María Jesús Pérez

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.

A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal

BACKGROUND Suspicion of catheter-related bloodstream infection (CR-BSI) leads frequently to unnecessary catheter withdrawals, and many catheter-tip cultures yield negative results. The objective of this study was to compare the yield of 3 microbiological procedures to assess CR-BSI without catheter withdrawal. METHODS The study was prospectively performed in a group of patients without neutropenia or blood disorders who were admitted to the intensive care unit during a 37-month period with sepsis suspected on clinical grounds and who had central venous catheters inserted for >48 h. The microbiological procedures compared were semiquantitative cultures from hub and skin (superficial), differential quantitative blood cultures, and differential time to positivity between cultures of blood obtained from catheter hubs and peripheral blood. RESULTS Of the 204 episodes of suspected CR-BSI included in the study, 28 were confirmed to be CR-BSI. We obtained the following results for sensitivity, specificity, positive and negative predictive values, and accuracy: superficial cultures, 78.6%, 92.0%, 61.1%, 96.4%, and 90.2%, respectively; differential quantitative blood cultures, 71.4%, 97.7%, 83.3%, 95.6%, and 94.1%, respectively; and differential time to positivity, 96.4%, 90.3%, 61.4%, 99.4%, and 91.2%, respectively. CONCLUSIONS CR-BSI can be assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Convenience, use of resources, and expertise should determine the technique of choice in different medical contexts. Because of ease of performance, low cost, and wide availability, we recommend combining semiquantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique.

A Prospective, Randomized, and Comparative Study of 3 Different Methods for the Diagnosis of Intravascular Catheter Colonization

BACKGROUND Demonstration of catheter tip colonization is usually performed by use of Makis semiquantitative technique, although the superiority of quantitative techniques has been claimed on the basis of their purported ability to detect both endoluminal and exoluminal microorganisms. METHODS We prospectively compared Makis semiquantitative technique and the quantitative methods of sonication and vortexing for the detection of colonization of intravascular catheter tips and catheter-related bloodstream infections. All 3 techniques were performed on the tip of each catheter, and the order in which each technique was performed was randomly assigned. RESULTS Of the 1000 catheter tips that were processed, 329 (32.9%) had positive results for at least 1 of the 3 techniques when a breakpoint of >or=100 colony-forming units (cfu)/catheter segment was used for the quantitative techniques and a breakpoint of >or=15 cfu was used for Makis technique. Eighty-two of the catheter tips for which results were positive were from patients with catheter-related bloodstream infections. For each technique, the likelihood of detection decreased progressively depending on the order in which the technique was performed (i.e., second vs. first and third vs. second). The likelihood of detection of catheter colonization for each technique, when the technique was performed first and when 2 breakpoints (>or=100 cfu/catheter segment [criterion B] and >or=1000 cfu/catheter segment [criterion A]) were used for the quantitative techniques and a breakpoint of >or=15 cfu was used for Makis technique, was as follows: 99.1% and 100% for Makis technique, 95.1% and 92.9% for sonication, and 93.1% and 72.8% for vortexing (for criteria B and A, respectively). No inferiority of Makis technique could be demonstrated when results were compared according to whether catheter placement was short term (i.e., <7 days) or long term (i.e., >or=7 days), either for the detection of colonization or for the detection of catheter-related bloodstream infections. CONCLUSIONS According to data from the present study, the quantitative techniques of sonication and vortexing were not superior to Makis technique under the test conditions used. The greater simplicity of Makis semiquantitative technique makes it the procedure of choice for routine work in the microbiology laboratory.

BK virus in liver transplant recipients: a prospective study.

BACKGROUND BK virus (BKV) is a polyomavirus that is associated with nephropathy and graft loss among kidney transplant recipients. The role of BK virus in nonrenal solid organ transplant recipients has not been clearly established; only anecdotal case reports have been published. METHODS From August 2005 to September 2007, all liver transplant (OLT) recipients who gave their consent were enrolled in this prospective longitudinal study. BK viral load was measured using real-time quantitative polymerase chain reaction assays of urine and plasma, using samples collected at week 1 and months 1, 3, 6, 9, 12, 15, 18, 21, and 24 posttransplantation. We also collected demographic and clinical data, including serum creatinine and immunosuppressive therapy. RESULTS The mean age of the 62 patients was 51.4 years including 14 (22.5%) women. Hepatitis C infection was present in 24 patients (38.7%). BK viruria was detected in 14.5% of 290 samples, corresponding to 13 patients (21%). BK viremia was detected in 5.1% of 317 samples, corresponding to 11 patients (18%). Almost all cases of BK viremia (91%) occurred in the first 3 months after OLT. BKV viremia was more common among patients experiencing a rejection episode (10.6 vs 40%, P = .01). We did not observe a relationship between single episodes of BKV replication and renal function: median plasma creatinine 1.1 mg/dL in patients without versus 1.2 mg/dL with BKV viremia. The three patients with persistent viremia displayed renal insufficiency; one of them died due to multiorgan failure of unknown origin. CONCLUSIONS BKV is frequently detected in OLT recipients (viruria 21% and viremia 18%) early after transplantation. It is more common among patients with rejection episodes. Persistent BKV viremia may be related to renal dysfunction in OLT patients.

Effect of a yellow filter on mesopic contrast perception and differential light sensitivity in the visual field.

Purpose: Previous studies on the effects of yellow filters in the visual performance have been carried out, presenting discrepancies among the different investigations. Our study reports the influence of the yellow filter without residual reflections on contrast perception and differential light sensitivity (DLS) under mesopic conditions. Methods: Contrast sensitivity, low contrast visual acuity and luminance thresholds in the central visual field (30°) were measured in a group of 38 adult subjects with and without a coated yellow lens (482-nm cut-off) under mesopic conditions. Results: The contrast sensitivity mean was significantly better with the filter at low- and middle-range spatial frequencies (1.5 cycles/degree p = 0.002 and 6 cycles/degree p = 0.02). At 5% contrast, the mesopic low contrast visual acuity improved significantly (p = 0.004) when interposing the yellow filter. The increase in DLS was statistically significant [e.g. all visual fields p = 0.0003 and macular visual field (9.5°) p = 0.00001] through the yellow filter on the different established areas of the visual field (30°). Conclusions: The yellow filter without residual reflections had a positive influence on the brightness and contrast perception of healthy subjects, for which its use would be beneficial under mesopic conditions.

Endothelin stimulates tyrosine phosphorylation of p125FAK and p130Cas in rat cerebral cortex

Stimulation of rat cerebral cortex with endothelin-1 (ET-1) caused an increase in the tyrosine phosphorylation of several proteins. Two of these phosphoproteins were identified by the immunoprecipitation assays as being the focal adhesion kinase p125FAK and crk-associated substrate p130Cas. This effect was time- and dose-dependent, with an EC50 value of 3.9 x 10(-8) M. In addition, the cerebral cortex ET receptor subtype involved in this action was determined by using BQ-123 and BQ-788, which are ET(A) and ET(B) receptor antagonists respectively. Our results indicate that the ET-1 effect on protein tyrosine phosphorylation occurred through ET(B) receptors. The requirement for extracellular Ca2+ on ET-1 action was also studied. ET-1-stimulated tyrosine phosphorylation of both p125FAK and p130Cas was abolished in the absence of external Ca2+ or in the presence of nimodipine, a Ca2+ channel-blocker. These results suggest that the ET-1-stimulated protein tyrosine phosphorylation was secondary to Ca2+ influx through the dihydropyridine Ca2+-channel. In slices where protein kinase C was inhibited, ET-1-stimulated tyrosine phosphorylation of both proteins was reduced. These results indicate that ET-1 modulates the tyrosine phosphorylation of specific proteins, which may be involved in adhesion processes in the brain.

Is it feasible to diagnose catheter-related candidemia without catheter withdrawal?

Many bloodstream infections (BSI) in patients with central venous catheters (CVC) are not catheter-related (CR). Assessment of catheter involvement without catheter withdrawal has not been studied in candidemia. We assessed the value of conservative techniques to evaluate catheters as the origin of candidemia in patients with CVC in a prospective cohort study (superficial Gram stain and culture, Kite technique (Gram stain and culture of the first 1 cm blood drawn from the CVC), proportion of positive blood cultures (PPBCs), differential time to positivity (DTP), and minimal time to positivity (MTP)). All catheters were cultured at withdrawal. From June 2008 to January 2012, 22 cases fulfilled the inclusion criteria. CR-candidemia (CRC) was confirmed in 10. Validity values for predicting CRC were: superficial Gram stain (S, 30%; Sp, 81.83%; PPV, 60%; NPV, 56.3%; Ac, 57.1%), superficial cultures (S, 40%; Sp, 75%; PPV, 57.1%; NPV, 60%; Ac, 59.1%), Kite Gram stain (S, 33.3%; Sp, 66.7%; PPV, 50%; NPV, 50%; Ac, 50%), Kite culture (S, 80%; Sp, 66.7%; PPV, 66.7%; NPV, 80%; Ac, 72.7%), PPBC (S, 50%; Sp, 41.7%; PPV, 41.7%; NPV, 50.0%; Ac, 45.5%), DTP (S, 100%; Sp, 33.3%; PPV, 55.6%; NPV, 100%; Ac, 63.6%), and MTTP (S, 70%; Sp, 58.3%; PPV, 58.3%; NPV, 70%; Ac, 63.6%). While combinations of two tests improved sensitivity and NPV, more than two tests did not improve validity values. Classic tests to assess CR-BSI caused by bacteria cannot be reliably used to diagnose CRC. Combinations of tests could be useful, but more and larger studies are required.

Uretrosonografía. Comparación con la uretrografía convencional en la estenosis de uretra masculina

Resumen Objetivo Definir el papel de la uretrosonografia en el estudio de la estenosis de la uretra masculina. Material y metodos Se realizo un estudio prospectivo de 19 pa-cientes, con estenosis de uretra masculina, seleccionados consecutivamente mediante uretrografia convencional y a los que, posteriormente, se les practico la uretrosonografia. Para la realizacion de la uretrosonografia se introducia una sonda de Foley (8 o 10 F) inflando lentamente el balon en la fosa navicular de la uretra. A continuacion se inyectaba solucion salina esteril a un ritmo lento y continuo mientras se realizaba la ecografia colocando el transductor en la cara ventral del pene y en la region perineal para identificar las diferentes partes de la uretra. Se analizaron la localizacion y mediciones de la estenosis mediante ambos metodos radiologicos y la apreciacion ecografica de areas de fibrosis adyacente (espongiofibro-sis) correlacionandose en 10 casos con los hallazgos anatomopatologicos. Resultados En la localizacion de la estenosis existio un buen acuerdo entre ambos metodos (kappa = 0,81). Sin embargo, en la me-dicion de la estenosis hubo diferencias significativas (p = 0,01). La uretrosonografia mostro zonas de espongiofibrosis visualizadas como areas de diferente ecogenicidad, adyacente a la estenosis, cuya medi-cion no mostro diferencias significativas cuando se compararon con los resultados anatomopatologicos. Conclusiones La uretrosonografia es una tecnica superior a la ure-trografia convencional en el estudio de la estenosis de uretra, ya que puede medir y localizar de forma precisa la estenosis y visualizar el area de espongiofibrosis, determinante para la planificacion quirurgica.