Antibiotic-resistant microorganisms in patients with bloodstream infection of intraabdominal origin: risk factors and impact on mortality.

BACKGROUND: Knowledge of resistance patterns is essential to choose empirical treatment. We aimed to determine the risk factors for antibiotic-resistant microorganisms (ARM) in intraabdominal infections (IAI) and their impact on mortality. METHODS: Retrospective cohort study of patients with bacteremia from IAI origin in a single hospital between January 2006 and July 2017. RESULTS: A total of 1485 episodes were recorded, including 381 (25.6%) due to ARM. Independent predictors of ARM were cirrhosis (OR 2; [95% CI 1.15-3.48]), immunosuppression (OR 1.49; 1.12-1.97), prior ceftazidime exposure (OR 3.7; 1.14-11.9), number of prior antibiotics (OR 2.33; 1.61-3.35 for 1 antibiotic), biliary manipulation (OR 1.53; 1.02-2.96), hospital-acquisition (OR 2.77; 1.89-4) and shock (OR 1.48; 1.07-2). Mortality rate of the whole cohort was 11.1%. Age (OR 1.03; 1.01-1.04), cirrhosis (OR 2.32; 1.07-4.38), urinary catheter (OR 1.99; 1.17-3.38), ultimately (OR 2.28; 1.47-3.51) or rapidly (OR 13.3; 7.12-24.9) fatal underlying disease, nosocomial infection (OR 2.76; 1.6-4.75), peritonitis (OR 1.95, 1.1-3.45), absence of fever (OR 2.17; 1.25-3.77), shock (OR 5.96; 3.89-9.13), and an ARM in non-biliary infections (OR 2.14; 1.19-3.83) were independent predictors of 30-day mortality. Source control (OR 0.24; 0.13-0.44) and 2015-2017 period (OR 0.29; 0.14-0.6) were protective. CONCLUSION: Biliary manipulation and septic shock are predictors of ARM. The presence of an ARM from a non-biliary focus is a poor-prognosis indicator. Source control continues to be of paramount importance.

Relation of depression to heart rate nonlinear dynamics in patients > or =60 years of age with recent unstable angina pectoris or acute myocardial infarction.

Depression is common among older patients and it has been related to a worsened coronary prognosis. The basis for this association is controversial. The aim of this study was to ascertain whether patients with a recent acute coronary event show depression-related changes of heart rate variability (HRV) nonlinear dynamics. Alterations of the HRV have been recently shown to predict mortality in patients recovering from an acute myocardial infarction. In 52 patients > or =60 years (52% women) with recent (within 24 to 72 hours) unstable angina pectoris or myocardial infarction, we obtained conventional time- and frequency-domain HRV measurements, along with nonlinear HRV measurements, including SD of the instantaneous beat-to-beat variability (SD1), scaling exponent alpha1 (alpha1), and approximate entropy (ApEn) from 10-minute RR-interval recordings. We also evaluated the presence of clinical depression and measured its severity by means of a 21-item Hamilton Depression Scale. On admission to the coronary care unit, 19 patients (37%) were depressed; alpha1 was higher (1.23 +/- 0.21 vs 1.03 +/- 0.30, p <0.05), whereas SD1 (10.4 +/- 3.7 vs 14.4 +/- 7.3, p <0.05) and ApEn (0.98 +/- 0.22 vs 1.16 +/- 0.15, p <0.001) were lower in depressed patients. Also, alpha1 increased (r = 0.31, p <0.05) and both SD1 (r = -0.46, p <0.01) and ApEn (r = -0.28, p <0.05) decreased with worsening depressive symptoms. In our sample, depression was associated with increased correlation and decreased complexity of the interbeat interval time series in older adults who had recently developed an acute coronary syndrome.

Worsening of depressive symptoms 6 months after an acute coronary event in older adults is associated with impairment of cardiac autonomic function.

BACKGROUND: Depression increases mortality of coronary patients, and autonomic dysfunction has been proposed as an explanation for this association. METHODS: In a sample of 38 adults > or = 60 years with myocardial infarction or unstable angina, we studied depression (presence of a major depressive episode and 21-item Hamilton depression score) and heart rate variability (HRV) of 550 normal beats shortly after admission to the coronary care unit (CCU). Thirty patients were alive at 6 months and were studied at that time as well. Spectral HRV measurements included power in the high-frequency range (HF, 0.15-0.55 Hz, a measure of parasympathetic activity) and low-frequency range (LF, 0.03-0.15 Hz). Nonspectral HRV measurements included standard deviation of normal beats (SDNN) and two measures of vagal activity: percentage of adjacent cycles differing by >50 ms (pNN50) and the root-mean-square of differences in successive beats (rMSNN). RESULTS: Patients who died within 6 months (n=8) had a higher Hamilton-D score than survivors (13.9+/-6.5 vs. 18.4+/-5.6, P=0.039) and were more likely to have an episode of major depression upon admission to the CCU (71 vs. 27%, P=0.027). An increase in Hamilton-D score at 6 months correlated with a decrease in total (r=-0.48, P=0.014), high-frequency (r=-0.49, P=0.007), and low-frequency HRV (r=-0.46, P=0.014). LIMITATIONS: Patients belonged to a single institution and there was a small proportion of men. CONCLUSIONS: Progression of mood symptoms 6 months after an acute coronary event is associated with an impairment of autonomic control of the heart in elderly individuals.

Cardiac parasympathetic dysfunction related to depression in older adults with acute coronary syndromes.

OBJECTIVE: To determine whether depression is associated with cardiac autonomic alterations in elderly patients with recent acute coronary syndromes (ACSs). METHODS: Cross-sectional study on the association between a major depressive episode or isolated depressive symptoms (21-item Hamilton depression score) and heart rate variability abnormalities in 56 adults (31 women, 55%) 60 years of age and older with a recent (24-72 h) myocardial infarction (MI) or unstable angina (UA). RESULTS: Spectral and nonspectral parameters of respiratory sinus arrhythmia, indicative of parasympathetic activity on the heart, were decreased in patients with depression (high-frequency heart rate variability [log ms(2)] 2.12+/-0.4 vs. 2.52+/-0.5, P=.024; pNN50 [%] 1+/-2 vs. 9+/-15, P=.006; and rMSNN [ms] 16+/-6 vs. 28+/-22, P=.009). Also, high-frequency heart rate variability decreased with increasing depressive symptom severity. CONCLUSION: In a sample of older adults suffering from ACSs, depression was associated with impaired parasympathetic control of the heart.

[Purulent pericarditis with pericardial tamponade caused by Streptococcus agalactiae and Salmonella enterica no typhi]. / Pericarditis purulenta con taponamiento cardiaco por asociación de Streptococcus agalactiae y Salmonella enterica no typhi.

Purulent pericarditis (PP) is an uncommon condition with high mortality. In the preantibiotic period, Staphyloccocus aureus and Streptococcus pneumoniae were the most common etiologic agents. We describe the case of a 75-year old man with septic shock, PP and cardiac tamponade caused by Streptococcus agalactiae and Salmonella enterica no-typhi. To our knowledge this association of pathogenic organisms has not been previously reported in the literature. The pathogenesis is here reviewed, and in our patient presumably, purulent pericarditis occurred via hematogeneus spread undergoing upper gastrointestinal endoscopy. The patient's course was complicated and he died on 34th hospital day. After this case report it is considered that differential etiologic diagnosis of PP should include these agents, especially in immunodepressed patients with predisposing factors.

[Double conventional doses of streptokinase in a massive pulmonary thromboembolism with a free-floating thrombus in the right atrium]. / Doble dosis de estreptocinasa en tromboembolismo pulmonar masivo con trombo flotante libre en la aurícula derecha.

We present a case of severe thromboembolism, with right ventricular dysfunction, high vasoactive drug requirements, sustained shock and a free-floating thrombus in right atrium. Hemodynamic and clinical picture as well as the echocardiographic image were solved after intravenous infusions of two complete doses of streptokinase, separated by an interval of 72 hours.

[Comparison between electrocardiographic test with dobutamine and exercise stress testing on coronary risk stratification]. / Valor del test de dobutamina comparado con la ergometría en la evaluación de riesgo coronario.

The exercise testing is still the most common test used to stratify the patients's risk of new events following an acute myocardial infarction, but about 20 to 40% of the patients can not perform it appropriately. Since the electrocardiographic test with dobutamine has proved to be easy and safe, our aim was to evaluate its capacity to predict the results of the exercise testing on patients after an acute myocardial infarction. A total of 210 patients (average of age 60.5+/-11.7 years old and 23.3% females) recovering from a first uncomplicated myocardial infarction, were consecutively included. An electrocardiographic test with dobutamine was performed during the fifth day of admission, and an exercise test during the sixth. The development of chest pain and/or a descending ST segment > or = 1 mm during a test qualified it as positive for ischemia. The sensitivity, specificity, positive and negative predictive values of both tests were determinated, as well as the congruence on their results, a p-value < 0.05 was considered as statistically significative. Whereas 91 patients achieved a positive result on the electrocardiographic dobutamine tests, 54 patients were positive during exercise. On the other hand, both tests came up positive in 49 patients, and negative in 114 patients. The hemodynamic variables were similar during both tests, except in those patients with negative results with both methods, who developed a higher maximal arterial pressure and double product during exercise. Accordingly, the electrocardiographic dobutamine test showed a sensivity 90.17%, a specificity 73%, positive and negative predictive values 54% and 95.8%, respectively, to predict the results of the exercise testing, with a Kappa value of 0.52. In conclusion, the electrocardiographic dobutamine test showed not only to predict the results of the exercise testing adequately with a high negative predictive value, but also to be safe, a useful and simple diagnostic tool for the evaluation of patients after an acute myocardial infarction.

Risk factors and management of Gram-positive bacteraemia.

The incidence of Gram-positive bloodstream infections has been increasing steadily. The virulence of coagulase-negative staphylococci is based mainly on their ability to produce biofilms, and thus cause infections of intravascular devices and foreign bodies, which must be removed to resolve the infection. Staphylococcus aureus is the leading cause of endocarditis, and it is important to recognize patients at risk of the complications of S. aureus bloodstream infections. The rate of meticillin resistance is higher in healthcare-related infections, although clones of community-acquired meticillin-resistant S. aureus carrying the Panton-Valentine leukocidin have recently emerged. Vancomycin minimum inhibitory concentration (MIC) creep gives cause for concern, and MICs >1 microg/mL are associated with higher failure rates and mortality in patients with S. aureus bacteraemia treated with vancomycin. Daptomycin should be considered the optimal empirical treatment for S. aureus bloodstream infections in settings with medium to high prevalence of meticillin-resistant Staphylococcus aureus infections. Enterococci are the third leading cause of Gram-positive bacteraemia in our institution. Management of this disease is difficult because of its intrinsic resistance to antibiotics, mainly in Enterococcus faecium infections. The recently described synergism of ampicillin plus ceftriaxone is a good therapeutic option for Enterococcus faecalis bacteraemia and endocarditis caused by high-level aminoglycoside-resistant strains.

Pericarditis purulenta con taponamiento cardiaco por asociacion de streptococcus agalactiae y salmonella enterica no typhi / Purulent pericarditis with pericardial tamponade caused by streptococcus agalactiae and salmonella enterica no typhi

La pericarditis purulenta (PP) es una condición infrecuente, pero con elevada mortalidad. Previo a la era antibiótica, los agentes etiológicos más comúnmente hallados eran Streptococcus pneumoniae y Staphylococcus aureus. Se presenta el caso de un paciente de sexo masculino de 75 años de edad con un cuadro de shock, PP y taponamiento cardíaco, producto de una sepsis por Streptococcus agalactiae y Salmonella entérica no typhi. No se ha hallado ningún caso similar en la literatuta. Se destaca el antecedente previo inmediato de la realización de una endoscopia digestiva alta con toma de biopsia de esófago como posible causa de bacteriemia e impacto pericárdico. El curso evolutivo fue malo y el paciente falleció a los 34 días. Esta inusual asociaíón bacteriana en un huésped debilitado e inmunodeprimido, debería ser incluida dentro de los diagnósticos etiológicos diferenciales de la pericarditis purulenta.

Comparison of dobutamine electrocardiographic stress test and exercise test in two different groups of patients with unstable angina

Exercise testing is a well known means of evaluating patients with unstable angina, but in recent years, alternative methods have been proposed. We prospectively compared standard exercise testing with dobutamine electrocardiographic stress testing for patients who admitted with a diagnosis of unstable angina. A total of 43 patients were studied, divided into two different groups, according to the presence (group A n = 26) or absence (group B n = 17) of a previous history of coronary artery disease and/or electrocardiographic changes compatible with ischemia on admission. Dobutamine electrocardiographic stress testing was performed in a standard manner at 3 + 1 days after admission in group A and at 16 + 8 hours after admission in group B. Exercise testing was performed, on average 5 + 1 days following the event in group A and 2 days after admission in group B. Agreement between both tests was observed in 39 (91 percent) cases, Kappa value: 0.81. The dobutamine test predicted the result of the exercise test with a sensitivity of 79 percent (95 percent CL 54-90), and a specificity of 100 percent (95 percent CL 86-100), with a positive predictive value of 100 percent and a negative predictive value of 86 percent. It can be concluded that dobutamine electrocardiographic stress testing is an objective and reliable procedure that accurately predicts the results of standard exercise testing in patients with a diagnosis of unstable angina. It this result were confirmed with a greater number of patients, it would be a good option for definitive diagnosis and risk stratification, in addition to being inexpensive and easy to perform. It can also be particularly useful for patients who cannot perform exercise.

Efecto del diltiazem sobre las alteraciones cardiacas inducidas por el frio en la esclerosis sistemica / Effect of diltiazem on cold-induced left ventricular dysfunction in patients with systemic sclerosis

Los pacientes con esclerosis sistémica (ES) presentan disfunción ventricular inducida por la exposición al frío. Considerando que la misma podría estar vinculada a un fenómeno de Raynaud coronario se desarrolló la siguiente investigación. En el presente estudio se ha evaluado el efecto del diltiazem sobre la disfunción ventricular izquierda inducida por frío en pacientes com ES sin alteraciones cardíacas clínicamente evidentes. Se incluyeron 12 pacientes, 11 mujeres y 1 hombre de 49,9 + 3,8 años de edad con ES 9,3 + 4,8 años de evolución de la enfermedad, en quienes se verificó una caída de la fracción de eyección del ventrículo izquierdo (Fey VI) mayor al 10 por ciento de su valor basal con el enfriamiento corporal. Finalizado el estudio basal se les indicó diltiazem (DTZ) 90 mg vía oral cada 8 horas durante 48 hs y se repitió el estudio basal y post-frío. Durante el procedimiento se empleó monitoreo electrocardiográfico continuo y control de la presión arterial al finalizar cada una de las etapas del estudio. Resultados: Un paciente fue excluido del análisis final por no completar el protocolo. No se observaron diferencias significativas en la Fey VI basal con o sin diltiazem (DTZ) (63,1 + 1,8 y 64,8 + 2,6 respectivamente). Luego del enfriamiento se observó una caída significativa de la Fey VI (p < 0,00001) acompañada de trastornos en la motilidad parietal sin DTZ. Con el empleo del fármaco no se verificaron caída significativa de la Fey VI ni trastornos en la motilidad parietal con el enfriamiento corporal. Los hallazgos del presente estudio indican que el DTZ previene la disfunción ventricular inducida por el frío en este grupo de pacientes, posiblemente por disminuir la presencia del fenómeno de Raynaud a nível de las arterias coronarias.

Efecto de la administración precoz de amiodarona sobre la mortalidad en el infarto agudo de miocardio: resultados del estudio GEMICA / Effect of early administration of amiodarone on mortality in acute myocardial infarction results of the GEMICA study

Se estudió el efecto de la amiodarona administrada en forma intravenosa y oral sobre la mortalidad en pacientes afectados de un infarto agudo de miocardio durante un seguimiento de 6 meses. Se incluyeron 1073 pacientes en clase funcional Killip-Kimball A y B dentro de las 24 horas del comienzo de los síntomas, de los cuales 539 recibieron amiodarona y 534 placebo. La mortalidad global fue del 10,72 por ciento, 11,69 por ciento en el grupo amiodarona y 9,74 por ciento en el grupo placebo (p= NS). Asimismo, no se observaron diferencias significativas entre los dos grupos en la incidencia de los principales eventos cardíacos posinfarto

Comparación entre dosis altas y moderadas de amiodarona asociadas o no a betabloqueantes en pacientes con arritmias durante la evolución del infarto agudo de miocardio / Comparison between high and moderate dosis of amiodarone asociated or not with beta-blockers in patients with arrhythmias during acute myocardial infarction evolution

Se estudiaron 1073 pacientes ingresados con diagnóstico de infarto agudo de miocardio randomizados a doble ciego con amiodarona-placebo. Según las dosis recibidas quedaron divididas dos poblaciones denominadas como altas y moderadas dosis, y analizadas en relación a su asociación con betabloqueantes. Se analizó la incidencia de arritmias con altas o moderadas dosis de amiodarona asociada o no a betabloqueantes durante los primeros 30 días del IAM. Se definieron 4 grupos a los cuales se les analizó la incidencia de diferentes arritmias ventriculares y supraventriculares. Las altas dosis de amiodarona demostraron mayor incidencia de nuevos trastornos de conducción y de muerte súbita. En los pacientes con altas dosis de amiodarona y betabloqueantes se observó mayor incidencia de nuevos trastornos de conducción y una tendencia a un mayor número de asistolia y muerte súbita. En el grupo que recibió moderadas dosis de amiodarona y betabloqueantes se observó una reducción de arritmias ventriculares graves no fatales sin aumento de la mortalidad global o por causa arrítmica ni de trastornos de conducción. Los pacientes tratados solamente con amiodarona en altas dosis tuvieron mayor incidencia de muerte súbita y los de bajas dosis mayor incidencia de arritmias ventriculares graves. Al comparar altas y moderadas dosis de amiodarona sin tomar en cuenta la presencia o no de betabloqueantes, con altas dosis se observó un aumento de nuevos trastornos de conducción y un significativo incremento en los casos de muerte súbita. Las conclusiones fueron: 1) la alta dosis de amiodarona sola o asociada a betabloquenates reduce las arritmias ventriculares graves no fatales pero aumenta la incidencia de trastornos de conducción y de muerte súbita; 2) la amiodarona a moderadas dosis demostró menor incidencia de nuevos trastornos de conducción y de muerte súbita, respecto de las altas dosis; 3) la asociación de amiodarona a dosis moderada y betabloqueantes en los primeros 30 días del infarto tiene efecto beneficioso pues reduce significativamente las arritmias ventriculares graves no fatales sin efectos adversos ni aumento de la mortalidad

Amiodarona y dispersión del intervalo QTc en el infarto agudo de miocardio / Amiodarone and QTc interval dispersion in the acute myocardial infarction

La dispersión del intervalo QTc fue medida al alta hospitalaria en 193 pacientes con infarto agudo de miocardio, enrolados en un estudio de administración de amiodarona en altas dosis vs placebo desde las primeras horas del cuadro. Los resultados mostraron que no hubo diferencias significativas en la dispersión del intervalo QTc entre ambos grupos, tanto cuando fueron comparados globalmente o separados por ubicación del infarto, clase funcional Killip y Kimball y tratamientos asociados. Este hallazgo confiere una mayor seguridad a los efectos antiarrítmicos de la amiodarona

Valor del test de dobutamina comparado con la ergometria en la evaluacion de riesgo coronario / Comparison between electrocardiographic test with dobutamine and exercise stress testing on coronary risk stratification

La ergometría es el método de elección para estratificar el riesgo de eventos luego de un infarto agudo de miocardio, pero el 20-40% de la población no puede realizarla. La utilización de dobutamina con control electrocardiográfico es una propuesta segura, fácil de realizar y reproducible. Nuestro objetivo fue evaluar la utilidad de dicho test para predecir los resultados de la ergometría en pacientes (49 mujeres), edad: 60.5+/- 11.7 años con primer infarto agudo de miocardio no complicado. Se realizó al quinto día del test de dobutamina con control electrocardiográfico y al sexto día la ergometría. Se consideró positiva la presencia de angor y/o infradesnivel del segmento ST mayor ou igual 1mV en ambas pruebas. Se determinó sensibilidad, especificidad, valor predictivo positivo y negativo del test de dobutamina, test de concordancia y valor kappa, con p>0.05. El test de dobutamina fue positivo en 91 casos. La ergometría fue positiva en 54 pacientes. No hubo diferencias hwemodinámicas entre ambos métodos. Cuarenta y nueve presentaron ambas pruebas positivas sin diferencias en las variables analizadas; 114 pacientes ambas negativas, en los que durante la ergometría se alcanzó mayor presión arterial y doble producto máximo. En 47 los resultados fueron discorfdantes. El test dobutamina predijo los resultados de la ergometría con sensibilidad: 90.7% (IC95%:78.9-96.5%), especificidad: 73%(IC95%:65.3-79.7%), valor predictivo positivo:54% (IC95%:43.1-62.2%) y negativo: 95.8% (IC95%:89.9-98.4%), concordancia: 77% (IC95%:53-74) y valor kappa:0.52 (IC95%:0.41-0.63). El test de dobutamina predijo los resultados de la ergometría con adecuadas sensibilidad, especificidad y valor predictivo positivo; se destaca el alto valor predictivo negativo del método que resultó un procedimiento seguro, eficaz y sencillo.