Javier Hortal

Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease

BACKGROUND Saccharomyces cerevisiae is well known in the baking and brewing industry and is also used as a probiotic in humans. However, it is a very uncommon cause of infection in humans. METHODS During the period of 15-30 April 2003, we found 3 patients with S. cerevisiae fungemia in an intensive care unit (ICU). An epidemiological study was performed, and the medical records for all patients who were in the unit during the second half of April were assessed. RESULTS The only identified risk factor for S. cerevisiae infection was treatment with a probiotic containing Saccharomyces boulardii (Ultralevura; Bristol-Myers Squibb). This probiotic is used in Europe for the treatment and prevention of Clostridium difficile-associated diarrhea. The 3 patients received the product via nasograstric tube for a mean duration of 8.5 days before the culture result was positive, whereas only 2 of 41 control subjects had received it. Surveillance cultures for the control patients admitted at the same time did not reveal any carriers of the yeast. Strains from the probiotic capsules and the clinical isolates were identified as S. cerevisiae, with identical DNA fingerprinting. Discontinuation of use of the product in the unit stopped the outbreak of infection. A review of the literature identified another 57 cases of S. cerevisiae fungemia. Overall, 60% of these patients were in the ICU, and 71% were receiving enteral or parenteral nutrition. Use of probiotics was detected in 26 patients, and 17 patients died. CONCLUSIONS Use of S. cerevisiae probiotics should be carefully reassessed, particularly in immunosuppressed or critically ill patients.

Continuous Aspiration of Subglottic Secretions in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

OBJECTIVE Aspiration of endotracheal secretions is a major step in the prevention of ventilator-associated pneumonia (VAP). We compared conventional and continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS). MATERIALS AND METHODS Randomized comparison during a 2-year period. RESULTS A total of 714 patients were randomized (24 patients were excluded from the study; 359 CASS patients; 331 control subjects). The results for CASS patients and control subjects (per protocol and intention-to-treat analysis) were as follows: VAP incidence, 3.6% vs 5.3% (p = 0.2) and 3.8% vs 5.1%, respectively; incidence density, 17.9 vs 27.6 episodes per 1,000 days of mechanical ventilation (MV) [p = 0.18] and 18.9 vs 28.7 episodes per 1,000 days of MV, respectively; hospital antibiotic use in daily defined doses (DDDs), 1,213 vs 1,932 (p < 0.001) and 1,392 vs 1,932, respectively (p < 0.001). In patients who had received mechanical ventilation for > 48 h, the comparisons of CASS patients and control subjects were as follows: VAP incidence, 26.7% vs 47.5% (p = 0.04), respectively; incidence density, 31.5 vs 51.6 episodes per 1,000 days of MV, respectively (p = 0.03); median length of ICU stay, 7 vs 16.5 days (p = 0.01), respectively; hospital antibiotic use, 1,206 vs 1,877 DDD (p < 0.001), respectively; Clostridium difficile-associated diarrhea, 6.7% vs 12.5% (p = 0.3), respectively; and overall mortality rate, 44.4% vs 52.5% (p = 0.3), respectively. Reintubation increased the risk of VAP (relative risk [RR], 6.07; 95% confidence interval [CI], 2.20 to 16.60; p < 0.001), while CASS was the only significant protective factor (RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 vs 1.5 euro for the conventional tube. CONCLUSIONS CASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. CASS use should be encouraged, at least in patients undergoing MHS.

Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe.

IntroductionPatients undergoing major heart surgery (MHS) represent a special subpopulation at risk for nosocomial infections. Postoperative infection is the main non-cardiac complication after MHS and has been clearly related to increased morbidity, use of hospital resources and mortality. Our aim was to determine the incidence, aetiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients who have undergone MHS in Europe.MethodsOur study was a prospective study of patients undergoing MHS in Europe who developed suspicion of VAP. During a one-month period, participating units submitted a protocol of all patients admitted to their units who had undergone MHS.ResultsOverall, 25 hospitals in eight different European countries participated in the study. The number of patients intervened for MHS was 986. Fifteen patients were excluded because of protocol violations. One or more nosocomial infections were detected in 43 (4.4%) patients. VAP was the most frequent nosocomial infection (2.1%; 13.9 episodes per 1000 days of mechanical ventilation). The microorganisms responsible for VAP in this study were: Enterobacteriaceae (45%), Pseudomonas aeruginosa (20%), methicillin-resistant Staphylococcus aureus (10%) and a range of other microorganisms. We identified the following significant independent risk factors for VAP: ascending aorta surgery (odds ratio (OR) = 6.22; 95% confidence interval (CI) = 1.69 to 22.89), number of blood units transfused (OR = 1.08 per unit transfused; 95% CI = 1.04 to 1.13) and need for re-intervention (OR = 6.65; 95% CI = 2.10 to 21.01). The median length of stay in the intensive care unit was significantly longer (P < 0.001) in patients with VAP than in patients without VAP (23 days versus 2 days). Death was significantly more frequent (P < 0.001) in patients with VAP (35% versus 2.3%).ConclusionsPatients undergoing aortic surgery and those with complicated post-intervention courses, requiring multiple transfusions or re-intervention, constitute a high-risk group probably requiring more active preventive measures.

Ethanol Lock Therapy (E-Lock) in the Prevention of Catheter-Related Bloodstream Infections (CR-BSI) after Major Heart Surgery (MHS): A Randomized Clinical Trial

Background Lock-therapy with antimicrobials has been used for the treatment and prevention of catheter-related bloodstream infections (CR-BSI). Experiences with Ethanol-Locks (E-locks) have included therapeutic interventions with variable results. Patients undergoing Major Heart Surgery (MHS) are a high-risk population for CR-BSI.The aim of this study was to assess the efficacy and tolerance to E-Locks in the prevention of CR-BSI of patients undergoing MHS. Methods and Findings This is an academic, prospective, randomized, non-blinded and controlled clinical trial assessing the incidence of CR-BSI of patients with E-locks (E-lock) and the tolerance to the procedure in comparison with patients receiving conventional catheter-care (CCC). Patients undergoing MHS with intravascular catheters for more than 48 hours were randomly assigned into treatment or control group by a computer-generated list of randomly assigned numbers. In the treatment group, all their catheter lumens were locked with an ethanol solution at 70% for two hours, every three days (E-Locks). The control group received conventional catheter-care (CCC). Overall, 200 patients with 323 catheters were included in the study, which was stopped after 10 months due to adverse events. Of them, 179 catheters (113 patients) had E-Locks and 144 catheters (87 patients) were CCC. Euroscore Surgical Risk in both groups was 4.04 vs 4.07 p = 0.94 respectively. The results for the E-Locks and CCC were as follows: Incidence of CR-BSI/1000 days of exposure 2.1 vs 5.2 (p = 0.33), catheter tip colonization 14 (7.8%) vs 6 (4.2%) patients (p = 0.17), median length of hospital stay, 15 vs 16 days (p = 0.77). Seven patients (6.19%), all in the ethanol branch, had to discontinue the trial due to intolerance or adverse events. Conclusions We do not recommend prophylaxis of CR-BSI with ethanol-lock on a routine basis in patients undergoing Major Heart Surgery. Trial Registration Clinical Trials.gov NCT01229592

Early intravenous immunoglobulin replacement in hypogammaglobulinemic heart transplant recipients: results of a clinical trial.

Immunoglobulin G (IgG) hypogammaglobulinemia (HGG) is a risk factor for development of severe infections after heart transplantation. We performed a clinical trial to preliminarily evaluate the efficacy and safety of early administration of intravenous immunoglobulin (IVIG) for prevention of severe infection in heart recipients with post‐transplant IgG HGG.

Impact of selective digestive decontamination without systemic antibiotics in a major heart surgery intensive care unit

Purpose The incidence density of ventilator‐associated pneumonia (VAP) is higher in patients undergoing major heart surgery than in other populations, despite the introduction of bundles of preventive measures, because many risk factors are not amenable to intervention. Selective digestive decontamination (SDD) has been shown to be efficacious for decreasing the frequency of VAP, although it has not been incorporated into the routine of most intensive care units. The objective of our study was to evaluate the efficacy of SDD without parenteral antibiotics for preventing VAP in a major heart surgery intensive care unit. Methods We compared the incidence of VAP before the introduction of SDD (17 months) and during the 17 months after the introduction of SDD and examined its ecologic influence. Results The rates of VAP in the overall population before and during the intervention were 16.26/1000 days and 6.80 episodes/1000 days of mechanical ventilation, respectively (P = .01). The rates of VAP in the 173 patients remaining under mechanical ventilation > 48 hours after surgery were, respectively, 25.85/1000 days of mechanical ventilation versus 12.06 episodes/1000 days of mechanical ventilation (P = .04). We found a significant reduction in the number of patients with multidrug‐resistant microorganisms (P = .01) in the second period of the study. Conclusions Our study shows that SDD without parenteral antibiotics can reduce the incidence of VAP in high‐risk patients after major heart surgery, with no significant ecologic influence.

Lower Rates of Death in Heart Recipients with Secondary Antibody Deficiency and Severe Infection After Therapy with Intravenous Immunoglobulin

Background Secondary antibody deficiency defined as IgG hypogammaglobulinemia (HGG) is a risk factor of severe infection in heart recipients. Single center studies (distinct induction protocols; various centers around the world); a multicenter prospective study; evaluation of reproducibility of IgG testing among centers and a metanalysis support the usefulness of this biomarker. Interventional studies evaluating the effect of the modification of the risk factor are necessary. We evaluated the impact of therapeutic intervention of intravenous immunoglobulin (IVIG) in heart recipients with severe infections and HGG on clinical outcomes. Methods Retrospective analysis of prospectively collected data of 233 patients in a single center. 91 patients that developed severe infections in the post-heart transplantation period and were found to have HGG (serum IgG<600 mg/dL), received non-specific 5% IVIG in addition to conventional antimicrobial therapy with the aims of contributing to control of infection (secondary prevention of re-infection) and normalization of IgG (IgG>750 mg/dL). IVIG was administered at a dose of 300-400 mg/kg/month up to three months after infections were resolved (negative bacterial culture or CMV DNAmia). 142 heart recipients from the same center that where not treated with IVIG, were analyzed as controls. Results Severe infections included non pneumonic bacterial infection (30%), bacterial pneumonia (18%), CMV disaese + bacterial infection (12%), CMV disease + severe fungal infection (12%). Mean IgG level at the time of infection was 481 mg/dL (198-599 mg/dL). Mean time to the first IVIG infusion was 65.4 days (7-180 days). Normalization of IgG levels was obtained in 75 of 91 patients (82.4%) after addition of IVIG. Both groups were comparable in terms of demographic and clinical variables. IVIG treated recipients disclosed a lower rate of death (p=0.006). In multivariate regression analysis, IVIG use (RH 0.27, 95%CI 0.09-0.82, p=0.017), use of non-cytolitic induction (anti-CD25) vs cytolitic (ATG) (RH 0.28, 95%CI 0.09-0.82, p=0.017) and number of episodes of acute rejection (per each increase, RH 2.17, 95% CI 1.25-3.78, p=0.0062) remained in the final regression model as protective factors and risk factors respectively. Conclusions Personalized immunoguided intervention of IVIG in heart recipients with severe infections and HGG is associated with a lower rate of death during long term follow-up after heart transplantation. A multicenter randomized clinical trial is in due course in Spain to further evaluate this new IVIG indication. Instituto de Salud Carlos III. Project FIS Clinical Trial EC11084. With participation of FEDER funds. A way of making Europe.

Infections in patients after Berlin Heart®EXCOR assist device implantation

Berlin Heart® EXCOR devices (BHED) are ventricular assist devices (VAD) used mainly as a bridge to heart transplantation (HT) in pediatric population. The aim of our study is to report the infections diagnosed in adult patients undergoing a BHED implantation.

A Reversible Cause of Acute Right Ventricular Failure After Heart Transplant

We report the case of a 41-year-old man, who was an active smoker, with no prior history of cardiac conditions or other history of interest, and who was admitted to hospital for anterior STelevation myocardial infarction in Killip class IV. During admission, he experienced cardiac arrest unresponsive to advanced cardiopulmonary resuscitation. Peripheral venoarterial extracorporeal membrane oxygenation was used initially during the arrest and was subsequently switched to central extracorporeal membrane oxygenation. Intra-aortic balloon counterpulsation was also required. Coronary artery disease was detected in 3 vessels with chronic occlusion of the circumflex artery and right coronary artery and acute occlusion of the proximal left anterior descending artery, which was revascularized with conventional stenting. After a favorable assessment and confirmation of the absence of serious neurological damage, the patient was placed on the heart transplant waiting list with top priority. Orthotropic heart transplant was finally performed with the Shumway technique

Cardiogenic shock due to septic coronary embolism: treatment options for a rare entity

(Sorin-Carbomedics, Austin, TX, USA) was implanted, but refractory cardiogenic shock (CS) developed afterwards. The electrocardiogram showed ST-segment elevation in anterior leads, and thus, a septic coronary embolism was suspected. Decision was made to initiate peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with a Cardiohelp® device (Maquet, Germany), and an emergent coronary angiogram was scheduled. The coronary angiography revealed a left main coronary (LM) embolism (Fig. 2a, Video 2 on supplementary material). Despite multiple aspirations with a Capturer® aspiration catheter (iVascular, Barcelona, Spain), the embolus persisted. A Fogarty-like maneuver was then performed from left anterior descending artery (Fig. 2b), but unfortunately the embolus was partially displaced to circumflex ostium. At this point, 3 drug eluting stents were placed using a minicrush technique (Fig. 2c, Video 3 on supplementary material), with final TIMI 3 flow. However, the patient persisted in CS and signs of lower limbs ischemia appeared in the next hours, so a Centrimag (Levitronix LLC, Walthan, MA, USA) biventricular assist device was implanted due to concurrent right ventricular dysfunction. Interestingly, native valve analysis was positive for polymerase chain reaction for Granulicatella Adiacens and specific antibiotic treatment was indicated. Cardiac recovery was not achieved, infection was consider controlled after obtaining different negative blood cultures with enriched supplemental media, finally a heart transplantation was performed 2-weeks later. Unfortunately, the patient developed severe biventricular primary graft dysfunction and finally died. On the explanted heart no mycotic aneurysm was observed (Fig. 2d). Cardiogenic shock may occur as a result of acute myocardial damage caused by myocardial infarction, its prognosis depends on the treatment during the acute phase Sirs: We present the case of a 19-year-old man with previous history of congenital severe aortic stenosis, he was admitted with a 3-weeks history of malaise, dyspnea and fever. On admission, signs of heart failure and a diastolic murmur were evident. Laboratory data revealed anaemia, renal failure and elevated liver enzymes, but blood cultures were negative. Transthoracic echocardiogram showed a 21 mmvegetation together with severe aortic regurgitation, left ventricular ejection fraction was preserved (Fig. 1a, b; Video 1 on supplementary material). An abdominal computed tomography (CT) showed multiple embolisms (liver, spleen and right kidney). Valve replacement surgery was scheduled, and it was performed 4 days later. At the time of the anaesthetic induction, the patient developed multiple ventricular fibrillation episodes, after 10 min of advanced cardiopulmonary resuscitation, return of spontaneous circulation was achieved and conventional aortic valve replacement surgery was resumed although the procedure had to be performed emergently due to secondary pulmonary oedema. The intraoperative transesophageal echocardiogram revealed an extensive anterolateral akinesis. Eventually, a 23 mm Carbomedics valve