Mediastinal Mucormycosis: Case report, review of literature and treatment with continuous liposomal amphotericin B irrigation.

Mediastinal mucormycosis is an uncommon but lethal infection associated with an 83% mortality. We describe a case of fatal Rhizopus microsporus mediastinitis despite three exploratory mediastinal surgeries and complementary systemic and mediastinal irrigation with liposomal amphotericin B. We further review the literature on surgical and antifungal management of mediastinal mucormycosis.

Campath-1H induction and the incidence of infectious complications in adult renal transplantation.

BACKGROUND: The purpose of this study was to evaluate adult renal transplantation patients who received a alemtuzumab (Campath-1H)-based induction protocol for the incidence of infectious complications. METHODS: We began using 30 mg Campath-1H intravenously for induction therapy in May 2003. The patients were treated with a maintenance regimen of tacrolimus or mycophenolate mofetil (MMF), and rapidly tapered prednisone; valganciclovir was used for CMV prophylaxis. Forty-nine adult patients who received renal transplants between May 1, 2003 and June 7, 2004 were included. The mean follow-up time was 13.7 months with a range of 10-24 months. Data were collected via a retrospective chart review. RESULTS: The infectious complications noted in the Campath-1H group were compared with a historical group of 56 patients receiving conventional immunosuppression. There was one case of cytomegalovirus (CMV) viremia and two cases of CMV disease (one pneumonitis and one enteritis). There were four cases of urinary tract infection and one extremity cellulitis. One patient developed Cryptococcal meningitis. Eight of the 49 (16%) patients in the Campath group had an infectious complication, compared to 18 out of 56 (32%) in the historical group. CONCLUSION: Campath-1H induction for renal transplantation appears to have a low incidence of associated infectious complications when compared to historical regimens.

Prosthetic Device Infections.

The immunocompromised host is a particularly vulnerable population in whom routine and unusual infections can easily and frequently occur. Prosthetic devices are commonly used in these patients and the infections associated with those devices present a number of challenges for both the microbiologist and the clinician. Biofilms play a major role in device-related infections, which may contribute to failed attempts to recover organisms from routine culture methods. Moreover, device-related microorganisms can be difficult to eradicate by antibiotic therapy alone. Changes in clinical practice and advances in laboratory diagnostics have provided significant improvements in the detection and accurate diagnosis of device-related infections. Disruption of the bacterial biofilm plays an essential role in recovering the causative agent in culture. Various culture and nucleic acid amplification techniques are more accurate to guide directed treatment regimens. This chapter reviews the performance characteristics of currently available diagnostic assays and summarizes published guidelines, where available, for addressing suspected infected prosthetic devices.

Impact of chronic kidney disease stage on lower-extremity arthroplasty.

End-stage renal disease and dialysis is commonly associated with poor outcomes after joint replacement surgery. The goal of this study was to evaluate postoperative complications in patients with less advanced chronic kidney disease undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients who underwent THA or TKA between 2004 and 2011 with stage 1, 2, or 3 chronic kidney disease were retrospectively reviewed via an electronic medical record. The authors compared 377 patients who had stage 1 to 2 chronic kidney disease with 402 patients who had stage 3 chronic kidney disease. No significant differences in 90-day readmission or revision rates were found between the stage 1 to 2 and stage 3 patient groups. For patients with stage 3 chronic kidney disease, the overall mortality rate was greater than that in patients with stage 1 to 2 chronic kidney disease. However, when adjusted for comorbid disease, no significant increases were seen in joint infection, readmission, or early revision between patients with stage 1 to 2 chronic kidney disease vs patients with stage 3 chronic kidney disease. The overall incidence of infection was high (3.5%) but far less than reported for patients with end-stage renal disease, dialysis, and kidney transplant. In conclusion, patients with stage 1, 2, or 3 chronic kidney disease may have a higher than expected rate of prosthetic joint infection (3.5%) after total joint arthroplasty. Patients with stage 3 chronic kidney disease are at higher risk for postoperative mortality compared with those with lesser stages of kidney disease.

Death and cardiovascular events after bacteriuria among adult women with chronic kidney disease.

BACKGROUND: The impact of bacteriuria on mortality and cardiovascular risk has not been previously reported for patients with chronic kidney disease (CKD). OBJECTIVE: To assess the relationship between outpatient episodes of bacteriuria and mortality and cardiovascular risk among women with CKD. DESIGN: Retrospective cohort study using an electronic health database from an integrated healthcare system in central Pennsylvania. SUBJECTS: Adult women with CKD receiving primary care at Geisinger Health System between January 1, 2004 and December 31, 2009 were eligible, and were followed through December 31, 2010 for study outcomes. MAIN MEASURES: The study exposure was bacteriuria, defined as an outpatient urine culture with bacterial growth of 10(4) cfu/mL. Treatment history (antibiotic prescription within 90 days) was identified. Study outcomes were death and the composite of hospitalization for myocardial infarction, congestive heart failure, or stroke. Multivariate-adjusted Cox models incorporated all bacteriuria episodes and antibiotic prescriptions in time-dependent fashion (in addition to other covariates) to account for the cumulative impact of infections, treatment, and hospitalization during follow-up. KEY RESULTS: 6807 women were followed for a median (interquartile range) of 5.2 (3.4, 5.9) years. In adjusted models, each untreated bacteriuria episode was associated with an increased risk of death (hazard ratio [HR] 1.56, 95% CI 1.35-1.81) and the composite cardiovascular outcome (HR 1.32, 95% CI 1.05-1.65); treated episodes were not associated with an increased risk of death or cardiovascular events. CONCLUSION: Among female patients with CKD, untreated bacteriuria occurring in the outpatient setting is associated with an increased risk of death and cardiovascular morbidity.

Propionibacterium acnes as a cause of prosthetic valve aortic root abscess.

Propionibacterium acnes isolates usually have relatively low virulence and are often classified as contaminants when isolated from blood and tissue cultures. We report a patient with Propionibacterium acnes bacteremia and late prosthetic valve endocarditis, complicated by an aortic root abscess.