Seven-day antibiotic therapy for Enterobacterales bacteremia in high-risk neutropenic patients: toward a new paradigm.

PURPOSE: Data on short courses of antibiotic therapy for Enterobacterales bacteremia in high-risk neutropenic patients are limited. The aim of the study was to describe and compare the frequency of bacteremia relapse, 30-day overall and infection-related mortality, Clostridiodes difficile infection and length of hospital stay since bacteremia among those who received antibiotic therapy for 7 or 14 days. METHODS: This is a multicenter, prospective, observational cohort study in adult high-risk neutropenic patients with hematologic malignancies or hematopoietic stem cell transplant and monomicrobial Enterobacterales bacteremia. They received appropriate empirical antibiotic therapy, had a clinical response within 7 days, and infection source control. Clinical, epidemiological and outcomes variables were compared based on 7 or 14 days of AT. RESULTS: Two hundred patients were included (100, 7-day antibiotic therapy; 100, 14-day antibiotic therapy). Escherichia coli was the pathogen most frequently isolated (47.5%), followed by Klebsiella sp. (40.5%). Among those patients that received 7-day vs. 14-day antibiotic course, a clinical source of bacteremia was found in 54% vs. 57% (p = 0.66), multidrug-resistant Enterobacterales isolates in 28% vs. 30% (p = 0.75), and 40% vs. 47% (p = 0.31) received combined empirical antibiotic therapy. Overall mortality was 3% vs. 1% (p = 0.62), in no case related to infection; bacteremia relapse was 7% vs. 2% (p = 0.17), and length of hospital stay since bacteremia had a median of 9 days (IQR: 7-15) vs. 14 days (IQR: 13-22) (p = < 0.001). CONCLUSIONS: These data suggest that seven-day antibiotic therapy might be adequate for patients with high-risk neutropenia and Enterobacterales bacteremia, who receive appropriate empirical therapy, with clinical response and infection source control.

Development of a Clinical Score to Stratify the Risk for Carbapenem-Resistant Enterobacterales Bacteremia in Patients with Cancer and Hematopoietic Stem Cell Transplantation.

Identifying the risk factors for carbapenem-resistant Enterobacterales (CRE) bacteremia in cancer and hematopoietic stem cell transplantation (HSCT) patients would allow earlier initiation of an appropriate empirical antibiotic treatment. This is a prospective multicenter observational study in patients from 12 centers in Argentina, who presented with cancer or hematopoietic stem-cell transplant and developed Enterobacterales bacteremia. A multiple logistic regression model identified risk factors for CRE bacteremia, and a score was developed according to the regression coefficient. This was validated by the bootstrap resampling technique. Four hundred and forty-three patients with Enterobacterales bacteremia were included: 59 with CRE and 384 with carbapenem-susceptible Enterobacterales (CSE). The risk factors that were identified and the points assigned to each of them were: ≥10 days of hospitalization until bacteremia: OR 4.03, 95% CI 1.88-8.66 (2 points); previous antibiotics > 7 days: OR 4.65, 95% CI 2.29-9.46 (2 points); current colonization with KPC-carbapenemase-producing Enterobacterales: 33.08, 95% CI 11.74-93.25 (5 points). With a cut-off of 7 points, a sensitivity of 35.59%, specificity of 98.43%, PPV of 77.7%, and NPV of 90.9% were obtained. The overall performance of the score was satisfactory (AUROC of 0.85, 95% CI 0.80-0.91). Finally, the post-test probability of CRE occurrence in patients with none of the risk factors was 1.9%, which would virtually rule out the presence of CRE bacteremia.

Clostridioides difficile infection in solid organ and hematopoietic stem cell transplant recipients: A prospective multinational study.

BACKGROUND: Clostridioides difficile infection (CDI) is a significant cause of morbidity and mortality in recipients of solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT). In retrospective single center analyses, severe disease and relapse are common. We undertook an international, prospective cohort study to estimate the response to physician determined antibiotic treatment for CDI in patients with SOT and HSCT. METHODS: Adults with a first episode of CDI within the first 2 years of SOT or HSCT were enrolled. Demographics, comorbidities, and medication history were collected, and over 90 days of follow-up clinical cure, recurrences, and complications were assessed. Logistic regression was used to study associations of baseline predictors of clinical cure and recurrence. Odds ratios (ORs) and 95% confidence intervals (CIs) are cited. RESULTS: A total of 132 patients, 81 SOT and 51 HSCT (32 allogeneic), were enrolled with a median age of 56 years; 82 (62%) were males and 128 (97%) were hospitalized at enrollment. One hundred and six (80.3%) were diagnosed by DNA assay. CDI occurred at a median of 20 days post-transplant (interquartile range, IQR: 6-133). One hundred and eight patients (81.8%) were on proton pump inhibitors; 126 patients (95.5%) received antibiotics within the 6 weeks before CDI. The most common initial CDI treatments prescribed, on or shortly before enrollment, were oral vancomycin alone (50%) and metronidazole alone (36%). Eighty-three percent (95% CI: 76, 89) of patients had clinical cure; 18% (95% CI: 12, 27) of patients had recurrent CDI; global clinical cure occurred in 65.2%. Of the 11 patients who died, two (1.5% of total) were related to CDI. In multivariable logistic regression analyses, the type of initial treatment was associated with clinical cure (p = .009) and recurrence (p = .014). A history of cytomegalovirus (CMV) after transplant was associated with increased risk of recurrence (44% with versus 13% without CMV history; OR: 5.7, 95% CI: 1.5, 21.3; p = .01). CONCLUSIONS: Among adults who develop CDI after SOT or HSCT, despite their immunosuppressed state, the percentage with clinical cure was high and the percentage with recurrence was low. Clinical cure and recurrence varied by type of initial treatment, and CMV viremia/disease was associated with an increased risk of recurrence.

Estudio multicéntrico argentino sobre la utilidad del panel de neumonía de FilmArray® / Argentine multicenter study on the utility of the FilmArray® pneumonia panel

Resumen Las infecciones de las vías respiratorias inferiores se encuentran entre aquellas en las que el uso inadecuado de antimicrobianos es frecuente, por lo que es fundamental contar con una prueba diagnóstica rápida, sensible y específica. El sistema de FilmArray es un análisis de PCR múltiple con un panel de neumonía que incluye 26 microorganismos y 7 marcadores de resistencia antimicrobiana. Los objetivos de este estudio fueron: a) establecer la correlación entre los cultivos cuantitativos para agentes bacterianos de muestras de vías respiratorias inferiores (MRVB) y la detección fenotípica de mecanismos de resistencia con los correspondientes resultados de FilmArray; b) determinar el cambio terapéutico generado con el informe del resultado inmediato. Se incluyó un total de 194 MRVB correspondientes a 191 pacientes con neumonía y se documentaron 277 bacterias. FilmArray identificó 253/277 (91%) bacterias y 161/277 (58%) se aislaron del cultivo, 58 (23%) coincidieron con el mismo recuento, 116 (46,7%) dieron mayores recuentos con FilmArray y 72 (28,9%) fueron detectadas por este método pero el cultivo fue negativo. Se detectaron marcadores de resistencia antimicrobiana en 63 aislados, pero solo 28 fueron confirmados por métodos fenotípicos. Estos resultados podrían haber provocado cambios en el tratamiento antibiótico en el 74,6% (174/194). FilmArray es una herramienta útil para optimizar el tratamiento antimicrobiano en pacientes con neumonía.

Abstract Lower respiratory tract infections are among those in which the inappropriate use of antimicrobials is common, so it is essential to have a rapid, sensitive and specific diagnostic test. The FilmArray system is a multiplex PCR assay with a pneumonia panel that includes 26 microorganisms and 7 antibiotic resistance markers. The objectives of this study were: a) to establish the correlation between quantitative cultures for bacterial agents from lower respiratory tract samples (MRVB) and the phenotypic detection of resistance mechanisms with the corresponding results of FilmArray b) to determine the therapeutic change generated with the immediate result report. A total of 194 MRVB corresponding to 191 patients with pneumonia were included and 277 bacterial strains were documented. FilmArray identified 253/277 (91%) bacteria and 161/277 (58%) were isolated from culture, 58 (23%) matched the same count, 116 (46.7%) yielded higher counts with FilmArray, and 72 (28.9%) with negative culture were detected by this method. Antibiotic resistance markers were detected in 63 strains, but only 28 were confirmed by phenotypic methods. These results may cause changes in the antimicrobial treatment in 74.6% (174/194). FilmArray is a useful tool to optimize antimicrobial therapy in patients with pneumonia.

Resumo As infecções do trato respiratório inferior estão entre aquelas em que o uso inadequado de antimicrobianos é comum, por isso é essencial um teste diagnóstico rápido, sensível e específico. O sistema FilmArray é um ensaio de PCR multiplo com um painel de pneumonia que inclui 26 microrganismos e 7 marcadores de resistência antimicrobiana. Os objetivos deste estudo foram: a) estabelecer a correlação entre as culturas quantitativas de agentes bacterianos de amostras do trato respiratório inferior (MRVB) e a detecção fenotípica de mecanismos de resistência com os resultados correspondentes do FilmArray b) determinar a alteração terapêutica gerada com o relatório de resultado imediato. Um total de 194 MRVB correspondendo a 191 pacientes com pneumonia foram incluídos e 277 cepas bacterianas foram documentadas. FilmArray identificou 253/277 (91%) bactérias e 161/277 (58%) foram isoladas da cultura, 58 (23%) coincidiram com mesma contagem, 116 (46,7%) deram contagens mais altas com FilmArray e 72 (28,9%) foram detectados por este método, mas a cultura foi negativa. Marcadores de resistência antimicrobiana foram detectados em 63 cepas, mas apenas 28 foram confirmados por métodos fenotípicos. Esses resultados puderam causar alterações no tratamento antibiótico em 74,6% (174/194). FilmArray é uma ferramenta útil para otimizar a terapia antimicrobiana em pacientes com pneumonia..

Complete remission and proviral load negativization after allogeneic-SCT in a patient with Adult T-cell lymphoma: Case report.

Adult T-cell lymphoma is an aggressive and poor prognosis HTLV1-associated lymphoma. There is no standard treatment, but it is known that intensive chemotherapy regimens are necessary, with or without concomitant antiretroviral therapy, plus consolidation with allogeneic stem cell transplantation. Our case report shows a favorable outcome after 2 cycles of chemotherapy and allogeneic stem cell transplantation without antiretroviral agents, achieving complete remission, and a negative proviral load.

Chagas disease reactivation: cutaneous manifestations in a transplanted patient

Abstract: Chagas disease is an endemic zoonosis caused by a protozoan agent called Trypanosoma cruzi. It is mainly transmitted by a hematophagous vector, and less frequently by blood transfusion, transplacental and solid organ transplant. In most cases, primary infection is not diagnosed and the disease progresses to a chronic phase. Immunosuppressed patients are a vulnerable population that may present an acute, atypical and severe reactivation of the chronic form of this disease. We hereby report a case of a female patient, who received a renal transplant with immunosuppressive treatment, who was diagnosed with a chagasic hypodermitis secondary to an acute reactivation of a chronic phase of this disease. We describe the clinical features, epidemiological and histopathological findings, treatment and course.

Extended antibiotic therapy versus placebo after laparoscopic cholecystectomy for mild and moderate acute calculous cholecystitis: A randomized double-blind clinical trial.

BACKGROUND: Acute calculous cholecystitis (ACC) is the most common complication of cholelithiasis. Laparoscopic cholecystectomy (LC) is the gold standard treatment in mild and moderate forms. Currently there is consensus for the use of antibiotics in the preoperative phase of ACC. However, the need for antibiotic therapy after surgery remains undefined with a low level of scientific evidence. METHODS: The CHART (Cholecystectomy Antibiotic Randomised Trial) study is a single-center, prospective, double blind, and randomized trial. Patients with mild to moderate ACC operated by LC were randomly assigned to receive antibiotic (amoxicillin/clavulanic acid) or placebo treatment for 5 consecutive days. The primary endpoint was postoperative infectious complications. Secondary endpoints were as follows: (1) duration of hospital stay, (2) readmissions, (3) reintervention, and (4) overall mortality. RESULTS: In the per-protocol analysis, 6 of 104 patients (5.8%) in the placebo arm and 6 of 91 patients (6.6%) in the antibiotic arm developed postoperative infectious complications (absolute difference 0.82 (95% confidence interval, -5.96 to 7.61, P = .81). The median hospital stay was 3 days. There was no mortality. There were no differences regarding readmissions and reoperations between the 2 groups. CONCLUSION: Although this trial failed to show noninferiority of postoperative placebo compared to antibiotic treatment after LC for mild and moderate ACC within a noninferiority margin of 5%, the use of antibiotics in the postoperative period does not seem justified, because it was not associated with a decrease in the incidence of infectious and other types of morbidity in the present study.

Risk factors and outcomes of pyogenic liver abscess in adult liver recipients: a matched case-control study.

BACKGROUND: Adult liver recipients (ALR) differ from the general population with pyogenic liver abscess (PLA) as they exhibit: reconstructed biliary anatomy, recurrent hospitalizations, poor clinical condition and are subjected to immunosuppression. The aim of this study was to identify risk factors associated with PLA in ALR and to analyze the management experience of these patients. METHODS: Between 1996 and 2016, 879 adult patients underwent liver transplantation (LT), 26 of whom developed PLA. Patients and controls were matched according to the time from transplant to abscess in a 1 to 5 relation. A logistic regression model was performed to establish PLA risk factors considering clusters for matched cases and controls. Risk factors were identified and a multivariate regression analysis performed. RESULTS: Patients with post-LT PLA were more likely to have lower BMI (p = 0.006), renal failure (p = 0.031) and to have undergone retransplantation (p = 0.002). A history of hepatic artery thrombosis (p = 0.010), the presence of Roux en-Y hepatojejunostomy (p < 0.001) and longer organ ischemia time (p = 0.009) were independent predictors for the development of post-LT PLA. Five-year survival was 49% (95%CI 28-67%) and 89% (95%CI 78%-94%) for post-LT PLA and no post-LT PLA, respectively (p < 0.001). CONCLUSION: history of hepatic artery thrombosis, the presence of hepatojejunostomy and a longer ischemia time represent independent predictors for the development of post-LT PLA. There was a significantly poorer survival in patients who developed post-LT PLA compared with those who did not.

Trasplante cardíaco en paciente infectado con el virus de la inmunodeficiencia humana / Heart transplantation in an HIV-infected patient

Hasta la consolidación del tratamiento antirretroviral combinado, la infección por HIV constituía, debido a su mal pronóstico, una contraindicación para el trasplante de órganos sólidos. El tratamiento antirretroviral combinado prolongó la expectativa de vida de estos pacientes, pero también permitió la manifestación a largo plazo de enfermedades directa o indirectamente ligadas al HIV, como hepatopatías, nefropatías y enfermedades cardiovasculares. Se presenta un caso de miocardiopatía dilatada tratada con trasplante cardíaco en un paciente con diagnóstico reciente de infección HIV. A los 24 meses, el paciente presentó CD4 en aumento y carga viral no detectable, sin complicaciones ni signos de rechazo. En nuestro conocimiento, no existen antecedentes de trasplante cardíaco en pacientes con HIV en Sudamérica. A la luz de la buena evolución de este caso y los pocos comunicados en la bibliografía internacional, consideramos que el trasplante cardíaco es una opción terapéutica en pacientes HIV positivos adecuadamente seleccionados.

Because of its own unfavourable evolution, HIV infection was until recently considered a contraindication for organ transplantation. The introduction of highly active antiretroviral therapy prolonged the life expectancy of these patients and allowed the manifestation of disorders directly or indirectly related to HIV infection, mainly liver, kidney and cardiovascular diseases. We present a case of cardiac transplantation due to dilated cardiomyopathy that was performed in a patient with a recently detected HIV infection. At 24 month follow-up, the patient is in very good health status, his CD4 are increasing and the viral load is undetectable. He did not present transplant rejection or any other complication. To our knowledge, there is no previous publication on heart transplantation in patients with HIV in South America. In view of the successful outcome of our case and of the few cases reported in the international literature, we consider that heart transplantation is a therapeutic option in correctly selected HIV patients.

Protocol for extended antibiotic therapy after laparoscopic cholecystectomy for acute calculous cholecystitis (Cholecystectomy Antibiotic Randomised Trial, CHART).

INTRODUCTION: Acute calculous cholecystitis represents one of the most common complications of cholelithiasis. While laparoscopic cholecystectomy is the standard treatment in mild and moderate forms, the need for antibiotic therapy after surgery remains undefined. The aim of the randomised controlled Cholecystectomy Antibiotic Randomised Trial (CHART) is therefore to assess if there are benefits in the use of postoperative antibiotics in patients with mild or moderate acute cholecystitis in whom a laparoscopic cholecystectomy is performed. METHODS AND ANALYSIS: A single-centre, double-blind, randomised trial. After screening for eligibility and informed consent, 300 patients admitted for acute calculus cholecystitis will be randomised into two groups of treatment, either receiving amoxicillin/clavulanic acid or placebo for 5 consecutive days. Postoperative evaluation will take place during the first 30 days. Postoperative infectious complications are the primary end point. Secondary end points are length of hospital stay, readmissions, need of reintervention (percutaneous or surgical reinterventions) and overall mortality. The results of this trial will provide strong evidence to either support or abandon the use of antibiotics after surgery, impacting directly in the incidence of adverse events associated with the use of antibiotics, the emergence of bacterial resistance and treatment costs. ETHICS AND DISSEMINATION: This study and informed consent sheets have been approved by the Research Projects Evaluating Committee (CEPI) of Hospital Italiano de Buenos Aires (protocol N° 2111). RESULTS: The results of the trial will be reported in a peer-reviewed publication. TRIAL REGISTRATION NUMBER: NCT02057679.

Successful treatment with telaprevir of post-transplant fibrosing cholestatic hepatitis C in an HIV co-infected patient.

Hepatitis C recurrence is the main cause of graft loss in liver transplant patients co-infected with human immunodeficiency virus (HII). These patients have higher risk of fibrosing cholestatic hepatitis, which is the most severe type of hepatitis C recurrence. Until direct antiviral agents were released, only a minority of patients could be satisfactorily treated. We describe the successful treatment with pegylated-interferon, ribavirin and telaprevir of an hepatitis C virus (HCV)/HIV co-infected patient who developed fibrosing cholestatic hepatitis after liver transplantation. A 40-year- old male (HCV genotype 1a; IL-28 CC) underwent liver transplantation for decompensated cirrhosis. On post-transplant day 60, he rapidly developed progressive jaundice, worsening of liver function tests and ascites. A transjugular liver biopsy confirmed the diagnosis of fibrosing cholestatic hepatitis. Treatment with peglated-interferon, ribavirin and telaprevir was indicated for 48 weeks, achieving sustained virological response at 12 weeks of follow-up. The rapid negativization of the viral load observed during the first 4 weeks of treatment was associated with regression of ascites andjaundice. Red blood cell transfusions, erythropoietin and filgrastim were required for the management of anemia and neutropenia. Triple therapy with telaprevir might be indicated for the treatment of severe HCV recurrence in selected HCV/HIV co-infected patients, especially in countries with limited access to pegylated-interferon-free regimens.

[Pneumocystis jiroveci infection in patients with and without HIV: A comparison]. / Comparación de infecciones por Pneumocystis jiroveci en pacientes con y sin diagnóstico de infección por VIH.

BACKGROUND: Respiratory infection caused by Pneumocystis jiroveci is a common opportunistic infection in patients with human immunodeficiency virus (HIV) with CD4 counts < 200 cells/mm(3). However, it has also been reported in patients with other causes of immunosuppression. OBJECTIVES: To compare the characteristics, severity and mortality of respiratory infection by P. jiroveci in patients with and without HIV infection. METHODS: Retrospective cohort follow-up of adult patients admitted to our hospital with infection by P. jiroveci since 2006 to 2013. RESULTS: We included 82 patients with respiratory infection by P. jiroveci of which 55% (45) were not infected with HIV. In this group, 68.8% (31) had diagnosis of cancer and 20% (9) received solid-organ transplant. 57.9% (26) were hospitalized in an intensive care unit. 42.2% (19) suffered multiple organ failure (MOF), 46.7% (21) required mechanical ventilation (MV) and 40.9% (18) inotropic drugs. Mortality was 33.3% (15). Statistically significant differences were observed between groups in age (p < 0.001), requirement of MV (p < 0.001) inotropic drugs (p 0.001) and MOF (p < 0.001). Mortality was higher in the HIV-positive group, reaching statistical significance (p 0.007). CONCLUSION: Pneumocystis pneumonia mortality was higher in patients without HIV, who suffered more complications and progression to respiratory failure with MOF.

Experiencia argentina con pacientes positivos para el virus de la inmunodeficiencia humana en lista de espera para trasplante hepático: análisis preliminar / [The Argentine experience with human immune deficiency virus positive patients in the waiting list for liver transplantation: preliminary analysis].

UNLABELLED: After the introduction of high active antiretroviral therapy (HAART), the human immunodeficiency virus (HIV) was no longer considered a contraindication for transplantation. Yet, liver disease in this population is characterized by an accelerated course that may impact on the waiting list. OBJECTIVE: To evaluate the experience in Argentina with HIV positive patients listed for liver transplantation. PATIENTS AND METHODS: We analyzed 52 HIV positive patients listed between July 2005 and March 2010 (Group HIV positive). Results were compared with 462 HIV negative patients included during the same period (Group HIV negative). Data were obtained from INCUCAI, the Argentinian procurement organism and from the Transplantation Centers. RESULTS: The etiology of liver disease in the Group HIV positive was hepatitis C 40, HBV 3, fulminant hepatitis 3, alcohol 2, retrasplant 2 and others 2. The mean MELD at the time of listing was 1615 (lower than 19 in 40 cases, higher than 19 in 8, emergency in 3) in the group HIV positive and 16.64 in the group HIV negative (NS). The outcome in the waiting list for HIV positive and negative patients respectively was: death 14 (27

) (NS), mean time from listing to death 270.70 298.11 days vs 267.29 266.53 days (NS), mean time from listing to transplant 70.26 74.05 vs 261 187.6 days (P < 0.01), mean MELD at the time of death 12.54 (13 cases lower than 15, 1 higher than 19) vs 19.6 9.7 (P < 0.05), mean MELD at the time of transplantation 24.33 vs 24.1 7.6 (NS). CONCLUSION: HIV positive patients have high mortality in the waiting list and low access to liver transplantation. MELD score underscores the severity of liver disease in this population when compared to HIV negative patients.

Indications of a new antibiotic in clinical practice: results of the tigecycline initial use registry

Tigecycline is the first of a new class of antibiotics named glycylcyclines and it was approved for the treatment of complicated intra-abdominal infections and complicated skin and skin structure infections. Notwithstanding this, tigecycline's pharmacological and microbiological profile which includes multidrug-resistant pathogens encourages physicians' use of the drug in other infections. We analyzed, during the first months after its launch, the tigecycline prescriptions for 113 patients in 12 institutions. Twenty-five patients (22 percent) received tigecycline for approved indications, and 88 (78 percent) for "off label" indications (56 percent with scientific support and 22 percent with limited or without any scientific support). The most frequent "off label" use was ventilator associated pneumonia (VAP) (63 patients). The etiology of infections was established in 105 patients (93 percent). MDR-Acinetobacter spp. was the microorganism most frequently isolated (50 percent of the cases). Overall, attending physicians reported clinical success in 86 of the 113 patients (76 percent). Our study shows that the "off label" use of tigecycline is frequent, especially in VAP. due to MDR-Acinetobacter spp., where the therapeutic options are limited (eg: colistin). Physicians must evaluate the benefits/risks of using this antibiotic for indications that lack rigorous scientific support.

High active local levels of vancomycin without nephrotoxicity released from impacted bone allografts in 20 revision hip arthroplasties.

BACKGROUND: Cancellous bone can act as a delivery vehicle for vancomycin without impairment of graft incorporation. However, local and systemic antibiotic levels, biological activity of vancomycin, interaction with antibiotic-loaded cement, and also nephrotoxicity of these composites have not yet been studied clinically. MATERIAL AND METHODS: Blood, drainage and urine samples of 20 consecutive patients undergoing revision total hip arthroplasties with impaction grafting technique utilizing 1 g of vancomycin per femoral head were studied. Plain PMMA cement was used in 10 cases, while PMMA with gentamycin was used in 5 cases and tobramycin was used in the remaining 5 cases. Biological activity of vancomycin was studied using kinetic killing curves in three ATCC organisms (methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosas). Quantification was done with fluorescent polarized immunoassay. Renal function was evaluated with preoperative and postoperative urea and creatinine. RESULTS: Local active bactericidal levels of vancomycin reached 1400 microg/mL (average 5-point level = 367 microg/mL) without nephrotoxicity. Vancomycin was present in urine until the fifteenth day. Both aminoglycosides in the cement had activity against Pseudomonas aeruginosas. INTERPRETATION: Local levels of vancomycin were 35 times greater than the highest levels reported with vancomycin-loaded PMMA. A synergistic effect was observed between vancomycin released from impacted allografts and aminoglycoside-loaded PMMA.

Transmission of T. cruzi infection via liver transplantation to a nonreactive recipient for Chagas' disease.

Chagas' disease is an endemic zoonosis of South America caused by a protozoan parasite Trypanosoma cruzi. About 30% of infected people develop the disease. This disease is known to reactivate in immunocompromised hosts, such as patients with acquired immunodeficiency syndrome, leukemia, and transplantation. There is some experience with transplantation of infected renal grafts into negative recipients, resulting in an index of transmission of 35%. No cases have been reported involving other organ transplants up to 2002, when the Centers for Disease Control and Prevention reported 3 cases of Chagas' disease transmission to 3 recipients (liver, kidney, and pancreas-kidney) from a single chagas infected donor. Here we report on a case of orthotopic liver transplant from a chagas infected donor into a negative recipient in clinical emergency status. The recipient was monitored by direct parasitological Strout method and serological tests with detection of transmission on the 84 th day by both studies, without clinical signs. The patient was put on benznidazole with rapid clearance of the parasitemia. However, we propose that chagas infected donors may be accepted for liver transplant recipients only in emergency status.