Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management.

BACKGROUND: Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR). AIM: To identify pVOM risk factors and evaluate management strategies. METHODS: From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors. FINDINGS: Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067). CONCLUSION: Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.

Differences between endocarditis caused by Streptococcus bovis and Enterococcus spp. and their association with colorectal cancer.

Streptococcus bovis group and Enterococcus spp. share phenotypic characteristics and intestinal habitat. Both have been associated with endocarditis and colorectal neoplasm (CRN). We studied all cases of endocarditis diagnosed between 1988 and 2014 in our centre and caused by S. bovis (109, 48.8 % of the bacteremia) and by Enterococcus spp. (36, 3.4 % of the bacteremia). Patients were seen until death or during a long-term follow-up, in order to rule out a concomitant CRN. The 109 cases of S. bovis endocarditis (SbIE) compared with the 36 caused by enterococci showed: a higher proportion of males (91 % vs. 72 %, p=0.005), more multivalvular involvement (28 % vs. 6 %, p=0.004), embolic complications (44 vs. 22 %, p=0.02) and colorectal neoplasm (64 % vs. 25 %, p=0.001). SbIE showed fewer co-morbidities (32 vs. 58 %, p=0.005), and less frequently urinary infection source (0 vs. 25 %, p=0.001) and healthcare-related infection (2 vs. 44 %, p=0.001). A total of 123 patients were followed up for an extended period (mean: 65.9 ± 57.5 months). During the follow-up, 6 of 28 (21 %) cases with enterococcal endocarditis and 43 of 95 (45.2 %, p=0.01) cases with SbIE developed a new CRN. These neoplasiae appeared a mean of 60.4 months later (range 12-181 months). Among the 43 cases with SbIE and CRN, 12 had had a previously normal colonoscopy and 31 had had a previous CRN and developed a second neoplasm. Cases of SbIE present important differences with those caused by Enterococcus spp. Colonoscopy must be mandatory both in the initial evaluation of SbIE, as during the follow-up period.

The clinical epidemiology and malignancies associated with Streptococcus bovis biotypes in 506 cases of bloodstream infections.

OBJECTIVES: To determine the incidence of Streptococcus bovis (Sb) biotypes causing bacteraemia and associated malignancies. METHODS: This is a retrospective analysis of patients with Sb bacteraemia, pulled out from a prospective surveillance protocol of bacteraemia cases, in three areas of Spain (1990-2013): a cattle area (Lugo), a fishing area (Ferrol) and an urban area (Barcelona). Colonoscopy and Sb biotypes (Sb-I and Sb-II) were determined in most cases. RESULTS: 506 patients with Sb bacteraemia; mean age 68.1 (±14.1) years, and 66.2% were males. The cattle area, compared with the fishing and urban areas, had higher incidence of bacteraemia by SbI (40.29 vs 9.38 vs 6.15 cases/10(6) person-years, P < 0.001) and bacteraemia by Sb-II (29.07 vs 9.84 vs 13.37 cases/10(6) person-years, P < 0.001). The Sb-I cases (n = 224), compared with Sb-II cases (n = 270), had greater rates of endocarditis (77.6% vs 9.6%, P < 0.001) and colorectal neoplasm (CRN) (50.9% vs 16.6%, P < 0.001), and smaller rates of biliary tract infection (2.2% vs 29.6%, P < 0.001) and non-colorectal malignancy (8.9% vs 31.4%, P < 0.001). CONCLUSION: There was a link between the cattle area and higher incidence of Sb bacteraemia. Sb-I differed from Sb-II cases in clinical findings and associated malignancies. Colonoscopy is mandatory in cases of endocarditis or bacteraemia caused by Sb-I.

Is Streptococcus bovis a urinary pathogen?

The Streptococcus bovis group (SBG) comprises several microorganisms associated with human infections. They have been associated with bacteremia, endocarditis, biliary tract infection, meningitis, and colorectal cancer, but their role as urinary pathogens is not well known. The objective of this investigation was to discover the incidence and clinical significance of the bacteriuria associated with this complex. A retrospective analysis of all adult patients with bacteriuria caused by SBG during the period 1995-2012 was carried out. During the study period, SBG was isolated in 153 adult patients, who had a mean age of 67 years, most of them being women (80%). Most of our patients (65%) had some underlying disease, with urologic disease being the most common (37%), followed by diabetes mellitus (27%) and neurologic disease (25%). Among the 88 patients in whom we were able to correctly assess symptoms, 45% had asymptomatic bacteriuria, 35% had lower urinary tract infection, and 20% had upper urinary tract infection. In 14 cases (9%), SBG was also isolated in blood cultures. Most of the isolates of SBG (72%) were S. gallolyticus subsp. pasteurianus. All isolates were susceptible to penicillin, 98% to nitrofurantoin, and 77% to fosfomycin. Although SBG bacteriuria is uncommon, it should not always be taken as a contaminant, mainly when S. pasteurianus is isolated, because it may cause urinary tract infections and, occasionally, sepsis, whereas when S. gallolyticus is isolated from urine, it may be a marker of underlying endocarditis and colorectal cancer.

Is colonoscopy necessary in cases of infection by Streptococcus bovis biotype II?

The association of colorectal neoplasia (CRN) with Streptococcus bovis biotype I (SBI) infection is well recognized. However, this is not the case for Streptococcus bovis biotype II (SBII). We conducted this study in order to analyze the relationship between SBII and CRN. We analyzed all cases of bacteremia due to SBI (n = 99) and SBII (n = 36) diagnosed in our hospital (during the period 1988-2011) that were followed up with colonoscopy. In addition, we reviewed the literature (during the period 1982-2011) to select all cases of infection of SB that had undergone colonoscopy or other adequate form of colorectal examination. A multivariate analysis was performed to detect CRN risk factors in patients infected with SB. From the 223 cases of SB infection included in the analysis (135 from our institution and 88 from the literature review), 159 were due to SBI and 64 were caused by SBII. As compared with SBI, the SBII cases had a lower frequency of CRN (27 % vs. 67 %, p <0.001), advanced adenomas (8 % vs. 29 %, p <0.01), and carcinomas (6 % vs. 21 %, p <0.01). In a multivariate analysis, and after adjusting for age, sex, type of infection, and biotype, SBII infection was not associated with CRN: odds ratio (OR) = 0.17; 95 % confidence interval (CI) = 0.09 to 0.33. The only factor independently associated with CRN was SBI infection: OR = 5.7; 95 % CI = 3.0 to 10.9. The prevalence of CRN in patients infected with SBII is significantly lower than patients with SBI and does not appear to be higher than the CRN prevalence among the general population.

Streptococcus bovis group and biliary tract infections: an analysis of 51 cases.

Streptococcus bovis is a well-known cause of endocarditis, but its role in other infections has not been well described. We analysed prospectively all patients with biliary tract infections caused by S. bovis group during the period 1988-2011. We selected those cases associated with cholangitis and cholecystitis, defined according to Tokyo guidelines. Identification of the strains was performed using the API 20 Strep and the GP card of the Vitek 2 system, and was confirmed by molecular methods. Our series included 51 cases (30 cholangitis and 21 cholecystitis). The associated microorganisms were: Streptococcus infantarius (biotype II/1) 29 cases (57%), Streptococcus gallolyticus subsp. pasteurianus (biotype II/2) 20 cases (39%) and Streptococcus gallolyticus subsp. gallolyticus (biotype I) two cases (4%). The only difference found between S. infantarius and S. gallolyticus subsp. pasteurianus was a greater association of the first with malignant strictures of the bile ducts: 48% (14/29) versus 5% (1/20), p <0.001. Thirty-seven of the cases also had bacteraemia, causing 20% (37/185) of all S. bovis bacteraemia, with differences between S. gallolyticus subsp. gallolyticus (2/112; 2%) and the other two microorganisms: S. infantarius and S. gallolyticus subsp. pasteurianus (35/73; 48%; p <0.001). The vast majority of biliary tract infections due to S. bovis group are caused by S. infantarius and S. gallolyticus subsp. pasteurianus (S. bovis biotype II), and nearly half of the bacteraemia due to these two species has a biliary source (43% of the S. infantarius and 56% of S. gallolyticus subsp. pasteurianus).

[The internist's role in the medical evaluation of surgical patients]. / Papel del internista como consultor de servicios quirúrgicos.

OBJECTIVE: To describe the characteristics of the consultations carried out by surgical services to an Internal Medicine service and to determine what factors influence the prognosis of these patients. METHODS: A prospective study of the consultations carried out by the surgical services of a 540-bed hospital to an Internal Medicine service. Analyzed variables were: age, sex, service of reference, reason for consultation, medical and admission diagnoses done during the admission, and clinical evolution. RESULTS: In the study 453 interconsultations were included, corresponding to 0.96 new interconsultations by working day and to 4.05 interconsultations per every 100 admissions in surgical services during the period study. The reasons for the more common consultations were dyspnea, fever, electrolytic and metabolic disorders, assessment of multiple conditions and acute confusional syndrome. Two or more diagnoses were carried out in 257 patients (56.7%). The average number of visits carried out by patient was 3.9 +/- 3.9. The average hospital stay in the study group was 28 +/- 33.05 days, while the average hospital stay of patients admitted in the surgical services during the same period was 11.6 days. Fifty patients (11%) had died at the time of the "medical discharge", and this percentage amounted to 20.5% (93 cases) upon considering the end of the hospital admission, compared with the global mortality of 3.7% registered during that period in the surgical services. The number of medical diagnoses and the age were independent predictors of mortality in the multivariate analysis. CONCLUSIONS: The interconsultations of the surgical services to an Internal Medicine service imply an important workload. The patients are complex from the medical standpoint. The average hospital stay and mortality of these patients are different from that of the patients cared in surgical services.

Strangulated volvulus of the sigmoid colon with inviable mucosal appearance in a non-surgical patient. Endoscopic devolvulation.

Colonoscopy is presently always performed before surgical management of a volvulus in the sigmoid colon. It leads to know the viability of the mucosa and, when possible, to resolve the volvulus conservatively. Besides, with endoscopic control, we can place a decompression tube proximal to the volvulated sigmoid colon, favouring a non-surgical resolution. With this conservative approach it is possible to overcome the acute period, and to restore the viability of the sigmoid wall, waiting for a definitive surgical management with less morbidity and mortality. Only with endoscopy, revolvulation does occur in 35-50% of cases. We present the clinical case of a sigmoid volvulus with compromised sigmoid wall in an 82-year-old man with several clinical problems contraindicating surgery. Endoscopic devolvulation with tube placement was adequate to resolve this sigmoid volvulus.

Giant cell arteritis in Lugo, Spain, is associated with low longterm mortality.

OBJECTIVE: To assess the longterm survival of patients with giant cell arteritis (GCA) in a well defined area in Northwestern Spain. METHODS: A followup study of consecutive biopsy proven patients with GCA diagnosed in Lugo, Spain January 1, 1982-March 31, 1996 was performed. Patients were followed from time of diagnosis until either their death or October 1, 1996. Time and cause of death were reviewed. Statistical methods included standardized mortality ratio (SMR), and Kaplan-Meier product-limit survival analysis. Cox proportional hazard models were used to identify clinical features and laboratory findings associated with survival. RESULTS: By October 1, 1996, full information about 109 biopsy proven patients with GCA (59 men/50 women) was available. The mean age +/- SD at the time of diagnosis was 73.9 +/- 7.3 years for women and 74.1 +/- 5.8 for men (p = NS). After a median followup of 54 months, 22 patients (20.2%) had died. Three died within the first month after diagnosis due to either vascular complications related to GCA or therapy complications. Apart from a history of severe underlying diseases (comorbid condition unrelated to GCA), neither sex nor any clinical features of GCA were significantly associated with an increase in mortality. As in the general population of the same age in Lugo, the majority of deaths were due to cardiovascular and cerebrovascular complications. SMR was 0.80 (95% CI 0.47-1.13). One, 2, 5, and 10 year survival rates were 95, 91, 81, and 62%, respectively. Hazard function was 1.8% at Day 30 after diagnosis and remained low until the end of the first year of treatment. Thereafter, mortality increased slightly. As this function was constant, we applied an exponential model. The estimated risk of death with this model was 5.3% per year. CONCLUSION: Longterm mortality of GCA in our area is low. However, it may be possible to further lower the mortality rate through early diagnosis and careful followup.