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Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision-making for challenging presentations. This document will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.
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Procedimientos de Cirugía Plástica , Infecciones Relacionadas con Prótesis , Humanos , Prótesis Vascular/efectos adversos , Grupo de Atención al Paciente , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Injerto Vascular/efectos adversos , Literatura de Revisión como AsuntoRESUMEN
Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision making for challenging presentations. This review will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.
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Procedimientos de Cirugía Plástica , Infecciones Relacionadas con Prótesis , Humanos , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Prótesis Vascular/efectos adversos , Grupo de Atención al Paciente , Aneurisma Falso/cirugía , Aneurisma Falso/etiología , Arterias/cirugíaRESUMEN
INTRODUCTION: Gram-negative bacillary bloodstream infection (GN-BSI) is a frequent clinical challenge among immunocompromised hosts and is associated with a high mortality. The utility of follow-up blood cultures (FUBCs) for GN-BSI in this population, particularly in the setting of neutropenia, is poorly defined. METHODS: We conducted a single-center, retrospective cohort study between the period of July 2018 and April 2022 to investigate the utility of FUBCs and delineate risk factors for positive cultures among neutropenic patients with monomicrobial GN-BSI. Univariate logistic regression was performed to assess risk factors associated with positive FUBCs. RESULTS: Of 206 patients, 98% had FUBCs performed, and 9% were positive. Risk factors for positive FUBCs included multidrug-resistant GN infection (OR 3.26; 95% confidence interval [CI] 1.22-8.72) and vascular catheter source (OR 4.82; CI 1.76-13.17). Among patients lacking these risk factors, the prevalence of positive FUBCs was low (2.8%) and the negative predictive value was 92%. Those with positive and negative FUBCs had similar rates of all-cause mortality (16.7% vs. 16.6%; p = .942) and microbiologic relapse (11.1% vs. 6.0%; p = .401) within 90-days of treatment completion. However, positive FUBCs were associated with prolonged hospitalization and longer duration of antimicrobial therapy. CONCLUSION: Positive FUBCs were infrequent in neutropenic patients with GN-BSI, and their occurrence did not significantly impact mortality or microbiologic relapse. Risk factors for positive FUBCs included multidrug resistant Gram-negative infection and vascular catheter source. Prospective studies will be necessary to elucidate the benefits and risks of FUBCs when managing GN-BSI in patients with underlying immune compromise.
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Bacteriemia , Infecciones por Bacterias Gramnegativas , Neutropenia , Sepsis , Humanos , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Infecciones por Bacterias Gramnegativas/epidemiología , Infecciones por Bacterias Gramnegativas/microbiología , Estudios de Seguimiento , Cultivo de Sangre , Estudios Retrospectivos , Estudios Prospectivos , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/epidemiología , Bacteriemia/microbiología , Bacterias Gramnegativas , Neutropenia/complicaciones , Sepsis/tratamiento farmacológico , Factores de Riesgo , Huésped Inmunocomprometido , RecurrenciaRESUMEN
Leptotrichia species are anaerobic, Gram-negative bacilli increasingly recognized as pathogens capable of causing invasive infections such as bloodstream infection (BSI), particularly among immunocompromised patients. However, there is a paucity of data regarding epidemiology, antimicrobial susceptibility, optimal treatment, and clinical outcomes among patients with Leptotrichia bacteremia. Patient risk factors, treatment approaches, and outcomes of a retrospective cohort of adult patients with Leptotrichia BSI at a tertiary medical center (Mayo Clinic Rochester [MCR]) were evaluated. Concurrently, species, temporal trends, and antimicrobial susceptibility testing (AST) results of Leptotrichia isolates submitted to a reference laboratory (Mayo Clinic Laboratories) over the past 10 years were examined. We identified 224 blood culture isolates of Leptotrichia species, with 26 isolates from patients treated at MCR. The most frequent species included L. trevisanii (49%), L. buccalis (24%), and L. wadei (16%). Leptotrichia species demonstrated >90% susceptibility to penicillin, metronidazole, ertapenem, and piperacillin-tazobactam. However, 96% (74/77) of isolates were resistant to moxifloxacin. For patients treated at MCR, the mean patient age was 55 years (standard deviation [SD], 17), with 9 females (35%), and all were neutropenic at the time of BSI. The primary sources of infection were gastrointestinal (58%), intravascular catheter (35%), and odontogenic (15%). Patients were treated with metronidazole (42%), piperacillin-tazobactam (27%), or carbapenems (19%). The mean duration of treatment was 11 days (SD, 4.5), with a 60-day all-cause mortality of 19% and no microbiologic relapse. Leptotrichia species are rare but important causes of BSI in neutropenic patients. Due to evolving antimicrobial susceptibility profiles, a review of AST results is necessary when selecting optimal antimicrobial therapy.
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Antiinfecciosos , Bacteriemia , Sepsis , Adulto , Femenino , Humanos , Persona de Mediana Edad , Metronidazol , Leptotrichia , Estudios Retrospectivos , Bacteriemia/microbiología , Combinación Piperacilina y Tazobactam , Bacterias Gramnegativas , Antibacterianos , Pruebas de Sensibilidad MicrobianaRESUMEN
OBJECTIVES: Whipple's disease (WD) results from infection of the bacteria Tropheryma whipplei (TW). This disease is characterized by macrophage infiltration of intestinal mucosa and primarily affects Caucasian males. Genetic studies of host susceptibility are scarce. Nucleotide-binding oligomerization domain containing protein 2 (NOD2) is an innate immune sensor, resides mainly in monocytes/macrophages and contributes to defense against infection and inflammatory regulation. NOD2 mutations are associated with autoinflammatory diseases. We report the association of NOD2 mutations with TW and WD for the first time. METHODS: A multicenter, retrospective study of three patients with WD was conducted. Patients received extensive multidisciplinary evaluations and were cared for by the authors. NOD2 and its association with infection and inflammation were schematically represented. RESULTS: All patients were Caucasian men and presented with years of autoinflammatory phenotypes, including recurrent fever, rash, inflammatory arthritis, gastrointestinal symptoms, and elevated inflammatory markers. All patients underwent molecular testing using a gene panel for periodic fever syndromes and were identified to carry NOD2 mutations associated with NOD2-associated autoinflammatory disease. Despite initially negative gastrointestinal evaluations, repeat endoscopy with duodenal tissue biopsy ultimately confirmed WD. After initial ceftriaxone and maintenance with doxycycline and/or hydroxychloroquine, symptoms were largely controlled, though mild relapses occurred in follow up. CONCLUSION: Both NOD2 and TW/WD are intensively involved in monocytes/macrophages. WD is regarded as a macrophage disease. NOD2 leucin rich repeat-associated mutations in monocytes/macrophages cause functional impairment of these cells and consequently may make the host susceptible for TW infection and WD, especially in the setting of immunosuppression.
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BACKGROUND: In the management of Gram-negative bloodstream infection (GN-BSI), short antimicrobial courses have been increasingly demonstrated to be non-inferior to prolonged therapy, with lower risk of Clostridioides difficile infection (CDI) and emergence of multi-drug resistant (MDR) organisms. However, immunocompromised hosts were excluded from these studies. We investigated outcomes of short (≤10 days), intermediate (11-14 days), and prolonged (≥15 days) antimicrobial durations for GN-BSI in neutropenic patients. METHODS: A retrospective cohort study was conducted on neutropenic patients with monomicrobial GN-BSI between 2018 and 2022. The primary outcome was a composite of all-cause mortality and microbiologic relapse within 90 days after therapy completion. The secondary outcome was a composite of 90-day CDI and development of MDR-GN bacteria. Cox regression analysis with propensity score (PS) adjustment was used to compare outcomes between the three groups. RESULTS: A total of 206 patients were classified into short (n = 67), intermediate (n = 81), or prolonged (n = 58) duration. Neutropenia was predominantly secondary to hematopoietic stem cell transplantation (48%) or hematologic malignancy (35%). The primary sources of infection included intra-abdominal (51%), vascular catheter (27%), and urinary (8%). Most patients received definitive therapy with cefepime or carbapenem. No significant difference in the primary composite endpoint was observed for intermediate versus short (PS-adjusted hazard ratio [aHR] 0.89; 95% confidence interval [95% CI] 0.39-2.03) or prolonged versus short therapy (PS-aHR 1.20; 95% CI 0.52-2.74). There was no significant difference in the secondary composite endpoint of CDI or MDR-GN emergence. CONCLUSION: Our data suggest that short antimicrobial courses had comparable 90-day outcomes as intermediate and prolonged regimens for GN-BSI among immunocompromised patients with neutropenia.
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Antiinfecciosos , Bacteriemia , Infecciones por Clostridium , Neoplasias Hematológicas , Trasplante de Células Madre Hematopoyéticas , Neutropenia , Sepsis , Humanos , Antibacterianos/uso terapéutico , Estudios Retrospectivos , Recurrencia Local de Neoplasia/tratamiento farmacológico , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Bacteriemia/microbiología , Antiinfecciosos/uso terapéutico , Neoplasias Hematológicas/complicaciones , Neoplasias Hematológicas/terapia , Bacterias Gramnegativas , Neutropenia/complicaciones , Infecciones por Clostridium/tratamiento farmacológico , Sepsis/tratamiento farmacológicoRESUMEN
The literature regarding Clostridioides difficile infection (CDI) in left ventricular assist devices (LVADs) patients is limited. Therefore, we aimed to characterize the clinical course, risk factors, management, and outcomes of LVAD patients who developed CDI. Adult patients who underwent LVAD placement during 2010-2022 and developed CDI were included. To determine risk factors and outcomes, we matched CDI patients with LVAD patients who did not develop CDI. Each CDI case was matched with up to two control subjects by age, sex, and time from LVAD implantation. Forty-seven of 393 LVAD patients (12.0%) developed CDI. The median time from LVAD implantation to CDI was 147 days (interquartile range 22.5-647.0). The most common CDI treatment was oral vancomycin (n = 26, 55.3%). Thirteen patients (27.7%) required treatment extension because of a lack of clinical response. Three patients (6.4%) developed recurrent CDI. When 42 cases were matched to 79 control subjects, antibiotic exposure within 90 days was significantly associated with CDI (adjusted odds ratio 5.77; 95% confidence interval, 1.87-17.74; p = 0.002). Moreover, CDI was associated with 1 year mortality (adjusted hazard ratio 2.62; 95% confidence interval, 1.18-5.82; p = 0.018). This infection occurs most often within the first year after LVAD implantation and was associated with 1 year mortality. Antibiotic exposure is an important risk for CDI.
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Infecciones por Clostridium , Corazón Auxiliar , Adulto , Humanos , Corazón Auxiliar/efectos adversos , Estudios Retrospectivos , Antibacterianos/uso terapéutico , Infecciones por Clostridium/etiología , Infecciones por Clostridium/inducido químicamente , Factores de RiesgoRESUMEN
The role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) convalescent plasma in the treatment of Coronavirus Disease 2019 (COVID-19) in immunosuppressed individuals remains controversial. We describe the course of COVID-19 in patients who had received anti-CD20 therapy within the 3 years prior to infection. We compared outcomes between those treated with and those not treated with high titer SARS-CoV2 convalescent plasma. We identified 144 adults treated at Mayo clinic sites who had received anti-CD20 therapies within a median of 5.9 months prior to the COVID-19 index date. About one-third (34.7%) were hospitalized within 14 days and nearly half (47.9%) within 90 days. COVID-19 directed therapy included anti-spike monoclonal antibodies (n = 30, 20.8%), and, among those hospitalized within 14 days (n = 50), remdesivir (n = 45, 90.0%), glucocorticoids (n = 36, 72.0%) and convalescent plasma (n = 24, 48.0%). The duration from receipt of last dose of anti-CD20 therapy did not correlate with outcomes. The overall 90-day mortality rate was 14.7%. Administration of convalescent plasma within 14 days of the COVID-19 diagnosis was not significantly associated with any study outcome. Further study of COVID-19 in CD20-depleted individuals is needed focusing on the early administration of new and potentially combination antiviral agents, associated or not with vaccine-boosted convalescent plasma.
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COVID-19 , Adulto , Humanos , COVID-19/terapia , SARS-CoV-2 , ARN Viral , Inmunización Pasiva , Sueroterapia para COVID-19 , Anticuerpos Antivirales/uso terapéuticoRESUMEN
This report presents a classic case of CMV esophagitis, which may be puzzling to distinguish from other infectious esophageal lesions. Giant (>1 cm) and deep esophageal lesions in immunocompromised patients may suggest CMV esophagitis. A biopsy with immunostaining is needed to confirm the diagnosis.
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Monkeypox virus, a member of the Orthopoxvirus genus, was first identified as the etiology of monkeypox in 1970 in the Democratic Republic of Congo and remains endemic in regions of Central and West Africa. Following the most recent outbreak of monkeypox in multiple countries throughout Europe and North America, the infection has been declared a public health emergency by the Centers for Disease Control and Prevention. Within this report, we aim to provide clinicians with a focused overview of the epidemiology, clinical manifestation, diagnosis, and approaches to treat and prevent monkeypox infection amidst the global outbreak.
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Mpox , África Occidental/epidemiología , Brotes de Enfermedades/prevención & control , Humanos , Mpox/diagnóstico , Mpox/epidemiología , Monkeypox virus/genética , Salud PúblicaRESUMEN
Coccidioidomycosis is an endemic fungal infection that is typically asymptomatic or associated with pulmonary disease. Extrapulmonary disease may involve the skin, bones, or central nervous system, yet endovascular infections are exceedingly rare. We report the first case, to our knowledge, of coccidioidomycosis of the native aorta in an immunocompromised host.
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Management of infections in the immunocompromised patient requires unique considerations that are not typically seen in the immunocompetent. Immunocompromised hosts require a broad set of differential diagnoses when presenting with febrile illness involving a wide variety of microbiology. Moreover, fungal infections are common, and cotreatment of fungal and bacterial infections occurs with regularity. Fungal coinfection, however, is rare. Here, we describe a patient with Aspergillus and recurrent Cryptococcus neoformans coinfection following completion of treatment for pulmonary cryptococcosis.
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To inform the efficient allocation of testing resources, we evaluated the characteristics of those tested for COVID-19 to determine predictors of a positive test. Recent travel and exposure to a confirmed case were both highly predictive of positive testing. Symptom-based screening strategies alone may be inadequate to control the ongoing pandemic.
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Betacoronavirus/aislamiento & purificación , Técnicas de Laboratorio Clínico , Infecciones por Coronavirus/diagnóstico , Neumonía Viral/diagnóstico , Reacción en Cadena de la Polimerasa , Viaje , Adulto , Infecciones Asintomáticas , COVID-19 , Prueba de COVID-19 , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/transmisión , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Minnesota , Pandemias , Neumonía Viral/epidemiología , Neumonía Viral/transmisión , Medición de Riesgo , SARS-CoV-2RESUMEN
OBJECTIVE: Presently, evidence guiding clinicians on the optimal approach to safely screen patients for coronavirus disease 2019 (COVID-19) to a nonemergent hospital procedure is scarce. In this report, we describe our experience in screening for SARS-CoV-2 prior to semiurgent and urgent hospital procedures. DESIGN: Retrospective case series. SETTING: A single tertiary-care medical center. PARTICIPANTS: Our study cohort included patients ≥18 years of age who had semiurgent or urgent hospital procedures or surgeries. METHODS: Overall, 625 patients were screened for SARS-CoV-2 using a combination of phone questionnaire (7 days prior to the anticipated procedure), RT-PCR and chest computed tomography (CT) between March 1, 2020, and April 30, 2020. RESULTS: Of the 625 patients, 520 scans (83.2%) were interpreted as normal; 1 (0.16%) had typical features of COVID-19; 18 scans (2.88%) had indeterminate features of COVID-19; and 86 (13.76%) had atypical features of COVID-19. In total, 640 RT-PCRs were performed, with 1 positive result (0.15%) in a patient with a CT scan that yielded an atypical finding. Of the 18 patients with chest CTs categorized as indeterminate, 5 underwent repeat negative RT-PCR nasopharyngeal swab 1 week after their initial swab. Also, 1 patient with a chest CT categorized as typical had a follow-up repeat negative RT-PCR, indicating that the chest CT was likely a false positive. After surgery, none of the patients developed signs or symptoms suspicious of COVID-19 that would indicate the need for a repeated RT-PCR or CT scan. CONCLUSION: In our experience, chest CT scanning did not prove provide valuable information in detecting asymptomatic cases of SARS-CoV-2 (COVID-19) in our low-prevalence population.
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Prueba de Ácido Nucleico para COVID-19 , COVID-19 , Control de Infecciones/métodos , Neumonía Viral/diagnóstico , SARS-CoV-2/aislamiento & purificación , Adulto , COVID-19/diagnóstico , COVID-19/epidemiología , COVID-19/prevención & control , Prueba de Ácido Nucleico para COVID-19/métodos , Prueba de Ácido Nucleico para COVID-19/estadística & datos numéricos , Práctica Clínica Basada en la Evidencia , Reacciones Falso Positivas , Femenino , Humanos , Masculino , Tamizaje Masivo/métodos , Tamizaje Masivo/normas , Minnesota/epidemiología , Neumonía Viral/etiología , Administración de la Seguridad , Servicio de Cirugía en Hospital/organización & administración , Tomografía Computarizada por Rayos X/métodos , Tomografía Computarizada por Rayos X/normas , Tomografía Computarizada por Rayos X/estadística & datos numéricosRESUMEN
INTRODUCTION: Kytococcus schroeteri is an infrequently isolated Gram-positive coccus often encountered as a commensal bacterium. Only eighteen cases of human infection associated with this organism have been previously reported. Most of these cases involved patients with implanted prosthetic materials or patients with immunosuppressive conditions. It has been described in prosthetic valve endocarditis and in select patients with hematologic diseases but only one prior report as being involved in osteoarticular infections. CASE PRESENTATION: We describe a case of postsurgical osteoarticular hardware-related infection by K. schroeteri and discuss a possible association with implanted prosthetic material. CONCLUSION: Other clinical presentations of K. schroeteri, including reported infection syndromes, antimicrobial susceptibility profiles, and treatment outcomes, are also reviewed.
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OBJECTIVE: To evaluate the diagnostic yield of fungal smears and cultures from bronchial lavage and wash specimens obtained from immunocompetent patients in the intensive care unit (ICU) because respiratory tract samples from patients in the ICU often undergo extensive microbiological testing. PATIENTS AND METHODS: In total, we enrolled 112 immunocompetent adult patients treated in the medical and surgical ICU between July 1, 2016, and June 30, 2017. We evaluated whether the results of fungal smears and cultures of specimens obtained from bronchoscopy and bronchoalveolar lavage changed patient care. RESULTS: In total, 131 bronchoscopic specimens and 31 bronchoalveolar lavage specimens were tested for fungi. Cultures were held for an estimated 4680 culture-days. Two results changed patient therapy. In both cases, other routine tests provided the same information as fungal culture before these results were returned. CONCLUSION: In immunocompetent, critically ill patients, fungal culture of respiratory tract specimens does not add diagnostic value. Routine fungal culture of respiratory tract specimens should be discouraged in this population.