RESUMO
BACKGROUND: Surgical site infections (SSIs), mainly caused by Staphylococcus aureus, pose a significant economic burden in Europe, leading to increased hospitalization duration, mortality, and treatment costs, particularly with drug-resistant strains such as meticillin-resistant S. aureus. AIM: To conduct a case-control study on the economic impact of S. aureus SSI in adult surgical patients across high-volume centres in France, Germany, Spain, and the UK, aiming to assess the overall and procedure-specific burden across Europe. METHODS: The SALT study is a multinational, retrospective cohort study with a nested case-control analysis focused on S. aureus SSI in Europe. The study included participants from France, Germany, Italy, Spain, and the UK who underwent invasive surgery in 2016 and employed a micro-costing approach to evaluate health economic factors, matching S. aureus SSI cases with controls. FINDINGS: In 2016, among 178,904 surgical patients in five European countries, 764 developed S. aureus SSI. Matching 744 cases to controls, the study revealed that S. aureus SSI cases incurred higher immediate hospitalization costs (8,810), compared to controls (6,032). Additionally, S. aureus SSI cases exhibited increased costs for readmissions within the first year post surgery (7,961.6 versus 5,298.6), with significant differences observed. Factors associated with increased surgery-related costs included the cost of hospitalization immediately after surgery, first intensive care unit (ICU) admission within 12 months, and hospital readmission within 12 months, as identified through multivariable analysis. CONCLUSION: The higher rates of hospitalization, ICU admissions, and readmissions among S. aureus SSI cases highlight the severity of these infections and their impact on healthcare costs, emphasizing the potential benefits of evidence-based infection control measures and improved patient care to mitigate the economic burden.
Assuntos
Infecções Estafilocócicas , Infecção da Ferida Cirúrgica , Humanos , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/epidemiologia , Estudos Retrospectivos , Masculino , Estudos de Casos e Controles , Feminino , Pessoa de Meia-Idade , Infecções Estafilocócicas/economia , Infecções Estafilocócicas/epidemiologia , Idoso , França/epidemiologia , Europa (Continente) , Espanha/epidemiologia , Reino Unido/epidemiologia , COVID-19/economia , COVID-19/epidemiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Adulto , Alemanha/epidemiologia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Staphylococcus aureusRESUMO
BACKGROUND: The aim of this study was to estimate the incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infections (SA-PJI) after primary hip and knee arthroplasty in European centres. METHODS: This study was conducted in patients who underwent primary hip and knee arthroplasty in 19 European hospitals between 2014 and 2016. The global incidence of PJI and SA-PJI was calculated. The associated disease burden was measured indirectly as infection-related mortality plus loss of function. For healthcare utilization, number and duration of hospitalizations, number and type of surgical procedures, duration of antibiotic treatments, and number of outpatient visits were collected. Subgroup and regression analyses were used to evaluate the impact of SA-PJI on healthcare utilization, controlling for confounding variables. RESULTS: The incidence of PJI caused by any micro-organism was 1.41%, and 0.40% for SA-PJI. Among SA-PJI, 20.7% were due to MRSA with substantial regional differences, and were more frequent in partial hip arthroplasty (PHA). Related deaths and loss of function occurred in 7.0% and 10.2% of SA-PJI cases, respectively, and were higher in patients with PHA. Compared with patients without PJI, patients with SA-PJI had a mean of 1.4 more readmissions, 25.1 more days of hospitalization, underwent 1.8 more surgical procedures, and had 5.4 more outpatient visits, controlling for confounding variables. Healthcare utilization was higher in patients who failed surgical treatment of SA-PJI. CONCLUSIONS: This study confirmed that the SA-PJI burden is high, especially in PHA, and provided a solid basis for planning interventions to prevent SA-PJI.
Assuntos
Artroplastia de Quadril , Infecções Relacionadas à Prótese , Infecções Estafilocócicas , Humanos , Staphylococcus aureus , Incidência , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Estudos Retrospectivos , Artroplastia de Quadril/efeitos adversos , Infecções Estafilocócicas/epidemiologia , Hospitais , Aceitação pelo Paciente de Cuidados de Saúde , Efeitos Psicossociais da DoençaRESUMO
To determine the most relevant pathogens for CAP in Germany, patients with radiologically confirmed pulmonary infiltrates and at least one clinical sign of lung infection were prospectively recruited within the CAPNETZ cohort from 2004 until 2016. In 990 out of 4.672 patients (21%) receiving complete diagnostics the most prominent change of pathogens was a decrease of S. pneumoniae (58% in 2004 to 37.5% in 2016; p ≤ 0.001, ρ = - 0.148) and an increase of H. influenzae (12.2% to 20.8%; p = 0.001, ρ = 0.104).
Assuntos
Infecções Comunitárias Adquiridas , Pneumonia Bacteriana , Bactérias , Infecções Comunitárias Adquiridas/epidemiologia , Haemophilus influenzae , Humanos , Pneumonia Bacteriana/diagnóstico , Pneumonia Bacteriana/epidemiologia , Streptococcus pneumoniaeRESUMO
BACKGROUND: For patients with bacteraemia caused by methicillin-sensitive Staphylococcus aureus anti-staphylococcal penicillins (ASPs) or cefazolin are agents of choice. While ASPs are potentially nephrotoxic, cefazolin may be less effective in some S. aureus strains due to an inoculum effect. OBJECTIVES: To perform a systematic literature review and meta-analysis assessing current evidence comparing cefazolin with ASPs for patients with S. aureus bacteraemia (SAB). METHODS: We searched MEDLINE, ISI Web of Science (Science Citation Index Expanded) and the Cochrane Database as well as clinicaltrials.gov from inception to 26 June 2018. All studies investigating the effects of cefazolin versus ASP in patients with methicillin-sensitive SAB were eligible for inclusion regardless of study design, publication status or language. Additional information was requested by direct author contact. A meta-analysis to estimate relative risks (RRs) with the corresponding 95% confidence intervals (CIs) was performed. Statistical heterogeneity was estimated using I2. The primary endpoint was 90-day all-cause mortality. The Newcastle-Ottawa Scale (NOS) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used for study and data quality assessment. RESULTS: Fourteen non-randomized studies were included. Seven reported the primary endpoint (RR 0.71 (0.50, 1.02), low quality of evidence). Cefazolin treatment may be associated with lower 30-day mortality rates (RR 0.70 (0.54, 0.91), low quality of evidence) and less nephrotoxicity (RR 0.36 (0.21, 0.59), (low quality of evidence)). We are uncertain whether cefazolin and ASP differ regarding treatment failure/relapse as the quality of the evidence has been assessed as very low (RR of 0.84 (0.59, 1.18)). For patients with endocarditis (RR 0.71 (0.12, 4.05)) or abscesses (RR 1.17 (0.30, 4.63)), cefazolin treatment may be associated with equal 30-day and 90-day mortality (low quality of evidence). CONCLUSIONS: Cefazolin seemed to be at least equally as effective as ASPs while being associated with less nephrotoxicity.
Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Cefazolina/uso terapêutico , Penicilinas/uso terapêutico , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus/efeitos dos fármacos , Humanos , Falha de TratamentoRESUMO
BACKGROUND: There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia. OBJECTIVE: To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018. SOURCES: The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). CONTENT: Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality. IMPLICATIONS: HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.
Assuntos
Infecções Bacterianas/epidemiologia , Infecções Bacterianas/patologia , Enterobacteriaceae/isolamento & purificação , Pneumonia Associada a Assistência à Saúde/diagnóstico , Pneumonia Associada a Assistência à Saúde/patologia , Pseudomonas aeruginosa/isolamento & purificação , Staphylococcus aureus/isolamento & purificação , Idoso , Idoso de 80 Anos ou mais , Infecções Bacterianas/microbiologia , Regras de Decisão Clínica , Gerenciamento Clínico , Farmacorresistência Bacteriana Múltipla , Enterobacteriaceae/classificação , Enterobacteriaceae/efeitos dos fármacos , Feminino , Pneumonia Associada a Assistência à Saúde/microbiologia , Pneumonia Associada a Assistência à Saúde/mortalidade , Humanos , Incidência , Masculino , Pseudomonas aeruginosa/efeitos dos fármacos , Staphylococcus aureus/efeitos dos fármacos , Estados UnidosRESUMO
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of ßlactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).
Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Gestão de Antimicrobianos , Biomarcadores , Monitoramento de Medicamentos , Humanos , Unidades de Terapia Intensiva , Choque Séptico/tratamento farmacológico , beta-Lactamas/farmacocinética , beta-Lactamas/uso terapêuticoRESUMO
OBJECTIVES: To evaluate whether a hospital-wide infection control programme (ICP) is effective at reducing the burden of healthcare-associated infections (HAIs) and associated severe sepsis/septic shock or death (severe HAIs). METHODS: Prospective, quasi-experimental study with two surveillance periods (September 2011 to August 2012; May 2013 to August 2014). Starting October 2012, the ICP included hand hygiene promotion and bundle implementation for common HAIs. We applied segmented mixed-effects Poisson regression and multi-state models. We reported adjusted incidence rate ratios (aIRR) and adjusted hazard ratios (aHR) with 95% confidence intervals (CI). RESULTS: Overall, 62 154 patients were under surveillance, with 1568 HAIs identified in 1170 patients (4.3 per 100 admissions) in the first and 2336 HAIs identified in 1711 patients (4.9 per 100 admissions) in the second surveillance period. No differences were found in the overall HAI incidence rates between the periods in the general wards (aIRR 1.29, 95% CI 0.78-2.15) and intensive care units (ICUs) (aIRR 0.59, 95% CI 0.27-1.31). However, the HAI incidence rate was declining in the ICUs after starting the ICP (aIRR 0.98, 95% CI 0.97-1.00 per 1-week increment), in contrast to general wards (aIRR 1.01, 95% CI 1.00-1.02). A reduction in severe HAIs (aIRR 0.13, 95% CI 0.05-0.32) and a lower probability of HAI-associated in-hospital deaths (aHR 0.56, 95% CI 0.31-0.99) were observed in the second period in the ICUs. CONCLUSIONS: There was no overall reduction in HAIs after implementation of the ICP. However, there was a significant reduction in severe HAIs in ICUs. Whether this difference was a consequence of the ICP or improvement in HAI case management is not clear.
Assuntos
Infecção Hospitalar/epidemiologia , Controle de Infecções/métodos , Choque Séptico/epidemiologia , Choque Séptico/mortalidade , Idoso , Enterobacteriaceae/isolamento & purificação , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Pessoa de Meia-Idade , Quartos de Pacientes/estatística & dados numéricos , Estudos Prospectivos , Pseudomonas/isolamento & purificação , Enterococos Resistentes à Vancomicina/isolamento & purificaçãoRESUMO
BACKGROUND: Here, we report the case of an HIV positive patient under a dual antiretroviral drug regimen with tenofovir disoproxil and darunavir/ritonavir with stable clinical, virological, and immunological response over 126 weeks. Dual antiretroviral therapy has the advantage of reduced toxicity and lower health care costs, treatment failure and fostering drug resistance are perceived risks. Optimal drug combinations and indication criteria for dual treatment remain controversial. Nevertheless, first clinical trials indicate non-inferiority for combinations of nucleoside reverse transcriptase inhibitors and protease inhibitors. This case presents the combination of tenofovir disoproxil in combination with a protease inhibitor as a new potential dual treatment regimen. METHOD: We performed a systematic literature search and meta-analysis of trials comparing dual to triple ART. RESULTS: Literature review revealed nine studies in which dual therapy with a protease inhibitor and an NRTI was compared to triple therapy. We performed a meta-analysis of six trials that reported a 48-week follow-up. In treatment-naïve patients as well when ART switch was assessed, there was no difference in the treatment success in patients with dual ART versus triple. CONCLUSION: We conclude that dual therapy with a protease inhibitor and NRTI is safe and effective. The use of tenofovir in dual treatment as described in our case needs to be assessed in future clinical trials.
Assuntos
Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Inibidores da Protease de HIV/uso terapêutico , HIV-1/efeitos dos fármacos , Inibidores da Transcriptase Reversa/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Contagem de Linfócito CD4 , Darunavir/administração & dosagem , Infecções por HIV/imunologia , Inibidores da Protease de HIV/administração & dosagem , HIV-1/imunologia , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Transcriptase Reversa/administração & dosagem , Ritonavir/administração & dosagem , Tenofovir/administração & dosagem , Fatores de Tempo , Resultado do Tratamento , Carga ViralRESUMO
Infective endocarditis (IE) is a life-threatening disease, caused by septic vegetations and inflammatory foci on the surface of the endothelium and the valves. Due to its complex and often indecisive presentation the mortality rate is still about 30%. Most frequently bacterial microorganisms entering the bloodstream are the underlying origin of the intracardiac infection. While the disease was primarily restricted to younger patients suffering from rheumatic heart streptococci infections, new at risk categories for Staphylococcus (S.) aureus infections arose over the last years. Rising patient age, increasing drug resistance, intensive treatment conditions such as renal hemodialysis, immunosuppression and long term indwelling central venous catheters but also the application of modern cardiac device implants and valve prosthesis have led to emerging incidences of S. aureus IE in health care settings and community. The aetiologic change has impact on the pathophysiology of IE, the clinical presentation and the overall patient management. Despite intensive research on appropriate in vitro and in vivo models of IE and gained knowledge about the fundamental mechanisms in the formation of bacterial vegetations and extracardiac complications, improved understanding of relevant bacterial virulence factors and triggered host immune responses is required to help developing novel antipathogenic treatment strategies and pathogen specific diagnostic markers. In this review, we summarize and discuss the two main areas affected by the changing patient demographics and provide first, recent knowledge about the pathogenic strategies of S. aureus in the induction of IE, including available experimental models of IE used to study host-pathogen interactions and diagnostic and therapeutic targets. In a second focus we present diagnostic (imaging) regimens for patients with S. aureus IE according to current guidelines as well as treatment strategies and surgical recommendations.
Assuntos
Endocardite Bacteriana/fisiopatologia , Infecções Estafilocócicas/fisiopatologia , Staphylococcus aureus/patogenicidade , Animais , Modelos Animais de Doenças , Endocardite Bacteriana/cirurgia , Endocardite Bacteriana/terapia , Próteses Valvulares Cardíacas/microbiologia , Interações Hospedeiro-Patógeno , Humanos , Incidência , Camundongos , Estudos Retrospectivos , Infecções Estafilocócicas/complicaçõesRESUMO
OBJECTIVES: The 23-valent pneumococcal polysaccharide vaccine (PPV) is recommended for prevention of pneumococcal diseases in adults at risk. Few data exist on time-, age- and sex-dependent vaccine effectiveness on outcomes in pneumonia. METHODS: We performed a population-based cohort study including adults ≥60 years of age (n = 738 927) based on statutory health insurance data from 2005 to 2011. Primary outcomes were all-cause pneumonia incidence and 30-day all-cause mortality. Pneumonia was identified by International Classification of Diseases, 10th Revision, German Modification (ICD-10-GM) codes, with ambulatory cases validated by antibiotic prescription within 7 days. The effect of PPV within 5 years was analysed after propensity score-based matching (three controls per case with PPV vaccination) including comorbidities, care status, age, sex and influenza vaccination. Evaluations were stratified by age group, sex and time of PPV. RESULTS: Two-year incidence of all-cause pneumonia in 213 431 vaccinated individuals was 7501 (3.51%) of 213 431 vs. 23 243 (3.63%) of 640 293 in matched controls (difference -0.11, 95% confidence interval (CI) -0.22 to -0.002, p 0.046). After sex-dependent analysis, PPV effectiveness on pneumonia incidence was observed only in women (difference -0.15, 95% CI -0.28 to -0.02, p 0.02). Thirty-day mortality in vaccinated individuals with pneumonia was 1302 (17.36%) of 7501 vs. 4267 (18.96%) of 22 503 in matched controls (difference -1.60%, 95% CI -2.83 to -0.38, p 0.011). After analysis according to age group, significant mortality reduction was present only in adults aged 60 to 79 years (difference -2.31, 95% CI -3.79 to -0.83, p 0.002). Year of PPV vaccination showed no effect on outcomes. CONCLUSIONS: The findings support consideration of sex and age dependence of PPV effectiveness in future studies.
Assuntos
Vacinas Pneumocócicas/imunologia , Pneumonia Pneumocócica/epidemiologia , Pneumonia Pneumocócica/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Mortalidade , Avaliação de Resultados em Cuidados de Saúde , Vacinas Pneumocócicas/administração & dosagem , Pneumonia Pneumocócica/mortalidade , Vigilância da População , Vacinação , Cobertura VacinalAssuntos
Aciclovir/administração & dosagem , Antivirais/administração & dosagem , Farmacorresistência Viral , Infecções por HIV/complicações , Herpes Genital/tratamento farmacológico , Herpesvirus Humano 2/isolamento & purificação , Mutação de Sentido Incorreto , Aciclovir/farmacologia , Adulto , Antivirais/farmacologia , Técnicas de Genotipagem , Herpes Genital/virologia , Herpesvirus Humano 2/efeitos dos fármacos , Herpesvirus Humano 2/genética , Humanos , Masculino , Recidiva , Timidina Quinase/genética , Falha de Tratamento , Carga ViralRESUMO
The spread of antimicrobial resistance challenges the empirical treatment of urinary tract infections (UTIs). Among others, nitrofurantoin is recommended for first-line treatment, but acceptance among clinicians is limited due to chronic nitrofurantoin-induced lung toxicity and insufficient coverage of Enterobacteriaceae other than Escherichia coli. Nitroxoline appears to be an alternative to nitrofurantoin owing to its favourable safety profile, however data on its current in vitro susceptibility are sparse. In this study, susceptibility to nitroxoline was tested against 3012 urinary clinical isolates (including multidrug-resistant bacteria and Candida spp.) by disk diffusion test and/or broth microdilution. At least 91% of all Gram-negatives (n = 2000), Gram-positives (n = 403) and yeasts (n = 132) had inhibition zone diameters for nitroxoline ≥18 mm. Except for Pseudomonas aeruginosa, nitroxoline MIC90 values were ≤16 mg/L and were 2- to >16-fold lower compared with nitrofurantoin. In extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae and methicillin-resistant Staphylococcus aureus (MRSA), MIC90 values of nitroxoline were two-fold higher compared with non-ESBL-producing enterobacteria and methicillin-susceptible S. aureus (MSSA). The in vitro efficacies of nitroxoline and nitrofurantoin against ATCC strains of E. coli, Enterococcus faecalis and Proteus mirabilis were compared by time-kill curves in Mueller-Hinton broth and artificial urine. Nitroxoline was non-inferior against E. coli, P. mirabilis and E. faecalis in artificial urine. In conclusion, nitroxoline showed a broad antimicrobial spectrum, with inhibition zone diameters and MICs of nitroxoline well below the EUCAST breakpoint for E. coli for most organisms, and thus may also be a target for therapy of uncomplicated UTIs.
Assuntos
Acinetobacter baumannii/efeitos dos fármacos , Anti-Infecciosos Urinários/farmacologia , Candida/efeitos dos fármacos , Enterobacteriaceae/efeitos dos fármacos , Nitrofurantoína/farmacologia , Nitroquinolinas/farmacologia , Pseudomonas aeruginosa/efeitos dos fármacos , Acinetobacter baumannii/isolamento & purificação , Candida/isolamento & purificação , Testes de Sensibilidade a Antimicrobianos por Disco-Difusão , Farmacorresistência Bacteriana Múltipla , Enterobacteriaceae/isolamento & purificação , Humanos , Pseudomonas aeruginosa/isolamento & purificação , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/microbiologiaAssuntos
Anti-Infecciosos Urinários/uso terapêutico , Nitroquinolinas/uso terapêutico , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/microbiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anti-Infecciosos Urinários/administração & dosagem , Anti-Infecciosos Urinários/efeitos adversos , Feminino , Humanos , Masculino , Nitroquinolinas/administração & dosagem , Nitroquinolinas/efeitos adversos , Estudos Prospectivos , Resultado do TratamentoRESUMO
Eosinophilia can be caused by a variety of diseases including allergies, autoimmune diseases, vasculitides, dermatoses, malignancies and drug-induced side effects as well as parasitic and non-parasitic infections. In patients returning from the tropics parasitic infections are the most frequent cause of eosinophilia. The extent of eosinophilia can provide information about the type of pathogen. The diagnostic approach to eosinophilia in travelers returning from the tropics primarily includes three stool examinations for worm eggs and, if necessary, serological tests for helminths. Additionally, a chest xray, an ultrasound of the abdomen and an electrocardiogram (ECG) provide information about organ involvement. Recently, specialized laboratories use molecular techniques (multiplex PCR) to detect worm eggs and intestinal parasites in the stool, which provide a significantly higher sensitivity than traditional stool examination techniques. Cryptococcosis, endemic systemic mycoses (coccidioidomycosis, very rarely histoplasmosis) and invasive mould infections (Aspergillus fumigatus, Mucor spp.) are non-parasitic causes of eosinophilia in blood and bronchoalveolar lavage (BAL).
RESUMO
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).
Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/tratamento farmacológico , Sepse/diagnóstico , Sepse/tratamento farmacológico , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Farmacorresistência Bacteriana , Humanos , Unidades de Terapia Intensiva , Sepse/microbiologia , Sepse/mortalidade , Choque Séptico/diagnóstico , Choque Séptico/tratamento farmacológicoRESUMO
PURPOSE: Infective endocarditis (IE) is often associated with multiorgan dysfunction and mortality. The impact of perioperative liver dysfunction (LD) on outcome remains unclear and little is known about factors leading to postoperative LD. METHODS: We performed a retrospective, single-center analysis on 285 patients with left-sided IE without pre-existing chronic liver disease referred to our center between 2007 and 2013 for valve surgery. Sequential organ failure assessment (SOFA) score was used to evaluate organ dysfunction. Chi-square, Cox regression, and multivariate analyses were used for evaluation. RESULTS: Preoperative LD (Bilirubin >20 µmol/L) was present in 68 of 285 patients. New, postoperative LD occurred in 54 patients. Hypoxic hepatitis presented the most common origin of LD, accompanied with high short-term mortality. In-hospital mortality was higher in patients with preoperative and postoperative LD compared to patients without LD (51.5, 24.1, and 10.4%, respectively, p < 0.001). 5-year survival was worse in patients with pre- or postoperative LD compared to patients without LD (20.1, 37.1, and 57.0% respectively). A landmark analysis revealed similar 5-year survival between groups after patient discharge. Quality of life was similar between groups when patients survived the perioperative period. Logistic regression analysis identified duration of cardiopulmonary bypass and S. aureus infection as independent predictors of postoperative LD. CONCLUSIONS: Perioperative liver dysfunction in patients with infective endocarditis is an independent predictor of short- and long-term mortalities. After surviving the hospital stay, 5-year prognosis is not different and quality of life is not affected by LD. S. aureus and duration of cardiopulmonary bypass represent risk factors for postoperative LD.
Assuntos
Endocardite/mortalidade , Mortalidade Hospitalar , Tempo de Internação , Hepatopatias/mortalidade , Período Perioperatório , Idoso , Endocardite/complicações , Endocardite/diagnóstico , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Hepatopatias/diagnóstico , Hepatopatias/etiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/fisiologiaRESUMO
Tularaemia is a highly contagious infectious zoonosis caused by the bacterial agent Francisella tularensis. The aim of this study was to investigate the presence of antibodies to F. tularensis in febrile patients in northeastern Kenya. During 2014-2015, 730 patients were screened for anti-F. tularensis antibodies using a combination of ELISA and Western blot. Twenty-seven (3.7%) individuals were positive for F. tularensis. Tularaemia was not suspected by the treating clinicians in any of them. Our results suggest that tularaemia may be present in Kenya but remain unreported, and emphasizes the need for local clinicians to broaden their diagnostic repertoire when evaluating patients with undifferentiated febrile illness.
RESUMO
Antibiotic resistance is a part of bacterial evolution and therefore unavoidable. In the context of missing novel treatment options, the restrictive use of available antibiotics in order to decelerate the spread of resistance is of high importance. This is the aim of Antibiotic Stewardship (ABS). ABS consists of two sides: a structural one and an individual one. The former deals with the formation of ABS teams, the analysis of antibiotic usage and resistance development, and the implementation of certain measures to improve antibiotic use; the latter is reflected by concrete bedside decisions: How can (broad) spectrum antibiotics be spared without harming the patient? This can be achieved, for example, by de-escalation, limiting duration of treatment, and avoiding nonindicated use. Typical nonindicated uses in both in- and outpatients are viral respiratory tract infections, asymptomatic bacteriuria and nonbacterial exacerbations of chronic obstructive pulmonary disease. Furthermore, respiratory colonization in ventilated patients, ventilator-associated tracheobronchitis, "prolonged" perioperative prophylaxis, and contaminated blood cultures reflect situations where antibiotics should be avoided. In the future, ABS will benefit from accelerated pathogen and resistance detection because early adequate treatment not only lowers the usage of antibiotics but can also improve patient outcome.