Bacterial peritonitis in paediatric appendicitis; microbial epidemiology and antimicrobial management.

BACKGROUND: Appendicitis remains a common surgical emergency in children. Empirical antibacterial treatment is indicated to reduce infective complications. We investigate the bacterial pathogens identified intra-operatively during appendectomies in children to guide empirical surgical antimicrobial prophylaxis options. METHODS: A retrospective analysis of patients (< 18 years old) undergoing an appendectomy across a multisite London hospital (Nov 2019-March 2022) was undertaken. Patient-related outcomes including length of hospital stay (LOS), days of antibacterial therapy (DOT), intra-operative microbiology and post-operative radiology reports were interrogated. RESULTS: 304 patients underwent an appendectomy during this period; 39.1% of patients had intraoperative samples cultured. Bacterial pathogens were found in 73/119 (61.3%) cases; the most common isolates being Escherichia coli (42.0%), Pseudomonas aeruginosa (21.0%), milleri Streptococcus spp. (14.3%) and Bacteroides fragilis (5.9%). Polymicrobial infection was common (32/73). Isolation of Pseudomonas spp. from intra-operative sampling was associated with a greater LOS (7.0 vs. 5.0 days; p = 0.011) but nil effect on the incidence of postoperative collections. Presence of milleri Streptococcus spp. was associated with longer LOS (7.0 vs. 5.0 day; p = 0.007), DOT (12.0 vs. 8.5 day; p = 0.007) but had no observed outcome on postoperative collections (29.4% vs. 18.6%; p = 0.330). 48% of E. coli positive cultures were co-amoxiclav resistant and prolonged LOS compared to the non-resistant group (7.0 vs. 5.0 days; p = 0.040) but had no difference in post-operative collections (29.2% vs. 17.9%; p = 0.260). CONCLUSION: A high proportion of children with appendicitis have Pseudomonas spp. isolated, leading to a prolonged LOS. Evolving Enterobacterales resistance and the presence of Pseudomonas spp. necessitate extended antibacterial coverage for paediatric appendectomies with evidence of peritonitis.

Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection.

Importance: Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown. Objective: To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites. Design, Setting, and Participants: A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants. Exposures: Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis. Main Outcomes and Measures: The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset. Results: In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality. Conclusions and Relevance: The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

ICD-10-AM codes for cirrhosis and related complications: key performance considerations for population and healthcare studies.

OBJECTIVE: The utility of International Classification of Diseases (ICD) codes relies on the accuracy of clinical reporting and administrative coding, which may be influenced by country-specific codes and coding rules. This study explores the accuracy and limitations of the Australian Modification of the 10th revision of ICD (ICD-10-AM) to detect the presence of cirrhosis and a subset of key complications for the purpose of future large-scale epidemiological research and healthcare studies. DESIGN/METHOD: ICD-10-AM codes in a random sample of 540 admitted patient encounters at a major Australian tertiary hospital were compared with data abstracted from patients' medical records by four blinded clinicians. Accuracy of individual codes and grouped combinations was determined by calculating sensitivity, positive predictive value (PPV), negative predictive value and Cohen's kappa coefficient (κ). RESULTS: The PPVs for 'grouped cirrhosis' codes (0.96), hepatocellular carcinoma (0.97) ascites (0.97) and 'grouped varices' (0.95) were good (κ all >0.60). However, codes under-detected the prevalence of cirrhosis, ascites and varices (sensitivity 81.4%, 61.9% and 61.3%, respectively). Overall accuracy was lower for spontaneous bacterial peritonitis ('grouped' PPV 0.75; κ 0.73) and the poorest for encephalopathy ('grouped' PPV 0.55; κ 0.21). To optimise detection of cirrhosis-related encounters, an ICD-10-AM code algorithm was constructed and validated in an independent cohort of 116 patients with known cirrhosis. CONCLUSION: Multiple ICD-10-AM codes should be considered when using administrative databases to study the burden of cirrhosis and its complications in Australia, to avoid underestimation of the prevalence, morbidity, mortality and related resource utilisation from this burgeoning chronic disease.

Comparative Effectiveness of Local Application of Chlorhexidine Gluconate, Mupirocin Ointment, and Normal Saline for the Prevention of Peritoneal Dialysis-related Infections (COSMO-PD Trial): a multicenter randomized, double-blind, controlled protocol.

BACKGROUND: Current international guidelines recommend the use of a daily topical exit-site antimicrobial to prevent peritoneal dialysis (PD)-related infections. Although nonantibiotic-based therapies are appealing because they may limit antimicrobial resistance, no controlled trials have been conducted to compare topical antimicrobial agents with usual exit-site care for the prevention of PD-related infections among the Thai PD population. We propose a controlled three-arm trial to examine the efficacy and safety of a daily chlorhexidine gluconate-impregnated patch versus mupirocin ointment versus usual exit-site care with normal saline for the prevention of PD-related infections. METHODS/DESIGNS: This study is a randomized, double-blind, multicenter, active-controlled, clinical trial. Adult patients aged 18 years or older who have end-stage kidney disease and are undergoing PD will be enrolled at three PD Centers in Thailand. A total of 354 PD patients will be randomly assigned to either the 2% chlorhexidine gluconate-impregnated patch, mupirocin ointment, or usual exit-site care with normal saline dressing according to a computer-generated random allocation sequence. Participants will be followed until discontinuation of PD or completion of 24 months. The primary study outcomes are time to first PD-related infection (exit-site/tunnel infection or peritonitis) event and the overall difference in PD-related infection rates between study arms. Secondary study outcomes will include (i) the rate of infection-related catheter removal and PD technique failure, (ii) rate of nasal and exit-site Staphylococcus aureus colonization, (iii) healthcare costs, and (iv) skin reactions and adverse events. We plan to conduct a cost-utility analysis alongside the trial from the perspectives of patients and society. A Markov simulation model will be used to estimate the total cost and health outcome in terms of quality-adjusted life years (QALYs) over a 20-year time horizon. An incremental cost-effectiveness ratio in Thai Baht and U.S. dollars per QALYs gained will be illustrated. A series of probabilistic sensitivity analyses will be conducted to assess the robustness of the cost-utility analysis findings. DISCUSSION: The results from this study will provide new clinical and cost-effectiveness evidence to support the best strategy for the prevention of PD-related infections among the Thai PD population. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02547103. Registered on September 11, 2015.

[Peritonitis aggressiveness assessment]. / Opredelenie agressivnosti techeniia peritonita (pilotnoe issledovanie).

Peritonitis due to perforated duodenal ulcer was taken as a model. Patients were conditionally divided into three groups depending on the time after perforation: 6-12, 13-24 and over 24 hours. Analysis of microflora and pH of abdominal exudate was performed immediately after laparotomy. AIM: simple and reproducible method for determining the aggressiveness of peritonitis was developed. The authors believe that the diagnostic test is useful to individualize surgical approach in patient with advanced. peritonitis regardless time after perforation.

Utility of gray-scale histogram analysis in the assessment of treatment response in patients with infected cirrhotic ascites.

OBJECTIVE: To evaluate the utility of B-mode gray-scale histogram analysis in the management of patients with infected cirrhotic ascites. METHODS: A total of 97 patients (mean(SD) age : 66.8(14.2) years, 50.5% were males) diagnosed with cirrhotic ascites were included in this non-interventional study. Paracentesis for ascitic fluid analysis [culture tests, white blood cell count, albumin and protein levels, serum ascites albumin gradient (SAAG)] and gray-scale histogram analysis for ascites/subcutaneous echogenicity ratio (ASER) were performed at baseline in each patient and on Day 2 and Day 5 of treatment in patients with infected ascites. Receiver operating characteristics (ROC) curve was plotted to determine performance of ASER in identification of antibiotic resistance with calculation of area under curve (AUC) and ideal cut-off value of % change in ASER to detect antibiotic resistance. RESULTS: Treatment was associated with a significant decrease in median (min-max) ASER [from 0.005(0.0002-0.02) at baseline to 0.003(0.0001-0.01) on Day 2 and 0.0005(0.0001-0.009) on Day 5] and ascitic fluid polymorphonuclear leukocyte (PMNL) count [from 600(300-2200) at baseline to 350(50-1250) on Day 2 and 100(50-1100) on Day 5] (p<0.001 for each). ROC analysis revealed that less than 38% reduction in ASER [AUC: 0.923, 95% CI (0.797-0.982), p<0.001] was a potential marker of antibiotic resistance with a sensitivity of 90.9% and a specificity of 95.0%. CONCLUSIONS: In conclusion, our findings emphasize potential utility of gray-scale histogram based quantitative analysis of ascitic fluid echogenicity as an adjunct non-invasive method in the assessment of treatment response and early recognition of treatment failure in patients with infected ascites.

Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit.

BACKGROUND: Mortality from intra-abdominal candidiasis in intensive care units (ICUs) is high. It takes many days for peritoneal-fluid fungal culture to become positive, and the recommended empirical antifungal therapy involves excessive costs. Polymerase chain reaction (PCR) should produce results more rapidly than fungal culture. OBJECTIVES: To perform a cost-effectiveness analysis of the combination of several diagnostic and therapeutic strategies to manage Candida peritonitis in non-neutropenic adult patients in ICUs. METHODS: We constructed a decision tree model to evaluate the cost effectiveness. Cost and effectiveness were taken into account in a 1-year time horizon and from the French National Health Insurance perspective. Six strategies were compared: fluconazole or echinocandin as an empirical therapy, plus diagnosis by fungal culture or detection by PCR of all Candida species, or use of PCR to detect most fluconazole-resistant Candida species (i.e., Candida krusei and Candida glabrata). RESULTS: The use of fluconazole empirical treatment and PCR to detect all Candida species is more cost effective than using fluconazole empirical treatment without PCR (incremental cost-effectiveness ratio of €40,055/quality-adjusted life-year). Empirical treatment with echinocandin plus PCR to detect C. krusei and C. glabrata is the most effective strategy, but has an incremental cost-effectiveness ratio of €93,776/quality-adjusted life-year. If the cost of echinocandin decreases, then strategies involving PCR plus empirical echinocandin become more cost-effective. CONCLUSIONS: Detection by PCR of all Candida species and of most fluconazole-resistant Candida species could improve the cost-effectiveness of fluconazole and echinocandin given to non-neutropenic patients with suspected peritoneal candidiasis in ICUs.

Combating multidrug-resistant Gram-negative bacteria with structurally nanoengineered antimicrobial peptide polymers.

With the recent emergence of reports on resistant Gram-negative 'superbugs', infections caused by multidrug-resistant (MDR) Gram-negative bacteria have been named as one of the most urgent global health threats due to the lack of effective and biocompatible drugs. Here, we show that a class of antimicrobial agents, termed 'structurally nanoengineered antimicrobial peptide polymers' (SNAPPs) exhibit sub-µM activity against all Gram-negative bacteria tested, including ESKAPE and colistin-resistant and MDR (CMDR) pathogens, while demonstrating low toxicity. SNAPPs are highly effective in combating CMDR Acinetobacter baumannii infections in vivo, the first example of a synthetic antimicrobial polymer with CMDR Gram-negative pathogen efficacy. Furthermore, we did not observe any resistance acquisition by A. baumannii (including the CMDR strain) to SNAPPs. Comprehensive analyses using a range of microscopy and (bio)assay techniques revealed that the antimicrobial activity of SNAPPs proceeds via a multimodal mechanism of bacterial cell death by outer membrane destabilization, unregulated ion movement across the cytoplasmic membrane and induction of the apoptotic-like death pathway, possibly accounting for why we did not observe resistance to SNAPPs in CMDR bacteria. Overall, SNAPPs show great promise as low-cost and effective antimicrobial agents and may represent a weapon in combating the growing threat of MDR Gram-negative bacteria.

Assessment of aquo-ethanolic extract of Camellia sinensis against Carbapenem Resistant Escherichia coli: In Vivo Trials in a Murine Model.

The prevalence of Carbapenem Resistant Escherichia coli (CRE) has increased considerably during the last decade, which can be ascribed to relative scarcity of effective non toxic antimicrobial agents. The present study was conducted to evaluate the antimicrobial activity of aquo-ethanolic (1:1) extract of leaves of Camellia sinensis (PTRC-31911-A) against Carbapenem Resistant Escherichia coli at preclinical level using peritonitis infection model in Sprague Dawley rats. Efficacy analysis of PTRC-31911-A involved enumeration of CRE colonies in blood and urine samples of test animals for a period of 5 days from infection. A reduction in microbial count of biological fluids was considered as the primary endpoint of the selected murine model. Physical, biochemical, hematological and histological indices of toxicity were employed as secondary relative indicators of the induced disease. Physical manifestations of infected rats included significantly high body temperature (TempInfected=103.18°F, ∼5% increase) and noteworthy reduction in weight (WeightInfected=126.83g, ∼15% decrease) as compared to control. Significant (P<0.05) increase in total white blood cells, eosinophil and monocyte counts as well as a significant decrease (P<0.05) in erythrocytes count, hematocrit volume, red blood cell distribution width and hemoglobin concentration were observed in the infected group as compared to the control group. Furthermore, noteworthy increase in liver and kidney function test parameters were observed in case of infected groups. All the hematological and biochemical parameters were found to be within optimum range in case of treatment group, indicating restoration of homeostasis. Histopathological studies also presented symptoms of hemorrhage and glomerular damage with structural distortion in glomerular capillary loops of infected groups, which were later recovered in treated groups, indicating the nephro-protective potential of PTRC-31911-A. The study clearly points out that Camellia sinensis extract (PTRC-31911-A; single dose of 5mg/Kg bwt; oral,+24h) is highly effective against Carbapenem Resistant Escherichia coli owing mainly to the presence of flavonoids and polyphenolic compounds, identified by LCMS. Ongoing studies are expected to further unravel the mechanism of action and bioactivity determinants of this broad spectrum plant extract.

Antibacterial gauzes are effective in preventing infections after percutaneous endoscopic gastrostomy placement: a retrospective analysis.

OBJECTIVES: The most common complication after percutaneous endoscopic gastrostomy (PEG) placement is peristomal wound infection (up to 40% without antibiotic prophylaxis). Single-dose parenteral prophylactic antibiotics as advised by current guidelines decrease the infection rate to 9-15%. We assume a prolonged effect of local antibiotic treatment with antibacterial gauzes. This study is the first to describe the effect of antibacterial gauzes in preventing infections in PEG without the use of antibiotics. METHODS: A retrospective data analysis was carried out of all patients with PEG insertion between January 2009 and October 2014 in the Catharina Hospital Eindhoven. Data include placement and the period of the first 2 weeks after PEG placement, and long-term follow-up. All patients received a locally applied antibacterial gauze polyhexamethylene biguanide immediately following PEG insertion for 3 days. No other antibiotics were administered. The main outcomes were wound infection, peritonitis, and necrotizing fasciitis; secondary outcomes included other complications. RESULTS: A total of 331 patients with only antibacterial gauzes were analyzed. The total number of infections 2 weeks after PEG insertion was 9.4%, including 8.2% minor and 1.2% major infections (peritonitis). No wound infection-related mortality or bacterial resistance was found. Costs are five times lower than antibiotics, and gauzes are more practical and patient friendly for use. CONCLUSION: Retrospectively, antibacterial gauzes are at least comparable with literature data on parenteral antibiotics in preventing peristomal wound infection after PEG placement, with an infection rate of 9.4%. Rates of other complications found in this study were comparable with current literature data.

Plasma and peritoneal fluid population pharmacokinetics of micafungin in post-surgical patients with severe peritonitis.

OBJECTIVES: Limited information about the pharmacokinetics of micafungin in the peritoneal cavity is available. The aim of this study was to explore the pharmacokinetics/pharmacodynamics of micafungin in plasma and peritoneal fluid in post-surgical critically ill patients with proven or suspected intra-abdominal fungal infection. METHODS: Patients were administered 100 mg/day micafungin. Serial blood and peritoneal fluid samples were collected on day 1 and day 3 (steady-state) of treatment. Concentrations were determined by validated chromatography and were subject to a population pharmacokinetic analysis with Pmetrics(®). Monte Carlo simulations were performed for AUC0-24/MIC ratios in plasma. The PTA was calculated using AUC0-24/MIC cut-offs: 285 for Candida parapsilosis and 3000 for non-parapsilosis Candida spp. RESULTS: Ten patients were included; six were male. The median (range) age, APACHE II score and Mannheim peritonitis index were 72 (43-85) years, 15 (11-36) and 26 (8-37), respectively. On day 1, median (SD) penetration of micafungin into the peritoneal cavity was 30% (30%-40%). A three-compartment model adequately described the data. The mean (SD) estimates for clearance and volume of distribution of the central compartment were 1.27 (0.75) L/h and 9.26 (1.11) L, respectively. In most patients, the PTA in plasma was ≥ 90% for MICs of 0.008-0.016 mg/L for Candida spp. and 0.125-0.25 mg/L for C. parapsilosis. CONCLUSIONS: After the first dose, micafungin at 100 mg/day achieves pharmacokinetic/pharmacodynamic targets in plasma for Candida spp. and C. parapsilosis MICs of 0.008-0.016 and 0.125-0.25 mg/L, respectively.

Percutaneous versus surgical insertion of PD catheters in dialysis patients: a meta-analysis.

PURPOSE: Several small studies have suggested that the percutaneous method of peritoneal dialysis (PD) catheter insertion is effective and has a lower complication rate than surgical techniques (open, laparoscopic or peritoneoscopic), although no randomized, controlled study has compared these methods. Our objective was to compare percutaneous PD catheter insertion vs surgical placement in terms of 1-year catheter survival, catheter dysfunction, fluid leak and incidence of peritonitis. METHODS: We searched Medline for English-language literature from 1966 through June 2014, along with national conference proceedings and reference lists of all included publications to identify relevant studies. Inclusion criteria were having a measure of catheter survival at 1 year, catheter dysfunction, peritonitis rate per patient-month or fluid leak as outcomes. Studies were excluded if they were not in English or if they included pediatric patients. Random effects models were used to derive the pooled risk ratios, differences in patency and their variations. RESULTS: Thirteen studies with a total of 2,681 subjects met the inclusion criteria. There was no significant difference in 1-year catheter survival in percutaneous vs surgical PD catheter placement (relative risk [RR] = 0.81; 95% confidence interval [CI]: 0.59-1.11, p = 0.19). Catheter dysfunction also did not differ significantly between the groups (pooled odds ratio [OR] = 0.86; 95% CI: 0.57-1.29, p = 0.46). The prevalence of peritoneal fluid leak also was similar for percutaneous and surgical groups (OR = 1.10; 95% CI: 0.58-2.09, p = 0.77). However, there was a significant lower incidence of peritonitis among those with percutaneous placement (incidence rate ratio [IRR] = 0.77; 95% CI: 0.62-0.96, p = 0.02). Significant heterogeneity was detected across studies (I2 = 78.4%, p<0.0001). CONCLUSIONS: Our results suggest that there is no significant difference in catheter survival between percutaneous and surgical placement of PD catheters. Whether there are significant benefits from percutaneous placement in terms of peritonitis rates requires further robust studies. These findings have significant implications for future design of clinical trials in the placement of PD catheters and the delivery of dialysis-related services.

The incidence and economic impact of the Escherichia coli peritonitis syndrome in Dutch poultry farming.

The incidence and economic impact of the Escherichia coli peritonitis syndrome (EPS), characterized by acute mortality, were estimated in chicken egg-producing farms in the Netherlands in 2013. The incidence was significantly higher (P < 0.05) in the meat-sector (35% affected farms) compared to the layer-sector (7% affected farms). In consumption egg-producing farms EPS occurred on 12% of the free range and organic farms, while it was found on 1% and 4% of the cage and barn farms, respectively. Data from four layer and two broiler breeder flocks with EPS were used to estimate the overall economic impact of the disease. Mean numbers of eggs lost were 10 and 11 per hen housed (phh), while mean slaughter weight loss was 0.2 and 0.5 kg phh in the four layer and two broiler breeder flocks, respectively. Total losses including costs of destruction of dead hens, compensated for reduced feed intake due to a smaller flock size, ranged from €0.28 phh (cage farms) to €9.75 phh (grandparent farms) in the layer-sector and from €1.87 phh (parent farms) to €10.73 phh (grandparent farms) in the meat-sector. Antibiotics against EPS were given often and repeatedly especially in the meat-sector. Including the costs of antibiotics, total losses were estimated at €0.4 million, €3.3 million and €3.7 million for the layer-sector, the meat-sector and poultry farming as a whole, respectively. Research focusing on the prevention and treatment of EPS is justified by its severe clinical and economic impact.

[Assessment of the fulfillment of paracentesis in cirrotic patients admited in two services of internal medicine in hospitals of median complexity]. / Evaluación de la realización de paracentesis en pacientes cirróticos ingresados a dos servicios de medicina interna de hospitales mediana complejidad.

UNLABELLED: The Spontaneous Bacterial Peritonitis (SBP) is a severe complication of cirrhosis. The prognosis depends on the time of initiation of therapy that is required for early diagnosis. OBJECTIVE: To evaluate the performance of diagnostic paracentesis (DP) in cirrhotic patients with ascites during hospitalization. MATERIALS AND METHODS: An observational, analytical, prospective, study conducted during October 2009 to June 2010. RESULTS: There were 92 income, average age was 60.3 years (SD 11.7), corresponding to 57.6% men, the most common etiology of CH was alcohol (48.9%). There were 40 PD (43.5%), of which 35% positive SBP. Of the DP, 47.5% were performed on admission and / or submission of warning signs. The average period of hospitalization was higher in those who underwent late DP. The MELD score both at admission and discharge was significantlyhigher in patients on admission punctured. CONCLUSION: DP was done in less than half of hospitalized cirrhotic, and its timely completion only 1 in 5 of revenues. The DP perform at the right time reduces hospital days.

Evaluación de la realización de paracentesis en pacientes cirróticos ingresados a dos servicios de medicina interna de hospitales mediana complejidad / Assessment of the fulfillment of paracentesis in cirrotic patients admited in two services of internal medicine in hospitals of median complexity

La peritonitis bacteriana espontánea (PBE) es una complicación severa de la cirrosis hepática (CH). Su pronóstico depende del momento de inicio de la terapia para lo que se requiere un diagnóstico oportuno. Objetivo: Evaluar la realización de paracentesis diagnóstica (PD) en cirróticos con ascitis durante su hospitalización. Materiales y métodos: Estudio observacional, analítico y prospectivo, realizado en un período de 11 meses consecutivos. Resultados: Se registraron 92 ingresos, el promedio de edad fue de 60,3 años (DE 11,7), correspondiendo un 57,6% a hombres, la etiología de CH más frecuente fue alcohólica (48,9%). Se realizaron 40 PD (43,5%), de ellas 35% con PBE positiva. Del total de PD, un 47,5% se efectuaron al ingreso y/o al presentar signos de alarma. El promedio de días de hospitalización fue mayor en aquellos en que se realizó la PD tardíamente. El MELD (Model for the End stage Liver Disease) tanto al ingreso como egreso es significativamente mayor en los pacientes puncionados al ingreso. Conclusión: Se realiza PD en menos de la mitad de los cirróticos hospitalizados, siendo su realización oportuna solo en 1 de cada 5 de los ingresos. El realizar PD en el momento adecuado disminuye los días de hospitalización y morbimortalidad.

The Spontaneous Bacterial Peritonitis (SBP) is a severe complication of cirrhosis. The prognosis depends on the time of initiation of therapy that is required for early diagnosis. Objective: To evaluate the performance of diagnostic paracentesis (DP) in cirrhotic patients with ascites during hospitalization. Materials and methods: An observational, analytical, prospective, study conducted during October 2009 to June 2010. Results: There were 92 income, average age was 60.3 years (SD 11.7), corresponding to 57.6% men, the most common etiology of CH was alcohol (48.9%). There were 40 PD (43.5%), of which 35% positive SBP. Of the DP, 47.5% were performed on admission and / or submission of warning signs. The average period of hospitalization was higher in those who underwent late DP. The MELD score both at admission and discharge was significantly higher in patients on admission punctured. Conclusion: DP was done in less than half of hospitalized cirrhotic, and its timely completion only 1 in 5 of revenues. The DP perform at the right time reduces hospital days.

Reevaluation of ceftazidime dosing recommendations in patients on continuous ambulatory peritoneal dialysis.

While intraperitoneal (i.p.) ceftazidime is commonly used to treat continuous ambulatory peritoneal dialysis (CAPD)-related infections, the ability of i.p. regimens to achieve critical pharmacodynamic targets in both blood and dialysate has not been reported. To understand the pharmacodynamic profile of ceftazidime during CAPD, data were obtained from a single-dose pharmacokinetic (PK) i.p. ceftazidime study that included 10 CAPD patients who received i.p. ceftazidime at 15 mg/kg of body weight. The probability of target attainment (concentrations maintained above the MIC for >60% of the dosing interval [60% T > MIC]) was determined for six simulated regimens. A 3-compartment model with each dialysis dwell modeled as a separate differential equation was fit to ceftazidime concentrations using BigNPAG. Embedded with the final PK model, serum and dialysate concentration-time profiles of ceftazidime at 1, 1.5, and 2 g i.p. every 24 h (q24h) to q48h were simulated using ADAPT 5. The mean population pharmacokinetic parameters were as follows: apparent volume of the central compartment (Vc), 7.57 liter; apparent volume of the peritoneal cavity (Vpd), 2.44 liter; clearance from the central compartment (CL), 0.379 liter/h; intercompartmental transfer rate constants (first order) between the central and peripheral compartments (k12 and k21), 4.66 and 4.88 h(-1), respectively; and intercompartmental transfer rate constants (first order) between the central and peritoneal compartments (k13 and k31), 0.111 and 0.227 h(-1), respectively. In serum, the probability of target attainment for MICs of ≤8 mg/liter exceeded 90% for 1.5 to 2 g i.p. q24h to q48h. However, no tested regimen provided adequate dialysate exposure at MICs of ≥8 mg/liter on day 1 without the use of a 3-g loading dose (post hoc analysis). On day 2, 1.5 to 2 g i.p. q24h or 2 g i.p. q48h provided adequate exposure in the peritoneal cavity. These results should be validated in the presence of infection. Ceftazidime i.p. at 1.5 or 2 g q24h to q48h is recommended for nonperitoneal infections. For peritonitis, a 3-g load with maintenance dosing of 1 to 2 g i.p. q24h or 2 g i.p. q48h is recommended.

Assessment of the efficacy of polyclonal intravenous immunoglobulin G (IVIG) against the infectivity of clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) in vitro and in vivo.

The response to treatment of severe methicillin-resistant Staphylococcus aureus (MRSA) infections with the traditional antibiotics is sometimes unsatisfactory and multiple antibiotic resistance is common. Adjuvant therapy such as intravenous immunoglobulin G (IVIG) could possibly be helpful in the treatment of such infections. The effect of IVIG on the capacity of human neutrophils to phagocytose and kill MRSA was investigated in vitro using the MTT assay and measuring the production of reactive oxygen species (ROS) and nitric oxide (NO). The efficiency of IVIG in neutralizing α-hemolysin and coagulase of MRSA was also assessed. The capability of IVIG in the treatment and prevention of MRSA infections was also evaluated in a murine peritonitis model. IVIG significantly enhanced (p < 0.01) the killing of MRSA by neutrophils at all concentrations tested (0.1-5 mg/ml) by 30-80 % of control values. It significantly (p < 0.01) increased the level of NO production in a dose-dependent manner, giving up to 60 µM at 5 mg/ml. The ROS level significantly increased (p < 0.01) in the presence of IVIG. In addition, IVIG significantly reduced the hemolytic activity of MRSA 10-fold and its coagulation capabilities by 50 %. When tested in vivo, groups receiving IVIG via tail vein infusion showed no significant improvement in their survival. Only when delivered to the same site of infection did IVIG show an improvement in the survival of mice (n = 80). These results could pave the way for a better understanding of the mechanism of action of IVIG and suggest its clinical potential as an adjuvant preventive and therapeutic agent against life-threatening infections caused by MRSA and other bacteria.

Prevalence and factors affecting peritonitis in CAPD patients in Maharat Nakhon Ratchasima Hospital under universal coverage scheme during 2008-2010: a three-year experience.

OBJECTIVE: Since 2008, the Thai government has subsidized the package to cover chronic ambulatory peritoneal dialysis (CAPD) for end stage renal disease (ESRD) patients under the universal coverage scheme (UCS) in Thailand. The aim of the program is to keep longer life in poor people instead of death due to inaccessibility to renal replacement therapy as usual. The present study was conducted to evaluate the prevalence and factors affecting peritonitis in patients with CAPD therapy under the UCS at Renal unit, Maharat Nakhon Ratchasima Hospital, during January 1, 2008-December 31, 2010. MATERIAL AND METHOD: Medical records of ESRD patients undergoing CAPD under UCS at Maharat Nakhon Ratchasima Hospital during January 1, 2008-December 31, 2010 were reviewed. The collected data included demographic details, underlying diseases, body mass index (BMI), laboratory findings, peritonitis rate, and outcome of therapy at December 31, 2010. RESULTS: There were 318 ESRD patients with the mean age of 49.9 +/- 14.3 years and mean BMI of 23.1 +/- 3.9 kg/m2. The common causes of ESRD were hypertension (60.1%) and diabetes mellitus (34.9%). In the follow-up period, 318 patients received the treatment over a total observation period of 3,262.2 patient-months. The patient survival was 51.0% at 3 years. Most of the patients (74.8%) had no peritonitis. There were 128 peritonitis episodes. The mean duration from starting CAPD to the first episode of peritonitis was 25.5 patient-months per episode. Staphylococcus spp. was the most common organism causing peritonitis which is the major cause of technical failure. The factors affecting peritonitis is included age > 60 years, hypokalemia (< 3.5 mEq/L), and hypoalbuminemia (< 3.5 g/dl). CONCLUSION: To improve clinical outcome of CAPD patients by decreasing the peritonitis rate, the factors affecting peritonitis should be corrected. The patients and care-givers should also be educated about the importance of hygiene and exchanging methods to decrease the peritonitis rate in CAPD patients.

Chronic kidney disease-epidemiology formula and model for end-stage liver disease score in the assessment of renal function in candidates for liver transplantation.

Assessment of renal function in patients with end-stage liver disease (ESLD) awaiting liver transplantation (OLT) is critical. Various conditions may cause renal damage in ESLD. Renal and liver functions are intertwined due to splanchnic hemodynamic relationships; renal failure rarely occurs in patients without advanced decompensated cirrhosis. The recent literature suggests that evaluation of renal function should include an assessment of liver function. The aim of this study was to evaluate different methods to estimate glomerular filtration rate (GFR) in patient among ESLD candidates for OLT over 1 year. We also correlated renal and hepatic functions. Fifty-two cirrhotic patients Model for End-Stage Liver Disease [MELD] > 10) were enrolled in the study. All patients were evaluated at baseline and every 4 months (T1-T4) thereafter for 1 year. The GFR was calculated by creatinine clearance, and estimated by Cockroft and Gault, Modified Diet Renal Disease (MDRD) 4 and 6 variable and Chronic Kidney Disease-Epidemiology (CKD-EPI) formulae. Hepatic functions were evaluated by MELD score, albumin, bilirubin, and International Normalized Ratio (INR). We observed not statistically significant increase mean value of MELD score, bilirubin, serum creatinine, and blood urea nitrogen and a reduced serum sodium. There were no significant differences among various methods to evaluate GFR at each time over 1 year. We did not observe any association between renal and hepatic function, except at T4 for MELD and GFR estimated with MDRD 4 (P = .009) and 6 (P = .008) parameters or CKD-EPI (P = .036), and MELD and sodium (P = .001). Our results showed that evaluation of renal function in cirrhosis should include an evaluation of hepatic function. In our case, MDRD and CKD-EPI seemed to be the more accurate formulae to evaluate renal function in relation to hepatic function.

[Possibilities of combined and isolated application of carbapenems in patients with secondary widespread peritonitis].

The expediency of meronem (Ronem) application for empiric (beginning) therapy in patients, suffering secondary extended peritonitis were analized.