Successful cure of a patient with urosepsis using a combination of extracorporeal membrane oxygenation and continuous renal replacement therapy: A case report and literature review.

Holmium laser lithotripsy (HLL) is one of the common surgical methods for urolithiasis. It causes minor surgical trauma, but complications are not rare. Extracorporeal membrane oxygenation (ECMO) treatment of sepsis is common, but venoarterial (VA)-ECMO treatment of urosepsis has not been reported yet. In this article, we reported a 67-year-old female patient with refractory septic shock caused by HLL under percutaneous nephroscope, involving breathing, heart, kidney and other organs, and organs support treatment was ineffective for the patient. Finally, we successfully treated the patient under VA-ECMO with continuous renal replacement therapy (CRRT). Combined ECMO and CRRT may provide a solution for addressing refractory sepsis. Here we present the case and review relevant literature, so as to provide a treatment strategy for patients with refractory urogenic sepsis and to reduce the mortality rate.

Validation of the mutant selection window hypothesis with fosfomycin against Escherichia coli and Pseudomonas aeruginosa: an in vitro and in vivo comparative study.

The purpose of this study was to validate the mutant selection window (MSW) hypothesis in vitro and in vivo with Escherichia coli and Pseudomonas aeruginosa exposed to fosfomycin. Two standard strains of Gram-negative bacteria, those are E. coli ATCC 25922 and P. aeruginosa ATCC 27853, were exposed to fosfomycin at concentrations below MIC, between the MIC and the mutant prevention concentration (MPC), and above the MPC in Luria-Bertani broth and in a tissue-cage infection model, respectively. With the in vitro time-kill studies, there were bacterial re-growth and emergence of resistance thereafter for both strains at antibiotic concentrations of × 4, × 8 and × 16 MIC. In our animal model, the loss in susceptibility of P. aeruginosa at fosfomycin concentrations fluctuated between the lower and upper boundaries of the MSW. In contrast, the emergence of resistant mutants of E. coli was not observed in vivo, regardless of fosfomycin dosage. Interestingly, the in vitro-isolated resistant mutants of E. coli showed a decreased growth rate compared with the susceptible parental strains, whereas no fitness cost in P. aeruginosa was observed. The emergence of antibiotic resistance is shaped by several factors. MSW theory may not apply to all antimicrobial-pathogen combinations. Before it can be used as a framework for the design of antimicrobial therapy, the existence of the window must be demonstrated not only in vitro but also in vivo.

Galleria mellonella as an in vivo model for assessing the efficacy of antimicrobial agents against Enterobacter cloacae infection.

BACKGROUND/PURPOSE: Enterobacter cloacae is a well-recognized nosocomial pathogen. Use of a rapid, in vivo infection model for E. cloacae that can determine the efficacy of antibiotic therapies could help facilitate screening for new treatments. Nonmammalian model systems of infection, such as Galleria mellonella, have significant logistical and ethical advantages over mammalian models. MATERIALS AND METHODS: We utilized G. mellonella larvae to determine the utility of this infection model to study antibacterial efficacy. G. mellonella killing with heat-killed or live clinical isolates (E. cloacae GN1059 and GN0791) was tested. We also investigated the effect of postinoculation incubation temperature on the survival of infected larvae. The protection of administration of antibiotics to infected larvae was investigated. Finally, we determined the G. mellonella hemolymph burden of E. cloacae after administration of different antibiotics. RESULTS: With live bacterial inocula, G. mellonella killing was significantly dependent on the number of E. cloacae cells injected in a dose-dependent manner. Further, we observed that survival was reduced with increasing the postinoculation temperature. Treatment of a lethal E. cloacae infection with antibiotics that had in vitro activity significantly prolonged the survival of larvae compared with treatment with antibiotics to which the bacteria were resistant. The therapeutic benefit arising from administration of antibiotic correlated with a reduced burden of E. cloacae cells in the hemolymph. CONCLUSION: The G. mellonella infection model has the potential to be used to facilitate the in vivo study of host-pathogen interactions in E. cloacae and the efficacy of antibacterial agents.

[Effect of albumin and hemoglobin level on prognosis of patients with uncomplicated severe traumatic brain injury: a retrospective cohort study].

OBJECTIVE: To evaluate the best level of albumin and hemoglobin for the patients with uncomplicated severe traumatic brain injury (TBI). METHODS: A retrospective cohort study was conducted. One hundred and sixty-eight patients with uncomplicated severe TBI admitted to intensive care unit (ICU) of Anhui Provincial Hospital were enrolled. The relationship between albumin and hemoglobin level within 3 days after admission and prognosis was analyzed. Mean 3-day albumin level was obtained, and then the patients were divided into <25, 25-28, 29-31 and ≥32 g/L groups according to quartiles based on mean albumin, and also were divided into <90, 90-99, 100-109 and≥110 g/L groups according to the mean hemoglobin concentration. Multivariable log-binomial regression was used to model the association between mean albumin and hemoglobin concentration and prognosis. RESULTS: One hundred and nine patients were enrolled based on inclusion/exclusion criteria. Among them, 32 patients (29.4%) received a red blood cell (RBC) transfusion, and 24 patients (22.0%) were given albumin treatment. According to the average level of albumin, there were significant differences in mortality among <25, 25-28, 29-31 and ≥32 g/L groups [85.2%(23/27), 59.3%(16/27), 32.1%(9/28), 44.4%(12/27), respectively, P=0.001]. According to the hemoglobin level, there was no significant difference in mortality rate among <90, 90-99, 100-109 and ≥110 g/L groups[61.8%(34/55), 43.8%(7/16), 53.3%(8/15), 47.8%(11/23), respectively, P>0.05]. When using the albumin level, Glasgow coma score (GCS), age and time of onset for logistic analysis, albumin level and age had influence on the mortality of patients, and mortality rate was generally decreased with an increase in albumin. But when the levels of albumin was ≥32 g/L, the risk of death was higher than in the 29-31 g/L group[relative risk (RR) of albumin 29-31 g/L=0.070, 95% confidence interval (95%CI) 0.015-0.331, P=0.001; RR of albumin≥32 g/L=0.153, 95%CI 0.035-0.663, P=0.012; RR of age=0.691, 95%CI 0.526-0.907, P=0.008]. When the hemoglobin level, GCS, age and time of onset were used for logistic regression analysis, only GCS entered the regression model (RR=0.696,95%CI 0.550-0.880, P=0.002), illustrating that the hemoglobin level had no significant influence on mortality, and mortality rate declined with an increase in GCS. CONCLUSIONS: The most favorable level of albumin for uncomplicated severe traumatic brain injury is 29-31 g/L. There is no difference in mortality rate when hemoglobin >90 g/L.

[Effects of hyperbaric oxygen on the acute lung injury induced by oleic acid in rats].

OBJECTIVE: To explore the effect of hyperbaric oxygen (HBO) on acute lung injury (ALI) induced by oleic acid (OA) in rats. METHODS: Eighty healthy Sprague-Dawley (SD) rats were randomly divided into four groups. In OA group (n=30), ALI was produced by injection of OA 0.15 ml/kg through tail vein. Ten rats were randomly selected and sacrificed after injection of OA at the time of 4 hours, 3 days, and 7 days, respectively. In OA plus HBO group (n=20), rats received HBO intervention in a special box with oxygen of 2.5 atm (1 atm=101.325 kPa) for 90 minutes. Ten rats were randomly respectively sacrificed at 3 days and 7 days. In simple HBO group, 20 rats were sacrificed at 3 days and 7 days of HBO intervention, respectively. Other 10 rats were assigned as control group. Blood, lung specimens were collected after sacrifice. Serum contents of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta) and IL-6 were measured. Gross changes and pathological findings of the left lung were recorded. The wet to the dry weigh (W/D) of the right lung was determined. RESULTS: Partial pressure of oxygen in arterial blood (PaO2, mm Hg, 1 mm Hg=0.133 kPa) fell from 107.70+/-5.37 to 57.40+/-2.63 in OA group. Congestion, bleeding and edema could be seen grossly. They could also be found under microscope with disappearance of normal structure, and accumulation of fluid in interstitium with inflammatory cell infiltration and hyaline membrane formation were also found. Lung W/D ratio was increased as compared with the control group (6.94+/-0.44 vs. 4.59+/-0.44, P<0.05). A marked increase was found in serum TNF-alpha, IL-1 beta, IL-6 levels [TNF-alpha (microg/L): 18.52+/-1.20 vs. 5.27+/-0.61, IL-1 beta (microg/L): 13.73+/-1.37 vs. 6.13+/-1.51, IL-6 (microg/L): 14.51+/-1.21 vs. 11.14+/-0.89]. After HBO therapy for 3 days and 7 days, PaO2 (mm Hg, 3 days: 79.20+/-1.68 vs. 59.00+/-2.70, 7 days: 94.30+/-3.77 vs. 74.00+/-3.85) and lung W/D (3 day: 7.43+/-0.73 vs. 9.82+/-0.99, 7 days : 6.75+/-1.14 vs. 8.77+/-1.60) of HBO group were ameliorated to varying degrees compared with OA model group (P<0.05 or P<0.01). HBO therapy for 3 days could lower levels of IL-1 beta (microg/L) in the serum (6.46+/-1.99 vs. 9.09+/-1.09, P<0.05). CONCLUSION: It is suggested that HBO treatment for ALI in rats had effects of improving arterial blood gases and the lung water transport, and inhibiting inflammatory mediators production.

[Individualized and comprehensive therapy for severe acute pancreatitis in early stage: analysis of 110 cases].

OBJECTIVE: To investigate the risk factors of exacerbation of severe acute pancreatitis (SAP) in early stage, in order to formulate therapeutic strategies including minimally invasive intervention and organ support, and to finalize an individualized and comprehensive therapy for the SAP in early stage to decrease the mortality. METHODS: Fifty-three patients with SAP admitted from 1995 to 1999 was categorized as group 1, and 57 patients admitted from 2000 to 2005 as group 2, were analyzed retrospectively. Ranson's score, acute physiological and chronic health evaluation II (APACHE II) score, Balthazar CT grade, presence or absence of biliary tract obstruction, hypoxia, lung infection, shock, abdomen compartment syndrome (ACS), hyperlipemia, pleural effusion were analysed logistically. Mortality following different treatments and incidence rate of complications were also evaluated. RESULTS: In the two groups, 13 patients of the group 1 and 14 of group 2 were complicated with multiple organ dysfunction syndrome (MODS) in the early stage. There was difference in Ranson's score, APACHE II, Balthazar CT grade, between the groups with and without MODS (all P<0.05). Higher incidences of shock, biliary tract obstruction, ACS, hyperlipemia, pleural effusion were seen in group with MODS (P<0.01). Mortality of group 2 patients was lowered after receiving a comprehensive therapy including bedside hemodialysis (CBP) and artificial liver support (P<0.01). CONCLUSION: Development of MODS in SAP and its mortality are related to strategies of treatment, and adoption of an individualized and comprehensive therapy for the SAP in early stage can decrease the complications and the mortality.