Intraoperative red blood cell transfusion, delayed graft function, and infection after kidney transplant: an observational cohort study.

BACKGROUND: Kidney transplant patients are frequently anemic and at risk for red blood cell (RBC) transfusion. Previous studies suggest that pre-transplant RBC transfusion may improve kidney transplant outcomes; however, RBC transfusion is also associated with infection. The purpose of our study was to characterize the relationships between intraoperative RBC transfusion, delayed graft function (DGF), postoperative surgical site infection (SSI), and sepsis. METHODS: Analysis was performed on a historical cohort of adult kidney transplant patients from a single medical center during a two-year period. Crude odds ratios for DGF, superficial and deep SSI, and sepsis were calculated for transfused patients and multivariate regression was used to control for potential confounders when significant relationships were identified. RESULTS: Four hundred forty-one patients had kidney transplant during the study period; 27.0% had RBC transfusion, 38.8% had DGF, 7.0% had superficial SSI, 7.9% had deep SSI, and 1.8% had sepsis. High dose RBC transfusion was associated with improved graft function, but this was negated after adjusting for confounders (OR = 0.86, 95% CI 0.26 to 2.88). There was no association between RBC transfusion and SSI. RBC transfusion was independently associated with sepsis (OR = 8.98, 95% CI 1.52 to 53.22), but the confidence interval was wide. CONCLUSIONS: Intraoperative RBC transfusion during kidney transplant is not associated with improved allograft function or incisional SSI, but is associated with postoperative sepsis. RBCs should not be liberally transfused during kidney transplant surgery to improve graft outcomes.

Healthcare-Associated Infections in Cardiac Surgery Patients With Prolonged Intensive Care Unit Stay.

BACKGROUND: Healthcare-associated infections (HAIs) are responsible for many deaths of hospitalized patients each year. Patients with prolonged hospitalization are at high risk for HAIs. Increased efforts have been made to decrease these infections, but a recent report from the Centers for Disease Control suggests that some HAIs may be increasing. We hypothesized that HAIs would remain frequent among cardiac surgery patients with prolonged intensive care unit stay and would be associated with increased mortality. METHODS: We performed a retrospective cohort study of adult cardiac surgery patients with prolonged intensive care unit stay (more than 7 days) over a 3-year period. Mortality differences were calculated based on whether particular HAIs occurred. Multivariable logistic regression was used to examine risk factors associated with the development of HAI. The relationship between HAI and mortality was estimated using propensity score adjusted logistic regression analysis. RESULTS: Of 2,595 patients, 388 (15.0%) had a prolonged intensive care unit stay. Of these patients, 48.5% had at least one HAI. Unadjusted inhospital mortality for patients with HAI was 28.7%, versus 13.0% for patients without. Red blood cell transfusion was associated with increased HAI risk. After propensity score adjustment, surgical site infection and central line associated blood stream infection were associated with increased mortality. The HAIs caused by vancomycin-resistant Enterococcus sp, methicillin-resistant Stapholococcus aureus, and multidrug-resistant organisms appeared to be associated with disproportionally high mortality. CONCLUSIONS: Healthcare-associated infections remain frequent among cardiac surgery patients with prolonged intensive care unit stay and are associated with increased mortality. Evidence-based strategies are needed to reduce these infections.

Validation of a Dosing Strategy for Cefazolin for Surgery Requiring Cardiopulmonary Bypass.

BACKGROUND: A prospective, single center, open-label study was conducted to determine if the standard practice for surgical prophylaxis, which includes standardized dosing of cefazolin, at the University of Maryland Medical Center (UMMC) is adequate for patients placed on bypass during cardiac surgery. METHODS: All patients were given the same standard dosing regimen regardless of weight: two grams of cefazolin administered within 1 h of incision, an additional one gram injected into the bypass circuit at the onset of bypass, and two grams every 3 h after the initial dose. Cefazolin serum concentrations were collected immediately after incision, after the start of bypass, each hour of bypass, at the end of bypass and at sternal closure. RESULTS: Ten patients were consented and completed the study with an average age of 62 y, average weight of 84.7 kg and average cardiopulmonary bypass time of 116 min. The free serum concentrations of cefazolin stayed above the pre-defined inhibitory threshold of 16 mcg/mL throughout the procedure for 100% of participants. The mean total serum concentration in the blood throughout surgery was 160 mcg/mL. No patients were found to have surgical site infections using standard criteria and no adverse events were observed. CONCLUSIONS: For patients undergoing cardiac surgery with cardiopulmonary bypass, the UMMC dosing regimen surpassed targeted cefazolin concentrations during the entire surgical procedure for all patients regardless of weight or time on bypass.

Prior colonization is associated with increased risk of antibiotic-resistant Gram-negative bacteremia in cancer patients.

We hypothesized that prior colonization with antibiotic-resistant Gram-negative bacteria is associated with increased risk of subsequent antibiotic-resistant Gram-negative bacteremia among cancer patients. We performed a matched case-control study. Cases were cancer patients with a blood culture positive for antibiotic-resistant Gram-negative bacteria. Controls were cancer patients with a blood culture not positive for antibiotic-resistant Gram-negative bacteria. Prior colonization was defined as any antibiotic-resistant Gram-negative bacteria in surveillance or non-sterile-site cultures obtained 2-365 days before the bacteremia. Thirty-two (37%) of 86 cases and 27 (8%) of 323 matched controls were previously colonized by any antibiotic-resistant Gram-negative bacteria. Prior colonization was strongly associated with antibiotic-resistant Gram-negative bacteremia (odds ratio [OR] 7.2, 95% confidence interval [CI] 3.5-14.7) after controlling for recent treatment with piperacillin-tazobactam (OR 2.5, 95% CI 1.3-4.8). In these patients with suspected bacteremia, prior cultures may predict increased risk of antibiotic-resistant Gram-negative bacteremia.

Infection prevention in the cancer center.

Cancer patients are frequently immunosuppressed and at risk for a wide range of opportunistic and healthcare-associated infections. A good infection prevention program is extremely important to reduce risk of infection. This review focuses on infection prevention measures specific to patients, healthcare personnel, and visitors in the cancer center.

Risk factors for central line-associated bloodstream infections in the era of best practice.

BACKGROUND: Best clinical practice aims to eliminate central line-associated blood stream infections (CLABSIs). However, CLABSIs still occur. This study's aim was to identify risk factors for CLABSI in the era of best practice. METHODS: Critically ill surgical patients admitted over 2 years to the intensive care unit (ICU) for ≥ 4 days were studied. Patients with CLABSI as cause for ICU admission were excluded. Patients who developed CLABSI (National Healthcare Safety Network definition) were compared with those who did not. Hand hygiene, maximal sterile barriers, chlorhexidine scrub, avoidance of femoral vein, and proper maintenance were emphasized. Variables collected included demographics, diagnosis, and severity of illness using the Acute Physiology and Chronic Health Evaluation (APACHE) IV database and the hospital central data repository. RESULTS: Of 961 patients studied, 51 patients (5.2%) developed 59 CLABSIs. Mean time from ICU admission to CLABSI was 26 days ± 26 days. The CLABSI group was more likely to be male (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.02-3.68), more critically ill on ICU admission (APACHE IV score 85.2 ± 21.9 vs. 65.6 ± 23.2, p < 0.01), more likely admitted to the emergency surgery service (OR 1.92, 95% CI 1.02-3.61), and had an association with reopening of recent laparotomy (OR 2.08, 95% CI 1.10-3.94). CONCLUSION: In the era of best practice, patients who develop CLABSI are clinically distinct from those who do not develop CLABSI. These CLABSIs may be due to deficiencies of the CLABSI definition or represent patient populations requiring enhanced prevention techniques. LEVEL OF EVIDENCE: III, prognostic study.

Gastrointestinal infections in immunocompromised hosts.

PURPOSE OF REVIEW: Gastrointestinal infections in the immunocompromised host continue to have significant morbidity and mortality throughout the world. They all have similar exposures to viruses, bacteria and parasites and respond to these infections in a similar way. This review will summarize the latest reports on the epidemiology, diagnosis and treatment of known and emerging infections over the last 12 months. RECENT FINDINGS: Highly active antiretroviral therapy has reduced esophageal opportunistic infections in HIV patients compared to patients who are not taking this therapy. Esophageal candidiasis responds to escalating doses of micafungin as effectively as fluconazole. HIV-infected patients with untreated Mycobacterium avium-complex diarrhea are associated with a wasting syndrome that disrupts the somatostatin axis. Polymerase chain reaction testing has improved diagnosis of microsporidial infections. Cytomegalovirus polymerase chain reaction of tissue may improve the diagnosis of cytomegalovirus disease of the gastrointestinal tract in organ-transplant recipients. The treatment of hypogammaglobulinemia in transplant recipients with recurrent cytomegalovirus gastrointestinal disease may resolve their symptoms. Community viruses are an emerging threat to transplant recipients and may affect drug levels. Lastly, anti-tumor necrosis factor alpha therapy in the treatment of inflammatory conditions may cause Listeria monocytogenes to disseminate. SUMMARY: Immunocompromised hosts remain at risk for severe gastrointestinal and even disseminated infections. Management includes an early rapid diagnosis with rapid restoration of the immune system and appropriate anti-infective therapy. With the immunocompromised population rapidly increasing, prevention of these infections remains the greatest challenge.