Morbimortality study of infection in patients undergoing different types of dialysis in a renal replacement therapy center

INTRODUCTION: Renal replacement therapy is the treatment of end-stage chronic kidney disease and can be performed through dialysis catheters, arteriovenous fistulas/grafts, and peritoneal dialysis. Patients are usually immunocompromised and exposed to invasive procedures, leading to high rates of infection and increased mortality. OBJECTIVES: To compare the prevalence of infection and related deaths, as well as the sensitivity profile of the putative bacteria in patients treated with peritoneal dialysis, arteriovenous fistula hemodialysis and catheter hemodialysis. METHODS: This is case-control study. Six hundred forty-four patients undergoing renal replacement therapy were selected. Patients were divided into three groups according to the modality of dialysis treatment: peritoneal dialysis (126 patients), arteriovenous fistula hemodialysis (326 patients), and catheter hemodialysis (192 patients). RESULTS: One hundred sixteen patients (18.01%) developed infection. There was a higher incidence of infection in the peritoneal dialysis group (44 patients; 34.92%; OR: 3.32; CI 95% = 2.13-5.17; p = 0.0001). In the catheter hemodialysis group, 48 patients (25%) had infection (OR: 1.88; CI 95%: 1.24-2.85; p = 0.0035). In the arteriovenous fistula hemodialysis group, 24 patients (7.36%) developed infection (OR: 0.19; CI 95%: 0.12-0.31; p = 0.0001). Five patients (4.31%) died due to infection (four in the peritoneal dialysis group and one in the catheter hemodialysis group). There were no deaths due to infection in the arteriovenous fistula hemodialysis group. CONCLUSIONS: Peritoneal dialysis is the treatment with greater risk of infection and mortality, followed by catheter hemodialysis. The lowest risk of infection and mortality was observed in arteriovenous fistula hemodialysis group. .

Association of late-onset neonatal sepsis with late neurodevelopment in the first two years of life of preterm infants with very low birth weight / Associação de sepse neonatal tardia com atraso do neurodesenvolvimento nos primeiros dois anos de vida de recém-nascidos pré-termos de muito baixo peso

OBJECTIVE: To establish the influence of late-onset sepsis on neurodevelopment of preterm infants with very low birth weight (VLBW), according to the etiologic agent METHOD: This was a cohort of newborns with birth weight < 1,500 g and gestational age less than 32 weeks, admitted to the institutional intensive care unit (ICU) with up to 48 hours of life, and followed-up at the outpatient follow-up clinic for preterm infants with VLBW until 2 years of corrected age. Exclusion criteria: death within the first 72 hours of life, congenital malformations and genetic syndromes, children with congenital infection by the human immunodeficiency virus (HIV), congenital infection (STORCH), presence of early-onset spesis and cases with more than one pathogen growth in blood cultures. Septic and non-septic infants were compared regarding neonatal outcomes and mortality. Neurodevelopment was assessed using the Bayley Scale (BSDI-II) at 18 to 24 months of corrected age. RESULTS: 411 preterm infants with VLBW were eligible; the mean gestational age was 29 ± 2.2 weeks and mean birth weight was 1,041 ± 281grams. Late-onset sepsis occurred in 94 preterm infants with VLBW (22.8%). VLBW infants with Gram-positive infection showed motor deficit when compared to the non-septic group, 68.8% vs. 29.3%, respectively (OR 6; 1.6-21.8, p = 0.006); the cognitive development was similar between the groups. The overall mortality rate from infection was 26.7%; considering the pathogens, the rates were 18.7% for coagulase-negative Staphylococcus, 21.8% for Gram-positive bacteria, and 50% for Gram-negative bacteria and fungi. CONCLUSION: Neonatal sepsis has a significant influence on late neurodevelopment at 2 years of corrected age in preterm infants with VLBW, and Gram-positive infections are associated with motor deficit. .

OBJETIVO: Estabelecer a influência da sepse tardia no neurodesenvolvimento de prematuros de muito baixo peso (MBP) recém-nascidos (RNs) de acordo com o agente etiológico. MÉTODOS: Coorte de RN com peso de nascimento < 1.500 g e idade gestacional < 32 semanas,internados na UTI da instituição dentro de 48 horas de vida, e atendidos no ambulatório de MBP para até dois anos de idade corrigida. Foram excluídos: a morte nas primeiras 72 h de vida, malformações congênitas e síndromes genéticas, filhos de mães HIV-positivas e infecção congênita, presença de sepse precoce, e os casos com mais de um microorganismo identificado em hemoculturas. RNs sépticos e não sépticos foram comparados quanto resultados neonatais, mortalidade e neurodesenvolvimento avaliados através das escalas Bayley (BSDI-II) aos 18-24 meses de idade corrigida. RESULTADOS: Um total de 411 RNs prematuros de muito baixo peso eram elegíveis, com idade gestacional = 29 ± 2,2 semanas e peso de nascimento = 1.041 ± 281 g. Sepse tardia ocorreu em 94 casos (22,8%). MBP RN com infecção causada por microrganismos Gram-positivos apresentaram atraso motor, quando comparado com o grupo sem sépsis - 68,8% vs 29,3% (OR 6; 1,6-21,8,p = 0,006), e atraso cognitivo, foi semelhante. Taxa de mortalidade global de infecção foi de 26,7%, e as taxas de mortalidade por grupo microorganismo foram: Staphylococcus coagulase negativa, 18,7%; Gram-positivos, 21,8%; Gram-negativas e fungos, 50%. CONCLUSÃO: A sepse neonatal tem uma influência significativa no atraso no desenvolvi mento neuropsicomotor aos dois anos de idade corrigida em prematuros de muito baixo peso RN e as infecções por germes gram-positivos estão associadas com atraso motor. .

Colangitis bacteriémica en adultos en un hospital general en Chile / Bacteremic colangitis in adults in a general hospital in Chile

Background: Some aspects of bacteremic cholangitis are unknown in Chile. Aim: To gather more information on clinical, microbiological aspects as well as risk factors for ICU admission, recurrence and antimicrobial resistance. Material and Methods: A retrospective research was performed using medical records of adult patients in a general hospital. Results: Between 2006-2012, 22 patients with 29 bacteremic events were identified. Previous cholangitis events were reported by 27.3%, 45.5% had recent admissions and, 50% had used antimicrobial compounds. Coledocholithiasis was the most common cause of obstruction (45.5%) followed by cancer (36.4%). One third developed shock (31%), the only factor associated with ICU admission (OR 30, p < 0.05). In 24 of the 29 bacteremic events, the biliary tract was intervened (82.8%) and in 80.8% during the first 72 hours. Gram negative bacilli were predominant (> 80%) and some infrequent agents such as Staphylococcus warneri, Shewanella spp. and, Aeromonas spp. were observed. Among enteric gram negative bacilli, 29.2% presented fluoroquinolone resistance and, 26.1% resistance to third generation cephalosporins, both associated with previous endoscopic retrograde cholangiography (OR 35 and 16.5, respectively p < 0.05). A favorable response was observed in 93.1% of bacte-remic events but in 31.8% of patients cholangitis recurred with or without bacteremia. Recurrence was associated to recent admission (OR 16.5, p = 0.01) and in all cases occurred before 81 days. In-hospital mortality was 9.1% (n = 2), but in only one case associated to sepsis. Average length of stay (LOS) was 17.8 days. Conclusions: Early intervention of the biliary tract allows a favorable response in patients affected by bacteremic cholangitis, but this condition use intensive care resources, had a prolonged LOS, a recurrent pattern, and is associated with several bacterial species, some of them resistant.

Introducción: La información sobre los cuadros de colangitis aguda bacteriémica es fragmentaria en Chile. Objetivo: Analizar las características clínicas, evolución, microbiología y factores de riesgo asociados a ingreso a UCI, recurrencia y resistencia antimicrobiana. Pacientes y Métodos: Estudio retrospectivo descriptivo con adultos atendidos entre el 2006 y el 2012 en un hospital general. Resultados: Se identificaron 22 pacientes con 29 episodios de bacteriemia. Un 27,3% tenía historia previa de colangitis aguda, 45,5% de hospitalizaciones en los últimos tres meses y 50% recibió previamente antimicrobianos. La coledocolitiasis fue la causa más frecuente de obstrucción (45,5%) y las neoplasias ocuparon el segundo lugar (36,4%). El 31% desarrolló shock hemodinámico y fue el factor determinante para ingresar a la UCI (OR 30, p < 0,01) En 24 de los 29 eventos de colangitis bacteriémica se efectuaron intervenciones sobre la vía biliar (VB) o complicaciones asociadas (82,8%), las que se realizaron predominantemente en las primeras 72 h de hospitalización (80,8%). Las especies bacterianas mayoritarias fueron bacilos gramnegativos entéricos o no fermentadores (> 80% del total) y se observaron agentes inusuales como Staphylococcus warneri, Shewanella spp y Aeromonas spp. Entre los bacilos gramnegativos entéricos, 29,2% presentó resistencia a fluoroquinolonas y 26,1 % a cefalosporinas de tercera generación, fenómenos asociados al antecedente de colangiografía endoscópica retrógrada (OR 35 y 16,5 respectivamente, p < 0,05). El 93,1% de los eventos de bacteriemia tuvo una respuesta favorable pero 31,8% de los pacientes presentó recu-rrencia de colangitis, con o sin bacteriemia, un hecho asociado a hospitalización reciente (OR 16,5, p = 0,01) y que se dio en todos los casos antes de 81 días. Dos pacientes con cáncer fallecieron en la misma hospitalización (9,1%), aunque uno solo de ellos en forma atribuible a la infección. La estadía hospitalaria promedio fue de 17,8 días. Conclusiones: Con la intervención precoz sobre la VB, los cuadros de colangitis bacteriémica han logrado una baja letalidad pero usan recursos intensivos, tienen una estadía prolongada, un patrón recurrente, pueden estar asociados a cáncer y a una diversidad de agentes bacterianos, algunos de ellos resistentes.

Fatal meningitis caused by vancomycin-resistant enterococci: Report of two cases from south India.

Vancomycin-resistant enterococci rarely cause meningitis and present a therapeutic challenge. Antimicrobial susceptibility testing was done for strains of Enterococcus species isolated from CSF samples of patients with meningitis by phenotypic methods. Multiplex polymerase chain reaction was performed to determine the genetic basis of vancomycin resistance of such isolates. We report here two cases of enterococcal meningitis caused by vancomycin-resistant Enterococcus species. One of the isolates was identified as Enterococcus faecalis and the other as Enterococcus gallinarum. We also report the simultaneous presence of vanC1 and vanA resistance genes in the strain of E. gallinarum. To the best of our knowledge, this is the first report of vanA resistance gene in an isolate of E. gallinarum from the Indian subcontinent. This is also the first Indian report of vancomycin-resistant Enterococcus causing meningitis.

Endocarditis infecciosa activa: 152 casos / Active infective endocarditis: 152 cases

La endocarditis infecciosa es una enfermedad de baja incidencia que en las últimas décadas mostró modificaciones respecto de su presentación, posibilidad diagnóstica y tratamiento. A pesar de estos avances, la mortalidad hospitalaria sigue siendo muy elevada. Nuestro objetivo fue analizar las características de los pacientes con endocarditis infecciosa activa y su relación con la mortalidad hospitalaria a lo largo de 16 años. Se realizó un registro prospectivo entre 1994 y 2010 de pacientes ingresados con endocarditis. Se analizaron características clínicas, evolución y tratamiento y se registraron los eventos intrahospitalarios. Ingresaron 152 pacientes, 64.5% varones, edad 45 ± 16 años, las causas más frecuentes de cardiopatía de base fueron: congénita 32 (21%) y reumática 20 (13.2%). Los motivos de internación fueron síndrome febril 116 (76.3%) e insuficiencia cardíaca 61 (40.1%). Se identificó el agente infeccioso en 106 (69.7%) de los casos, el más frecuente fue Streptococcus viridans. El ecocardiograma mostró vegetaciones en 123 (80.9%) de los pacientes y 88 (57.8%) presentaron complicaciones durante su internación, siendo la más frecuente la insuficiencia cardíaca. Se indicó tratamiento quirúrgico en 96 (63.1%) de los casos, fundamentalmente por insuficiencia cardíaca en 66. La mortalidad hospitalaria global fue 46 (30.2%). El desarrollo de complicaciones en la internación, la indicación de cirugía y la presencia de insuficiencia cardíaca refractaria al tratamiento fueron predictores independientes de mortalidad hospitalaria, mientras que la presencia de vegetaciones resultó un predictor independiente de mejor supervivencia. La identificación temprana de estos predictores descriptos podría ayudar a mejorar los resultados.

Active infective endocarditis (IE) is a disease of low incidence that has showed changes in presentation, diagnosis and treatment options during the past decades. Despite these advances, mortality remains very high. Our goal was to analyze the characteristics of patients with active IE and their relationship with in-hospital mortality over 16 years. Between 1994 and 2010 we performed a prospective registry of 152 consecutive patients (64.5% male, age 45 ± 16 years) admitted with IE. Clinical characteristics, treatment and inpatient outcomes were analyzed. The most common causes of underlying heart disease were: congenital (21%) and rheumatic fever (13.2%). The reasons for hospitalization were fever (76.3%) and heart failure (40.1%). The infectious agent was identified in 69.7% of cases, and the most frequent was Streptococcus viridans. The echocardiogram showed vegetations in 80.9% of patients and 57.8% of them presented complications (the most frequent was heart failure) during hospitalization. Surgical treatment was indicated in 63.2% of cases, mainly due to heart failure. The overall hospital mortality was 30.2%. The presence of complications, requirement of surgical treatment and refractory heart failure were independent predictors of mortality whereas the single presence of vegetation showed better survival rate. The identification of these predictors could help to improve the outcomes in IE.

Bacteriemia en daño hepático crónico / Bacteremia in patients with liver cirrhosis

Las infecciones bacteriémicas son más frecuentes en el paciente cirrótico que en la población general. Se identificaron retrospectivamente 59 pacientes cirróticos con bacteriemia, hospitalizados entre los años 2005 y 2008. La bacteriemia sin foco fue la más frecuente (29 por ciento), seguida de aquellas de origen pulmonar (22 por ciento). Cincuenta y dos por ciento de los agentes aislados correspondieron a cocáceas grampositivas y 48 por ciento a bacilos gramnegativos, siendo estos últimos los agentes predominantes en las bacteriemias nosocomiales. Los principales agentes aislados fueron Staphylococcns aureus (24 por ciento) y Escherichia col i (22 por ciento). La mortalidad de los pacientes cirróticos bacteriémicos fue mayor que la del total de cirróticos hospitalizados (37 vs 9,4 por ciento; p < 0,001) y la medición del puntaje de MELD a las 72 horas se correlacionó significativamente con la mortalidad. Conclusión: La bacteriemia es una complicación grave del paciente cirrótico y el MELD podría ser útil en su categorización de riesgo.

Bacteremic infections are more frequent in patients with cirrhosis, as their immune system is compromised. Series of cirrhotic patients with bacteremia has seldom been reported in Chile. We retrospectively collected, from 2005 to 2008, 59 episodes of bacteremia in cirrhotics representing 9 percent of the overall number of bacteremic episodes seen in our center in the period. Spontaneous bacteremia accounted for 29 percent followed by those of pulmonary origin (22 percent). Grampositive cocci and gramnegative bacilli were responsible in 52 percent and 48 percent respectively, however gramnegative rods predominated in nosocomial bacteremias. Overall, the most frequent organisms were Staphylococcus aureus (24 percent) and Escherichia col i (22 percent). Mortality in bacteremic patients was significantly higher compared with all cirrhotic patients hospitalized in the period (37.0 vs 9.4 percent; p < 0.001) and MELD score was significantly correlated with mortality. Conclusion: bacteremia is a severe complication of cirrhosis and MELD score could be a useful tool to stratify risk in these patients.

Neonatal meningitis according to the microbiological diagnosis: a decade of experience in a tertiary center / Meningite neonatal de acordo com diagnóstico microbiológico: uma década de experiência em centro terciário

The aim of this study was to evaluate the incidence of and mortality due to meningitis and compare data according to microbiological diagnosis. This was a ten-year retrospective study conducted at a neonatal intensive care unit (NICU). Newborns with meningitis confirmed by positive CSF culture were included; those with congenital infection or malformations that made lumbar puncture impossible were excluded. The variables investigated were birth weight, gestational and postnatal age, procedures, hematological and CSF parameters, and complications. Parametric and non-parametric tests were used (statistical value p<0.05). The incidence of meningitis was 0.6 percent and mortality was 27 percent. Of the 22 cases, 59 percent involved Gram-negative bacteria; 36 percent Gram-positive and 5 percent fungi. The groups did not differ in relation to birth weight, gestational and postnatal age, procedures or hematological and CSF parameters. Sepsis, convulsions and deaths were frequent in both groups, without statistical difference. Gram-negative cases showed abscesses and higher frequency of ventriculitis and hydrocephaly. Meningitis was infrequent, but presented high mortality and frequent complications.

O objetivo do estudo foi avaliar incidência e mortalidade da meningite e comparar dados de acordo com o diagnóstico microbiológico. Estudo retrospectivo, de 10 anos, em UTI Neonatal. Incluídos RNs com meningite confirmada por cultura de líquor positiva; RN com infecção congênita ou malformações que impedem punção lombar foram excluídos. Variáveis: peso ao nascimento, idades gestacional e pós natal, procedimentos, parâmetros hematológicos e liquóricos, complicações. Testes paramétricos e não paramétricos foram utilizados (valor estatístico p<0,05). A incidência de meningite foi de 0,6 por cento e mortalidade de 27 por cento. Dos 22 casos, 59 por cento foram por bactérias Gram-negativas; 36 por cento por bactérias Gram-positivas e 5 por cento por fungos. Grupos não diferiram quanto ao peso ao nascimento, idades gestacional e pós-natal, procedimentos e por parâmetros hematológicos e liquóricos. Sepse, convulsões e óbitos foram frequentes e não diferiram entre os grupos. Gram-negativos causaram abscessos e mais frequentemente ventriculite e hidrocefalia. Meningite não foi freqüente, mas apresentou alta mortalidade e complicações.

Clinical, epidemiological, and microbiological characteristics of bacteremia caused by high-level gentamicin-resistant Enterococcus faecalis

Enterococcus spp bacteremia is associated with high mortality and the appearance of high-level gentamicin resistance (HLGR) created additional challenges for the treatment of these infections. We evaluated the epidemiological and clinical characteristics of patients with bacteremias caused by HLGR and non_HLGR Enterococcus faecalis isolates at a teaching hospital in the State of São Paulo, Brazil. Patients with bacteremia due to E. faecalis diagnosed between January 1999 and December 2003 were included in the study. We collected clinical, epidemiological, and microbiological data from medical records. Banked isolates were typed using pulsed-field gel electrophoresis. We identified 145 cases of E. faecalis bacteremia: 66 (45.5 percent) were caused by HLGR isolates and 79 (54.5 percent) by non_HLGR. In the univariate analysis, patients with HLGR infection were older, had higher rates of bladder catheterization, and more often had treatment with cephalosporin, quinolone, and/or carbapenem compared with patients with non_HLGR infection (P < 0.05). Multivariate analysis indicated that older age, hematological malignancy, and previous use of vancomycin were independently associated with HLGR (P < 0.05). Mortality rates were not significantly different among patients with HLGR (50 percent) and non_HLGR (43 percent) infections (P = 0.40). Of the 32 genotyped isolates, 16 were distributed into 6 main electrophoresis patterns and 16 others had distinct patterns. E. faecalis bacteremia is associated with high mortality and is frequently caused by HLGR isolates at this teaching hospital. The variability among genotyped isolates suggests that endogenous infections, rather than patient-to-patient transmission of E. faecalis, are more common at this institution.