A population-based analysis of risk factors and outcomes of prostatic abscess.

BACKGROUND: Prostate abscess is a severe complication of acute bacterial prostatitis. To date, a population-based analysis of risk factors and outcomes of prostatic abscess has not been performed. METHODS: Using the National Inpatient Sample from 2010 to 2015, we identified rates of prostatic abscess among non-elective hospitalizations for acute prostatitis. Significant Elixhauser comorbidities and risk factors were analyzed using survey-weighted logistic regression. Additional survey-weighted regression models were constructed to analyze sepsis, in-hospital mortality, length of hospital stay (LOS), and total hospital charges. RESULTS: A weighted total of 126,103 hospitalizations for acute prostatitis was identified, with 6,775 (5.4%) hospitalizations with prostatic abscess. Numerous risk factors for prostatic abscess were identified, with a history of prostate biopsy (adjusted OR: 5.7; p < 0.001), complicated diabetes mellitus (adjusted OR: 3.23, p < 0.001), and urethral stricture (adjusted OR: 3.15; p < 0.001) having the greatest magnitude of developing abscess. Moreover, those diagnosed with prostatic abscess had increased odds of sepsis (adjusted OR: 1.71, p < 0.001), in-hospital mortality (adjusted OR: 2.73, p < 0.001), LOS (adjusted Incidence Rate Ratio: 1.86, p < 0.001), and total hospital charges (adjusted Ratio: 2.06, p < 0.001). CONCLUSIONS: Numerous risk factors were associated with the development of prostatic abscess, with those diagnosed experiencing greater odds of sepsis, in-hospital mortality, longer LOS, and greater hospital charges. Ultimately, better understanding of risk factors associated with this condition will enable clinicians to identify patients at high risk, thereby expediting and tailoring management.

Fournier's gangrene by perianal abscess / Gangrena de Fournier por abscesso perianal

ABSTRACT Objective: To describe and analyze the cases of Fournier's Gangrene caused by perianal abscess treated in a tertiary hospital in western Paraná, correlating possible factors that influence mortality, with emphasis on late diagnosis and therapy. Methods: A retrospective and descriptive case series was carried out based on the analysis of medical records of patients with Fournier's Gangrene due to perianal abscess from January 2012 to December 2017. Results: Thirty-one patients with Fournier's Gangrene due to perianal abscess were treated in the period: 26 men and 5 women. Mean age was 53.51 ± 14.5 years. The most prevalent comorbidity in this group was type 2 diabetes mellitus, showing a strong correlation with mortality. The mean time from disease progression, from the initial symptom to the admission at the service, was 9.6 ± 6.81 days. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 3.25 ± 2.89 procedures/patient. Seven (22.58%) patients died and all of them showed signs of sepsis on admission; only 2 patients with sepsis did not die. Conclusion: The presence of sepsis on admission and type 2 diabetes mellitus were strongly correlated with mortality.

RESUMO Objetivo: Descrever e analisar os casos de gangrena de Fournier por abscesso perianal atendidos em hospital terciário do oeste do Paraná, correlacionando possíveis fatores que influenciem a mortalidade, com ênfase ao diagnóstico e terapêuticas tardias. Métodos: Realizou-se um estudo de série de casos, retrospectivo e descritivo baseado na análise de prontuários de pacientes portadores de gangrena de Fournier devido a abscesso perianal no período de Janeiro de 2012 à Dezembro de 2017. Resultados: Foram tratados 31 pacientes com gangrena de Fournier por abscesso perianal no período, sendo 26 homens e 5 mulheres. A média de idade foi de 53,51 ± 14,5 anos. A comorbidade de maior prevalência neste grupo foi diabete melitus tipo 2, demonstrando forte correlação com mortalidade. A média do tempo de evolução da doença, do sintoma inicial até entrada no serviço, foi de 9,6 ± 6,81 dias. Todos os pacientes foram submetidos à antibioticoterapia e tratamento cirúrgico com média de 3,25 ± 2,89 procedimentos/paciente. Sete (22,58%) pacientes evoluíram para óbito e todos estes apresentavam sinais de sepse na admissão; apenas 2 pacientes com sepse não evoluíram a óbito. Conclusão: Presença de sepse a admissão e diabete melitus tipo 2 foram fortemente correlacionadas com mortalidade.

Higher incidence of perivalvular abscess determines perioperative clinical outcome in patients undergoing surgery for prosthetic valve endocarditis.

BACKGROUND: Cardiac surgery for prosthetic valve endocarditis (PVE) is associated with substantial mortality. We aimed to analyze 30-day and 1-year outcome in patients undergoing surgery for PVE and sought to identify preoperative risk factors for mortality with special regard to perivalvular infection. METHODS: We retrospectively analyzed data of 418 patients undergoing valve surgery for infective endocarditis between January 2009 and July 2018. After 1:1 propensity matching 158 patients (79 PVE/79 NVE) were analyzed with regard to postoperative 30-day and 1-year outcomes. Univariate and multivariable analyses were performed to identify potential risk factors for mortality. RESULTS: 315 patients (75.4%) underwent surgery for NVE and 103 (24.6%) for PVE. After propensity matching groups were comparable with regard to preoperative characteristics, clinical presentation and microbiological findings, except a higher incidence of perivalvular infection in patients with PVE (51.9%) compared to NVE (26.6%) (p = 0.001), longer cardiopulmonary bypass (166 [76-130] vs. 97 [71-125] min; p < 0.001) and crossclamp time (95 [71-125] vs. 68 [55-85] min; p < 0.001). Matched patients with PVE showed a 4-fold increased 30-day mortality (20.3%) in comparison with NVE patients (5.1%) (p = 0.004) and 2-fold increased 1-year mortality (PVE 29.1% vs. NVE 13.9%; p = 0.020). Multivariable analysis revealed perivalvular abscess, sepsis, preoperative AKI and PVE as independent risk factors for mortality. Patients with perivalvular abscess had a significantly higher 30-day mortality (17.7%) compared to patients without perivalvular abscess (8.0%) (p = 0.003) and a higher rate of perioperative complications (need for postoperative pacemaker implantation, postoperative cerebrovascular events, postoperative AKI). However, perivalvular abscess did not influence 1-year mortality (20.9% vs. 22.3%; p = 0.806), or long-term complications such as readmission rate or relapse of IE. CONCLUSIONS: Patients undergoing surgery for PVE had a significantly higher 30-day and 1-year mortality compared to NVE. After propensity-matching 30-day mortality was still 4-fold increased in PVE compared to NVE. Patients with perivalvular abscess showed a significantly higher 30-day mortality and perioperative complications, whereas perivalvular abscess seems to have no relevant impact on 1-year mortality, the rate of readmission or relapse of IE.

Association between the timing of surgery for complicated, left-sided infective endocarditis and survival.

BACKGROUND: In patients with active infective endocarditis (IE), the relationship between timing of surgery and survival is uncertain. The objective was to evaluate clinical characteristics associated with timing of surgery and the association between surgical timing and 6-month survival in complicated, left-sided IE. METHODS: In a prospective, multicenter, observational registry (The International Collaboration on Endocarditis-PLUS, registry from 2008 to 2012), clinical factors associated with timing of surgery during the index hospitalization were determined among 485 adult patients with definite, complicated, left-sided IE who underwent cardiac surgery during their index hospitalization. The relationship between early surgical intervention (<7 days from admission to surgery center) and outcome after surgery was analyzed. The primary end point of the study was 6-month survival. RESULTS: The median time to surgery from admission to surgical center was 7 (interquartile range 2-15) days. Patients who underwent earlier surgery were more likely transferred to the surgical center (74.2% vs 46.4%, P < .001) and had a lower percentage of preexisting heart failure (before IE diagnosis) (6.0% vs 17.3%, P < .001) but higher rate of acute heart failure (53.2% vs 38.4%, P = .001). Variables independently associated with surgery <7 days from admission were patient transfer, acute heart failure, and nonelective surgical status (C-index = 0.84), but predicted operative risk was not. Cox proportional hazards modeling with inverse probability of treatment weighting found that earlier surgery was associated with a trend toward higher 6-month mortality compared with later surgery (hazard ratio = 1.68, 95% CI 0.97-2.96; P = .065), particularly surgery within 2 days of admission or transfer. Mortality was significantly associated with operative risk and complicated IE, including Staphylococcus aureus infection and presence of abscess. CONCLUSIONS: Earlier surgery in IE is strongly associated with acute heart failure and surgical urgency. After adjustment for operative risk and IE complications, earlier surgery <7 days from admission was associated with a trend toward higher 6-month overall mortality compared with surgery later in the index hospitalization.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.

Percutaneous drainage and management of fluid collections associated with necrotic or cystic tumors in the abdomen and pelvis.

PURPOSE: The purpose of the study was to evaluate the efficacy and safety of percutaneous drainage for palliation of symptoms and sepsis in patients with cystic or necrotic tumors in the abdomen and pelvis. MATERIALS AND METHODS: This is a single center retrospective study of 36 patients (18 men, mean age = 51.1 years) who underwent percutaneous drainage for management of cystic or necrotic tumors in the non-postoperative setting over an 11-year period. Nineteen patients with intraabdominal fluid collections associated with primary malignancies included: cervical (n = 7), colorectal (n = 3), urothelial (n = 3), and others (n = 6). The 17 patients with fluid collections associated with intraabdominal metastases stemmed from the following primary malignancies: oropharyngeal squamous cell carcinoma (n = 3), colorectal (n = 3), ovarian (n = 2), lung (n = 2), melanoma (n = 2) along with others (n = 5). Indications for percutaneous drainage were as follows: pain (36/36; 100%); fever and/or leukocytosis (34/36; 94%), and mass effect (21/36; 58%). Seven patients underwent additional sclerosis with absolute alcohol. Criteria for drainage success were temporary or definitive relief of symptoms and sepsis control. RESULTS: Successful sepsis control was achieved in all patients with sepsis (34/34; 100%) and 30/36 (83%) patients had improvement in pain. Duration of catheterization ranged from 2 to 90 days (mean = 22 days). There were four cases of fluid re-accumulation and one patient developed catheter tract seeding. Alcohol ablation was successful in two patients (2/7; 29%). Nearly all patients (34/36; 94%) died during the follow-up period. CONCLUSIONS: Percutaneous drainage was effective for palliative treatment of symptomatic cystic and necrotic tumors in the majority of patients in this series.

Outcome of surgical intervention for aortic root abscess: a meta-analysis.

OBJECTIVES: Aortic root abscess (ARA) is a catastrophic complication of aortic root endocarditis, involving both native and prosthetic valves, which often warrants surgical intervention. Currently, aortic valve replacement (AVR) and aortic root replacement (ARR) are the most widely employed techniques. However, evidence that directly compares these methods is scarce. In this meta-analysis, we aimed to describe the surgical outcome of ARA when using different surgical methods. METHODS: In this meta-analysis, we performed literature searches in the EMBASE and PubMed databases and reviewed articles describing postoperative results of ARA that were published before 30 June 2016. After extracting the published data, we used a random-effects model to perform meta-analysis and compare the postoperative outcomes of ARA after management with AVR or ARR. RESULTS: Seven published studies were included in this meta-analysis, which includes 781 episodes of infective endocarditis complicated with ARA. There was no significant difference in the 30-day postoperative mortality rate among patients receiving ARR [23.8%, 95% confidence interval (CI) 17.8-30.6] compared with AVR (19.1%, 95% CI 13.3-26.1%), with a relative risk ratio of 1.30 (95% CI 0.84-2.00). However, patients receiving ARR were associated with statistically significant lower rates of reoperation within 1 year (relative risk 0.50, 95% CI 0.26-0.94). CONCLUSIONS: In our meta-analysis, ARR was associated with a 50% risk reduction of reoperation within 1 year among patients with ARA. There was no significant difference in the 30-day postoperative mortality rate between patients receiving ARR and patients receiving AVR; comparison of the long-term outcomes after these 2 procedures warrants further investigation.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess.

BACKGROUND: Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial. OBJECTIVES: To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality. SEARCH METHODS: We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials. SELECTION CRITERIA: We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess. DATA COLLECTION AND ANALYSIS: Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS: We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities. AUTHORS' CONCLUSIONS: It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

Recent Surgical Results for Active Endocarditis Complicated With Perivalvular Abscess.

BACKGROUND: Surgical treatment for endocarditis patients with a perivalvular abscess is still challenging.Methods and Results:From 2009 to 2016, 470 patients underwent surgery for active endocarditis at 11 hospitals. Of these, 226 patients underwent aortic valve surgery. We compared the clinical results of 162 patients without a perivalvular abscess, 37 patients who required patch reconstruction of the aortic annulus (PR group) and 27 who underwent aortic root replacement (ARR group). Patients with a perivalvular abscess had a greater number ofStaphylococcusspecies and prosthetic valve endocarditis, a greater level of inflammation at diagnosis and symptomatic heart failure before surgery, especially in the ARR group. Nevertheless, the duration between diagnosis and surgery was similar, because of a high prevalence of intracranial hemorrhage in the ARR group. Hospital death occurred in 13 (9%) patients without a perivalvular abscess, in 4 (12%) in the PR and in 7 (32%) in the ARR group. Postoperative inflammation and end-organ function were similar between the groups. Overall survival of patients without a perivalvular abscess and that of the PR group was similar, but was significantly worse in the ARR group (P=0.050, 0.026). Freedom from endocarditis recurrence was similar among all patients. CONCLUSIONS: Patients treated with patch reconstruction showed favorable clinical results. Early surgical intervention is necessary when a refractory invasive infection is suspected.

Management of Septic emboli in patients with infectious endocarditis.

BACKGROUND AND AIM: Septic emboli (SE) associated with infectious endocarditis (IE) can result in splenic abscesses and infectious intracranial aneurysms (IIA). We investigated the impact of SE on patient outcomes following surgery for IE. METHOD: From January-2000 to October-2015, all patients with surgical IE (n = 437) were evaluated for incidence and management of SE. RESULTS: Overall SE was found in 46/437 (10.52%) patients (n = 17 spleen, 13 brain, and 16 both). No mortality was seen in the brain emboli groups, but in the splenic abscess group the in-hospital mortality was 8.69% (n = 4); and was associated with Age >35 (OR = 2.63, 1.65-4.20) and congestive heart failure (OR = 14.40, 1.23-168.50). Patients with splenic emboli had excellent mid-term outcome following discharge (100% survival at 4-years). Splenic emboli requiring splenectomy was predicted by a >20 mm valve vegetation (OR = 1.37, 1.056-1.77) and WBC >12000 cells/mm (OR = 5.58, 1.2-26.3). No patient with streptococcus-viridians infection had a nonviable spleen (OR = 0.67, 0.53-0.85). Postoperative acute-kidney-injury was higher in the splenectomy group (45.45% vs 9%) (p = 0.027). There were 6 patients with symptomatic IIAs that required coiling/clipping which was associated with age <30 years, (OR = 6.09, 1.10-33.55). Survival in patients with cerebral emboli decreased to 78% at 3-4 years. Patients with both splenic and brain emboli had a 92% survival rate at 1-year and 77% at 2-4 years. CONCLUSION: Septic emboli is common in endocarditis patients. Patients with high preoperative WBC level and large valve vegetations require CT imaging of the spleen. Both spleen and brain interventions in the setting of IE can be performed safely with excellent early and mid-term outcomes.

[TRANSCUTANEOUS PUNCTURE DRAINING OF THE LIQUID ACCUMULATIONS IN RETROPERITONEAL CELLULAR TISSUE IN PURULENT­SEPTIC COMPLICATIONS OF AN ACUTE PANCREATITIS].

The results of miniinvasive transcutaneous interventions for purulent­septic complications of pancreonecrosis are presented. The computeric tomography (CT) and the ultrasound investigation data where compared while choosing of transcutaneous access towards purulent focus. Peculiar attention was drawn to searching of extraperitoneal trajectory for the drain conduction way. The drains were installed, using a one­staged method with a stylet catheters, owing 10 ­ 12 Fr in diameter, or a two­staged one. While comparing various methods of treatment of the pancreonecrosis purulent­septic complications there was established efficacy of miniinvasive interventions, performed for pancreatogenic abscesses and relatively delimited purulent foci in retroperitoneal cellular tissue.

Spontaneous Nasal Septal Abscess Presenting as a Soft Tissue Mass in a Child.

BACKGROUND: Nasal septal abscess (NSA) is a rare condition most commonly seen as a complication of nasal trauma. The diagnosis of NSA requires emergent treatment, because delayed management can result in significant morbidity. Typically, NSA presents as a purulent collection that can be managed with drainage, either surgically or at bedside. CASE REPORT: We report an unusual presentation of a spontaneous NSA in a 7-year-old boy as a solid nasal mass eroding the nasal septum. The solid, tumor-like nature of the mass necessitated intervention beyond drainage and was ultimately excised. Imaging initiated in the emergency department revealed a partially cystic mass and erosion of the septum, which was key to the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the ease with which a diagnosis of NSA may be missed and the need for urgent management upon diagnosis of a NSA, we aim to highlight the clinical, radiologic, and histopathologic aspects that aid in diagnosis of NSA. Imaging, obtaining culture results, and initiation of antibiotics are paramount in management. In addition, NSAs may also necessitate bedside drainage given their emergent nature.

[Infections of non-prosthetically treated joints]. / Infektion des nichtprothetisch versorgten Gelenkes.

BACKGROUND: Septic arthritis is a common orthopedic emergency. Immediate establishment of the diagnosis and administration of an adequate therapy is paramount in minimizing morbidity and mortality in this severe condition. OBJECTIVE: The aim of the present review was to evaluate the existing evidence in order to give an overview on current best practice in diagnostics and treatment of septic arthritis in adults and children. RESULTS: Joint infections result from either hematogenous spread or direct inoculation of bacteria into the joint, mostly iatrogenically. Predisposing risk factors include recent orthopedic joint surgery, i. v. drug abuse, pre-existing inflammatory and degenerative joint diseases and old age. Although pathogens differ in different populations and age groups Staphylococcus aureus is the single most frequently isolated causative organism, followed by streptococci. Although diagnosis is based on an integration of medical patient history, clinical and laboratory findings and imaging studies, joint fluid analysis remains the mainstay in establishing a valid diagnosis. The range of differential diagnostics is broad and includes non-infectious inflammatory joint diseases, such as gout or reactive arthritis. Once a diagnosis has been established treatment should be started immediately. Treatment is based on adequate antibiotic therapy and joint drainage until dryness. There is a paucity of studies on the optimal antibiotic regimen, route of application and duration of therapy. Moreover, no high-quality studies exist on the optimal mode of joint drainage. While superiority has yet to be shown, operative treatment in terms of arthroscopic lavage must be considered the standard of care in Germany. Finally, despite promising results in children, the role of corticosteroids as an adjunct to antibiotic treatment in adults has yet to be clarified.

Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses.

OBJECTIVES: To evaluate the early and long-term outcomes in patients undergoing complex aortic root reconstructions for complicated aortic root abscesses. METHODS: A total of 1199 patients underwent aortic valve surgery for aortic valve endocarditis between July 1999 and June 2012. Of these, 150 patients, who underwent complex isolated aortic root operations for aortic root abscesses, were included in this study. Radical resection of the abscess was performed in all patients followed by an aortic root replacement (ARR) in 91 (61.7%) or an aortic valve replacement with patch reconstruction of the aortic root in 59 (39.3%) patients. Prosthetic valve endocarditis was observed in 74 patients (49.3%). Logistic regression analysis identified the predictors of 30-day mortality. Estimated mean follow-up was 7.0 ± 0.5 years (range 0-12.6 years). RESULTS: Mean age was 62 ± 15 years and 87% (n = 130) were male. The majority of patients (91%; n = 137) underwent urgent or emergent surgery. Overall 30-day mortality was 19% (n = 29; ARR 21%; AVR 17%; P = 0.4). Postoperative low cardiac output, stroke and dialysis developed in 10.7, 4.7 and 25.3% of patients, respectively. Sepsis was the only independent predictor of 30-day mortality (odds ratio: 2.8; 95% confidence interval: 1.1-7.3; P = 0.03). The 1-, 5- and 10-year survival was 66 ± 5, 54 ± 5 and 51 ± 6%, respectively. Overall, 9% of surviving patients required a reoperation for recurrent endocarditis resulting in a 1-, 5- and 10-year freedom from reoperation of 93 ± 2, 91 ± 3 and 85 ± 5%, respectively, which was not influenced by surgical technique used (ARR vs AVR with patch reconstruction; log rank P = 0.9). CONCLUSIONS: The surgical treatment of aortic root abscess is a challenging operation and is associated with a high early morbidity and mortality. However, the long-term survival and freedom from reoperation is satisfactory.

Echocardiographic Findings Predict In-Hospital and 1-Year Mortality in Left-Sided Native Valve Staphylococcus aureus Endocarditis: Analysis From the International Collaboration on Endocarditis-Prospective Echo Cohort Study.

BACKGROUND: Staphylococcus aureus left-sided native valve infective endocarditis (LNVIE) has higher complication and mortality rates compared with endocarditis from other pathogens. Whether echocardiographic variables can predict prognosis in S aureus LNVIE is unknown. METHODS AND RESULTS: Consecutive patients with LNVIE, enrolled between January 2000 and September 2006, in the International Collaboration on Endocarditis were identified. Subjects without S aureus IE were matched to those with S aureus IE by the propensity of having S aureus. Survival differences were determined using log-rank significance tests. Independent echocardiographic predictors of mortality were identified using Cox-proportional hazards models that included inverse probability of treatment weighting and surgery as a time-dependent covariate. Of 727 subjects with LNVIE and 1-year follow-up, 202 had S aureus IE. One-year survival rates were significantly lower for patients with S aureus IE overall (57% S aureus IE versus 80% non-S aureus IE; P<0.001) and in the propensity-matched cohort (59% S aureus IE versus 68% non-S aureus IE; P<0.05). Intracardiac abscess (hazard ratio, 2.93; 95% confidence interval, 1.52-5.40; P<0.001) and left ventricular ejection fraction <40% (odds ratio, 3.01; 95% confidence interval, 1.35-6.04; P=0.004) were the only independent echocardiographic predictors of in-hospital mortality in S aureus LNVIE. Valve perforation (hazard ratio, 2.16; 95% confidence interval, 1.21-3.68; P=0.006) and intracardiac abscess (hazard ratio, 2.25; 95% confidence interval, 1.26-3.78; P=0.004) were the only independent predictors of 1-year mortality. CONCLUSIONS: S aureus is an independent predictor of 1-year mortality in subjects with LNVIE. In S aureus LNVIE, intracardiac abscess and left ventricular ejection fraction <40% independently predicted in-hospital mortality and intracardiac abscess and valve perforation independently predicted 1-year mortality.

Isolation of a bacteriophage and its depolymerase specific for K1 capsule of Klebsiella pneumoniae: implication in typing and treatment.

BACKGROUND: Klebsiella pneumoniae causing community-acquired pyogenic liver abscess complicated with metastatic meningitis and endophthalmitis has emerged recently, most frequently associated with the K1 capsular type. METHODS: A bacteriophage (NTUH-K2044-K1-1) that infects K. pneumoniae NTUH-K2044 (capsular type K1) was isolated and characterized. RESULTS: The phage infected all K1 strains, and none of the strains with other capsular types. Capsule deletion mutants were not lysed by this phage, suggesting that the capsule was essential for phage infection. Complete genome sequencing revealed the phage was a novel phiKMV-like virus. The gene-encoding capsule depolymerase was identified. The recombinant enzyme demonstrated specific lysis of the K1 capsule. Treatment with the phage or the recombinant enzyme provided significantly increased survival in mice infected with NTUH-K2044 strain, including one treated after the detection of a neck abscess by imaging. No obvious disease was observed after administration of this phage in mice. Phage was retained at detectable levels in liver, spleen, brain, and blood 24 hours after administration in mice. CONCLUSIONS: These results demonstrate this phage and its capsule depolymerase exhibit specificity for capsular type K1 and can be used for the diagnosis and treatment of K1 K. pneumoniae infections.

[A retrospective analysis of 19 splenic abscess patients].

OBJECTIVE: To analyze the clinical manifestations, diagnosis, treatment and prognosis of patients with splenic abscess. METHOD: The clinical data, including baseline clinical data, clinical features, past history, pathogen culture result, treatment and the prognosis were retrospectively analyzed in the patients with the discharge diagnosis splenic abscess from January 1991 to March 2012 in Peking Union Medical College Hospital. RESULTS: The media time from onset to Peking Union Medical College Hospital of the 19 patients were 29 days. Among them, 9 patients were cured, 8 were improved and 2 died. Risk factors, such as tumor burden, diabetes, and using immunosuppressive agents etc, can be found in most patients with splenic abscess. All the 19 patients had splenic image changes and non-specific clinical features. The most common three clinical symptoms were fever (18 cases), chills (12 cases) and shivering (11 cases). The most common three signs were abdominal tenderness (9 cases), left upper quadrant sensitive to percussion (7 cases) and splenomegaly (4 cases). The most common etiological culture results were gram negative bacilli (9 cases), gram positive coccus (8 cases), and fungi (4 cases). CONCLUSIONS: Clinical features are non-specific in splenic abscess patients. Related exam such as ultrasound should be performed on patients with splenic abscess risk factors to avoid misdiagnosis. Empiric antibiotic administration should begin right after the diagnosis based on the image. Pathogen culture should be timely conducted after pus collection. Individual therapeutical protocol should be chosen according to patient's condition.

Open surgical management of complications from indwelling radial artery catheters.

BACKGROUND: Cannulation of the radial artery is frequently performed for invasive hemodynamic monitoring. Complications arising from indwelling catheters have been described in small case series; however, their surgical management is not well described. Understanding the presentation and management of such complications is imperative to offer optimal treatment, particularly because the radial artery is increasingly accessed for percutaneous coronary interventions. METHODS: We conducted a retrospective review to identify patients who underwent surgical intervention for complications arising from indwelling radial artery catheters from 1997 to 2011. RESULTS: We identified 30 patients who developed complications requiring surgical intervention. These complications were categorized into ischemic and nonischemic, with 15 patients identified in each cohort. All patients presenting with clinical hand or digital ischemia underwent thrombectomy and revascularization. Complications in the nonischemic group included three patients with deep abscesses with concomitant arterial thrombosis, two with deep abscesses alone, and 10 with pseudoaneurysms. Treatment strategy in this group varied with the presenting pathology. Among the entire case series, three patients required reintervention after the initial surgery, all in individuals initially presenting with ischemia who developed recurrent thrombosis of the radial artery. There were no digital or hand amputations in this series. However, the overall in-hospital mortality in these patients was 37%, reflecting the severity of illness in this patient cohort. Three patients who were positive for heparin-induced thrombocytopenia antibody had 100% mortality compared with those who were negative (P = .04, Fisher exact test). In-hospital mortality was higher in patients presenting with initial ischemia than in those with nonischemic complications (53% vs 20%; P = .06). Among 10 patients who presented with pseudoaneurysms, five (50%) were septic at presentation with positive blood cultures, and six (60%) had positive operating room cultures. Staphylococcus aureus was identified as the causative organism in all of these patients. CONCLUSIONS: Complications of radial artery cannulation requiring surgical intervention can represent infectious and ischemic sequelae and have the potential to result in major morbidity, including digital or hand amputation and sepsis, or death. Although surgical treatment is successful and often required in these patients to treat severe hand ischemia, hemorrhage, or vascular infection, these complications tend to occur in critically ill hospitalized patients with an extremely high mortality. This must be taken into consideration when planning surgical intervention in this patient cohort. Finally, radial arterial cannulation sites should not be overlooked when searching for occult septic sources in critically ill patients.

Further experience with the "no-react" bioprosthesis in patients with active infective endocarditis: 11-year single center results in 402 patients.

OBJECTIVES: We investigated early, midterm, and long-term results following valve replacement with the "No-React" bioprosthesis in patients with active infective endocarditis (AIE).Patients and Methods Between February 2000 and February 2011, a total of 402 patients (median 61 years, 17 to 91 years) received "No-React" bioprostheses due to single valve AIE in 315 (aortic valve replacement n = 158, aortic conduit n = 30, mitral valve replacement n = 116, tricuspid valve replacement n = 11) and double valve AIE in 87 cases. Prosthetic AIE was found in 105 patients (26.1%). Mean follow-up was 2.8 ± 3.2 years (1 month to 11.4 years) with 1,124 patient years, completed in 97.1%. This retrospective study analyzes both prospectively updated data (n = 255) and patients recently operated upon (n = 147). RESULTS: There was a highly significant difference in the survival between patients operated on urgently and patients operated on in an emergency (30-day, 1-, 5-, and 10-year survival were 80.9 ± 2.3%, 63.8 ± 2.9%, 48.3 ± 3.3%, and 39.7 ± 4.1% vs. 61.3 ± 4.5%, 45.0 ± 4.7%, 33.1 ± 4.6%, and 14.0 ± 5.1%, respectively, p < 0.001), due to native versus prosthetic AIE (p = 0.032), single versus double valve replacement (p = 0.005), and with or without abscess formation (p < 0.001). Thirty-day, 1-, 5-, and 10-year freedom from reoperation due to recurrent endocarditis were 100%, 95.1 ± 1.4%, 86.4 ± 2.6%, and 82.1 ± 3.6% and due to structural valve deterioration (SVD) were 100%, 100%, 98.9 ± 0.8%, and 91.4 ± 4.0%, respectively. There was no difference in prosthesis durability between the older (> 60 years) and the younger patients. CONCLUSIONS: Our experience in the use of "No-React" bioprostheses in patients with native and prosthetic AIE shows satisfactory early, midterm, and long-term results, in particular low rates of reoperation due to recurrent endocarditis and SVD. Because these prostheses are readily available and their implantation straightforward, we strongly recommend their use in patients with AIE. Patients' survival differed significantly depending on their surgical urgency. Early mortality was independently predicted by septic shock, abscess formation, and number of implanted valves besides age per 10 years.

Clinical characteristics and the usefulness of the QuantiFERON-TB Gold In-Tube test in hematologic patients with hepatic or splenic lesions.

BACKGROUND/AIMS: Hepatic or splenic lesions in hematologic patients are not defined well because they are not easy to evaluate due to limitations of invasive procedures. Management typically depends on the clinical diagnosis with few microbiological data. METHODS: We reviewed the medical records of consecutive hematologic patients with hepatic or splenic lesions in the infectious diseases unit from April 2009 to December 2010 at the Catholic Hematopoietic Stem Cell Transplantation Center in Korea. RESULTS: Twenty-six patients were identified. Their mean age was 46.0 ± 14.7 years, and 16 (61.5%) were male. Underlying diseases were acute myelogenous leukemia (n = 15, 57.7%) and myelodysplastic syndrome (n = 6, 23.1%). Among the nine nontuberculous infectious lesions, two bacterial, six fungal, and one combined infection were identified. The numbers of confirmed, probable, and possible tuberculosis (TB) cases were one, three, and four, respectively. Two patients had concurrent pulmonary TB. QuantiFERON-TB Gold In-Tube (QFT-GIT, Cellestis Ltd.) was positive in seven cases, among which six were diagnosed with TB. The sensitivity and specificity of QFT-GIT were 75% and 81.3%. Nine (34.6%) were defined as noninfectious causes. CONCLUSIONS: Causes of hepatic or splenic lesion in hematologic patients were diverse including TB, non-TB organisms, and noninfectious origins. TB should be considered for patients not responding to antibacterial or antifungal drugs, even in the absence of direct microbiological evidence. QFT-GIT may be useful for a differential diagnosis of hepatosplenic lesions in hematologic patients.