Vincenzo Emmi

Pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension: hemodynamic characteristics and changes.

OBJECTIVE To see whether degree of pulmonary hypertension or severity of cardiac failure affect the success of pulmonary thromboendarterectomy (PTE) in chronic thromboembolic pulmonary hypertension. METHODS From May 1996 to June 1999, 33 patients, all in New York Heart Association (NYHA) class 3 or 4 were treated with PTE. Preoperative hemodynamic values were: central venous pressure (CVP) 8+/-6 (1-23), mean pulmonary artery pressure (mPAP) 50+/-10 (30-69), cardiac output (CO) 3.3+/-0.9 (1.8-5.2), pulmonary vascular resistance (PVR) 1056+/-344 (523-1659), and right ventricle ejection fraction (RVEF) 12+/-5 (5-21). To establish whether some hemodynamic or cardiac variables correlate with surgical failure (early death or functional non-success), these patients were divided into a low risk or a high risk group for each variable: CVP (<9 or > or =9), mPAP (<50 or > or =50), CO (> or =3.5 or <3.5), PVR (> or =1100 or <1100), and RVEF (> or = 10 or <10). The duration of 3-4 NYHA class period (<24 or > or = 24 months) was also included in the study. RESULTS Three patients (9. 1%) died in hospital, one (3.0%) underwent lung transplant shortly after PTE, and in five cases (15.2%) mPAP and PVR at the 3-month follow-up examination corresponded with our definition of functional nonsuccess (mPAP and PVR decreased by less than 40% of preoperative values). One of the five functional nonsuccess patients underwent lung transplant 3 months after the operation and another died 17 months after the operation from a non-related cause. Thus PTE was successful in 24 patients and unsuccessful in nine. None of the hemodynamic variables considered was found to be associated with the disparate outcomes. At the 3-month examination, all surviving patients were in NYHA class 1 or 2 except for three in NYHA class 3. At 2 years, hemodynamic values were: CVP 2+/-2 (0-4), mPAP 16+/-3 (12-21), CO 5.0+/-1.0 (3.4-6.5), PVR 182+/-51 (112-282), and RVEF 35+/-5 (26-40). All differences were significant with respect to baseline values (P<0.001). Preoperative mPAP and RVEF values had a strict linear correlation (R=0.45; P=0.014). CONCLUSIONS None of the variables considered was correlated with early death or functional nonsuccess. Neither preoperative severity of pulmonary hypertension nor degree of cardiac failure influenced the outcome of the operation. PTE leads to hemodynamic recovery even in very compromised patients.

Catheter-related bacteremia due to Lactobacillus rhamnosus in a single-lung transplant recipient.

There is still a major debate about the pathogenicity of Lactobacillus spp. and some reports emphasize that these microorganisms are never isolated from endovascular devices. In this report we present a case of catheter-related bacteremia due to L. rhamnosus in a patient who underwent a single-lung transplant.

Bacillus cereus Fatal Bacteremia and Apparent Association with Nosocomial Transmission in an Intensive Care Unit

Bacillus cereus has sometimes been implicated in food poisoning and in opportunistic infections of seriously ill patients. This report describes an unusual case of persistent bacteremia and multiple organ failure associated with B. cereus in a patient admitted to our institution for lung cancer. The patient was undergoing treatment with an antimicrobial agent (imipenem) that was shown to be effective against the micro-organism in vitro. No portal of entry for the strain was detected. After treatment with vancomycin, also shown to be effective in vitro, no clinical improvement was noted and the patient died. Molecular studies showed that the same strain caused an episode of pseudobacteremia in another patient admitted to the same ICU room.Bacillus cereus has sometimes been implicated in food poisoning and in opportunistic infections of seriously ill patients. This report describes an unusual case of persistent bacteremia and multiple organ failure associated with B. cereus in a patient admitted to our institution for lung cancer. The patient was undergoing treatment with an antimicrobial agent (imipenem) that was shown to be effective against the micro-organism in vitro. No portal of entry for the strain was detected. After treatment with vancomycin, also shown to be effective in vitro, no clinical improvement was noted and the patient died. Molecular studies showed that the same strain caused an episode of pseudobacteremia in another patient admitted to the same ICU room.

Control of MRSA infection and colonisation in an intensive care unit by GeneOhm MRSA assay and culture methods

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) is one of the major nosocomial pathogens. Due to the diffusion of MRSA strains in both hospital and community settings, prevention and control strategies are receiving increased attention. Approximately 25% to 30% of the population is colonised with S. aureus and 0.2% to 7% with MRSA. The BD GeneOhm MRSA real-time PCR assay offers quicker identification of MRSA-colonised patients than do culture methods.MethodsNinety-five patients admitted to the Intensive Care Unit of IRCCS Policlinico San Matteo of Pavia (Italy) for a period > 24 h were screened for MRSA colonisation with both the culture method and the GeneOhm assay.ResultsOf the 246 nasal swabs collected from 95 patients, 36 samples were found to be positive by both methods (true-positive). 30% of colonised patients had developed the MRSA infection.ConclusionOur results show that the GeneOhm MRSA assay is a valuable diagnostic tool for detecting MRSA quickly in nasal swabs. This study confirms that colonisation represents a high risk factor for MRSA infection, and that good MRSA surveillance in an Intensive Care Unit is therefore an excellent way to prevent MRSA infection.

Extended-Spectrum β-lactamase-Producing Enterobacteriaceae in an Italian Intensive Care Unit: Clinical and Therapeutical Remarks

Abstract In this study we evaluated the prevalence of Enterobacteriaceae and the epi-demiology of ESBL+microorganisms in an ICU of our Institution over a 5-year peri-od and analyzed the clinical features and outcomes of the infections caused by these microorganisms. The most frequent ESBL+ isolate was Proteus mirabilis (69 isolates, 58%); a high rate of positive results in the double-disk synergy test (DDS) was also recognized for Klebsiella pneumoniae (52 isolates, 51%), whereas this phenomenon was observed less frequently in other species. In 312 cases the isolat-ed microorganism was considered to be the cause of infection; we documented 103 wound infections, 89 UTIs, 62 LRTIs, 30 primary bacteremias, 27 infections of indwelling catheters and 1 CNS infection. The overall mortality rate due to ESBL+ strains was 1%, compared with 10.6% rate caused by ESBL-negative Enterobacteriaceae. This could be explained because ESBL+ strains caused mostly localized infections (wound infections and UTIs), whereas systemic or severe infec-tions were sustained by ESBL-negative strains, and therapy with carbapenems was started promptly after ESBL+ isolation (always within 24h after strain isolation).

The Problem of Fever in ICU Patients

Fever is a complex, coordinated autonomic, neuroendocrine, and behavioral response that is adaptive and is used by nearly all vertebrates as part of the acutephase reaction to immune challenge [1].