Elena Múñez

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.

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.

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.

Post-kala-azar Dermal Leishmaniasis and Uveitis in an HIV-positive Patient

Visceral leishmaniasis (VL) caused by Leishmania infantum frequently appears in HIV-positive patients in southwest Europe [1, 2]. Some patients present cutaneous involvement during the course of VL that may exhibit different clinical manifestations [3–5]. VL relapses have been observed in patients receiving antiretroviral treatment who have adequate immunologic responses [3]. Therefore, there is no definitive CD4 cell count that allows secondary leishmanial prophylaxis to be withheld without any risk of VL relapse [3]. A 36-year-old woman was admitted to our hospital in April 2003 because of fever, weight loss, vomiting, and nocturnal cough. She had cervical inguinal lymphadenopathies and hepatosplenomegaly. Analyses showed that HIV serology was positive, the CD4 cell count was 84 cells/ml and HIV-RNA was 1,000,000 copies/mm. In this case, the HIV infection risk factor was having unprotected sex with men. The patient had also 1,800 leukocytes/mm, 9 g/dl hemoglobin, 93,000 platelet/mm, and polyclonal hypergammaglobulinemia. A diagnosis of VL was made on the basis of her clinical evaluation, antiLeishmania antibody titer (direct agglutination test 1:1,024), and the finding of amastigotes in a bone marrow biopsy. The parasite present on the biopsy samples was identified by sequence analysis of the PCR products obtained by two different methods namely, LnPCR [6] and ITS-1 PCR [7]. The first method identified the parasite as belonging to the Leishmania donovani complex, and the second more precisely as L. infantum/Leishmania chagasi. Taking into account that no history of travel to Latin America was reported by the patient, it could be concluded that the causative agent was L. infantum. Antiretroviral treatment was started with nelfinavir (1,250 mg bid), lamivudine (150 mg bid), stavudine (30 mg bid), and meglumine antimoniate 20 mg/kg per day was administered intramuscularly for 28 days. Clinical and hematologic recovery ensued but the patient refused VL maintenance therapy. In September 2003, due to virologic failure (1,500,000 copies/mm, CD4 cell count 225 CD4 cells/ml) the antiretroviral treatment was changed to lopinavir (400 mg bid), ritonavir (100 mg bid), efavirenz (600 mg qd), didanosine (250 mg qd), and zidovudine (250 mg bid). Two weeks later she presented with fever, without any other symptoms, which was attributed to VL relapse. Meglumine antimoniate 850 mg was administered intramuscularly for 28 days with a clinical improvement. Once again VL prophylactic therapy was refused. Her CD4 cell count during the following year (2004) was between 231 and 285 cells/ml, and her viral load was undetectable (< 50 copies/ml). In January 2005 she presented with fever, vomiting, diarrhea, hepatomegaly (10 cm), and painful splenomegaly (15 cm). Her CD4 cell count was 165 cells/ml and HIV-RNA was undetectable (< 50 copies/ml). Meglumine antimoniate 850 mg was administered intravenously for 7 days without response. Subsequently, amphotericin B liposomal 3 mg/kg daily was administered intravenously on days 1–5, 10, 17, 24, 31, 38, which led to complete clinical regression. The patients continued receiving the same therapy monthly. In May 2005 the patient reported a painful papuloerythematous eruption on her face, arms, and legs (Figure 1). Reaginic syphilis and lyme serologies were negative. A skin biopsy revealed a granulomatous reaction with scanty intracellular leishmania amastigotes.

Mucosal leishmaniasis mimicking squamous cell carcinoma in a liver transplant recipient

Organ transplant recipients living in endemic regions are at increased risk of Leishmania infections. Visceral leishmaniasis is the most common kind of presentation in the Mediterranean basin. Rarely, Leishmania infantum may cause localized mucosal disease. We present the first case, to our knowledge, of a liver transplant recipient with localized mucosal leishmaniasis. Twenty‐two years after transplantation, a painless, very slow growing ulcer appeared on the inner side of the patients upper lip. A biopsy performed in the community hospital showed non‐specific chronic inflammation without neoplastic signs. Because of a high suspicion of malignancy, the patient was transferred to the referral hospital to consider complete excision. The excisional biopsy revealed a granulomatous inflammatory reaction together with intracellular Leishmania amastigotes within macrophages. Leishmaniasis was confirmed by the nested polymerase chain reaction assay. The clinical and laboratory findings did not suggest visceral involvement. The patient received meglumine antimoniate for 21 days without relevant adverse effects.

Rhodotorula species fungaemia causes low mortality in haematopoietic stem-cell transplantation. A case report and review.

Rafael Forés, Antonio Ramos, Beatriz Orden, Almudena de Laiglesia, Guiomar Bautista, Martı́n Cabero, Elena Muñez, Isabel Sánchez-Romero, Belén Navarro, Julio Bravo and Rafael Cabrera Department of Hematology, Hospital Universitario Puerta de Hierro, 28220 Majadahonda, Madrid, Spain, Department of Internal Medicine (Infectious Disease Unit), Hospital Universitario Puerta de Hierro, 28220 Majadahonda, Madrid, Spain and Department of Microbiology, Hospital Universitario Puerta de Hierro, 28220 Majadahonda, Madrid, Spain

Brain Abscess due to Panton-Valentine Leukocidin-Positive Staphylococcus aureus

AbstractPanton–Valentine leukocidin (PVL) is a cytotoxin produced by Staphylococcus aureus that exhibits highly specific lytic activity against polymorphonuclear cells, monocytes, and macrophages. A 34-year-old man admitted for right parietal brain abscess and thickened dura mater in close proximity to a lytic bone lesion is presented. The abscess culture yielded methicillin-sensitive S. aureus that produced PVL. The patient did well after surgery and antibiotic treatment. A hematogenous infection, route of bone infection with progression to dura mater and brain parenchyma was hypothesized. To our knowledge this is the first reported case of a brain abscess due to PVL-positive S. aureus.

Risk Factors for Clostridium Difficile Diarrhea in Patients With Solid Organ Transplantation

Background: There is limited knowledge about specific risk factors for Clostridium difficile infection (CDI). Method: A retrospective study comparing cases of CDI in solid organ transplant (SOT) recipients with controls (SOT recipients who did not present CDI). Results: Thirty patients with SOT from 1340 transplantation recipients had at least 1 episode of CDI (2.23%). The accumulated incidence was 3.06% in liver transplantation, 2.78% in lung transplantation, 2.36% in kidney transplantation, and 0.33% in heart transplantation. Seven (23%) cases occurred during the first 2 months. Fifteen (50%) cases were community acquired. Colonoscopy was performed in 6 (20%) cases, but pseudomembranes were observed in only 1 (16%) case. Independent variables found to be related to CDI were previous treatment with proton pump inhibitors (PPIs; odds ratio [OR] 5.5; 95% confidence interval [CI] 1.2-32.0), immunosuppressive regimen including mycophenolate (OR 5.2; 95%CI 1.1-18), hospitalization during the previous 3 months (OR 5.1; 95%CI 1.1-17), and antibiotic treatment during the previous month (OR 6.7; 95%CI 1.4-23). Five (16.7%) patients did not respond to the initial treatment. Recurrences were noted in 6 (20%) patients. Conclusions: Liver transplant recipients presented the highest incidence. Risk factors for CDI were previous treatment with PPIs, immunosuppressive regimen containing mycophenolate, prior hospitalization, and prior antibiotic treatment.

Etiología de las infecciones quirúrgicas en pacientes sometidos a craneotomía

BACKGROUND Postoperative infections in patients undergoing craniotomy constitute significant complications associated with increased hospital stay and patient morbidity and mortality. Knowing the aetiology of surgical infections after craniotomy may contribute to improving antibiotic prophylaxis and empirical treatment. METHOD Information relating to surgical infections in patients undergoing craniotomy was obtained from a series of annual surveys on prevalence of infections in Spanish hospitals (EPINE) during the period 1999-2006. The study protocol collected relevant clinical information on patients with infection. Presence of infection was determined according to the Centres for Disease Control infection criteria. RESULTS During the time period considered, 107 cases of surgical infections in patients undergoing craniotomy were diagnosed. Forty patients were women (37%) and 67 were male (63%). The mean age was 51.7 years (median 55, range 6-86 years). The duration of the intervention was over 180minutes in 49 patients (45.8%).Thirty-eight patients (35.5%) underwent emergency surgery. Seventy-eight patients (73%) received surgical prophylaxis. Thirty-eight patients (35.5%) had superficial infection of the surgical wound, 38 patients (35.5%) had deep wound infection (including bone flap) and 31 patients (29%), postoperative infections of organ or space (meningitis, subdural empyema or brain abscess). The most common aetiology corresponded to staphylococci (50%), mainly S. aureus (one third of them methicillin-resistant), Pseudomonas aeruginosa (11%), Enterobacter spp (10%) and Acinetobacter baumannii (9%). CONCLUSION Empirical treatment of these infections should include a glycopeptide such as vancomycin and a beta-lactam with coverage against non-fermenting gram-negative bacilli.