill patients. Risk factors associated with candidaemia are diverse and include exposure to broad spectrum antimicrobial agents, mucosal colonization by Candida spp., indwelling vascular catheters, prior surgery and cancer chemotherapy. During the last 20 years, there has been an increasing incidence worldwide in invasive candidiasis, but differences in geographical epidemiology are emerging, in particular regarding a shift towards non -albicans species. This shift has been correlated with routine fluconazole prophylaxis adopted in some patients, and the intrinsic/acquired azole resistance of Candida spp., which represents a very real problem, in terms of both selecting the appropriate empirical therapeutic approach and making prophylactic choices.

Vascular access: an historical perspective from Sir William Harvey to the 1956 Nobel prize to André F. Cournand, Werner Forssmann, and Dickinson W. Richards

Sir William Harvey (1578–1657), who had many precursors, discovered blood circulation in 1628 after a significant number of anatomic dissection of cadavers; his studies were continued by Sir Christopher Wren and Daniel Johann Major. The first central vein catheterization was performed on a horse by Stephen Hales, an English Vicar. In 1844, a century later, the French biologist Claude Bernard attempted the first carotid artery cannulation and repeated the procedure in the jugular vein, again on a horse. He was first to report the complications now well known to be associated with this maneuver. In 1929 Werner Forssmann tried cardiac catheterization on himself, but could not investigate the procedure further since his findings were rejected and ridiculed by colleagues. His work was continued by André Frédéric Cournand and Dickinson Woodruff Richards Jr in the United States. In 1956 the three physicians shared the Nobel Prize for Medicine for their studies on vascular and cardiac systems. The genius and the perseverance of the three physicians paved the way towards peripheral and central catheter vein placement, one of the most frequently performed maneuvers in hospitals. Its history still remains unknown to most and deserves a short description.

Unexpected obstacle in catheter removal could be due to knots spontaneously forming in peripherally inserted central catheters (PICC)

As usual a nurse removed the sutureless device ensuring the PICC at the upper arm and began to slip off the PICC. The PICC moved 24 cm and then abruptly stopped; the nurse detected a resistance in the procedure, and the patient experienced pain at the insertion site. The physician in charge of the patient ordered a standard chest x-ray that showed the PICC with three knots in the vessel portion of the catheter (Fig. 1). every effort to force the dissolution of the knots with repeated flushes of saline solution was useless. Finally, a vascular surgeon surgically removed the knotted PICC by exposure and suture of the basilica vein after local anesthesia and sedation (Fig. 2). The patient was discharged the next day without any further problems. PICCs have been proposed as an alternative to standard central venous catheters (CVCs) for both inpatients and outpatients for medium-term infusion therapy. They are non-tunneled vascular devices that can be inserted at the bedside by nurses and physicians (4). PICCs are safe well-known devices; however, some complications have been reported, such as catheter fracture, tip migration and accidental cuts near the hub (5). Recently, a high rate of thrombosis has been associated with these devices, if compared to standard CVCs in post-critically ill patients (4). Our experience suggests that when a PICC does not work perfectly, not only in aspiration but also in infusion, a differential diagnosis with thrombosis must be considered, not forgetting the possibility of the catheter kinking or knotting. In the above-mentioned case, the PICC could have been knotted both in the final days of the patient’s hospitalization and during catheter removal; since drug infusion and patient hydration had been regular in the preceding days, the formation of knots could be due to removal maneuvers. A standard chest x-ray can help to visualize the catheter run and to demonstrate possible stops if Unexpected obstacle in catheter removal could be due to knots spontaneously forming in peripherally inserted central catheters (PICC)

On the Shoulders of Giants: A 1500-Year-Old Aphorism

We appreciate your recent editorial and would like to comment on how its content reverberates over the wellknown aphorism “On the shoulders of giants,” commonly abridged as OTSOG, used as an exergue. As medical doctors practicing different disciplines, pathology, anesthesiology, and infectious diseases, we are well aware that in medicine some things are continuously changing at a precipitous pace while others have not changed since the day we graduated. It is often not easy for physicians to find the origin of a patient’s problem or the reason for a specific result in a study. In both cases, as we investigate more thoroughly, we find, often serendipitously, different and unexpected findings. An example of this phenomenon is the true origin of the OTSOG aphorism, frequently attributed, as in the editorial, to Isaac Newton. However, the definitive work by Merton leaves no doubt. The famous aphorism was used by others before Newton, although Burton was wrong when attributing it in The Anatomy of Melancholy (1621) to Didacus Stella, erroneously traced back by Bartlett’s Quotations to Lucan’s Civil War. Approximately 50 years ago, Merton concluded that the OTSOG aphorism was first used in the sixth century by Priscian, a Latin grammarian born and raised in Caesarea (modern Cherchell, Algeria), who wrote in the Institutiones Grammaticae that the younger the grammar’s authors were, the more perceptive they would be. Priscian’s grammar remained the standard textbook to study Latin during the Middle Ages and was extensively studied and cited by many authors in several countries. In 1159, John of Salisbury attributed the giants’ aphorism in Metalogicon to Bernard of Chartres, writing “according to Bernard, men are like dwarfs who standing on the shoulders of giants can grow in art and culture.”

Aetiology and antibiotic resistance issues regarding urological procedures

Abstract There are specific indications in urological procedures [transurethral resection of the prostate (TURP), transurethral resection of the bladder (TURB), endoscopic procedures, and all interventions classified as contaminated or dirty] requiring antibiotic prophylaxis. Most postoperative infections are caused by enterococci of the Gram-positive strains and Enterobacteriaceae of the Gram-negative ones. As reported by the European Center for Disease Prevention and Control (ECDC), there are increasing numbers of antibiotic-resistant pathogens. Most Enterococcus faecium strains are ampicillin-resistant and the Enterobacteriaceae have a high prevalence of extended-spectrum beta-lactamase (ESBL) producers, for which the cephalosporins and penicillins are not drugs of choice. In recent years, there are also increasing numbers of Gram-negative strains that are able to produce carbapenemases and for which the only therapeutic options are gentamicin, tigecycline and colistin. An alternative to these drugs, from a prophylactic point of view, is fosfomycin, an old antibiotic that maintains bactericidal activity against both enterococci and multidrug-resistant Enterobacteriaceae. Available in an oral formulation as trometamol salt, fosfomycin reaches high plasma and urine concentrations, and is therefore a possible alternative to other drugs both for therapy and urological prophylaxis.

A rare association of emphysematous pyelonephritis with unrecognized diabetes and polycystic kidney.

Emphysematous pyelonephritis (EPN) is a rare, severe, gas-forming infection for which the treatment of choice is often an immediate nephrectomy, although many reports exist of conservative treatment of cases with antibiotic therapy and percutaneous drainage of abscesses. It usually occurs in diabetic patients and less frequently in subjects with an obstruction of the corresponding renoureteral unit; other predisposing factors are not common. We report here the case of a 51 year-old woman with a rare association of unrecognized diabetes and bilateral polycystic kidney disease who developed monolateral EPN. She had an emergency right nephrectomy and was admitted to Intensive Care Unit (ICU) for septic shock after surgery, requiring intensive resuscitation. The patient was managed with Coupled Plasma Filtration Adsorption (CPFA). Her clinical conditions rapidly improved and the hemofiltration was soon suspended. Urine and blood cultures were positive for the same Escherichia coli, which was susceptible to all tested antibiotics. The patient was transferred to the Nephrology Division and was discharged from the hospital without further dialysis after 34 days. This case report is somewhat unique because of the unusual association between undetected diabetes and polycystic kidney as predisposing factors of a severe infection of the urinary tract.

Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study

Background: Policies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed‐suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed‐suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality. Methods: This study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed‐suction drains (n = 131) were used according to the operating surgeons choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered. Results: The open passive drain and closed‐suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30‐day morbidity, postoperative pancreatic fistula, intra‐abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed‐suction drain cohorts. Conclusion: The use of open passive drains and closed‐suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.

A prediction rule for early recognition of patients with candidemia in Internal Medicine: results from an Italian, multicentric, case–control study

PurposeIncreasing prevalence of candidemia in Internal Medicine wards (IMWs) has been reported in recent years, but risk factors for candida bloodstream infection in patients admitted to IMW may differ from those known in other settings. The aim of this study was to identify risk factors and define a prediction rule for the early recognition of the risk of candidemia in IMW inpatients.MethodsThis was a multicentric, retrospective, observational case–control study on non-neutropenic patients with candidemia admitted to IMWs of four large Italian Hospitals. Each eligible patient with candidemia (case) was matched to a control with bacteremia. Stepwise logistic regression analyses were performed.ResultsOverall, 300 patients (150 cases and 150 controls) were enrolled. The following factors were associated with an increased risk of candidemia and weighted to build a score: total parenteral nutrition (OR 2.45, p = 0.008; 1 point); central venous catheter (OR 2.19, p = 0.031; 1 point); peripherally inserted central catheter (OR 5.63, p < 0.0001; 3 points), antibiotic treatment prior (OR 2.06; p = 0.059; 1 point) and during hospitalization (OR2.38, p = 0.033; 1 point); neurological disability (OR 2.25, p = 0.01; 1 point); and previous hospitalization within 3 months (OR 1.56, p = 0.163; 1 point). At ROC curve analysis, a final score ≥ 4 showed 84% sensitivity, 76% specificity, and 80% accuracy in predicting the risk of candidemia.ConclusionsThe proposed scoring system showed to be a simple and highly performing tool in distinguishing bloodstream infections due to Candida and bacteria in patients admitted to IMW. The proposed rule might help to reduce delay in empirical treatment and improve appropriateness in antifungal prescription in septic patients.

Therapeutic recommendations of the multidisciplinary group

Some of the invasive surgical procedures of the urinary tract can result in significant local or systemic infections such as fever, urosepsis, prostatitis, and epididymitis due to uropathogens. The...

La breve storia del laringoscopio: dal teatro lirico al teatro operatorio

RiassuntoL’intubazione endotracheale permette l’introduzione del tubo nella trachea del paziente per permettergli di respirare; per questa manovra è indispensabile l’utilizzo del laringoscopio, uno strumento che ha rivoluzionato la gestione delle vie aeree. Le fonti attendibili sull’origine del laringoscopio sono scarse; sono numerosi, invece, gli aneddoti al riguardo. Partendo dalla prima “laringoscopia rudimentale” attribuita ad Aulo Cornelio Celso, arriviamo alla dettagliata descrizione anatomica dell’intubazione a opera di Andreas van Wesel, italianizzato in Andrea Vesalio nel 1543. Dopo le esperienze degli inglesi Robert Hooke e Benjamin Guy Babington, con la parentesi italo-germanica di Philipp Bozzini, la storia del laringoscopio viene scritta soprattutto dal maestro di canto spagnolo Manuel Patricio Rodríguez García, che dette un enorme impulso allo sviluppo della laringoscopia. Lo strumento di García fu perfezionato dal medico tedesco Alfred Kirstein, che lo costruÌ cosÌ come lo conosciamo e utilizziamo oggi. Con Henry Harrington Janeway il laringoscopio assume la sua forma odierna e perde ogni funzione diagnostica, diventando lo strumento indispensabile per l’intubazione orotracheale. Le lame furono successivamente perfezionate da due anestesisti, Robert Arden Miller e Robert Reynold Macintosh, rispettivamente nel 1941 e nel 1943. Dopo essere passato nelle aule di canto liriche il laringoscopio ha conosciuto innumerevoli ritocchi e perfezionamenti, fino alla sua forma elettronica, con l’invenzione del videolaringoscopio, a opera del chirurgo americano John Allen Pacey.SummaryTracheal intubation is one of the most widely used manoeuvres and laryngoscope is one of the most used devices in medicine. The first mentioned laryngoscopy is attributed to the Roman physician Aulus Cornelius Celsus. In the following centuries the contributions of Andreas van Wesel, known also with his Italian name Vesalio, of the English scientists Robert Hooke and Benjamin Guy Babington and the efforts of the German-Italian physician Philipp Bozzini and, particularly, of the Spanish singing teacher Manuel Patricio Rodríguez García were important. The ancestor of the laryngoscope used today was built by Alfred Kirstein, while the straight blades were designed by Robert Arden Miller and the curve blades by Robert Reynold Macintosh, respectively in 1941 in United States and in 1943 in United Kingdom. Only with Henry Harrington Janeway the laryngoscope lost its diagnostic function and became the essential device for tracheal intubation. Nowadays, the “digital revolution” of 21th century has brought newer technology to the science of tracheal intubation, and the GlideScope, a laryngoscope incorporating a video camera connected to a high resolution LCD monitor designed by the surgeon John Allen Pacey, is one of the most recent devices.