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(1) Background: Infections are among the most frequent and life-threatening complications of cardiovascular implantable electronic device (CIED) implantation. The aim of this study is to compare the outcome and safety of a single-procedure device extraction and contralateral implantation versus the standard-of-care (SoC) two-stage replacement for infected CIEDs. (2) Methods: We retrospectively included 66 patients with CIED infections who were treated at two Italian hospitals. Of the 66 patients enrolled in the study, 27 underwent a single procedure, whereas 39 received SoC treatment. All patients were followed up for 12 months after the procedure. (3) Results: Considering those lost to follow-up, there were no differences in the mortality rates between the two cohorts, with survival rates of 81.5% in the single-procedure group and 84.6% in the SoC group (p = 0.075). (4) Conclusions: Single-procedure reimplantation associated with an active antibiofilm therapy may be a feasible and effective therapeutic option in CIED-dependent and frail patients. Further studies are warranted to define the best treatment regimen and strategies to select patients suitable for the single-procedure reimplantation.
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Although progress has led to a drop in infections, meningitis still represents a threat worldwide, affecting some areas more than others. As a medical emergency, it requires prompt recognition and treatment. Moreover, diagnosis relies on invasive methods, while representing a tug-of-war with timely therapeutic interventions, since delays are burdened by mortality and life-long sequalae. While counterbalancing the overuse of antimicrobials, it is imperative to assess correct interventions in order to optimize treatments and reduce negative outcomes. Because the drop in mortality and consequences has been consistent, although not as impactful as with other vaccine-preventable diseases, the WHO has traced a roadmap detailing actions to reduce the meningitis burden by 2030. There are currently no updated guidelines, whereas novel diagnostic methods as well as pharmacological interventions are increasing, along with the shifting epidemiology. In light of the above, this paper wishes to summarize existing data and evidences and suggest potential novel solutions to a complex problem.
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Meningitis , Micosis , Humanos , Sistema Nervioso Central , Micosis/diagnóstico , Micosis/tratamiento farmacológicoRESUMEN
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; no current clinical measure adequately reflects the concept of dysregulated response. Coagulation plays a pivotal role in the normal response to pathogens (immunothrombosis), thus the evolution toward sepsis-induced coagulopathy could be individuate through coagulation/fibrinolysis-related biomarkers. We focused on the role of D-dimer assessed within 24 h after admission in predicting clinical outcomes in a cohort of 270 patients hospitalized in a 79 months period for meningitis and/or bloodstream infections due to Streptococcus pneumoniae (n = 162) or Neisseria meningitidis (n = 108). Comparisons were performed with unpaired t-test, Mann-Whitney-test or chi-squared-test with continuity correction, as appropriate, and multivariable logistic regression analysis was performed with Bayesian model averaging. In-hospital mortality was 14.8% for the overall population, significantly higher in S. pneumoniae than in N. meningitidis patients: 19.1 vs. 8.3%, respectively (p = 0.014). At univariable logistic regression analysis the following variables were significantly associated with in-hospital mortality: pneumococcal etiology, female sex, age, ICU admission, SOFA score, septic shock, MODS, and D-dimer levels. At multivariable analysis D-dimer showed an effect only in N. meningitidis subgroup: as 500 ng/mL of D-dimer increased, the probability of unfavorable outcome increased on average by 4%. Median D-dimer was significantly higher in N. meningitidis than in S. pneumoniae patients (1,314 vs. 1,055 ng/mL, p = 0.009). For N. meningitidis in-hospital mortality was 0% for D-dimer <500 ng/mL, very low (3.5%) for D-dimer <7,000 ng/mL, and increased to 26.1% for D-dimer >7,000 ng/mL. Kaplan-Meier analysis of in-hospital mortality showed for N. meningitidis infections a statistically significant difference for D-dimer >7,000 ng/mL compared to values <500 ng/mL (p = 0.021) and 500-3,000 ng/mL (p = 0.002). For S. pneumoniae the mortality risk resulted always high, over 10%, irrespective by D-dimer values. In conclusion, D-dimer is rapid to be obtained, at low cost and available everywhere, and can help stratify the risk of in-hospital mortality and complications in patients with invasive infections due to N. meningitidis: D-dimer <500 ng/mL excludes any further complications, and a cut-off of 7,000 ng/mL seems able to predict a significantly increased mortality risk from much <10% to over 25%.
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Combinación Amoxicilina-Clavulanato de Potasio/uso terapéutico , Antibacterianos/uso terapéutico , Cefalosporinas/uso terapéutico , Endocarditis Bacteriana/tratamiento farmacológico , Enterococcus faecalis/efectos de los fármacos , Anciano , Biopelículas , Quimioterapia Combinada , Enterococcus faecalis/aislamiento & purificación , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
OBJECTIVES: Ceftobiprole is a relatively new cephalosporin with broad-spectrum activity and good tolerability. Despite its promising characteristics, to our knowledge, only two case reports, previously published also by some of us, is available concerning its administration for the treatment of infective endocarditis. Hereby we report our experience in this field. METHODS: All the patients with infective endocarditis treated with ceftobiprole were enrolled. RESULTS: 12 cases of endocarditis were treated with ceftobiprole, 11/12 in combination with daptomycin and 1/12 as monotherapy. Gram-positive bacteria were isolated in 12/12 patients; 3 cases were polymicrobial. Cure rate was 83% (10/12 patients). In 9/12 (75%) cases, patients were switched to ceftobiprole following failure of previous antimicrobial regimen. In 3/3 patients in which ceftobiprole was administered because of persistently positive blood culture, bacteraemia clearance was rapidly achieved. CONCLUSIONS: Ceftobiprole, especially in combination, could be a promising alternative treatment for infective endocarditis.
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Cefalosporinas/administración & dosificación , Daptomicina/administración & dosificación , Endocarditis/tratamiento farmacológico , Bacterias Grampositivas/aislamiento & purificación , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Cefalosporinas/farmacología , Daptomicina/farmacología , Quimioterapia Combinada , Endocarditis/microbiología , Femenino , Bacterias Grampositivas/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Infective endocarditis (IE) is characterized by high rates of in-hospital death, and Staphylococcus aureus infection predicts a worse prognosis. We aimed to assess if admission inflammatory biomarkers (white blood cell - WBC - count, C-reactive protein - CRP, and procalcitonin) are informative on microbiological etiology and short-term outcomes. METHODS: Data from 236 patients admitted for IE from January 2013 to June 2018 were retrieved from a multicenter registry. RESULTS: Fifty-two patients (22%) were infected by S. aureus. WBC, CRP and procalcitonin had area under the curve (AUC) values for S. aureus infection of 0.595, 0.675, and 0.727, respectively. Adding procalcitonin to WBC improved discrimination over WBC alone (pâ¯=â¯0.045), and procalcitonin predicted S. aureus infection independently from the other inflammatory biomarkers and patient characteristics. Patients with WBCâ¯≥â¯12,800/mm3, CRPâ¯≥â¯130â¯mg/L, and procalcitoninâ¯≥â¯1.7â¯ng/mL had an almost 20-fold higher risk of S. aureus infection than patients with all biomarkersâ¯<â¯cut-offs. AUC values for in-hospital death were 0.702, 0.725 and 0.727 for the WBC, CRP, and procalcitonin, respectively. Among inflammatory biomarkers, WBC and procalcitonin independently predicted in-hospital death. Procalcitonin refined risk stratification when added to WBC, and to the combination of WBC and CRP. Patients with WBCâ¯≥â¯10,535/mm3, CRPâ¯≥â¯85â¯mg/dL, and procalcitoninâ¯≥â¯0.4â¯ng/mL had a 27-fold higher risk of in-hospital death than patients with all biomarkersâ¯<â¯cut-offs. CONCLUSIONS: Among patients with IE, high levels of inflammatory biomarkers on admission, particularly procalcitonin, are associated with a higher likelihood of S. aureus infection, and a higher risk of in-hospital mortality.
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Proteína C-Reactiva/análisis , Endocarditis Bacteriana , Recuento de Leucocitos/métodos , Polipéptido alfa Relacionado con Calcitonina/sangre , Infecciones Estafilocócicas , Staphylococcus aureus/aislamiento & purificación , Anciano , Biomarcadores/sangre , Pruebas Diagnósticas de Rutina/métodos , Endocarditis Bacteriana/sangre , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Italia/epidemiología , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Medición de Riesgo , Infecciones Estafilocócicas/sangre , Infecciones Estafilocócicas/diagnósticoRESUMEN
A correct, fast, reliable identification method is pivotal in nosocomial environments to guide treatment strategies, whereas misidentification might lead to treatment failure. For routine identifications the Vitek system and CHROMagar are widely used but not always reliable, especially now with an increasing number of new emerging fungal pathogens that need careful identification. Here we describe two cases of candidemia, due to Candida palmioleophila previously misidentified as Candida albicans by using the Vitek2 system and CHROMagar. The first case is a 54-year-old man with an infected ulcer in the lower right limb, treated with a targeted therapy using a central venous catheter (CVC). After two months he developed a CVC-related candidemia MDR identified as C. albicans. The second case is a 2-month-old male baby that was admitted to the neonatal unit with acute respiratory failure due to a severe community-acquired bilateral pneumonia; blood cultures were all positive for C. albicans MDR. The isolated strains where re-identified with Maldi-Tof and DNA sequencing as C. palmioleophila. From the identification point of view, CHROMagar can be clearly misleading, especially because CHROMagar types currently available are not designed to discriminate new emerging species, suggesting that systems other than MALDI-TOF and marker sequencing may be inadequate even for routine identification and could contribute to producing misleading identifications and therapeutically wrong practices, leading to failures and patient death.
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Candida , Candidemia , Técnicas Microbiológicas , Candida/genética , Candida/aislamiento & purificación , Candida albicans , Candidemia/microbiología , Infecciones Relacionadas con Catéteres/microbiología , Catéteres Venosos Centrales , ADN de Hongos/genética , Humanos , Lactante , Italia , Masculino , Técnicas Microbiológicas/normas , Persona de Mediana Edad , Insuficiencia Respiratoria/microbiología , Análisis de Secuencia de ADNRESUMEN
Streptococcus pneumoniae is the main pathogen in invasive, life-threatening diseases such as bacteremia, meningitis, and pneumonia. We describe three cases of breakthrough pneumococcal severe life-threatening infections, including two meningitis and one bloodstream infection in patients treated with cefixime for otitis, sinusitis and pneumonia, respectively. Cefixime does not seem to be fully effective in treating invasive pneumococcal diseases. Because penicillin non-susceptibility might be linked to cefixime failure, the prompt knowledge of susceptibility to penicillin in S. pneumoniae might be very useful. Furthermore, MIC of cefixime should be measured because values >0.5 mg/L might be related to failure.
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Bacteriemia/epidemiología , Cefixima/efectos adversos , Meningitis/epidemiología , Infecciones Neumocócicas/tratamiento farmacológico , Neumonía/epidemiología , Streptococcus pneumoniae/efectos de los fármacos , Adolescente , Adulto , Antibacterianos/efectos adversos , Bacteriemia/inducido químicamente , Femenino , Humanos , Incidencia , Italia/epidemiología , Masculino , Meningitis/inducido químicamente , Infecciones Neumocócicas/microbiología , Neumonía/inducido químicamente , Pronóstico , Adulto JovenRESUMEN
A 62-year-old man developed a blood stream infection and meningitis due to Listeria monocytogenes, 20 days after an episode of pseudo-membranous colitis. The patient, hospitalized for the first time for transurethral prostatectomy, was readmitted 20 days later with watery diarrhea. Pseudo-membranous colitis was diagnosed and treated successfully, without testing for Clostridium difficile infection (CDI). After 15 more days, the patient developed again diarrhea, fever and confusion. Hospitalized again, blood and cerebrospinal fluid cultures resulted positive for L. monocytogenes. The patient was treated successfully and a diagnosis of recurrent CDI was confirmed following culture and nucleic acid amplification assays both positive for C. difficile. This is the first report of an invasive listeriosis after CDI underlines the importance of taking greater awareness in complicated blood stream infections that may arise after CDI.
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Antibacterianos/uso terapéutico , Clostridioides difficile/efectos de los fármacos , Enterocolitis Seudomembranosa/complicaciones , Enterocolitis Seudomembranosa/tratamiento farmacológico , Listeriosis/complicaciones , Listeriosis/diagnóstico , Diarrea/diagnóstico , Diarrea/tratamiento farmacológico , Diarrea/etiología , Diarrea/microbiología , Enterocolitis Seudomembranosa/diagnóstico , Enterocolitis Seudomembranosa/microbiología , Humanos , Italia , Listeria monocytogenes/aislamiento & purificación , Listeria monocytogenes/fisiología , Listeriosis/sangre , Listeriosis/tratamiento farmacológico , Masculino , Meningitis Bacterianas/diagnóstico , Meningitis Bacterianas/tratamiento farmacológico , Meningitis Bacterianas/microbiología , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Most clinicians in developed countries have limited experience in making clinical assessments of malaria disease severity and/or monitoring high-level parasitemia in febrile patients with imported malaria. Hyperparasitemia is a risk factor for severe P. falciparum malaria, and procalcitonin (PCT) has recently been related to the severity of malaria. In developed countries, where not all hospital have skilled personnel to count parasitemia, a rapid test might be useful for the prompt diagnosis of malaria but unfortunately these tests are not able to count the number of parasites. In this context, PCT might have a prognostic value for the assessment of severe malaria, especially in children with cerebral malaria. We describe two children with severe cerebral malaria, who were directly admitted to the ICU with a high level of PCT and extremely high (>25%) parasitemia. Our conclusion is that PCT may also be a measure of severity of P. falciparum malaria in children.
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Calcitonina/sangre , Malaria Falciparum/sangre , Malaria Falciparum/patología , Plasmodium falciparum , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Antimaláricos/administración & dosificación , Antimaláricos/uso terapéutico , Artemisininas/administración & dosificación , Artemisininas/uso terapéutico , Artesunato , Ceftriaxona/administración & dosificación , Ceftriaxona/uso terapéutico , Preescolar , Femenino , Humanos , Lactante , MasculinoRESUMEN
After implementation of programmes for active immunization against Haemophilus influenzae b, Streptococcus pneumoniae and Neisseria meningitidis became the most common agents of bacterial meningitis in childhood. Over a 9-year period, children showing clinical and laboratory findings of meningitis on the basis of their positive cultures of blood or cerebro-spinal fluid (CSF) for S. pneumoniae were enrolled. Predisposing conditions, clinical and laboratory findings, and microbiological and imaging studies were considered. Meningitis-related death or neurological sequelae defined an unfavourable outcome. Sixty-four patients met the inclusion criteria. Thirty-one (48%) children had predisposing conditions to pneumococcal meningitis. Fever and neck stiffness were the main symptoms; 14 patients (22%) reported seizures before admission. Twenty-one patients required treatment in the intensive care unit (ICU). Streptococcus pneumoniae strains were penicillin susceptible in 54 cases (84%). Forty-eight children (75%) showed complete recovery. Two patients (3%) died, and 14 (22%) had sequelae. Patients with a low CSF cell count, low neutrophils, early admission to ICU or infection by penicillin-nonsusceptible strains of S. pneumoniae had an unfavourable outcome more frequently. Low blood neutrophils, low CSF cell count, early admission to ICU and infection by penicillin-nonsusceptible strains are the main factors predicting an unfavourable outcome in children with pneumococcal meningitis.
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Meningitis Neumocócica/epidemiología , Streptococcus pneumoniae/aislamiento & purificación , Adolescente , Antibacterianos/farmacología , Sangre/microbiología , Líquido Cefalorraquídeo/citología , Líquido Cefalorraquídeo/microbiología , Niño , Preescolar , Farmacorresistencia Bacteriana , Humanos , Lactante , Recuento de Leucocitos , Estudios Longitudinales , Meningitis Neumocócica/complicaciones , Meningitis Neumocócica/microbiología , Meningitis Neumocócica/mortalidad , Pruebas de Sensibilidad Microbiana , Enfermedades del Sistema Nervioso/microbiología , Penicilinas/farmacología , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Meningitis sustained by streptococci other than pneumoniae, infrequent in community medicine, is emerging as a hospital-acquired infection. We describe four cases of meningitis caused by streptococci other than pneumoniae in adults.
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Meningitis Bacterianas/diagnóstico , Meningitis Bacterianas/microbiología , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/microbiología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Toscana virus was detected by reverse transcription-nested PCR in 5.6% of cerebrospinal fluid (CSF) samples from patients with meningitis and encephalitis during the summer in southern Italy. The central nervous system infections were associated with young adults and with a substantially benign clinical course. Presenting features and CSF findings are also discussed in the present report.
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Encefalitis Viral/epidemiología , Meningitis Viral/epidemiología , Fiebre por Flebótomos/epidemiología , Virus de Nápoles de la Fiebre de la Mosca de los Arenales/aislamiento & purificación , Adolescente , Adulto , Líquido Cefalorraquídeo/virología , Encefalitis Viral/líquido cefalorraquídeo , Encefalitis Viral/virología , Femenino , Humanos , Italia/epidemiología , Masculino , Meningitis Viral/líquido cefalorraquídeo , Meningitis Viral/virología , Fiebre por Flebótomos/líquido cefalorraquídeo , Fiebre por Flebótomos/virología , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Virus de Nápoles de la Fiebre de la Mosca de los Arenales/clasificación , Virus de Nápoles de la Fiebre de la Mosca de los Arenales/genéticaRESUMEN
BACKGROUND: HBV-DNA quantitation, the HBe antigen status and the appearance of mutations in the core promoter, precore and polymerase regions are important elements in the management of chronic HBV infection. METHODS: We performed a technical evaluation of 3 new kits, affigene HBV VL, affigene HBV mutant VL and affigene HBV DE/3TC assays (Sangtec Molecular Diagnostics) in comparison with the Amplicor HBV Monitor assay (Manual Test, Roche), direct sequencing and direct sequencing/Inno-LIPA HBV DR (Innogenetics), respectively. We evaluated the clinical application of these tests in the management of patients with chronic (HBeAg positive) hepatitis B. Serial sera of 11 chronic HBeAg positive patients were studied before, during and after lamivudine/interferon treatment. RESULTS: HBV-DNA quantitation detected with affigene HBV VL showed a high correlation with the Amplicor HBV Monitor test (r=0.85). affigene HBV mutant VL (positions G1764A, G1896A) and affigene HBV DE/3TC (positions rtL180M, rtM204V/I) were able to detect a low presence of mutants in a mixed population (wild type and mutant) compared to direct sequencing and Inno-LIPA HBV DR, which identified only the dominant population. CONCLUSIONS: These three sensitive assays, performed with the same DNA extraction, give clinicians useful information for the management of chronic hepatitis B and for timing treatment.
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ADN Viral/sangre , ADN Polimerasa Dirigida por ADN/genética , Antígenos del Núcleo de la Hepatitis B/genética , Virus de la Hepatitis B/genética , Hepatitis B Crónica/virología , Reacción en Cadena de la Polimerasa/métodos , Juego de Reactivos para Diagnóstico , Adolescente , Adulto , Antivirales/uso terapéutico , Niño , Sistemas de Computación , Análisis Mutacional de ADN , ADN Viral/genética , Femenino , Genes Virales , Antígenos e de la Hepatitis B/sangre , Hepatitis B Crónica/sangre , Hepatitis B Crónica/tratamiento farmacológico , Humanos , Interferón-alfa/uso terapéutico , Lamivudine/uso terapéutico , Masculino , Mutación Missense/genética , Mutación Puntual/genética , Regiones Promotoras Genéticas/genética , Inhibidores de la Transcriptasa Inversa/uso terapéutico , Sensibilidad y Especificidad , Análisis de Secuencia de ADN , Carga ViralRESUMEN
UNLABELLED: Aim of the study was to evaluate the prevalence and characteristics of non operative spondylodiskitis (SD) in our geographic area. METHODS: We evaluated retrospectively epidemiological, clinical, laboratory and radiological features of patients with non operative SD observed between 1990 and 2001 in our department of the "D. Cotugno" hospital - Naples. RESULTS: Eighteen patients with diagnosis of SD were evaluated. Etiologic agent was identified in 17 patients: M. tuberculosis in 5, brucella spp. in 4 and pyogenic bacteria in 8. Ten patients had underlying diseases or risk factors (4 diabetes mellitus, 3 arthrosis, 1 CRF, 1 IVDA and 2 previous back trauma). Symptoms preceded observation between 2 days and 12 months (median value 15 days). Seventeen patients presented fever, 13 back pain, 6 meningitis, 3 were comatous and 2 had severe sepsis. Ten patients showed high white blood cells count with granulocyte prevalence. Eritrosedimentation rate or C reactive protein were elevated in all patients. Diagnosis was confirmed in 8 patients only with radiographs of the spine, while 3 needed a CT and 11 a RMN imaging. Antimicrobial therapy was perfomed for at least 6 months in patients with brucellosis, 12 months in patients with tuberculosis and 2 months in patients with pyogenic SD. Persistent neurological deficit were observed in 2 patients. CONCLUSIONS: Neurological deficit may be avoid in patients affected by SD only with a carefull diagnosis and an accurate antibiotic therapy.