Josep A. Capdevila

Value of differential quantitative blood cultures in the diagnosis of catheter-related sepsis

A prospective study was performed to assess the value of differential quantitative blood cultures in the diagnosis of catheter-related sepsis when this condition is suspected on clinical grounds and to establish a reliable discriminative value for application without removal of the inserted catheter. A total of 107 central venous catheters from 64 patients were used for the study. Blood was obtained simultaneously through the suspected infected device and from a peripheral venipuncture. The catheter was removed and its tip cultured semiquantitatively. Catheter-related sepsis occurred in 17 patients. Using as cut-off value a colony count fourfold higher in blood drawn through the catheter than in simultaneously drawn peripheral blood, a sensitivity of 94 %, specificity of 100 % and positive predictive value of 100 % were obtained. A single bacterial count > 100 cfu/ml in the quantitative culture of the catheter blood specimen in the presence of a positive qualitative peripheral blood culture of the same organism was also highly suggestive of catheter-related sepsis. Differential quantitative blood culture is a reliable method for the diagnosis of catheter-associated sepsis without catheter removal.

Bacteremia Caused by Capnocytophaga Species in Patients with Neutropenia and Cancer: Results of a Multicenter Study

We investigated 28 cases of bacteremia caused by Capnocytophaga species that occurred during an 8-year period, most of which were in patients with hematologic malignancy and neutropenia. Infections were uncomplicated, without serious organ involvement and without any apparent source except ulcerations of the oropharyngeal mucosa, and only 1 isolate showed resistance to beta-lactam antibiotics; 9 of 16 isolates were resistant to ciprofloxacin.

Rhodococcus equi Pneumonia in Patients Infected with the Human Immunodefficiency Virus. Report of 2 cases and review of the literature

Rhodococcus equi is a cause of lung infection in immunosuppressed hosts. Since the start of the HIV epidemic, 76 cases of R. equi lung infection (MEDLINE 1985-96) affecting this population have been described. We report 2 additional cases and review the clinical data, radiological findings, treatment and outcome of these 78 patients. The mean age of these patients was 33 y; 69 were male. 71 met the criteria for AIDS (CDC 1993). Fever and cough were the presenting complaints in the majority of patients (84.3%). A single cavitary lung lesion in the upper lobes was the most common radiological finding (57.7%), although multiple cavitations, alveolar infiltrates and pleural effusion were also found. Treatment usually was based on synergistic antibiotic combinations for a long period of time determined on an individual basis. Surgery was performed only in 11 patients. Death attributable directly to R. equi infection is low (15.4%), however only half of the patients (53.8%) were completely cured. We conclude that R. equi infection should be strongly considered in any HIV patient who presents with cavitary lesions in the lung, especially if mycobacteria are not identified. Treatment must be based on synergistic antibiotic combinations, and surgery relegated to cases of chronic single cavitary lesions not responding to antibiotics.

Resistance to the migration of microorganisms of a needle-free disinfectable connector

The aim of this study was to assess the efficacy of a disinfectable needle-free connector in reducing the pass of micro-organisms to the lumen of the catheter. A prospective, controlled, experimental trial was performed in which a laboratory model simulated the insertion of a peripheral venous catheter. Catheters inserted in sterile conditions in a hemoculture bottle were closed with the disinfectable needle-free connector (study group) or with a cap (control group). After 9 days of contamination and manipulation of the connector and cap external surfaces, 100% of bottles in the control group were contaminated whereas 60% remained sterile in the study group. The disinfectable needle-free connector showed more resistance to the pass of microorganisms than the conventional cap according to our experimental model.

Pseudomonas vesicularis bacteraemia

SummaryA case of repeated episodes ofPseudomonas vesicularis bacteraemia, in a 54-year-old woman with a past history including systemic lupus erythematosus and chronic active autoimmune hepatitis is reported. She was treated with tobramycin and ceftazidime but bacteraemia persisted until surgical resection of the infected tissue was performed.ZusammenfassungBei einer 54jährigen Frau mit systemischem Lupus erythematodes und chronisch aktiver Autoimmunhepatitis traten wiederholt Bakteriämien durchPseudomonas vesicularis auf. Sie wurde mit Tobramycin und Ceftazidim behandelt. Die Bakteriämie persistierte jedoch, bis das infizierte Gewebe durch Resektion entfernt worden war.

Microbiological study of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and the usefulness of analytical and clinical parameters in its identification (VIRAE study)

Purpose Respiratory infection is the most common cause for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The aim of this work was to study the etiology of the respiratory infection in order to assess the usefulness of the clinical and analytical parameters used for COPD identification. Patients and methods We included 132 patients over a period of 2 years. The etiology of the respiratory infection was studied by conventional sputum, paired serology tests for atypical bacteria, and viral diagnostic techniques (immunochromatography, immunofluorescence, cell culture, and molecular biology techniques). We grouped the patients into four groups based on the pathogens isolated (bacterial versus. viral, known etiology versus unknown etiology) and compared the groups. Results A pathogen was identified in 48 patients. The pathogen was identified through sputum culture in 34 patients, seroconversion in three patients, and a positive result from viral techniques in 14 patients. No significant differences in identifying etiology were observed in the clinical and analytical parameters within the different groups. The most cost-effective tests were the sputum test and the polymerase chain reaction. Conclusion Based on our experience, clinical and analytical parameters are not useful for the etiological identification of COPD exacerbations. Diagnosing COPD exacerbation is difficult, with the conventional sputum test for bacterial etiology and molecular biology techniques for viral etiology providing the most profitability. Further studies are necessary to identify respiratory syndromes or analytical parameters that can be used to identify the etiology of new AE-COPD cases without the laborious diagnostic techniques.

La neumonía como comorbilidad en la enfermedad pulmonar obstructiva crónica (EPOC). Diferencias entre la exacerbación aguda de la EPOC y la neumonía en los pacientes con EPOC

INTRODUCTION Pneumonia is considered an independent entity in chronic obstructive pulmonary disease (COPD), to be distinguished from an infectious exacerbation of COPD. The aim of this study was to analyze the clinical characteristics and progress of the exacerbation of COPD (ECOPD) compared to pneumonia in COPD (PCOPD) patients requiring hospitalization. PATIENTS AND METHODS Prospective, longitudinal, observational cohort study including 124 COPD patients requiring hospital admission for lower respiratory tract infection. Patients were categorized according to presence of ECOPD (n=104) or PCOPD (n=20), depending on presence of consolidation on X-ray. Demographic, clinical, laboratory, microbiological and progress variables were collected. RESULTS Patients with ECOPD showed more severe respiratory disease according to the degree of obstruction (P<.01) and need for oxygen therapy (P<.05). PCOPD patients showed increased presence of fever (P<.05), lower blood pressure (P<.001), more laboratory abnormalities (P<.05; leukocytosis, elevated CRP, low serum albumin) and increased presence of crepitus (P<.01). Microbiological diagnosis was achieved in 30.8% of cases of ECOPD and 35% of PCOPD; sputum culture yielded the highest percentage of positive results, predominantly Pseudomonas aeruginosa. Regarding the progress of the episode, no differences were found in hospital stay, need for ICU or mechanical ventilation. CONCLUSIONS Our data confirm clinical and analytical differences between ECOPD and PCOPD in patients who require hospital admission, while there were no differences in subsequent progress.

Seudotumor pancreático de etiología tuberculosa

Fundamento Revisar las caracteristicas clinicas de la tuberculosis pancreatica y su diagnostico diferencial con las tumoraciones pancreaticas. Pacientes y metodo Descripcion de tres casos de tuberculosis pancreatica diagnosticados du-rante un periodo de 2 anos en un hospital universitario de 850 camas. Resultados En los tres casos, las tecnicas de imagen realizadas demostraron afeccion del pan-creas, en forma de desestructuracion, agrandamiento e imagenes hipodensas e hipoecoicas. Uno de los pacientes fue diagnosticado inicialmente de forma erronea de una neoplasia pan-creatica. Se establecio el diagnostico de tuberculosis pancreatica por puncion de absceso sub-cutaneo en un caso, por sospecha clinica en otro y por laparoscopia exploradora en el tercero. Solo un paciente presentaba una inmunodepresion de base. Los tres pacientes se curaron contratamiento antituberculoso triple habitual. Conclusiones La tuberculosis pancreatica se debe considerar en todo paciente que se presentacon una masa pancreatica.

Differences in Hypotensive vs. Non-Hypotensive Sepsis Management in the Emergency Department: Door-to-Antibiotic Time Impact on Sepsis Survival

Background: Sepsis diagnosis can be incorrectly associated with the presence of hypotension during an infection, so the detection and management of non-hypotensive sepsis can be delayed. We aimed to evaluate how the presence or absence of hypotension, on admission at the emergency department, affects the initial management and outcomes of patients with community-onset severe sepsis. Methods: Demographic, clinical, laboratory, process of care, and outcome variables were recorded for all patients, at the emergency department of our university hospital, who presented with community-onset severe sepsis, between 1 March and 31 August in three consecutive years. Patient management consisted of standardized bundled care with five measures: Detection, blood cultures and empirical antibiotics, oxygen supplementation and fluid resuscitation (if needed), clinical monitoring, and noradrenalin administration (if needed). We compared all variables between patients who had hypotension (mean arterial pressure <65 mmHg), on admission to the emergency department, and those who did not. Results: We identified 153 episodes (84 (54.5%) men; mean age 73.6 ± 1.2; mean Sequential Organ Failure Assessment (SOFA) score 4.9 ± 2.7, and 41.2% hospital mortality). Hypotension was present on admission to the emergency department in 57 patients (37.2%). Hemodynamic treatment was applied earlier in patients who presented hypotension initially. Antibiotics were administered 48 min later in non-hypotensive sepsis (p = 0.08). A higher proportion of patients without initial hypotension required admission to the intensive care unit (ICU) (43.1% for patients initially hypotensive vs. 56.9% in those initially non-hypotensive, p < 0.05). Initial hypotension was not associated with mortality. A delay in door-to-antibiotic administration time was associated with mortality [OR 1.150, 95%CI: 1.043–1.268). Conclusions: Initial management of patients with community-onset severe sepsis differed according to their clinical presentation. Initial hypotension was associated with early hemodynamic management and less ICU requirement. A non-significant delay was observed in the administration of antibiotics to initially non-hypotensive patients. The time of door-to-antibiotic administration was related to mortality.