Joaquín López-Contreras

Etiology of surgical site infections after primary total joint arthroplasties

We sought to characterize the causative pathogens of surgical site infections (SSIs) following primary total joint arthroplasties and to evaluate trends in the microbial etiology. We analyzed the etiology of SSIs following 2,632 total hip arthroplasty and knee arthroplasty procedures performed at our institution from 2004 through 2010. We calculated the annual proportion of SSIs accounted for each of the most common organisms and evaluated trends using the χ2 test for trend. SSIs were identified in 111 procedures (4.2%). The annual incidence of SSIs did not change significantly during the study period. Staphylococci were the most common cause of infection (59.6%) and most of infections were monomicrobial (82.8%). From 2004 to 2010, the annual proportion of infections due to gram‐negative bacilli (GNB) increased from 21.4% to 66.7% (p = 0.085 for trend). This increase was accompanied by a decline in the proportion of SSIs from coagulase‐negative staphylococci (p = 0.003). Additionally, we found an increase in the percentage of polymicrobial infections (from 7.1% in 2004 to 41.7% in 2010, p = 0.014). Multivariate analysis corroborated these trends. Our study reports an emergence of GNB as a cause of SSIs after primary total joint arthroplaties and an increase of polymicrobial infections.

Surveillance of surgical site infections in elective colorectal surgery. Results of the VINCat Program (2007–2010)

The VINCat Program is a standardized surveillance program of healthcare infections in Catalonia, Spain. This program includes monitoring of surgical site infections (SSI) of elective colorectal surgery. The aim of this study was to define SSI rates in colorectal surgery among VINCat hospitals over a period of 4 years. We included consecutive elective colorectal interventions performed in VINCat hospitals from 2007 to 2010. Follow-up visits were performed 30 days after surgery. Prospective monitoring of SSI in colorectal surgery was performed according to standardized VINCat methodology. SSI was defined according to the Centers for Disease Control (CDC) and surgical risk factors according to the National Healthcare Safety Network (NHSN) classification. From 2007 to 2010, 49 centers performed 10,104 surgical procedures. The cumulative incidence of SSI was 20.8% (95% CI: 20.03-21.63). The annual cumulative SSI incidence rate did not vary significantly over the study period; however, there were significant differences among hospital infection rates. The relative frequency of organ-space infection increased from 25% in 2007 to 40% in 2010 (p<0.001). Laparoscopic surgery also increased (28% in 2007 to 42% in 2010, p<0.001). However, no changes were observed in mean surgery duration, ASA score and degree of surgical contamination. The VINCat Program incorporated a large number of Catalan hospitals that participated in standardized monitoring of colorectal surgery. The cumulative incidence rate of SSI for colorectal surgery was 20.8%, although there were large variations between hospitals.

Spontaneous gram-negative bacillary meningitis in adult patients: characteristics and outcome

BackgroundSpontaneous meningitis caused by gram-negative bacilli in adult patients is uncommon and poorly characterized. Our objective is to describe and compare the characteristics and the outcome of adult patients with spontaneous gram-negative bacilli meningitis (GNBM) and spontaneous meningitis due to other pathogens.MethodsProspective single hospital-based observational cohort study conducted between 1982 and 2006 in a university tertiary hospital in Barcelona (Spain). The Main Outcome Measure: In-hospital mortality.ResultsGram-negative bacilli meningitis was diagnosed in 40 (7%) of 544 episodes of spontaneous acute bacterial meningitis. The most common pathogens were Escherichia coli and Pseudomonas species. On admission, characteristics associated with spontaneous gram-negative bacilli meningitis by multivariate modeling were advanced age, history of cancer, nosocomial acquisition of infection, urinary tract infection as distant focus of infection, absence of rash, hypotension, and a high cerebrospinal fluid white-cell count. Nine (23%) episodes were acquired in the hospital and they were most commonly caused by Pseudomonas. The in-hospital mortality rate was 53%. The mortality rate was higher among patients with Gram-negative bacillary meningitis than among those with other bacterial meningitis and their risk of death was twenty times higher than among patients infected with Neisseria meningitidis (odds ratio 20.47; 95% confidence interval 4.03-103.93; p<0.001).ConclusionsGram-negative bacilli cause 9% of spontaneous bacterial meningitis of known etiology in adults. Characteristics associated with GNBM include advanced age, history of cancer, nosocomial acquisition, and urinary tract infection as distant focus of infection. The mortality rate is higher among patients with gram-negative bacillary meningitis than among those with other bacterial meningitides.

Disseminated Cytomegalovirus Infection in an Immunocompetent Adult Successfully Treated with Ganciclovir

We report the case of a previously healthy man who suffered a disseminated cytomegalovirus infection. He presented with prolonged fever, weight loss of 8 kg, anicteric hepatitis, upper digestive tract bleeding from gastric ulcers, acute polyneuritis and bilateral retinitis. Immunodeficiency was not detected either during admission or during a 3-year follow-up period. The patient was treated with ganciclovir (5 mg/kg BID) during 4 weeks with a favourable clinical outcome. To our knowledge, this is the first reported case with such characteristics.

Epidemiology of surgical site infections after total hip and knee joint replacement during 2007-2009, a report from the VINCat Program

The VINCat Program is a system for epidemiological surveillance of healthcare-related infections in which the majority of Catalan hospitals participate. It has a specific module for surgical site infections (SSI) surveillance. Primary hip and knee arthroplasties are basic indicators of the program due to their high frequency and the important morbidity of SSI of these sites. Results are presented for surgical site infection (SSI) surveillance of primary hip and knee arthroplasties for the first three years of the VINCat Program. The program requires SSI surveillance to be performed in a standardized, prospective and continuous manner by an infection control team from the centers. With primary arthroplasties, as with all procedures involving implants, the surveillance is maintained for 1 year after the intervention. The VINCat Program uses the SSI definitions of the Centers for Disease Control (CDC) and patients are stratified by surgical risk, following the classification of the National Healthcare Safety Network (NHSN). During the period 2007-2009, 51 Catalan hospitals participated in the SSI surveillance of prosthetic orthopedic surgery. The overall SSI rate in the interventions for total primary hip prosthesis (7,804 procedures) was 3.0% (IC 95%: 2.6-3.4) and for total primary knee prosthesis (16,781 procedures) was 3.3% (IC95%: 3.0-3.6). During the period 2007-2009, the overall SSI rates for total primary hip and knee arthroplasty were higher than those published by some surveillance systems in our environment. There were significant differences in the infection rates by procedure and in those adjusted by risk among the different hospitals.

Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial

Importance The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, Setting, and Participants Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main Outcomes and Measures The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, −0.6% to 1.1%), 0.6% (95% CI, −0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and Relevance Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care. Trial Registration ClinicalTrials.gov Identifier: NCT02208154

Esophageal ulcers in AIDS.

TO THE EDITOR: We read with interest the recent report by Wilcox and associates [1] and noted two outstanding findings: 1) the high prevalence of idiopathic esophageal ulcers and the excellent initial response to prednisone therapy and 2) the high percentage of patients with ulcer recurrence. In 13 of 35 patients with esophageal ulcers (37.1%), ulcerations recurred despite an initial clinical and endoscopic response [1]. We have recently cared for seven HIV-infected patients who had idiopathic esophageal ulcers. All had advanced disease. Three patients were initially treated with a 2-week regimen of prednisone, 0.5 mg/kg of body weight per day, but clinical and endoscopic relapse was documented between 2 and 4 weeks after the prednisone dose was tapered. Four patients initially received thalidomide, 100 mg/d for 10 days, and symptoms rapidly disappeared after treatment began. After a follow-up period of 4 to 10 months, ulceration had not recurred in our patients. In all the prednisone recipients who had ulcer recurrence, a course of thalidomide resulted in resolution of clinical symptoms and ulcer healing. No recurrence was documented in two patients during follow-up periods of 11 and 16 months, respectively. In another patient, numerous episodes of ulcerations occurred, despite effective courses of thalidomide therapy. The patient died 5 months after the first episode. Recurrence of idiopathic esophageal ulcers may represent an important problem in HIV-infected patients, both from a diagnostic and nutritional viewpoint, as Wilcox and colleagues reported [1]. Although prednisone therapy is useful for the initial treatment of HIV-associated esophageal ulcers, disease will recur in more than a third of patients [1, 2]. In our experience and in that of others [3, 4], thalidomide has been very effective in treating HIV-associated ulcerations, including idiopathic esophageal ulcerations that had not responded to prednisone therapy. Although no conclusions can be drawn from our limited number of cases, our experience is encouraging because it suggests that thalidomide can be used both as a first-choice drug or as a safe alternative to corticosteroid therapy in HIV-infected patients with idiopathic esophageal ulcerations.